Goniotomy Surgery

Introduction

Goniotomy surgery is a specialized procedure used primarily to treat congenital glaucoma, a rare eye condition present at birth. The surgery involves creating an opening in the trabecular meshwork of the eye to allow for better fluid drainage and reduce intraocular pressure. This procedure is typically performed on infants and young children but can also be employed in adults with specific types of glaucoma.

The Anatomy of the Eye

To understand goniotomy, it is essential to have a basic knowledge of the eye’s anatomy. The eye is a complex organ made up of several components, including the cornea, iris, lens, retina, and optic nerve. The trabecular meshwork, located in the anterior chamber angle of the eye, plays a critical role in draining the aqueous humor, a fluid that maintains intraocular pressure. In congenital glaucoma, this meshwork is often malformed or blocked, leading to increased pressure and optic nerve damage.

Indications for Goniotomy

Goniotomy is primarily indicated for patients with congenital glaucoma, particularly those who do not respond adequately to medical treatment. This type of glaucoma is characterized by high intraocular pressure, corneal clouding, and an enlarged eye. Early intervention is crucial to prevent irreversible vision loss and optic nerve damage. The surgery may also be considered for other types of glaucoma, such as juvenile open-angle glaucoma, where traditional treatments have failed.

The Goniotomy Procedure

Preoperative Preparation

Before undergoing goniotomy surgery, a thorough preoperative evaluation is performed. This includes a detailed medical history, comprehensive eye examination, and diagnostic tests to assess the extent of glaucoma and intraocular pressure. The patient’s overall health is also evaluated to ensure they are suitable candidates for surgery.

Surgical Technique

Goniotomy is typically performed under general anesthesia, especially in young children. The patient is positioned, and a goniolens, a specialized optical instrument, is placed on the cornea to provide a clear view of the anterior chamber angle. The surgeon then makes a small incision in the cornea to access the trabecular meshwork. Using a goniotomy knife or other microsurgical instruments, an opening is created in the trabecular meshwork to facilitate aqueous humor outflow. The incision is usually self-sealing, but sometimes a suture may be required.

Postoperative Care

After goniotomy surgery, patients are closely monitored for complications and the success of the procedure. Eye drops or ointments are prescribed to reduce inflammation and prevent infection. Regular follow-up visits are essential to assess intraocular pressure, corneal clarity, and overall eye health. In some cases, additional surgeries may be necessary if intraocular pressure remains uncontrolled.

Outcomes and Success Rates

The success rate of goniotomy varies depending on several factors, including the patient’s age, the severity of glaucoma, and the surgeon’s experience. In infants and young children, the procedure has a relatively high success rate, with significant improvement in intraocular pressure control and preservation of vision. However, the success rate may decrease with age and the progression of the disease. Long-term follow-up is crucial to ensure sustained intraocular pressure control and detect any recurrence of glaucoma.

Potential Complications

As with any surgical procedure, goniotomy carries certain risks and potential complications. These may include:

• Hyphema: bleeding in the anterior chamber of the eye, which is usually temporary and resolves on its own.
• Infection: a rare but serious complication that requires prompt treatment with antibiotics.
• Corneal damage: accidental injury to the cornea during surgery, which can affect vision.
• Failure to control intraocular pressure: in some cases, goniotomy may not adequately reduce intraocular pressure, necessitating additional surgeries or treatments.

Advances in Goniotomy Techniques

Recent advancements in goniotomy techniques and instruments have improved the safety and efficacy of the procedure. Minimally invasive glaucoma surgery (MIGS) devices, such as the Kahook Dual Blade and the Trabectome, offer alternative methods to perform goniotomy with potentially better outcomes and fewer complications. These devices allow for more precise and controlled incisions in the trabecular meshwork, enhancing aqueous humor outflow and lowering intraocular pressure.

Nursing Care of a Patient with Goniotomy Surgery

Goniotomy is a surgical procedure performed to treat glaucoma by improving the outflow of aqueous humor from the eye, thereby reducing intraocular pressure. Effective nursing care is essential to ensure the patient’s recovery and prevent complications. This document outlines the key aspects of nursing care for patients undergoing goniotomy surgery.

Pre-operative Care

Patient Education

• Inform the patient and their family about the procedure, its benefits, and potential risks.
• Explain the importance of adhering to pre-operative instructions, such as fasting and discontinuing certain medications.

Pre-operative Assessment

• Conduct a thorough medical and ocular history review.
• Check for any allergies, especially to medications or anesthesia.
• Perform baseline assessments, including visual acuity and intraocular pressure measurements.

Post-operative Care

Monitoring and Assessment

• Regularly monitor the patient’s vital signs, with a focus on blood pressure and heart rate.
• Assess the operated eye for signs of hyphema, infection, or increased intraocular pressure.
• Perform visual acuity tests to detect any changes in vision.

Pain Management

• Administer prescribed analgesics to manage post-operative pain.
• Provide cold compresses to reduce swelling and discomfort.

Medication Administration

• Ensure the patient receives prescribed post-operative medications, including antibiotics and anti-inflammatory eye drops.
• Educate the patient on the proper technique for administering eye drops and stress the importance of adherence to the medication regimen.

Infection Prevention

• Maintain strict aseptic techniques when handling the patient’s eye and administering medications.
• Instruct the patient to avoid rubbing or touching the operated eye.
• Advise the patient to avoid swimming, using hot tubs, or engaging in activities that expose the eye to potential contaminants.

Complication Management

• Be vigilant for signs of complications, such as hyphema, infection, or increased intraocular pressure.
• Report any abnormal findings to the ophthalmologist promptly.
• Assist with further interventions or treatments as needed, based on the surgeon’s recommendations.

Patient Education and Follow-up

Home Care Instructions

• Provide detailed instructions on post-operative care at home, including activity restrictions and the importance of follow-up appointments.
• Educate the patient on recognizing signs of complications and the need to seek immediate medical attention if they occur.

Follow-up Appointments

• Schedule and remind the patient of follow-up visits with the ophthalmologist to monitor recovery and intraocular pressure.
• Assist in coordinating additional treatments or interventions if required.

REFERENCES

1.  Rebecca Taylor, Goniotomy Makes a Comeback in Adults, Updated on AUG 01, 2023, https://www.aao.org/eyenet/article/goniotomy-makes-a-comeback-in-adults
2. Binenbaum G, Davidson SL. Ophthalmology. In: Shah SS, Ronan JC, Catallozzi M, Frank G, eds. The Philadelphia Guide: Inpatient Pediatrics. 3rd ed. McGraw Hill; 2022.
3. Gurnani B, Tripathy K. Minimally Invasive Glaucoma Surgery. https://www.ncbi.nlm.nih.gov/books/NBK582156/). 2023 Aug 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. 
4. Kaur K, Gurnani B. Primary Congenital Glaucoma. https://www.ncbi.nlm.nih.gov/books/NBK574553/). 2023 Jun 11. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. 
5. Kyari F, Abdull MM. The basics of good postoperative care after glaucoma surgery. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5100471/). Community Eye Health. 2016 Oct;29(94):29-31.
6. Leonard CY. Surgical Pearls for Goniotomy. https://www.reviewofophthalmology.com/article/surgical-pearls-for-goniotomy. Review of Ophthalmology. Published online 4/10/2023.
7. Nipp GE, Aref AA, Stinnett SS, Muir KW. Glaucoma Fellows-in-Training Recent Surgery Trends. https://pubmed.ncbi.nlm.nih.gov/37336267/). Ophthalmol Glaucoma. 2023 Nov-Dec;6(6):651-656.
8. Salim S, Walton DS. Goniotomy and Trabeculectomy. In: Yanoff M, Duker JS, eds. Ophthalmology. 6th ed. Elsevier. 2023:1069-1073.
9. Shute T, Green W, Liu J, Sheybani A. An Alternate Technique for Goniotomy: Description of Procedure and Preliminary Results. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9185202/). J Ophthalmic Vis Res. 2022 Apr-Jun;17(2):170-175. 
10. Williams PJ, Hussain Z, Paauw M, et al. Glaucoma Surgery Shifts Among Medicare Beneficiaries After 2022 Reimbursement Changes in the United States. https://pubmed.ncbi.nlm.nih.gov/37671492/). J Glaucoma. 2024 Jan;33(1):59-64.

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