This video demonstrates a goniotomy like procedure using a new device called TRAB 360. This 3-year-old child presented with primary infantile glaucoma. A trabeculotomy was performed over 340 degrees but the angle was opened over 360 degrees.
Surgeon: Dr. James Brandt, University of California, Davis
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DR BRANDT: So this is a three-year-old little boy who presented with primary infantile glaucoma. We have done some examination here. His pressure, just after anesthesia was induced, was 41 millimeters of mercury in this eye. The axial length of this eye was about 27 or 28 millimeters, compared to 21 or 22 in the other eye. He has a cup-to-disc ratio of easily 0.6 or greater in this eye, compared to 0.2 or so in the other eye. This was examined in the clinic. We did not dilate him, because we anticipated doing angle surgery here. And we’re gonna get started and do a goniotomy, which is a very straightforward procedure. We’re gonna try with a new device that is available now, called a TRAB 360, which allows us to perform a goniotomy-like procedure, but over 360 degrees. And this little device allows us to go into the canal and thread a suture 180 degrees, and then tear it out, so that it essentially performs a 180-degree trabeculotomy, and then we can retract it and turn it around in the opposite direction. That doesn’t always feed correctly, so if it does not, we’ll simply stop and do a goniotomy. Which should work very well in this child. His pupil is a little bit more dilated than I would like it to be, just at its resting level, so I’m gonna go ahead and put a little miotic in the eye. So I’m going to start with a Super Sharp… Okay. So I am overinflating the anterior chamber with viscoelastic. I’m also gonna make a very small incision here, just so that I can access the chamber separately, to flush out the Healon at the end of the case. Put a little bit of gel on the surface of the eye. It makes it a little bit easier to couple. So I’ll now take the Swan Jacob lens… So I’m going to advance it. Notice that I’ll advance it under visualization, across but not with the gonioprism on yet. Okay. Now I’ll take the gonioprism. Okay. So now I have injected the cannula into the angle, as you can see. And I’m advancing it around. And now I will remove it by not withdrawing, but by in fact tearing… And you can see that it’s opening the angle. And you’ll be able to see how it comes around, all the way. So I have now done a goniotomy or a trabeculotomy over 180 degrees. I will now withdraw this back in. And I will flip it over to do the same thing in the opposite direction. And look here. You can see a perfect goniotomy done by this device. And so now I do the same thing here. And we have now performed a trabeculotomy, over 360 degrees, or probably 340 degrees, because we probably did not incise the anterior chamber angle down here. But we’ve opened up the angle almost 360 degrees. So you can already see blood coming back over here. That tells me that we have connected into the canal. Sometimes with these sorts of procedures, at the end of the operation, there can be a very large hyphema. So I am now confident that we did the — we were in the right anatomy, and we’re getting blood reflex. Not quite as much as I usually get, but certainly plenty enough. And so we’re certainly getting blood from where we would normally get — over about 120 degrees — with a goniotomy. This is a smaller than usual phaco wound that you would leave without — you would not necessarily suture in an adult. But in children, the cornea is very, very flexible and floppy, and also, if the child were to rub the eye, they could collapse the chamber. So I’m going to secure the wound with a suture of 10-0 vicryl, which will reabsorb in a few weeks. So we are not obligated to take the child back, to anesthetize him, just to remove a suture. If I was doing this in an older child or an adult, I would do this with nylon and just remove the suture at the slit lamp. So the big advantage of this approach is that we can see the anatomy, so that we know exactly where we were. Whereas if you go externally with the metal trabeculotome, you usually think you’re in the right place, but you can never be completely sure that you did not create a false passage and simply force the metal through the sclera, and weren’t really in the canal. The other advantage to this approach is that you do not touch the conjunctiva, except for these injections, and maybe these two little places where I put sutures. So the success rate, if you have to do a trabeculectomy or a glaucoma drainage device, we think, is much, much more likely to succeed, because we have not induced scarring in this area.