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TRANSCRIPT
Secondary Glaucoma & Surgical Complex Anterior Segment
Faran Vafaie OD, MSc, BSc Lead OD EyeLABS Glaucoma Program
OD/MD Collaborative Unit Prism Eye Institute Friday June 14 2019
Financial Disclosures
Outline
Secondary Glaucoma
Surgical Glaucoma and Complex Anterior Segment
• 59 year old male
• Lost to follow up (last seen 2015)
• Has not taken glaucoma medication for past year
• 59 year old male
• Lost to follow up (last seen 2015)
• Has not taken glaucoma medication for past year
• History of phaco/IOL/iStent and right RD w/ pneumatic retinopexy
• 59 year old male
• Lost to follow up (last seen 2015)
• Has not taken glaucoma medication for past year
• History of phaco/IOL/iStent and right RD w/ pneumatic retinopexy
• IOP: 34/28
Dr. Chua http://www.mrcophth.com/pd/kruka.html
Risk factors:
• Myopes
• Males in 30s, females in 40s
• Race (African ancestry <5% of PDS although could be under-reported)
• Concave iris
Clinical signs and symptoms:
• Blurry vision/haloes with exercise or in dark
• Increased TM pigmentation
• Krukenberg spindles
• Transilluminatory iris defects
Pigment Dispersion Glaucoma
• 59 year old male
• Lost to follow up and has not taken glaucoma medication for over one year
• History of phaco/IOL/iStent and right RD w/ pneumatic retinopexy
• IOP: 34/28
• Diagnosis:
• Pigment dispersion glaucoma moderate OS, mild OD based on RNFL
• Testing stable although IOP above target
• Poor compliance as evidenced by missed appointments
• Treatment:
• Gentle SLT OU w/ post laser HRT/ORA
Glaucoma Today. Not a Routine Case of Pigmentary Dispersion Syndrome or Uveitic Glaucoma. Vikas Chopra, MD; Sourabh Arora, MD; and Brian A. Francis, MD, MS
IOP 17/29 on 0/2 drop classes
Atlas of Ophthalmology Online Database
Glaucoma Today. Not a Routine Case of Pigmentary Dispersion Syndrome or Uveitic Glaucoma. Vikas Chopra, MD; Sourabh Arora, MD; and Brian A. Francis, MD, MS
IOP 17/29 on 0/2 drop classes
Atlas of Ophthalmology Online Database
Glaucoma Today. Not a Routine Case of Pigmentary Dispersion Syndrome or Uveitic Glaucoma. Vikas Chopra, MD; Sourabh Arora, MD; and Brian A. Francis, MD, MS
IOP 17/29 on 0/2 drop classes
Glaucoma Today. Not a Routine Case of Pigmentary Dispersion Syndrome or Uveitic Glaucoma. Vikas Chopra, MD; Sourabh Arora, MD; and Brian A. Francis, MD, MS
IOP 17/29 on 0/2 drop classes
U G H ! ! !
• Uveitic-Glaucoma-Hyphema Syndrome
Etiology:
• Chafing caused by IOL against iris
• Typically seen in ACIOLs but also in sulcus-placed IOLs
Pigment Dispersion Glaucoma
U G H ! ! !
Glaucoma Today. Not a Routine Case of Pigmentary Dispersion Syndrome or Uveitic Glaucoma. Vikas Chopra, MD; Sourabh Arora, MD; and Brian A. Francis, MD, MS
Image courtesy of Rendia
Image courtesy of Rendia💥
Glaucoma Today. Not a Routine Case of Pigmentary Dispersion Syndrome or Uveitic Glaucoma. Vikas Chopra, MD; Sourabh Arora, MD; and Brian A. Francis, MD, MS
Image courtesy of Alcon
1-piece• “Capsule friendly” (less wrinkles)• Lower risk of zonular tearing• Lower risk of PCO
3-piece• Quick to implant• Can be placed outside of
capsular bag
TAKE HOME: 1-PIECE IOL SHOULD NOT BE IN SULCUS
Images courtesy of NanoMedical Group
OpticHaptic
U G H ! ! !
Intermediate term follow-up after a single-piece-acrylic intraocular lens implantation in the ciliary sulcus- a cross-sectional studyBMC Ophthalmology 2013
• 77 year old male
• History of complex left phaco/IOL due to floppy iris, and iris prolapse with subsequent IOP spikes
• Referred for right phaco/IOL with deeper level of sedation not available locally
• IOP 27/16
• VA OD 20/60 OS 20/30
• Right: 2+NS, mod AC, CD 0.5 w/ inf thinning
• Left: PCIOL, deep AC, CD 0.3
Zonulopathy
• Deficiency of zonular support for the lenticular capsule
• May include lens/IOL subluxation or dislocation
• Etiology:• pseudoexfoliation
• trauma
• iatrogenic
• dense cataracts
• Marfan’s
Zonulopathy
Capsular tension ring:• Mild zonular weakness• <4 clock hrs of loss• Redistributes tension from areas of
healthy zonules to weak/missing zonules
Capsular tension segment:• >4 clock hrs of loss• Sutured to sclera
Signs:
Fibrin deposits on anterior lens capsule
Pseudoexfoliation
Image Courtesy of Science Direct Image Courtesy of Department of Ophthalmology and Vision Sciences University of Iowa
Signs:
Poor pupil dilation with peripupillary transillumination defects
Pseudoexfoliation
Image Courtesy of American Academy of Ophthalmology Pseudoexfoliative syndrome: Revisited Journal of Clinical Ophthalmology and Research. Purvi R Bhagat, Granthali A Pawar
Signs:
Increased TM pigmentation
Pseudoexfoliation
Image Courtesy of American Academy of Ophthalmology
Signs:
Zonulopathy
• AC shallowing
• Subluxation
• Phacodonesis
Pseudoexfoliation
Image Courtesy of Ophthalmology Web
https://www.youtube.com/watch?v=Z1Wc2kQ8L6s (dackakorot)
Pseudoexfoliation
https://www.youtube.com/watch?v=Z1Wc2kQ8L6s (dackakorot)
Risk Factors:
• Age >70
• Possible genetic prevalence
• Specific populations (ie Scandinavia)
Etiology:
• Elastic and laminin fibril deposition caused by irregular turnover of extracellular matrix
• Systemic disease assoc w/:
• myocardial infarction
• cerebrovascular events
• systemic hypertension
Pseudoexfoliative glaucoma
Image Courtesy of American Academy of Ophthalmology
Image Courtesy of Science Direct
Conversion of PXE to ACG:1
• Caused by zonular weakness
• PACS: 9-18%
• PAC: 2.2%
Missed ACG in general:2
• 1234 glaucoma referrals from ophthalmologists
• 179 had recorded angle data in chart stating angle status as open
Pseudoexfoliative glaucoma
Angle Closure: A Bad Connection an McWherter, OD, and Richard Mangan, OD Review of Optometry
Image Courtesy of Science Direct
1The Medical and Surgical Management of Pseudoexfoliation Glaucoma. Int Ophthalmol Clin. Manishi A. Desai, MD and Richard K. Lee, MD, PhD2Undetected angle closure in patients with a diagnosis of open-angle glaucoma. CJO. Varma et al
POAG 100%
POAG 91%(163)
ACG 9%(16)
POAG 91%(163)
ACG 9%(16)
POAG w/ PXG 13.5%
ACG w/ PXG25%
Take home points:TM dysfunction —> PXG is aggressive!
Zonulopathy —> Do not sit on these cataracts!
Pseudoexfoliative glaucoma
Take home points:TM dysfunction —> PXG is aggressive!
Zonulopathy —> Do not sit on these cataracts!
Pseudoexfoliative glaucoma
Take home points:TM dysfunction —> PXG is aggressive!
Zonulopathy —> Do not sit on these cataracts!
Pseudoexfoliative glaucoma
• Up to 60% of trauma will develop some degree of angle recession
• 3-6% will develop ARG
• Can take days, months or years
• Higher incidence of ARG when hyphema present:
• Acute IOP spike
• Long-term IOP rise from scarring/fibrosis
Angle recession glaucoma
Image Courtesy of EyeWiki
Image Courtesy of Retina Image Bank
Angle recession glaucoma
Image Courtesy of EyeWiki
Check the other eye!
>180° AR
Hyphema
Image Courtesy of Glaucoma Service, Asociación Para Evitar la Ceguera en México
Image Courtesy of Glaucoma Service, Asociación Para Evitar la Ceguera en México
Image Courtesy of Glaucoma Service, Asociación Para Evitar la Ceguera en México
Image Courtesy of Glaucoma Service, Asociación Para Evitar la Ceguera en México
• Seen in ischemic disease
• If adequate visual potential, tube surgery is indicated - regardless refer for PRP
Neovascular glaucoma
Image Courtesy of Glaucoma Service, Asociación Para Evitar la Ceguera en México
• TM dysfunction and steroid response
• More often than not will require incisional surgery
• Taper steroid very carefully postop
Uveitic glaucoma
MTMTIs glaucoma a disease best treated alone
Surgical Options
Surgical Options
• Patient Ed
• Patient Prep
• Collab Care
Surgical Options
• Lasers
• MIGS
• Tubes/Trabs
Surgical Options
• Lasers
• MIGS
• Tubes/Trabs
Laser Trabeculoplasty
• ALT (Argon):
• Structural change to TM
• SLT (Selective):
• Targets melanin-containing cells
0%
25%
50%
75%
100%
>20% IOP lowering
1 year 5 years
31%
58%
13%
46%
ALT SLT
Barkana Y, Belkin M. Selective laser trabeculoplasty. Surv Ophthalmol. 2007;52(6):634-54.
Laser Trabeculoplasty
Video courtesy of Dr. Christopher Teng
• ALT (Argon):
• Structural change to TM
• SLT (Selective):
• Targets melanin-containing cells
• MLT (Micro):
• Less likely to have postop IOP spike
• Less inflammation
Laser Trabeculoplasty
Good candidates:Mild or mod OAG
Compliance issues
Drop intolerance
Drop administration challenges
Pigment dispersion
Pseudoexfoliation
NTG
OHTN
Bad candidates:Narrow angles
Neovasc glaucoma
Uveitic glaucoma
Advanced OAG
Cyclophotocoagulation
Image courtesy of Andrew Pearson MA MRCP FRCOphth
At risk of snuff-out
Cyclophotocoagulation
Image courtesy of Andrew Pearson MA MRCP FRCOphth
• Cyclodestructive: secretory epithelium of ciliary body
• Transscleral CPC indications:
• Pain relief in elevated IOP
• Poor visual potential
• Conjunctical scarring precluding filtering surgery
• Painful
• Vision loss: 13-50%
• Risk of phthisis, endophthalmitis, malignant glaucoma, hypotony
Endocyclophotocoagulation
• Combined with phaco
• Goals: 1) Aqueous suppression. 2) Shrinkage of ciliary body
Endocyclophotocoagulation
• Combined with phaco
• Goals: 1) Aqueous suppression. 2) Shrinkage of ciliary body
Endocyclophotocoagulation
• Combined with phaco
• Goals: 1) Aqueous suppression. 2) Shrinkage of ciliary body
Video courtesy of Dr. Martin Uram
Surgical Options
• Lasers
• MIGS
• Tubes/Trabs
MIGS
Image courtesy of www.megadget.com
Image courtesy of Thieme, H Dtsch Arztebl Int 2012; 109(40):
MIGS
MIGS
IOP lowering effect Invasiveness/risk
iStent
Hydrus
Gonioto
my
GATTCypass Xen
MIGS
IOP lowering effect Invasiveness/risk
iStent
Hydrus
Gonioto
my
GATT
Avenues of increased drainage: 1) TM/Schlemm’s Canal2) Uveoscleral/Suprachoroidal Outflow3) Subconjunctival Bleb4) External
Cypass Xen
Image courtesy of Elizabeth A. Dale, MD, and Marlene R. Moster, MD Glaucoma Today
Image courtesy of Christopher Kent. Review of Ophthalmology
MIGS
IOP lowering effect Invasiveness/risk
iStent
Hydrus
Gonioto
my
GATT
Avenues of increased drainage: 1) TM/Schlemm’s Canal 2) Uveoscleral/Suprachoroidal Outflow3) Subconjunctival Bleb4) External
Cypass Xen
MIGS
Video courtesy of Dr. Leonard Seibold
MIGS
IOP lowering effect Invasiveness/risk
iStent
Hydrus
Gonioto
my
GATT
Avenues of increased drainage: 1) TM/Schlemm’s Canal2) Uveoscleral/Suprachoroidal Outflow 3) Subconjunctival Bleb4) External
Cypass Xen
Image courtesy of Review of Ophthalmology
MIGS
IOP lowering effect Invasiveness/risk
iStent
Hydrus
Gonioto
my
GATT
Avenues of increased drainage: 1) TM/Schlemm’s Canal2) Uveoscleral/Suprachoroidal Outflow3) Subconjunctival Bleb 4) External
Cypass Xen
Image courtesy of XEN glaucoma treatment system in the management of refractory glaucomas: a short review on trial data and potential role in clinical practice. Clinical Ophthalmology. De Gregorio A, Pedrotti E, Stevan G, Bertoncello A, Morselli S
MIGS
IOP lowering effect Invasiveness/risk
iStent
Hydrus
Gonioto
my
GATTCypass Xen
Avenues of increased drainage: 1) TM/Schlemm’s Canal2) Uveoscleral/Suprachoroidal Outflow3) Subconjunctival Bleb4) External
Surgical Options
• Lasers
• MIGS
• Tubes/Trabs
Tubes/Trabs
Image courtesy of Dr. Ian Murdoch. Community Eye Health Journal. Image courtesy of Dr. Steve Sarkisian. Review of Ophthalmology.
• PTVT (Tube vs Trabeculectomy Study - Ophthalmology 2018):
• “Trabeculectomy with MMC had a higher surgical success rate than tube shunt implantation after 1 year”
• “The frequency of serious complications producing vision loss or requiring reoperation was lower after tube shunt surgery relative to trabeculectomy with MMC.”
Tubes/Trabs
• ABC (Ahmed Baerveldt Comparison) and AVB (Ahmed versus Baerveldt) - Am J Ophthalmology 2017
• “Baerveldt group had a lower failure rate … and lower mean IOP on fewer medications than the Ahmed group.”
• “Baerveldt implantation carried a higher risk of hypotony.”
Tubes/Trabs
Video courtesy of Dr. Ike Ahmed
Tubes/Trabs
• Filtering blebs:
• Subconjunctival blister of aqueous fluid
• Eventually filter through conj, absorbed by adjacent vasculature or lymphatic vessels, or through aqueous veins
Image courtesy of Gardiner, Bruce & W Smith, David & Coote, Michael & Crowston, Jonathan. (2010). Computational Modeling of Fluid Flow and Intra-Ocular Pressure following Glaucoma Surgery. PloS one.
Image courtesy of International Glaucoma Association
Tubes/Trabs
• Filtering blebs complications:
• Hyperencapsulation
• Hypotony (IOP < 6.5):
• Overfiltration
• Bleb leakage
• Hyposecretion
• FlatImages courtesy of University of Iowa Health Care Ophthalmology and Visual Sciences
Tubes/Trabs
Tubes/Trabs
• Filtering blebs adverse events:
• Bleb leakageImages courtesy of University of Iowa Health Care Ophthalmology and Visual Sciences
Video courtesy of Dr. Christopher Teng
Tubes/Trabs
• Filtering blebs adverse events:
• Bleb leakage
• Blebitis Image courtesy of University of Iowa Health Care Ophthalmology and Visual Sciences
Endophthalmitis: State of the art - Scientific Figure on ResearchGate.
Tubes/Trabs
• Filtering blebs adverse events:
• Bleb leakage
• Blebitis
• Conjunctival erosion
Jutley, Gurjeet & Yang, Elizabeth & Bloom, Philip. (2018). Surgical management of raised IOP in the hostile ocular surface: recurrent tube erosion in a patient with systemic sclerosis.. BMC Ophthalmology.
A Netland, Peter & Chaku, Meenakshi & Ishida, Kyoko & Rhee, Douglas. (2016). Risk factors for tube exposure as a late complication of glaucoma drainage implant surgery. Clinical Ophthalmology.
Jutley, Gurjeet & Yang, Elizabeth & Bloom, Philip. (2018). Surgical management of raised IOP in the hostile ocular surface: recurrent tube erosion in a patient with systemic sclerosis.. BMC Ophthalmology.
A Netland, Peter & Chaku, Meenakshi & Ishida, Kyoko & Rhee, Douglas. (2016). Risk factors for tube exposure as a late complication of glaucoma drainage implant surgery. Clinical Ophthalmology.
QUESTIONS?