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Cyclodestructive Techniques

Summary Cyclodestructive techniques have evolved over the last century and the currently available techniques provide an alternative surgical treatment for those with medically uncontrolled glaucoma or in those with high risk of failure of glaucoma drainage surgery. Both Nd : YAG and diode laser cyclophotocoagulation are simple, effective, and relatively safe means of controlling IOP in the short to medium term; the diode laser is more widely used…

Further Surgical Options in Children

Summary Table 121-1 compares the success rates and different features of interventions for refractory pediatric glaucoma. To date, no treatment has shown reliable IOP lowering over long periods of follow-up in all patients. In selecting a treatment, the practitioner must consider the long-term risks and benefits. The infection-prone anterior bleb following a successful trabeculectomy with mitomycin C has deterred many surgeons from this procedure as second-line…

Goniotomy and Trabeculotomy

Summary Goniotomy Goniotomy was the first of the angle surgery procedures to be introduced for the treatment for pediatric glaucoma with remarkable results. Where corneal clarity allows, it least affects overall integrity of the eye while directly addressing the site of aqueous outflow obstruction and so has numerous advantages over trabeculotomy. Direct visualization of the angle allows precise location of the incision to angle structures, making…

Aqueous Shunts and Keratoplasty

Summary Aqueous shunts have been effectively employed to control IOP before, during, and after corneal transplantation. The special issues related to aqueous shunts in association with corneal grafts include the concern that host immune surveillance and graft rejection may be enhanced, that mechanical contact between the tube and graft may occur, or that DSEK grafts may decenter or dislocate in the presence of a robustly functioning…

Aqueous Shunts after Retinal Surgery

Summary Elevated IOP is a common occurrence following VR surgery and is more likely with increasing complexity of the repair such as with the use of silicone oil or intravitreal gas with pars plana vitrectomy. The cause of the intraocular pressure rise is multifactorial and intervention should be based on the mechanism of pressure elevation. The rise is usually transient with most patients successfully controlled with…

Glaucoma Implants: Results

Summary Implants have several characteristics that make them preferable to conventional filtering surgeries. Recognition of a safer long-term postoperative period has made glaucoma surgeons consider their use in more primary cases, with intact conjunctiva, especially in children and for combined procedures. The evidence regarding the need for a graft patch to cover the tube is slowly accumulating against this practice, but surgical techniques that avoid their…

Postoperative Complications

Summary Glaucoma drainage devices (GDDs) are a very important and effective tool for glaucoma surgery, especially in complicated and secondary glaucoma. Complications are not uncommon and are varied in nature. The risk of many of the complications associated with the used of these devices may be minimized and most complications can be managed while maintaining good success rates. The use of GDDs for the treatment of…

Other Glaucoma Implants

Summary Alternate drainage implant devices not already discussed in the previous three chapters, some primarily of historical interest and others currently used in various parts of the world, are described in this chapter. Pearls for insertion of implants and on prevention and management of complications are described. Introduction The ultimate goal of glaucoma surgical treatment is to perform a fistulizing procedure communicating the aqueous humor in…

Surgical Technique 3 (Ahmed Glaucoma Valve Drainage Implant)

Summary The Ahmed Glaucoma Valve is designed to drain aqueous humor from the anterior chamber through a silicone tube and across flow-resistant valve mechanism, and then onto a silicone or polypropylene plate located posterior to the limbus. The incorporation of a flow-resistant valve in the design of the Ahmed Glaucoma Valve distinguishes this implant from other open-tube designs, including the Baerveldt and Molteno implants. During the…

Surgical Technique 2 (Baerveldt Glaucoma Implant)

Summary The Baerveldt glaucoma implant continues to play an important role in the management of patients with glaucoma. Careful preoperative planning and meticulous operative technique will help minimize complications. At present the implant is generally recommended for the surgical management of secondary glaucomas and for eyes with previous surgery. The results of a prospective randomized trial comparing the use of a Baerveldt 350 mm implant versus trabeculectomy…

Surgical Technique 1 (Molteno Glaucoma Implant)

Summary Results depend on the etiology of the glaucoma and previous ocular history. The Otago Glaucoma Surgery Outcome Study follows surgically treated cases of glaucoma at Dunedin Hospital, New Zealand. Long-term IOP control at 5 years (and 10 years if available) after single- or double-plate implant surgery ranges from 100% in primary glaucoma, through 87% (77%) in uveitic glaucoma, 85% (78%) in juvenile open-angle glaucoma, 80%…

Aqueous Shunts: Choice of Implant

Summary Since publication of the Tube vs. Trabeculectomy Study there has been increased interest in the use of aqueous shunts for the management of glaucoma. Evidence suggests that long-term IOP control after aqueous shunts is determined, not only by the size of the end-plate on the shunt, but also on plate material, profile and surface texture. Two of the most commonly used implants are the Ahmed…

Preoperative Evaluation of Patients Undergoing Drainage Implant Surgery

Summary The ultimate goal to be wished for with the use of a glaucoma implant is pressure lowering. Most studies reported in the literature, with the use of glaucoma implants, define success as pressures of 21 mmHg or lower. Most severe glaucoma cases, and this usually includes most cases in which a glaucoma implant will be used, require pressures in the low teens, a level often difficult…

Goniosynechialysis

Summary Goniosynechialysis (GSL) is a surgical procedure designed to strip the synechiae from the angle wall and restore the trabecular outflow. The success of the procedure depends not only on the preoperative duration but also the recurrence of the PAS. Goniosynechialysis becomes more effective when performed after lens removal. An increase in the anterior chamber space provides ample room to perform the procedure and reduces the…

Combined Cataract and Nonpenetrating Glaucoma Surgery

Summary ▪ Although phacotrabeculectomy is the most widely reported combined procedure, nonpenetrating glaucoma surgery (NPGS) combined with phaco appears to be a less invasive approach. ▪ Phacoemulsification offers the advantages associated with small incisions, while NPGS avoids ocular decompression and bleb-related complications. ▪ Phacoemulsification combined with deep sclerotomy (DS) or viscocanalostomy (VC) is safer and would appear to be as effective as phacotrabeculectomy in the surgical…

Combined Cataract Extraction and Glaucoma Drainage Implant Surgery

Summary Combined phacoemulsification and glaucoma device implant surgery is a viable alternative in eyes with cataract and refractory glaucoma. Its success rate and complications are similar to those observed with implant surgery alone. This procedure should be considered in selected cases. Introduction The occurrence of concomitant cataract and glaucoma is frequent in the elderly population. When medical treatment is not enough to promote adequate intraocular pressure…

One-site Combined Surgery/Two-site Combined Surgery

Summary There is no single approach to the patient with coexisting cataract and glaucoma. Each case must be individualized in terms of glaucoma type and severity, rate of progression, response to glaucoma therapy, and degree of cataract. In addition, there are evolving surgical techniques that must be taken into consideration. Phacotrabeculectomy should be considered in situations of uncontrolled glaucoma and lens opacity presently or likely soon…

Cataract Surgery in Patients with Functioning Filtering Blebs

Summary Cataract surgery may impair the function of the filtering bleb following trabeculectomy even with modern clear cornea phacoemulsification. This fact has an impact on the overall long-term outcome of trabeculectomy when cataract formation is considered a usual long-term complication of filtering surgery. This problem has been hitherto underestimated in studies with short- or medium-term follow-up. The Problem of Cataract Formation after Glaucoma Surgery Cataract formation…

The Role of Lens Extraction in Primary Angle-Closure Glaucoma

Summary Lens extraction effectively reverses the anatomical predisposition to PACG, and reduces IOP and glaucoma drugs in PACG eyes. It may be performed alone, or in combination with other established IOP-lowering surgery in PACG eyes to achieve disease stabilization. Introduction Primary angle-closure glaucoma (PACG) is a form of glaucoma caused largely by ocular hypertension secondary to closure, apposition or synechia, of the anterior chamber drainage angle.…