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Thread: Advanced glaucoma

  1. #1

    Default Advanced glaucoma

    By Prof Dr.Gehad Elnahri

    When you become a glaucoma specialist in a weak health system, you are flooded with cases of advanced nearly absolute glaucoma, everyone wants to get rid of
    Glaucoma is one of the "revealing" diseases. My definition of a "Revealing" disease is "One by which you can gauge the integrity of the health system in a society". The characteristics of these diseases are
    1)must be relatively common and not a rare health problem
    2)nearly symptomless disease that needs screening for detection
    3)dangerous to QOL or life itself if left untreated
    The most striking example of such disease in Egypt is Hepatitis C infection

    Now back to advanced glaucoma, what are the general features?

    1)Visual acuity is suffering in the range of cf to 6/6. Frequently this is the only eye
    2)very narrow or tubular field
    3)patient on full medication and oral cidamex with poorly controlled IOP
    4)no one wants to operate on, everyone is treating or modifying treatment until the patient finds the surgeon ready to operate which is a rare event
    Advanced glaucoma attachment.php?attachmentid=3247&d=1504613989
    Why is surgery on advanced glaucoma feared?
    1)glaucoma surgery is generally much more difficult than cataract surgery not in execution but in outcome and full of surprises, on the other hand cataract is much more common and with more predictable outcome
    2)surgery on advanced glaucoma with tubular field is threatened with the "Wash-out" or Wipe-out phenomenon in which the remaining vision, even with uncomplicated surgery, is lost
    3)the chances of failure for glaucoma surgery (failure to control IOP) are more in advanced glaucoma than early cases
    The solution to this dilemma is early detection of rapidly progressive cases and bold decision making. I will re-mention some of the criteria of rapid progression,

    which needs considering surgery
    1)IOP in mid to high 20's with 3 antiglaucoma drugs
    2)intermittent use of oral cidamex to control IOP in the low 20s
    3)any loss of visual acuity related only to glaucoma
    4)rapid field progression over 1-2 years
    5)younger age of patient
    6)clear non adherence
    7)areas with shortage of medical follow up
    These cases should be referred early for considering surgery and this is the duty of general ophthalmologists

    By Dr.Hala AbdulwahabDo you believe washout/Wipeout is a real entity or just the natural history of the disease prof Gehad Elnahri? Cause many people fear operating because of this.
    By Dr.Gehad ElnahriI do not believe, i know, saw it few times
    By Dr.Nagwa HamadRegarding the washout phenomenon..does happens with tubular vision only??in other words when do you personally or at which stage of field loss are afraid of surgery dr.??
    By Dr.Gehad Elnahri Nagwa Hamad i am never afraid with surgery whenever indicated. Vision below 3/60 is dangerous

    By Dr.
    Costas KatsoulosThe wash - out phenomenon is real, but what are the reasons? IOP spikes during the operation and in the immediate post operative period that extinguish the fragile nerve?
    By Dr.Gehad ElnahriSure no, i saw couple cases where this never happened

    By Dr.
    Ashraful Huq RidoyIn my observation wash out phenomenon is more in combined Phaco + Trab. In most cases I saw further thinning of RNFL then before surgery.
    Its just my observation in few case (around 20).
    Any comment about this sir?
    By Dr.
    Gehad ElnahriMay be you do many combined surgeries, i prefer pure glaucoma surgery in advanced cases
    By Dr.Ashraful Huq RidoyGehad Elnahri Sir, what you prefer in a case of medically uncontrolled IOP and G 2-3 Cataract?
    By Dr.
    Gehad ElnahriAshraful Huq Ridoy if other eye good, combined, if poor glaucoma surgery

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