Trabeculectomy in ICE syn.
Group no. 4
Instructors:
Berger Yoav
Robinson Anat
Team:
Platner Eva
Birger Yael
Gagarin Oksana
Wasserzug Yael
Miller Ariela
Case Presentation
42 YOF
OS Sharp Decrease in VA
OD – WNL
OS- hyperemic conjunctiva, corneal edema ++,
increased IOP (42 mmHg), A/C Deep and
Quiet, Gonioscopy- PAS with corresponding
corectopia, clear lens, C/D ratio 0.8
Failure of medical treatmentCosopt + Xalatan (IOP-38mmHg)
Iridocorneal Endothelial
Syndrome
Unilateral
Progressive
Non-familial
Young adults, F>M
Unknown etiology
Iridocorneal Endothelial
Syndrome
Abnormal endothelium with production of an
abnormal BM
3 subtypes:
– Iris nevus/Cogan-Reese syn.
– Chandler syn.
– Essential/progressive iris atrophy
Iridocorneal Endothelial
Syndrome
Dx criteria (2 of 3):
- Typical iris changes
- abnormal corneal endothelium
- PAS
Associated:
- Glaucoma (50%)
- Corneal edema
Iridocorneal Endothelial
Syndrome
Management of glaucoma
Medical Rx- mostly ineffective for long term
Surgical Rx– Trabeculectomy + antifibrotic agents
– Drainage devices
Management of corneal edema
Medical Rx- hypertonic saline, Soft contact
lenses
Surgical Rx- KPL
Our Case
Diagnosis:
ICE syndrome with intractable glaucoma
(high IOP with advanced disc damage)
Management: Glaucoma surgery
with possible subsequent KPL
Preferred glaucoma surgery:
Trabeculectomy + MMC
Why Trabeculectomy with MMC?
Current literature recommendations:
First use trabeculectomy with MMC in
ICE Syndrome
- Doe et al, Ophthalmology 2001
- Kim et al, Ophthalmlogy 1999
- Cornea – Fundamentals, diagnosis and
management (p. 975-983)
Why Trabeculectomy with MMC ?
Lower mean IOP was noted with
trabeculectomy !
62 trabeculectomies Vs. 55 Ahmed glaucoma
valve implants (11-13 months follow-up)
Wilson et al, AJO 2000
Why Trabeculectomy with MMC?
-
80% success rate for trabeculectomy and
MMC in ICE Syndrome patients
(10 patients, 30 months follow-up)
Lanzl at al, Ophthalmology, 2000
-
60% success rate for trabeculectomy and
MMC in ICE Syndrome patients
(22 patients, 1-17 years follow-up)
Laganowski et al, Arch Ophthalmol, 1992
Why Trabeculectomy with MMC?
Most surgeons are more familiar and
experienced with filtration surgery
6/9
of glaucoma specialists in this audience do not
perform GDI’S at all
2/3
of surgeons familiar with this procedure prefer
to use GDI’S as second surgical procedure in
failed trabeculectomy
Why Not GDI?
Complications of GDI’s:
-
Early over-filtration resulting in flat A/C , tubecorneal touch, compromised cornea, hypotony and
choroidal effusion
-
Tube obstruction/ migration/ erosion: All may
require surgical revision
-
Motility disturbances and diplopia
-
Chronic inflammation
Why Not GDI?
Valve malfunction:
ICE is associated with a possible
dysfunction of the tube caused by a
membranous overgrowth of the lumen
and dislocation of the tube.
Lanzl et al, Ophthalmology, 2000
Why Not GDI?
Corneal decompensation is one of the main
complications following GDI, up to 30%
Topouzis et al, Am J Ophthalmol 1999
Why Not GDI?
-
GDI is an independent risk factor for
graft failure - 40% at one year and 75%
failure in the second year
Alvarenga LS, Mannis MJ et al, AJO 2004
-
10-51% (mean 36%) graft failure/rejection
in patients with KPL and glaucoma after
GDI surgery
- Ayyala et al, Ophthalmology 1998
- Rapuano et al, Cornea 1995
Therefore….
For our patient, having:
ICE syndrome
Intractable glaucoma
Possible future KPL
Trabeculectomy & MMC is
the best treatment!!!
THANK
YOU!!!