Secondary Glaucoma & Surgical Complex Anterior Segment€¦ · Angle recession glaucoma Image Courtesy of EyeWiki Image Courtesy of Retina Image Bank. Angle recession glaucoma Image

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




• 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


• Lost to follow up and has not taken glaucoma medication for over one year


• 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



Atlas of Ophthalmology Online Database





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 ! ! !


Image courtesy of Rendia

Image courtesy of Rendia💥


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


• 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)

https://www.youtube.com/watch?v=Z1Wc2kQ8L6s

Pseudoexfoliation

https://www.youtube.com/watch?v=Z1Wc2kQ8L6s (dackakorot)

https://www.youtube.com/watch?v=Z1Wc2kQ8L6s

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


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!








• 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




• Seen in ischemic disease

• If adequate visual potential, tube surgery is indicated - regardless refer for PRP

Neovascular glaucoma


• 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.


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


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







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):

http://www.megadget.com

MIGS

MIGS

IOP lowering effect Invasiveness/risk

iStent

Hydrus

Gonioto

my

GATTCypass Xen

MIGS


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


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


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


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


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


• 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


• 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?

Documents

Secondary Glaucoma & Surgical Complex Anterior Segment€¦ · Angle recession glaucoma Image Courtesy of EyeWiki Image Courtesy of Retina Image Bank. Angle recession glaucoma Image