Young patient trabeculectomy. Assessment of risk factors for failure

Outcomes of Filtering Surgery Versus Clear Lens Extraction in Young Patients With Angle-Closure Glaucoma

PURPOSE

To compare the effect of filtering surgery versus clear lens extraction in young patients with medically uncontrolled angle-closure glaucoma (ACG).

DESIGN

Retrospective, nonrandomized, comparative, interventional study.

METHODS

We reviewed the medical charts of patients with the following scenarios: (1) age ≤40 years; (2) diagnosis of ACG without cataract, including primary angle-closure glaucoma (PACG), nanophthalmic ACG, and ACG combined with retinal dystrophies; and (3) ACG undergoing filtering surgery or clear lens extraction. The main outcomes including intraocular pressure (IOP), number of medications, best-corrected visual acuity, and severe complications were extracted at the postoperative early (within 1 week) and late stage (>3 months) follow-up.

RESULTS

Data from 160 eyes of 130 young patients with ACG were available. Eyes with 76 PACG, 12 nanophthalmic ACG, and 26 ACG with retinal diseases underwent filtering surgery, whereas eyes with 22 PACG, 12 nanophthalmic ACG, and 12 ACG with retinal diseases received clear lens extraction. Overall, filtering surgery and clear lens extraction resulted in significant but comparable IOP and drug reductions at the postoperative late stage in each ACG subgroup, with similar complete success rates between 2 treatments (all P > .05). Regarding the safety, filtering surgery and patients with retinal diseases were independent factors associated with postoperative malignant glaucoma (P < .05 in both multivariable logistic regression models).

CONCLUSIONS

This study highlights that the efficacy of clear lens extraction is comparable to that of filtering surgery in medically uncontrolled ACG in young patients, but clear lens extraction is safer, especially for young patients with ACG comorbid with retinal diseases.

Pediatric Glaucoma-From Screening, Early Detection to Management

Pediatric glaucoma (PG) covers a rare and heterogeneous group of diseases with variable causes and presentations. Delayed diagnosis of PG could lead to blindness, bringing emotional and psychological burdens to patients' caregivers. Recent genetic studies identified novel causative genes, which may provide new insight into the etiology of PG. More effective screening strategies could be beneficial for timely diagnosis and treatment. New findings on clinical characteristics and the latest examination instruments have provided additional evidence for diagnosing PG. In addition to IOP-lowering therapy, managing concomitant amblyopia and other associated ocular pathologies is essential to achieve a better visual outcome. Surgical treatment is usually required although medication is often used before surgery. These include angle surgeries, filtering surgeries, minimally invasive glaucoma surgeries, cyclophotocoagulation, and deep sclerectomy. Several advanced surgical therapies have been developed to increase success rates and decrease postoperative complications. Here, we review the classification and diagnosis, etiology, screening, clinical characteristics, examinations, and management of PG.

TUBE VERSUS TRABECULECTOMY IN JUVENILE-ONSET OPEN ANGLE GLAUCOMA - TREATMENT OUTCOMES IN TERTIARY HOSPITALS IN MALAYSIA

AIM OF THE STUDY

To compare the intraocular pressure (IOP) lowering effect and postoperative complications between primary augmented trabeculectomy and glaucoma drainage device (GDD) implantation as primary surgical intervention in patients with juvenile-onset open angle glaucoma (JOAG).

PATIENTS AND METHODS

A retrospective review study involving 20 eyes that underwent primary augmented trabeculectomy with mitomycin (MMC) and 10 eyes GDD implantation in 3 tertiary centres in Malaysia between 1 January 2013 and 31 December 2019. They were followed up for at least 12 months postsurgical intervention. Intraocular pressure (IOP), number of topical IOP lowering medication and complications were evaluated at 1, 3, 6 and 12 months post-intervention. Based on the IOP, the success was divided into complete and partial success, and failure. IOP and postsurgical complications were compared using the Repetitive Measure Analysis of Variance (RM ANOVA) and the Pearson chi-square test.

RESULTS

Both methods were effective in lowering the IOP. Eyes with primary augmented trabeculectomy have significant lower IOP compared to GDD implantation (p = 0.037). There was a higher incidence of postoperative hypotony (30%) in the trabeculectomy group. There was also a significant reduction of mean number of topical pressure-lowering drugs required postoperatively (p = 0.015). Complete success was achieved in 100% of eyes with trabeculectomy and 67% in GDD implantation (p = 0.047).

CONCLUSIONS

Primary augmented trabeculectomy and GDD implantation are good surgical options for the treatment of JOAG. Both methods provide IOP lowering at 1 year. However, trabeculectomy provides better pressure lowering, compared to GDD implantation in patients with JOAG.

Trabeculotomy Versus Combined Trabeculotomy-Trabeculectomy for Management of Primary Congenital Glaucoma

PRCIS

Trabeculotomy (T) alone is as safe and effective as combined trabeculotomy-trabeculectomy (TT) in patients with primary congenital glaucoma (PCG) and requires significantly fewer examinations under anesthesia in the postoperative period.

PURPOSE

The purpose of this study was to compare the outcomes of T and combined TT as the initial surgical procedure for patients with PCG.

METHODS

In this retrospective study, medical records of patients who had undergone T or TT as the initial procedure for PCG were reviewed. The primary outcome measure was a surgical success, defined as 5≤ intraocular pressure (IOP) ≤21 mm Hg, IOP reduction of at least 20% with no need for further glaucoma surgery. Secondary outcome measures were the number of glaucoma medications and complications.

RESULTS

A total of 134 eyes from 134 patients with a mean follow-up of 8±6.6 years were included consisting of 106 and 28 eyes, which had undergone T and TT, respectively. Success rates were comparable with both surgical procedures at 1, 2, 3, 4, and 5 years with no statistically significant difference. IOP was significantly decreased from 27.5±4.2 mm Hg preoperatively to 15.62±3.4 mm Hg at the 5-year follow-up visit in the T group and from 25.3±6.5 to 17.1±3.2 mm Hg in the TT group (P=0.1) there was no significant difference between the 2 groups in the number of glaucoma medications (P=0.2). Patients in the T group required significantly fewer examinations under anesthesia than the TT group (7.3±4.4 vs. 10.1±3.9, P=0.04).

CONCLUSION

Trabeculotomy alone seems as effective as combined trabeculotomy-trabeculectomy and may significantly reduce exposure to anesthesia in primary congenital glaucoma patients.

Factors affecting the surgical success of trabeculectomy performed as the first surgery in primary pediatric glaucoma

PURPOSE

To present the outcomes and factors affecting the success of trabeculectomy performed as the first surgery in primary pediatric glaucoma.

METHODS

Pediatric patients with primary glaucoma who underwent trabeculectomy as the first surgery were retrospectively reviewed. Age, gender, preoperative intraocular pressure (IOP), operation age, axial length, corneal diameter, anterior segment findings, antimetabolite used, complications, and 1-month, 3-months, 1-year, and most recent postoperative findings were recorded. Postoperative IOP with/without medication of 18 mmHg or less was considered successful. Factors that may have affected surgical success were also evaluated using multivariate analysis.

RESULTS

Included in the study were 48 patients, of whom 30 had primary congenital glaucoma and 18 had juvenile glaucoma. The mean preoperative IOP was 36.84 ± 6.30 mmHg, and the mean follow-up time was 7.95 ± 6.93 years. The median operation age value was 100.00 ± 100.83 (median: 60; IQR: 153) months. The postoperative IOP at the 1-month, 3-months, 1-year, and most recent follow-ups were 15.39 ± 6.88, 15.70 ± 7.36, 16.28 ± 7.86, and 17.48 ± 8.44 mmHg, respectively (p = 0.565). While there were no postoperative complications in 24 of the patients (50.0%), the most common complications were choroidal detachment and hypotony. Postoperative complication development was found to be significant as a factor affecting surgical success in the multivariate logistic regression analysis. Surgical success rates for all of the patients were 71.7%, 65.9%, 65.0%, and 61.4% at the 1-month, 3-months, 1-year, and most recent follow-ups, respectively. A significant difference was found between the congenital and juvenile groups in terms of surgical success only at 3 months (p = 0.953, p = 0.042, p = 0.191, p = 0.218; respectively).

DISCUSSION/CONCLUSION

The fact that surgical success was partially higher in the juvenile group confirmed the idea that the results of trabeculectomy will be more favorable in patients of older age and without anterior segment anomalies.

Ahmed and Baerveldt Drainage Implants in the Treatment of Juvenile Open-angle Glaucoma

PRECIS

Ahmed and Baerveldt implants succeed in 90.7% of cases for lowering intraocular pressure (IOP) <21 mm Hg at 1 year when used for the treatment of juvenile open-angle glaucoma.

PURPOSE

The purpose of this study was to report the 1-year outcomes of Ahmed and Baerveldt tubes as the treatment for juvenile open-angle glaucoma at an academic institution.

PATIENTS AND METHODS

Patients 18 to 40 years of age at the time of juvenile open-angle glaucoma diagnosis, who had inadequately controlled glaucoma with an IOP of 18 mm Hg or more on maximum tolerated antiglaucoma therapy that underwent tube shunt surgery with at least 6 months of follow-up were eligible for the study. Exclusion criteria included evidence of neovascular, uveitic or inflammatory, steroid-induced or primary congenital glaucoma, or if they did not have light perception vision. Postoperative failure was defined as an IOP, with or without antiglaucoma drops, >21 mm Hg for 2 consecutive visits after 3 months from surgery, <20% decrease in IOP at 1 year, no light perception, or revision of an implant due to high IOP.

RESULTS

The study population included 32 eyes from 25 patients who underwent tube shunt surgery. The failure rate at 1-year follow-up was 9.3%, and the postoperative complication rate at 1-year follow-up was 9.3%. The average change from baseline to 1 year for IOP was a decrease of 9.8±9.10, for the number of antiglaucoma drops number was a decrease of 0.38±1.06, and for the visual acuity was an increase of 0.03±0.27.

CONCLUSIONS

Ahmed and Baerveldt implantation succeeded in lower IOP in 90.7% of patients at 1 year. Continuation of antiglaucoma drops to maintain the IOP after surgery is likely required.

Efficacy and Safety of Sutureless Trabeculectomy with Using Porous Collagen (Ologen) in Management of Glaucoma Patients

Purpose

This study aims to investigate the safety, efficacy and feasibility of sutureless trabeculectomy using a porous collagen matrix that contains a connected porous structure (Ologen) in the control of intraocular pressure (IOP) in glaucoma patients.

Methods

The study includes 25 eyes from 24 patients that met the inclusion criteria. All eyes underwent trabeculectomy with the Ologen implant that provides a space with a dynamic and physiological aqueous reservoir system. The operation was considered successful if IOP is <15 mmHg without need of IOP-lowering drops at 18 months of follow-up.

Results

The target IOP was achieved in 21 out of the 25 eyes (84%), the remaining four eyes all had an IOP of 16 mmHg at 18 months. Short-term complications consisted of seven cases of bleb leakage treated with bandage contact lens and one case of mild choroidal effusion which resolved after observation alone.

Conclusions

We can conclude that this technique can provide safety, effectiveness and short learning curve for ophthalmology trainees with lower incidence of perioperative and postoperative complications. Further studies may be required to prove stability and long-term efficacy in management of glaucoma patients.

Learning from the past: Mitomycin C use in trabeculectomy and its application in bleb-forming minimally invasive glaucoma surgery

Trabeculectomy has been performed since the mid-1960s and remains the gold standard for glaucoma surgery. Newer surgical options have evolved, collectively referred to as minimally invasive glaucoma surgeries. Despite producing large intraocular pressure decreases, full-thickness procedures into the subconjunctival space may be limited by fibrosis. Mitomycin C (MMC) and 5-fluorouracil have been in use with trabeculectomy with good evidence of significantly increased success at the cost, however, of an increased risk of complications. Off-label MMC application can be found in almost all clinical trials, including in combination with minimally invasive glaucoma surgeries. We explore current evidence for MMC use in trabeculectomy and how this may differ for minimally invasive glaucoma surgery devices and analyze the range of agents and doses that are used. Although we found that most studies could not show any correlation between MMC dosage and the surgical outcome, the success rates with the Xen® microshunt seemed to be higher when using 20 mcg of MMC than when using 10 mcg. Certain important methodological considerations make this hard to confirm definitively, and other factors such as placement of the device may play a more substantial role. For the PreserFlo® microshunt, preliminary data suggest higher success rates with higher MMC dosage at the cost of higher device-related adverse events and reoperations. Although the ideal dose still needs to be established, it seems very likely that MMC provides significant improvement in outcomes in bleb-forming minimally invasive glaucoma procedures.

Prediction of Surgical Outcome After Trabeculectomy for Neovascular Glaucoma With Anterior-segment Optical Coherence Tomography

PURPOSE

To determine the potential of anterior-segment optical coherence tomography (AS-OCT) to predict posttrabeculectomy outcomes in neovascular glaucoma (NVG).

PATIENTS AND METHODS

We recruited 45 eyes of 40 NVG patients who underwent trabeculectomy. The patients were divided into success and failure groups based on the posttrabeculectomy outcome after 12 months. AS-OCT findings were compared in the success and failure groups at 1 and 2 weeks and 1, 3, 6, and 12 months. We also analyzed early posttrabeculectomy bleb parameters with multiple logistic regression, stepwise multiple regression, and the receiver operating characteristic curve to evaluate the power of these parameters to predict long-term outcomes.

RESULTS

Intraocular pressure at 6 and 12 months was lower in the success group than the failure group (P<0.0016=0.0048). Reflectivity of the bleb wall was higher in the failure group than the success group throughout the study (all: P<0.0016). Age and reflectivity of the bleb wall at 1 week were risk factors for failure with odds ratios for failure of 0.91 and 1.67. The area under the receiver operating characteristic curve for reflectivity of the bleb wall at 1 week was 0.943 with the cutoff set at 128.9 (sensitivity: 85.7%; specificity: 100.0%). Stepwise multiple regression analysis showed that reflectivity of the bleb wall at 1 week independently indicated the bleb survival period (β=-0.84; P<0.001).

CONCLUSIONS

AS-OCT-measured reflectivity of the bleb wall, measured at 1 week of trabeculectomy for NVG, might be able to predict of the final status of the bleb.

Low-Dosage Mitomycin C as an Adjunct to Trabeculectomy. A Prospective Controlled Study

PURPOSE

To assess the advantages and adverse effects of intraoperative low-dose Mitomycin C in filtering glaucoma surgery.

METHODS

Sixty eyes of 48 patients undergoing surgery for uncontrolled glaucoma were randomized to two groups: one underwent standard trabeculectomy, the other had trabeculectomy with intraoperative application of 0.1 mg/ml mitomycin C. Follow-up was at least one year.

RESULTS

The success rate (IOP < 18 mmHg) was 96.6% in the mitomycin C group and 73.3% in the control group. Mean IOP at one year of successful cases was 11.1 +/- 3.1 mmHg in the mitomycin C group and 16.4 +/- 6.1 mmHg in controls (p < 0.0001). Two patients in the mitomycin C group (6.6%) and six (20%) in the control group needed antiglaucomatous drugs to keep IOP below 18 mmHg.

CONCLUSIONS

Mitomycin C is a useful adjunct to glaucoma surgery. Adverse effects at the dosage used are mainly due to hypotony and are preventable with two-layer suture. Low-dose mitomycin C may be useful in standard primary trabeculectomy.

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.

Pediatric Glaucoma: A Literature's Review and Analysis of Surgical Results

The purpose of this paper is to review the surgical options available for the management of pediatric glaucoma, to evaluate their advantages and disadvantages together with their long-term efficacy, all with the intent to give guidelines to physicians on which elements are to be considered when taking a surgical decision. Currently there is a range of surgical procedures that are being used for the management of pediatric glaucoma. Within these, some are completely new approaches, while others are improvements of the more traditional procedures. Throughout this vast range of surgical options, angle surgery remains the first choice in mild cases and both goniotomy and trabeculotomy have good success rates. Trabeculectomy with or without mitomycin C (MMC) is preferred in refractory cases, in aphakic eyes, and in older children. GDIs have a good success rate in aphakic eyes. Nonpenetrating deep sclerectomy is still rarely used; nevertheless the results of ongoing studies are encouraging. The different clinical situations should always be weighed against the risks associated with the procedures for the individual patients. Glaucomatous progression can occur many years after its stabilization and at any time during the follow-up period; for this reason life-long assessment is necessary.

Phacoemulsification and intraocular lens implantation before, during, or after canaloplasty in eyes with open-angle glaucoma: 3-year results

PURPOSE

To report 3-year results evaluating the effect on safety and efficacy of canaloplasty to treat open-angle glaucoma when combined with cataract surgery.

PATIENTS AND METHODS

This was a retrospective subset analysis of a prospective, international, multicenter study evaluating 133 eyes of 133 adult, open-angle glaucoma patients who underwent canaloplasty with tensioning suture placement. Eighty-two phakic eyes that received canaloplasty alone were compared with 51 eyes that underwent cataract surgery before or during canaloplasty.

RESULTS

Phakic eyes that received combined cataract-canaloplasty surgery (phacocanaloplasty) had a mean±SD baseline IOP of 23.5±5.2 mm Hg and mean glaucoma medication usage of 1.5±1.0 decreasing to a mean IOP of 13.6±3.6 mm Hg on 0.3±0.5 medications at 3 years postoperatively. Pseudophakic eyes undergoing canaloplasty had a mean baseline IOP of 23.9±5.2 mm Hg on a mean of 1.8±0.8 glaucoma medications decreasing to 15.6±3.5 mm Hg on 1.1±0.8 medications at 3 years. In phakic eyes, reductions in IOP were significantly greater and less postoperative IOP lowering medication was needed after undergoing phacocanaloplasty compared to eyes which had canaloplasty alone.

CONCLUSIONS

Clear corneal phacoemulsification performed before or in combination with canaloplasty is a safe and effective surgical procedure to reduce IOP in adult patients with open-angle glaucoma.

Intraocular pressure outcomes after endophthalmitis associated with glaucoma surgery

PURPOSE

To determine long-term intraocular pressure (IOP) outcomes and risk factors for failure of IOP control in patients with previous glaucoma surgery that was complicated with infectious endophthalmitis.

PATIENTS AND METHODS

Retrospective case series of 12 patients with previous glaucoma surgery that presented with infectious endophthalmitis to the University Hospital, Newark, NJ between 1995 and 2006. IOP control failure was stratified into 2 groups: IOP of ≥22 mm Hg and IOP ≥16 mm Hg at 3 consecutive follow-up visits. A Kaplan-Meier survival analysis was used to determine failure rate and Cox proportional hazards model to analyze effects of pertinent variables on survival. P values <0.05 were considered statistically significant.

RESULTS

Twelve patients that had previously undergone glaucoma surgery (8 trabeculectomies and 4 bleb revisions) and were complicated with infectious endophthalmitis were identified. Mean follow-up time was 43.7 months (range, 10 to 98 mo). Of 12 patients, 9 (75%) failed, 2 (17%) consistently maintained IOP<22 mm Hg, and 1 (8%) maintained IOP<16 mm Hg during the follow-up period. Median survival time was 9.25 months. Age of the subject 65 years and older (P=0.0002) was associated with increased risk of IOP failure, whereas initial treatment selection with vitrectomy did not. Six patients required additional glaucoma surgery during the follow-up period.

CONCLUSIONS

IOP control after resolution of endophthalmitis in patients with previous glaucoma surgery was maintained in only 25% of cases. Half the patients required additional glaucoma surgery.

Needle bleb revision with bevacizumab and mitomycin C compared with mitomycin C alone for failing filtration blebs

PURPOSE

To report the 6-month comparative outcomes and bleb morphology for needle revision with bevacizumab and mitomycin C (MMC) versus MMC alone of failed trabeculectomy and ExPRESS shunt blebs.

METHODS

Patients undergoing bleb needle revision procedures were enrolled in this study. All patients received a subconjunctival injection of 0.1 mL MMC (0.4 mg/mL) mixed with 0.1 mL preservative-free lidocaine (1%) at the beginning of the procedure. The patients were randomized into 2 cohorts assigned to receive either 1.0 mg (0.04 mL of 25 mg/mL) subconjunctival bevacizumab (treatment group) or 0.04 mL of balanced salt solution (control group) injected in an identical manner posterior to the bleb after the bleb needling. Success was defined as ≥20% reduction in intraocular pressure (IOP) without any IOP-lowering medications. Qualified success was defined as ≥20% reduction of IOP with IOP-lowering medications. Failure was defined as IOP>21 mm Hg, IOP reduction <20%, or need for additional surgery. Bleb morphology was classified using the Indiana Bleb Appearance Grading Scale.

RESULTS

Six months postoperatively, in treatment group (n=29), 57% of patients achieved complete success, and 43% failed. In control group (n=29), 41% of patients achieved complete success, 7% achieved qualified success, and 52% failed. The difference in success rates between the 2 groups was not statistically significant (P=0.35). At 6 months, the mean IOP was 11.52 in treatment group and 12.83 in control group (P=0.45); patients in treatment group were on a mean of 0.16 medications as compared with 0.58 medications in control group (P=0.058). For bleb morphology of treatment group compared with control group, the blebs had less vascularity (0.76 vs. 1.20, respectively, on a scale of 0 to 4, P<0.05) and greater extent (2.68 vs. 2.36, on a scale of 0 to 3, P=0.022) in treatment group.

CONCLUSIONS

There was no significant difference between the success rates and IOPs at postoperative month 6 between treatment and control groups. Postoperative blebs in the treatment group were less vascular and had greater extent.

Trabeculectomy versus combined trabeculotomy-trabeculectomy in pediatric glaucoma

PURPOSE

To compare outcomes between trabeculectomy and combined trabeculotomy-trabeculectomy in children with glaucoma.

METHODS

This was a retrospective, comparative study of 40 eyes in 33 patients with pediatric glaucoma: 17 eyes treated with trabeculectomy and 23 eyes treated with combined trabeculotomy-trabeculectomy. Both groups were treated with intraoperative mitomycin C. Success was defined as intraocular pressure (IOP) of 21 mm Hg or less and greater than 5 mm Hg with no additional glaucoma surgery.

RESULTS

Mean follow-up was 38.3 months. There was no significant difference in mean IOP lowering between groups during the follow-up period. Log-rank survival analysis showed a significantly higher success rate after combined surgery compared with trabeculectomy (P = .027). Treatment failures occurred in 5 patients with trabeculectomy and in 2 patients undergoing combined trabeculotomy-trabeculectomy. Failures resulted from increased IOP (n = 3) or hypotony (n = 4). There were no significant differences in complications observed after surgery in both groups.

CONCLUSION

Trabeculectomy and combined trabeculotomy-trabeculectomy with mitomycin C were equally effective at lowering average IOP in children. Combined trabeculotomy-trabeculectomy was associated with greater long-term success.

ReGAE 9: baseline factors for success following augmented trabeculectomy with mitomycin C in African-Caribbean patients

BACKGROUND

To identify the baseline factors influencing success following trabeculectomy with mitomycin C in a case series of African-Caribbean patients.

DESIGN

A prospective, observational and non-comparative cohort study.

PARTICIPANTS

Forty-seven consecutive African-Caribbean patients (47 eyes) with glaucoma.

METHODS

Association between trabeculectomy survival and study factors was examined using Fisher's exact test and the Wilcoxon rank sum test at 12, 24 and 36 months following trabeculectomy. Logistic regression was used to establish the combination of factors best predicting survival.

MAIN OUTCOME MEASURES

Surgical success was based upon intraocular pressure reduction to ≤21 mmHg, ≤18 mmHg and ≤15 mmHg without glaucoma medication (criterion 1), or intraocular pressure reduction to ≤21 mmHg, ≤18 mmHg and ≤15 mmHg with or without glaucoma medication (criterion 2).

RESULTS

Trabeculectomy survival at 36 months was significantly decreased with the use of preoperative acetazolamide, pseudophakic status and higher preoperative intraocular pressure (P < 0.05). In pseudophakic eyes, there was a lower rate of success for criterion 2 when aiming for an intraocular pressure ≤15 mmHg at 2 years post-trabeculectomy, the odds ratio being 12.

CONCLUSIONS

Three major independent risk factors were identified that influenced trabeculectomy failure at 3 years in African-Caribbean ethnicity: the preoperative use of acetazolamide, pseudophakic status and higher preoperative intraocular pressure. The presence of these risk factors may guide the clinician to use a more aggressive antiproliferative and postoperative management regime to enhance survival rates in this high-risk population.

Combined Baerveldt glaucoma implant and scleral buckling surgery for patients with retinal detachment and coexisting glaucoma

PURPOSE

To report on the usefulness of combined Baerveldt glaucoma implantation (BGI) and scleral buckling surgery for patients with glaucoma requiring a scleral buckle for retinal detachment repair.

METHODS

Retrospective, consecutive, noncomparative, and interventional case series of 30 eyes (30 patients) that underwent simultaneous scleral buckle and BGI surgery, using a staged (group 1, n=21 patients) or nonstaged (group 2, n=9 patients) approach to BGI implantation. Successful intraocular pressure (IOP) control was defined as 6 mm Hg≤IOP≤18 mm Hg.

RESULTS

Although not statistically significant, mean best corrected visual acuity (LogMAR) improved from 2.0 before surgery to 1.7 after surgery (P=0.13) with a mean follow-up of 27.7 months. Of the 21 patients in group 1, only 13 (62%) required second-stage tube insertion at a mean of 7.0±8.0 months (range, 1 to 24 mo) postoperatively. For these eyes combined with group 2 eyes, mean IOP was reduced from 31.1±10.8 to 12.7±6.0 mm Hg (P<0.0001), and the mean number of glaucoma medications was reduced from 2.9±1.4 to 1.2±1.3 (P<0.001). Life table rates of successful IOP control were 90% and 80% at 12 and 24 months, respectively.

CONCLUSIONS

Combined scleral buckle and BGI is an effective technique for managing coexisting glaucoma and retinal detachment and provides the clinician with a useful surgical option while minimizing surgical risk.

Mitomycin C-augmented deep sclerectomy in primary open-angle glaucoma and exfoliation glaucoma: a three-year prospective study

PURPOSE

To investigate the efficacy and safety of mitomycin C (MMC)-augmented deep sclerectomy with implant (DSCI) in primary open-angle glaucoma (POAG) and exfoliation glaucoma (ExG) patients.

METHODS

A total of 68 eyes of 68 patients with POAG and ExG were enrolled consecutively to undergo DSCI with MMC (0.4 mg/ml for 2 min). The intraocular pressure (IOP), number of antiglaucoma medications, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser goniopuncture treatments and complications were compared postoperatively after 36- month follow-up. Surgery was considered as a complete success when IOP was <18 mmHg without antiglaucoma medication.

RESULTS

Preoperatively the mean IOPs were 23 ± 6 mmHg and 25 ± 8 mmHg, and 13 ± 4 mmHg and 11 ± 4 mmHg in the POAG and ExG groups, respectively, at 36 months. At 36 months, 74% and 73% of surgeries were a complete success in the POAG and ExG group, respectively [not significant (NS)]. Two patients (8%) of the POAG group and one of the ExG group (3%) were receiving antiglaucoma medication at 36 months (NS). Nd:YAG laser goniopuncture was performed more often in the ExG group (87%) than in the POAG group (61%, p = 0.024). Postoperatively choroidal detachment occurred in 16% of eyes in the POAG group and in 11% of eyes in the ExG group (NS).

CONCLUSIONS

DSCI with MMC augmentation appears to be as effective in patients with ExG and POAG in lowering IOP to target levels at medium term with few immediate postoperative complications.

Efficacy of amniotic membrane-assisted bleb revision for elevated intraocular pressure after filtering surgery

Purpose:

To compare the effectiveness of standard revision surgery using mitomycin C (MMC) with revision using amniotic membrane transplantation and MMC for elevated intraocular pressure (IOP) after trabeculectomy.

Patients and methods:

A retrospective, nonrandomized comparative study of 36 eyes of 36 patients with a failed trabeculectomy. Patients were divided into two groups, ie, a nonamnion-transplanted group and an amnion-transplanted group. The amniotic membrane was placed on the scleral flap under the conjunctiva in the amnion-transplanted group. Both groups recovered filtration of aqueous humor from the surgical site with the adjunctive use of MMC. The changes in IOP and cumulative survival rate were compared for the two groups. Success was defined as a 30% reduction in IOP from the preoperative IOP and maintenance below 21 mmHg with or without the use of antiglaucomatous agents.

Results:

The mean preoperative IOP was not significantly different in the two groups. The mean postoperative IOP in the nonamnion group, 12.1 ± 5.5 mmHg, was significantly lower than the IOP in the amnion group, 16.0 ± 3.7 mmHg. Survival curves in the two groups did not reach significantly different levels.

Conclusions:

Conventional surgical bleb revision with MMC can significantly reduce the elevated IOP associated with a failed filtration bleb. The use of an amniotic membrane transplant did not improve the surgical outcome in our cases.

Mitomycin-C-augmented deep sclerectomy in patients with primary open-angle glaucoma and exfoliation glaucoma: a 1-year prospective study

PURPOSE

To investigate the efficacy and safety of mitomycin C (MMC)-augmented deep sclerectomy with implant (DSCI) in patients with primary open-angle glaucoma (POAG) and exfoliation glaucoma (ExG).

METHODS

A total of 68 eyes of 68 patients with POAG and ExG were enrolled consecutively to undergo DSCI with MMC (0.4 mg/ml for 2 min). The intraocular pressure (IOP), number of antiglaucoma medications, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser goniopunctures and complications were compared postoperatively. Surgery was considered as a complete success when IOP was < 18 mmHg without antiglaucoma medication.

RESULTS

Preoperatively, the mean IOPs were 23.1 +/- 5.8 and 25.4 +/- 8.3 mmHg, and 13.8 +/- 6.1 and 11.2 +/- 5.6 mmHg in the POAG and ExG groups, respectively, at 12 months. 77.4% and 75.7% of surgeries were a complete success in the POAG and ExG groups, respectively [not significant (NS)]. Five patients (16.1%) in the POAG group but none in the ExG group (0%) were receiving antiglaucoma medication at 12 months (NS). Nd:YAG laser goniopuncture was performed in 29.0% of eyes in the POAG group and in 55.6% of eyes in the ExG group (p = 0.047). Postoperatively, choroidal detachment occurred in 16.1% of eyes in the POAG group and in 10.8% of eyes in the ExG group (NS). We encountered no serious complications related to MMC use.

CONCLUSION

DS with MMC augmentation appears to be equally effective in ExG and POAG patients in lowering IOP to target levels, at least in the short term, with few immediate postoperative complications.

[Visual field progression after trabeculectomy in primary open-angle glaucoma: preliminary results]

INTRODUCTION

Our purpose was to evaluate the changes in the visual field (VF) after trabeculectomy and to indentify factors influencing variation for a better follow-up of patients with primitive open-angle glaucoma (POAG).

MATERIAL AND METHODS

We conducted a prospective study at the A. Le Dantec Hospital in Dakar, Senegal. Seventeen eyes of POAG patients were studied. The parameters noted for each patient were age, sex, affected eye, pre- and postoperative intra-ocular pressure (IOP), cup disk, sensitivity thresholds on pre- and postoperative perimetry, severity of glaucoma, and medication taken by the patient. Each patient had a frequency doubling technology (FDT) visual field examination before and the after surgery. None of them had an associated pathology that could cause VF troubles. The postoperative visual field was noted. All these parameters were correlated using the chi square test in order to determine factors influencing a threshold variation.

RESULTS

Our patients were new in 70.6% of cases, and the mean age was 45 years. The mean preoperative IOP was 25.7mmHg, 29.4% of the eyes had a cup disk up to 0.7. The VF showed severe glaucoma in 58.8%; 70.6% of eyes had only beta-blocker treatment. Peritomy with limbic hinge was performed in 88.2% of trabeculectomies. No surgical complication was noted. After trabeculectomy, the mean IOP was 14mmHg with a mean decrease of 42.8%. Before surgery, 94.1% of eyes had lower temporal quadrant involvement. For 94.1% of eyes, central vision was preserved. After surgery, progression was better in 18%, stable in 41%, and worse in 41% of cases. Of the factors studied, only age and graded follow-up time from surgery had a statistically significant influence on VF after trabeculectomy.

CONCLUSION

Trabeculectomy was necessary in treatment of POAG, because of poor observance of medical treatment and severity of lesions at the time of diagnosis. The results (59% improvement or stability), in spite of the small sample size, argue in favor of this surgical treatment for some patients with POAG in our country.

The critical role of the conjunctiva in glaucoma filtration surgery

This review considers the critical role of the conjunctiva in determining the success or failure of glaucoma filtration surgery. Glaucoma filtration surgery can be defined as an attempt to lower intraocular pressure (IOP) by the surgical formation of an artificial drainage pathway from the anterior chamber to the subconjunctival space. Many types of glaucoma filtration surgery have been developed since the first attempts almost 180 years ago. The wide range of new techniques and devices currently under investigation is testament to the limitations of current techniques and the need for improved therapeutic outcomes. Whilst great attention has been paid to surgical techniques and devices to create the drainage pathway, relatively little attention has been given to address the question of why drainage from such artificial pathways is often problematic. This is in contrast to normal drainage pathways which last a lifetime. Furthermore, the consequences of potential changes in aqueous humour properties induced by glaucoma filtration surgery have not been sufficiently addressed. The mechanisms by which aqueous fluid is drained from the subconjunctival space after filtration surgery have also received relatively little attention. We propose that factors such as the degree of tissue damage during surgery, the surrounding tissue reaction to any surgical implant, and the degree of disruption of normal aqueous properties, are all factors which influence the successful formation of long term drainage channels from the conjunctiva, and that these channels are the key to successful filtration surgery. In recent years it has been suggested that the rate of fluid drainage from the subconjunctival space is actually the determining factor in the resultant IOP reduction. Improved knowledge of aqueous humour induced changes in such drainage pathways has the potential to significantly improve the surgical management of glaucoma. We describe for the first time a novel type of drainage surgery which attempts to minimise surgical trauma to the overlying conjunctiva. The rationale is that a healthy conjunctiva allows drainage channels to form and less opportunity for inflammation and scar tissue formation which are a frequent cause of failure in glaucoma filtration surgery. Successful drainage over extended periods of time has been demonstrated in monkey and rabbit eyes. Long lasting drainage pathways were clearly associated with the presence of lymphatic drainage pathways. A new philosophy in glaucoma drainage surgery is proposed in which minimisation of surgical trauma to the conjunctiva and the encouragement of the development of conjunctival drainage pathways, particularly lymphatic pathways, are central pillars to a successful outcome in glaucoma filtration surgery.

Intravitreal bevacizumab and augmented trabeculectomy for neovascular glaucoma in young diabetic patients

PURPOSE

To report two cases of young diabetic patients with intractable neovascular glaucoma (NVG) who were successfully managed with bevacizumab and mitomycin C-augmented trabeculectomy.

RESULTS

Two young patients present with severe NVG secondary to diabetic proliferative retinopathy. The glaucoma was unresponsive to conventional medical therapy and complete panretinal photocoagulation. Both patients underwent augmented trabeculectomy with MMC and intravitreal injection of bevacizumab. Iris rubeosis resolved within 48 h. Both patients have a follow-up period of 6 months and the intraocular pressure (IOP) remain between 10-15 mmHg.

CONCLUSIONS

Controlling IOP due to NVG in young diabetic patients is difficult and augmented trabeculectomy has a very high failure rate. The addition of intravitreal bevacizumab in the management of NVG particularly in young diabetic patients may improve the success rate of IOP control. It is known that bevacizumab retards neovascularisation. It may also be modulating wound-healing response as well. Bevacizumab may have a potential role in the surgical management of NVG.

Glaucoma drainage implants in the treatment of refractory glaucoma in pediatric patients

PURPOSE

The aim of this study is to report the clinical course, effectiveness, and safety of glaucoma drainage implants (Molteno and Baerveldt devices) in primary and secondary childhood glaucomas refractory to conventional surgical treatments and medical therapy.

METHODS

This retrospective study included 76 children (76 eyes) younger than 18 years who underwent glaucoma drainage device (GDD) implantation in our clinic between 1990 and 2004. The mean age at time of surgery was 6.9+/-5.3 years (range: 4 months to 17.5 years). Intraocular pressure (IOP), visual acuity, corneal diameter, axial length, intraoperative and postoperative complications, and number of glaucoma medications were evaluated. Criteria for success were defined as IOP between 7 and 22 mmHg with or without glaucoma medications, no further glaucoma surgery, the absence of visually threatening complications, and no loss of light perception. Results were compared for children with primary and secondary glaucomas. The mean follow-up was 7.1+/-6.5 years (range: 1.6 to 15.2 years).

RESULTS

Mean preoperative and postoperative IOP was 33.6+/-11.4 mmHg and 17.1+/-6.5 mmHg (p<0.001), respectively. Kaplan-Meier survival analysis showed cumulative probability of success: 93% at 6 months, 91% at 1 year, 82% at 2 years, 76% at 3 years, 71% at 4 years, 67% at 5 years, and 65% at 6 years. There was no difference between patients with primary (n=31 eyes) and secondary glaucoma (n=45 eyes) in terms of cumulative success (p=0.186), final IOP, number of medications, or length of follow-up. On average, the GDI surgery was successful for a mean period of 6.7 years. Fourteen eyes of 76 (18.4%) failed: 10 eyes with uncontrolled IOP, 2 eyes with retinal detachment, and 2 eyes with no light perception. Statistical regression model did not show influence of gender and previous surgery. Lower age at the time of surgery was found to be associated with higher probability of treatment failure.

CONCLUSIONS

Molteno and Baerveldt glaucoma drainage implants surgery seems to be safe and effective treatment for primary and secondary pediatric glaucoma refractory to the initial surgical procedure and medical therapy.

[Wound healing modulation in glaucoma surgery]

The wound healing response is one of the major determinants of filtering surgery success. Over the last two decades, antifibrotic agents, 5-fluorouracil (5-FU) and mitomycin C (MMC), have modified the prognosis of filtering surgery, particularly in patients at high risk for failure. Nevertheless, these agents are associated with severe complications. In order to maximize their benefits and minimize the rate of complications, the use of these powerful treatments has to be carefully evaluated in relation to patient risk factors for scarring. The choice of an antifibrotic agent, mode, dose and duration of application should be made with complete knowledge of the different effects of these treatments and adapted for each patient after an exhaustive preoperative evaluation.

Non-penetrating glaucoma surgery augmented with mitomycin C or 5-fluorouracil in eyes at high risk of failure of filtration surgery: long-term results

PURPOSE

To investigate the long-term efficacy and safety of non-penetrating glaucoma surgery (NPGS) augmented with mitomycin C (MMC) or 5-fluorouracil (5FU) in eyes at high risk of failure of glaucoma filtration surgery.

METHODS

Prospective study of all eyes, undergoing NPGS with 0.04% MMC (1 to 2 min topical or 0.04 mL subconjunctival injection into the superior fornix) or 5FU (25 mg/mL topically for 5 min). Complete success was an intraocular pressure (IOP)<or=21 mmHg on no medication and qualified success an IOP<or=21 mmHg with topical medication. An additional criterion for success was a >or=20% drop in IOP or a reduction of at least two medications.

RESULTS

Twenty-three eyes of 22 patients with a mean follow up of 41.4 months were reviewed. Fifteen eyes had failed trabeculectomy and seven had uveitic glaucoma. Mean preoperative IOP reduced from 25.8+/-7.8 to 15.4+/-4.9 mmHg at final visit, a mean change of 41%. Median number of preoperative medications decreased from 3 to 0 postoperatively. Cumulative probability of success was 100% at 2 years, 94% at 3 years and 85% at 4 years. No patient developed any long-term complications. Complete success was achieved in 11 eyes and qualified success in 10 eyes. Two eyes failed and required further surgery.

CONCLUSION

NPGS augmented with small-volume MMC/5FU provides good long-term IOP control in eyes at high risk of failure with a lower incidence of complications compared with augmented trabeculectomy and eliminates the need for postoperative bleb or suture manipulation.

Use of amniotic membrane as an adjuvant in refractory glaucoma

PURPOSE

To evaluate the results after amnion-shielded trabeculectomy with concomitant use of mitomycin C.

METHODS

The study comprised patients with severely refractory glaucomas who had previously undergone two or more regular trabeculectomies with mitomycin C and, in one case, cyclodestructive cryotherapy. The patients were admitted for surgery between May 2003 and May 2004. Trabeculectomy was performed through a limbus-based incision in nine eyes of nine patients. Cryopreserved human amniotic membranes obtained from our biobank were impregnated with 0.4 mg/ml mitomycin C and washed for 2 mins in balanced salt solution. One membrane was sutured to the scleral surface and partly positioned under the scleral flap, and another was secured to subconjunctival tissue.

RESULTS

The mean preoperative intraocular pressure (IOP) was 32.2 mmHg (range 22-44 mmHg). After a follow-up of 6-18 months (mean 9.8 months), the mean IOP was 16.4 mmHg (range 11-26 mmHg). The mean number of glaucoma medications was reduced from 2.4 preoperatively to 1.4 postoperatively. There were no devastating complications.

CONCLUSIONS

Amnion-shielded trabeculectomy is a procedure that should be evaluated as an option in refractory glaucoma.

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.

Focus on triamcinolone acetonide as an adjunct to glaucoma filtration surgery

Glaucoma is one of the most common causes of irreversible blindness worldwide. Despite continued advances in medical and laser therapy, incisional surgery still appears to be an important and for many cases the only option by which intraocular pressure is controlled. Unlike many other types of surgery in which complete healing of tissue would be a desirable outcome, glaucoma surgery seeks to achieve incomplete healing to allow aqueous humor to escape the eye. Pharmacologic modulation of wound healing is a hot topic in glaucoma filtration surgery. Although routine antifibrotic medications are associated with good results in modulating wound healing in glaucoma surgery, they carry with them the possibility for significant morbidity due to the adverse effects of treatment. Challenge continues to be to find a safe and effective agent for this purpose. Because of beneficial effects of triamcinolone acetonide in some conditions which are associated with secondary glaucoma and also potential effects of this agent in modulating wound healing process, we propose it as a useful adjunct to glaucoma filtration surgery. This approach may allow modulation of wound healing with less of the toxicity associated with commonly used antifibrotics (5-FU and mitomycin C).

Trabeculectomy with mitomycin C in pseudophakic patients with open-angle glaucoma: outcomes and risk factors for failure

PURPOSE

To evaluate tonometric outcomes of trabeculectomy with mitomycin C in pseudophakic patients with open-angle glaucoma and associated risk factors for failure.

DESIGN

Retrospective cohort study.

METHODS

Seventy-three pseudophakic patients (89 eyes) with primary open-angle, normal-tension, exfoliative, or pigmentary glaucoma were recruited. Success rates were defined according to three criteria: (A) intraocular pressure (IOP) < or = 18 mm Hg and IOP reduction > or = 20%; (B) IOP < or = 15 mm Hg and IOP reduction > or = 25%; and (C) IOP < or = 12 mm Hg and IOP reduction > or = 30%. IOP, visual acuity, complications, and additional interventions were documented after surgery. Cox's proportional hazard regression analysis was used to identify risk factors for failure.

RESULTS

Mean IOP (+/-SD) decreased from a preoperative value of 18.8 +/- 6.6 mm Hg to 10.2 +/- 5.1 mm Hg at one year and to 10.0 +/- 4.2 at two years (P < .001 for both). Average number of preoperative medications decreased from 3.0 +/- 1.1 to 0.5 +/- 1.0 at one year and to 0.5 +/- 0.9 at two years (P < .001 for both). For criteria A, B, and C, success rates (+/-SE) were 87% +/- 4%, 83% +/- 5%, and 76% +/- 5% at 1 year and 67% +/- 4%, 58% +/- 8%, and 50% +/- 7 at two years. Laser suture lysis was performed in 30 eyes, and 11% of those required a second glaucoma procedure.

CONCLUSION

Increasing age, use of a limbus-based conjunctival flap, and performance of laser suture lysis were factors that were associated with a smaller risk of failure. Present findings indicate that trabeculectomy with mitomycin C provides acceptable long-term success rates in pseudophakic patients, with a low incidence of complications.

Options in pediatric glaucoma after angle surgery has failed

PURPOSE OF REVIEW

Congenital glaucoma is primarily a surgical disease with medical management serving as a temporizing measure before surgery or as postoperative adjunctive treatment. First-line surgery for congenital glaucoma consists of incisional procedures on the anterior chamber angle: goniotomy and trabeculotomy. Angle surgery has a high success rate with few complications. Despite the high initial success rate, almost 20% of angle procedures eventually fail, and surgeons are confronted with a choice of what procedure to do next: a trabeculectomy with or without adjunctive antifibrosis therapy, glaucoma drainage surgery, or cyclodestructive procedures. This review will discuss and compare these procedures as reported in recent studies and how variables such as age, number of prior procedures, and type of glaucoma have clarified the order in which these procedures might be performed after failed angle surgery.

RECENT FINDINGS

Clinical reports in refractory pediatric glaucoma consist solely of retrospective studies of varying size and quality. Recent studies of trabeculectomy in this population suggest mitomycin C is associated with increased risk of late infectious complications. Trabeculectomy has worse outcome among younger patients Glaucoma drainage devices have a success rate approaching 80% at 1 year, but less with longer follow-up. Cyclodestructive procedures are generally reserved for advanced cases, but low-dose cyclodiode therapy and endocyclophotocoagulation may prove useful earlier in the disease (< 2 years).

SUMMARY

Refractory pediatric glaucoma remains a challenge. Glaucoma drainage devices appear to be the most predictable and possibly safest procedure to consider after failed conventional angle surgery.

Glaucoma in children: are we making progress?

BACKGROUND

Glaucoma in children presents difficult clinical challenges. Even when appropriately treated, blindness can occur.

DESIGN

Retrospective interventional case series and literature review.

METHODS

All clinical records of children seen by the author with a diagnosis of glaucoma established before 16 years of age were reviewed from 1977 to 2003. Glaucoma was classified as primary infantile, aphakic, syndrome-related, and secondary. The best-corrected visual acuity, refractive error, configuration of the optic nerve cup, and perimetry were recorded. The intraocular pressure (IOP) for each visit was recorded. IOP measurements of 19 mm Hg or less were considered "good." The percentage of "good" readings was calculated for each eye. Representative visual acuities, refractive errors, IOP, disk configuration, and perimetry were recorded at 6, 12, 18, and 24 years of age for each patient. The admitting ophthalmologic diagnosis for each child at the Western Pennsylvania School for Blind Children was recorded from 1887 to 2003.

RESULTS

One hundred twenty-six children (204 eyes) were studied: infantile glaucoma, 52 eyes; aphakic glaucoma, 40 eyes; syndrome associated, 69 eyes; and secondary glaucoma, 43 eyes. The mean follow-up was 11.6 years (1 to 30 years). Overall, 60 (29.4%) of 204 eyes had a 6/12 (20/40) or better corrected visual acuity at the most recent visit. The percentage with this acuity remained stable throughout the follow-up period. Eyes with infantile glaucoma had the best acuity, and 40% had 6/12 (20/40) or better. Amblyopia was common and responded to treatment. Eyes with aphakic glaucoma had the worst acuity with only 10% achieving 6/12 or better. These eyes had a bimodal onset of glaucoma; eyes with an early onset had an angle closure configuration and eyes with a delayed onset had an open angle. Early cataract removal and microcornea were risk factors for glaucoma. If the IOP was maintained at 19 mm Hg or less (good) on 80% of the determinations over time, the optic nerve cup compared with the diameter of the optic nerve (C/D ratios) were stable. Eight patients had multiple, good quality, visual fields performed over 3 to 15 years. If the patients had "good" IOP on 70% of the measurements, the visual fields remained stable. A historical perspective of glaucoma control was gained by looking at the admitting diagnosis at the Western Pennsylvania School for Blind Children. From 1910 to 1970, an average of 9.2 children blind due to glaucoma were admitted each decade. From 1971 to 2003, there were only three children with glaucoma admitted over 30 years.

CONCLUSION

Removal of congenital cataracts should be delayed until 3 to 4 weeks of age. Consideration should be given for using 19 mm Hg or less to measure the success of glaucoma treatment in children. Treatment of amblyopia is as important as IOP control in children. Imaging technology such as optical coherence tomography and measurement of central corneal thickness may play an important future role in the assessment of children with suspected or known glaucoma.

Otago Glaucoma Surgery Outcome Study

OBJECTIVE

To provide data on the results of patients with nonneovascular juvenile glaucoma who had Molteno implant surgery in the province of Otago, New Zealand.

DESIGN

Prospective noncomparative case series.

PARTICIPANTS

Fifty-five operations in 52 eyes of 45 patients with nonneovascular juvenile glaucoma who had Molteno implant surgery between the ages of 9 and 49 years from 1976 to 2003 at Dunedin Hospital and were observed for a mean of 12.2 years (range, 0.1-25).

INTERVENTION

Insertion of a Molteno implant.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) and visual acuity (VA).

RESULTS

Insertion of a Molteno implant controlled IOP at < or =21 mmHg with probabilities of 0.89 (95% confidence interval [CI], 0.81-0.97) at both 1 and 2 years and 0.85 (95% CI, 0.75-0.95), 0.78 (95% CI, 0.66-0.90), and 0.71 (95% CI, 0.58-0.85) at 5, 10, and 15 years, respectively. Mean VA was 20/100 preoperatively; improved to 20/60 at 1 year; and stabilized at 20/120 at 5, 10, and 15 years postoperatively. Twenty-nine eyes had their preoperative VA maintained or improved at final follow-up, and the VAs of 17 eyes deteriorated but were at least light perception at final follow-up.

CONCLUSION

The use of Molteno implants in cases of nonneovascular juvenile glaucoma controlled IOP with a probability of 0.71 15 years postoperatively, whereas 53% maintained or improved their vision from their preoperative VA at final follow-up.

Altered transcripts expression of matrix metalloproteinases and their tissue inhibitors in tenon capsule of patients with glaucoma

PURPOSE

To determine the transcripts expression of matrix metalloproteinases (MMPs) and their tissue inhibitors (TIMPs) in Tenon capsule of patients with primary glaucoma and non-glaucomatous patients who serve as the control.

PATIENTS AND METHODS

Specimens of Tenon capsule were obtained intraoperatively and evaluated with the reverse transcriptase-polymerase chain reaction method. The transcripts levels of MMP-1, MMP-2, MMP-9, TIMP-1, and TIMP-2 relative to that of glyceraldehyde phosphate dehydrogenase were determined.

RESULTS

The transcripts levels of MMP-1, MMP-2, MMP-9, TIMP-1, and TIMP-2 were not correlated with age in the control group. There were differences in the transcripts expression of MMP-2 (P < 0.001), MMP-9 (P = 0.017), TIMP-1 (P < 0.001), and TIMP-2 (P = 0.001) among the control, primary open angle glaucoma, and primary angle-closure glaucoma groups (Kruscal-Wallis H test). Comparing with the controls, open angle glaucoma had decreased transcripts levels of MMP-2 (P = 0.001) and TIMP-1 (P = 0.006) while angle-closure glaucoma had decreased transcripts levels of MMP-2 (P < 0.001), MMP-9 (P = 0.004), TIMP-1 (P < 0.001), and TIMP-2 (P < 0.001) (Mann-Whitney U tests).

CONCLUSION

The transcripts expression of certain MMPs and TIMPs is altered in Tenon capsule of glaucoma patients, which might result from long-term application of topical glaucoma medications.

Comparison between Results of Trabeculectomy in Primary Congenital Glaucoma with and without the Use of Mitomycin C

PURPOSE

To evaluate the results of trabeculectomy with and without the use of mitomycin C in children with primary congenital glaucoma.

METHODS

The authors retrospectively studied the data of 91 patients who underwent the first trabeculectomy for primary congenital glaucoma, with 19 years of follow-up. Success criteria were set with two distinct values of intraocular pressure: lower or equal to 15 mm Hg or lower than 21 mm Hg and separately analyzed.

RESULTS

Among the studied patients, 61 had undergone trabeculectomy without mitomycin C and 30 with mitomycin C. The comparison between the groups of patients showed age homogeneity (P = 0.152) and did not demonstrate any difference in preoperative (P = 0.234) and postoperative (P = 0.907) intraocular pressure. Success rates through time, for both pressure limits was not different between the groups. Both age and the presence of previous trabeculotomy did not influence the success of trabeculectomy through time, for the two pressure limits considered. The complication rate was higher among the patients who received mitomycin C (P = 0.010).

CONCLUSIONS

The success of trabeculectomy for primary congenital glaucoma with mitomycin C was not different than that of trabeculectomy with mitomycin C in the studied patients. Mitomycin C was associated with a higher incidence of complications.

Update on antifibrotic use in glaucoma surgery, including use in trabeculectomy and glaucoma drainage implants and combined cataract and glaucoma surgery

PURPOSE OF REVIEW

This paper summarizes the use of antifibrotic agents adjunctive to glaucoma surgery, reviews recently published studies that address current use of these antifibrotics, and reviews new methods of wound modulation.

RECENT FINDINGS

The use of antifibrotic agents, namely, 5-fluorouracil and mitomycin C, in conjunction with glaucoma surgery has resulted in lower postoperative intraocular pressures after trabeculectomy or combined cataract and glaucoma surgery. Mixed results have been seen when these agents are used with glaucoma drainage device surgery. The use of antifibrotic agents has also created and increased complications. Therefore, methods of antifibrotic use have become more refined and modified for specific circumstances. Promising new wound modulation agents, such as CAT-152, are currently under study.

SUMMARY

Antifibrotics are potent adjuncts to glaucoma surgery, but along with their beneficial use are risks that need to be considered. While we continue to look for more efficacious agents and methods to treat glaucoma, we must continue to modify techniques with the individual patient's best interest in mind.

Surgical strategies in patients with combined cataract and glaucoma

PURPOSE OF REVIEW

In the elderly population, the combined presence of cataract and glaucoma is a frequent condition. In this situation, several surgical options are possible: cataract surgery only and later maybe trabeculectomy, trabeculectomy only and later maybe cataract surgery, or combined cataract and glaucoma surgery. This review compares the different surgical options on the basis of their achievable postoperative intraocular pressure (IOP) level and success and complication rates.

RECENT FINDINGS

The impression of better IOP regulation with trabeculectomy than with phacotrabeculectomy has been recently confirmed by an evidence-based review. Contrary to this finding, the success of deep sclerectomy or trabeculotomy does not seem to be compromised by simultaneous phacoemulsification. In eyes with previous glaucoma-filtering surgery, cataract surgery with clear corneal incision has no effect on mean IOP but increases the 3-year failure probability. For phacotrabeculectomy, moderate evidence of a beneficial effect of MMC on IOP regulation and only weak evidence for separating the incisions has been recently reported by another evidence-based review.

SUMMARY

The choice of the preferred surgical method depends on the target pressure, the amount of glaucomatous damage, and the grade of visual disturbance caused by the cataract. Phacotrabeculectomy combined with mitomycin C achieves the best IOP lowering of all types of combined cataract and glaucoma surgery currently possible but is associated with potentially sight-threatening complications. In the absence of a low target pressure, phacotrabeculotomy or the combination of phacoemulsification with viscocanalostomy or deep sclerectomy may be the therapy of choice.

Factors associated with success in first-time trabeculectomy for patients at low risk of failure with chronic open-angle glaucoma

PURPOSE

To examine the relationships between study factors and trabeculectomy outcome in a representative sample of United Kingdom ophthalmology surgeons and patients.

DESIGN

Cross-sectional observational study by questionnaire.

PARTICIPANTS

All ophthalmic surgeons performing trabeculectomy in the National Health Service were invited to select their 4 most recent consecutive trabeculectomy cases satisfying study eligibility criteria before June 1996. Three hundred eighty-two surgeons supplied baseline data for 1450 patients and 1-year follow-up data for 1240 (85.3%) patients. All patients had undergone first-time trabeculectomy for chronic open-angle glaucoma.

METHODS

Data were collected by self-administered questionnaires at baseline and 6 and 12 months postoperatively. Univariate analysis of the relationships between study factors and success was performed by chi-square test (categorical variables) and Student's t or Mann-Whitney U tests (continuous variables). Multiple logistic regression modeling of explanatory variables significant at a P value of </=0.1 was then performed.

MAIN OUTCOME MEASURE

Trabeculectomy success, defined as a final intraocular pressure (IOP) less than two thirds of the preoperative IOP, excluding patients on antiglaucoma medications.

RESULTS

After multiple logistic regression modeling, diabetes (odds ratio [OR] = 0.485, 95% confidence interval [CI] = 0.271-0.868, P = 0.015), superior rectus traction suture (OR = 0.580, 95% CI = 0.348-0.959, P = 0.034), subconjunctival anesthetic (OR = 0.172, 95% CI = 0.065-0.459, P<0.0001), and nonspecialist surgeons (OR = 0.539, 95% CI = 0.335-0.865, P = 0.010) remained significantly associated with poorer outcome.

CONCLUSIONS

In this nationally representative sample of glaucoma patients undergoing first-time trabeculectomy, we have identified important associations between diabetes, superior rectus traction suture, subconjunctival anesthetic, nonspecialist surgeons, and diminished trabeculectomy success. These associations merit further examination.

The Advanced Glaucoma Intervention Study (AGIS): 11. Risk factors for failure of trabeculectomy and argon laser trabeculoplasty

PURPOSE

To investigate the association of pre-intervention and post-intervention patient and eye characteristics with failure of argon laser trabeculoplasty (ALT) and trabeculectomy.

DESIGN

Cohort study of participants in the Advanced Glaucoma Intervention Study.

METHODS

This multicenter study took place between 1988 and 2001. Between 1988 and 1992, 789 eyes of 591 patients aged 35 to 80 years with advanced glaucoma were randomized into one of two surgical treatment sequences: argon laser trabeculoplasty (ALT)-trabeculectomy-trabeculectomy or trabeculectomy-ALT-trabeculectomy. Upon study-defined failure (based on maximum medications, sustained intraocular pressure (IOP) elevation, visual field defect, and disk rim deterioration) of each intervention, patients were offered the subsequent intervention. Potential follow-up was 8 to 13 years. This report is based on data from 779 eyes that had at least 3 months of follow-up. The main outcome measures are failure of ALT and trabeculectomy, whether as first or second interventions. Effect size is measured by the hazard ratio (HR) and its corresponding 95% confidence interval (CI) obtained from Cox multiple regression analysis, where HR corresponds to the coefficient of change in risk associated with a unit increase in a factor. For binary factors, this corresponds to the change in risk in eyes with the factor relative to the risk in eyes without the factor.

RESULTS

Pre-intervention factors associated with failure of ALT are younger age (HR = 0.98, CI = 0.96-0.99, P =.009) and higher IOP (1.11, 1.08-1.15, P <.001). Pre-intervention factors associated with failure of trabeculectomy are younger age (HR = 0.97, CI = 0.95-0.99, P =.005) and higher IOP (1.04, 1.01-1.06, P =.002), as well as diabetes (2.86, 1.88-4.36, P <.001) and any postoperative complication (1.99, 1.35-2.93, P <.001). Individual postoperative complications significantly associated with increased risk of failure of trabeculectomy are elevated IOP (3.4, 1.9-6.1, P <.001) and marked inflammation (2.4, 1.3-4.6, P =.006).

CONCLUSIONS

In this study, ALT failure was associated with younger age and higher pre-intervention IOP. Trabeculectomy failure was associated with younger age, higher pre-intervention IOP, diabetes, and one or more postoperative complications, particularly elevated IOP and marked inflammation.