During this live webinar, we will discuss all aspects of goniotomy from case selection, to informed consent, to set-up, to post-op, and beyond. We will also examine various alternatives. Videos will be incorporated into this session with ample time for questions. (Level: All)
Lecturer: Dr. Alex Levin, Ophthalmologist, Flaum Eye Institute, Golisano Children’s Hospital and University of Rochester Medical Center, USA
>> Hello everyone. So nice to see you here. I’m going to share my screen. When I have the privilege of traveling around the world with Orbis, one of the things that is often asked of me is to teach goniotomy. It’s an operation that seems a little foreign to many people, but it’s so, so helpful and has such great utility. We’re going to talk about goniotomy and go through everything you wanted to know but were afraid to ask. I’m Dr. Alex Levin from the University of Rochester, New York and I look forward to sharing this information with you. Thanks for coming. Let’s start with a pretest, the first question is and you’ll be able to vote as you know, indications for goniotomy include, A, goniodysgenesis, B, closed angle glaucoma, C, Peters anomaly, and D iris Bombe. Which do you think would be an indication? We have Goniodysgenis and closed angle glaucoma as a tie. No. 2, the most important thing in doing a goniotomy is making sure there is no Haab stria. Getting a good view of the angle. Having a Koeppe lens. Making sure there is no cataract. What do you think is the most important thing in doing a goniotomy? The answers. Good view of the angle. 77 percent. We’ll spend a lot of time talking about that. Next slide. And lastly, compared to GATT, a procedure, gonio assisted, goniotomy is faster, cheaper, easier or all of the above? What would you say? The answer is, wow, we have a lot of people saying all of the above. Maybe that’s why you’re here to learn how to do goniotomy. Let’s get on with the talk and we’ll talk about goniotomy. What is it. It’s a Goniolytic procedure connecting the anterior chamber to Schlemm’s canal in the face of an obstruction or a clogging such as goniodysgenis. The No. 1 indication for goniotomy. The pros, the reasons for it, it’s very easy to do once you know how to do it. It’s very fast, it literally takes me about a minute to do a goniotomy. And no conjunctival damage that is with other procedures and these kids often need future glaucoma surgery. You need to be able to see the angle, you need experience and you only get one chance once you’re in the eye and there is a small risk of cataracts. Compared to trabeculotomy, everybody has a level of comfort raising the trab flap. You’re going exterior and you can combine it with a filter. A Trabeculotomy or Trabeculotomy. The downsides are it can be difficult. It ruins sclera and conjunctiva in the area where you did the cut down. The risks are higher than with goniotomy, particularly for hyphema. It takes longer. For those reasons, I prefer goniotomy. There is also 360-degree trabeculotomy. It’s harder and takes longer. It’s more expensive. Especially if you’re using the eye track machine. Using a Vicryl suture is not more expensive. And there is a higher incidence of 8-ball hyphema. The outcomes are the same. It may save you an operation because you have 360-degree angle open. But the outcomes by all the literature so far is the same. A harder, longer, more expensive operation with higher complications is being used. For GATT or MIGSs they’re harder on a soft pediatric eye, more expensive, longer to do and they may not be available. Same with a dual blade. More expensive and might not be available. Goniotomy is a cheap, fast, easy solution to try to connect the anterior chamber to Schlemm’s canal. And the outcomes of all these procedures are about the same as goniotomy. I’m thinking goniotomy is a good procedure. When do I do id? Whenever I can. Congenital infantile glaucoma. Infants with SWS with a goniodysgenesis. If there is an angle glaucoma, it can work. Maybe not an — in juvenile angle glaucoma, it’s my first procedure. Instead of a cut, we’re pushing down. When the iris starts to turn up into the angle, the iris root, we can push it down and open up a cleft. And uveitic glaucoma, 85 percent success rate. In an other — I need a deep anterior chamber. A clear cornea to be able to see. And if it’s your first goniotomy, you want to go nasally through a temporal incision. Be comfortable, prepared, and a clear view of the angle is essential. Is the cornea going to be clear enough for you to see the angle? Ask yourself, can I see the iris detail with a slit lamp. If there is haze, is it epithelial edema. And of course, the more experience you have, to go through a blurrier cornea and when you start you want a clear cornea. One way to tell, if you take a blunt instrument and touch the cornea and take it away, you’ll have this pitting edema just like in an ankle of a diabetic. That edema is from the epithelium and can be scraped away to clarify the view. There are risks when you’re getting an informed content. 50 percent of patients have hyphema that rarely needs anything done about it you just opened up a cleft for it to train to. It will fail 10 to 50 percent. 10 to 20 percent need a reoperation. But it’s so easy and cheap it’s worth taking the chance. The risk of cataract is shown here. Can be avoided by techniques I’m going to show you. Retinal detachment and other things are incredibly rare. Especially when you compare them to tubes and the general anesthetic. In the postop, expectations are important. Any child with glaucoma with any operation is still going to need medications after surgery. There’s a book that we wrote that might be helpful. This is available online at www PGCFA.org. It’s in English but it can answer every question you can think about for this surgery and many others. Preop, I made a decision the patient’s pathology fits goniotomy. Closed angle glaucoma, I couldn’t do it because I can’t see the angle. Iris Bombe, I can’t do it. I have a goniodysgenesis. I can see the cornea. All the pieces are in place. And now we have to go and do it. Preop, I may use medication for a few days to try to clear the cornea. Latanoprost, timolol. I might use acetazolamide to get through of epithelial edema to make it clearer when I get there. In some diagnosis, I want to maximize medication before going to surgery. But if I have congenital or infantile glaucoma, I want to for sure do this operation rather than medications. Some people use pilocarpine to pull the pupil in. That narrows the anterior chamber and I don’t use it. Abnormal a uveitic, I do three days of oral steroids before surgery to quiet the eye. Apraclonidine one percent. You need a microscope that tilts about 30 to 45 degrees from the plane of the floor. This has been done by some with loupes or a Heine microscope. But a microscope is best. The eye needs to be fixated while doing the procedure. You don’t want the eye to turn when you do the cut. We cut that, usually we do it with two forceps with an assisted. One is assisted and good that is holding an eye and you’re holding the lens with a forceps. I will show more detail later. You’re coming in from here to make your incision to the eye. How do you hold the eye? Well, your assistant can use free hand 0.12 at 2 point fixation making sure to grab exactly at the limbus at the conj is not tilted up. This is the best I think, you can put your hands in any position. You have great control. It’s good for Buphthalmous. But you need a good assistant and they must be at the limbus and it can get crowded with your hands and their hands but it’s easy to do. You can use locking forceps on the muscles themselves. The problem is that, it’s very reliable and easy to hold and there is a lot more room because your hands are out of the way of the assistant, but it causes chemosis. They can slip off. You can get a subconjunctival hemorrhage and it’s difficult in the eye to find the muscles because they’re so far out of view. I prefer not to do this. You can use custom refractive forceps shown here. They’re good for buphthalmous. They don’t cause chemosis. If you twist instead of rotating, you can perforate the eye. I don’t prefer these either. I like the cheap, easy to have, 0.124. Then the Barkan lens. It’s a goniotomy lens. With a cut edge under which the needle you’re going to do with this slides. I prefer the smallest size, the 9 mm. The premature size because it gives you the ability to move around the cornea. And you just have to make sure that curvature matches the curvature of the eye. If you’re not getting a good lay of the lens on the eye, you might want to go to a different size. They come with an infusion. I don’t think it’s made anymore. They come with self-fixation. There is a flange on the lens. I don’t do that. I just have a good assistant. I like a surgeon held lens. Either the handle lens which is a Swan Jacob with a handle coming up the back or a forcep held which is my favorite. I take the .2 forceps and put them in the two holes. Don’t lift up the lens but you can move the lens around in the eye. The lens is needed because of total internal reflection. It will give you a view of the angle. It’s similar to the Koeppe lens, but the Koeppe lens is a nonsurgical lens. It’s a self-retaining lens that goes in the eye to view the angle. It’s not for surgery. You need a goniotomy lens. A Barkan lens or a Swan Jacob. Here the lens is on the eye. You see the cut edge here. We go under that to do the surgery. These forceps are going to move the lens, they just move it with the nondominant hand. I’m doing surgery with my left hand and holding with my right. Here is a lens that is too big. Way too big for the eye. You can’t move it around. The eye has been entered with a needle but there is no way to move this lens around. That is why we use the smaller lens. You can go in the eye with a knife or a needle. The Swan Jacob is a two sided blade. There is something called a needle knife. I go 25 gauge needle on any kind on Healon. It’s all you need. You don’t need a suture. And if you have Healon available, if you have bleeding, you can control the bleeding by injecting the Healon during the procedure. You have to know the anatomy. Know what a normal angle looks like. In infantile glaucoma, you have a high insertion of patches. Maybe prominent vessels in the angle you need to avoid. TM may be covered. Here is a view I’m going to show you. But remember, when I show you this, the cornea is invisible under the lens. Therefore, you’re looking in the eye and there is a tendency for the needle to rise towards the cornea. You don’t want that. I’ve seen the cornea perforated during this surgery. You have to keep the needle flat, close to the iris. So here is an example. Here is a Barkan lens, the cut edge, we go in here. You can see these patches of high iris insertion. That’s characteristic of infantile glaucoma. And we want to put our blade in right or needle in, right above that iris insertion. That will get us into Schlemm’s canal. Here is another view. We see this high iris insertion. In patches you can see here, patches, patches, patches. And our target is right in front of that. That is where you’re going to find Schlemm’s canal. Here is the other eye in front of Schlemm’s canal is where we want to be. You want the patient to be pretty much flat on the table. The first thing we do is set up microscope and make sure that we got a good view. Before you do anything, make sure you have a good view. We want to bring the child towards the surgeon. The surgeon sits on the side. You may want to have a hand rest to keep your head still while I put my pinky on the forehead. Tilt the scope and make sure it’s zeroed so you have room to manipulate once you’re in the eye. The head of the microscope is facing you. You focus on the eye, the far iris towards the angle. Here is the position for surgery. Here is what it looks like. I got my assistant here holding. I’m holding the lens. My needle goes into the clear cornea. Clear cornea as you can see. Goes across to make the procedure. This is not the view that I have during the surgery because I’m looking through the microscope. It’s no show you what the surgery looks like. Here is a better picture. See my thumb is on the Healon cannula. I’m ready to inject. I go through clear cornea, I’m holding the lens. My assistant has two forceps at the limbus on either side. After I know that I can see, before I do anything, before I go into the eye, I put a little Healon under the lens and put it back on the eye are. You can set up again to make sure I’m focused before my needle enters the eye. I want the eye in a bit of adduction towards the nose. I want to micro focus on the angle. Once I’m in the eye, I don’t want to fool around. I want to be all set and ready to go. If I still have a blurry view before I put my needle in, I can scrape off the epithelium with a 7400 blade. I can use Goniosol or a cotton swab. The important thing when scraping the epithelium, you don’t want do this with Aniridia. Never spray contact lens wearers. If there is a corneal lens transplant. You never need to scrape to the limbus. You only need a window. I take off a window. I’m sitting over here and taking this hockey stick or round debris and scraping off the epithelium. I don’t need to take off the far side. I’m looking through the near side through the lens. I don’t need to go to the limbus, that is where the stem cells are. I put the lens back on, view the angle again, and make sure that I’ve got a good view before proceeding. If the view is satisfactory after these steps. I checked. I’m cloudy, I take off the epithelium. Before that I made sure I had the right diagnosis and right reason to do it. Then I put the Barkan lens on. I put the Barkan lens away from me. I’m focused on the angle. This is blurry when I go in. I go in short, about the length of the bevel and flatten my hand to get a self-sealing wound. Go you want to continue if there is tenuous cornea. You only continue if you feel comfortable and can see well. Otherwise you convert to another procedure. You have to move fairly quickly. Once you’re in, get in. Nondominant hand fixing the lens. The dominant hand has the needle or the blade. As the lens goes in, it’s going to be pluri here. You go 1 mm anterior to the limbus, that short up going tract and flatten your hand prior to the iris to self-seal it. You slide the lens towards you. As it comes there is a blind spot under the cut edge of the lens. You have to move this more towards you until you see the tip of the needle in the eye. And then can carry it forward. If you come up too far onto your needle, you’ll get air. Just make sure you’re not too far. Keep your eyes the whole time on the needle tip. Just focus on the needle tip. Your natural depth of field will give you everything you need to know. You just have to hover over the iris as you go in. Get past that blind spot. Moving the lens towards you. When the needle is past the blind spot, stay 1 to 2 mm over the iris. Remember that invisible cornea, don’t drift up to the invisible cornea. You want to engage the anterior trabecular meshwork where is usually where the iris edge is. You enter as deep as the widest point of the bevel on the needle. You go one direction, right or left, and then back the other way: You should feel nothing. The only time you feel something is when the angle is dysgenic that happens in neuro fibroma toe surfactants and severe glaucoma. And sometimes iritis is gritty. As you give them, this pigment, that means you’re too far posterior in the supra choroidal space. You want to move forward. And you’ll see this white line. That line is referred to as hunter’s trail. That line made famous by an ophthalmologist from Orbis. Hunter’s trail is the line that indicates you’re in Schlemm’s canal. Here the lens is held with a finger instead of forceps. There is locking forcepses on the muscle. It goes in through here, you move the lens back away now that you’re in so you can see the angle. You go into the angle and move the lens one way and then the other. This is a self-infusion lens with a Swan Jacob’s knife and you can see the same thing, it’s cutting in. Here again, hunter’s trail. You can see the iris is up here. When my blade goes in, it’s making hunter’s trail into Schlemm’s canal as it goes around and the iris drops back when it’s done. It’s a bright silvery white space, Schlemm’s canal. Here we see it again. You can see the iris is up. It falls back after you have made your incision. Here again, it’s fallen back and you can see hunter’s trail right there. You follow that white line, you’ll be in Schlemm’s canal. Histologically, you can see the dysgenic angle before goniotomy. After goniotomy, this drops back after you make your incision. Now your assistant has to be very good. You’re telling them to float back, adduct, abduct. And then you want them to incyclotort the eye and excyclotort the eye. Before you do that, you poop out the needle 1 to 2 mm and they slowly rotate the eye with your needle back and you reengage where you left off and you continue along hunter’s trail to enlarge the goniotomy cleft. If you do 120 degrees, easily. You withdraw the needle of knife. No reason to sew up. You put Healon into the eye before coming out and remove the fixation without pushing on the eye. I put a lot of Healon in. There is a lot of places for it to go. You took out the cleft. I removed the drape. I put in steroid ointment. I do not inject steroids or antibiotics. We put Dobradex. Some people like atropin. I use nothing. If it’s a uveitic glaucoma, I put in Apraclonidine or brimonidine. What were the key points? Enter a clear cornea. You may have to make the cornea clear with preoperative medications, particularly in infants. Your may have to make it clear at surgery by scraping the epithelium at 75 percent. Taking care not to invade the limbus. Not to do aniridia or contact lens wearers or not to do corneal transplants. You want to make sure that you don’t look at the cornea. Just ignore it. If you look for the cornea, your needle will rise up and hit it. Keep your eyes focused on the needle point and keep it just above the iris. You should feel nothing. Feels like butter as it goes in. You should see the iris insertion drop back. Those are the key points of goniotomy. No. 1 being make sure you can see the angle before you start. So what happens? Let’s go through some problems. What happens if it gets shallow while doing the procedure? Put in some Healon. Or if you have a syringe with fluid on it, put that in. What you don’t want to do is take your needle out. Once your needle is out, you don’t get a second chance. If you’re dragging iris, because the iris insertion is so high, back off on the needle and restart a little more anterior. So you don’t drag the iris. Looking for that hunter’s trail to make sure you’re in Schlemm’s. If there are iris processes or PAS, bend them with the needle and go around them. You can skip that area, go around and go to another area. What if you lose your view? Well, if it’s bleeding you’re not going to be able to do anything. You want to prevent that. The minute you see a little blood coming out of the angle that you cut, put some Healon on it. If you have Haab stria, you may need to move the eye and move around it. If you have a hazy cornea that you just can’t see, you may have to abandon the procedure. If you get air on the needle, at the end of the needle that came out of the cannula, just push it out of the way with Healon. Again, if the needle comes out, you’re going to have to abandon. Some people tried to put in a 30 gauge cannula to inflate the anterior chamber and usually it’s shallow at that point and hard to do. So doing it right is the way to get it done. If you unroof the ciliary body, just stop. Go 1 mm or half a mm anterior so you get into Schlemm’s canal. If you can’t rotate the eye because the assistant’s forceps are caught on the speculum, lean the speculum in. Then rotate and lean them out. Lean the forceps in and go around and lean them out again you can get more room. So here is the Haab stria. I rotate the eye so I can look to the right, to the left. Sometimes it’s a little harder. If you rotate around these Haab stria, you’ll get a view. Thousand there are some variants on goniotomy. And aniridia and uveitic glaucoma. There the movement is a down push instead of sliding. Especially in the uveitic glaucoma, the angle cracks open on its own and goes around. Just come across and opens as you go. You want to look for that clefting. Especially with iritis, it’s easy to get into the supra ciliary space because things are so fragile and friable. Here we see in this picture, you can see if you push down to open up the angle, the iris will drop back and the cleft will open. If you can’t see, there is another way that I’m just mentioning for interest. Endoscopic goniotomy. That requires two wounds. Of course you need an endoscope to do it. And it can’t be totally white, the cornea, you have to see a little bit. Use a standard endoscopy entrance with a gonio needle. 30 to 45 degrees away at the temporal limbus. You need Healon when you go in. The needle comes with a sheath. You can see the angle nicely. Here we see the needle is in there doing a goniotomy. You can see there is hunter’s trail up there. Here is another one, a view of doing it. That’s an option but I realize very few places have that device. Postop, I patch for 24 hours. Put in an antibiotic, gentamicin. Take off the patch in 24 hours. Start antibiotics 4 times a day for about a week. I start prednisolone acetate is percent. QID. If there is hyphema, I give it 6 times a day for a week. And rapidly come down BID for a week or taper down. I see the patient one day postop, 3 to 5 days postop, one week, two weeks. At 4 to 6 weeks I know it’s working and I might consider doing the exam under-anesthesia. I keep the patch on the eye. I really stress that with parents. You have a hole in the eye. It’s not sewn shut. If the kid is screaming and crying you raise the chance of getting a hyphema. Use no NSAIDs: They promote bleeding. Use acetaminophen for pain. Antinausea. We don’t want vomiting. These usually aren’t problems but you can prevent the problems by instructing the family. On day one, all I care about is the anterior chamber deep. Is there a hyphema. If the anterior chamber is deep, I’m fine. If there is corneal edema, that means the pressure may be high but if I’ve scraped off the corneal epithelium, there is no edema because it’s not healed yet. If the pressure is high on day one, it’s just because there is blood lining my cleft. It’s okay. Just use the pred and it will go away. If there is hypotony, make sure it’s not posterior. You just wait and get past the early problems. One critical thing, don’t do finger tension. At least 7 days. There’s a hole in the eye, no suture, you don’t want to burp fluid out of the anterior chamber. As I said, hyphema occurs in 50 percent of patients. That really doesn’t need treatment. If they don’t go away out the cleft that you made, you can increase the pred or add a steroid or ointment at night. It’s usually just blood with elevated IOP. You may need a beta locker to get you through. Spikes from the Healon are rare, because there is a place for it to go. If the pressure is truly low, it means you have a leak somewhere. It’s either leaking out the goniotomy, leaking into the supra choroidal space but you should know that because you saw and avoided that pigmented supra choroidal space when doing the procedure. Or it could be going out through the goniotomy itself. You have a great drainage through the goniotomy which is perfectly fine. And you know, if the AC is shallow, I’m going to start high intensity dilators, short acting like cyclopentolate and phenylephrine to push the diaphragm back, that can help. If it’s Seidel positive, I might put a patch on. Sometimes the patch pushes the fluid out of the eye. And patience and dilation and steroids. I never had to go back and do something. These kids will get better. A flat anterior chamber, I would just patch. The only time you have to go back and do something is if you have a wound that needs to be sewed shut. That doesn’t usually happen with the temporal approach. It’s more of a problem with a nasal approach to the temporal angle as I’ll show you. If there is a cataract, wait. Often the cataract is localized and won’t spread. It won’t need anything. You don’t want to get a cataract. I had two in my entire career. Both were mistakes on my part. One happened because I was too brave. I went in on the temporal approach and I didn’t have a good view, I should have stopped the procedure. The other is when the needle came out and I tried to go back in. It was a mistake. Both were early in my career. You can avoid cataract. You can avoid that complication. If your goniotomy fails and by 4 to 6 weeks you’re not getting anywhere. You can do a temporal goniotomy. There you’re going over the nose shown here. So that your needle is on a steeper plane. And to compensate for that, the eye has to be pulled by your assistant down in this direction. Infratemporal direction to flatten the plane of the needle relative to the eye so you’re not pointing directly at the lens. The only problem with this entry, sometimes it’s hard to get back to starting point and get that needle to come straight out and you can lacerate the wound with the tip of the needle which may need a suture. I always recommend looking at the end of the case to make sure your closed. Okay. What I want to do is show you some videos of these procedures. How we doing on time? Perfect timing. I’m going to stop sharing and we’ll walk through a case. This is a case of juvenile glaucoma. If Andy or Larry can please bring that up. There we go. Here we have an eye. You’re going to see, key that up to 1 minute 30 seconds. We have the lens on the eye. It’s choppy. Here is my forceps holding it. Here is my assistant grabbing the limbus. You have a clear view and now I’m going to try to move it away so I can see that angle really clearly. And to bear — coming in. Let’s keep that going forward, Andy. Technical difficulty. Okay. Go back to 1:30. The assistant is regrasping. Pulls it away and shows the angle. We slide the lens away so I can see where I need to go. The needle is going to come into view in a second. I’m a little blurry at the limbus there. The needle is beveled up. It’s on Healon. I go up a little bit as I start 1 mm anterior to the limbus, see the lens moved away. I’m going to go up and lift my hand to flatten the view, move the lens towards me, there’s the blind spot, move the lens until I see, there is my needle in the anterior chamber. I keep my eye on the needle as across. Now the assistant moves the needle away to show the angle. Endanger the trabecular meshwork. Push down, there is hunter’s trail. That white line. I move it in that direction to open up into hunter’s trail. I’m going to go the other direction. And then did you see my assistant had to lift her hand because they were pushing so hard I couldn’t see. I pull the needle back a bit. Ask the assistant to incyclotort the eye. There is hunter’s trail. I am going to go around. Notice here, that we have some tenting of the conjunctiva because the assistant isn’t directly at the limbus. I’m going to touch up and make sure I have a nice clean trail. I’m in Schlemm’s. That’s the bright. I come around the eye and adduct so I can see where I left off. There is hunter’s trail and keep going around. After I’m done as far as I can go, this is about 180 even this goniotomy, I’m going to go back to the position I started at. So my needle is straight. I inject Healon into the anterior chamber, fill it up. I pull the needle back. When it comes back you see Healon come out of the wound and take the lens off quickly. You can stop that video. You can see the anterior chamber stays very deep. Let me show you another video. This is a patient with uveitis. I was going to show you more of the friability of the angle. Here the needle is in. You can see the hunter’s trail, the white line. I come along, right, my assistant is holding the eye. Tenting the conjuval too much. It’s choppy but that’s okay. Hunter’s trail there. We go back, the other side of where I left off. You can see the angle is not as clean in uveitis. It’s often very friable. But we’re doing the same thing. Okay. We can stop that video. You can stop sharing and I will reshare my screen. So that’s what goniotomy looks like. Goniotomy is all about preparation, preparation. It takes me about 15 minutes to prep, drape, and set up and make sure I can view before the needle goes in. Once the needle is in, it’s a minute procedure. No stitches, I’m out, I’m done. Let’s get back to our pretest and do the post test answers. Indications for goniotomy include, well, goniodysgenesis is the perfect one. You can have another chance to answer. Go ahead. Wait for the answers. There we go. We reduced the closed angle. The reason is closed angle glaucoma, you can’t get in because the insertion is steep. There is peripheral anterior synechiae. Dysgenesis is a high iris insertion. That is not typical closed angle glaucoma. That is glaucoma after retinopathy of immaturity or Peter’s anomaly. You can’t see it because you have a corneal scar: You can’t scrape the scar away: You have a shallow anterior chamber. And iris Bombe, the iris is tented up. You have a clean view of the angle. The reason to do the procedure, meaning that fluid can’t get to Schlemm’s canal because of a dysgenic trabecular meshwork. Let’s go to the next question. The most important thing in goniotomy is. Making sure no Haab stria. Good view of the angle. Having a Koeppe lens. Or absence of a cataract. Let’s see what you got. Absolutely. That is great. 91 percent. You can do it with Haab stria, not a problem. Just makes it harder. Koeppe lens is not the lens for goniotomy. The Barkan lens for goniotomy or a Swan Jacob lens. And whether you have a cataract of not is not important because that is behind where you’re doing surgery and doesn’t affect the view. It’s a risk of the surgery but it doesn’t make you not guilty do the surgery. And lastly, compared to GATT, goniotomy is — you got this right the first time, gang. Let’s see if you’re still getting it right. Let’s see the answers. Sure enough we’ve got all of the above. It is definitely faster than the MIGS procedure, it’s cheaper than the MIGS. It’s easier in most hands once you get used to it. I am right on time, one minute over time. I’m going to stop sharing my screen and take questions from the audience. I have them here in my Q&A. So I’ll read them out and feel free to put any questions that you have in the Q&A and I’m happy to answer. No. 1, is there a difference in technique of goniotomy in PCG and JAAG? No. It’s the exact same procedure. JOAG is easier because the eye is good size. No corneal opacities or corneal edema. It’s the exact same procedure. It’s a little more challenging finding the entry point because in congenital glaucoma, you can use the high iris as the guiding spot where to go in. But if you know your angle anatomy, you can get to the right spot. No. 2, do I suture the needle wound? No. I do not suture the wound. If you go up and then flatten your hand, I get to the screen where you can see better. Let me take off the blur here so you can see better. If you start your incision upwards and flatten your hand and go across, that is going to give you a self-sealing wound. That self-sealing wound is going to not require a stitch. And then you also asked, do I wash out any of the OVD? No. I leave it there. So it’s not a problem at all. Because you just made this big cleft for it to drain out. Rarely, rarely do you get a pressure spike. I leave it all in there. Even if it clouds up the cornea, it will go away. The next question, what is the national for leaving the Healon in? The rational is two things. No. 1, to prevent hyphema. You’re putting your finger, putting pressure on the blood vessels. We know the rate of hyphema is 50 percent. That is tamponading any blood vessels. No. 2, it keeps things deep which is helpful and doesn’t affect the postop IOP. If you have done the procedure in the right place you should be fine. The percentage of failure? Failure rates run about 20 to 25 percent. I must tell you, I see kids all the time that I did a goniotomy on nine or ten years ago, they are on no medications or one medication and they’re perfectly controlled for years and years. For a quick and cheap and easy operation with a low, low risk, sometimes it’s a great choice. If it fails, you go onto another procedure. I highly recommend it. Let me just see here, I think I skipped one bear with me. How much IOP lowering do you get. You can get the pressure from 50 to 10. You’re correcting the problem. So this is a dramatic procedure that gets you good results when it works. Leaving an air bubble in the AC is also a possibility. The air bubble can tamponade blood vessels. It can maintain the anterior chamber. The problem is it makes it harder to see once the air bubble is in. You can see through Healon. If you want to touch something up or there is a little blood vessel and you want to put Healon in. You can’t swap syringes during the case. You have to make the decision before. I prefer Healon. Or some viscoelastic. If you don’t have a microscope that can rotate, that’s a problem. There really is no way to do this procedure without a rotating — having said that, if you use a MIGS gone owe prism lens, then you can do the procedure with the lens held under the microscope. You can put a needle in the limbus and do a very similar procedure. You’re essentially doing a MIGS procedure at that point. That can be done. Thank you. Can you tell me the exact location of hunter’s trail? It’s when you’re in the trabecular meshwork. That is anterior to the sclera spur. That’s where the top of that iris insertion in the anterior trabecular meshwork, the sclera spur, the Schlemm’s canal is behind that. If you leave an air bubble in if you choose that, the air bubble goes away by itself. It just diffuses. How long does its last? It can last for years. If I have excessive hyphema after surgery, I do nothing. It goes away. If I made a cleft — the only time I did something was in the case of neurofibromatosis where there, it’s so dysgenic, it’s hard to make it go away. Let’s see. Do I recommend it in adults — I don’t take care of adults. Adults tend to get more of the MIGS procedures. Goniotomy is done less than that. There is a recent paper showing that goniotomy works in adults. Not sure why they don’t do more goniotomy. But I’m only talking about kids with glaucoma here. After cataract surgery, if the pressure is high, I would use medications first. If medications fail, I would look at the angle. I would see if it’s a dysgenic angle that looks abnormal. I might try goniotomy. It’s as easy enough operation to do. How do I compare GATT with 5-0 proline. This is the same question that I answered regarding trabeculotomy. Here is a person saying, I find that goniotomy in small consecutive cuts is technically easier. Is it less effective? I have no idea. The question is why would I do it in small cuts when I can goat the whole angle open. Once you have done it allot and practiced the full sweeping movement, you can get a lot more angle open. The more angle you have open, the harder it is to close as well. A little spot can close. Sometimes the iris creeps up and closes the angle. Sometimes the angle shuts on its own. Sometimes there is not enough surface area. The more surface area, the harder it is to close and the more drainage you get. This is a great question, what is the coupling agent I use for the contact lens. If tear gel is not available, I don’t use that. I use the Healon on the syringe. I put a bit on the base of the lens and put it on the eye. Whatever viscoelastic I can use. Tear gel. Anything ointment like that is clear that is used to couple the lens to the eye. You don’t actually need it as much to see. You need it for lubrication so you can move the lens clearly on the corneal surface. If there is corneal edema, it means the pressure is high. In this case can we use preop mannitol, sure. You can use mannitol. If it’s epithelial edema, you just scrape it off and avoid the mannitol. Mannitol is unlikely to clear chorial stromal edema. It’s the epithelial edema you’re after. How do I assess the depth of the needle entry. The needles are all structured the same way. They go up and out and then they come to a point. I go to the widest point of the needle which is about half the needle bevel. If the needle comes out, what should you do? That’s a really tough situation. If the anterior chamber is very flat, I’m going to do nothing. I’m going to come back another day. And either try the procedure over again or do another procedure. If there is still some room in the anterior chamber, I might try to snake in a 30 gauge cannula: Remember I’m using a 25 gauge needle so a 30 gauge cannula will go in the wound and try to deepen the chamber. Only if it’s deep would I try to go in again. The needle size or the knife size does not depend on the eyeball size. It’s the same entry point either way. That’s a nonissue. In case of postop hypotony, should we proceed again. If you have swallowing of the anterior chamber. Deepen with dilating drops. If it’s not shallow, it’s a low pressure, congratulations, you have low pressure. Hypotony is good. It’s only when it’s shallow you need to do something. Any use of hypertonic saline in clearing the cornea edema prior to surgery? I’m not worried because I can take off the epithelium. I use the medications to avoid taking it off. Maybe hypertonic saline can help. But once it’s stopped at the same of surgery, the morning of surgery for the night before, you have some recurrence of the edema and you’ll be in the same place having to take it off. Opposed to medications that can lower the pressure a bit to help the cornea clear. Do you get good results in peds with aphakia and pseudo-aphakia glaucoma. They are amenable to this procedure. The rates seem to be more successful when the angle is dysgenic. As if it’s a combination of cataract plus the dysgenic angle that led to the glaucoma. So those cases tend to do better. If it’s closed angle glaucoma, I’m not going to do it. I’m not going to see. If there is vitreous through the pupil, I’m not going to do it. That will get in the way. I will always try medications to manage pseudophakic glaucoma and aphakic glaucoma before a goniotomy. Nine out of ten times I try a goniotomy first. It’s easy, it’s cheap, it’s quick. It’s a low-risk procedure. I can always do another operation for that disorder. So that comes to the end of our time. One minute. The end of our questions. I want to thank you all very, very much for your time and your attendance. It was great to be here. Thank you to Orbis. To Andy and Lawrence that do an absolute spectacular job of making these sessions happen. Keep going to Cybersight. It’s a wonderful platform where you can find more webinar ands case quizzes that are posted. You can find learning content, there are courses. And in addition, there is the consult service that allows you to ask questions of individual practitioners from around the world, experts in the field in every aspect. In genetics, glaucoma, cornea, plastics and get responses. Join Cybersight, it’s free, it’s available, make use of it. Thank you very much, have a great day.