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Manolito R. Reyes, MD, DPBOGlaucoma Consultant
Far Eastern University Medical Center
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Practical tips on deciding whether to do trabeculectomy
alone or combined surgery
1). Glaucoma well controlled Visually significantcataract on multiple topical glaucoma meds
combined cataract+ filter
2). Glaucoma well controlled Visually significantcataract just one glaucoma medication (except
Prostaglandin) cataract surgery alone
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Practical tips on deciding whether to do trabeculectomy
alone or combined surgery
3). Glaucoma well controlled Visually significantcataract good filter surgery cataract surgery
alone (clear cornea temporal approach)
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Practical tips on deciding whether to do
trabeculectomy alone or combined surgery
5). Glaucoma not well contolled on maximum medicaltherapy or intolerant to glaucoma meds or financially not
capable to comply with glaucoma meds not visually
significant cataract filter alone
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Advantages of combined procedure
A). Risk of early post-operative rise in IOP is reduced (14%
of eyes had 10 mmHg IOP rise in combined procedure,70% had IOP rise in cataract alone )
B). Long term control of glaucoma is also improved with
most patients requiring the same or less medicationsthan preoperatively
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Disadvantages of combined procedure
A). Higher incidence of suprachoroidal hemorrhage
B). Higher incidence of aqueous leakage which can lead to
hypotony, flat anterior chamber and endophthalmitis
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` L.M
` 58/F
` Dx: Chronic closed angle glaucoma, OU; Cataract
presenile, OU` BCVA: OD: 20/40 OS: 20/100
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` Borderline controlled Glaucoma on Multiple drug
therapy
` Significant cataract
` Visual field progression
` PLAN: ???
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` For Combined Procedure Phaco -Trab with
Mitomycin C
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VA: 20/50
IOP: 12 mmHg
No antiglaucoma
meds
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` A.F.
` 74 / F
` BCVA: OD: 20/100 OS: 20/200
` IOP: OD: 24 mmHg OS: 25 mmHg
` Dx: Chronic Open Angle Glaucoma, OU
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` Uncontrolled Glaucoma on Multiple Drug Therapy
` Significant Lens Opacity
` Plan: For Combined Procedure, OS
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VA: 20/100 20/50
IOP: 14 mmHg
No Antiglaucoma
meds
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Post-penetrating Keratoplasty Glaucoma (PKPG)
Glaucoma is one of the most serious complication
following PKP.After corneal graft rejection, glaucoma isthe second most common reason for corneal graft failure
(7-30%)
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Mechanism of IOP elevation after PKP
1.Trabecular meshwork collapse
2.Angle closure glaucoma with PAS formationa) Pupillary block
b) Chronic Uveitis
c) Choroidal detachment with ciliary body rotation
d) Aqueous diversion syndrome
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Mechanism of IOP elevation after PKP
3. Steroid induced glaucoma
4. Worsening of pre-existing glaucoma
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Glaucoma meds
1. Beta blocker
2.Alpha adrenergic
Potential Problems in
Patients w/ PKPG
SPK, corneal anesthesiaDry eyes, Subconjunctival
Fibrosis
SPK, allergic reactions
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Glaucoma meds
3. Miotics
4. CAIs
Potential problems in
patients w/ PKPG
Inflammation, graft rejection,R.D., Subconj fibrosis
Induced permanent graft
failure in eyes w/borderline endothelial
counts
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Glaucoma meds
5. PGs
Potential problems in
patients w/ PKPG
Uveitis, CME in aphakia &Pseudophakia, recurrent
herpes simplex keratitis
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Surgical treatment for PKPG
1.Trabeculectomy w/ mitomycin
- success rate is 69-90% (ave 80%)- graft failure rate 12-18% (ave 15%)
2. Glaucoma drainage device
- success rate is 71-96% (ave 84%)- graft failure rate is ave 36%
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Surgical treatment for PKPG
3. Cyclodestructive procedure
- success rate 30-50%- graft failure rate 11-65%
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Complications of cyclodestructive procedure1. Decrease V/A
2. Peristent hypotomy
3.Anterior uveitis
4. Persistent epithelial defect
5. Vision loss
6. Severe intractable pain
7. Phthisis Bulbi
8. Hypopyon
9. Sympathetic ophthalmia
10. Scleral thinning
11.Vitreous hemorrhages
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Practical tips in decision making whether to do glaucoma
surgery or combined PKP+glaucoma surgery
1). Patients with uncontrolled or borderline IOP on twoor more medications glaucoma surgery first or
combined glaucoma+PKP
2) Patients not responding to medications should be treatedsurgically
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Practical tips in decision making whether to do glaucoma
surgery or combined PKP+glaucoma surgery
3. Trabeculectomy w/ mitomycin C is the safest operationin terms of both IOP control and graft survival
4. GDD is the preferred operation over trabeculectomy in
patients w/ PKPG who have extensive limbal conjuctivalscarring, shallowAC, extensive PAS & failed trabec
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Practical tips in decision making whether to do glaucoma
surgery or combined PKP+glaucoma surgery
5. Cyclodestructive measure should be reserved for patientswhich have failed all other intervention
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