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

Very Deep Sclerectomy 353

Fig. 21.6: UBM after VDSCI. Hypoechoic areas in the suprachoroidal space indicative of uveoscleral outflow can be seen

the patient is seen on the first postoperative day, where a complete ophthalmic examination is performed, with particular attention given to the appearance of the bleb and the depth of anterior chamber. After that, the patient is seen weekly for the first month, and then at month 2 , 3, 6, and, finally every 6 months with visual field examinations every year.

We use a topical regimen of corticosteroids and antibiotics in the immediate postoperative period. Tobradex© (Tobramycin and Dexamethasone) is

354 Step by Step Minimally Invasive Glaucoma Surgery

Fig. 21.7: UBM after VDSCI. The suture securing the collagen implant can be seen

administered beginning on the first postoperative day. Drops are given every 6 hours during waking hours for at least four weeks. In the next stage, patients are treated with a non-steroidal anti-inflammatory drug for two months.

CONCLUSION

In our first study with up to12 months of follow-up, there is no statistically significant difference between very deep sclerectomy with a collagen implant and standard deep sclerectomy in terms of intraocular pressure, complete and

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qualified success rates, and reduction of number of medications. In VDSCI, UBM showed a statistically significant increase in amount of suprachoroidal effusion associated with a tendency towards smaller size of the subconjunctival bleb compared to DSCI. We therefore conclude that VDSCI might be a good alternative to standard penetrating surgery by decreasing the complications and discomfort related to the subconjunctival bleb. However, at this stage, longer follow-up is needed to assess the safety and efficacy of this new procedure.

REFERENCES

1.Stegmann RC. Visco-canalostomy: a new surgical technique for open angle glaucoma. An Inst Barraquer Spain 1995;25:229-32.

2.Kozlov VI, Bagrov SN, Anisimova SY, et al. Nonpenetrating deep sclerectomy with collagen. Eye Microsurg (Russian) 1995;3:44-46.

3.Watson PG, Jakeman C, Ozturk M, et al. The complications of trabeculectomy: a 20-year follow-up. Eye 1990;4:425-38.

4.Jonescu-Cuypers C, Jacobi P, Konen W, Krieglstein G. Primary viscocanalostomy versus trabeculectomy in white patients with open-angle glaucoma: A randomized clinical trial. Ophthalmology 2001 Feb;108(2):254-58.

5.Shaarawy T, Mansouri K, Schnyder C, Ravinet E, Achache F, Mermoud A. Long-term results of deep sclerectomy with collagen implant. J Cataract Refract Surg 2004 Jun; 30(6):1225-31.

6.Mermoud A, Schnyder CC, Sickenberg M, Chiou AG, Hediguer SE, Faggioni R. Comparison of deep sclerectomy with collagen implant and trabeculectomy in open-angle glaucoma. J Cataract Refract Surg 1999 Mar;25(3):323-31.

7.Bill A. The aqueous humor drainage mechanism in the cynomolgus monkey (Macaca irus) with evidence for unconventional routes. Invest Ophthalmol 1965 Oct; 4(5):911-19.

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8.Chiou AG, Mermoud A, Hédiguer SE, et al. Ultrasound biomicroscopy of eyes undergoing deep sclerectomy with collagen implant. Br J Ophthalmol 1996;80:541-44.

9.Shaarawy T, Flammer J, Smits G, Mermoud A. Low first postoperative day intraocular pressure as a positive prognostic indicator in deep sclerectomy. Br J Ophthalmol 2004 May;88(5):658-61.

10.Pavlin CJ, Sherar MD, Foster FS. Subsurface ultrasound microscopic imaging of the intact eye. Ophthalmology 1990 Feb;97(2):244-50.

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INTRODUCTION

Here we introduce a new concept in the primary therapy of glaucoma where a G-Probe of an Iris Medical Diode laser is used to treat glaucoma along with phacoemulsification on a primary basis, i.e. a first glaucoma procedure of choice!

MATERIALS AND METHODS

During the course of a year at the Mehta International Eye Institute Mumbai, 50 patients had combined phacoemulsification and G-probe performed in the same sitting for coexisting cataract and glaucoma. Only those patients with IOP>21 on maximum tolerated medication were chosen. A peribulbar block was given and the G –probe was applied for 24 applications circumferentially (1 for each clock hr) over the ciliary body at 2W for 2 seconds. Then clear corneal phaco was performed and an injectable intraocular lens implanted in all cases. The IOP was measured on day 1 week 1 and months 1, 3 and 6. All surgery was carried out by the same surgeon (CM) using the Alcon Infinity unit, Iris Medical Diode laser and G-Probe. Pressures were measured with Topcon-CT80 air puff tonometer (Figs 22.1 to 22.4).

CLASSIFICATION

Glaucoma surgery can be broadly classified into:

1.Cyclodestructive (reducing inflow). or

2.Filtering (increasing outflow): Filtration surgery, typically trabeculectomy and more recently, nonpenetrating techniqueshave usually been the procedure of choice as an initial intervention because of their efficacy and relative safety and predictability. Ciliary

G-Probe as Primary Glaucoma Procedure 361

destruction has been reserved for more refractory cases of glaucoma and in eyes which have little or no visual potential. Refractory or relatively “untreatable” glaucomas include neovascular glaucoma, posttraumatic angle recession glaucoma,aphakic glaucoma severe congenital/developmental glaucoma, postretinal surgery glaucoma especially with the use of silicon oil and glaucoma associated with penetrating keratoplasties.

In the past, cyclodestructive glaucoma procedures have been carried out by either surgical excision, diathermy, cryotherapy, or by laser. Laser cyclophotocoagulation has now become the principal method for what has been termed as “turning down the tap.” Beckman and Sugar pioneered the use of trans-scleral cyclophotocoagulation (TCP) thirty odd years ago. In the beginning they tried the procedure with a Ruby laser but they found that the (Nd:YAG) laser was more effective in penetrating the sclera and optimizing energy absorption by the ciliary epithelium. The delivery of laser energy through the sclera may be performed by either the non-contact or contact method. In the non-contact approach, a slit lamp is employed to apply laser energy through the conjunctival/scleral eyewall. The focus of energy delivery is 1–1.5 mm behind the limbus, through a contact lens so that maximal effect is at the level of the ciliary body. The total number of laser applications are usually about 32 (eight per quadrant), avoiding the 3 and 9 o’clock positions in order to preserve the long posterior ciliary arteries.

More recently, contact cyclophotocoagulation has gained favor as a preferred modality. Using the Nd:YAG laser (Surgical Laser Technologies (SLT), a hand-held sapphire tipped probe is placed on the conjunctiva and