Presentation on theme: "Vanderbilt Eye Institute"— Presentation transcript:
1Vanderbilt Eye Institute Grand RoundsVanderbilt Eye Institute12/15/06Ryan Tarantola M.D. PGY-2
2Initial Evaluation 10/18/06 CC: Elevated IOP OS HPI: 69 yo Female POAG x 10 yrsTreated with gtt and ALT OUIOP OS has been poorly controlledRed eyes OS>OD for many yearsReferred by outside ophthalmologist for possible filtering procedure.
3POH: POAGS/P ALT OUNo history of trauma or steroid exposureAllergies: NKDAFH: No hx of eye disease
4SH: Denies tobacco, alcohol, or drug use. ROS: NegativeMeds: Lumigan OU QHSAzopt OU BID
5VAcc at Distance: OD: 20/25OS: 20/25Pupils: 42mm, no RAPD OUTA: OD: 19OS: 26Visual Fields: FTFC OUMotility: Full OU
22Auscultation: No orbital bruit appreciated Cerebral Angiogram: Additional TestingHertel: Base 96mmOD:16mmOS:17mmAuscultation: No orbital bruit appreciatedCerebral Angiogram:Unremarkable anterior and posterior intracranial circulation.No evidence of carotid cavernous fistulaNo evidence of flow-limiting stenosis, aneurysm, occlusion, ormalformation.
23Idiopathic Elevated Episcleral Venous Pressure Presentation:Typically presents in elderly with no FHMost cases are unilateralFamilial cases have been reported but typically sporadicOften have previous diagnosis of POAGOften complain of red eye
24Idiopathic Elevated Episcleral Venous Pressure Signs/Symptoms:Elevated IOP despite medical therapyTortuous dilated episcleral veinsOpen-angle glaucoma with characteristic nerve and fieldsBlood in Schlemm’s canal on gonioscopyNo exophthalmosRuled out other etiologies of increased EVP
25Idiopathic Elevated Episcleral Venous Pressure Diagnostic Testing:Orbital ultrasound/MRI: Evaluate retrobulbar spaceMRA: Detect carotid-cavernous or dural-cavernous fistulaCarotid Angiography: Gold standard to rule out fistulaEndocrine workup: Evaluated for Thyroid eye diseaseHertel: Detect exophthalmosAuscultation: Detect orbital bruit
26Idiopathic Elevated Episcleral Venous Pressure Management:Medical:b-blockersa2 agonistsCarbonic Anhydrase inhibitorsSurgical:TrabeculectomyTube ShuntNonpenetrating deep sclerectomyIncreased risk of uveal effusion and expulsive hemorrhageRecommended that prophylactic sclerotomies be routinely performed during surgery
27Our PatientFollow up visit 10/26/06:IOP OD:22 OS:30Follow up 11/15/06:IOP OD:22 OS:34Elected to proceed with ExPRESS mini glaucomashunt procedure.
28ExPRESS Mini Glaucoma Shunt Biocompatible miniature stainless steel implantPreviously placed directly beneath conjunctiva but caused manycomplicationsIn newer technique shunt is placed beneath a scleral flapDiverts aqueous humor to a subconjunctival filtration bleb
29A 6 × 3 mm fornix-based conjunctival flap is created in the upper quadrant.
30A 50% depth, 5 × 5 mm limbal-based scleral flap is created. Mitomycin C may be applied beneath the flap at the surgeons discretion
31With a 26-gauge needle, a pre-perforation is made into the anterior chamber under the scleral flap, in the center of the blue-gray transition zone between the white sclera andclear cornea.
32The glaucoma drain is inserted into the anterior chamber via the perforation site.
33The scleral flap is then securely sutured with 10-0 nylon sutures.
34The conjunctiva is sutured back in place with 1 or 2 buried 8/0 absorbable sutures.
35ExPRESS Mini Glaucoma Shunt Ex-PRESS implant inserted in 24 eyes of 23 patients with severe OAGSixteen eyes of the 24 (66%) had had previous failed filtering surgeryRemaining 8 eyes (33%) were high risk for failures casesIOP was reduced from 27.2 ± 7.1 mm Hg pre-op to:14.5 ± 5.0 mm Hg at 12 months (n = 21)14.2 ± 4.2 mm Hg at 24 months (n = 8)Two patients needed anti-glaucoma meds to keep IOP below 21 mm HgDahan et. al. Implantation of a Miniature Glaucoma Device Under a Scleral Flap. Journal of Glaucoma. April 2005.14(2):
36ExPRESS Mini Glaucoma Shunt Dahan et. al. Implantation of a Miniature Glaucoma Device Under a Scleral Flap. Journal of Glaucoma. April (2):
37ExPRESS Mini Glaucoma Shunt Dahan et. al. Implantation of a Miniature Glaucoma Device Under a Scleral Flap. Journal of Glaucoma. April (2):
38Take Home PointsUnderstand the venous drainage of the orbit and how abnormalities can resultin elevated EVP and thus elevated IOP.Be suspicious of elevated EVP in patients previously diagnosed with POAG.Know the possible causes of elevated EVP and how to evaluate for each.Be aware that the ExPRESS mini glaucoma shunt is a new procedure thatappears to be safe and effective at lowering IOP in Glaucoma patients whenplaced beneath a scleral flap.
39References Allingham et al. Shields’ Textbook of Glaucoma p.347-352 Clayton et al. CT angiography and MR angiography in the Evaluation of Carotid Cavernous Sinus Fistula Prior to Embolization: A Comparison of Techniques. Am J Neuroradiol. 26: October 2005.Dahan et al. Implantation of a Miniature Glaucoma Device under a Scleral Flap. J Glaucoma 2005;14:Greenfield et al. Glaucoma associated with elevated episcleral venous pressure.J Glaucoma :5. John et al. Dural and Carotid Cavernous Sinus Fistulas. Ophthalmology 94:6. Moses et al. Mechanism of Glaucoma secondary to increased venous pressure. Arch Ophthalmol. 1985;103:1701.7. Talusan et al. Increased Pressure of dilated episcleral veins with open-angle glaucoma without exophthalmos. Ophthalmology 1983;90:257.