 Okay, good morning everybody and so I'm Beatrice and I'm in practice in 15 years and I would like to take that opportunity to thank Dr. Alson to accept me you know after being in practice active clinic surgery research and trying to participate in an academic center it's a good thing to be able to stop and to look what you're doing and compare what is done and how it could be done differently and thank you for to everybody who's teaching me a lot this year also and so today I will talk about the transconjunctival sutures and I would like to share with you my experience with that technique so if you would like to give your opinions throughout the talk feel free to raise your hand I'm ready to stop and I would like it to be a discussion and I have some cases that I will present also and if you want to give comments or anything I will be happy to to have your opinion on my cases and and for those those who don't do any traps you can see that talk that talk as a culture of tomology culture that is an extra option for option for hypotony in post-op traps my disclosure so I will start with explaining a little bit coming back and what is hypotony the consequences the technique of a transconjunctival the suture how it has been described and I will do a little review of the literature and then I will show you some cases that I had and my difficult cases and complications and I will give a little bit of the recommendation of how I have been doing that technique throughout my last six years so I put in his describe as a pressure under 6.5 millimeter of mercury that's a statistical definition the clinical definition would be under four because often the clinical decrease of vision or things like that will happen more with a pressure around four sometimes we can still see it between four and six but it's more frequently under four so there's an increase of expression regarding the production the managed pressure is still nine so when there's an hypotony post postop or for any other reason that means that the aqueous found another way to get out in this channel so the causes are hyperfiltration post-trab leaking post-trab cycle dialysis areado cyclitis original detachment detachment use of hyperosmotic agents or vascular occlusive disease those are the main cause and as complication of hypotony depending if it's a recent or a more chronic hypotony we could have almost no when it starts we can have no a complaint no decreased vision and a pressure of five with a nice vision a nice bubble no no leak or anything then we just observe that patient but when it gets more chronic basis the vision can decrease we can have some corneal failure some shallow anterior chamber coradal detachment a cataract and maculopathy when it gets really and some when the maculopathy is there then the vision is really decreased with metamorphosis usually and the hypotony is associated with fondness anomalies like macular folds coradal detachment falls or thickening and vascular tertiary papillodema and that is all caused by an edema that is chronic behind in the posterior pole so here we have some falls and some papillodema with fixed macular folds often we will think that the natural history of the hypotonic maculopathy and we know that it could resolve by itself inside the first few weeks even if the maculopathy is there but if it goes over four months usually it it's gonna stuck there so we try to react before that time and since I'm doing those transcontactival sutures I tend to be a little bit more aggressive in the treatment of macular hypotony maculopathy I don't wait for months as often so multiple treatment does exist like injecting in the anterior chamber can help and I put hypotony but as you know it won't stay for a long time it will go away and you will have to do it again and over again and a lot of different technique have been described to try to stop those over filtration post-trav like technique to shallow the blood with patch Simon shell compressive sutures or to modify the blood like injecting injecting blood acidic trichloroacidic acid or doing laser creat cryotherapy I don't do those thing anymore though those those are things that I've learned in fellowship in 98 99 and they were still trying a lot of things now I tend to go more faster to my transcontactival sutures we can also do a surgical revision then we have to open the content we sutured the flap the flap the scroll flap using a patch or not depending on what we see when we open the conch it is more invasive and time-consuming and it leads to a lot of blip scarring we open everything so the major problem in the dose I were over filtration post-trav is that we have an over filtration but the blip is working well so we're trying to find a way to save our play at the most we can so the technique has been described by Shirato in 2009 and his first description was done with 10 cases and inside this 10 cases it went really well for 9 over 10 cases and he used single sutures he used two sutures in only one of his cases so we I use I do that technique at this little lamb and we use a suture that goes through the conch and then I crap the skull flap and go out to the mascara I read that this picture is upside down but when I do it I will I will turn like this and that's how I feel comfortable doing it and we pre treat the patient with silo antibiotic and providing iodine and we have to identify the school that because of that big over filtration you don't know where is your school of thought often you just don't see it so I will use a goniolence the corner of a goniolence to just put my as a conch down and try to identify my the border of my so we tend to do the first stitch close enough to the limb is at first I was a little bit too far and I was not able to grab the flap so now I came back closer to the limb is to be able to grab the flap and I use a needle spatula 910 0 5 in you and then the patient as post-op treatment as canal on and corticosterone and the patient will be seen back one day post-op and depending few weeks the week after usually this is was the second study of she read or published into a way where we present 50 cases of transcontractable suture and his indication were poor iPod on the maculopathy or chronic carotid all detachment so here we have a shallow chamber chamber and he seems to be putting a stitch from the scleral side and go to the flap after if I we look the orientation of the stitch I do the opposite but the goal is the same and we want just to put a suture to bring the skull flat down and most of the time it's not leaking after that suture and the chamber enter your chamber gets deeper this is one of my case and what I want to show in that slide is that it's surprising but that suture will migrate throughout the congenitiva by itself with time and it's not long inside the first week it's sent to disappear under epithelium so it was side of negative but we still have complication even if in those article describe the technique that goes pretty well we can have emerges we can have leaking sometimes those are minor leakings and we wait 24 48 hours and it's not paid the result by itself sometimes leaking is severe enough that we have to have another stitch just around the hole to close that hole and and sometimes it could lead directly to the vitis and then my this I don't I didn't have any cases of my this for now with my transcontractable suture we have a hypergenic post op often it is desired and we'll see later the articles that showed how high we would expect the pressure to be or we would like the pressure to be to resolve the iPod and but sometimes it's really excessive and then I trend I tend to wait few weeks before cutting that stitch that I just put in if I don't want the iPod I need to come back so we tolerate that kind of hyper pressure after the suture so this is one of my case of a me myopic lady of 55 years old who to whom I put that first for first of all she was a post-op of trap and her vision post of the one was six nine and pressure of 15 and after one month she was holding a 612 plus two I didn't wrote that plus two with a pressure of six it start bothering me to see that pressure coming down so I've been checking her and later on her vision decrease again and her pressure also so at that time I decided to do my transcontractable suture and and I had to put two sutures after one month she ended up with a pressure of vision of six nine and pressure of eight and sometime with those post-op and when we do have an iPod only post-op and we will try to have a compromise between the best vision I can have and the best pressure I can have for that same patient sometime I will tolerate a 612 plus three if I know that it's really a bad glaucoma and I you know I don't want also the pressure to all the 25 or something like that so it's really a compromise between those two things that's our post-op so if we look a little bit of the articles that have been published on those and this technique Pfeiffer described in described into a way 16 cases of a patient and the majority of them at improvement of their pressure and visual acuity is post-op day one at pressure around 25 so that's it was really tight and or sometime he was using multiple the stitch of Shirato into a studied 56 patient and we'll look at his result the last one is retrospectives does the study that we've did in Quebec City our glaucoma group and it has been published in 209 I will come back later on that last one so Shirato showed that for in his hand he started with pressure on 2.9 and bring the pressure up around seven which is not not so high and that the end at three month is pressure or good and the vision was holding also so it seems to be a little bit of kind of a discussion how I do we need to bring the pressure if we look at Pfeiffer paper he likes a pressure to be 25 and post-op one and then in the first month to flatten that hypothermic maculopathy in our study we had a pressure around 15 and post-op day one so it's kind of a mean between those two and we also had a good the improvement of vision and the pressure was holding at six months and this is the visual acuity in the Shirato paper and that was also an improvement of the vision in his study Shirato we are over a 56 eyes he had to remove the suture for hyper-opic pressure in 40 14 cases he needed to do a revision needle revealing revision in four cases and surgical revision in one so he concludes saying that this technique is simple non-invasive efficient to treat majority of a hypothermic maculopathy or chronic or adult attachment without major complications and in our study we looked at 35 30 highs and the the main thing that we bring with that study is that we could find that in the patient highly myopic patient we didn't have a so good result the other patient were there was no difference between the other groups of patient the duration even the duration of the hypothermia which is surprising but for myopic patient those one really don't respond well and also our study was a six month one so we could see that the pressure and the vision were maintained were maintained at six months then after that paper into online then I went to the academy and I went to a breakfast with the expert to try to see what kind of complication do you have with that technique but unfortunately at that time the expert at the two cases and the other one were in that that the other one that that breakfast wanted to start but haven't started yet and he was recommending multiples to sutures for rapid increase of pressure and the to do the technique in your and I show another little case where I sort of was not totally in agreement with the expert because of you will see my cases I have one case of trauma and I think we have to remember that when that suture is placed if the patient gets it's in the eye it will open it's still a point of vulnerable conjunctiva is really vulnerable at that site and it's pretty put predisposed to to leaking so that patient was leaking enough that I had to put in another stitch this patient has been referred to me for an hypotony following a trap and there was a bleblik so I did a revision for a bleblik when I do a revision for a bleblik usually I don't necessarily put a patch on my his clothes site because the problem is at the congenital level so I repair the congenital and in post-op he had still he was maintaining and I I bought on even if there was no leak anymore so in that case I use multiple transconjunctival sutures I went to three and the leaking was persisting it was oozing from every point every almost every sutures that I put and later on it's sort of stopped leaking but the pressure was still low so that patient has been revised major revision with skull patch on the trap site before closing again and but the thing is that when we use multiple sutures as you could think that we when we go back and you are it's sticky we put stitches everywhere the eyes and flame it's a revision that it's much more complicated than it has been done as first what do you see here that is my only case of infiltrate in the side of my transconjunctival suture and since the pressure was good the vision was good the eye was inflamed just here but the patient has no pain I just treated topically with an antibiotic and wait and I was watching that patient close enough to be sure that nothing was going bad and it sort of disappeared so I thought it could be infectious but it could be also inflammatory also I didn't do any because it was so small and limited I and it went away so now that we didn't many cases we talked with Dr. Casner at Miguel there's the study of being done with him also and we sort of made our list of indications so we use that technique for I thought primary I bought any after a trap or a secondary I put any after a suture lysis so now when I cut a suture I will wrote in the chart which suture I cut and where was it so if I have an iPod any after I will put back a suture exactly at that space so maybe we do too many suture lysis and we use it also for for a persistent major corridor detachment or for Dysastasia sometime but this disease has to be really major and usually I have tried something else before or clues closing an expansion I haven't done that but because I don't do expression but my colleague did once and it worked my little pearls for that technique is we use we work in vascularized zone not too many minutes so but it has to be vascularized if the blood is too thin then we will end up having leaks so we select our patients it induce fibrosis of vascularization and leaking if we use more multiple sutures I think that if I put two sutures and it doesn't work then I go to the you are and I will do one suture at a time and also for the patient selection I need a patient that is able to collaborate because he has to look down and stay still while I'm doing that technique it's short it's fast but I still have to put too tight the nut so the complication emerges leaking secondary transcend to hypertonic sometimes it's totally inefficient it can be irritating and some patient described night pain so we give them Tylenol and it goes away with time what I recommend to the patient is to avoid valsalva or any intense activities avoid direct compression on the eye use a shield at night especially for the first month and the biotic and then to inflammatory for the first 10 days and to be careful with his eye all the time so many ophthalmologists are afraid of that technique because they think they will make a big hole but it's rarely the case and it it's really for me avoids me to go back to the you are it preserve the integrity of the filtration in the end and even if I show you some complication it's rare usually it goes pretty well so it really made my life easier with my post-ops the major key point is also to prevent post-hypotonic maculopathy but we cannot always prevent it so I've showed you the maculopathy and their consequences my technique at this little amp few studies with good result I don't I haven't found any studies that were just looking at complications or mainly they often say there were no complications and I would recommend you to try it if you haven't tried yet and good luck and do you have any comments or experience with that technique or complication that I haven't seen yet because for sure we'll see some more but it goes pretty easily I can feel it when I grab my conch Oh more than that so you're kind of yes and at the meantime the the lab is so big often because if yeah but even if I try to go far I don't get so far the conch if you remember seeing my post-op like five days it we didn't really see the conch dragging as much as five to two seven days yeah around those days I guess what you have is a lot of concern probably because then even if 10 on island is small probably it's speak yeah and the conch around it sort of repeat buys probably quickly yeah I don't see always I can't see a minor one there was one I will observe it and see the patient another day 48 hours and if there's a minor leak I will see the patient every day until it resolved to that point now after cutting a suture even if I tend to use I tend to use tree stitch even if I I could put two but I think I will put the third one in parallel to the lamb is close to the chest to hold it there not to prevent that I bought any with my first or second or a second suture in our center there's a tendency to cut a lot of suture post-op and rapidly and all of them inside five weeks so maybe that may that we have maybe more and probably that's why I have experience with I try to hold on on suture lysis but some would do 100% of suture lysis in every case I don't do that but yeah because you probably you have access to it easily my or our time is limited at four o'clock I have to be done so if I already put an extra trap to do or then I end up being packed on my order so it's a good thing for me to be able to do it and I'm not well organized with them microscope and I could yeah but it's probably more comfortable for the patient