Surgical Techniques in Ophthalmology: Glaucoma Surgery Ashok Garg, Boris Malyugin, Bojan Pajic, Tanuj Dada, Jorge L Alio, Jerome Jean Bovet, Roberto G Carassa, André Mermoud, Jes N Mortensen, Shlomo Melamed, Ehud I Assia, Ahmad K Khalil, CS Dhull, Gabor B Scharioth, Gabriel Simon
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1SURGICAL TECHNIQUES IN OPHTHALMOLOGY: GLAUCOMA SURGERY
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3SURGICAL TECHNIQUES IN OPHTHALMOLOGY: GLAUCOMA SURGERY
Editors-in-Chief Ashok Garg MS PhD FIAO (Bel) FRSM ADM FAIMS FICA International and National Gold Medalist Chairman and Medical Director Garg Eye Institute and Research Centre 235 Model Town, Dabra Chowk Hisar-125005, Haryana, India
Jorge L Alió MD PhD Professor and Chairman of Ophthalmology Medical Director VISSUM, Instituto Oftalmologico De Alicante Avda de Denia S/n 03016 Alicante, Spain Foreword Tarek Shaarawy
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Editors
Shlomo Melamed MD Professor of Ophthalmology Sackler Medical School Tel Aviv University Head and Chairman Sam Rothberg Glaucoma Centre Goldschleger Eye Institute Sheba Medical Centre Tel-Hashomer, Israel
Boris Malyugin MD PhD Professor of Ophthalmology Chief of Dept. of Cataract and Implant Surgery, Dy Director General S Fyodorov Eye Microsurgery Complex State Institution 127486 Beskundnikovsky blvd 59A, Moscow Russia
Jerome Jean Bovet MD Consultant Ophthalmic Surgeon FMH, Clinique de L'oeil 15, Avenyue Du Bois-de-law CH-1213, Onex Switzerland
André Mermoud MD Ancien Prof. Associe a I'Hopital Ophthalmique Specialiste FMH en ophthalmochirurgie Centre de Glaucome Clique de montachoisi Chemin des Allinges 10 CH-1006 Lausanne Switzerland
Ahmad K Khalil MD Associate Prof of Ophthalmology Research Institute of Ophthalmology Saridar Clinic Tower 92, Tahrir St, Dokki Cairo, Egypt
Jes Mortensen MD Consultant Ophthalmologist The Eye Department Orebro University Hospital SE-70185, Orebro Sweden
Ehud I Assia MD Professor of Ophthalmology Director Department of Ophthalmology Meir Medical Centre 59, Tschernihovsky Str Kfar – Saba, 44281 Israel
Tanuj Dada MD Associate Professor of Clinical Ophthalmology RP Centre for Ophthalmic Sciences AIIMS, Ansari Nagar New Delhi, India
CS Dhull MS PhD FIAO Senior Professor and Head Regional Institute of Ophthalmology and Director, PGIMS Rohtak-124001 India
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Gabor B Scharioth MD Consultant Ophthalmologist Aurelios Augenzenturm Recklinghausen Erlbruch 34–36 D-45657, Recklinghausen Germany
Bojan Pajic MD Chairman and Medical Director Swiss Eye Research Foundation Eye Clinic Orasis, Titlisstrasse 44 5734 Reinach AG Switzerland
Gabriel Simon MD Consultant Ophthalmologist Fuebcarral 7 Madrid 28004 Spain
Cyres K Mehta MS, FSVH, FAGE Director and Consultant Mehta International Eye Institute Seaside, 147, Colaba Road Mumbai-400005 India
Roberto G Carassa MD Director Italian Glaucoma Centre Piazza Repubblica 30 20124 Milano Italy
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Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Surgical Techniques in Ophthalmology (Glaucoma Surgery)
© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error (s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 2010
9788184489583
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset
7Dedicated to
— Ashok Garg
— Jorge L Alió
— Shlomo Melamed
— André Mermoud
— Ehud I Assia
— Boris Malyugin
— Ahmad K Khalil
— Tanuj Dada
— Jerome Bovet
— Jes Mortensen
— CS Dhull
— Gabor B Scharioth
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— Roberto G Carassa
— Bojan Pajic
— Cyres K Mehta
9Contributors 13Foreword
It is without doubt the period most interesting in the saga of glaucoma surgery. What has started in the middle of the 19th century by Friedrich Wilhelm Ernst Albrecht von Graefes (or Gräfe; May 22, 1828 – July 20, 1870) innovation continues to exponentially evolve. Iridectomy was a true revolution as it offered a real surgical solution to a disease that was, and we can argue that it is still, not well understood. From there on the frontiers were wide open to pioneers in the field to experiment with an increasingly complex surgical techniques, and what started with a single step has been a tremendous leap in our field, where we now have access to a variety of methods in our surgical antiglaucoma armamentarium.
Surgery offers multiple advantages. It is compliance-free, overcoming the single most hindrance to medical therapy. It does not reduce chances of success for future medical therapy, while medical therapy, because of its noxious effect on the conjunctiva, does. In many regions it is the only option, when medications are unavailable or inaccessible. It seems to provide more stable diurnal pressure curves, and remains, contrary to medications, devoid of systemic complications.
The Achilles heel of glaucoma surgery though is its significant risk of local postoperative complications. These can range from hypotony related complications, to the most dreaded; endophthalmitis. In fact recent studies have shown that trabeculectomy is more efficient in inducing cataract and less so in reducing pressure. This basically draws the attention to the fact that whenever we make choices with our patients, safety is to be stressed at least as much as efficacy. Non-penetrating procedures provide what is possibly the highest profile in terms of safety, but its widespread use is hindered by its complexity.
In your hands is a book that does not only speak about the present but also about the future, as you go through the list of contents you will be able to view gold standard procedures as well as other procedures that are serious contenders to the throne. They may not be all backed by evidence-based information, but with their promise of a more efficacious, safer and simpler technique, they simply deserve a chance.
The Chief Editors Dr Ashok Garg, Dr Jorge Alió, Editors and Contributors of this book, all well recognized in their field as opinion leaders, are to be congratulated for the ample width and depth of what they offer.
Tarek Shaarawy md
Médecin adjoint du chef de service
Service d'ophthalmologie
Hôpitaux universitaires de Genève
22 rue Alcide Jentzer,
1211 Genèva 14, Switzerland
Tel. +41 22 3828 400 / 022 382 84 83
Fax. +41 22 3828 382
Email: Tarek.Shaarawy@hcuge.chd
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15Preface
Ophthalmic surgery technology has undergone rapid advancements and innovations in last two decades. From modest and conventional surgical techniques in early eighties, now it has become high-tech surgery with least indoor stay and excellent visual outcomes. Microincision surgery in both anterior and posterior segments, corneal and lenticular refractive surgery, modern keratoplasty techniques, pediatric and strabismus surgery, oculoplasty and reconstructive surgery and stem cell transplantation have entirely changed the scenario in ophthalmic surgery today.
Modern ophthalmic surgery is a vast subject. It is important for ophthalmologists to master various surgical steps in the ophthalmic surgery procedures of their interest. There are very few quality international Surgical Techniques in Ophthalmic book which can teach and guide the ophthalmologists to master various surgical techniques properly. Keeping in view of this factor, we have conceptualized the present series of Surgical Techniques in Ophthalmology which shall contain eight volumes. These volumes shall cover all aspects of ophthalmic surgery in a comprehensive and easy-to-read format. These volumes shall focus on especially Cataract Surgery, Refractive Surgery, Oculoplasty and Reconstructive Surgery, Corneal Surgery, Glaucoma Surgery, Retinal Surgery, Strabismus Surgery, and Pediatric Ophthalmic Surgery. A panel of International Eminent Ophthalmologists are contributing chapters in these volumes for the benefit of ophthalmologists worldwide.
This volume is dedicated to Glaucoma Surgery which is one of the most important and rapidly improving branch of ophthalmic surgery. All conventional and recently introduced high-tech glaucoma surgery techniques have been discussed in details step-by-step for the benefit of ophthalmic surgeons worldwide who want to master these hills to deal with glaucoma contingencies in a better and effective way to eradicate one of the leading cause of blindness. Several international master glaucoma surgeons have discussed latest glaucoma surgical techniques in a comprehensive and easy-to-read format. Specially, minimally penetrative glaucoma surgery with microtubes, various glaucoma shunts, pars plana AGV, canaloplasty, CO2 laser assisted deep sclerectomy and titanium-sapphire laser trabeculoplasty. We are sure that glaucoma surgeons shall be enriched with recently knowledge from these new techniques.
Our gratitudes are due to Shri Jitendar P Vij (CEO), Mr Tarun Duneja (Director, Publishing) and all staff members of our publisher M/s Jaypee Highlights Inc. who took keen interest in this project and for speedy completion of this mega task.
We expect that present series of Surgical Techniques in Ophthalmology shall serve as quick look reference book for ophthalmologists worldwide to sharpen their surgical skills.
Editors