High Frequency Deep
Sclerotomy (HFDS)
Dr. Dipak Gulhane
Dr. Rita Dhamankar
HFDS What is it ?
“ Sclerothalamotomy ab interno”
 Glaucoma filtration surgery
 Treatment modality for primary open-angl...
Surgical Treatment modality for primary open-
angle glaucoma (POAG)
Surgical
Treatment
Penetrating
Trabeculectomy
Shunt
No...
Surgical anatomy of anatomy anterior
chamber
Trabeculectomy
 First described in the 1960’s
 Gold standard glaucoma surgery
 Bypass the resistance of the trabecular ...
Trabeculectomy – Complications
 Intraoperative Complications
 Conjunctival buttonhole
 scleral flap tear
 Bleeding
 E...
Trabeculectomy – Complications
 Late Postoperative
 Late hypotony
 Late bleb failure
 Cataract formation
 Late bleb l...
Trabeculectomy – Complications
 COMPLICATIONS OF ANTIMETABOLITES
 Wound leak
 Epithelial erosions
 Endothelial damage ...
Nonpenetrating
glaucoma surgery Need ?
 Low complication rates
 Elimination / reduction of pressure-reducing
medication
NON-PENETRATING GLAUCOMA
SURGERY
ab externo ab interno
Viscocanalostomy
Canaloplasty
Deep sclerectomy
High frequency deep ...
NON-PENETRATING GLAUCOMA
SURGERY
Nonpenetrating
glaucoma surgery
ab externo
Canal of Schlemm
Viscocanalostomy
Canaloplasty...
HFDS Why ?
 Alternative to trabeculectomy
 Lesser complications
 Less invasive
 Consistent reduction of IOP
HFDS
 Minimally invasive, safe and efficacious technique
 Avoids damage to episcleral and conjunctival tissues
as in tra...
HFDSindications
 POAG - mild to moderate
 Not controlled with drugs
 Non compliance with drugs
 Not willing for topica...
HFDS indications
Monocular patient
Large diurnal fluctuations
Pigment dispersion glaucoma
Pseudoexfoliation glaucoma
High ...
HFDS contraindications
 Angle closure glaucoma
 Neovascular glaucoma
 Occludable angles
The Ideal Patient
 COAG
 POAG, exfoliation, pigmentary, steroid response
 High IOP on maximal medication
 Target IOP o...
High-Frequency Diathermic Probe (abee®
Glaucoma Tip, Oertli Instrumente AG)
 An inner platinum electrode which is isolate...
High-Frequency Diathermic Probe (abee®
Glaucoma Tip, Oertli Instrumente AG)
Surgical Procedure
 A clear cornea incision 1.2 mm wide
in temporal upper quadrant
 A second corneal incision is
perform...
Surgical Procedure
 Tip penetrates up to 1mm nasal into
the sclera through the trabecular
meshwork and Schlemm canal
 Fo...
HFDS Video animation
HFDS Video
Schematic – HFDS Opening
SL-OCT - HFDS POST OP
Complications
 Hypotony not severe
 Hyphaema - disappears within the first 2 weeks after
surgery
 Transient fibrin form...
Case
 SK
 64 years Male
 5 years
 BCVA 6/9 , N6
 Gonioscopy - open angles
 Intraocular pressure OD 20 OS 16 mm of Hg...
Case
 Impression – OU Posterior Polar Cataract primary open-
angle glaucoma
 Treatment – OU Timolet e/d BD
 BE Cataract...
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
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...
Study Of Effect Of High Frequency
Deep Sclerotomy & Intraocular
Pressure In Glaucoma Patients.
Inclusion criteria-
 Patient of either sex of age group 18-80 yrs
 Uncontrolled IOP with primary open angle glaucoma &
j...
Methodology-
 Design: prospective study
 Set-up: Laxmi Eye Institute and Laxmi Charitable Trust
hospital
 Sample size: ...
Methodology
 The parameters assessed for the purpose of research includes
 Demographics
 Visual acuity
 IOP by Applana...
Results
Pre op POD I POD II POD III POD IV
IOP 14.18[7.52] 13.64[4.62] 18.65[13.5
5]
In this study data of 18 patients is ...
Results
22.89
14.81
13.64
18.04
14.73
0
5
10
15
20
25
pre op post op visit1 post op visit 2 post op visit 3 post op visit 4
IOP
Re...
Discussion-
 According to our observation at 3 months follow up
,mean reduction in IOP is 8.16 [6.86] mm Hg& observed
com...
NON-PENETRATING GLAUCOMA
SURGERY
 Viscocanalostomy
 Canalplasty
 AqueSys
 CyPass Micro-Stent
 Hydrus Microstent
 iSt...
Viscocanalostomy
 Described by Stegmann
 A fornix-based conjunctival flap
 A second near-full thickness flap
 1 mm ins...
Video Viscocanalostomy
NON-PENETRATING AB EXTERNO
GLAUCOMA SURGERY
Canaloplasty
 Microcatheter or tube placed in the Canal of Schlemm
 250-µm fiber-optic OM catheter is guided by
fibreopt...
Video Canalplasty
Goniotomy
 Treatment for congenital glaucoma
 Instrument - goniotomy knife
 90–120 degrees of arc incisions in the ante...
Video Goniotomy
Trabeculotomy ab interno
 Directs flow of aqueous into the canal
and then into the collector channels
 Direct visualizat...
Video Trabeculotomy
iStent
 Inserted through a small temporal clear corneal
incision
 Placed in Schlemm's canal at the lower nasal
quadrant....
AqueSys
 Collagen-derived gelatin.
 To create outflow of aqueous from the anterior
chamber subconjunctival space.
 Gela...
AqueSys contd .
 The gelatin material is cross-linked - makes it
permanent.
 Clear corneal incision via a preloaded IOL-...
AqueSys contd .
CyPass Micro-Stent
 Implanted in the supraciliary space to establish a
permanent passage via uveoscleral outflow
 Negati...
Optical coherence tomography image of a
CyPass Micro-Stent in the supraciliary space.
Stent loaded on the guide wire
impla...
The Hydrus Microstent
 It is made of nitinol a nickel-titanium alloy
 Safe and biocompatibile
 Under topical anesthesia...
The Hydrus Microstent
The Hydrus Microstent is designed to dilate 3 clock
hours of Schlemm canal. The inlet at the right i...
The Hydrus Microstent
.
.The device 30 days after its implantation into
Schlemm canal.
The Hydrus Microstent
iStent Inject
 Single-piece, heparin-coated titanium stent
 Length of 360 µm , width of 230 µm
 Designed for retention ...
iStent Inject
Two stents positioned with 2
clock hours of separation
between them
The flanged end penetrates the trabecula...
iStent Supra
• Shunting aqueous to suprachoroidal space, the aqueous
exits either via a transscleral route or by choroidal...
iStent Supra
 Stent is implanted right below the scleral spur
 Combination with cataract surgery or alone
 Visibility o...
Solx Gold Shunt
 Made of biocompatible gold
 GMS and the GMS Plus
 Width 25 µm
 Height
 GMS model is 44 µm
 GMS Plus...
Solx Gold Shunt
 Outflow into the suprachoroidal
space
 Placed at the level of the scleral
spur
 Enhance uveoscleral ou...
Video Solx Gold Shunt
Animation Solx Gold Shunt
Take home message
 High frequency deep sclerotomy is conjunctival sparing minimally
invasive nonpenetrating glaucoma surg...
THANK YOU
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High Frequency Deep Sclerotomy (HFDS)

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High Frequency Deep Sclerotomy (HFDS)

  1. 1. High Frequency Deep Sclerotomy (HFDS) Dr. Dipak Gulhane Dr. Rita Dhamankar
  2. 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. 3. Surgical Treatment modality for primary open- angle glaucoma (POAG) Surgical Treatment Penetrating Trabeculectomy Shunt Nonpenetrating Ab externo Ab interno
  4. 4. Surgical anatomy of anatomy anterior chamber
  5. 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. 6. Trabeculectomy – Complications  Intraoperative Complications  Conjunctival buttonhole  scleral flap tear  Bleeding  Early Postoperative  Shallow anterior chamber  Low filtration  Choroidal effusion
  7. 7. Trabeculectomy – Complications  Late Postoperative  Late hypotony  Late bleb failure  Cataract formation  Late bleb leaks  Blebitis and endophthalmitis
  8. 8. Trabeculectomy – Complications  COMPLICATIONS OF ANTIMETABOLITES  Wound leak  Epithelial erosions  Endothelial damage and ciliary body destruction  Infection  Scleritis  Scleral thinning
  9. 9. Nonpenetrating glaucoma surgery Need ?  Low complication rates  Elimination / reduction of pressure-reducing medication
  10. 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. 11. NON-PENETRATING GLAUCOMA SURGERY Nonpenetrating glaucoma surgery ab externo Canal of Schlemm Viscocanalostomy Canaloplasty Deep sclerectomy ab interno Suprachoroidal space iStent Supra Solx Gold Shunt Canal of Schlemm iStent Inject Hydrus Microstent
  12. 12. HFDS Why ?  Alternative to trabeculectomy  Lesser complications  Less invasive  Consistent reduction of IOP
  13. 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. 14. HFDSindications  POAG - mild to moderate  Not controlled with drugs  Non compliance with drugs  Not willing for topical medication
  15. 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. 16. HFDS contraindications  Angle closure glaucoma  Neovascular glaucoma  Occludable angles
  17. 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. 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. 19. High-Frequency Diathermic Probe (abee® Glaucoma Tip, Oertli Instrumente AG)
  20. 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. 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. 22. HFDS Video animation
  23. 23. HFDS Video
  24. 24. Schematic – HFDS Opening
  25. 25. SL-OCT - HFDS POST OP
  26. 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. 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. 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. 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. 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. 31. Study Of Effect Of High Frequency Deep Sclerotomy & Intraocular Pressure In Glaucoma Patients.
  32. 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. 33. Methodology-  Design: prospective study  Set-up: Laxmi Eye Institute and Laxmi Charitable Trust hospital  Sample size: 30 eyes  Duration : 1 year
  34. 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. 35. Results Pre op POD I POD II POD III POD IV IOP 14.18[7.52] 13.64[4.62] 18.65[13.5 5] 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. 36. Results
  37. 37. 22.89 14.81 13.64 18.04 14.73 0 5 10 15 20 25 pre op post op visit1 post op visit 2 post op visit 3 post op visit 4 IOP Results
  38. 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. 39. NON-PENETRATING GLAUCOMA SURGERY  Viscocanalostomy  Canalplasty  AqueSys  CyPass Micro-Stent  Hydrus Microstent  iStent Inject  Solx Gold Shunt
  40. 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. 41. Video Viscocanalostomy
  42. 42. NON-PENETRATING AB EXTERNO GLAUCOMA SURGERY
  43. 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. 44. Video Canalplasty
  45. 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. 46. Video Goniotomy
  47. 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. 48. Video Trabeculotomy
  49. 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. 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. 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. 52. AqueSys contd .
  53. 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. 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. 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. 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. 57. The Hydrus Microstent . .The device 30 days after its implantation into Schlemm canal.
  58. 58. The Hydrus Microstent
  59. 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. 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. 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. 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. 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. 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. 65. Video Solx Gold Shunt
  66. 66. Animation Solx Gold Shunt
  67. 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. 68. THANK YOU
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