Ординатура / Офтальмология / Английские материалы / Terminology and Guidelines for Glaucoma 3rd edition_European Glaucoma Society_2008

TREATMENT GUIDELINES

General advantages of surgical iridectomy:

it can be performed even when the cornea is cloudy

it allows deepening of the anterior chamber, breaking freshly formed PAS. General disadvantages of surgical iridectomy:

all the potential risks of any intraocular procedure.

Anterior chamber paracenthesis is being evaluated to break the attack in cases refractory to medical management [II, C].

4.4.1.2 - Intermittent Angle-Closure Glaucoma (IACG)

Pupillary constriction, iridotomy, iridoplasty or lens extraction are to be considered according to the main mechanism determining angle occlusion [II,D]

4.4.1.3 - Chronic angle-closure glaucoma

Medical treatment rarely effective

If the synechial closure is less than half the circumference, iridectomy/iridotomy may be suffi cient [I,C] Since complications of iridotomy are uncommon, its use as the initial procedure is justifi ed in practically every case [I,D]

Argon laser trabeculoplasty is not indicated as it may increase synechial angle-closure [I,D]

If IOP cannot be controlled, a fi ltering procedure is indicated [II,D] These eyes are more frequently prone to develop posterior aqueous misdirection and the necessary precautions must be taken when considering surgery.

Lens removal may be considered and could relieve the problem [II,D]

4.4.1.4 – Status Post Acute angleclosure attack-

Management according to angle, lens, IOP and disc/ VF.

4.4.2 - THE “OCCLUDABLE” ANGLE; ACR (ANGLE-CLOSURE RISK)

If fellow eye of primary angle-closure, treatment is clearly indicated, starting with laser iridotomy [I,B]. All other cases must be assessed individually [II,D]. In general, the risks of treatment are to be balanced against the perceived risk of angle-closure.

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TREATMENT GUIDELINES

4.5 - SECONDARY ANGLE-CLOSURE GLAUCOMAS

4.5.1 - SECONDARY ANGLE-CLOSURE GLAUCOMAS WITH PUPILLARY BLOCK

Several steps may be considered, according to the clinical picture of causative mechanisms [II,D]

a)Topical and systemic IOP lowering medication

b)Nd:YAG laser iridotomy

c)Peripheral surgical iridectomy

d)Lens extraction, vitrectomy

e)Discontinuing miotics in miotic-induced pupillary block

f)Pupillary dilation

g)Nd:YAG laser synechiolysis of posterior synechiae

4.5.2- SECONDARY ANGLE-CLOSURE GLAUCOMAS WITH ANTERIOR “PULLING” MECHANISM WITHOUT PUPILLARY BLOCK

4.5.2.1- Neovascular glaucoma [II,D]

a)Topical atropine or equivalent

b)Topical steroid initially

c)Topical and systemic IOP lowering medication as needed

d)Retinal ablation with laser or cryotherapy

e)Cyclodestruction

f)Filtering procedure with antimetabolites

g)Aqueous drainage devices Miotics are contraindicated

Intravitreal injection of anti-VEGF compounds has shown some benefi t but is not approved yet for this indication [II,C]

4.5.2.2- Iridocorneal endothelial syndrome [II,D]

a)Topical and systemic IOP lowering medications as needed

b)Filtering procedure, with antimetabolite according to risk factors

c)Aqueous drainage device

4.5.2.3- Posterior polymorphous dystrophy [II,D]

a)Topical and systemic IOP lowering medication as needed

b)Filtering procedure, with antimetabolite according to risk factors

4.5.2.4- Peripheral anterior synechiae due to prolonged primary angle-closure glaucoma [II,D]

a)Topical and systemic IOP lowering medication as needed

b)Filtering procedure

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TREATMENT GUIDELINES

4.5.2.5- Epithelial and fibrous ingrowth after anterior segment surgery or penetrating trauma [II,D]

a)Topical and systemic IOP lowering medication as needed

b)Excision, destruction of the immigrated tissue

c)Filtering procedure, with antimetabolite according to risk factors

d)Aqueous drainage device

e)Cyclodestruction

4.5.2.6- Inflammatory membrane [II,D]

a)Anti-infl ammatory medications and cycloplegics

b)Topical and systemic IOP lowering medication as needed

c)Filtering procedure with antimetabolite

d)Aqueous drainage device

e)Cyclodestruction

4.5.2.7- Peripheral anterior synechiae after ALT and endothelial membrane covering the trabecular meshwork late after ALT [II,D]

a)Topical and systemic IOP lowering medication as needed

b)Filtering procedure

4.5.2.8– Aniridia [II,D]

a)Topical and systemic IOP lowering medication as needed

b)Trabeculotomy

c)Filtering procedure with antimetabolites

d)Aqueous drainage device

e)Cyclodestruction

4.5.3 - SECONDARY ANGLE-CLOSURE GLAUCOMAS WITH POSTERIOR “PUSHING” MECHANISM WITHOUT PUPILLARY BLOCK

4.5.3.1- Aqueous misdirection glaucoma [II,D]

a)Long-term pupillary dilation and cycloplegia

b)Topical and systemic IOP lowering medication as needed

c)Laserorsurgicaldissectionoftheanteriorhyaloidfaceorlenscapsuleand/oriridotomy

d)Vitrectomy with dissection of the anterior hyaloid face

Miotics are contraindicated

4.5.3.2- Iris and ciliary body cysts, intraocular tumours [II,D]

a)Topical and systemic IOP lowering medication as needed

b)Cyst destruction with laser or surgical excision

c)Tumour irradiation

d)Filtering surgery

e)Cyclodestruction

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TREATMENT GUIDELINES

4.5.3.3- Silicon oil or gas implanted in the vitreous cavity [II,D]

a)Topical/systemic IOP lowering medications as needed

b)Silicon oil or gas aspiration

c)Filtering surgery

d)Drainage device

e)Cyclodestruction

4.5.3.4- Uveal effusion due to [II,D]

1.infl ammation (scleritis, uveitis, HIV infection)

2.increased choroidal venous pressure (nanophthalmos, scleral buckling, panretinal photocoagulation, central retinal vein occlusion, artero-venous communication)

3.tumour

a)Anti-infl ammatory medication (for 1)

b)Topical and systemic IOP lowering medication as needed (for 1,2 and 3)

c)Relaxation of scleral buckling; vitrectomy, sclerectomy in nanophthalmus (for 2)

d)Tumour excision or irradiation (for 3)

e)Cyclodestruction

4.5.3.5- Retinopathy of prematurity (stage V) [II,D]

a)Topical and systemic IOP lowering medications

b)Cyclodestruction

c)Filtering procedure with or without antimetabolite

d)Drainage devices

4.5.3.6- Congenital anomalies that can be associated with secondary glaucoma

Treatment to be adapted to the primary anomaly, the mechanism of IOP elevation and the quality of life of the patient [II,D]

References

For references, see corresponding topics in Ch. 2 and Ch. 3.

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