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Episode summary
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 Key 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: This was performed to remove the dislocated lens and address any possible associated vitreoretinal pathology.
- «we did a, um, a lensectomy, exactly, yes, with complete vitrectomy, mm«
- Synechiolysis: This was performed to release the synechiae (adhesions) between the iris and other anterior segment structures, caused by inflammation and contact.
- «undo synechiae, widen the space of the, of the, of the angle, uh, more space, the trabecular meshwork in particular visible, so«
- Goniotomy: A minimally invasive procedure was added to improve trabecular meshwork function and lower intraocular pressure, given the angle collapse and suspected trabecular damage. It was performed after the vitrectomy in order to have working space in the anterior segment.
- «since I, as a glaucoma specialist, have working space in the anterior segment, I can add certain minimally invasive procedures when needed, um, undo synechiae, widen the space of the, of the, of the angle, uh, more space, the trabecular meshwork in particular visible, so«
- 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 the 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 also used, uh, the, the modified Yamane technique fixation approach that, that Dr. Maldonado does, so we had to use a three-piece lens from siis, which is the one we are, uh, using for this type of case«
- Rationale for the 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 think that if you can solve the greatest, the greatest, uh, uh, number of, of, of situations or problems the eye has in one procedure, I think that would be best, and not have to, one way or another, uh, have to, like you said, oh well, we need to give it a laser, right, or we need to give it, now I have to put it through a, um, an Otomí, right, or a cinecol surgically afterward«
- 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 lower chance of ending up hypertensive in the postoperative period, why not add something that won't cause more complications, because most likely they will become hypertensive even with the procedure, yes, most likely yes«
- 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 hold here that, oh, this is no longer a MIX because you already did a vitrectomy, you already did, no, no, no, no. I mean, uh, either way we did something to lower, as much as possible, the probability of their intraocular pressure going up. 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, for both pressure and vision, has been quite, quite good, quite, quite good, quite. Yes, yes«
- «Let's see, let's see, I'm opening his latest one, I mean, exactly, 20 20 25 2025, this eye, the first one, the first one, the one that was in crisis, scleral fixation with modified Yamane, with vitre, 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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