Glaucoma filtering surgery with 5-fluorouracil

Glaucoma Tube Outcomes with and without Anti-VEGF in Patients with Age-related Macular Degeneration

PURPOSE

To compare glaucoma tube outcomes of wet age-related macular degeneration (AMD) eyes receiving anti-VEGF injections versus dry AMD eyes and no anti-VEGF.

DESIGN

Retrospective clinical cohort study.

PARTICIPANTS

Patients with wet AMD and a history of anti-VEGF within a year prior or after stand-alone glaucoma tube surgery and eyes with dry AMD and no history of anti-VEGF with at least 6 months of follow-up. Eyes with neovascular glaucoma or anti-VEGF for reason other than wet AMD were excluded.

METHODS

A Kaplan-Meier analysis compared survival for wet versus dry AMD eyes. Failure was defined as intraocular pressure (IOP) > 21 mmHg or < 20% IOP reduction from baseline or IOP ≤ 5 mmHg for 2 consecutive postoperative visits starting at month 3, additional glaucoma surgery, or no light perception. Complete success was defined as no failure or medications at final follow-up. Hypertensive phase was defined for valved tubes as IOP > 21 mmHg within 3 months of surgery after a reduction to < 22 mmHg during the first postoperative week. Intraocular pressure, percent reduction in IOP, number of glaucoma medications, and early (< 1 year) and late (> 1 year) complications were compared through 5 years.

MAIN OUTCOME MEASURES

Survival analysis, IOP, number of medications.

RESULTS

Baseline IOP, number of medications, or tube type were not significantly different between wet (n = 24) and dry AMD eyes (n = 54). No wet AMD eyes failed versus 10 (18%) dry AMD eyes (P = 0.03). Five-year survival was estimated as 100% for wet AMD and 72% for dry AMD (P = 0.04). Wet AMD eyes had lower IOP (10.6 vs. 12.7 mmHg, P = 0.05), greater IOP reduction (60% vs. 49%, P = 0.04), fewer medications (1.2 vs. 2.1, P = 0.02), and more complete success (50% vs. 15%, P = 0.001) at final follow-up (32 vs. 36 months, P = 0.42). Fewer wet than dry AMD eyes experienced hypertensive phase (0/10 [0%] vs. 4/10 [40%], P = 0.04). There were no significant differences in early or late complications.

CONCLUSIONS

Exposure to anti-VEGF may influence postoperative wound healing and capsule formation which may improve glaucoma tube surgical outcomes. Prospective data is needed to consider perioperative administration of anti-VEGF for glaucoma tube surgery.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Bleb Morphology on Anterior-Segment Optical Coherence Tomography after XEN Gel Stent Implantation

We investigated the internal morphology of filtration blebs after XEN gel stent implantation using anterior segment optical coherence tomography (AS-OCT) and identified factors related to intraocular pressure (IOP) postoperatively. Eighteen eyes of 18 patients who had undergone XEN gel stent implantation were analyzed. Blebs were imaged using Visante OCT (Carl Zeiss Meditec AG, Germany) at 6 months and 1 year after surgery and evaluated for quantitative parameters including bleb height, maximum height of internal cavity, maximum bleb wall thickness, and maximum bleb epithelial thickness. Subjects were classified into two groups according to the presence or absence of a definite internal cavity between the conjunctiva and sclera using AS-OCT imaging. Nine eyes (50%) were assigned to the internal cavity group and 9 (50%) to the uniform group. Postoperative IOP was significantly lower in the internal cavity group than in the uniform group both at 6 months and 1 year after surgery (p = 0.024 and p = 0.040). Postoperative IOP showed statistically significant negative correlations with bleb height and the height of the internal cavity (Spearman correlation coefficient r = -0.518, p = 0.028 and r = -0.453, p = 0.034, respectively). AS-OCT facilitates analysis of bleb morphology after XEN gel stent implantation. A larger height of the internal cavity of the bleb appeared to correlate with lower IOP after XEN implantation.

Decellularized Porcine Conjunctiva in Treating Severe Symblepharon

This prospective study aimed to evaluate the effectiveness of decellularized porcine conjunctiva (DPC) in the management of severe symblepharon. Sixteen patients with severe symblepharon were enrolled in this study. After symblepharon lysis and Mitomycin C (MMC) application, tarsus defects were covered with residual autologous conjunctiva (AC), autologous oral mucosa (AOM), or DPC throughout the fornix, and DPC was used for all the exposed sclera. The outcomes were classified as complete success, partial success, or failure. Six symblepharon patients had chemical burns and ten had thermal burns. Tarsus defects were covered with DPC, AC, and AOM in two, three, and eleven cases, respectively. After an average follow-up of 20.0 ± 6 months, the anatomical outcomes observed were complete successes in twelve (three with AC+DPC, four with AC+AOM+DPC, and five with AOM+DPC) (75%) cases, partial successes in three (one with AOM+DPC and two with DPC+DPC) (18.75%) cases, and failure in one (with AOM+DPC) (6.25%) case. Before surgery, the depth of the narrowest part of the conjunctival sac was 0.59 ± 0.76 mm (range, 0-2 mm), tear fluid quantity (Schirmer II tests) was 12.5 ± 2.26 mm (range, 10-16 mm), and the distance of the eye rotation toward the opposite direction of the symblepharon was 3.75 ± 1.39 mm (range, 2-7 mm). The fornix depths increased to 7.53 ± 1.64 mm (range, 3-9 mm), eye movement was significantly improved, and the distance of eye movement reaching 6.56 ± 1.24 mm (range, 4-8 mm) 1 month after the operation; the postoperative Schirmer II test (12.06 ± 2.90 mm, range, 6-17 mm) was similar to that before surgery. Goblet cells were finally found in fifteen patients by conjunctival impression cytology in the transplantation area of DPC, except for one patient who failed. DPC could be considered an alternative for ocular surface reconstruction of severe symblepharon. Covering tarsal defects with autologous mucosa is necessary for extensive reconstruction of the ocular surface.

Impact of Early COVID-19 Pandemic on Common Ophthalmic Procedures Volumes: A US Claims-Based Analysis

PURPOSE

The COVID-19 pandemic has had a profound effect on the delivery of healthcare in the United States and globally. The aim of this study was to evaluate the impact of COVID-19 on common ophthalmic procedure utilization and normalization to pre-pandemic daily rates.

METHODS

Leveraging a national database, Clinformatics™ DataMart (OptumInsight, Eden Prairie, MN), procedure frequencies and daily averages, defined by Current Procedural Terminology codes, of common elective and non-elective procedures within multiple ophthalmology sub-specialties were calculated. Interrupted time-series analysis with a Poisson regression model and smooth spline functions was used to model trends in pre-COVID-19 (January 1, 2018-February 29, 2020) and COVID-19 (March 1, 2020-June 30, 2020) periods.

RESULTS

Of 3,583,231 procedures in the study period, 339,607 occurred during the early COVID-19 time period. Anti-vascular endothelial growth factor injections (44,412 to 39,774, RR 1.01, CI 0.99-1.02; p = .212), retinal detachment repairs (1,290 to 1,086, RR 1.07, CI 0.99-1.15; p = .103), and glaucoma drainage implants/trabeculectomies (706 to 487, RR 0.93, CI 0.83-1.04; p = .200) remained stable. Cataract surgery (61,421 to 33,054, RR 0.77; CI 0.76-0.78; p < .001), laser peripheral iridotomy (1,875 to 890, RR 0.82, CI 0.76-0.88; p < .001), laser trabeculoplasty (2,680 to 1,753, RR 0.79, CI 0.74-0.84; p < .001), and blepharoplasty (1,522 to 797, RR 0.71, CI 0.66-0.77; p < .001) all declined significantly. All procedures except laser iridotomy returned to pre-COVID19 rates by June 2020.

CONCLUSION

Most ophthalmic procedures that significantly declined during the COVID-19 pandemic were elective procedures. Among these, the majority returned to 2019 daily averages by June 2020.

Direct Injection of 5-Fluorouracil Improves Outcomes in Cicatrizing Conjunctival Disorders Secondary to Systemic Disease

PURPOSE

Conjunctival cicatrizing conditions are vision threatening, with poor outcomes despite aggressive systemic therapy. This study tests the utility of serial injections of 5-fluorouracil (5-FU) into the fornices to treat conjunctival scarring in patients with ocular cicatricial pemphigoid or Stevens-Johnson syndrome/toxic epidermal necrolysis.

METHODS

Retrospective cohort study. Fisher exact test and multivariable logistic regression analyses were used to compare clinical outcomes of patients who were administered 5-FU injections versus patients who were not injected. Model fit was examined for multivariable regression.

RESULTS

One hundred twelve eyes (56 patients) met the inclusion criteria. Thirty-eight eyes (34%) had Stevens-Johnson syndrome/toxic epidermal necrolysis, and 74 eyes (66%) were diagnosed with ocular cicatricial pemphigoid. Twenty-five eyes received ≥1 injection of 5-FU. Sixteen eyes received 1-4 injections, while 9 received ≥5. Median follow-up until last encounter was 18 months. Analysis of each disease entity alone and in combination revealed that 5-FU injections were associated with improvement in final visual acuity, corneal scarring, trichiasis, need for/number of mucous membrane graft surgeries, and severity of symblephara.

CONCLUSIONS

Serial injection of 5-FU in the affected fornices is a promising treatment for severe vision-threatening conjunctival scarring from ocular cicatricial pemphigoid and Stevens-Johnson syndrome/toxic epidermal necrolysis. Given the excellent safety profile of 5-FU around the eye, the solid biologic foundation for using 5-FU in this setting, and the severe risk of vision loss from these disorders, the authors suggest that serial 5-FU injections be adopted as therapy for conjunctival scarring from ocular cicatricial pemphigoid or Stevens-Johnson syndrome/toxic epidermal necrolysis despite the limitations of this retrospective study.

Identification and Correction of Restrictive Strabismus After Pterygium Excision Surgery

PURPOSE

To report the characteristics of patients with restrictive diplopia following pterygium excision and a successful treatment approach for the strabismus.

DESIGN

Retrospective interventional case series.

METHODS

This study was set in a single academic institution and included 15 patients with restrictive diplopia after pterygium excision. Patients with any other reason for strabismus were excluded. Patients were evaluated for deficits with special attention to diplopic measures. The intervention was a combined procedure by a strabismologist and oculoplastic surgeon to correct the diplopia. The primary outcome measurements were subjective and objective improvement of diplopia.

RESULTS

Fifteen patients (mean age = 49 years) who developed diplopia after pterygium excision were included. Mean time to diplopia was 6 months. All patients had limited abduction in the previously operated eye causing esotropia in the abductive field (mean deviation = 18 prism diopters). After intervention, all patients were no longer diplopic in primary gaze. In the abductive field, 11 (73%) patients had residual small angle esotropia (mean = 7 prism diopters) in ipsilateral extreme end-gaze only. Only 2 patients required additional surgical intervention for scar tissue removal. No patients underwent medial rectus recession.

CONCLUSIONS

Restrictive diplopia is a potential complication after pterygium excision, particularly for patients with a history of recurrent pterygia requiring multiple excisions and previous amniotic membrane graft placement with fibrin glue. However, diplopia after pterygium excision in primary position is surgically correctable with scar tissue removal and ocular surface reconstruction, without needing medial rectus recession. Given the high volume of pterygium excision, awareness of postoperative restrictive strabismus and the potential for correction is critical.

[Profile of neovascular glaucoma in Senegalese patients]

OBJECTIVE

To describe the etiologies, clinical presentation and therapeutic management of neovascular glaucoma (NVG) in Senegalese patients.

PATIENTS AND METHODS

We retrospectively studied the records of patients followed for NVG between 1993 and 2016. We included eyes with Iridis rubeosis with or without ocular hypertension. We recorded age, sex, medical and ophthalmologic history, results of the eye examination, treatment modalities broken up into hospitalisation, procedural interventions and number of antiglaucoma medications prescribed. The data analysis was performed by epi-info 7.

RESULTS

Forty-eight eyes of 44 patients were included. The mean age was 59.7 years and sex ratio 2.1. Etiologies were type 2 diabetes in 31.8 % cases and central retinal vein occlusion in 16.6 % cases. All eyes were blind. Eye pain was present in 75 % of eyes, a limbal flush in 29.1 % of eyes and mydriasis in 31.25 % of eyes. Mean intraocular pressure was 49.7mmHg. Corneal edema occured in 54.1 % of eyes. Fundus examination showed proliferative retinopathy in 14.5 %. Treatment required hospitalisation for 43.75 % of patients. Therapeutic procedures were cyclocryoapplication for 31.25 % of eyes, retrobulbar xylo-alcohol injection for 14.5 % of eyes and panretinal laser photocoagulation (PRP) for 12.5 % eyes. Antiglaucoma preparations were used in dual therapy for 29 % of eyes, in triple therapy and quadruple therapy for 25 % of eyes each.

DISCUSSION

The etiologies are comparable to those described in the literature. The diagnosis was late and treatment limited by adverse economic conditions.

CONCLUSION

NVG in Senegalese patients is an affection of men in their sixties. It is responsible for irreversible painful blindness for which treatment is difficult - thus the interest in prevention by strict monitoring and prompt treatment of any retinal ischemia.

Combined cataract extraction with a new nonvalved glaucoma drainage device in adult eyes with cataract and refractory glaucoma

Purpose:

The purpose of the study is to report the outcomes of simultaneous cataract extraction (CE) and a new nonvalved glaucoma drainage device (GDD), Aurolab Aqueous Drainage Implant (AADI), in eyes with cataract and refractory glaucoma.

Methods:

This was a non-comparative, interventional, retrospective study. Consecutive patients who underwent AADI together with phacoemulsification from June-2015 to January-2017 by a single fellowship trained glaucoma surgeon with documented 3-months of follow-up were included. The main outcomes were intraocular pressure (IOP), antiglaucoma medication (AGM), visual acuity, and complications.

Results:

We included 19 eyes of 17 patients with average follow-up of 14.4 ± 8.4 months. IOP and AGM reduced from 36.9 ± 11.1 mmHg and 4 ± 0.8 preoperatively to 12 ± 4.5 mmHg and 0.8 ± 1.2, respectively (P < 0.001). Complications were seen in seven eyes (36.8%). Total success was seen in 17 eyes (89.5%). None of the patients lost vision.

Conclusion:

Combining cataract extraction with the new non-valved Aurolab Aqueous Drainage Implant, appears to be an effective and safe technique in eyes with refractory glaucoma and cataract. Larger studies and further follow-up is recommended for such patients.

Factors Associated with Outcomes of Combined Phacoemulsification and Ahmed Glaucoma Valve Implantation

Purpose

To evaluate outcomes and factors associated with surgical failure in patients who underwent combined phacoemulsification and Ahmed glaucoma valve (AGV) implantation.

Methods

This retrospective and longitudinal study enrolled 40 eyes (38 patients) that underwent combined phacoemulsification and AGV implantation. Visual acuity, intraocular pressure (IOP), and number of antiglaucoma medications were evaluated preoperatively and postoperatively. Complete success was defined as a last follow-up IOP of 6 to 21 mmHg without medication, qualified success as an IOP of 6 to 21 mmHg with medication, and failure as an IOP of >21 or <6 mmHg.

Results

The mean follow-up period was 18 ± 10 months. Preoperative diagnoses were chronic angle closure glaucoma (35.0%), neovascular glaucoma (22.5%), uveitic glaucoma (17.5%), primary open-angle glaucoma (15.0%), and other (10.0%). IOP decreased from a mean of 30.5 ± 8.7 to 14.5 ± 3.7 mmHg at the last follow-up visit (p < 0.001). Treatment was classified as qualified success in 18 eyes (45%), complete success in 15 (37.5%), and failure in seven (17.5%). Twenty-two eyes (55%) showed improvement in visual acuity. The most common postoperative complication was a transient hypertensive phase (five eyes, 12.5%). Tube-iris touch was associated with surgical failure (hazard ratio, 8.615; p = 0.008).

Conclusions

Combined phacoemulsification and AGV implantation is an effective and safe surgical option for patients with refractory glaucoma and cataract. Postoperative tube-iris touch is an indicator of poor prognosis.

Conjunctival Fibrosis after Application of Mitomycin C: An Animal Experimental Study

Mitomycin C (MMC) is widely used as an antimetabolite to minimize scarring of filtering blebs. Its effectiveness has been demonstrated in several clinical studies. The drug's mechanism of action is attributed to its antiproliferative effect on the subconjunctival cells, reducing the wound healing response. We placed sponges soaked with various concentrations of MMC, from 0.05 to 1.0 mg/ml, under the conjunctiva of 18 rabbits. Four weeks later, there was marked concentration-dependent scarring of the substantia proppria of the conjunctiva. Macrophages were more numerous in treated eyes, as determined by immunohistochemistry. The reason for MMC-related fibrosis in this animal model is not clear but may be related to the substances toxic effects. Whether it is only present in rabbits remains to be clarified.

Fluorouracil Filtering Surgery Study One-Year Follow-up

Two hundred thirteen patients participated in the Fluorouracil Filtering Surgery Study, a randomized clinical trial, to determine the efficacy and safety of subconjunctivally injected 5-fluorouracil after filtering surgery in eyes with poor prognoses. Twenty-eight (27%) of the 105 eyes in the 5-fluorouracil group and 54 (50%) of the 108 eyes in the standard group were classified as failures, defined by reoperation for control of intraocular pressure during the first year or an intraocular pressure greater than 21 mm Hg at the one-year visit (P = .0007, Mantel-Haenszel chi-square). Corneal epithelial toxicity and transient visual acuity loss were more common in the 5-fluorouracil group (P < .001, chi-square); however, the visual acuities and the mean visual field sensitivities were not significantly different at one year. We recommend the use of subconjunctivally injected 5-fluorouracil after trabeculectomy in eyes with uncontrolled glaucoma and poor prognoses, specifically after previous cataract extraction or unsuccessful filtering surgery.

Effects of Latanoprost and GLC756, a Novel Dopamine D2 Agonist and D1 Antagonist, on Cultured Normal Human Dermal Fibroblasts

Purpose

Proliferation of subconjunctival fibroblasts plays a critical role in scarring and failure of glaucoma filtering surgery. Long-term topical glaucoma medications appear to increase fibroblast proliferation. In this study, the effects of topical antiglaucoma drugs latanoprost and GLC756, a novel dopamine D2 agonist and D1 antagonist, on cultured normal human dermal fibroblasts (NHDF) were examined.

Methods

The NHDF cell line was incubated with latanoprost, prostaglandinF2α (PGF2α), GLC756, or 5-fluorouracil as a positive control at concentrations of 3 and 30 μM for 6, 18, and 24 hours. Fibroblast growth was measured by 5-bromodeoxyuridine (BrdU) uptake using laser scanning cytometry.

Results

Latanoprost and PGF2α had a biphasic response on the number of cultured NHDF positively stained with BrdU. A stimulating effect on proliferation occurred early, 6 hours after incubation, and an inhibitory effect 18 to 24 hours after incubation. GLC756, in contrast, revealed only inhibitory effects on BrdU uptake 18 to 24 hours after incubation. The pattern of GLC756 was similar to that of the positive control 5-fluorouracil.

Conclusions

Latanoprost seemed to have a biphasic response on the proliferation of cultured NHDF. First there was a stimulating thereafter a secondary negative modulating effect. GLC756 had a fully antiproliferative effect on the NHDF, indicating an additional potential of novel dopamine compounds for topical glaucoma medication.

PERIPHERAL RETINAL DEGENERATIONS AND RHEGMATOGENOUS DETACHMENT IN PRIMARY CONGENITAL GLAUCOMA

BACKGROUND

To determine the prevalence of peripheral retinal degenerations (PRD) and rhegmatogenous retinal detachment in patients with primary congenital glaucoma (PCG).

METHODS

Records of all patients with PCG operated from year 2000 onwards were evaluated to look for the prevalence of rhegmatogenous retinal detachment. Of these, those children who were old enough to cooperate and had sufficient medial clarity were screened with an indirect ophthalmoscopy in a cross-sectional evaluation from 2010 to 2014. Peripheral retina was examined, and prevalence of PRD was estimated in this subset. For statistical purposes, only one eye of each patient was considered in this cross-sectional analysis.

RESULTS

Of the 310 eyes (180 patients with PCG) operated from the year 2000 onwards, a rhegmatogenous retinal detachment was noted in 13 eyes (4%). Mean axial length of these eyes was 26.3 ± 3.2 mm (range, 19.8-34.7 mm). Among the eyes screened for PRD (n = 60), prevalence of pathologic PRD (lattices with/without atrophic holes and isolated holes/tears) was 15%. The average follow-up between glaucoma filtering surgery and the date of last examination was 8.55 ± 3.98 years (range, 5-20 years) in this subset. Mean axial length was significantly greater in eyes with pathologic PRD than in those without (28.1 ± 3.3 mm vs. 25.8 ± 2.6 mm; P = 0.01). For axial length ≥ 26 mm, the odds of having a pathologic PRD were 14.4 times more than those with axial length < 26 mm (P < 0.001; 95% confidence interval, 1.7-120.5).

CONCLUSION

Prevalence of PRD among eyes with PCG is high. Peripheral retinal screening should be performed in eyes with PCG, especially those with axial lengths ≥ 26 mm.

Combined Phacoemulsification and Ahmed Glaucoma Drainage Implant Surgery for Patients With Refractory Glaucoma and Cataract

PURPOSE

To examine the indications, safety, efficacy, and complications of combined phacoemulsification and Ahmed glaucoma drainage implant surgery.

METHODS

A retrospective case review of 35 eyes (31 patients) subjected to combined phacoemulsification and Ahmed glaucoma drainage implant surgery. Demographic characteristics of the study population, indications for combined surgery, and operative and postoperative complications were recorded. Visual acuity, intraocular pressure (IOP), and number of glaucoma medications were evaluated preoperatively and postoperatively. Complete success was defined as IOP ≤ 21 mm Hg without medication, qualified success if IOP ≤ 21 mm Hg with ≥ 1 medications, and failure if IOP>21 mm Hg or ≤ 5 mm Hg on ≥ 2 consecutive visits.

RESULTS

Mean follow-up was 29.5 months (range, 6 to 87 mo). The most common indication for combined surgery was a history of prior failed trabeculectomy (60%). Postoperative visual acuity improved in 30 of 35 eyes (85%) (P<0.01) regardless of the indication for combined surgery. IOP was reduced from a mean of 24.7 to 15.0 mm Hg at the last follow-up visit (P<0.01). The number of IOP-lowering medications was reduced from a median of 3.1 preoperatively to 1.7 at the last follow-up (P<0.01). Overall, there were 31 eyes (89%) classified as qualified success and 4 eyes (11%) as complete success. The most common postoperative complication was a hypertensive phase in 18 eyes (51%).

CONCLUSIONS

Combined phacoemulsification and Ahmed glaucoma drainage implant surgery seems to be a safe and effective surgical option, providing good visual rehabilitation and control of IOP for patients with refractory glaucoma and cataract.

Current and Future Techniques in Wound Healing Modulation after Glaucoma Filtering Surgeries

Filtering surgeries are frequently used for controlling intraocular pressure in glaucoma patients. The long-term success of operation is intimately influenced by the process of wound healing at the site of surgery. Indeed, if has not been anticipated and managed accordingly, filtering surgery in high-risk patients could end up in bleb failure. Several strategies have been developed so far to overcome excessive scarring after filtering surgery. The principal step involves meticulous tissue handling and modification of surgical technique, which can minimize the severity of wound healing response at the first place. However, this is usually insufficient, especially in those with high-risk criteria. Thus, several adjuvants have been tried to stifle the exuberant scarring after filtration surgery. Conventionally, corticosteroids and anti-fibrotic agents (including 5-fluorouracil and Mitomycin-C) have been used for over three decades with semi-acceptable outcomes. Blebs and bleb associated complications are catastrophic side effects of anti-fibrotic agents, which occasionally are encountered in a subset of patients. Therefore, research continues to find a safer, yet effective adjuvant for filtering surgery. Recent efforts have primarily focused on selective inhibition of growth factors that promote scarring during wound healing process. Currently, only anti-VEGF agents have gained widespread acceptance to be translated into routine clinical practice. Robust evidence for other agents is still lacking and future confirmative studies are warranted. In this review, we explain the importance of wound healing process during filtering surgery, and describe the conventional as well as potential future adjuvants for filtration surgeries.

Amniotic membrane transplantation in failed trabeculectomy

PURPOSE

To determine the efficacy and safety of amniotic membrane transplantation for trabeculectomy in patients with previous failed filtering blebs.

METHODS

A consecutive series of 19 eyes from 18 patients with 1 or more failed trabeculectomies were enrolled in this retrospective study. Trabeculectomy, with amniotic membrane positioned as a "graft" under the scleral flap, was performed, and the intraocular pressure (IOP), number of antiglaucoma medications, appearance of the filtering bleb, and intraoperative and postoperative complication data were retrospectively analyzed for a period of 24 months. Success was defined as IOP<21 mm Hg at the end of the follow-up period.

RESULTS

The median preoperative pressure was 29 mm Hg [interquartile range (IQR)=5 mm Hg], with an average of 2.8 glaucoma medications (range, 1 to 4). At 6 months postoperatively the median IOP was 18 mm Hg (IQR=1.75 mm Hg) with no further significant increases recorded, settling at 19 mm Hg (IQR=3.25 mm Hg) at the end of the 24-month follow-up. Success was achieved in all 19 cases (100%), and only 1 patient (5%) required postoperative antiglaucoma therapy to reach the target pressure. At 24 months after surgery, 18 of 19 (95%) amniotic membrane filtering blebs were functioning well without antiglaucoma therapy. No patients had severe intraoperative or postoperative complications.

CONCLUSIONS

Amniotic membrane transplantation in trabeculectomy seems to be a safe and useful procedure for improving the surgical outcome and maintaining low postoperative IOP in patients with a high risk of surgical failure.

Wound Healing Modulation in Glaucoma Filtration Surgery-Conventional Practices and New Perspectives: The Role of Antifibrotic Agents (Part I)

Glaucoma filtration surgery is regularly performed for the treatment of glaucoma and trabeculectomy is often regarded as the ‘gold standard' glaucoma operation. The biggest risk of failure of the operation is bleb scarring. The advent of anti-fibrotic agents, such as mitomycin C (MMC) and 5-fluorouracil (5FU) has vastly prolonged the longevity of the bleb, but concerns remain regarding the potential increase in postoperative complications. More selective therapeutic targets have therefore been explored. One of these is vascular endothelial growth factor (VEGF) inhibition. Vascular endothelial growth factor inhi bition has a role not only in sub conjunctival angiogenesis inhi bition but also it has direct anti-fibrotic properties. Newer phar macological compounds and materials have also been developed in recent years in attempt to modulate the wound healing in different ways after glaucoma surgery. These include physical barriers to scarring and vehicles for sustained release of pharmacological agents, and early promising results have been demonstrated. This two-part review will provide a discussion of the application of anti-fibrotic agents in glaucoma filtration surgery and evaluate the newer agents that have been developed.

How to cite this article: Fan Gaskin JC, Nguyen DQ, Ang GS, O'Connor J, Crowston JG. Wound Healing Modulation in Glaucoma Filtration Surgery–Conventional Practices and New Pers pectives: The Role of Antifibrotic Agents (Part I). J Curr Glaucoma Pract 2014;8(2):37-45.

Post-trabeculectomy topical bevacizumab preventing bleb failure: a preliminary study

This study aims to evaluate the efficacy and safety of post-trabeculectomy topical bevacizumab, in preventing bleb failure. A total of 11 females and 12 males were enrolled for the study. After a complete ophthalmic evaluation, the patients underwent trabeculectomy. Full ophthalmic examination was done the next day, which included visual acuity, intraocular pressure (IOP), and bleb morphology. Next, two drops of bevacizumab [0.25 mg (0.01 ml)] were instilled over the wound area with a tuberculin (1 ml) syringe. Pressure was applied at the medial canthus to prevent it from going into the lacrimal passage. Similar postoperative procedures were repeated at 1, 2, 3, and 4 weeks. So in all, five instillations of bevacizumab were completed. Later, the patients were followed at 1-month interval for 6 months. Target IOP was achieved in all eyes and was maintained during the study period of 6 months without any anti-glaucoma medication. Average IOP before trabeculectomy was 27.27 ± 8.92 mmHg, which decreased postoperatively to 8.77 ± 0.97 mmHg at 3 months and 9.27 ± 1.16 mmHg at 6 months. This drop in IOP was statistically significant on both occasions (p = 0.00). A nice low filtering bleb was formed after the surgery, and it remained the same during the study period. The other parameters like cup-to-disc ratio and visual field did not change during the 6 months of study as expected because glaucoma is a slow progressive disease. Modulating the wound at multiple sites by bevacizumab (inflammation, proliferative, and remodeling stages) can lead to success of trabeculectomy.

Five-year results of 5-fluorouracil augmented needling revision of failing blebs

BACKGROUND AND OBJECTIVE

To report the 5-year intraocular pressure (IOP) outcomes of patients requiring a 5-fluorouracil (5-FU) needling revision compared to a matched sample.

PATIENTS AND METHODS

Forty eyes receiving 5-FU bleb needling revision were matched to 40 patients not needled. IOP was recorded preoperatively and annually to 5 years. The main outcome measure was surgical success: IOP control without medications or surgery.

RESULTS

Thirty-two patients with 5-FU needling revision (80.0%) required anti-glaucoma medication postoperatively versus 28 control patients (70%) (P > .05). Thirty-two patients with 5-FU needling revision were complete or qualified successes compared to 36 control patients (P = .34). Eight patients with 5-FU needling revision (20%) had a reoperation versus 4 control patients (10%) (P > .05).

CONCLUSION

5-FU needling revision can produce long-term IOP control levels similar to those who did not require the procedure. No statistically significant differences between the two groups was seen in either the use of medications or further surgery.

The use of amniotic membrane in trabeculectomy for the treatment of primary open-angle glaucoma: a prospective study

BACKGROUND

To investigate the effectiveness of amniotic membrane transplantation (AMT) on improving the outcomes of trabeculectomy in primary open-angle glaucoma (POAG).

METHODS

Fifty-nine eyes affected by primary open-angle glaucoma were enrolled in this prospective randomized study. Thirty-two eyes underwent amnion-shielded trabeculectomy (study group) and 27 eyes underwent trabeculectomy without any antimetabolites (control group). Success was defined as intraocular pressure (IOP) <21 mmHg without any medications at 24 months follow-up. The two groups were compared in terms of IOP, bleb morphology, bleb survival and risk of failure, glaucoma medications, and complications.

RESULTS

There was no statistically significant difference in terms of postoperative IOP between the two groups and at 24 months median IOP was 15.5 mmHg for the AMT group and 16 mmHg for the control group. IOP postoperative reduction was 8 mmHg for the AMT group versus 6 mmHg for the non AMT group (P = 0.276). Two patients from the study group developed IOP >21 mmHg in contrast to seven patients from the classic trabeculectomy group. The study group had 61.0% less risk of developing IOP >21 mmHg (P = 0.203). No major complications in the AMT group were observed. AMT blebs were diffuse with mild vascularization.

CONCLUSION

In patients with POAG, AMT showed favorable effects on bleb survival, however data failed to provide firm evidence that AMT could be used as a routine procedure in trabeculectomy.

Longitudinal rates of postoperative adverse outcomes after glaucoma surgery among medicare beneficiaries 1994 to 2005

PURPOSE

To determine longitudinal rates of postoperative adverse outcomes after incisional glaucoma surgery in a nationally representative longitudinal sample.

DESIGN

Retrospective, longitudinal cohort analysis.

PARTICIPANTS

Medicare beneficiaries >or=68 years who underwent a primary trabeculectomy (PT), trabeculectomy with scarring (TS), or glaucoma drainage device (GDD) implantation from 1994 to 2003 with follow-up through 2005.

INTERVENTION

Primary trabeculectomy, TS, and GDD were identified from International Classification of Diseases (ICD-9-CM) and Current Procedural Terminology (CPT) procedure codes. Change in rates of postoperative adverse outcomes associated with these 3 surgical interventions was analyzed by cumulative incidence rates and Cox proportional hazards model regression; regression analysis controlled for prior adverse outcome measures (3-year run-up) and demographic variables.

MAIN OUTCOME MEASURES

First-, second-, and sixth-year cumulative rates and probability of experiencing serious adverse outcomes (retinal detachment, endophthalmitis, suprachoroidal hemorrhage), less serious adverse outcomes (choroidal detachment, corneal edema, hypotony), and receipt of additional glaucoma surgery were identified through Medicare claims for each treatment group.

RESULTS

At the 1-year follow-up, rates of severe adverse outcomes were higher among beneficiaries in the GDD group (2.0%) relative to the PT (0.6%) and TS groups (1.3%). Controlling for prior adverse outcomes to the surgery and demographic factors in Cox proportional analysis, differences were often reduced, but generally remained statistically and clinically significant. Rates of severe outcomes, less severe outcomes, corneal edema, and low vision/blindness were higher for persons undergoing GDD than PT or TS. However, rates of reoperation were higher for TS than GDD.

CONCLUSIONS

The risk for adverse outcomes was higher in GDD than in PT surgery or TS, controlling for a number of important case mix and demographic factors.

Hemorrhagic complications from glaucoma surgery in patients on anticoagulation therapy or antiplatelet therapy

PURPOSE

To determine the incidence of and risk factors for hemorrhagic complications in patients on anticoagulation (ACT) or antiplatelet therapy (APT) having glaucoma surgery.

DESIGN

Retrospective case-control study.

METHODS

Medical records of patients who had glaucoma surgery between July 1, 1998 and March 31, 2005 were reviewed. Patients who either used ACT/APT continuously throughout the perioperative period or discontinued its use prior to surgery were compared to case-matched control patients who were not on such therapies. Patients on ACT/APT who experienced postoperative hemorrhagic complications were compared to those who did not. Outcome measures included hemorrhagic complications and thromboembolic events.

RESULTS

Three hundred and forty-seven patients (eyes) who were on ACT or APT prior to glaucoma surgery had a higher rate of hemorrhagic complications than 347 control patients (10.1% vs 3.7%, respectively, P = .002). Patients on ACT had a higher rate of hemorrhagic complications than patients on APT (22.9% vs 8.0%, respectively, P = .003). Patients who continued ACT during glaucoma surgery had the highest rate of hemorrhagic complications (31.8%) when compared to patients who discontinued ACT prior to surgery or patients who used APT alone (P = .001). Hemorrhagic complications following glaucoma surgery were more frequently associated with preoperative ACT, arrhythmia, and higher preoperative and postoperative intraocular pressures (IOP).

CONCLUSION

Chronic ACT/APT was associated with a statistically significant increase in the rate of hemorrhagic complications, and perioperative ACT and a high preoperative IOP are potential risk factors for hemorrhagic complications in patients undergoing glaucoma surgery.

Pars plana vitrectomy and panretinal photocoagulation combined with trabeculectomy for successful treatment of neovascular glaucoma

BACKGROUND

Treatment of neovascular glaucoma (NVG) must be focused on the reduction of intraocular pressure (IOP) and prompt application of pan retinal photocoagulation (PRP). A combination of complete PRP during vitrectomy with trabeculectomy should theoretically be a better method to lower the IOP rapidly in eyes with NVG. The purpose of our study is to assess the efficacy of combining pars plana vitrectomy and PRP with trabeculectomy assisted by mitomycin C (MMC) on NVG eyes secondary to diabetic retinopathy.

METHODS

Twenty-five eyes with NVG associated with diabetic retinopathy had pars plana vitrectomy, followed by PRP and trabeculectomy with MMC. The eyes were divided into two groups: nine eyes with vitreous hemorrhage, fibrovascular membrane and/ or retinal detachment were placed in the Proliferation group; and 16 eyes without vitreous hemorrhage, fibrovascular membrane, or retinal detachment were placed in the PC (photocoagulation) group. These eyes had vitrectomy performed so that PRP could be safely performed from ora to ora. The surgical outcome in the two groups was assessed by Kaplan-Meier survival analysis. The criteria for success were a postoperative intraocular pressure (IOP) < or =21 mmHg and a preservation of light perception.

RESULTS

In the Proliferation group, Kaplan-Meier life-table analysis showed that the success rate was 55.6% after 1 year and 18.5% after 2 years. The success rate in the PC group was 81.2% from 1 to 3 years after surgery. The surgical outcome was significantly better in the PC group than in the Proliferation group (P=0.009). In the Proliferation group, four eyes had preoperative vitreous hemorrhage, three eyes had a fibrovascular membrane, and two eyes had a retinal detachment. Three of four eyes with vitreous hemorrhage achieved good IOP control. On the other hand, the IOP of all eyes with retinal detachment and fibrovascular membrane were not lowered significantly.

CONCLUSIONS

Complete PRP combined with trabeculectomy with MMC can effectively reduce the elevated IOP in eyes with NVG. However, this combined treatment is not effective in eyes with proliferative membranes and retinal detachments.

The role of antimetabolites in filtration surgery for neovascular glaucoma: intermediate-term follow-up

PURPOSE

To compare the intermediate-term efficacy of 5-fluorouracil (5-FU) and Mitomycin C (MMC) as adjunctive antimetabolites in neovascular glaucoma (NVG) filtration surgery.

METHODS

Forty consecutive eyes of 40 patients with NVG refractory to medical therapy were randomized to receive antimetabolite-augmented trabeculectomy. Eighteen eyes received postoperative 5-FU (5-FU group) and 22 eyes received intraoperative, low-dose (0.2 mg/ml) MMC for 2 mins (MMC group). The main outcome measure was intraocular pressure (IOP). Surgical success was defined as IOP < 21 mmHg with topical treatment (qualified success) or without topical treatment (complete success). Surgical failure was defined as IOP > or = 21 mmHg, despite postoperative topical treatment, and by postoperative blindness.

RESULTS

The mean follow-up period was 35.8 +/- 22.6 months in the 5-FU group and 18.6 +/- 17.2 months in the MMC group. This difference was not significant. Mean IOP decreased from 40.4 +/- 10.3 mmHg to 14.7 +/- 3.4 mmHg (p < 0.0001) in the 5-FU group and from 42 +/- 11.3 mmHg to 22.9 +/- 13.3 mmHg (p = 0.0006) in the MMC group; however, the difference between the 5-FU and MMC groups was not significant at any point. The success rate in the 5-FU group was 55.5% (44.4% complete, 11.1% qualified), compared with 54.5% (9.1% complete, 45.4% qualified) in the MMC group. This difference was not significant.

CONCLUSIONS

The percentage of patients who achieved postoperative IOP < 21 mmHg was similar in both groups, although a larger proportion of patients treated with MMC-augmented trabeculectomy required topical treatment in comparison with the 5-FU group.

Trabeculectomy with mitomycin C for treatment of neovascular glaucoma in diabetic patients

BACKGROUND

To assess the efficacy and to determine the risk factors of trabeculectomy with mitomycin C (MMC) in eyes with neovascular glaucoma (NVG) secondary to diabetic retinopathy.

METHODS

Kaplan-Meier survival analysis of the surgical outcome was performed on 35 eyes with NVG. Age, extent of peripheral anterior synechia, surgical history (cataract, glaucoma, vitrectomy), and concurrent retinal cryotherapy were evaluated to determine factors influencing the surgical outcome. The main criterion for success was a postoperative intraocular pressure (IOP) of < or = 21 mm Hg.

RESULTS

The cumulative probability of success was 67.0% at 1 year and 61.8% after 2 to 3 years. The surgical outcome was significantly better in patients without a previous vitrectomy (p = 0.03). Extensive preoperative peripheral anterior synechia was also a risk factor for surgical failure (p = 0.013).

CONCLUSIONS

Trabeculectomy with MMC can effectively reduce the elevated IOP associated with NVG. The extent of peripheral anterior synechia and a history of vitrectomy are significant negative predictors of surgical outcome.

Dose, timing and frequency of subconjunctival 5-fluorouracil injections after glaucoma filtering surgery

BACKGROUND

Although adjunctive postoperative 5-fluorouracil (5-FU) injections are known to improve the success rate of glaucoma surgery, it is still unknown what dose, timing and frequency of application will give the best results with respect to the inhibition of postoperative scarring and intraocular pressure regulation. We therefore designed the following retrospective investigation.

METHODS

We studied 172 eyes from 172 patients who had undergone trabeculectomy with adjuvant 5-FU-therapy. Variations of dosage, timing and frequency were analysed retrospectively. Surgery was defined as a complete success when the patient reached an intraocular pressure under 21 mmHg and a reduction of 20% 12 months after the operation. A relative success was achieved with these criteria under additional local medication. Not reaching these postoperative criteria for a complete success was classified as failure.

RESULTS

On average, adjunctive 5-FU-treatment was started 4.6+/-5.85 days postoperatively. The injections contained between 2 mg and 5 mg FU, and the mean total dose was 26.6+/-13.2 mg (range 5-65 mg). Surgery on 94 patients (54.65%) was classified as "complete success", that on 25 patients (14.53%) was classified as "relative success" and that on 53 eyes (30.81%) was classified as "failure" 12 months (+/-3 months) postoperatively. The best results were obtained when the treatment started on or before the first postoperative day (68.0-71.4% complete success; P<0.05). In contrast, an increase in 5-FU dosage did not result in an increased success rate of trabeculectomy. None of the 172 patients suffered from vision-threatening complications such as endophthalmitis or hypotony maculopathy.

CONCLUSION

Early treatment with 5-FU significantly increases the success rates of filtering surgery.

Rescue of failed filtering blebs with ab interno trephination

We evaluated the effectiveness of ab interno automated trephination as a technique for rescuing failed mature filtering blebs. A retrospective chart review of 40 failed blebs of 38 patients who had a posttrephination follow-up period of at least 3 months was done. With success defined as intraocular pressure (IOP) <21 mm Hg and at least a 20% reduction from baseline on the same or fewer number of pretrephination medications, 30/40 eyes (75%) fit these criteria over the entire course of follow-up. Among all 40 eyes, there was a significant reduction of IOP from pretrephination to 3 months (P<.001). The percentage of patients requiring 2 or more medications declined from 90% pretrephination to 21% at 3 months (P<.0001), and was stable thereafter. Some patients were able to eliminate all medications. Patients who did not meet the criteria of success regained successful IOP control with other modalities of management. Complications were few. We believe that ab interno trephination is an excellent option for rescuing selected failed filtering blebs.

Topical application of autologous serum for the treatment of late-onset aqueous oozing or point-leak through filtering bleb

PURPOSE

To evaluate the efficacy of topical autologous serum application to stop aqueous oozing or point-leak through filtering bleb after trabeculectomy.

PATIENTS AND METHODS

A total of 21 consecutive eyes with oozing and 21 eyes with a point-leak through a functional bleb after trabeculectomy with 5-fluorouracil or mitomycin C were enrolled in this randomized, case-control study. In eyes randomly assigned to the serum group, an antibiotic and the autologous serum, which was sterilely diluted to 20% with physiological saline, were topically applied four times a day for up to 12 weeks. In eyes assigned to the control group, the antibiotic alone was applied according to the same protocol. Intraocular pressure (IOP) and the presence of oozing or a point-leak were tested before and every 2 weeks after starting the treatments.

RESULTS

In the serum and control groups, oozing stopped in 62.5 and 0% of eyes, respectively (P=0.003), and point-leaks stopped in 27.3 and 18.2%, respectively (P>0.9). IOP significantly increased from 10.0+/-3.2 (mean+/-standard deviation) to 11.8+/-3.3 mmHg in eyes in which oozing stopped (P=0.066), and from 11.4+/-2.7 to 15.4+/-2.3 mmHg in eyes in which a point-leak stopped (P=0.042).

CONCLUSIONS

Autologous serum application was significantly effective to stop aqueous oozing but not point-leaks. Stopping oozing or point-leaks was significantly associated with an increase in IOP.

A New Model of Glaucoma Filtering Surgery in the Rat

PURPOSE

The most common reason for long-term failure of glaucoma filtering surgery (GFS) is scarring of the external filtering "bleb" tissues. The identification of the factors that mediate this process, as well as the development and initial testing of new therapies to limit scarring is enhanced by the use of appropriate animal models. The standard animal model for studying GFS is the rabbit but newer investigative tools that examine changes induced in biologic systems at a genetic level have made development of a rat model desirable.

METHODS

Glaucoma filtering surgery was performed on 20 Sprague-Dawley rats by introducing a 30-gauge silicone cannula through a penetrating scleral tunnel, under a limbal-based conjunctival flap and suturing the conjunctiva closed. Identical GFS was performed on 3 additional rats, which underwent histologic evaluation at days 2, 5, and 11, following surgery.Fistulizing surgery was also performed on 6 Sprague-Dawley rats, for comparison, by creating a full-thickness needle sclerostomy under a limbal-based conjunctival flap and suturing the conjunctiva closed.

RESULTS

Following the cannula GFS, well-elevated filtering blebs formed and these gradually failed over the course of 8 to 13 days. Needle tract sclerostomy filtering blebs formed at the site of the fistulizing surgery but rapidly failed over the course of 2 to 3 days.

CONCLUSION

Cannulated filtering surgery in the rat provides a longer lasting and more predictable model than needle tract sclerostomy for studying wound healing following GFS and may facilitate the study of induced changes at the gene level.

Postoperative 5-fluorouracil versus intraoperative mitomycin C in high-risk glaucoma filtering surgery: extended follow up

PURPOSE

To compare the long-term efficacy and safety of postoperative subconjunctival 5-fluorouracil (5-FU) injections with that of intraoperative mitomycin C (MMC) in eyes at high risk for failure of trabeculectomy.

METHODS

In a retrospective, non-randomized comparative trial, 36 eyes of 36 consecutive patients at high risk for failure of trabeculectomy underwent glaucoma filtering surgery with either postoperative subconjunctival 5-FU injections (19 eyes) or intraoperative application of MMC (17 eyes). Intraocular pressure, number of postoperative antiglaucoma medications, postoperative visual acuity, interventions, and complications were evaluated.

RESULTS

Overall success (intraocular pressure </=21 mmHg) at 1 year was 73.6% in the 5-FU group and 82.3% in the MMC group. The cumulative 4-year success was 52.6% in the 5-FU group and 60.5% in the MMC group (P = 0.6). At 4-year follow up, mean +/- SD intraocular pressures were 17.58 +/- 4.01 mmHg in the 5-FU group and 13.33 +/- 3.36 mmHg in the MMC group (P = 0.01). There was no significant difference in the number of post-operative medications (P = 0.84), appearance of blebs (P = 0.20), final visual acuity (P = 1.00), and complications (P > 0.05) between the groups.

CONCLUSIONS

These results suggest that both postoperative 5-FU injections and intraoperative MMC application have long-term success in high-risk patients. However, MMC results in a greater decrease in intraocular pressure than 5-FU.

Antifibrotics and wound healing in glaucoma surgery

When medical and laser therapy fail to control intraocular pressure, glaucoma filtration surgery needs to be performed. Glaucoma surgery is unique in that its success is linked to interruption of the wound-healing response in order to maintain patency of the new filtration pathway. In this article we will review the wound-healing pathway and the pharmacologic interventions that have been employed clinically and experimentally to interrupt wound healing, particularly steroids and the antifibrotic agents 5-fluorouracil and mitomycin C. A review of the published literature looking at use of these agents to enhance success as well as the associated complications are presented, critiqued, and interpreted in order to put the studies in proper perspective. Future directions and recommendations regarding use of these agents are available and an introduction to newer wound modulating agents such as anti-transforming growth factor beta 2 is presented.

Toxic effects of subconjunctival 5-fluorouracil and mitomycin C on ciliary body of rats

PURPOSE

The effects of subconjunctival injection of mitomycin C and different concentrations of 5-fluorouracil on the epithelium of the ciliary body of twenty Sprague Dawley SD rats was studied.

METHODS

Twenty rats were divided into four treatment groups. The first three groups received 0.2 ml of 5, 10, and 30 mg of 5-fluorouracil subconjunctivally respectively, and the fourth group 0.2 ml of 0.4 mg/ml mitomycin C subconjunctivally. The right eye received 0.2 ml of the antimetabolite, while the left eye was injected with 0.2 ml of saline subconjunctivally, as a control. The eyes were examined histologically, in a masked fashion, by light and by transmission electron microscopy. In each treatment group, two eyes were examined after one week, and three eyes were examined one month after the subconjunctival injection.

RESULTS

Electron microscopy revealed toxic effects in the epithelium of the ciliary body of all treatment groups. The 5-fluorouracil group revealed focal mitochondrial edema, enlargement of intercellular spaces, and dilatation of intracellular spaces. The mitomycin C group showed pyknotic nuclei, enlargement of intercellular spaces, and irregular flattened epithelial cells. The severity of changes correlated with concentration and length of exposure. No pathology was found by light microscopy in all groups.

CONCLUSIONS

This study demonstrates that subconjunctival antimetabolites mitomycin C and 5-fluorouracil can penetrate the sclera and exert toxic effects on the epithelium of the ciliary body, even in low doses. These changes were only apparent by electron microscopy and were still present one month after the injection. These findings may contribute to the theory that the application of antimetabolites during or after surgery has a direct effect on the epithelium of the ciliary body, besides its known effect on the conjunctiva. Further studies are needed to evaluate its effect on intraocular pressure.

Anti-inflammatory fibrosis suppression in threatened trabeculectomy bleb failure produces good long term control of intraocular pressure without risk of sight threatening complications

AIMS

To determine the long term outcome of systemic anti-inflammatory fibrosis suppression in cases of threatened trabeculectomy bleb failure in open angle glaucoma.

METHODS

This prospective non-comparative case series followed 77 eyes of 63 patients which showed signs of threatened early bleb failure and were treated with oral anti-inflammatory fibrosis suppression of prednisone, a non-steroidal anti-inflammatory agent, and colchicine taken for a mean period of 6 weeks, in addition to standard postoperative topical treatment, for a mean follow up of 6 years.

RESULTS

Trabeculectomy with anti-inflammatory fibrosis suppression controlled the IOP at < or =21 mm Hg with a probability of 0.91 (95% CI: 0.81 to 1.0) at 8 years and 0.89 (95% CI: 0.56 to 1.1) at 12 years. There were no reported cases of endophthalmitis, hypotonous maculopathy, late bleb leak, or serious systemic side effects.

CONCLUSION

Anti-inflammatory fibrosis suppression provided good control of bleb fibrosis without risk of sight threatening complications in a patient group at high risk of bleb failure.

Combined cataract extraction and Baerveldt glaucoma drainage implant: indications and outcomes

PURPOSE

To report the indications and outcomes of simultaneous cataract extraction (CE) and Baerveldt glaucoma drainage implant surgery.

DESIGN

Noncomparative, interventional, retrospective, consecutive case series.

PARTICIPANTS

Thirty-three eyes of 33 patients.

INTERVENTION

Combined phacoemulsification CE and Baerveldt glaucoma drainage implant (BGI) surgery at two tertiary care referral centers.

MAIN OUTCOME MEASURES

Visual acuity, intraocular pressure (IOP), and complications.

RESULTS

The study included 33 eyes of 33 patients followed for an average of 15.4 months (range, 3.0-46.9). The most common indication for combined CE and Baerveldt glaucoma drainage implant surgery was a history of prior failed trabeculectomy. Postoperative visual acuity at last follow-up was > or =20/40 in 12 of 33 patients (36%). IOP was reduced from a mean (+/- standard deviation) of 21 +/- 7.3 mmHg preoperatively to 13.1 +/- 3.5 mmHg at last follow-up visit ( P < 0.001). The number of antiglaucoma medications was reduced from a mean (+/- standard deviation) of 2.3 +/- 1.0 preoperatively to 0.7 +/- 1.1 at last follow-up (P < 0.001). Three eyes met our criteria for failure, and cumulative survival of the glaucoma surgery at 18 months was 89%. Intraoperative complications were all related to the cataract surgery, whereas early and late postoperative complications were related both to the CE and BGI surgery.

CONCLUSIONS

Combined CE and Baerveldt glaucoma drainage implant placement seems to be a safe and effective surgical option and may be preferred in certain clinical situations.

Late-onset transconjunctival oozing and point leak of aqueous humor from filtering bleb after trabeculectomy

PURPOSE

To estimate the prevalence and identify factors related to late-onset transconjunctival aqueous oozing and point leak from functioning blebs after trabeculectomy with 5-fluorouracil (5-FU) or mitomycin C.

DESIGN

Cross-sectional study.

METHODS

SETTING

The study took place at the outpatient clinic of the Department of Ophthalmology, University of Tokyo Graduate School of Medicine (Tokyo, Japan). Four hundred three consecutive patients (403 eyes) with functional blebs at least 3 months after previously performed trabeculectomy were examined between December 1997 and February 1998. The Seidel test was performed with extended observation up to 15 seconds. Oozing was identified as transconjunctival aqueous egress without interruption of the conjunctival tissue or aqueous stream on the bleb wall. Logistic regression analyses of oozing and point leak in 331 eyes with an avascular area were performed using independent variables, including age, gender, glaucoma diagnosis, prior incisional surgery, antimetabolite use, combined cataract surgery, postoperative follow-up period, intraocular pressure (IOP), concurrent glaucoma therapy, bleb size, and avascular area size.

RESULTS

Of 403 eyes, 48 eyes (11.9%) had oozing and 8 eyes (2.0%) had point leak. Intraocular pressure was significantly lower and an avascular area was more frequent in eyes with oozing or leak than in eyes without (P <.001). Logistic regression analysis revealed that oozing was significantly more common after use of 5-FU than mitomycin C (P =.024), whereas point leak was associated with a larger avascular area (P =.045).

CONCLUSIONS

After trabeculectomy with antimetabolites, transconjunctival oozing is much more frequent than point leak. Oozing was significantly associated with the use of 5-FU and point leak with a larger avascular area in the bleb.

Long-term follow-up of initial 5-fluorouracil trabeculectomy in primary open-angle glaucoma in Japanese patients

PURPOSE

To evaluate the long-term efficacy and safety of initial trabeculectomy with subconjunctival 5-fluorouracil in Japanese patients with primary open-angle glaucoma.

SUBJECTS AND METHODS

Clinical records of 117 eyes from 117 patients with records of up to 14 years were retrospectively analyzed using the appropriate statistical methods.

RESULTS

The mean follow-up period was 6.2 +/- 3.6 years. Criteria for successful intraocular pressure control and success probability by Kaplan-Meier method at 12 years were intraocular pressure < 21 mm Hg without medication plus a 30% or more reduction in intraocular pressure, 50.4 +/- 5.2% (SE) 38.2 +/- 5.3%; and intraocular pressure < 16 mm Hg without medication plus a 30% or more reduction in intraocular pressure, 45.9 +/- 5.1% (36.5 +/- 5.2%). Cox multiple regression analysis showed that a younger age was associated with a higher success probability (P <0.01). Eyes with lower postoperative intraocular pressure tended to show more positive value of the MD slope (P = 0.0669), whereas 7% of successfully treated eyes showed a negative postoperative MD slope (P < 0.1). The probabilities for developing bleb leaks and bleb-related infections in eyes with a functioning bleb were 28.9 +/- 12.5% and 13.0 +/- 10.4% at 12 years.

CONCLUSION

Trabeculectomy with 5-fluorouracil as an initial surgery in Japanese patients with primary open-angle glaucoma was effective for long-term control of glaucoma. However, the probability of late-onset bleb-related complications was not low in eyes with a functioning bleb, stressing the importance of constant care regarding bleb status.

Delayed suprachoroidal hemorrhage after glaucoma filtration procedures

OBJECTIVES

To determine the incidence of, risk factors for, and outcomes of delayed suprachoroidal hemorrhage (DSCH) after glaucoma filtration surgery.

DESIGN

Retrospective case-control study.

PARTICIPANTS

All patients undergoing glaucoma filtration procedures between 1986 and 2000 at Indiana University who were diagnosed postoperatively with suprachoroidal hemorrhage. A total of 66 patients with DSCH were identified. These were compared with a randomly selected group of patients who underwent similar procedures but did not have suprachoroidal hemorrhage.

METHODS

Total cases of DSCH were initially compared with the total number of glaucoma surgeries to determine the overall incidence and the incidence in the different procedures. Subsequently, a case-control study was performed comparing the group with hemorrhage to the control group to identify risk factors. Finally, outcomes and prognostic factors were determined by comparing vision preoperatively and postoperatively and parameters of patients with good and poor outcomes.

MAIN OUTCOME MEASURES

Incidence of DSCH, risk factors associated with its occurrence, visual outcomes, and factors important for prognosis.

RESULTS

Of a total of 2285 glaucoma filtration procedures, 66 (2.9%) cases of DSCH were identified. It developed in 9 of 615 (1.5%) trabeculectomies without antimetabolite, 30 of 1248 (2.4%) trabeculectomies with antimetabolite, 2 of 72 (2.8%) valved tube shunt implantations, and 25 of 350 (7.1%) nonvalved tube shunt implantations. The increased incidence of DSCH after tube shunts compared with trabeculectomy-associated DSCH was significant (P < 0.0001) with an odds ratio of 3.2. The risk factors for DSCH after glaucoma surgery include white race (P = 0.012), anticoagulation (P = 0.034), severe postoperative hypotony (P = 0.033), and aphakia/anterior chamber intraocular lens (P = 0.002). The visual outcomes of patients with hemorrhage were poor, with a decrease in logarithm of the minimum angle of resolution visual acuity from 0.72 to 1.36, which was statistically significant compared with the controls (P < 0.009).

CONCLUSIONS

Delayed suprachoroidal hemorrhage occurs more frequently after tube shunt implantation than after trabeculectomy. Caution should be exercised when operating on patients with known risk factors, because the visual outcomes after DSCH are poor.

The use of autologous fibrinogen concentrate in treating ocular hypotony after glaucoma filtration surgery

Antimetabolite therapy with 5-fluouracil (5-FU) or mitomycin-C (MMC) has significantly improved the success rate of glaucoma filtration surgery. However, in some eyes, when filtration is excessive, persistent hypotony may develop. In this study, we describe the experience of using autologous fibrinogen concentrate (AFC) to treat patients with persistent hypotony after glaucoma filtration surgery. Among seven MMC-augmented trabeculectomy patients who developed persistent postoperative hypotony, the effects of AFC intrableb injections were evaluated. Under a microscope, 0.2 ml AFC and bovine thrombin were injected into the blebs of the patients from both sides of the filtering blebs. Postoperative best-corrected visual acuity, anterior chamber status, intraocular pressure (IOP) and fundus examination were followed and compared with those preoperative. On the second day, the mean IOP of seven eyes elevated from preoperative 3.4 +/- 2.1 mmHg to 12.6 +/- 4.2 mmHg, and the anterior chamber became deep without obvious inflammatory response. Within two weeks, macular edema and visual acuity were noted to improve in six eyes (85.7%). In addition, after a mean follow-up of 25 months, the trabeculectomy procedure remained successful in all eyes. AFC appears to be safe and effective in the treatment of ocular hypotony after glaucoma filtration surgery.

Formulation factors for preparing ocular biodegradable delivery system of 5-fluorouracil microparticles

Microparticles containing 5-fluorouracil (5-FU) were prepared using poly(DL-lactide-co-glycolide) with an oil-in-oil emulsion/solvent extraction technique. Particle characteristics including size distribution, 5-FU loading efficiencies, in vitro release and degradation were investigated. The dispersed phase was composed of PLG dissolved in dichloromethane, and the continuous phase was paraffin oil containing lecithin. 5-FU was successfully entrapped in the microparticles with trapping efficiencies up to 76%, loading level 10% w/v, and particle size 3 microm. Release profiles of 5-FU loaded microparticles were determined to follow a first-order-time relationship. An optimized preparation of 5-FU microparticles was achieved and was capable of controlling the release of 5-FU over 21 days with an in vitro delivery rate of 0.4 microg 5-FU/mg particles/day in the study. Preliminary animal studies indicated that the 5-FU loaded microparticles as an ocular delivery system showed no ocular toxicity and no significant inflammatory response in rabbits for 2 months. The 5-FU loaded microparticles approach, with PLG, might be a potential for the application of long-term delivery of hydrophilic drugs in the eye.

A murine cell culture model for post-trabeculectomy anfibrotic treatment: Induction of apoptosis by Cyclosporin

PURPOSE

Experimental trials aimed at the research of selective antifibrotic agents are under development for the alternative treatment of glaucoma patients who are usually considered high-risk post-surgical individuals after trabeculectomy. Authors present here an in vitro model system for the treatment of post-trabeculectomy patients. The study is aimed at the evaluation of different drugs in a mouse fibroblast model.

METHODS

The antifibrotic activity of Cyclosporin A, Interferon 2alpha, 5-Fluorouracyl was investigated on 3T6 cells in culture. Cell viability and proliferation was assessed after drug treatment. Molecular analysis of DNA degradation was evaluated by means of radioactive labeling and gel electrophoresis.

RESULTS

The three drugs were shown to affect cell proliferation and viability in a differential fashion. However, only Cyclosporin A was able to control cell proliferation, inducing apoptosis. This phenomenon was reduced by supplementation of trolox, a compound known to inhibit programmed cell death. These results strongly suggest that this model system might be useful as a test of pharmacological functionality.

CONCLUSION

A rapid and efficient model system is described for the assessment of cell viability and proliferation after treatment with agents of potential pharmacological use. Cyclosporin A induces a significant apoptosis. This is important for the negative control of fibrotic degeneration in post-trabeculectomy that is required for successful surgery in glaucoma patients. Therefore, Cyclosporin A might become a clinically interesting drug for the antifibrotic treatment of post-trabeculectomy.