TET-Bleb, 10 years and still saving a sight!

in Russian / по-русски
Коллега по-дружески прислал привет из Замбии с фотографией фильтрационной подушки пациентки, которую я прооперировал 10 (!) лет назад (2014 год). На сегодня это единственное доказательство, что мои трабекулэктомии могут иметь долгосрочный положительный результат:) 10 лет сохраняет зрение, и будет делать это дальше, если не случатся неприятные осложнения, возможные при кистозно изменённых подушках (так характерных для трабекулэктомий с фторурацилом). Учитывая то, что пациенты приходят по поводу глаукомы только тогда, когда у них остаётся счёт пальцев или пара десятых с тотальной экскавацией – я лягу сегодня спать очень счастливым за эту больную.
update: на фотографиях 2 глаза…))) Лягу спать вдвойне счастливым.

In English
A colleague kindly sent greetings from Zambia along with a photo of the filtration bleb of a patient I operated on 10 (!) years ago (a year 2014). As of today, this is the only evidence that my trabeculectomies can have a long-term positive result :). She has retained her vision for 10 years, and will continue to do so, provided no unpleasant complications arise, which are possible with cystic walled blebs (a very characteristic of 5-FU Trabeculectomy). Considering that patients with glaucoma usually seek help only when they have finger counting vision or a couple of tenths left with total cupping, I will go to bed tonight feeling very happy for this patient.
update: the colleague confirmed, that here on the photos we see TWO eyes. I feel good.

Pupillotomy for miotic pupils by MSICS? Is this not barbaric?

Mechanical Pupillotomy for narrow pupils

No, it is definitely not. On this picture you will see one in a 70 year old lady, who underwent a complications free MSICS with massive pseudoexfoliations and miotic pupil.

In EnglishPupillotomy is an excellent method for defusing a potential bomb during MSICS with narrow pupils when:
1) mechanical stretching of the pupil has not yielded any results (e.g., in PEX),
2) iris hooks or a Malyugin ring are not available,
3) additional risks, such as a wrinkled fibrous capsule or a very large nucleus, are present.

At that time (and up to date) I couldn’t find a better solution. By the way, it’s a fairly mature MSICS, with several hundred operations under my belt.

After patients had been living with just a perception of light, this cosmetic issue didn’t matter to them. A complication-free surgery in situations where such complications would be nearly impossible to fix far outweighs any cosmetic concerns. Interestingly, the remaining sphincter still works somehow 🙂 – The pupil even reacts a little.
P.S. At the 1 o’clock position, there is hyperpigmentation, which often occurs during the healing of a conjunctival wound in patients with racial melanosis. A year 2016.

in Russian / по-русски Коллеги, это конечно разрезанный в двух местах зрачок. Пупиллотомия – шикарнейший метод обезвреживания потенциальной бомбы для MSICS (да и для фако в общем-то, при соответствующих условиях) на узких зрачках, когда
1) механический стретчинг зрачка ни к чему не привёл (например, при ПЭС)
2) радужных крючков или кольца Малюгина в наличии нет
3) а доп. риски (например, в виде морщинистой фиброзированной капсулы или очень крупного ядра или очень плотного ядра) – в наличии.
Лучшего решения я тогда не нашёл. Да и по сей день не знаю. Это, кстати, вполне себе зрелый MSICS с несколькими сотнями операций за спиной.

После того, как пациенты жили в ощущении света, им эта косметическая проблема не важна. Функциональная проблема на артифакичном глазу – ничтожна. А операция, проведённая без осложнений там, где эти осложнения починить практически невозможно, – перевешивает эту косметику в разы. А остатки сфинктера кстати каким-то образом работают:) – Этот зрачок чуточку играет.
Всегда удивляло, что никакого кровотечения при пупиллотомии, перерезающий малый сосудистый круг радужки, – не наблюдал.
П.С. на 1 часе гиперпигментация, которая часто бывает при заживании конъюнктивальной раны у пациентов с расовым меланозом. 2016 год.

How my MSICS began

Senanga town, Western Province of Zambia. April 2014.

Senanga, April 2014


Here is how it all happened that day. My future wife was with me on my first day in the operating room and was able to take these photos. It was incredibly unusual, my heart was bursting with a thirst for new experiences, surrounded by new people, new impressions every working day. In April, my boss and later a good friend David finally agreed to teach me manual small incision cataract surgery (MSICS). Before that, I had the honor of observing his art for several months non-stop. The burning call of fearless youth… Even now, as I study phaco, it’s not as sharp or exciting as it used to be that days.
Mistakes were surely made. My teacher had to correct my sclerocorneal tunnels more than once.
Pay attention to the instrument table. That is exactly how much you need to effectively remove cataracts without a phaco machine and sutures.

And after the operating days, we sat together on the banks of the Zambezi River and enjoyed the sunset, not knowing that those were some of the best days of our lives.

Zambezi River, Zambia
Senanga, September 2015

Later, when I grew up and my teacher left me, I started doing independent outreach trips. This next photo is from the same town of Senanga, but already from September 2015.

Behind me are cataract patients operated on in one day. Yes, the amount of good that can be done using that limited set of instruments from the previous photos is global in both direct and figurative senses. Global ophthalmology rocks.

Journals for publication of tropical case reviews

Dear all,

for those of you interested in publishing case reviews of your tropical experience or studies, I think these journals are the best for that, most of them are fee free:

Journals for publications
– Zambian Medical Journal (indexed journal
ZMJ)
– COECSA Journal
– Pan Afr Med J free PMC
– Middle East Afr J Ophthalmol.
– BMJ Global Health
– BMC Ophthalmol
– Am J Trop Med Hyg
– PLoS One free PMC
– Niger Postgrad Med J.
– medRxiv
– tropicalophthal.com – Tropical Ophthalmology Jour
– Tropical journal of Ophtha and Otolaryngology
– J Travel Med
– PLoS Negl Trop Dis
– West Afr J Med.
– https://www.intechopen.com/journals
– https://www.cureus.com/

Best,

Anton