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Trabeculectomy Operation for Congenital Glaucoma
1,427 views | Added Jan 6, 2013 | Rate View top rated
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With Dr. Mohamed Abdalla Mohamed Salih.
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Glaucoma (207)
Dr.mohamed abdalla mohamed salih | commented on November 18, 2013
Thank you for your care.Believe me it works.Ihave done that hundreds of times with reasonable success.I,m following some patients for over 15years.Goniosc­opy is impassible in eyes with gross corneal oedema as seen in the video due to lack of visibility as you must observed. It is a challenging operation ,but a rescue procedure.Instr­umentation makes life easy but should never stop you from helping children.One last point I never charge glaucoma children,,,than­ks again
John_Thygesen | commented on November 17, 2013
The surgeon talks about congenital cataract when showing trabeculectomy. This kind of surgery in congenital glaucoma should be avoided using inappropriate knives and methods. What this video shows is what not to do. What its recommended internationally is either to use goniotomy or trabeculotomy, not trabeculectomy in congenital glaucoma. Please read the new WGA Consensus book on Childhood glaucoma just published by Kugler Publishing Nov 7, 2013
GabrielO | commented on October 10, 2013
Trabeculectomy is not a good choice for congenital glaucoma. If one or two trabeculotomies have failed, I prefer to insert a glaucoma implant. The surgical technique he showed in videos, is an excellent synthesis of all things that you must to avoid in a trabeculectomy.
dr mohamed salih | commented on April 2, 2013
thank you dr Bordianu for your care.your comments reflect your great surgical skills.for me I was pressed by the need of our community to use sim;le inexpensive methods to cure our patients.Starti­ng from what you've said(if God wants.....) I've done over 160000 glaucoma surgeries with satisfying results.One last thing medicine is god's gift and facilities are only facilities thank you again .Ihave the post operative photographs of that particular patient .
Bordeianu | commented on March 29, 2013
The video presentation contains a number of gestures which should be avoided, gestures particularly evident in the first video presentation. 1. Do not use cotton swabs during trabeculectomy: they may leave filaments buried under the conjunctiva, under the scleral flap, or even into the AC. 2. Do not use inappropriate knives for such delicate surgery: this huge knife explains why the flap was so poor in its left side. Here, the final closure was practically nonexistent. 3. Keep always in mind the fact that you work on thin sclera. That is why the scleral flap should be perfect. If the flap is not perfect on all sides, abandon the site and tailor a perfect flap tangent to the imperfect one. In both video presentations, the left margin of the flap is imperfect and will contribute to the final poor closure. 4. Keep always in mind the fact that you work on elastic sclera. After flap dissection, take measures to prevent flap retraction: otherwise, reaching at the end of surgery, you will find that you cannot suture the flap in its place. The video presentation is extremely illustrative in this direction: at the end of surgery, the trabeculectomy area was not covered by the flap. 5. Do not forget that fibroblasts are particularly dense at the sclera surface, that their proliferation and migration is triggered by the enzymes delivered from the cells destroyed by our surgical manoeuvres (cuts, crushes, perforations, cauterizations)­, and that in developing organisms like the one of a congenital glaucoma child, the wound closure mechanisms are particularly intense. Avoid unnecessary gestures. 6. Do not use the belly of the knife for opening the AC: knife is for dissection and perforation. In both video presentations, this huge knife was used for the whole trabecular excision. This gesture wouldn't be condemnable “per se”, but the manner in which it was performed, certainly is. First, 4 non perforating incisions were practised: OK with this, but in the first video presentation the posterior incision was a perforant one. In this situation, at least 4 disadvantages emerge: - the perforation of the anterior incision with the belly of the knife on a soft eye was difficult and traumatizing for the delicate eye structures. Such repeated gestures represent unnecessary traumas, gestures that may trigger an expulsive haemorrhage if the eye showed preoperative intense eye hypertonia; - on an emptied AC, it is difficult to know when the cut has perforated: if the horizontal cutting manoeuvres will continue after perforation, the lens or the zonule may be unnecessarily traumatized under the thin iris cover; - when one tries to cut on a soft eye, the cut tends to migrate anteriorly, because the sclera is depressed by the knife: one must change the knife orientation, maintaining its perpendicularit­y on the depressed sclera. If one maintains the knife perpendicular to the initial shape of the sclera – as the surgeon did, the position of the knife becomes anteriorly angled when the sclera is depressed: as a result, the cut migrates anteriorly; - when the surgeon has completed the last cut, he broke the golden rule of the anterior pole ophthalmic surgery: never work blindly on eye structures, always observe what you are doing with the tip of your instruments. When cutting the left side of the flap, the raised flap obstructed the view of the knife tip: this resulted in an uncontrolled excision, possibly passing beyond the scleral spur, producing cyclodialysis, and certainly exceeding the cover possibilities of the flap. Combined with the poor left side of the flap, this unintended excision will contribute to the impossibility to close the site without iris apposition or inclusion—eleme­nts of failure. 7. Adapt the dimension of the deep scleral excision zone after the possibilities to fully cover it with the superficial scleral flap. Before excising, take a look at the flap dimensions after its retraction and at the flap quality on all its 3 sides. In both presentations, the excision zone cannot be fully covered by the flap. 8. As a result of so many erroneous gestures, instead of trabeculectomy, the surgery was in fact a sort of Lagrange sclerectomy, with all its disadvantages. - The first disadvantage is excessive hypotonia, which will trigger the closure mechanism of the newly created pathway at the surface of sclera: in the subconjunctival space will arrive plasma-like aqueous humour, rich in fibrin precursors. Here, the fibrin precursors will find the necessary enzymes freed from the micro-organites of the cells destroyed by our surgical manoeuvres – iridectomy included. The result will be excessive fibrin deposition and closure at the surface of the sclera. - The second disadvantage consists in the natural response to eye hypotonia: the block of the trabeculectomy area with iris, lens capsule, zonule and/or vitreous. This will lead to the closure of the newly created pathway at its entrance, in the angle. If we take into consideration that the surgery was performed in Africa, where the population manifest excessive wound closure and where the trabeculectomy produces poor results even in adults, it seems to me that the presented surgery was done only to be done, after the principle: “if God wants, the surgery will succeed”. At the end of such surgery, the frequent consequence is failure with scleral staphyloma developed on the site of trabeculectomy area. My approach is different, but it would take too much to be described in this space. Could Healio host my experience in a 2-3 pages contribution? Sincerely Yours, Dr CD Bordeianu, Ploiesti, Romania
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