Cornea, Lens & Glaucoma Management - Final

8/6/2019 Cornea, Lens & Glaucoma Management - Final

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Manolito R. Reyes, MD, DPBOGlaucoma Consultant

Far Eastern University Medical Center


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Practical tips on deciding whether to do trabeculectomy

alone or combined surgery

1). Glaucoma well controlled Visually significantcataract on multiple topical glaucoma meds

combined cataract+ filter

2). Glaucoma well controlled Visually significantcataract just one glaucoma medication (except

Prostaglandin) cataract surgery alone


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Practical tips on deciding whether to do trabeculectomy

alone or combined surgery

3). Glaucoma well controlled Visually significantcataract good filter surgery cataract surgery

alone (clear cornea temporal approach)


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Practical tips on deciding whether to do

trabeculectomy alone or combined surgery

5). Glaucoma not well contolled on maximum medicaltherapy or intolerant to glaucoma meds or financially not

capable to comply with glaucoma meds not visually

significant cataract filter alone


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Advantages of combined procedure

A). Risk of early post-operative rise in IOP is reduced (14%

of eyes had 10 mmHg IOP rise in combined procedure,70% had IOP rise in cataract alone )

B). Long term control of glaucoma is also improved with

most patients requiring the same or less medicationsthan preoperatively


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Disadvantages of combined procedure

A). Higher incidence of suprachoroidal hemorrhage

B). Higher incidence of aqueous leakage which can lead to

hypotony, flat anterior chamber and endophthalmitis


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` L.M

` 58/F

` Dx: Chronic closed angle glaucoma, OU; Cataract

presenile, OU` BCVA: OD: 20/40 OS: 20/100


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` Borderline controlled Glaucoma on Multiple drug

therapy

` Significant cataract

` Visual field progression

` PLAN: ???


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` For Combined Procedure Phaco -Trab with

Mitomycin C


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VA: 20/50

IOP: 12 mmHg

No antiglaucoma

meds


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` A.F.

` 74 / F

` BCVA: OD: 20/100 OS: 20/200

` IOP: OD: 24 mmHg OS: 25 mmHg

` Dx: Chronic Open Angle Glaucoma, OU


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` Uncontrolled Glaucoma on Multiple Drug Therapy

` Significant Lens Opacity

` Plan: For Combined Procedure, OS


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VA: 20/100 20/50

IOP: 14 mmHg

No Antiglaucoma

meds


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Post-penetrating Keratoplasty Glaucoma (PKPG)

Glaucoma is one of the most serious complication

following PKP.After corneal graft rejection, glaucoma isthe second most common reason for corneal graft failure

(7-30%)


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Mechanism of IOP elevation after PKP

1.Trabecular meshwork collapse

2.Angle closure glaucoma with PAS formationa) Pupillary block

b) Chronic Uveitis

c) Choroidal detachment with ciliary body rotation

d) Aqueous diversion syndrome


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Mechanism of IOP elevation after PKP

3. Steroid induced glaucoma

4. Worsening of pre-existing glaucoma


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Glaucoma meds

1. Beta blocker

2.Alpha adrenergic

Potential Problems in

Patients w/ PKPG

SPK, corneal anesthesiaDry eyes, Subconjunctival

Fibrosis

SPK, allergic reactions


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Glaucoma meds

3. Miotics

4. CAIs

Potential problems in

patients w/ PKPG

Inflammation, graft rejection,R.D., Subconj fibrosis

Induced permanent graft

failure in eyes w/borderline endothelial

counts


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Glaucoma meds

5. PGs

Potential problems in

patients w/ PKPG

Uveitis, CME in aphakia &Pseudophakia, recurrent

herpes simplex keratitis


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Surgical treatment for PKPG

1.Trabeculectomy w/ mitomycin

- success rate is 69-90% (ave 80%)- graft failure rate 12-18% (ave 15%)

2. Glaucoma drainage device

- success rate is 71-96% (ave 84%)- graft failure rate is ave 36%


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Surgical treatment for PKPG

3. Cyclodestructive procedure

- success rate 30-50%- graft failure rate 11-65%


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Complications of cyclodestructive procedure1. Decrease V/A

2. Peristent hypotomy

3.Anterior uveitis

4. Persistent epithelial defect

5. Vision loss

6. Severe intractable pain

7. Phthisis Bulbi

8. Hypopyon

9. Sympathetic ophthalmia

10. Scleral thinning

11.Vitreous hemorrhages


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Practical tips in decision making whether to do glaucoma

surgery or combined PKP+glaucoma surgery

1). Patients with uncontrolled or borderline IOP on twoor more medications glaucoma surgery first or

combined glaucoma+PKP

2) Patients not responding to medications should be treatedsurgically


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3. Trabeculectomy w/ mitomycin C is the safest operationin terms of both IOP control and graft survival

4. GDD is the preferred operation over trabeculectomy in

patients w/ PKPG who have extensive limbal conjuctivalscarring, shallowAC, extensive PAS & failed trabec


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5. Cyclodestructive measure should be reserved for patientswhich have failed all other intervention

Cornea, Lens & Glaucoma Management - Final

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