Ординатура / Офтальмология / Английские материалы / Step by Step Minimally Invasive Glaucoma Surgery_Garg, Melamed, Bovet, Pajic, Carassa, Dada_2006
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332 Step by Step Minimally Invasive Glaucoma Surgery
shape allowing the conjunctival flap to relax in the opening.
•Exposing the sclera by dissecting Tenon’s capsule with care.
•Use the lightest possible electrocoagulation in order to spare the draining vessels as much as possible.
Incision of the scleral flap
•6 × 4 mm, the width being of less importance than the length
•depth of 300 microns, cut with a 30º diamond (Meyco, Switzerland) or with a diamond for KR (Meyco, Switzerland) up to the lames corneostromales.
It is important to make a flap which is thick enough
not to tear when one arrives in the corneal stroma (Fig. 20.2).
It is important to dissect the lames corneennes, starting from the limb, the cut allowing more room when making the incision of the second flap.
Fig. 20.2
Bimanual Microphaco and Deep Sclerocanalostomy 333 
2nd Stage: Cataract
Bimanual Microphaco 19G
Two paracenteses are made at temporal level, with a 20 gauge diamond knife. Then we make an intracameral injection of a solution of lidocaine diluted 0.2 percent without preservative. This allows the iris to be anesthetized in case of mobilization.
Enlargement of the 2 paracenteses to exactly 1.2 mm 19G (Fig. 20.3) and filling the anterior chamber with viscous.
Capsulorhexis
Capsulorhexis with a special capsulorhexis cannula (Fig. 20.4).
Fig. 20.3
334 Step by Step Minimally Invasive Glaucoma Surgery
Fig. 20.4
Hydrodissection and hydrodelineation of the nucleus and the epinucleus. Penetration in the anterior chamber, first with a Nagahara irrigation cannula of 19G, then introduction of our phacotip of 0.9 mm diameter, without sock. The difference between 19G (1,2 mm) and 0.9 mm allows complete cooling of the cannula (Fig. 20.5).
Any type of phaco-emulsification machine can be used for this new procedure, but the most appropriate are the machines that allow a strong aspiration mixing the peristaltic rotative force with the force of the Venturi pump.
Parameters
The parameters are the following:-
•Irrigation 65 cc/min
•Aspiration strength minimal 150 mm Hg
•Power 40 percent
Bimanual Microphaco and Deep Sclerocanalostomy 335 
Fig. 20.5
Flip and Chop Phacoemulsification
Flip and chop phacoemulsification technique, after having aspirated the viscous and the superior cortex: We first make a groove using maximum aspiration, then we lift the nucleus slightly in order to pass the irrigation cannula behind it and break it into 1/8 slices that are each sucked up as we go along. We repeat this procedure until we have emulsified the nucleus in its entirety.17
In order to avoid the collapse of the chamber, first, we remove the phacotip and only after that, do we remove the Nagahara irrigation chopper.
Then, we introduce the irrigation-aspiration cannula (de Duet 19G) to aspirate the cortex and occasionally the rest of the nucleus. Once this procedure is done, we fill up the anterior chamber with viscous (Fig. 20.6).
336 Step by Step Minimally Invasive Glaucoma Surgery
Fig. 20.6
Lens Implantation
We enlarge the paracentisis from 1.2 to 1.7 mm and an acrylic hydrophobe and hydrophile Acri Smart 36a implant is injected (Acritec Germany, inserted in a silicone special capsule), This enables us to avoid introducing the capsule into the anterior chamber and to inject solely the implant (Fig. 20.7).
The implant is very easily positioned in the anterior chamber.
Once the implant is in situ, we leave in the viscous and proceed to the second stage of the glaucoma operation.
3rd Stage Glaucoma
2nd Scleral Flap
5 mm dissection, with a 30º diamond knife (Meyco, Switzerland), of the length of the second triangular flap of
Bimanual Microphaco and Deep Sclerocanalostomy 337 
Fig. 20.7
all the depth of the sclera leaving some scleral plates in order to just reveal the choroidien tissue. This allows getting exactly at the scleral spur, at the beginning of Descemet’s membrane (Fig. 20.8).
Dissection, holding on to the second flap, with a triangular swab in order to push back the stroma. In this way, we free Descemet’s membrane. Those who practice deep lamellar keratoplasty (“keratoplastie lamellaire”) operations will have no difficulty in finding the plane of dissection.
Separation of the Descemet from the stromal tissue is quite easy, so long as one is in the right plane.
The 1.5 mm incision in Descemet’s membrane is made in order that the Schlemm canal is not covered at the time of the cutting of the flap.
338 Step by Step Minimally Invasive Glaucoma Surgery
Fig. 20.8
On this level, each side, in the scleral tissue, a slight bleeding can be seen at the cut in the drainage vein of the Schlemm canal.
Removal of the second flap with the diamond.
This part of the operation is delicate and has to be done with great care. Because, on a number of occasions, when using Vannas or other scissors, Descemet’s membrane has been torn (Fig. 20.9).
Cut up the scleral flap in half: one half is soaked for 5 minutes in 0.04 percent mytomicin, then rinsed.
Schlemm canal dissection: Using Bonn forceps with micro teeth, a 5 mm dissection of the interior wall of the Schlemm canal is made, allowing us to see some seepage of the aqueous humor.
Canalostomy: The Schlemm canal vein gives the location of the Schlemm canal. Introduction of an extra fine
Bimanual Microphaco and Deep Sclerocanalostomy 339 
Fig. 20.9
Grieshaber cannula on both sides of the sclera of the Schlemm canal until some resistance is felt. Slow injection of high viscosity viscous (Healon, G V AMO) whilst removing the microcatheter (Fig. 20.10).16,14
Implant/Mitomycine C: Put in place, in the bed of the second flap, the previously prepared implant, the implant having been, beforehand, soaked in Mitomycine and rinsed before being used.1,13
Close the first flap with inverted stitches using nylon 10.0, at each corner of the flap pulling the stitches tight.
Close the conjunctive with 3 inverted stitches using 9.0 re-absorbable thread (Fig. 20.11).
Remove the viscous from the anterior chamber, and also from behind the lens, in order to avoid any of the viscous remaining. Any left remaining could cause postoperative hypertension.
340 Step by Step Minimally Invasive Glaucoma Surgery
Fig. 20.10
POSTOPERATIVE TREATMENT
This combined operation, is carried out as ambulatory surgery and with local anesthetic, there is no need to cover the eye with a dressing.
Patients are treated with cortisone and antibiotic drops. Dosage is 1 drop 3 x a day for 3 weeks.
POSTOPERATIVE CHECK-UPS
The postoperative follow-up must be rigorous.
The patient is checked, one hour after the operation, before leaving the clinic, after 1 day, 1 week, and 1 month.
Bimanual Microphaco and Deep Sclerocanalostomy 341 
Fig. 20.11
Usually, all eye hypotensor treatments are stopped, even if it is necessary for them to be re-introduced at a later date.
The filtration bubble that is found when trabectomy is used, does not exist using this technique. As a result, the patient has to be checked controlling the ocular tension in both the eyes. If possible, the measure has to be taken each time at the same hour, in order to avoid obtaining distorted results because of the curve of the nychthemeral ocular pressure.
Patients who are cortisone respondent need particularly special attention.
Continuous check-ups to control postoperative pressure are necessary in cases of glaucoma.