SURGICAL THERAPY FOR GLAUCOMA PART 1 - SOG · PDF fileAndré Mermoud, MD Montchoisi...

André Mermoud, MD

Montchoisi Glaucoma Center

Lausanne

SURGICAL THERAPY FOR GLAUCOMA PART 1

Surgical Therapy for Glaucoma

• Trabeculectomy

• Deep sclerectomy

• Other MIGS (Minimally Invasive Glaucoma Surgery)

• Tubes

Surgical Therapy for Glaucoma

•Trabeculectomy • Deep sclerectomy

• Other MIGS (Minimally Invasive Glaucoma Surgery)

• Tubes

• Most frequent surgery for glaucoma worldwide

• Resection of deep sclerocorneal tissue (including Schlemm's canal)

• Fistula between the anterior chamber and the subconjunctival space

GENERAL

• size

• Shape

• Scleral depth

• Conjunctival incision: Limbal vs fornix

• Fix or releasable sutures

• Anti-metabolites

MODIFICATIONS

TRABECULECTOMY

SUCCESS RATE 90%

TRABECULECTOMY

SUCCESS FUNCTIONAL

RESULTS SUCCESS CRITERIA

FAILURE OF MEDICAL THERAPY

INAPPROPRIATE THERAPIES

TARGETED IOP NOT REACHED

ADVANCED STAGE OF DISEASE & NOT RESPONSIVE TO

MEDICAL THERAPY

INDICATIONS

PREMEDICATION

• Alprazolam IV

• Midazolam IV PERFUSION IN SURGERY

ROOM

Sedation

TOPIC

• Oxybuprocaine drops

• Lidocaine gel

PAIN

• Sub-conjunctival or sub- thenon Injection of lidocaine

ANESTHESIA

• TOPIC WITH SEDATION

LOCAL ANESTHESIA • Retro-ocular

• Peri-ocular

LIDOCAINE 2% + BUPIVACAINE

0,5%

AVOID EYE COMPRESSION

Prejudicial when Visual field is very damaged

ANESTHESIA

CONJUNCTIVAL EXAMINATION GONIOSCOPY EXAMINATION

SURGICAL TECHNIQUE

• Corneal traction

• Silk 6 or 7/0

• Globe tilted to expose the superior quadrant

GLOBE EXPOSITION

LIM

BA

L B

ASE

D

• Smaller filtering bleb

• Ring of steal

FOR

NIX

BA

SED

• Biger filtering bleb

• More Leaking blebs

CONJUNCTIVAL INCISION

SCLERAL FLAP

3 x 4 mm • Variable shape

USE A CRESCENT BLADE

• Dissect until

transparent

sclero-corneal

zone

DEPTH: 2/3 OF SCLERAL THICKNESS

• Slow eye decompression

• BSS injection if IOP too

low

15 DEGREE BLADE SYSTEMATIC

PARACENTESES

OPENING OF THE ANTERIOR CHAMBER

Perpendicular blade

• Trans lucid zone is anterior of Schlemm’s canal

Vannas scissors

«Punch»

TRABECULECTOMY

AVOID CILIARY BODY AND THE MAJOR IRIS CERCLE

Avoid incarceration of iris root

into the trabeculectomy

dissection

• Radial

• Full thickness

BASAL IRIDECTOMY

WATERTIGHT

• Nylon 10/0

NUMBER

• Adjusted according to aqueous flow after injecting BSS in the AC through the paracentesis

DON'T USE SYSTEMATICALLY VISCOELASTIC SUBSTANCE

SCLERAL FLAP SUTURE

• Thin resorbable suture

• Small atraumatic round body

needle

• Single Running suture

• Or 2 running lateral sutures

LIMBUS

(OR POSTERIOR)

CONJUNCTIVAL SUTURE

BSS INJECTION

• Filtering bleb formation

• Tension on conjunctival suture

• Water tightness

• Add conjunctival suture if needed

END OF INTERVENTION

ATROPINE 1%

CYCLO-PLEGIC

MALIGNANT GLAUCOMA PREVENTION

ANTIBIOTICS CORTICOSTEROID

STEROIDS (ANTI-INFLAMMATORY THERAPY)

Several weeks

6-12 weeks

Regressive posology

NSAI

From the 4th week for 3-4 months

ANTIBIOTICS

AS LONG AS CONJUNCTIVAL SUTURES

ARE IN PLACE

To avoid infectious

complications

POST-OP CARE

SCARING BLEB FORMATION

MYDRIASIS CYCLOPLEGICS (ATROPINE)

• Malignant glaucoma with ciliary body block

• In shallow anterior chambers

ANTI-INFLAMMATORY RX

AND/OR

ANTIMETABOLITES INJECTIONS (MMC OR 5-F-U)

• Cicatrisation

POST–OP CARE

MITOMYCIN-C (MMC) 5-FLUOROURACIL (5-FU)

ANTI-METABOLITES

RISK FACTORS

LOW IOP CHOICE OF SUBSTANCE

DOSE

ANTI-METABOLITES

• To get low post-op IOP CICATRISATION

ANTI-METABOLITES

RISK FACTORS

• Young age

• African origin, middle eastern, Hispanics

• Inflammatory diseases of the eye

• Long term topical treatment

• Aphakic

• Recent eye surgery

• Any conjunctival surgery

• Failed glaucoma surgery

• Neovascular glaucoma

• Corneal erosions

• Epitheliopathy

• Late hypotony

• Bleb leaks

• Blebitis

• Endophthalmitis

RISKS OF COMPLICATIONS

AFTER ANTIMETABOLITES

INJECTIONS

ANTI-METABOLITES

5-FU INTRA-OPERATIVE

• 25-50mg/ml (not diluted)

• On sponge

• 5 min

• Wash: 20ml SBS

POST-OPERATIVE

• Check for corneal erosion

• 0,1ml (not diluted solution 50mg/ml)

• Around the bleb, 30G + insulin syringe

• Avoid reflux to prevent corneal

erosion

• Repeat every day

ANTI-METABOLITES - ADMINISTRATION

MMC INTRA-OPERATIVE

• 0,02mg/ml

• On 1-3 sponges

• Avoid too near the scleral flap (risk of

intra-cameral injection)

• 1-5 min

• Wash: 20ml BSS

POST-OPERATIVE

• 0,1ml (0,02mg/ml)

• Around the bleb, 30G + insulin

syringe

• Wash 10 ml BSS

• Once per week

ANTI-METABOLITES - ADMINISTRATION

GLAUCOMA SURGERY COMPLICATIONS

PEROPERATIVE

EARLY POST-OPERATIVE

LATE POST-OPERATIVE

PERIOPERATIVE COMPLICATIONS

TRACTION SUTURE

SUPERFICIAL

Break

Replacement

DEEP

Corneal

Perforation

BSS Injection

GLOBE EXPOSITION


• Button holes during the dissection

• Aqueous humor leakage

• Sutured (8/0 or 10/0, round body needle)

THIN AND/OR FIBROSED

CONJUNCTIVAL


TOO THIN

• Break

• Sutured or re-dissected ?

• Tutoplast graft

TOO THICK

• Viewing of ciliary body

• Ok in absence of perforation

SCLERAL FLAP


- Dissection

- anticoagulants, antiplatelets,

capillary fragility, preoperative

conjunctival hyperemia

- Aqueous hemostasis

PERIOPERATIVE HEMORRHAGES

CONJUNCTIVAL


Bleeding at the scleral flap

- Tamponade

Iridectomy

- Anterior chamber washing

- Tamponade by viscoelastic product

PERIOPERATIVE HEMORRHAGES

SCLERAL


Uveal effusion

Athalamy with hypertony

- Slow globe decompensation

- Osmotic agents

Expulsive hemorrhage

- Posterior sclerectomy (3mm from limbus)

UVEAL EFFUSION AND HEMORRHAGE

• Spontaneous reabsorption CONJUNCTIVAL, SUB-

CONJUNCTIVAL, INTRACAMERULAR (HYPHEMA)

• More severe

• High myopia SUPRACHOROIDAL

• Semi-sit position

• Anti-inflammatories

• Mydriatics HYPHEMA

EARLY POSTOPERATIVE COMPLICATIONS

PREVENTION Interrupt oral antiplatelet and/or anticoagulant medication

HEMORRHAGES

• Aphakia

• Sturge-Weber Syndrome

• Nanophtalmia

• High hyperopia


UVEAL EFFUSION

SEROUS HEMORRHAGIC MIXED CHOROIDAL HEMATOMA

CHOROIDAL DETACHMENT

• Hypotony

• Compression of vorticose veins

CILIARY BODY DETACHMENT

• Reduction in aqueous humor production

• Risk of infection

• Stop corticosteroids

• Antibiotics

• Bandage

• Large diameter soft contact lens

• Nd:YAG laser

• Biologic glue

• Autologous blood injection

• Secondary sutures


AQUEOUS HUMOR LEAKAGE

TYPE SITE

DIMENSION

CONJUNCTIVAL SUTURE CONJUNCTIVAL GRAFT

PREVENTED BY INSTILLING ANTI-INFLAMMATORY DROPS

Steroids in case of no steroid-response phenomenon

May induce:

Posterior Synechias

Cataract

Protein or cellular AC flair


INFLAMMATION

• Local Anesthetic

• Contact Lens (Hoskins, Mandelkorn, Posner)

• Laser (argon or diode)

• 0,05s

• 50μ

• 800-1200 mW

CUTTING OF A SCLERAL FLAP SUTURE BY ARGON LASER

OCULAR MASSAGE


FLAP TOO TIGHT

OCULAR HYPERTONY

FLAT BLEB

MEDICAL

TREATMENT

• Cycloplegia

SURGERY

• Suture on scleral flap

PREVENTION

• Sutures on the scleral flap

• Releasable sutures


FLAP TOO LOOSE

HYPOTONY

SHALLOW ANTERIOR CHAMBER

• Iris incarceration

• Ocular hypertony

Nd:YAG Laser • Base of the

synechia

ARGON LASER • Iris retraction


INTERNAL OBSTRUCTION

MAIN FILTRATION SURGERY COMPLICATION

Fibroblastic Proliferation

Epithelialization + contraction

CYSTIC OR ENCAPSULATED BLEB (15%)

Anti-inflmmatory treatment 3 weeks

before

Needling + anti-inflammatories /

anti-metabolites


SUB-CONJUNCTIVAL FIBROSIS

• Vascularization

• Corkscrew vessels

• Closure of the conjunctival suture

• Elevation

• Bleb area and extension

• Thickness of bleb wall

• Avascular areas (cystic blebs)

• Sub-conjunctival blood

• Microcysts

• Bleb leakage (early / late)

• Water bubble in the blood vessels

BLEB EVALUATION

• Slit lamp / Operating room

• Topical anesthesia

• Antibiotics and/or povidone-iodine

• Phenylephrine (or apraclonidine)

• 30G

• Anesthesia to detach conjunctiva

• Enter through lateral wall of cystic bleb

• Lowering of cyst– IOP controlled

Antimetabolite


SUB-CONJUNCTIVAL FIBROSIS- NEEDLING

Late phase (high IOP)

Bleb encapsulation

Needling of encysted filtering bleb

Ideal filtering bleb

Diffused subconjunctival

filtering bleb

Microcyst formation

Fibrosis of the filtering bleb

Subconjunctival antimetabolite injection

Mitomycin-C 0.1 cc (0.2 mg/ml)

5-Fluorouracil (5mg)

Others (AntiTGFβ

Taxol Gêne ttt)

• Hypermetropia

• Narrow angle

RISK FACTORS

• Painful red eye

• Very shallow or absent (athalamy) anterior

chamber

• Very high or normal IOP

• Iridectomy blocked by anterior crystalloid

CLINICAL


MALIGNANT GLAUCOMA

INTRA-OCULAR INFECTION RISK

CREATE COMMUNICATION BETWEEN ANTERIOR CHAMBER AND SUB-CONJUNCTIVAL SPACE

> THAN CATARACT SURGERY

• 0,1-0,2%


ENDOPHTHALMITIS

Very excavated optic discs and advanced visual field defects

0,5% of eyes are at risk

+++ fixation point moved vertically


VISUAL FIELD AND/OR OF FIXATION POINT LOSS

• Direct surgical traumatism

• Shallow anterior chamber

• Cornea-lens contact

• Pre-existing lens opacities

• Steroids (prolonged use)

• Uveitis

• Myotics

LATE POSTOPERATIVE COMPLICATIONS

CATARACT

VISION LOSS RISK

• Hypotony maculopathy

• Choroidal folds

• Optic nerve edema

• Alteration of central vision

+++ FILTRATION BLEB LEAKAGE + ANTIMETABOLITES

• Infection risk

TREATMENT

• Autologous blood injection in bleb

• Surgical repair of the bleb


HYPOTONY- LATE ENDOPHTHALMITIS

PROMINENT

BOTHERING DAILY LIFE ACTIVITIES

• Visual acuity fluctuations

• Dysesthesia due to bad distribution of the tear film

CORNEAL IMPACT • Ulceration by the bleb (dellen)

• Esthetical problems


BLEB DISCOMFORT

LUBRICANT

SUTURE

SURGERY

SURGICAL THERAPY FOR GLAUCOMA PART 1 - SOG · PDF fileAndré Mermoud, MD Montchoisi...

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