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Intrascleral Filtering Procedure for Glaucoma
INTRASCLERAL F I L T E R I N G PROCEDURE FOR GLAUCOMA DAVID B. SOLL,
M.D.
Philadelphia, Pennsylvania
Recently, I have employed a surgical pro cedure that is useful in glaucomatous pa tients requiring a filtering operation. Basi cally, it consists of a filtering mechanism created by the use of thermal cautery1'2 un der a large scierai flap.3 MATERIALS AND METHODS
The usual akinesia and retrobulbar anes thesia are used if local anesthesia is em ployed. These steps may be omitted if gen eral anesthesia is used. An eyelid speculum is inserted and a supe rior rectus 4-0 black silk traction suture is placed. A 10 mm conjunctival incision is made at the level of the insertion of the su perior rectus muscle. Just anterior to this conjunctival incision a scierai flap is raised. The scierai flap is rectangular in shape, 8-10 mm wide and is attached to the cornea ante riorly. The proper thickness of the scierai flap is indicated by the grayish-blue appear ance in the bed of the flap. The flap is dissected anteriorly far enough so that 1 mm of clear cornea is exposed in its bed at the most anterior aspect. Thus the flap extends from the area just anterior to the in sertion of the superior rectus muscle to 1 mm into clear cornea (Fig. 1). At the corneoscleral junction, which cor responds to the level of Schwalbe's line in the interior of the globe, a central, 5 mm wide, cut down, nonpenetrating incision is made. This area is treated with thermal cau tery (Fig. 2). Light, scattered thermal cau tery also is applied to the entire surface of the scierai bed, undersurface of the scierai flap, and any bleeding points. While the an terior chamber may be entered using a No. From the Department of Ophthalmology of the University of Pennsylvania. Reprint requests to David B. Soll, M.D., 5001 Frankford Avenue, Philadelphia, Pennsylvania 19124.
Fig. 1. (Soil). Surgeon's view of eye. A 10 mm wide rectangular scierai flap has been dissected 1 mm into clear cornea superiorly.
15 Bard-Parker blade, I prefer an opening gently made with the thermal cautery instru ment itself. Once the anterior chamber is entered, the incision is enlarged to a full central 5 mm width, using corneoscleral scissors. The iris is made to prolapse and either a peripheral or sector iridectomy is performed (Fig. 3). The scierai flap is gently laid back into place. Initially, I made no attempt to suture the flap ; however, in the last few cases, 8-0 chromic catgut sutures were used to secure the edge of the flap to the adjacent scierai bed. This allows for more rapid formation of the anterior chamber. The conjunctiva is sutured with interrupted plain catgut 6-0 su tures (Fig. 4) or a running suture. RESULTS
To date 35 operations have been per formed. The results are summarized in Ta ble 1. Satisfactory postoperative results, with intraocular pressures ranging from 1020 mm Hg, were obtained in all patients with chronic open-angle glaucoma with anterior synechiae chronic narrow-angle glaucoma, and pigmentary glaucoma. The two patients with hemorrhagic glaucoma did not maintain a satisfactory long-term tension. The longest follow-up is 27 months (Fig. 5).
390
VOL. 75. NO. 3
INTRASCLERAL FILTERING FOR GLAUCOMA
391
Figs. 2 (Soil). Thermal cautery is applied to the grooved central 5 mm incision at the corneoscleral junction. (Left: Schematic drawing of photograph.)
In several instances, between the second and fourth week there was evidence that the external filtration was decreasing, since the intraocular pressure started to rise above 18 mm Hg. After a series of several Vactro suction treatments, at a level of 60-70 mm of negative pressure for a period of eight min utes, the filtering mechanism stabilized. The intraocular pressure in these patients, as in all the others, has leveled to between 10-20 mm Hg by applanation tonometry.
I prefer the use of suction rather than dig ital massage during the postoperative man agement of filtering operations and con sider this an important factor in the postop erative management in this operation. There is a possibility of lens dislocation with ocular massage.
Fig. 3 (Soil). The anterior chamber has been entered and a peripheral iridectomy performed. The scierai flap is elevated ; the cleft into the anterior chamber is visible.
Fig. 4 (Soil). Immediate postoperative appear ance of eye. The scierai flap has been replaced to its original position and only the conjunctiva is su tured.
DISCUSSION
I feel that the use of thermal cautery in treating the undersurface of the scierai flap
RE:
Chronic narrow-angle: MB (F, 51) January, 1971
RE:
BT (M, 78) October, 1964
RE:
RS (F, 69) February, 1969
RE: LE:
EK (M, 60) March, 1967
RE: LE:
PH (M, 69) March, 1971
LE:
AB (F, 70) August, 1963
LE:
MB (F, 44) May, 1970
RE: LE:
AS (F, 72) January, 1968
RE:
JS (M, 71) April, 1970
RE: LE:
SR (M, 70) August, 1970
RE: LE:
IS ( I t , 41) June, 1969
RE: LE:
Chronic open-angle: DA (M, 72) t November, 1968
Patient, Sex, Age in Years, and Date First Seen
20/60
20/60
20/60
20/80 20/100
HM HM
20/80
20/25
20/30 20/40
20/40
20/60 20/60
20/30 20/25
20/25 20/20
Best Corrected Vision
42-15
38-18
38-22
36-16 37-12
46-34 46-21
34-16
50-14
38-18 42-22
38-22
36-28 28-20
52-17 50-17
36-20 31-22
Range of Intraocular Pressure* (in mm Hg)
Preoperative Data
TABLE 1
February, 1971
June, 1970
February, 1972
March, 1972 June, 1972
April, 1971 January, 1972
July, 1971
August, 1970
April, 1971 June, 1971
March, 1971
July, 1971 April, 1971
August, 1971 July, 1971
May, 1971 December, 1971
Date of Surgery
15
13
22
28 18
18 13
22
30
12 14
28
7 15
18 20
11 21
Intraocular Pressure at One Month (in mm Hg)
February, 1972: 12
July, 1972: 4
July, 1972: 13
18
July, 1972: 16
20
July, 1972: 18
May, 1972: 18
June, 1972: 16
16
February, 1972: 15
June, 1972: 16
11
June, 1972: 11
14
April, 1972: 14
16
April, 1972: 16
Final Intraocular Pressure (in mm Hg)
Postoperative Data
ANALYSIS OF RESULTS IN 26 GLAUCOMATOL'S PATIENTS
Vactro suction
Vactro suction
Cataract extraction, January, 1972, and vactro suction
Comments
20/60
20/30
20/60
20/100 20/100
Cataract extraction May, 1972
Vactro suction Vactro suction
20/200-f- Cataract extractions, R E : September, 1971 LE: May, 1972 HM
20/25
20/30
20/40 20/30
20/60
20/30 20/60
20/60 20/20
20/40 20/25
Final Vision
AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH, 1973
59
HM
35
46-22
CF at one foot
20/100
44
20/200
55-30
50-38
20/60
LP
50
LP
54-44
50-38
20/80
20/60
38-18 50-40
20/20 20/25
42
70-18 30-18
20/20 20/20 -
CF at two feet
May. 1971 January, 1971
38-18 54-30
20/2520/40
18 18
November, 1971
22
February, 1972
May. 1971
13
March, 1970
16
10
December, 1971
June, 1971
9
June. 1971
4
9
September, 1971
July. 1972
18
September, 1971
May, 1972: 35
CF
NLP June, 1972: 30
Comfortable eye, progression of retinopathy
Comfortable eye, progression of retinopathy
Acute attack, April, 1972 20/200
20/200
Old central retinal vein occlusion, acute attack, February, 1972, vactro suction
at two feet
EDTA to cornea preoperatively
Acute attack, June, 1971
Acute attack, September, 1971
Acute attack (RE), December, 1970. Patient did not use medication for one month
Acute attack, April, 1972
HM
CF
HM-CF
10/200
LP
20/80
20/20 20/60
20/60 20/40
20/40 20/80
20/40
June, 1972: 18
June, 1972: 17
April, 1972: 16
July, 1971: 13
April, 1972: 10
March, 1972: 11
May, 1972: 18
March, 1972: 11
June, 1972: 10 10
13 4
July, 1971 December, 1970
March, 1972: 11 11
May, 1972: 11
October, 1971: 15 15
7 20
16
21 18
December, 1970 1971
April, 1972
55-15
20/60
* Best controlled with medication, t Black patient.
FM (M, 68) April, 1972 LE: Pigmentary glaucoma: MH. (F. 68) May, 1971 LE: Hemorrhagic glaucoma: ML fF. 71) November, 1969 RE: CH (F, 76) October, 1971 LE:
MH (F, 74) February, 1972 LE: EH (F, 73) January, 1971 RE: LE: IK (F. 60) November, 1969 RE: LE: HS (F, 59) December, 1970 RE: LE: AS (F, 78) September, 1971 LE: PK (F. 70) September, 1971 RE: MH (F. 70) June, 1971 LE: LM (F, 70) September, 1971 LE: J D (M, 52) March, 1970 RE: AS (F, 85) February, 1972 RE:
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AMERICAN JOURNAL OF OPHTHALMOLOGY
MARCH, 1973
tinued filtration of aqueous has a permanent effect on the scierai collagen in the area of the cleft, thus helping to insure permanent functioning of the filtering tract.5"7 SUMMARY
Fig. 5 (Soil). Appearance of filtering area two and one-half months after surgery. The conjunctiva is succulent, but the actual filtering tract is pro tected by the scierai flap.
and the area of entrance into the anterior chamber significantly helps to insure the per manent patency of the cleft. The scierai flap acts as a protective mechanism for the area of filtration. The filtering areas in all cases were flat—there were no instances of cystic blebs (Fig. 5). The entrance into the anterior chamber is more anterior than is possible with the use of a conventional conjunctival flap alone. Thus, the surgeon is less likely to injure the zonules and the cleft is created anterior to the area of Schlemm's canal. This procedure differs from the creation of filtering areas under scierai flaps in which punches or trephines are used4 in that the thermal cautery has an immediate effect on the properties of scierai collagen which abets the continued patency of the cleft. The con
An external filtering procedure was modi fied by utilizing thermal cautery under a sub stantial scierai flap. The use of thermal cau tery aids in maintaining a functioning cleft. The scierai flap serves as a protective mecha nism for the area of filtration. Also, there is less chance of injury to the zonules, since the anterior chamber is entered anterior to the area of Schlemm's canal. ACKNOWLEDGMENT
I express my appreciation to Riva Lee Asbell for her editorial assistance. REFERENCES
1. Scheie, H. G. : Retraction of scierai wound edges. Am. J. Ophth. 45 :220, 1958. 2. · : An evaluation of iridectomy with scierai cautery. Tr. Ophth. Soc. Aust. 26:44, 1967. 3. Cairns, J. E. : Trabeculectomy, preliminary re port of a new method. Am. J. Opth. 68:673, 1968. 4. Smith, Barry F., Schuster, H., and Seidenberg, B. : Subscleral sclerotomy: A double-flap operation for glaucoma. Arch. Ophth. 71:884, 1971. 5. Kornbleuth, W., and Tenenbaum, E. : The in hibitory effect of aqueous humor on the growth of cells in tissue cultures. Am. J. Ophth. 42:70, 1956. 6. Teng, C. C, Chi, H. H., and Katzin, H. M. : Histology and mechanism of filtering operations. Am. J. Ophth. 47:16, 1959. 7. : Aqueous degenerative effect and the protective role of endothelium in eye pathology. Am. J. Ophth. 50:365, 1960.
M.D.
Philadelphia, Pennsylvania
Recently, I have employed a surgical pro cedure that is useful in glaucomatous pa tients requiring a filtering operation. Basi cally, it consists of a filtering mechanism created by the use of thermal cautery1'2 un der a large scierai flap.3 MATERIALS AND METHODS
The usual akinesia and retrobulbar anes thesia are used if local anesthesia is em ployed. These steps may be omitted if gen eral anesthesia is used. An eyelid speculum is inserted and a supe rior rectus 4-0 black silk traction suture is placed. A 10 mm conjunctival incision is made at the level of the insertion of the su perior rectus muscle. Just anterior to this conjunctival incision a scierai flap is raised. The scierai flap is rectangular in shape, 8-10 mm wide and is attached to the cornea ante riorly. The proper thickness of the scierai flap is indicated by the grayish-blue appear ance in the bed of the flap. The flap is dissected anteriorly far enough so that 1 mm of clear cornea is exposed in its bed at the most anterior aspect. Thus the flap extends from the area just anterior to the in sertion of the superior rectus muscle to 1 mm into clear cornea (Fig. 1). At the corneoscleral junction, which cor responds to the level of Schwalbe's line in the interior of the globe, a central, 5 mm wide, cut down, nonpenetrating incision is made. This area is treated with thermal cau tery (Fig. 2). Light, scattered thermal cau tery also is applied to the entire surface of the scierai bed, undersurface of the scierai flap, and any bleeding points. While the an terior chamber may be entered using a No. From the Department of Ophthalmology of the University of Pennsylvania. Reprint requests to David B. Soll, M.D., 5001 Frankford Avenue, Philadelphia, Pennsylvania 19124.
Fig. 1. (Soil). Surgeon's view of eye. A 10 mm wide rectangular scierai flap has been dissected 1 mm into clear cornea superiorly.
15 Bard-Parker blade, I prefer an opening gently made with the thermal cautery instru ment itself. Once the anterior chamber is entered, the incision is enlarged to a full central 5 mm width, using corneoscleral scissors. The iris is made to prolapse and either a peripheral or sector iridectomy is performed (Fig. 3). The scierai flap is gently laid back into place. Initially, I made no attempt to suture the flap ; however, in the last few cases, 8-0 chromic catgut sutures were used to secure the edge of the flap to the adjacent scierai bed. This allows for more rapid formation of the anterior chamber. The conjunctiva is sutured with interrupted plain catgut 6-0 su tures (Fig. 4) or a running suture. RESULTS
To date 35 operations have been per formed. The results are summarized in Ta ble 1. Satisfactory postoperative results, with intraocular pressures ranging from 1020 mm Hg, were obtained in all patients with chronic open-angle glaucoma with anterior synechiae chronic narrow-angle glaucoma, and pigmentary glaucoma. The two patients with hemorrhagic glaucoma did not maintain a satisfactory long-term tension. The longest follow-up is 27 months (Fig. 5).
390
VOL. 75. NO. 3
INTRASCLERAL FILTERING FOR GLAUCOMA
391
Figs. 2 (Soil). Thermal cautery is applied to the grooved central 5 mm incision at the corneoscleral junction. (Left: Schematic drawing of photograph.)
In several instances, between the second and fourth week there was evidence that the external filtration was decreasing, since the intraocular pressure started to rise above 18 mm Hg. After a series of several Vactro suction treatments, at a level of 60-70 mm of negative pressure for a period of eight min utes, the filtering mechanism stabilized. The intraocular pressure in these patients, as in all the others, has leveled to between 10-20 mm Hg by applanation tonometry.
I prefer the use of suction rather than dig ital massage during the postoperative man agement of filtering operations and con sider this an important factor in the postop erative management in this operation. There is a possibility of lens dislocation with ocular massage.
Fig. 3 (Soil). The anterior chamber has been entered and a peripheral iridectomy performed. The scierai flap is elevated ; the cleft into the anterior chamber is visible.
Fig. 4 (Soil). Immediate postoperative appear ance of eye. The scierai flap has been replaced to its original position and only the conjunctiva is su tured.
DISCUSSION
I feel that the use of thermal cautery in treating the undersurface of the scierai flap
RE:
Chronic narrow-angle: MB (F, 51) January, 1971
RE:
BT (M, 78) October, 1964
RE:
RS (F, 69) February, 1969
RE: LE:
EK (M, 60) March, 1967
RE: LE:
PH (M, 69) March, 1971
LE:
AB (F, 70) August, 1963
LE:
MB (F, 44) May, 1970
RE: LE:
AS (F, 72) January, 1968
RE:
JS (M, 71) April, 1970
RE: LE:
SR (M, 70) August, 1970
RE: LE:
IS ( I t , 41) June, 1969
RE: LE:
Chronic open-angle: DA (M, 72) t November, 1968
Patient, Sex, Age in Years, and Date First Seen
20/60
20/60
20/60
20/80 20/100
HM HM
20/80
20/25
20/30 20/40
20/40
20/60 20/60
20/30 20/25
20/25 20/20
Best Corrected Vision
42-15
38-18
38-22
36-16 37-12
46-34 46-21
34-16
50-14
38-18 42-22
38-22
36-28 28-20
52-17 50-17
36-20 31-22
Range of Intraocular Pressure* (in mm Hg)
Preoperative Data
TABLE 1
February, 1971
June, 1970
February, 1972
March, 1972 June, 1972
April, 1971 January, 1972
July, 1971
August, 1970
April, 1971 June, 1971
March, 1971
July, 1971 April, 1971
August, 1971 July, 1971
May, 1971 December, 1971
Date of Surgery
15
13
22
28 18
18 13
22
30
12 14
28
7 15
18 20
11 21
Intraocular Pressure at One Month (in mm Hg)
February, 1972: 12
July, 1972: 4
July, 1972: 13
18
July, 1972: 16
20
July, 1972: 18
May, 1972: 18
June, 1972: 16
16
February, 1972: 15
June, 1972: 16
11
June, 1972: 11
14
April, 1972: 14
16
April, 1972: 16
Final Intraocular Pressure (in mm Hg)
Postoperative Data
ANALYSIS OF RESULTS IN 26 GLAUCOMATOL'S PATIENTS
Vactro suction
Vactro suction
Cataract extraction, January, 1972, and vactro suction
Comments
20/60
20/30
20/60
20/100 20/100
Cataract extraction May, 1972
Vactro suction Vactro suction
20/200-f- Cataract extractions, R E : September, 1971 LE: May, 1972 HM
20/25
20/30
20/40 20/30
20/60
20/30 20/60
20/60 20/20
20/40 20/25
Final Vision
AMERICAN JOURNAL OF OPHTHALMOLOGY MARCH, 1973
59
HM
35
46-22
CF at one foot
20/100
44
20/200
55-30
50-38
20/60
LP
50
LP
54-44
50-38
20/80
20/60
38-18 50-40
20/20 20/25
42
70-18 30-18
20/20 20/20 -
CF at two feet
May. 1971 January, 1971
38-18 54-30
20/2520/40
18 18
November, 1971
22
February, 1972
May. 1971
13
March, 1970
16
10
December, 1971
June, 1971
9
June. 1971
4
9
September, 1971
July. 1972
18
September, 1971
May, 1972: 35
CF
NLP June, 1972: 30
Comfortable eye, progression of retinopathy
Comfortable eye, progression of retinopathy
Acute attack, April, 1972 20/200
20/200
Old central retinal vein occlusion, acute attack, February, 1972, vactro suction
at two feet
EDTA to cornea preoperatively
Acute attack, June, 1971
Acute attack, September, 1971
Acute attack (RE), December, 1970. Patient did not use medication for one month
Acute attack, April, 1972
HM
CF
HM-CF
10/200
LP
20/80
20/20 20/60
20/60 20/40
20/40 20/80
20/40
June, 1972: 18
June, 1972: 17
April, 1972: 16
July, 1971: 13
April, 1972: 10
March, 1972: 11
May, 1972: 18
March, 1972: 11
June, 1972: 10 10
13 4
July, 1971 December, 1970
March, 1972: 11 11
May, 1972: 11
October, 1971: 15 15
7 20
16
21 18
December, 1970 1971
April, 1972
55-15
20/60
* Best controlled with medication, t Black patient.
FM (M, 68) April, 1972 LE: Pigmentary glaucoma: MH. (F. 68) May, 1971 LE: Hemorrhagic glaucoma: ML fF. 71) November, 1969 RE: CH (F, 76) October, 1971 LE:
MH (F, 74) February, 1972 LE: EH (F, 73) January, 1971 RE: LE: IK (F. 60) November, 1969 RE: LE: HS (F, 59) December, 1970 RE: LE: AS (F, 78) September, 1971 LE: PK (F. 70) September, 1971 RE: MH (F. 70) June, 1971 LE: LM (F, 70) September, 1971 LE: J D (M, 52) March, 1970 RE: AS (F, 85) February, 1972 RE:
a r > d n o
*J
o
Ξ o
w
3 P
>
M S)
o r
> m
o
53
O
<
394
AMERICAN JOURNAL OF OPHTHALMOLOGY
MARCH, 1973
tinued filtration of aqueous has a permanent effect on the scierai collagen in the area of the cleft, thus helping to insure permanent functioning of the filtering tract.5"7 SUMMARY
Fig. 5 (Soil). Appearance of filtering area two and one-half months after surgery. The conjunctiva is succulent, but the actual filtering tract is pro tected by the scierai flap.
and the area of entrance into the anterior chamber significantly helps to insure the per manent patency of the cleft. The scierai flap acts as a protective mechanism for the area of filtration. The filtering areas in all cases were flat—there were no instances of cystic blebs (Fig. 5). The entrance into the anterior chamber is more anterior than is possible with the use of a conventional conjunctival flap alone. Thus, the surgeon is less likely to injure the zonules and the cleft is created anterior to the area of Schlemm's canal. This procedure differs from the creation of filtering areas under scierai flaps in which punches or trephines are used4 in that the thermal cautery has an immediate effect on the properties of scierai collagen which abets the continued patency of the cleft. The con
An external filtering procedure was modi fied by utilizing thermal cautery under a sub stantial scierai flap. The use of thermal cau tery aids in maintaining a functioning cleft. The scierai flap serves as a protective mecha nism for the area of filtration. Also, there is less chance of injury to the zonules, since the anterior chamber is entered anterior to the area of Schlemm's canal. ACKNOWLEDGMENT
I express my appreciation to Riva Lee Asbell for her editorial assistance. REFERENCES
1. Scheie, H. G. : Retraction of scierai wound edges. Am. J. Ophth. 45 :220, 1958. 2. · : An evaluation of iridectomy with scierai cautery. Tr. Ophth. Soc. Aust. 26:44, 1967. 3. Cairns, J. E. : Trabeculectomy, preliminary re port of a new method. Am. J. Opth. 68:673, 1968. 4. Smith, Barry F., Schuster, H., and Seidenberg, B. : Subscleral sclerotomy: A double-flap operation for glaucoma. Arch. Ophth. 71:884, 1971. 5. Kornbleuth, W., and Tenenbaum, E. : The in hibitory effect of aqueous humor on the growth of cells in tissue cultures. Am. J. Ophth. 42:70, 1956. 6. Teng, C. C, Chi, H. H., and Katzin, H. M. : Histology and mechanism of filtering operations. Am. J. Ophth. 47:16, 1959. 7. : Aqueous degenerative effect and the protective role of endothelium in eye pathology. Am. J. Ophth. 50:365, 1960.