Professional Documents
Culture Documents
217
218
Pre-operative considerations
In order to reduce intraoperative complications
like choroidal hemorrhage, the IOP should be reduced
preoperatively using osmotic agents. This also shrinks
the vitreous and may help having a slightly deeper
anterior chamber intraoperatively. Placing the patient
in a slight reverse-Trendelenburg position on the
operating table and using the minimal amount of
tension on the lid speculum will also help to reduce
posterior positive pressure.
Intraoperative considerations
Angle closure glaucoma has some difficult ocular
situations for surgery, such as a shallow anterior
chamber, the lens often bulky, and the pupil is frequently
small from miotic treatment or ischemic iris atrophy.
The presence of posterior synechiae, sometimes over
the whole 360 degree of the pupillary margin, and a
relatively small pupil, which are not unusual findings in
patients with CACG, pose daunting difficulties. When
necessary, the pupil is dilated with sphincterotomies,
stretching the iris with Sinski hooks bimanually, or iris
retraction hooks (Figure 1, panels A and B). These may
result in an atonic and atrophied iris, which not only
has a tendency to plug any surgical wounds and increase
the possibility of postoperative uveitis, but also is more
prone to further PAS formation. The iris must be dealt
with gently to avoid excessive postoperative uveitis.
In those patients that phacoemulsification is not
possible because of reduced working space due to
crowded anterior chamber, a vitreous tap (a limited pars
plana dry vitrectomy) can deepen anterior chamber. In
clear cornea temporal phacoemulsification, the entrance
into the vitreous cavity can be 3.5 mm posterior to
limbus at supero- or inferotemporal quadrants. After
performing a dry vitrectomy by vitrectomy machine the
anterior chamber is filled with a viscoelastic agent and
phacoemulsification is performed. Using a 25-gauge
vitrector have the following benefits, easy to perform
during anterior segment surgery, the sclerotomy wound
requires no sutures, and the minimal conjunctival
damage does not hamper future filtration surgery.
However, potential complications associated with
vitrectomy including retinal detachment and vitreous
hemorrhage, should be addressed.
Viscogoniosynechialysis
SURGICAL TECHNIQUE
Performing phacoemulsification in the context of
PACG warrants a number of considerations to minimize
the risk of complications and adverse events.
219
Figure 1. Performing combined phacoemulsification and viscogoniosynechialysis in a patient with angle-closure glaucoma and a miotic
pupil. A) fashioning a path for iris retraction hooks using a 27-gauge needle, B) inserting the iris retraction hooks, C) accomplishing anterior
capsulorhexis, D) performing phacoemulsification, E) placing the intraocular lens in the bag, F and G) perfoming viscogoniosynechalysis,
H)removing the viscoelastic material, I) stomal hydration.
220
Phaco or Phacoviscogoniosynechailysis
Indications
Acute angle-closure
221
222
REFERENCES
1.
2.
3.
4.
CONCLUSION
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
223
17. Aung T, Ang LP, Chan SP, Chew PT. Acute primary angleclosure: long-term intraocular pressure outcome in Asian eyes.
Am J Ophthalmol. 2001; 131:7-12.
18. Imaizumi M, Takaki Y, Yamashita H. Phacoemulsification and
intraocular lens implantation for acute angle closure not treated
or previously treated by laser iridotomy. J Cataract Refract Surg
2006; 32:85-90.
19. Tham CC, Kwong YY, Leung DY, et al. Phacoemulsification
versus combined phacotrabeculectomy in medically uncontrolled
chronic angle closure glaucoma with cataracts. Ophthalmology.
2009; 116:725-31, 731 e1-3.
20. Tham CC, Leung DY, Kwong YY, Li FC, Lai JS, Lam DS. Effects
of phacoemulsification versus combined phaco-trabeculectomy
on drainage angle status in primary angle closure glaucoma
(PACG). J Glaucoma. 2010; 19:119-23.
21. Gunning FP, Greve EL. Lens extraction for uncontrolled angleclosure glaucoma: long-term follow-up. J Cataract Refract Surg.
1998; 24:1347-56.
22. Lai JS, Tham CC, Chan JC. The clinical outcomes of cataract
extraction by phacoemulsification in eyes with primary angleclosure glaucoma (PACG) and co-existing cataract: a prospective
case series. J Glaucoma. 2006; 15:47-52.
23. Shin HC, Subrayan V, Tajunisah I. Changes in anterior chamber
depth and intraocular pressure after phacoemulsification in eyes
with occludable angles. J Cataract Refract Surg. 2010; 36:128995.
24. Markowitz SN, Morin JD. The endothelium in primary angleclosure glaucoma. Am J Ophthalmol. 1984; 98:103-4.
25. Ko YC, Liu CJ, Lau LI, Wu CW, Chou JC, Hsu WM. Factors
related to corneal endothelial damage after phacoemulsification
in eyes with occludable angles. J Cataract Refract Surg. 2008;
34:46-51.
26. Mullaney PB, Wheeler DT, al-Nahdi T. Dissolution of
pseudophakic fibrinous exudate with intraocular streptokinase.
Eye (Lond). 1996; 10:362-6.
27. Siatiri H, Beheshtnezhad AH, Asghari H, Siatiri N, Moghimi
S, Piri N. Intracameral tissue plasminogen activator to prevent
severe fibrinous effusion after congenital cataract surgery. Br J
Ophthalmol. 2005; 89:1458-61.
28. Yeh PC, Ramanathan S. Latanoprost and clinically significant
cystoid macular edema after uneventful phacoemulsification
with intraocular lens implantation. J Cataract Refract Surg.
2002; 28:1814-8.
29. Yonekawa Y, Kim IK. Pseudophakic cystoid macular edema.
Curr Opin Ophthalmol. 2012; 23:26-32.
First author:
M. Reza Razeghinejad, MD
Poostchi Ophthalmology Research Center,
Shiraz University of Medical Sciences,
Shiraz, Iran.