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ocular disease II: glaucoma > to chop or to drop > Flashcards

to chop or to drop Flashcards

1
Q

medication first advantage

A

! Drugs are safer than surgery- ! Less complications
! Less discomfort
! Drug effects can reversed or is short acting
! Less expensive in the short run
! Multiple drugs can be combined to achieve successful reduction in IOP
! Better quality of life when compared to surgery first (Lichter et al., Ophthalmology 2001)

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2
Q

medications first disadvantages

A

! May be more expensive in the long run ! Multiple drugs
! Compliance, adherence and persistence issues
! Chronic drug uses and its effect on future surgical outcomes?
! Preservatives effect?
! Inflammation leading to failure of future procedures*
! Increased chances of cataract formation

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3
Q

surgery first advantages

A

! If successful and large drop in IOP may be obtained ! No issues related to patient compliance, adherence
and persistence
! Good in situations where obtaining continuous supply of medications is a problem
! May be cheaper long term

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4
Q

surgery first disadvantages

A

! Outcomes may be variable
! Long term may loose efficacy
! May still require additional topical medications
! Complications may be dire
! Comfort and quality of life may be lower
! Chances of cataract formation is greater than topical medications
! Age- young vs. older individuals

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5
Q

race and management options

A

! Race – white versus individuals with greater pigment
! Individuals with greater pigment- greater risk of pos- operative scarring*
! Medications –first choice

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6
Q

age and management options

A

! Younger individuals
! Accelerated wound healing systems
! Thick fleshy periocular tissues heals rapidly
! Thus older individuals better suited for surgical options

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7
Q

what does it mean if right eye got surgery and got endophthalmitis; now left eye got it, what is it called

A

idk

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8
Q

current practice patterns

A

! Unacceptable high pressures will inevitably destroy optic nerve tissue
! Safe levels of IOP by any means warranted ! If these don’t work or not sufficient
! drugs like – prostaglandins
! reduction in inflow – beta blockers
! Maximal medical therapy ! Consider surgery

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9
Q

what iop can lead to glaucoma and lose significant vision?

A

40 mm Hg

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10
Q

! Stage of disease “ Visual field status
! Stage of nerve damage “ Rim tissue remaining
! Type of glaucoma
! Open angle glaucoma – medical first makes sense ! Secondary glaucoma
! Congenital glaucoma treated differently ! Complete angle closure
! Adherence, compliance, persistence issues
! Effect of medications and future outcomes of surgery

A

! Stage of disease “ Visual field status
! Stage of nerve damage “ Rim tissue remaining
! Type of glaucoma
! Open angle glaucoma – medical first makes sense ! Secondary glaucoma
! Congenital glaucoma treated differently ! Complete angle closure
! Adherence, compliance, persistence issues
! Effect of medications and future outcomes of surgery



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11
Q

if anyone has advanced glaucoma, where do we want the pressures?

A

low teens; or else will have continuous damage

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12
Q

target pressure

A

! A theoretical value below which visual field and ONH appear stable (not deteriorating).
! Calculated from highest recorded IOP. ! Conventionally 20-30% decrease in IOP. ! 40% or more if severe glaucoma

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13
Q

indication for medication

A 
! Early glaucoma
! Compliant patient
! Target IOP achieved
! Works with life style/ physical ability
! Not too many medications (ocular)
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14
Q

indication for surgery

A

! Moderate to advanced glaucoma
! Chances of serious loss of vision
! Unable to take medications- various reasons
! Unable to achieve and maintain target IOP

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15
Q

argon laser trabeculoplasty (ALT) theory

A

! Enhances aqueous outflow
! How does it cause increase outflow
! Exact mechanism unknown

! Mechanical theory
“ Mechanical tightening of trabecular meshwork
“ Opens adjacent untreated spaces !

Laser induced cellular changes
“ Macrophages migrate to the location “ Clears trabecular debri

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16
Q

which laser therapy do we use to lower oag?

A

SLT

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17
Q

alt indications

A

! Open angle
! Require decrease in IOP
! Both POAG and secondary like pseudoexfoliation or pigmentary

18
Q

poor candidates for alt

A

! Angle recession, uveitic glacuoma, aphakia, high IOP (35 or
greater), high episcleral venous pressure ! Very young individuals
! Previous 360 degree ALT

19
Q

preoperative considerations of alt

A

! Depends on status of disease
! Continue IOP lowering medications (if on it)
! If moderate loss or damage
! Preoperative 1% apraclonidine or hyperosmotic agent
! Best performed undilated
! Does not require pupil constriction either

20
Q

procedure of alt

A

! Anesthetic and goniolens with coupling fluid ! Clear view is a must
! Ideal lens Ritch lens (good view, optics most suitable and least collateral damage)
! Recommended spot size is 50 micro meter and 0.1 second duration
! Power 0.5 W to1.0 W
! Ideally tissue should blanch or small bubble should form
! Anesthetic and goniolens with coupling fluid ! Clear view is a must
! Ideal lens Ritch lens (good view, optics most suitable and least collateral damage)
! Recommended spot size is 50 micro meter and 0.1 second duration
! Power 0.5 W to1.0 W
! Ideally tissue should blanch or small bubble should form

21
Q

post operative management

A

! Remain in office for 1 hour at least
! Monitor IOP
! 1% apraclonidine immediately after procedure
! Topical CAI or pilocarpine may be considered or oral hyperosmotic agents
! Steroid use for 4 days
! Prednisolone acetate 1% 4 times a day for 4 days
! Continue IOP lowering medications if already on it
! Follow-up schedule 1,4 and 8 weeks (approx 2 months)

22
Q

outcome of alt

A

! If IOP still high

! Consider doing other 180 degree if option (4 weeks later)

23
Q

summary of alt

A

! Laser burns to trabecular meshwork
! Enhances aqueous flow and thus lowers IOP ! Usually an adjunct therapy
! Treatment benefit seen 4-6 weeks
! 180 degrees at a time, 360 can be done ! Retreatment not effective

24
Q

results of alt

A

! POAG success rate 75-80%
! Average reduction in IOP reduction is 30%
! 50% still controlled after 5 years
! Failure if occurred usually first year
! NTG success rate 50-70%
! Absolute reduction in pressure not as good as POAG
! Pseudoexfoliation glaucoma ! Excellent results
! Not as good in other secondary glaucoma ! Does not work in pediatric glaucoma

25
Q

whats failure of surgery?

A

pressures climb back up; this happens within first year or so

26
Q

why is ntg not as successful as poag?

A

iop is not high to begin with

27
Q

why does pseudoexfoliation glaucoma have good success rate?

A

lens material, flaky dandruff material, pigment can get out easier

28
Q

alt vs. slt

A

Unlike ALT SLT does not scar
! Autopsy specimens – confirm no coagulative damage
after SLT
! Ultrastructural measurements show
! Crackling of intracytoplasmic pigment granules ! Disruption of trabecular endothelial cells
! In-vitro studies pulsed laser
“ longer than 1 microsecond –non selective damage of pigmented
cells
“ 10 nanosecond to

29
Q

moa of slt

A

! 5-8 fold increase in monocytes and macrophages in TM
! after treatment with SLT
! Hypothesis
! Injury via laser causes releasing of chemoattractant
! This in turn recruits monocytes that are transformed into macrophages
! Macrophages clear pigment granules and exit via Schlemm’s canal

30
Q

preoperative considerations

A

! Alpha 2 agonists preoperative (Brimonidine or Apraclonidine)
! Helps reduce post-operative spikes
! Untreated eyes- timolol may also work ! Topical anesthetic before procedure

31
Q

slt procedure

A 
!  Frequency doubled Q-switched Nd:YAG laser !  532 nm
!  Pulse 3 nanosecond
!  Spot size 400 micro meter
!  Beam focused over pigmented TM
!  Standard therapy 50-100 adjacent non-overlapping spots
over 180-360 degrees
!  Power 0.8mJ (0.2 to 1.7mJ)
!  Heavily pigmented eyes – lower power
!  Endpoint- tiny “champagne” bubbles
32
Q

how does power of slt compare to alt?

A

lower

*not that in heavily pigment eyes, u use even lower power

33
Q

SLT

A

! Selectively targets melanin pigment of TM
! More safe compared to ALT (because lower power) ! Equally effective as ALT
! Can be repeated if first attempt is not effective

34
Q

post operative considerations

A

! Anti-inflammatory medications –post SLT
prophylaxis
! NSAID or steroids
! Does not give added benefit in lowering IOP
! No robust evidence in suggesting use or not to use anti-inflammatory agents post SLT

35
Q

indication for slt

A

! Acute primary angle closure
! One to two days after attack
! Once eye is settled and edema is cleared
! Fellow eye of acute primary angle closure ! 50% chance of angle closure
! Chronic angle closure ! Narrow or occuludable angle

36
Q

contraindication for slt

A 
! Significant edema
!  Unable to visualize iris
! Thick iris
!  Dilated pupil. bunched up iris
! High risk of complications !  Significant inflammation
37
Q

laser iridoplasty

A

! Procedure to open an appositionally closed angle
! Series of laser burns ! Low power
! Large spot
! Longer duration
! Extreme peripheral iris
! This causes tightening of peripheral iris creates a space between anterior iris surface and trabecularmeshwork

38
Q

if patient has PI, and it narrows. this can turn into combined mechanism glaucoma. what does this mean?

A

narrow angle with anatomical structures that dont help;
a version of this is a pt who does not open up significantly after PI is done. this means structures behind iris are pushing iris forward. anatomical reason iris is not opening up?

39
Q

what do we need to make sure of with PI?

A

angle is narrow and doesnt open up over time

40
Q

trabeculectomy

A

! Creates a fistula that allows aqueous from anterior chamber to subtenons space
! Fistula guarded by scleral flap
! The belb should not be fully vascularized neither
completely avascular
! Mytomycin C (alkylating agent) or other antimetabolites (example 5-flurouracil) prevents scarring and failure

41
Q

glaucoma implants indications

A

! Uncontrolled glaucoma
! Poor candidates for tabeculectomy “ Neovascular glaucoma,
“ penetrating keratoplasty or retinal detachments with glaucoma
“ ICE syndromes traumatic glaucoma, previously failed trabeculectomy

ocular disease II: glaucoma (6 decks)

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