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Summer Final: Glaucoma > Laser Surgery And Glaucoma > Flashcards

Laser Surgery And Glaucoma Flashcards

1
Q

Historically, how are lasers viewed for glaucoma

A

Drops until failure, then laser, then invasive surgery

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2
Q

Advantages of glaucoma drops

A
  • choices
  • effective
  • familiar to patients and well received
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3
Q

Disadvantage of glaucoma drops

A
  • compliance
  • cost
  • side effects
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4
Q

Glaucoma laser trial (GLT)

A

Timolol-ALT for newly diagnosed POAG

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5
Q

SLT/Med study

A

SLT is a variable first line treatment for POAG

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6
Q

UpToDate

A

We recommend pharmocologic laser therapy as first line treatment

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7
Q

Academy of ophthalmology and laser for glaucoma

A

Lasers can be considered as initial therapy in selected patients

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8
Q

OD role in laser surgery for glaucoma

A
  • initial diagnosis
  • intimate drops
  • perform laser
  • decision to refer for surgery (educate patient on expectations, outcomes)
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9
Q

Information for the referral for surgery

A
  • max IOP
  • IOP on current treatment
  • current meds and any that were previously ineffective or not tolerated
  • baseline and current VF
  • baseline and correct OCT
  • gonio findings
  • eye surgery/injury history
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10
Q

Laser variables that’s influence interaction

A
  • wavelength
  • spot size
  • pulse duration
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11
Q

Tissue variables that’s influence interaction

A

Transparency

Pigment

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12
Q

Laser variables

A

Wavelength

  • varies by laser (YAG vs ARGON)
  • determines which tissue is impacted

Spot size
-smaller=higher density

Pulse duration
-sometimes variable (argon); sometimes fixed (YAG)

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13
Q

Tissue variables

A

Transparency
-depends on wavelength

Pigment

  • argon: pigment absorbed laser light and converted energy to heat
  • more pigment=better absorption
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14
Q

Selective laser trabeculoplasty (SLT)

A
  • wavelength output is 532nm green

- burn time is 3ns

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15
Q

Thermal relaxation time of SLT

A

Amount of time it takes melanin to convert light energy to heat

1micro second

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16
Q

SLT pulse duration is

A

3 nanoseconds

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17
Q

Thermal damage of SLT

A

No thermal damage, “cold laser”

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18
Q

What does SLT target

A

Intracellualr melanin

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19
Q

Effect on adjacent non melanin containg cells in SLT

A

No effect. “Selective”

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20
Q

Proposed mechanism of SLT

A
  • targetcels activate cytokines, which activate macrophages
  • macrophages clean area, decreasing outflow resistance
  • no mechanical damage/scars (unlike ALT). Potentially repeatable
21
Q

Trabeculoplasty recommendations

A
  • POAG
  • OHTN
  • NTG
  • pigment dispersion glaucoma
  • PXG
22
Q

Predicting SLT success

A

Looked at

-pre treatment IOP, current meds, phakic status, level of pigmentation, steroid use, age, gender

23
Q

MIGS

A

Minimally invasive glaucoma surgery

-mild-mod glaucoma

24
Q

Conventional surgery

A

More invasive

Moderate-sever glaucoma

25
Q

What is MIGS

A
  • minimal truama/disruption to normal anatomy
  • Ab interno, micro incisional approach
  • modest IOP reduction
  • safe
  • often combined with cataract surgery (and sometimes multiple MIGS prcoredures)
  • rapid post op recovery
  • first FDA approval in 2012
  • now 15 different techniques
26
Q

iStent

A

MIGS

  • inserted from AC into schlemms canal. Creates channel from AC to schlemms
  • increases aqueous outflow by bypassing the TM
27
Q

Trabectome

A
  • MIGS
  • electrocautery device used to perform partial trabeculotomy
  • TM and interior wall of schlemms canal are cauterized and eliminated
28
Q

Endocyclophotocoagulation (ECP)

A
  • MIGS

- a laser probe is used to destroy the anterior ciliary processes

29
Q

Transscleral cyclophotocoagulation (CPC)

A
  • MIGS

- laser energy is delivered at he limbus through the sclera and to the ciliary process

30
Q

ECP and CPC both do what

A

Decrease aqueous production

31
Q

Xen gel stent

A
  • 6mm tube
  • inserted from AC, through schlemms canal, into subconjunctival space
  • creates a bleb
32
Q

Difference between ALT and SLT

A

ALT has a longer burn time and causes burn damage to the TM. Not repeatable

SLT actually causes macrophages to come in and act like drane-o without burn damage. Repeatable

33
Q

Incisional surgery

A
  • more invasive than MIGS
  • historically, the only surgical options
  • tubes (aqueous tube shunt) and trabs (trabeculectomy)
34
Q

Tube shunts

A
  • divert aqueous humor to an external reservoir
  • baerveldt vs Ahmed
  • external incision through conjunctiva and tenons capsule
  • implant is placed subconjunctivally with the tube entering the anteiror chamber
35
Q

-otomy

A

Cutting into, putting a hole in

36
Q

Ectomy

A

Removing tissue

37
Q

Endo

A

Camera used for surgeon to see tissue

38
Q

Cyclo

A

CB

39
Q

Photo

A

Laser or light energy

40
Q

Bleb

A

Between sclera and conjunctiva for aqueous to collect

41
Q

Filtering blebs

A

Xen gel stent

42
Q

Trabeculectomy

A
  • the most establishes (oldest) of these procedures
  • surgeon creates an opening into the AC from underneath a scleral flap
  • aq flows into the subconjunctival space and creates a filtering bleb
  • no tube is placed. Mitomycin C (MMC): antimetabolite; prevents fibrosis and grab failure
43
Q

Tubes vs trabs

A

TVT study; similar IOP reduction
-trabs have higher failure rate (complications, need for more surgery, NLP vision)

Increasing usage of tubes over past 20 years

44
Q

Post op care of MIGS

A
  • similar to cataract surgery
  • 1 day, 1 week, 1 month
  • check for inflammation and infection
  • judge IOP repsosne at 1 month. Consider reducing meds
45
Q

Post op care of icisional surgery

A

The ideal bleb

  • low lying
  • minimal vascualrity
  • IOP in teens
  • well formed AC
  • negative Seidel sign
46
Q

Bleb complications

A

Hypotony

  • IOP less than 5mmHg
  • no visible bleb

Bleb leak
-positive Seidel test

Blebitis

  • milky white bleb
  • pain, blurry vision
  • if AC and or vitreous involved-endopthalmitis
47
Q

Tube complications

A

Same a bleb complications
Also diplopia
-tube plate is placed near EOMs

48
Q

Micropulse diode laser trabeculoplasty(mDLT)

A
  • delivers small, repetitive micropiulses rather than one continuous pulse
  • cooling periods between micropulses reduces tissue damage
49
Q

Annual low-power SLT for OHTN

A
  • repeatedly yearly, regardless of IOP level
  • followed 3-10 years
  • mean treated IOP similar to transitional SLT
  • fewer patients needed medications to control IOP vs traditional SLT

Summer Final: Glaucoma (15 decks)

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