to chop or to drop Flashcards
(41 cards)
medication first advantage
! 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)
medications first disadvantages
! 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
surgery first advantages
! 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
surgery first disadvantages
! 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
race and management options
! Race – white versus individuals with greater pigment
! Individuals with greater pigment- greater risk of pos- operative scarring*
! Medications –first choice
age and management options
! Younger individuals
! Accelerated wound healing systems
! Thick fleshy periocular tissues heals rapidly
! Thus older individuals better suited for surgical options
what does it mean if right eye got surgery and got endophthalmitis; now left eye got it, what is it called
idk
current practice patterns
! 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
what iop can lead to glaucoma and lose significant vision?
40 mm Hg
! 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
! 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


if anyone has advanced glaucoma, where do we want the pressures?
low teens; or else will have continuous damage
target pressure
! 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
indication for medication
! Early glaucoma ! Compliant patient ! Target IOP achieved ! Works with life style/ physical ability ! Not too many medications (ocular)
indication for surgery
! Moderate to advanced glaucoma
! Chances of serious loss of vision
! Unable to take medications- various reasons
! Unable to achieve and maintain target IOP
argon laser trabeculoplasty (ALT) theory
! 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
which laser therapy do we use to lower oag?
SLT
alt indications
! Open angle
! Require decrease in IOP
! Both POAG and secondary like pseudoexfoliation or pigmentary
poor candidates for alt
! Angle recession, uveitic glacuoma, aphakia, high IOP (35 or
greater), high episcleral venous pressure ! Very young individuals
! Previous 360 degree ALT
preoperative considerations of alt
! 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
procedure of alt
! 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
post operative management
! 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)
outcome of alt
! If IOP still high
! Consider doing other 180 degree if option (4 weeks later)
summary of alt
! 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
results of alt
! 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
