Another frequent interventional combination, cataract-glaucoma surgery, which enables simultaneous operative treatment of both diseases, has made significant progress over the last few years.
Bimanual Phaco-Punch is a two-port approach with which it is possible to perform trabeculectomy without modifying the phakoexeresis technique described in previous chapters. The main advantage of two-port approaches is their better efficacy as regards filtration of the aqueous humour, resulting from the separation of the two surgery areas.
The procedure starts with a typical corneal bimanual phaco as previously described, up to the cortical matter irrigation-aspiration phase. Once having filled the anterior chamber with viscoelastic product and prior to installing the implant, the surgeon performs trabeculectomy between the two corneal incisions.
After limbal conjunctival disinsertion with a lateral rupture line towards the posterior area, the sclera should be appropriately exposed with gentle haemostasis of the episcleral vessels performed using bipolar diathermy under irrigation with BSS.
A 3 mm linear scleral incision is made 3 mm behind the limbus. It is tunnelled up to 1 mm anteriorly to the limbal vascular arcades by means of a Crescent knife. The depth of this intrascleral tunnel should be 50% of the thickness of the sclera, as this is important for the strength of the trabeculectomy flap.
Penetration into the anterior chamber takes place in a plane parallel to the iris, using a precalibrated 3.2 mm knife, just 1 mm anteriorly to the limbal vascular arcades. Implantation takes place through the sclera with a classic implant being injected into the capsular bag.
This cameral approach constitutes the first trabeculectomy incision and is completed with either a punch forceps or straight Vannas scissors. Peripheral iridectomy completes the antiglaucoma surgery phase.
The conjunctiva can then be reinserted at the limbus by means of two resorbable Vicryl 7/0 suture points.The procedure is completed with the corneal ablation of the intracameral viscous substance as at the end of bimanual phaco.
