IN OPEN-ANGLE GLAUCOMA. - PDF Document

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  1. FOUR-YEAR EXPERIENCE WITH CANALOPLASY IN OPEN-ANGLE GLAUCOMA. Paolo Brusini e Claudia Tosoni Department of Ophthalmology Azienda Ospedaliero-Universitaria S. Maria della Misericordia di Udine, Italy Purpose: to present surgical results, advantages, limits and complications of canaloplasty for open- angle glaucoma based on our four-year experience. Material and methods: 174 patients (179 eyes; mean age 61±14) affected with different types of open-angle glaucoma (117 pseudoexfoliative glaucoma, 4 juvenile glaucoma, 3 pigmentary glaucoma) under maximum tolerated medical therapy underwent canaloplasty under local anesthesia (Figs.1 to 4). Patients were recruited from our glaucoma clinic from February 2008 to March 2012. All patients underwent a complete ophthalmic examination definition of “qualified success” was based on three different criteria: post-operative IOP 21 mmHg, 18 mmHg, and 16 mmHg with or without any medical treatment. The success was defined as “complete” when the same IOP levels were obtained without any medical treatment. Follow-up period ranged from 1-49 months (mean 17.1 ± 8.9). primary OAG, 55 Fig.1. The first step is to perform a well done deep sclerectomy. Fig.2. The flashing red light shows the position of the microcatheter. every 6 months. The Fig.4. The suture is then knotted under tension. Fig.3. A 10-0 prolene suture is tied to the tip of the microcatheter. Results: A total of 119 eyes with at least 12 month follow-up were considered in the analysis of results. The procedure needed to be converted to either a deep sclerectomy or a viscocanalostomy in 31 cases (17.3%) due to the inability in cannulating Schlemm’s canal and/or other intra-operative complications. The mean pre-operative IOP was 29.3 mmHg ± 7.5 (range 18-58). The mean IOP at the last visit was 16.6 mmHg ± 4.1(43.3% IOP reduction). The mean IOP values at various follow-ups up to 42 months are shown in the box plot diagram (Fig.5). The scatter plot in Fig.6 shows the pre- and post-operative IOP values. Qualified success rates based on post-operative IOP mmHg were respectively obtained in 111 (93.3%), 98 (82.4%), and 76 (63.8%) eyes. Complete success for the same IOP levels were obtained in 79 (66.4%), 71 (59.7%), and 59 (49.6%) eyes, respectively. The number of medications used pre- and after canaloplasty was 3.2 ± 0.9, and 1.1 ± 1.3, respectively. Complications were seldom observed, and tended to be transient and non sight-threatening, which included: hyphema (23%); aqueous leakage (<1%); hypotony (4%); transient IOP spike (6%); and, Descemet membrane detachment (6%; Figs.7 and 8). 21 mmHg, 18 mmHg, and 16 60 60 50 Preoperative IOP (mmHg) 50 40 40 IOP mmHg 30 30 20 20 10 10 0 0 0 10 20 30 40 50 60 Pre 1d 7d 1m 3m 6m 12m 18m 24m 30m 36m 42m Last follow-up IOP (mmHg) n=119 n=119 n=119 n=119 n =119 n=119 n=119 n=89 n=45 n=28 n=19 n=9 Fig.8. Anterior segment OCT clearly shows the Descemet’s membrane detachment with a blood clot inside. Fig. 5. Box-plot representation of IOP values over time. Fig.6. Scattergram with pre- and post- operative IOP. Fig.7 Descemet’s membrane detachment after canaloplasty. Conclusions: Canaloplasty is a rather difficult and challenging procedure, however, it can successfully be performed by surgeons with adequate previous experience in non-perforating surgical techniques. The main advantages of canaloplasty include: absence of a conjunctival filtering bleb; low percentage of complications; effective IOP lowering that is maintained over time in most eyes; and, the option of considering this surgery even in eyes with chronic conjunctivitis or conjunctival scarring without the use of antimetabolites. In addition to the technical difficulties in performing surgery, the main limits of canaloplasty include: inability in cannulating Schlemm’s canal in about 10% of cases; sub-optimal IOP lowering effect in some eyes; and, the need of specifically designed and expensive instruments. Although long-term outcomes are currently not known, canaloplasty appears to be a promising technique, which should be considered as a surgical option in all cases of early to moderate open- angle glaucoma in which target IOP is not too low. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. Lewis RA, von Wolff K, Tetz M et al. Canaloplasty: circumferential viscodilationand tensioning of Schlemm's canal using a flexible microcatheter for the treatment of open-angle glaucoma in adults. Interim clinical study analysis. J Cataract Refract Surg. 2007;33:1217-1226. Lewis RA, von Wolff K, Tetz M et al. Canaloplasty: circumferential viscodilationand tensioning of Schlemm canal using a flexible microcatheter for the treatment of open-angle glaucoma in adults. Two-year interim clinical study analysis. J Cataract Refract Surg. 2009;35:814-824. GrieshaberMC, PienaarA, Olivier J, Stegmann R. Clinical evaluationof the aqueous outflow system in primary open-angle glaucoma for canaloplasty. Invest Ophthalmol Vis Sci. 2010;51:1498-1504. GrieshaberMC, PienaarA, Olivier J, Stegmann R. Canaloplasty for open-angleglaucoma: long term outcome. Br J Ophthalmol. 2010;94:1478-1482. Lewis RA, von Wolff K, Tetz M, et al. 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