Esclerectomía profunda no perforante y facoemulsificación en dos tiempos en pacientes con glaucoma y catarata / Non-penetrating Deep Sclerectomy and Phacoemulsification Performed in Two Stages in Patients with Glaucoma and Cataract

Fundamento: el tratamiento quirúrgico a pacientes con glaucoma crónico primario y catarata sigue siendo un dilema para los oftalmólogos. Objetivo: evaluar los resultados posoperatorios de la esclerectomía profunda no perforante con mitomicina C y la facoemulsificación realizadas en dos tiempos en pacientes con glaucoma crónico primario y catarata. Métodos: estudio descriptivo prospectivo, en 200 pacientes que fueron operados mediante la esclerectomía profunda no perforante con mitomicina C e iridotomía periférica con Nd YAG láser previa, en un primer tiempo y facoemulsificación con implante del lente intraocular de PMMA, en un segundo tiempo. Se analizaron la agudeza visual con corrección, el comportamiento de la tensión ocular y de la bula de filtración, la relación excavación – papila; y las complicaciones intra y posoperatorias. Resultados: la agudeza visual de 0,4 en el preoperatorio mejoró a 0,7 al año. El 62 % de las ampollas de filtración se mantuvieron prominentes y funcionales. Luego de la facoemulsificación el 17 % de los ojos continuaron con el uso de medicamentos y el 83 % mantuvieron presiones intraoculares por debajo de 17 mmHg, sin tratamiento. Las complicaciones posoperatorias fueron: la iridociclitis moderada (74 %) y la opacidad capsular posterior al año (46 %). Hubo 18 ojos (9 %) con descompensación endotelial leve y transitoria.Conclusiones: la esclerectomía profunda no perforante con mitomicina C y la facoemulsificación en dos tiempos permiten obtener el control quirúrgico del glaucoma crónico primario y una buena visión.

Background: surgical treatment of patients with primary chronic glaucoma and cataract remains a dilemma for ophthalmologists. Objective: to assess the postoperative results of non-penetrating deep sclerectomy with mitomycin C and phacoemulsification performed in two stages in patients with primary chronic glaucoma and cataract. Methods: a prospective descriptive study was conducted in 200 patients who underwent non -penetrating deep sclerectomy with mitomycin C and Nd:YAG laser peripheral iridotomy in the first stage and phacoemulsification with intraocular PMMA lens implantation in the second stage. Corrected visual acuity, intraocular pressure and filtering blebs, cup-to-disc ratio and intra -and postoperative complications were analyzed. Results: visual acuity improved from 0.4 before surgery to 0.7 a year after surgery. Sixty-two percent of the filtering blebs remained prominent and functional. After phacoemulsification, 17 % of the eyes continued under medication and 83% maintained the intraocular pressure below 17 mmHg, without treatment. Postoperative complications included moderate iridocyclitis (74 %) and posterior capsular opacity after a year (46%). Eighteen eyes (9 %) developed mild and transient endothelial decompensation. Conclusions: non -penetrating deep sclerectomy with mitomycin C and phacoemulsification performed in two stages lead to the surgical management of primary chronic glaucoma and good vision.

Late recurrent iris synechia following laser goniopuncture for deep sclerectomy enhancement: case report / Sinéquia iriana tardia após goniopunctura a laser para esclerectomia profunda não penetrante: relato de caso

We report a case of recurrent iris synechiae one year after Nd:YAG laser goniopuncture for deep sclerectomy enhancement in the only functional eye of a patient with end-stage glaucoma. The possible pathophysiology of this uncommon complication and laser treatment aspects are discussed.

A ocorrência de sinéquias irianas após goniopunctura a laser com finalidade de aumentar a filtração após esclerectomia não penetrante é evento raro e que pode levar à crise glaucomatosa aguda e suas consequências. Relatamos a ocorrência deste evento em olho único de paciente portadora de glaucoma em estágio final, um ano após a realização de goniopunctura. Os possíveis mecanismos fisiopatológicos desta complicação incomum, assim como aspectos do tratamento a laser para reverter o quadro são discutidos.

Microdevice for aqueous humor drainage Maldonado Bas - Pförtner / Microdispositivo para drenaje de humor acuoso Maldonado Bas - Pförtner

PURPOSE: A microdevice for the treatment of refractory glaucoma is presented. The underlying concepts, its mechanisms of action and the surgical technique for implanting are explained and the results are analyzed. The microdevice was developed and the surgeries were performed at the Maldonado-Bas Eye Clinic (Cordoba, Argentina), under the rules established in the protocol approved by the provisions of the National Administration of Drugs, Food and Medical Technology 430/7. File No.:1-47-25-649-07-1. METHODS: In a prospective study, following the protocol, 16 eyes with refractory glaucoma were included and operated. Intraocular pressure <21mmHg with or without additional medication was considered successful. The follow-up was one year. Averages, percentages and their 95 percent confidence bands were calculated. Analysis of variance for repeated measures was used to compare averages. RESULTS: The average preoperative intraocular pressure was 32.81 mmHg, SD ± 10.94 mmHg in a range of 14 to 50 mmHg. The average post-surgical intraocular pressure at one year was 12.43 mmHg, SD ± 2.85 mmHg in a range of 7 to 19 mmHg. The difference between the pre-and post-surgery average intraocular pressure was 20.38 mmHg. The number of successes was 14 eyes (87.5 percent, confidence interval (CI) 95 percent 61.6 percent - 98.6 percent). The number of failures was two eyes (12.5 percent, CI 95 percent 1.43 percent - 38.4 percent). CONCLUSIONS: The results show that the microdevice is successful for the treatment of refractory glaucoma.

OBJETIVO: Se presenta un microdispositivo para el tratamiento del glaucoma refractario. Se explican los conceptos con los que fue desarrollado, su mecanismo de acción, la técnica quirúrgica para implantarlo y se analizan los resultados obtenidos. Realizado en la Clínica de ojos Maldonado-Bas (Córdoba- Argentina), bajo la reglamentación establecida en el protocolo aprobado por disposición de la Administración Nacional de Medicamentos, Alimentos y Tecnología Médica 430/7. Expediente:1-47-25-649-07-1. MÉTODOS: En un estudio prospectivo, según la reglamentación del protocolo se incluyeron e intervinieron 16 ojos con glaucoma refractario. Se consideró éxito presión intraocular <21mmHg con o sin medicación adicional. El seguimiento fue de un año. Se calcularon promedios, porcentajes y sus bandas de confianza del 95 por ciento según estuviera indicado. Para comparar promedios se empleó Análisis de la Varianza para mediciones repetidas. RESULTADOS: El promedio de la presión intraocular pre-quirúrgica fue de 32,81 mmHg, SD ± 10,94 mmHg con un rango entre 14 y 50 mmHg. La presión intraocular post-quirúrgica promedio al año fue de 12,43 mmHg, SD ± 2,85 mmHg con un rango entre 7 y 19 mmHg. La diferencia entre el promedio de la presión intraocular pre y pos-quirúrgica fue de 20,38 mmHg. El número de éxitos fue de 14 ojos (87,5 por ciento; IC95 por ciento 61,6 por ciento - 98,6 por ciento). El número de fracasos fue de dos ojos (12,5 por ciento; IC95 por ciento 1,43 por ciento - 38,4 por ciento). CONCLUSIONES: Los resultados demuestran que el microdispositivo es eficaz para el tratamiento del glaucoma refractario.

Estudo pressórico da esclerectomia profunda com implante de SkGel no glaucoma primário de ângulo aberto / Intraocular pressure in non penetrating deep sclerectomy with SkGel implant in patients with primary angle glaucoma

OBJETIVO: Avaliar a eficácia, em termos de redução da pressão intraocular (PIO) da esclerectomia profunda não penetrante (EP) com uso de implante de SkGel. MÉTODOS: Trata-se de um estudo observacional, retrospectivo através da revisão de prontuários do Instituto de Oftalmologia Tadeu Cvintal. Foram avaliados 45 olhos de 37 pacientes submetidos à EP com implante de Skgel nos últimos 10 anos por glaucoma primário de ângulo aberto (GPAA). O estudo analisou resultados pressóricos após 12 meses de acompanhamento em um período de 10 anos, de 1997-2007. Todos os pacientes apresentavam PIO não controlada com medicação hipotensora ocular máxima tolerada ou PIO controlada, porém com dano glaucomatoso em progressão. RESULTADOS: A população global estudada foi composta de 37 pacientes, sendo 23 (62,16%) mulheres e 14 (37,83%) homens, com um total de 45 olhos. A média de idade da população em estudo foi de 57,4 +/- 14,5 anos. A PIO média pré-operatória foi de 20,50 +/- 6,40 mmhg, após 12 meses de acompanhamento, a PIO média pós-operatória foi de 14,00 +/- 3,90 mmhg. A redução média da PIO foi de - 6,50 mmhg +/- 7,20 mmhg. As taxas de sucesso absoluto (PIO<21mmhg sem medicação hipotensora) e relativo (PIO<21mmhg com medicação hipotensora) observadas foram de 71,10% e de 26,70% respectivamente. CONCLUSÃO: A EP não penetrante com uso de implante mostrou-se no presente estudo ser uma ótima alternativa aos procedimentos cirúrgicos antiglaucomatosos em pacientes com GPAA.

OBJECTIVE: The aim of this study is to evaluate the eficacy about reducing intraocular pressure (IOP) in patients with primary angle glaucoma treated with non penetrating deep sclerectomy with SkGel implant. METHODS: This is an observacional, retrospective study from revision of charts from Tadeu Cvintal Eye Institute. We evaluated 45 eyes from 37 patients that undergone to non penetrating deep sclerectomy with SkGel Implant in the past 10 years. IOP was checked 12 months in a period of 10 years, from 1997 thru 2007. All patients had uncontrolled IOP with maximum antiglaucoma medications or controlled IOP with progressive glaucoma damage. RESULTS: there was 37 patients, 23 (62,16%) were female and 14 (37,83%) were male, with 45 eyes in total. The mean age was 57,4 +/- 14,5 years. The mean IOP before surgery was 20,50 +/- 6,40 mmhg, after 12 months from surgery the mean IOP was -6,50 mmhg +/- 7,20 mmhg. The absolute IOP rate success (IOP<21 mmhg without antiglaucoma medication) and relative (IOP<21 mmhg with antiglaucoma medication) were 71,10% and 26,70%. CONCLUSION: Non penetrating deep sclerectomy with SkGel Implant can be a good way to treat patients with primary angle glaucoma.

Goniossinéquia como complicação na esclerectomia profunda não penetrante por uso inadvertido de midriático: relato de caso / Goniosynechiae as a complication of non-penetrating deep sclerectomy by inappropriate use of mydriatic: case report

A esclerectomia profunda não penetrante tem sido uma alternativa à trabeculectomia, pois tem como vantagem a redução da pressão intra-ocular (PIO), sem penetrar na câmara anterior. Desta forma, evitando descompressão brusca, câmara anterior rasa. Neste trabalho, descrevemos o caso de uma paciente, 53 anos, negra, com diagnóstico de glaucoma primário de ângulo aberto, com controle clínico insatisfatório e que foi submetida à esclerectomia profunda não penetrante. A paciente evoluiu com formação de goniossinéquia na região da esclerectomia, após uso inadvertido de colírio midriático no pós-operatório, levando ao aumento da PIO e conseqüente falência da cirurgia. O uso de colírio midriático no pós-operatório da esclerectomia profunda não está indicado, pois neste caso, ocasionou o insucesso da cirurgia.

Non-penetrating deep sclerectomy has been an alternative to trabeculectomy, because it has the advantage of reducing intraocular pressure (IOP), without penetrating the anterior chamber. Thus, it avoids a sudden decompression and a plain anterior chamber. In this paper, we described a case of a female patient, 53 years old, black, with diagnosis of open-angle primary glaucoma, with unsatisfactory clinical control and who was submitted to non-penetrating deep sclerectomy. The patient developed goniosynechiae at the site of the sclerectomy, after inappropriate use of mydriatic eye-drops during the postoperative period, leading to an increase of IOP and, therefore, failure of the surgery. The use of mydriatic eye-drops during the postoperative period of deep sclerectomy is not indicated, because in this case, it led to surgery failure.

Biomicroscopia ultra-sônica em esclerectomia profunda: relato de caso / Ultrasound biomicroscopy in deep sclerectomy: case report

Relato do caso de um paciente com diagnóstico de glaucoma primário de ângulo aberto, que foi submetida a esclerectomia profunda em olho direito, com sucesso. No pós-operatório de 3 meses, o procedimento cirúrgico foi avaliado com biomicroscopia ultra-sônica (UBM) utilizando-se dois equipamentos distintos (UBM 840-Zeiss; UBM-VUMAX-Sonomed) com transdutores de 50 MHz. O método diagnóstico com biomicroscopia ultra-sônica pode ser usado como método não invasivo para avaliar a arquitetura interna ocular na topografia da esclerectomia profunda. Permite identificar as estruturas do segmento anterior, sua relação anatômica, bem como a membrana trabéculo-Descemet íntegra e o espaço intra-escleral. Biomicroscopia ultra-sônica demonstrou utilidade na avaliação pós-operatória do procedimento cirúrgico.

Case report of a woman with the diagnosis of primary open-angle glaucoma who was submitted to a successful surgical procedure of deep sclerectomy in the right eye. In the postoperative period, at month 3, the surgical procedure was evaluated with ultrasound biomicroscopy (UBM) utilizing two distinct equipments (UBM 840-Zeiss; UBM-VUMAX-Sonomed), with 50-MHz transducers. The diagnostic method of ultrasound biomicroscopy can be utilized as a non invasive method to evaluate the internal architecture of the eye at the topography of deep sclerectomy. It allows to identify the anterior segment structures, their anatomical relationship, and also the intact trabecular-Descemet membrane and the intrascleral space. Ultrasound biomicroscopy showed to be useful in evaluating postoperative status of the surgical procedure.

Mitomicina c en la esclerectomía profunda no perforante / Mitomycin C in non-penetrating deep sclerostomy

Nuestro propósito en este trabajo es evaluar la eficacia de la Mitomicina C como inhibidor fibroblástico en la esclerectomía profunda no perforante (EPNP). Se realizó EPNP en 40 ojos con glaucoma crónico primario; 20 sin Mitomicina C y 20 con aplicación tópica intraoperatoria de Mitomicina C (0,5 mg/mL) durante 5 min, evaluándose al 1, 6 y 12 meses. En la EPNP sin Mitomicina C la PIO se redujo de 27,40 ± 4,76 mmHg a 15,80 ± 2,50 mmHg requiriendo betabloqueadores 5 ojos (25 %) a diferencia (p=,0001) de una reducción de 27,35 ± 2,91 mmHg a 7,15 ± 1,67 mmHg sin necesidad de betabloqueadores; con ampolla de filtración extensa, pálida, transparente y avascular y escasas complicaciones como hifema y dehiscencia conjuntival segmentaria. La EPNP con Mitomicina C fue más efectiva en el control de la PIO y su monodosificación tópica transoperatoria bien tolerada por los pacientes.

We intend in this paper to assess the effectiveness of Mitomycin C as a fibroblastic proliferation inhibitor in the non-penetrating deep sclerostomy (NPDS). This procedure was performed in 40 eyes with primary chronic glaucoma, 20 of them were treated with intraoperative topycal Mitomycin C at 0,5 mg/mL for five minutes and 20 were not applied this drug. They were followed up and assessed one, six and twelve months after the surgery. In the NPDS without mitomycin C group, intraocular pressure was reduced from 27,40 ± 4,76 mmHg to 15,80 ± 2,50 mmHg, but 5 eyes required betablockers compared to a reduction from 27,35 ± 2,91 mmHg to 7,15 ± 1,67 mmHg without betablockers in the NPDS with Mitomycin C group, which presented and extensive, pale, transparent and avascular filtering ampulla and slight complications such as hyphema and dehiscence. The NPDS with mitomycin C was more effective in controlling intraocular pressure and transoperative topycal monodosage of this drug was well tolerated by the patients.

Erbium: YAG Laser Sclerostomy in Rabbits

The present study investigates the effects of the new Erbium:YAG(yttrium aluminum garnet) laser sclerostomy in eight rabbits eyes. The energy was set at 10mJ per pulse with the frequeny of 10Hz, and the total energy for the full thickness sclerostomy procedure was rated at 90 to 150ml. Following the procedure, the mean intraocualar pressure was significantly reduced for up to 7 days, and the histopathological observation at day 7 revealed clearly demarcated wound margins at the resected sites. The sesults suggest that te Erbium:YAG laser sclerostomy may be a good supportive procedures to conventional treatment of glaucoma.

Aqueous and Vitreous Concentration of Mitomycin C Administered Topically after Holmium Laser Sclerostomy in Rabbits

Mitomycin C is an antibiotic isolated from the broth of Streptomyces caespitosus which has been used as the adjunctive drug to reduce the fibroblast proliferation. Holmium laser sclerostomy can minimize conjunctival damage. We examined pharmacokinetics of mitomycin C following topical administration. Holmium laser sclerostomy was performed on one eye of each 15 rabbits and the other eye was served as a control. Next day, mitomycin C solution(0.4mg/ml) was administered by topical drops in both eyes of each rabbit. The concentrations of mitomycin C in the aqueous and the vitreous compartments of operated and control eyes were determined by HPLC at 0.5, 1, 2, 3, 6 hours after topical administration. The peak aqueous concentration was 0.07 microgram/ml in operated eyes and 0.06 microgram/ml in control eyes. The peak vitreous concentration was 0.10 microgram/ml in operated eyes and 0.09 microgram/ml in control eyes. The levels of detected mitomycin C at all time intervals were higher than the IC50(0.002 microgram/ml) for the inhibition of conjunctival fibroblast proliferation. These results suggest that topical mitomycin C easily crosses the intact and minimally damaged conjunctiva and therefore increases the success rate of Holmium laser sclerostomy.

The Effect of Mitomycin C on the Holmium Laser Sclerostomy in Rabbits

This experiment is to evaluate the effects of subconjunctival mitorrycin injection on the holmium laser sclerostomy in rabbits. Three hours before laser sclerostomy, subconjunctival injection of normal saline(in control group, n=10 yes) or 0.04% mitomycinGn experiment group, n=10 eyes) was performed. After laser sclerostomy, change of intraocular pressure and appearance of filtering bleb were observed in each group. The duration of success with low intraocular pressure and presence of filtering blebs were evaluated. The duration of success was 5.1 +/- 2.5 days in control group and 29.8 +/- 12.6 days in experiment group. In the former, mean intraocular pressure was not significantly low compared with preoperative one five days after sclerostomy, but latter showed significantly low intraocular pressure 35 days after operation. These results suggest that subconjunctival injection of 0.04% mitomycin C three hours before operation was effective to the success of holmium laser sclerostomy.

The Effects of Mitomycin C and Ascorbic Acid on the Holmium Laser Sclerostomy in Rabbits

Several methods of mitomycin administration or subconjunctival injection of ascorbic acid was combined with holmium laser scleorstomy for the evaluation of their effects in the sclerostomy. Thirty rabbits(60 eyes) were divided into 6 groups. Group 1 received topical application of 0.04% mitomycin for 2 weeks ostoperatively. Group 2 received subconjunctival injection of 0.04% mitomycin 3 hours before sclerostomy combined with postoperative topical use of mitomycin. Group 3 received subconjunctival injection of 0.04% mitomycin just before operation. Suconjunctival injection of 0.004% mitomycin was underwent 3 hours before surgery in group 4 and just before scierostomy in group 5. After subconjuctival injection of 25mg ascorbic acid, sclerotomy was performed on group 6. We evaluated duration of success and complication, mean duration of success was 7.4 days, in group 1, 35 days in group 2, 11.9 days in group 3, 7.2 day in group 4, 10.1 days in group 5, and 10.7 days in group 6. All methods were less effective than Subconjunctival mitomycin injection 3 hours before surgery. Corneal erosion, corneal, opacity, hyphema, and early hypotony were found in mitomycin use. Ascorbic acid injection did not develop complications. In these results, the subconjunctival injection of 0.04% mitomycin C 3 hours before the holmium laser sclerostomy was regarded as the most effective to holmium laser sclerostomy without complications. Subconjunctival injection of ascorbic acid was helpful for sclerostomy but less effective than mitomycin use.

Diode Laser Ab Externo Sclerostomy in Rabbits

Sclerostomy is preferable full-thickness filtration surgery, if very low pressure are desired or if guard filtration surgery had failed. Laser sclerostomy can be performed in a less invasive manner than standard procedure, so it reduces scar formation and minimizes postoperative complications. The objective of this investigation was to determine the feasibility and parameters of laser sclerostomy using a diode laser. The diode laser with a fiberoptic delivery system is lightweight, portable and utilizes a 100 Volt outlet. Eighteen eyes of pigmented rabbits underwent a diode laser ab externo sclerostomy with energy 2 W, duration 1-2 seconds by applying endolaser probe, 0.5 mm from the limbus. Gross and histopathologic examination were done at 1 hour and 7 days after treatment. A patent fistula with formation of filtering bleb was achieved in all cases. There was a flattening of the filtration bleb at 3.3 postoperative days.