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Laser Peripheral Iridoplasty

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on 30 September 2013

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Transcript of Laser Peripheral Iridoplasty

Emerging Treatments in Acute Angle Closure Glaucoma:
Anterior Chamber Paracentesis &
Laser Peripheral Iridioplasty
9/4/13
9/5/13
Wednesday
.
Thursday

began Monday (9/2/13) evening, "grandbaby hit my eye with his hand"

"Pain in my Eye"

painful, tender globe OS
ciliary flush above left limbus
no visible abrasion


Exam

OD: 20/20
OS: 20/60 --



Visual Acuity

more congested eye, "steamy" cornea



Exam:

IOP
ㅇㄴㄹㄴㅇㄹㄴ
Monday

OD: 20/20 -
OS: 20/
150



Visual Acuity
Shagun Dhaliwal, MS IV
Texas A&M Health Science Center College of Medicine
.
Management
"mildly" cyclopleged with cyclopentolate
administered in clinic:
Durezol (difluprednate)
Ilevro (Nepafenac )
prescribed:
Durezol QHS
return to clinic tomorrow AM
OD: 17.4
OS:
48



Management
administered in clinic:
Symbrinza x3 OS
Combigan x2 OS
Azopt x2 OS
Durezol x2 OS
Acetozolamide x2 (750mg, 500mg)

IOP: OS: 48 --> 41.8 to 43
emergent referal to Dr. Ayyala
9/5/13
Thursday
IOP
OD: 20/20
OS: 20/
200
Visual Acuity
OS:
60
Management
medically resistant attack
Paracentesis of Anterior Chamber

prescribed
Pilocarpine QID OS
Predforte QID OS
Symbrinza QID OS
Combigan QID OS
Vigamox QID OS
Diamox 500mg PO BID
Past Medical History
Glaucoma
Hypertension
Diabetes
Breast Cancer
Past Surgical History
Cholecystectomy
Hysterectomy
Breast Biopsy
Family History
Social History
Glaucoma
- Sister
1/2 pack per day smoker
no alcohol
Allergies
NKDA
Diagnosis:
Acute Angle Closure Glaucoma
Increasing Eye Pain
Argon Laser Peripheral Iridoplasty
Indications
Acute angle closure, medically resistant
Plateau Iris Syndrome
Angle closure due to size or position of lens

1977 - Krasnov - penetrating laser burns at iris root, only 90 degrees
insufficient retraction

1979 - Kimbrough – 360 degrees through gonioscopy

contraction burns along iris periphery, contracts iris stroma, pulling iris stroma away from trabecular meshwork and opening angle

opens appositonally closed angle
Background
ALPI contracts the peripheral iris stroma, creating a space between the anterior iris surface and the trabecular meshwork, and thereby opening the angle
Accepted:
Medically Resistant Acute Angle Closure
accepted indication for application of laser peripheral iridoplasty

small prospective study of 10 eyes with 2–5d attacks
mean prelaser IOP - 54.9
2–4 hours
postlaser - 18.9
effective in prescence of extensive PAS
Acute Angle Closure Crisis

Medical Therapy
View Clear
Paracentesis, Iridoplasty, Compression, Topical Glycerin
Prompt Laser Iridotomy
Definitive Managment
Laser Peripheral Iridoplasty, Paracentesis
Incisional Iridectomy, Cataract Surgery +/- Goniosynechialysis or Trabeculectomy
Prompt Iridotomy in fellow eye, if chamber anatomically similar
Algorithm for Management
NO
YES
PATENT
NO
NO
Plateau Iris Syndrome
large or anteriorly positioned ciliary body pushes iris root into proximity with the trabecular meshwork

gonioscopy, the iris root angulates forward and then centrally

angle remains appositionally closed or
occludable following laser iridotomy
Plateau Iris Syndrome
6 yr follow up of 23 eyes
20 - remained open
3 - re-closure years later
maintained open after repeat treatment x1

shorter duration
of angle closure associated with a higher success rate

propose: ALPI and PI in one sitting

Phacomorphic Glaucoma
enlarged lens or pressure posterior to the lens
malignant glaucoma, aqueous misdirection, ciliary block

angle remains appositionally
closed following laser iridotomy

eye is severely inflamed, usually having been referred after being treated unsuccessfully for a few days

ALPI (days - 1 wk) resolves inflammation permitting c
ataract extraction under conditions closer to ideal
Phacomorphic Glaucoma
IOP lowering drug treatments may fail to reduce IOP in up to
37.5%

ALPI effective as an initial treatment

small prospective study of 10 patients recieveing ALPI as initial treatment

mean IOP reduction: 56.1 ± 12.5 to...
37.6 ± 7.5 at 30 min
25.5 ± 8.7 at 120 min
13.6 ± 4.2 at 1 d
re-established corneal clarity at
1 d
uncomplicated cataract extraction at 2 d

Acute Angle Closure Glaucoma, First Line
conventional treatment algorithm recommends IOP lowering medications

multiple limitations
fails to reduce IOP
hours or days to reduce IOP
systemic side effects - of issue in patients with multiple comorbities

proposed alternative: laser peripheral iridoplasty as first line treatment
rapid reduction of IOP
more effective IOP reduction
Acute Angle Closure Glaucoma, First Line
ALPI vs systemic IOP meds
73 eyes with IOP > 40 
33 - timolol + pilocarpine + immediate ALPI
40 - aceteazolamide x4d + oral K +/- mannitol

*matched for controls age, duration of attack, IOP at presentation

ALPI IOP significantly lower at 15 min, 30min, 1 hr
ALPI IOP significantly lower at 15 min, 30min, 1 hr
9/9/13
IOP
OD: 20/20-
OS: 20/50--



Visual Acuity
OD: 11
OS:
9
ALPI OS
Tuesday
9/10/13
OD: 12
OS: 11
IOP
ALPI OD, Pre-Op

Management
acute attack controlled with IOP lowering medications,
Anterior Chamber Paracentesis
and
Argon Laser Peripheral Iridoplasty

Cataract Extraction to follow as definitive treatment, OS then OD
Expanded:
Acute angle closure, first line
*per AAO guidelines
Summation
simple and effective procedures

established roles as a second-line management strategy

value as first-line management in acute attack
*referring ophthalmologist
*referring ophthalmologist
*Dr. Ayyala
Exam:
Conjunctiva:
OD - quiet and white
OS - injected
Cornea:
OD - clear
OS - microcystic edema
shallow AC OS>OD
Gonioscopy:
OD - angle occludable open to <10 degrees, 360 degress
OS - closed angle
Lens:
OD - 3+ NSC
OS - 3+ NSC
Iris:
OD - normal
OS - mid-dilated
Cup: Disc:
OD - 0.9
OS - 0.9
Management
Argon Laser Peripheral Iridoplasty
to follow, OS then OD

Cataract Extraction as definitive treatment, OS then OD
Gonioscopy
OS: crowded angle
*I have no financial disclosures to report.
Argon Laser Peripheral Iridoplasty & Anterior Chamber Paracentesis
simple and effective, although underused

I will address:

1) Advantages of ACP
2) Accepted Indications for Application of ALPI
3) New Frontiers/ Expanded Application of ALPI

controlled drainage of aqueous from the anterior chamber
by the use of a needle or blade at a slit lamp
under topical anesthesia and aseptic conditions
Anterior Chamber Paracentesis
Advantages
Rapid
reduction of IOP and relief from symptoms

Repeatable
performed multiple times to lower IOP as required

Accessible
performed at slit lamp, without specialized equipment

Rapid Reduction of IOP
Early Studies - John et al

ACP vs Medication
28 patients post-cataract extraction
IOP > 30

ACP more rapid reduction in IOP within 1st hr
rapid rebound - 2 hrs after treatment

Rapid Reduction of IOP
Lam et al

ACP + Medication VS Medication alone

20 eyes
ACP + Meds - immediate IOP control within 15 min
Meds - at least 2 hours to show effect

within 2 hrs IOP levels comprable between groups
short lived effect, requires
definitive treatment
Gonioscopy
OD:
:angle occludable open to <10 degrees, 360 degress
Thank You!
Questions?
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