Grehn F
Universitäts-Augenklinik, Mainz, Bundesrepublik Deutschland.
Fortschr Ophthalmol. 1990;87 Suppl:S175-86.
During recent years, glaucoma surgery has been modified by the introduction of new antiglaucoma drugs and by laser therapy. Various glaucoma operations have, however, retained their value in the treatment of severe glaucoma cases. Acute angle-closure glaucoma is best treated by iridectomy. When a clear cornea is present, laser iridectomy can be performed. Prophylactic treatment of the contralateral eye is mandatory. In chronic open-angle glaucoma, filtration surgery with a scleral flap is usually performed (goniotrephination or trabeculectomy). Modifications in the conjunctival incision and the use of antifibroblastic drugs may reduce the failure rate for difficult cases in the future. Individual adjustment of postoperative treatment is of great importance for the development of functioning filtering blebs. Reoperations retain their high incidence of subconjunctival scarring. In congenital glaucoma, the success rate of trabeculotomy equals the success rate of goniotomy. Trabeculotomy has advantages when the cornea is cloudy, but may be more difficult to perform in eyes with a stretched anterior segment or in secondary congenital glaucomas. In neovascular glaucoma, cryotherapy of the peripheral retina often normalizes the intraocular pressure by reduction of neovascularization. Cyclocryotherapy of the anterior pars plicata often results in cataract and phthisis bulbi and is only rarely used. In non-neovascular secondary glaucoma or numerous reoperations for primary glaucoma, the implantation of a Molteno or Schocket implant may be helpful. Cyclodialysis is seldom used because its outcome is extremely variable. It is mostly replaced by modified filtering surgery, including ciliary tendon disinsertion (Watson trabeculectomy). If the IOP is high in coexisting glaucoma and cataract, two separate procedures are normally performed successively: when the filtering surgery has been successfully performed and settled, a separate extracapsular cataract operation is performed via a clear corneal incision. Simultaneous procedures, if necessary, can be performed with a trabeculotomy or with a filtering operation. If the IOP is borderline, an extracapsular cataract operation is normally sufficient to lower the IOP for some mmHg. Cataract formation after filtering surgery has become a less severe complication, as posterior chamber lens implantation is also possible in glaucomatous eyes. Therefore, filtering surgery nowadays seems indicated at earlier stages of glaucoma.
近年来，青光眼手术因新型抗青光眼药物的引入和激光治疗而有所改进。然而，各种青光眼手术在治疗严重青光眼病例中仍具有价值。急性闭角型青光眼最好通过虹膜切除术治疗。当角膜透明时，可进行激光虹膜切除术。对侧眼的预防性治疗是必不可少的。在慢性开角型青光眼中，通常进行带巩膜瓣的滤过手术（房角切开术或小梁切除术）。结膜切口的改进以及抗成纤维细胞药物的使用可能会降低未来困难病例的失败率。术后治疗的个体化调整对于功能性滤过泡的形成非常重要。再次手术结膜下瘢痕形成的发生率仍然很高。在先天性青光眼中，小梁切开术的成功率与房角切开术的成功率相当。当角膜混浊时，小梁切开术具有优势，但在前段拉伸的眼睛或继发性先天性青光眼中可能更难进行。在新生血管性青光眼中，周边视网膜冷冻疗法通常通过减少新生血管形成使眼压恢复正常。前房角睫状体冷冻疗法常导致白内障和眼球痨，很少使用。在非新生血管性继发性青光眼或原发性青光眼的多次再次手术中，植入莫尔顿或肖克特植入物可能会有帮助。睫状体分离术很少使用，因为其结果差异极大。它大多被改良的滤过手术所取代，包括睫状肌腱离断术（沃森小梁切除术）。如果同时存在青光眼和白内障且眼压较高，通常依次进行两个单独的手术：当滤过手术成功完成并稳定后，通过透明角膜切口进行单独的白内障囊外摘除术。如有必要，可同时进行小梁切开术或滤过手术。如果眼压处于临界值，白内障囊外摘除术通常足以使眼压降低若干毫米汞柱。滤过手术后的白内障形成已成为一种不太严重的并发症，因为青光眼患者也可以植入后房型人工晶状体。因此，如今滤过手术似乎在青光眼的早期阶段就有必要进行。
