|Year : 1981 | Volume
| Issue : 3 | Page : 153-155
Simultaneous trabeculectomy and cataract extraction
Manzoor Ahmad, Gauhar Ahmad, Ghulam Rasool Dar
Department of Ophthalmology, Medical College, Srinagar, India
Department of Ophthalmology, Medical College, Srinagar-190010
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ahmad M, Ahmad G, Dar GR. Simultaneous trabeculectomy and cataract extraction. Indian J Ophthalmol 1981;29:153-5
Glaucoma and cataract are encountered fairly often in patients seeking relief from visual impairment. Either those patients who are known to be suffering from chronic simple glaucoma and are maintained on drugs develop lens opacities which reduce their vision to such an extent that surgical intervention becomes imperative, or glaucoma is diagnosed when intraocular tension is found to be raised prior to lens extraction in a case of senile cataract. Most drugs used to control intraocular tension in chronic simple glaucoma themselves accelerate the development of lens opacities. Extraction of cataract alone rarely relieves a coexisting glaucoma. According to Witmar nearly all eyes with these combined disorders need medical treatment for glaucoma three to six months after lens extraction, which in such eyes is a very difficult proposition.
These difficulties have been recognized for a long time and many different operations have been devised and advocated for such cases. The main objection to these operations is the higher incidence of post operative complications. We have also had disappointing results with such operations.
Following encouraging results of trabeculectomy for control of intraocular tension for chronic simple glaucoma with relatively fewer complications and good results of combined trabeculectomy and lens extraction reported by Jerndal et a1, Hildsdorf and others we adopted this procedure of simultaneous trabeculectomy and lens extraction in 20 cases.
| Materials and methods|| |
Patients having advanced lens opacities associated with raised intra ocular tension (over 25 mm Hg.) and vision of less that 3(60 were taken up for the present study. Only seven patients were known to be suffering from chronic simple glaucoma, and the patients hedpseodo exfoliation of the lens capsule probably giving rise to glaucoma.
Gonioscopy was done in every case to rule out angle closure.
All patients were put on miotics (2% Pilocarpine) three times a day and tablet Diamox 250 mg. six hourly to bring down the intra ocular tension below 15 mm Hg. Only six patients responded to this therapy and thus other received I.V. Mannitol 20% an hour before the operation to reduce the intraocular tension. The pupil was dilated with 5% Phenylephrine, an hour before surgery.
Patients were operated upon under local anaesthesia with 50 mg. Pethidine and 10 mg. Diazepam as premedicater. Under an operating microscope with lOX magnification after raising fornix based flap a trabeculectomy procedure was undertaken. A 3 mm spuare piece of sclera including the corneo scleral and uveal trabecular mesh work, the canal of Schlemm the scleral spur and the adjacent scleral portion was disected and removed. A peripheral iridectomy was performed through this opening and the limbal incisions were then enlarged with spring scissors on either side. Two 8 or 9/0 mono filament nylon sutures were placed at about two and ten o'clock positions.,
Intracapsular lens extraction was performed with a cryo in 13 cases and with forceps in 7 cases. Immediately after delivery of the lens the two post placed sutures were tied and air was injected into the anterior chamber. Four more corneo scleral sutures were applied to close the wound, two of these sutures being placed at the corners of the scleral flap. The scleral flap was replaced to cover the trabeculectomy opening and was kept in position by two sutures at its upper end. Air was finally withdrawn from the anterior chamber which was then reformed with normal saline. The conjunctival flap was pulled down and two 6/0 silk sutures passed through it at 3 and 9 o'clock positions to hold it in position. A drop of 1 % Atropine and 1 % Chloramphenicol ointment were instilled in the conjunctival sac, only the operated eye was bandaged for five days. The patients were discharged on the sixth day. The two conjunctival sutures were removed at the time of discharge and the monofilament sutures remained burried under the conjunctiva.
Patients were advised to instil steriod drops in the operated eye three times a day for two weeks. Patients were examined at weekly intervals for six to eight weeks and then every month for three months., and then every three months. Intra ocular tension was recorded at the time of discharge from the hospital and then every time the patient came for follow up. Total follow up varied from two to ten months.
Pre and postoperative intraocular tension were recorded with applanation tonometer. No effort was made to determine the exact nature of glaucoma but phakomorphic glaucomas cases were excluded from this study. Preoperative tension ranged from 17 to 45 mm Hg. and postoperative from 9 to 24 mm Hg. Eight patients showed a definite filtering bleb at the time of discharge and another three the bleb was seen two weeks later. Only one case required postoperative medication to further reduce the intra ocular tension. Visual improvement was seen in all but three cases.
| Observations|| |
Vitreous loss occured in one case, but the vitreous was completely cleared from the anterior chamber and the wound was secured with six corneo scleral sutures. This patient subsequently did well, her intra ocular tension was controlled and her vision improved from hand movements to 6/36.
One of the frequent complication encountered was hyphaema, filling almost half of the anterior chamber was seen in seven cases but in all the cases the blood got absorbed completely within a week. This complication was encountered only in the earlier cases and could be avoided by placing two additional sututres to close the corneo scleral wound as we felt that the blood leaks from the lips of the wound and anters the anterior chamber. Blood after getting absorbed did not recur again.
| Discussion|| |
Like Jendal et. al ., Bregeat, and Hilsdorf, our results of the combined procedure of trabeculectomy and lens extraction have been highly rewarding and devoid of serious complications. In a series of 17 cases Jerndal et. Al. reported normalisation of tension in fourteen cases without any post operative medication, whereas only one of our cases out of 20 needed post operative miotics to control intra ocular tension. None of our cases had post operative tension of less than 10 mm Hg. or mare than 24 mm Hg. By using the micro-surgical atraumatic technique the eyes had very little post operative inflammatory reaction. The combined procedure is no more traumatic and complicated than ordinary cataract extraction and the effects on intra ocular tension are highly favourable. The chief concern of the patient is visual recovery which also occured in all but three cases. Vision could not improve in three cases because of a glaucomatous optic atrophy.
We have made a slight deviation from the standard surgical procedure by making a fornix based conjunctival flap to expose the sclera. We found this more convenient than the limbus based flap as in a fornix based flap the conjunctiva is well clear from the wound and does not come in the way while enlarging the section or placing sutures.
In conclusion we find the combined procedure a very safe and an effective operation and no more traumatic than cataract extraction alone. We advocate this procedure for cases of increased intra ocular tension associated with cataract regardless of the aetiology.
| Summary|| |
In a combined trabeculectomy and cataract extraction procedure on 20 eyes, the intra ocular tension was normalised in all but one case. Visual acuity improved in 17 of the twenty cases. The only significant post operative complication was hyphaema.
| References|| |
Witmar, R., 1972, Ophthalmologica 165 :203.
Jerndal, T. and Lundstrom, M. 1976 Amer. J. Oththalmol. 81 : 227.
Hilsdorf, C., 1974, Klin. Monatsbl. Augenhelk 164 : 298.
Bregeat, P. 1975, Min. Monatsbl. Augenheilk. 167 : 505.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]