Ординатура / Офтальмология / Английские материалы / Step by Step Minimally Invasive Glaucoma Surgery_Garg, Melamed, Bovet, Pajic, Carassa, Dada_2006

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7.In case of glaucoma implant the implant should be inserted at this level of the surgery and sutures to sclera as in conventional deep sclerectomy.14

8.The flap is gently laid in its normal anatomic position (Fig. 12.12). Two 10-0 nylon stitches were placed at both edges of the superficial flap and tied fairly (not very tight and not very loose). The suture ends were cut and the knots were parried to prevent the suture tips from eroding the conjunctiva. After closing the scleral flap repositioning of the conjunctiva was then done with 2 lateral 10/0 nylon stitches (Figs 12.13 to 12.15).

Fig. 12.12: The scleral flap is reposted at the end of the surgery

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Fig. 12.15: The diffuse filtering bleb as appeared at the end of the 6th month in group II

POSTOPERATIVE FOLLOW-UP

Treatment

Antibiotic-steroidal combination; Tobradex® (Lab Alcon Cusi, Inc. Barcelona. Spain) eyedrops were instilled postoperatively 4 times daily for 1 week and slowly withdrawn over one month period. No viscoelastics was injected into the Schlemm canal, and the procedure was completed without the use of collagen device or mitomycin C at any stage of the surgery in our series.

Follow-up

Patients were scheduled for follow-up visits at 1 day, 1 week then 1, 3 and 6 months after surgery. The postoperative evaluation included the IOP, presence of

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functioning bleb, gonioscopy, visual acuity status and possible surgical and postoperative complications.

RESULTS

The study performed by the authors included 41 eyes (41 patients). The mean age of the patients was 67.9 ± 10.9 (range 50 to 80) years. The preoperative diagnoses had confirmed that all eyes have medically uncontrolled primary open-angle glaucoma. The mean preoperative cup/disk ratio was 0.7 ± 0.25. The mean angle grading as reported by gonioscopic findings was 3.6 ± 0.61 according to shaffer grading system.

The eyes were divided into 2 groups: group I (20 eyes) underwent milling procedure and group II (21 eyes) underwent combined procedure, milling and phacoemulsification procedures. In both groups, the milling procedure was done without the use of collagen device or MMC. The other eye of each patient was operated by conventional deep sclerectomy and combined phaco and deep sclerectomy and their results are behind the scope of this chapter.

The past medical history of the patients included hypertension in 36 percent patients, and one patient had history of diabetes mellitus. Among the eyes included in the study, 23.7 percent had history of cataract extraction and IOL implantation, 7.2 percent had history of previous glaucoma surgery (deep sclerectomy). Preoperative history of anti-glaucoma therapy is shown in Figures 12.16A and B.

The study included 16 eyes (10 right and 6 left) of 13 patients. The mean age of the patients was 67.9 ± 10.9 (range 50 to 80) years. The patients included female, and 8 male. All eyes were diagnosed as having primary open angle glaucoma medically uncontrolled. Only one eye 1/16

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(6.25%) had a previous unsuccessful glaucoma surgery (deep sclerectomy). The data of the 6th month postoperative visits are available for 100 percent of the eyes, and those for the 1st year follow up visits are available only for 37.5 percent of the eyes.

Group I (Milling Procedure)

Visual results and refractive results of this group: refer to Table 12.1. Intraocular pressure (IOP) and its results during the study are shown in Table 12.2. Figure 12.17 shows the IOP results of both groups during the follow-up period of the study.

Table 12.1: Shows the results of group I, milling trabeculoplasty

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Group II (Milling Procedure combined with Phaco)

Visual results and refractive results of this group: refer to Table 12.3. Intraocular pressure (IOP) and its results during the study are shown in Table 12.4. Figure 12.17 shows the IOP results of both groups during the follow-up period of the study.

DISCUSSION

Non-penetrating glaucoma surgeries including viscocanalostomy and deep sclerectomy are difficult to perform, need a high learning curve and time consuming. In both non-penetrating glaucoma surgeries and milling

Table 12.3: Shows the results of group II, milling trabeculoplasty plus phacoemulsification at the same session

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Table 12.4: Shows the results of IOP in group II, milling trabeculoplasty plus phacoemulsification at the same session

surgery, both the postoperative recovery and follow-up are faster and the level of IOP reduction achieved is satisfactory when compared with the results of trabeculectomy.

Milling trabeculoplasty in this prospective, pilot study on 41 eyes has shown good results as it led to a 30-40 percent reduction of IOP in both groups operated with the technique. The percent of success of surgery at the 6th month without the use of collagen device or MMC was 60 percent for group I and 80 percent for group II (Fig. 12.18). The rate of postoperative bleb fibrosis and the use of postoperative anti-glaucoma therapy was found to be similar to that found with deep sclerectomy.

The followings are the potential advantages of the Milling trabecuoloplasty over the non-penetrating glaucoma surgeries:

1.Facilitate the surgical procedure of nonpenetrating technique as the refining is carried anteriorly and down until the roof of Schlemm´s canal can barely be visible. Unlike deep non-penetrating sclerectomy,