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Professor Zhu Yihua talks about the "new pattern" of combined blue-white surgery

Posting time:2022-10-06 02:41:07

Professor Zhu Yihua talks about the "new pattern" of combined blue-white surgery

Editor's Note Glaucoma and cataract are both age-related eye diseases, and as the population ages, the coexistence of the two is increasing. In the past, trabeculectomy combined with phacoemulsification was the main choice for the treatment of glaucoma complicated with cataract. However, the classic trabeculectomy often faced complications such as shallow anterior chamber, choroidal detachment, bleb leakage, low intraocular pressure, and endophthalmitis. And the surgical trauma is large. With the development of ophthalmic surgery technology, some new combined glaucoma and cataract surgery and improved methods are continuously applied in clinical practice, bringing a new treatment pattern. At the 2022 Vision China conference, Professor Zhu Yihua from the First Affiliated Hospital of Fujian Medical University introduced his views on the new thinking and new progress of combined blue-white surgery. The ideal combined glaucoma and cataract surgery should have the advantages of good intraocular pressure lowering effect, few complications, simple operation and minimally invasive surgery. Cataract combined with glaucoma can be treated with simple cataract surgery (such as Phaco/Phaco+IOL, ECCE/ECCE+IOL, ICCE, etc.), staged surgery (with glaucoma or cataract surgery respectively), and combined glaucoma and cataract surgery (such as trabeculectomy, goniotomy, Ex-press drainage nail implantation, trabecular ablation, iStent implantation, Schlemn canal plasty, XEN gel implant, CLASS, ECP, etc. combined with cataract surgery) and other methods. More and more evidence shows that minimally invasive anti-glaucoma surgery (MIGS) combined with cataract surgery may be the preferred method and development direction of combined glaucoma and cataract surgery. (Figure 1) Figure 1. MIGS surgical classification MIGS surgery (XEN, EXPRESS, INNFOCUS) combined with cataract phacoemulsification through the subconjunctival external drainage channel is undoubtedly the best surgical method for combined glaucoma and cataract surgery. Compared with other MIGS surgery, it can maximize the To reduce intraocular pressure, however, due to factors such as price and access, XEN and INNFOCUS operations cannot be generally carried out, so Professor Zhu's team improved the Ex-press drainage nail implantation. (Fig. 2) The Ex-press drainage pin is made of medical stainless steel and has good biocompatibility. No valve, about 3mm long, 400μm outer diameter, 50μm and 200μm inner diameter (P50, P200), composed of drainage tube, short protrusion and wing collar. The presence of Ex-press drainage pins also did not affect the results of head MRI. Figure 2. The structure and characteristics of the Ex-press mini-drainage nail. Several clinical studies have confirmed that the Ex-press drainage nail has better efficacy and safety in open-angle glaucoma or glaucoma with a deep anterior chamber. However, the incidence of glaucoma in my country over the age of 50 is mainly angle-closure glaucoma, often combined with cataracts. Cataract extraction can relieve the abnormal pathological anatomy of angle-closure glaucoma, deepen the anterior chamber and open the angle of the chamber. For angle-closure glaucoma patients with cataract, the combination of Ex-PRESS drainage pin implantation and cataract surgery can be used. Surgical method of Ex-press drainage nail. ●Subconjunctival implantation (1) Make a 2.0-4.0 mm annular conjunctival incision at 10.0-15.0 mm posterior to the limbus (2) The bolus is slid between the conjunctiva and the sclera (under Tenon's capsule). To the corneal limbus (3) parallel to the iris, push into the anterior chamber at the junction of the cornea and sclera (4) to retract the bolus, and suturing Post-bubble endophthalmitis. Implantation under the scleral flap (with the fornix as the base) (1) Conjunctival flap with the fornix as the base, 3mm×6mm (2) Make a square scleral flap of 1/3 or 1/2 scleral depth of 5mm×5mm (3) Place mitomycin C and flushing ⑷ 26-gauge needle to puncture the anterior chamber and maintain a stable anterior chamber ⑸ puncture into the anterior chamber at 0.5mm behind the junction of the limbus of the cornea Example of 2-needle conjunctiva Subscleral flap implantation (with the limbus as the base) (1) Conjunctival flap with the limbus as the base (2) Making a square or trapezoidal sclera of 3 x 3 mm or 3 x 4 mm with 1/3 or 1/2 scleral depth Flap (3) Place mitomycin C and flushing (4) Anterior chamber puncture and maintain a stable anterior chamber depth (5) Puncture into the anterior chamber at 0.5mm behind the limbus junction (6) Implant a drain, and the aqueous humor slowly leaks from the drain port (7) Modification of Ex-PRESS drainage nail surgery with 4-needle suture of scleral flap and continuous suture of conjunctiva Modified incision Ex-PRESS drainage nail + Phaco + IOL operation steps (1) Subconjunctival lidocaine infiltration anesthesia (2) "L"-shaped bulbar conjunctival flap with the fornix as the base, about 3.5mm in length, 1.5mm in width, scleral surface cauterization for hemostasis (3) Make a triangular scleral flap, the size is about 2.5mm×2.5mm, and the thickness is about 1/2 of the sclera ⑷Conventional 11-point corneal puncture makes a 1.8mm~2.2mm main incision, injects viscoelastic agent into the anterior chamber, and makes a 0.8mm lateral incision at 2 points Oral ⑸ continuous annular capsulorhexis, water separation of the lens nucleus and cortex ⑹ phacoemulsification suction of the lens nucleus and cortex ⑺ viscoelastic injection into the anterior chamber and lens capsular bag, implantation of the posterior chamber intraocular lens into the capsular bag ⑻ puncture under the scleral flap Enter the anterior chamber, inject Healon to deepen the anterior chamber, place drainage pins? (9) Adjust the position of the intraocular lens, and absorb the residual viscoelastic agent with IA. (10) Suture the scleral flap and the conjunctival flap with 10-0 silk thread. Press drainage nail implantation has a relatively wide range of applications, not only for primary open-angle glaucoma, but also for refractory glaucoma with poor effect of conventional filtering surgery, including neovascular glaucoma caused by various reasons, Primary glaucoma, uveitis glaucoma and various secondary glaucoma after multiple failed filtering operations. Angle-closure glaucoma is not an absolute contraindication to the implantation of Ex-press drainage pins. For angle-closure glaucoma patients with cataracts, the combined treatment of Express-press implantation and cataract surgery can also be performed. In recent years, the rapid development of Ex-press drainage nail implantation has brought more surgical options for glaucoma patients. Expert Profile Zhu Yihua Doctor of Ophthalmology, Professor, Chief Physician, Doctoral Supervisor, Director of the Ophthalmology Center of the First Affiliated Hospital of Fujian Medical University. He is also the chairman of the Ophthalmology Branch of the Fujian Medical Association, the vice president of the Ophthalmologist Branch of the Fujian Medical Association, the national member of the Ophthalmology Branch of the Chinese Medical Association, the standing member of the Ophthalmologist Branch of the Chinese Medical Association, and the standing member of the Chinese Ophthalmology Professional Committee of Integrated Traditional Chinese and Western Medicine. He is a member of the Glaucoma Group of the Ophthalmology Branch of the Chinese Medical Association, a member of the Glaucoma Group of the Ophthalmologist Branch of the Chinese Medical Doctor Association, and a member of the Cataract and Refractive Surgery Group of the Ophthalmology Professional Committee of the Cross-Strait Medical Exchange Association. He presided over 4 general projects of the National Natural Science Foundation of China, 1 major project and 1 key project of the Natural Science Foundation of Fujian Province, and presided over or participated in more than 20 other scientific research projects. Editor-in-chief of "Neovascular Eye Diseases", deputy editor of 3 books including "Evidence-Based Ophthalmology", and co-edited more than 20 books including "Chinese Ophthalmology". He has published more than 70 papers in professional journals of ophthalmology, including more than 30 SCI papers. He is the editor or correspondent editor of various professional journals such as "Chinese Journal of Ophthalmology" and "Chinese Journal of Experimental Ophthalmology". Won 3 provincial third prizes for scientific and technological progress.

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