The 16th Annual Video Session: Complications and a Reay of Hope, which always closes out ASCRS Glaucoma Day, did not disappoint in its delivery of “a whole bunch of blood and guts,” as Program Co-Chair Manjool Shah, MD, joked. This session, he continued in his introduction, is “near and dear to a lot of our hearts,” featuring “brave young folks” sharing their complicated cases.
Of the three case video presentations, the winner was Jonathan D. Tijerina, MD, who presented on “Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) Using Retroillumination of the Trabecular Silhouette.” Dr. Tijerina called it the “light on the other side of the tunnel.”
Source: ASCRS
He described the case involving a 36-year-old patient with developmental delay. This patient had a history of chronic eye rubbing that resulted in keratoconus that required a corneal graft. The patient experienced acute graft rejection that was treated with steroids, but the patient had a steroid response. The patient’s IOP was 40 mm Hg; it eventually stabilized to the high teens with latanoprost QHS, dorzolamide/timolol BID, and loteprednol BID. The patient developed bullous keratopathy and recurrent edema with a cataract in the left eye.
The patient was referred to the glaucoma service for cataract surgery and MIGS “if able to optimize for DSAEK under PKP,” Dr. Tijerina presented. The patient’s preop BCVA was 20/200.
Dr. Tijerina showed the cataract extraction procedure using an endoilluminator. A 3-piece IOL was placed in the sulcus. When it came to performing a MIGS procedure, however, the gonioscopic view was impeded.
This is where Dr. Tijerina got creative. He already had the endoilluminator out for phaco, and he realized he could see the shadow of the trabecular meshwork—the trabecular silhouette—using this tool. With that view, he was able to perform a nearly 360-degree GATT procedure.
At postop month 4, the patient was BCVA 20/30 with an IOP of 8 mm Hg on two classes of medications. A repeat PKP was avoided so far.
Dr. Tijerina concluded that the endoilluminator improves visualization with corneal opacities and/or in the absence of a red reflex. The endoilluminator should be positioned outside the anterior chamber or intraocularly through a separate incision.
This technique may help facilitate many angle-based procedures, in addition to GATT, such as blade goniotomy, canaloplasty, and trabecular meshwork stenting, Dr. Tijerina said.
One of the panelists asked Dr. Tijerina why he didn’t use an illuminated catheter in this case. He said it was due to surgeon preference but acknowledged that an iTrack (Nova Eye Medical) would have been helpful in this case.
Editors’ note: Dr. Tijerina has no relevant financial disclosures.
