The Use of SLT in Secondary Open Angle Glaucomas ( PEXG, PDG)
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1 The Use of SLT in Secondary Open Angle Glaucomas ( PEXG, PDG) Prof. S. Melamed The Sam Rothberg Glaucoma Center Tel Aviv University Medical School Israel
2 Wear and Tear Glaucoma * Particulate Matter Glaucoma * EC Material in Trabecular Spaces and JCT blocking Aqueous Outflow * Trabecular cells are reduced in number, worn out, less phagocytic activity * Includes POAG, PEXG and PDG
3 PEX Glaucoma * A type of Elastosis * LOXL1 is defective, affecting Elastin formation * Fibrillar material is secreted by anterior segment organs, accumulating in JCT * MMP s activity is reduced * High Tension Glaucoma
4 Both ALT and SLT enhance Biological Activity of Trabecular Meshwork Outflow Facility is increased by: * Inducing Trabeculitis * Recruiting Macrophages * Enhancing Phagocytic Activity of TM cells * Increased Interleukins and Cytokines activity * Affecting Inner Wall of SC Tight Junctions and JCT Inner Wall Complex (Herniations)
5 Argon Laser Coagulation of TM
6 TEM 1 hr after ALT
7 TEM enhanced phagocytosis
8 4 weeks after ALT (monkey)
9 SEM - 4 weeks after ALT
10 ALT induced trabeculitis
11 ALT scarred lasered region
12 ALT non lasered region (ferritin)
13
14 Histology of successful ALT Johnson 2007
15 Histology of successful ALT Johnson 2007
16 However, You do not need the Over-Kill of ALT in order to induce biological enhancement of the TM A more gentle Rx of Pigmented Cells alone will achieve similar effects!
17 SLT Selective Rx of Melanin containing trabecular cells only. * No coagulative necrosis * Induced synthesis of IL 1 alpha and beta * Recruitment of macrophages
18 SLT Biological and Physiological Studies (Alvarado, IGS, Athens, 2007) * Aqueous Outflow is increased after SLT * Laser Activated TM cells synthesize ligands which increase permeability of inner wall of SC * Media conditioned by SLT increases SC cells permeability when added to naive control
19 So, if ALT/SLT enhances TM biological activity All Wear and Tear Glaucomas should benefit most from Laser Trabecular Treatment However, not to much was published on ALT/SLT in PEXG and PDG
20 Accumulation of PXM on Anterior Lens Surface Scanning Electron Microscopy
21 TEM of PXM accumulating under inner wall of Schlemm s Canal From Richardson & Epstein, Ophthalmology 1981
22 ALT in PEXG Threlkeld et al, J Glaucoma, 1996 * 1 year failure rate : POAG 40% PEXG - 18% * 3 years failure rate : POAG 58% PEXG - 47% * Initial response to ALT in PEXG is greater, but long term outcome is similar to POAG
23 ALT in PEXG Sherwood & Svedberg, BJO, 1985 * 70% success after 15 months * 40% could reduce or stop Medical Rx * More early IOP spikes * Less Diurnal Curve Fluctuations
24 ALT in PEXG Higginbotham&Richardson BJO 86 * 360 degrees Rx * Better initial response to ALT in PEXG * Faster rate of long term failure than POAG
25 SLT Factors influencing success: Baseline IOP Only The higher the IOP at treatment, the greater the reduction Not related to: Age Sex Race Family history Other glaucoma risk factors Type & severity of OAG Trabecular meshwork pigmentation (unlike ALT) Pseudoexfoliation Number of glaucoma medications (unlike ALT) Previous ALT (unlike ALT) SLT as primary therapy Systemic Hypertension Diabetes Mellitus Hodge 2005; Nagar 2005; Chen 2004
26 SLT can be used to treat various forms of OAG Melamed Arch. Ophth. 2003;121:957 78% 64% SLT for PXF & POAG at 18 months no significant differences in: IOP reduction (31.4 vs. 35.1% ) Success rate ( 20% ) Gračner EJO 2002;12:287
27 SLT PDG & PEXG The amount of TM pigmentation was not a significant predictor of success [Hodge 2005] No race differences, but four of the six eyes with PDG and PXF failed to respond [Nagar 2005] PDG & PXF similar IOP reduction to POAG & OHT [Melamed 2003] No difference between results of PXF & PDG and other types, but TM pigmentation delayed IOP lowering [Chen 2004] However there are 6 case reports of paradoxical IOP rise [up to 20%] in heavily pigmented angles [Harasymowycz 2005; Van de Viere 2006] SLT can be used regardless of angle pigmentation, but there may be more complications in eyes with heavily pigmented trabeculum
28 SLT for PEXG Song et al.,j Glaucoma, 2007 * A retrospective study of 94 eyes * Failure definitions: less than 3 mm Hg or 20% IOP reduction * 86% to 92% failure after 14.5 months!!! * Average time to failure 6 months
29 Is there an advantage/disadvantage to SLT over ALT in PEXG or PDG? * A comparative study of ALT vs. SLT in PEXG is under way * Very few retrospective studies focusing on PEXG or with large number of patients have been reported
30 Why should we use SLT in PEXG or PDG? * Very impressive short term success in PEXG, with mid-long term success comparable to POAG * Safety of SLT allows Rx in elderly patients, minimizing side effects of drugs * Repeatability of SLT is an advantage * Use minimal energy in PDG or heavily pigmented TM to avoid IOP spikes * We need randomized prospective comparative studies
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