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3F: Surgery Final > Laser Therapy For Angle Closure Glaucomas > Flashcards

Laser Therapy For Angle Closure Glaucomas Flashcards

1
Q

Indication for LPI

A

Any form of angle closure glaucoma that has pupillary block as a component

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2
Q

Pupillary block

A

Restriction of aqueous flow format the posterior chamber to the anterior chamber as it moves between the posterior surface of the iris and the anterior surface of the lens

Iris bombe: bowing forward of the iris

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3
Q

Relative pupillary block

A

Functional, or partial restriction of flow

Most common mechanism

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4
Q

Absolute pupillary block

A

Posterior synechiae completely binds down itis

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5
Q

LPI indications

A 
AACG
Malignant glaucoma 
Pigment dispersion syndrome and glaucoma 
Phacomorphic glaucoma 
Eyes with occludable angles
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6
Q

Acute angle glaucoma

A

Urgent but uncommon dramatic symptatomic event with blurring of vision, painful red eye, headache, nausea, vomitting. Diagnosis is made by noting high IOP, corneal edema, shallow anterior chamber, and a closed angle on gonio. Medical or surgical therapy is directed at widening the angle and preventing further angle closure. If glaucoma has developed, it is treated with therapies to lower IOP

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7
Q

History and exam for AACG

A

Key factors for AACG

  • presence of risk factors (hyperopia, thick cataractous lens)
  • Halos around lights
  • aching eye or brow pain
  • HA
  • nausea, vomitting
  • reduced VA
  • eye redness
  • closed angle on gonio
  • extremely elevated IOP
  • corneal edema
  • engorged conjunctival vessels
  • fixed dilated pupil
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8
Q

What do we do in office to treat AACG

A

Put whatever OHTN drops you have in their eye and get the pressure below 40, put pilo in and do an LPI

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9
Q

Narrow angles and occludable angles

A

Narrow angles are just arrow

  • may watch and consider other risk factors for the development of glaucoma
  • intermittent IOP spikes
  • intermittent eye pain

Narrow angle glaucoma
-indication for LPI

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10
Q

Malignant glaucoma

A

After any type of surgery for angle closure glaucoma, it is possible for the anterior chamber to become shallow OT flattened and for the IOP to become elevated. Aqueous humor flow can be forced backward into the vitreous by ciliary body apposition to the lens and/or vitreous

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11
Q

Occludable angle

A

Less than 20%=probable

Less than 10%=likely

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12
Q

Definitive treatment for malignant glaucoma

A

Vitrectomy

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13
Q

Difference between iris bombe and malignant glaucoma

A

The lens is being shoved forward in malignant glaucoma

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14
Q

Malignant glaucoma and LPI

A

Unsuccessful in treatment, although is useful if differentiating from pupillary books
-ant seg OCT very valuable

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15
Q

What’s the difference between PI configuration and syndrome

A

IOP

Configuration: anatomical anomaly but not causing pupillary block commenting causing increased IOP

If it doesnt cause IOP spike its sybdrome

Both have anteirorly placed CB

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16
Q

Plateau iris

A

Double hump on indentation gonioscopy

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17
Q

LPI in pigmentary dispersion syndrome

A

LPI: iris is bowed backwards and rubbing pigment. The fluid coming from the posterior cant get to the angle in bombe, but the physics are the same here. You equalize the pressure between the anterior and posterior and you get the iris to flatten, this decreases the amount of rubbing on the lens, which decreases the amount of pigment and decreases the stopping up of the TM, which decreases IOP

This only works if their iris is concave. There are some people that don’t have concave iris. These people would not benefit from an LPI.

18
Q

When is LPI indicated for PDS

A

If they have concavity on iris

19
Q

Spaeth

A

Complicated system involving he location of the insertion of the iris, the angle it formes with schwalbes line. The iris configuration, and pigment level

20
Q

Importance of ant segment OCY

A

CYA when you do a LPI

21
Q

Work up of peripheral iridotomy

A

Comprehensive exam, diagnosis, DFE

22
Q

Pre op for LPI

A
  • VA< IOP, Med/allergy check, vitals
  • brimonidine, iopidine
  • pilo
  • informed consent
23
Q

Vitals before a LPI

A

BP, temp, pulse, oximetry

24
Q

If you do a procedure without informed consent

A

It’s considered assault and battery

25
Q

Lens for LPI

A

Abraham
-66D

Can also use Wise

  • 103D
  • easy to get lost
26
Q

Why use a lens on LPI

A
  • magnifies iris with good depth of field
  • concentrates laser energy
  • speculum
  • heat sink to minimize corneal damage
  • control the eye
  • focus energy of laser, less to retina (increases cone angle)
27
Q

Lasers for LPI

A

Nd:YAG
-3-6mL

Argon (or green diode)
-600mW

28
Q

Thermal YAG

A

Argon, green diode

  • reduces risk of bleeding
  • may require more energy
29
Q

LPI with a YAG

A

-generally most accepted method, especially light eyes

30
Q

LPI, thermal or YAG?

A

Some advocate pre treat with thermal, esp dark irides and then finish with YAG

31
Q

Treatment location for an LPI

A

Conventional wisdom
-11 or 1 o’clock

Paradigm shift
3 or 9 o’clock

NEVER 12 O’CLOCK

32
Q

Size for LPI

A

About 1.5mm

33
Q

Hemorrhage in LPI

A

Just push on it

-gentle pressure with laser lens for a few seconds will tamponade the hemorrhage

34
Q

IOP spike in LPI

A

Elevation >10mmHg in the first 3 hours occurs in ab out 25%

Most are transient, and respond to topical medications

35
Q

Transient uveitis after LPI

A
  • mild uveitis occurs in virtually 100% of iridotomy patients
  • responds well to topical steroids
36
Q

Diplopia and glare with LPI

A
  • Placement is crucial

- specialty contacts with opaque periphery in very rare cases

37
Q

Iridotomy closure after LPI

A

Confirmation of patency can be challenging, transillumination may fool you

38
Q

Post op care for LPI

A
  • Check IOP about 1 hour post procedure
  • topical pred acetate 1% QID
  • recheck in 5-7 days (global period is 10 days)
39
Q

LPI summary

A
  • confirm Dx with gonio
  • perform with YAG, green or both
  • pre treat with pilo, brimonidine
  • consider temporal placement
  • post is pred QID/re check in a week
40
Q

Iridoplasty

A

Thermal laser to pull iris away from the TM

Rarely performed

  • most useful in PI
  • multiple burns placed concentrically close to iris insertion; more burns=more contraction

3F: Surgery Final (5 decks)

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