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‘Atwal's balanced approach’ for glaucoma filtration surgery presented
The procedure combines a microtrabeculectomy with a transciliary filtration approach. Early follow-up is encouraging.
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Since the U.S. Food and Drug Administration approval of the transciliary filtration procedure for glaucoma, interest in its use has been gradually growing.
We started using subconjunctival transciliary filtration (TCF) procedures in December 2004. We soon had to think of modifying the procedure because after 2 to 3 postoperative weeks of excellent IOP control, the failure rate became greater than 30% (five out of 15 procedures). Additional cases were tried using similar fornix-based conjunctival flaps while performing TCF under half-thickness 3-mm by 3-mm scleral flaps. Failure rate after 2 to 3 weeks for these 35 procedures was nearly 40%.
I searched for a better procedure that would be simple, effective and not require daily monitoring and that had a low incidence of failure with minimal risk of complications. I have found that the combination of TCF and microtrabeculectomy (Atwal’s balanced approach), when performed with the Fugo blade (Medisurg Corp.), gives the best results. The technical ease and effectiveness of the Fugo blade to achieve microfiltration (200-µm pore by ablation of tissue — not cutting or cauterizing) is an innovative breakthrough. In my experience, Dr. Singh’s TCF, when combined with microtrabeculectomy (both done with the Fugo blade), increases the success rate of glaucoma filtration surgery tremendously, while eliminating most of the complications.
A combined procedure
From past experiences using the Holmium laser or mini shunt for microtrabeculectomy alone, we know that the incidence of flat or shallow anterior chamber is high. This complication is preventable when microtrabeculectomy is combined with TCF.
This procedure can be performed in phakic or pseudophakic eyes, or in combination with phaco and IOL implantation. Most procedures in our study were performed as combined phaco/IOL/Atwal’s balanced approach procedures.
As a combined procedure, under topical anesthesia, phacoemulsification and IOL implantation is performed through a clear corneal incision at the 10 o’clock position and away from the Atwal’s balanced approach site. All viscoelastic is replaced with balanced salt solution in the anterior and posterior chambers. A 1-cm long, fornix-based conjunctival peritomy is made at the 12 o’clock position after infiltrating 1 mL of xylocaine 2% with epinephrine under Tenon’s capsule; Tenon’s capsule is pushed back while minimally cauterizing before and after a half thickness 3-mm-by-3-mm scleral flap is lifted towards the limbus.
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Using the round Fugo blade tip, an ablation pit is made 1 mm to 2 mm behind the limbus until blue ciliary body is seen. With the sharp Fugo blade tip, the posterior chamber is entered through the pit and the pars plicata. This creates a 200-µm ablation path through which aqueous percolates. At this stage, with the same sharp Fugo tip, a microtrabeculectomy is created anterior to the TCF into the anterior chamber. Aqueous percolates much faster through the microtrabeculectomy site. If needed, the anterior chamber is formed with saline through the cataract incision. The scleral flap is then pushed back into position without sutures. The conjunctival peritomy is sutured back with two 10-0 nylon sutures or just cauterized at either end. The eye is then patched overnight. Postoperative management is no different from a cataract/IOL procedure without Atwal’s balanced approach.
Advantages
I have performed Atwal’s balanced approach in more than 50 eyes with follow-up of 1 to 4 months. In my experience, almost all the complications of traditional trabeculectomy are eliminated, and the success rate is over 98%.
The potential advantages of Atwal’s balanced approach over trabeculectomy are numerous. Atwal’s balanced approach does not cause postop collapse of the anterior chamber. Aqueous flow through TCF behind the iris and through microfiltration at the trabeculectomy site is in perfect balance, especially in early critical postop periods. The advantages are several, including quick visual acuity recovery, prevention of hypotony and choroidal effusion, minimal incidence of hyphema and no need to use antimetabolites.
For Your Information:
- Amarjit Singh Atwal, MD, can be reached at Atwal Eye Care, 3095 Harlem Road, Cheektowaga, NY 14225; 716-896-8831. Dr. Atwal has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.