Minimalinvasive Kammerwinkelchirurgie mit dem Trabektom

Zusammenfassung

Das Trabektom ist ein Instrument zur Elektroablation des beim Glaukom pathologisch veränderten juxtakanalikulären Trabekelmaschenwerks. Der Schlemm-Kanal wird zur Vorderkammer eröffnet, wodurch der Abfluss von Kammerwasser in das intra- und episklerale Gefäßsystem ermöglicht wird. In den bisher veröffentlichten Studien zum Trabektom wird eine Drucksenkung von im Mittel 30 % und eine simultane Medikamentenreduktion um 42 % berichtet. Das Trabektom ist bei primären und sekundären Offenwinkelglaukomen einsetzbar, wobei sich bei Pseudoexfoliationsglaukomen eine besonders gute Wirksamkeit zeigt. Durch seinen wenig invasiven und vor allem bindehautneutralen Operationszugang ist das Trabektom zudem besonders gut geeignet bei Patienten mit chronischen Erkrankungen der Augenoberfläche. Der operative Zugang erfolgt über einen kornealen Tunnel. Der Eingriff mit dem Trabektom lässt sich über einen Zugangsweg gut mit einer Phakoemulsifikation und Hinterkammerlinsenimplantation kombinieren. In den bisherigen Studien zeigte sich keine über das allgemeine Risiko eines bulbuseröffnenden Eingriffs hinausgehende Rate ernster Komplikationen. Das Trabektom stellt eine sichere und effektive Methode der operativen Augeninnendrucksenkung bei Patienten mit Offenwinkelglaukom und einem Zieldruckniveau um 16 mmHg dar.

Abstract

The main barrier reducing outflow of aqueous humor in open angle glaucomas is the juxtacanalicular trabecular meshwork. The trabectome removes this pathophysiologically altered tissue by electroablation, thus allowing for the collector channels draining Schlemmʼs canal to directly communicate with the anterior chamber. In studies published so far, about 30 % decrease of intraocular pressure and a simultaneous 42 % reduction of pressure-lowering eyedrops could be achieved in primary and secondary open angle glaucomas. A clear cornea tunnel is used to advance the trabectome to the trabecular meshwork, leaving the conjunctiva unaffected. Hence minimally invasive chamber angle surgery using this device is in particular suitable for patients with an altered ocular surface. Lowering of intraocular pressure and reduction of needed topical medication seems to be distinct in pseudoexfoliative glaucoma. Surgery with the trabectome and phacoemulsification can easily be combined in one procedure. Using a minimally invasive approach, the complication profile of the trabectome is rather advantageous, not exceeding the general risks of globe-opening surgery. Ab-interno trabeculotomy is a safe and effective method for treatment of patients with primary or secondary open angle glaucomas and moderate target pressures.

Schlüsselwörter

Glaukom - minimalinvasive Kammerwinkelchirurgie - Trabektom

Key words

glaucoma - minimally invasive glaucoma surgery - trabectome

• Literatur

• 1 Baerveldt G, Chuck R. Minimally invasive glaucoma surgical instrument and method.. US Patent 6979328, 2005
• 2 WuDunn D. Mechanobiology of trabecular meshwork cells. Exp Eye Res 2009; 88: 718-723
• 3 Schlunck G, Han H, Wecker T et al. Substrate rigidity modulates cell matrix interactions and protein expression in human trabecular meshwork cells. Invest Ophthalmol Vis Sci 2008; 49: 262-269
• 4 Selbach JM, Gottanka J, Wittmann M et al. Efferent and afferent innervation of primate trabecular meshwork and scleral spur. Invest Ophthalmol Vis Sci 2000; 41: 2184-2191
• 5 Tektas OY, Lütjen-Drecoll E. Structural changes of the trabecular meshwork in different kinds of glaucoma. Exp Eye Res 2009; 88: 769-775
• 6 Wecker T, Han H, Börner J et al. Effects of TGF-β2 on cadherins and β-catenin in human trabecular meshwork cells. Invest Ophthalmol Vis Sci 2013; 54: 6456-6462
• 7 Kagemann L, Wollstein G, Ishikawa H et al. Visualization of the conventional outflow pathway in the living human eye. Ophthalmology 2012; 119: 1563-1568
• 8 Hann CR, Bentley MD, Vercnocke A et al. Imaging the aqueous humor outflow pathway in human eyes by three-dimensional micro-computed tomography (3D micro-CT). Exp Eye Res 2011; 92: 104-111
• 9 Tamm ER. Funktionelle Morphologie der Abflusswege des Kammerwassers und ihre Veränderungen beim Offenwinkelglaukom. Ophthalmologe 2013; 110: 1026-1035
• 10 Rulli E, Biagioli E, Riva I et al. Efficacy and safety of trabeculectomy vs. nonpenetrating surgical procedures: a systematic review and meta-analysis. JAMA Ophthalmol 2013; 131: 1573-1582
• 11 Zhou J, Smedley GT. A trabecular bypass flow hypothesis. J Glaucoma 2005; 14: 74-83
• 12 Sit AJ, McLaren JW. Measurement of episcleral venous pressure. Exp Eye Res 2011; 93: 291-298
• 13 Barkan O. Operation for congenital glaucoma. Am J Ophthalmol 1942; 25: 552-568
• 14 Barkan O. A new operation for chronic glaucoma. Restoration of physiological function by opening Schlemmʼs canal under direct magnified vision. Am J Ophthalmol 1936; 19: 951-955
• 15 Harms H, Dannheim R. Epicritical consideration of 300 cases of trabeculotomy ‘ab externo . Trans Ophthalmol Soc U K 1970; 89: 491-499
• 16 Jacobi PC, Dietlein TS, Krieglstein GK. Technique of goniocurettage: a potential treatment for advanced chronic open angle glaucoma. Br J Ophthalmol 1997; 81: 302-307
• 17 Minckler D, Baerveldt G, Ramirez MA et al. Clinical results with the Trabectome, a novel surgical device for treatment of open-angle glaucoma. Trans Am Ophthalmol Soc 2006; 104: 40-50
• 18 Francis BA, See RF, Rao NA et al. Ab interno trabeculectomy: development of a novel device (Trabectome) and surgery for open-angle glaucoma. J Glaucoma 2006; 15: 68-73
• 19 Allingham RR, de Kater AW, Ethier RC. Schlemmʼs canal and primary open angle glaucoma: correlation between Schlemmʼs canal dimensions and outflow facility. Exp Eye Res 1996; 62: 101-110
• 20 Jordan JF. [Minimally invasive iridocorneal angle surgery]. Ophthalmologe 2012; 109: 713-723 (quiz 724)
• 21 Saheb H, Ahmed IIK. Micro-invasive glaucoma surgery: current perspectives and future directions. Curr Opin Ophthalmol 2012; 23: 96-104
• 22 Dietlein TS. [Glaucoma in the aged–barriers to understanding and compliance]. Ophthalmologe 2006; 103: 755-758
• 23 Dietlein TS, Jordan JF, Lüke C et al. Self-application of single-use eyedrop containers in an elderly population: comparisons with standard eyedrop bottle and with younger patients. Acta Ophthalmol 2008; 86: 856-859
• 24 Gupta R, Patil B, Shah BM et al. Evaluating eye drop instillation technique in glaucoma patients. J Glaucoma 2012; 21: 189-192
• 25 Fechtner RD, Godfrey DG, Budenz D et al. Prevalence of ocular surface complaints in patients with glaucoma using topical intraocular pressure-lowering medications. Cornea 2010; 29: 618-621
• 26 Servat JJ, Bernardino CR. Effects of common topical antiglaucoma medications on the ocular surface, eyelids and periorbital tissue. Drugs Aging 2011; 28: 267-282
• 27 Minckler D, Mosaed S, Dustin L et al. Trabectome (trabeculectomy-internal approach): additional experience and extended follow-up. Trans Am Ophthalmol Soc 2008; 106: 149-159 (discussion 159–160)
• 28 Mosaed S. The first decade of global trabectome outcomes. Clin Surg Ophthalmol 2014; 32: 21-29
• 29 Ting JLM, Damji KF, Stiles MC. Ab interno trabeculectomy: outcomes in exfoliation versus primary open-angle glaucoma. J Cataract Refract Surg 2012; 38: 315-323
• 30 Jordan JF, Wecker T, van Oterendorp C et al. Trabectome surgery for primary and secondary open angle glaucomas. Graefes Arch Clin Exp Ophthalmol 2013; 251: 2753-2760
• 31 Klamann MKJ, Gonnermann J, Maier AKB et al. Influence of Selective Laser Trabeculoplasty (SLT) on combined clear cornea phacoemulsification and Trabectome outcomes. Graefes Arch Clin Exp Ophthalmol 2014; 252: 627-631
• 32 Ahuja Y, Ma Khin Pyi S, Malihi M et al. Clinical results of ab interno trabeculotomy using the trabectome for open-angle glaucoma: the Mayo Clinic series in Rochester, Minnesota. Am J Ophthalmol 2013; 156: 927.e2-935.e2
• 33 Mosaed S, Rhee DJ, Filippopoulos T et al. Trabectome outcomes in adult open angle glaucoma patients: one year follow up. Clin Surg Ophthalmol 2010; 28: 8
• 34 Morales J, Al Shahwan S, Al Odhayb S et al. Current surgical options for the management of pediatric glaucoma. J Ophthalmol 2013; 2013: 763735
• 35 Pantcheva MB, Kahook MY. Ab interno trabeculectomy. Middle East Afr J Ophthalmol 2010; 17: 287-289
• 36 Maeda M, Watanabe M, Ichikawa K. Evaluation of trabectome in open-angle glaucoma. J Glaucoma 2013; 22: 205-208
• 37 Ahuja Y, Malihi M, Sit AJ. Delayed-onset symptomatic hyphema after ab interno trabeculotomy surgery. Am J Ophthalmol 2012; 154: 476.e2-480.e2
• 38 Vold SD, Dustin L. Trabectome Study Group. Impact of laser trabeculoplasty on Trabectome® outcomes. Ophthalmic Surg Lasers Imaging 2010; 41: 443-451
• 39 Töteberg-Harms M, Rhee DJ. Selective laser trabeculoplasty following failed combined phacoemulsification cataract extraction and ab interno trabeculectomy. Am J Ophthalmol 2013; 156: 936.e2-940.e2
• 40 Jea SY, Mosaed S, Vold SD et al. Effect of a failed trabectome on subsequent trabeculectomy. J Glaucoma 2012; 21: 71-75
• 41 Minckler DS, Baerveldt G, Alfaro MR et al. Clinical results with the Trabectome for treatment of open-angle glaucoma. Ophthalmology 2005; 112: 962-967
• 42 Francis BA, Minckler D, Dustin L et al. Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma: initial results. J Cataract Refract Surg 2008; 34: 1096-1103
• 43 Van Oterendorp C, Ness T, Illerhaus G et al. The trabectome as treatment option in secondary glaucoma due to intraocular lymphoma. Glaucoma 2012; [Epub ahead of print]