1. >>0 >>1 >> 2 >> 3 >> 4 >> FULL PANRETINAL PHOTOCOAGULATION IMPROVES THE OUTCOME OF TRABECULECTOMY IN NEOVASCULAR GLAUCOMA Saleh alobeidan MD Essam osman FRCS Saleh alamro FRCS Ahmed Abuelasrar MD PhD

2. >>0 >>1 >> 2 >> 3 >> 4 >> 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. FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG

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4. 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

5. >>0 >>1 >> 2 >> 3 >> 4 >> 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

6. >>0 >>1 >> 2 >> 3 >> 4 >> 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

7. >>0 >>1 >> 2 >> 3 >> 4 >> FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG Steps of management Admission. Topical steroids. Atropine drops. Antiglaucoma RX. Full PRP. MMC Trab. Close follow up. Prolonged tapering of steriods.

8. >>0 >>1 >> 2 >> 3 >> 4 >> FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG PATIENT DEMOGRAPHICS (23 eyes, 21 patients) Patients and methods Gender:M15F8 Age: (yrs.) Mean 53.1+ 10.4 Range 32-72 Etiology of NVG : DR 19CRVO 4 Lens Status:Phakic 20Pseudophakic 3

9. >>0 >>1 >> 2 >> 3 >> 4 >> 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

10. >>0 >>1 >> 2 >> 3 >> 4 >> 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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12. >>0 >>1 >> 2 >> 3 >> 4 >> 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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14. 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

15. >>0 >>1 >> 2 >> 3 >> 4 >> 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

16. >>0 >>1 >> 2 >> 3 >> 4 >> 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

17. >>0 >>1 >> 2 >> 3 >> 4 >> FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG SUCCESS RATE _______________________________________ Complete Success 20/23(87%) Qualified Success 3/23(13%) continuation

18. >>0 >>1 >> 2 >> 3 >> 4 >> PRP FOLLOWED BY TRABECULECTOMY IN NVG __________________________________________ Table 1.1 Previous Studies (16 eyes) Current Study (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

19. >>0 >>1 >> 2 >> 3 >> 4 >> PRP FOLLOWED BY TRABECULECTOMY IN NVG __________________________________________ Table 1.2 Previous Studies (16 eyes) Current Study (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

20. >>0 >>1 >> 2 >> 3 >> 4 >> 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

21. >>0 >>1 >> 2 >> 3 >> 4 >> 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

22. >>0 >>1 >> 2 >> 3 >> 4 >> 5 CONCLUSION Neovascular glaucoma is a treatable condition Full PRP improves the outcome of trabeculectomy with MMC.