Davinder S. Grover

Gonioscopy-assisted Transluminal Trabeculotomy (GATT): Thermal Suture Modification With a Dye-stained Rounded Tip.

Purpose:To describe a novel technique for thermally marking the tip of a suture, in preparation for a gonioscopy-assisted transluminal trabeculotomy. Patient:One patient was used as an example for this technique. Methods:Technique report. Results and Conclusions:The authors introduce a modification of a novel surgical procedure (GATT) in which a suture is marked and thermally blunted allowing a proper visualization while performing an ab interno, minimally invasive, circumferential 360-degree suture trabeculotomy. The authors have previously reported on the GATT surgery with the use of an illuminated microcatheter, which allowed for visualization of the tip of the catheter as it circumnavigated Schlemm canal. This modification allows for similar visualization of the tip of the suture, however, is much more cost-effective while still maintaining similar safety.

Treatment of late-onset capsular distension syndrome with a neodymium:YAG laser peripheral iridotomy and anterior capsulotomy.

We describe a new approach to treat late-onset capsular distension syndrome in which the fluid in the capsular bag is cloudy and prevents a posterior neodymium:YAG (Nd:YAG) laser capsulotomy. A peripheral laser iridotomy is created through which the anterior lens capsule peripheral to the IOL optic is accessed. This opening in the iris provides an access point through which an anterior Nd:YAG laser capsulotomy can be performed. Following disruption of the anterior lens capsule, the capsular fluid is released into the anterior chamber and absorbed through the inherent drainage system of the eye. This approach avoids the need for a more invasive surgical intervention.

Micropulse Cyclophotocoagulation: Initial Results in Refractory Glaucoma

Purpose: The purpose of this study is to evaluate the use of micropulse transscleral cyclophotocoagulation (MP-TSCPC), a new and increasingly popular treatment, in patients with uncontrolled glaucoma. Methods: A retrospective chart review was performed for all patients who underwent a MP-TSCPC at the Glaucoma Associates of Texas. Results: A total of 84 eyes were treated with MP-TSCPC in this study with a mean follow-up time of 4.3 months. The mean age of treated patients was 74 years and 48 (57%) were female. Preoperatively, mean intraocular pressure (IOP) was 27.7 mm Hg and mean number of ocular antihypertensive medications used was 3.3. Mean postoperative IOP at months 1, 3, 6, and 12 were lowered to 16.3 mm Hg (41.2% reduction), 14.6, 13.0, and 11.1 mm Hg, respectively. Postoperative ocular antihypertensive medication use was also lowered to 1.9, 2.0, 2.0, and 2.3 medications at months 1, 3, 6, and 12, respectively. Five patients required further laser or surgical intervention for adequate IOP control. Complications included hypotony, IOP spike, hyphema, serous choroidal detachment, persistent inflammation, and vision loss. At 3 months, inflammation was still present in 46% of eyes and vision loss of at least 1 line was present in 41% of eyes. Conclusions: MP-TSCPC is effective at lowering IOP and decreasing the need for ocular antihypertensive medications. Eyes with limited visual potential or at high risk for incisional glaucoma surgery can successfully be treated with MP-TSCPC as a reasonable and effective alternative to traditional CPC. These results present short-term data and both longer follow-up and further studies are necessary.

Outcomes for Ab Interno Bleb Revision With a Novel Translimbal Sclerostomy Spatula

Purpose: To report outcomes for a novel ab interno bleb revision technique and spatula. Patients and Methods: This is a retrospective chart review. Results: A total of 21 eyes of 21 patients underwent ab interno bleb revision with the Grover-Fellman biplanar sclerostomy spatula. Mitomycin C was given at least 1 week preoperation. The mean age of the patients and blebs were 67 and 6.75 years, respectively. The mean follow-up is 10.6 months (range: 3 to 17 mo). Mean preoperative intraocular pressure (IOP) (SD) was 21.9 (9.1) mm Hg on 3.7 (1.2) glaucoma medications. At 12 months follow-up, the mean IOP was 12.1 mm Hg on 0.86 medications. Four eyes failed due to uncontrolled IOP needing a tube shunt. One eye failed due to uncontrolled IOP but was lost to follow-up before a tube shunt could be performed. All failures occurred within 3 months. Two eyes had an IOP of <5 mm Hg after 1 month with no evidence of hypotony maculopathy. These cases resolved after 3 months without surgical intervention. All successful cases had blebs that were low, diffuse, and posterior. Conclusions: After a failed filtration surgery, a low-diffuse bleb was reestablished by pretreating with subconjunctival mitomycin C followed by ab interno bleb revision with the Grover-Fellman biplanar sclerostomy spatula, decreasing further more invasive glaucoma procedures.

New Developments in the Surgical Treatment of Glaucoma

Purpose of ReviewIn this review, we aimed to provide, in a structured format, an evidenced based review of the current state of minimally invasive surgical glaucoma management.Recent FindingsNumerous studies, mostly non-comparative, have demonstrated several new, safe, effective, and minimally invasive surgeries for the management of various stages of open-angle glaucomas. These surgeries can either be combined with cataract surgery or performed in isolation of cataract surgery. Most of the newer minimally invasive procedures ensure safety with a mild to moderate intraocular pressure (IOP) lowering effect. Two novel shunts, the InnFocus MicroShunt and XEN45, however, can provide substantial IOP reduction in a relatively safe fashion.SummaryThe future of glaucoma surgery is very bright, and there continue to be several safe, effective, and novel procedures for the management of various types of glaucomas.

Adjustable Dual Muscle Speculum for Simplified Placement of a 350 Baerveldt Implant

The authors have designed a muscle hook speculum that simultaneously allows the surgeon to isolate and expose both rectus muscles (either the superior and temporal or medial and inferior) for ease of placement of a 350-mm Baerveldt implant. This instrument facilitates the exposure and subsequent placement of either a superior-temporal tube or an infero-nasal tube in a more independent manner. By using the dual muscle hook speculum, an individual surgeon, without a glaucoma-trained assistant, can hook typically both the superior and lateral recti muscles while gaining simultaneous exposure of the quadrant. The purpose of this report is to describe the instrument, how it is used, and how it can improve efficiency in the operating room.

Gonioscopy Assisted Transluminal Trabeculotomy (GATT) for the Treatment of Adult and Developmental Glaucomas

Gonioscopy Assisted Transluminal Trabeculotomy (GATT) is a novel technique that allows for the performance of circumferential trabeculotomy via an ab-interno approach. The procedure offers several distinct advantages to traditional glaucoma filtering procedures in the treatment of adult and developmental glaucomas. Importantly, the procedure is performed via clear corneal incisions and therefore spares conjunctival tissue. Important preoperative considerations include the degree of corneal clarity, intraocular lens stability, and gonioscopic view of the anterior chamber angle. The procedure may be performed with either a suture or an illuminated microcatheter. Postoperatively, patients are treated with topical steroidal, nonsteroidal, and antibiotic eyedrops. Intraocular pressure (IOP)-lowering eyedrops may also be used as necessary. In a recent study reporting on results achieved with the GATT procedure, 57 patients with POAG achieved an IOP reduction of 7.7 mmHg [(SD, 6.2 mmHg) or 30.0 % (SD, 22.7 %)] with an average decrease in glaucoma medications of 0.9 (SD, 1.3) at 6 months. The GATT procedure is a minimally invasive, conjunctival sparing surgical technique that improves upon conventional ab externo trabeculotomy in adults and children. Success rates are at least equivalent to previously published studies of ab externo circumferential trabeculotomy.