|Year : 1983 | Volume
| Issue : 6 | Page : 777-779
Microsurgery in congenital glaucoma
HC Agarwal, NN Sood, BR Kalra, Y Dayal
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All-India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
H C Agarwal
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All-India Institute of Medical Sciences, Ansari Nagar, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Agarwal H C, Sood N N, Kalra B R, Dayal Y. Microsurgery in congenital glaucoma. Indian J Ophthalmol 1983;31:777-9
The presence of advanced corneal changes in nearly 80% cases of congenital glaucoma has been emphasised in earlier studies from this Centre.,In such eyes goniotomy and goniopuncture are of possible. Trabeculotomy ab-externo has also not yielded good results., This communication describes a new modified technique Trabeculotomy-cum-trabeculectomy in such cases.
| Material and methods|| |
Trabeculotomy-cum-trabeculectomy was carried out as primary procedure fin forty four eyes afnd as repeat procedure in four eyes of twenty six cases of congenital glaucoma during 1978 to 1981.
The operation is performed under general anaesthesia using an operating microscope with 10 X to 40 X magnification. After passing the lid and superior sutures, a limbus based conjuntival flap 6 mm. long and 8 mm. away from limbus is made. A triangular cornea scleral flap with 4 mm. base towards limbus and the apex towards the fornix is mapped out. 'An eight zero perlon suture is passed out at the apex of the triangle and a deep nearly 2/3 thickness sceleral lamellar flap is dissected out from the sclera. The dissection extends anteriorly for 1 mm. in the cornea. A rectangular block of 4 mms. X 2 mms. is mapped out. The magnification is changed to the highest to visualize the blue and white zone carefully. The scleral spur appears as a white as a white band at the end of tthe white zone. The canal of schlemm lies just anterior to the scleral spur. A superficial radial incision starting from the blue zone & extending towards the white zone is made. A stream of normal saline over the site of incision helps in better visualization. The incision is very carefully deepened until the aqueous oozes from the cut ends. Small horizontal incisions are made on either side of this and the right sided Harm's Trabeculotomy is inserted till the heal of the traveculotomc lies in the radial incision. Then the trabeculotome is rotated into the anterior chamber. A very gentle rotational force is sufficient to rapture the inner wall of schlemm's canal. If the resistance required is more, the trabeculotome is lying in the wrong plane. It should be withdrawn and is introduced again in a slightly different plane. When the blade of trap-culotome enters into the anterior chamber, there is sudden release of resistance and simultaneously aqueous mixed with blood oozes at the site of radial incision. Slight bleeding may occur into the anterior chamber. The trabeculotome is then graudally withdrawn. Siimilar procedure ris carried out on the other side of the radial incision witth left sided trabeculotome.
The rectangular glap containing trabecular meshwork and canal of schlernm as mapped out earlier is excised. A peripheral iridectomy is performed. The corneo scleral flap is reposited and sutured with one at the apex and one on each side of the triangular flap. The conjuctival flap is reposited in place and sutured. Antibiotic ointment is applied and the eye is bandaged.
| Observations|| |
The technique was succeessful as primary procedure in forty one (93.1%) eyes and as repeat procedure in three eyes (75%) without any antiglaucoma treatment after the operation. A total success rate of 91.6 was achieved, [Table - 1]. The period of follow iup varied from one year to over 3 years [Table - 2].
| Complications|| |
The operative complications were encountered in tthe beginning. Latter on with experience these complications were minimised [Table - 3].
| Discussion|| |
It is a common experience of most ophthalmologist that cases of congenital glaucoma present late. The presence of corneal changes adds to the problems. Both these factors reduce the success rates oof goniotomv goniopuncture. Trabeculotomy ab-externo although effective in such cases, however fails when done in cases of new horn glaucoma. Therefore, it was desirable to try out this combined approach of trabeculotomy-cum-traheculectomy.
The preliminary report shows 93.1% success rate in primary procedures and nearly 75% success rate in respect procedures. The number of cases in secondary procedures arc small to draw any definite conclusion. But it appears that the success rate is better when the operation is parformed as primary procedure. The period of follow-up varied from one year to over 3 years.
The complications did not affect the final result of surgery. In none of our cases any serious post operative complication was encountered.
This is a preliminary report on this new operative technique. Before any definite conclusion can be drawn a larger series with longer follow up period is required.
The new operative technique may be effective due to removal of pathological resistance in pretrabecular area due to presence of embryonal mesodermal tissue by Trabeculotomy, and in the region of trabecular meshwork as well as in the collector channels by trabeculectomy which provides alternative passage for the flow of aqueous into subconjunctival.
| Summary|| |
A new modified operative technique, trabeculotomy-cum-trabeculectomy has been described in detail. The operation is particularly indicated in cases of congenital glautoma with advanced corneal changes. It has been found to be effective as primary procedure in 93.1% eyes. However, the operation is relatively less successful in repeat procedure. There were no serious operative and post operative complications.
| References|| |
Agarwal H.C., Sood, N.N. and Dayal, Y. 1981 Proceedings of All India Ophthalmological Society Conference.
Agarwal, H.C., Sood, N.N., Kalra, B.R.and Dayal, Y. 1982 Proceedings of All-India Ophthalmological Society Conference (In press)
Meller, P.M. 1977,Acta ophthalmol. 55: 436-442.
Dannheim, R and Hear, H. 1980 Klin, Monatshl. Augenheilkd., 177: 296-306.
[Table - 1], [Table - 2], [Table - 3]