Ординатура / Офтальмология / Английские материалы / Glaucoma Surgery_Trope_2005

is not usually required. Slit-lamp examination and tonometry as well as Seidel testing should usually be performed 15 min after the procedure.

After the procedure, a topical steroid (e.g., Prednisolone 1%) and an antibiotic (e.g., Chloramphenicol 0.5%) are usually prescribed for 1 week or 10 days. A course of 4 days of subconjunctival 5-FU can be applied to the eye (10).

1.1.Interval Between the Surgery and Needling

In some reports, blebs have been needled as early as 3 days postoperatively (14). On the other end of the spectrum, some surgeons have attempted needling years after the initial surgery (6,8,9,15). A short interval between the initial surgery and needling has been associated with success (3), whereas other studies showed that time interval is of no importance with respect to a successful outcome (14,15).

We suggest that massage and suture removal/lysis be performed prior to needling during the first 6 weeks post surgery.

1.2.Repeated Needling

Needling can be repeated if it is deemed necessary. Some eyes can undergo multiple needling procedures when an initial improvement is followed by recurrence of fibrosis. Up to 10 separate needlings have been reported in the literature (5).

1.3.Adjunctive Antimetabolite Use with Needling

Antimetabolites can be injected during needling. This has been repeatedly advocated, (3,4,10,12) but no randomized controlled trials have been performed to determine whether there are any benefits of adjunctive 5-FU or MMC. Authors using either 5-FU or MMC have justified their methodology on hypothetical basis (10).

In light of our knowledge of the pathophysiological process involved in wound healing, and as the needling manipulation by itself constitutes further trauma and thus further stimulus for wound healing, the use of adjunctive antimetabolites is reasonable. We recommend the use of 5-FU for 4 days post needling.

1.4.How much to Inject?

5-FU has been administered in concentrations ranging from 25 mg/mL to 50 mg/mL and in volumes ranging from 0.1 mL to 0.2 mL. Total doses ranged from 1 mg to 5 mg. MMC concentrations of 0.28 mg/mL to 0.50 mg/mL have been used (12).

The nontoxic dose of 5-FU injected intravitreal has been reported as 1 mg (16 18), which probably explains why needling procedures where 5-FU is injected into or very close to the bleb have not been reported to be associated with increased incidence of complications (5,8,15). Mitomycin is a toxic drug and we do not use it with our needling procedures.

1.5.Where to Inject?

Some surgeons prefer to inject antimetabolites in the quadrant opposite to the site of surgery, whereas other authors inject at the same site of the needling (5,8,15). We prefer the former site.

2.COMPLICATIONS

Needling is a relatively safe procedure that is generally not associated with grave complications. Common and transient complications include subconjunctival hemorrhage, transient conjunctival wound leak, and hyphema. Ocular hypotony may occur, and although rare, choroidal effusion has been reported (19,20). Aqueous may occasionally leak from the needle entry site for several days but does not usually require repair.

One group reported that rapid closure of the entry wound is facilitated by immediate postneedling tamponade of the entry site with a cotton bud soaked in local anesthetic (15). The incidence of minor complications has been reported between 20% and 38%.

Fortunately, more serious complications are unusual. Malignant glaucoma or aqueous misdirection has been reported following needling (21,22). Libre (23) reported a case of transient lens clouding 5 min after needling and 5-FU injection, the patient’s vision decreased to counting fingers due to anterior lens capsule opacification. This resolved ,24 h, with the patients vision returning to preneedling levels. It was concluded that entry of 5-FU into the anterior chamber after needling precipitated the lens-clouding. Chen and Palmberg (24) reported a case of endophthalmitis after needling.

3.POTENTIAL RISK FACTORS FOR FAILURE OF NEEDLING PROCEDURE

Generally speaking, needling procedures tend to fail in younger rather than in older patients. Success is usually higher in White patients compared to Afro-Caribbean or Asian patients. Etiologically, success seems to be higher in patients suffering from primary open angle glaucoma compared eyes with other glaucoma forms. It seems that patients with previous exposure to 5-FU, MMC, or b-irradiation have a lower success rates. This perhaps reflects the fact that antifibrotic agents are usually used in eyes considered to be at a greater risk of failure. None of these parameters were found to be statistically significant in the largest prospective interventional study by Broadway et al. (15).

They did, however, find a statistically significant difference in success following bleb needling in patients in whom the IOP immediately postneedling was ,11 mmHg.

Shin et al. (8) reported that immediate postneedling IOP was .10 mmHg as a statistically significant predictor for failure of needling. Shin et al. also found that preneedling IOP was .30 mmHg and lack of MMC use during the trabeculectomy or combined procedures to be clinically significant predictors of needling failure.

Kaplan Meier survival analysis of bleb survival following needling suggests a 3 year survival of 40% (with IOP reduced by 30% from baseline with no or reduced medication) in Broadway et al. (Fig. 20.2) and a 28% survival in Shin et al. (success as target IOP achieved with no more than two medications).

4.TAKE-HOME MESSAGE

Bleb needling should be considered when a bleb fails post surgery. It has multiple advantages over re-operations. It can be done at the slit-lamp in an office setting, is simple and repeatable, and has the potential to be effective. Also, it is relatively safe. Needling does not prevent the surgeon from later resorting to other methods of IOP reduction if it fails.

Figure 20.2 Kaplan Meier survival analysis of bleb survival following needling. Three year survival of 40% (with IOP reduced by 30% from baseline with no or reduced medication) (15).

The needling procedure is more likely to succeed if an immediate lowering of IOP below 11 mmHg is achieved.

REFERENCES

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2.Pederson JE, Smith SG. Surgical management of encapsulated filtering blebs. Ophthalmology 1985; 92:955 958.

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decompression, severe intraocular inflammation, aphakia, and high myopia in young patients. Suggested vascular factors contributing to suprachoroidal hemorrhage include arterial hypertension, generalized arteriosclerosis, local vascular sclerosis, necrosis of intraocular arterioles, hypotension, and diabetes (22). Intraoperative sudden uncontrolled decompression of the anterior chamber, vitreous loss, and use of antimetabolites increase the risk of suprachoroidal hemorrhage (23). Conditions with increased venous pressure or vascular anomalies such as Sturge Weber syndrome, orbital AV fistulas, prominent episcleral vessels, and nanophthalmos are known to precipitate intraoperative suprachoroidal hemorrhage. Postoperatively, prolonged hypotony, use of antimetabolites (24,25), excessive inflammation, and Valsalva’s maneuver can precipitate the occurrence of a suprachoroidal hemorrhage. Events leading to delayed non-expulsive choroidal hemorrhage (DNECH) include coughing and vomiting associated with recovery from general anesthesia (15,23,26,27). General anesthesia has been implicated in suprachoroidal hemorrhage (23,26 28); therefore, local anesthesia is preferable for glaucoma procedures. Should the use of general anesthesia be mandatory, preoperative use of antiemetics has been suggested (23). Thiopental sodium is known to cause elevation of intraocular pressure, so it should be avoided for induction (29).

A history of suprachoroidal hemorrhage in one eye should always alert the surgeon, as it places the patient at a higher risk for suprachoroidal hemorrhage in the second eye.

3.CLINICAL PICTURE AND DIAGNOSIS

Sudden excruciating pain with a flat anterior chamber and raised intraocular pressure either intraoperatively or postoperatively and a choroidal mass should lead to the prompt suspicion of suprachoroidal hemorrhage.

The diagnosis is made by careful clinical examination and ultrasonography. Ophthalmoscopy will show an immobile, smooth dome-shaped elevation. Ultrasonography is of hallmark importance, as it helps distinguish serous choroidal detachments from hemorrhagic choroidal detachments and determines the right time for surgical drainage. Ultrasonographically, the choroidal detachments appear as immobile, smooth, thick dome-shaped echoes on B scan [Fig. 21.1(A), (B), (C)]. A scan shows high reflective echoes with fresh blood and low reflective echoes in areas if mixed with serous fluid (30) [Fig. 21.1(A)]. Suprachoroidal hemorrhage occurring during surgery is composed of arterial blood. Those occurring postoperatively can have a serous component. This is due to hemorrhage occurring in hypotonous eye with serous choroidal effusions. About 10 14 days after the hemorrhage, lysis of the clot occurs and the reflectivity decreases. Once the suprachoroidal reflectivity is reduced, drainage of the suprachoroidal blood will be facilitated owing to this liquefaction process.

4.PREVENTION

It is essential to control intraocular pressure preoperatively to reduce the effects of sudden decompression during filtration surgery. This can be done by using topical medications, osmotic diuretics, acetazolamide, and slow-controlled decompression via a surgical paracentesis. In high-risk cases such as nanophthalmos, Sturge Weber syndrome, superior vena cava syndrome, and orbital AV fistulas, prophylactic posterior sclerotomy (23) should be performed.

A prophylactic posterior sclerotomy (31,32) is created by performing a full thickness sclerotomy, 1.5 2 mm long, 3 4 mm posterior to the surgical limbus. This sclerotomy serves to drain suprachoroidal blood, preventing elevation of intraocular pressure and

Figure 21.1 (A) B scan of a patient with suprachoroidal hemorrhage, (B) B scan showing 3608 choroidal detachment with suprachoroidal blood, and (C) B scan picture showing choroidal detach ment with blood in suprachoroidal space and vitreous cavity.

related complications. We also recommend closure of the eye as quickly as possible in an at-risk situation.

Tip: In cases undergoing filtration surgery predisposed to suprachoroidal hemorrhage, we recommend the use of a preplaced scleral suture utilizing a 10/0 nylon suture through the scleral flap into the scleral bed margin prior to entering the anterior chamber. Leave the suture long enough, so a loop can be made to allow the flap to be adequately retracted. Once the sclerectomy has been created and peripheral iridectomy performed, the wound should be quickly closed with the help of this preplaced suture. Rapid restoration of intraocular pressure via rapid wound closure and anterior chamber reformation with air or viscoelastic may prevent choroidal hemorrhage.

5.TREATMENT

Intraoperatively, the prompt identification of a suprachoroidal hemorrhage is of hallmark importance. Failure to identify this in time can lead to expulsion of the intraocular contents. Sudden pain with unexplained shallowing of the anterior chamber and iris prolapse must alert the surgeon. The eye will feel hard. At the earliest suspicion, the first step should

be to close the surgical wound as quickly as possible (see preceeding Tip) and to examine the eye for a suprachoroidal hemorrhage. A full thickness sclerotomy should be made in the involved quadrant, 3 4 mm posterior to the limbus to help drain the suprachoroidal blood. If the hemorrhage is massive, sclerotomies should be placed in all four quadrants. A sclerostomy is made by creating a 5 mm conjunctival opening parallel to the limbus followed by a cut down through the sclera to the suprachoroidal space. Once the sclera is exposed, a No. 57 blade is used to gently scratch the sclera radially, 1.5 mm in length, 3 4 mm from the limbus taking care to avoid cutting through the choroidal tissue, thus preventing intraocular hemorrhage and vitreous loss. The scleral wound is not sutured but the conjunctiva is sutured in two layers.

In cases of DNECH, diagnosis is confirmed by ophthalmoscopy and ultrasonography. Transillumination with a muscle light will show loss of red reflex. The increased intraocular pressure should be monitored closely and attempts made to lower the intraocular pressure by all available medical methods. Visualization of the posterior segment can be difficult in cases where hemorrhage has broken through the retina causing a vitreous hemorrhage. Serial ultrasonography should be used to monitor the status of the detachment and the reflectivity of the suprachoroidal collection. The suprachoroidal contents are highly reflective on A scan in a fresh case of suprachoroidal hemorrhage. Serial monitoring of the clot and its liquefaction is done by assessing declining reflectivity on A scan. The ideal time to drain is 10 14 days (33); by this time blood is typically fluid enough to drain easily through a sclerotomy.

The suprachoroidal blood is best drained by a vitreoretinal surgeon performing posterior sclerotomies as described earlier with simultaneous injection of saline or balanced salt solution into the vitreous cavity using a continuous infusion line via pars plana (34). Various additional maneuvers have been described such as rolling a cotton-tipped applicator towards the drainage site and introducing blunt cyclodialysis spatula into the suprachoroidal space to displace the clots (35). However, we feel that the suprachoroidal blood should be allowed to drain passively with reformation of the anterior chamber and intravitreal injection of balanced salt solution. No attempt should be made to grasp or pull the clots physically. Use of continuous air infusion with an air pump connected to the eye (30), heavy perfluorocarbon liquids to express the suprachoroidal blood (36), and injections of viscoelastics (37) can also been utilized. In the presence of extensive vitreous incarceration or partial extrusion of ocular contents, vitrectomy is indicated (38). The use of more aggressive vitreous surgery with newer adjuncts such as perfluorocarbon in cases of suprachoroidal hemorrhage associated with rhegmatogenous retinal detachment has improved the prognosis for more complex cases which were previously considered inoperable (30,36,38).

6.PROGNOSIS

Visual recovery can be highly variable. The reported results range from loss of light perception to 20/40 (15,27,28,30,36,38,39). Visual prognosis and poorer outcomes are reported in eyes with complex hemorrhages, that is, those associated with vitreous incarceration in the wound and retinal detachment (40).

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