Sclerostomy

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

A sclerostomy is a procedure in which the surgeon makes a small opening in the outer covering of the eyeball to reduce intraocular pressure (IOP) in patients with open-angle glaucoma. It is classified as a type of glaucoma filtering surgery. The name of the surgery comes from the Greek word for “hard,” which describes the tough white outer coat of the eyeball, and the Greek word for “cutting” or “incision.”

Purpose

Sclerostomies are usually performed to reduce IOP in open-angle glaucoma patients who have not been helped by less invasive forms of treatment, specifically medications and laser surgery. In some cases—most commonly patients who are rapidly losing their vision or who cannot tolerate glaucoma medications—an ophthalmologist (eye specialist) may recommend a sclerostomy without trying other forms of treatment first.

As of 2003, glaucoma is not considered a single disease but rather a group of diseases characterized by three major characteristics: elevated intraocular pressure (IOP) caused by an overproduction of aqueous humor in the eye or by resistance to the normal outflow of fluid; atrophy of the optic nerve; and a resultant loss of visual field. A sclerostomy works to reduce the IOP by improving the outflow of aqueous humor. Between 80% and 90% of aqueous humor leaves the eye through the trabecular meshwork while the remaining 10-20% passes through the ciliary muscle bundles. A sclerostomy allows the fluid to collect under the conjunctiva, which is the thin membrane lining the eyelids, to form a filtration bleb.

Demographics

In 1995, the World Health Organization (WHO) reported that over five million people around the world have lost their sight due to complications of glaucoma; about 120,000 Americans are blind as a result of glaucoma. According to the National Eye Institute (NEI), nearly three million people in the United States have the disorder; however, nearly half are unaware that they have it. Primary open-angle glaucoma (POAG) accounts for 60-70% of cases. “Primary” means that the glaucoma is not associated with a tumor, injury to the eye, or other eye disorder.

Although glaucoma can occur at any age, it is most common in adults over 35. One major study reported that less than 1% of the United States population between 60 and 64 suffer from POAG. The rate rises to 1.3% for persons between 70 and 74, however, and rises again to 3% for persons between 80 and 84.

With regard to race, African-Americans are four times as likely to develop glaucoma as Caucasians, and six to eight times more likely to lose their sight to the disease. African Americans also develop glaucoma at earlier ages; while everyone over age 60 is at increased risk for POAG, the risk for African Americans rises sharply after age 40. A 2001 study reported that the rate for Mexican Americans lies between the rate of POAG in African Americans and that in Caucasians. Mexican Americans, however, are more likely to suffer from undiagnosed glaucoma—62% as compared to 50% for other races and ethnic groups in the United States. In addition, the rate of POAG in Mexican Americans was found to rise rapidly after age 65; in the older age groups, it approaches the rates reported for African Americans. Among Caucasians, people of Scandinavian, Irish, or Russian ancestry are at higher risk of glaucoma than people from other ethnic groups.

The question of a sex ratio in open-angle glaucoma is debated. Three studies done in the United States between 1991 and 1996 reported that the male to female ratio for open-angle glaucoma is about one to one. Three other studies carried out in the United States, Barbados, and the Netherlands, however, found that the male to female ratio was almost two to one. A 2002 study from western Africa reported a male to female ratio of 2.26 to one. It appears that further research is needed in this area.

Description

Most sclerostomies are performed as outpatient procedures under local anesthesia . In some cases the

KEY TERMS

Angle— The open point in the anterior chamber of the eye at which the iris meets the cornea.

Aqueous humor— The watery fluid produced in the eye that ordinarily leaves the eye through the angle of the anterior chamber and Schlem’s canal.

Atrophy— Wasting away or degeneration. Atrophy of the optic nerve is one of the defining characteristics of glaucoma.

Bleb— A thin-walled auxiliary drain created on the outside of the eyeball during filtering surgery for glaucoma. It is sometimes called a filtering bleb.

Conjunctiva— The thin membrane that lines the eyelids and covers the visible surface of the sclera.

Cornea— The transparent front portion of the exterior cover of the eye.

Endophthalmitis— An infection on the inside of the eye, which may result from an infected bleb. Endophthalmitis can result in vision loss.

Glaucoma— A group of eye disorders characterized by increased fluid pressure inside the eye that eventually damages the optic nerve. As the cells in the optic nerve die, the patient gradually loses vision.

Gonioscopy— A technique for examining the angle between the iris and the cornea with the use of a special mirrored lens applied to the cornea.

Hyphema— Blood inside the anterior chamber of the eye. Hyphema is one of the risks associated with sclerostomies.

Hypotony— Intraocular fluid pressure that is too low.

Insidious— Developing in a stealthy and inconspicuous way. Open-angle glaucoma is an insidious disorder.

Ocular hypertension— A condition in which fluid pressure inside the eye is higher than normal but the optic nerve and visual fields are normal.

Open-angle glaucoma— A form of glaucoma in which fluid pressure builds up inside the eye even though the angle of the anterior chamber is open and looks normal when the eye is examined with a gonioscope. Most cases of glaucoma are open-angle.

Ophthalmology— The branch of medicine that deals with the diagnosis and treatment of eye disorders.

Peripheral vision— The outer portion of the visual field.

Schlemm’s canal— A circular channel located at the point where the sclera of the eye meets the cornea. Schlem’s canal is the primary pathway for aqueous humor to leave the eye.

Sclera— The tough white fibrous membrane that forms the outermost covering of the eyeball.

Tonometry— Measurement of the fluid pressure inside the eye.

Trabecular meshwork— The main drainage passageway for fluid to leave the anterior chamber of the eye.

Visual field— The total area in which one can see objects in one’s peripheral vision while the eyes are focused on a central point.

patient may be given an intravenous sedative to help him or her relax before the procedure.

Conventional sclerostomy

After the patient has been sedated, the surgeon injects a local anesthetic into the area around the eye as well as a medication to prevent eye movement. Using very small instruments with the help of a microscope, the surgeon makes a tiny hole in the sclera as a passageway for aqueous humor. Some surgeons use an erbium YAG laser to create the hole. Most surgeons apply an antimetabolite drug during the procedure to minimize the risk that the new drainage channel will be closed by tissue regrowth. The most common antimetabolites that are used are mitomycin and 5-fluouracil.

After the surgery, the aqueous humor begins to flow through the sclerostomy hole and forms a small blister-like structure on the upper surface of the eye. This structure is known as a bleb or filtration bleb, and is covered by the eyelid. The bleb allows the aqueous humor to leave the eye in a controlled fashion.

Enzymatic sclerostomy

A newer technique that was first described in 2002 is enzymatic sclerostomy, which was developed at the Weizmann Institute of Science in Israel. In enzymatic sclerostomy, the surgeon applies an enzyme called collagenase to the eye to increase the release of aqueous humor. The collagenase is applied through an applicator that is attached to the eye with tissue glue for 22-24 hours and then removed. According to the researchers, the procedure reduced the intraocular pressure in all patients immediately following the procedure and in 80% of the subjects at one-year follow-up. None of the patients developed systemic complications. Enzymatic sclerostomy is considered experimental as of mid-2003.

Diagnosis/Preparation

Diagnosis

Open-angle glaucoma is not always diagnosed promptly because it is insidious in onset, which means that it develops slowly and gradually. Unlike closed-angle glaucoma, open-angle glaucoma rarely has early symptoms. It is usually diagnosed either in the course of an eye examination or because the patient has noticed that they are having problems with their peripheral vision—that is, they are having trouble seeing objects at the side or out of the corner of the eye. In some cases the patient notices that he or she is missing words while reading; having trouble seeing stairs or other objects at the bottom of the visual field; or having trouble seeing clearly when driving. Other symptoms of open-angle glaucoma may include headaches, seeing haloes around lights, or difficulty adjusting to darkness. It is important to diagnose open-angle glaucoma as soon as possible because the vision that has been already lost cannot be recovered. Although open-angle glaucoma cannot be cured, it can be stabilized and controlled in almost all patients. Because of the importance of catching open-angle glaucoma as early as possible, adults should have their eyes examined every two years at least.

HIGH-RISK GROUPS. Not everyone is at equal risk for glaucoma. People with any of the risk factors listed below should consult their doctor for advice about the frequency of eye checkups:

• Age over 40 (African Americans) or over 60 (other races and ethnic groups).
• Ocular hypertension. The normal level of IOP is between 11 mm Hg and 21 mm Hg. It is possible for people to have an IOP above 21 mm Hg without signs of damage to the optic nerve or loss of visual field; this condition is referred to as ocular hypertension. Conversely, about one out of six of patients diagnosed with open-angle glaucoma have so-called normal-tension glaucoma, which means that their optic nerve is being damaged even though their IOP is within the “normal” range. Ocular hypertension does, however, increase a person’s risk of developing glaucoma in the future.
• Family history of glaucoma in a first-degree relative. As of 2003, at least six different genes related to glaucoma have been identified.
• An unusually thin cornea (the clear front portion of the outer cover of the eye). A recent National Eye Institute (NEI) study found that patients whose corneas are thinner than 555 microns are three times as likely to develop glaucoma as those whose corneas are thicker than 588 microns.
• Extreme nearsightedness. People who are very nearsighted are two to three times more likely to develop glaucoma than those who are not nearsighted.
• Diabetes.
• History of traumatic injury to the eye or surgery for other eye disorders.
• Use of steroid medications.
• Migraine headaches or sleep-related breathing disorder.
• Male sex.

Some patients should not be treated with filtration surgery. Contraindications for a sclerostomy include cardiovascular disorders and other severe systemic medical problems; eyes that are already blind; or the presence of an intraocular tumor or bleeding in the eye.

DIAGNOSTIC TESTS. Ophthalmologists use the following tests to screen patients for open-angle glaucoma:

• Tonometry. Tonometry is a painless procedure for measuring IOP. One type of tonometer blows a puff of pressurized air toward the patient’s eye as the patient sits near a lamp; it measures the changes in the light reflections on the patient’s corneas. Another method of tonometry involves the application of a local anesthetic to the outside of the eye and touching the cornea briefly with an instrument that measures the fluid pressure directly.
• Visual field test. This test measures loss of peripheral vision. In the simplest version of this test, the patient sits directly in front of the examiner with one eye covered. The patient looks at the examiner’s eye and indicates when he or she can see the examiner’s hand. In the automated version, the patient sits in front of a hollow dome and looks at a central target inside the dome. A computer program flashes lights at intervals at different locations inside the dome, and the patient presses a button whenever he or she sees a light. At the end of the test, the computer prints an assessment of the patient’s responses.
• Gonioscopy. Gonioscopy measures the size of the angle in the anterior chamber of the eye with the use of a special mirrored contact lens. The examiner numbs the outside of the eye with a local anesthetic and touches the outside of the cornea with the gonioscopic lens. He or she can use a slit lamp to magnify what appears on the lens. Gonioscopy is necessary in order to distinguish between open-and closed-angle glaucoma; it can also distinguish between primary and many secondary glaucomas.
• Ophthalmoscopic examination of the optic nerve. An ophthalmoscope is an instrument that contains a perforated mirror as well as magnifying lenses. It allows the examiner to view the interior of the eye. If the patient has open-angle glaucoma, the examiner can see a cup-shaped depression in the optic disk.

Newer diagnostic devices include a laser-scanning microscope known as the Heidelberg retinal tomograph (HRT) and ultrasound biomicroscopy (UBM). UBM has proved to be a useful method of long-term follow-up of sclerostomies.

Preparation

Preparation for a sclerostomy begins with the patient’s decision to undergo incisional surgery rather than continuing to take medications or having repeated laser procedures. Three factors commonly influence the decision: the present extent of the patient’s visual loss; the speed of visual deterioration; and the patient’s life expectancy.

With regard to the procedure itself, patients may be asked to take oral antibiotic and anti-inflammatory medications for several days prior to surgery.

Aftercare

Patients can use their eyes after filtering surgery, although they should have a friend or relative to drive them home after the procedure. They can go to work the next day, although they will probably notice some blurring of vision in the operated eye for about a month. Patients can carry out their normal activities with the exception of heavy lifting, although they should not drive until their vision has completely cleared. Most ophthalmologists recommend that patients wear their eyeglasses during the day and tape an eye shield over the operated eye at night. They should apply eye drops prescribed by the ophthalmologist to prevent infection, manage pain, and reduce swelling. They should also avoid rubbing, bumping, or getting water into the operated eye. Complete recovery after filtering surgery usually takes about six weeks. Long-term aftercare includes avoiding damage to or infection of the bleb.

It is important for patients recovering from filtering surgery to see their doctor for frequent checkups in the first few weeks following surgery. In most cases the ophthalmologist will check the patient’s eye the day after surgery and about once a week for the next several weeks.

Risks

The risks of a sclerostomy include the following:

• Infection. Infections may develop in the bleb (blebitis), but may spread to the interior of the eye (endophthalmitis). The symptoms of an infection include pain and redness in the eye, blurred vision, teariness, and a discharge. Infections must be treated promptly, as they can lead to loss of vision.
• Hyphema. Hyphema refers to the presence of blood inside the anterior chamber of the eye. Hyphemas are most common within the first two to three days after surgery and are usually treated with corticosteroid medications to reduce inflammation.
• Suprachoroidal hemorrhage. A suprachoroidal hemorrhage, or massive bleeding behind the retina, is a serious complication that can occur during as well as after eye surgery.
• Cataract formation.
• Hypotony (low IOP). If hypotony is not corrected, it an lead to failure of the bleb and eventual cataract formation.
• Loss of central vision. This is a very rare complication.
• Bleb leak or failure. Blebs can develop leaks at any time from several days after surgery to years later. Bleb failure usually results from inadequate control of the intraocular pressure and a new obstruction of aqueous humor outflow.
• Closing of the opening in the sclera by new tissue growth. A sclerostomy can be repeated if necessary.

Normal results

According to the National Eye Institute, sclerostomy is 80-90% effective in lowering intraocular pressure. The success rate is highest in patients who have not had previous eye surgery.

Morbidity and mortality rates

Mortality following a sclerostomy is very low because the majority of procedures are performed under local anesthesia. The most common complications of filtering surgery are cataract formation (30% of patients develop cataracts within five years of a sclerostomy) and closure of the drainage opening requiring additional surgery (10-15% of patients). Bleeding or infection occur in less than 1% of patients.

Alternatives

Nonpenetrating deep sclerectomy

There are two surgical alternatives to sclerostomy that are called nonpenetrating deep sclerectomies

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Sclerostomies are performed by ophthalmologists, who are physicians who have completed four to five years of specialized training following medical school in the medical and surgical treatment of eye disorders. Ophthalmology is one of 24 specialties recognized by the American Board of Medical Specialties.

Sclerostomies are usually done as outpatient procedures, either in the ophthalmologist’s office or in an ambulatory surgery center; however, they may also be performed in a hospital with sedation as well as local anesthesia.

because they do not involve entering the anterior chamber of the eye. The first alternative, viscocanalostomy, is a procedure that involves creating a window in Descemet’s membrane (a layer of tissue in the cornea) to allow aqueous humor to leave the anterior chamber; and injecting a viscoelastic substance into Schlemm’s canal, which is the main pathway for aqueous humor to leave the eye. The viscoelastic helps to keep the canal from scarring shut following surgery.

The second type of nonpenetrating surgery involves implanting a device called the Aquaflow® collagen wick about 0.8 in (2 cm) long under the sclera. The wick keeps open a space created by the surgeon to allow drainage of the aqueous humor. The wick is made of a material that is absorbed by the body within six to nine months, but the drainage pathway remains open after the wick is absorbed. The Aquaflow wick was approved by the Food and Drug Administration (FDA) in July 2001.

Both types of nonpenetrating deep sclerectomies allow patients to recover faster, with fewer complications than traditional sclerostomies. Their drawbacks include a lower success rate and the need for additional procedures to control the patient’s IOP. Viscocanalostomy in particular is not as effective in reducing IOP levels as traditional filtering surgery.

Complementary and alternative (CAM) approaches

Bilberry (European blueberry) extract has been recommended as improving night vision; it was given to pilots during World War II for this reason. There is evidence that 80-160 mg of bilberry extract taken

QUESTIONS TO ASK THE DOCTOR

• How many sclerostomies have you performed?
• Do you prefer using miniature instruments or a laser, and why?
• What are my chances of developing a cataract if I have this procedure?
• Would you recommend nonpenetrating surgery? Why or why not?

three times a day does improve night vision temporarily. The plant does not have any serious side effects, but it should not be used in place of regular eye examinations or other treatments for glaucoma.

People who support the medicinal use of marijuana have argued that cannabinoids, the active chemical compounds found in the plant, lower intraocular pressure in patients with glaucoma. According to the Glaucoma Research Foundation, however, very high doses of marijuana are required to produce any significant effect on IOP. A Canadian researcher has concluded that the effects of cannabinoids on IOP “…are not sufficiently strong, long lasting or reliable to provide a valid basis for therapeutic use [of marijuana].”

Resources

BOOKS

Pelletier, Kenneth R., MD. “CAM Therapies for Specific Conditions: Eye Disorders.” In The Best Alternative Medicine. New York: Simon & Schuster, 2002.

“Primary Open-Angle Glaucoma.” In The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

PERIODICALS

Daboue, A., N. D. Meda, and A. Ahnoux-Zabsonre. “Eye Tension and Open-Angle Glaucoma in a Burkina Faso Hospital.” [in French] Journal français d’ophtalmologie 25 (January 2002): 39–41.

Dan, J. A., S. G. Honavar, D. A. Belyea, et al. “Enzymatic Sclerostomy: Pilot Human Study.” Archives of Ophthalmology 120 (May 2002): 548–553.

Kalant, H. “Medicinal Use of Cannabis: History and Current Status.” Pain Research and Management 6 (Summer 2001): 80–91.

Kazakova, D., S. Roters, C. C. Schnyder, et al. “Ultrasound Biomicroscopy Images: Long-Term Results After Deep Sclerectomy with Collagen Implant.” Graefe’s Archive for Clinical and Experimental Ophthalmology 240 (November 2002): 918–923.

Lachkar, Y., and P. Hamard. “Nonpenetrating Filtering Surgery.” Current Opinion in Ophthalmology 13 (April 2002): 110–115.

Luke, C., T. S. Dietlin, P. C. Jacobi, et al. “A Prospective Randomized Trial of Viscocanalostomy Versus Trabeculectomy in Open-Angle Glaucoma: A 1-Year Follow-Up Study.” Journal of Glaucoma 11 (August 2002): 294–99

Mizota, A., M. Takasoh, K. Kobayashi, et al. “Internal Sclerostomy with the Er:YAG Laser Using a Gradient-Index (GRIN) Endoscope.” Ophthalmic Surgery and Lasers 33 (May-June 2002): 214–220.

Mizota, A., M. Takasoh, Y. Tsuyama, et al. “Sclerostomy with an Erbium YAG Laser. The Relationship with Pulse Energy.” Japanese Journal of Ophthalmology 45 (January 2001): 111.

Pascotto, Antonio, MD, Giorgio Cusati, MD, Elena Soreca, MD, and Sergio Sacca, MD. “Glaucoma, Complications and Management of Glaucoma Filtering.” eMedicine, November 15, 2002 [cited May 17, 2003]. http://www.emedicine.com/oph/topic720.htm.

Rastogi, Shobit, MD, Enrique Garcia-Valenzuela, MD, and Monica Allen, MD. “Hyphema, Postoperative.” eMedicine, October 26, 2001 [cited May 18, 2003]. http://www.emedicine.com/oph/topic68.htm.

Shaarawy, T., C. Nguyen, C. Schnyder, and A. Mermoud. “Five-Year Results of Viscoanalostomy.” British Journal of Ophthalmology 87 (April 2003): 441–445.

ORGANIZATIONS

American Academy of Ophthalmology. P.O. Box 7424, San Francisco, CA 94120-7424. (415) 561-8500. http://www.aao.org.

American Optometric Association. 243 North Lindbergh Blvd., St. Louis, MO 63141. (314) 991-4100.

Canadian Ophthalmological Society (COS). 610-1525 Carling Avenue, Ottawa ON K1Z 8R9. http://www.eyesite.ca.

(The) Glaucoma Foundation. 116 John Street, Suite 1605, New York, NY 10038. (212) 285-0080 or (800) 452-8266. http://www.glaucomafoundation.org.

Glaucoma Research Foundation. 490 Post Street, Suite 1427, San Francisco, CA 94102. (415) 986-3162 or (800) 826-6693. http://www.glaucoma.org.

National Eye Institute. 2020 Vision Place, Bethesda, MD 20892-3655. (301) 496-5248. http://www.nei.nih.gov.

Prevent Blindness America. 500 East Remington Road, Schaumburg, IL 60173. (800) 331-2020. http://www.preventblindness.org.

Wills Eye Hospital. 840 Walnut Street, Philadelphia, PA 19107. (215) 928-3000. http://www.willseye.org.

OTHER

Lewis, Thomas L., O. D., Ph.D. Optometric Clinical Practice Guideline: Care of the Patient with Open Angle Glaucoma. 2nd ed. St. Louis, MO: American Optometric Association, 2002.

National Eye Institute (NEI). Facts About Glaucoma. Bethesda, MD: NEI, 2001. NIH Publication No. 99–651.

NEI Statement. Prevalence of Glaucoma in Mexican-Americans. Bethesda, MD: NEI, December 2001 [cited May 18, 2003]. http://www.nei.nih.gov/news/statements/glauc-mexamer.htm.

Prevent Blindness America. Vision Problems in the U.S.: Prevalence of Adult Vision Impairment and Age-Related Eye Disease in America. Schaumburg, IL: Prevent Blindness America, 2002.

Rebecca Frey, Ph.D.