Presentation on theme: "NON-PENETRATING GLAUCOMA SURGERY"— Presentation transcript:
1NON-PENETRATING GLAUCOMA SURGERY Dr.Jyoti ShettyMedical Director,Bangalore West Lions Superspeciality Eye Hospital
2PRINCIPLEIntended to facilitate the passage of aqueous humor through the trabeculum and Schlemm's canal bypassing the the juxta-canalicular meshwork which is the site of highest resistance to aqueous outflow without opening the anterior chamber and decompressing the eye.TRAB MESHWORKROOF OF SCHLEMS CANALSCHLEMS CANALANTERIOR CHAMBER
3INDICATIONSPatients requiring target IOP at moderate levels between 15-18mmHg with poor compliance for medical therapy to achieve the same.
5Ab-externo trabeculectomy Involves removal of the diseased endothelial layer of Schlemm’s canal and the Juxtacanalicular Trabecular Meshwork using a diamond microdrill.
6Ab-externo trabeculectomy- Conjunctival FlapA deep scleral flap is dissected (2.5x1.5mm) such that the roof of the Schlemms Canal is reached and then it is unroofed.1.5mm2.5mm
7Mitomycin-C(0.08%) is then applied under the scleral flap. In the floor of the scleral flap, aqueous leak will be seen if the Schlemm’s Canal has been unroofed .Mitomycin-C(0.08%) is then applied under the scleral flap.Scleral flapUnroofed Schlems canal
8Tight conjunctival closure.. The diamond microdrill is then used to remove the floor of the Schlemm’s Canal and the juxta-canalicular meshworkTight conjunctival closure..Diamond Microdrill
9According to Arenas, an opening of 100µ is sufficient for functional drainage as Aqueous Humour elimination from AC is a very passive and metabolic process-A big fistula is not required to control IOP.
10DEEP SCLERECTOMY Fornix or limbal based conjunctival flap. Superficial scleral flap - 5 x 5 mm ,1/3 of the scleral thickness (300 microns).In order to be able to dissect down to Descemet’s membrane later, the scleral flap is dissected 1 to 1.5 mm into clear cornea5mmDissection extended 1-1.5mm into clear cornea5mm
11A deep scleral flap is then dissected to 95% of remaining thickness of the sclera .Deep Scleral FlapSuperficial Scleral Flap
12Schlemm’s canal is unroofed at the level of the scleral spur to expose the TM
13Descemet’s membrane is carefully dissected away from the corneal stroma using a sponge or a spatula When the anterior dissection is complete, the deep scleral flap is cut anteriorlyEndothelium of floor of Schlemm’s canal and the juxtacanalicular portion of the trabeculum are peeled off
14When the anterior dissection is complete, the deep scleral flap is cut anteriorly
15Endothelium of floor of Schlemm’s canal and the juxtacanalicular portion of the trabeculum are peeled off
16Implant sutured onto the scleral bed To avoid a secondary collapse of the superficial flap over the Trabeculo-Descemet’s membrane and the remaining very thin scleral bed, an implant is placed in the scleral bed.Implants-Porcine collagen,Reticulated hyaluronic acidHEMAImplant sutured onto the scleral bed
17Two interrupted 10-0 nylon sutures are used to suture the the scleral flap. The conjunctiva is closed with wet field cautery.
18VISCOCANALOSTOMY Fornix or limbal based conjunctival flap. Superficial scleral flap - 5 x 5 mm ,1/3 of the scleral thickness (300 microns).In order to be able to dissect down to Descemet’s membrane later, the scleral flap is dissected 1 to 1.5 mm into clear cornea
19A deep scleral flap is then dissected to 95% of remaining thickness of the sclera Schlemm’s canal is unroofed at the level of the scleral spur to expose the TM.Deep Scleral FlapSuperficial Scleral Flap
20A finely polished cannula with an outer diameter of 150 µm is introduced into and a Schlemm's canal, and a high-viscosity viscoelastic (Healon GV) is injected 4.0 to 6.0 mm on each side.Dilated cut ends of Schlemm’s Canal after Visco injection
21The viscoelastic injection increases the diameter of Schlemm's canal from its usual diameter of 25 to 30 µm to about 230 µm and increases the patency of the outflow channelsAqueous is removed by a paracentesis to prevent rupture of TDM.
22Descemet's membrane is separated 1 to 2 mm from the corneoscleral junction by applying gentle pressure on Schwalbe's line using a cellulose sponge.
23This creates an intact window in Descemet's membrane through which aqueous humor diffuses from the anterior chamber into the subscleral lake bypassing the inner wall (floor) of Schlemm's canal.The deep scleral flap is then excised at its baseThe superficial flap is sutured using five 11-0 nylon suture in a watertight mannerViscoelastic is subsequently injected into the subscleral lake.The conjunctival flap is closed with sutures.
24LASER TRABECULAR ABLATION Topical anesthesiafornix based conjunctival flapA circle straddling the limbus marked with the help of a 4.25 mm optic zone marker
25A corneo scleral incision with a diamond knife calibrated at 350 microns. The flap is dissected and bent forward over the clear cornea to expose the area that will be treatedReflected scleral flap
26A specially designed mask with a 2 x 4 mm window, is placed to protect the surrounding tissue from the excimer raysMask with 2x4mm window
27Ablation proceeds in the following order- The ablation of the deep scleral wall is made using PTK software that removes successive layers of 0.25 to 2 micronsAblation proceeds in the following order-Deep sclero- corneal tissueRoof of Schlemms canalPart of its internal wallAdjacent corneal stroma 1 millimeter in front of the Schlemm’s canalAblation is continued up to the moment when a drop of aqueous humor appears
28CANALOPLASTY360 degree viscodilatation of Schlemm’s canal with an illuminated beacon tipped microcatheter.Diameter of the microcatheter -200µA 10-0 prolene suture is also passed through the entire Schlemm’s canal and tightened towards the AC-Produces a further 2-3mm fall in IOP.
29COMPLICATIONS1)Moderate transient hypotony in the first post-operative week.2)High IOP on 1st post op day-Due to insufficient dissection of the TDM.Treated with Nd:YAG goniopuncture.3)Rupture of the TDM postoperatively-Due to vigorous eye rubbing,valsalva.Due to rupture of the TDM,iris prolapse occurs and blocks the filtration site causing elevation of IOP . Treatment-revision of the filtration site and conversion into a conventional trabeculectomy
304)PAS at filtration site-Treated with YAG iridoplasty 5)Descemets Membrane detachment-Rare complication. More common with Viscocanalostomy.Usually transient.Severe cases, Descemets Membrane reposition maybe necessary.6)Scleral ectasia-Rare complication
31RESULTSDeep Sclerectomy provides much better results when performed using implants or antimetabolites or both.Viscocanalostomy shows the same results with or without implants and antimetabolitesWhen the above were compared with trabeculectomy,72% of patients who underwent trab. With antimetabolite achieved a target IOP of <21mmHg .51% of patients who had deep Sclerectomy with implant and 34% of patients who underwent Viscocanalosiomy with antimetabolite achieved a target IOP <21mmHg .