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Michele Fortunato
Lugano 14.11.2019 Congresso satellite Gentilino\Ticino
E’ una neuropatia ottica che si instaura a causa di un
ipertono oculare in gestazione,alla nascita o durante i primi anni di vita a causa di un difetto congenito del deflusso dell’umore acqueo.
TRABECULOGONIODISGENESIA
Secondo Shaffer-Weiss
Glaucoma congenito e infantile primario
Glaucoma associato ad anomalie congenite
Glaucoma secondario
Axenfeld
Bing-Neil
Ehler-Danlos
Gorlin-Golz
VH.Lindau
Hurler
Kartagener
Kimmelstiel Wilson
Klippel Trenaumay
Weber
Krabbe
Marchesani
Meyer Scwickerath
Weyers
Miller
Nieden
Ota
Posner Schlossman
Reklingausen
Riegers Silverman Ulrich Wagner
V.K.Harada
Stckler
Aniridia S. Di Sturge Weber Neurofibromatosi S. di Marfan Omocistinuria Goniodisgenesia (Axenfeld-Rieger, Peters)* S. di Lowe Microsferofachia/microcornea/microftalmo Anomalie cromosomiche PVPI Linee guida dell’European Glaucoma Society
Deriva da alterato sviluppo del tessuto della cresta neurale da cui origina endotelio, stroma trabecolare e irideo, canale di schlemm.
S. di Axenfeld: Filamenti di tessuto irideo a forma di T si estendono a ponte alla linea di Schwalbe, atrofia stromale iride anteriore. Fino a 60% sviluppa glaucoma S. di Rieger: Adesione della media periferia iridea alla cornea, ipoplasia iridea, microcornea, policoria, ectopia pupillare. Fino a 50% sviluppa glaucoma. Anomalie dentarie, facciali, neurologiche. S. di Peters: Leucoma corneale centrale, bilaterale, sinechie iridocorneali e corneo-lenticolari. Fino al 50% sviluppa glaucoma.
Retinoblastoma
ROP
Malattie infiammatorie,autoimmuni
Tumori
Post-traumatico
Afachico,pseudofachico
ADUTI
Tonometria Studio della papilla
ottica Perimetria Gonioscopia Pachimetria Altro
BAMBINI
Tonometria? Papilla ottica? Perimetria? Gonioscopia? Pachimetria? Altro (Angioct)
Lacrimazione
Fotofobia
Occhio più grande di dimensioni
Colore bluastro della cornea
Attenzione alle miopie evolutive dell’adolescenza,specie quelle monolaterali
Il glaucoma è una sindrome multifattoriale Studio della malattia sistemica Narcosi con studio completo delle strutture
angolari,pachimetrico ecc. Elettrofisiologia Ove possibile: terapia medica Trattamento chirurgico più appropriato Possibilità di reintervento
Anamnesi Esame obiettivo Biomicroscopia corneale Misurazione della IOP (Schiotz + Perkins) Misurazione dei diametri corneali Ispezione dei nervi ottici
Gonioscopia Ecobiometria Ecografia (A-P e L-L) PEV (da effettuare da svegli o sedati) Esame del fondo OCT Pachimetria
Questi esami vanno effettuati in narcosi,ma bisogna tener conto che
alcuni anestetici generali diminuiscono la PIO
normale buftalmo
Diam orizz 11.6 16
Spessore centr 0.900 0.600
Spessore perif 1.1 0.47
Raggio curv 7.8/48.2 11.8/31
gonioscopia
OCT
Lo scopo è di preservare l’acuità visiva, l’integrità oculare e il campo visivo
B-bloccanti (possono essere usati come scelta
primaria, se le condizioni generali lo permettano), 2 volte al giorno o in mono somministrazione.
Dorzolamide collirio,2-3 volte al giorno
Pilocarpina,Iopidine,Glamidolo ,3-4 volte al giorno (miopizzazione)
Prostaglandine,1 volta al giorno
Acetazolamide,Antidrasi per bocca,15 mg/kg/giorno in 3 microdosi
Dev Ophthalmol. 2012;50:157-72. doi: 10.1159/000334798. Epub 2012 Apr 17.
Surgical management of pediatric glaucoma.
Ou Y, Caprioli J.
Glaucoma Division, Department of Ophthalmology, University of California, San Francisco, Calif, USA. Pediatric glaucoma surgery is challenging because of the differences in anatomy from the adult, differences in the behavior of the tissues of a child's glaucomatous eye, the variety in causes of the disease, and difficulties with postoperative management. Goniotomy and trabeculotomy are the preferred initial treatments for primary congenital glaucoma. Trabeculectomy with adjunctive mitomycin C is more likely to succeed in older, phakic patients, but carries the long-term risk of bleb-associated endophthalmitis. Glaucoma drainage devices may be preferred in younger children and in patients with aphakic glaucoma, but these devices can cause tube-related complications. Lastly, cyclodestructive procedures are reserved for patients in whom filtering surgery has failed, given its more unpredictable effects and serious complications.
Ophthalmologe. 2011 Jul;108(7):618-23. doi: 10.1007/s00347-010-2292-7. Glaucoma surgery in childhood Klink T, Grehn F. Author information: Julius-Maximilians-Universität Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Deutschland. [email protected] Technical characteristics and a long-term therapeutic strategy due to a long life expectancy play a key role in pediatric glaucoma surgery. The well-established angle surgery (goniotomy and trabeculotomy) achieves successful results in primary childhood glaucoma. Trabeculectomy seems to have been displaced as a secondary approach by glaucoma drainage devices (GDD) in primary childhood glaucoma due to inferior results, especially for children under 3 years of age. Even for secondary childhood glaucoma the results of GDD are encouraging, especially for therapy refractory aphakic glaucoma. In the first 2 years after GDD surgery success rates are about 80% for pediatric glaucoma and the results appear to be independent of the type of glaucoma and implant used. The complications of GDD are balanced to the faster intraocular pressure (IOP) control during the phase of visual acuity development. Cyclodestructive procedures may be applied as a secondary adjuvant approach but they increase the risk of conjunctival scarring and hypotony for subsequent procedures.
Prima scelta se la cornea è sufficientemente trasparente Tecnica: o Anestesia generale o Posizionamento microscopio inclinato di 10°-15° o Fissazione del bulbo o Apposizione lente gonioscopica o Paracentesi in cornea piena e ingresso del goniotomo fino a
raggiungere le strutture angolari del lato opposto o Introduzione di viscoelastico o Goniotomia con movimento “a ventaglio” di 180° o Eventuale sutura della paracentesi in Nylon 10/0 o In una seconda seduta si effettua nei 180° controlaterali
Complicanza: ipoema.
Strategie non perforanti: Viscocanalostomia Sclerectomia Canaloplastica Sistemi drenanti altro
Atalamia Ipoema Ectopia iridea Chiusura della bozza Cataratta Emovitreo Distacco di coroide Endoftalmite Espulsiva
Atalamia Ipoema
. J Pediatr Ophthalmol Strabismus. 2011 Jan-Feb;48(1):30-7. doi: 10.3928/01913913-20100420-05. Epub 2010 Apr 22.
Dilation and probing of Schlemm's canal and viscocanalostomy in pediatric glaucoma.
Kay JS, Mitchell R, Miller J. Department of Ophthalmology, University of Arizona Health Sciences Center, Tucson, AZ 85704, USA.
PURPOSE: To describe the authors' experience using a novel surgical technique for treatment of childhood glaucoma. METHODS: Medical records of 24 consecutive patients and 39 eyes that underwent dilation and probing of Schlemm's canal and viscocanalostomy between September 2002 and June 2008 were reviewed. Surgical success was defined as an intraocular pressure (IOP) of less than 23 mm Hg with or without glaucoma medication and without further surgical intervention. RESULTS: Mean age at surgery was 66 ± 66 months, with a mean preoperative IOP of 40.4 ± 10.2 mm Hg. Surgical success was achieved in 27 of 39 eyes (69%) with an average follow-up of 22 months. In patients without history of previous surgery and the diagnosis of primary congenital or juvenile glaucoma, surgical success was achieved in 17 of 19 eyes (89%) with an average follow-up of 20 months. There were no serious surgical complications associated with this procedure. CONCLUSION: Goniosurgery with dilation and probing of Schlemm's canal in combination with viscocanalostomy appears to be a safe and effective surgical modality to lower IOP. The procedure appears to be most effective in surgically naïve primary congenital and juvenile glaucoma.
Am J Ophthalmol. 2005 Sep;140(3):490-6.
Primary viscocanalostomy for juvenile open-angle glaucoma. Stangos AN, Whatham AR, Sunaric-Megevand G. Department of Clinical Neurosciences, Division of Ophthalmology, University Hospitals of Geneva, 16 Plateau de Champel, 1206 Geneva, Switzerland. PURPOSE: To evaluate the efficacy and safety of primary viscocanalostomy for medically uncontrolled juvenile open-angle glaucoma (JOAG). DESIGN: Prospective, noncomparative, interventional case-series study. METHODS: The study included 20 eyes of 20 consecutive patients with medically uncontrolled JOAG who were treated by viscocanalostomy at one institution. No surgical or laser procedure preceded viscocanalostomy. Surgical outcome was defined as an overall success by the following criteria: no visual field deterioration, no optic-neuropathy progression, postoperative intraocular pressure IOP < or =20 mm Hg, and IOP reduction > or =30% compared with baseline values with or without medication. When medications were not required, success was defined as complete. Cases that did not fulfill the aforementioned criteria and cases in which a surgical revision or further goniopuncture was performed were defined as a failure. RESULTS: Gender distribution was similar. Fourteen eyes belonged to the white race; five eyes belonged to the black race, and one eye belonged to Arab ethnicity. Mean age (+/-SD) at operation was 33.77 +/- 6.16 years, with the mean preoperative IOP (+/-SD) at 22.9 +/- 4.77 mm Hg. Thirty-six months after operation, 16 cases (80%) were considered an overall success. In 11 cases (55%), success was complete. Four cases (20%) were considered failures. No serious complications were documented either during or after operation. In two cases (10%), we documented a spontaneously reabsorbed microhyphema. Trabeculo-Descemet-membrane microperforation occurred in two cases (10%). In two other cases (10%), Trabeculo-Descemet-membrane perforation occurred and was accompanied by iris prolapse that needed peripheral iridectomy.
CONCLUSION: Primary viscocanalostomy can efficiently and safely reduce intraocular pressure in cases of medically uncontrolled JOAG and provide a rational alternative to conventional surgical modalities.
Viscocanalostomia : - Stegmann Sclerectomia profonda : - Koslov con impianti diversi - collagene - acido ialuronico - gel, etc. Canaloplastica - ab esterno - ab interno
Chirurgia Non Perforante
- dilatatione del canale di Schlemm - rottura della parete interna e del Trabecolato
Evita le complicazioni della trabeculectomia - ipotonia - atalamia - distacco di coroide - cataratta Possibilità di utilizzo del settore inferiore
Curr Opin Ophthalmol. 2006 Apr;17(2):132-7.
Options in pediatric glaucoma after angle surgery has failed Tanimoto SA, Brandt JD. Author information: Department of Ophthalmology and Vision Science, University of California, Davis, California 95817-2307, USA. PURPOSE OF REVIEW: Congenital glaucoma is primarily a surgical disease with medical management serving as a temporizing measure before surgery or as postoperative adjunctive treatment. First-line surgery for congenital glaucoma consists of incisional procedures on the anterior chamber angle: goniotomy and trabeculotomy. Angle surgery has a high success rate with few complications. Despite the high initial success rate, almost 20% of angle procedures eventually fail, and surgeons are confronted with a choice of what procedure to do next: a trabeculectomy with or without adjunctive antifibrosis therapy, glaucoma drainage surgery, or cyclodestructive procedures. This review will discuss and compare these procedures as reported in recent studies and how variables such as age, number of prior procedures, and type of glaucoma have clarified the order in which these procedures might be performed after failed angle surgery. RECENT FINDINGS: Clinical reports in refractory pediatric glaucoma consist solely of retrospective studies of varying size and quality. Recent studies of trabeculectomy in this population suggest mitomycin C is associated with increased risk of late infectious complications. Trabeculectomy has worse outcome among younger patients Glaucoma drainage devices have a success rate approaching 80% at 1 year, but less with longer follow-up. Cyclodestructive procedures are generally reserved for advanced cases, but low-dose cyclodiode therapy and endocyclophotocoagulation may prove useful earlier in the disease (< 2 years). SUMMARY: Refractory pediatric glaucoma remains a challenge. Glaucoma drainage devices appear to be the most predictable and possibly safest procedure to consider after failed conventional angle surgery.
Curr Opin Ophthalmol. 2009 Mar;20(2):126-30. doi: 10.1097/ICU.0b013e328323d519. Tube shunt complications and their prevention Sarkisian SR Jr. Author information: Department of Ophthalmology, University of Oklahoma Health Science Center, Dean McGee Eye Institute, Oklahoma City, Oklahoma 73104, USA. [email protected] PURPOSE OF REVIEW: Glaucoma drainage devices (GDDs) have been generally accepted as a treatment of refractory glaucoma. GDDs have their own unique set of complications that are important to evaluate to prevent them. RECENT FINDINGS: Tube shunts are typically used in eyes with refractory glaucoma. There is increased interest in studying the efficacy of GDDs. Most of the attention has been focused on comparing trabeculectomy with the Baerveldt implant (Advanced Medical Optics, Inc., Santa Anna, California, USA). The other leading implant is the Ahmed Glaucoma Valve. There are several retrospective studies comparing these two devices and a prospective study is ongoing. There is great interest in the complication rate of tube shunts and these have been published both retrospectively and prospectively. Complications such as hypotony, diplopia, strabismus, proptosis, tube erosion, failure, corneal decompensation, endophthalmitis, and visual loss are all important and some have recently been reviewed in the literature. Moreover, the use of glaucoma drainage implants in the pediatric population has been evaluated. SUMMARY: Glaucoma drainage implants have been a powerful tool in our surgical fight to prevent blindness; however, they are not without complications or controversy.
Ophthalmol Clin North Am. 2005 Sep;18(3):431-42, vii. Glaucoma drainage implants in pediatric patients Ishida K, Mandal AK, Netland PA. Author information: Hamilton Eye Institute, Department of Ophthalmology, University of Tennessee Health Science Center, 903 Madison Avenue, Suite 100, Memphis, TN 38163, USA. Approximately, one fifth of primary congenital glaucoma patients fail primary surgery. Also, some pediatric glaucomas respond poorly to goniotomy or trabeculectomy. In these situations, clinicians often choose trabeculectomy with mitomycin-C or a drainage implant as a surgical treatment. Glaucoma drainage device implantation is a useful option in refractory patients. When other surgical treatments have a poor prognosis for success, prior conventional surgery fails, or significant conjunctival scarring precludes filtration surgery, glaucoma drainage implant may effectively control intraocular pressure. Patients often require adjunctive glaucoma medications after surgery and may develop complications. Most of these complications, however, are reversible or resolve spontaneously, and most are not associated with vision loss.
Non valvolati: Berveldt,Krupen,Molteno
Valvolati: Ahmed
X-Press
Atalamia Ipoema Estrusione tubicino di silicone Cataratta Fibrosi Emovitreo Distacco di coroide Endoftalmite Espulsiva
Goniotomia Trabeculotomia /Diatermotrabeculotomia
Trabeculectomia
Trabeculotomia+trabeculectomia (+ /- mitomicina C) Canaloplastica Viscocanalostomia
Valvole/sistemi drenanti Laserterapia/Crioterapia
Ciclodiastasi
1990 2019 512
Trabeculotomia +
trabeculectomia
Casistica personale
Trabeculectomia
Goniotomia
Viscocanalostomia
Sistemi drenanti
Canaloplastica
Novità Canalografia
12444PTIT
A nostro parere la terapia chirurgica penetrante è sempre quella più utilizzata ed efficace,ma con possibili complicanze,
spesso gravi.
La chirurgia non penetrante ,da eseguire con angolo aperto, è quasi scevra di
complicanze, può essere una valida alternativa,ma meno
efficace di quella penetrante ed i cui tempi di apprendimento per il chirurgo possono
essere molto lunghi.
I sistemi drenanti ,in età pediatrica, non sono consigliati,nella nostra esperienza, come strategia
primaria. Tali sistemi possono essere utili in casi particolari: per
evitare un ipertono secondario dopo interventi di PK,di DR,nel glaucoma dell’ afachico, nel glaucoma post-traumatico ed in caso di fallimenti reiterati della
chirurgia angolare. Tuttavia,soprattutto in età pediatrica,possono dare molte
complicanze e la loro azione di controllo del tono è a volte imprevedibile e/o temporanea.
La diffusione, anche ambulatoriale, della nuova diagnostica
del glaucoma,la canalografia, sicuramente cambierà l’approccio chirurgico anche nel glaucoma pediatrico
Oggi la prognosi del glaucoma congenito è molto migliorata
e i ritrattamenti sono notevolmente ridotti di numero grazie:
- alla possibilità di diagnosi precoce; - alla buona riuscita della terapia chirurgica; - all’aiuto della terapia medica,che si avvale sempre più
di un largo campionario di farmaci. Tutte queste condizioni spesso si dimostrano efficaci a preservare nel tempo la funzionalità visiva e ad impedirne un rapido e fatale declino.
Primum non nocere
Ringraziamenti
F.Simona P.Leuemberger
P.Vadalà
M.Fortunato
Ringraziamenti
Giugno 2020
[email protected] 0039.3382763317 0039.380.5082243 Fax 0039.0635451414-39742614 Michele Fortunato Via Polibio,n.4 00136 Roma Italy
