Ординатура / Офтальмология / Английские материалы / Shields Textbook of Glaucoma, 6th edition_Allingham, Damji, Freedman_2010

27 - Principles of Medical Therapy and Management Page 245 of 267

rotate the processes into better view. Typical argon laser settings are 0.1 to 0.2 second, 100 to 200 µ m, and an energy level that is sufficient to produce white discoloration, as well as a brown concave burn, often with pigment dispersion or gas bubbles (usually 700 to 1000 mW). All visible portions of the ciliary process should be treated, which typically requires three to five applications per process. All visible processes should be treated

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up to a total of 180 degrees. Additional processes can be treated at subsequent sessions, if required. The reported results with transpupillary cyclophotocoagulation have been variable (102, 103, 104, 105, 106 and 107). Those cases in which the procedure fails may be due, in part, to the number of ciliary processes that can be visualized and treated and to the intensity of the laser burns to each process (102, 104). However, the number of treated processes and the intensity of treatment do not always correlate

with the extent of the IOP reduction (107). Another factor that may contribute to failure of transpupillary cyclophotocoagulation is the angle at which the processes are visualized gonioscopically. Even with scleral indentation, only the anterior tips of the ciliary ridges are usually exposed, preventing destruction of the entire ciliary process (107).

CYCLOCRYOTHERAPY

The use of a freezing source as the cyclodestructive element was suggested by Bietti (108) in 1950. Cyclocryotherapy was generally thought to be somewhat more predictable and less destructive than penetrating cyclodiathermy, and it gradually replaced the latter technique as the most commonly used cyclodestructive operation. It is still used by some surgeons, especially when laser technology is not readily available. Histologic studies of eyes treated with cyclocryotherapy show destruction of vascular, stromal, and epithelial elements of the ciliary processes with replacement by fibrous tissue (109). Mechanism of Action

Cyclocryotherapy presumably destroys the ability of ciliary processes to produce aqueous humor by the biphasic mechanism of intracellular ice crystal formation and ischemic necrosis (110). Initially, freezing of extracellular fluid concentrates the remaining solutes, which leads to cellular dehydration and is the probable mechanism of cell death associated with a slow freeze. When the rate of cooling is rapid, intracellular ice crystals develop. Although these crystals are not always lethal to the cell, a slow thaw leads to the formation of larger crystals, which are highly destructive to the cell by an uncertain mechanism. Maximum cell death is achieved with a rapid freeze and a slow thaw. A second and later mechanism of cryoinduced cell death is a superimposed hemorrhagic infarction, which results from obliteration of the microcirculation in the frozen tissue. Ischemic necrosis is the histologic hallmark of cryoinjured tissue.

In addition to decreasing the IOP, cyclocryotherapy may provide relief of pain by destroying corneal nerves. Wallerian degeneration of corneal nerve fibers was observed in rabbits following cyclocryotherapy, although regeneration began within 9 to 16 days (111).

Techniques Cryoinstruments

Nitrous oxide or carbon dioxide gas cryosurgical units may be used. The diameters of the more commonly used cryoprobe tips range from 1.5 to 4 mm, and it has been suggested that 2.5 mm may be optimum for cyclocryotherapy (112). A modified cryoprobe with a curved 3 × 6-mm tip has been developed to reduce the number of applications required (113). An automatic timer to monitor the duration of each application has also been described (114).

Cryoprobe Placement

With the 2.5-mm tip, placement of the anterior edge of the probe 1 mm from the corneolimbal junction temporally, inferiorly, and nasally, and 1.5 mm superiorly is believed to concentrate the maximum freezing effect over the ciliary processes (112) (Fig. 41.10). It has also been suggested that transillumination may be helpful by delineating the pars plicata (115, 116), although this is not usually necessary unless the anatomic landmarks are distorted, as with an eye that has buphthalmos. The cryoprobe should be applied with firm pressure on the sclera, because this may reduce ciliary blood

flow, thereby contributing to faster penetration of the ice ball to the ciliary processes (112). Number of Cryoapplications

Most surgeons treat two to three quadrants, with three to four cryoapplications per quadrant. A study in cats showed that graded cyclocryotherapy of 90, 180, or 270 degrees produced graded destruction of the ciliary epithelium and proportionally related changes in IOP and aqueous humor dynamics (117). The number of cryolesions may be based to a degree on preoperative parameters, such as the type of glaucoma, the IOP level, and the number of previous cyclocryotherapy procedures. It has also been shown that younger patients generally require a larger number of cryoapplications than older individuals do to achieve satisfactory pressure reduction (118). However, there are no precise guidelines by which an individual patient's response to therapy can be predicted, and it is best to err on the side of undertreatment rather than to run the risk of phthisis. One recommended approach is to limit each treatment session to six applications or fewer over 180 degrees of the globe (115).

Freezing Technique

Studies indicate that temperature levels warmer than -60°C to -80°C or a duration of freeze less than 60 seconds does not provide adequate destruction of the ciliary process, whereas values much greater than these increase the risk of phthisis (112). Most surgeons, therefore, prefer applications of-60°C to -8 0°C for 60 seconds (119). As previously noted, a rapid freeze and slow, unassisted thaw produce the maximum cell death (110). If the initial procedure does not adequately lower the IOP after approximately 1 month, cyclocryotherapy may be repeated one or more times as required. In one series, 14 of 61 eyes required two or more procedures (119).

Postoperative Management

For approximately the first 24 hours, the patient may experience intense pain, and use of strong analgesics is often required. It has been noted that use of subconjunctival steroids at the end of the procedure also minimizes the postoperative pain (115). In addition, frequent administration of topical corticosteroids and a cycloplegic-mydriatic agent should be used routinely, starting on

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the day of surgery. Because the IOP may remain elevated for 1 or more days after the treatment, it is advisable to keep the patient on the preoperative antiglaucoma medications, with the exception of miotics, until a pressure reduction is observed.

Figure 41.10 Cyclocryotherapy technique. A: The probe tip is placed roughly 2.5 mm from the limbus. The temperature at the probe tip is reduced to approximately -80°C and maintained for 60 seconds. B: Typical ice ball 30 seconds after initiating freezing. C: The probe is irrigated with saline solution before removing the probe from the conjunctiva. Note the hyperemia around the probe tip.

Complications

Transient Intraocular Pressure Elevation

A marked rise in IOP may occur during cyclocryotherapy and in the early postoperative period. In one study, pressures of 60 to 80 mm Hg were recorded in the freezing phase, with return to baseline during the thawing phase (120). The researchers in that study thought this component of IOP elevation was due to volumetric changes, possibly related to scleral contraction, and they described a technique for controlling the complication with manometric regulation of the pressure during surgery. They also noted a second IOP rise that averaged 50 mm Hg and peaked 6 hours after the procedure. The mechanism for this component of the IOP elevation is unclear but is probably associated with the marked inflammatory response. Gonioscopic evaluation after cyclocryotherapy revealed frozen aqueous humor in the anterior chamber angle (121), with the obvious consequences that this may have on the remaining conventional outflow system.

Uveitis

Uveitis occurs in all cases and is usually intense, with the frequent formation of a fibrin clot. Results of one study suggested that the inflammation is prostaglandin induced and might be minimized by pretreatment with aspirin (122). However, a comparison of topical flurbiprofen, dexamethasone, and placebo suggested that cyclocryotherapy-induced inflammation is difficult to control with any topical medication (123). A chronic aqueous flare usually persists because of permanent disruption of the blood-aqueous barrier (124), but this does not require treatment.

Pain

Pain, as previously noted, may be intense after cyclocryotherapy and may last for days. It is most likely a consequence of the IOP elevation and inflammation, both of which should be treated vigorously, along with the use of strong analgesics.

Hyphema

Hyphema is a common complication, especially in eyes with neovascular glaucoma, and usually clears with conservative management.

Hypotony

A major disadvantage of all cyclodestructive procedures is that nothing can be done to reverse the hypotony or phthisis, if it occurs. Although this complication is less common with cyclocryotherapy than with cyclophotocoagulation, it does occur and is best avoided by treating a limited area each time. It is far better to repeat the treatment several times than to produce phthis as a result of overtreatment. Other Complications

Other complications associated with cyclocryotherapy include choroidal detachment, which may lead to a flat anterior

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chamber (125). Intravitreal neovascularization from the ciliary body, with vitreous hemorrhage, may follow cyclocryotherapy and may regress after panretinal photocoagulation (126). Anterior segment ischemia has been reported in eyes with neovascular glaucoma after 360 degrees of cyclocryotherapy (127). Rare complications have included subretinal fibrosis, subluxation, and sympathetic ophthalmia (128, 129, 130 and 131).

Indications

Although cyclodestruction with laser is preferred to cryotherapy, cyclocryotherapy can be used for situations in which other glaucoma operations have repeatedly failed or in which the surgeon wishes to avoid incisional surgery. Conditions in which this procedure has been reported to have particular value include glaucoma after penetrating keratoplasty, chronic openangle glaucoma in an aphakic eye, and congenital glaucoma (118, 132, 133, 134, 135 and 136). Cyclocryotherapy is thought by some surgeons to be useful in the management of neovascular glaucoma, although others think that the main benefit of the surgery in this and other disorders is relief of pain.

KEY POINTS

Cyclodestructive operations decrease IOP by reducing aqueous inflow. The most commonly used methods for cycloablative therapy involve transscleral and endoscopic approaches.

Transscleral laser methods for cyclodestruction provide more precise tissue destruction with a significant reduction in complications compared with cyclocryotherapy. The opinion of the American Academy of Ophthalmology is that diode laser cyclophotocoagulation “appears to possess the best combination of effectiveness, portability, expense, and ease of use at this time” (56).

ECP offers distinct advantages over transscleral diode cyclophotocoagulation in the management of refractory pediatric and adult glaucomas. It permits selective treatment of the ciliary epithelium with minimal energy and less damage to underlying tissues. There is less risk of vision loss, hypotony, and phthisis. However, there is the potential for complications related to intraocular surgery.

Major indications for cyclodestructive surgery include the following:

refractory forms of glaucoma associated with neovascularization, trauma, aphakia, congenital glaucoma, uveitis, penetrating keratoplasty, silicone oil, conjunctival scarring, and others;

eyes with limited visual potential and uncontrolled IOP (although with ECP, eyes with reasonable visual potential can also be treated);

eyes without vision and that have pain, thought to be secondary to elevated IOP.

Complications associated with cyclodestructive procedures include conjunctival burns, anterior uveitis, vision loss, post operative pain, hyphema, vitreous hemorrhage, rise in IOP, hypotony, choroidal detachment, phthisis bulbi, malignant glaucoma, cataracts, and, rarely, sympathetic ophthalmia.

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Shields > SECTION III - Management of Glaucoma >

42 - Surgical Approaches for Coexisting Glaucoma and Cataract

Authors: Allingham, R. Rand

Title: Shields Textbook of Glaucoma, 6th Edition Copyright ©2011 Lippincott Williams & Wilkins

> Table of Contents > SECTION III - Management of Glaucoma > 42 - Surgical Approaches for Coexisting Glaucoma and Cataract

42

Surgical Approaches for Coexisting Glaucoma and Cataract

In the management of a patient with a visually significant cataract and coexisting glaucoma, there are three basic surgical approaches: (a) cataract extraction alone, which may need to be followed by a trabeculectomy later; (b) glaucoma filtering surgery alone, followed by cataract removal later (two-stage approach); and (c) combined cataract and glaucoma surgery. Combined procedures have certain advantages and disadvantages compared with the other two options. Compared with cataract surgery alone—which itself is associated with an increased risk for posterior capsule break in glaucomatous eyes, particularly when exfoliation is present (1, 2, 3 and 4)—combined procedures are associated with a greater risk for postoperative complications, such as increased inflammation, hyphema, hypotony, shallow anterior chambers, and choroidal detachments; however, they have the advantage of reducing early intraocular pressure (IOP) rise. Compared with filtering surgery alone, with or without subsequent cataract extraction, the combined procedures may have a lower chance of long-term glaucoma control, but have the obvious advantage of a single surgery instead of two. For these reasons, the surgeon should