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Trabeculectomy in ICE syn.

Trabeculectomy in ICE syn. Group no. 4 Instructors: Berger Yoav Robinson Anat Team: Platner Eva Birger Yael Gagarin Oksana Wasserzug Yael Miller Ariela. Case Presentation. 42 YOF OS Sharp Decrease in VA OD – WNL OS- hyperemic conjunctiva, corneal edema ++,

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Trabeculectomy in ICE syn.

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  1. Trabeculectomy in ICE syn. Group no. 4 Instructors: Berger Yoav Robinson Anat Team: Platner Eva Birger Yael Gagarin Oksana Wasserzug Yael Miller Ariela

  2. Case Presentation 42 YOF OS Sharp Decrease in VA OD – WNL OS- hyperemic conjunctiva, corneal edema ++, increased IOP (42 mmHg), A/C Deep and Quiet, Gonioscopy- PAS with corresponding corectopia, clear lens, C/D ratio 0.8 Failure of medical treatment- Cosopt + Xalatan (IOP-38mmHg)

  3. Iridocorneal Endothelial Syndrome • Unilateral • Progressive • Non-familial • Young adults, F>M • Unknown etiology

  4. Iridocorneal Endothelial Syndrome • Abnormal endothelium with production of an abnormal BM • 3 subtypes: • Iris nevus/Cogan-Reese syn. • Chandler syn. • Essential/progressive iris atrophy

  5. Iridocorneal Endothelial Syndrome • Dx criteria (2 of 3): - Typical iris changes - abnormal corneal endothelium - PAS • Associated: - Glaucoma (50%) - Corneal edema

  6. Iridocorneal Endothelial Syndrome Management of glaucoma Medical Rx- mostly ineffective for long term Surgical Rx- • Trabeculectomy + antifibrotic agents • Drainage devices Management of corneal edema Medical Rx- hypertonic saline, Soft contact lenses Surgical Rx- KPL

  7. Our Case Diagnosis: ICE syndrome with intractable glaucoma (high IOP with advanced disc damage) Management: Glaucoma surgery with possible subsequent KPL Preferred glaucoma surgery: Trabeculectomy + MMC

  8. Why Trabeculectomy with MMC? Current literature recommendations: First use trabeculectomy with MMC in ICE Syndrome -Doe et al, Ophthalmology 2001 - Kim et al, Ophthalmlogy 1999 - Cornea – Fundamentals, diagnosis and management (p. 975-983)

  9. Why Trabeculectomy with MMC ? Lower mean IOP was noted with trabeculectomy ! 62 trabeculectomies Vs. 55 Ahmed glaucoma valve implants (11-13 months follow-up) Wilson et al, AJO 2000

  10. Why Trabeculectomy with MMC? -80% success rate for trabeculectomy and MMC in ICE Syndrome patients (10 patients, 30 months follow-up) Lanzl at al, Ophthalmology, 2000 - 60% success rate for trabeculectomy and MMC in ICE Syndrome patients (22 patients, 1-17 years follow-up) Laganowski et al, Arch Ophthalmol, 1992

  11. Why Trabeculectomy with MMC? Most surgeons are more familiar and experienced with filtration surgery 6/9 of glaucoma specialists in this audience do not perform GDI’S at all 2/3 of surgeons familiar with this procedure prefer to use GDI’S as second surgical procedure in failed trabeculectomy

  12. Why Not GDI? Complications of GDI’s: • Early over-filtration resulting in flat A/C , tube-corneal touch, compromised cornea, hypotony and choroidal effusion • Tube obstruction/ migration/ erosion: All may require surgical revision • Motility disturbances and diplopia • Chronic inflammation

  13. Why Not GDI? Valve malfunction: ICE is associated with a possible dysfunction of the tube caused by a membranous overgrowth of the lumen and dislocation of the tube. Lanzl et al, Ophthalmology, 2000

  14. Why Not GDI? Corneal decompensation is one of the main complications following GDI, up to 30% Topouzis et al, Am J Ophthalmol 1999

  15. Why Not GDI? -GDI is an independent risk factor for graft failure - 40% at one year and 75% failure in the second year Alvarenga LS, Mannis MJ et al, AJO 2004 - 10-51% (mean 36%) graft failure/rejection in patients with KPL and glaucoma after GDI surgery - Ayyala et al, Ophthalmology 1998 - Rapuano et al, Cornea 1995

  16. Therefore…. For our patient, having: ICE syndrome Intractable glaucoma Possible future KPL Trabeculectomy & MMC is the best treatment!!!

  17. THANK YOU!!!

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