Case study 1
48 year old , Female
RE RETINA SURGEYR 20 YRS BACK
RE CATARACT SURGERY 2 YEARS BACK
IOP – 24 ON MTT(3 BOTTLES )
BUCKLE
2 yr
UNEVENTFUL
TRABECULECTOMY
Day 5
RIGHT PATIENT FOR
GLAUCOMA
SURGERY
DR. NISHTHA SINGH
CONSULTANT- GLAUCOMA SERVICES
DRISHTI EYE HOSPITAL
Medical management is the treatment of
choice .
Glaucoma surgery is the last option
INDICATIONS OF GLAUCOMA SURGERY
Uncontrolled Advanced
iop glaucoma
Failed
Glaucoma
medical
progression
therapy
Drug
Comp
tolera
liance bility
What are the surgical options available
1.Glaucoma Filtration Surgery
2.Glaucoma Drainage Devices
3. Minimally Invasive Glaucoma Surgery
TRABECULECTOMY
•An ostium is created into the anterior
chamber underneath a partial thickness
scleral flap
•Allow for aqueous flow out of the eye.
•The aqueous flows into the subconjunctival
space
•Elevation of the conjunctiva
• FILTERING BLEB
PROBLEMS WITH TRABECULECTOMY
No surgery is complication free
Surgical success decreases with time
Pre operative planning
Complication
Bleb Failure
Hypotony
Choroidal
detachment
Cataract
Vision loss
Tenon caps
Patient selection
•History of prior ocular inflammation or infection
•History of prior ocular procedures.
•Intraocular pressure range.
•History of bleeding disorders or consumption of
anticoagulative medications.
•History of ocular trauma
•History of topical antiglaucoma (NO & DURATION )
PREOPERATIVE ASSESSMENT
•Lid hygiene and severe blepharitis. •Signs of prior intraocular
•Any areas of conjunctival scarring, inflammation.
irregularity or hyperaemia. •Refractive status .
•Any areas of scleral thinning. •Lens status
•Gonioscopic findings. (PAS,NVA ) •Severity of glaucoma
•Level of Intraocular pressure •Etiology of glaucoma
•Any evidence of prior intraocular
surgery.
Freely mobile virgin conjunctiva
Conjunctiva Scarring &
Conjunctiva Inflammation
Previous ocular surgery Secondary Glaucoma
Band buckle Uveitis
Ppv Nvg
Corneal Transplant ICE
TOPICAL STEROIDS BEFORE SURGERY
Anti metabolites – MMC, 5 FU,OLOGEN ,ANTI-VEGF
DURATI
ON
INFLAMMATORY
PRESER MEDIATORS
VATIVE NO OF
TOXICIT DRUGS
Y
•SHALLOW AC – PACG
•CATARACT PROGRESSION
•COMBINED SURGERY
PHAKIA
•HYPOTONY-CD
•SUPRACHOROIDAL HMRHAGE
LENS STATUS APHAKIA
•PCR – BLEB FAILURE
CHOROIDAL DETACHMENT
PSEUDOPHAKIA
•COMBINED SURGERY -Visually significant cataract with high iop / iop controlled on > 2 bottle
•EARLY LENS EXTRACTION IN PACG - Decrease medicine load / need of surgery
REFRACTION &AXIAL LENGTH
AQUEOUS
MISDIRECTION
HYPEROPIA
NANOPHTHALMOS
MYOPIA
CHOROIDAL EFFUSION
•All surgeries safe in mild /moderate stage of glaucoma
•The extent and location of damage may alter the threshold for
surgery.
GLAUCOMA SEVERITY
•Analyse the risk of wipe out in advanced macula involving
glaucoma
PATIENT FACTORS
1. Age and vulnerability
2. Access to health care
3. Support system
4. One eyed status
5. Adherence to treatment
6. Hygiene
Poor understanding of instruction
Poor compliance to medication
Poor attendance on follow up visits
CLASSIFY AS PER RISK OF FAILURE AND COMPLICATIONS ?
AVERAGE MODERATE HIGH RISK
•Joag/young •Nvg
•Poag
•Ice
•Pigmentary •Uveitic
•Steroid •Secondary to trauma
•Pxf induced /chemical injury
•Previous ocular
•Chronic topical surgery
•Elderly therapy •VR SX(PPV,BB/ silicon
oil )
•Combined •Corneal transplant
surgery •Aphakia
GDD
Augmented
Trabeculectomy
Mietz H, Raschka B, Krieglstein GK Risk factors for failures of trabeculectomies performed without antimetabolite
sBritish Journal of Ophthalmology 1999;83:814-821.
CASE STUDY
35 YR MALE
LE 6/12
IOP-45 MMHG
ICE SYNDROME
PHAKIC
1ST SURGERY
SHALLOW AC 50
COST
45
40 IOP
35
CONSTRAINTS 30
25
20
Trabeculectomy 15
10 VN – 6,9
with ologen iplant and mmc 5
0
0 1 7 30 60 180 365 2yr 2.5 yr 2.6 yr
iop
Right patient for glaucoma filtering surgery
Virgin
Low risk
conjunctiva
< 2 drugs
category
Right
Patient
Uneventful post op period
Target pressure achieved
Surgeons Role
Intra op
MMC /OLOGEN Post OP
Pre op Filtration (over
Conjunctiva
suturing /under)
IOP Control Bleb massage
Pre op Mannitol Releasable sutures
Atropine Seidels
Topical steroids 5 FU
Infusion / AC
maintainer ALS
COMPREHENSIVE INTERACTIVE
EXAMINATION APPROACH
CHOOSING THE RIGHT PATIENT
Change is the only constant
