17 Single-Pass Four-Throw Pupilloplasty for Angle-Closure Glaucoma

Summary

Secondary angle-closure glaucoma (ACG) often develops due to the fall back of iris tissue in the anterior chamber (AC) angle, thereby inadvertently blocking the trabecular outflow. Performing surgical pupilloplasty in the initial stages helps to prevent the formation of peripheral anterior synechiae (PAS) as well as break the newly formed PAS. This chapter deals with the aspect of preventing the further progression of AC angle changes in selected cases of secondary ACG and treating them with surgical pupilloplasty. Single-pass four-throw pupilloplasty helps to pull the peripheral iris, thereby preventing the trabecular meshwork from being blocked mechanically in cases with plateau iris syndrome, Urrets-Zavalia syndrome, and select cases of secondary angle closure.

17.1 Introduction

Glaucoma is one of the leading causes of blindness worldwide. It is further categorized as open-angle or angle-closure glaucoma (ACG). ACG may be primary or secondary in nature and it may also be either acute or chronic in nature. Laser peripheral iridotomy (LPI) is the modality of treatment for ACG in cases with suspected pupillary block. However, in cases with plateau iris, Urrets-Zavalia syndrome (UZS), ^{1 , 2 , 3 , 4} and secondary angle closure due to development of peripheral anterior synechiae (PAS), LPI works seldom. The creeping of the iris tissue on the trabecular meshwork followed by the development of PAS over a long-standing period leads to raised intraocular pressure (IOP).

Surgical pupilloplasty with single-pass four-throw (SFT) technique ^{5 , 6 , 7} has been found helpful in resolving the raised IOP with breakage of PAS and opening of the angle structures in cases with plateau iris, UZS, and silicone oil-induced secondary angle closure (▶Fig. 17.1 and ▶Fig. 17.2).

17.2 Surgical Technique

In cases with UZS and in secondary angle closure due to the formation of PAS, the initial step is performed a bit differently (▶Video 17.1). With an end-opening forceps introduced inside the AC, the peripheral edge of the iris tissue is held and is pulled slightly in a controlled way towards the center of the pupil. This helps to assess the amount of peripheral iris tissue available for the pupilloplasty procedure, and secondly, it also helps to relieve and break the PAS that are formed.

Specific to all the cases of ACG, it is beneficial to perform the procedure under infusion fluid rather than viscoelastic as the eyes are already inflamed with raised IOP. Any trace of viscoelastic left at the end of the surgery can increase the postoperative IOP spike.

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