Ординатура / Офтальмология / Английские материалы / Step by Step Minimally Invasive Glaucoma Surgery_Garg, Melamed, Bovet, Pajic, Carassa, Dada_2006
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372 Step by Step Minimally Invasive Glaucoma Surgery
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374 Step by Step Minimally Invasive Glaucoma Surgery
INTRODUCTION
The association of a primary open-angle glaucoma (POAG) and a cataract has led many ophthalmic surgeons to perform combined procedures, to treat the two diseases at the same time, in spite of the well-known hypotensive effect of catatact extraction alone, which seems to be limited in duration, rarely exceeding one year in actual glaucoma patients. Intraocular pressure (IOP) results were improved when going from extracapsular extraction to phacoemulsification, probably because of the reduction of the size of the incision, leading to less postoperative inflammation, but significant complications from hypotony were sometimes encountered after trabeculectomy associated to phacoemulsification. The combined procedure with deep sclerectomy and placement of a non-absorbable, hydrophilic acrylic drain (T-Flux®, IolTech Laboratories) is a safe procedure which can provide a sustained IOP reduction in glaucomatous eyes requiring cataract extraction.
SURGICAL TECHNIQUE
The combined surgery begins with cataract removal using phacoemulsification through a 2.8 mm clear-corneal incision followed by implantation of a foldable intraocular lens (IOL). Then the anterior chamber is refilled with the rest of the ophthalmic viscoelastic device (OVD) used for phacoemulsification (Fig. 23.1), in order to begin sclerectomy on a firm eye. The conjunctiva is opened at the limbus using Vannas scissors (Fig. 23.2); a superficial (one-third of the sclera) 4.5 × 4.5 mm scleral flap is dissected quite anteriorly using a disposable Crescent knife (Fig. 23.3). Then a trapezoidal profound flap is pre-cut (Fig. 23.4) with a disposable 15° blade and dissected with the Crescent knife. At this step, it is particularly important to enter
Combined Phacoemulsification & Deep Sclerectomy 375 
Fig. 23.1
Fig. 23.2
376 Step by Step Minimally Invasive Glaucoma Surgery
Fig. 23.3
Fig. 23.4
Combined Phacoemulsification & Deep Sclerectomy 377 
directly into the Schlemm’canal at the end of the dissection (Fig. 23.5). Next, Mitomycin-C at concentration 0.2 mg/ml is applied for one to two minute (Fig. 23.6), this time being used: first, to check the permeability of the two openings of the Schlemm’s canal with a trabeculotome (Fig. 23.7), or a Rycroft cannula, and secondly to remove the trabeculum of the inner wall of the Schlemm’s canal using the disposable capsulorhexis forceps (Fig. 23.8). This step is facilitated by the absence of aqueous outflow through the surgical wound from the trabecular area, as the anterior chamber is filled with the OVD (“dry technique”). After having carefully rinsed the Mitomycin-C, the nonabsorbable, hydrophilic acrylic drain is placed beneath the superficial scleral flap and embedded into the deep sclerectomy to create a permanent drainage space. No suture fixation is required, as the two lateral tips of the device enter the Schlemm’s canal (Fig. 23.9), preventing
Fig. 23.5
378 Step by Step Minimally Invasive Glaucoma Surgery
Fig. 23.6
Fig. 23.7
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Fig. 23.8
Fig. 23.9
380 Step by Step Minimally Invasive Glaucoma Surgery
any migration. There is also no need for suturing of the superficial flap; only two 10/0 Vicryl sutures are placed to close the conjunctiva at the limbus (Fig. 23.10). Finally, the OVD is completely aspirated beneath and below the IOL with the I/A cannula (Fig. 23.11).
PERSONAL STUDY
Here is presented a retrospective study of 200 consecutive eyes of 158 patients aged 72 ± 11 were operated on between September 2001, and November 2003. Follow-up for the group averaged 26 ± 8 months and ranged from 16 to 41 months. Prior to surgery, mean IOP was 19.2 ± 4.4 mm Hg and patients were using an average of 1.4 ± 0.9 glaucoma medications, with at least one medication being used in about 80 percent of eyes. The preoperative best distance corrected visual acuity (BCDVA) was 0.37 ± 0.24; the
Fig. 23.10
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Fig. 23.11
spherical equivalent was - 3.5 diopters ± 6.4 (-26 to +6 D) with 95 myopes > -1D (47.5%) and 34 hyperopes >+1D (17%). About one half of the eyes had POAG (Fig. 23.12).
The surgery was initially successful in all but one eye, which went on to trabeculectomy after six months. For the entire group, mean IOP was reduced to 13.1 + 6 mm Hg on the first postoperative day, remained at 13.6 mm Hg at 12 months, and was only slightly higher at 24 and 36 months (15.2 ± 3.3 mm Hg and 15.1 ± 3.3 mm Hg, respectively) (Fig. 23.13).
IOP control has been maintained without the need for goniopuncture in any eye and with minimal use of topical hypotensive medication. At the last available visit, medical therapy was being used in only 36 (21%) of 171 eyes. That treatment consisted of a single agent in 19 eyes, a betablocker plus a prostaglandin in 16 eyes, and 3 medications in a single eye. The postoperative BCDVA was