The introduction of a commercially available solution of sodium hyaluronate (Healon®) has had a major influence on ophthalmic surgical techniques.1 Healon is a 1% solution of bovine sodium hyaluronate, which has a molecular weight of more than 2 x 106 daltons. The solution is essentially nontoxic, transparent, and extremely viscous. These physical properties have led to its widespread use in a variety of ophthalmic surgical procedures.2-26
Goniotomy is effective for treating congenital glaucoma27; however, there frequently are a number of complications. The intraoperative loss of the anterior chamber, poor visualization of the angle, and injury to the iris, lens, and corneal endothelium are well-recognized problems. Consequently, many glaucoma surgeons avoid goniotomy and recommend alternatives such as trabeculotomy ab externo.28
Two reports12,29 have described the use of hyaluronate for goniotomy. No large series or controlled studies have been reported. We report our experience with hyaluronate for goniotomy and describe some technical modifications that may be advantageous.
MATERIALS AND METHODS
The procedure is performed with endotracheal anesthesia. Using an operating microscope with coaxial illumination, a pediatric lid speculum is positioned. The conjunctiva is grasped at the limbus at the 6- and 12-o'clock positions with two locking forceps maintaining the globe in the adducted or abducted position. A stab incision with a no. 75 blade (Beaver) is made temporally at the limbus (Figure 1). Gentle pressure on the posterior lip of the wound is applied, removing the fluid from the anterior and posterior chambers (Figure 2 ). The anterior chamber is filled with hyaluronate through the stab incision site. Care is taken to avoid placing hyaluronate in the posterior chamber. A flat posterior chamber allows a much broader inlet to the angle. Prior to placing a goniotomy lens, a 1½-inch 25-gauge disposable needle attached to the hyaluronate syringe is introduced through the original stab incision and advanced across the anterior chamber, stopping just short of the opposite anterior chamber angle (Figure 3). This step makes it easier to avoid accidental damage to the surrounding structures. Hyaluronate is then applied to the surface of the cornea and a Swan-Jacob's lens is positioned for viewing the angle.
The 25-gauge needle is then advanced into the angle (Figure 4), and the goniotomy performed as described by Barkan30 (Figure 5). Because the needle is attached to the hyaluronate syringe, it is easy to maintain adequate depth of the angle with hyaluronate during the goniotomy. Because of the excellent stability and control provided by the locking forceps, it is easy to obtain a 100° goniotomy.
FIGURE 1: Two locking forceps clamp the conjunctiva at the 6- and 12-o'clock positions allowing steady positioning of the globe in abduction. A stab incision is made at the temporal limbus.
FIGURE 2: The anterior and posterior chambers have been emptied.
FIGURE 3: Hyaluronate has been injected into the chamber, and the 25-gauge needle is advanced across the pupil.
FIGURE 4: The goniotomy being performed.
FIGURE 5: Note the widening of the angle to the right of the needle as the iris falls posteriorly while the goniotomy is being performed.
FIGURE 6: After completion of the goniotomy, the hyaluronate is aspirated from the anterior chamber with a blunt 25-gauge cannula.
The needle is slowly withdrawn using additional hyaluronate as needed to prevent iris, lens, and corneal endothelial damage. A 25-gauge blunt cannula is then used to aspirate the hyaluronate from the anterior chamber, and the anterior chamber is reformed with balanced salt solution (BSS®) (Figure 6). Suturing is rarely required to close the wound.
CASE 1: An 8-month-old girl had signs and symptoms suggesting infantile glaucoma in both eyes. Findings and postoperative course are summarized in Table 1. Surgical procedures were performed in the left eye at 1 and 5 weeks, and in the right eye at 3 weeks after initial examination.
CASE 2: A 3-month-old girl had signs and symptoms of infantile glaucoma in both eyes. Findings and postoperative course are summarized in Table 2. Surgical procedures were performed in the right eye one day after the initial examination, and in the left eye at 1 week, 6 weeks, and 9 months after presentation.
Both patients have remained symptom-free after 1 year with intraocular pressures consistently less than 22 mm Hg and no progression in cup size, corneal diameter, or myopia.
Our two cases illustrate the frequent need for several surgical procedures to control intraocular pressure (IOP) in congenital glaucoma. A single goniotomy was sufficient in one eye of each patient. Corneal clouding on the left prevented satisfactory visualization for goniotomy in Case 1, so a trabeculotomy ab externo was done initially. The IOP was reduced, but a subsequent goniotomy was needed to control the glaucoma completely. In Case 2, the left eye required an initial goniotomy, a trabeculotomy ab externo, and a second goniotomy before the pressure was fully controlled.
It has been our experience with the classical goniotomy technique as described by Barkan30 that several operative complications occur: appearance of air bubbles under the goniotomy lens, loss of the anterior chamber when rotating the goniotomy needle to extend the goniotomy, intraoperative bleeding, and, occasionally, damage to the corneal endothelium. Injury to the lens is another complication that may occur when the anterior chamber flattens while the goniotomy needle is in the vicinity of the lens.
Theoretical advantages to the use of hyaluronate, as described in this report, are various: It allows the same index of refraction on both sides of the cornea and prevents the appearance of air bubbles under the lens. Damage to the corneal endothelium, iris, and lens seems less likely while coated with hyaluronate. Unexpected anterior chamber collapse during the goniotomy, a frequent complication of the technique as described by Barkan,30 appears to be prevented. Substitution of aqueous humor by hyaluronate avoids dilution in the aqueous humor of any bleeding. Intraocular hyaluronate has also been shown to have a procoagulant effect.31 Both mechanisms would minimize any bleeding that could interfere with the visualization of the angle. The two previous reports of goniotomy with hyaluronate12,29 do not describe emptying the posterior chamber prior to the instillation of hyaluronate into the anterior chamber, nor do they describe coating the corneal surface with hyaluronate prior to placing a goniotomy lens. We emphasize the importance of both maneuvers that allow maximum widening of the anterior chamber angle and superb visualization. The viscosity of hyaluronate is important in preventing air bubble formation under the goniotomy lens. In both reports,12-29 the authors leave the hyaluronate in the eye. Because hyaluronate has repeatedly been shown to cause dose-related pressure elevation during the initial 24 hours after intraocular surgical procedures,1,5,32,33 we recommend removing the hyaluronate solution from the anterior chamber. This postoperative pressure rise has not been documented after goniotomy with hyaluronate, so we can only assume that the same phenomenon occurs. This may be critical in babies with extensively damaged optic nerves. The pressure rise also can be a source of significant postoperative pain.
Summary of Findings and Procedures for Case 1
Summary of Findings and Procedures for Case 2
No operative or postoperative complications occurred in the five goniotomies performed on our two cases. It is not yet known whether this technique will provide long-term control of IOP that is superior to present techniques for congenital glaucoma. A controlled study will be necessary to determine if the use of hyaluronate facilitates the technique and diminishes complications in goniotomy. Our technique, however, is easy, controlled, and provides excellent visualization, which may make goniotomy a safer procedure.
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Summary of Findings and Procedures for Case 1
Summary of Findings and Procedures for Case 2