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Transscleral cyclophotocoagulation + modified Yamane
- Main Topics and Key Points:
- Podcast and Philosophy Start:
- The podcast emerged as an initiative to analyze complex cases in ophthalmology, those that are not always presented or presumed, and that often do not have simple solutions or completely satisfactory results.
- Mario Riquelme comments: "The intention of this channel is to analyze complex cases, which are not always or necessarily the cases we like to show or boast about because sometimes they have not even been fully resolved."
- The importance of planning surgeries and procedures outside of the clinical setting, in a calmer environment, is emphasized. Mario mentions: "I believe that many surgeries don't just stay in the office sometimes, but they begin to be planned, I think, from home."
- The idea of future podcasts about life before and after surgery, as well as stress management in complex cases, is being discussed.
- Importance of the Multidisciplinary Approach:
- A central theme is the need for collaboration between different specialists (glaucoma, retina, cornea, immunology, rheumatology, gynecology) to address complex cases in a comprehensive manner.
- José Maldonado states: "We try to make our best approach in complex cases, the truth is the cases that go away or the intention as Mario said is to try to see how to give the best result to that case that probably uh And many times you already know that it probably will not end in 2020 in a refractive surgery that the patient is fine but that we have to try to make the best effort multidisciplinarily."
- Mario Riquelme adds: "definitely two, three, four heads are better than one, and experience has taught us that sometimes, even though I'm a glaucomatologist, we have someone who is a retinal or cornea specialist or something like that, they may also have an opinion or something that you haven't considered."
- Clinical Case Presentation:
- The case of a 32-year-old female patient referred for bilateral angle-closure glaucoma with extremely high intraocular pressures (72 OD, 64 OI) and significant low vision is described.
- Mario Riquelme highlights the initial stress of having to "save a functioning eye in a very young patient who has her whole life ahead of her."
- The multiple procedures initially performed are mentioned, including lensectomy, transscleral endocyclophotocoagulation, and deep sclerotomy.
- A suspicion of an underlying inflammatory component was identified, corroborated by consultations with immunology and rheumatology, and the finding of early ovarian failure.
- Complications and New Approach:
- Despite a deep sclerotomy with a toric lens, the patient developed persistent low-grade inflammation and reservoir collapse, with elevated intraocular pressure.
- UGH (uveitis-glaucoma-hyphema) syndrome was suspected, although not always present with hyphema.
- A VBM (ultrasound biomicroscopy) revealed an Elschnig pearl and contact between the anterior lens and iris (Rose), contributing to the inflammation. José Maldonado describes the pearl as "literally like cords, almost like subretinal cords." I know they're not the pearls, but thick, tense, elastic cords were visible.
- It was decided to remove the plate lens and perform a complete posterior vitrectomy, followed by the placement of a sclera-anchored intraocular lens using the modified Yamane technique (through trocars 27).
- José Maldonado explains the modification of Yamane's technique: "instead of doing it with needles, it is done through a 27 trocar. Through a size 602 lens […] and therefore, the attics are obviously externalized through a 27 grip forceps and the cap is made."
- Postoperative Results and Discussion:
- Initially, intraocular pressure decreased significantly after three-quadrant destructive cyclophotocoagulation and combined surgery. Mario Riquelme mentions: "Initially, as with all cyclodestructive procedures, the pressure did drop significantly. I remember the initial postoperative pressure was around 11 or 13, and it dropped quite a bit."
- However, the pressure escalated again, and the patient developed corneal edema.
- 5-Fluorouracil (5-FU) injections were performed into the deep sclerotomy reservoir bleb, achieving a more consistent pressure decrease.
- The patient required a dissection (descemetopexy) and her current management is focused on the cornea.
- It is acknowledged that the case did not have a "happy ending," but the lessons learned are emphasized.
- Justification of the Approach and Modified Yamane Technique:
- The reasons for choosing scleral anchoring are discussed, considering inflammation and the need to preserve the conjunctiva for future glaucoma procedures.
- José Maldonado highlights the nobility of the Yamane technique in the management of the conjunctiva: "This technique, if you realize, we only really use two meridians and, obviously, considering that the reason this patient came to the consultation was for a diagnosis of glaucoma, it does not rule us out, apart from the current problem she has with the succorne, which obviously requires follow-up."
- Mario Riquelme emphasizes that the failure of the destruction cycle was a surprise and that all future solutions for the patient will be connective tissue-dependent.
- It is mentioned that the Yamane technique leaves a good posterior space, facilitating future corneal or glaucoma procedures.
- Advantages of the Yamane Technique with Trocar 27:
- We discuss how the use of trocar 27 in the Yamane technique can reduce the possibility of lens rotation or movement, and how tunneling with the trocar could better internalize the haptic cap, decreasing the risk of extrusion, erosion, or infection.
- José Maldonado explains: "With trocar 27, as there is a difference in the thicknesses of the most distal part to the most proximal part at the entrance of the trocar, this generates a kind of tunnel, like a funnel […] I believe that this benefit of the trocar can, to a certain degree, internalize a little, maybe not all, but part of this cap. And consequently, it could hide a part and not generate this extrusion of the optic."
- Invitation to Discussion and Collective Learning:
- The presenters invite other ophthalmologists to share their experiences with similar cases, alternative techniques, and results.
- Mario Riquelme says: "It's always good, I say it would be interesting to hear what you would have done, what you would have changed, what you would have done differently, not this one, and specifically this space is for that, no. I mean, to study these complex cases, always about J, more eh, they have more meat, let's put it like that."
- It is emphasized that the goal of the podcast is to learn from complex cases, even those with less than ideal outcomes, and to improve patient care through knowledge sharing.
- Conclusions:
- The first episode of the podcast "The Complicated Thing About the Difficult..." offers an honest and detailed look at the management of a complex ophthalmologic case. Drs. Maldonado and Riquelme emphasize the importance of multidisciplinary work, meticulous planning, and critical reflection on decisions made. The discussion of the modified Yamane technique with a 27-gauge trocar provides valuable technical insight and opens a debate on the advantages of different surgical approaches. Despite not presenting a case with a completely successful outcome, the podcast fulfills its objective of generating learning and fostering discussion among ophthalmology professionals, inviting them to share experiences and knowledge to address future challenging cases.
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