Bimanual trabecular aspiration in pseudoexfoliation glaucoma: an alternative in nonfiltering glaucoma surgery.

摘要

OBJECTIVE: The primary cause of intraocular pressure (IOP) elevation in pseudoexfoliation glaucoma is obstruction of the intertrabecular spaces by exfoliation material. Previously, the authors reported on a new concept of nonfiltering glaucoma surgery-trabecular aspiration-designed to increase trabecular outflow in pseudoexfoliation glaucoma. In the current study, a description of the modified instrument, its refined surgical technique, and long-term clinical results will be given to substantiate the efficacy of trabecular aspiration in the surgical management of pseudoexfoliation glaucoma. STUDY DESIGN: The study design was a prospective and nonrandomized study. PARTICIPANTS: A total of 68 eyes of 54 patients suffering from medically uncontrolled pseudoexfoliation glaucoma were treated by bimanual trabecular aspiration. Thirty-four eyes of 28 pseudoexfoliative patients treated by standard trabeculectomy constituted the control group. INTERVENTION: Trabecular debris and pigment were cleared with a suction force of 100 to 200 mmHg under light tissue-instrument contact using a modified intraocular aspiration probe. The aspiration cannula is 400 microm in diameter and horizontally angulated at 45 degrees. Irrigation of the anterior chamber was performed via a separate irrigation cannula. MAIN OUTCOME MEASURES: The IOP and number of medications before and after surgery were measured. RESULTS: In 42 eyes of 36 patients, trabecular aspiration was performed in combination with cataract extraction and lens implantation. The IOP dropped from 32.4 +/- 7.2 mmHg (range, 23-52 mmHg) under maximal tolerated medical therapy before surgery to 18.7 +/- 1.7 mmHg (range, 16-23 mmHg) at 2 years after surgery, with 54% of patients being controlled without medication. In 22 eyes of 19 patients, trabecular aspiration was performed as primary surgical intervention. The IOP dropped from 31.3 +/- 7.1 mmHg (range, 23-42 mmHg) before surgery to 16.8 +/- 3.4 mmHg (range, 12-23 mmHg) at 18 months after surgery, with 45% of patients not taking medication. CONCLUSIONS: Bimanual trabecular aspiration is safe and efficacious in decreasing IOP both with and without cataract extraction in pseudoexfoliation glaucoma. However, there seems to be a slight regression in effect over time attributed to undisturbed liberation of exfoliative debris. Argon-laser trabeculoplasty before trabecular aspiration reduces the IOP-lowering effect of this procedure. A prospective, randomized, multicenter study is warranted to finally assess the potential of trabecular aspiration in pseudoexfoliation glaucoma.