Endoscopic Goniotomy


Table 2: Change of Pre- to Post-operative values of Intraocular Pressure and Antiglaucoma Medication


∆IOP (mmHg) Percentage p Value ∆AGM Percentage p Value


All -4.41 ± 6.18 -21.99 % p<0.05 -1.02 ± 1.47 -73.91 % p<0.05 SG 1 -1.40 ± 4.58 -8.75 % p<0.05 -1.20 ± 1.47 -48.58 % p<0.05 SG 2 -8.79 ± 5.27 -34.70 % p<0.05 -0.79 ± 1.50 -54.11 % p<0.05


For all study eyes and subgroup (SG) 1 with a pre-operative intraocular pressure (IOP) <22 mmHg and SG 2 with a pre-operative IOP >21 mmHg. AGM = antiglaucoma medication.


the laser tip must make contact with the tissue (see Figure 2). After laser application, a formation of bubbles can be seen together with a small retrograde bleeding. This indicates the perforation of the TM and the inner wall of Schlemm’s canal (see Figure 3). Bleeding stops spontaneously almost immediately. At the end of the surgical procedure, the viscoelastics are removed with aspiration and irrigation and the globe is pressurized to approximately 15 mmHg.


We conducted a preliminary study that included 28 eyes of 28 patients with a pre-operative IOP of over 21 mmHg (mean 25.33 ± 2.85 mmHg). One year after combined phaco-ELT we found a mean IOP reduction of 8.79 ± 5.28 mmHg (-37.70 %, p<0.001). During the same period, the number of antiglaucoma medications could be reduced by an average of 0.79 ± 1.50 per patient (-62.70 %, p=0.017). The complication rate was similar to that of normal cataract surgery and no serious complications occurred. The success rate was 64.3 % (as defined by post-operative IOP < 21 mmHg in addition to IOP reduction of ≥20 % with or without medical therapy and no further glaucoma surgery within the follow-up period).78


A larger study is ongoing. In this study, eyes with IOP less than 22 mmHg are also included. The preliminary results of 73 eyes of 64 patients with a mean age of 76.51 ± 9.36 years after a follow-up period of 12 months post-surgery are shown in Table 2.


Conclusion


A range of surgical options to lower IOP is available. TE with antimetabolites is still the gold standard. The goal of minimizing post-operative complications demands minimally invasive procedures. In the event of a very low target IOP, TE is the treatment of choice. However, it may also be possible to achieve a sufficient reduction in IOP with endoscopic surgical methods. Goniotomy is mostly used in infantile glaucoma, and goniopuncture is an option following deep sclerectomy. Excimer laser trabeculotomy could become more popular in combination with a phacoemulsification in minimally invasive endoscopic surgery, as it causes fewer complications compared to TE. For a selected cohort of glaucoma patients, in particular those with an IOP over 21 mmHg and at least moderate cataract, the combined procedure of ELT and


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US OPHTHALMIC REVIEW Retrograde bleeding TM Laser fiber


Figure 2: Image of the Anterior Chamber Angle before Laser Treatment, as seen through the Endoscopic Optics


Iris The laser fiber is in direct contact with the trabecular meshwork (TM).


Figure 3: Image of the Anterior Chamber Angle immediately after Excimer Laser Trabeculotomy, as seen through the Endoscopic Optics


Laser fiber


Iris


The formation of some bubbles is visible, as is a small retrograde bleed, indicating the perforation of the anterior wall of Schlemm’s canal.


phacoemulsification appears to be a promising approach to avoid (or at least to delay for some years) the onset of TE. n


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