Glaucoma surgery

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Glaucoma surgery
Conventional surgery to treat glaucoma EDA11.JPG
Trabeculectomy for treating glaucoma
ICD-9-CM 12.1-12.7

Glaucoma is a group of diseases affecting the optic nerve that results in vision loss and is frequently characterized by raised intraocular pressure (IOP). There are many glaucoma surgeries, and variations or combinations of those surgeries, that facilitate the escape of excess aqueous humor from the eye to lower intraocular pressure, and a few that lower IOP by decreasing the production of aqueous humor.

Contents

Procedures that facilitate outflow of aqueous humor

Laser trabeculoplasty

A trabeculoplasty is a modification of the trabecular meshwork. Laser trabeculoplasty (LTP) is the application of a laser beam to burn areas of the trabecular meshwork, located near the base of the iris, to increase fluid outflow. LTP is used in the treatment of various open-angle glaucomas. [1] The two types of laser trabeculoplasty are argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT). As its name suggests, argon laser trabeculoplasty uses an argon laser to create tiny burns on the trabecular meshwork. [2] Selective laser trabeculoplasty is newer technology that uses a Nd:YAG laser to target specific cells within the trabecular meshwork and create less thermal damage than ALT. [3] [4] SLT shows promise as a long-term treatment. [5] In SLT a laser is used to selectively target the melanocytes in the trabecular meshwork. Though the mechanism by which SLT functions is not well understood, it has been shown in trials to be as effective as the older ALT. However, because SLT is performed using a laser with much lower power than ALT, it does not appear to affect the structure of the trabecular meshwork (based on electron microscopy) to the same extent, so retreatment may be possible if the effects from the original treatment should begin to wear off, although this has not been proven in clinical studies. ALT is repeatable to some extent with measurable results possible.[ citation needed ]

Iridotomy

An iridotomy involves making puncture-like openings through the iris without the removal of iris tissue. Performed either with standard surgical instruments or a laser, it is typically used to decrease intraocular pressure in patients with angle-closure glaucoma. A laser peripheral iridotomy (LPI) is the application of a laser beam to selectively burn a hole through the iris near its base. LPI may be performed with either an argon laser or Nd:YAG laser. [6] [7]

There is currently no sufficient evidence to show any benefit on the use of iridotomy versus no iridotomy to slow down visual field loss. This is based on analysing four studies with a sample of 3,086 eyes of 1,543 participants; iridotomy seems to improve gonioscopic findings, but does not show to be clinically significant. [8]

Iridectomy

An iridectomy , also known as a corectomy or surgical iridectomy, involves the removal of a portion of iris tissue. [9] [10] A basal iridectomy is the removal of iris tissue from the far periphery, near the iris root; a peripheral iridectomy is the removal of iris tissue at the periphery; and a sector iridectomy is the removal of a wedge-shaped section of iris that extends from the pupil margin to the iris root, leaving a keyhole-shaped pupil.

Clear lens extraction

Clear lens extraction , a surgical procedure in which clear lens of the human eye is removed, may be used to reduce intraocular pressure in primary angle closure glaucoma. [11] A study found that CLE is even more effective than laser peripheral iridotomy in patients with angle closure glaucoma. [12] [13]

Filtering procedures: penetrating vs. non-penetrating

Filtering surgeries are the mainstay of surgical treatment to control intraocular pressure. [14] An anterior sclerotomy or sclerostomy is used to gain access to the inner layers of the eye [15] [16] in order to create a drainage channel from the anterior chamber to the external surface of the eye under the conjunctiva, allowing aqueous to seep into a bleb from which it is slowly absorbed. Filtering procedures are typically divided into either penetrating or non-penetrating types depending upon whether an intraoperative entry into the anterior chamber occurs. [17] [18]

Penetrating filtering surgeries

Penetrating filtering surgeries are further subdivided into guarded filtering procedures, also known as protected, subscleral, or partial thickness filtering procedures (in which the surgeon sutures a scleral flap over the sclerostomy site [19] ), and full thickness procedures. [20] Trabeculectomy is a guarded filtering procedure that removes of part of the trabecular meshwork. [21] [22] Full thickness procedures include sclerectomy, posterior lip sclerectomy (in which the surgeon completely excises the sclera on the area of the sclerostomy [19] ), trephination, thermal sclerostomy (Scheie procedure), iridenclesis, and sclerostomy (including conventional sclerostomy and enzymatic sclerostomy). [18] [23]

Anterior chamber paracentesis is a penetrating surgical procedure done to reduce intraocular pressure of the eye. [24]

Non-penetrating filtering surgeries

Non-penetrating filtering surgeries do not penetrate or enter the eye's anterior chamber. [25] [26] There are two types of non-penetrating surgeries: Bleb-forming and viscocanalostomy. [27] [28] Bleb forming procedures include ab externo trabeculectomy and deep sclerectomy. [28] Ab externo trabeculectomy (AET) involves cutting from outside the eye inward to reach Schlemm's canal, the trabecular meshwork, and the anterior chamber. Also known as non-penetrating trabeculectomy (NPT), it is an ab externo (from the outside), major ocular procedure in which Schlemm's canal is surgically exposed by making a large and very deep scleral flap. The inner wall of Schlemm's canal is stripped off after surgically exposing the canal. Deep sclerectomy, also known as nonpenetrating deep sclerectomy (PDS) or nonpenetrating trabeculectomy, is a filtering surgery where the internal wall of Schlemm's canal is excised, allowing subconjunctival filtration without actually entering the anterior chamber. [29] In order to prevent wound adhesion after deep scleral excision and maintain good filtering results, it is sometimes performed with a variety of biocompatible spacers or devices, such as the Aquaflow collagen wick, [30] ologen Collagen Matrix, [31] [32] [33] or Xenoplast glaucoma implant. [34]

Viscocanalostomy is also an ab externo, major ocular procedure in which Schlemm's canal is surgically exposed by making a large and very deep scleral flap. In the VC procedure, Schlemm's canal is cannulated and viscoelastic substance injected (which dilates Schlemm's canal and the aqueous collector channels).

Surgical adjuvants Where wound modulation is needed to prevent closure of surgically created drainage channels, adjuvants such as the ologen collagen matrix implants may be used to facilitate healthy tissue regeneration. Scar formation at the site of excision or operation may block aqueous humor circulation, while healthy tissue regeneration will keep newly created drainage channels functional. [35] [36] [37] [38]

Other surgical procedures

Goniotomy and trabeculotomy are similar simple and directed techniques of microsurgical dissection with mechanical disruption of the trabecular meshwork. [39] [40] Goniotomy procedures include surgical goniotomy and laser goniotomy. A surgical goniotomy involves cutting the fibers of the trabecular meshwork to allow aqueous fluid to flow more freely from the eye. [41] [42] [43] Laser goniotomy is also known as goniophotoablation and laser trabecular ablation . In many patients with congenital glaucoma, the cornea is not clear enough to visualize the anterior chamber angle. Although an endoscopic goniotomy, which employs an endoscope to view the anterior chamber angle, may be performed, [44] a trabeculotomy which accesses the angle from the exterior surface of the eye, thereby eliminating the need for a clear cornea, is usually preferred in these instances. A specially designed probe is used to tear through the trabecular meshwork to open it and allow fluid flow. [41] [45]

Tube-shunt surgery or drainage implant surgery involves the placement of a tube or glaucoma valves to facilitate aqueous outflow from the anterior chamber. [41] [46] [47] Trabeculopuncture uses a Q switched Nd:YAG laser to punch small holes in the trabecular meshwork. [48] [49] Goniocurretage is an "ab interno" (from the inside) procedure that used an instrument "to scrape pathologically altered trabecular meshwork off the scleral sulcus". [14] A surgical cyclodialysis is a rarely used procedure that aims to separate the ciliary body from the sclera to form a communication between the suprachoroidal space and the anterior chamber. [10] A cyclogoniotomy is a surgical procedure for producing a cyclodialysis, in which the ciliary body is cut from its attachment at the scleral spur under gonioscopic control. [10]

A ciliarotomy is a surgical division of the ciliary zone in the treatment of glaucoma. [10] [50]

Canaloplasty

Canaloplasty is a nonpenetrating procedure utilizing microcatheter technology. To perform a canaloplasty, an incision is made into the eye to gain access to Schlemm's canal in a similar fashion to a viscocanalostomy. A microcatheter will circumnavigate the canal around the iris, enlarging the main drainage channel and its smaller collector channels through the injection of a sterile, gel-like material called viscoelastic. The catheter is then removed and a suture is placed within the canal and tightened. By opening the canal, the pressure inside the eye can then be relieved. Canaloplasty has two main advantages of over more traditional glaucoma surgeries. The first of these advantages is an improved safety profile over trabeculectomy. As canaloplasty does not require the creation of a bleb, significant long-term risks such as infection and hypotony (extremely low eye pressure) are avoided. The second main advantage is that when combined with cataract surgery, the IOP is reduced even further than when done alone. [51] Long term (three year) results have been published both in the US [51] and Europe [52] demonstrating a significant and sustained reduction in both eye pressure and the number of glaucoma medications required for glaucoma control.

Procedures that decrease production of aqueous humor

Cyclocryotherapy (frozen spot visible) Cyclocryotherapy.jpg
Cyclocryotherapy (frozen spot visible)

Certain cells within the eye's ciliary body produce aqueous humor. A ciliary destructive or cyclodestructive procedure is one that aims to destroy those cells in order to reduce intraocular pressure. [53]

Cyclocryotherapy, or cyclocryopexy, uses a freezing probe. [54] Cyclophotocoagulation, also known as transscleral cyclophotocoagulation, ciliary body ablation, [41] cyclophotoablation, [55] and cyclophototherapy, [40] uses a laser. [56] Cyclodiathermy uses heat generated from a high frequency alternating electric current passed through the tissue, [10] while cycloelectrolysis uses the chemical action caused by a direct current. [10]

A systematic review seeking to assess the safety and effectiveness of diode transscleral cyclophotocoagulation found one study in Ghana comparing patients who received low-energy versus high-energy variations of the procedure to treat glaucoma. [57] Overall, the review found that 47% of eyes treated with transscleral cytophotocoagulation saw an IOP decrease of at least 20%. [57] There were no differences between the low-energy and high-energy variations of the procedure in all reported outcomes, such as IOP control, and number of medications used after treatment. [57] Another Cochrane Systematic Review explored whether cyclodestructive procedures are better than other glaucoma treatments for the treatment of refractory glaucoma; however, the evidence was inconclusive. [58]

See also

Related Research Articles

<span class="mw-page-title-main">Glaucoma</span> Group of eye diseases

Glaucoma is a group of eye diseases that lead to damage of the optic nerve, which transmits visual information from the eye to the brain. Glaucoma may cause vision loss if left untreated. It has been called the "silent thief of sight" because the loss of vision usually occurs slowly over a long period of time. A major risk factor for glaucoma is increased pressure within the eye, known as intraocular pressure (IOP). It is associated with old age, a family history of glaucoma, and certain medical conditions or medications. The word glaucoma comes from the Ancient Greek word γλαυκός, meaning 'gleaming, blue-green, gray'.

<span class="mw-page-title-main">Eye surgery</span> Surgery performed on the eye or its adnexa

Eye surgery, also known as ophthalmic surgery or ocular surgery, is surgery performed on the eye or its adnexa. Eye surgery is part of ophthalmology and is performed by an ophthalmologist or eye surgeon. The eye is a fragile organ, and requires due care before, during, and after a surgical procedure to minimize or prevent further damage. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. It continues to be a widely practiced class of surgery, with various techniques having been developed for treating eye problems.

<span class="mw-page-title-main">Aqueous humour</span> Fluid in the anterior segment of the eye

The aqueous humour is a transparent water-like fluid similar to blood plasma, but containing low protein concentrations. It is secreted from the ciliary body, a structure supporting the lens of the eyeball. It fills both the anterior and the posterior chambers of the eye, and is not to be confused with the vitreous humour, which is located in the space between the lens and the retina, also known as the posterior cavity or vitreous chamber. Blood cannot normally enter the eyeball.

<span class="mw-page-title-main">Cataract surgery</span> Removal of opacified lens from the eye

Cataract surgery, also called lens replacement surgery, is the removal of the natural lens of the eye that has developed a cataract, an opaque or cloudy area. The eye's natural lens is usually replaced with an artificial intraocular lens (IOL) implant.

<span class="mw-page-title-main">Ciliary muscle</span> Eye muscle which is used for focussing

The ciliary muscle is an intrinsic muscle of the eye formed as a ring of smooth muscle in the eye's middle layer, the uvea. It controls accommodation for viewing objects at varying distances and regulates the flow of aqueous humor into Schlemm's canal. It also changes the shape of the lens within the eye but not the size of the pupil which is carried out by the sphincter pupillae muscle and dilator pupillae.

<span class="mw-page-title-main">Trabecular meshwork</span> Area of tissue in the eye

The trabecular meshwork is an area of tissue in the eye located around the base of the cornea, near the ciliary body, and is responsible for draining the aqueous humor from the eye via the anterior chamber.

<span class="mw-page-title-main">Schlemm's canal</span> Lymphatic-like vessel in the eye

Schlemm's canal, also known as the canal of Schlemm, and as the scleral venous sinus, is a circular lymphatic-like vessel in the eye. It collects aqueous humor from the anterior chamber and delivers it into the episcleral blood vessels. Canaloplasty may be used to widen it.

Ocular hypertension is the presence of elevated fluid pressure inside the eye, usually with no optic nerve damage or visual field loss.

A glaucoma valve is a medical shunt used in the treatment of glaucoma to reduce the eye's intraocular pressure (IOP).

<span class="mw-page-title-main">Iridectomy</span> Surgical removal of part of the iris

An iridectomy, also known as a surgical iridectomy or corectomy, is the surgical removal of part of the iris. These procedures are most frequently performed in the treatment of closed-angle glaucoma and iris melanoma.

<span class="mw-page-title-main">Posterior chamber of eyeball</span> Region of the eyeball between the iris and lens

The posterior chamber is a narrow space behind the peripheral part of the iris, and in front of the suspensory ligament of the lens and the ciliary processes. The posterior chamber consists of small space directly posterior to the iris but anterior to the lens. The posterior chamber is part of the anterior segment and should not be confused with the vitreous chamber.

<span class="mw-page-title-main">Trabeculectomy</span> Surgical procedure used in the treatment of glaucoma

Trabeculectomy is a surgical procedure used in the treatment of glaucoma to relieve intraocular pressure by removing part of the eye's trabecular meshwork and adjacent structures. It is the most common glaucoma surgery performed and allows drainage of aqueous humor from within the eye to underneath the conjunctiva where it is absorbed. This outpatient procedure was most commonly performed under monitored anesthesia care using a retrobulbar block or peribulbar block or a combination of topical and subtenon anesthesia. Due to the higher risks associated with bulbar blocks, topical analgesia with mild sedation is becoming more common. Rarely general anesthesia will be used, in patients with an inability to cooperate during surgery.

<span class="mw-page-title-main">Scleral spur</span> Annular structure composed of collagen in the human eye

The scleral spur in the visual system is a protrusion of the sclera into the anterior chamber. The spur is an annular structure composed of collagen in the human eye.

Trabeculoplasty is a laser treatment for glaucoma. It is done on an argon laser equipped slit lamp, using a Goldmann gonioscope lens mirror. Specifically, an argon laser is used to improve drainage through the eye's trabecular meshwork, from which the aqueous humour drains. This helps reduce intraocular pressure caused by open-angle glaucoma.

<span class="mw-page-title-main">Canine glaucoma</span>

Canine glaucoma refers to a group of diseases in dogs that affect the optic nerve and involve a loss of retinal ganglion cells in a characteristic pattern. An intraocular pressure greater than 22 mmHg (2.9 kPa) is a significant risk factor for the development of glaucoma. Untreated glaucoma in dogs leads to permanent damage of the optic nerve and resultant visual field loss, which can progress to blindness.

The Trabectome is a surgical device that can be used for ab interno trabeculotomy, a minimally invasive glaucoma surgery for the surgical management of adult, juvenile, and infantile glaucoma. The trabecular meshwork is a major site of resistance to aqueous humor outflow. As angle surgeries such as Trabectome follow the physiologic outflow pathway, the risk of complications is significantly lower than filtering surgeries. Hypotony with damage to the macula, can occur with pressures below 5 mmHg, for instance, after traditional trabeculectomy, because of the episcleral venous pressure limit. The Trabectome handpiece is inserted into the anterior chamber, its tip positioned into Schlemm's canal, and advanced to the left and to the right. Different from cautery, the tip generates plasma to molecularize the trabecular meshwork and remove it drag-free and with minimal thermal effect. Active irrigation of the trabectome surgery system helps to keep the anterior chamber formed during the procedure and precludes the need for ophthalmic viscoelastic devices. Viscoelastic devices tend to trap debris or gas bubbles and diminish visualization. The Trabectome decreases the intra-ocular pressure typically to a mid-teen range and reduces the patient's requirement to take glaucoma eye drops and glaucoma medications. The theoretically lowest pressure that can be achieved is equal to 8 mmHg in the episcleral veins. This procedure is performed through a small incision and can be done on an outpatient basis.

Micro-invasive glaucoma surgery (MIGS) is the latest advance in surgical treatment for glaucoma, which aims to reduce intraocular pressure by either increasing outflow of aqueous humor or reducing its production. MIGS comprises a group of surgical procedures which share common features. MIGS procedures involve a minimally invasive approach, often with small cuts or micro-incisions through the cornea that causes the least amount of trauma to surrounding scleral and conjunctival tissues. The techniques minimize tissue scarring, allowing for the possibility of traditional glaucoma procedures such as trabeculectomy or glaucoma valve implantation to be performed in the future if needed.

<span class="mw-page-title-main">Excimer laser trabeculostomy</span> Minimally invasive glaucoma surgery

Excimer laser trabeculostomy (ELT) is a procedure to create holes in the trabecular meshwork to reduce intraocular pressure. It uses a XeCl 308 nm excimer laser. It is considered a minimally invasive glaucoma surgeries, and was first described in 1987 by Michael Berlin.

<span class="mw-page-title-main">Secondary glaucoma</span>

Secondary glaucoma is a collection of progressive optic nerve disorders associated with a rise in intraocular pressure (IOP) which results in the loss of vision. In clinical settings, it is defined as the occurrence of IOP above 21 mmHg requiring the prescription of IOP-managing drugs. It can be broadly divided into two subtypes: secondary open-angle glaucoma and secondary angle-closure glaucoma, depending on the closure of the angle between the cornea and the iris. Principal causes of secondary glaucoma include optic nerve trauma or damage, eye disease, surgery, neovascularization, tumours and use of steroid and sulfa drugs. Risk factors for secondary glaucoma include uveitis, cataract surgery and also intraocular tumours. Common treatments are designed according to the type and the underlying causative condition, in addition to the consequent rise in IOP. These include drug therapy, the use of miotics, surgery or laser therapy.

<span class="mw-page-title-main">Uveitic glaucoma</span> Glaucoma caused by uveitis or its treatments

Uveitic glaucoma is most commonly a progression stage of noninfectious anterior uveitis or iritis.

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  52. ↑ Bull, Holger; Kurt von Wolf; Norbert Körber; Manfred Tetz (October 2011). "Three-year canaloplas ty outcomes for the treatment of open-an gle glaucom a: European study results". Graefes Arch Clin Exp Ophthalmol. 249 (10): 1537–45. doi:10.1007/s00417-011-1728-3. PMID   21732110. S2CID   22142101.
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  54. ↑ "Glaucoma Service Foundation to Prevent Blindness: Glaucoma Education: Cyclocryotherapy for Endstage Glaucoma". Archived from the original on 2006-09-25. Retrieved 2006-10-11.
  55. ↑ Hamel P, Levin A (December 2003). "Glaucoma Surgical Techniques in Children: From Past to Future (Part 1 of 2)". Techniques in Ophthalmology. 1 (4): 227–34. doi:10.1097/00145756-200312000-00007.
  56. ↑ "EyeMDLink.com - Cyclophotocoagulation". Archived from the original on 2006-11-11. Retrieved 2006-10-11.
  57. 1 2 3 Michelessi M, Bicket AK, Lindsley K (2018). "Cyclodestructive procedures for non-refractory glaucoma". Cochrane Database Syst Rev. 2018 (4): CD009313. doi:10.1002/14651858.CD009313.pub2. PMC   6277057 . PMID   29694684.
  58. ↑ Chen MF, Kim CH, Coleman AL (2019). "Cyclodestructive procedures for refractory glaucoma". Cochrane Database Syst Rev. 10 (3): CD012223. doi:10.1002/14651858.CD012223.pub2. PMC   6409080 . PMID   30852841.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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