Step by Step Minimally Invasive Glaucoma Surgery

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Step by Step Minimally Invasive Glaucoma Surgery

Step by Step Minimally Invasive Glaucoma Surgery Editors Ashok Garg MS, PhD, FIAO (Bel) FRSM, ADM, FAIMS, FICA International and National Gold Medalist Medical Director Garg Eye Institute and Research Centre 235-Model Town, Dabra Chowk Hisar-125005 (India)

Shlomo Melamed MD, PhD Profesor of Ophthalmology Sackler Medical School Tel-Aviv University Head and Chairman Sam Rothberg Glaucoma Centre Tel-Hashomer, Israel

Jerome Jean – Phillippe Bovet MD Consultant Ophthalmic Surgeon FMH Clinique de L’oeil 15, Avenyue Du Bois-de-law Chapelle CH-1213, Onex Switzerland

Bojan Pajic MD Chief of Glaucoma Department Chief Corneal and Refractive Surgery Department, Vision Care Klinik Pallas, Louis Giroud Str. 20 4600 Olten, Switzerland

Roberto G Carassa MD Associate Professor of Ophthalmology Director, Glaucoma Service Deptt. of Ophthalmology and Visual Sciences, University Hospital S. Raffaele, Milano, Italy

Tanuj Dada MD Additional Professor of Clinical Ophthalmology RP Centre for Ophthalmic Sciences AIIMS, Ansari Nagar New Delhi-110029, India

Foreword

Robert Jay Weinstock

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi

Published by Jitendar P Vij

Jaypee Brothers Medical Publishers (P) Ltd EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672 Fax: +91-11-23276490, +91-11-23245683 e-mail: [email protected] Visit our website: www.jaypeebrothers.com Branches • 2/B, Akruti Society, Jodhpur Gam Road Satellite Ahmedabad 380015 Phone: +91-079-30988717 • 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East Bangalore 560 001, Phones: +91-80-22285971, +91-80-22382956, +91-80-30614073 Tele Fax : +91-80-22281761 e-mail: [email protected] • 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road Chennai 600 008, Phones: +91-44-28262665, +91-44-28269897 Fax: +91-44-28262331 e-mail: [email protected] • 4-2-1067/1-3, Ist Floor, Balaji Building, Ramkote Cross Road Hyderabad 500 095, Phones: +91-40-55610020, +91-40-24758498 Fax: +91-40-24758499 e-mail: [email protected] • 1A Indian Mirror Street, Wellington Square, Kolkata 700 013 Phones: +91-33-22456075, +91-33-22451926 Fax: +91-33-22456075 e-mail: [email protected] • 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital Parel, Mumbai 400 012 Phones: +91-22-24124863, +91-22-24104532, +91-22-30926896 Fax: +91-22-24160828 e-mail: [email protected] • “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road, Nagpur 440 009 (MS) Phones: +91-712-3945220, + 91-712-2704275 e-mail: jpmednagpur @rediffmail.com

Step by Step Minimally Invasive Glaucoma Surgery © 2006, Editors All rights reserved. No part of this publication and interactive DVD ROM should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher. This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition: 2006 ISBN 81-8061-738-6 Typeset at JPBMP typesetting unit Printed at Paras Press

Dedications • My Respected Param Pujya Guru Sant Gurmeet Ram Rahim Singh Ji for his blessings & motivation. • My Respected Parents, teachers, my wife Dr. Aruna Garg, son Abhishek and daughter Anshul for their constant support and patience during all these days of hard work. • My dear friend Dr. Amar Agarwal, a leading International Ophthalmologist from India for his continued support and guidance. Dr. Ashok Garg • To my loving wife Shuvit.

Dr. Shlomo Melamed

• Yveric, Luc and Fanny Laure. • Silvio Korol, who was not only a teacher but also an intellectual guide and a friend. Dr. Jerome Bovet • To my son Valentin Aleksandar.

Dr. Bojan Pajic

• To my collaborators Dr. Marina Fiori and Dr. Paolo Bettin, for their constant help and support in my clinical work and research. Dr. Roberto G Carassa • The Revered Sufi Saint Hazoor Maharaj Gurmeet Ram Rahim Singh Ji, Dera Sacha Sauda Ashram, Sirsa, Haryana, India. Dr. Tanuj Dada

CONTRIBUTORS Ahmed Galal MD, Ph D

Vissum/Instituto Oftalmologico De Alicante Alicante Spain Amar Agarwal

Bojan Pajic MD Chief, Cornea and Refractive Surgery Deptt., Vision Care Klinik Pallas Louis Giroud Str. 20 4600 Olten, Switzerland Cyres K Mehta

MS, FSVH, FAGE MS, FRCS, FRC Ophth. Director & Consultant

Director Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086 India André Mermoud MD Prof. of Ophthalmology Jules Gonin Eye Hospital CH-1004 Lausanne Switzerland Ashok Garg MS, Ph D, FRSM

Medical Director Garg Eye Institute & Research Centre 235-Model Town Dabra Chowk Hisar-125005 (India)

Mehta International Eye Institute Seaside, 147, Colaba Road Mumbai-400005, India Daljit Singh MS, DSC 57, Joshi Colony Amritsar-143001, India Ehud I Assia MD Deptt. of Ophthalmology Meir Hospital Sapir Medical Centre Tsharnihovski St. 44281, Kafar, Saba Israel Guillérmo Avalos-Urzua MD Terranova No. 676-101 Col. Providencia Guadalajara, Jal Mexico CP-44630

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Step by Step Minimally Invasive Glaucoma Surgery

Harsh Kumar MD Chief Glaucoma Service Centre for Sight Safdarjung Enclave New Delhi, India J Agarwal MS Director Dr. Agarwal’s Eye Hospital Pvt. Ltd. 19, Cathedral Road Chennai-600086, India Jens Funk MD Prof. of Ophthalmology AugenklinikUniversitatsklinikum Killianstr. 5 79106 Freiburg Germany Jerome Bovet MD Consultant Ophthalmic Surgeon, FMH Clinique de I’oeil 15, Avenue du Bois-de-laChapelle CH-1213 Onex Switzerland Jorge L Alió MD, PhD Director Instituto Oftalmologico De Alicante Avda. Denia 111, 03015 Alicante Spain

Jose L Rodriguez - Prats MD Instituto Oftalmologico De Alicante Avda. Denia 111, 03015 Alicante Spain JT Lin PhD 4532, Old Carriage Trail OVIEDO Florida 32765 USA Kamaljeet Singh MS Associate Professor Ophthalmology 4A/7, Panna Lal Road Allahabad, India Kaweh Mansouri MD Jules Gonin Eye Hospital Lausanne, Switzerland Keiki R Mehta MS, DO, FIOS

Chairman & Medical Director Mehta International Eye Institute 147, Shahid Bhagat Singh Road Colaba Road Mumbai-400005, India Khristo Takhchidi MD Director General, S.N. Fyodorov Eye Microsurgery Complex Moscow, Russia

Contributors

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Mordechai Goldenfeld MD The Sam Rothberg Glaucoma Centre Goldschleger Eye Institute Sheba Medical Centre Tel-Hashomer Israel

Roberto G Carassa MD Director Glaucoma Service Deptt. of Ophthalmology and Visual Sciences University Hospital S. Raffaele via Olgettina 60 20132 Milano, Italy

Mona Pache MD AugenklinikUniversitatsklinikum Killianstr. 5 79106 Freiburg Germany

Shlomo Melamed MD Prof. of Ophthalmology Sackler Medical School Tel Aviv University Head and Chairman Sam Rothberg Glaucoma Centre Goldschleger Eye Institute Sheba Medical Centre Tel-Hashomer, Israel

Nikolai Ereskin MD Consultant, S.N. Fyodorov Eye Microsurgery Complex, Moscow, Russia Pascal Rozot MD Clinique Monticelli Marseilles France

Subrata Mandal MD Dr. RP Centre for Ophthalmic Sciences, AIIMS New Delhi, India Sunita Agarwal MS, DO, PSVH

Ranjit H Maniar MS 17, Vithal Court, 6th Floor 151, August Kranti Marg Mumbai-400036, India Richard J Fugo MD, PhD 100, West Fornance Street The Fugo Building Norristown, PA-19401 USA

Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086, India 15, Eagle Street, Langford Town, Bangalore, India Sylvian Roy MD Jules Gonin Eye Hospital CH 1004, Lausanne Switzerland

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Tanuj Dada MD Associate Professor Dr. R.P. Centre for Ophthalmic Sciences AIIMS, Ansari Nagar New Delhi-110029, India T Agarwal FORCE, DO, FICS

Director Dr. Agarwal’s Eye Hospital 19, Cathedral Road Chennai-600086, India

Vivek Kadambi MD, DOMS Director Kadambi Laser Vision Clinic & Research Foundation Pvt. Ltd. 157, Defence Colony 4th Main Road, Indira Nagar Bangalore-560038 India

FOREWORD One of the most wonderful and stimulating aspects of modern ophthalmology is the continued spirit of ingenuity in advancing the treatment of ophthalmic disease. This is manifested by continuous research in both medical and surgical techniques in the quest to improve our patient’s vision and prevent and treat eye disease. The ophthalmic subspecialty of glaucoma continues to be one of the most interesting and dynamic areas of ophthalmology with numerous improvements in not only the pharmacologic treatment of glaucoma but also the surgical arena. Traditionally glaucoma has been managed with medications until the disease has progressed to a significantly advanced state requiring more than pharmacologic therapy. However, recent trends indicate that surgeons throughout the world are transitioning to a more aggressive mind set with quicker movement towards interventional glaucoma procedures and techniques that reduce intraocular pressure and treat the disease surgically. Dr. Ashok Garg and his colleagues have compiled a brilliant book with concentration on the most novel and successful glaucoma procedures and surgeries available today. The authors, who hail from a diverse international population, have managed to come together and present a

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thorough analysis of the latest technological modalities for treating glaucoma. Through advancements in communication and technology over the past decade these surgeons have been able to share their experiences and technologies leading to the rapid advancement of minimally invasive glaucoma surgery. It is rare to find a text with such a complete and thorough analysis of all the different possible treatment technologies available today. I commend the editors for their diligence in assembling such a diverse and comprehensive text of glaucoma therapy and surgery. Their tireless efforts has enabled surgeons, worldwide, to assemble and share their knowledge and skills in one of the most advanced treatises on glaucoma to date. This book serves not only as an excellent core book on treatment modalities for glaucoma but also serves to introduce and educate all glaucoma specialists to up and coming progressive technologies that they will be using for years to come. I am sure you will enjoy this book as much as I have and in this new era of minimally invasive glaucoma surgery you will come away with a tremendous amount of knowledge and hope for the future of our glaucoma patients. Dr. Robert Jay Weinstock MD The Eye Institute of West Florida 148 13th Street SW Largo, Florida 33770 , USA Tel. (727) 585-6644

PREFACE Glaucoma is a complex multifactorial slowly progressive neurodegenerative disorder associated with raised intraocular pressure leading to death of retinal ganglion cells and degeneration of their connected optic nerve fibers and subsequent visual loss. The aim of Modern Glaucoma Treatment is to preserve visual function with minimal side effects. Effective management of Glaucoma requires a reduction of intraocular pressure to a level appropriate for the stage of disease. There is tremendous improvement in Medical Management of Glaucoma with newer drugs but burden of daily treatment, cost factor, possible side effects and inconvenience and poor compliance leads to progression of disease inspite of early diagnosis and prompt treatment. There are lot of surgical procedures available for Glaucoma management but they have their own postoperative complications which are sometimes difficult to treat leading to the frustration of the patient. In last 5 years tremendous advances have been made specially in minimally invasive glaucoma surgery with minimal postoperative complications and better visual results. This step by step book has been written specially to acquaint ophthalmologist with latest minimally invasive glaucoma surgical techniques. Seventeen chapters of this book are written by International known Glaucoma specialists covering MIGS specially Excimer Laser Trabeculotomy, Sclerothalamotomy, Trans-scleral Diode Laser Cyclophotocoagulation, Milling Trabeculoplasty, VDSCI, Customized Laser Assisted Filtration Surgery (CLAFS), SLT, Pneumatic Trabeculoplasty, Femtosecond Lasers and Neuroprotective Therapeutic approach. These

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are all high techniques with excellent visual results available in this single Internatioonal book. An added attraction of this book is interactive CD showing all latest MIGS techniques. We are highly grateful to Shri Jitendar P Vij (Chairman and Managing Director), Mr. Tarun Duneja, General Manager (Publishing) and all staff members of our publisher M/s Jaypee Brothers Medical Publishers (Pvt) Ltd. who took active interest in this project and prepared this handy high quality book in a short time. We are quite certain this step by step MIGS book shall be a useful companion to every ophthalmologist who do Glaucoma work. Editors

CONTENTS 1. Minimally Invasive Glaucoma Surgery (MIGS) – A New Approach ........................................................ 1 Ashok Garg (India) 2. YAG Laser Iridotomy ................................................ 9 Kamaljeet Singh (India) 3. Laser Sclerotomy ....................................................... 23 J Agarwal, T Agarwal, Sunita Agarwal, Ashok Garg (India) 4. Laser Trabeculoplasty .............................................. 33 Kamaljeet Singh (India) 5. Laser Treatment in Glaucomas .............................. 43 Andre Mermoud, Sylvian Roy (Switzerland) 6. Miscellaneous Laser Applications ........................ 81 Harsh Kumar, Tanuj Dada (India) 7. Trabecular Meshwork Ablation as an Alternative to Invasive Glaucoma Surgery ........ 97 Mona Pache, Jens Funk (Germany) 8. Sclerothalamotomy ab Interno a Minimally Invasive Glaucoma Surgery ................................. 113 Bojan Pajic (Switzerland) 9. Laser Surgical Treatment of Glaucoma by Excimer Laser with 193 nm Wavelength ........... 135 Khristo Takhchidi, Nikolai Ereskin (Russia)

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10. Topical Anesthetic and the Subconjunctival Bubble in Glaucoma and Combined Operations ................................... 147 Jérôme Bovet (Switzerland) 11. Cyclophotocoagulation ......................................... 161 Tanuj Dada, Subrata Mandal (India) 12. Milling Trabeculoplasty: A New Technique for Non-penetrating Glaucoma Surgery ........... 197 Jose L Rodriguez-Prats, Jorge L Alió, Ahmed Galal (Spain) 13. Deep Sclerectomy with T-flux Implant with “Outside In” Drainage ...........................................225 Ranjit Maniar (India) 14. Viscocanalostomy ................................................... 247 Roberto G Carassa (Italy) 15. Pneumatic Trabeculoplasty – A Noninvasive Glaucoma Treatment ............................................. 261 Guillérmo Avalos-Urzua (Mexico) 16. Selective Laser Trabeculoplasty ..........................271 Mordechai Goldenfeld, Shlomo Melamed (Israel) 17. Customized Laser Assisted Filtration Surgery (CLAFS) Using a Solid-State UV Laser ..............281 JT Lin (USA), Vivek Kadambi (India) 18. Non-penetrating Filtration Surgery with the CO2 Laser .................................................297 Ehud I Assia (Israel) 19. Open Angle Filter Surgery for Glaucoma: Deep Sclerocanalostomy (DSC) – A New Technique ................................................... 309 Jerome Bovet (Switzerland)

Contents

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20. Bimanual Microphaco and Deep Sclerocanalostomy (BMP and DSC) – A New Technique ................................................... 327 Jerome Bovet (Switzerland) 21. Very Deep Sclerectomy — or How to Increase Uveoscleral Outflow .............................. 345 Kaweh Mansouri, André Mermoud (Switzerland) 22. G-Probe as Primary Glaucoma Procedure in Cases of Coexisting POAG and Cataract ..... 357 Cyres K Mehta, Keiki R Mehta (India) 23. Combined Phacoemulsification and Deep Sclerectomy with T-Flux® ...................................... 373 Pascal Rozot (France) 24. Glaucoma Surgery Techniques with the Fugo Blade® .............................................................................. 387 Daljit Singh (India), Richard J Fugo (USA) Index ........................................................................... 425

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INTRODUCTION Glaucoma is a complex disorder to treat. Increased intraocular pressure (IOP) accompanied with optic nerve damage requires a life long mandatory treatment to maintain IOP level at acceptable level with visual acuity preservance. Medical management of glaucoma is usually first line of defence which has its own side effects and complications on prolonged use. Second line of treatment is conventional glaucoma surgery – Trabeculectomy which has its own postoperative complications specially bleb leakage. In last one decade intensive research work has been done in glaucoma surgery. When conventional methods fail patients can be well served by innovative new surgical techniques specially non-penetrating glaucoma surgery also known as minimally invasive glaucoma surgery. These new techniques clear the way for restored fluid passage through the eye. These infrastructure improvements are essentially extraocular techniques which has improved visual success rate with minimum postoperative complications. CLASSIFICATION Minimally invasive glaucoma surgery (MIGS) are broadly classified in following groups : a. Surgical-based MIGS or NPGS. b. Laser-based MIGS or NPGS. c. Scleral expansion bands. Here, I am giving broad outlines as the details are described in different chapters of this book.

Minimally Invasive Glaucoma Surgery — A New Approach

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Surgical Based MIGS Surgical based MIGS have made tremendous strides in last one decade. It includes viscocanalostomy, deep sclerectomy, milling trabeculoplasty, sclerothalamotomy ab interno and deep sclero-canalostomy (DSC). Viscocanalostomy Viscocanalostomy introduced by Dr. Robert Stegmann (South Africa) in early nineties increases the aqueous outflow through different mechanism of action. It creates a bypass by which aqueous humor can reach Schlemm’s canal skipping the trabecular meshwork which is the site of the increased outflow resistance in OAG. Viscocanalostomy has several potential advantages over conventional trabeculectomy the major being the absence of external filtration thus independent of conjunctival and episcleral scarring. Postoperative management is comparatively easy with minimal complications. However, this technique is technically strong and requires a long learning curve. Deep Sclerectomy Deep sclerectomy is another non-penetrating glaucoma surgery which has offered excellent results. This techniques has been advocated with the implantation of a collagen drainage device. Dr. Andre Mermoud (Switzerland) has shown the excellent results of deep sclerectomy alone and very deep sclerectomy with collagen implant (VDSCI) which is relatively a new technique. It has been clinically documented that deep sclerectomy significantly lowers the complication rates of glaucoma surgery.

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Milling Trabeculoplasty Milling trabeculoplasty developed by Dr. Jorge L. Alio (Spain) is considered a variation of deep sclerectomy with more refining. This technique provides the opportunity to perform a non-penetrating glaucoma surgery with greater attention for the dissection of the deep scleral flap or the deroofing of the Schlemm’s canal with the additional advantage that is being much faster. Certainly milling trabeculoplasty is an evolving technique for sclapel free NPGS. It is a promising technique specially for surgical management of POAG. Sclerothalamotomy (STT) Sclerothalamotomy ab interno is a new NPGS technique developed by Dr. Bojan Pajic (Switzerland). STT ab interno circumvents the trabecular meshwork resistance by creating a drainage canal in the sclera but the site of perforation is reached from inside and four sclerectomy sites are created using a special high frequency diathermy probe. STT is certainly a promising technique which ensures an efficacy and longevity of filtration. Deep Sclerocanalostomy (DSC) Deep sclerocanalostomy technique has been shown by Dr. Jerome Bovet (Switzerland). This combined new technique of NPGS is all connected with dissection or injection of the Schlemm canal. DSC allows a synthesis of the three main surgical techniques for non-penetrative Filter surgery. This reduces the risks of each while increasing the long-term chances of such in term of IOP control.

Minimally Invasive Glaucoma Surgery — A New Approach

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Laser-Based MIGS Besides the conventional laser techniques in glaucoma management, a number of new techniques are on the horizon with better IOP control and visual acuity management. Research ophthalmologists have shown new techniques with the use of Excimer Laser, Infrared Laser, CO2, Laser and Selective Laser Trabeculoplasty (SLT). Excimer Laser Trabeculotomy Excimer laser trabeculotomy ab interno (ELT) developed by Jens Funk (Germany) is a minimally invasive procedure that uses an excimer laser to ablate pores in the trabecular meshwork of patients with open angle glaucoma. As this procedure uses photoablation, no thermal effect is generated thus helps in thermal necrosis and scar formation potentially allowing a persistent effect over the years. ELT is certainly effective as monotherapy. Prof. Khristo Takhchidi (Russia) has designed a special excimer laser unit with 193 nm wavelength for glaucoma surgery. This new technique of NPGS that uses the excimer laser can reduce the risk of perforating the trabeculodescemetic membrane. With this technique the ablation is precise and homogenous. Titanium Sapphire Laser Trabeculoplasty Dr. Gabriel Simon (Spain) has evolved a new technique of titanium Sapphire Laser Trabeculoplasty (TiSaLT) using infra red laser. In this techniques laser energy targets and is absorbed by pigment inciting shock waves through the tissue ablating the tissue and unclogging blocked passage ways. This procedure causes minimal thermal damage and can be repeated.

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Non-penetrating Glaucoma Surgery with the CO2 Laser Dr. Ehud Assia (Israel) has shown a new technique of nonpenetrating glaucoma surgery with the CO2 laser. The clinical studies have shown that CO2 laser can effectively ablate the dry tissue without tissue perforation. In this procedure deep ablation down to the trabecular meshwork and Descemet’s membrane leaving a microthin wall 30u-50u thick with no perforation. This promising procedure enables accurate dissection of the scleral wall and unroofing of the Schlemm’s canal without penetration into the anterior chamber. Selective Laser Trabeculoplasty Selective laser trabeculoplasty (SLT) is another promising MIGS technique Dr. Mark. A Latina (USA) has pioneered this technique. In this procedure we can selectively treat the trabecular meshwork. With an Nd : YAG laser without creating a thermal burn. This procedure has been developed as an alternative to argon laser trabeculoplasty (ALT). In SLT ophthalmic surgeon selectively target pigmented trabecular meshwork cells instead of complete photocoagulation of the trabecular meshwork which is not necessary. SLT is certainly a better procedure with minimal side effects with good efficacy at lowering of IOP over a longer period. Scleral Expansion Bridge (SEB) Scleral expansion bridge (SEB) best known for their use in presbyopia has been recently shown to be useful in glaucoma management. The cornerstone behind use of SEBs is the Schachar theory of accommodation. This procedure is in early stages of development with essential

Minimally Invasive Glaucoma Surgery — A New Approach

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principle of increasing the effective working distance of the lens by expanding the sclera which shall reverse presbyopia and increase the tension of the longitudinal muscle improve aqueous outflow and thus reduces intraocular tension. The scleral expansion band offers a new potentially reversible, safe surgical alternative to the management of ocular hypertension and primary open angle glaucoma. By these state of Art MIGS techniques, in near future we can indeed personalize an operation for every given glaucoma patient with maximal visual acuity preservance, effective IOP control and minimum complications. Certainly glaucoma customization holds great future.

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INTRODUCTION Meyer Schwickerath reported for the first time the use of Xenon arc photocoagulator in cracking a hole in the iris.1 But the heat produced by xenon led to corneal and lenticular damage.1,2 Ruby laser was tried for some time without much success.3 The first successful laser iridotomy by argon laser was reported in 1970s.4-7 In 1980 the laser iridotomy replaced the surgical iridotomy. Later Nd:YAG laser was found more successful for this procedure.8-10 It is now most commonly applied laser for iridotomy. INDICATIONS • Acute/subacute angle closure glaucoma with symptoms • Chronic congestive glaucoma with anterior synechiae • Occludable angles with positive provocative tests • Occludable angle with signs of previous attack/ critically narrrow angle • Fellow eye • Iris bombe • Subluxated or luxated lens with intact vitreous face • Phacomorphic glaucoma with pupillary block mechanism • Aphakic/pseudophakic pupillary block • Nanophthalmos • Incomplete surgical iridectomy • Mixed mechanism glaucoma if filtering surgery is not required • Aqueous miss direction syndrome • Phakic IOLs • Plateau iris syndrome • Pigmentary glaucoma • To deepen narrow angle before laser trabeculoplasty

YAG Laser Iridotomy

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CONTRAINDICATIONS • • • • •

Opaque or cloudy cornea Widely dilated pupil Flat anterior chamber with iridocorneal touch Active inflammation Rubeosis irides

ABRAHAM CONTACT LENS Abraham contact lens is most commonly used lens for performing this procedure.11 It has a 66 planoconvex button bounded in the front surface of the lens. When laser beam falls on this lens its size is reduced to half of the original size on the iris and doubles the original size on cornea. This increases the power density on the iris and decreases power density to one-fourth on cornea. This helps immensely during the argon laser iridotomy. Same lens is very useful for YAG laser iridotomy also. A high magnification up to 40X should be used on slit-lamp for performing this procedure (Fig. 2.1). Contact lens helps in the following ways: 1. The lids remain separated. 2. Chances of corneal epithelial burns are reduced as the lens absorbs heat energy by acting as a heat sink. 3. The eye movements can be controlled by the lens. PREOPERATIVE PREPARATION Pilocarpine eye drops are instilled preoperatively. It stretches the iris, which thins the iris stroma and also facilitates in the penetration of laser beam because cutting a well-stretched thin paper is easier than cutting a loose paper.

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Fig. 2.1: Slit lamp

If the patient has already had an attack of acute congestive glaucoma, first medical treatment is carried out (Box 2.1). This will reduce the corneal edema. In addition, the pupil can be easily constricted by pilocarpine. The steroid drops should also be instilled if iritis is present for a couple of days before proceeding for laser iridotomy. If acute attack does not abort, one can proceed with iridotomy. So, preoperatively pilocarpine eye drops are instilled one hour prior to constrict the pupil to maximum. Apraclonidine 1 percent is instilled one hour prior to the procedure to prevent postoperative pressure spike.12 Topical proparacaine 0.5 percent is instilled just before the procedure to anesthetize the conjunctiva and cornea. THE SELECTION OF IRIDOTOMY SITE It is usually superonasal between the peripheral and middle third of iris. The reasons for this are (a) the superior

YAG Laser Iridotomy

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Box 2.1 We follow the New York Eye and Ear Infirmary approach1 to acute angle closure glaucoma, which is as follow: 1. Careful history of symptoms relating to intermittent angle closure attacks, attacks in the other eye, use of prescription or nonprescription drugs which may precipitate attacks, and type of activity precipitating the attack. 2. Examination of the affected eye and other eye with attention to central and peripheral anterior chamber depth as well as shape of the peripheral iris. 3. Administration of oral isosorbide, acetazolamide as aqueous suppressants, and even intravenous mannitol at our place. 4. The patient lies supine to permit the lens to fall posteriorly with vitreous dehydration. 5. The eye is reassessed after 1 hour. IOP is usually decreased, but the angle usually remains appostionally closed. One drop of 2 or 4 percent pilocarpine is given and patient is reexamined 30 minutes later. 6. If IOP is reduced and the angle is open, the patient may be treated medically with topical low dose pilocarpine, aqueous suppressants and steroids, until the eye quiets and laser iridotomy may be performed. 7. If IOP is unchanged or elevated and angle remains closed. Lens related angle closure should be suspected, further pilocarpine is withheld and the attack broken by argon laser peripheral iridoplasty. Peripheral iridoplasty does not eliminate pupillary block and is not a substitute for laser iridotomy, which must be performed as soon as the eye is quiet. However, even in eyes with extensive synechial closure, IOP is lowered sufficiently for a few days for the inflammation to resolve. Peripheral iridoplasty is much safer than attempting surgical iridectomy on an inflammed eye with elevated IOP. The risks of intraoperative surgery are avoided and even if malignant glaucoma is present the angle remains open long enough for inflammation to clear. Peripheral iridoplasty is highly effective in ameliorating attacks of angle closure glaucoma in Asian eyes. 1. Kramer P, Ritch R. The treatment of angle closure glaucoma revisited (editorial). Ann Ophthalmol 1984;16:1101-03.

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site remains covered by the lid (b) the nasal side remains away from the macula preventing foveal burn (c) the junction of middle and peripheral third helps in easy penetration. (d) crypt is selected because here the iris is thinnest and easy to penetrate (e) the iris should be examined for any strands. If present, they should be avoided, as they are difficult to penetrate. (f) the lower site is chosen in silicon filled eye because the silicon oil floats and can go to upper site and block the iridotomy. LASERS USED Several lasers can be used. But the commonly used lasers are Nd: YAG and argon. We will describe here the YAG laser iridotomy. Nd: YAG Laser Iridotomy This is most frequently applied method for laser iridotomy. There are several advantages of using YAG laser. This produces extremely high energy, which acts by mechanical disruption. When compared to argon laser, it does not require pigment for absorption for its thermal effect. The spot size is usually fixed to one size (50-75 um) in lasers from different companies. The pulse duration is also fixed for each instrument. The energy levels can be varied. Depending on the color of iris the required energy levels for penetration can be between 5-15 mJ. More energy is required for brown iris. The pulses can be between 1 to 3, which depends largely on the choice of surgeon. YAG laser penetrates simultaneously the iris stroma and pigment epithelium. The only problem with YAG laser iridotomy is bleeding from iris capillaries, which should be avoided if visible.

YAG Laser Iridotomy

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After selecting the site and applying the Abraham’s lens the laser shot is placed at the iris surface after properly focusing the laser beam. Usually one shot is sufficient for blue iris, but at times more than may be required. In brown iris more shots may be needed and the required energy levels may be also be high. The created opening should not be less than 150-200 um,13 otherwise there are chances of its closure. If some difficulty is experienced in enlarging the hole another site may be chosen. Two sites, even if small, are less likely to close (Fig. 2.1). Argon and YAG Laser Combined My technique is first using low intensity large size 200 um argon laser burns to create a crator and then utilizing single pulse low intensity shot of Argon laser also coagulates the capillaries thus reducing the chances of iris bleed.14 POST-LASER TREATMENT • Steroid drops are given to prevent mild iritis. • Pilocarpine eye drops are advised to keep the pupil constricted so that the opening remains patent. COMPLICATIONS 1. Common complications — Transient IOP rise — Iridocyclitis 2. Others — Closure of iridotomy — Hyphema — Corneal damage cataract formation 3. Rare complications — Retinal burns — Malignant glaucoma

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— Monoocular blurring — Endothelial cell loss — Posterior synechia Common Complications Transient Rise of IOP This is commonest complication. The rise of IOP occurs due to decrease in aqueous outflow facility, although aqueous outflow facility gets reduced.15 Other studies suggest that it could be because of release of prostaglandins16-18 and prostaglandin like substances into the aqueous,19 which occurs due to breakdown in the blood aqueous barrier. The blood plasma and fibrin are also released, which may also block the iridotomy site or angle leading to IOP rise. For preventing this rise 1 percent apraclonidine eye drops should be instilled one hour prior to laser iridotomy and also immediately after the procedure. Iridocyclitis As a reaction to YAG laser insult a mild iritis can occur.20 This can easily be managed by giving steroid drops for 3-5 days. However, rarely severe iridocyclitis,21 cystoid macular edema22 and even endophthalmitis23 have been reported. Other Communications Hyphema If the laser beam hits iris capillaries, the blood may be seen leaking from them.8,9 This bleeding can be easily managed by applying pressure with the help of contact lens. If

YAG Laser Iridotomy

17

previous to the YAG laser, Argon laser is utilized the chances of bleeding are reduced as it coagulates the capillaries. Closure of Iridotomy The size of iridotomy should be about 150-200 um,13 because small iridotomy may close due to pigment granules and debris release from the iris by YAG laser disruption. For keeping the iridotomy patent pilocarpine should be instilled postoperatively. If it seems to the clinician that confirmation of patency is required, a provocative mydriatic test should be done after stopping pilocarpine drops. Although most of the time a slit-lamp evaluation done under high magnification confirms the patency, wherein anterior capsule’s visibility suffices. Long-term patency rates of YAG laser iridotomy are very good in dark Asian irides in line with other studies in white and AfroCaribbean eyes.24-26 Cataract Formation The incidence of cataract formation is much less with YAG laser than with argon laser iridotomy. It is said that they are non-progressive. Laser peripheral iridotomy disrupts the natural flow of aqueous in the eye and results in significant increase in lens-iris contact.27 Theoretically, this may predispose to a more rapid development of cataract since less aqueous is in contact with the lens epithelium. Several studies have attempted to look at this issue, but follow-up has been short, no lens grading system was used, and no acceptable control groups were studied.28-29 Focal lenticular opacities seen after argon laser peripheral iridotomy are said not to progress, but once again, followup has been short in published reports.

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Step by Step Minimally Invasive Glaucoma Surgery

Rare Complications Retinal Burns Retinal burns may occur due to YAG laser iridotomy since the laser beam may hit the retina. If the precautions mentioned previously are not taken it may also hit the fovea and cause sudden diminution of vision. The best way of avoiding this complication is by choosing the superonasal site. Some authorities believe that using the Abraham lens also prevents damage to fovea. Malignant Glaucoma This is also rarely described complication and has been reported in one eye and both eyes too. Endothelial Cell Loss One study documented a higher rate of endothelial cell loss after argon laser peripheral iridotomy than after YAG laser peripheral iridotomy.24 Posterior Synechia Another potential complication of laser peripheral iridotomy is the development of posterior synechiae following laser iridotomy.25 Posterior synechiae can both limit vision in dim environments and make later cataract surgery more challenging. Failure of Iridotomy Several studies demonstrate a relation between the extent of angle closure by PAS and failure of iridotomy to control IOP and progression of glaucoma. 30-32 Iridectomy or

YAG Laser Iridotomy

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iridotomy is less effective in eyes with glaucomatous visual field loss and further surgical or medical treatment is often required to control IOP.33,34 REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Meyer-Schwickerath G. Erfahrungen mit der lichokoagulation der Netzhaut und der iris. Doc Ophthalmol 1956;10:91. Hogan MF, Schwartz A. Experimental photocoagulation of the iris of guinea pigs. Am J Ophthalmol 1960;49:629. Perkins AS. Laser iridotomy for secondary glaucoma. Trans Ophthalmol UK 1971;91:777. Khuri CH. Argon laser iridectomies. Am J Ophthalmol 1973;76:490. Anderson DR, Forster RK, Lewis M. Laser iridotomy for aphakic pupillary block. Arch Ophthlol 1975;93:343. Yassur Y, Melamed S, Cohen S, Ben-Sira I. Laser iridotomy in closed angle glaucoma. Arch Opthalmol 1979;97:1920. Pollack IP. Use of argon lasr to produce iridotomies. Ophthalmic Surg 1980;11:506. Latina MA, Puliafito CA, Steinert RR, Epstein DL. Experimental iridotomy with a Q-switched Nd: YAG laser. Arch Ophthalmol 1984;102:1211. Klapper RM. Q-switched Nd: YAG laser iridotomy. Ophthalmology 1984;91:1017. Vernon SA, Cheng H. Freeze frame analysis on high-speed cinematography of Nd: YAG laser explosions in ocular tissues. Br J Ophthalmol 1986;70:321. Abraham RK. Procedure for outpatient argon laser iridectomies for angle closure glaucoma. Int Ophthalmol Clin 1976;16:1. Krupin T, Stank T, Feitl ME. Apraclonidine pretreatment decreases the acute intraocular pressure rise after laser trabeculoplasty or iridotomy. J Glau 1992;1:79. Fleck BW. How large must an iridotomy be? Br J Ophthalmol 1990;74:583.

20 14.

15. 16.

17. 18. 19. 20.

21. 22. 23. 24. 25.

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Del-Priore LV, Robin AL, Pollack IP. Neodymium: YAG and argon laser iridotomy. Long-term follow-up in a prospective, randomized clinical trial. Ophthalmology 1988;95:1207-11. Wetzel W. Ocular aqueous humour dynamics after photodisruptive laser surgery. Ophthalmics Surg 1994;25: 298. Sugiyama K, Kitazawa Y, Kawai K, Enya T. Biphasic intraocular pressure response to Q-switched Nd: YAG laser irradiation of the iris and the apparent mediatory role of prostaglandins. Exp Eye Res 1990;51:531. Gailitis R, Peyman G A, Pulido J, et al. Prostaglandin release following Nd: YAG iridotomy in rabbits. Ophthalmic Surg 1986;17:467. Joo CK, Kim JH. Prostaglandin E in rabbit aqueous humour after Nd: YAG laser photodisruption of iris and the effect of topical indomethacin pretreatment. 1992;33: 1685. Weinreb RN, Weaver D, Mitchell MD. Prostanoids in rabbit aqueous humour: effect of the laser photocoagulation of the iris. Invest Ophthalmol Vis Sci 1985;26:1087. Schrems W, van Dorp HP, Wendel M, Krieglstein GK. The effect of YAG laser iridotomy on the blood aqueous barrier in the rabbit. Graefes Arch Clin Exp Ophthalmol 1984;221: 179. Cohen JS, Biblar L, Tucker D. Hypopyon following laser iridotomy. Ophthalmic Surg 1984;15:604. Margo CE, Lessner A, Goldey SH, Sherwood M. Lensinduced endophthalmitis after Nd: YAG laser iridotomy. Am J Ophthalmol 1992;113:97. Choplin NT, Bene CH. Cystoid macular oedema following laser iridotomy. Ann Ophthalmol 1983;15:172. Schwartz LW, Moster MR, Spaeth GL, et al. NeodymiumYAG laser iridectomies in glaucoma associated with closed or occludable angles. Am J Ophthalmol 1986;102:41-44. Canning CR, Capon MRC, Sherrard ES, et al. Neodymium: YAG laser iridotomies short-term comparison with

YAG Laser Iridotomy

26.

27. 28. 29. 30. 31. 32. 33. 34.

21

capsulotomies and long-term follow-up. Graefes Arch Clin Exp Ophthalmol 1988;226:49-54. Del-Priore LV, Robin AL, Pollack IP. Neodymium: YAG and argon laser iridotomy. Long-term follow-up in a prospective, randomized clinical trial. Ophthalmology 1988;95:1207-11. Caronia RM, Liebmann JM, Stegman Z, et al. Increase in iris-lens contact after laser iridotomy for pupillary block angle closure. Am J Ophthalmol 1998;122:53-57. Robin AL, Pollack IP. A comparison of neodymium: YAG and argon laser iridotomies. Ophthalmology 1984;91:101116. Quigley HA. Long-term follow-up of laser iridotomy. Ophthalmology 1981;88:218-24. Salmon JF. Long-term intraocular pressure control after Nd: YAG laser iridotomy in chronic angle-closure glaucoma. J Glaucoma 1993;2:291-96. Yamamoto T, Shirato S, Kitazawa Y. Treatment of primary angle-closure glaucoma by argon laser iridotomy: a longterm follow-up. Jpn J Ophthalmol 1985;29:1-12. Kim YY, Jung HR. Dilated miotic-resistant pupil and laser iridotomy in primary angle-closure glaucoma. Ophthalmologica 1997;211:205-08. Gelber EC, Anderson DR. Surgical decisions in chronic angle-closure glaucoma. Arch Ophthalmol 1976;94:148184. Richardson P, Cooper RL. Laser iridotomy. Aust NZ J Ophthalmol 1987;15:119-23.

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INTRODUCTION Lasers have been in use for the treatment of glaucoma for the last few decades. A bloodless sutureless technique of using the Nd:Yag laser has been started by the authors (SA) to treat glaucoma. This is called laser sclerotomy. If the patient has a cataract then one can do the cataract removal with the Laser Phakonit technique followed by either a Rollable or Foldable IOL implantation. HISTORY The author first performed this technique on a diabetic patient who was already undergoing hemodialysis as a result of renal failure. His renal failure made the use of acetazolamide an absolute contraindication. Using the ND:Yag laser of the Paradigm machine which is also used for cataract surgeries by the author, the author performed the laser sclerotomy. In this, the idea was to create a hole via the clear corneal incision in the trabecular meshwork. The hole passes through and through to exit the sclera forming a filtering channel into the subconjunctival space. ND:YAG LASER It is a solid state laser having an ionizing effect causing photodisruption, thermal effect causing photovaporization, photocoagulation and photocarbonization. The laser fiberoptic (Fig. 3.1) has a Helium Neon aiming beam with the diameter of the optic end being 380 μ. This fiberoptic is encased within a silicon sleeve. The ‘male socket’ connects the fiberoptic to the laser machine. The laser machine the author advocates is the Paradigm Photon machine which works at 3 Watts.

Laser Sclerotomy

25

Fig. 3.1: Nd:YAG laser fiberoptic (1) laser fiberoptic (2) male socket (3) diameter of ocular end of laser fiberoptic is 380 (4) helium neon aiming beam

LASER SCLEROTOMY WITH ND:YAG – INSTRUMENTATION • 0.9 mm diamond blade: Custom made diamond blade similar to the one used in laser Phakonit. • Viscoelastic: Hydroxy methyl cellulose used for maintenance of anterior chamber with protection of corneal endothelium. • Nd:Yag laser fiberoptic. • Paradigm laser machine. SURGICAL TECHNIQUE Paracentesis The anterior chamber is filled initially with viscoelastics to facilitate a smooth incision (Fig. 3.2). Hydroxymethyl propyl cellulose (viscon) is the preferred viscoelastic. The site of paracentesis is preferably 45 degrees away from the main incision so that a repository may be used later on for control of the eye ball during the procedure.

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Fig. 3.2: Paracentesis with viscoelastic injection

Clear Corneal Incision A keratome/diamond blade of 0.9 mm size (Fig. 3.3) is used to make a clear corneal incision superiorly depending on the site planned for sclerotomy. The entry point may be directly opposite the planned site of sclerotomy or juxtaposed to the planned site of sclerotomy. Depending on the surgeon’s preferences the director of the blade may be adjusted accordingly with the initial entry point parallel to the limbus and the tunnel incision varying according to the planned site of sclerotomy. Recently the author has opted for a variation in the conventional corneal tunnel with the initial entry point parallel but about 2 mm away from the limbus and the tunnel directed towards the limbus. The sclerotomy is then performed in the same area. Laser Sclerotomy After the corneal incision is made the anterior chamber is filled with more viscoelastic (Fig. 3.4) and then the laser

Laser Sclerotomy

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Fig. 3.3: 0.9 mm diamond blade for clear corneal incision

Fig. 3.4: Anterior chamber filled with viscoelastic

fiberoptic (Fig. 3.5) is introduced through the clear corneal incision. A short burst of laser is given directly opposite the intended site of sclerotomy (Fig. 3.6). The procedure is

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Fig. 3.5: Laser fiberoptic introduced through main incision and repositor is used to support the laser fiberoptic

Fig. 3.6: Laser ablation through the trabecular meshwork

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performed without the need of an operative goniolens using just the aiming beam as a guide. When the aiming beam is seen about 1.5 mm (Fig. 3.7) from the limbus a short burst of laser brings the laser fiberoptic out of the scleral bed and under the conjunctiva. Following this the fiberoptic is removed and the anterior chamber washed with BSS to remove traces of viscoelastic. BSS is injected near the sclerotomy site and sub-conjunctival bleb formation (Fig. 3.8) is looked for to assess the patency of the sclerotomy. Peripheral Iridectomy Depending on whether a PBI was done before or not a peripheral iridotomy (Fig. 3.9) may be done near the area of sclerotomy using the laser itself but preferably only in pseudophakic or aphakic patients lest the crystalline lens gets damaged inadvertently.

Fig. 3.7: Laser ablation carried through the sclera 1.5 mm from corneal limbus

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Fig. 3.8: BSS is injected into the anterior chamber to form bleb

Fig. 3.9: Peripheral iridectomy is made in the area of sclerotomy using ND:Yag laser or iris scissors

Laser Sclerotomy

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Closure of Incision The clear corneal incision is closed by stromal hydration (Fig. 3.10). Laser Phakonit and IOL Implantation If the patient has a cataract then one can perform the cataract extraction with the Laser Phakonit technique followed by an IOL implantation. This concludes a triple procedure which is less traumatic than performing a triple procedure with trabeculectomy. Phakic Laser Sclerotomy Laser sclerotomy has been performed safely in phakic individuals. Care has to be exercised when the laser is used, to prevent inadvertent damage of the crystalline lens with

Fig. 3.10: Anterior chamber is reformed and incision sealed with stromal hydration

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Step by Step Minimally Invasive Glaucoma Surgery

the laser energy. Iris pigmentation of the lens is the only complication seen in 20 percent of the phakic patients treated. Laser Sclerotomy in Pseudophakia and Aphakia About 55 percent of the patients who underwent laser sclerotomy were already operated for cataract. Results varied according to the degree of pre-operative IOP and the type of glaucoma. A case of keratoplasty with pseudophakos was treated with this procedure. When impending ciliary staphyloma formation conventional trabeculectomy could not be performed. Also long-term use of anti-glaucoma medication has resulted in subconjunctival fibrosis. The laser sclerostomy in this case was useful.

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INTRODUCTION Zwing and Flocks in 1961 introduced for the first time the concept of using selectively Xenon Arc photocoagulation in the filtration angle of animals and reported lowering of intraocular pressure (IOP). Several workers tried this by different techniques of creating holes in trabecular meshwork (TM), but failed as the holes closed due to fibrous scarring. It goes to the credit of Wise and Witter in 1979, who described the successful protocol of laser trabeculoplasty. ARGON LASER TRABECULOPLASTY Indications • Chronic open-angle glaucoma as initial treatment and as a supplement to maximum tolerable medical therapy • Exfoliation syndrome • Pigmentary glaucoma • Open-angle glaucoma in aphakia and pseudophakia • Previous history of single operation failed trabeculoplasty. The best laser for trabeculoplasty is Green laser. A gonio prism having antireflective coating on the front surface is best for visualizing the angle. Goldmann three mirror or single mirror lens can be used, but both of these require rotation of lens for viewing the 360° of angle. A Thorpe four-mirror gonioscopy lens can also be used. In this lens all the mirrors are inclined at 62°. The best lens, however is Ritch trabeculoplasty laser lens. It has two mirrors inclined at 59° for viewing the inferior quadrants and the other two at 64° for viewing the superior angle. It also has 17 D plano-convex button lens over the mirrors. This provides ×1.4 magnification and also reduces the 50 um

Laser Trabeculoplasty

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spot to 35 um. Therefore we get a 35 um burn on the trabeculum. This produces a burn, which is slightly more than 35 um. Whereas, a 50 um spot produces a burn of 70 um or more, which causes more damage to TM and surrounding structures. The Technique Before beginning actual treatment with argon laser, the instrument should be made parfocal with the surgeon’s eyes. This can be accomplished by placing a paper as target at the same distance where patient’s eye is usually placed. The surgeon then focuses each eye separately on the paper. The aiming beam should make a round circle without any distortion. This makes the instrument parfocal with the surgeon’s eyes. The slit-lamp should be used with ×25 magnification. Too high a magnification can reduce the field whereas, too less magnification will provide with a reduced detail. Preoperatively, Apraclonidine eye drops are instilled to reduce the chances of post-laser spike of IOP. Paracaine eye drops instilled immediately before the procedure is sufficient to give adequate anesthesia for placing Gonio lens in the eyes. The laser settings are 50 um spot, 0.1 sec, energy of 400600 mw. In heavily pigmented trabeculum more energy may be required. The aim is to get a depigmentation spot or a gas bubble at the focussed site. The laser beam is applied in between the pigmented and nonpigmented trabeculum. A posterior placement will burn iris and is likely to produce anterior synechia. Whereas, an anterior placement of the aiming beam can lead to corneal burn. We prefer to apply 50 laser shots on the inferior 180° and then watch the IOP for about three

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Step by Step Minimally Invasive Glaucoma Surgery

months for its control. If the IOP is not well controlled, the superior portion is lasered as second stage procedure (Fig. 4.1). How Does ALT help? Argon laser improves the outflow of aqueous by photocoagulation of the trabecular meshwork (TM). A number of theories have been proposed to explain this effect of ALT on aqueous outflow. The most widely accepted are the mechanical and cellular theories. According to the mechanical theory, ALT causes coagulative damage to the trabecular meshwork, which results in collagen shrinkage and subsequent scarring of the TM. This tightens the meshwork in the area of each burn and reopens the adjacent, untreated intertrabecular spaces.2-4 The cellular theory proposes that in response to coagulative necrosis induced by the laser, there is migration

Fig. 4.1: Argon laser trabeculoplasty: 1, 2, 3 are correct reaction 1: Blenching 2: Small bubble, 3: Large bubble with pigment fallout, 4: Posterior placement of reaction leading to anterior synechia formation

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of macrophages, which phagocytose debris and thus clear the TM. Complications Transient Rise of IOP This is the most commonly encountered complication after laser trabeculoplasty. In majority of the patients a mild rise of IOP occurs, which may remain high for a period for 24 hours only. The pressure starts rising with in 2 hours of trabeculoplasty. Therefore IOP should be rechecked within hours of the procedure. The next day usually the pressure comes down. Special care should be observed for those patients, who have advanced glaucoma. Apraclonidine 1 percent eye drops 1 hour prior and immediately after the procedure is instilled to prevent this complication. Transient Mild Iritis This is also a commonly seen complication in early postoperative period, especially in exfoliation syndrome and pigmentary glaucoma. Postoperatively, steroid eye drops prednisolone or fluoromethalone are given 6 hourly for at least 5-7 days. Other Complications • Corneal burn causing change in the size of corneal endothelial cells • Formation of anterior synechia. Results The 5 years success rate with ALT is reported to be 50 percent, with a decrease of 6 to 10 percent per year. The

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reduction in IOP is between 6 and 9 mmHg. The pressure reduction starts occurring after first day and continues for a period of one month. After this, usually the pressure reduction does not occur. The reduction caused by ALT may be sufficient for some eyes. But in others, it can only help in reducing the number eye drops that the patient is instilling in his eyes. Factors Influencing the Response of ALT 1. Higher the pretreatment IOP more is the response. But if initial pressure has been more than 30 mmHg the response may not be very good. 2. Type of glaucoma. Good Responders • Chronic open-angle glaucoma • Exfoliation syndrome • Pigmentary glaucoma. Fair Responders • Open-angle glaucoma in aphakia and pseudophakia • Previous history of single operation failed trabeculoplasty. Poor Responders • Previous history of multiple surgery • Glaucoma associated with uveitis angle recession glaucoma • Congenital or juvenile glaucoma • Angle recession glaucoma.

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Repeat Trabeculoplasty If 360° ALT has already been done and the desired reduction is not obtained a repeat trabeculoplasty may not be of any use. But if reduction has been achieved once, and the effect has reduced over a period of time, a repeat trabeculoplasty may be beneficial in some patients. Comparison of Selective Laser Trabeculoplasty and ALT Selective laser trabeculoplasty (SLT) is an alternative laser treatment introduced by Latina et al in 1995. SLT utilizes a Q switched, frequency doubled NdYAG laser ( = 532 nm) that selectively targets the pigmented TM cells without adversely affecting the TM in vitro, rendering the TM architecture more preserved. There have been a number of studies that compared the efficacy of ALT and SLT based on post-treatment IOP reduction, and all reported that SLT is as effective as ALT in terms of IOP lowering. In general, both modalities lower IOP an average of 5 mm of mercury 6 months post-treatment. Furthermore, compared to ALT, SLT did not cause ablation craters at the border of pigmented and non-pigmented cells in the TM, and the cellular changes induced by SLT did not extend beyond the Schlemm’s canal as it would after ALT. In addition, SLT appears not to cause the membrane formed by migrating endothelial cells in the necrotic TM seen after ALT treatment. SLT allows the use of 80 to 100 times lower levels of energy and less laser spots on the TM, causing less damage to the TM. Based on the above observations and results, SLT appears to be less destructive and may be more repeatable clinically than ALT.

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BIBLIOGRAPHY 1.

2. 3.

4.

5. 6.

7.

8.

9.

Agarwal HC, Sihota R, Das C, Dada T. Role of argon laser trabeculoplasty as primary and secondary therapy in openangle glaucoma in Indian patients. British J Ophthalmol 2002;86:733-36. Alexander R, Grierson I. Morphological effects of argon laser trabeculoplasty upon the glaucomatous human meshwork. Eye 1989;3:719-26. Cvenkel B, Hvala A, Drnovsek-Olup B, et al. Acute ultrastructural changes of the trabecular meshwork after selective laser trabeculoplasty and low power argon laser trabeculoplasty. Lasers Surg Med 2003;33:204-08. Damji KF, Shah KC, Rock WJ, et al. Selective laser trabeculoplasty vs argon laser trabeculoplasty: A prospective randomized clinical trial. Br J Ophthalmol 1999;83: 218-22. Feldman RM, Katz LJ, Spaeth GL, et al. Long-term efficacy of repeat argon laser trabeculoplasty. Ophthalmology 1991;98:1061-65. Hollo G. Argon and low energy, pulsed Nd:YAG laser trabeculoplasty. A prospective, comparative clinical and morphological study. Acta Ophthalmol Scand 1996;74:12631. Koller T , Sturmer J, Reme C, et al. Membrane formation in the chamber angel after failure of argon laser trabeculoplasty: Analysis of risk factors. Br J Ophthalmol 2000;84:48-53. Kramer T, Noecker R. Comparison of the morphologic changes after selective laser trabeculoplasty and argon laser trabeculoplasty in human eye bank eyes. Ophthalmology 2001;108:773-79. Martinez-de-la-Casa J, Garcia-Feijoo J, Castillo A, et al. Selective vs argon laser trabeculoplasty: Hypotensive efficacy, anterior chamber inflammation, and postoperative pain. Eye 2004;18:498-502.

Laser Trabeculoplasty

10. 11.

12.

13.

14. 15. 16. 17. 18.

19. 20.

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Melamed S, Pei J, Epstein D. Short-term effect of argon laser trabeculoplasty in monkeys. Arch Ophthalmol 1985;103: 1546-52. Mermound A, Herbort CP, Schnyder CC, et al. Comparison of the effects of trabeculoplasty using the Nd:YAG laser and argon laser. Klin Monatsbl Augenheilkd 1992;200:40406. Odberg T, Sandvik L. The medium and long-term efficacy of primary argon laser trabeculoplasty in avoiding topical medication in open-angle glaucoma. Acta Ophthalmol Scand 1999;77:176-81. Popiela G, Muzyka M, Szelepin L, et al. [Use of YAG-selecta laser and argon laser in the treatment of glaucoma] (abstract only; article in Polish). Klin Oczna 2000;102:12933. Reiss GR, Wilensky JT, Higginbotham EJ. Laser trabeculoplasty. Surv Ophthalmol 1991;35:407-28. Ritch R, Liebmann J, Robin A, et al. Argon laser trabeculoplasty in pigmentary glaucoma. Ophthalmology 1993;100:909-13. Shingleton BJ, Richter CU, Dharma SK, et al. Long-term efficacy of argon laser trabeculoplasty. A 10-year followup study. Ophthalmology 1993;100:1324-29. The Glaucoma Laser Trial Research Group. The Glaucoma Laser Trial (GLT), II: Results of argon laser trabeculoplasty vs topical medicines. Ophthalmology 1990;97:1403-13. Weinreb RN, Tsai CS. Laser trabeculoplasty. In: Ritch R, Shields MB, Krupin T, (Eds): The glaucomas: Glaucoma therapy, 2nd ed. Missouri: Mosby-Year Book, 1996;III: 157579. Wise JB, Witter SL. Argon laser therapy for open-angle glaucoma. Arch Ophthalmol 1979;97:319-22. Zweng HC, Flocks M. Experimental photocoagulation of the anterior chamber angle: A priliminary report. Am J Ophthalmol 1961;52:163.

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LASER PRINCIPLE AND INTRODUCTION The word laser was first used in the 60s when light was generated by stimulated emission of radiation. The word LASER is an abbreviation for Light Amplification by Stimulated Emission of Radiation.9 The physical and wavelength characteristics of the laser light were so specific that they gained rapid interest in the field of medical treatment. Laser light is monochromatic and spatially and temporally coherent. This results in a laser beam that is highly directional with little divergence, thus enabling focusing of the beam into a very small spot of high power per unit area. Monochromaticity means that the laser beam is composed of almost a single wavelength, which has great consequences in the surgical eye treatment. This allows light to be effectively absorbed by the pigments contained in the ocular tissues, e.g. the melanin, hemoglobin or the xanthophyll pigments.4 The molecules in biologic tissues are not transparent to wavelength shorter than 300 nm or greater than 100 nm. Between this range, the molecules absorb selectively the light depending on the spectral absorption characteristic of the pigments in the tissues. Laser effects in tissues can be summarized into three groups: photochemical, thermal and ionization effects. The photochemical effect results in photon absorbtion by molecules inducing chemical reactions. A thermal effect is present when photon absorbtion by electrons increases the molecular vibrations to a temperature peak that results in denaturation of proteins in biologic tissues. When the temperature reaches 60°C, the weak van der Waals forces that maintain the molecular bonds are broken and denaturation of the several intracellular proteins occurs.1 If laser energy is strong enough to tear electrons from the outer orbit, the atoms or molecules become ionized and relax this metastable state

Laser Treatment in Glaucomas

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by producing mechanical (pressure) waves (photodisruption effect).7 The efficiency of laser beam onto biological tissues depend on the absorption spectra of cellular pigments.5 Melanin best absorbs wavelengths between 400 and 100 nm. Hemoglobin, naturally presents a red appearance that strongly reduces its absorption characteristics in the long wavelengths above 650 nm. Xanthophyll absorbs very well in the short wavelengths below 500 nm. The laser delivery systems used in laser glaucoma treatments are divided into two groups: non-contact and contact laser source.8 The non-contact delivery system produces a beam that is focused onto the area to be treated via a slit-lamp biomicroscope. It may be useful to place a contact lens to stabilize the eye and the lids, to reduce the optical aberrations of the anterior surface of the cornea and to gain access to structures that are otherwise invisible without a contact lens. The contact delivery system consists of laser source and optical guidance device such as fiberoptic and delivery tip that directly apply onto the tissue to be treated.10,11 The energy distribution of the laser beam can be set on two different modes.7 The fundamental mode gives a sharp focus spot with maximum energy at the focus point and minimum energy anterior or posterior to that point. The mode locking produces a series of brief spikes of photon, with a peak of energy that is much higher than the average energy of equivalent photon bursts that are delivered in a continuous flow. It is also possible to modulate the production of the laser light before delivery by placing an electronic shutter that keeps the excited molecules to a high energy level before relaxation. When the shutter opens, an extremely brief pulse (20 ns) of high energy is produced (Q-switch mode).7

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Step by Step Minimally Invasive Glaucoma Surgery

Several wavelengths are used in ophthalmic laser photocoagulators. Krypton lasers produce red light (647 and 676 nm). Argon lasers produce green light (514.5 nm) and green and blue light (514.5 and 488 nm). Both are used in photocoagulation,14 whereas Nd:YAG lasers deliver infrared light (1064 nm) which is used with Q-switch mode in photodisruption. Diode lasers deliver red (640 nm) and infrared light (800-820 nm) that can be guided through a fiberoptic device for contact photocoagulation. A new type of laser has recently been developed to enhance the photodissociative effect of the YAG laser in intraocular surgery. It is made by combination of a classic YAG laser on which an erbium component has been added to produce fragmentation effects. The wavelength of 2940 nm is longer than Nd:YAG, thus water absorbs most of the energy with an important water absorption photothermal effect.6 The transfer of heat to the adjacent tissue is therefore reduced. The beam is directed through a fiberglass tip with a ceramic end. The first attempts have been made in cataract surgery to replace the ultrasonic emulsification currently used.13 But technical problems regarding the safety of this method in respect to the posterior capsule have not yet been completely solved. New attempts have been made in glaucoma therapy to increase the aqueous outflow by disrupting the trabecular meshwork and inner wall of Schlemm’s canal by an ab-interno approach. A quartz fiber contact endoprobe (320 micron core-diameter, 385 micron coating-diameter) applying single neighboring laser pulses (5-7 mJ) to the trabecular meshwork. The procedure was gonioscopically visualized. Although IOP lowering effect of erbium:YAG laser trabecular ablation did not prove as effective as in filtering procedures. LTA might be a valuable alternative in glaucoma surgery especially in order to avoid conjunctival scarring and postoperative hypotony.3-5 It is

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not known whether this new technique can be widely used in the field of glaucoma laser surgery to add new prospectives or replace existing and efficient laser technique and procedure that will be explained in more details in the subsequent chapters. The physical properties of the laser beam are such that safety aspects should always be considered when using or being in close proximity to laser devices. Every laser delivery system protects the operator from direct damages when using the laser by shutting off the beam with a filter. But this is not the case for personnel being nearby and staring at the laser system, for the filter will not prevent hazardous direct or reflected beam from reaching the retina of the observers.12 LASER IRIDOTOMY Laser iridotomy is a laser surgical procedure by which a small aperture through the iris is created to treat several forms of angle-closure glaucomas and more recently pigmentary glaucoma.25,31 It was introduced in the 80’s with the development of laser surgeries.21 The indication for laser iridotomy is given in the case of acute angle-closure glaucoma when the acute attack has been medically controlled, and the cornea is clear enough to allow sufficient penetration of the laser beam into the anterior chamber without excessive scattering.5,26 In the case of chronic angleclosure glaucoma, or eyes with peripheral anterior synechia, laser iridotomy may reduce the intraocular pressure (IOP) and allow the angle structures to resume a wider space, by deepening the anterior chamber.24 Pupillary block may be relief thus allowing a better control of the IOP. In aphakic or pseudophakic eyes, pupillary block from pockets of aqueous behind the iris plane could be relieved by adequate

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laser iridotomy.1,6,30 In eyes with intumescent cataracts, or in the fellow eye of an acute angle-closure glaucoma eye, prophylactic laser iridotomy can be performed in order to avoid an attack of angle-closure glaucoma.30 In eyes with narrow angle, good visualization of the angle structures may be rendered difficult by the geometric disposition of the iris over the angle. This situation could prevent the performance of laser trabeculoplasty in such eyes. To avoid this complication, laser iridotomy can be performed to open a too narrow angle. In the plateau iris syndrome, anteriorly located ciliary processes support the peripheral iris. Variation in the angle values between dark and light are solely related to changes in iris thickness. Pilocarpine produces iris thinning and is an effective method of opening the angle.18 General disturbance of the geometry of the eye, like in the case of nanophthalmos, have greater risks for developing angle-closure glaucoma. A prophylactic laser iridotomy could reduce the incidence of such complications. In pigment dispersion syndrome, the iris often presents a marked concavity, forming an inverted pupillary block. Accommodation increases iris concavity in some patients with pigment dispersion syndrome. The most likely explanation is an accommodation-induced relative increase in anterior chamber pressure, secondary to anterior movement of the lens surface. Iridotomy prevents change in the iris profile with accommodation.19 In this case too, performance of laser iridotomy would reduce the pressure differential between the anterior and posterior plane of the iris, by creating a channel through the iris.2,4,7,12,22 In the field of refractive surgery, the placement of an intraocular contact lenses (ICL) in the posterior chamber in front of the anterior capsule of the lens reduces the angle and increases the risk for angle-closure glaucoma. Laser iridotomy performed before refractive surgery prevents the likelihood

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of such complications.22 Conversely, in the presence of strong hypermetropic eyes, the current IOL may not have sufficient refractive power for the intended emmetropization. Two intraocular lenses (piggyback) have been placed simultaneously in the capsular bag, thus also reducing the depth of the chamber. In that case too, a laser iridotomy will prevent an attack of angle-closure glaucoma.14 Laser iridotomy is contraindicated in any situation where the angle-closure is not mechanicaly reversible by deepening the anterior chamber, for instance, a flat anterior chamber, synechial closure of the angle by uveitis, neovascular glaucoma or by iridocorneal endothelial syndrome (ICE). In this situation they are absolute contraindications for laser iridotomy. Any corneal edema or opacities will strongly reduce the quality of the transmission of the laser, and are relative contraindications for the performance of the treatment. A gonioscopic contact lens, like the Goldmann is placed on the cornea of the patient after topical anesthesia. It sometimes happens that the iris is not contracted enough to present a smooth surface and thin stroma. Only a few shallow crypts are visible. The use of pilocarpine will contract the sphincter iridae and enlarge the angle of view before treatment. In some cases, the IOP rises a few hours after laser iridotomy.3,27 To prevent the peak of pressure, an alpha agonist such as apraclonidine can be given preand perioperatively.28 The location of the iridotomy should be either the 11 or 1 O’clock positions, so that the upper lid will cover the aperture made by the laser and prevent monocular diplopia (Fig. 5.1).11,16 A crypt should be selected if possible to facilitate the creation of the crater. As laser light is absorbed by ocular pigments, very light iridies are more difficult to perforate than darker. Conversely, very dark pigmented iris have generally thicker stroma and are

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Fig. 5.1: Iris aspect after Nd:YAG laser iridotomy located at 12 O’clock position. Note the depigmentation of the anterior surface of the stroma around the aperture

also difficult to penetrate.13 Laser energy used will then depend on color and density of irides pigments. Current power level for argon type laser ranges from 500 upto 1500 mW for a duration of 0.1 sec. Spot size is set at 50 μm. Nd:YAG laser energy level is set between 2.0 and 8.0 mJ with single burst mode. Small bubbles form around the spot site and, in case of dark brown pigmented iris, some pigments will be released into the anterior chamber. This can severely reduce visibility of the treated area and preclude the completion of the treatment. In such case, a break between laser applications should be made. When passing through the posterior plane of the iris, clouds of pigments burst in the iridotomy crater may appear. As soon as the iris stroma has been totally penetrated, a flow of aqueous humor “leaks” through the aperture and the iris

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stroma moves slightly backwards. Retroillumination through the pupil will reveal a red reflex via the iridotomy. Care should be exercised not to be overconfident in the patency of the iridotomy, as red reflex is not enough to ensure complete burn of iris stroma. Some very thin transparent membranes could still be present, preventing aqueous from freely flowing through the iridotomy. Gonioscopy should always be performed in doubtful cases. Ultrasound biomicroscopy will show an increase in the iridocorneal angle after completion of a successful iridotomy (Fig. 5.2). Corneal edema and epithelial erosion can occur when performing laser iridotomies. Such complications generally resolve in a few days. Endothelial cell can be affected by Nd:YAG laser, caused by the shock waves produced during the treatment. Endothelial cells count have shown that proper application of laser burn with Nd:YAG laser does

Fig. 5.2: Ultrasound biomicroscopy of the anterior chamber angle after patent iridotomy through the iris stroma, the angle is wider

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not significantly increase the endothelial cells lost.15,17,23 Nevertheless, caution should be exercised not to focus the laser beam onto the Descemet’s membrane. The iris stroma is strongly vascularized by arteries from the major iris circle, and injury to arterioles cause instant bleeding in the anterior chamber. When this complication occurs, a gentle pressure with the contact glass will temporarily increase the IOP and promote hemostasis. Dramatic hyphema have been reported after such laser procedures.29 Argon laser, or Nd:YAG laser set on multi-mode iridotomy, generally prevent such complications, as the thermal effect of the laser burns coagulates the vessels and avoids bleeding when hitting a vascular branch.13 The stroma and iris pigment epithelium dispersion phenomena observed during completion of laser iridotomies increase the amount of particles in the anterior chamber. Inflammation and anterior uveitis are generally present after the procedure. To prevent extension and persistence of this inflammation, topical steroids are given and tapered in a few days. Posterior synechiae may develop as a result of prolonged inflammation.10 As mentioned before, the IOP rises in the next few hours after laser therapy. Close monitoring of the IOP is mandatory and adequate medication given in case of persistent elevated values. Some case of damages to the lens have been reported as the result of excessive laser application to the capsule behind the iris plane.32,33 Care should therefore be exercised when applying laser energy on an patent iridotomy. LASER TRABECULOPLASTY When laser burns are applied on the trabecular meshwork, persistent IOP reduction is followed. 30,31 The pathophysiology of the laser burns on the trabecular

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meshwork was hypothesized as follows: Thermal effect of the burns induces collagen shrinkage and scarring of the meshwork. This leads to mechanical traction on the adjacent intertrabecular space that becomes open, thus increasing the outflow facility.5,27 Argon blue-green laser (488 nm) was the laser of choice for this procedure. This has been named argon laser trabeculoplasty (ALT). It can be used in several forms of open-angle glaucoma. A Nd:YAG laser trabeculoplasty (YLT) has also been used as an alternative to the ALT. In case of hypopigmented trabeculum meshwork, YLT is a safe and effective alternative technique to perform laser trabeculoplasty, which is especially useful in poorly pigmented angles where ALT is known to be less effective.14 A non-contact laser delivery system coupled with a slitlamp, is used for the ALT procedure. To gain access to the entire angle structure, a contact lens with a gonioscopic mirror (CGI from LASAG, Bern, Switzerland) is placed on the cornea of the patient after topical anesthesia. In some cases, when the angle is too narrow to allow a good visibility of the trabecular meshwork, use of pilocarpine may enlarge the angle to enable the treatment. Laser spot parameters are set commonly with 50 μm spot size, 0.1 sec. of duration and 800 mW of power. The correct effect of the laser burns should be a blanching of the trabecular meshwork. When too much power is applied, a bubble will form and intense blanching and scarring will result. The power should then be reduced just enough to get blanching with minimal bubble creation. The amount of power required to get this result may vary with the degree of pigmentation of the trabecular meshwork.20 It is important to readjust the power setting throughout the laser session to get homogeneous treatment all over the treated quadrants. The laser beam spot must be kept on focus over

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the entire portion of the treated zone. The spots should be placed evenly over the anterior half portion of the trabecular meshwork (Fig. 5.3). Attention should be paid not to burn adjacent structures of the meshwork such as the ciliary body, the iris processes or the cornea. Correct placement of the spot minimize the possibility of early postoperative IOP rise25 and peripheral anterior synechiae formations.23 Should hemorrhage occur during the laser treatment, it could be kept under control by gently applying a slight pressure to the globe through the contact lens. This relatively rare event might be the result of an inadvertent burn of a peripheral iris vessel from the ciliary circle. Caution should also be exercised not to damage the structure of the cornea. The corneal epithelium may be inadvertently removed when placing or moving the contact lens. The resulting corneal abrasion will heal within hours often without treatment. Corneal endothelium lesions are of greater importance and may lead to permanent corneal lesions. Corneal edema results from insult to the corneal endothelium and may persist for several months, severely impairing the visual outcome of the patient. Pre-existent

Fig. 5.3: Artist’s view of gonioscopic aspect of laser burns after argon and Nd:YAG laser trabeculoplasty, and complication of peripheral anterior synechiae (Courtesy Dr A Mermoud)

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endothelial pathology such as Fuch’s endothelial dystrophy or cornea guttata have greater risks to induce complications of the corneal endothelium.28 Care should be given not to treat too many areas of the trabecular meshwork. An experimental glaucoma model in rhesus monkey has been created by giving a large number of long duration laser burns.8 Postoperative IOP rise peak may also depend on the number of burns.25 Generally, 50 to 70 burns over 180° are enough to create a sustained consistent IOP drop overtime.13,26 It should be kept in mind that the long-term overall outcome of ALT is about 50 percent after 5 years.18,19 Most of the patients will probably require other types of treatment, for instance a filtration surgery. In order not to compromise the result of further filtrating surgery, it is advisable not to treat the upper quadrant, and to leave the trabecular meshwork untouched. It is not uncommon to encounter some pressure spike after argon ALT. To prevent or avoid the extension of such pressure rise, α-2 agonist may be given before and/or just immediately after the laser treatment.17 Apraclonidine or brimonidine are the therapy of choice.1,2,4 Even with an adequate postoperative therapy, the IOP sometimes remains elevated several weeks after the ALT. It should be emphasized that the ALT produces or enhance inflammation in the anterior chamber and over the trabecular meshwork.15 Inflammatory cells and inflammation products collect into the trabecular meshwork and dramatically reduce the outflow facility, resulting in persistent IOP elevation. This inflammatory reaction is thought to be the result of transient breakdown of the bloodaqueous barrier and is correlated with the type of glaucoma. Pigmentary and pseudoexfoliative glaucoma show the greatest inflammatory reaction after ALT compared with chronic open-angle glaucoma.

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Beside the inflammatory reaction, the ALT can also induce other reactions or changes in the anterior chamber. Laser burns placed too posteriorly result in creation of peripheral anterior synechiae.19 This complication does not happen when burns are placed in the anterior trabecular meshwork. It is still unclear whether peripheral anterior synechiae play a role in the long-term outcome of ALT or not.12 The long-term results of the ALT is relatively modest. A mean success rate of 45 percent 5 years after ALT has been reported in several studies.3,6,18,19 Despite this rate, the ALT might be indicated in patients where classical filtrating surgeries cannot be performed for general health state reasons, for ophthalmological reasons, or because of nonmotivated patients.7,9,11,29 Primary ALT gives a longlasting and favorable effect in chronic open-angle glaucoma where 2/3 of the eyes were still managed without additional medication for 8 years. The success in pseudoexfoliation glaucoma was even higher the first 3 years, and stayed above 50 percent for 10 years.3,16,22 In young patients below 50 years, the overall results without additional medication is even higher.10 Some variations in the efficiency of the ALT may be seen between individuals having different intensity in the pigmentation of the trabecular meshwork. The caucasian patients have generally less pigmented meshwork in comparison to the black African patients, and the former may respond poorly to the ALT.21,24 LASER PERIPHERAL IRIDOPLASTY Not every angle-closure glaucoma may be relieved by laser iridotomy. Structural modifications of the anterior chamber angle, like appositional angle closure in the plateau-iris syndrome, peripheral anterior synechiae or attacks of

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severe acute angle-closure glaucoma with corneal edema, anterior chamber flattening and inflammation, will prevent laser iridotomy to be effective.4,5 In case of narrow anterior chamber angle induced by lens intumescence or anterior chamber crowding as the result of short anteroposterior axis eyes (hypermetropia or nanophthalmos), the trabecular meshwork might be also difficult to see through the gonioscopic mirror. In such situations, alternative laser procedures on the iris could be performed to open the angle.5,7,10 Localized heat application onto biological tissues induces protein coagulation and shrinkage around the burn spot. This produces contractions of the tissue fibers and can be used as mechanical retractors. The argon laser peripheral iridoplasty consists of using the thermal effect of argon laser burns of large spot size, long duration and low power applied at the iris periphery to promote contractions of the iris stroma that will retract the iris root and open the angle.8,6,10,11 The treatment is performed with a contact lens under topical anesthesia. In order to have maximum efficiency, the iris surface should be as smooth as possible. To stretch the iris stroma, pilocarpine 4 percent is given one hour before initiating the procedure. Alpha-agonist is also recommended to avoid postoperative rise of the IOP. The laser is set at 500 μm, 0.5 sec and 400 mW of power, depending on the irides coloration. Excess power results in bubble formation and pigment dispersion. In that case, power should be reduced. Enough power should be applied to produce a noticeable stromal contraction. Lighter irides require more power than darker, as pigments are less dense in the former and absorb less power at a time. Location of the burns must be at the most peripheral part of the iris to produce better results. Should the burns

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be placed less peripherally, the contraction would not be acting directly against the iris root and the resulting effect would be much less effective. For instance, placement of burns in the mid-periphery would lead to failure of this procedure. The effect of laser burns on tissues is almost immediate and iris stroma shrinkage is followed by local opening of the anterior angle and local deepening of the anterior chamber. The spots are placed around the circumference of the iris over 360 degrees with two to three spot diameters inbetween. Postoperative treatment consists of an alpha-agonist like apraclonidine given once just after the laser session and topical steroids 3 times a day for a week. Caution should be given to the IOP rise in the early hours and adequate medication be administered accordingly. Complications are relatively seldom and consist in mild iritis lasting no longer than a few days. Corneal burns and endothelial decompensation might occur as the laser beam strikes the iris plane with a narrow angle in the case of plateau iris and shallow anterior chamber. Contrary to laser iridotomy, the iris is not cut through the entire stromal portion and the lens or retina will not suffer from damages linked to laser application. 2,3,9 A case of malignant glaucoma has been reported.1 CYCLOCOAGULATION WITH YAG AND DIODE LASER The intraocular pressure can be lowered not only by enhancing the outflow through the trabeculum meshwork, but also by reducing the production of aqueous humor from the ciliary body.1,18,21 During the era when laser techniques were not currently used, cyclodestruction was made by applying either an intense and focal heat onto the ciliary body, a procedure called cyclodiathermy, or by freezing

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the ciliary processes with the help of a cryoprobe applied close to the limbus.3,19 The laser technique used to destroy the ciliary body belongs to the group of cyclophotocoagulation, a way of reducing the activity of the ciliary body by the means of light as a vector of energy. Nd:YAG laser and diode laser are both used to achieve this goal. The laser delivery system can be of contact or non-contact type, if the laser beam has to be directed through a fiberoptic end probe or applied through the air to the globe via the optic devices of a slit lamp. The latter has the advantage that the end part of the delivery system does not carry the risk of transmitting infectious diseases and does not need to be sterilized, while the former can be more compact and easier to use on a patient in a bed. The energy delivery mode can be set on a pulse mode, whereas during short time intervals a predetermined burst of energy is emitted, or the beam is continuously emitted from the laser source during a preset time. The Nd:YAG laser produces a laser beam of 1064 nm, that is well below the lowest visible wavelengths. The pulse-wave mode creates a mechanical photodisruption that is concentrated in the pigment epithelium of the ciliary body. The continuous wave mode gives a very high level of energy that is mostly absorbed thermally over the ciliary body and partially absorbed in the sclera.16 The effects of Nd:YAG laser application onto the ciliary body result in destruction of tissue, inflammation fibrosis and coagulation necrosis. At the end stage, the production of aqueous humor is markedly reduced, thus lowering the IOP.12,20 The patient is given a retrobulbar injection of anesthetic to reduce the pain induced by the laser treatment and to avoid unexpected eye movements during the procedure. With a non-contact delivery system, the patient is seated

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in front of a slit-lamp. The laser beam is set with the maximum offset value to separate the aiming beam from the Nd:YAG beam. The energy is set between 5 and 10 J/ pulse, the duration of the continuous mode is 20 ms. The beam is pointed between 1 and 2 mm from the limbus and burns are made around evenly spaced. The number of burns varies between 20 and 40. When using a contact delivery system, the probe is placed at less than 1 mm from the limbus and the energy level limited to 5 J. The diode laser produces a laser beam of 810 nm which is slightly lower than the lowest visible wavelength.15,22 There is only one mode, the continuous-wave mode. Two delivery systems can equally be used, the contact and noncontact, in the same way the Nd:YAG laser is being used (Fig. 5.4). The effects on the ciliary body are mostly due to the thermal action of the laser beam absorbed by the melanin pigments of the ciliary epithelium. Coagulation necrosis and tissue shrinkage are the main changes observed after diode laser cyclophotocoagulation.8 The patient is prepared according to the same protocol used for the Nd:YAG treatment. The power level for non-contact

Fig. 5.4: Diode cyclophotocoagulation probe for contact cyclocoagulation

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diode treatment is set between 1000 and 2000 mW, the duration is 2 sec, and the spot size varies between 150 and 500 μm.9 In the contact mode, the duration is slightly longer, giving a power level of 2000 mW.17 The laser beam or the diode probe are placed 1 mm behind the limbus and 20 to 40 burns are made over the entire 360 degrees of the limbus (Fig. 5.5).7,10,13 A new technique for controlling refractory glaucoma has been developed that acts directly from inside the eye instead of acting through the sclera. One reason for failure of trans-scleral cyclophotocoagulation, particularly in congenital glaucoma, may be the displacement of the ciliary processes. This displacement does not permit the indirect treatment to reach the appropriate area. Because endoscopic laser cyclophotocoagulation allows direct visualization of the processes, treatment can be accurately

Fig. 5.5: Inflammation is noticeable after Nd:YAG cyclophotocoagulation, with mixed perilimbal conjunctival injection. The laser burns are clearly visible around the limbus as white scars evenly spaced

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applied to the very individual ciliary processes.6,14 Endoscopic cyclophotocoagulation treatment encompassed 180 to 360 degrees of the ciliary body circumference and is performed through a limbal incision. An 810 nm pulsed continuous-wave diode laser capable of 1.2 W output is being used. Generally, 800 mW are being used for less than 1 second, for a total of 0.8 J per treatment. Early results suggest that endoscopic cyclophotocoagulation is a safe and effective therapeutic modality for refractory glaucomas.11 The postoperative care of patients undergoing cyclophotocoagulation consists of patching the eye for one day with topical steroids to control the postoperative inflammatory stage (Fig. 5.5). The steroids are gently tapered and antiglaucoma medication adjusted according to the postoperative examinations. The conjunctiva is frequently burned and uveitis is present after every laser treatment but subsides with steroids application. The pain might be moderate to severe, generally lasting no longer than a few days. The most severe complication implies prolonged hypotony and phthisis bulbi, a feared event that had already occurred in several cases after cyclocryocoagulation.5 These complications tend to be less frequent when using the diode laser cyclophotocoagulation.2 The pressure lowering effect of laser cyclophotocoagulation is variable but values of 15 to 30 mm Hg might be achieved, and results overtime remain quite stable. Nd:YAG and diode laser cycloablations are relatively safe and effective at controlling IOP in eyes with advanced refractory glaucoma in the short and medium term.4 Glaucoma medications are generally also reduced after one or more laser sessions. Repeated treatments are nevertheless required in some patients when the intended lowering effect is not reached at the first session.

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LASER TREATMENTS AFTER FILTERING SURGERY After classical filtering surgery that has been performed without complications, it may happen that filtration progressively decreases. The IOP rises again to values measured before surgery. The main cause for such failure is an overscarring of the filtration bleb. The trabeculectomy technique requires a good closure of the scleral flap to prevent excessive aqueous outflow resulting in hypotony and shallow anterior chamber. But a too tight closure of the scleral flap may result in excessive elevation in IOP in the postoperative period. To prevent prolonged elevation in the IOP, it is possible to selectively cut some sutures to release the tension of the scleral flap.7,9 Scleral flap sutures are made of nylon or polypropylene sutures that are either black or deep blue. The thermal effect of argon laser is efficient in lysis of such material through the conjunctiva. Technically, the procedure is performed with a contact glass applied to the conjunctiva, using the Hoskins or the Ritch lens. 4,11 This allows a better visualization of the suture by flattening the Tenon and conjunctiva layers. It is better not to perform ocular massage immediately before the laser lysis, as the massage brings some subconjunctival fluid that will scatter laser light and reduce visibility and accessibility to the suture. The laser setting is 50 μm for the spot size, with a duration of 0.1 sec and power of 300 to 500 mW. The laser beam is focused on the suture and shots are applied until the suture is being cut. Intraocular pressure is then measured to ascertain the degree of efficiency reached. Gentle massage of the globe might also be performed to promote the outflow. Caution should be exercised not to excessively treat by cutting too many sutures resulting in hypotony, shallow anterior chamber, choroidal effusion, optic disk

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and macular edema.1 The ideal time to perform suture lysis is 1 to 2 weeks after surgery in case of elevated IOP. After this period, the result is less prone to be efficient, probably because of scarring of the scleral flap.3 Other causes of elevated pressure like iris incarceration into the internal sclerostomy or malignant glaucoma, should be investigated and eliminated accordingly. Overfiltration on the other hand is a troublesome complication that requires efficient treatment. Overfiltrating bleb can be brought to a less effective size by enhancing the fibrosis. Invasive techniques like autologous blood injection in the bleb have been reported to be efficient. Noninvasive methods using laser techniques can also be developed to prevent persistent hypotony and create some local subconjunctival bleeding. By applying gentle laser spots onto the conjunctiva with a Nd:YAG laser, the conjunctival vessels are disrupted and bleeding occurs.2 The idea is to create adhesion scars between the conjunctival bleb and the Tenon shield that reduce the size and efficiency of the bleb. It is also possible to physically promote scarring of the subconjunctival space and Tenons and mechanically tighten the two layers. To achieve this goal, several burns are made at the edge of the bleb by using the Hoskins or the Ritch lens to depress the conjunctiva. The spot size is set between 50 and 100 μm, with a duration of 0.1 sec, a power of 200 to 400 mW. The beam is focused on the Tenon or slightly deeper to avoid perforation of the conjunctiva, and the spots are evenly spaced all around the bleb. Power should not be excessive as this will result in conjunctival buttonhole or formation of subconjunctival bubbles that will increase the bleb size instead of helping scar formation.6 Laser treatment in the postoperative period can also be used in conjunction with other surgical techniques used

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to treat refractory glaucoma. In this case, drainage devices are being used to create an effective outflow from the anterior chamber to the subconjunctival and sub-Tenon’s space. But this technique requires an adequate control of the outflow that can be achieved by placing a stent suture around the tube. In the postoperative period, the IOP is monitored and the suture may be released should the pressure be elevated.8 It may also happen that the tube opening in the anterior chamber becomes blocked by fibrin clots and this results in failure of the shunt technique. Nd:YAG laser membranectomy will clean the tube and thus restore a patent drainage to the external plate.12 In the new non-perforating techniques, like deep sclerectomy with collagen implants or viscocanalostomy, the trabecular meshwork remains untouched and only the inner wall of Schlemm’s canal and the juxtacanalicular meshwork are removed. 5,13 A very thin membrane prevents the anterior chamber to collapse during the filtering surgery. But after a few weeks or months, the trabeculodescemetic membrane may become fibrotic because of elevated IOP and should be open to allow better outflow. This procedure is called goniopuncture, and can easily be done with a Nd:YAG laser. The goal of this technique is to perforate the remaining trabecular meshwork at the surgery site by performing an internal trabeculotomy or descemetomy. A gonioscopic contact glass is set on the eye of the patient after topical anesthesia to gain access to the anterior chamber angle. The trabecular meshwork at the surgery site appears as a thin less pigmented membrane, some light from the sclerectomy being transmitted through the wall (Fig. 5.6). The laser beam is pointed to this membrane and several impacts are shot. The power level is set at 5 mJ. Some air-bubbles may be generated during the treatment. It is sometimes difficult

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to ascertain the patency of the trabeculotomy, as the perforation diameter is very small, being less than 70 μm and the edge barely distinguishable from the surrounding poorly pigmented trabecular tissue. In such case, it is best advisable to measure the pressure a few days later and perform a second session if necessary. The postoperative treatment consists of topical corticosteroids 3 times a day, tapered in a few days. The hypotensive medication if required before goniopuncture, should be continued or stopped after laser treatment according to the IOP lowering effect achieved.10 SCLEROSTOMIES The technical approach of glaucoma surgery is based on the creation of a fistula that drains into a filtering bleb.

Fig. 5.6: Gonioscopic view of the anterior chamber, and inner aspect of the trabeculodescemetic membrane after Nd:YAG goniopuncture. Note the black suture used to secure the collagen implant

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Mechanical techniques that involve the use of cutting blades, blunt dissection, tissue removal and titrated sutures promote inflammatory responses that will modulate the healing and scarring processes. Overacting fistulas or inefficient filtering blebs result from variation of standard procedure and lead to the need of complementary surgery or adjunctive treatment. Laser, by its physical property, is a very useful tool that can provide calibrated beams at various energy levels. By developing adequate delivery systems to the trabecular meshwork, it is possible to perform a direct fistula through the tissue, a so-called sclerostomy.7 The advantages of such techniques are that the fistula diameter can be better predicted, tissue trauma could be less extended, especially regarding the development of the filtering bleb.3 Three methods have been developed to achieve this goal. All are based on the kind of delivery system being used to apply laser energy to create a channel through the sclera and trabecular meshwork. Basically there are two approaches possible, from outside the eye, the ab-externo procedure, or from inside, the ab-interno procedure. The latter can further be divided into two categories, invasive or non-invasive procedure. To perform a non-invasive ab-interno sclerostomy, a modification of the current laser technique has to be made before completion of the treatment. A pulse-dye laser is used to get a beam for the non-contact delivery system connected to the slit-lamp. A gonioscopy lens is applied on the eye to allow good visualization of the angle structures. The laser produces a beam at 660 nm, set at 200 μm spot size, 10 μsec duration and 200 to 400 mJ energy level. In order to get the most effects from the beam at that wavelength, the site of sclerostomy must be dyed with methylene blue dye with an iontophoresis marker.14 The

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beam is then directed to the blue patch that is visible in the gonioscopic lens. Shots are given repetitively until the whole sclera has been drilled and the anterior chamber shallows and the conjunctival bleb develops.8 The invasive ab-interno sclerostomy consists of introducing an endolaser probe in the anterior chamber to deliver laser beam directly to the trabecular meshwork.11 The main advantage consists of leaving the conjunctiva untouched avoiding scar formation. Disadvantages of this technique are those related to any intraocular approach; the infectious risks, trauma to the endothelium, the iris structures and the lens. Thermal damages due to accumulation of heat at the impact site are also related to this technique. To introduce the endolaser probe, a paracentesis is performed on the cornea and the anterior chamber is filled with a viscoelastic agent. The fiberoptic probe is introduced and the tip is brought into perpendicular contact with the corneoscleral tissue, taking care to avoid the posterior trabecular meshwork. Laser beam is actuated and tissue ablation begins. The probe is moved forward as ablation removes tissue leaving space for further ablation. The end of the procedure is determined when the tip is seen through the conjunctiva, and the aqueous humor and viscoelastic agent flow into the bleb.1 The ab-externo sclerostomy consists in creating a channel through the sclera to the anterior chamber.12,13 A contact probe is placed at the limbus to guide the laser beam. The conjunctiva is cut 15 mm away from the intended treatment site to allow the probe to be placed correctly thus allowing an adequate contact with the sclera. A holmium:YAG laser is used to produce the energy required to ablate the tissue. The energy level is set at 100 mJ/pulse. The beam is applied to the sclera and can be seen through the cornea into the anterior chamber. Progression of creation of the channel can therefore be

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monitored until completion. At that stage, aqueous humor flows through the fistula into the subconjunctival space.10 After removal of the probe, the conjunctival incision is closed with a single suture and topical antiinflammatory medication given.2,5,6,9 REFERENCES Laser Principle and Introduction 1.

Birngruber R. Thermal modeling in biological tissues. In Hillenkamp F, Praetesi R, Sacchi CA (Eds): Laser in Biology and Medicine Plenum: New York, 1980. 2. Dietlein TS, Jacobi PC, Krieglstein GK. Ab-interno infrared laser trabecular ablation: Preliminary short-term results in patients with open-angle glaucoma. Graef’s Arch Clin Exp Ophthalmol 1997;235(6):349-53. 3. Dietlein TS, Jacobi PC, Krieglstein GK. Erbium: YAG laser trabecular ablation (LTA) in the surgical treatment of glaucoma. Lasers Surg Med 1998;23(2):104-10. 4. Hillenkamp F. Interaction between laser radiation and biological systems. In Hillenkamp F, Praetesi R, Sacchi CA (Eds): Laser in Biology and Medicine. Plenum: New York, 1980. 5. L’Esperance FA Jr. Ophthalmic Laser: Photocoagulation, Photoradiation and Surgery (3rd edn): Mosby: St. Louis 1989. 6. Loertscher H, Shi WQ, Grundfest WS. Tissue ablation through water with erbium: YAG lasers. IEEE Trans Biomed Eng 1992;39:86-88. 7. Mainster MA, Sliney DH, Blecher CD, et al. Laser photodisruptors: Damage mechanisms, instrument design and safety. Ophthalmology 1983;90:973-91. 8. Mainster MA, Ho PC, Mainster KJ. Argon and krypton laser photocoagulators. Ophthalmology 1983;90: 48-54. 9. Ready JF. Industrial applications of lasers. Academic Press: New York, 1978.

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Anderson DR, Forster RK, Lewis ML. Laser iridotomy for aphakic pupillary block. Arch Ophthalmol 1975;93:343-46. 2. Breingan PJ, Esaki K, Ishikawa H, et al. Iridolenticular contact decreases following laser iridotomy for pigment dispersion syndrome. Arch Ophthalmol 1999;117(3):32528. 3. Brooks AMV, Harper CA, Gillies W. Occurrence of malignant glaucoma after iridotomy. Br J Ophthalmol 1989;73:617-20. 4. Carassa RG, Bettin P, Fiori M, et al. Nd:YAG laser iridotomy in pigment dispersion syndrome: An ultrasound biomicroscopic study. Br J Ophthalmol 1998;82(2):150-53. 5. Fleck BW, Wright E, Fairley EA. A randomised prospective comparison of operative peripheral iridectomy and Nd:YAG laser iridotomy treatment of acute angle closure glaucoma: 3-year-visual acuity and intraocular pressure control outcome. Br J Ophthalmol 1997;81(10):884-88.

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Pavlin CJ, Foster FS. Plateau iris syndrome: Changes in angle opening associated with dark, light, and pilocarpine administration. Am J Ophthalmol 1999;128(3):288-91. Pavlin CJ, Macken P, Trope GE, et al. Accommodation and iridotomy in the pigment dispersion syndrome. Ophthalmic Surg Lasers 1996;27(2):113-20. Pesando PM, Ghiringhello MP, Tagliavacche P. Posterior chamber collamer phakic intraocular lens for myopia and hyperopia. J Refract Surg 1999;15(4):415-23. Pollack IP. Use of argon laser energy to produce iridotomies. Ophthalmic Surg 1980;11:506-15. Potash SD, et al. Ultrasound biomicroscopy in pigment dispersion syndrome. Ophthalmology 1994;101:332-39. Power WJ, Collum LMT. Electron microscopic appearances of human corneal endothelium following Nd:YAG laser iridotomy. Ophthalmic Surg 1992;23:347-50. Quigley HA. Long-term follow-up of laser iridotomy. Ophthalmology 1981;88:218-24. Ritch R, Podos SM. Argon laser treatment of angle-closure glaucoma. Perspect Ophthalmol 1980;4:129-34. Ritch R, Solomon IS. Glaucoma surgery. In L’Esperance FA (Ed): Ophthalmic Lasers (3rd edn): Mosby: St Louis, 1989. Robin AL. Intraocular pressure rise after iridotomy (letter). Arch Ophthalmol 1986;104:1117. Robin AL, Pollack IP, DeFaller JM. Effects of topical ALO 2145 (p-aminoclonidine hydrochloride) on intraocular pressure rise following argon laser iridotomy. Arch Ophthalmol 1987;105:1208-11. Rubin L, Arnett J, Ritch R. Delayed hyphema after argon laser iridectomy. Ophthalmic Surg 1984;15:852-53. Samples J, et al. Pupillary block with posterior chamber intraocular lenses. Am J Ophthalmol 1987;105:335-37. Schwartz LW, et al. Argon laser iridotomy in the treatment of patients with primary angle-closure or pupillary block glaucoma: A clinicopathologic study. Ophthalmology 1978;85:294-309.

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Wollensak G, Eberwein P, Funk J. Perforation rosette of the lens after Nd:YAG laser iridotomy. Am J Ophthalmol 1997;123(4):555-57. Zadok D, Chayet A. Lens opacity after neodymium: YAG laser iridectomy for phakic intraocular lens implantation. J Cataract Refract Surg 1999;25(4):592-93. Zaldivar R, Davidorf JM, Oscherow S. Posterior chamber phakic intraocular lens for myopia of ~8 to ~19 diopters. J Refract Surg 1998;14(3):294-305.

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Barnebey HS, et al. The efficacy of brimonidine in decreasing elevation in intraocular pressure after laser trabeculoplasty. Ophthalmol 1993;100:1083-88. Barnes SD, Campagna JA, Dirks MS, et al. Control of intraocular pressure elevations after argon laser trabeculoplasty: comparison of brimonidine 0.2 percent to apraclonidine 1.0 percent. Ophthalmology 1999;106(10): 2033-37. Bergea B, Bodin L, Svedbergh B. Primary argon laser trabeculoplasty vs pilocarpine. IV Long-term effects on optic nerve head. Acta Ophthalmol Scand 1995;73(3):21621. Brown RH, et al. ALO 2145 reduces the IOP elevation after anterior segment surgery. Ophthalmol 1988;95:378-84. Brubaker RF. Liesegang TJ. Effect on trabecular photocoagulation on the aqueous humor dynamics of the human eye. Am J Ophthalmol 1983;96:139-47. Chen TC, Wilensky JT, Viana MA. Long-term follow-up of initially successful trabeculectomy. Ophthalmology 1997;104(7):1120-25. Damji KF, et al. Selective laser trabeculoplasty vs argon laser trabeculoplasty: A prospective randomised clinical trial. Br J Ophthalmol 1999;83(6):718-22. Gaasterland D, Kupfer C. Experimental glaucoma in rhesus monkey. IOVS 1974;13:455-57.

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Guzey M, et al. Effects of frequency-doubled Nd:YAG laser trabeculoplasty on diurnal intraocular pressure variations in primary open-angle glaucoma. Ophthalmologica. 1999;213(4):214-18. Jacobi PC, Dietlein TS, Krieglstein GK. Primary trabeculectomy in young adults: Long-term clinical results and factors influencing the outcome. Ophthalmic Surg Lasers 1999;30(8):637-46. Jampel HD. Initial treatment for open-angle glaucomamedical, laser, or surgical? Laser trabeculoplasty is the treatment of choice for chronic open-angle glaucoma. Arch Ophthalmol 1998;116(2): 240-41. Koller T, Sturmer J, Reme C, et al. Membrane formation in the chamber angle after failure of argon laser trabeculoplasty: Analysis of risk factors. Br J Ophthalmol 2000;84(1):48-53. Lustgarten J, et al. Laser trabeculoplasty: A prospective study of treatment parameters. Arch Ophthalmol 1984;102:517-19. Mermoud A, Herbort CP, Schnyder CC, et al. Comparison of the effects of trabeculoplasty using the Nd-YAG laser and the argon laser. Klin Monatsbl Augenheilkd 1992; 200(5):404-06. Mermoud A, Pittet N, Herbort CP. Inflammation patterns after laser trabeculoplasty measured with the laser flare meter. Arch Ophthalmol 1992;110:368-70. Odberg T, Sandvik L. The medium and long-term efficacy of primary argon laser trabeculoplasty in avoiding topical medication in open angle glaucoma. Acta Ophthalmol Scand 1999;77(2):176-81. Robin AL. Argon laser trabeculoplasty medical therapy to prevent the intraocular pressure rise associated with argon laser trabeculoplasty. Ophthalmic Surg 1991;22:31-37. Shingelton BJ, et al. Long-term efficacy of argon laser trabeculoplasty. Ophthalmol 1987;94:1513-19.

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Schwartz AL, Love DC, Schwartz MA. Long-term followup of argon laser trabeculoplasty for uncontrolled openangle glaucoma. Arch Ophthalmol 1985;103:1482-84. Schwartz LW, et al. Variation of techniques on the results of argon laser trabeculoplasty. Ophthalmol 1983;90:78184. The Advanced Glaucoma Intervention Study (AGIS): 4. Comparison of treatment outcomes within race. Sevenyear-results. Ophthalmology 1998;105(7):1146-64. Ticho U, Nesher R. Laser trabeculoplasty in glaucoma. Tenyear-evaluation. Arch Ophthalmol 1989;107(6):844-46. Traverso CE, Greenidge KC, Spaeth GL. Formation of peripheral anterior synechiae following argon laser trabeculoplasty: A prospective study to determine relationship to position of laser burns. Arch Ophthalmol 1984;102:861-63. Varma R. Trabeculoplasty, trabeculectomy, and race: Is there a difference in response to treatment between blacks and whites? Ophthalmology 1998;105(7):1135-36. Weinreb RN, et al. Immediate intraocular pressure response to argon laser trabeculoplasty. Am J Ophthalmol 1983;95:279-86. Weinreb RN, et al. Influence of the number of laser burns administered on the early results of argon laser trabeculoplasty. Am J Ophthalmol 1983;95:287-92. Wickham MG, Worthen DM, Binder PS. Physiologic effects of laser trabeculectomy in rhesus monkey eyes. IOVS 1977;16:624-28. Wilensky JT, Jampol L. Laser therapy for open-angle glaucoma. Ophthalmol 1981;88:213-17. Wise JB. Ten-year-results of laser trabeculoplasty. Does the laser avoid glaucoma surgery or merely defer it? Eye 1987;1(Pt 1):45-50. Wise JB, Witter SL. Argon laser therapy for open-angle glaucoma: A pilot study. Arch Ophthalmol 1979;97:31922. Wise JB. Status of laser treatment of open-angle glaucoma. Ann Ophthalmol 1981;13:149-50.

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Laser Peripheral Iridoplasty 1. 2.

3. 4.

5.

6. 7. 8. 9. 10. 11.

Fourman S. “Malignant” glaucoma post laser iridotomy. Ophthalmology 1992;99(12):1751-52. Karjalainen K, Laatikainen L, Raitta C. Bilateral nonrhegmatogenous retinal detachment following neodymium-YAG laser iridotomies. Arch Ophthalmol 1986;104:1134. Karmon G, Savir H. Retinal damage after argon laser iridotomy. Am J Ophthalmol 1986;101:554-60. Lai JS, Tham CC, Lam DS. Limited argon laser peripheral iridoplasty as immediate treatment for an acute attack of primary angle closure glaucoma: A preliminary study. Eye 1999;13(Pt 1):26-30. Lam DS, Lai JS, Tham CC. Immediate argon laser peripheral iridoplasty as treatment for acute attack of primary angle-closure glaucoma: A preliminary study. Ophthalmology 1998;105(12):2231-36. Ritch R, Liebmann JM. Argon laser peripheral iridoplasty. Ophthalmic Surg Lasers 1996;27(4):289-300. Ritch R. Plateau iris is caused by abnormal positioned ciliary processes. J Glaucoma 1992;1:23-27. Sassani JW, et al. Histopathology of argon laser peripheral iridoplasty. Ophthalmic Surg 1993;24:740-45. Shapiro A, Tso MO, Goldberg MF. Argon laser-induced cataract. Arch Ophthalmol 1984;102:579-83. Verma N, Fromberg G. Combined argon laser iridoplasty and trabeculoplasty in the management of open angle glaucomas. Indian J Ophthalmol 1986;34:221-23. York K, Ritch R, Szmyd LJ. Argon laser peripheral iridoplasty: Indications, techniques and results. IOVS 1984;25(Suppl): 94.

Cyclocoagulation with YAG and Diode Laser 1.

Albaugh CH, Dunphy EB. Cyclodiathermy. Arch Ophthalmol 1942;27:543.

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Azuara-Blanco A, Dua HS. Malignant glaucoma after diode laser cyclophotocoagulation. Am J Ophthalmol 1999;127(4): 467-69. Bietti G. Surgical intervention on the ciliary body: New trends for the relief of glaucoma. JAMA 1950;142:889. Bloom PA, Tsai JC, Sharma K, et al. “Cyclodiode”. Transscleral diode laser cyclophotocoagulation in the treatment of advanced refractory glaucoma. Ophthalmology 1997; 104(9):1508-19. Brindley G, Shields MB. Value and limitation of cyclocryotherapy. Graefe’s Arch Clin Exp Ophthalmol 1986;224: 545-48. Chen J, Cohn RA, Lin SC, et al. Endoscopic photocoagulation of the ciliary body for treatment of refractory glaucomas. Am J Ophthalmol 1997;124(6):787-96. Detry-Morel M, Gilon B. Treatment of refractory glaucoma with trans-scleral cyclophotocoagulation using a diode laser. Bull Soc Belge Ophthalmol 1999;272: 45-52. Hennis HL, Stewart WC. Transcleral cyclophotocoagulation using a semiconductor diode laser in cadaver eyes. Ophthalmic Surg 1991;22:274-78. Kida K, et al. Non-contact transscleral semi-conductor diode laser cyclophotocoagulation for refractory glaucoma. IOVS 1992;33 (Suppl): 1267. Linsen MC, Mannes C, Zeyen T. Diode laser cyclophotocoagulation in refractory glaucoma. Bull Soc Belge Ophthalmol 1998;270:69-73. Mora JS, et al. Endoscopic diode laser cyclophotocoagulation with a limbal approach. Ophthalmic Surg Lasers 1997;28(2):118-23. Nassise MP, et al. Inflammatory effects of continuous-wave Nd:YAG laser cyclocoagulation. IOVS 1992;33:2216. Oguri A, Takahashi E, Tomita G, et al. Trans-scleral cyclophotocoagulation with the diode laser for neovascular glaucoma. Ophthalmic Surg Lasers 1998;29(9):722-27. Plager DA. et al. Intermediate-term results of endoscopic diode laser cyclophotocoagulation for pediatric glaucoma. J AAPOS 1999;3(3):131-37.

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Schlote T, Kreutzer B, Kriegerowski M, et al. Diode laser cyclophotocoagulation in treatment of therapy refractory glaucoma. Klin Monatsbl Augenheilkd 1997;211(4):250-56. Schubert HD, Agarwal A. Quantitative CW Nd:YAG pars plana trans-scleral photocoagulation in postmortem eyes. Ophthalmic Surg 1990;21:835-39. Schuman JS, et al. Energy levels and probe placement in contact trans-scleral semiconductor diode laser cyclophotocoagulation in human cadaver eyes. Arch Ophthalmol 1991;109:1534-38. Stocker FW. Response of chronic simple glaucoma to treatment with cyclodiathermy puncture. Arch Ophthalmol 1945;34:181. Vogt A Versuche zur intraokularen Druckherabsetzung mittels Diathermieschadigung des corpus ciliare (Zyklodiatermiestichelung) Klin Monatsbl Augenheilkd 1936;97:672. Weekers R, et al. Effects of photocoagulation of ciliary body upon ocular tension. Am J Ophthalmol 1961;52:156. Weve H. Die Zyklodiatermie das corpus ciliare bei Glaukom Zentralbl Ophthalmol 1933;29:256. Wong EY, Chew PT, Chee CK, et al. Diode laser contact trans-scleral cyclophotocoagulation for refractory glaucoma in Asian patients. Am J Ophthalmol 1997;124(6): 797-804.

Laser Treatments After Filtering Surgery 1.

Bardak Y, Cuypers MH, Tilanus MA, et al. Ocular hypotony after laser suture lysis following trabeculectomy with mitomycin C. Int Ophthalmol 1997-98;21(6):325-30. 2. Bettin P, Carassa RG, Fiori M, et al. Treatment of hyperfiltering blebs with Nd:YAG laser-induced subconjunctival bleeding. J Glaucoma 1999;8(6):380-83. 3. Chopra H, et al. Early postoperative titration of bleb function: Argon laser lysis and removable sutures in trabeculectomy. J Glaucoma 1992;1:54.

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Hoskins HD Jr, Migliazzo C. Management of failing filtering blebs with the argon laser. Ophthalmic Surg 1984;15:731. Karlen ME, Sanchez E, Schnyder CC, et al. Deep sclerectomy with collagen implant: Medium term results. Br J Ophthalmol 1999;83(1):6-11. Lanzl IM, Katz LJ, Shindler RL, et al. Surgical management of the symptomatic overhanging filtering bleb. J Glaucoma 1999;8(4):247-49. Lieberman MF. Suture lysis by laser and goniolens. Am J Ophthalmol 1983;95:257. Liebmann J, Ritch R. Intraocular suture ligature to reduce hypotony following Molteno seton implantation. Ophthalmic Surg 1992;23:51. Macken P, Buys Y, Trope GE. Glaucoma laser suture lysis. Br J Ophthalmol 1996;80(5):398-401. Mermoud A, Karlen ME, Schnyder CC, et al. Nd:YAG goniopuncture after deep sclerectomy with collagen implant. Ophthalmic Surg Lasers 1999;30(2):120-25. Ritch R, Potash SD, Liebmann JM. A new lens for argon laser suture lysis. Ophthalmic Surg 1994;25:126. Singh K, Eid TE, Katz LJ, et al. Evaluation of Nd:YAG laser membranectomy in blocked tubes after glaucoma tubeshunt surgery. Am J Ophthalmol 1997;124(6):781-86. Stegmann R, Pienaar A, Miller D. Viscocanalostomy for open-angle glaucoma in black African patients. J Cataract Refract Surg 1999;25(3):316-22.

Sclerostomies 1. 2. 3.

Berlin MS, Rajacich G, Duffy M, et al. Excimer laser photoablation in glaucoma filtering surgery. Am J Ophthalmol 1984;103:713-14. Friedman DS, Katz LJ, Augsburger JJ, et al. Holmium laser sclerostomy in glaucomatous eyes with prior surgery: 24month results. Ophthalmic Surg Lasers 1998;29(1):17-22. Haring G, Behrendt S, Wetzel W. Evaluation of laser sclerostomy fistulas using ultrasound biomicroscopy. Int Ophthalmol 1997-98;21(5):261-64.

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Iwach AG, Hoskins HD Jr. Laser sclerostomy for the management of glaucoma. Curr Opin Ophthalmol 1993;4(2):85-92. Iwach AG, Hoskins HD Jr, Drake MV, et al. Subconjunctival THC:YAG (“Holmium”) laser thermal sclerostomy abexterno. A one year report. Ophthalmol 1993;100:356-65. Jacobi PC, Dietlein TS, Krieglstein GK. Prospective study of ab externo erbium: YAG laser sclerostomy in humans. Am J Ophthalmol 1997;123(4):478-86. Kendrick R, Kollarits CR, Khan N. The results of ab-interno laser thermal sclerostomy combined with cataract surgery versus trabeculectomy combined with cataract surgery 6 to 12 months postoperatively. Ophthalmic Surg Lasers 1996;27(7):583-86. Latina MA, Melamed S, March WF, et al. Gonioscopic abinterno laser sclerostomy: A pilot study in glaucoma patients. Ophthalmol 1992;99:1736-44. Luntz MH, Fliegler RD, Mastrobattista J. Subconjunctival THC:YAG laser sclerostomy under a partial thickness flap. Eur J Ophthalmol 1996;6(3):268-72. Mannino G, et al. Ultrasound biomicroscopy in the clinical evaluation of ab-externo holmium: YAG laser sclerostomies. Ophthalmic Surg Lasers 1998;29(2):157-61. Melamed S, Neumann D. Internal sclerostomy with laser: A new approach to glaucoma surgery. Lasers Surg Med 1991;11(5):440-44. Onda E, Ando H, Jikihara S, et al. Holmium YAG laser sclerostomy ab-externo for refractory glaucoma. Int Ophthalmol 1996-97;20(6):309-14. Spiegel D, Wetzel W, Birngruber R. Ab-externo erbium YAG laser sclerostomy versus conventional trabeculectomy. Treatment of glaucoma patients. Ophthalmologe 1998;95(8):537-41. Wang Y, Cohen RE, Schuman JS. Iontophoresis of indocyanine green and monastral blue B for gonioscopic diode laser sclerectomy. Ophthalmic Surg Lasers 1996; 27(6):484-87.

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NEODYMIUM YAG LASER IRIDOLENTICULAR SYNECHIOLYSIS Presence of a bound down pupil in patients of granulomatous uveitis is a well known phenomenon. This can lead to an obstruction to aqueous and secondary glaucoma. A sizeable percentage, especially from the poorer socioeconomic strata where medical attention is neither sought nor easily available tends to have the bound down pupil or ring synechiae with the pupil bound down in the miosed position. Most of these cases also have a complicated cataract in the posterior subcapsular area resulting in a profound visual loss. Many authors have reported using the argon laser photomydriasis in such cases but Nd:YAG laser has seldom been used for sectioning of iridolenticular adhesions are very few (Fig. 6.1).

Fig. 6.1: Bound down pupil with iridolenticular adhesions

Miscellaneous Laser Applications

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Pre-laser Workup All patients are initially given a trial of pupillary dilatation by 2 percent homatropine and 10 percent phenylephrine eye drops (rule out hypertension) after which additional dilatation is tried by tropicamide 1 percent eye drops. One percent Atropine eye ointment is used in twice daily dosage on a long-term basis in these patients. Informed consent must be obtained. Technique of Laser Therapy They are seated on a Q-switched Nd:YAG laser machine and an Abraham type of iridotomy lens is used. The synechiae are cut by 1mJ of power by focusing the laser towards the iris rather than the lens surface starting in the inferior quadrant so that the debris and hemorrhage are not dispersed in the anterior chamber, impeding further laser. If excess debris and hemorrhage are dispersed in the anterior chamber then the next sitting is tried after 30 minutes and if again visualization is inadequate then the procedure is carried out after 48 hours. Postoperatively IOP is recorded hourly for 4 hours, then at 12 hours and thereafter daily till 7 days. It is also recorded subsequently whenever patient visits the outpatient department. Dilatation is tried by putting 2 percent homatropine and 10 percent phenylephrine drops starting immediately after laser at every 5 minutes for 30 minutes (Fig. 6.2). Patients are continued on antiglaucoma medications of 0.25 percent timolol maleate BD along with 1 percent tropicamide eye drops four times daily for 2 weeks. Postoperatively pupillary diameter, change in visual acuity along with any lenticular damage is recorded.

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Fig. 6.2: Dilatation of pupil after YAG laser synechiolysis

Clinical Results A study was conducted at Dr RP Centre for Ophthalmic Sciences, New Delhi (unpublished data) to evaluate the above technique. Fifteen patients of chronic granulomatous uveitis with bound down pupil or presence of ring synechiae where dilatation was not possible by pharmacological means were chosen for the study. Shallow anterior chamber, hazy cornea, active anterior uveitis and secondary glaucoma formed the contraindications to such a laser therapy. Each patient also has an associated complicated cataract in the posterior subcapsular zone with pigment dispersal on lens and cornea contributing to the visual loss. Each patient had a full work up and was under constant medical supervision at our uvea clinic. Every patient was given a choice of surgery or laser but all the

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first 15 cases opted for an initial laser procedure after having been explained the possible complications and risks involved with such a procedure. The mean age of 15 patients was 31.80 ± 9.52 years. The mean pre-laser IOP was 22.61 mm Hg while the average post-laser IOP was 17.33 ± 3.59 mm Hg at 4 weeks followup. The average pre-laser pupillary size was 3.6 ± 1.0 mm while the average post-laser pupillary size was 5.06 ± 1.50 mm (p 22 mmHg, (2) Preoperative IOP • 22 mmHg. KaplanMeier survival curves were calculated. Success criterion was 20 percent decrease of IOP in combinaton with IOP • 21 mmHg and postoperative IOP-lowering medication • preoperative IOP-lowering medication. Follow-up time was 1 year. For group a) ELT, 1. Preoperative IOP > 22 mmHg, 2. Preoperative IOP • 22 mmHg: Kaplan-Meier survival curves showed a success rate of 57 percent in subgroup 1 and of 41 percent in subgroup 2 (Figs 7.7 and 7.8) For group b) Combined cataract and ELT procedure, 1. Preoperative IOP > 22 mmHg, 2. Preoperative IOP • 22 mmHg: Success rate was 91 percent in subgroup 1 and 52 percent in subgroup 2 (Figs 7.9 and 7.10). Side effects of the ELT were rare: In two cases, an iris adhesion at the tunnel occurred, in 3 cases there was a fibroid reaction that responded very well to topical steroids. One patient developed an occlusion of the central retinal vein 5 months after surgery. IOP however was wellcontrolled at that time, indicating that there was no connection between the CRVO and the ELT procedure. Our data indicate that ELT is not only a safe and efficient IOP-lowering procedure, but also that it is most effective

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Fig. 7.7: ELT: Kaplan-Meier-survival curve, preoperative IOP > 22 mmHg

Fig. 7.8: ELT: Kaplan-Meier-survival curve, preoperative IOP • 22 mmHg

Trabecular Meshwork Ablation

Fig. 7.9: ELT+Phako: Kaplan-Meier-survival curve, preoperative > 22 mmHg

Fig. 7.10: ELT+Phako: Kaplan-Meier-survival curve, preoperative • 22 mmHg

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in patients with a high preoperative IOP. The 2-year-followup data are now available for many patients, and it seems obvious that the IOP-lowering effect of ELT is conserved also after this longer period of time. We have a prospective multicenter study ongoing in this field and are looking forward to its result. Due to its sufficient IOP-lowering effect and the minimal invasiveness of the procedure, ELT has become the therapy of choice for patients who suffer from cataract and glaucoma. We recommend the combined procedure in all cataract patients with an IOP of more than 22 mmHg without therapy. ELT as a stand-alone procedure is performed in patients whose IOP is above 22 mmHg despite maximally tolerated therapy. In patients with low preoperative IOP, such as patients with normal-tension glaucoma, ELT has proven to be less powerful. We assume that in such cases, the episcleral venous pressure limits the chances of success and prefer a trabeculectomy instead. CONCLUSION Excimer-Laser-Trabeculotomy is a promising IOPlowering technique both as a stand-alone procedure and in combination with cataract surgery. It is especially suitable for patients with high preoperative IOP levels and can easily be combined with cataract surgery. REFERENCES 1.

2.

Quigley HA. Proportion of those with open-angle glaucoma who become blind. Number of people with glaucoma worldwide. Ophthalmology 1999;106(11):203941. Quigley HA. Number of people with glaucoma worldwide. Br J Ophthalmol 1996;80(5):389-93.

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Kass MA, Heuer DK, Higginbotham EJ, Johnson CA, Keltner JL, Miller JP, et al. The Ocular Hypertension Treatment Study: A randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol 2002;120(6):701-13; discussion 829-30. Miglior S, Zeyen T, Pfeiffer N, Cunha-Vaz J, Torri V, Adamsons I. Results of the European Glaucoma Prevention Study. Ophthalmology 2005;112(3):366-75. Feiner L, Piltz-Seymour JR. Collaborative Initial Glaucoma Treatment Study: A summary of results to date. Curr Opin Ophthalmol 2003;14(2):106-11. Heijl A, Leske MC, Bengtsson B, Hyman L, Hussein M. Reduction of intraocular pressure and glaucoma progression: Results from the Early Manifest Glaucoma Trial. Arch Ophthalmol 2002;120(10):1268-79. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration.The AGIS Investigators. Am J Ophthalmol 2000;130(4):429-40. Comparison of glaucomatous progression between untreated patients with normal-tension glaucoma and patients with therapeutically reduced intraocular pressures. Collaborative Normal-Tension Glaucoma Study Group. Am J Ophthalmol 1998;126(4):487-97. Friedman DS, Nordstrom B, Mozaffari E, Quigley HA. Glaucoma Management among Individuals Enrolled in a Single Comprehensive Insurance Plan. Ophthalmology 2005. Vogel M, Lauritzen K, Quentin CD. Punktuelle Ablation des Trabekelwerks mit dem Excimer-Laser beim primären Offenwinkelglaukom. Ophthalmologe 1996;93(5):565-68. Funk J, Schlunck G. Endoskopisch kontrollierte ErbiumYAG-Laser-Goniotomie. Erste präklinische Versuche. Ophthalmologe 1998;95(1):33-36. Funk J, Feltgen N, Asbeck D. Augendrucksenkung durch endoskopisch kontrollierte Erbium: YAG-Goniotomie. Ophthalmologe 2000;97(7):473-77.

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Feltgen N, Mueller H, Ott B, Frenz M, Funk J. Combined endoscopic erbium:YAG laser goniopuncture and cataract surgery. J Cataract Refract Surg 2003;29(11):2155-62. Feltgen N, Mueller H, Ott B, Frenz M, Funk J. Endoscopically controlled erbium:YAG goniopuncture versus trabeculectomy: Effect on intraocular pressure in combination with cataract surgery. Graefes Arch Clin Exp Ophthalmol 2003;241(2):94-100. Philippin H, Wilmsmeyer S, Feltgen N, Ness T, Funk J. Combined cataract and glaucoma surgery: Endoscopecontrolled erbium:YAG-laser goniotomy versus trabeculectomy. Graefes Arch Clin Exp Ophthalmol 2005. Walker R, Specht H. Theoretical and physical aspects of excimer laser trabeculotomy (ELT) ab-interno with the AIDA laser operating at 308 nm. Biomedizinische Technik 2002;47(5):106-10. Berlin MS. Perspectives on new laser techniques in managing glaucoma. Ophthalmology Clinics of North America 1995;8(2):341-63. Berlin MS. We need a trabecular meshwork procedure that works. American Glaucoma Society Annual Meeting, San Jose 2002. Berlin MS. ELT Eximer Laser Trabeculostomy: Update 2003. ASCRS 2003. Berlin MS, Funk J, Pache M, Wilmsmeyer S, Giers U, Kleineberg L, et al. Excimer Laser Trabeculostomy. A new, minimally invasive surgical procedure for the treatment of open-angle glaucoma. Glaucoma Today 2004;2-6.

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INTRODUCTION The ongoing devote on recent developments in glaucoma surgery reflects that an ideal solution is not available which would promise long-term IOP reduction and eliminate the necessity of supplementary pressurereducing medication at low complication rates. Trabeculectomy, first described in the sixties, 3,9,30 is probably the most widespread approach in glaucoma surgery presently. The intention of trabeculectomy is to bypass the resistance of trabecular meshwork by channelling aqueous humor directly to the Schlemm’s canal. In literature the success rate of trabeculectomy ranges between 32-96 percent.1,4,9,12,14,16-18,21-23,30,32-35 On the other hand, postoperative complications like hypotony and choroidal detachment are reported up to 24 percent.6 Variation of success rates may be explained by different criteria of surgical indications, selection of cases, various diagnoses, the various degrees of surgical experience and variations in postoperative medical treatment. Failure of pressure regulations is associated with the assence of a filtering bleb and depends on the duration of follow-up involved. It has become evident that successful reduction in IOP following trabeculectomy is clearly related to the presence of a filtering bleb.26 The more recent method of non-penetrating deep sclerectomy, was first described by Fjodorov in the eighties.8 This techniques tries to achieves an improved uveoscleral outflow and therefore is not depending on the presence of a filtering bleb. Koslov13 expanded this method by introducing a collagen implant. Literature on nonpenetrating deep sclerectomy indicates a success rate of 58 to 74 percent without collagen implant and 74 to 90 percent with collagen implantation.5,24

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In 1976, Benedikt2 described that the exposure of the ciliary body (i.e. a form of penetrating sclerectomy) was leading to successful long-term IOP regulation in 27 of 38 cases involving hemorrhagic, aphakic and irreversible angle-closure glaucoma after initially failed filtering surgery. This technique was the basis for later development of perforating deep sclerectomy, a method which has been used since 1985 was described previously 20 as “sclerothalamectomy”). Bypassing of the trabecular meshwork is an alternative for aqueous humour outflow from the anterior chamber to the Schlemm canal. It is the principal mechanism for non-penetrating glaucoma surgery, in particular, for deep sclerectomy and viscocanalostomy. These surgical procedures provide effective IOP reduction as well as the elimination of typical filtration bleb complications.7,15,31 So far clinical application of these procedures has been limited by technical difficulties to perform this kind of surgery and a poor predictability of pressure reduction. The concept of trabecular meshwork bypass as a surgical principle for glaucoma treatment evolved from the discovery that pathologic outflow resistance is caused primarily by the juxtacanicular conjunctive tissue of the trabecular meshwork and, in particular, by the inner wall of the Schlemm canal.10,11 A further publication in this area indicates that 35 percent of the outflow resistance arises distally to the inner wall of the Schlemm canal.25 Spiegel et al29 have described a new surgical technique involving the use of an implanted tube, the so-called trabecular meshwork bypass tube shunt, which should provide a direct connection between Schlemm canal and the anterior chamber. This surgical technique avoids technical difficulties of non-penetrating deep sclerectomy, especially the delicate microperforation of the trabecular

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meshwork in order to ensure the permeability of the descemet membrane. Furthermore, these techniques avoid the disadvantages of filtration blebs. All surgical procedures for glaucoma involving the creation of external access may be complicated by the risk of fibroblast proliferation and failure of filtration. The novel procedure published offers a chance to avoid some of the above-mentioned disadvantages. We refer to this technique as sclerothalamotomy ab interno.19 PATIENTS AND METHODS Before beginning the clinical study phase, the tips used for the STT ab interno procedure were developed using a large number of pigs’ eyes. The high-frequency diathermic technique was already very well known in the application for capsulorhexis in cataract surgery. It was important to create a design for optimal application of the STT probe in the iridocorneal angle and to evaluate the characteristic of the achieved deep sclerotomy. By virtue of this results the STT ab interno probe development as describe below. 53 sclerothalamotomies ab interno in 53 patients were carried out in primary open-angle glaucoma between 1 April 2002 and 31 July 2002. Main inclusion criterion into this study was an insufficient response to medical treatment of IOP. Data was documented according to a prospective study protocol. Mean age of patients was 72.3±12.3 years (range: 15-92 years) (Fig. 8.1). 17 patients (32%) were female, 36 patients (68%) male. In 25 cases (47.4%) the right eye in 28 cases (52.6%) the left eye was treated. There was no patient who received bilateral surgery. Snellen visual acuity was 0.7±0.3 (range 0.1 to 1.0) preoperatively. In 5 cases a moderate cataract was observed which didn’t have influence on the visual acuity.

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Fig. 8.1: Mean age

A complete ophthalmologic status check was carried out in each patient prior to surgery including: uncorrected and best corrected visual acuity, IOP applanation tonometry, biomicroscopy of anterior segment, funduscopy (in particular, stereoscopic evaluation of the optic nerve head) and computerized visual field testing (Octopus 101, program G2). Complete ophthalmologic follow-up examinations were carried out postoperatively at day 1, 2, 3 and 4, after 1, 2 and 4 weeks, and 2, 3, 6, 12, 15, 18, 21, 24, 27, 30, 33 and 36 months. In a pilot study with at least of 24 months follow-up, 5 patients with therapy-resistant juvenile glaucoma were treated.

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HIGH-FREQUENCY DIATHERMIC PROBE The high-frequency diathermic probe consists of an inner platinum electrode which is isolated from the outer coaxial electrode. The platinum probe tip is 1 mm in length, 0.3 mm high and 0.6 mm width and is bent posteriorly at an angle of 15° (Figs 8.2A and B). The external diameter of

Figs 8.2A and B: STT Glaucoma Tip (Oertli Reference VE 201750)

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the probe measures 0.9 mm. Modulated 500 kHz current generates a temperature of approximate 130°C at the tip of the probe. The set-up provides high frequency power dissipation in close vicinity of the tip. As a result, heating of tissue is locally very limited and is applied as a rotationed ellipsoid. SURGICAL PROCEDURE A clear cornea incision (1.2 mm wide) was placed in the temporal upper quadrant using a diamond knife. A second corneal incision was performed 120° apart from the first followed by injection of Healon GV. The high-frequency diathermic probe (Oertli) was inserted through the temporal corneal insertion (Fig. 8.3). Visual inspection of

Fig. 8.3: Insertion of the high-frequency diathermic probe (Oertli) through the temporal corneal insertion

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the target zone (opposite iridocorneal angle) was observed by a 4-mirror gonioscopic lens (Fig. 8.4). The high frequency tip penetrates up to 1mm nasal into the sclera through the trabecular meshwork and Schlemm canal, forming a deep sclerotomy (i.e. “thalami”) of 0.3 mm high and 0.6 mm width (Figs 8.5 and 8.6). This procedure was repeated 4 times within one quadrant. Healon GV was evacuated from the anterior chamber with bimanual irrigation/aspiration (Fig. 8.7). Tobramycin/Dexamethason eye drops were then applied 3x daily for 1 month and Pilocarpin 2 percent eye drops 3x daily for 10 days. EVALUATION OF THE RESULTS Statistical evaluation of results was calculated with SPSS Program Version 10. Two-tailed Student t-test was used

Fig. 8.4: Visual inspection of the target zone (opposite iridocorneal angle) by a 4-mirror gonioscopic lens

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Fig. 8.5: Penetration of the high frequency tip

Fig. 8.6: Penetration up to 1mm nasal into the sclera through the trabecular meshwork and Schlemm canal

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Fig. 8.7: Healon GV was evacuated from the anterior chamber with bimanual irrigation/aspiration

for statistical evaluation of parametric data. The unit of significance was set at a critical p value of