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Eyes with associated zonular dialysis, subluxation, capsular fibrosis, or cataract secondary to ocular inflammation were excluded. Preoperative evaluation included refraction, complete slit-lamp biomicroscopic examination, Goldmann applanation tonometry, and fundus evaluation by B-scan for posterior segment evaluation surgery eye. The intumescence of the cataract was diagnosed clinically by slit-lamp examination, where the surgeon noticed fluid clefts between cortical fibers and confirmed by shallow ACD in optical biometry with increased lens thickness when compared to the other eye phakic eyes.
The same was confirmed on the table while performing capsulorhexis. Tropicamide 1. The procedure is performed under peribulbar anesthesia with lidocaine hydrochloride 2. The anterior chamber is filled with an ophthalmic viscosurgical device Appavisc, Appasamy associates, India.
Multiple small centripetal tears are created in the center of the anterior lens capsule in the shape of a star by using a regular G cystotome introduced through the side port [ Fig. This distributes the forces acting due to increased intralenticular pressure on the capsular margin uniformly and helps to avoid unidirectional or bidirectional tear extension. Subsequently, by using a G flat-tipped fine cannula connected to a 5-mL syringe half filled with BSS, the free capsular flap is grasped with vacuum and suction pressure is created by withdrawing the piston of the syringe in a controlled motion to create a circular rhexis.
This is done without withdrawing the instrument from the anterior chamber and aspirating liquefied or viscous cortex by using the same cannula. The Video is available on www. The study included patients that underwent cataract surgery between April and March with an average follow-up period of 3. Of these, patients were male and patients were female.
Double rhexis was done in 33 cases None of the cases had an Argentinean flag sign. In one case that had rhexis extension, phacoemulsification was performed taking all precautions to avoid wrap-around tear.
All eyes had in-the-bag IOL implantation, except in one case that had rhexis extension. Howard Gimbel and Thomas Neuhann introduced capsulorhexis, which has become the standard method of anterior capsulorhexis.
Performing a well-centered, circular, optimally sized capsulorhexis not only offers safety to phacoemulsification but also decreases the rate of posterior capsular opacification and minimizes the IOL shift in the postoperative period. Intumescent cataract challenges surgeons in many ways.
There is no red glow and the anterior capsule is convex with increased intralenticular pressure and a shallow anterior chamber. The primary factor to address in intumescent cataracts for a successful capsulorhexis is to decrease the intralenticular pressure. This debulks the intralenticular pressure and distributes forces acting due to increased intralenticular pressure on the capsular margin to avoid unidirectional or bidirectional tear extension.
Then, by using a G flat-tipped fine cannula, the free capsular flap is vacuumed and capsulorhexis is carried out gently in circular motion without withdrawing the instrument from AC. A G cannula was used because it is neither too small to create insufficient vacuum nor too large to aspirate too much OVD with subsequent AC collapse or cause flap amputation.
Our technique has the advantage of decompressing the capsular bag first and then performing capsulorhexis without any chamber collapse. This technique is an improvisation of our own technique of CanVac CCC,[ 2 ] with an additional step of creating star-shaped centripetal anterior capsular tears to debulk the distended capsular bag and hence minimize rhexis extension. Brierley described a vacuum capsulorhexis technique that uses a G cannula attached to a phaco irrigating handpiece and an anterior chamber maintainer.
Our technique is inexpensive and can be adopted in intumescent cataracts in manual small incision cataract surgery as well as phacoemulsification. The learning curve is not steep, and it is a useful, inexpensive, safe technique and may be an alternative promising method to routine CCC by using a G cystotome, Utrata, or microrhexis forceps in challenging cases such as white intumescent cataracts. In conclusion, STAR CanVac CCC is a safe and inexpensive technique in white intumescent cataracts and helps to avoid Argentinean flag sign or rhexis extension and further complications associated with the same.
Indian J Ophthalmol. Published online Apr Author information Article notes Copyright and License information Disclaimer. Correspondence to: Dr. Road, R. Puram, Coimbatore - , Tamil Nadu, India. E-mail: moc. Investigated parameters were intraocular pressure IOP , number of medications, visual field findings, and visual acuity. All patients had either stabilization or improvement of their visual fields.
Four of the five patients also showed an improvement in visual acuity. This novel approach of combined gauge goniotomy and intra-scleral ciliary sulcus suprachoroidal microtube insertion surgery is safe and is an affordably effective means of managing patients with moderate to advanced refractory glaucoma, leading to a reduction in IOP and the number of medications with no serious adverse effects.
Glaucoma, a progressive optic neuropathy, is the second most prevalent eye condition worldwide. According to Tham et al. The effects of selective laser treatment, although initially successful will often need additional medical therapy. The IOP lowering among MIGS procedures is often limited to expensive devices that target three anatomical areas: Schlemm's canal, the suprachoroidal space, and the subconjunctival space.
They all attempt to improve outflow by bypassing the resistance at the trabecular meshwork. Recently, combination MIGS has been performed to try to achieve lower intraocular pressures IOPs , similar to those achieved with trabeculectomy, but with improved safety.
Pantalon et al. In this study, eyes with ocular hypertension or early to moderate open angle glaucoma were randomized to two groups. The second group consists of patients who underwent Phaco-iStent 46 eyes. Myers et al. Although very successful, combination MIGS with these devices can be quite costly. These procedures may not be accessible to resource poor areas. Both are lower cost options to provide MIGS. We report five patients who underwent combined procedures to obtain lower IOPs on fewer medications.
The combination of goniotomy using gauge cystotome and intrascleral ciliary sulcus-suprachoroidal microtube has not been reported in the literature. A 25 mm straight gauge cystotome Eagle labs was used to perform goniotomy [ Fig. This technique has been described elsewhere. The surgical technique of placing the tube into the ciliary sulcus and suprachoroidal space has been previously described.
The different options of glaucoma surgery procedures were discussed with the patients. The benefits and risks were discussed in detail, including the risk of complete sight loss. The patients agreed to the risks and benefits. Informed consent was obtained from all of the patients. Goniotomy with a 23 gauge cystotome[ 8 ] was performed, followed by intrascleral ciliary sulcus suprachoroidal microtube surgery.
She had a history of trabeculectomy in both eyes. IOP was 14 mmHg on bimatoprost 0. Anterior segment exam revealed a flat conjunctival bleb right eye and bleb left eye. Posterior chamber IOLs were in place bilaterally. Cup to disc ratio was 0. Humphrey visual field at the time also revealed a central island of vision in the right eye with a mean deviation MD of — The patient agreed to undergo goniotomy with suprachoroidal microtube insertion in the right eye to decrease IOP and reduce dependence on medications.
Her IOP on postoperative day 3 was 8 mmHg on no medications. Her IOP remained stable at 7 mmHg on no medications at 1 month and 3 months. At the 6 month visit, IOP remained at 7 mmHg on no medications.
A year-old female monocular patient with history of primary open angle glaucoma, dry eye syndrome, and macular drusen left eye, had presented to the office with blurry vision and elevated IOP. The patient had previous enucleation of the right eye. She had undergone multiple surgeries in the left eye including selective laser trabeculoplasty, trabeculectomy, and cataract extraction with istent.
Anterior segment revealed a failed conjunctival bleb left eye. Posterior chamber IOL was in place in the left eye. The cup to disc ratio was 0. Humphrey visual field at the time also revealed MD of The patient agreed to undergo goniotomy with suprachoroidal microtube insertion in the left eye to lower the IOP on less medication.
IOP remained stable at 15 mmHg 1 month after this visit but went up to 17 mmHg on three medications at the 6 month follow-up visit. Brimonidine was then added, which reduced the IOP to 13 mmHg. An year-old male with a history of primary open angle glaucoma, diabetes mellitus, hypertension, thyroiditis, and pseudophakia both eyes status post cataract extraction with IOL implant presented for follow-up evaluation. Gonioscopy revealed Schaffer grade III, grade 3 inferior pigmentation, and flat iris bilaterally.
There is superior thinning of the optic disc in the left eye. Humphrey visual field at the time also revealed full field in the right eye and mild depression of the visual field MD of However, the visual field of the left eye was unreliable due to several false positives and did not correspond to the advanced cupping of the optic nerve. The patient agreed to undergo goniotomy with suprachoroidal microtube insertion in the left eye to lower the IOP on fewer medications.
The goal was to improve compliance and reach a lower target. His IOP on postoperative day one 1 in the left eye was 12 mmHg on no medications, and 12 mmHg on no medications after 1 month. At his 4 month follow-up, IOP remained stable at 9 mmHg. IOP at the 6 month visit was 10 mmHg.
Intraocular pressure, number of medications, visual acuity, and visual field test in patients who underwent combination microinvasive glaucoma surgery; gauge cystotome goniotomy and intra-scleral ciliary sulcus suprachoroidal microtube surgery. A year-old male with a history of primary open angle glaucoma and pseudophakia both eyes status post cataract extraction with IOL presented to the office for follow-up glaucoma care.
His surgical history was trabeculectomy in the right eye. The patient's current topical regimen included bimatoprost 0. Slit lamp biomicroscopy exam showed superonasal bleb in the right conjunctiva, clear corneas bilaterally, and anterior chambers were deep and quiet. There were posterior chamber IOLs in good position: the cup to disc ratio was 0. There was significant loss of nerve fiber layer in the right eye with optic disc pallor.
No retinal hemorrhages or edema were observed. The patient agreed to undergo goniotomy with suprachoroidal microtube insertion in the right eye to lower the IOP and to take fewer medications. His IOP in the right eye on postoperative day 1 was 12 mmHg on no medications, 11 mmHg on no medications at 1 month, 13 mmHg on no medications at 3 months, and 15 mmHg on one drop of daily bimatoprost at 6 months.
An year-old female with a history of angle-closure glaucoma, hypertensive retinopathy, cataract right eye, monocular exotropia right eye, and chronic obstructive pulmonary disease presented with worsening vision in the left eye. She has a family history of glaucoma. The surgical history included iridotomy right eye, cataract extraction with IOL, trabeculectomy, and YAG capsulotomy left eye.
Gonioscopy of the left eye revealed Schaffer grade III, grade 1 pigment, and flat iris. Humphrey visual field revealed infranasal central island of vision with MD of IOP remained stable at 10 on three medications at 6 months. Her visual field at the 6 month follow-up revealed stabilized central island of vision.
In the cases we described herein, we have demonstrated excellent efficacy of combination MIGS using gauge cystotome goniotomy and intra-scleral ciliary sulcus suprachoroidal microtube surgery. The patients tolerated the procedures well. All patients had mild hyphema, which is common with goniotomy, and it resolved in all cases. The microtube made of silicone is biocompatible and well tolerated in the ciliary sulcus, sclera, and the suprachoroidal space. The suprachoroidal space has no IOP floor and utilizes its own negative gradient to drain aqueous via the uveoscleral pathway leading to a drastic decrease in IOP.
The Cypass Alcon was removed from the market due to safety concerns of corneal endothelial cell loss attributed to the position of the tube near the cornea. The patients had no adverse effects from potential complications, such as iritis, corneal edema, loss of visual acuity, cystoid macular edema, choroidal effusion, persistent hypotony, tube obstruction, retinal detachment, ciliary body detachment, ocular hypertensive crisis from sudden suprachoroidal closure, or persistent IOP elevations.
All patients in this case series had preserved retinal integrity 6 months after surgery.
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WebOverview. Disposable Irrigating Cystotomes and Capsulorhexis Cystotomes with various shaft and tip styles. Each cystotome has a bent, pointed tip and is available in 23 to 30 gauge in size. Ranges in gauge and shaft styles. Overall length ranges from 16mm to 22mm. Sold 10 per box, unless specified otherwise. Web Alcon jobs. Apply to the latest jobs near you. Learn about salary, employee reviews, interviews, benefits, and work-life balance. AdSign Up Today To Find Nursing Jobs Across The US. Apply Now. Search Nurse Jobs Across The USA And Apply online. Register Now!