Peripheral Anterior Synechiae Treatment

Laser Trabeculoplasty ALT SLT MLT for Glaucoma

So why don't we start with (again well, I got these up here just to help us mentally categorize these things) so in terms of the noninvasive, enhancing procedures, laser Trabeculoplasty. Now argon laser Trabeculoplasty has been around for a few decades. Lasers have been available ally for use in 1970s and argon Trabeculoplasty really is has kind of a neat history it's one of those of many medical advances that were really kind of stumbled upon, okay. So when lasers first came out everybody thought they were really cool because they made holes. Alright? Made a hole on anything you want to make a hole at. And they made holes, when you bounced it off the mirror in the trabecular meshwork. Geez! Isn't this obvious? Make a bunch of little holes in

the trabecular meshwork. Get flow into the canal out the collector channel system we're good to go. So they tried that monkeys and sure enough they made holes but then what happens in the eye, as well as anywhere else when you make a you know hole or incision where it shouldn't be, scarreddown, closed up. So the holes aren't working but you know what if we laser these monkeys' trabecular meshwork not quite enough to make a hole just enough to coagulate it to melt in a bit, it actually results in the pressure going up! So now we've got a monkey model of glaucoma. How great is that Well now we can induce glaucoma on monkeys and now we can study other treatments on these monkeys. So they took a failure and they created a laboratory

success. Except that the monkeys this is one of those stories (sorry it just keeps going). except it turns out that some of these monkeys who had enough laser therapy to coagulate but not enough to penetrate actually ended up with their pressures going down after the initial postoperative inflammatory response. So some brights, scholars, scientists, researchers said, quot;Wait a second pressure went down, something's going on this could actually be a treatment for glaucoma!quot; So, they titrate it down a little bit more. Not quite enough to, you now, make a big coagulative mess but enough to make some structural change, and lo and behold ALT argon laser Trabeculoplasty was discovered. It was really stumbled upon. And to this day we really

don't know how it works. There are all these theories about how it stretches the trabecular meshwork in between the spots or it actually creates microscopic openings or tears. Nobody really knows. It works well for openangle glaucoma. It can be performed in one to two sessions but the problem is it does still result in microscopic scars and also may limit future surgeries, alright. So surgeries that involved opening up that Schlemm's canal, it can actually be problematic because now you've got these scars that are essentially sealing the canal, so surgery such as Canaloplasty and potentially some of the newer surgeries that are not yet available could be limited by argon laser Trabeculoplasty. So more recently in the 1990s Latina

developed Selective Laser Trabeculoplasty. Now, it's called selective laser Trabeculoplasty because the laser is selectively absorbed by pigment. So, the melanin granules in the trabecular meshwork and the neat thing about it is that it only uses 1 percent of the energy of argon laser Trabeculoplasty, and does not cause coagulative damage. So because it doesn't cause any coagulative damage, it doesn't limit future surgeries. It doesn't cause any kind of PAS we've all seen aggressive peripheral anterior synechiae. I call them sawtooth PAS. When somebody has had aggressive ALT and it has, you look under gonio you can see little see sawteeth. You won't see that with selective laser Trabeculoplasty. And because it doesn't cause any Damage it can

actually be repeated. So it works about seventy percent of the time. Works about as well as a drop, which is also about as well as argon laser Trabeculoplasty work so it's not really any better in terms of how of effective it is but it's its repeatable and it doesn't close future doors. Selective laser Trabeculoplasty when it first came out was crazy expensive. It was a one trick pony laser. So not too many people are going to be buying it. Not too many people did. So, some companies developed another technology called micropulse laser Trabeculoplasty (MLT). This essentially segments the pulses into these tiny little superfast pulses and by doing so you don't get the Heat. You don't get the increase in temperature. So you don't get coagulative damage and

Surgical Procedures For Glaucoma Currently Available and Pending FDA Approvals

What we're going to be talking about tonightis: What's new in glaucoma surgery and you know glaucoma is really kind of the underdogof surgical treatment. We all hear about cataract surgery and femtosecond and even with retinalsurgery epiretinal membrane peeling and, there's a lot that's really sexy and excitingbut glaucoma. doesn't really generate that kind of buzz, that kind of excitement. Tonight,I'm going to introduce you to some things that I think are actually pretty exciting.Now if you'd told me five years ago that glaucoma was exciting. I would have said you neededLexapro or something. Just briefly this this information here, everyone here, I believe,knows me, David Richardson Now, the quot;patientfocused

ophthalmologistquot; that's not just kind ofa quot;taglinequot; Most of you are aware that a couple years ago I actually completely turned mypractice upside down. And the reason I did that was because I found that when I was inthe exam room I could no longer be focused on my patients. I was too busy thinking aboutwhat kind of code am I going to use or you know what kind of documentation check marksdo I need, did I meet all the criteria for the exam and I just it was too distractingfor me and I'm a little OCD and that was just not good for me. So I've actually, as manyof you know, changed my practice so that patients who come and see me. it's just between meand the patient. So I'm not involved with

any insurances or even Medicare and so whenI'm in the room with a patient, I can truly be focused on the patient and I found, atleast for me, again with my own kind of neuroses to be very freeing experience and I hope thatthose of us who share patients that your patients also tell you that that's the experience they'vehad but it's truly if you ever get the chance to have that experience, whether through volunteeringor something else, it's something that. it's just. it's an epiphany to have. So,anyway, a little bit about my background. many of you know me already personallyand professionally. I grew up here in Southern California and Santa Paula, a little townof 20,000 and my father was a selfproclaimed

ditch digger for one of the local utilitycompanies and I'm very fortunate; he was so dedicated and so supportive and you know reallyit's my mother pushed me academically and they saved and they scrimped enabled me toget an outstanding education I consider myself to be one of the products of, you know, theAmerican dream. Two generations from abject poverty and so every chance that I get togive back i try to do so. And I hope that in those of you, again, who (you know)do regularly share patients with me, know my practice is not a concierge practice, whereI only treat the wealthy of San Marino. My office may be, in San Marino but I very muchenjoy keeping my fees at a level where people

such as my parents could afford to come andsee me. Alright; and I do on a patientbypatient basis see people at no charge. And so if youever have somebody who feel you know, you really want them to see me don't hesitateto give me a call, speak to me on the phone, and (you know) I enjoy what I do. So let'sget to the talk: Glaucoma Surgery. Now, it used to be there only couple o'clock on thesurgeries to think about so we could handle this whole talk in 15 minutes we didn't haveto parse things into categories but now we're going to actually talk about a number of differenttypes of surgeries and techniques and I find it helpful, just personally, to categorizethings it helps me think about what surgery

fits for what type of patient and so we cansplit glaucoma surgery into roughly three categories using this categorical criteria.One is noninvasive so a laser would be noninvasive. Minimally invasive this is really a wholenew type of glaucoma surgery that we'll be talking about in more detail, and then thepenetrating or the standard glaucoma surgery what we think of as Trabeculectomy and GlaucomaDrainage Devices. And clearly of those three most people would prefer to avoid that lastone. We can also think of glaucoma surgery in terms if a mnemonic that I use SEA:Shunts, which is essentially creating a nonphysiologic pathway from the anterior chamber into usuallySubconjunctival space but it could be something

Category: Neuropathic Pain

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