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Larrosa JM, Martínez-de-la-Casa JM, Giménez Gómez R, Goñi FJ, Milla E, Pazos M, Perucho Martínez S, Urcola Carrera JA. XEN-45 in the management of early glaucoma surgery: A national Delphi consensus study. Arch Soc Esp Oftalmol (Engl Ed) 2024; 99:98-108. [PMID: 38216051 DOI: 10.1016/j.oftale.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/29/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND AND OBJECTIVE Recommendations on general glaucoma management and the use of early minimally invasive and microincisional surgeries are limited. This study aimed to establish consensus regarding glaucoma management, focusing on the XEN-45 gel stent implant. METHODS A Delphi consensus-driven process was used. The scientific committee led the study, identified the expert panel, and participated in elaborating the questionnaire. Fifty-one panelists were invited to complete, on a nine-point Likert scale, an 89-item questionnaire covering three topic blocks. Two Delphi rounds were performed. Consensus was achieved if ≥66.6% of panelists reached agreement or disagreement. RESULTS Panelists agreed on 84 items related to the patients' quality of life, the therapeutic algorithm and patient profile, and surgical and pre- and post-operative management. Panelists agreed on the suitability of XEN stent implants to treat glaucoma at different stages and for different patient profiles: young patients, elderly or with significant comorbidities, and with myopic glaucoma, patients who failed previous surgeries, and with previous poor post-operative experience. XEN surgery was considered a therapeutic step prior to classic filtering surgery and a possible first surgical option in elderly patients with comorbidities and uncontrolled intraocular pressure. XEN surgery allows the patient to return to routine daily activities faster than conventional filtering surgeries and to reduce and/or eliminate topical treatments. CONCLUSIONS This Delphi-driven consensus resulted in a series of general recommendations for glaucoma management, including those related to patient quality of life, therapeutic algorithm, and patient profile, and specific ones regarding the use of XEN stent gel surgery.
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Affiliation(s)
- J M Larrosa
- Hospital Universitario Miguel Servet, Zaragoza, Spain; Instituto de Investigaciones Sanitarias de Aragón, Zaragoza, Spain
| | - J M Martínez-de-la-Casa
- Hospital Clínico San Carlos, Madrid, Spain; Facultad de Medicina, Universidad Complutense, Madrid, Spain.
| | | | - F J Goñi
- Departamento de Oftalmología, Hospital de Mollet del Vallès, Mollet del Vallès, Barcelona, Spain
| | - E Milla
- Unidad de Glaucoma, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M Pazos
- Unidad de Glaucoma, Hospital Clínic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - S Perucho Martínez
- Hospital de Fuenlabrada, Madrid, Spain; Facultad de Medicina, Universidad Rey Juan Carlos, Madrid, Spain
| | - J A Urcola Carrera
- Servicio de Oftalmología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain; Departamento de Dermatología, Oftalmología y Otorrinolaringología, Universidad del País Vasco, Leioa, Spain
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Ortiz-Arismendi GE, Huertas-Bello M, Castro Cárdenas CJ, Albis-Donado O. Results of a modified ab-external trabeculectomy surgical technique in patients with open angle glaucoma. Arch Soc Esp Oftalmol (Engl Ed) 2023; 98:640-645. [PMID: 37748683 DOI: 10.1016/j.oftale.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/09/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE Assess the safety and efficacy of a Modified Ab-externo Trabeculectomy surgical technique in controlling intraocular pressure (IOP) in open-angle glaucoma patients. METHODS AND ANALYSIS Patients diagnosed with primary or secondary open-angle glaucoma underwent this modified technique as the first filtering surgical treatment were included. The preoperative and final follow-up assessed IOP, hypotensive medications, the need for additional treatments, and early and late complications. RESULTS Forty-eight eyes of 38 patients were included. The mean age was 63.1 years (25-85 years), and the mean follow-up time was 35.3 months (range of 1147 months). The mean preoperative IOP was 25.21±3.48mmHg and 15.83±4.4mmHg by the follow-up end. Subsequent laser goniopuncture was performed on 14 eyes (29%) and needling in 4 eyes (8.4%). Complete success was achieved in 18 eyes (37.5%), qualified success in 17 (35.4%), and failed in 13 eyes (27.1%). Kaplan-Meier survival analysis shows a success rate of 81.7% at two years and 54.9% from year 4 to year 12. Multivariate analysis with generalized estimating equations (GEE) shows younger age as the main predictor for failure. Two eyes had choroidal detachment, three eyes progressed to cataracts that needed surgery, and five eyes had early bleb leaks. CONCLUSIONS This proposed technique is an effective surgical procedure for treating open-angle glaucoma with effective long-term IOP control and a low incidence of surgical complications and could be used in selected complex cases based on these results.
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Affiliation(s)
- G E Ortiz-Arismendi
- Ophthalmologist, Glaucoma Subspecialist, Universidad Nacional de Colombia, Colombia.
| | | | | | - O Albis-Donado
- Ophtalmologist, Glaucoma Subspecialist, Private Practice, Visual Sense, Mexico City, México
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Rosales-Rosales L, Garbín-Fuentes I. Efficacy and safety of the XEN45 implant in glaucoma surgery: Retrospective study of our first 73 cases. Arch Soc Esp Oftalmol (Engl Ed) 2023; 98:558-563. [PMID: 37640140 DOI: 10.1016/j.oftale.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/19/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE To analyze the results of the Xen45 implant in our hospital center, both in terms of efficacy and safety. METHODS Observational, retrospective, single-center study of patients undergoing Xen45 surgery at the University Hospital of Jaén between January 1, 2018 and June 31, 2021. RESULTS A total of 73 patients were implanted with the Xen45 device (48 with in combined surgery with phacoemulsification of the crystalline lens and 25 standalone Xen45 surgery). IOP decreased from 19.9 ± 4.9 mmHg at the first visit to a mean of 17.1 ± 5.3 (P = .001) at the sixth month. Drug use required between the first visit and Xen implantation was reduced from 2.1 ± 0.9 to 0.6 (P < .000). A second surgery was necessary in 18 patients (26.6%) in the first 6 months. CONCLUSIONS Glaucoma surgery by Xen45 implant, alone or combined with cataract surgery, is an effective and safe procedure for IOP lowering.
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Affiliation(s)
- L Rosales-Rosales
- Servicio de Oftalmología, Hospital Universitario de Jaén, Jaén, Spain.
| | - I Garbín-Fuentes
- Servicio de Oftalmología, Hospital Universitario de Jaén, Jaén, Spain
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Güemes Villahoz N, Morales Fernández L, Narváez Palazón C, Moreno MN, Gómez de Liaño Sánchez MR. Management of strabismus related to infantile glaucoma: Case series. Arch Soc Esp Oftalmol (Engl Ed) 2021; 96:293-298. [PMID: 34092283 DOI: 10.1016/j.oftale.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/10/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the different modalities of treatment of the strabismus related to infantile glaucoma, its complications, and results. METHODS The clinical history of 7 patients with infantile glaucoma which required strabismus surgical treatment were analyzed. Age at onset of glaucoma, type of glaucoma, glaucoma surgeries, type of strabismus, strabismus surgical treatment and postoperative results were studied. RESULTS Four patients required strabismus surgery, two were treated with botulinum toxin and one required both. Primary congenital glaucoma was the most common (71,42%), 14,28% had an anterior segment dysgenesis and 14,28% had secondary glaucoma. Regarding strabismus, 4 patients had exotropia and 3 had esotropia. The main difficulty involved the management of the conjunctiva and the filtering blebs. CONCLUSION Strabismus is a frequent complication in infantile glaucoma. The management of these patients should be individualized. In our case series, treatment of strabismus improved eye alignment. Surgery should be the mainstay of treatment while preserving the conjunctiva and interfere the less with glaucoma surgeries. Botulinum toxin is a reasonable option when conservative treatment is needed.
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Affiliation(s)
- N Güemes Villahoz
- Servicio de Oftalmología, Hospital Clínico San Carlos, Madrid, Spain.
| | - L Morales Fernández
- Servicio de Oftalmología, Hospital Clínico San Carlos, Madrid, Spain; Servicio de Oftalmología, Hospital Quirónsalud, Madrid, Spain
| | - C Narváez Palazón
- Servicio de Oftalmología, Hospital Clínico San Carlos, Madrid, Spain
| | - M N Moreno
- Servicio de Oftalmología, Hospital Universitario La Paz, Madrid, Spain
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Güemes Villahoz N, Morales Fernández L, Narváez Palazón C, Moreno MN, Gómez de Liaño Sánchez MR. Management of strabismus related to infantile glaucoma: Case series. ACTA ACUST UNITED AC 2020. [PMID: 33268281 DOI: 10.1016/j.oftal.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the different modalities of treatment of the strabismus related to infantile glaucoma, its complications, and results. METHODS The clinical history of 7 patients with infantile glaucoma which required strabismus surgical treatment were analyzed. Age at onset of glaucoma, type of glaucoma, glaucoma surgeries, type of strabismus, strabismus surgical treatment and postoperative results were studied. RESULTS Four patients required strabismus surgery, two were treated with botulinum toxin and one required both. Primary congenital glaucoma was the most common (71,42%), 14,28% had an anterior segment dysgenesis and 14,28% had secondary glaucoma. Regarding strabismus, 4 patients had exotropia and 3 had esotropia. The main difficulty involved the management of the conjunctiva and the filtering blebs. CONCLUSION Strabismus is a frequent complication in infantile glaucoma. The management of these patients should be individualized. In our case series, treatment of strabismus improved eye alignment. Surgery should be the mainstay of treatment while preserving the conjunctiva and interfere the less with glaucoma surgeries. Botulinum toxin is a reasonable option when conservative treatment is needed.
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Affiliation(s)
- N Güemes Villahoz
- Servicio de Oftalmología, Hospital Clínico San Carlos, Madrid, España.
| | - L Morales Fernández
- Servicio de Oftalmología, Hospital Clínico San Carlos, Madrid, España; Servicio de Oftalmología, Hospital Quirónsalud, Madrid, España
| | - C Narváez Palazón
- Servicio de Oftalmología, Hospital Clínico San Carlos, Madrid, España
| | - M N Moreno
- Servicio de Oftalmología, Hospital Universitario La Paz, Madrid, España
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El Afrit MA, Saadouli D, Hachicha G, Ben Mansour K, El Afrit N, Yahyaoui S. The outcome of surgical treatment in advanced glaucoma. ACTA ACUST UNITED AC 2021; 96:189-94. [PMID: 32654827 DOI: 10.1016/j.oftal.2020.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/18/2020] [Accepted: 05/29/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION There is uncertainty regarding the outcomes of glaucoma surgery for patients with advanced glaucoma, because it may be associated with the «wipe out» phenomenon. The aim of this study was to evaluate the outcome of surgical treatment in advanced glaucoma. METHODS This retrospective study included 67eyes of 49 patients with end-stage glaucoma in which glaucoma surgery was carried out. The clinical records prior to and after surgery were reviewed. Follow up period was 14.4months. RESULTS The mean age was 50.2years and the sex ratio was 0.75. All the patients had a tubular visual field with persistence of a central island. The mean value of the mean deviation on automated perimetry was 18.94dB±4.7. The mean intraocular pressure (IOP) before surgery was 27.16mmHg±8.9. Postoperatively the overall success rate was 93% (IOP <18mmHg with stable visual acuity). The mean IOP was 14.25mmHg±4.12 (P<.001). There was no significant change in the mean visual acuity. The mean value of the mean deviation was 18.83±4.69 (P=.07). No occurrence of wipe-out phenomenon was noted. The early postoperative complications were hypotony, hyphema and ocular hypertension and they were transient without causing any visual loss. Long term complications were late bleb fibrosis and progression of cataract. CONCLUSION Glaucoma surgery had beneficial effects in the majority of patients with advanced glaucoma. Postoperative IOP was in general under control and visual acuity was preserved without any cases of wipe-out.
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Kudsieh B, Casado López de la Franca E, Díez Gómez MA, Ruiz Moreno JM. Open angle glaucoma secondary to endogenous cortisone due to pituitary microadenoma in a young patient, a case report. ACTA ACUST UNITED AC 2020; 95:353-6. [PMID: 32423629 DOI: 10.1016/j.oftal.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/08/2020] [Accepted: 03/18/2020] [Indexed: 11/23/2022]
Abstract
CASE REPORT A 31-year-old male was referred for evaluation after being diagnosed with Cushing syndrome secondary to a pituitary microadenoma. He presented with a reduced visual acuity and high intraocular pressure (IOP) of 48mmHg in both eyes. The examination with biomicroscopy showed normal anterior segment, increased cup to disc ratio, and open angle. There was a moderate-advanced involvement in the visual field. The patient was diagnosed with glaucoma secondary to endogenous corticosteroids, and medical treatment was initiated pending the removal of the adenoma. The IOP did not return to normal after the incomplete removal of the adenoma, so a trabeculectomy was performed to control the IOP. As conclusions: In the case of an ocular hypertension with pituitary tumour, secondary glaucoma to endogenous cortisone should be suspected. Early treatment of the tumour is necessary to bring the cortisone and IOP levels back to normal. Late diagnosis or incomplete treatment of these tumours may lead to not obtaining adequate IOP control.
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Logioco C, Perrone LD, Caruso D, Albertazzi R, Valvecchia G, Zanutigh V. Assessment of efficacy and safety of micropulse diode laser treatment in glaucoma: One year follow-up. ACTA ACUST UNITED AC 2020; 95:327-33. [PMID: 32409244 DOI: 10.1016/j.oftal.2020.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the effectiveness and safety of the micropulse transscleral technique in lowering intraocular pressure in patients with glaucoma. MATERIALS AND METHODS A retrospective cohort study was conducted on 143 eyes with various glaucoma subtypes between October 2016 and December 2018. Patients were grouped for analysis based on glaucoma subtypes, preoperative demographics, previous surgical procedures, and postoperative results. The data collected was based on intra- and post-operative complications, intraocular pressure, visual acuity, the need of micropulse re-treatment, incisional glaucoma surgery, and increasing the dose/quantity of medications. A logistic and Cox regression model was performed to determine predictors of therapeutic failure, in addition to building Kaplan-Meier curves. RESULTS The mean follow-up was 268 days, and 63% of the patients completed one year. The micropulse procedure achieved a mean intraocular pressure decline of 7.3mmHg (excluding neovascular glaucoma), independent of the glaucoma subtype. The percentage of patients who achieved intraocular pressure less than 20mmHg at 24h was 78%, with 80% at 3 months, 77% at 6 months, and 78% at 12 months. During the follow-up, 29.6% of the patients required additional treatment or a dose increase. Only 2patients presented with minimal postoperative complications. CONCLUSION The treatment with transscleral micropulse is a safe and efficient technique for use in glaucoma, attaining a reduction in intraocular pressure and decrease in need of antihypertensive medications within the first year following the procedure.
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Pérez-Sarriegui A, Casas-Llera P, Díez-Álvarez L, Contreras I, Moreno-López M, Figueroa MS, González-Martín-Moro J, Muñoz-Negrete FJ, Rebolleda G. Phaco-non-penetrating deep sclerectomy in ocular hypertension secondary to dexamethasone intravitreal implant. Arch Soc Esp Oftalmol (Engl Ed) 2018; 93:580-585. [PMID: 30266279 DOI: 10.1016/j.oftal.2018.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/12/2018] [Accepted: 06/15/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE To evaluate the characteristics and progression of patients treated with a 0.7mg dexamethasone intravitreal implant (Ozurdex®) and required glaucoma filtering surgery (phaco-non-penetrating deep sclerectomy) to control ocular hypertension (OHT). METHODS A retrospective observational study including patients treated with Ozurdex® in a tertiary-care university hospital from May 2011 to April 2016. RESULTS In five years of follow-up, 1.10% (4/363) of patients treated with 0.7mg dexamethasone intravitreal implant required phaco-non-penetrating deep sclerectomy (PNPDS) to control OHT refractory to topical treatment. All four patients started or increased previous antihypertensive topical treatment since the first dexamethasone intravitreal implant. Three or more dexamethasone intravitreal implants were injected in the four cases before intraocular pressure (IOP) became uncontrolled and PNPDS was performed. All four patients have a successfully controlled IOP without treatment after PNPDS. Two patients required additional treatment with dexamethasone intravitreal implants after PNPDS, maintaining IOP under control without treatment. CONCLUSIONS To the best of our knowledge, this is the first study describing the successful results of PNPDS in OHT secondary to dexamethasone intravitreal implant. All four patients have achieved controlled IOP without treatment. Re-treatment with dexamethasone intravitreal implant in those patients who underwent PNPDS is also possible, and IOP remains controlled.
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Affiliation(s)
- A Pérez-Sarriegui
- Departamento de Oftalmología, Hospital de Mendaro, Mendaro, Guipúzcoa, España
| | - P Casas-Llera
- Department of Glaucoma Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - L Díez-Álvarez
- Departamento de Oftalmología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Ramón y Cajal, Madrid, España.
| | - I Contreras
- Departamento de Oftalmología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Ramón y Cajal, Madrid, España
| | - M Moreno-López
- Departamento de Oftalmología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Ramón y Cajal, Madrid, España
| | - M S Figueroa
- Departamento de Oftalmología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Ramón y Cajal, Madrid, España
| | | | - F J Muñoz-Negrete
- Departamento de Oftalmología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Ramón y Cajal, Madrid, España
| | - G Rebolleda
- Departamento de Oftalmología, Instituto Ramón y Cajal de Investigación Sanitaria, Hospital Ramón y Cajal, Madrid, España
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Hernández Pardines F, Tapia-Quijada H, Hueso-Abancens JR. A case of aminoglycosides induced retinal toxicity treated with megadoses of steroids and an intravitreal dexamethasone implant (Ozurdex(®)). ACTA ACUST UNITED AC 2016; 91:288-91. [PMID: 26922137 DOI: 10.1016/j.oftal.2016.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 01/13/2016] [Accepted: 01/14/2016] [Indexed: 11/21/2022]
Abstract
CASE REPORT The case is described of a patient who had a sudden loss of vision in her right eye after glaucoma surgery. A diagnosis of retinal toxicity due to tobramycin (an aminoglycoside) was reached, which was characterised by retinal whitening with a red cherry stain, macular oedema, and vasculitis that progressed to papillary and macular atrophy with arteriolar sclerosis. Given the severity of symptoms an early attempt was made with megadoses of steroids and an intravitreal dexamethasone implant (Ozurdex®, Allergan S.A.), without response. DISCUSSION Aminoglycoside toxicity is a rare, idiosyncratic, very serious complication for which there is no effective treatment.
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Marín-Montiel J, López-Sánchez E, Chaqués-Alepuz V. [Bubble mirror technique for express shunt surgery]. ACTA ACUST UNITED AC 2014; 90:335-7. [PMID: 25443194 DOI: 10.1016/j.oftal.2014.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Revised: 12/08/2013] [Accepted: 03/18/2014] [Indexed: 11/17/2022]
Abstract
SURGICAL TECHNIQUE The bubble mirror technique consists of the stabilization of the anterior chamber by means of a plug made with a combination of conveniently placed air and viscoelastic material. A line arises at interface between the air and viscoelastic where the anterior chamber angle reflected can be seen as in a mirror (bubble mirror). DISCUSSION The viscoelastic-air plug offers three advantages in glaucoma surgery with the Ex-PRESS implant: 1) plug effect of viscoelastic, giving stability to the anterior chamber and preventing it from collapsing; 2) toning effect of the air bubble; and 3) specular effect at the interface, which allows the surgeon to visually control the chamber angle during the Ex-PRESS implantation.
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Affiliation(s)
- J Marín-Montiel
- Servicio de Oftalmología, Hospital Universitario Arnau de Vilanova, Valencia, España; Facultad de Medicina, Universidad Católica de Valencia San Vicente Mártir, Valencia, España.
| | - E López-Sánchez
- Servicio de Oftalmología, Hospital Universitario Arnau de Vilanova, Valencia, España; Facultad de Medicina, Universidad Católica de Valencia San Vicente Mártir, Valencia, España
| | - V Chaqués-Alepuz
- Servicio de Oftalmología, Hospital Universitario Arnau de Vilanova, Valencia, España; Facultat de Medicina i Odontología, Universitat de València, Valencia, España
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