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Summer Final: Glaucoma > Surgical Managment > Flashcards

Surgical Managment Flashcards

1
Q

Surgery of the AC angle and iris

A 
Laser trabeculoplasty 
-ALT
-ALT
laser iridotomy 
LPI
Laser pupilloplasty 
Iris sphincterotomy 
Incisional iridectomy 
Trabeculotomy 
Cnaaloplasty
Cyclodialyss
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2
Q

Laser trabeculoplasty

A
  • laser treatment targeting TM
  • reduces IOP by improving the facility of outflow
  • can have IOP spikes post op (within 24 hour). Treat with A2 agonist 1 hour before and immediately after procedure to reduce risk. Eyes with higher pretreatment IOPs tend to have a greater decrease in IOP, except if IOP was greater than 30mmHg
  • common comoplcaitions: iritis, peripheral anterior synechiae
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3
Q

Types of laser trabeculoplasty

A

Argon laser trabeculoplasty (ALT)

Selective laser trabeculoplasty (SLT)

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4
Q

Argon laser trabeculoplasty (ALT)

A
  • treat 180 degrees first treatment
  • causes scarring-cannot repeat treatment in same area
  • IOP reduction: 6-9hhMhg; may occur weeks later
  • most successfully in POAG, XF, pigmentary glaucoma
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5
Q

Selective laser trabeculoplasty (SLT)

A
  • targets pigment TM cells (melanin) without causing structural damage to nonpigemtned cells
  • IOP reduction: 3-18mmHg; may occur weeks later
  • 64.4% success rare of 4.4mmHg pressure drop in 180 degree treatment
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6
Q

Laser iridotomy

A
  • creates a hole in peripheral iris with an argon or Nd:YAG laser
  • creates equalization of pressure between posterior and anterior chambers, deepens AC, opens AC chamber angle
  • procedure of choice for angle closure glaucoma
  • Abraham contact lens is helpful to: keep lids separated, minimizes corneal epitheliual burns by acting as a heat sink, provides some control of eye movement
  • complications: transient IOP spike, mild anterior uveitis, hyphema, corneal damage, cataract, retinal burn, monocular blurring, closure of iridotomy (first few weeks, argon, from accumulation of pigment granules and debris)
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7
Q

Laser peripheral iridoplasty (gonioplasty or peripheral iris retraction)

A

-Argonne laser to create contraction burns or peripheral iris-opening up angle. Tightening of the peripheral iris, pulls it posteriorly from TM

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8
Q

Indications of laser peripheral iridoplasty (gonioplasty or peripheral iris retraction)

A

Patent iridotomy fails (possible in microophthalmic or nanophthlamic eye), swelling or forward rotation of CB (plateau iris syndrome) or presence of peripheral anterior synechiae

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9
Q

Complications of laser pioperhal iridoplasty (gonioplasty or peripheral iris retraction)

A

IOP elevation, mild transient iritis

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10
Q

Laser pupilloplasty

A

Partially dilates pupil by applying contraction burns near the pupillary portion of the iris

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11
Q

Indications of laser pupilloplasty

A

Alternative method for pupillary block when laser iridotomy not possible (cloudy cornea); pupillary block glaucoma in aphakia or pseudophakia

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12
Q

Complications of laser pupilloplasty

A

IOP rise, transient iritis

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13
Q

Iris sphinctoerotomy

A

Pupil is enlarged, reshaped, or repositioned by making a linear cut across the iris with an argon laser, allowing the intrinsic tension of the iris to spread the cut apart

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14
Q

Incisional iridectomy

A

A procedure in which a small section of peripheral iris is excised through limbal incision

Studies show: incision vs laser have similar efficacy and safety

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15
Q

Incision vs laser iridectomy

A

Have similar efficacy and safety

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16
Q

Acute angle closure and incisional iridectomy

A

Filtering surgery more likely required after laser than incisional

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17
Q

Complications of incisional iridectomy

A

Hemes from iris or CB if accidentally cut, incomplete iridectomy (cutting only stroma, leaving pigment epithelium intact), injury to the lens, endophthalmitis

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18
Q

Trabeculotomy

A
  • create an eopning in the TM to establish a direct communication between the AC and schlemms canal
  • laser or incisional techniques
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19
Q

Complications of trabeculotomy

A

If schlemms canal is not properly identified, a false passage may be created into either the AC or the supraciliary space: create of a cyclodialysis and possible hyphema

20
Q

Trabectome

A

Probe is inserted through TM and into schlemms canal: thermal ablation is used to remove TM and internal wall of schlemms canal for 60-140 degrees

21
Q

Canaloplasty

A

-utilizes a microcatheter or tube placed in the schlemms canal to enlarge the drainage canal, relieving pressure inside the eye

22
Q

Indications of canaloplasty

A

Open angle glaucoma, especially patients at high rusk for infection or bleeding; patients who have had complications in the other eye from trabeculectomy; patients who wear contact lenses may also be good candidates for this procedure

23
Q

Cyclodialysis

A

Separation of the ciliary body from the scleral spur (using a cyclodialysis spatula): creates direct communication between AC and suprachoroidal space

24
Q

What does cyclodialysis do

A

Increases uveoscleral outflow and reduces aqueous production (from changing ciliary body anatomy)

25
Q

Indications of cyclodialysis

A

Alternative to filtering surgery, especially in aphakic eye or in combination with cataract extraction

26
Q

Complications of cyclodialysis

A

Heme, damage to descemets membrane, corneal damage, tearing ciliary body or iris, lens injury, vitreous loss

27
Q

MOA of drainage fistula

A

Creation of an opening/fistula at the limbus which allwosa for direct communication between AC and subconjunctival space

  • fistula bypasses TM, schlemms canal, and collecting channels
  • aqueous is absorbed by surrounding subconjunctival space or crosses conjunctival epithelium and drains with tears through the NLD
28
Q

MOA of filtering Bleb

A

Elevation of conjunctiva at the surgical site

  • blebs with good IOP control are associated with decreases vascualrity with numberou microcysts in the epithelium and are low and diffuse or more circumscribed and elevated
  • functioning blebs have loosely arranges tissue with histological clear spaces
  • failed blebs have Dense collagenous CT
  • aqueous filters through conjunctiva and mixes with tear film or is absorbed by vascular or perivascualr conjunctival tissue
29
Q

Basic technique: corneal traction suture

A

Rectus suture OR corneal suture; to move eye during surgery

30
Q

Basic technique: limbal stab incision (paracentesis site)

A

Self healing incision into the AC at the limbus (usually temporally at the horisztonal meridian or IT quadrant) to inject fluid at the end of the procedure

31
Q

Basic technique: preparation of the conjunctival flap

A
  • critical step: most common cause for failure is scarring of the filtering bled
  • flap at 12 o’clock (wider limbus in this area) or one of the superior quadrants
  • limbus-based vs fornix-based flap: similar success rates
  • to minimize fibroblasts/scarring: preserve tenon capsule by dissecting dessecting between capsule and episcerla when preparing the flap
32
Q

Basic technique: mitomycin C

A

An antimetabolite used during the initial stages of a treabeculectomy to prevent excessive post op scarring and thus reduce the risk of failure

33
Q

Basic technique: viscoelastic agents

A
  • Na hyaluronate, healon
  • injected into AC to reduce risk of hypotony, suprachoroidal effusion, minimize intraoperative bleeding
  • complications: iris prolapse during surgery, higher early post op IOP
34
Q

Basic technique: PI

A
  • some surgeons perform and others do not, based on specific surgery
  • may occur after fistula created or after, based on specific surgery
35
Q

Basic technique: closure of conjunctival flap

A
  • suture to close wound

- leaking wound may lead to a persistent flat bleb to anteiror chamber or both

36
Q

Most critical step in incisional glaucoma surgery

A

Conjunctival flap

-higher rate of bleb failure if scarring

37
Q

Post op managment of glaucoma surgery

A
  • topical mydriatic-cycloplegics 2-3 weeks to maintain AC depth
  • topical antibiotic 7-10 days
  • topical steroids to reduce conjunctival scarring 4-6 weeks. Associated with higher trabeculectomy success rates. Some prefer los does topical steroid indefinitely
38
Q

Complications of glaucoma surgery

A

Elevated IOPs and flat AC
-delayed suprachoroidal heme (few days post op, pain, nausea, reduced vision)

Elevated IOP and deep AC

  • failing bleb: typically low to flat; heavily vascualriaed with no microcysts
  • TX: topical steroids q1-2 hours, lyse scleral flap sutures, digital pressure (apply steady pressure with index finger to inferior sclera through lower lid for 15s)
39
Q

Other early post op complications

A

Uveitis
Hyphema
Dellen (local causer like depression in the peripheral cornea)
Loss of central vision
Ocular decompression retinopathy (intraretinal heme immediately after trabeculectomies)

40
Q

Late post op complications

A
  • late failure of filtration
  • leaking filtering bleb (always do Seidel test at exam)
  • bleb related infections (blebitis, endopthalmitis)
  • cataracts
  • overhanging filtering bleb) large bleb may gradually extend down over the cornea, treat iwth argon laser to bled or incisional surgery to lift bleb)
  • spontaneous hyphema
  • hypotony and ciliochorifal detachment
  • corneal changes )reduced endothelial cell count)
  • eyelid changes
  • sympathetic ophthalmia
41
Q

Indications of drainage device surgery

A
  • failed trabeculectomy
  • young patients: 1 month-13 years old for childhood glaucoma
  • NVG
  • uveitis glaucoma
  • severe conjunctival scarring and previous ocualr surgery
  • aniridia
42
Q

Drainage devices for glaucoma

A
  • device is implanted in the eye, extending from AC to subconjunctival space
  • design: silicone tube that extends from AC to a plate/disc/encircling element beneath conjunctiva and tenon capsule. Devices with open tubes are likely to habe early post op hypotony, so requires temporary closure with ligament or stent
  • elevated IOPs in first few weeks/months after implantation due to fibrous capsule formation around the implant plate=hypertensive phase. Filtering bleb may fail due to increases thickness of fibrous capsule
43
Q

Open tube drainage devices

A
  • baerveldt implant: non valves; typically under rectus muscel in ST quadrant
  • Molteno implant
  • schocket tube shunt: silicone tube is extended from AC to a 360 degree encircling silicone band
44
Q

Flow restrictive drainage devices

A

Valve mechanism to decrease hypotony

  • Ahmed glaucoma valve
  • Krupin implants
45
Q

Complications of drainage devices

A

Hypotony

  • early post op Tx-injection of dense viscoelastic into AC
  • late post op Tx- permanently occlude tube
Elevated IOP
Migration, extrusion, erosion of tube
Endopthalmitis 
Visual loss
Corneal compensation and graft failure 
Diplopia and ocualr motility disturbance

Summer Final: Glaucoma (15 decks)

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