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NonPenetrating Glaucoma Surgery

NonPenetrating Glaucoma Surgery. Elie Dahan Oxford Eye Center University of the Witwatersrand Johannesburg South Africa. Early surgery is superior to Medicine & Laser. Migdal, Gregory & Hitchings

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NonPenetrating Glaucoma Surgery

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  1. NonPenetrating Glaucoma Surgery Elie Dahan Oxford Eye Center University of the Witwatersrand Johannesburg South Africa

  2. Early surgery is superior to Medicine & Laser Migdal, Gregory & Hitchings Long-term functional outcome after early surgery compared with laser and medicine in open-angle glaucoma. Ophthalmology 1994; 101:1651-1657.

  3. If SurgeryIs the Treatment of Choice in Glaucoma The Conditions Should Be That Surgery Is Safe & Successful

  4. Advantages of NPGS over Classic Trabeculectomy • No flat anterior chamber (25% versus 2%) • Less Choroidal detachment (5-10% versus 2-3%) • Less Hyphema (10% versus 3%) • Less Cataractogenic • Less prostaglandins • Smoother IOP decrease • Viewing the site of Pathology

  5. Intraoperative IOP Flow Chart

  6. NPGS 02.1992-02.2001Complete Success As a Function of Time (IOP<20mmHg w/o Rx)

  7. N.P.G.S Feb’92-Feb’01re-intervention rate

  8. Survival of NPGS (IOP <18mmHG W/O Rx) 1997-2002

  9. NPGS With Cataract Extraction 02.1992-02.2001Complete Success As a Function of Time (IOP < 20mmhg w/o Rx

  10. NPGS Dahan’s Technique • An inverted “L” shaped fornix based conjunctival flap is the most appropriate for NPGS. It is simple, least traumatic and repeatable.

  11. NPGS Dahan’s Technique • A trapezoidal superficial Scleral flap 5x5x1.5mm at 40% depth is raised.

  12. NPGS Dahan’s Technique • The superficial scleral flap is temporarily sutured at 6h00 with an 8/0 virgin silk for better exposure. A 90% depth deep sclerectomy is done.

  13. NPGS Dahan’s Technique • The deep sclerectomy is done to uncover the trabeculo-descemetic membrane.

  14. T Flux NPGS Implant • The T Flux is a non-absorbable hydrophilic glaucoma implant. It prolongs the NPGS longevity by maintaining a permanent intrascleral space. It is highly biocompatible because of its high water content.

  15. NPGS Dahan’s Technique • The T Flux implant is positioned in the deep sclerectomy, with its arms tucked into the Schlemm’s Canal. The position of the hole in the trunk is marked on the sclera for placing the fixation sutures.

  16. NPGS Dahan’s Technique • Securing the T Flux in the deep sclerectomy.

  17. NPGS Dahan’s Technique • T Flux 2nd fixation suture

  18. NPGS Dahan’s Technique • A T Flux secured in the deep sclerectomy with a 10/0 nylon suture.

  19. NPGS Dahan’s Technique When the T Flux has been secured in the deep sclerectomy, the superficial flap is sutured with one suture on its apex and the conjunctiva is replaced with one buried suture

  20. NPGS T Flux study1997-2002 E. Dahan, E. Ravinet, A. Mermoud Oxford Eye Center Johannesburg Jules Gonin Eye Hospital Lausanne

  21. Inclusion Criteria • Primary Open Angle Glaucoma >18 years Old • Phakic Patients who do not need cataract surgery • Exclusion: Trauma, Uveitis, Congenital & Infantile Glaucoma

  22. With T Flux No 25 Age 59 Preop IOP 27.5 Cupping 74% No of Rx 2.3 Without T Flux 23 65 24.8 73% 2.3 Demographics & preoperative data

  23. With T Flux IOP 12.5 No of Rx 0 in % 48.2% Goniopunct 6 (24%) F/U 19.9 Without T Flux 13.3 0.3 44% 6 (26%) F/U 27.5 Postoperative data

  24. Mean Preop IOP & Last IOP

  25. Mean IOP decrease in %

  26. Mean Preop IOP & last IOPin patients with F/U > 23months

  27. Mean IOP decrease in %in patients with F/U > 23months

  28. IOP Flow Chart With & Without T Flux

  29. With T Flux One T Flux (which was not sutured) migrated to the A/C following severe coughing and/or rubbing Without T Flux 2 iris incarcerations following goniopunctures and/or rubbing Complications

  30. Conclusions (1) • During the first two years, there is little difference between the two groups. • In patients with follow up longer than 2 years, the T Flux group yields better results. • The T Flux prevents iris incarcerations

  31. Reminder • METICULOUS Surgery isPRIMORDIAL & far more important than any sort of IMPLANT. • Mediocre surgical technique will fail even with the Best Glaucoma Implant.

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