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Latest deep sclerectomy modifications displaying improved results, safety
The gap between nonpenetrating and penetrating surgery is not as wide as it used to be, surgeon says.
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FLORENCE – Positive long-term results and recent modifications of nonpenetrating glaucoma surgery are making the technique well accepted internationally and more widely used as an alternative to trabeculectomy, according to one surgeon here.
“If at first there was some skepticism due to the relatively less satisfactory IOP levels obtained, the developments that have gradually been introduced in this surgical treatment modality have made its efficacy almost comparable to trabeculectomy. On the other hand, the lower complication rate of nonpenetrating procedures remains an indisputable advantage,” said Roberto Carassa, MD, at the Florence Symposium.
As one of the advocates of nonpenetrating glaucoma surgery, Dr. Carassa said he is proud of the technique, the success of which is now well-documented.
“Small groups of surgeons in Europe, especially in France and Italy, have always believed in the potential of this surgery and have actively contributed to make it grow and spread throughout the world,” he said.
He said that nonpenetrating surgery is undergoing a series of modifications that aim to maintain the safety profile of the technique and, at the same time, improve its capability of achieving long-term IOP control.
“These modifications are crucial in providing a viable alternative to trabeculectomy,” Dr. Carassa said.
Optimizing results
One crucial step of deep sclerectomy is the opening of Schlemm’s canal, which allows the outflow of aqueous. A more recent variation has introduced the stripping of the internal walls of the canal, which improves aqueous drainage and IOP reduction.
“This maneuver has now become part of the standard procedure of most glaucoma surgeons,” according to Dr. Carassa.
The use of an implant with deep sclerectomy has been shown by a number of studies to lower IOP more than deep sclerectomy alone, he added.
“From the results of these studies, we have learned that the use of an implant in deep sclerectomy is no longer an option, but a necessity,” Dr. Carassa said.
The advantages of the implant are not only functional, but also anatomical. Histology shows the presence of less dense fibrotic tissue and larger outflow vessels in the intrascleral lake when an implant is used, he said.
Should IOP rise between months 6 and 8 after surgery, he recommended performing Nd:YAG goniopuncture.
“The procedure is relatively easy and safe and is therefore widely practiced following nonpenetrating procedures. Only pay attention that goniopuncture, by perforating the pre-descemetic membrane created during surgery, might cause a sudden decrease of IOP and iris prolapse,” Dr. Carassa said.
In order to prevent these complications, excessively high IOP should be adequately lowered prior to goniopuncture, and the patient should be warned not to practice digital massage or any pressure on the eyeball following the procedure.
For Your Information:
- Roberto Carassa, MD, can be reached at Ospedale San Raffaele, Via Olgettina 60, 20132 Milano, Italy; +39-02-2643-3591; fax: +39-02-2641-2912; e-mail: carassa@tin.it.
- Michela Cimberle is an OSN Correspondent based in Treviso, Italy.