Ординатура / Офтальмология / Английские материалы / Glaucoma Surgery_Bettin, Khaw_2012
.pdfvisual acuity, quicker visual recovery, less postoperative care, and fewer short-term and long-term complications.
The effectiveness of IOP reduction after cataract surgery may last one year. Then, the IOP tends to return to baseline levels [66–68].
If surgery is recommended in order to lower IOP, as in the case of an inadequate IOP control in a POAG patient with progressive visual field loss and visually significant cataract, the phacoemulsification alone is not likely to be sufficient to maintain an adequate IOP control.
Recent literature has suggested that combined surgery extends the IOP decrease longer than cataract extraction. This outcome does not appear to be true for trabeculectomy alone, although some authors have found similar results [68–70]. These data are not confirmed in the case of nonpenetrating glaucoma surgery, which seems to cause a less pronounced blood-aqueous barrier breakdown with a lower probability of failure after phacoemulsification [72, 73].
Patients with severe medically uncontrolled glaucoma, advanced visual field defects and mild visual impairment would benefit from trabeculectomy alone. Cataract extraction could be performed after the IOP stabilization. Furthermore, we have to bear in mind the cataractogenous effect of trabeculectomy, especially in eyes operated on using mitomycin C (MMC) [74, 75].
In the presence of a medically uncontrolled glaucoma and a visually significant cataract, cataract extraction alone would not be sufficient to stabilize the IOP. In these cases, combined cataract and glaucoma surgery should be performed. POAG patients undergoing combined surgery may display a long-term mean IOP decrease of 6–7 mmHg versus the 1–2 mmHg drop obtained by cataract surgery alone [76, 77].
Phacoemulsification and Trabeculectomy
Combined intervention is less efficient than trabeculectomy alone in lowering IOP. On the other hand, it avoids the postoperative IOP spikes that may occur after phacoemulsification [78]. With respect to the sole cataract extraction, this effect is also relevant for nonpenetrating surgery [73].
In patients with cataract and glaucoma, it is essential to consider whether for each individual patient it is more important to reduce IOP as much as possible despite a higher risk of postoperative complications, or to probably get less complications but a more limited tensional success.
The Advanced Glaucoma Intervention Study showed that approximately half of the patients with open-angle glaucoma inadequately controlled on medical therapy develop a cataract [22]. Cataract formation or progression is a common event following uneventful trabeculectomy, and this risk also depends on whether patients develop complications following trabeculectomy or not [74, 75].
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Moreover, a functioning trabeculectomy may be negatively affected by secondary cataract surgery: it has been suggested that cataract extraction following successful trabeculectomy may compromise bleb function and lead to IOP rise [79–81], and an IOP increase may lead to a further hypotensive surgery. Iris manipulation, age under 50, preoperative IOP over 10 mmHg, early postoperative IOP over 25 mmHg and cataract surgery less than 6 months after trabeculectomy have been identified as risk factors for decreased bleb function after cataract extraction. These are therefore key factors for optimal choice and timing of surgery. Failure in patients under 50 years of age is likely to be caused by an excessive fibrotic activity. The risk of failure increases if cataract surgery is performed within 6 months after trabeculectomy. This is remarkable because it suggests that, within this time period, blebs are more susceptible to inflammation [80].
Once the decision to perform combined surgery is taken, we need to decide if the ‘1-site’ or the ‘2-site’ phacotrabeculectomy is better and safer.
In 1-site phacotrabeculectomy, the trabeculectomy partial-thickness scleral flap is created first, an antimetabolite is applied, following which cataract surgery is completed through this scleral flap. Trabeculectomy surgery is concluded by creating a sclerostomy and the scleral flap is closed. In 2-site phacotrabeculectomy, clear cornea phacoemulsification with in-the-bag intraocular lens implantation is undertaken first, followed by conventional trabeculectomy [82].
The problem of performing phacotrabeculectomy through 1 or 2 sites remains controversial: some studies suggest that there is no significant difference in terms of visual acuity, IOP control and glaucoma medication requirements between the two options [83–87]. Other studies emphasize the major control in reducing IOP for 2-site phacotrabeculectomy with respect to the 1-site procedure. The 1-site approach allows faster surgical time and a reduced number of corneal incisions. In contrast, limited superior exposure and absence of irrigation underneath the conjunctival flap during phacoemulsification are elements that may favor a 2-site approach thanks to a more predictable intraoperative antimetabolite effect [88].
Finally, as for antimetabolite agent use, during combined surgery with trabeculectomy this is highly recommended in association with phacoemulsification. In fact, the effect of the use of antimetabolites during trabeculectomy is well known [43, 89–91], and MMC-enhanced glaucoma surgery is associated with a high incidence of bleb avascularity, transconjunctival aqueous oozing and delayed bleb leaks [92]. A recent study showed that there are no significant differences between 5-FU and MMC application in terms of IOP reduction in eyes undergoing primary trabeculectomy [93].
New Combined Interventions
In some cases, the use of microinvasive surgical techniques to treat glaucoma could be associated with phacoemulsification to avoid the most common complications
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of trabeculectomy while effectively decreasing IOP [94, 95]. Even though combined cataract extraction and trabeculectomy are more effective in lowering IOP than phacoemulsification alone, postoperative management is more complicated and requires more intensive care. In addition, it increases the likelihood of complications, such as hypotony and anterior chamber shallowing [88].
More recently, nonpenetrating procedures have been developed as an alternative to trabeculectomy: deep sclerectomy, viscocanalostomy, canaloplasty, ab-interno trabeculotomy (Trabectome), trabecular meshwork bypass stents (iStent) as well as suprachoroidal implants (Gold Shunt) or drainage devices (tube shunts) [96–105].
Deep sclerectomy combined with cataract surgery is associated with an IOP reduction similar to phacotrabeculectomy with the same visual outcome [98]. In a multicenter prospective study, the authors found that canaloplasty achieved a significant IOP decrease with a low rate of complications in patients with open-angle glaucoma and cataract [82]. Data from Trabectome surgeries demonstrate a mid-teens IOP lowering effect and a reduced number of IOP-lowering medications. This was especially true for the combined Trabectome-phacoemulsification cases with minor, if any, postoperative complications [99]. A recent randomized controlled trial in POAG patients with cataract revealed that IOP reduction was significantly greater one year after cataract surgery with iStent implantation than with phacoemulsification alone. Moreover, the overall safety profile was similar to cataract surgery alone [100]. A pilot study of supraciliary gold microshunt, showed a surgical success of 79% after a mean follow-up time of 11.7 months with a mean IOP decrease of 9 mmHg [101]. Combined cataract extraction and Baerveldt glaucoma drainage implant placement seems to be a safe and effective surgical option and may represent the best choice when patients are deemed ‘high risk’ for failure with trabeculectomy (including neovascular or uveitic glaucomas and severe secondary glaucomas) and for patients who previously failed trabeculectomy [102].
The latest technological advances offer potential improvements for the surgical treatment of glaucoma. These techniques are more often combined with cataract surgery due to the low rate of severe complications, limited ocular tissue manipulation (especially concerning the conjunctiva) and faster visual recovery than traditional glaucoma surgeries. Moreover, these methodologies do not preclude further traditional penetrating glaucoma surgery. Initial experience has allowed for safe and effective IOP control, while avoiding many of the complications associated with trabeculectomies or tube shunts.
The newest techniques (Canaloplasty, Trabectome, iStent, Gold Shunt) may be especially indicated for patients who require only a mild to moderate lowering of IOP in addition to conventional cataract surgery [96, 97, 103–105]. Moreover, being bleb-free, these procedures could be valuable alternatives to classic filtering surgery in patients with enhanced wound healing and scar formation.
Further randomized controlled trials are needed to assess if these new surgical procedures allow for significant and sustained IOP reduction in glaucomatous patients and if they guarantee an excellent shortand long-term postoperative safety profile.
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Conclusions
Our current approach to the surgical management of cataract and glaucoma is based on the following suggestions:
1When glaucoma is adequately treated by medication and visual field defects are moderate and stable, phacoemulsification alone is to be preferred, since it may lead to an IOP decrease sufficient to prevent glaucoma progression.
2When cataract and glaucoma are both present, but the latter requires three or more types of medication to reduce IOP, or when the offset is unpredictable, phacoemulsification followed by glaucoma surgery at two different times allows for an IOP reduction higher than cataract extraction alone. Following phacoemulsification, monitoring of IOP fluctuations is crucial: systemic
acetazolamide (250 mg twice a day) is to be administered to avoid IOP spikes.
3When glaucoma prevails and IOP spikes after phacoemulsification are expected to cause significant damage to the optic nerve and a clinically detectable visual field loss, combined surgery (two separate sites) allows for greater IOP decrease than phacoemulsification alone as well as for a more predictable low IOP range in the immediate postoperative period. Corneal incisions exceeding 2.75 mm
should be closed with a 10-0 nylon stitch, especially when MMC is applied, to prevent iris prolapse following digital massage, should this be necessary. During the postoperative period, the IOP must be diligently controlled.
4The latest techniques (iStent, Gold Shunt, Trabectome, canaloplasty) may be a potential option to reduce IOP in conjunction with cataract surgery. To date, the literature reports do not allow an evaluation of the true effectiveness of these methods due to lack of consistent long-term data.
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Giorgio Marchini
Eye Clinic, Department of Neurological and Visual Sciences
University of Verona
IT–37126 Verona (Italy)
Tel. +39 045 812 2340, E-Mail giorgio.marchini@univr.it
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Bettin P, Khaw PT (eds): Glaucoma Surgery. Dev Ophthalmol. Basel, Karger, 2012, vol 50, pp 157–172
Surgical Management of Pediatric Glaucoma
Yvonne Oua Joseph Capriolib
aGlaucoma Division, Department of Ophthalmology, University of California, San Francisco, Calif., bGlaucoma Division, Jules Stein Eye Institute, University of California, Los Angeles, Calif., USA
Abstract
Pediatric glaucoma surgery is challenging because of the differences in anatomy from the adult, differences in the behavior of the tissues of a child’s glaucomatous eye, the variety in causes of the disease, and difficulties with postoperative management. Goniotomy and trabeculotomy are the preferred initial treatments for primary congenital glaucoma. Trabeculectomy with adjunctive mitomycin C is more likely to succeed in older, phakic patients, but carries the long-term risk of bleb-associated endophthalmitis. Glaucoma drainage devices may be preferred in younger children and in patients with aphakic glaucoma, but these devices can cause tube-related complications. Lastly, cyclodestructive procedures are reserved for patients in whom filtering surgery has failed, given its more unpredictable effects and serious complications.
Copyright © 2012 S. Karger AG, Basel
Angle Surgery
Goniotomy and trabeculotomy ab externo are the preferred treatments for primary congenital glaucoma and have high success rates. By incising the uveal trabecular meshwork under direct visualization, goniotomy is hypothesized to increase aqueous outflow by providing aqueous humor with more direct access to Schlemm’s canal. Trabeculotomy ab externo is performed when corneal clouding prevents adequate visualization of angle structures with gonioscopy.
Goniotomy
Goniotomy without visualization of the angle was first described in 1893 by the Italian ophthalmologist Carlo de Vincentiis [1]. It had poor outcomes in adults and thus was initially abandoned. With the development of gonioscopy, Otto Barkan modified the technique for primary congenital glaucoma in 1938 [2] and included direct visualization of the angle. The goal of goniotomy is to incise the anterior trabecular
meshwork to open a route for aqueous humor to enter Schlemm’s canal. However, the precise mechanisms of intraocular (IOP) reduction are poorly understood, although it is widely accepted that improvement in outflow facility occurs.
Technique
Goniotomy requires minimal equipment but the surgeon must be well versed in angle anatomy. It also requires careful surgical planning and patient positioning. Preoperatively, the IOP should be medically managed to optimize corneal transparency. Pilocarpine 1 or 2% should be used to constrict the pupil, open the angle for optimal visualization, and protect the lens from injury during surgery. Topical apraclonidine 0.5% may also be applied to the eye for IOP reduction and prevention of intraoperative bleeding, but its use should be judicious to prevent pupillary dilation.
Surgical planning includes re-examining the angle with the goniolens, of which there are several choices, including the Barkan and Swan-Jacobs lens. This is to ensure identification of anatomical landmarks and adequate visualization of the angle. If there is diffuse epithelial edema, the epithelium can be peeled off; however, stromal edema with breaks in Descemet’s membrane will not resolve with this maneuver. If stromal edema prevents adequate visualization of the angle structures, then conversion to trabeculotomy should be considered. There are also reports of using endoscopic visualization to perform goniotomy during cases where the cornea is too hazy [3–5].
To perform the procedure, the surgeon sits opposite from the portion of the angle to be operated with the head of the patient tilted away from the surgeon. Control of the eye can be achieved with locking forceps to grasp the superior and inferior rectus muscles, or with a stay suture placed beneath the insertion of the muscles. The trabecular meshwork is incised with a goniotomy knife or 25-gauge needle attached to irrigation or to a syringe containing viscoelastic. The latter offers the advantage of maintaining the anterior chamber without extra maneuvers. The trabecular meshwork is engaged just posterior to Schwalbe’s line, and the knife or needle is used to make a circumferential incision for 4 to 5 clock hours. Care must be taken not to incise too deeply and damage the outer wall of Schlemm’s canal. Often, a cleft with exposure of less pigmented tissue is observed as the incision is made, with widening of the angle and posterior movement of the peripheral iris. The length of the incision can be elongated by having an assistant rotate the eye. Upon knife or needle withdrawal, blood reflux commonly occurs and usually resolves with elevation of the IOP and reformation of the anterior chamber with BSS. Topical apraclonidine 0.5% or diluted intracameral epinephrine (1:16,000) can help to decrease bleeding. The postoperative regimen should include a topical antibiotic, a steroid and some also recommend the use of postoperative miotics.
Complications
Complications after goniotomy include hyphema, which usually resolves without intervention over the first postoperative week. Head elevation and bedtime topical
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