1. NonPenetrating Glaucoma Surgery
Elie Dahan
Oxford Eye Center
University of the Witwatersrand
Johannesburg South Africa

2. Early surgery is superior to Medicine & Laser
Migdal, Gregory & Hitchings
Long-term functional outcome after early surgery compared with laser and medicine in open-angle glaucoma. Ophthalmology 1994; 101:

3. If Surgery Is the Treatment of Choice in Glaucoma
The Conditions Should Be That Surgery Is
Safe & Successful

4. Advantages of NPGS over Classic Trabeculectomy
No flat anterior chamber (25% versus 2%)
Less Choroidal detachment (5-10% versus 2-3%)
Less Hyphema (10% versus 3%)
Less Cataractogenic
Less prostaglandins
Smoother IOP decrease
Viewing the site of Pathology

5. Intraoperative IOP Flow Chart

6. NPGS 02.1992-02.2001 Complete Success As a Function of Time (IOP<20mmHg w/o Rx)

7. N.P.G.S Feb’92-Feb’01 re-intervention rate

8. Survival of NPGS (IOP <18mmHG W/O Rx) 1997-2002

9. NPGS With Cataract Extraction 02. 1992-02
NPGS With Cataract Extraction Complete Success As a Function of Time (IOP < 20mmhg w/o Rx

10. NPGS Dahan’s Technique
An inverted “L” shaped fornix based conjunctival flap is the most appropriate for NPGS. It is simple, least traumatic and repeatable.

11. NPGS Dahan’s Technique
A trapezoidal superficial Scleral flap 5x5x1.5mm at 40% depth is raised.

12. NPGS Dahan’s Technique
The superficial scleral flap is temporarily sutured at 6h00 with an 8/0 virgin silk for better exposure. A 90% depth deep sclerectomy is done.

13. NPGS Dahan’s Technique
The deep sclerectomy is done to uncover the trabeculo-descemetic membrane.

14. T Flux NPGS Implant
The T Flux is a non-absorbable hydrophilic glaucoma implant. It prolongs the NPGS longevity by maintaining a permanent intrascleral space. It is highly biocompatible because of its high water content.

15. NPGS Dahan’s Technique
The T Flux implant is positioned in the deep sclerectomy, with its arms tucked into the Schlemm’s Canal. The position of the hole in the trunk is marked on the sclera for placing the fixation sutures.

16. NPGS Dahan’s Technique
Securing the T Flux in the deep sclerectomy.

17. NPGS Dahan’s Technique
T Flux 2nd fixation suture

18. NPGS Dahan’s Technique
A T Flux secured in the deep sclerectomy with a 10/0 nylon suture.

19. NPGS Dahan’s Technique
When the T Flux has been secured in the deep sclerectomy, the superficial flap is sutured with one suture on its apex and the conjunctiva is replaced with one buried suture

20. NPGS T Flux study 1997-2002 E. Dahan, E. Ravinet, A. Mermoud
Oxford Eye Center Johannesburg
Jules Gonin Eye Hospital Lausanne

21. Inclusion Criteria Primary Open Angle Glaucoma >18 years Old
Phakic Patients who do not need cataract surgery
Exclusion: Trauma, Uveitis, Congenital & Infantile Glaucoma

22. Demographics & preoperative data
With T Flux No
Age
Preop IOP 27.5
Cupping 74%
No of Rx 2.3
Without T Flux 23 65
24.8
73%
2.3

23. Postoperative data With T Flux IOP 12.5 No of Rx 0 in % 48.2%
Goniopunct 6 (24%)
F/U 19.9
Without T Flux
13.3
0.3
44%
6 (26%)
F/U 27.5

24. Mean Preop IOP & Last IOP

25. Mean IOP decrease in %

26. Mean Preop IOP & last IOP in patients with F/U > 23months

27. Mean IOP decrease in % in patients with F/U > 23months

28. IOP Flow Chart With & Without T Flux

29. Complications With T Flux
One T Flux (which was not sutured) migrated to the A/C following severe coughing and/or rubbing
Without T Flux
2 iris incarcerations following goniopunctures and/or rubbing

30. Conclusions (1)
During the first two years, there is little difference between the two groups.
In patients with follow up longer than 2 years, the T Flux group yields better results.
The T Flux prevents iris incarcerations

31. Reminder
METICULOUS Surgery is PRIMORDIAL & far more important than any sort of IMPLANT.
Mediocre surgical technique will fail even with the Best Glaucoma Implant.