Download full prp improves the outcome of trabeculectomy in nvg

FULL PANRETINAL PHOTOCOAGULATION
IMPROVES
THE
OUTCOME
OF
TRABECULECTOMY IN NEOVASCULAR
GLAUCOMA
Saleh alobeidan MD
Essam osman FRCS
Saleh alamro FRCS
Ahmed Abuelasrar MD PhD
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
Neovascular Glaucoma is one of the most
Challenging forms of secondary glaucomas. It
occurs when the fibrovascular tissue proliferates
onto the chamber angle, obstructs the trabecular
meshwork, and produces peripheral anterior
synechiae and progressive angle closure. The
elevated intraocular pressure is often difficult to
control and frequently results in loss of vision.
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TUBE SURGERY IN NVG
“ 60 eyes long term results ”
_______________________________________
Success rate
:
62.1% at 1 year
10.5% at 5 years
Complications
:
48 % lost light perception
18% phthysis bulbi
Mermoud A. et al
Ophthalmology, June 1993
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5 FU FILTERING SURGERY IN NVG
“ 34 eyes long term results ”
_______________________________________
Success rate
:
71% at 1 year
28% at 5 years
Complications
:
35 % lost light perception
24% phthysis bulbi
Tsai J.C. et al
Ophthalmology, June 1995
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
“If the neovascular element can be
removed and further neovascularisation
prevented, then we are left with an
uncomplicated angle-closure problem
which should be amenable to classical
drainage surgery.”
Flanagan D.W. & Blach R.K.
Br J. Ophtamol 1983;67,526-8
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
• Steps of management
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Admission.
Topical steroids.
Atropine drops.
Antiglaucoma RX.
Full PRP.
MMC Trab.
Close follow up.
Prolonged tapering of steriods.
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
PATIENT DEMOGRAPHICS
(23 eyes, 21 patients)
Patients and methods
Gender:
M
15
F
8
Age: (yrs.) Mean 53.1+ 10.4 Range 32-72
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Etiology of NVG :
DR 19
Lens Status:
Phakic 20 Pseudophakic 3
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CRVO 4
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
PATIENT DEMOGRAPHICS
(23 eyes; 21 patients)
Patients and methods
Initial IOP mmHg: Mean 53.1+10.7 Range 20-55 mmHg
Gonioscopy: Open - 4 Closed - 14 NA - 5
Initial V/A:
Range HM - 20/40
PRP:
No. of shots mean 1293.7+337.7
Rubeosis at surgery:
3 Cases
No. of medications: Mean 3.0+0.3 Range 2-4
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
Surgical Technique
__________________________________________
Procedure
- Standard Trabeculectomy
- Mitomycin “C” 0.2mg/ml/2mins.
Precautions - Gradual decompression
of the eye
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VIDEO
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
_______________________________________
 Short Term Complications:
 Transient hypotony - 14/23
(61%)
 Hyphema - 8/23
(35%)
 Choroidal Detachment - 2/23
(9%)
 Leaking Bleb - 1/23
(4%)
 Long Term Complications:
 Cataract prog. – 2/23
(9%)
 NLP
 Hypotony Maculopathy
Non
 Phthisis Bulbi
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CRITERIA FOR SUCCESS
_______________________________________
 Complete success
 IOP < 22 mmHg without medications
 Qualified success
 IOP < 22 mmHg with medications
 Complete failure
 Eyes required further surgery to control IOP
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
Results
F/U: 24.3+25.1 (3-94 mos.)
Preop IOP: 53+10.7
Final IOP: 14.0+4.9 (6-22 mmHg)
(P<0.001; Wilcoxon Test)
Final V/A: HM – 20/40
9/23 measurable improvement
5/23 no change
9/23 VA
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
Results
No. of Preop med : 3.0+3
(2-4)
No. of Postop med : 0.2+0.5
(0-2)
(P<0.001; Wilcoxon Test)
Bleb: Present in all cases at the last follow-up.
continuation
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
SUCCESS RATE
_______________________________________
Complete Success
20/23
(87%)
Qualified Success
3/23
(13%)
continuation
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PRP FOLLOWED BY TRABECULECTOMY
IN NVG
__________________________________________
Table 1.1
Previous Studies
Current Study
(16 eyes)
(23 eyes)
Age
Mean
Range
56.44+7.8
19-80
53.1+10.4 years
32.72
Etiology
DR
CRVO
7 (43.7%)
9 (56.2%)
19 (82.61%)
4 (17.39%)
Presenting IOP
Mean
Range
48.8+10.4
32-68
53.1+10.7
20-55
Allen et al. Ophthalmology 1982;89:1181-7
D.W. Flanagan & R.K. Blach. Br JO 1983;67:526-8
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PRP FOLLOWED BY TRABECULECTOMY
IN NVG
__________________________________________
Table 1.2
Previous Studies
Current Study
(16 eyes)
(23 eyes)
Final IOP
Mean
Range
20.3+8.5
11-42
14.0+4.9
6-22
F/U (months)
Mean
Range
12.00+7.1
1-33
24.3+25.1
3-94
Success
Complete
Qualified
Failure
8(50%)
5(31.2%)
3(18.7%)
20 (86.96%)
3 (13.04%)
Allen et al. Ophthalmology 1982;89:1181-7
D.W. Flanagan & R.K. Blach. Br JO 1983;67:526-8
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• FULL PRP IMPROVES THE OUTCOME
OF TRABECULECTOMY IN NVG
• “If the neovascular element can be
removed and further neovascularisation
prevented, then we are left with an
uncomplicated angle-closure problem
which should be amenable to classical
drainage surgery.”
Flanagan D.W. & Blach R.K.
Br J. Ophtamol 1983;67,526-8
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FULL PRP IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NVG
• It is our impression that patients whose retinal
disease is well treated before filteration surgery
do much better surgically than those who are
not.
• It is also our impression that mitomycin C
produces better results, at least for the first year,
than does 5 FU. After only another 10 years will
we know if these additional medications will
further enhance the long term results of
filteration surgery in eyes with NVG.
Rich.R Ophthalmology 1995
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CONCLUSION
5
Neovascular glaucoma is
a treatable condition
•Full PRP improves the outcome of
trabeculectomy with MMC.
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