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Summary document
This episode of the ophthalmology podcast/videoblog presents a complex clinical case of a 50-year-old male patient who presented with ocular pain, red eye, and photophobia, presenting with bilateral anterior chamber collapse and elevated intraocular pressure (above 40 mmHg).
The case is most likely attributed to a lens subluxation or dislocation secondary to an electric shock suffered by the patient a year earlier. The therapeutic approach required a combined intervention by the retina and glaucoma services, including lensectomy, complete vitrectomy, synechiolysis, and goniotomy. Despite an unspecified setback during the second surgery, the outcome in terms of intraocular pressure and visual acuity was "quite good." The doctors emphasize the usefulness of scleral fixation with the modified Yamane technique and the importance of considering minimally invasive procedures (MIX) such as goniotomy in complex cases to optimize outcomes and reduce the likelihood of postoperative complications, such as ocular hypertension.
Main Topics and Important Data:
- Case Presentation:
- 50-year-old male patient, active.
- Initial symptoms: eye pain, red eye, photophobia.
- Examination findings: ocular inflammation, complete collapse of the anterior chamber in both eyes, extensive irido-corneal contact (360 degrees in one eye), elevated intraocular pressure (> 40 mmHg).
- Relevant history: electric shock approximately one year prior, coinciding with the onset of vision problems. Genetic causes such as Marfan syndrome have been ruled out.
- Presumptive diagnosis: Bilateral subluxation or dislocation of the lens secondary to electrical trauma.
- Initial Management and Diagnostic Challenges:
- Acute management with maximum tolerated medical therapy, including oral acetazolamide, achieved an initial reduction in blood pressure.
- Biometrics with the Optopol biometer presented difficulties in obtaining complete readings due to the collapse of the anterior chamber, requiring segmented measurements and reconstruction of the values.
- The use of pilocarpine helped reduce the pressure, although the anterior chamber remained collapsed. The patient was informed of the risk of recurrence and the need for surgery.
- Combined Surgical Approach:
- Lensectomy and Complete Vitrectomy: It was performed to remove the dislocated lens and address any associated vitreoretinal pathology.
- «We did this one, a lensectomy. Exactly. Yes, with complete vitrectomy. MM.«
- Synechiolysis: It was performed to release synechiae (adhesions) between the iris and other anterior segment structures, caused by inflammation and contact.
- «undo synechiae expand the space of the angle eh more space of the particular trc mesh visible then«
- Goniotomy: A minimally invasive procedure was added to improve trabecular meshwork function and reduce intraocular pressure, given the angle collapse and suspected trabecular damage. It was performed after vitrectomy to create working space in the anterior segment.
- «As a glaucomatologist, I have work space in the anterior segment, so I can add certain minimally invasive procedures when required. This can undo synechiae, expand the space of the angle, and then give more space to the particular visible TRC mesh.«
- Goniotomy was performed using the Bank technique using a 27 gauge needle mounted in a viscoelastic vial to facilitate injection during the procedure and maintain space.
- It was performed under indirect vision with a mirror, given the presence of the vitrectomy trocars.
- Scleral Fixation with Modified Yamane Technique:
- A three-piece ISIS intraocular lens and the Yamane scleral fixation technique modified by Dr. Maldonado were used to ensure correct lens position and stability in the absence of capsular support.
- «We use the same approach to fixation using the modified Yamane technique that Dr. Maldonado uses. So we had to use a three-piece Siis lens, which is what we are using for these types of cases.«
- Justification for Combined Procedures and the Use of MIX:
- It is argued that in complex cases, addressing multiple problems in a single procedure can be beneficial for the patient, avoiding multiple surgeries and optimizing the outcome.
- «I believe that if you can resolve the majority of situations or problems that the eye has in a procedure, I believe that would be the best and not have to, in one way or another, have to, as you said, Ah, well, you have to give it a laser, no, or you have to give it now, do I have to subject it again to a, this, to an Otomi, no, or to a cinecol after surgery?«
- The addition of goniotomy (a MIX) is justified by the high likelihood of postoperative hypertension due to preexisting damage to the trabecular meshwork. The goal is to reduce this likelihood without adding significant complications to the primary procedure.
- «If I can offer the patient a way to reduce the possibility of becoming hypertensive postoperatively, why not add something that will not cause more complications because it is most likely that the patient will develop hypertension even after the procedure? Yes, it is most likely that it will.«
- The validity of combining MIX with more invasive procedures such as vitrectomy is defended, arguing that the goal is to improve ocular function and reduce dependence on medication for intraocular pressure.
- «I don't think the argument would be valid here that Ah, this is no longer a mix because you already did a vitrectomy, you already did no no no no I mean eh Anyway, we did something to lower the probability of his intraocular pressure rising as much as possible. Okay«
- Postoperative Results:
- Despite an unspecified “setback” at the second surgery, the overall outcome was good in terms of intraocular pressure (20 mmHg in both eyes at the last mentioned review).
- «The result, both in terms of pressure and visual, has been quite quite good quite quite good quite Yes yes«
- «Let's see, let's see, I open the last one. I say exactly 20 20 25 2025, this eye, the first one, the first one that was in crisis, scleral fixation with modified Yamane with vitreous with goniotomy 20 2» (It is inferred that the second eye also had a similar result of 20/25).
- The patient initially experienced photophobia due to the lack of pupillary response (mydriasis) resulting from the previous hypertensive crisis.
- Correct alignment of the intraocular lens with the visual axis is highlighted as a factor in good visual outcomes.
- Conclusions and Key Messages:
- MIX can be useful and efficient tools, especially in combination with other procedures, to address complex glaucoma problems.
- It is important to individualize treatment and consider the addition of MIX in complex surgeries to optimize long-term outcomes, such as intraocular pressure control.
- The modified Yamane scleral fixation technique is a valuable option in cases of absence of capsular support.
- The audience is invited to leave questions, comments, and share clinical cases.
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