Case Report: Suprachoroidal Catheterization “ab-interno” for Treatment of Open Angle Glaucoma: “BABLY TECHNIQUE”

A cataractous and open angle glaucomatous right eye of a 60 year old man was surgically treated in a different way. First, phacoemulsification with posterior chamber intraocular lens was done, then, under gonioscopy, I track, I science microcatheter was introduced in the suprachoroidal space and heavy viscoelastic was injected. Preoperatively, intra ocular pressure was 28 mmHg on three topical medications, Travatan, Cosopt and Alphagan. One month postoperatively, IOP was reduced to 16 mmHg without medications. Suprachoroidal catheterization is a safe, easy and effective technique in treatment of open angle glaucoma. Studies with long-term follow up are needed to assess efficacy and safety of the procedure. Suprachoroidal catheterization should be tried in different types of glaucoma.


INTRODUCTION
Up to this moment, Canaloplasty was the only surgical technique that used microcatheter in treatment of open angle glaucoma [1,2,3]. Nowadays, we can further use the microcatheter to enter the suprachoroidal space through the anterior chamber and inject viscoelastic to create

Case Study
suprachoroidal pouch connected to the anterior chamber [4].

CASE REPORT
A 60-year-old gentleman presented to the clinic with defective visionin both eyes, uncorrected visual acuity of the right eye was hand movement with good projection and was counting fingers (1 meter) in the left eye. The patient's intraocular pressure was 28 mmHg in both eyes topical anti-glaucoma medications 10 years ago. The patient's last visual field assessment revealed double arcuate scotoma mature senile cataract in both eyes. showed Shaffer grade 3 angle, while fundus could not be seen due to mature cataract. After obtaining ethics committee approval from Riyadh National Hospital, Riyadh, Saudi Arabia and signed informed consent from the patient, combined cataract and glaucoma surgery was performed. Routine phacoemulsificatio posterior chamber intra ocular lens performed, Swan Jacob goniolens was used to visualize the angle, 1.1 stab knife created small incision between the scleral spur and the ciliary body ( Fig. 1), the iTrack TM 250 micron diameter canaloplasty microcatheter with lumen (I science, United States) was introduced through the paracentesis to the anterior chamber then directed about 4mm into the suprachoroidal space using a forceps (Fig. 2). Small amount of Healon GV (3 full rounds of the injector scr was injected suprachoroidally (Fig. postoperatively, the intraocular pressure was reduced to 12 mmHg. One month postoperatively, intraocular pressure was stable at 16 mmHg without medications, then 18 mmhg over the following 6 months. 849 suprachoroidal pouch connected to the anterior gentleman presented to the clinic with defective visionin both eyes, uncorrected visual acuity of the right eye was hand movement with good projection and was counting fingers (1 meter) in the left eye. The patient's intraocular th eyes under three glaucoma medications 10 years ago. The patient's last visual field assessment in addition to mature senile cataract in both eyes. Gonioscopy showed Shaffer grade 3 angle, while fundus due to mature cataract. After obtaining ethics committee approval from Riyadh National Hospital, Riyadh, Saudi Arabia and signed informed consent from the patient, combined cataract and glaucoma surgery was performed. Routine phacoemulsification plus posterior chamber intra ocular lens was performed, Swan Jacob goniolens was used to visualize the angle, 1.1 stab knife created small incision between the scleral spur and the ciliary 250 micron diameter microcatheter with lumen (I science, United States) was introduced through the paracentesis to the anterior chamber then directed about 4mm into the suprachoroidal 2). Small amount of 3 full rounds of the injector screw) . 3). First day intraocular pressure (IOP) mmHg. One month postoperatively, intraocular pressure was stable mmHg without medications, then 18 mmhg small incision between ciliary body and scleral spur

DISCUSSION
The idea of approaching the suprachoroidal space ab-interno was used by The CyPass [5] Micro-Stent (a 6.35-mm long polyimide tube with an outer diameter of about 0.5 mm). The advantage of suprachoroidal catheterization over the cypass that it creates a localized suprachoroidal pouch which enhances the aqueous drainage [6,7]. The learning curve for that surgery is very short, so it would be easy for the non-glaucoma specialists to perform such surgery. Long-term follow up and ultrasound biomicroscopy are a must, to check if the pouch disappeared and if the intraocular pressure returned back to higher levels. Different amounts of viscoelastics have to be tried to reach the proper amount suitable for each glaucoma level, also different sites and numbers of viscoelastics injections have to be tested to meet different grades of glaucoma. Almost no bleeding in the angle had been noticed. While this case was ; Article no. BJMMR.2015.259 is in the anterior chamber through paracentesis

Fig. 3. Microcatheter is in the suprachoroidal space with transillumination of the
The idea of approaching the suprachoroidal interno was used by The CyPass [5] mm long polyimide tube with an outer diameter of about 0.5 mm). The advantage of suprachoroidal catheterization over it creates a localized suprachoroidal pouch which enhances the aqueous drainage [6,7]. The learning curve for that surgery is very short, so it would be easy for glaucoma specialists to perform such term follow up and ultrasound are a must, to check if the pouch disappeared and if the intraocular pressure returned back to higher levels. Different amounts of viscoelastics have to be tried to reach the proper amount suitable for each glaucoma level, numbers of viscoelastics injections have to be tested to meet different grades of glaucoma. Almost no bleeding in the angle had been noticed. While this case was successful, a larger study is required to demonstrate safety and efficacy.

CONCLUSION
Visco dilation of the suprachoroidal space abinterno by canaloplasty microcatheter is novel, effective, safe and easy technique for the treatment of open angle glaucoma.