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      New superior modified fornix-based twin-site phacotrabeculectomy

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          Abstract

          Phacotrabeculectomy is the preferred surgical management of coexisting visually significant cataract and moderate to advanced glaucoma. We report the surgical technique of a new modified fornix-based separate-site phacotrabeculectomy, with mitomycin C (MMC) application, in both primary open angle and angle closure glaucoma. In this new separate-site technique, both phaco and filtration are accommodated superiorly, side by side, hence called twin-site. This was achieved in an efficacious and safe manner with sparing of limbal stem cells without compromising safety. It is not only MMC-compatible but also has a low incidence of wound leak. The technique has no adverse consequence on the survival of the bleb, and we achieved complete success in 79.2% and total success in 93.1% in 130 eyes of 117 patients, in the intermediate term. Furthermore, the time taken for this separate-site surgical technique is comparable to published one-site procedures.

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          Trabeculectomy in the 21st century: a multicenter analysis.

          Peter Shah, M. King, Angie Kirwan … (2013)
          To evaluate the efficacy and safety of current trabeculectomy surgery in the United Kingdom. Cross-sectional, multicenter, retrospective follow-up. A total of 428 eyes of 395 patients. Consecutive trabeculectomy cases with open-angle glaucoma and no previous incisional glaucoma surgery from 9 glaucoma units were evaluated retrospectively. Follow-up was a minimum of 2 years. Surgical success, intraocular pressure (IOP), visual acuity, complications, and interventions. Success was stratified according to IOP, use of hypotensive medications, bleb needling, and resuturing/revision for hypotony. Reoperation for glaucoma and loss of perception of light were classified as failures. Antifibrotics were used in 400 cases (93%): mitomycin C (MMC) in 271 (63%), 5-fluorouracil (5-FU) in 129 (30%), and no antifibrotic in 28 (7%). At 2 years, IOP (mean ± standard deviation) was 12.4 ± 4 mmHg, and 342 patients (80%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP without IOP-lowering medication, whereas 374 patients (87%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP overall. An IOP ≤18 mmHg and 20% reduction of preoperative IOP were achieved by 337 trabeculectomies (78%) without IOP-lowering treatment and by 367 trabeculectomies (86%) including hypotensive medication. Postoperative treatments included suture manipulation in 184 patients (43%), resuturing or revision for hypotony in 30 patients (7%), bleb needling in 71 patients (17%), and cataract extraction in 111 of 363 patients (31%). Subconjunctival 5-FU injection was performed postoperatively in 119 patients (28%). Visual loss of >2 Snellen lines occurred in 24 of 428 patients (5.6%). A total of 31 of the 428 patients (7.2%) had late-onset hypotony (IOP 2 Snellen lines. Bleb leaks were observed in 59 cases (14%), 56 (95%) of which occurred within 3 months. Two patients developed blebitis. Bleb-related endophthalmitis developed in 1 patient within 1 month postoperatively and in 1 patient at 3 years. There was an endophthalmitis associated with subsequent cataract surgery. This survey shows that good trabeculectomy outcomes with low rates of surgical complications can be achieved, but intensive proactive postoperative care is required. Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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            The National Survey of Trabeculectomy. III. Early and late complications.

            Stefanie Salmon, S. Thompson, Arthur Edmunds … (2002)
            There is a considerable body of literature relating to trabeculectomy, however there are no data representative of the national experience of trabeculectomy in the United Kingdom (UK). The Department of Health funded a national survey of trabeculectomy to establish current practice patterns and the outcome of trabeculectomy in the National Health Service (NHS). In this paper we present the reported complications of first-time trabeculectomy from a nationally representative cohort of patients with chronic open angle glaucoma. Cross-sectional study of consultant ophthalmologists performing trabeculectomy in the NHS. Participants recruited their four most recent consecutive first-time trabeculectomy cases with chronic open angle glaucoma according to study eligibility criteria and data were collected by self-administered questionnaire. one year post-trabeculectomy. occurrence of early and late complications. Clinical outcome data were available for 1240 (85.3%) of cases. Early complications were reported in 578 (46.6%) cases and late complications in 512 (42.3%) cases. Some cases had more than one complication. The most frequent early complications were hyphaema (n = 304, 24.6%), shallow anterior chamber (n = 296, 23.9%), hypotony (n = 296, 24.3%), wound leak (n = 216, 17.8%) and choroidal detachment (n = 175, 14.1%). The most frequent late complications were cataract (n = 251, 20.2%), visual loss (n = 230, 18.8%) and encapsulated bleb (n = 42, 3.4%). The occurrence of most complications was not associated with a consultant's specialist interest, level of activity, type of hospital or region. Encapsulated bleb was reported more frequently in a university hospital setting. The complication rates reported in this paper represent the national experience of first-time trabeculectomy for open angle glaucoma in the UK. These are similar to previous published studies and highlight in particular, the impact of trabeculectomy on visual acuity in the first year following surgery. This survey provides valid and clinically relevant data on the complications of trabeculectomy for the production of guidelines and standards for audit at regional, local and individual level.
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              Surgical strategies in patients with combined cataract and glaucoma.

              R. Menapace, William Vass (2004)
              In the elderly population, the combined presence of cataract and glaucoma is a frequent condition. In this situation, several surgical options are possible: cataract surgery only and later maybe trabeculectomy, trabeculectomy only and later maybe cataract surgery, or combined cataract and glaucoma surgery. This review compares the different surgical options on the basis of their achievable postoperative intraocular pressure (IOP) level and success and complication rates. The impression of better IOP regulation with trabeculectomy than with phacotrabeculectomy has been recently confirmed by an evidence-based review. Contrary to this finding, the success of deep sclerectomy or trabeculotomy does not seem to be compromised by simultaneous phacoemulsification. In eyes with previous glaucoma-filtering surgery, cataract surgery with clear corneal incision has no effect on mean IOP but increases the 3-year failure probability. For phacotrabeculectomy, moderate evidence of a beneficial effect of MMC on IOP regulation and only weak evidence for separating the incisions has been recently reported by another evidence-based review. The choice of the preferred surgical method depends on the target pressure, the amount of glaucomatous damage, and the grade of visual disturbance caused by the cataract. Phacotrabeculectomy combined with mitomycin C achieves the best IOP lowering of all types of combined cataract and glaucoma surgery currently possible but is associated with potentially sight-threatening complications. In the absence of a low target pressure, phacotrabeculotomy or the combination of phacoemulsification with viscocanalostomy or deep sclerectomy may be the therapy of choice.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Indian J Ophthalmol
                Journal ID (iso-abbrev): Indian J Ophthalmol
                Journal ID (publisher-id): IJO
                Title: Indian Journal of Ophthalmology
                Publisher: Wolters Kluwer - Medknow (India )
                ISSN (Print): 0301-4738
                ISSN (Electronic): 1998-3689
                Publication date (Print): November 2019
                Publication date (Electronic): 22 October 2019
                Volume: 67
                Issue: 11
                Pages: 1870-1872
                Affiliations
                [1]Department of Glaucoma, Centre for Sight, L V Prasad Eye Institute, Banjara Hills, Hyderabad, India
                [1 ]VST Centre for Glaucoma, L V Prasad Eye Institute, Banjara Hills, Hyderabad, India
                Author notes
                Correspondence to: Dr. Vanita Pathak Ray, Centre for Sight, Road No. 2, Banjara Hills, Hyderabad - 500 034, Telangana, India. E-mail: vpathakray@ 123456gmail.com
                Article
                Publisher ID: IJO-67-1870
                DOI: 10.4103/ijo.IJO_237_19
                PMC ID: 6836580
                PubMed ID: 31638052
                SO-VID: e1214552-91d0-4c01-8d79-52ec8f66c3ee
                Copyright © Copyright: © 2019 Indian Journal of Ophthalmology
                License:

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                Date received : 31 January 2019
                Date revision received : 28 May 2019
                Date accepted : 24 June 2019
                Categories
                Subject: Surgical Technique

                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: fornix-based,phacotrabeculectomy,separate-site phacotrabeculectomy,twin-site phacotrabeculectomy
                Data availability:
                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: fornix-based, phacotrabeculectomy, separate-site phacotrabeculectomy, twin-site phacotrabeculectomy

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