Methodology
open-angle glaucoma, choroidals, conjunctival leak, dry cellulose, glaucoma, OAG, Glaucoma, fornix-based
NEOVASCULAR GLAUCOMA, SCHEIE, INFLAMMATION, OPEN-ANGLE GLAUCOMA, CORNEA, ANGLE CLOSURE GLAUCOMA, LENS, GLAUCOMA, CONJUNCTIVA, GLAUCOMA
This is a prospective interventional randomized comparative study that compared sutureless versus conventional deep sclerectomy as a primary surgical management for open-angle glaucoma (OAG). The study included 60 eyes of 50 patients with OAG who were indicated for surgical intervention. The study patients were recruited from the Glaucoma Subspecialty Clinic of the Cairo University Teaching Hospital during the period between September 2018 and April 2020. Patients were divided into two groups: group A (they underwent sutureless deep sclerectomy) and group B (underwent conventional deep sclerectomy). Randomization was done in the outpatient clinic where the recruited cases were given numbers from 1 to 60 with eyes with odd numbers added to group A and those with even numbers added to group B. All patients signed a written consent to participate in the study and to approve sharing of the study data after thorough explanation of the surgical technique and its expected drawbacks. The study was performed according to the tenets of the Declaration of Helsinki and was approved by the Scientific Committee of the Ophthalmology Department of the Faculty of Medicine, Cairo University.Inclusion criteria for the study were patients with open-angle glaucoma who were indicated for surgical intervention due to failure to control IOP despite the use of maximally tolerated medical treatment, non-adherence, or intolerance to anti-glaucoma medications. Exclusion criteria were angle closure glaucoma, uveitic glaucoma, neovascular glaucoma, and history of previous glaucoma surgery.The selected cases were diagnosed as OAG on basis of clinical examination, visual field examination, and retinal nerve fiber layer analysis with spectral domain-optical coherence tomography (SD-OCT) according to the European Glaucoma Society guidelines [History was taken from each patient with emphasis on family history, previous ocular surgeries, and number and duration of glaucoma medications used. Then, each patient underwent full ophthalmological examination including corrected distance visual acuity (CDVA) using Snellen chart and recorded in Log MAR, anterior segment examination using Slit lamp, posterior segment examination using slit lamp biomicroscopy and 90-D lens (Volk, VOLK Optical; Mentor, Ohio, USA), IOP measurement using Goldmann applanation tonometer GAT (HAAG-STREIT AT 900, Edinburgh Way, Harlow, UK), and gonioscopy using three-mirror Goldmann contact lens (Volk, VOLK Optical; Mentor, Ohio, USA) with grading of the angle according to the Scheie classification system [All patients underwent deep sclerectomy under peri-bulbar anesthesia by the only 2 surgeons (A. M. A. and M. K.); each surgeon has done equal number of patients of the 2 groups. A superior corneal traction suture was taken using 7–0 Vicryl. The conjunctiva was dissected by doing fornix-based flap followed by minimal diathermy application to cauterize the bleeders. Superficial scleral flap (4 × 3 mm) was dissected using crescent blade, and the dissection was carried out anteriorly into the peripheral 2 mm of clear cornea. Mitomycin C (MMC) (Kyowa Co., Hakko Kirin, Japan) with concentration (0.4 mg/ml) was applied for 2 min underneath the superficial scleral flap before dissecting the deep one and that under the dissected conjunctiva, and then washed by 20 ml of balanced salt solution (BSS). Paracentesis was done using microvitreoretinal (MVR) blade. The same crescent blade was used to dissect the deep scleral flap just inside the margins of the superficial one with deroofing of the Schlemm’s canal and exposing the trabeculo-Descemetic membrane. The deep flap was then excised using fine scissors, and the percolation was tested to be adequate with cellulose microsponge. In group A, the superficial scleral flap was left un-sutured to freely float and return in position, and the conjunctival edges were re-approximated with low-power diathermy (30 to 40%) (Fig. One eye of sutureless deep sclerectomy group at the end of surgery with the scleral flap left un-sutured under the conjunctival flap that was re-approximated with 30–40% diathermyIn group B, the superficial scleral flap was sutured in place with two 10/0 Nylon sutures, and the conjunctiva was sutured in place using 8/0 polyglactin sutures. The presence of conjunctival leak was tested by using a dry cellulose sponge. An ointment with combination of steroid and antibiotic was applied to the ocular surface at the end of the surgery.Follow up was done at the 1st day, 1 week, 1 month, 3 months, and 6 months postoperatively. In each visit, the eye was examined for IOP, depth of anterior chamber with any signs of inflammation, any conjunctival leak, and changes in the fundus especially choroidals. Ultrasound biomicroscopy (UBM) was done for all patients at 1 month and 6 months postoperatively.Complete success was defined if IOP ranged from 6 to 18 mmHg throughout the follow-up period without use of glaucoma medications, while qualified success was defined if IOP ranged from 6 to 18 mmHg with anti-glaucoma medications. Use of anti-glaucoma medications or interventions done for reducing IOP was reported at different spots of follow up.