Trabeculectomy Augmented with Limited Deep Sclerectomy and Cyclodialysis with Use of Scleral Tissue as a Spacer

Abstract

Trabeculectomy remains the most commonly performed surgery for medically uncontrolled glaucoma. Its success in primary open angle glaucoma is approximately 82% in the initial year after surgery and 64% at the end of five years. Lower success rates have been found in secondary glaucomas like neovascular glucoma, uvietic glaucoma, post-traumatic glaucoma, and for repeat surgeries. To illustrate improvement of the efficacy of trabeculectomy, enhancement with cyclodialysis has been introduced. This involves the creation of a cyclodialysis cleft in a controlled manner to allow additional suprachoroidal drainage of the aqueous. Cyclodialysis is the result of the separation of the longitudinal ciliary muscle fibers from the scleral spur, which creates an additional pathway for aqueous humor drainage. However, such a cleft often closes on its own due to associated inflammation caused by the filtration surgery. Deep sclerectomy is a non-penetrating surgery that involves dissection of a scleral patch and excision of a block of scleral tissue, retaining a thin membrane for aqueous drainage. In this study, we introduce a novel surgical technique of combining trabeculectomy with a limited deep sclerectomy and a cyclodialysis in two pseudophakic patients who developed secondary glaucoma after vitreo-retinal surgery with silicone oil insertion. In this technique the excised scleral tissue obtained after deep sclerectomy was utilized as a spacer to maintain the patency of the cyclodialysis cleft.

Clinical and Optical Coherence Tomography Evidence of Aqueous Humor Flow from the Suprachoroidal Space to Conjunctival Lymphatics

“…The non-trabecular outflow pathway has been exploited by surgeons to enhance the hypotensive effect of other surgical procedures for the treatment of glaucoma. Dada et al [ 59 ] combined trabeculectomy with a limited deep sclerectomy and cyclodialysis in two pseudophakic patients who developed secondary glaucoma after vitreoretinal surgery with silicone oil insertions. In this technique, the authors used excised scleral tissue obtained after performing a deep sclerectomy as a spacer to maintain the patency of the cyclodialysis cleft.…”

Recent Advancements in Glaucoma Surgery—A Review

“…In 2022, Dada et al [ 13 ] further enhanced the LDS-augmented trabeculectomy by creating a cyclodialysis in two patients who had high IOP after vitrectomy. In this surgical modification, a controlled separation of the ciliary body from the scleral spur is performed at the site of the scleral flap.…”

“…In this surgical modification, a controlled separation of the ciliary body from the scleral spur is performed at the site of the scleral flap. The excised deep scleral tissue during LDS is used as a spacer in the cyclodialysis cleft ( Figure 2 ) [ 13 ], which prevents closure and fibrosis of the cleft, and ensures suprachoroidal drainage of aqueous [ 13 ]. The spacer also inhibits the excessive aqueous outflow that commonly occurs with standard cyclodialysis procedures.…”

“…These alternative drainage pathways alleviate the IOP-lowering burden on the subconjunctival bleb and minimise the risk of bleb-related complications, such as fibrosis and bleb leak. Good short-term IOP outcomes, from 38 mmHg to 12 mmHg and 44 mmHg to 10 mmHg, were seen in both patients, without leaking blebs at 6 months [ 13 ]. Unfortunately, the long-term efficacy and safety of this procedure have yet to be reported.…”

“… ( A ) The making of a partial-thickness scleral flap to create a deep crater; ( B ) further dissection of the scleral block to create an even deeper crater; ( C ) cyclodialysis cleft made using cyclodialysis spatula; and ( D ) deep scleral tissue inserted at the cyclodialysis cleft. Courtesy of Dada et al [ 13 ]. …”