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Surgeon: nonpenetrating deep sclerectomy successful psychologically, physically
An experienced surgeon maintains that technical progress cannot be separated from more human aspects of the profession.
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SAN BENEDETTO DEL TRONTO, ITALY – Nonpenetrating deep sclerectomy has been a breakthrough in the treatment of open-angle glaucoma. However, its 85% success rate can be improved with the use of antimetabolites, and more ophthalmologists should be encouraged to use it, according to Roberto Sampaolesi, MD, professor emeritus at Buenos Aires University, Argentina.
“It’s a technique that will be developed more and more in the future, because long follow-ups have now demonstrated that its results are as good as those of trabeculectomy, with a success rate of 85%. On the other hand, it is far less traumatic than trabeculectomy,” he said in an interview at the Visiva 2002 meeting here.
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Trabeculectomy, he said, is a type of surgery that patients do not like. With atropine instilled in the eyes for about 7 days, patients are unable to have good postop vision for a long time.
“Before surgery they could see well, but afterwards they are unable to see well for 3 weeks. The psychological effects of this is that they believe that the operation hasn’t gone well at all,” he said.
In case of hyphema, it takes 15 days before the blood settles and vision is restored, he added, and in case of flat anterior chamber the patient has to put up with a lot of discomfort and special medications. Choroidal detachment is the most distressing complication, as the patient cannot see well for 1 to 3 months.
“People become frightened by all these problems, and often don’t want to have the second eye operated on. It takes some effort to convince them they will eventually get better, but in some cases they won’t come back at all,” Prof. Sampaolesi said.
Advantages
Nonpenetrating deep sclerectomy is a completely different matter, Prof. Sampaolesi said. IOP decreases just as well and quickly as in trabeculectomy, but there is less threat of postop complications, no pain, no atropine in the eye after surgery.
“The patient goes home with nothing on the eye, and 2 or 3 days later can watch TV, go to the cinema or read. The postoperative course of deep sclerectomy is absolutely wonderful,” he said.
These are the reasons why, after 50 years of practice in ophthalmic surgery, Prof. Sampaolesi has changed his approach and happily opened the door to the new technique.
“There are still cases in which the disease is at such an advanced stage, and the ocular tissues so badly deteriorated by decades of medications, that trabeculectomy is the only possible answer. But with relatively young patients, when the disease has just begun to affect the optic nerve, the tissues can respond very well to the treatment and deep sclerectomy is the best option,” he said.
Moreover, deep sclerectomy works well in the case of combined procedures.
“Trabeculectomy and cataract surgery have never gone well together, because they aim at creating almost opposite ocular conditions. The day after cataract surgery we want a full and well-formed anterior chamber, while a shallow anterior chamber is good sign of aqueous drainage in trabeculectomy. With deep sclerectomy there is no penetration, and therefore no flattening of the anterior chamber. It’s the first time that two such procedures are so well matched,” he said.
Thanks to the most recent developments in computerized perimetry, such as frequency doubling technology and short-wavelength automated perimetry (SWAP), which permit early detection of visual field defects, surgical treatment with deep sclerectomy can be performed earlier than it used to be.
“We can gain as much as 5 years on the treatment schedule, avoiding long periods of medical therapy. In the future, there will be far fewer cases of visual loss in connection with glaucoma,” he said.
Anatomic knowledge
One reason why there might still be some resistance toward deep sclerectomy is that it is an objectively difficult surgical technique.
“It requires a deep and precise knowledge of the anatomy of the eye, of the kind you gain with years of surgical experience,” Prof. Sampaolesi said. “It wasn’t difficult for me, as I had already carried out more than 500 trabeculotomies (a procedure that is in many ways similar to deep sclerectomy), but for the less experienced surgeon, the first few attempts can be discouraging.”
There is a precise portion of tissue that has to be removed, and a thin membrane, the trabeculo-Descemet’s membrane, that has to be left.
“This membrane is sufficiently strong to prevent the anterior chamber from emptying, and sufficiently weak to allow aqueous filtration and IOP lowering,” he said.
The entire success depends on infinitesimal precision, like in a watch mechanism and the slightest mistake can mean surgical failure.
Give time to preoperative evaluation
Careful patient selection and an accurate preoperative evaluation are also mandatory, Prof. Sampaolesi said.
“You can’t rely on just one daily measurement of IOP, say at 3 o’clock in the afternoon. There are pressure spikes early in the morning that are the main cause of glaucomatous damage, and there is a 24-hour pressure curve for each one of our patients that we should always be aware of,” he said.
If a truly accurate daily curve can only be obtained with hospitalized patients, then there is a method of IOP measurement that should at least be applied in all cases.
“If the patient is seen at 9 o’clock in the morning and laid down on a bed for half an hour, his or her IOP will be the same as in the early morning, at 6:00 a.m., with the patient still in bed,” he explained.
Time and accuracy should also be given to all the other diagnostic examinations.
“Glaucoma is a very complicated disease, and nowadays we are always in a hurry. In our clinic, we spend 4 hours for a complete visit, over a period of several days,” he said.
Postop analysis of the removed tissues should also be performed in all cases, according to Prof. Sampaolesi.
“This also takes time, but it’s the only way we can be sure of what exactly has been removed, and this can be precious information that helps in case of postop complications,” he said.
This procedure is contraindicated in narrow-angle glaucomas.
Training surgeons
In a complicated surgical procedure like deep sclerectomy, with a longer learning curve, surgeons who have less experience should be encouraged by more expert colleagues and should practice side-by-side with them to learn the technique, Prof. Sampaolesi said. He is a surgeon with long experience, has taught many ophthalmologists and is strongly convinced that a good teacher-student relationship is essential in helping to develop a surgeon’s talents.
Prof. Sampaolesi believes the most important thing for those willing to use this technique who at first cannot locate Schlemm’s canal — both young and not so young but surgeons inexperienced in this technology — is to correlate the anatomy of the chamber angle with each surgical time. He believes the schematic representations and photographs of the different surgical steps to be of help to beginners.
“We have learned from surgeons in the United States. In South America, and in Europe, we have a tendency to give our students few opportunities to develop their skills, to practice and take responsibility for what they do,” he said.
“When I went to the United States at the age of about 30 to do some training in a university clinic, I was astonished to see that there were about 20 residents, all of them doing surgery at advanced levels. When I was appointed at a university in Argentina I followed this example, and in 22 years I have had 80 residents. Each one stayed with us for 3 years, and had to do a minimum of 150 surgical operations, trying out all kinds of ocular surgery. These 80 are now among the best specialists in Argentina. In glaucoma surgery, and in deep sclerectomy in particular, they have gone beyond my teachings, innovating the technique and using laser as a supplement to this technique, for example, which I don’t use for the time being.”
Listen to patients
Another important point made by Prof. Sampaolesi concerned the relationship between physician and patient.
“If we want to be successful in our diagnosis and treatment, we must learn (or perhaps learn again) to listen to our patients, not only because they have a right to be listened to, but also because we have a lot to learn from them,” he said. “If we let our patients talk about their problems, after about 15 minutes we almost invariably discover that they have made their own diagnosis. But we must be able to listen to them, write down everything they say in their own words, without translating it into our medical jargon.”
In his long experience with congenital glaucoma, Prof. Sampaolesi found it was often the mother who made the diagnosis before the physician.
“We must be friends with our patients, and this will reciprocally help them and our profession at the same time,” he said. “This again may contrast with today’s philosophy of doing as much as possible in as little time as possible and making as much money as possible. But medicine is not like any other business, and we should have this difference very clear in our hearts and minds.”
For Your Information:
- Roberto Sampaolesi, MD, can be reached at Paranà 1239-1 A, Buenos Aires CF 1018, Argentina; (54) 11-4811-7075; fax: (54) 11-4814-2092.