1

WHEN OUR GLAUCOMA

MEDS FAIL US:

WHAT’S NEXT?

CHRIS CAKANAC, OD, FAAO

• NO DISCLOSURES

GLAUCOMA TREATMENT

IN THE UNITED STATES

• MEDICAL THERAPY

• LASER THERAPY

• SURGICAL THERAPY

WHAT IS MAXIMAL

MEDICAL THERAPY?

• 2 BOTTLES?

• 3 BOTTLES?

• MORE?

HOW LOW DO YOU GO ?

THE LOWER THE BETTER!

2

TARGET IOP

• AGIS (ADVANCED GLAUCOMA

INTERVENTION STUDY)

• IOP < 18 MM = NO VF PROGRESSION

TARGET IOP

• OHTS (OCULAR HYPERTENSION

STUDY)

• PXS WITH IOP 24-32 MM

RANDOMIZED TO TX OR NO TX

• TX ( 20% IOP REDUCTION )

TARGET IOP

• OHTS (OCULAR HYPERTENSION

STUDY)

• TX ( 20% IOP↓) = 4.4% GO ON TO VF LOSS

• NO TX = 9.5% GO ON TO VF LOSS

HOW LOW DO YOU GO?

(PRACTICALLY)

• AGE DEPENDENT

• DISC DEPENDENT

• VISUAL FIELD DEPENDENT

TODAY’S TOPICS

• LASER

• SELECTIVE LASER TRABECULOPASTY

• MINIMALLY INVASIVE GLAUCOMA

PROCEDURES (MIGS)

• SURGERY

• TRABECULECTOMY

• TUBE SHUNTS

LASER THERAPY

• ARGON LASER TRABECULOPLASTY

(ALT)

• SELECTIVE LASER

TRABECULOPLASTY (SLT)

3

ALT

• HIGH ENERGY,

SMALL SPOT

• AIM ABOVE TBM

• TREAT 180

• THE OTHER 180 IF

NECESSARY

• CAN NOT

RETREAT

ALT

HOW DOES IT WORK?

• DESTROYS TBM

• STRETCHES TBM

• STIMULATES

MACROPHAGES

ALT

• USUALLY REDUCES IOP BY 20%

• 5 YR WINDOW

• CAN NOT BE REPEATED

SELECTIVE LASER

TRABECULPLASTY

• LARGE SPOT, LOW

ENERGY

• AIM AT TBM

• TREAT 180 OR

360

• REPEATABLE!

SLT

4

HOW DOES IT WORK?

• STIMULATES

MACROPHAGES

• NO TISSUE

DAMAGE

SLT - ADVANTAGES

• USUALLY 20% REDUCTION IN

IOP

• REPEATABLE WHEN EFFECT

WEARS OFF

• PRIMARY THERAPY?

• REDUCES COMPLIANCE ISSUES

SLT - DISADVANTAGES

• IS 20% ENOUGH?

• WORKS IN 80% OF PATIENTS

• WEARS OFF 2-5 YEARS

COMANAGEMENT OF SLT

• TOPICAL ANESTHESIA

• IOPIDINE PREOP

• EXPECT IOP SPIKE DAY1

• EXPECT AC INFLAMMATION WEEK 1

• ADJUST MEDS?

Selective Laser Trabeculoplasty:

NSAIDs vs Steroids in Post-Operative Management

Jennifer Calafati MD, Donna Williams-

Lyn PhD,

Iqbal Ike K. Ahmed MD, FRCSCAuthors have no financial interest

Results

IOP Control

0

5

10

15

20

25

30

Pre-Op 1 hr 0.25 mo 1 mo 3 mo 6 mo 12 mo

Time

IOP

(m

mH

g)

NSAID (V)

Steroid (PF)

5

ResultsGTTS (Between Groups)

Steroid NSAID p value

Preop gtts 0.89 0.80 0.776

6 mo gtts 0.88 0.68 0.460

1 yr gtts 0.78 0.74 0.967

Pain (Between Groups)

Steroid NSAID p value

Preop gtts 0 0 1

6 mo gtts 0 0 1

1 yr gtts 0 0 1 *Pain grading: Patient reported; 0=none, 10=most severe ever felt

Conclusion

•Both steroids and NSAIDs can be considered equally successful treatment options for IOP control following selective laser trabeculoplasty.

• Both steroids and NSAIDs can be considered equally successful treatment options for the management of inflammation following selective laser trabeculoplasty.

• Patient comfort (as reflected by patient-reported pain scores) is satisfactory with both therapies.

TODAY’S TOPICS

• LASER

• SELECTIVE LASER TRABECULOPASTY

• MINIMALLY INVASIVE GLAUCOMA

PROCEDURES

• SURGERY

• TRABECULECTOMY

• TUBE SHUNTS

MIGS

• DONE THROUGH CLEAR

CORNEAL INCISION

• PRESERVES CONJUNCTIVA

• MINIMAL COMPLICATIONS

• FOR MODERATE GLAUCOMA

• LOWER IOP TO MID-TEENS

MIGS – MINIMALLY

INVASIVE GLAUCOMA

PROCEDURES

• ISTENT

• TRABECTOME

• ENDOCYCLOPHOTOCOAGULATION

ISTENT (GLAUKOS)

• TITANIUM STENT

• IMPLANTED IN SCHLEMS CANAL

6

INITIAL APPROVAL 2012

• INDICATED FOR USE IN

CONJUNCTION WITH

CATARACT SURGERY FOR MILD

TO MODERATE GLAUCOMA

CURRENTLY TREATED WITH

MEDICATION

ISTENT RESULTS

• IOP REDUCED BY 16 – 30%

• 1.2 MEAN REDUCTION IN MEDS

7

RESULTS

(SAMUELSON ET AL)

• 72% OF IMPLANTED EYES HAD

IOP<21MM (VS 50% FOR NO

IMPLANT)

ADVANTAGES

• DONE DURING CATARACT

SURGERY

• LEAST INVASIVE

• MINIMAL TRAUMA

• REVERSIBLE

DISADVANTAGES

• LEAST IOP LOWERING OF MIGS

• RESTRICTIVE INDICATION AND

REIMBURSEMENT

• MAY REQUIRE MORE MULTIPLE

STENTS

DISADVANTAGES

• LEAST IOP LOWERING OF MIGS

• RESTRICTIVE INDICATION AND

REIMBURSEMENT

• MAY REQUIRE MORE MULTIPLE

STENTS

8

RESTRICTIVE

• NOT A STAND ALONE PROCEDURE

• MULTIPLE STENTS NOT APPROVED

• PART OF THE FACILITY FEE

DISADVANTAGES

• LEAST IOP LOWERING OF MIGS

• RESTRICTIVE INDICATION AND

REIMBURSEMENT

• MAY REQUIRE MULTIPLE

STENTS

TWO OR THREE STENTS

(BELOVAY ET AL)

• 70% IMPLANTED EYES HAD IOP

OF 15 MM OR LESS

• 2.4 REDUCTION IN NUMBER OF

MEDS

COMPLICATIONS

• TOUCHING ADJACENT TISSUES

• IRIS – 7%

• ENDOTHELIUM – 1%

FAILURE TO IMPLANT – 2%

STENT MALPOSTION – 1%

ISTENT

COMANAGEMENT

• SAME PROTOCOL AS CATARACT

SURGERY

• GONIO IF NEEDED

MIGS – MINIMALLY

INVASIVE GLAUCOMA

PROCEDURES

• ISTENT

• TRABECTOME

• ENDOCYCLOPHOTOCOAGULATION

9

TRABECTOME (NEOMEDIX)

• ELECTRO CAUTERY PROBE

• VAPORIZES TBM, SCHLEMM’S INNER WALL

• 60-120 DEGREES TREATED NASALLY

INDICATIONS

• INITIAL- OPEN ANGLE GLAUCOMA

WITH UNCONTROLLED IOP

• NEWER

• PSEUDOEXFOLIATION

• PIGMENT DISPERSION

• UVEITIC

• NEOVASCULAR

• INFANTILE

10

ADVANTAGES DISADVANTAGES

• REQUIRES CLEAR ANGLE VIEW

• DESTRUCTIVE

• IOP IN MID TEENS

COMPLICATIONS

• 1 DAY POST OP INCREASE

• EARLY HYPHEMA

• LATE HYPHEMA

POST PROCEDURE CARE

ENDOCYCLOPHOTCOAGULATION

(ENDO OPTIKS)

ENDOLASER

CYCLOPHOTOCOAGULATION

(ECP)

• 810 NM DIODE LASER

• TREAT TIPS OF CILIARY PROCESSES

• DECREASES AQUEOUS PRODUCTION

• USEFUL FOR ALL TYPES OF GLAUCOMA

11

ECP: HOW ITS DONE ECP – HOW ITS DONE

OLDER TYPES OF

CYCLODESTRUCTION

• CYCLOCRYODESTRUCTION

• TRANS-SCLERAL

CYCLOPHOTOABLATION

• 24% RISK OF COMPLICATIONS

ECP – ADVANTAGES

• USES ENDOSCOPY TO

DIRECTLY VIEW CILIARY TIPS

• MORE CONTROL

• LESS COMPLICATIONS

12

ECP VS OTHER PROCEDURES ECP RESULTS

• DECREASE IOP 18 - 34%

• MINIMAL RISK OF HYPOTONY

• 6% RISK OF VA LOSS OF > 2

LINES (CME)

ECP ADVANTAGES

• COMMONLY DONE WITH

CATARACT SURGERY

• CAN ELIMINATE OR REDUCE

MEDS

• ONLY MIG TO DECREASE

AQUEOUS PRODUCTION

ECP DISADVANTAGES

• CAUSES INFLAMMATION

• DESTRUCTIVE

• HOW LONG DOES IT LAST?

COMANAGEMENT OF ECP

• DAY 1 • MORE INFLAMMATION

• HIGHER IOP

• STEROID IS Q2H

• MAINTAIN GLAUCOMA MEDS

• WEEK 1• MINIMAL INFLAMMATION

• IOP TAKES 1-4 WEEKS TO REDUCE

• TAPER STEROID

• 1 MONTH• RE-EVALUATE NEED FOR GLAUCOMA MEDS

TODAY’S TOPICS

• LASER

• SELECTIVE LASER TRABECULOPASTY

• MINIMALLY INVASIVE GLAUCOMA

PROCEDURES

• SURGERY

• TRABECULECTOMY

• TUBE SHUNTS

13

SURGICAL THERAPY

TRABECULECTOMY

DRAINAGE DEVICES

TRABECULECTOMY

• ALLOWS AQUEOUS TO BYPASS TBM

• FLOWS INTO SUBCONJ SPACE

• ABSORBED BY EPIVENOUS SYSTEM

“Establishment of trans-scleral

aqueous outflow sufficient to

maintain a steady state pressure

gradient of just the right amount

represents a highly abnormal

state and can only be achieved

by causing a partial failure of the

normal wound healing process” –

Healey and Troupe

TBC INDICATIONS

• LOSS OF FUNCTION DESPITE

MAXIMAL MEDICAL THERAPY

• TARGET PRESSURE NOT

ACHEIVED

HOW LOW DO YOU GO ?

6-12 MM

ADVANTAGES OF TBC

• MORE EFFICIENT AT LOWERING

IOP THAN:• MEDICAL THERAPY

• LASER

• MIGS

• LESS RELIANCE ON PATIENT

COMPLIANCE

14

DISADVANTAGES OF TBC

• COMPLICATIONS!!!

• “IN TRABECULECTOMY, LIKE

NO OTHER OCULAR SURGERY,

THE BATTLE IS WON OR LOST

AFTER THE SURGERY IS DONE”

– A. IWACH

CIGTS

• (COLLABORATIVE INITIAL

GLAUCOMA TREATMENT STUDY)

• RANDOMIZED PTS TO MEDICAL

OR SURGICAL MGMT

CIGTS

• SURGICAL

• LOWER AVG IOP

• SAME VF

PROGRESSION

• MEDICAL

• LESS LIKELY TO

HAVE MAJOR

VISION LOSS

EVENT

• BETTER

QUALITY OF

LIFE SCORE

THE PROCEDURE

NEXT… FINALLY…

15

ANTIMETABOLITES

• DECREASE WOUND HEALING

RESPONSE

• IMPROVE BLEB SURVIVAL

RATES

• INCREASE COMPLICATIONS

ANTIMETABOLITES

• 5 FLUOROURACIL

• TEMPORARILY

INHIBITS DNA

REPLICATION

• REVERSIBLE

• USES

• DURING SURGERY

• POSTOP INJECTION

• MITOMYCIN-C

• PERMANENTLY

BINDS DNA

• 100X MORE POTENT

• NONREVERSIBLE

• USES

• DURING SURGERY

POST OP MEDS

• TOPICAL ANTIBIOTIC

• PRED FORTE QIH WHILE AWAKE

• ATROPINE QID

RESTRICTIONS

• NO PHYSICAL ACTIVITY

• NO BENDING OR LIFTING

• NO READING

• SHIELD DURING SLEEP

1 DAY POST OP

• IOP – USUALLY LOW

• ANTERIOR CHAMBER - FORMED

• BLEB STATUS – DIFFUSE AND

AVASCULAR

• FUNDUS - NORMAL

16

1 WEEK POST OP

• IOP – INCREASING

• ANTERIOR CHAMBER

• FUNDUS

• BLEB STATUS

BLEB STATUS –

GOOD SIGNS

• DIFFUSE

• LARGE AREA

• THIN WALL

• RELATIVELY

AVASCULAR

• POLYCYSTIC

BLEB STATUS –

GOOD SIGNS

BLEB STATUS –

BAD SIGNS

• SMALL AREA

• THICK WALL

• VASCULARIZED

• CORKSCREW

VESSELS

BLEB STATUS BLEB STATUS

17

COMPLICATIONS

• IOP

• ANTERIOR CHAMBER

COMPLICATIONS

• HIGH IOP – FORMED AC

• HIGH IOP – SHALLOW AC

• LOW IOP – FORMED AC

• LOW IOP – SHALLOW AC

COMPLICATIONS

• HIGH IOP – FORMED AC• BLEB PROBLEM

• HIGH IOP – SHALLOW AC• IRIS PROBLEM

• LOW IOP – FORMED AC• OVERFILTRATION

• LOW IOP – SHALLOW AC• LEAK

HIGH IOP – FORMED ACBLEB PROBLEM

• SCLEROSTOMY BLOCKED• DO GONIO

• SCLERAL FLAP TOO TIGHT• OCULAR MASSAGE

• RELEASE SUTURES

MASSAGE

• DAY 1 – 6 MO

• FOCAL STEADY

PRESSURE

• 10 SECONDS/QID

• CHECK IOP BEFORE

AND AFTER

• THEORETICAL

WORSENING?• IOP > 100 MM

• ↓ BLOODFLOW TO ONH

HIGH IOP – FORMED AC

• SCLEROSTOMY BLOCKED• DO GONIO

• SCLERAL FLAP TOO TIGHT• OCULAR MASSAGE

• RELEASE SUTURES

18

RELEASE SUTURES

ADJUSTABLE SUTURES

RELEASE SUTURES

ARGON LASER SUTURE LYSIS

• DONE DAY 3 TO

WEEK 3

• START CLOSEST

TO LIMBUS

• CUT ONE

SUTURE AT A

TIME

• DO OCULAR

MASSAGE

• MEASURE IOP

HIGH IOP – SHALLOW ACIRIS PROBLEM

• SHALLOW AC

• NARROWING OF

THE ANGLE

• PERIPHERAL

IRIS CORNEA

TOUCH

• FLAT CHAMBER

• LENTICULAR

CORNEAL

TOUCH

HIGH IOP – SHALLOW AC

• PUPILLARY BLOCK

• LESS COMMON

• SUPRACHOROIDAL HEM

• AQUEOUS MISDIRECTION

PUPILLARY BLOCK• CYCLOPLEGICS

• RELAXES IRIS

DIAPHRAM

• PREVENTS

FORWARD

MOVEMENT

• DISCOURAGES

AC SHALLOWING

• SUPRESS

AQUEOUS PROD.

COMPLICATIONS

• HIGH IOP – FORMED AC

• HIGH IOP – SHALLOW AC

• LOW IOP – FORMED AC

• LOW IOP – SHALLOW AC

19

LOW IOP – FORMED ACOVERFILTRATION

• IOP < 5MM

• OVERFILTRATION• TOO MUCH 5FU OR MMC

• TOO LARGE SCLEROSTOMY

CAN IOP BE TOO LOW?

• HYPOTONY = IOP < 5 MM

• FLUCTUATING VISION, ESPECIALLY

WITH BLINK

• CHOROIDAL EFFUSIONS

• HYPOTONY MACULOPATHY

CHOROIDAL EFFUSIONS

• FLUID COLLECTS

IN

SUPRACHOROIDAL

SPACE

• D/C STEROIDS,

GLAUCOMA MEDS

• DRAIN IF

“KISSING”

HYPOTONY

MACULOPATHY

• LINES RADIATING

FROM FOVEA

• ENGORGED

VESSELS

• NO FA LEAKAGE

• MISALIGNED

PHOTORECEPTORS

OVERFILTRATION

TREATMENT

• D/C STEROIDS AND GLAUCOMA

MEDS

• ADD FLAP SUTURES

• AUTOLOGOUS BLOOD?

COMPLICATIONS

• HIGH IOP – FORMED AC

• HIGH IOP – SHALLOW AC

• LOW IOP – FORMED AC

• LOW IOP – SHALLOW AC

• LEAK

20

BLEB LEAK

• TEARY EYE,

FLUCTUATING

VA

• FLAT BLEB

• POSITIVE

SEIDEL SIGN

BLEB LEAK TREATMENT

• D/C STEROIDS

• GIVE AQUEOUS SUPPRESSANTS

• BANDAGE CL

• GLUE

• AUTOLOGOUS BLOOD?

• SURGICAL PATCH

COMPLICATIONS

• HIGH IOP – FORMED AC• BLEB PROBLEM

• HIGH IOP – SHALLOW AC• IRIS PROBLEM

• LOW IOP – FORMED AC• OVERFILTRATION

• LOW IOP – SHALLOW AC• LEAK

POST OP INFECTIONS

• BLEBITIS

• ENDOPHTHALMITIS

BLEBITIS

• PAIN,

DISCHARGE

• INJECTION

• “WHITE ON

RED”

• INFILTRATE

• CELLS IN AC

• NO VIT CELLS

BLEBITIS RISK FACTORS

• BLEPHARITIS

• DRY EYE

• CL WEAR

• BLEB LEAK

• INCIDENCE 5% PER YR

21

BLEBITIS BUGS

• EARLY POST OP PERIOD

• STAPH EPIDERMIDIS

• LATER

• STREPTOCOCCUS

BLEBITIS TREATMENT

• FLUOROQUINILONE QIH

• POLYTRIM QIH

• ORAL FLUOROQUINOLONE

BLEB RELATED

ENDOPHTHALMITIS

• BLEBITIS

• HYPOPYON

• VIT CELLS

ENDOP TREATMENT

• VITREOUS TAP

• INTRAVITREAL ANTIBIOTICS

• FORTIFIED ANTBIOTICS

• VANCOMYCIN 50 MG/ML QIH

• CEFTAZ 50 MG/ ML QIH

• ORAL FLUOROQUINOLONE

GLAUCOMA DRAINAGE

DEVICES

GLAUCOMA DRAINAGE

DEVICES (GDD)

• AQUEOUS SHUNT

• TUBE

• TUBE SHUNT

• SETON

22

GDD TYPES OF GDD’S

• NONVALVE

• BAERVELDT

• MOLTENO

• VALVE

• AHMED

• KRUPEN

INDICATIONS FOR

GDD’S

• WHEN TBC HAS FAILED

• TWO SITES

• WHEN TBC IS LIKELY TO FAIL

• NEOVASCULAR GLAUCOMA

• CHRONIC UVEITIS OR INFLAMM

ADVANTAGES OF GDD’S

• LESS INVASIVE

• NO WOUND HEALING EFFECTS

• LESS EARLY HYPOTONY

• LESS LONG TERM SIDE EFFECTS

DISADVANTAGES OF

GDD’S

• IOP MAY NOT BE LOW ENOUGH

TUBE VS TRABECULECTOMY

STUDY

23

RESULTS

(IOP> 21 MM WITH NO MEDS)

• FAILURES AT 3 YRS

• TUBE – 15%

• TRAB – 30%

• FAILURES AT 5 YRS

• TUBE – 30%

• TRAB – 47%

POST OP CARE –

1 DAY

• EXPECT LOW IOP

• TOPICAL ANTIBIOTIC

• PRED ACETATE 1% QID

• NO CYCLOPLEGICS NEEDED

1 WEEK

• IOP SHOULD BE

HIGHER

• REMOVE SUTURE

(IF PREVIOUSLY

PLACED)

1 MONTH

• IOP SHOULD BE EQUALIZING

• D/C POST OP MEDS

COMPLICATIONS

• DIPLOPIA

• BLOCKED TUBE

• TUBE MIGRATION

• ENDOTHELIAL DECOMPENSATION

• TUBE EROSION

24

DIPLOPIA

• VERTICAL DEVIATION

• SCARRING AROUND

EXTRAOCULAR MUSCLES

• CORRECT WITH PRISM

• MOVE GDD

BLOCKED TUBE

• YAG LASER

• ARGON LASER

• TPA INJECTION

• REVISION

TUBE MIGRATIONENDOTHELIAL

DECOMPENSATION

TUBE EROSION