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OKAP Glaucoma Review Undiagnosed POAG

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OKAP Glaucoma Review Undiagnosed POAG Powered By Docstoc
					                                                                                                                                                                                                                                                     3/18/2010




                                                                                                                                   What is Glaucoma?                                      What is Glaucoma?
                              OKAP                                                                                                                                    Initiation of Apoptosis

                         Glaucoma - Review
                                         Celso Tello, MD                                                                                                                                                    Ganglion cell death
                                                                                                                                                                                                            and axon loss
                  Associate Professor of Ophthalmology
                  Director, Glaucoma Glaucoma Clinic
                                                                                                                                                                                                                                      NFL & ON changes
                    New York Eye and Ear Infirmary




                                                                                                               Permanent Changes Occur at All Levels of the Visual
        Pathophysiology of Glaucoma                                                                                  Pathway Prior to Detectable Disease                          Primary Open-Angle Glaucoma
                                                     Retinal nerve fiber
                                                                                                                                                                                      Prevalence in the USA
                                                  layer change (detectable)

                                                                  Short wavelength automated
                           Retinal nerve fiber
                           layer change (undetectable)
                                                                        perimetry VF changes
                                                                                                                                                                                ** > 2.2 million individuals aged 40 and
               Ganglion cell death
                                                                                  Standard automated
                                                                                  perimetry VF change
                                                                                                                                                                                older in the USA diagnosed with glaucoma.
               /axon loss
                                                                                                                Retinal                                                                        3.4                      2020
                                                                                                                                                                                ** Estimated 3 4 million individuals in 2020.
                                                                                     VF change (moderate)       Ganglion
      Initiation of apoptosis                            Risk factors                                           Cells Die By                                                    ** Glaucoma in 4 to 5 times more common
                                                   - IOP          - C/D ratio                                   Apoptosis
                                                   - CCT          - VF loss
                                                                                          VF change (severe)                                                                    in African Americans than in Caucasians.
                                                   - Age          - Other
   Normal
                                                                                                 Blindness                                                                      ** African Americans are 8 to 10 times
                                                                                                                                                                                more likely to become blind from glaucoma.
                    Ocular hypertensionGlaucoma Functional Loss
                                                                                                                                                2000;18:378-
                                                                                                                 Yucel et al. Arch Ophthalmol. 2000;18:378-384.
                                                                                                                  Yucel al. Prog Retin Eye Res. 2003;22:465-81
                                                                                                                                                  2003;22:465-
                                                                                                                Yucel et et al. Prog Retin Eye Res. 2003;22:465-81.
                                                                                                                                                    2003;22:465-
Adapted from RN Weinreb, et al. Am J Ophthalmol. 2004;In Press.




                                                                                                                                                                                     Structural Damage May Precede
                     Undiagnosed POAG                                                                                                                                                     Functional Vision Loss
                                                                                                                          INTRAOCULAR PRESSURE                                                                                     Functional Loss
                                                                                                                                                                                                                                   Structural Loss


           – More than 50% of glaucoma patients                                                                        – Most important risk factor for developing
                                                                                                                                                                        Worse




             are unaware they have the disease.                                                                          glaucoma
           – Many have severe VF loss before                                                                           –C                        ifi     i f
                                                                                                                         Currently the only modifiable risk factor
             diagnosed.                                                                                                – 7% - 8% of the population > 40 year old
                                                                                                                         have elevated IOP ( approximately
                                                                                                                         10 million individual in the USA)
                                                                                                                                                                                                                Time
                                                                                                                                                                      Weinreb. Presented at: The AGS Subspecialty Day Lecture: Getting Closer to Glaucomatous
                                                                                                                                                                      Optic Neuropathy; October 19, 2002; Orlando, Fla.




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Structure or Function - What Changes First?                                     Five Rules for Assessment of the         Five Rules for Assessment of the
                   VF                  SWAP                  FDT
                                                                                    Optic Disc in Glaucoma                   Optic Disc in Glaucoma
                                     Koniocellular         Magnocellular                                               1 Observe the scleral Ring
                                                                              1 Observe the scleral Ring
                                                                                                                         to identify the limits of
                                                                                to identify the limits of
                                                                                                                         the optic disc and its size
                                                                                the optic disc and its size
                                                                                                                       2 Identify the size of the
                                                                                                                         Rim
                                  It Depends
     ON                 RNFL        CSLO             SLP        OCT




Courtesy of RN Weinreb, MD.




          Five Rules for Assessment of the                                      Five Rules for Assessment of the         Five Rules for Assessment of the
              Optic Disc in Glaucoma                                                Optic Disc in Glaucoma                   Optic Disc in Glaucoma
  1 Observe the scleral Ring                                               1 Observe the scleral Ring               1 Observe the scleral Ring to
    to identify the limits of                                                to identify the limits of                identify the limits of the
    the optic disc and its size                                              the optic disc and its size              optic disc and its size

                                                                                                                    2 Identify the size of the Rim
  2 Identify the size of the                                               2 Identify the size of the
    Rim                                                                      Rim                                    3 Examine the Retinal nerve
                                                                                                                      fiber layer
  3 Examine the Retinal                                                    3 Examine the Retinal
                                                                             nerve fiber layer                      4 Examine the Region of
    nerve fiber layer
                                                                                                                      parapapillary atrophy
                                                                           4 Examine the Region of
                                                                             parapapillary atrophy                  5 Look for Retinal and
                                                                                                                      optic disc hemorrhages




              Low-tension Glaucoma                                                  Low-tension Glaucoma                       Exfoliation Syndrome
                                                                           • Abnormal ON structure                  • Overall, the most common
  • IOP <21 mmHg                                                               – Thinner rim
                                                                                                                      identifiable cause of
                                                                               – Cupping and disc area larger
  • 20-30% non-Asian with OAG                                                                                         glaucoma worldwide,
                                                                               – Increase prevalence of acquired
  • In Japan, OAG is most commonly associate                                     pits                                 accounting for the majority
                                                                               – Increase prevalence of disc hemo
    with low IOP                                                                                                              p      g glaucoma
                                                                                                                      of the open-angle g
  • CNTGS: reducing IOP by 30 % - slow                                     • Visual Field defects
                                                                              i      i      f                         in some countries
                                                                              – More focal loss
    progression
                                                                              – Deep scotoma close to
                                                                                                                    • Incidence increases with age
  • Associated with abnormal blood flow of ON                                   fixation                              most common 60-70 yrs
  • Associated with vasoespastic diseases( Migraines,                      • Thinner Central Corneal                  especially in women
    Raynauds)                                                                Thickness                              • Bilateral but usually
                                                                           • Immune-related serum
                                                                             abnormalities are more common
                                                                                                                      asymmetric.
                                                                             than in POAG




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   Glaucoma in XFS - Prognosis                                   XFS in Open-Angle Glaucoma              GLAUCOMA IN XFS
                                                                 •   Spain         1.4 - 44.5%
  • Higher IOP, worse disc and visual field                      •   Hungary       3 - 38%            • Philadelphia         7% (OHT 15%)
    damage at presentation than POAG                             •   Japan         16%
                                                                 •   New Zealand   18%
                                                                                                      • New York             23%
  • Greater failure rate with medical therapy
                                           py
                                                                 •   Turkey        47%                • N
                                                                                                        Norway               23%
  • More frequent need for surgery                               •   Ireland       58%
  • Greater proportion of blindness                              •   Iceland       74%




                                                                                                      Angle pigmentation in XFS
                                                                                                 • More pigment in
                                                                                                   involved eye in
                                                                                                   “unilateral” cases
                                                                                                 • Eyes with glaucoma
                                                                                                     y        g
                                                                                                   tend to have greater
                                                                                                   pigment than fellow
                                                                                                   eyes without glaucoma
                                                                                                 • Tends to correlate with
                                                                                                   severity of damage




     XFS - Open-angle glaucoma                                   XFS - Ocular Associations             XFS - Ocular Associations
• Blockage of TM by                                          •   Posterior synechiae
  exfoliation material
• Blockage of TM by                                          •   Zonular destruction
  pigment                                                    •   Cataract
                                                                 C t     t
• Trabecular cell
  dysfunction             Glycosaminoglycans synthesized
                                                             •   Retinal vein   occlusion
• Concomitant POAG        by an abnormal basement membrane

  (HTG, NTG)




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         XFS - Systemic Associations                              Pigmentary Glaucoma                                                           Pigmentary Glaucoma

                                                        • Epidemiology                                                              • Clinical Features
                                                           – Caucasians                                                               – Krukenberg spindle
                                                           – Myopic males                                                             – Increased TM
                                                                                                                                        pigmentation
                                                           – Age of onset: 20-30 years
                                                                                                                                      – Iris
                                                           – Association with lattice                                                   transillumination
                                                             degeneration                                                               defects
                                                           – Autosomal dominant inheritance                                           – Concave iris
                                                             with incomplete penetrance                                                 configuration




                                                                                                                                        Fuchs heterochromic iridocyclitis
    Corticosteroid-induced Glaucoma                      Iridocorneal Endothelial Syndrome
                                                                                              Chandler's Syndrome
                                                                                                                                      • Heterochromia (lighter)
       •   2-6 weeks after the initiation of steroid   • Abnormal corneal                                                             • Low grade AC reaction,
                                                         endothelium                                                                    stellate KP
       •   Topical more likely than systemic                                                                                          • Gonio: fine vessels that
                                                       • Clinically unilateral,
       •   IOP may improve 2-4 weeks after DC
                  y p                                    present between 20-
                                                                           20                                                           cross TM- may cause
                                                                                                                                             t         t       ti
                                                                                                                                        spontaneous or traumatic
       •   POAG patients are most likely to show         50 yrs of age, more                                                            hyphema
           response (45-90%) than general                often in women                                                               • Posterior subcapsular
           population (5-10%)                          • ? Viral etiology                                  Essential Iris Atrophy       cataract
                                                       • Specular microscopy                                                          • Secondary OAG
                                                         can confirm diagnosis                                                        • Unilateral
                                                                                                                                      • Middle age men/women
                                                                                    Cogan-Reese Syndrome




             Glaucoma secondary to                                                                                                       Pathophysiology - Congenital
       elevated episcleral venous pressure                     Congenital Glaucoma                                                               Glaucoma
• Po = F/C + Pev                                            • About 1 in 10,000 live                                                    •Anomalous development of trabecular
                                                                                                                                        meshwork and/or Schlemm’s canal
                                                              births
•   ARTERIOVENOUS MALFORMATION                                                                                                          •“Barkan”
    – Carotid Cavernous Fistula                             • Birth to age 3-4                                                              membrane
    – Orbital varices
    – Stuge-weber syndrome                                  • 75% bilateral                                                             •Cleavage/
•   VENOUS OBSTRUCTION                                      • 65% male                                                                      sliding defect
    – Retrobulbar tumor
    – Thyroid ophthalmopathy                                • 90% sporadic
    – Thrombosis: Cavernous sinus, Superior
      ophthalmic vein, jugular vein                         • 2% remit
                                                              spontaneously
•   SUPERIOR VENA CAVA SYNDROME




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                                                                                                                                                                                                          Congenital Glaucoma - signs               Congenital Glaucoma
           Congenital Glaucoma -
                Symptoms                                                                                                                                                                                   • Buphthalmos
  •   Photophobia                                                                                                                                                                                                                       • Surgical treatment
                                                                                                                                                                                                           • Corneal haze
                                                                                                                                                                                                                                               –Goniotomy
  •   Epiphora                                                                                                                                                                                             • Haab’s striae
                                                                                                                                                                                                                                                Trabeculotomy
                                                                                                                                                                                                                                               –Trabeculotomy
  •   Blepharospasm                                                                                                                                                                                        • Increased axial length            –Trabeculectomy
  •   Frequent                                                                                                                                                                                             • Reversible cupping
      sneezing




                PAX6 mutations                                                                                                                                                                                     Axenfeld-Rieger
                                                                                                                                                                                                                                              Pathophysiology, Diagnosis
•PAX6 mutations involved                                                                                                                                                                                • Spectrum of disease                    and Management of
 in spectrum of diseases                                                                                                                                                                                  involving anterior
 including; aniridia, Peters’                                                                                                                                                                             segment dysgenesis                     Angle-
                                                                                                                                                                                                                                                 Angle-Closure Glaucomas
 anomaly, and Wilms tumor.                                                                                                                                                                              • Axenfeld anomaly-
 PAX6 involved in                                                                                                                                                                                         prominent Schwalbe’s
 neuroectoderm                                                                                                                                                                                            line                                                   Celso T ll
                                                                                                                                                                                                                                                                 C l Tello, MD
 development                                                                                                                                                                                            • Reiger’s anomaly-above                    Associate Professor of Ophthalmology
                                QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.                                                                                         plus iris abnormalities                        Director, Glaucoma Clinic
•When deletion involves its                                                                                                                                                                             • Reiger’s syndrome-                           New York Eye & Ear Infirmary
 adjacent genes, i.e., in the                                                                                                                                                                             above plus systemic
 PAX6-WT1 critical region                                                                                           QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.

                                                                                                                                                                                                          abnormalities
 (WTCR), patients are
 predisposed to Wilms tum




            Angle-Closure Glaucoma
            Angle-                                                                                                                                                                                                                       Ultrasound Biomicroscopy (UBM)
                                                                                                                                                                                                                                          •   - Newer imaging technique
                                                                                                                                                                                                                    Diagnostic Tests      •   - Uses high frequency ultrasound
                                                                                                                                                                                                                                              (50 MHz)
      • Group of disorders                                                                                                                                                                                                                -    Produces images at high           QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.




                                                                                                                                                                                                                                              resolution (50 u)
      • Iridotrabecular                                                                                                                                                                                    • Slit-lamp                    -   4-5 mm tissue penetration
        contact
      • Elevated IOP
                                                                                                                                                                                                           • Gonioscopy - Indentation
      • Optic nerve damage
      • Visual field defects
      • Different anatomic                                                                                                                                                                                 • Ultrasound Biomicroscopy
        and pathophysiologic                                                                                                                                                                               (UBM)
                                                                      Pupillary Block
        mechanisms




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     Epidemiology of ACG                    Anatomical difference ACG-Normal                             Anatomical Classification
                                                                                                       Pupillary Block                        Plateau Iris
• Race: highest incidence in Eskimos,            • Short axial length
  Asian of Chinese ancestry
                                                 • Smaller corneal diameter
• Sex: Women 3-4 times as often as men
                                                 • Smaller radius of anterior corneal
• Age: increases with age, peaking 55-70
    ge: c e ses w       ge, pe    g 55 70          curvature (steeper)
  years
                                                 • Thicker lens
• Refraction: typically associated with                                                             Phacomorphic Glaucoma
  hyperopia                                      • Smaller radius of anterior lens curvature
                                                   (steeper)
• Inheritance: polygenetic
                                                 • More anterior lens position
                                                                                                                                    Malignant Glaucoma
                                                 • More shallow anterior chamber




           Pupillary Block                                   Pupillary Block                                       Pupillary Block
                                                                                                     • Absolute pupillary block (posterior
                                             •   Relative pupillary block (physiologic)                synechiae)
                                             •   Asymptomatic                                        • Acute angle closure glaucoma
                                             •   Chronic ACG or Acute ACG                               – Decreased visual acuity, halos around lights,
                                                                                                          intense pain, conjunctival injection, excesive
                                             •   Predisposing factors that convert RPB to A               lacrimation, lid edema
                                                 ACG :                                                  – Anxiety, fatigue, vasovagal response
                                                  – Fatigue, anxiety, excitement, close work, the       – Corneal edema, shallow AC, pupil fixed and
                                                    actual mechanism still unclear                        mid-dilated
                                                                                                        – Fellow eye narrow angle and shallow AC




           Laser Iridotomy                                      Plateau Iris                        Argon Laser Peripheral Iridoplasty
            Pre-iridotomy                                                                                        Pre-iridoplasty




            Post-iridotomy                                                                                       Post-iridoplasty




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                   Pseudoplateau Iris                                                                                                       Phacomorphic Glaucoma                                           Malignant Glaucoma
                                                                                                                                                                                                    (Ciliary block glaucoma, aqueous misdirection)

                                                                                                                                                                                              • Complication of
                                                                                                                                                                                                Intraocular surgery
                                                                                                                                                                                              • Shallow anterior chamber
                                                                                                                                                                                              • P t t LI
                                                                                                                                                                                                Patent
                                                                                                                                                                                              • Elevated IOP
                                                                                                                                                                                              • Unremarkable posterior
                                                                                                                                                                                                segment (ophthalmoscopy,
                                                                                                                                                                                                B-can)




                 Pathopysiology of                                                                                                              Pathopysiology of                                            Risk factors for
                Malignant Glaucoma                                                                                                             Malignant Glaucoma                                           Malignant Glaucoma
• Not clearly understood                                                                                                       • Not clearly understood                                       • Most commonly after
• Shaffer:                                                                                                                     • Shaffer:                                                       filtration surgery in eyes with
   – Aqueous flow is diverted into the                                                                                            – Aqueous flow is diverted into the                           CACG
     posterior segment
     p           g                                                                                                                  p           g
                                                                                                                                    posterior segment
                                                                                                                                                                                              • Cataract extraction
   – Abnormal vitreociliary relationship                                                                                          – Abnormal vitreociliary relationship
                                                                                                                                                                                              • Nd:YAG TSCPC
                                           QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.



• Epstein:                                                                                                                     • Epstein:
   – Forward displacement of vitreous                                                                                             – Forward displacement of vitreous                          • Laser iridectomy
   – Thickening anterior hyaloid                                                                                                  – Thickening anterior hyaloid                               • Laser suturolysis
• UBM                                                                                                                          • UBM                                                          • Associated : CRVO, ROP,
   – With and without Ciliary body                                                                                                – With and without Ciliary body                               initiation of pilocarpine in
     detachment                                                                                                                     detachment
                                                                                                                                                                                                filtered eyes.




                  Management of                                                                                                                  Management of                                                Management of
                Malignant Glaucoma                                                                                                             Malignant Glaucoma                                           Malignant Glaucoma
                                                                                                                                        • Medical management
        • Medical management                                                                                                                – Topical steroids                                         • Surgical management
             – First-line treatment
               First line                                                                                                                       • Reduce inflammation                                     – Laser or incisional surgery
             – Goal:                                                                                                                        – Intensive cycloplegia                                          • High IOP resistant to
                • Restore normal flow of aqueous humor into AC                                                                                  • Reverse anterior rotation of ciliary body
                • Interrupt abnormal vitreociliary relationship
                                                                                                                                                                                                               medical treatment
                                                                                                                                            – Aqueous suppressants
             – Effective in 50% cases within 4-5 days                                                                                                                                                        • Lens-cornea or IOL-cornea touch
                                                                                                                                            – Hyperosmotics
                                                                                                                                                • Decompress the vitreous




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              Management of                                                                                                              Management of                                         Management of
            Malignant Glaucoma                                                                                                         Malignant Glaucoma                                    Malignant Glaucoma
• Nd:YAG laser
  – Treatment of choice for Aphakic                                                                                       • Incisional Surgery                                   • Incisional Surgery
    and Pseudophakic eyes
                                                                                                                             – Ciliary body
                                                                                                                                     y    y                                         – Ciliary body
                                                                                                                                                                                            y    y
  – R         f      i h l id
    Rupture of anterior hyaloid
                                                                                                                               effusion                                               attached
  – Equalize pressure between the
    posterior and anterior segment                                                                                           – Surgical drainage                                    – Pars plana
  – In pseudophakics through                                                                                                                                                          vitrectomy
    peripheral iridectomy                                                                                                                                                                                       QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.


                                      QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture.




              Management of
                                                                                                                                           Laser Iridotomy                        Argon Laser Peripheral Iridoplasty
            Malignant Glaucoma
                                                                                                                                                                                                                     Pre-iridoplasty
                                                                                                                                                              Pre-iridotomy
                                                                                                                            • Treatment of pupillary
  – Cataract extraction,                                                                                                                                                          • Indications
                                                                                                                              block                                                                                                                                     Closed Angle
    lensectomy or IOL                                                                                                                                                                – Appositional closure
                                                                                                                            • Almost all cases of                                      with patent laser
    e p a tat o
    explantation                                                                                                              ACG have some                                            i id
                                                                                                                                                                                       iridotomy
  – In persistent AC                                                                                                          component of pupillary                                                                   Post-iridoplasty
                                                                                                                                                              Post-iridotomy         – Unable to do laser
                                                                                                                              block
    flattening refractory                                                                                                                                                              iridotomy
    to vitrectomy                                                                                                           • Settings:                                              – AACA in patients with                                                              Open Angle
                                                                                                                               – Size 50 u                                             patent laser iridotomy
                                                                                                                               – Power = 200 - 1500 mw
                                                                                                                               – Durations = 0.2 - 0.01 sec




   Argon Laser Peripheral Iridoplasty                                                                                        Argon Laser Peripheral Iridoplasty                   Argon Laser Peripheral Iridoplasty
                                                                                                                                                                               • Parameters
  • Pre-operative
    Pre-                                                                                                                  • Parameters
                                                                                                                                                                                 – Six spots / quadrant
    assessment                                                                                                              – Size: 500 µm
                                                                                                                                                                                 – Total 24 spots / 360º
     – Out-patient basis                                                                                                    – Duration: 0.5 seconds
       Out-                                                                                                                                                                      – Avoid too many or too
     – Alpha-2 Agonists
       Alpha-                                                                                                               – Power: 200-300 mW
                                                                                                                                      200-                                         close laser applications
     – Pilocarpine 2% or 4%


  • Laser contact lens




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                                                                                                                                                                                                                                                                                                                                                                                                                                                                    3/18/2010




                                                                                                                                                                                                                                                                                                                                                    Reported Progression Rates
  Argon Laser Peripheral Iridoplasty                                                                                                                                      Argon Laser Peripheral Iridoplasty                                                                                                                                        Treated Patients With OHT
                                                                                                                                                                                                                                                                                                                                                                                      Disease Progression*

                                                                                                                                                                                                • Complications                                                                                                                                                                 OHT                                         Glaucoma
                                                                                                                                                                                                                                                                                                                                                                                                                                            Unilateral
                                                                                                                                                                                                                                                                                                                                                                                                                                            Blindness
                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Unilateral
                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Blindness
                                                                                                                                                                                                                                                                                                                                                                                                                                           (Untreated)           (Treated)
                                                                                                                                                                                                       – Mild post-operative
                                                                                                                                                                                                                post-                                                                                                                                   MODEL 1
 • Post-operative
   Post-                                                                                                                                                                                                 iritis                                                                                                                                             OHTS                                    5 Years
                                                                                                                                                                                                                                                                                                                                                                                                                             9.5%
   treatment                                                                                                                                                                                           – Corneal endothelial
                                                                                                                                                                                                                                                                                                                                                 St. Lucia (AGIS)                                                                   10 Years
                                                                                                                                                                                                                                                                                                                                                                                                                                               16%
                                                                                                                                                                                                                                                                                                                                                       Total Risk                                                                              1.5%                0.3%
     – Al h -2 agonist
       Alpha
       Alpha-        it                                                                                                                                                                                  burns
                                                                                                                                                                                                                                                                                                                                                                                                                                    15 Years

                                                                                                                                                                                                                                                                                                                                                          MODEL 2
     – Topical steroids, 4 to 5                                                                                                                                                                        – Mildly dilated pupil                                                                                                                                OHTS                                                            9.5%
                                                                                                                                                                                                                                                                                                                                                                                                    5 Years
       days                                                                                                                                                                                                                                                                                                                                                Olmsted                                                                             27%
                                                                                                                                                                                                       – Transient rise in IOP                                                                                                                                                                                                      10 Years
                                                                                                                                                                                                                                                                                                                                                         Total Risk                                                                 15 Years
                                                                                                                                                                                                                                                                                                                                                                                                                                               2.6%                0.6%
                                                                                                                                                                                                                                                                                                                                              REPORTED RISK*
                                                                                                                                                                                                                                                                                                                                                    Olmsted                                                                        15 Years
                                                                                                                                                                                                                                                                                                                                                                                                                                               10.5%               2.4%

                                                                                                                                                                                                                                                                                                                                               15-
                                                                                                                                                                                                                                                                                                                                   *Cumulative 15-year progression.
                                                                                                                                                                                                                                                                                                                                                                   2004;138:458-
                                                                                                                                                                                                                                                                                                                                   Weinreb et al. Am J Ophthalmol. 2004;138:458-467.




 OHTS: Treatment Reduces Incidence of                                                                                                                                              Early Treatment Reduces & Delays                                                                                                                  Lowering IOP Reduces Vision Loss in NTG
     Glaucoma in OHT Patients                                                                                                                                                        Glaucoma Progression: EMGT                                                                                                                                 Patients: CNTGS
     • 1636 patients with OHT                                                                                                                                           • 255 patients with newly detected                                                                                                                         • 145 eyes with NTG                                                            1.0
                                                              Proportion of participan developing POAG




                                                                                                                                                                          glaucoma                                                                                                                                                    – (Medical tx ± surgery) vs




                                                                                                                                                                                                                                                                                                                                                                                           Proportion surviving
         – Medical tx vs observation                                                                     0.15                                                                                                                                                                         80                                                                                                                          0.8
                                                                                                                                                                            – (ALT + medical tx) vs                                                                                                                                     observation
     • Target IOP                                                                                                                                                             observation                                                                                             70       62%                                                                                                                0.6
                                                                                                                                                                                                                                                       Incidence of Progression (%)




         – ≥20% reduction to ≤24                                                                                                                                                                                                                                                                                                   • Target IOP
         – Avg IOP drop: 22.5% vs
                                                                                                                                     Observation group                  • Target IOP                                                                                                  60                                                                                                                          0.4
                                                                                                                                                                                                                                                                                                                                                                                                                             Treated
                                                                                                                                                                                                                                                                                                                                      – ≥30% IOP reduction                                                                   Untreated
           4.0% in untreated controls                                                                    0.10                                                               – No target set                                                                                                                          45%
     • Results (at 60 months)                                                                                                                                               – Avg IOP drop 25%                                                                                        50                                           • Results                                                                      0.2
                                                                                     nts




         – Cumulative probability of                                                                                                                                         (range 0-29%)                                                                                            40                                              – 80% survival (no progression)                                              0
           POAG                                                                                                                                                                                                                                                                                                                         in treated group vs 60% in                                                      0    1     2     3    4      5       6      7     8
                                                                                                                                                                        • Results




                                                                                                                                                                                                                                                                                                                                                                                      Eyes that progressed (%)
              • 4.4% in treated group vs                                                                                                                                                                                                                                              30                                                                                                                          45
                9.5% in observation                                                                      0.05                                                               – Disease progression 45% in
                                                                                                                                                                                                                                                                                                                                        control arm at 3 years                                                                    27%
                                                                                                                                                                                                                                                                                                                                                                                                                                          Time (years)
                group (P<0.001)
                                                                                                                                                                              treated vs 62% in untreated                                                                             20                                                (P=0.0018)
                                                                                                                                                                                                                                                                                                                                                                                                                  30
     • Conclusion                                                                                                                                                             (P=0.007)                                                                                               10                                              – VF progression 18% in treated
         – Medical therapy effective                                                                                                                                    • Conclusion                                                                                                                                                    vs 30% in untreated                                                                                                 12%
           in delaying/preventing                                                                                            Medical treatment group                                                                                                                                  0                                                                                                                           15
           onset of POAG in subjects                                                                     0.00 6 12 18 24 30 36 42 48 54 60 66 72 78 84                      – Treatment significantly delays                                                                                Untreated               Treated        • Conclusion
           with elevated IOP                                                                                                                                                  disease progression
                                                                                                                         Follow-
                                                                                                                         Follow-up month                                                                                                                                                                                              – Lowering IOP reduces risk of                                               0
                                                                                                                                                                            – Each 1-mm Hg reduction in                                                                                                                                 vision loss in NTG                                                                    Untreated eyes             Treated eyes
                                                                                                                                                                              IOP reduced risk of
                                                                                                                                                                              progression by 10%
                         Ophthalmol. 2002;120:701-
     Kass MA et al. Arch Ophthalmol. 2002;120:701-713.                                                                                                                       Heijl A et al. Arch Ophthalmol. 2002;120:1268-1279.
                                                                                                                                                                                                 Ophthalmol. 2002;120:1268-                                                                                                                                       1998;126:498-
                                                                                                                                                                                                                                                                                                                                          CNTGS. Am J Ophthalmol. 1998;126:498-505.




            Lowering IOP Minimizes VF                                                                                                                                               IOP Needs to Be Consistently                                                                                                                                     Glaucoma Clinical Trials:
                   Loss: CIGTS                                                                                                                                                             Low: AGIS                                                                                                                                                 Summary of Implications
                                                                                     30
                                                                                                                                                         Medicine      • 738 eyes with
• 607 patients with newly                                                                                                                                Surgery         uncontrolled glaucoma                                                                                                                                              • Lowering IOP does prevent development of
                                                Mean IOP (mm Hg)




                                                                                                                                                                                                                                                All visits <18                                          75 to 100% of visits <18
  diagnosed OAG                                                                      25
                                                                                                                                                                         – ALT vs surgery                                                       50 to 75% of visits <18                                 0 to 50% of visits <18                glaucoma in patients with OHT
  – Medical tx vs surgery                                                            20
                                                                                                                                                                       • Target IOP                                                                                                                                                         • Lowering of IOP does prevent progression of
• Target IOP                                                                                                                                                                                                                                    3.5                                                                   Mean IOP
                                                                                                                                                                                                                                                                                                                                              glaucoma
                                                                                     15                                                                                  – <18 mm Hg
                                                                                                                                                                                                                   Mean change in visua field




  – Low target pressure set by                                                                                                                                                                                                                    3                                                                   20.2 mm Hg
    formula                                                                                                                                                            • Results                                                                2.5                                                                                         • Patients with consistently low IOP at all time do
                                                                                                                                                                                                                                                                                                                                                                       y
                                                                                                                                                                                                                                      al




                                                                                     10                                                                                                                                                                                                                               16 9 mm Hg
                                                                                                                                                                                                                                                                                                                      16.9
• Results                                                                                8                 0    6   12   18     24    30   36   42   48     54    60
                                                                                                                                                                         – 100% of visits <18 mm                                                  2
                                                                                                                                                                                                                                                                                                                      14.7 mm Hg
                                                                                                                                                                                                                                                                                                                                              better that patients with fluctuating IOP
                                                                                         7                                                                                 Hg: no change in visual                                              1.5
                                                                                                                                                                                                                                                                                                                                            • Both medical treatment and surgery effectively
                                                   Mean visual field




  – Both medical tx and surgery                                                                                                                                            field
                                                                                         6                                                                                                                                                        1
                                                                                                                                                                                                                                                                                                                                              reduce IOP and risk of progression
    lower IOP & prevent VF
                                                                                         5                                                                               – <50% visits <18 mm Hg:
                                                       score




    loss                                                                                                                                                                                                                                        0.5
                                                                                                                                                                                                                                                                                                                                            • When pressures are low enough, patients on
                                                                                         4                                                                                 worsening of VF by 0.63                                                0                                                                   12.3 mm Hg
• Conclusion                                                                             3                                                                                 units                                                                -0.5                                                                                          average have much lower risk of progression
  – With aggressive therapy                                                              2
                                                                                         1                                                                             • Conclusion                                                                                                        Follow-up month
                                                                                                                                                                                                                                                                                           Follow-
    aimed at IOP-lowering, VF
    loss in general is minimal                                                           0                 0    6   12   1      2     30   36   42   4     54    60
                                                                                                                                                                         – Consistently low IOP
                                                                                                                         8      4                    8                     associated with reduced
                                                                                                                              Time (months)                                progression of VF defect                                                                                                                                                                               2002;120:1268-
                                                                                                                                                                                                                                                                                                                                               1. Heijl A et al. Arch Ophthalmol. 2002;120:1268-1279.
                                                                                                                                                                                                                                                                                                                                                                                    2001;108:1943-
                                                                                                                                                                                                                                                                                                                                               2. Lichter PR et al. Ophthalmology. 2001;108:1943-1953.
                                                                                                                                                                                                                                                                                                                                                                              2000;130:429-
                                                                                                                                                                                                                                                                                                                                               3. AGIS: 7. Am J Ophthalmol. 2000;130:429-440.
     Lichter PR et al. Ophthalmology. 2001;108:1943-1953.
                       Ophthalmology. 2001;108:1943-                                                                                                                                                                  2000;130:429-
                                                                                                                                                                             The AGIS Investigators. Am J Ophthalmol. 2000;130:429-440.




                                                                                                                                                                                                                                                                                                                                                                                                                                                                              9
                                                                                                                                                           3/18/2010




                                                              Factors to Consider in Setting
Medical Management of Glaucoma
                                                                     the Target IOP
                                                                                                                       Initial Target IOP
 • Target IOP                                                                                                    • Glaucoma Suspect = 20-25%
                                                            • IOP level at which optic nerve damage
   – Definition: A range of acceptable IOP levels             occurred                                             ( <21mmHg)
     within which the progression of
                                                            • Central corneal thickness                          • Early Glaucoma = 25-30%
     glaucomatous neuropathy will be delayed or
     g                   p y              y
     halted (AAO, 1996)                                     • Extent and rate of progression                       (Hi h teens)
                                                                                                                   (High t    )
                                                               – Lower target as disease advances                • Moderate Glaucoma = 30-35%
 • Target IOP range should be                                                                                      (Mid teens)
                                                            • Patient age and expected lifespan
   – Dynamic                                                                                                     • Advanced Glaucoma = >35%
   – Reviewed and adjusted over course of                   • Family history
     treatment                                              • Race                                                 (Low teens)




Medical Management of Glaucoma                                        Medical Management
                                                                                                                Medical Management: -blockers
 • General Principles                                       • Classes of medications
                                                               – Beta-adrenergic
   – Single drug - monocular trial                               antagonists
                                                                                                                • Properties
                                                               – Adrenergic agonists                              – B-1= cardiac, B-2 = pulmonary
   – Spacing and nasolacrimal occlusion
       p     g                                                 – C b i A h d
                                                                 Carbonic Anhydrase                               –b      2         blockade       i      d
                                                                                                                    beta-2 receptor bl k d on non-pigmented
      • patient education                                        inhibitors                                         cilliary epi.
                                                               – Parasympathomimetics
   – Diurnal curve, vary office visits                             • direct and indirect
                                                                                                                  – reduce aqueous production
   – Compliance                                                – Prostaglandin                                    – no effect on outflow
                                                                 analogues
                                                               – Hyperosmotics




                                                                                                                      Medical Management:
 Medical Management: -blockers                             Medical Management: -blockers
                                                                                                                       Adrenergic agonists
 • Classes                                                  • Side effects:
    – Non-selective                                            – bronchospasm(b-2) bradycardia        syncope
                                                                                                                   • Properties
       • timolol                                               –  exercise          heart block       BP           – alpha agonist activity:
       • levobunolol                                           – lethargy      depression       libido
                                                                                                                        • decreased aqueous formation
       • metipranolol                                          – impotence           allergy   SPK
    – Beta-1 selective                                         – Corneal anesthesia                                  – beta agonist activity:
       • Betaxolol - 85% (timolol)                                                                                      • increased aqueous formation
    – Non-selective with ISA                                   – reduced HDL, increased TG’s (non-selective)
       • carteolol (adrenergic agonist activity)                  • **less with carteolol**                             • increased conventional outflow
           – less cardiac and pulmonary side effects (not                                                               • increased uveoscleral outflow
             proven)
                                                                                                                     – net effect is decreased IOP




                                                                                                                                                                 10
                                                                                                                                                                         3/18/2010




           Medical Management:                                Medical Management:                                         Medical Management:
            Adrenergic agonists                                Adrenergic agonists                                         Adrenergic agonists
 • Drugs                                             • Drugs                                                     • Side effects - Epinephrine - Dipivefrin (pro-
   – epinephrine                                       – Apraclonidine (Iopidine)                                  drug / less systemic s-e)
      • non-selective alpha and beta agonist              • selective alpha-2 agonist ( production, ?             – mydriasys        conj blanching
                                                            EVP)
   – Dipivefrin (Propine)                                                                                           – lid retraction   adrenochrome deposits
                                                          • allergy in 20-50%
      • prodrug enhances corneal penetration              • tachyphyllaxis                                          – follicular conjunctivitis
      • corneal esterase hydrolyzes pivalic acid       – Brimonidine (Alphagan)                                     – tachycardia             arrhythmia
        side-chains                                       • selective alpha-2 agonist                                   hypertension
      • lower concentration so fewer side                 • less allergy and tachyphyllaxis                         – dry mouth drowsiness headache
        effects                                           • long term efficacy                                        nervousness
                                                                                                                    – CME in aphakia (may be permanent)




           Medical Management:                               Medical Management:                                          Medical Management:
            Adrenergic agonists                              Parasympathomimetics                                         Parasympathomimetics
                                                     • Properties                                                • Classes
• Side effects - alpha 2 (Aproclonidine > Br)           – muscarinic receptor stimulation (NT = Ach.)               – Direct Acting
                                                            • pupillary sphincter - contraction                        • Miochol
   – Eyelid retraction                                      • ciliary contraction (C.F) = myopia                       • Pilocarpine
   – Eyelid edema conjunc edema - blanching                 • ciliary contraction (L F)= tension on SS, TM and
                                                                                  (L.F)=            SS                 • Carbachol
   – Headache         nervousness     drowsiness              Schlemm’s canal = increased conventional outflow      – Indirect Acting (anticholinesterases)
                                                        – lacrimal glads - increased secretion                         • Reversible                  Irreversible
   – Insomnia         depression      anxiety           – decreased uveoscleral outflow                                    Demecarium (Humorsol)            echothiophate (PI)
     syncope                                            – No effect on aqueous production                                  Physostigmine (Eserine)
   – follicular conjunctivitis
   – dry mouth         ocular dryness




          Medical Management:                                 Medical Management:
                                                                                                                     Medical Management: CAI’s
          parasympathomimetics                                parasympathomimetics
                                                     • Side effects
• Side effects                                                                                                    • Properties
   –   miosis         night Va          brow ache      – retinal detachment (in eyes at risk)
                                                                                                                    – sulfonamide, diuretic agents
   –   myopia (up to 5 diopters < 60 y.o)               – paradoxical angle closure (miotic
                                                          induced)
                                                          i        )                                                – carbonic anhydrase:
   –   local reaction (follicles, chemosis …)
   –   disruption blood-aqueous barrier = inflamm.      – systemic (related to cholinergic                             • CO2 + OH  HCO3
   –   Cataractogenic - adults (indirect agents)          stimulation)                                              – reduces aqueous formation in C.B. 20-
   –   IPE cysts (indirect agents) - children               • nausea vomiting diarrhea                                40%
        • minimized phenylephrine 2.5%                      • sweating bronchial spasm
        • usually disappear with cessation of med
                                                            • bradycardia enuresis




                                                                                                                                                                                 11
                                                                                                                                                                                      3/18/2010




    Medical Management: CAI’s                                  Medical Management: CAI’s                                        Medical Management: CAI’s
   – Oral                                                   • Drugs                                                         • Side effects
      • Acetazolamide                                          – Topical agents                                                – malaise complex - malaise, fatigue, weight
      • Methazolamide                                             • equal efficacy
      • Dichlorphenamide (Daranide)
                                                                                                                                 loss, depression, anorexia, loss of libido
                                                                  • pH of dorzolamide = 5.5 = BURNING
                                                                    p
   – IV
                                                                  • pH of brinzolamide = 7.4 = Nice (suspension)
                                                                                                                               – nausea, heart burn, cramps, diarrhea
                                                                                                                                                                 i
      • Acetazolamide                                             • statistically equal to oral agents - ? Clinically          – paresthesias, carbonated drinks taste flat
   – Topical
                                                                  • can cause increase in corneal thickness                    – urinary frequency, nephrolithiasis (less
      • Dorzolamide                                               • side effects - burning, allergy, blurry Va                   w/meth)
      • Brinzolamide                                                  – can have similar systemic effects as oral




                                                                                                                                         Medical Management:
    Medical Management: CAI’s                                        Medical Management:                                                   Prostaglandins
 • Side effects
                                                                       Prostaglandins                                       • Side effects of latanoprost (PGF2 )
   – sulfa allergy                                                                                                             – IRIS COLOR CHANGE (irreversible)
                                                            • Biologically active products of arachidonic                           •   10-20% blue irides (18-24 months)
   – blood dyscrasias (aplastic anemia) - usually
                                                              acid                                                                  •   60% light brown, hazel-green irides (18-24 months)
     within first six months (2 weeks to 6 months)
                                                                                                                                    •
   – hypokalemia (if on diuretic). BE CAREFUL               • cyclooxygenase pathway                                                    nevi and freckles not affected
                                                                                                                                    •   Increased melanosomes within melanocytes
     WITH DIG.                                              • high doses  IOP and inflammation                                –   Hyperthricosis
   – Teratogenic (forelimb deformity in animals)            • low doses  IOP and  uveoscleral outflow                        –   Hyperpigmentation eyelashes, periorbita area
   – ocular side effects rare with systemics                • dosed qd in evening                                              –   Uveitis, CME
                                                                                                                               –   Worsening or development HSV kerititis




                                                                      Medical Management:                                               Medical Management:
Medical Management: hyperosmotics                                        hyperosmotics                                                     hyperosmotics
                                                            • Oral agents
                                                               – Glycerol                                                   • Oral agents
  • Properties                                                    • 1 to 1.5 g/kg body weight (1 ml = 1.24 g glycerol) so     – Isosorbide
                                                                    give 1 ml 100% glycerol/kg body weight
    – increase serum osmolality                                                                                                   • fewer side effects than glycerol
                                                                  • onset of action 10 to 30 minutes, max effect 2 hours,
       • shrinks vitreous 3-4% (0.12 to 0 16 l) - twice
          h i k i         3 4% (0 12 0.16ml)        i               duration 4 to 5 hours                                             – less nausea more diarrhea
                                                                                                                                             nausea,
         volume of posterior chamber and half of anterior         • metabolized by liver to glucose and ketone = less             • 1 to 1.5 g/kg body weight - 45% solution
         chamber                                                    diuresis                                                      • similar efficacy and duration as glycerol
    – systemic agents                                             • unpalatable sweetness (give with ice or OJ)                   • 95% excreted in urine - no caloric value
       • oral or IV                                               • very caloric (80 ml = 430 calories)                           • useful in diabetics




                                                                                                                                                                                             12
                                                                                                                                                3/18/2010




         Medical Management:                              Medical Management:
            hyperosmotics                                    hyperosmotics                                   Surgical Management of POAG
• IV agents                                      • Side effects
   – mannitol                                        – caution in elderly or cardiac, renal, hepatic
                                                       disease                                               •   Laser Trabeculoplasty
      • 1 to 1.5 g/kg body weight of 10 to 20%
        solution at 3 to 5 ml/minute                 – headache and back pain most common                    •   Trabeculectomyy
                                                     – nausea vomiting
      • onset 10 to 30 minutes                                                                               •   Non-penetrating procedures
                                                     – circulatory overload - CHF, pulmonary edema
      • peak effect 30 to 60 minutes                 – CNS effects from hyponatremia, dehydration,           •   Glaucoma Drainage Implant
      • duration 6 hours                               CSF acidosis with poor renal function - tx is         •   Cyclodestructive Procedures
      • penetrates eye poorly                          dialysis
                                                     – subdural heme., hypersensitivity rare




        Laser Trabeculoplasty                                   Trabeculectomy                                    Non-penetrating procedures
• ALT
     • 50 Microns
     • 0.1 Sec
     • 600-700 mW                                                                                      • Viscocanalostomy
                                                                                                       • D      l    t
                                                                                                         Deep sclerectomy
• SLT
     • 400 Microns
     • 3 n Sec
     • 0.8 mJ




                                                             Trabeculectomy                                              Trabeculectomy
         Glaucoma Tube Shunt
                                                        Intraocular complications                                   Intraocular complications
                                                 •   Anesthesia-related                                  •       Anesthesia-related
    • Resistance (valved) devices
                                                 •   Conjunctival flap                                   •       Conjunctival flap
        – Ahmed                                  •   Scleral flap                                        •       Scleral flap
        – Krupin                                 •   Intraocular                                         •       Intraocular
                                                     complications                                               complications
                                                     – Hyphema                                                   – Hyphema
    • Nonresistance (nonvalved) devices
                                                     – Vitreous loss                                             – Vitreous loss
        – Baerveldt                                  – Choroidal                                                 – Choroidal
        – Molteno                                      Hemorrhage                                                  Hemorrhage




                                                                                                                                                      13
                                                                                                                                                        3/18/2010




         Postoperative Complications                   Postoperative Complications - Early                           Postoperative Complications - Early
    • Classification
        – Early vs. Late
        – IOP                                            • Elevated IOP - deep A/C
        – Anatomy
                                                            – pressure spikes - IOP can be up to 50
                                                              mmHg w/in 24 hours of surgery*
    • Many related to surgical technique
                                                                • “snuff” phenomenon - loss of fixation
    • Avoidance and anticipation are most important             • blockage of internal ostium by Descemet’s, iris,
                                                                  blood, vitreous, fibrin, lens capsule, retained
                                                                  viscoelastic




        Postoperative Complications -                      Postoperative Complications -
                                                                                                                     Postoperative Complications - Early
                    Early                                              Early
•   Elevated IOP - deep A/C                                                                                            • Elevated IOP - shallow
    – tight scleral flap sutures                           • Elevated IOP -                                              A/C
        • releasable sutures vs. laser lysis                                                                              – Pupillary block
        • avoid release first few days,                      shallow A/C                                                      • rare with patent
          tightest first, one at a time
        • complete w/in 7-10 days w/o                          – Aqueous                                                        iridectomy
          antifibrosis,
          antifibrosis 2 wks with 5-FU and 1                     misdirection until
          month with MMC                                                                                                  – Choroidal detachment
        • with LSL, avoid conj manipulation                      proven otherwise                                           with anterior rotation of
          and buttonhole
                                                                                                                            ciliary body causing
        • bleb massage
                                                                                                                            angle closure

                                                                                                                          – Choroidal hemorrhage




    Postoperative Complications - Early                Postoperative Complications - Early                           Postoperative Complications - Early
    • Shallow A/C - decreased IOP                     • Shallow A/C - decreased
                                                        IOP - BLEB PRESENT
        – Overfiltration                                – Overfiltration                                             • Shallow A/C -
                                                           • more common after full-
        – Wound leak                                         thickness surgery                                         decreased IOP - BLEB
                                                           • loose scleral flap sutures                                PRESENT
        – Ciliochoroidal detachment/effusion               • management with external
        – Cyclodialysis cleft                                tamponade (CL, ring, shell)                               – Ciliochoroidal
                                                           • avoid re-operation (bleb                                    detachment/effusion
        – Decreased aqueous production (ciliary              failure)
                                                                                                                          • overfiltration
                                                           • consider temporary decrease
          detach, shock)                                     in steroids to enhance                                       • inflammation
                                                             scarring




                                                                                                                                                              14
                                                                                                                                          3/18/2010




 Postoperative Complications - Early         Postoperative Complications - Early                       Postoperative Complications
                                         •   Postoperative Complications - Early              •   Filtration failure
                                         •   Shallow A/C - decreased IOP - BLEB                    – Often results from lack of early
• Shallow A/C - decreased                    ABSENT                                                   intervention
  IOP - BLEB ABSENT                           – Ciliochoroidal detachment/effusion
                                                                                                   – Risk factors
                                                  • leakage, hyposecretion
     – Wound leak (UNTIL                      – Cyclodialysis cleft                                     • neovascular glaucoma
       PROVEN OTHERWISE)                          • surgical trauma                                     • uveitis
       • conj flap perforation or             – Decreased aqueous production (ciliary
                                                                                                        • black race
         buttonhole                             detach, shock)
       • post-cautery conj. necrosis              • failure to discontinue topical or                   • Aphakia/pseudophakia
                                                    systemic agents
       • wound dehiscence                         • cross-over effect from other eye’s meds
                                                                                                        • prior conjunctival surgery
       • thin filtration bleb +/-                                                                       • young age
         trauma                                                                                         • prolonged use of preoperative
       • more common with                                                                                 topical antiglaucoma meds
         antifibrosis agents




                                                    Postoperative Complications                        Postoperative Complications
         Postoperative Complications
• Filtration failure                                                                              • Bleb related Infections
                                                                                                     – Grade I = Vanco 50 mg/ml
     – Encapsulation (Tenon’s                                                                          (G+) and quinolones (G+-)
                                         • Bleb related Infections
       cyst)                                                                                         – Grade II = Vanco (G+) and
       • occurs 10-28% of time usually
                                              – Grade I = involves bleb                                quinolones (G+-) and AC
         w/in first 8 weeks                     only                                                   Vanco
                                              – G d II = involves bleb
                                                Grade      i   l    bl b                             – Grade III = Intravitreous
                                                                                                       Ceftaz, Vanco and steroid
       • risk factors include previous          and AC
         ALT, anterior uveitis,
                                              – Grade III = Bleb, AC and
         prolonged preoperative beta
         blocker and                            Vitreous
         parasympathomimetic use




 Postoperative Complications - Late
 •   Chronic hypotony (IOP < 5
     mmHg)
      – Overfiltration
      – Bleb leakage
      – Aqueous hyposecretion
        (inflammation or CB detach)
        Cyclodialysis l ft
      – C l di l i cleft
      – Undetected retinal detachment
      – Severe ocular ischemia




                                                                                                                                                15