GLAUCOMA SLIDES and its traetmentand pathophysilogy.pptx

Glaucoma is a group of eye diseases that cause damage to the optic nerve, often due to increased pressure inside the eye, which can lead to progressive and irreversible vision loss if not diagnosed and treated early.​

What is Glaucoma?
Glaucoma gradually damages the optic nerve—the part of the eye responsible for sending visual information to the brain—and is often called the “silent thief of sight” because vision loss usually happens slowly and without early warning symptoms. While increased intraocular pressure (IOP) is a major risk factor, glaucoma can also occur with normal eye pressure. Regular eye exams are critical for early detection since reversible treatment is possible when discovered promptly.​

Causes and Risk Factors
The most common cause is impaired drainage of the aqueous humor (fluid inside the eye), resulting in raised eye pressure:​

Genetics: Family history increases risk.​

Age: People above 60 are at higher risk.​

Ethnicity: Increased risk in African, Asian, and Hispanic populations.​

Medical conditions: Diabetes, eye injuries, and long-term use of corticosteroids can elevate risk.​

Other factors: Blocked blood vessels, eye infection, or abnormal eye development in children.​

Types of Glaucoma
Open-angle glaucoma: Most common; slow drainage outflow raises eye pressure over time.​

Angle-closure (closed-angle) glaucoma: Sudden blockage of fluid drainage causes rapid rise in eye pressure—a medical emergency.​

Normal-tension glaucoma: Optic nerve damage occurs even with normal eye pressure.​

Congenital glaucoma: Present at birth due to abnormal eye development.​

Secondary glaucoma: Results from another eye condition, injury, or medication.​

Symptoms
Most early cases cause no pain or symptoms; vision loss is often gradual and unnoticed until advanced.​

Advanced cases: Peripheral vision loss (tunnel vision), blind spots.​

Acute angle-closure glaucoma: Intense eye pain, blurry vision, red eyes, nausea, and halos around lights; requires urgent medical attention.​

Treatments
Medicated eye drops or oral medications to lower eye pressure.​

Laser therapy or surgical procedures if medications do not adequately control pressure.​

Early detection and regular treatment can help prevent further vision loss, but lost vision cannot be restored.​

Key Points
Glaucoma can happen in one or both eyes.

Vision loss from glaucoma cannot be reversed but its progression can be slowed or stopped with proper treatment.

Screening and regular eye exams are vital.

Visual Reference
A person with advanced glaucoma commonly experiences tunnel vision, where only central vision remains while peripheral vision is lost.

For more detailed medical advice or diagnosis, consult an ophthalmologist or eye care professional.
Glaucoma is a group of eye diseases that cause damage to the optic nerve, often due to increased pressure inside the eye, which can lead to progressive and irreversible vision loss if not diagnosed and treated early.​

1. SURGICAL MANAGEMENT OF GLAUCOMA Moderator: Dr.Samyakta Shetti Presentor:Dr.Athul M 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 1

2. Introduction Trabeculectomy Non penetrating glaucoma surgery Cyclodestructive procedures 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 2

3. Introduction  In 2020, approximately 76 million people worldwide were affected by glaucoma, with 3.61 million experiencing blindness and 4.14 million suffering from moderate to severe visual impairment. The annual incidence rate of primary open-angle glaucoma stands at 23.46 per 10,000 person-years among individuals aged 40-79 years, with exponential increases in advanced age groups. Glaucoma accounts for 8.39% of all global blindness, making it the second leading cause of irreversible vision loss after cataracts. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 3

4. Evolution of Glaucoma Surgery In 1856 when Von Graefe performed the first iridectomy for angle-closure glaucoma. This was followed in 1867 by de Wecker's description of the first external filtration procedure, the anterior sclerectomy, establishing the fundamental principle of creating alternative drainage pathways The early 20th century witnessed further innovations, including the introduction of cyclodialysis in 1906 – the first internal filtration surgery targeting the suprachoroidal space. However, the modern era of glaucoma surgery truly began in 1968 when Cairns introduced trabeculectomy, which became the gold standard filtering procedure for the next five decades. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 4

5. Surgical management of glaucoma Trabeculectomy Glaucoma drainage devices Laser procedures Non penetrating glaucoma surgery MIGS Cyclodestructive procedures PI Selective laser trabeculoplasty Argon laser trabeculoplasty Deep sclerectomy Viscocanalostomy Canaloplasty 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 5

6. TRABECULECTOMY Gold s tandard for intraocular pressure reduction in uncontrolled glaucoma. Creation of a fistula at the limbus which allows a direct communication between anterior chamber and subconjunctival space bypassing the trabecular meshwork, Schlemm canal and collecting channels.  Suprachoroidal drainage. Absorption by episcleral vessels and lymphatics. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 6

7. When to Perform Trabeculectomy ? Uncontrolled IOP on maximum tolerable medications that is anticipated to worsen the optic nerve, visual field or visual function. Documented progression of glaucoma damage at current level of intraocular pressure with treatment or without intervention. Poor compliance with medical therapy: cost, inconvenience, understanding of disease. Intolerance to medical therapy due to side effects. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 7

8. How To Modify Pre-op Medications? Drugs causing conjunctival inflammation Miotics : 2 weeks Prostaglandins: 2 weeks Start Acetazolamide + preop steroids 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 8

9. Guidelines for Stopping Antiplatelet Aggregates and Anticoagulants  Antiplatelet : Stop Preoperative Acetylsalicylic acid (ASA): 2 weeks Thienopyridines ( ticlopidine and clopidogrel): 2 weeks Dipyridamole: 1 week Nonsteroidal anti-inflammatory drugs (NSAIDs): 1 week  Oral vitamin K antagonists: 7-10 days Oral thrombin inhibitors (dabigatran): 1-2 days Oral Xa factor inhibitor (rivaroxaban): 1-2 days Start low molecular weight heparin (in high-risk patients); switch back 24 hours after surgery. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 9

10. How To Assess Preop Conjunctival Health? Chronic redness and increased vascularization due to glaucoma drugs (BAK induced); SWS; NVG- Activated conjunctiva Previous surgery with conjunctival scars Trachoma with fornix shortening Judicious use of MMC/ preop steroids- in such cases 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 10

11. How to Select the Filtration Site Slightly staggered to the nasal side L eaves space on the temporal side for a repeat surgery Superior limbus site is preferred as the bleb is snugly covered by the lid 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 11

12. MMC sponge applied posteriorly behind the conj flap HOW TO PREPARE MMC? Vial as purple color powder in 2 mg Freshly reconstituted with distilled water or normal saline Concentration of 0.2-0.4 mg/mi 10 ml of distilled water to the 2 mg bottle - 0.2g/ml or 0.02% 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 12

13. SHAPE OF SCLERAL FLAP Rectangular (3.5 × 4.5 mm) Triangular, partial thickness (z to 1/3) or Trapezoidal flap with base of 4-5 mm and posterior limit 2-3 mm SCLEROSTOMY Anterior corneoscleral entry into AC-a block of tissue approximately 1.5*2.5mm wide is removed just anterior to the scleral spur/white zone using Punch sclerostomy - Khaw /Kelly descement membrane punch 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 13

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15. PERIPHERAL IRIDECTOMY A small peripheral section of iris is removed using De Wecker scissors Pull only 0.5 mm iris out of ostium to make a small yet functional PI Performed from sclerostomy site with extent beyond sclerostomy margins to avoid obstruction of sclerostomy by peripheral iris . 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 15

16. SCLERAL FLAP CLOSURE Flap Sutures: Permanent or releasable. Permanent sutures: at two corners of the scleral flap Additional Releasable sutures:which can be tightened according to assessement of flow and wriggled loose post operatively 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 16

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18. Types of trabeculectomy Limbal based Fornix based Location of incision 8mm behind the limbus At the limbus Incision length Longer Shorter Manipulation More extensive Less handling Bleeding More Less Exposure Hampered by the hanging conjunctival flap Excellent exposure Scleral flap dissection Difficult Easier Mitomycin application Easier More cumbersome Risk of wound leak Minimal More Bleb morphology Over hanging blebs Posteriorly directed bleb Resurgery Difficult Easier 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 18

19. High Risk For Filtration Failure Type of glaucoma Secondary glaucoma, e.g., NVG, uveitic glaucoma, traumatic glaucoma Pre-existing ocular conditions Ocular surface disease: Ocular rosacea; Blepharitis/ Meibomitis, Contact lens users. Conjunctival scarring: Trachoma, previous surgery like SICS or scleral buckling or trab Previous surgery: Pseudophakia /penetrating keratoplasty African race or young patients 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 19

20. Superior rectus bridle suture f ibrosis at bleb area. Post-op: High inflammation High IOP in first two weeks 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 20

21. What is an Ideal Bleb? Shallow, widespread, pale But not avascular Limited to under the upper lid, and Rapidly develop epithelial microcysts 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 21

22. Complications Anesthesia-related complications How to prevent Injury to the globe or optic nerve Avoid retrobulbar block, give peribulbar block with 27G needle Retrobulbar hemorrhage Ask for anticoagulant history and aspirate before injection Subconjunctival hemorrhage Avoid subconj . or sub-tenon block Pre-operative Complications 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 22

23. Intraoperative Complications Complication How to prevent and manage Corneal perforation Put a new traction suture after forming the anterior chamber (AC) Superior rectus bleed or hematoma Use a sharp cutting needle, avoid using blunt or round body needle 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 23

24. Conjunctival Complications Complication How to prevent and manage Subconjunctival bleed Cauterize the vessel and wash the blood Conjunctival buttonhole Small circular hole: Purse string suture • Small linear cut: Running suture • Large tear: Conjunctiva flap may be needed but poor outcome Retained MMC sponge Count the number of sponge pieces put 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 24

25. Scleral Flap/Ostium Complications Complication How to prevent and manage Thin or thick flap TIP: Outline the flap at 2/3rd depth of sclera first if you are a beginner • Thin flap: A flap can be made underneath the same flap/gentle flap handling Premature entry into AC • Make a paracentesis and form the AC • Make the ostium using Kelly's punch Incomplete fistula or incomplete DM removal Use a dry sponge to dry the sclerostomy area and look for DM remnants Large PI/small PI Keep the Vanna's scissor blades parallel to the limbus CB bleed/iris bleed Cauterize the bleed and wash the AC to remove hyphemia 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 25

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28. Spaeth Classification of Post-op Shallow AC Grade 1 : Peripheral iris-cornea apposition but preserved AC in front of pupillary space. Grade 2 :Greater apposition between mid iris and cornea but space between lens and cornea in pupillary space is retained. Grade 3 : Flat AC with complete contact of iris and pupillary space with the posterior surface of the cornea. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 28

29. Long-term Bleb Outcomes Most seen with mitomycin c toxicity Thin cystic bleb Overhanging/ Encysted bleb Flat/Failing Overfiltering bleb bleb 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 29

30. Assessing And Managing A Failing Bleb Increased vascularity of the bleb. Vascular ingrowth leading to fibrosis and bleb failure. Needling the bleb and using an anti-fibrotic agent such as 5-f luro uracil. Topical application of mitomycin-c swab to the area of hypervascularity. Revision trabeculectomy if the bleb is failing and presents late in the postoperative period. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 30

31. Prevention of Bleb Complications Do not exceed mitomycin-c more than 0.2 milligrams per ml for 2-3 minutes. Use pre-operative steroids to decrease conjunctival inflammation. In a fornix-based flap, close the wound with nylon sutures in addition to v icryl to prevent leakage. If a wound leak is detected in a bleb postoperatively, immediate surgical repair is necessary to prevent blebitis and endophthalmitis. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 31

32. Conservative Therapy S hort course of Oral doxycycline therapy (100mg twice a day) can be tried to promote wound healing. Bandage contact lens or pad bandage with oral doxycycline can be used for small pinpoint leaks . 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 32

33. Post-operative Wound Leak - Management H ealthy over-filtering bleb - Transconjunctival suturing L ate bleb leak-Conjunctival overlay L arge conjunctival and scleral defect- Conjunctival rotation flap P ersistent hypotony with healthy conjunctiva - Open and explore S cleral thinning - Scleral patch graft 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 33

34. Transconjuctival suturing Used to address over-filtration and shallow anterior chamber postoperatively Multiple transconjunctival sutures are applied from conjunctiva to sclera and back to conjunctiva Monofilament nylon sutures are used Closing the sclera ostium and decreasing aqueous drainage reverses hypotony. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 34

35. Late Bleb Leak Management  Used for late bleb leaks or thin cystic blebs Diseased epithelium is excised from the area of the bleb Conjunctiva is cut and overlayed on the area of the diseased epithelium 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 35

36. Conjunctival And Scleral Defect Management Momine's repair technique Excise the entire ischemic bleb Create a lamellar scleral flap and rotate it anteriorly to close the scleral defect Raise a pedicle scleral flap from the adjacent conjunctiva and close the conjunctival defect Manage both the scleral defect and conjunctival defect without additional scleral or eye bang tissue 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 36

37. Non penetrating glaucoma surgery Three varieties of non-penetrating glaucoma surgery > Deep sclerotomy > Viscocanalostomy > Canaloplasty It is described by Krasnov in 1972 and Zimmerman in 1984 Advantage of this procedure prevents sudden fall of IOP and aqueous outflow by the Trabeculodescemets window(TBW). 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 37

38. DEEP SCLERCTOMY Reduce intracular pressure (IOP) by external filtration of aqueous humour Which slowly passes through the TDW. TDW formed by the inner wall of anterior and posterior pigmented trabecular meshwork and by adjacent Descemet's membrane. The inner wall of the Schlemm's canal and Juxtacanalicular trabeculum is peeled. This leads to the formation of Intrascleral lake which function as a decompression chamber. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 38

39. Goals Create a new aqueous outflow pathway and reduce intraocular pressure Removal of the deep scleral tissue and external wall of the Schlemm's canal and corneal stroma is done without perforating the eye Indication Primary open-angle glaucoma Pseudo exfoliative glaucoma Pigmentary glaucoma High IOP uncontrolled despite maximal medical therapy Patients with poor adherence to therapy 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 39

40. Contraindication Angle-closure glaucoma Eyes with extensive peripheral anterior synechiae Neovascular Glaucoma Iridocorneal endothelial syndrome Scarred conjunctiva Traumatic glaucoma Angle recession Eyes treated with Argon laser Trabeculoplasty 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 40

41. Preoperative Assessment Stop miotics and prostaglandins for 3-7 days before surgery Stop prostaglandins for 7 days if used for less than 6 months and 2 weeks if used for more than 6 months because they reduce interval hyperemia and allow filtration aqueous humour much better Stop epinephrine group of medication 1 week before surgery Stop aspirin and related compounds 3-5 days before surgery to avoid bleeding Check for systemic hypertension, diabetes, and pseudo exfoliation, as they can enhance bleeding and promote fibrosis. 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 41

42. CONJUCTIVAL MOBILITY Check conjunctival mobility and scarring The patient undergone cataractsurgery is more scarred so conjunctiva mobility will be low. The adequately mobile conjunctiva function is one through using proparacaine safely Non-tooth forceps used for checking conjunctival mobility 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 42

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44. Implants are available for maintaining intrascleral lake (absorbable and non-absorbable) Absorbable porcine collagen: Aqua flow, Star Surgical Reticulated Hyaluronic Acid implant: Heal flow Non absorbable implant: T-Flex Polymethyl methacrylate (PMMA) implant These are sutured to the scleral bed Suturing of scleral flap done using ten zero nylon applied in corners and conjunctiva is sutured using two interrupted wing sutures 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 44

45. Intraoperative Modifications Canaloplasty is one of the intraoperative modifications A nylon suture of size 5-0 is threaded into the Schlemm's canal 360 degrees A 9-0 prolene suture is tied to the leading edge of the 5-0 nylon suture The nylon suture is reversed and slowly withdrawn from the eye The prolene suture gets left in the eye The prolene suture is cut from the nylon suture and the two ends are tied together The tight prolene suture in the Schlemm's canal increases the dimensions of the canal and improves aqueous outflow Enhances the normal drainage mechanism of the eye The deep scleral flap is cut, and the superficial scleral flap is sutured 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 45

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48. Carbon Dioxide Laser-assisted Sclerotomy Carbon dioxide laser has ablative properties on the sclera Fluid such as aqueous humour mitigates the ablative properties of the laser The laser is applied to the scleral bed over the Schlemm's canal Aqueous humour outflow occurs once the roof of the Schlemm's canal is breached Laser effect is lost when applied to the trabecular descemetes window area Creation of the TDW is the end point of surgery 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 48

49. Intraoperative Complications Inability to find the Schlemm's Canal Perforation of the trabeculo-descemet's membrane Tears in the descemet's window (TDW) are small, round, linear, or transverse Tears usually occur at the junction of the decimate membrane to the anterior trabeculum causes iris immediately prolapses out of the eye. Iridectomy is required in these situations, converting the procedure into a penetrating trabeculectomy 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 49

50. Postoperative Complications Early Hypotony, choroidal effusions, small hyphema , intracular pressure spikes, iris prolapse, transient hemorrhage under the scleral flap, and malignant glaucoma Complications are reduced if the trabecular descemets window is intact Late complications include failure due to excessive scarring Progressive scarring can lead to a progressive increase in intraocular pressure Other complications include blebitis and scleral ectasia 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 50

51. Cyclodestructive procedures Decrease IOP by reducing the production of aqueous by destruction of ciliary processes (functional unit of aqueous humor production) located in the Pars plicata region of the ciliary body mainly the anterior portion along the tips Generally reserved as the last option for uncontrolled/refractory glaucoma in patients with poor visual potential 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 51

52. INDICATIONS Raised IOP with a painful blind eye Repeated failure of other glaucoma procedures Post VR surgery uncontrolled glaucoma Glaucoma in aphakia Congenital glaucoma unresponsive to standard therapy In very sick patients who cannot withstand incisional surgery 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 52

53. CYCLODESTRUCTION Cyclo Diathermy with a penetrating probe (Vogt): Low success rate and many complications(no longer using) Beta irradiation (1948): Not adopted for clinical use Cyclo Electrolysis (1949): Not used clinically Microwave cyclo destruction: Transscleral high-frequency electromagnetic radiation- only animal studies reported Using in human High-intensity focused therapeutic ultrasound Cryotherapy Laser Cyclo photocoagulation Route Transscleral Transpupillary* Intraocular 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 53

54. CYCLOCRYOTHERAPY Intracellular ice crystal formation Ischemic necrosis Also destroys corneal nerves and gives pain relief Technique Peribulbar/retrobulbar block after LA fitness and pulse-oxy monitoring Anterior edge of probe firmly on sclera 1 mm from corneolimbal junction 2-3 quadrants 3-4 applications per quadrant are usually treated Treat 180 degrees or 6 applications Temperature 6-80°C for 60 seconds duration 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 54

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56. Instrument Nitrous oxide or CO2 gas Cryoprobe tips 1,5-4 mm (2.5 mm commonly used) Distorted anatomy: we use trans illumination to delineate the pars plicata Postoperative Management Systemic analgesics Topical steroids and cycloplegic Preop glaucoma medicines except pilocarpine and PGAs Can be repeated after 4-6 weeks 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 56

57. Complications Transient IOP rise Pain Uveitis, hyphema Hypotony, choroidal detachment Neovascularization and vitreous hemorrhage Lens subluxation 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 57

58. INTRAOCULAR/ENDOSCOPIC CPC Aphakia Pseudophakia Thin sclera/ectasia Limbal or Pars Plana route Visualize by endoscope or transpupillary 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 58

59. ENDOSCOPIC PHOTOCOAGULATION The ECP probe (Endo Optiks, Little Silver, NJ) combines a diode endolaser , aiming beam, light source, and endoscope into a single intracular probe This allows for targeted, controlled ablation of the ciliary processes with direct visualization and titration of power. EFFICACY OF ENDOSCOPIC CYCLOPHOTOCOAGULATION Most commonly, ECP is performed in conjunction with phacoemulsification cataract surgery ( Phaco -ECP) Reports of IOP reductions range from 2.7-11.5 mmHg in ECP alone and 14.9-46,9%, ECP along with cataract surgery 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 59

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61. CYCLO PHOTOCOAGULATION Historical: Trans scleral Xenon arc in 1961 and Ruby laser in 1969 Nd YAG 1064 nm: Not used now Krypton laser Semiconductor Diode 750-810nm: Most commonly used now after AAO technical report recommendation Lesser energy, better absorption by uveal melanin Quicker, greater durability Portable and lower maintenance costs 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 61

62. Mechanism Reduced aqueous production by destruction of ciliary epithelium and reduced vascular perfusion Increased aqueous outflow to the pars plana or trans scleral 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 62

63. CONVENTIONAL VERSUS NEWER PROCEDURES Conventional: Hard to predict, high complication rate, inflammation, and damage to adjacent structures Recent: Endoscopic CPC and Micropulse CPC show promise of Rx in eyes with vision potential CONTINUOUS WAVE DIODE LASER PHOTOCOAGULATION Continuous-wave laser energy is delivered to the ciliary body via a laser probe (G probe) placed approximately 1.2 mm from the corneoscleral limbus 2.0 Watts (W) for 2 seconds and titrate the energy down depending on the audible "pop“ 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 63

64. TRANS-SCLERAL DIODE LASER WITH G PROBE Laser in progress with the G probe using continuous wave diode CPC G-probe fiber -optic laser tip protrudes 1.5 mm behind the anterior edge of the footplate and protrudes 0.7 mm Side Effects Hyphema Inflammation Hypotony 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 64

65. Drop in visual acuity Pain Lens subluxation Staphyloma formation Scleral perforation Sympathetic ophthalmia 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 65

66. Procedure Peribulbar anesthesia preferred The probe is positioned 3 mm posterior to the limbus The laser is applied in a sweeping motion in the superior and inferior quadrants for a total duration of 160 seconds This allows for a uniform, slow, and steady application of laser energy It should be remembered to avoid the 3 and 9 o'clock positions as well any bleb 16/10/2025 DEPT OF OPHTHALMOLOGY, JNMC 66