Ophthalmic Microsurgery of Glaucoma

Author: BARRAQUER, Jouquin
Publisher:
Publish Date: 2002-04-01
Features: This book is edited by the internationally renowned Spanish professor Jouquin Baitaquer. It covers new concepts and surgical advancements in glaucoma, introducing microsurgical techniques, laser therapy, and the use of antimetabolite drugs, particularly in complex and challenging cases such as glaucoma combined with cataract and corneal transplantation. The final chapter employs scientific methods like life statistics to conduct long-term follow-ups on various types of glaucoma and the long-term efficacy of different treatment methods. Based on the rich clinical data of the Banaquer Institute, the book selects numerous images captured during surgical procedures, vividly demonstrating the process with detailed illustrations. Especially noteworthy are the insightful summaries derived from the authors' extensive clinical experience, offering unique perspectives. This book serves as a reference for ophthalmologists, medical students, and blindness prevention workers.
Preface This book aims to serve as a clinical guide for glaucoma surgery based on practical experience, outlining the academic thoughts gradually formed by my teaching group during the "Doctorate in Ophthalmology" program from 1974 to 1995. It is not intended to replace a comprehensive textbook on glaucoma surgery but rather reflects a review of lessons learned based on years of experience at my center. Our surgical techniques, standards, and personal views are explained in outline and diagrams and validated in carefully selected cases. Through this work, we attempt to provide future glaucoma surgeons with the standards and concepts to develop their own approaches to microscopic glaucoma surgery. Some of our colleagues may not agree with certain ideas. Microscopic glaucoma surgery has multiple methods, derived from personal experience, and is more akin to an "art" or "skilled craft" than "science." There are no identical cases, making it impossible to specify standardized techniques in detail. Glaucoma microscopic surgery is constantly evolving, with improvements in outcomes every day, and many concepts will be updated again soon. We attempt to propose some fundamental concepts, hoping to collaborate with ophthalmologists in the near future to make glaucoma one of the world's leading causes of blindness. March 1997, Barcelona
Basic Concepts of Glaucoma The term glaucoma refers to a disease caused by pathological changes in the genome of a different species, with the naming criterion being elevated intraocular pressure in the affected eye. This leads to progressive changes in retinal nerve fibers and characteristic alterations in the optic disc and visual field. Glaucoma can occur at any age and is one of the world's leading irreversible causes of blindness, particularly in developing countries. The most common type, "primary open-angle glaucoma" or "chronic simple glaucoma," is a slow, insidious disease that may not show any symptoms until the late stages. Its incidence is higher in the elderly, making regular examinations for those over 50 years old extremely important, especially for those with a family history of glaucoma or certain risk factors. In addition to intraocular pressure and visual field tests, a careful evaluation of the optic disc is absolutely necessary. When following up on suspected glaucoma cases, attention must be focused on significant changes that indicate a definitive diagnosis. If suspected changes have progressed, they must be controlled with serious measures. After diagnosis, drug treatment is the first choice. If intraocular pressure cannot be reduced to "normal," the so-called "normal" intraocular pressure may still be too high for the patient, and further progression will lead to irreversible blindness. When drug treatment is ineffective, surgery is the only option to halt the progression, and it is always better to act early. Early diagnosis and correct classification of the type are crucial in determining surgical indications. In certain types of glaucoma, such as congenital glaucoma or infantile glaucoma, surgery is generally unavoidable. For primary angle-closure glaucoma with the first attack, iridectomy is often effective because it targets the pathogenesis. However, for other cases, regardless of the cause of glaucoma, the goal of surgery is only to lower intraocular pressure. Unfortunately, these surgeries do not always achieve or maintain normal intraocular pressure in the long term. Many patients require repeated surgeries, special techniques, or destructive procedures like ciliary body destruction to reduce aqueous humor production. The use of antimetabolite drugs that inhibit scar formation has brought new hope to glaucoma treatment, especially for the most challenging cases.
Pathophysiology The primary purpose of aqueous humor circulation is to provide nutrition to avascular tissues like the lens and cornea, while also carrying certain defensive components. Another important function is to maintain stable intraocular pressure, typically considered to be within the range of 1.33 to 2.23 mmHg (10 to 21 mmHg), which is significantly higher than in other parts of the body, helping to maintain the shape of the eyeball and its optical properties. According to the Goldmann formula, intraocular pressure is the result of the interaction of several factors: IOP = (F/C)Pv, where F is the volume of aqueous humor production (μl/min), C represents the outflow facility of aqueous humor (1/min/mmHg), and Pv is the suprachoroidal venous pressure (mmHg). Therefore, an increase in aqueous humor production, enhanced resistance to outflow, or elevated suprachoroidal venous pressure can all lead to elevated intraocular pressure. The most common cause is increased resistance to outflow. Histological examination of trabeculectomy specimens in primary open-angle glaucoma has revealed some abnormalities...