Phacoemulsification-deep sclerotomy converted to phacotrabeculectomy

Our Experience of Deep Sclerectomy at a Tertiary Center in the United Kingdom Over 14 Years

Background Deep sclerectomy (DS) is a non-penetrating surgical procedure for glaucoma, reducing the resistance to aqueous outflow and lowering intraocular pressure while maintaining a physiological barrier between the anterior chamber and the sub-scleral space. This offers a lower complication profile than penetrating procedures, though with less intraocular pressure (IOP) reduction. Methods We retrospectively reviewed the electronic record for all DS undertaken at our hospital (a tertiary care center) over 14 years, collecting data on demographics, diagnosis, IOP, visual acuity, complications, medications, and further procedures required. Results Eighty eyes of 69 patients underwent DS, with a mean follow-up period of 53.5 months. The mean pre-operative IOP was 23.55 mmHg (range 11-52, standard deviation 8.46); the mean final IOP was 13.61 mmHg (range 5-35, SD 4.73), with a mean reduction of 42.21%. The mean change in glaucoma medications was -1.64. 78.40% experienced a reduction in glaucoma treatment. Post-operatively, 43.80% had no complications; this improved to 85.0% when numerical hypotony and raised IOP without visual sequelae were excluded. Further procedures required included Nd:YAG goniopuncture (10%), bleb needling (13.75%) or revision (7.5%), iridectomy (3.75%), goniosynechiolysis (1.25%), and autologous blood injection (1.25%). Two eyes were converted to trabeculectomy peri-operatively, with seven overall (8.75%) requiring trabeculectomy over the course of follow-up. 3.75% underwent glaucoma drainage device implantation, and 3.75% underwent cyclodiode laser. Conclusion We have found DS to be a safe, effective procedure for selected patients where trabeculectomy has a high likelihood of failure or where a higher IOP can be tolerated.

Differences in Corneal Biomechanics in Nonpenetrating Deep Sclerectomy and Deep Sclerectomy Reconverted into Trabeculectomy

PURPOSE

To evaluate the differences in intraocular pressure (IOP) and in corneal biomechanics in eyes with uneventful nonpenetrating deep sclerectomy (NPDS) in 1 eye and with intended deep sclerectomy reconverted into trabeculectomy (RIT) in the fellow eye of the same patient.

PARTICIPANTS

Forty eyes of 20 patients with both types of glaucoma surgery and more than 6 months of follow-up, and 31 eyes of 50 controls.

METHODS

IOP was assessed with Goldmann applanation tonometry (GAT), ocular response analizer (ORA), and dynamic contour tonometer (DCT). Student t test for independent samples and a univariate generalized estimating equations model were used to analyze the results.

MAIN OUTCOME MEASURES

Overall, no significant differences were found between IOP of NPDS and RIT eyes when measured with 3 tonometers.

RESULTS

Although NPDS showed lower values of IOP measured with GAT and ORA, RIT presented lower IOP if DCT is the chosen tonometry. Biomechanically, NPDS eyes had higher corneal hysteresis (CH) and corneal resistance factor (CRF). When compared with control patients, eyes that underwent glaucoma surgery had lower IOP using GAT, DCT and ORA (P<0.001, 0.315, and 0.260, respectively), and lower CRF (P<0.001).

CONCLUSIONS

Eyes with NPDS tended to have higher values of CH and CRF and lower IOP than RIT eyes, as measured with 3 of 4 tonometry methods; these differences did not reach statistical significance.

Phacoemulsification combined with deep sclerectomy augmented with mitomycin and amniotic membrane implantation in chronic primary open angle glaucoma with cataract

OBJECTIVE

The aim of this study was to determine the safety and efficacy of combined phacoemulsification plus Intraocular lens (IOL) implantation with deep sclerectomy augmented with mitomycin C (MMC) and sub-flap implantation of amniotic membrane for the management of uncontrolled, chronic, primary open-angle glaucoma patients.

METHODS

This prospective study included 41 patients with chronic, primary, open-angle glaucoma and cataract uncontrolled with medical treatment who underwent combined phacoemulsification augmented with mitomycin C (MMC) application and amniotic membrane implantation under the scleral flap. Intraocular pressure (IOP), visual acuity, glaucoma medications, stabilization of visual field, complications, and viability of the success rate were assessed a 36-month follow-up period.

RESULTS

The mean age of cases was 54.8 ± 5.3 years. Sixty-one percent of cases were males, and 39% were females. The mean IOP decreased from 23.8 ± 1.8 mmHg preoperatively to 16.8 ± 2.3 mmHg postoperatively. The overall success rate was 97.5, 95, and 92.7% in the first, second, and third year, respectively. The overall success rate was 90% in the first year, but that decreased to 85.3 and 78% in the second and third year, respectively. Qualified success was 7.5, 10, and 14.7% in the first, second, and third year, respectively. Failure was recorded as 2.5, 5, and 7.3% in the first, second, and third year, respectively. IOP reduction was sustained through the follow-up period. Visual acuity improved from 0.13 ± 0.06 to 0.9 ± 0.07 (p < 0.001). The visual field improved significantly in the first assessment, from 14.0 ± 2.7 preoperatively to 12.6 ± 2.6 at three months postoperatively (p < 0.001), after which it became stable for the remainder of the follow-up period. One hundred percent of cases were on three anti-glaucoma drugs preoperatively, while postoperatively, 12.2% were on three drugs, 4.2% were on two drugs, and 82.9% were controlled without anti-glaucoma treatment. There were minor postoperative complications all of which were minor, such as a spike in the post-operative IOP and the formation of fibrinous material in the anterior chamber, both of which were treated medically without any adverse effects on the final results.

CONCLUSION

Amniotic membrane implantation in conjunction with MMC application may be an effective alternative to expensive implants in deep sclerectomy combined with phacoemulsification, and this approach can be used safely in advanced cases.

Phacoemulsification-deep sclerectomy modified by trabeculum microperforations and implantation of lens anterior capsule as autologous scleral implant

OBJECTIVE

To evaluate the efficacy and safety of Phacoemulsification-deep sclerectomy modified by trabeculum microperforations and anterior lens capsule as autologous scleral implant (mPDS) for open-angle glaucoma.

RESEARCH DESIGN AND METHOD

A case series study comprised 127 patients and 127 eyes after mPDS. The applied modification of deep sclerectomy consisted in creating microperforations within the posterior trabeculum and in fixing the anterior lens capsule, removed during phacoemulsification, in the scleral lake as an autologous intrascleral implant. Primary open-angle glaucoma without satisfying intraocular pressure (IOP) control (>or=21 mmHg) despite maximally tolerated medications or with progression of visual field and cataract was the indication for surgery. For statistical analyses paired Student's t-test, the Wilcoxon signed rank test and one-dimensional ANOVA with repeated measures were used; survival analysis was performed using the Kaplan-Meier method.

MAIN OUTCOME MEASURES

IOP, number of medications and best corrected visual acuity (BCVA) were examined. On the basis of the assessment of the anterior and posterior segments of the eye, the character and also the degree of intensification of postoperative complications were established. Follow-up examinations were performed on days 1 and 7, and at 1, 3, 6, 12, 18 and 24 months and thereafter every 6 months. The complete success rate was defined as IOP <or= 18 mmHg without, and the qualified success rate as IOP <or= 18 mmHg with and without antiglaucoma medications.

RESULTS

The mean follow-up was 32.2 +/- 9.1 months. Mean IOP decreased by 30.4%. Mean IOP decreased from 20.1 +/- 5.1 to 14.0 +/- 2.9 mmHg (p < 0.001). The mean number of medications was reduced from 2.2 +/- 0.7 to 0.6 +/- 0.8 (p < 0.001). Complete and qualified success rates were 74.4 % and 93.3 %, respectively. Mean logMAR of BCVA changed from 0.52 +/- 0.40 to 0.16 +/- 0.16 (p < 0.001). Subconjunctival 5-FU injections together with suturolysis because of bleb fibrosis were performed in 20 eyes, which represented 15.7% of the cases operated on. 5-FU-induced complications involved corneal epitheliopathy in nine eyes (7.1 % of cases) and irregular astigmatism in one eye (0.8% of cases). Among early complications the most frequent was transient hypotony observed in 55 eyes (41.7% of cases).

LIMITATIONS

The explanation of the role of the anterior capsule in the mechanism of mPDS requires inclusion into the study of histological observations of surgeries performed on an animal model as well as prospective ultrasound biomicroscopy (UBM) examinations performed in humans.

CONCLUSIONS

Phacoemulsification-deep sclerectomy modified by trabecular microperforations and anterior capsule as a scleral implant lead to an effective decrease in the IOP in medium-term follow-up. The profile of the observed complications indicates that it can be a safe procedure. However, a larger group of patients should be observed to confirm this.

Surgical strategies in patients with cataract and glaucoma

PURPOSE OF REVIEW

This review analyzes the most relevant studies on current surgical strategies to treat glaucoma patients with cataracts.

RECENT FINDINGS

No clear evidence has confirmed better results with trabeculectomy alone compared with phacotrabeculectomy. Recent studies have reported successful outcomes combining deep sclerectomy and two-site phacoemulsification. The phacoemulsification cataract extraction will not vary the intraocular pressure of patients with previous deep sclerectomy. Mitomycin C proved to be effective in maintaining lower pressure levels with the combined surgery technique; however, 5-fluorouracil did not show any improvement. Minimally invasive cataract surgery reduces surgical trauma, making it possible to obtain better results with combined surgery and previous glaucoma surgery.

SUMMARY

The surgical strategy decision must be customized to every patient. Only filtering surgeries are recommended in glaucoma patients with incipient cataract. Combined surgical procedures are recommended for progressive or advanced glaucoma. Two-site phacotrabeculectomy with mitomycin C achieves better stabilized results; however, combined phacoemulsification with deep sclerectomy or viscocanalostomy achieves similar results with a lower rate of complications. These promising findings need more study to be confirmed.