1.3.5 0.7 mm MICS Combined Procedures

Fig. 1.19 Bimanual irrigation aspiration started with the 0.7mm set

Fig. 1.20 Bimanual irrigation aspiration completed

1.3.5.1 0.7 mm MICS and Glaucoma Surgery

The combination of glaucoma surgery and cataract surgery with IOL implantation ideally should improve visual acuity and diminish visual patient recovery time. Glaucoma surgery and the cataract surgery are performed at all stages of the diseases. So the visual outcome is the problem that has to be solved. The combination of glaucoma surgery and cataract surgery results in a large decrease of IOP which is more than filtration surgery alone. But the standard trabeculectomy can increase corneal astigmatism. The conjunctival bleb, the scleral flap incisions, and the lack of tissue at the site of trabeculectomy can increase astigmatism. The use of minimal invasive surgery has become more important. Standard MICS surgery with MICS lenses can diminish corneal astigmatism and improve visual outcome of the operated eye [18, 19]. The use of micro filtration valves can decrease the IOP value by 50%. The mini shunt ExPress Corneal Surgery does not require the removal of the scleral and trabecular tissues. This nonvalved device was originally designed to provide a direct conduit from the anterior chamber to the sub-conjunctival space. The results of this procedure are very promising. The combination of MICS surgery and filtration surgery with mini shunt ExPress can diminish postoperative refractive error and be very useful in diminishing the postoperative IOP values in glaucomatous and cataract eyes [20] (Fig. 1.21).

Our first results of combined surgery of MICS and mini shunt ExPress after 3 months of follow-up on 5 patients indicated that BCVA and IOP had statistically improved. Before surgery, BCVA was 0.36 and was

Fig. 1.21 Combined procedure of MICS and filtration surgery. The ExPress shunt implantation

improved to 0.85 after surgery. The media IOP before surgery was 23 mmHg and was reduced to 12.5 mmHg 3 months after surgery. The 46% of IOP reduction in glaucoma eyes is an excellent outcome. Further fol- low-up is necessary to confirm and evaluate this result. But these preliminary results are very promising (Tables 1.3 and 1.4). Other authors confirm usefulness, biocompatibility and beneficial effects of mini shunt ExPress [21, 22].

Table 1.3 Results in BCVA and UCVA changes during 3 months after MICS and mini ExPress shunt surgery

Table 1.4 Results in IOP changes during 3 months follow up

after MICS and mini ExPress shunt surgery

Intraocular pressure (mmHg)

1.3.5.20.7 mm MICS and 25-Gauge Transconjunctival Sutureless Vitrectomy

It is very difficult to obtain stable conditions during combined surgery of the anterior and posterior segments of the eye. The problems with incisions and IOP may still occur. In earlier cataract and vitrectomy surgery techniques, the vitrectomy infusion cannula was inserted before phacoemulsification. The need to reduce complications leads to the application of less traumatic small incision surgery. One of the authors (Amar Agarwal) was the first to apply the combination of two surgical techniques: Transconjunctival Sutureless Vitrectomy (TSV25) and 0.7 mm MICS [23, 24]. The 0.7 mm MICS incisions are small, stable and self-sealing. They are able to withstand high intravitreal pressure during vitrectomy without leakage, chamber shallowing or iris prolapse (Fig. 1.22). The

Fig. 1.22 Combined 0.7 mm MICS and 25-gauge transconjunctival sutureless vitrectomy. Self-sealing 0.7 mm MICS cataract incisions withstand high intravitreal pressure during vitrectomy without leakage, chamber shallowing, or iris prolapse [23]

problems of reduced resistance of the eye globe and the instability of the incisions during the infusion cannula insertion are not encountered with the 0.7 mm MICS technique at the first stage of vitrectomy.