Combined Trabeculectomy Augmented

with 5 – Fluorouracil in Primary Angle

Closure Glaucoma

Melsa E L Situmeang*

Consultant:
Dr. Prima Maya Sari, SpM

OPHTHALMOLOGY DEPARTMENT OF DR MOH HOESIN HOSPITAL

SRIWIJAYA UNIVERSITY
2019
INTRODUCTION

GLAUCOMA
A group of disease
• Optic Neuropathy
• Remodeling of the connective tissue
elements of the optic disc
• Loss of neural tissue
• Development of distinctive patterns of
visual dysfunction

IOP ELEVATION
INTRODUCTION
INTRODUCTION

EUROPEAN GLAUCOMA SOCIETY CLASSIFICATION OF AC

• ITC > 180 deg., (-) TM or optic

PACS nerve damage

• ITC > 180 deg., (+) elevated

PAC IOP/PAS, (-) optic nerve damage

• ITC > 180 deg., (+) elevated

PACG IOP/PAS, (+) optic nerve damage
INTRODUCTION – Pathogenesis & Pathofisiology

Apposition / Adhesion of
peripheral iris to the TM

Appositional Synechial
 EPIDEMIOLOGY

Much more
Hyperopia >> small Older age >> lens
prevalent in Asians
eye, shallow AC thickens and pupil
>>91% bilateral
(2,5 mm) become smaller
blindness in china

Women 2-4 X risk Family history

 AIM

To report a case of an advance

primary angle closure glaucoma
managed with trabeculectomy
augmented with 5-FU
 IDENTIFICATION

Name: Mrs. FR

Age: 66 yr

Gender: Female

Ocupation: Housewive

Date of visit: July 25, 2019

Addres: Intown
CHIEF COMPLAINT

blurry vision, started about 2 years

before

History of the disease

• Blurry vision started, no redness

• Frequent headache, (-) nausea &
2 years vomiting
ago
History of Disesase

• Patients went to an ophthalmologist, were told that

her IOP was high
2 years
ago • Given 2 types of antiglaucoma  never showed up
for evaluation

• Vision’s the same, but headache became more

3 often, redness in eyes (+)
months • Referred to RSMH ; later was advised to undergone
trabeculectomy but she refused
after

• Blurry vision got worse, esp in right eye

2 months • Redness (+), headache (+), nausea & vomiting (-)
ago • After complete examination, pts’ advised for
trabeculectomy
2 years ago, LPI was performed in both eyes. Patients
was advised to have routine check on disease
progression, but she didn’t comply.
History of sistemic hipertension (+), pts take valsartan as a
medication, but poor compliance on regimen.

History of DM, asthma, autoimmune disease (-)

History of using glasses (-)

History of trauma to the eyes

History of the same disease within close family

members (-)
General Examination

General Status

•Sense. : Composmentis
•Pulse : 82 x/mnt
•RR : 20 x/mnt
•T : 36,8 C
 OPHTHALMOLOGY EXAMINATION
Status RE LE
Opthalmologic

VA 6/21 PH (-) 6/9 PH (-)

IOP 25,5 mmHg 15,6 mmHg
applanation applanation
(2 medication) (2 medication)
Ocular Orthophoria
Alignment
Ocular Good to all gaze Good to all gaze
Movement
Palpebra Normal Normal

Conjunctiva Normal Normal

Cornea Clear, edema (-) Clear, edema (-)

COA VH 2, cell (-), flare (-) VH 2, cell (-), flare (-)

Iris iridotomy (+) toward 1 Iridotomy (+) toward 11 o’clock

o’clock direction, direction,
iris atrophy (-), iris bombae (-) iris atrophy (-), iris bombae (-)
Pupil Round, central, LR(+), ϴ 3 Round, central, LR(+), ϴ 3 mm
mm

Lens Opaque, ST (+) Opaque, ST (+)

 Posterior Segment Examination
Fundus Reflex BE (+)
• RE:
• Papil: round, defined margin, normal colour, c/d 0,8, a/v 2:3,
nasalisation (+), cupping (+), splinter hemmorhage (-),
bayonett sign (-), peripapillary athrophy (-) peripapllary
bleeding (-)
• Macula: foveal reflex (+)
• Retina: normal blood vessel contour
• LE:
• Papil: round, defined margin, normal colour, c/d 0.6, a/v 2:3,
nasalisation (-), cupping (+), splinter hemmorhage (-),
bayonett sign (+). defined rim and rim, peripapillary
athrophy(+) peripapillary bleeding (-)
• Macula: foveal reflex (+)
• Retina: normal blood vessel contour
GONIOSCOPY
OD Inferior Superior Nasal Temporal
Schwalbe’s line + + + +
Trabecular meshwork - - - -
Scleral spur - - - -
Iris perifer - - - -
Pigmentasi - - - -
PAS + - - +
Neovaskularisasi - - - -
OS Inferior Superior Nasal Temporal
Schwalbe’s line + + + +
Trabecular meshwork - - - -
Scleral spur - - - -
Iris perifer - - - -
Pigmentasi - - - -
PAS + - - +
Neovaskularisasi - - - -

Interpretation: AC + PAS in inferior & temporal BE

Differential Diagnosis

• Primary Angle Closure Glaucoma

• Secondary Angle Closure Glaucoma
• Primary Open Angle Glaucoma

Working Diagnosis

• Primary Angle Closure Glaucoma ODS

(OD: advance stage, OS: moderate stage)
• Senile cataract ODS
MANAGEMENT

Informed consent

Timolol maleate 0,5% ED 1 drop/12 hours

RLE

Brinzolamide 1% ED 1 drop/8 hours RLE

Pro Trabeculectomy RE
PROGNOSIS

QUO AD • Bonam
VITAM

QUO AD
FUNCTIONAM • Dubia ad malam
 PRE OP EVALUATION

THORAX PA Lab. Work-up

Heart and lungs
are within normal
limits
Internal Medicine Department’s Pre OP Evaluation

A/ Heart and lungs are functionally in compensatory

state for stg II Hipertension

P/
 Amlodipine 5 mg / 24 hr PO
 Candesartan 8 mg / 24 hr PO
FOLLOW UP post op day 1
August 17, RE LE
2019

VA 6/30 ph (-) 6/15 ph (-)

IOP P = N + 0 ( tanpa obat ) P = N + 0 (2macam obat)
OC. ortophoria
ALIGNMENT
OC. good to all gaze good to all gaze
MOVEMENT
AUGUST 17,2019 RE LE

Palpebra Normal Normal

Conjunctiva Sub. conj bleeding (+), Normal

good suture,
bleb’s unidentified
Cornea Edema (+) Clear

COA VH2, cell (-), flare (-), clot VH2

(-)
Iris Iridectomy (+) at 12 Iridotomy (+) at 11
o’clock, iridotomy (+) at 1 o’clock
o’clock
Pupil Round, central, LR (+), d. Round, central, LR (+), d.
3 mm 3 mm
Lens ST (+), NO2 NC2 ST (+), NO2 NC2
POSTERIOR SEGMENT

Fundus Reflex RLE (+)

• FRE:
• Papil: round, defined margin, normal colour, c/d 0.8, a/v 2:3,
nasalisation (+), cupping (+), splinter hemmorhage (-), bayonett
sign (+), defined rim and rim, peripapillary athrophy (-)
peripapllary bleeding (-)
• Macula: foveal reflex (+)
• Retina: normal blood vessel contour
• FLE:
• Papil: round, defined margin, normal colour, c/d 0.6, a/v 2:3,
nasalisation (-), cupping (+), splinter hemmorhage (-), bayonett
sign (+). defined rim and rim, peripapillary athrophy(+)
peripapillary bleeding (-)
• Macula: foveal reflex (+)
• Retina: normal blood vessel contour
DIAGNOSIS
• Post trabeculectomy + 5 FU o.i Advanced stg Primary Angle
Closure Glaucoma RE
• Moderate stage PACG LE
• Senile cataract RLE

MANAGEMENT
-Cefixime 100mg/12 hours p.o
-Mefenamic Acid tab 500mg/8 hours p.o
-Deksametason 0,1%, Neomisin 3,5 mg, dan Polimiksin 6000 IU ED 1
drop/4 hours RE

-Levofloxacin ED 1 drop/4 hours RE

-Brinzolamide ED 1 drop/8 hours LE
-Timolol maleate 0,5% ED 1 drop/ 12 hours LE
FOLLOW UP post op week 1
August 23, 2019 RE LE

VA 6/21 ph (-) 6/15 ph (-)

IOP 6 mmHg P = N + 0 (2 macam obat)
OC. ALIGNMENT ortophoria

OC. MOVEMENT good to all gaze good to all gaze

AUGUST 23,2019 RE LE

Palpebra Normal Normal

Conjunctiva Sub. conj bleeding (+), Normal

good suture,
Bleb H1 V0 E3 S0
Cornea Edema (+) minimal Clear

COA VH2, cell (-), flare (-), clot VH2

(-)
Iris Iridectomy (+) at 12 Iridotomy (+) at 11
o’clock, iridotomy (+) at 1 o’clock
o’clock
Pupil Round, central, LR (+), d. Round, central, LR (+), d.
3 mm 3 mm
Lens ST (+), NO2 NC2 ST (+), NO2 NC2
POSTERIOR SEGMENT

Fundus Reflex RLE (+)

• FRE:
• Papil: round, defined margin, normal colour, c/d 0.8, a/v 2:3,
nasalisation (+), cupping (+), splinter hemmorhage (-), bayonett
sign (+), defined rim and rim, peripapillary athrophy (-)
peripapllary bleeding (-)
• Macula: foveal reflex (+)
• Retina: normal blood vessel contour
• FLE:
• Papil: round, defined margin, normal colour, c/d 0.6, a/v 2:3,
nasalisation (-), cupping (+), splinter hemmorhage (-), bayonett
sign (+). defined rim and rim, peripapillary athrophy(+)
peripapillary bleeding (-)
• Macula: foveal reflex (+)
• Retina: normal blood vessel contour
DIAGNOSIS
• Post trabeculectomy + 5 FU o.i Advanced stg Primary Angle
Closure Glaucoma RE
• Moderate stage PACG LE
• Senile cataract RLE

MANAGEMENT
-Deksametason 0,1%, Neomisin 3,5 mg, dan Polimiksin
6000 IU ED 1 drop/4 hours RE
-Levofloxacin ED 1 drop/4 hours RE

-Brinzolamide ED 1 drop/8 hours LE

-Timolol maleate 0,5% ED 1 drop/ 12 hours LE

DISCUSSION
 blurred
Female, Chief
vision History
Patient worsen
66 yo complain since 2 of
months ilness:
ago

Diagnosed PACG
symptom chronic
PACG 2 months
• complain
• Diagnosed for 2 years • Complain blurry got worse 
glaucoma. Got vision with red go to local
Timol & • Complain blurry eye, frequent hospital and
brinzolamide, 3 vision with no headache (+),
red eye.
referred to
months later nausea (+),
undergone LPI Frequent RSMH with 2
tunnel vision (-)
in both eye headache (+), 
drugs
• Never tunnel vision (-)
controlled. • Poor
compliance on
2 years drugs 2 years
Ophthalmology examination
• Increasing IOP
• COA VH II
• Seg.post:
• RE: c/d 0.8, bayonet sign (+), nasalisation (+)
• LE:c/d 0.6, bayonet sign (+), nasalisation (+),
peripapillary athropy (+)

OCT Humprey Gonioscopy

• RNFL thinning (+) • Visual field • Angle closure
defect (+) with PAS

Primary Angle Closure Glaucoma

RE: Advance
LE: Moderate
Advanced Glaucoma
• Trabeculectomy + anti-fibrotic agent

Moderate Glaucoma

• Preventive LI
• Follow up every 3 months
• Prepare for trabeculectomy if worsen

Prognosis

• Quo ad vitam  bonam

• Quo ad functionam  dubia ad malam
• Because there’s damage in optic nerve head and severe
defect in left eye
Can J Ophthalmol 2007;42:233–7
doi: 10.3129/can j ophthalmol.i07-012
Patogenesis PACG
• Pe↑resistensi masuknya akuos humor kedlm BMD
↓
• Iris melengkung ke depan
↓
• Menutup sudut drainase (sudut tertutup)
↓
• Drainase akuos humor menuju canalis schlemm
terhambat
↓
• Prod .tetap eksresi ↓
↓
• Imbalance prod. Dan ekskresi akuous humor
↓
• P↑ TIO
↓
• Glaukoma sudut tertutup

40
 Mekanisme kabur
mendadak
m↑ tahanan aliran
akuos humor yg IOP↑ Kompresi
melalui TM ke abnormal Kompresi
lempeng
canal sclemm arteri
optik retina

Kompresi
akson saraf Nutrisi
retina↓
optik

Aliran
aksonal
sitoplasma
terhambat

Nutrisi ke serabut
syaraf tdk
memadai

Kematian
Visual serabut saraf Kematian neuron yg
loss optik yg terkena
masuk ke
otak
42
 Mekanisme mata merah

• Pe↑TIO
↓
• Perfusi↓
↓
• Vasodilatasi
↓
• Hiperemis pada konjungtiva
↓
• Mata merah

43
 Mekanisme nyeri
• pe↑ TIO
↓
• Bola mata meregang
↓
• Menjepit pem.darah
↓
• Iskemik imbalance saraf otonom
↓ ↓
• P↑aktivitas anerob parasimpatik lebih aktif
↓ ↓
• Penimbunan asam laktat aktivasi vasovagal
↓ ↓
• Asam laktat bersifat nosiseptik mual muntah
↓
• nyeri

44
 Dinamika humor akuos
Bilik mata belakang
↓
Pupil
↓
Bilik mata depan (BMD)
↓
Sudut BMD

Pembuangan

Trabekula stroma
dan pem.darah
Kanal schlemm iris dan badan silier
Sal.kolektor
↓
V .Episklera
V. Konjungtiva
pembuluh darah
↓ suprakoroid
V.Siliaris anterior
V.Oftalmik superior
↓
vena korteks
Sinus kavernosus
45
 TIO Tinggi
AKUT K RONIK
↓ ↓
Ggn.integritas struktur ggn.intgritas struktur
Segmen anterior papil saraf optik
↓ ↓
Bendungan pem,darah iskemia papil
Konjungtiva dan iris hiperemis ↓
↓
Edema kornea suram gaung papil
Visus ↓ hallo
↓ ↓
Paralisis sfingter pupil skotoma pada lap.pandang
Pupil lebar fotofobia ↓
↓Nyeri mata skotoma meluas
↓ ↓
Rangsangan saraf otonom lapang pandang menyempit
↓ ↓
Mual,muntah hilang
↓
Buta

46
 Glaukoma sudut tertutup

• Penyebab utama blok pupil penyebab lain

↓ ↓
• Akuous terbendung di BMB #tarikan pada iris perifer
• Tekanan BMB ↑ dari depan
↓ ↓
• Menekan iris kedepan #dorongan pd iris
↓ IRIS BOMBAY perifer dari
belakang
• Iris perifer menempel pd trabekulum
↓
• Sudut tertutup

47
Kriteria akut
Grading glaukoma
• criteria suggested by the Preferred Practice Patterns of the
American Academy of Ophthalmology
Glaucoma Grading Scale (Hodapp-
Parrish-Anderson)
Pemeriksaan glaukoma
• Status oftalmologikus visus, TIO, seg.anterior
• Perubahan fungsional  defek lapangan pandang
(algoritma swiss sita standar)
• Perubahan struktural  perubahan papil (ONH)
• Morfologi : ukuran, cupping
• Peripapiler : ISNT rule
• Perdarahan peripapil: splinter hemorrhage
• Atropi peripapil
• Penipisan RNFL  dengan OCT
• Menunjukkan apoptosis sel-sel ganglion retina
Van Herick grading system
-SC (Slit on Cornea) adalah sinar yang jatuh di kornea
- SI (Slit on Iris) adalah sinar yang jatuh di iris
-CA (Anterior Chamber Depth) adalah daerah gelap antara SC dan SI
-Kedalaman COA dideskripsikan sebagai
perbandingan antara SC dan CA
Tonometri aplanasi
Algoritma gonioskopi
58
59
60
61 61
62
63
Target pressure
Target Pressure
Penilaian papil pada glaukoma
Localised rim thinning/notching
Peripapillary Atrophy

86
87
88
90
91
Localised RNFL loss

92
• (www.zeitzfrankozeitz.de/tl_files/Bilder/Dictionary/glaucoma%20optic%20disc%20pt2.jpg
Glaucomatous Visual Defect
 1

8 Zone 1: basic identification

2 Zone 2: reliability parameter
Zone 3: gray scale
Zone 4: total deviation plot
3 Zone 5: pattern deviation plot
7 Zone 6: global indices
Zone 7: glaucoma hemifield test
5 6 Zone 8: raw data

4
104
Terapi laser pada glaukoma
Mekanisme LPI
eliminating the pressure gradient between posterior
and anterior chambers

flattens the iris with the purpose of opening the angle

allowing aqueous humor bypass to the pupil

reducing intraocular pressure (IOP)

Ramulu P,Friedman D. Laser iridotomy. Angle closure glaucoma, Ed

C Hong e T Yamamoto, Kugler Publications, 2007:201-216
Indikasi LPI
• Indikasi laser iridotomi perifer antara lain :
• Sudut tertutup primer akut
• Mata sebelahnya dari mata dengan sudut tertutup
primer akut
• Sudut tertutup kronik dengan hipertensi okular,
dengan atau tanpa glaukoma
• Sudut sempit atau dapat tertutup
• Indikasi lain : Iridotomi yang tertutup komplit atau
inkomplit, melebarkan sudut untuk trabekuloplasti
Keuntungan LPI
• Membuat bypass
• Membuka sudut  bisa menurunkan TIO dengan
membuat iris flat
• Mencegah sinekia  e.c COA lebih dalam
Peripheral Anterior Sinekia (PAS)
Penyebab terbentuknya PAS
• Anterior chamber depth (ACD) < 2,4 mm  sudut
sempit
• Pada primary angle closure  sudut sempit
• Proses inflamasi  e.c fibrin dan peningkatan protein
aquos dari terganggunya barrier blood-aquos
• Edema iris perifer
• Menumpuknya debris di sudut
• Mostly in inferior angle
• Flat anterior chamber post-operatif
• Glaukoma neovaskuler  e.c kontraksi miofibroblas
membran fibrovaskular pada pembuluh darah yang
melintasi scleal spur, badan siliar dan trabekular
meshwork  menyebabkann terbentuknya PAS
Sumber: AAO 2014-2015
 PAS pada PAC PAS pada inflamasi
• Banyak ditemukan di • Banyak ditemukan di
superior inferior
• PAS yang terbentuk • PAS yang terbentuk
uniformed (teratur) nonuniformed (tidak
beraturan)

Sumber: AAO 2014-2015

• Asian irides are thicker and stickier than other
ethnicities, and therefore tend to form PAS more easily
• Presence of PAS may be not essential for the diagnosis of
chronic ACG. In eyes with ACG suspect or angle closure
hypertension, narrow PAS was more frequent.
• superior and temporal portions of the angle might be the
earliest sites of angle occlusion in chronic ACG, because
the incidence of synechial angle closure was higher in
superior and temporal quadrants than others
 Trabekulektomi

• Lubang pada trabekulum,ditutupi

sebagian tebal sklera sebagai atap (flap
sklera).
• AkuosBMBpupilBMDlubang
trabekulektomidibawah flap
sklerasubkonjungtivamembentuk
rongga penampung (bleb) TIO↓

113
Trabekulektomy

114
Dikutip dari Glaucoma Medical Theraphy:
Principles and management. Second
Edition. The American Academy of
Ophthalmology. Oxford University Press.
USA: 2008. Page 299
Dikutip dari Glaucoma Medical
Theraphy: Principles and
management. Second Edition.
The American Academy of
Ophthalmology. Oxford
University Press. USA: 2008.
Page 298
Dikutip dari Glaucoma Medical
Theraphy: Principles and
management. Second Edition.
The American Academy of
Ophthalmology. Oxford
University Press. USA: 2008.
Page 300
Dikutip dari Glaucoma Medical
Theraphy: Principles and
management. Second Edition.
The American Academy of
Ophthalmology. Oxford
University Press. USA: 2008.
Page 300
Dikutip dari Glaucoma Medical Theraphy: Principles and management. Second Edition. The American Academy
of Ophthalmology. Oxford University Press. USA: 2008. Page 300
Dikutip dari Glaucoma Medical Theraphy: Principles and management. Second Edition. The
American Academy of Ophthalmology. Oxford University Press. USA: 2008. Page 301
5-FU (Basa analog Pirimidin)

Anti Fibrosis

Konversi Intraselular

deoxynucleotide 5-fluoro-2’-
deoxyuridine-5’-monophosphate

Menghambat sintesis DNA

thymidylate synthase
 Mekanisme Kerja Mitomisin C

Mitomycin C pada kondisi aerobic Via lipid

MMC bereaksi dengan
diisolasi dari peroksidase
molekul Oksigen
Streptomyces menghasilkan radikal menyebabkan
caespitosus bebas sitotoksik

Memungkinkan MMC MMC menjadi

Agen alkilating yang
berikatan dengan
berikatan dengan toksik bagi
DNA diantara adenin
DNA dalam semua proliferasi dan non
dan guanin pada 3
fase siklus sel proliferasi sel.
titik yang berbeda

Menyebabkan
irreversible cross mereduksi cincin Menghambat migrasi sel
fibroblast, meurunkan
lingking & quinin dan produksi sel matrik,
menghambat sintesis methoxy menyebabkan apoptosis
nukleotida

125
 Bedah filtrasi yang berhasil diminggu pertama akan
memberikan gambaran klinik berupa:
1. Bilik mata depan terbentuk walaupun agak dangkal
2. Bleb terbentuk
3. TIO berada disekitar 8 – 10 mmHG

Dikutip dari dr. M.N.E Gumansalangi. Tarbekulektomi.Airlangga University Press, 1996

Dikutip dari Hand Book of Glaucoma. Martin
Dunitz Ltd. UK. 2002. page 215
1