J.F. Jordan

Modern concepts in antiglaucomatous implant surgery

BackgroundAntiglaucomatous implant surgery is a continously evolving field in glaucoma treatment.MethodsA literature search with the terms “glaucoma implant surgery”, “aqueous shunts” and “glaucoma drainage devices” was carried out, especially giving prominence to innovative surgical developments in glaucoma implant surgery and to recently established clinical evidence on traditional shunt surgery.ResultsEpiscleral glaucoma drainage devices have recently proven their efficacy in large studies. Longterm data about their clinical efficacy and their risk/safety profile are sufficiently available. New antiglaucomatous devices try to target alternative drainage routes, for example trabecular or uveoscleral outflow. Valid longterm data from prospective randomized clinical trials are not available for these devices as yet.ConclusionsAlthough valid data on clinical application of the new glaucoma implants are not available as yet, profound knowledge about their theoretical concept and their practical management is obligatory for all glaucoma clinicians.

Trabecular meshwork bypass surgery for glaucoma

ZusammenfassungDie trabekuläre Bypasschirurgie hat zum Ziel, eine direkte chirurgische Verbindung von Vorderkammer mit dem Schlemm-Kanal zu erzielen, um dadurch die Abflussleichtigkeit im Glaukomauge zu verbessern. Neben rein mechanischen Verfahren kann der trabekuläre Bypass mittels Laserverfahren, bipolarem Kauter oder durch Mikroimplantate erzielt werden. Aufgrund des niedrigen Risikoprofils ist ein solches Verfahren insbesondere bei der kombinierten Katarakt-Glaukom-Chirurgie sinnvoll. Als alleiniges Verfahren bei Glaukomaugen, die einen niedrigen Zieldruck brauchen, ist allerdings die Trabekulektomie mit Mitomycin C der trabekulären Bypasschirurgie in der Regel deutlich überlegen.AbstractThe outflow facility of the glaucomatous eye can be significantly enhanced by opening Schlemm’s canal to the anterior chamber. Surgical options for this approach include mechanical procedures, laser surgery, microbipolar cauterization and intracanalicular microstents. Especially in the area of combined cataract-glaucoma surgery these procedures are valuable options owing to their limited intraoperative and postoperative risk profiles. However, trabeculectomy with mitomycin C must still be regarded as the superior surgical option for glaucoma, which requires a low target pressure if combined surgery is unnecessary.The outflow facility of the glaucomatous eye can be significantly enhanced by opening Schlemms canal to the anterior chamber. Surgical options for this approach include mechanical procedures, laser surgery, microbipolar cauterization and intracanalicular microstents. Especially in the area of combined cataract-glaucoma surgery these procedures are valuable options owing to their limited intraoperative and postoperative risk profiles. However, trabeculectomy with mitomycin C must still be regarded as the superior surgical option for glaucoma, which requires a low target pressure if combined surgery is unnecessary.

Trabekuläre Bypasschirurgie beim Glaukom

ZusammenfassungDie trabekuläre Bypasschirurgie hat zum Ziel, eine direkte chirurgische Verbindung von Vorderkammer mit dem Schlemm-Kanal zu erzielen, um dadurch die Abflussleichtigkeit im Glaukomauge zu verbessern. Neben rein mechanischen Verfahren kann der trabekuläre Bypass mittels Laserverfahren, bipolarem Kauter oder durch Mikroimplantate erzielt werden. Aufgrund des niedrigen Risikoprofils ist ein solches Verfahren insbesondere bei der kombinierten Katarakt-Glaukom-Chirurgie sinnvoll. Als alleiniges Verfahren bei Glaukomaugen, die einen niedrigen Zieldruck brauchen, ist allerdings die Trabekulektomie mit Mitomycin C der trabekulären Bypasschirurgie in der Regel deutlich überlegen.AbstractThe outflow facility of the glaucomatous eye can be significantly enhanced by opening Schlemm’s canal to the anterior chamber. Surgical options for this approach include mechanical procedures, laser surgery, microbipolar cauterization and intracanalicular microstents. Especially in the area of combined cataract-glaucoma surgery these procedures are valuable options owing to their limited intraoperative and postoperative risk profiles. However, trabeculectomy with mitomycin C must still be regarded as the superior surgical option for glaucoma, which requires a low target pressure if combined surgery is unnecessary.The outflow facility of the glaucomatous eye can be significantly enhanced by opening Schlemms canal to the anterior chamber. Surgical options for this approach include mechanical procedures, laser surgery, microbipolar cauterization and intracanalicular microstents. Especially in the area of combined cataract-glaucoma surgery these procedures are valuable options owing to their limited intraoperative and postoperative risk profiles. However, trabeculectomy with mitomycin C must still be regarded as the superior surgical option for glaucoma, which requires a low target pressure if combined surgery is unnecessary.

Combined cataract and glaucoma surgery. Current options

Trabeculectomy is no longer the gold standard for combined cataract glaucoma surgery considering the successful results following cataract surgery combined with trabeculotomy, viscocanalostomy and canaloplasty. The main disadvantage of these mostly non-penetrating procedures is the induction of conjunctival scarring which jeopardizes subsequent filtering surgery. Ab interno glaucoma surgery, including trabecular surgery and endocyclophotocoagulation, does not interfere with the conjunctival situation. These surgical options have a relatively minor risk profile for combined cataract glaucoma surgery compared to traditional filtering surgery; however, the pressure reducing efficacy of these ab interno approaches is limited with respect to the absolute reduction of intraocular pressure (IOP) and the achievable level of IOP. This has to be kept in mind when planning surgery.ZusammenfassungDie kombinierte Katarakt-Glaukom-Chirurgie beschränkt sich schon seit Langem nicht mehr nur allein auf die traditionelle Trabekulektomie. Längst haben sich auch Verfahren wie die Trabekulotomie, Viskokanalostomie und Kanaloplastik im kombinierten Ansatz als erfolgreich erwiesen. Nachteil dieser meist zur nicht penetrierenden Chirurgie gehörenden Prozeduren ist die Induktion einer Bindehautvernarbung, die später notwendig werdende Filtrationseingriffe erschwert. Zu den Ab-interno-Verfahren, die diesen Nachteil nicht besitzen, gehören die Trabekelwerkchirurgie und die Endozyklophotokoagulation. Sie besitzen in Kombination mit der Kataraktchirurgie ein relativ günstiges Komplikationsspektrum verglichen mit der traditionellen Filtrationschirurgie. Bei diesen Ab-interno-Verfahren ist im Allgemeinen aber von einer begrenzten Drucksenkung auszugehen, die auch nicht den tief-normalen Augendruckbereich erreichen kann. Dies muss bei der Indikationsstellung bedacht werden.AbstractTrabeculectomy is no longer the gold standard for combined cataract glaucoma surgery considering the successful results following cataract surgery combined with trabeculotomy, viscocanalostomy and canaloplasty. The main disadvantage of these mostly non-penetrating procedures is the induction of conjunctival scarring which jeopardizes subsequent filtering surgery. Ab interno glaucoma surgery, including trabecular surgery and endocyclophotocoagulation, does not interfere with the conjunctival situation. These surgical options have a relatively minor risk profile for combined cataract glaucoma surgery compared to traditional filtering surgery; however, the pressure reducing efficacy of these ab interno approaches is limited with respect to the absolute reduction of intraocular pressure (IOP) and the achievable level of IOP. This has to be kept in mind when planning surgery.

Endocyclophotocoagulation for the treatment of glaucoma

ZusammenfassungDie Zyklophotokoagulation mittels Dioden- oder Neodym-YAG-Laser gilt bei der Behandlung therapierefraktärer Glaukome als Standardverfahren der Zyklodestruktion. Neben der transskleralen Zyklophotokoagulation steht seit Beginn der 1990er Jahre die endoskopische Zyklophotokoagulation zur Verfügung, deren technische Grundlagen und Durchführung in diesem Artikel dargestellt werden. Durch die direkte Visualisierung der koagulierten Ziliarkörperzotten und des somit scheinbar besser titrierbaren Effekts soll der endoskopische Zugangsweg dem transskleralen Verfahren überlegen sein. In der Literatur wird die Endozyklophotokoagulation als effektive Methode mit einer niedrigen Komplikationsrate beschrieben. Eigene retrospektive Daten zur endoskopischen Zyklophotokoagulation zeigen hingegen keine suffiziente Drucksenkung. Die Indikation zur endoskpischen und damit invasiven und bulbuseröffnenden Durchführung der Zyklophotokoagulation kann somit kontrovers diskutiert werden.AbstractCyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method, introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore questionable.Cyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method, introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore questionable.

Endozyklophotokoagulation bei der Behandlung des Glaukoms

ZusammenfassungDie Zyklophotokoagulation mittels Dioden- oder Neodym-YAG-Laser gilt bei der Behandlung therapierefraktärer Glaukome als Standardverfahren der Zyklodestruktion. Neben der transskleralen Zyklophotokoagulation steht seit Beginn der 1990er Jahre die endoskopische Zyklophotokoagulation zur Verfügung, deren technische Grundlagen und Durchführung in diesem Artikel dargestellt werden. Durch die direkte Visualisierung der koagulierten Ziliarkörperzotten und des somit scheinbar besser titrierbaren Effekts soll der endoskopische Zugangsweg dem transskleralen Verfahren überlegen sein. In der Literatur wird die Endozyklophotokoagulation als effektive Methode mit einer niedrigen Komplikationsrate beschrieben. Eigene retrospektive Daten zur endoskopischen Zyklophotokoagulation zeigen hingegen keine suffiziente Drucksenkung. Die Indikation zur endoskpischen und damit invasiven und bulbuseröffnenden Durchführung der Zyklophotokoagulation kann somit kontrovers diskutiert werden.AbstractCyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method, introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore questionable.Cyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method, introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore questionable.

Hornhautdickenmessung bei zur Tensionsmessung konträren Befunden

Eine 52-jährige Patientin stellte sich mit beidseits zunehmender Sehverschlechterung in unserer Poliklinik vor. Ein Offenwinkelglaukom war erstmals 4 Jahre zuvor diagnostiziert worden, damals mit bereits fortgeschrittener Papillenexkavation (CDR rechts 0,5; links 0,8) und Gesichtsfeldeinschränkung links. Der maximale Augendruck lag damals ohne Therapie bei 21 mmHg rechts und 33 mmHg links. Allgemeinanamnestisch lag ein unter β-Blockern oral therapierter arterieller Hypertonus vor. Trotz normotoner Tensionswerte bis maximal 15 mmHg unter Therapie mit Cosopt 2-mal täglich und Latanoprost z. N. war es im Verlauf 1 Jahres zu einem weiteren Gesichtsfeldverfall am linken Auge gekommen.

[Trauma-related secondary glaucoma in childhood: a therapeutic challenge].

CASE REPORT We performed a minimally invasive trabeculotomy using a trabectome on a 9-year-old boy with a trauma-related secondary glaucoma where the intraocular pressure (IOP) could not be controlled by conservative approaches. After a 1-year follow-up the patient showed well controlled IOP values without using drugs to reduce pressure. CONCLUSION Trabectome surgery seems to be a suitable first step intervention for trauma-related glaucoma in selected cases, even in children.

Traumatisches Sekundärglaukom im Kindesalter

CASE REPORT We performed a minimally invasive trabeculotomy using a trabectome on a 9-year-old boy with a trauma-related secondary glaucoma where the intraocular pressure (IOP) could not be controlled by conservative approaches. After a 1-year follow-up the patient showed well controlled IOP values without using drugs to reduce pressure. CONCLUSION Trabectome surgery seems to be a suitable first step intervention for trauma-related glaucoma in selected cases, even in children.

Traumatisches Sekundärglaukom im Kindesalter@@@Trauma-related secondary glaucoma in childhood: Eine therapeutische Herausforderung@@@A therapeutic challenge

CASE REPORT We performed a minimally invasive trabeculotomy using a trabectome on a 9-year-old boy with a trauma-related secondary glaucoma where the intraocular pressure (IOP) could not be controlled by conservative approaches. After a 1-year follow-up the patient showed well controlled IOP values without using drugs to reduce pressure. CONCLUSION Trabectome surgery seems to be a suitable first step intervention for trauma-related glaucoma in selected cases, even in children.