Irrigating bent ab-interno needle goniectomy (i-BANG) technique.

Background: The bent ab-interno needle goniectomy (BANG) represents a low-cost indigenous modification designed for ab-interno excisional goniectomy. This technique employs a reverse cystitome (24 G needle) and yields outcomes equivalent to those achieved with the Kahook Dual Blade goniectomy. However, reflux bleeding from Schlemm's canal, with or without anterior chamber shallowing, often impedes angle visualization, thereby limiting the desired treatment extent. Recommended preventive measures for managing or treating hyphema include avoiding treatment in high-risk patients (on anticoagulants), blood washing, employing cohesive ophthalmic viscosurgical device (OVD), hydrating wounds under high air pressure tamponade, and maintaining a propped-up position postoperatively. Despite these precautions, hyphema can impair intraoperative angle visualization. Among patients experiencing hyphema, a quarter require drainage. Washing blood away by re-injecting OVD or with bimanual irrigation aspiration often leads to intraoperative delay and subsequent rebleeding.

Purpose: This article describes a novel modification aimed at managing intraoperative angle bleeding and anterior chamber shallowing while ensuring a clear angle view, as performed in 27 eyes, including patients with primary open-angle and angle-closure glaucoma.

Synopsis: Our surgical technique, termed irrigating BANG (i-BANG), involves bending a 1 mm 24 G needle toward the bevel at a right angle to create a goniectome. The needle hub is connected to Alcon's CENTURION® system, and continuous infusion is initiated at 100 mmHg IOP. A 120° goniectomy is fashioned under continuous fluid infusion nasally, allowing for the clearance of any refluxing blood during the procedure. Air is injected through the side port as the irrigating needle is withdrawn, and the ports are hydrated.

Highlights: • i-BANG achieves passive aspiration at minimal cost. • It effectively addresses intraoperative hyphema and anterior chamber shallowing. • None of the 27 patients in our study experienced procedure abandonment or incomplete treatment during i-BANG. • Only 12 eyes exhibited minimal blood layering in the angle, which was completely absent by one week postoperatively.

Video link: https://youtu.be/YmPeoBDpN54.