NonPenetrating Glaucoma Surgery Elie Dahan Oxford Eye Center University of the Witwatersrand Johannesburg South Africa

Early surgery is superior to Medicine & Laser Migdal, Gregory & Hitchings Long-term functional outcome after early surgery compared with laser and medicine in open-angle glaucoma. Ophthalmology 1994; 101:1651-1657.

If Surgery Is the Treatment of Choice in Glaucoma The Conditions Should Be That Surgery Is Safe & Successful

Advantages of NPGS over Classic Trabeculectomy No flat anterior chamber (25% versus 2%) Less Choroidal detachment (5-10% versus 2-3%) Less Hyphema (10% versus 3%) Less Cataractogenic Less prostaglandins Smoother IOP decrease Viewing the site of Pathology

Intraoperative IOP Flow Chart

NPGS 02.1992-02.2001 Complete Success As a Function of Time (IOP<20mmHg w/o Rx)

N.P.G.S Feb’92-Feb’01 re-intervention rate

Survival of NPGS (IOP <18mmHG W/O Rx) 1997-2002

NPGS With Cataract Extraction 02. 1992-02 NPGS With Cataract Extraction 02.1992-02.2001 Complete Success As a Function of Time (IOP < 20mmhg w/o Rx

NPGS Dahan’s Technique An inverted “L” shaped fornix based conjunctival flap is the most appropriate for NPGS. It is simple, least traumatic and repeatable.

NPGS Dahan’s Technique A trapezoidal superficial Scleral flap 5x5x1.5mm at 40% depth is raised.

NPGS Dahan’s Technique The superficial scleral flap is temporarily sutured at 6h00 with an 8/0 virgin silk for better exposure. A 90% depth deep sclerectomy is done.

NPGS Dahan’s Technique The deep sclerectomy is done to uncover the trabeculo-descemetic membrane.

T Flux NPGS Implant The T Flux is a non-absorbable hydrophilic glaucoma implant. It prolongs the NPGS longevity by maintaining a permanent intrascleral space. It is highly biocompatible because of its high water content.

NPGS Dahan’s Technique The T Flux implant is positioned in the deep sclerectomy, with its arms tucked into the Schlemm’s Canal. The position of the hole in the trunk is marked on the sclera for placing the fixation sutures.

NPGS Dahan’s Technique Securing the T Flux in the deep sclerectomy.

NPGS Dahan’s Technique T Flux 2nd fixation suture

NPGS Dahan’s Technique A T Flux secured in the deep sclerectomy with a 10/0 nylon suture.

NPGS Dahan’s Technique When the T Flux has been secured in the deep sclerectomy, the superficial flap is sutured with one suture on its apex and the conjunctiva is replaced with one buried suture

NPGS T Flux study 1997-2002 E. Dahan, E. Ravinet, A. Mermoud Oxford Eye Center Johannesburg Jules Gonin Eye Hospital Lausanne

Inclusion Criteria Primary Open Angle Glaucoma >18 years Old Phakic Patients who do not need cataract surgery Exclusion: Trauma, Uveitis, Congenital & Infantile Glaucoma

Demographics & preoperative data With T Flux No 25 Age 59 Preop IOP 27.5 Cupping 74% No of Rx 2.3 Without T Flux 23 65 24.8 73% 2.3

Postoperative data With T Flux IOP 12.5 No of Rx 0 in % 48.2% Goniopunct 6 (24%) F/U 19.9 Without T Flux 13.3 0.3 44% 6 (26%) F/U 27.5

Mean Preop IOP & Last IOP

Mean IOP decrease in %

Mean Preop IOP & last IOP in patients with F/U > 23months

Mean IOP decrease in % in patients with F/U > 23months

IOP Flow Chart With & Without T Flux

Complications With T Flux One T Flux (which was not sutured) migrated to the A/C following severe coughing and/or rubbing Without T Flux 2 iris incarcerations following goniopunctures and/or rubbing

Conclusions (1) During the first two years, there is little difference between the two groups. In patients with follow up longer than 2 years, the T Flux group yields better results. The T Flux prevents iris incarcerations

Reminder METICULOUS Surgery is PRIMORDIAL & far more important than any sort of IMPLANT. Mediocre surgical technique will fail even with the Best Glaucoma Implant.