High Frequency Deep Sclerotomy (HFDS)

High Frequency Deep Sclerotomy

1. High Frequency Deep Sclerotomy ( HFDS) Dr. Dipak Gulhane Dr. Rita Dhamankar

2. HFDS What is it ? “ Sclerothalamotomy ab interno” Glaucoma filtration surgery Treatment modality for primary open-angle glaucoma (POAG) Bypass the resistance of the trabecular meshwork Channelling aqueous humour directly to Schlemm’s canal

3. Surgical Treatment modality for primary open-angle glaucoma (POAG)

4. Surgical anatomy of anatomy anterior chamber

5. Trabeculectomy First described in the 1960’s Gold standard glaucoma surgery Bypass the resistance of the trabecular meshwork Channelling aqueous humour directly to subconjunctival space Success rate of trabeculectomy - 32 and 96% Postoperative complication like hypotony and choroidal detachment in up to 24% of cases No repeatibility and reproducibility

6. Trabeculectomy – Complications Intraoperative Complications Conjunctival buttonhole scleral flap tear Bleeding Early Postoperative Shallow anterior chamber Low filtration Choroidal effusion

7. Trabeculectomy – Complications Late Postoperative Late hypotony Late bleb failure Cataract formation Late bleb leaks Blebitis and endophthalmitis

8. Trabeculectomy – Complications COMPLICATIONS OF ANTIMETABOLITES Wound leak Epithelial erosions Endothelial damage and ciliary body destruction Infection Scleritis Scleral thinning

9. Nonpenetrating glaucoma surgery Need ? Low complication rates Elimination / reduction of pressure-reducing medication

10. NON-PENETRATING GLAUCOMA SURGERY ab externo ab interno Viscocanalostomy Canaloplasty Deep sclerectomy High frequency deep sclerotomy AqueSys CyPass Micro-Stent Hydrus Microstent iStent Inject

11. NON-PENETRATING GLAUCOMA SURGERY

12. HFDS Why ? Alternative to trabeculectomy Lesser complications Less invasive Consistent reduction of IOP

13. HFDS Minimally invasive, safe and efficacious technique Avoids damage to episcleral and conjunctival tissues as in trabeculectomy and conventional non-penetrating surgery Low rate of postoperative complications

14. HFDSindications POAG - mild to moderate Not controlled with drugs Non compliance with drugs Not willing for topical medication

15. HFDS indications Monocular patient    Large diurnal fluctuations    Pigment dispersion glaucoma    Pseudoexfoliation glaucoma      High risk of choroidal effusions or hemorrhages    Axial myopia     Previously vitrectomized eye       History of choroidal effusion or hemorrhage       High risk of postoperative hypotony      Young patients    High myopes   

16. HFDS contraindications Angle closure glaucoma Neovascular glaucoma Occludable angles

17. The Ideal Patient COAG POAG, exfoliation, pigmentary , steroid response High IOP on maximal medication Target IOP of mid-teens Good visualization of angle structures No previous angle surgery/laser

18. High-Frequency Diathermic Probe ( abee ® Glaucoma Tip, Oertli Instrumente AG) An inner platinum electrode which is isolated from the outer coaxial electrode. Tip is 1 mm in length, 0.3 mm height and 0.6 mm width and is bent posteriorly at an angle of 15° The external diameter - 0.9 mm. Modulated 500 kHz current generates a temperature - 130°C at the tip

19. High-Frequency Diathermic Probe ( abee ® Glaucoma Tip, Oertli Instrumente AG)

20. Surgical Procedure A clear cornea incision 1.2 mm wide in temporal upper quadrant A second corneal incision is performed 120° apart Injection of Healon GV Probe inserted through the temporal corneal incision Opposite iridocorneal angle observed by a 4-mirror gonioscopic lens

21. Surgical Procedure Tip penetrates up to 1mm nasal into the sclera through the trabecular meshwork and Schlemm canal Forms a deep sclerotomy (i.e. “thalami”) of 0.3 mm high and 0.6 mm width Procedure repeated 6 times within one quadrant Healon GV evacuated from the anterior chamber with bimanual irrigation/aspiration.

22. HFDS Video animation

23. HFDS Video

24. Schematic – HFDS Opening

25. SL-OCT - HFDS POST OP

26. Complications Hypotony not severe Hyphaema - disappears within the first 2 weeks after surgery Transient fibrin formation – clears within early post op after frequent application of topical Dexamethasone

27. Case SK 64 years Male 5 years BCVA 6/9 , N6 Gonioscopy - open angles Intraocular pressure OD 20 OS 16 mm of Hg Anterior segment - Posterior Polar Cataract Fundus - C:D OD 0.6 OS 0.5 Inf notching Perimetry – Suprior paracentral defect OCT ONH – Thinning of inf rim

28. Case Impression – OU Posterior Polar Cataract primary open-angle glaucoma Treatment – OU Timolet e/d BD BE Cataract surgery done 2008 2010 OD 20 OS 16 mm of Hg C:D OD 0.7 OS 0.75 OU Brimonidine + Timolol e/d BD

29. Case 2012 C:D OD 0.8 OS 0.8 Intraocular pressure 14 18 mm of Hg Advice BE HFDS Post op Pilocatpine e/d BD

30. Case Intraocular pressure OD mm of Hg Intraocular pressure OS mm of Hg Pre op 14 18 Post op 1 week 14 08 Post op 1 month 8 12 Post op 3 month 10 10

31. Study Of Effect Of High Frequency Deep Sclerotomy & Intraocular Pressure In Glaucoma Patients.

32. Inclusion criteria- Patient of either sex of age group 18-80 yrs Uncontrolled IOP with primary open angle glaucoma & juvenile glaucoma Non compliance of patient to medical therapy

33. Methodology- Design: prospective study Set-up: Laxmi Eye Institute and Laxmi Charitable Trust hospital Sample size: 30 eyes Duration : 1 year

34. Methodology The parameters assessed for the purpose of research includes Demographics Visual acuity IOP by Applanation tonometry Cup disc changes Angles ( gonioscopy ) This parameters to be assessed at pre operatively as well as post operatively on Day 1 , 7 , 30, 90 POD visit I II III IV

35. Results Pre op POD I POD II POD III POD IV IOP 14.18[7.52] 13.64[4.62] 18.65[13.55] In this study data of 18 patients is analysed, 13 –males, mean age- 57.54[12.08] 5 females,mean age- 60.51[24.7] 22.89[8.19] 14.73[6.86]

36. Results

37. IOP Results

38. Discussion- According to our observation at 3 months follow up ,mean reduction in IOP is 8.16 [6.86] mm Hg& observed complication was hyphema which got resolved in 7 days post operatively Akafo SK et al,in 1990 Longterm post trabeculectomy intraocular pressure, success rate of IOP range[32 and 96%] postoperative complications like hypotony and choroidal detachment are reported in 24% Literature on non-penetrating deep sclerectomy by Demailly P, Lavat P, Kretz G et al indicates a success rate of 58–74% without a collagen implant and 74–90% with collagen implantation post operative filtering complication

39. NON-PENETRATING GLAUCOMA SURGERY Viscocanalostomy Canalplasty AqueSys CyPass Micro-Stent Hydrus Microstent iStent Inject Solx Gold Shunt

40. Viscocanalostomy Described by Stegmann A fornix-based conjunctival flap A second near-full thickness flap 1 mm inside this flap and slowly extended into Schlemms canal Stripping thin layers of deep tissue overlying Schlemm's canal and Descemet's membrane Gentle dilation of the cut ends of Schlemm's with Healon GV Superficial flap was secured in as watertight fashion as possible with 10/0 Vicryl

41. Video Viscocanalostomy

42. NON-PENETRATING AB EXTERNO GLAUCOMA SURGERY

43. Canaloplasty Microcatheter or tube placed in the Canal of Schlemm 250-µm fiber-optic OM catheter is guided by fibreoptic light source Opens up collapsed Schlemm’s canal Used to treat congenital glaucoma Steep learning curve

44. Video Canalplasty

45. Goniotomy Treatment for congenital glaucoma Instrument - goniotomy knife 90–120 degrees of arc incisions in the anterior trabecular meshwork 10% of a recurrence rate Complications – hyphema , damage to iris / ciliary body , cataract formation , inflammation in the anterior chamber; scarring of the cornea , subluxation or dislocation of the lens , retinal detachment

46. Video Goniotomy

47. Trabeculotomy ab interno Directs flow of aqueous into the canal and then into the collector channels Direct visualization with a gonioscopy lens Removes a 60-to 120-degree strip of the trabecular meshwork and the inner wall of Schlemm’s canal with electrocautery

48. Video Trabeculotomy

49. iStent Inserted  through a small temporal clear corneal incision Placed in Schlemm's canal at the lower nasal quadrant. By creating a patent bypass through Schlemm's   re-establishes physiologic outflow In vitro  - iStent ®  can improve facility of outflow by 84% (p<.003)

50. AqueSys Collagen-derived gelatin. To create outflow of aqueous from the anterior chamber subconjunctival space. Gelatin - well tolerated and noninflammatory . Soft, and this pliabile allows the device to conform to the ocular tissue

51. AqueSys contd . The gelatin material is cross-linked - makes it permanent. Clear corneal incision via a preloaded IOL-like inserter using an ab interno approach Can be placed over the course of the patient’s lifetime

52. AqueSys contd .

53. CyPass Micro-Stent Implanted in the supraciliary space to establish a permanent passage via uveoscleral outflow Negative pressure gradient between the suprachoroidal space and the anterior chamber - driving force Fenestrated, miniature stent Biocompatible, nonbiodegradable polyimide material 6.35 mm long and has an external diameter of 510 μm Inserter for the stent consists of a handpiece and a releasable guidewire

54. Optical coherence tomography image of a CyPass Micro-Stent in the supraciliary space. Stent loaded on the guide wire implanted in the supraciliary space. The surgeon views the device through a goniolens after implantation.

55. The Hydrus Microstent It is made of nitinol a nickel-titanium alloy Safe and biocompatibile Under topical anesthesia Dimensions and curvature similar as Schlemm canal. Loaded inside handheld injector Placed in nasal iridocorneal angle under direct gonioscopy

56. The Hydrus Microstent The Hydrus Microstent is designed to dilate 3 clock hours of Schlemm canal. The inlet at the right is positioned in the anterior chamber to facilitate aqueous flow across the trabecular meshwork and through Schlemm canal into the collector channels.

57. The Hydrus Microstent . .The device 30 days after its implantation into Schlemm canal.

58. The Hydrus Microstent

59. iStent Inject Single-piece, heparin-coated titanium stent Length of 360 µm , width of 230 µm Designed for retention within the trabecular meshwork Single-use injector system Injector - insertion sleeve retraction button and a stent release button Penetrates the trabecular meshwork Several clock hours of distance between the two stents Get into the canal of Schlemm  

60. iStent Inject Two stents positioned with 2 clock hours of separation between them The flanged end penetrates the trabecular meshwork and stops with the thicker, flat end in the anterior chamber

61. iStent Supra Shunting aqueous to suprachoroidal space, the aqueous exits either via a transscleral route or by choroidal absorption Made of poyethersulfone and has a coloured titanium sleeve Heparin coated ( Duraflo ) and is biocompatible Curved to match the suprachoroidal space Has retention rings to provide stability at the site of implantation Clear visibility of the angle structures and a knowledge of the angle landmarks

62. iStent Supra Stent is implanted right below the scleral spur Combination with cataract surgery or alone Visibility of the angle structures and a knowledge of the angle landmarks IMPORTANT

63. Solx Gold Shunt Made of biocompatible gold GMS and the GMS Plus  Width 25 µm Height GMS model is 44 µm GMS Plus 68 µm Two leaflets fused together

64. Solx Gold Shunt Outflow into the suprachoroidal space Placed at the level of the scleral spur Enhance uveoscleral outflow Size 5.2mm long 2.4mm wide anteriorly 3.2mm wide posteriorly

65. Video Solx Gold Shunt

66. Animation Solx Gold Shunt

67. Take home message High frequency deep sclerotomy is conjunctival sparing minimally invasive nonpenetrating glaucoma surgery with lesser complications . HFDS can be considered as primary line of treatment for primary open angle glaucoma Non compliant , non willing for topical medication Combined with cataract surgery Trabeculectomy is always there to take care of failure cases

68. THANK YOU