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Primary open angle glaucoma – surgical management

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Primary open angle glaucoma – surgical management

  1. 1. POAG – Surgical management Vinaykumar .S. Appannavar Roll no: 90
  2. 2.  Argon laser (ALT)  Diode laser (DLT)  Selective laser (SLT)  It is done in patients where IOP is uncontrolled despite maximal tolerated medical therapy  Where there is non-compliance to medical therapy it can be used Laser trabeculoplasty
  3. 3. Technique and role of (ALT) or (DLT)  Its hypotensive effect is caused by the producing collagen shrinkage on inner aspect of trabecular meshwork and opening the inter trabecular spaces  Its been shown to lower IOP by 8-10 mm of hg in patients – on medical therapy IOP by 12-16 mm of hg in patients – not on medical therapy  it consists of 50 spots on the anterior half of trabecular meshwork over 180 deg. Treatment regime
  4. 4. Transient acute rise of IOP , which can be prevented by pretreatment with apraclonidine and/or acetazolamide Transient inflammation which can be lessened by use of topical steroids for 3-4 days Other complications seen less commonly are haemorrahage , uveitis, peripheral anterior synechiae and reduced accommodation Complications
  5. 5. ( Selective laser trabeculoplasty)  It targets selectively pigmented trabecular meshwork cells without causing collateral damage to non-pigmented cells or stuctures unlike ALT or DLT. SLT
  6. 6. ND:YAG Laser • Pressure lowering effect of SLT is similar to ALT with the advantage of not causing damage and scarring to TM • Further, it can be used in patients treated with ALT SLT is performed using Q- switched frequency doubled 532nm ND:YAG laser with a pulse duration of 3 ms a spot size of 400 microns and 0.8mJ energy
  7. 7. Indications :  Uncontrolled glaucoma despite of maximal medical therapy & laser trabeculoplasty  Noncompliance of medical therapy & non availability of ALT/ SLT  Failure of medical therapy & unsuitable for ALT/SLT  Eyes with advanced disease , i.e., having very high IOP, advanced cupping & advanced field loss Types :  It primarly consists of a fistulizing surgery o Trabeculectomy . o Filtration operations Surgical therapy
  8. 8. Filtering operations It provide a new channel for aqueous outflow and successfully control IOP ( below 20 mm of Hg ) External filtration surgery Internal filtration surgery 1.Free-filtering operations 1.Cananoplasty 2.Gaurded filtering surgery 2.Trabectome ( trabeculectomy ) 3.iStent 3.non-penetrating filtration surgery ( deep sclerectomy & viscocanalostomy )
  9. 9. Trabeculectomy Indications :  Primary open-angle glaucoma  Primary angle-closure glaucoma with anterior synechial involving more than 270 deg. angle or where PI and medical treatment fail  Congenital and developmental glaucomas  Secondary glaucomas Mechanisms of filtration :  A new channel is created around the margin of scleral flap through which aqueous flow from anterior chamber subconjuctival space  If the tissue is dissected posterior to scleral spur, a cyclodialysis may be produced leading to increased uveoscleral outflow  Aqueous flows through the cut ends of Schlemm’s canal, now it is established that this mechanism has negligible role
  10. 10. Surgical technique  Initial steps of anaesthesia, cleansing, draping ,exposure of eyeball and fixation with superior rectus suture  Conjunctival flap , a fornix based conjunctival flap is fashioned and the underlying sclera is exposed.  Scleral flap , a partial thickness limbal based scleral flap of 5mm*5mm size is reflected down towards the cornea  Excision of trabecular tissue, a narrow strip of the exposed deeper sclera near the cornea containing the Schlemmn canal and trabecular meshwork  Peripheral iridectomy
  11. 11.  Closure, the scleral flap is replaced and 10-0 nylon sutures are applied then the conjunctival flap is reposited with or continuous suture  Subconjunctival injections of dexmethasone and gentamycin are given  Patching
  12. 12. Complications  Postoperative shallow anterior chamber, hyphaema, iritis, cataract due to accidental injury to the lens and endopthalmitis Use of antimetabolites Any of the following risk factors for the failure of conventional trabeculectomy are present  Previous failed filtration surgery  Glaucoma in aphakia  Secondary glaucomas  Patients treated with topical antiglaucoma medications  Chronic cicatrizing conjunctival inflammation
  13. 13. Antimetabolite agents  Either 5- fluorouracil or mitomycin -C can be used  A sponge soaked in 0.02% solution of mitomycin –C is placed at the site of filtration b/w the scleral and Tenon’s capsule of two minutes, followed by a thorough irrigation with balanced salt solution  Use of collagen implant with glaucoma filtration surgery  Technique: Usually a 6mm diameter and 1mm thick implant is sutured over the scleral flap.
  14. 14. Deep sclerectomy Viscocanalostomy Non-penetrating filtration surgeries
  15. 15. Canaloplasty Trabectome Internal filteration surgeries
  16. 16. iStent : is a titanium microdevice that is place inside the Schlemm’s canal
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    Dec. 11, 2018
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    Nov. 11, 2018
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  • Shabnamkamal

    Feb. 11, 2017
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    Dec. 28, 2016
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  • ameerhamza315213

    Aug. 17, 2016
  • VinaykumarSA

    Mar. 17, 2016

for UG level

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