Perforating deep sclerectomy: prospective evaluation of a new glaucoma filtering procedure adapted to resource scarcity in developing countries

Session Details

Session Title: Glaucoma Management

Session Date/Time: Monday 16/09/2019 | 16:30-18:00

Paper Time: 17:18

Venue: Free Paper Forum: Podium 4

First Author: : K.Gillmann SWITZERLAND

Co Author(s): :    A. Kalala   A. Mermoud                          

Abstract Details

Purpose:

Two of the hurdles that are facing ophthalmologists in Developing Countries are scarcity of resource and patient follow-up. Deep sclerectomy (DS) has proven less costly and more effective than topical therapies, and has a more favourable safety profile than trabeculectomy. The main factors preventing its use in Developing Countries are the necessity to perform laser goniopuncture in 40-80% of cases to maintain filtration and the risk of post-operative iris incarceration. The purpose of this study is to assess the efficacy and safety outcome in advanced open-angle glaucoma of a relatively new surgical technique designed to overcome this limitation: penetrating DS.

Setting:

This was an investigator-initiated, prospective and interventional study, conducted at a single ophthalmology centre in Kinshasa, Congo. The study was reviewed and approved by the local ethical committee (IRB) and written informed consent was obtained from all patients. The study was conducted in full compliance with the Declaration of Helsinki.

Methods:

Fifty-one eyes (34 patients) with uncontrolled advanced primary open-angle glaucoma (visual field mean deviation >10 dBs) were enrolled between October 2012 and June 2016. Age, gender, co-morbidities (arterial hypertension/diabetes), best-corrected visual acuity, topical medications, medicated and unmedicated intraocular pressure (IOP) were recorded. All patients underwent penetrating DS, in which, following standard dissection of the scleral flaps, the anterior chamber was penetrated through the trabeculo-Descemet membrane and an iridectomy was performed. Patients attended post-operative appointments at months 1, 3, 6 and 12. Surgical success was defined as a 20% reduction of IOP from baseline and a 12-month unmedicated IOP ≤12 mmHg.

Results:

Mean age was 64.5±14.0 years (44.1% female, 100% African). Mean IOP decreased from 20.2±6.1 (medicated) and 30.7±9.8 mmHg (unmedicated) preoperatively to 12.1±4.1 at 12 months. Concomitantly, the number of topical medications decreased from 1.5±0.7 to 0.0. Complete surgical success was achieved in 64.7%. None of the eyes lost light perception or underwent revision or additional surgery. A significant association between surgical failure and arterial hypertension was observed (HR=1.49; p=0.008). There were no intraoperative complications. Post-operatively, 4 bleb fibrosis (7.8%) and 1 iris incarceration (2%) were observed.

Conclusions:

The present study demonstrates that perforating DS achieved similar efficacy and safety results as traditional non-penetrating DS. In addition, it showed a lower potential for intraoperative complications, which could be associated with a more gentle surgical learning curve. Finally, the rates of serious postoperative complications (iris incarceration, choroidal detachment and hypotony) were significantly lower than in DS and trabeculectomy, and this technique does not require subsequent Nd:YAG laser goniopuncture to maintain filtration, making frequent follow-up visits less critical. In view of these findings, perforating deep sclerectomy could offer a viable option for glaucoma management in Developing Countries and globally.

Financial Disclosure:

None