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Canthotomy and cantholysis prior to ultrasound circular cyclocoagulation (UC3® Eye Tech Care) in refractory glaucoma
Ciclocoagulación circular mediada por ultrasonidos (UC3® Eye Tech Care) en glaucoma refractario tras cantotomía y cantólisis
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Immunohistochemistry with HMB45 was positive. (A) Stain with H&E ×40. (B) HMB45 ×40. (C) Melan-A ×10. (D) Melan-A ×40.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Ajamil Rodanés, C. García-Álvarez, M.A. Saornil Alvarez, F. López-Lara, J.M. Frutos Baraja, M. Quiñones" "autores" => array:6 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Ajamil Rodanés" ] 1 => array:2 [ "nombre" => "C." "apellidos" => "García-Álvarez" ] 2 => array:2 [ "nombre" => "M.A." "apellidos" => "Saornil Alvarez" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "López-Lara" ] 4 => array:2 [ "nombre" => "J.M." "apellidos" => "Frutos Baraja" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Quiñones" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669116301605" "doi" => "10.1016/j.oftal.2016.08.007" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669116301605?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579417300774?idApp=UINPBA00004N" "url" => "/21735794/0000009200000008/v1_201707250047/S2173579417300774/v1_201707250047/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Short communication</span>" "titulo" => "Canthotomy and cantholysis prior to ultrasound circular cyclocoagulation (UC3<span class="elsevierStyleSup">®</span> Eye Tech Care) in refractory glaucoma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "382" "paginaFinal" => "385" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Fernández, J. Raez-Balbastre, V. Elipe, F. Poyales" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Fernández" "email" => array:1 [ 0 => "afernandez@ioamadrid.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Raez-Balbastre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "V." "apellidos" => "Elipe" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Poyales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "IOA Madrid Innova Ocular, Oftalmología, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Fundación Jiménez Díaz, Oftalmología, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ciclocoagulación circular mediada por ultrasonidos (UC3<span class="elsevierStyleSup">®</span> Eye Tech Care) en glaucoma refractario tras cantotomía y cantólisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 132173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">application of ultrasound (UC3<span class="elsevierStyleSup">®</span>) after cantholysis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinic case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">The case of a pseudophakic patient is presented, age 82, diagnosed with primary open angle glaucoma, who underwent filtrating surgery on 3 occasions with poor evolution (nonperforating deep sclerectomy in upper quadrant and trabeculectomy with upper temporal iridectomy and limited filtration), exhibiting campimetric progression and intraocular pressure levels above target pressure while in treatment with 3 medicaments (2 eyedrops with beta blockers and prostaglandin, and carbonic anhydrase inhibitors, 34<span class="elsevierStyleHsp" style=""></span>mmHg). Visual acuity of the operated eye was 0.1 whereas the contralateral eye had a vision of 0.9. Considering this poor visual acuity in the affected eye, campimetric values could not be utilized. Optical coherence tomography of the papillary area showed nerve fiber layer of 54 microns, with a papilla cup of 85% and altered neuroretinal ring. As the case was refractory glaucoma that could not be submitted to additional filtrating surgery, after discussing the situation with relatives and considering the advanced age of the patient, it was decided to perform circular cyclo-coagulation with ultrasound instead of a more invasive surgery such as the implant of an Ahmed-type valve. At the time, the authors’ hospital did not have equipment to perform laser cyclo-coagulation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The size of the probe to be utilized was calculated with white–white measurements by means of Visante-OCT<span class="elsevierStyleSup">®</span> (Carl Zeiss Meditech, Inc.) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and Pentacam<span class="elsevierStyleSup">®</span> (OCULUS Optikgerate GmbH, Wetzlar, Germany), a key step for the ultrasound (US) to act on the ciliary body. The device to be used was Eyeop-pack 12. Secondarily, the patient exhibited extreme palpebral rigidity that, applying moderate strength, discovered the upper sclera. Said bilateral rigidity had no apparent cause and featured limited palpebral opening that was not measured.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Peribulbar anesthesia was applied for surgery (2<span class="elsevierStyleHsp" style=""></span>cc. 0.5% bupivacaine and 2<span class="elsevierStyleHsp" style=""></span>cc. 2% lidocaine) which increased the edema of the eyelid, for which reason a Honan balloon was placed and massage was applied during over 30<span class="elsevierStyleHsp" style=""></span>min, with the result that the necessary palpebral opening for placing the probe could not be achieved.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In order to apply adequately the UC3<span class="elsevierStyleSup">®</span> over the limbus it was necessary to perform canthotomy and cantholysis in order to separate both eyelids.</p><p id="par0025" class="elsevierStylePara elsevierViewall">After infiltrating the external canthus area with local anesthetic (2% lidocaine with adrenaline, 0.5–1<span class="elsevierStyleHsp" style=""></span>cc.), Westcott scissors were used to make a horizontal cut from the external canthus in the direction of the lateral orbital edge (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). This procedure only enabled a slightly bigger but still insufficient palpebral opening because the lower eyelid remained in its position, inserted in the lateral orbital edge through the lower arm of the lateral canthal tendon.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Cantholysis consists in cutting said lower arm of the lateral canthal tendon. To this end, after performing canthotomy, slight medial traction is applied on the eyelid and the fibrous tissue to be cut at a right angle from the free edge is located in the plane between the conjunctiva and the orbicular. Said cut is extended in the inferior nasal direction until the lower eyelid is deinserted from the lateral anchor and can be freely mobilized.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After completing cyclo-ablation (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), the palpebral edge must be reconstructed. To this end, an absorbable suture was used as it would reposition the medial end of the lower arm of the lateral canthal tendon and the tharsal plates in the orbital edge, as if making a tharsal strip. Subsequently, with an absorbable suture material (Vycril<span class="elsevierStyleSup">®</span> 6/0) canthopexia was performed to rejoin the upper and lower eyelids, making sure that the stitch in both eyelids was made at the level of the gray line and that the knot remained outside of the palpebral slit. Lastly, the resulting wound in the external canthus was sutured with loose stitches of 6/0 Prolene<span class="elsevierStyleSup">®</span>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Postop VA remained the same as before surgery, 0.1. During the first few weeks, intraocular pressure remained at 17<span class="elsevierStyleHsp" style=""></span>mmHg without any added treatment. The patient did not exhibit scleral wounds or burns that could be attributed to the treatment. One month later, intraocular pressure increased to 23<span class="elsevierStyleHsp" style=""></span>mmHg and it was decided to add carbonic anhydrase inhibitor eyedrops as treatment at 24-hour intervals. The situation remained unchanged until the demise of the patient a few months later.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Numerous procedures have been described for treating refractory glaucoma. Specifically for cyclo-destructive processes<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> there are 2 different access pathways, trans-scleral and endoscopic, with well-known results.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2–4</span></a> Circular cyclo-ablation with ultrasound (UC3<span class="elsevierStyleSup">®</span>) is a new technique that enables selective ciliary body coagulation. Its efficacy and safety has been published both for patients with previous filtrating surgery as well as first choice in patients.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a> The selection of the adequate size and the placement of the probe cone are key for the adequate execution of the procedure. The probe diameter is based on the white–white distance that can be measured by means of different devices (e.g., biometry, optical coherence tomography, ultrasound biomicroscopy). Generally, the adequate positioning of the cone does not entail difficulty and only a small amount of local anesthetic is necessary.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Lateral canthotomy associated or not to cantholysis has been proposed for quite some time as a simple technique for avoiding the eventually devastating consequences for vision in orbital compartmental syndrome cases. The lateral canthal tendon is chosen because of its superficial location and the absence of adjacent anatomical structures that could be damaged, as is the case of the lacrimal pathway for the medial canthal tendon approach.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7–9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Even though canthotomy is a very simple procedure within the reach of any ophthalmologist, in some occasions other procedures must be resorted to such as the one described in the present case which is not familiar to all glaucoma surgeons. In complex cases in which glaucoma surgery may be limited due to anatomic reasons, oculoplasty techniques could be of help to resolve said situations.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">All the authors declare that they have no commercial interest or any conflict of interests with any of the products referred to in this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres873572" "titulo" => "Abstract" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec862214" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres873571" "titulo" => "Resumen" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec862215" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinic case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-25" "fechaAceptado" => "2016-11-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec862214" "palabras" => array:4 [ 0 => "Glaucoma" 1 => "Cyclocoagulation" 2 => "UC3<span class="elsevierStyleSup">®</span>" 3 => "Cantholysis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec862215" "palabras" => array:4 [ 0 => "Glaucoma" 1 => "Ciclocoagulación" 2 => "UC3<span class="elsevierStyleSup">®</span>" 3 => "Cantólisis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case report</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The case is presented on a patient with primary open-angle glaucoma treated with the novel ultrasound circular cyclocoagulation technique (UC3<span class="elsevierStyleSup">®</span> [EyeTechCare, Rillieux La Pape, France]), who had previously undergone glaucoma surgery. Due to having extreme palpebral rigidity, worsened by the pre-operative local anesthesia injections, a canthotomy and cantholysis were needed to correctly position of the UC3<span class="elsevierStyleSup">®</span> probe cone. Clinical outcome as regards the IOP and the surgical wound was very satisfactory.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In complex cases of refractory glaucoma in which cyclo-destructive surgery is limited for anatomical reasons, a complementary oculoplasty technique may be a good option.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Discussion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Caso clínico</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una paciente operada previamente de cirugía de glaucoma a la cual indicamos una intervención de cicloablación mediada por ultrasonidos (UC3<span class="elsevierStyleSup">®</span>). Por presentar rigidez palpebral extrema, aumentada con la infiltración preoperatoria de anestésico local, fue necesaria la realización de cantotomía y cantólisis para la correcta introducción del cono. La evolución, tanto de la herida quirúrgica como de la presión intraocular resultó muy favorable.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discusión</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En pacientes complicados en los que la cirugía del glaucoma puede estar limitada por razones anatómicas, el empleo de técnicas de oculoplastia puede ser de gran ayuda para resolver estas situaciones.</p></span>" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "abst0015" "titulo" => "Caso clínico" ] 1 => array:2 [ "identificador" => "abst0020" "titulo" => "Discusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fernández A, Raez-Balbastre J, Elipe V, Poyales F. Ciclocoagulación circular mediada por ultrasonidos (UC3<span class="elsevierStyleSup">®</span> Eye Tech Care) en glaucoma refractario tras cantotomía y cantólisis. Arch Soc Esp Oftalmol. 2017;92:382–385.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 764 "Ancho" => 1000 "Tamanyo" => 137667 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Visante-OCT<span class="elsevierStyleSup">®</span> for the necessary white–white measurement to determine the probe cone size.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1334 "Ancho" => 1000 "Tamanyo" => 191258 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cantholysis.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 750 "Ancho" => 1000 "Tamanyo" => 132173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">application of ultrasound (UC3<span class="elsevierStyleSup">®</span>) after cantholysis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cyclodestructive procedures. 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