Double-Mirror Goniolens With Dual Viewing System for Goniosurgery Kazuhiko Mori, MD, PhD, Toru Ikushima, MD, Yoko Ikeda, MD, and Shigeru Kinoshita, MD, PhD PURPOSE: To compare the performance of the doublemirror goniolens with dual viewing system in goniosurgery, goniosynechialysis, and trabeculotomy ab externo with that of the conventional Swan-Jacob gonioprism (SJG). DESIGN: Prospective interventional case series. METHODS: We treated 10 patients (10 eyes) with medically uncontrollable chronic angle-closure glaucoma by goniosynechialysis and another 10 eyes with open-angle glaucoma by trabeculotomy ab externo (TLO). The 20 patients were divided randomly into two equal groups and underwent operation with the double-mirror goniolens or SJG instrument. RESULTS: There were no intraoperative complications, irrespective of the procedure or instrument that was used. Patients in the SJG group were required to tilt the head at a >30-degree angle to facilitate observation and manipulation of the quadrants. On the other hand, all structures could be observed and manipulated without head-tilting in the double-mirror goniolens group. CONCLUSION: The double-mirror goniolens with dual viewing system is more suitable than the conventional SJG for goniosurgery. (Am J Ophthalmol 2007;143: 154 –155. © 2007 by Elsevier Inc. All rights reserved.)
T
FIGURE 1. Schematic representation and photograph of double-mirror goniolens. It can provide a dual view of the angle and anterior chamber (AC).
illumination through the combination of the two internal mirrors and a central direct path. In this study, we compared the usefulness of the dmG in goniosurgery, goniosynechialysis, and trabeculotomy ab externo (TLO) with that of the conventional Swan-Jacob gonioprism (SJG; Ocular Instruments, Inc, Bellevue, Washington, USA). We enrolled 20 patients (20 eyes) who were seen at the Glaucoma Clinic in Kyoto Prefectural University of Medicine in this study. This study was approved by the Institutional Review Board for Human Studies of Kyoto Prefectural University of Medicine, and written informed consent was obtained from all patients before surgery. Of these, 10 patients had medically uncontrollable, chronic angle-closure glaucoma and were treated for goniosynechialysis; the other 10 patients had open-angle glaucoma and underwent TLO. We randomly divided the 20 patients into two equal groups; one group underwent surgery with the dmG, and the SJG was used on the other group. In patients who were treated for goniosynechialysis (n ⫽ 10 patients), we injected viscoelastic material (Healon; AMO Japan, Tokyo, Japan) into AC and then placed the SJG (n ⫽ 5 patients) or dmG (n ⫽ 5 patients) on the surface of the cornea. The SJG was held manually in place on the corneal surface by the operator. The dmG does have the ability to sit on the corneal surface unassisted, yet it needed to be held manually in place for stabilization while the procedure was performed. Goniosynechialysis was performed by moving a spatula toward the peripheral anterior synechia and pushing down the peripheral iris through the view of either lens. In patients who were treated by TLO, we first excised the deep scleral flap, dissected the outer wall of the Schlemm canal, and inserted trabeculotomy probes into the canal. Then the SJG (n ⫽ 5 eyes) or dmG (n ⫽ 5 eyes) was placed on the cornea to make sure that the probes were inserted correctly into the Schlemm canal without early perforation. After confirmation, either lens was removed, and probes were rotated into AC. In two of five cases, the trabecular meshwork offered resistance, and rotation of the
HE DIRECT SURGICAL GONIOSCOPE PROVIDES A
straight-on view of angle structures (AS) and requires tilting of the patient’s head and/or microscope during surgery. The double-mirror gonioscopic lens, which was first reported by Iwasaki and associates,1 provides an upright image of AS without tilting. However, the contact area of this lens to the cornea is designed too small to view the anterior chamber (AC) directly. During the performance of 360-degree goniomicrosurgery and with the lens kept on the eye, it is desirable to have a central direct view of AC to track the 3-dimensional location of surgical instruments. To surmount these difficulties, we developed a doublemirror goniolens with dual viewing system (dmG; Figure 1). The lens is made of glass with a polymethylmethacrylate plate on top and features a column with an external height of 21.6 mm and a diameter of 11.5 mm. It was designed along the principles of the double-mirror gonioscopic lens1 and was modified to provide a wider field-of-view and brighter coaxial Accepted for publication Jul 19, 2006. From the Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamigyoku, Kyoto, Japan. Inquiries to Kazuhiko Mori, MD, PHD, Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamigyoku, Kyoto, 602-0841, Japan; e-mail:
[email protected]
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Intraoperative Sclerotomy-related Retinal Breaks for Macular Surgery, 20- vs 25-Gauge Vitrectomy Systems Richard Scartozzi, MD, Amr S. Bessa, MD, Omesh P. Gupta, MD, and Carl D. Regillo, MD
FIGURE 2. Intraoperative microscopic view of angle structure (AS) through the double-mirror goniolens. The instrument yielded not only a coaxial view of the anterior chamber [AC] (central portion) and AS (double-mirror portion) during goniosynechialysis (Left) but also provided a double-mirror view of the AS during trabeculotomy without tilting the head and/or microscope. Note that the probe is clearly discernible through the trabecular meshwork (Right).
probes proved difficult; we added the goniotomy toward the leading edge of the probes under the view of the goniolens, which made the paracentesis 180 degrees away. With either lens, both procedures were performed without any complication. The sharpness of the angle image was almost identical with both instruments (Figure 2). However, the use of the dmG provided not only clear visualization of AS through the double-mirror but also an AC view through the central portion. Moreover, because the cornea was in the upright position during the gonioscopic surgical procedure when the dmG was used, tilting of the head and/or microscope was unnecessary. In contrast, the use of the SJG required a ⬎30-degree tilt of the head and microscope to allow visualization and manipulation of the entire quadrant. As our dmG provided a clear dual view of AC and AS, we concluded that this improved instrument would be useful in other goniomicrosurgery such as goniotomy, goniocurettage,2 trabecutome,3,4 and the placement of trabecular bypass stents.5,6 REFERENCES
1. Iwasaki N, Takagi T, Lewis JM, Ohji M, Tano Y. The double-mirror gonioscopic lens for surgery of the anterior chamber angle. Arch Ophthalmol 1997;115:1333–1335. 2. Jacobi PC, Dietlein TS, Krieglstein GK. Technique of goniocurettage: a potential treatment for advanced chronic open angle glaucoma. Br J Ophthalmol 1997;81:302–307. 3. Jacobi PC, Dietlein TS, Krieglstein GK. Microendoscopic trabecular surgery in glaucoma management. Ophthalmology 1999;106:538 –544. 4. Minckler DS, Baerveldt G, Alfaro MR, Francis BA. Clinical results with the trabecutome for treatment of open-angle glaucoma. Ophthalmology 2005;112:962–967. 5. Spiegel D, Kobuch K. Trabecular meshwork bypass tube shunt: initial case series. Br J Ophthalmol 2002;86:1228 –1231. 6. Bahler CK, Smedley GT, Zhou J, Johnson DH. Trabecular bypass stents decrease intraocular pressure in cultured human anterior segments. Am J Ophthalmol 2004;138:988 –994.
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PURPOSE: To compare the rate of intraoperative sclerotomy-related retinal breaks (SRRB) between 20- and 25-gauge vitrectomy systems for the correction of macular pucker (MP) and macular hole (MH). DESIGN: Retrospective interventional case series. METHODS: Single institution review of 347 consecutive eyes of 333 patients between August 2003 and May 2005 receiving pars plana vitrectomy (PPV) for MP or MH repair. Eyes were excluded if they had any form of proliferative retinopathy, or if there was an intraoperative conversion of any sclerotomy from 25- to 20- gauge. RESULTS: Fourteen (6.4%) of 219 eyes in the 20-gauge group had SRRB vs 4 (3.1%) of 128 eyes in the 25-gauge group (Fisher exact test, P value ⴝ .22). CONCLUSIONS: There was a trend for slightly lower rates of intraoperative sclerotomy-related retinal breaks, single or multiple, with 25-gauge PPV compared with 20-gauge PPV, but the differences were not statistically significant. (Am J Ophthalmol 2007;143:155–156. © 2007 by Elsevier Inc. All rights reserved.)
S
CLEROTOMY-RELATED RETINAL BREAKS (SRRB) ARE THE
most common serious complication of pars plana vitrectomy (PPV), and are thought to occur in relation to instrument insertion and withdrawal.1– 4 Reported rates of SRRB using standard 20-gauge PPV techniques range from 2.9% to 11%.4 Surgical techniques, however, have evolved over the years. One recent innovation in vitrectomy is the introduction of 25-gauge systems. This smaller sclerotomy approach allows for sutureless surgery and its potential related advantages, such as shorter operating times and faster ocular healing. These potential advantages appear to account for its rapid gain in popularity. Although initial published series on 25-gauge PPV show a good safety profile to date, it is not known whether the potentially serious complication of SRRB is more or less common compared with conventional 20gauge PPV. The purpose of this study is to compare the rate of intraoperative SRRB between 20-gauge without trocar and 25-gauge with trocar vitrectomy surgery for the correction of macular pucker (MP) and macular hole (MH). The operative reports of all patients who underwent PPV for uncomplicated MP or MH between August 2003 and May 2005 at the Wills Eye Hospital Retina Service were reviewed Accepted for publication Jul 20, 2006. From the Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania (R.S., O.P.G., C.D.R.), and the Department of Ophthalmology, Alexandria University School of Medicine, Alexandria, Egypt (A.S.B.). Inquiries to Carl D. Regillo, MD, Wills Eye Hospital, 840 Walnut Street, Suite 1020, Philadelphia, PA 19107; e-mail:
[email protected]
BRIEF REPORTS
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