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3F: Sugery > Gonio And Laser Theraoy > Flashcards

Gonio And Laser Theraoy Flashcards

1
Q

Iris insertion

A

If inserted anteriroly
-less CB shows

If inserted more posteriroly
-more CB shows

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2
Q

How to get more CB showing

A

Have the patient look into the lens

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3
Q

Ciliary body

A

Visibility-“width”

Pigmentation-typically related to systemic pigmentation

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4
Q

Scleral spur

A

Visible postrusion of sclera into the AC

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5
Q

Yellow scleral spur

A

More common in older patients

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6
Q

TM

A

Located at base of cornea

Responsible for draining the AH

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7
Q

Schwalbes line

A
  • line found on interior surface of eyes cornea
  • delineates outer limit of corneal endothelium layer
  • represents th extermination of descemets membrane
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8
Q

Scheie’s systems

A
  • Roman numerals used to describe the degree to which the angle is closed
  • openness: wide-narrow (wide-1-II-iii-IV)
  • pigmentation: 0-IV (non to lots)
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9
Q

Shaffer system

A

-numerals use to describe the degree to which the angle is open
-approximates the angle at chi hthe iris inserts relative to the TBM
Openness
-wide-narrow
-4-3-2-1-0

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10
Q

Angle presentations

A 
PI
Angle recession
Pigment dispersion
Iris processes
PAS
Closed angle 
foreign body
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11
Q

Plateau iris configuration

A

Some degree of pupillaryblock

LPI works in these cases

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12
Q

Plateau iris syndrome

A
  • uncommon form of primary angle closure
  • large ar anteriroly postiioned ciliary process that push PI forward
  • LPI does not work here

Gonio has double hump sign

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13
Q

Angle recession

A

+1 cause is trauma

  • always receive a comprehensive exam with gonio
  • do gonio 4-6 weeks after truama
  • risk of ARG correlates with extent/severity of AR
  • can occur many years after truam

Gonio: recessed iris/deeper angle

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14
Q

Pigment dispersions

A

-rubbing of iris pigment epithelium abasing lens zonules usually 2D to back-bowed iris. Mid peripheral iris transillumination defects

Gonio: Sanpalosi line, scheie stripe, and/or excess TBM pigment, kruckenburg spindle inferiorly.

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15
Q

Iris process

A
  • fine, lacy projections of peripheral iris
  • extend to scleral spur or TM
  • benign

Gonio: fine lacy strands

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16
Q

PAS

A
  • adhesions of peripheral iris to anterior chamber angle
  • secondary to: angle closure glaucoma, NVG, uveitis, ICE

Gonio: thick adhesions within angle

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17
Q

Narrow/closed angle

A 
Anatomical condition 
Risk factors
-increased age
-increasing lens thickness
-female gender 
-hyperopia 
-ethnicity (Eskimo, East Asian)

Gonio: few-no visible structures and/or PAS

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18
Q

Foreign Body

A 
After truama
-identify object
-identify holes in peripheral iris caused by passage of intracoualr FB
Surgical 
-implantation of filtration systems

Gonio: foreign item

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19
Q

St andres cross

A

-most posterior anatomical feature of angle
-rating angle openness
-additional findings
—pigment, synechiae, FB

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20
Q

Becker goniogram

A
  • drawing of gonioscopic findings
  • describe the variation of anatomical angle within a quadrant
  • synechiae
  • tumors
  • foreign body
  • pathology
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21
Q

Why do we need lasers

A
  • secondary cataracts
  • narrow angles/ angle closure
  • progressing glaucoma with max meds
  • compliance
  • cost
  • convenience/quality of life
  • systemic side effects of drops
  • dr preference
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22
Q

Why do we need lasers

A 
Secondary cataracts 
Narrow angles 
Progressing glaucoma with max meds
Compliance 
Cost
Convenience/quality of life
Systemic side effects of drops 
Doctor preference
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23
Q

Laser trabeculoplasty MOA

A

Increase aqueous humor outflow

  • ALT
  • SLT
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24
Q

Most common laser procure for often angle glaucoma

A

ALT 1990-2000

SLT 2000s to present

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25
Q

Primary vs secondary treatemtn of ALT and SLT

A

Historically used after meds fail to control IOP

Some use as a firsts line treatment

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26
Q

ALT vs topical meds for IOP

A

ALT as first line is actually better

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27
Q

Indications of laser trabeculoplasty

A 
POAG
NTG
OHTN
pigmentary dispersions glaucoma 
PSX glaucoma

Last two have higher risk and higher reward

28
Q

Contraindications of laser trabeculoplasty

A
  • advanced POAG
  • angle closure
  • inflamamtory glaucoma
  • NVG
  • prior LTP that failed
  • hazy media
  • angle recession glaucoma
  • congential glaucoma
29
Q

Negative predictors for LTP

A

<40
Little or no TB pigment
Cloudy, hazy cornea
-uveitis, angle closure, angle recession, congential glaucoma, aphakic ACIOL

30
Q

Positive predictor for LTP

A

> 65
Moderate to heavy TM pigment
Clear cornea
Pigmentary glaucoma, PSX G, LTG, POAG, phakci

31
Q

ALT

A

Traditional
-thermal relaxation time. Time for melanin to convert electromagnetic energy into thermal energy=1 microsecond

Burn occurs if pulse duration is > 1 microsecond. This how ALT works, causes burn and contraction of tissue

32
Q

Mechanical effects of ALT

A

The burn causes scar tissue=contraction=opening of adjacent areas of TM

33
Q

Biological effects of ALT

A

The burn increases inflamamtion=phagocytosis=clean up of the TM

34
Q

Complications of ALT

A

IOP spikes
Inflamamtion
PAS

35
Q

Pre op ALT

A

gonioscopy
SLE
Signed informed consent
Vitals

36
Q

Settings for ALT

A 
Energy-600mW
Spot spize-50 microns
Duration=0.1s
Pulses=1
Amount of burns=45-60/180 (dont do 360)
37
Q

Procedure of ALT

A
  • comfortable placement of patient
  • 1 drop alphagan 15-30m prior
  • 1 drop proparacaine OU
  • focus on anterior aspect of pigmented TM
  • adjuster energy PRN. Pigment blanching, small bubble formation
  • treat inferior 180 first
  • space burns about 2 spot sizes apart. 45-60 burns per 180 degrees
38
Q

Burn placement

A

X____X____X____X

Issue: no space in between, cant repeat the procedure

39
Q

Post op for ALT

A
  • 2 drop alphagan
  • recheck IOP 15-30m in office
  • continue all glacuaom medication
  • PF QID x 1 week
40
Q

Follow up for ALT

A

1-2 weeks

  • check IOP
  • check AC reaction

6 weeks

  • check IOP
  • consider reducing glaucoma meds
  • consider performing superior 180
41
Q

Long term outcome for ALT

A

1 year=80%
5 years=50%
10 years=30%

42
Q

Retreatments for ALT

A
  • increased complication

- 50% o fretreatments rewuire filtration surgery to lower IOP within 6m

43
Q

SLT

A

Newer form of laser therapy for patients with glaucoma

Alternative to filerting surgery whose glaucaom was not pharmacologically controllers

Thermal relaxation time: pulse duration is 3ns=noburn=cold laser. >1 microsecond burn

Effects:biological=the burn increases inflamamtion=phagocytosis=clean up of the TM

44
Q

Preferred laser for SLT

A

Q-switched frequency doubling 532nm Nd:YAG

  • targets melanocytes in the TM
  • release of cytokines that trigger macrophage recruitment leading to reduce IOP

Lumenis
Medlite

45
Q

Studies on SLT

A

Is effective and safe a primary treatment for patients with OHTN and POAG

IOP decreased 30% over fu period
89% had a decrease of >5mmHg

46
Q

Study B for SLT

A

SLT vs prostaglandin

  • same IOP reduction
  • # of treatments: much less for SLT

SLT is safe and effective for initial therapy for PAOG and OHTN

47
Q

Study Cfor SLT

A

SLT as first line treatment
- 97% for 1 year
92% 5 years
90% 7-10 years

80% effective i nsecond treatemtn

Given the amount of data and experience on SLT, we believe that Rxing medications instead of SLT for primary treatment of glaucoma today is analogous to performing intracapsular cataract extraction rather than phacoemsulifcaiyon. I can be done, but why would you

48
Q

Can SLT be used as first lien treatemtn

A

Yes

Even OMD does it

49
Q

Complications of SLT

A 
IOP spike
Inflammation 
Stroma haze/edema/ decreased endothelial cell count
PAS
Angle bleeds
50
Q

Prep SLT

A

-gonio
SLE
Signed informed sonsent
Vitals

51
Q

Settings for SLT

A 
Energy=0.8-1.2 mJ
Spot size 400 microns (fixed)
Duration=3ns (fixed)
Pulses=1
Amount of burns=100/360 degrees
52
Q

Burn placement of SLT

A

X__X__X__X__X
This procedure is repeatable since no scar tissue is created
Large spot size
Covers the entire TM

53
Q

Post op for SLT

A

1 drop alphagan
Recheck IOP 15-30m in office
Continue all glaucoma meds

No steroid
-Tylenol
Topical NSAID only PRN

54
Q

Follow up for SLT

A

1-2 weeks

  • IOP
  • AC reaction

6 weeks

  • IOP
  • take off glaucoma meds maybe
55
Q

Efficacy of SLT

A

80% at 1 year
50% at 5 years
30% at 10 years

Very effective from 12-60 months

56
Q

Predicting SLT succes

A

Alvarados insights
- if successful with prostaglandin, would be success with SLT since its similar process. If not, probably not. Not cumulative, cannot do preostalgnadin and SLT and expect double results. Maybe take them off prostaglandin before SLT, can use it periodically after SLT to prevent spikes but can use other drugs

57
Q

SLT and NTG

A

15% IOP reduction while using 27% less medication at 1 year compared to pre study levels
Blunts the nocturnal spikes

58
Q

SLT and PDS/PDG

A

High risk high reward

  • increased pigment=increase risk for pressure spike
  • it can shit down outflow-trabeculectomy

Test dose

  • 10 shots at 0.3mJ
  • no spike=one quadrant at a time
59
Q

Retreatmetn of SLT

A

Widely considered repeatable

  • no mechanical damage
  • based on anecdotal evidence and small studies

Retreatment may be less effective nor last as long

  • could be less effective, but still get some sort of IOP drop
  • could not last as long
60
Q

Coding and billing for SLT

A

65855

Paid $305.98/eye
Same day=100% first eye, 50% second eye

Global period
-wait outside 10 days to do the second eye to get full reimbursement

61
Q

Cost comparison for SLT and drops

A

SLT effective for 2 years

  • 1drop=$200 savings
  • 2 drops=1660 savings
  • 3 drops=$3000 savings
62
Q

Positives of SLT

A
  • works about 80-90% time
  • on average it takes the place of 1 medication
  • SLT IOP reduction of 30% as primary
  • SLT IOP reduction of 21-25% as secondary treatment
  • doesn’t interned with other treatments
  • blunts nocturnal IOP spike
  • saves patients money
63
Q

Negatives of SLT

A

Effect tends to diminch over time

64
Q

Procedure of SLT

A
  • Dr and patient comfortable placement
  • 1 drop alphagan 15-30m prior
  • 1 drop proparacaine
  • focus TM
  • adjust energy PRN (small bubble formation)
  • treat 360 degrees (mirror at 9 o’clock, clockwise-inferior 180 degrees first)
  • space burns ~1 spot size apart. About 25 burns/quadrant=100 burns/360 degrees
65
Q

Grade 1 on Shaffer system

A

<10 degrees=extremely narrow

Potential for closing off

3F: Sugery (5 decks)

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