Year : 1988 | Volume
: 36 | Issue : 2 | Page : 71--73
Trabeculectomy vs goniopunch-Combined with cataract extraction
AK Khurana, BK Ahluwalia
34/9J Medical Enclave, Rohtak-124 001, India
A K Khurana
34/9J Medical Enclave, Rohtak-124 001
A simple technique of combined gonio punch and intracapsular lens extraction with a fornix based conjunctival flap is described with encouraging results of pressure control (84%). It is ate as effective as trabeculectomy and an easy procedure for patients with cataract and either open or closed angle glaucoma The importance of frequent follow up in the post operative period especially in patients with primary open angle glaucoma emphasised.
|How to cite this article:|
Khurana A K, Ahluwalia B K. Trabeculectomy vs goniopunch-Combined with cataract extraction.Indian J Ophthalmol 1988;36:71-73
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Khurana A K, Ahluwalia B K. Trabeculectomy vs goniopunch-Combined with cataract extraction. Indian J Ophthalmol [serial online] 1988 [cited 2020 Apr 9 ];36:71-73
Available from: http://www.ijo.in/text.asp?1988/36/2/71/26145
Senile cataract and glaucoma are often present simultaneously in the geriatric population, yet the problem of how to manage these eyes when vision is sufficiently reduced to require a cataract extraction is controversial The therapeutic dilemma in these cases has been recognised for a long time and different combinations of cataract and glaucoma operations have been attempted with varying degrees of success ,. Encouraged by the good results and low rate of complications of single stage surgery ,, we combined goniopunch (a simple modification of trabeculectomy operation) with cataract extraction to determine whether it is also a safe, and effective procedure for patients in whom cataract and glaucoma coexist
Material and methods
The present series included 50 patients suffering from various types of glaucoma associated with an advanced stage of senile cataract In each patient intraocular pressure was lowered with intravenous mannitol and cataract extraction combined with goniopunch was performed as described below.
The surgical technique employed, primarily consisted of Goniopunch (a modification of trabeculectomy) coupled with intracapsular lens extraction with cryo. The majority of the operations were performed under local anaesthesia After a fomix based conjunctival flap had been reflected, a triangular limbus based scleral flap of approximately /3rd thickness was made in the anterior part of the trabecular zone. iris repositor was used to separate the ciliary body from the scleral spur. A 2 mm
block of tissue containing trabecular mesh work, Schelmri s canal and sclera was punched out with the help of Holth's scleral-punch forceps Limbal incision was then made on both sides and 8'o virgin silk sutures were preplaced in the section. A peripheral iridectorny was performed adjacent to the goniopunch site, followed by cataract extraction and wound closure. The lamellar triangular- scleral flap was sutured back with a single stitch at the apex and the fomix based conjunctival flap was anchored at the 3 and 9'o clock positions. A subconjunctival injection of the Gentamycin and dexamethasone was given.
Intraocular pressure was measured at the end of the first post-operative week and thereafter at monthly regular follow-up visits for six months The results were compilled and analysed.
Out of 50 patients, 21 were male and 29 females. The mean age was 5 3 ± 9.3 with a range from 42 to 70 years The type of cataract associated with glaucoma is depicted in [Table 1]. The complications encountered and the control of glaucoma in each category have been detailed in [Table 2][Table 3][Table 4], respectively.
The main problem with combining most glaucoma filtering techniques with a cataract extraction is the transient shallow or flat anterior chamber, which leads to significantly more complications in the inflammed aphakic eye. For this reason, the preferred combined operations employ a glaucoma procedure that is less likely to cause loss of the anterior chamber. Cyclodialysis and cataract extraction has been used as a combined procedure for many years, with reports of good results . However, in one large series, an analysis of the post operative cases suggested that the intraocular pressure reduction in many cases was due to the effect of cataract surgery, rather than the cyclodialysis . Since the introduction of trabeculectomy by Crains , many workers have reported encouraging results, combining this procedure with cataract extraction , .Recently, McPherson' has reported a technique in which he combined trabeculotomy with cataract extraction.
Considering the unpredictable nature of cyclodialysis and complex micro-surgical technique of trabeculectomy and trabeculotomy coupled with the fact that the subconjunctival filteration is now the accepted mechanism of lowering pressure in trabeculectomy, we have opted for combined goniopunch ( a simple modified form of trabeculectomy) and cataract extraction as an alternative simple combined surgery. The surgical procedure has been further simplified by fornix based conjunctival flap. We had fairly good experience of bleb formation with this type of flap (Well formed in 41 out of 50 eyes, out of the 9 eyes with no bleb, 2 had normal intraocular pressure.
The complications encountered with this combined surgery are neither more in frequency nor more severe than those observed by various workers in cataract surgery alone' except for hyphaema. This increased incidence of hyphaema following combined surgery may be due to increased inflammation and congestion in the glaucomatous eye. Moreover, the incidence of hyphaema too is similar to that reported in glaucoma surgery alone . Overall incidence of complications is almost the same as observed with combined trabeculectomy and cataract operation [Table 2] ,
Overall control of intraocular pressure (less than 21 mm of Hg) with this combined surgery was observed in 42 (84%) cases upto 6 months follow up [Table 3]. Out of 42 cases, 5 had pressure less than 10 mm of Hg, in the remaining eyes it ranged between 11 and 21 mm of Hg These results compare favourably with previous studies of trabeculectomy alone ,,or in combination with cataract extraction ,. Out of the eight eyes with surgical failure, pressure was controlled with additional medical therapy (0.5 percent Timolol maleate eye drops o. D.) in 4 eyes. In 3 patients the control was achieved with repeat goniopunch at a different site, while in one case it remained uncontrolled even after repeat surgery. Eye sight was lost in this eye and pressure was controlled ultimately with cyclocryotherapy.
As regards the diagnostic categories, the technique was equally effective in primary as well as in secondary glaucolnas [Table 4]. However, more patients with primary open angle glaucoma required additional medication to achieve control This fact is important and indicates a need for close supervision of these patients.
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