A TOUR OF THE WORLD OF

GLAUCOMA SURGERY
Dr. Jennifer Fan Gaskin
Glaucoma Specialist
Natural History of Open Angle Glaucoma
 Glaucoma Treatment Options

• Medical
• Laser
• Surgical

All work to reduce intraocular

pressure by aqueous outflow or
aqueous production
 Types of Glaucoma Surgery

• Filtration surgery
• Drainage implants
• Ciliary body ablation
• Recent innovations
FILTRATION SURGERY
FILTRATION SURGERY
 Filtration Surgery

• Small drainage hole made in the sclera

• Allows fluid to drain out of the eye under a thin flap
• Forms a reservoir of fluid called a bleb
• Reduces intraocular pressure
• 45 – 60 min
• Local anaesthetic and sedation
 Success Rate
Victorian Trabeculectomy Audit

• 2012
• 195 eyes
• 81% achieved <18 mmHg without eye drops at 1-
year
• 11.8% achieved <18 mmHg with eye drops at 1-year
• >90% able to achieve IOP <18 mmHg
 Success Rate
Royal Victorian Eye & Ear Hospital Trabeculectomy Audit

• 2013-2014
• 50 eyes
• 87% achieved ≤18 mmHg at 24 months without eye
drops
• 4% achieved ≤18 mmHg at 24 months with eye
drops
• >90% able to achieve ≤18 mmHg at 24 months
 Post-operative Course

• Redness, irritation, and watering

• Blurred vision can last up to 6 weeks
• Droopy eyelid possible
• Keep water out for 1 week
• No bending over or heavy lifting until advised
• Cessation of glaucoma eye drops
• Anti-inflammatory eye drops required up to 6-months
DRAINAGE IMPLANTS
DRAINAGE IMPLANTS
 Drainage Implants

• Pioneered by Tony Molteno in 1960s

• Baerveldt and Ahmed implants in
mid-1990s
• Generally reserved for eyes that have
failed filtration surgery or unlikely for
filtration surgery to succeed
• Evidence that comparable efficacy to
trabeculectomy
 Drainage Implants
• Silicone tube diverts aqueous to an external
reservoir
• Fibrous capsule forms around plate over 4-6 weeks
 Post-operative Course

• Similar to filtration surgery

• Shorter course of anti-inflammatory eye drops
ENDOSCOPIC CILIARY BODY
ABLATION
ENDOSCOPIC CILIARY BODY ABLATION
 Endoscopic Ciliary Body Ablation

• Developed in 1992 in New Jersey

• Endoscope containing 3 fibre
groupings:
– Image guide
– Light source
– Semiconductor diode laser
Martin Uram
• Allows direct visualisation of ciliary
processes
 Endoscopic Ciliary Body Ablation

• Advantage over external ciliary body ablation

through direction visualisation of ciliary processes
• Ability to titrate energy and deliver more
predictable outcome
 Post-operative Course

• Can be painful in early post-operative period

• Fewer restrictions
• Continue glaucoma eye drops to minimise pressure
spikes
• Anti-inflammatory eye drops for 1 month
RECENT INNOVATIONS
MINIMALLY INVASIVE GLAUCOMA
SURGERY
Minimally Invasive Glaucoma Surgery
• Aimed at preserving tissue, particularly conjunctiva
• Suitable for mild to moderate glaucoma
• Usually performed in conjunction with cataract
surgery
• Only two devices currently available in Australia
 iStent
• FDA approved in USA in 2012
• Titanium device
• Smallest available implant for human body
• Inserted into drainage channel through small
wound
• Multiple iStents can be implanted at same time
• Each implant ~$1000 AUD
 Success Rate
• FDA trial
• 116 patients receiving cataract surgery + iStent vs.
123 patients receiving cataract surgery only
• 68% of cataract + iStent patients achieved 21
mmHg at 12 months vs, 50% at 12 months
 Hydrus
• 8-mm long crescent-shaped open structure
• Schlemm’s canal scaffold
• Dilates the canal over 3 clock hours
• Titanium-coated nickel
 Hydrus
• July 2015, Ophthalmology
• 50:50 = Cataract surgery + Hydrus vs. cataract surgery only
• 80% of cataract surgery + Hydrus vs. 46% of cataract
surgery alone achieved 20% reduction of eye pressure
• Washed out mean eye pressure at 24 months was 16.9
mmHg (cataract + Hydrus) vs. 19.2 mmHg (cataract alone)
• 73% (cataract + Hydrus) vs. 38% (cataract alone) required
no glaucoma medication at 24 months
 Post-operative Course for MIGS
• Rapid recovery
• Similar to cataract surgery
• Complications include bleeding, scarring,
dislodgement of device
• No long- term data
 Summary
• Well-established role
• Rapidly developing area
• Surgical choice needs to be individualised