Final - Procedures McNulty

Question 1

Glauc therapy: historical approach

Answer 1

Drops until failure -> laser -> invasive sx

Question 2

Glauc drops

• advantages
• disadvantages

Answer 2

Choices
Effective
Familiar to pts, well rec’d

Compliance
Cost
SE

Question 3

Info for the referral

Answer 3

Max IOP
IOP on current tx
Current and past tx’s
Baseline and current VF, OCT, gonio findings
Eye sx/injury hx

Question 4

Laser tissue inxns

-laser variables that influence

Answer 4

Wavelength
-determines which tiss is impacted

Spot size
-smaller = higher density

Pulse duration
-sometimes variable, sometimes fixed

Question 5

Laser tissue inxns

-tissue variables that influence

Answer 5

Transparency
-depends on wavelength

Pigment
-argon: pigment absorbs light and converts energy to heat (more pigment = better absorption)

Question 6

SLT

• wavelength
• burn time and importance

Answer 6

532nm (green)

3 nanoseconds

• not enough time for melanin to convert light energy into heat (thermal relaxation time of 1 microsec) = “cold laser”
• no effect on adjacent non-melanin-containing cells (“selective”)

Question 7

SLT

• proposed mechanism
• vs ALT

Answer 7

Target cells activate cytokines -> activ macrophages -> clean area -> decr outflow resistance

No mechanical damage/scars (unlike ALT)
-potentially repeatable

Question 8

Trabeculoplasty indications

Answer 8

POAG
OHTN
NTG
Pigment dispersion G
PEX glaucoma

Question 9

MIGS

• stands for
• used for

Answer 9

Minimally invasive glaucoma surgery

Mild-moderate glaucoma

Question 10

Conventional/invasive surgery

-used for

Answer 10

Moderate-severe glaucoma

Question 11

MIGS

-what it is/why it’s used (6)

Answer 11

Minimal trauma/disruption to normal anatomy

Ab interno (from w/in the eye), micro-incisional approach

Modest IOP reduction

Safe

Often combined with cataract sx

Rapid post-op recovery

Question 12

Only consistent predictor of SLT success

Answer 12

IOP (max and pre-laser)

Question 13

MIGS

-first approved by FDA (2012) and how it works

Answer 13

iStent

Inserted from AC into Schlemm’s
Creates channel from AC to SC
Incr aqueous outflow by bypassing TM

Question 14

MIGS

-electrocautery device used to perfrom partial trabeculotomy

Answer 14

Trabectome

Question 15

MIGS

-laser probe used to destroy the anterior ciliary processes

Answer 15

Endocyclophotocoagulation (ECP)

Question 16

MIGS

-laser energy is delivered at the limbus, thru the sclera, to the ciliary processes

Answer 16

Trans-scleral cyclophotocoagulation (CPC)

Question 17

MIGS

-2 procedures that decr aqueous production

Answer 17

ECP

CPC

Question 18

MIGS

-6mm tube inserted from AC, thru Schlemm’s, into subconj space (creates a bleb)

Answer 18

Xen gel stent

Question 19

Incisional surgery

-“tubes and trabs”

Answer 19

Tube =aqueous tube shunt

Trab = trabeculectomy

Question 20

Tube shunts

• purpose
• incision
• implant placement

Answer 20

Divert AH to an external reservoir

External, thru conj and Tenon’s capsule

Subconj with tube entering AC

Question 21

Most established/oldest of these procedures

Answer 21

Trabeculectomy

Question 22

Trabeculectomy

• surgical opening
• aqueous flow
• tube

Answer 22

Into AC from under a scleral flap

Into subconj space, creating a filtering bleb

None placed - Mitomycin C (MMC) = antimetabolite, prevents fibrosis and trab failure

Question 23

Tubes vs trabs

-which is more common, why

Answer 23

Tubes - trabs have higher failure rate (complications, need for more sx, NLP vision)

Question 24

Postop care

-ideal bleb

Answer 24

Low-lying
Minimal vascularity
IOP in teens
Well-formed AC
(-) Seidel sign

Question 25

Bleb complications

Answer 25

Hypotony - most common

• IOP <5mmHg
• no visible bleb

Leak (positive Seidel)

Blebitis

• milky-white, pain, blurred vision
• may involve AC/vitreous -> endophthalmitis

Question 26

Tube complications

Answer 26

Same as bleb + diplopia (~5%, tube plate placed near EOMs)