surgery glaucoma
DESCRIPTION
my seminar on surgical management of glaucomaTRANSCRIPT
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SURGICAL MANAGEME
NT OF GLAUCOMA
ABINAYA.K.AROLL NO:1
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SURGICAL MANAGEMENT Laser surgeries Trabeculotomy and goniotomy Penetrating filtering surgeries-
trabeculectomy Non penetrating filtering surgeries Cyclo destructive procedures Artificial drainage implants
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LASER SURGERIES
Trabeculoplasty
Peripheral iridotomy-Nd:Yag laser
Cyclo ablation-diode laser
LASER filtration procedures
Argon laser
selective laser
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TRABECULOPLASTY Laser energy to trabecular meshwork
Cellular changes in angle
Increases the drainage Patient selection: Patients non-compliant with med therapy. Elderly Type of glaucoma-open angle Pigmentation-pseudo exfoliation type;
-pigmentary
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PRE-OPERATIVELY: The eye should be free from
inflammation Iop should not be too high It should not be end stage glaucoma
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ARGON LASER TRABECULOPLASTY Involves application of laser burns to the
trabeculum at blue-green wavelengths It enhances aqueous flow
Alt is ineffective in pediatric glaucoma and most of sec glaucoma except pigmentary and pseudo exfoliatory types
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Application of laser beam:at the junction of pigmented and non pigmented trabeculum.
Ideal reaction:minute gas bubble or blanching
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MECHANISM OF ACTION Mechanical effect: Tightening of TM Opening of intervening spaces Opening of collapsed schlemm’s canal
Biological response: Release of cytokines-signals the
macrophages to clear material that has accumulated in meshwork
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PROCEDURE Pre-op:brimonidine eye drops 15 mins
before Local anaesthetic Gonioscopic contact lens to visualise the
angle 180 or 360 treated per session Post-op:glaucoma eye drops,anti-
glaucoma medication ot be continued,short course of topical steroids
Follow up-6 wks later
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Complications: Peripheral anterior synechiae Small hemorrhages Elevation of IOP uveitis Adverse effect on subsequent filtering
surgery Success rate:POAG-75-80%
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SELECTIVE LASER TRABECULOPLASTY Nd:yag laser Laser targets only the pigmented cells
in TM Advantage over ALT-the surgeon can
repeat the surgery over the same angle
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PERIPHERAL IRIDOTOMY Definition:
-creating a full thickness hole in the peripheral iris in order to alleviate the pupillary block.
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Indications: PACG Fellow eye of a patient with acute
glaucoma Narrow occludable angles Secondary angle closure with pupil block Narrow angle in POAG Combined mech glaucoma
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PERIPHERAL IRIDOTOMY
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TECHNIQUE OF IRIDOTOMY PUPIL IS MIOSED PRE-OP SITE:PERIPHERY OF IRIS,SUPERIOR IRIS 11-1 o clock position TO PREVENT THE
IRRADIATION OF FOVEA. SUCCESSFUL IRIDOTOMY:GUSH OF PIGMENT
DEBRIS
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COMPLICATIONS: Bleeding Iritis Glare and diplopia Corneal burns
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SURGERY FOR CONGENITAL GLAUCOMA
1. Goniotomy2. Trabeculotomy3. trabeculectomy
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GONIOTOMY Done when cornea is clear or the angle
can be visualised. Mech:Incision of obstructing trabecular
meshwork
Direct conduit between AC & schlemm canal
Barkan goniotomy knife
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Pre-op care: Acetazolamide:one week before to clear
corneal opacity ARI & NLD obstruction – treated Complications: Post-op hyphema Injury to iris & lens DM detachment
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TRABECULOTOMY
Harm’s trabeculotome
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FILTERING PROCEDURETRABECULECTOMY
Patient selection:
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Pre-op considerations: Any type of glaucoma Intact,non-scarred conjunctivaSurgical technique: Incision through the conjunctica Partial thickness scleral flap A small hole in AC Iridectomy at this point Scleral flap closed with stitches Conjunctival tissue closed with stitches
to allow formation of bleb
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TRABECULECTOMY
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I.LIMBAL BASED CONJUNCTIVAL FLAP
II.OUTLINE OF SUPERFICIAL SCLERAL FLAP
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III.DISSECTION OF SUP.SCLERAL FLAP
IV.INCISION FOR DEEP SCLERECTOMY
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V.EXCISION OF DEEP SCLERAL BLOCK
VI.PERIPHERAL IRIDECTOMY
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Bleb is situated in superior aspect of eye covered by the upper eyelid
Anti-metabolites: 5 FU and mitomycin(0.02%) used. It prevents scarring of tissue Frequent use will lead to hypotony Anaesthesia:~retro bulbar / topicalo Post-op :o Success rate:65-70%
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THIN, POLYCYSTIC BLEB
SHALLOW, DIFFUSE FILTERING BLEB
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VASCULARISED, NON-PENTRATING BLEB
LEAKING BLEB
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POST-OP COMPLICATIONS Shallow anterior chamber Pupillary block Over filtration Malignant glaucoma Failure of filtration Bleb related complications Bleb leakage Blebitis Bacterial infection
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NON-PENETRATING FILTERING SURGERIES Intro: AC is not entered , so post-op hypotony
does not occur. Dis adv: Two types: Deep sclerectomy Visco-canalostomy
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ARTIFICIAL DRAINAGE DEVICES Intro: Plastic devices which create a
communication between AC and sub tenon space.
Indications: Uncontrolled glaucoma Sec. glaucoma-neo vascular
glaucoma,aniridia Severe conjunctival scarring
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IMPLANT TYPES With a valve:~ahmed and krupin Without a valve:~molteno and baerveldtSETON’S OPERATION
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Complications: Excessive drainage Corneal decompensation Cataract Diplopia Late endophthalmitis
Success rate:75%
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CYCLO DESTRUCTIVE PROCEDURES Surgical and laser procedures that
ablate the ciliary body to lower the iop surgery:-cyclo cryotherapy Laser-cyclophotocoagulation Feared complication:hypotony
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Thank
you!