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Stabilization of post-trabeculectomy flat anterior chamber with Healon and sulfur hexafluoride
Stabilization of post-trabeculectomy flat anterior chamber with Healon and sulfur hexafluoride Orna Geyer, MD, Eitan Segev, MD, Jordan M. Steinberg, MD, Gila Buckman, MD We present the management of 2 cases of post-trabeculectomy flat anterior chamber with hypotony due to an overflowing fistula. When separate attempts to reform the anterior chamber by intracameral injection of sulfur hexafluoride (SF6) and sodium hyaluronate 1.0% (Healon姞) failed, we injected SF6 100% with Healon into the anterior chamber. This stabilized the anterior chamber without compromising the integrity of the filtering bleb. No complications were observed. This simple, safe, and effective procedure offers another option for the management of a flat anterior chamber due to overfiltration. J Cataract Refract Surg 2003; 29:2026 –2028 © 2003 ASCRS and ESCRS
A
A 53-year-old phakic man with uncontrolled glaucoma had an uneventful trabeculectomy with a limbus-based flap.
The best corrected visual acuity before surgery was 20/30. On the second postoperative day, the patient had a type III shallow anterior chamber with lens-to-cornea touch and a nasal choroidal detachment. Reformation at the slitlamp of the anterior chamber with Healon failed twice. An attempt to stabilize the eye with sulfur hexafluoride (SF6) 40% also failed since most of the gas escaped through the paracentesis and the rest through the bleb. At this stage, 0.15 mL Healon was injected through the previously placed paracentesis. When the anterior chamber was half filled, 0.1 mL SF6 100% was injected through a new small paracentesis site 180 degrees from the first paracentesis. Topical steroids and antibiotics were prescribed. Cycloplegics were not given to reduce contact between the SF6 and the lens. The next day, the anterior chamber was deep, a gas bubble in the upper one-fourth of the chamber was blocking the bleb, and stationary cells were suspended in the viscoelastic material. The intraocular pressure (IOP) was 9 mm Hg. Healon cleared within 4 days, the gas bubble absorbed over the next week, and the choroidal detachment resolved. Topical medications were tapered over the next 2 weeks. Six-month follow-up examination revealed a visual acuity of 20/30, clear cornea, and a deep anterior chamber. The IOP stabilized in the teens without medication.
Accepted for publication February 20, 2003.
Case 2
flat anterior chamber with hypotony after trabeculectomy can, if untreated, cause corneal endothelial and/or stromal damage, peripheral anterior synechias, closure of the filtering fistula, and cataract. Hypotonic maculopathy and serious retinal detachment are other possible complications. The latter can be reduced with surgical precautions such as releasable sutures. When a flat anterior chamber is due to an overflowing fistula, suturing the scleral flap, patching, and injecting sodium hyaluronate 1.0% (Healon威)1,2 or gas3,4 into the anterior chamber have been suggested. We present 2 cases in which a combination of Healon and gas helped stabilize the eye after filtration surgery. To our knowledge, this technique has not been reported.
Case Reports Case 1
From the Department of Ophthalmology, Carmel Medical Center, Haifa, Israel. None of the authors has a financial or proprietary interest in any material or method mentioned. Correspondence to Orna Geyer, MD, Head, Department of Ophthalmology, Carmel Medical Center, 6 Michal Street, Haifa, Israel. E-mail: [email protected]. © 2003 ASCRS and ESCRS Published by Elsevier Inc.
A 64-year-old phakic man with 20/60 visual acuity had a viscocanalostomy in the right eye for the treatment of medically uncontrolled primary open-angle glaucoma. The next day, the IOP was 40 mm Hg and the anterior chamber was deep. The IOP remained high for the next week despite maximum medical therapy. Iris block was ruled out by slitlamp and gonioscopic examination and, subsequently, a revision of the surgical site was performed. On exposure of the trabeculo0886-3350/03/$–see front matter doi:10.1016/S0886-3350(03)00219-0
CASE REPORTS: GEYER
Descemet’s window, there was absence of aqueous humor percolation, confirming that the surgical site was plugged. Removal of the trabecular cornea membrane and a peripheral iridectomy were performed. The superficial scleral flap was closed tightly, and the Tenon’s capsule and conjunctiva were sutured. On the second postoperative day, a type III shallow anterior chamber with lens-to-cornea touch and a small temporal choroidal detachment were found. No wound leak was observed. The anterior chamber was reformed at the slitlamp by injecting sodium hyaluronate 2.3% (Healon威5). Topical atropine 1% and prednisolone 0.1% were prescribed. Two days later, a flat anterior chamber with lens-to-cornea touch and choroidal detachment had enlarged. Sulfur hexafluoride 40% was injected in the eye but escaped through the paracentesis and the fistula. Then, 0.15 mL of Healon was injected through the present paracentesis. Once the anterior chamber was half full, a small bubble of SF6 100% was injected through the same site, which occupied less than oneeighth of the anterior chamber. The next day, the anterior chamber was flat and no gas was seen since the bubble escaped through the fistula. We repeated the intracameral injection of Healon and SF6 100%. This time, a larger gas bubble was injected that occupied one-fourth of the anterior chamber and plugged the fistula. The following day, the filtering bleb was filled with the gas bubble and the anterior chamber was formed. The IOP was 9 mm Hg, the cornea clear, and a mild cortical cataract present. Five months postoperatively, visual acuity was 20/80, IOP was 17 mm Hg without medication, the cornea was clear, the anterior was chamber was deep, and a mild cortical cataract was present.
Discussion Postoperative choroidal detachment is frequently observed after filtering surgery. Prolonged hypotony causes enlargement of the choroidal detachment, leading to severe uncontrollable pain, prolonged retinal apposition, and vitreous hemorrhage. In these cases, drainage of the choroidal hemorrhage is indicated. The best method to decrease the risk of choroidal hemorrhage is to avoid hypotony.5 Both cases in this study were characterized by postoperative hypotony and choroidal detachment, and prompt intervention was indicated to normalize the IOP and prevent progression of the choroidal detachment. Injection of sodium hyaluronate1,2 and gases3,4 has been advocated for the reformation of a flat anterior chamber after filtering surgery. Ophthalmic viscosurgical material1 has been used to treat a flat anterior cham-
ber after trabeculectomy. Because the material tends to wash out of the anterior chamber by the third postoperative day, repeat injections are required to stabilize the eye. Healon5 is a new viscoadaptive formulation that exhibits high viscosity and cohesion. Despite these properties, Healon5 appears to be ineffective for the reformation of the flat anterior chamber.2 In our patients, both Healon and Healon5 failed to reconstruct the flat anterior chamber after filtering surgery. Gases for intraocular surgery have been reported as effective for the reformation of a flat anterior chamber after trabeculectomy.3,4 The aim of the gas is to seal the fistula and deepen the anterior chamber until aqueous gradually replaces it. However, this procedure may be accompanied by side effects. Animal studies have shown that SF6 causes transient corneal edema while perfluoropropane (C3F8) induces persistent corneal edema and fibrin deposition on the posterior surface of the endothelial cells. This is due to the mechanical barrier between the aqueous humor and corneal endothelial cells created by the gas, which leads to nutritional deprivation of this tissue. The longer this barrier is in place, the greater the damage can be. To reform the anterior chamber, a high volume of gas is needed, and this significantly prolonged contact time of gas with intraocular tissues increases the complication rate.6 – 8 To avoid these ocular side effects, an injection of diluted gases has been recommended. In our patients, the injection of SF6 40% failed to stabilize the anterior chamber because the gas escaped from the paracentesis and through the fistula. We used a combination of Healon and pure SF6 to stabilize the flat anterior chamber. The goal of the Healon was to cause immediate stabilization of the anterior chamber, while the aim of the gas that floats was to seal the fistula in the upper part of the eye. As pure gas was used, the small bubble expanded during the days after an intraocular injection to a size just sufficient to plug the fistula, preventing aqueous drainage and deepening the anterior chamber. Since the gas bubble occupied only part of the anterior chamber, it did not prevent corneal nutrition by causing a barrier between the aqueous humor and corneal endothelium, avoiding corneal hypoxia. One of our patients needed a repeat injection of Healon and pure gas to stabilize the anterior chamber because the size of the gas bubble used during the first injection was small and insufficiently plugged the fistula.
J CATARACT REFRACT SURG—VOL 29, OCTOBER 2003
2027
CASE REPORTS: GEYER
A cataract developed in our second case. We believe that it was caused by the prolonged hypotony and not by the gas–lens touch, which was of short duration. The use of the hyaluronic acid and pure gas combination for the reformation of a flat anterior chamber and choroidal detachment has advantages over the use of them separately. Viscosurgical material such as Healon or Healon5 may cause immediate stabilization of the anterior chamber but tends to wash out of the eye in 36 to 48 hours, which is not enough time for resolution of the choroidal detachment that is in part responsible for the flat chamber. Often, even large amounts of gas fail to push back the choroidal detachment and reform the anterior chamber and the gas is pushed out of the eye through the fistula or the paracentesis. Furthermore, filling the anterior chamber with a large gas bubble is deleterious to the cornea. The combination of hyaluronic acid and pure gas is preferred since the small gas bubble does not preclude aqueous nutrition of the cornea, avoiding the side effects of a large gas bubble. The cases presented indicate that slitlamp reconstruction of the anterior chamber with a combination of Healon and pure gas is simple, safe, and effective. This procedure is 1 of many options in the management of a flat anterior chamber due to overfiltration.
2028
References 1. Osher RH, Cionni RJ, Cohen JS. Re-forming the anterior chamber with Healon. J Cataract Refract Surg 1996; 22: 411–415 2. Hoffman RS, Fine IH, Packer M. Stabilization of flat anterior chamber after trabeculectomy with Healon5. J Cataract Refract Surg 2002; 28:712–714 3. Beigi B, O’Keefe M, Algawi K, et al. Sulphur hexafluoride in the treatment of flat anterior chamber following trabeculectomy. Eye 1997; 11:672–676 4. Weinstein O, Oshry T, Tessler Z, Lifshitz T. Use of sulphur hexafluoride for anterior chamber reformation following trabeculectomy [letter]. Br J Ophthalmol 1998; 82:1220 5. Liebmann JM, Ritch R. Complications of glaucoma filtering surgery. In: Ritch R, Shields MB, Krupin T, eds, The Glaucomas, 2nd ed. St Louis, Missouri, Mosby, 1996; 1707–1708 6. Lee DA, Wilson MR, Yoshizumi MO, Hall M. The ocular effects of gases when injected into the anterior chamber of rabbit eyes. Arch Ophthalmol 1991; 109:571–575 7. Van Horn DL, Edelhauser HF, Aaberg TM, Pederson HJ. In vivo effects of air and sulphur hexafluoride gas on rabbit corneal endothelium. Invest Ophthalmol 1972; 11:1028 – 1036 8. Foulks GN, de Juan E, Hatchell DL, et al. The effect of perfluoropropane on the cornea in rabbits and cats. Arch Ophthalmol 1987; 105:256 –259
J CATARACT REFRACT SURG—VOL 29, OCTOBER 2003
A
A 53-year-old phakic man with uncontrolled glaucoma had an uneventful trabeculectomy with a limbus-based flap.
The best corrected visual acuity before surgery was 20/30. On the second postoperative day, the patient had a type III shallow anterior chamber with lens-to-cornea touch and a nasal choroidal detachment. Reformation at the slitlamp of the anterior chamber with Healon failed twice. An attempt to stabilize the eye with sulfur hexafluoride (SF6) 40% also failed since most of the gas escaped through the paracentesis and the rest through the bleb. At this stage, 0.15 mL Healon was injected through the previously placed paracentesis. When the anterior chamber was half filled, 0.1 mL SF6 100% was injected through a new small paracentesis site 180 degrees from the first paracentesis. Topical steroids and antibiotics were prescribed. Cycloplegics were not given to reduce contact between the SF6 and the lens. The next day, the anterior chamber was deep, a gas bubble in the upper one-fourth of the chamber was blocking the bleb, and stationary cells were suspended in the viscoelastic material. The intraocular pressure (IOP) was 9 mm Hg. Healon cleared within 4 days, the gas bubble absorbed over the next week, and the choroidal detachment resolved. Topical medications were tapered over the next 2 weeks. Six-month follow-up examination revealed a visual acuity of 20/30, clear cornea, and a deep anterior chamber. The IOP stabilized in the teens without medication.
Accepted for publication February 20, 2003.
Case 2
flat anterior chamber with hypotony after trabeculectomy can, if untreated, cause corneal endothelial and/or stromal damage, peripheral anterior synechias, closure of the filtering fistula, and cataract. Hypotonic maculopathy and serious retinal detachment are other possible complications. The latter can be reduced with surgical precautions such as releasable sutures. When a flat anterior chamber is due to an overflowing fistula, suturing the scleral flap, patching, and injecting sodium hyaluronate 1.0% (Healon威)1,2 or gas3,4 into the anterior chamber have been suggested. We present 2 cases in which a combination of Healon and gas helped stabilize the eye after filtration surgery. To our knowledge, this technique has not been reported.
Case Reports Case 1
From the Department of Ophthalmology, Carmel Medical Center, Haifa, Israel. None of the authors has a financial or proprietary interest in any material or method mentioned. Correspondence to Orna Geyer, MD, Head, Department of Ophthalmology, Carmel Medical Center, 6 Michal Street, Haifa, Israel. E-mail: [email protected]. © 2003 ASCRS and ESCRS Published by Elsevier Inc.
A 64-year-old phakic man with 20/60 visual acuity had a viscocanalostomy in the right eye for the treatment of medically uncontrolled primary open-angle glaucoma. The next day, the IOP was 40 mm Hg and the anterior chamber was deep. The IOP remained high for the next week despite maximum medical therapy. Iris block was ruled out by slitlamp and gonioscopic examination and, subsequently, a revision of the surgical site was performed. On exposure of the trabeculo0886-3350/03/$–see front matter doi:10.1016/S0886-3350(03)00219-0
CASE REPORTS: GEYER
Descemet’s window, there was absence of aqueous humor percolation, confirming that the surgical site was plugged. Removal of the trabecular cornea membrane and a peripheral iridectomy were performed. The superficial scleral flap was closed tightly, and the Tenon’s capsule and conjunctiva were sutured. On the second postoperative day, a type III shallow anterior chamber with lens-to-cornea touch and a small temporal choroidal detachment were found. No wound leak was observed. The anterior chamber was reformed at the slitlamp by injecting sodium hyaluronate 2.3% (Healon威5). Topical atropine 1% and prednisolone 0.1% were prescribed. Two days later, a flat anterior chamber with lens-to-cornea touch and choroidal detachment had enlarged. Sulfur hexafluoride 40% was injected in the eye but escaped through the paracentesis and the fistula. Then, 0.15 mL of Healon was injected through the present paracentesis. Once the anterior chamber was half full, a small bubble of SF6 100% was injected through the same site, which occupied less than oneeighth of the anterior chamber. The next day, the anterior chamber was flat and no gas was seen since the bubble escaped through the fistula. We repeated the intracameral injection of Healon and SF6 100%. This time, a larger gas bubble was injected that occupied one-fourth of the anterior chamber and plugged the fistula. The following day, the filtering bleb was filled with the gas bubble and the anterior chamber was formed. The IOP was 9 mm Hg, the cornea clear, and a mild cortical cataract present. Five months postoperatively, visual acuity was 20/80, IOP was 17 mm Hg without medication, the cornea was clear, the anterior was chamber was deep, and a mild cortical cataract was present.
Discussion Postoperative choroidal detachment is frequently observed after filtering surgery. Prolonged hypotony causes enlargement of the choroidal detachment, leading to severe uncontrollable pain, prolonged retinal apposition, and vitreous hemorrhage. In these cases, drainage of the choroidal hemorrhage is indicated. The best method to decrease the risk of choroidal hemorrhage is to avoid hypotony.5 Both cases in this study were characterized by postoperative hypotony and choroidal detachment, and prompt intervention was indicated to normalize the IOP and prevent progression of the choroidal detachment. Injection of sodium hyaluronate1,2 and gases3,4 has been advocated for the reformation of a flat anterior chamber after filtering surgery. Ophthalmic viscosurgical material1 has been used to treat a flat anterior cham-
ber after trabeculectomy. Because the material tends to wash out of the anterior chamber by the third postoperative day, repeat injections are required to stabilize the eye. Healon5 is a new viscoadaptive formulation that exhibits high viscosity and cohesion. Despite these properties, Healon5 appears to be ineffective for the reformation of the flat anterior chamber.2 In our patients, both Healon and Healon5 failed to reconstruct the flat anterior chamber after filtering surgery. Gases for intraocular surgery have been reported as effective for the reformation of a flat anterior chamber after trabeculectomy.3,4 The aim of the gas is to seal the fistula and deepen the anterior chamber until aqueous gradually replaces it. However, this procedure may be accompanied by side effects. Animal studies have shown that SF6 causes transient corneal edema while perfluoropropane (C3F8) induces persistent corneal edema and fibrin deposition on the posterior surface of the endothelial cells. This is due to the mechanical barrier between the aqueous humor and corneal endothelial cells created by the gas, which leads to nutritional deprivation of this tissue. The longer this barrier is in place, the greater the damage can be. To reform the anterior chamber, a high volume of gas is needed, and this significantly prolonged contact time of gas with intraocular tissues increases the complication rate.6 – 8 To avoid these ocular side effects, an injection of diluted gases has been recommended. In our patients, the injection of SF6 40% failed to stabilize the anterior chamber because the gas escaped from the paracentesis and through the fistula. We used a combination of Healon and pure SF6 to stabilize the flat anterior chamber. The goal of the Healon was to cause immediate stabilization of the anterior chamber, while the aim of the gas that floats was to seal the fistula in the upper part of the eye. As pure gas was used, the small bubble expanded during the days after an intraocular injection to a size just sufficient to plug the fistula, preventing aqueous drainage and deepening the anterior chamber. Since the gas bubble occupied only part of the anterior chamber, it did not prevent corneal nutrition by causing a barrier between the aqueous humor and corneal endothelium, avoiding corneal hypoxia. One of our patients needed a repeat injection of Healon and pure gas to stabilize the anterior chamber because the size of the gas bubble used during the first injection was small and insufficiently plugged the fistula.
J CATARACT REFRACT SURG—VOL 29, OCTOBER 2003
2027
CASE REPORTS: GEYER
A cataract developed in our second case. We believe that it was caused by the prolonged hypotony and not by the gas–lens touch, which was of short duration. The use of the hyaluronic acid and pure gas combination for the reformation of a flat anterior chamber and choroidal detachment has advantages over the use of them separately. Viscosurgical material such as Healon or Healon5 may cause immediate stabilization of the anterior chamber but tends to wash out of the eye in 36 to 48 hours, which is not enough time for resolution of the choroidal detachment that is in part responsible for the flat chamber. Often, even large amounts of gas fail to push back the choroidal detachment and reform the anterior chamber and the gas is pushed out of the eye through the fistula or the paracentesis. Furthermore, filling the anterior chamber with a large gas bubble is deleterious to the cornea. The combination of hyaluronic acid and pure gas is preferred since the small gas bubble does not preclude aqueous nutrition of the cornea, avoiding the side effects of a large gas bubble. The cases presented indicate that slitlamp reconstruction of the anterior chamber with a combination of Healon and pure gas is simple, safe, and effective. This procedure is 1 of many options in the management of a flat anterior chamber due to overfiltration.
2028
References 1. Osher RH, Cionni RJ, Cohen JS. Re-forming the anterior chamber with Healon. J Cataract Refract Surg 1996; 22: 411–415 2. Hoffman RS, Fine IH, Packer M. Stabilization of flat anterior chamber after trabeculectomy with Healon5. J Cataract Refract Surg 2002; 28:712–714 3. Beigi B, O’Keefe M, Algawi K, et al. Sulphur hexafluoride in the treatment of flat anterior chamber following trabeculectomy. Eye 1997; 11:672–676 4. Weinstein O, Oshry T, Tessler Z, Lifshitz T. Use of sulphur hexafluoride for anterior chamber reformation following trabeculectomy [letter]. Br J Ophthalmol 1998; 82:1220 5. Liebmann JM, Ritch R. Complications of glaucoma filtering surgery. In: Ritch R, Shields MB, Krupin T, eds, The Glaucomas, 2nd ed. St Louis, Missouri, Mosby, 1996; 1707–1708 6. Lee DA, Wilson MR, Yoshizumi MO, Hall M. The ocular effects of gases when injected into the anterior chamber of rabbit eyes. Arch Ophthalmol 1991; 109:571–575 7. Van Horn DL, Edelhauser HF, Aaberg TM, Pederson HJ. In vivo effects of air and sulphur hexafluoride gas on rabbit corneal endothelium. Invest Ophthalmol 1972; 11:1028 – 1036 8. Foulks GN, de Juan E, Hatchell DL, et al. The effect of perfluoropropane on the cornea in rabbits and cats. Arch Ophthalmol 1987; 105:256 –259
J CATARACT REFRACT SURG—VOL 29, OCTOBER 2003