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

Effect of mitomycin C and 5-fluorouracil on wound healing in patients undergoing glaucoma surgery: A meta-analysis

Increased intraocular pressure (IOP) is a risk factor for glaucoma. One treatment option is trabeculectomy. Antimetabolic agents are used in the operation to decrease the post-operative scarring of the wound. The two most common medicines are Mitomycin C (MMC) and 5-Fluorouracil (5-FU). The aim of this research is to assess the effect of MMC on post-operation wound healing in comparison with 5-FU in addition to trabeculectomy. Well, we went through four common databases. Our language was limited to English during the study. The last time we looked at the e-databases was August 2023. Case control studies were performed where MMC resulted in better wound healing than 5-FU. Researchers selected a total of 1023 trials and eventually selected six trials for data analysis. Four hundred and ninety one cases of glaucoma were treated with trabeculectomy. Among them, 246 were given MMC and 245 were given 5-FU during operation. Six trials showed that there was no statistical difference between MMC and 5-FU in the incidence of post-operative wound leak in glaucoma patients who received trabeculectomy (OR, 1.21; 95% CI, 0.63-2.30 p = 0.57); Five trials demonstrated that MMC was associated with a reduced risk of post-operative corneal damage compared to 5-FU injection (OR, 0.18; 95% CI, 0.06-0.56 p = 0.003); In both trials, the incidence of post-operative bleeding was not significantly different from that of 5-FU injected in the MMC group (OR, 0.33; 95% CI, 0.05-2.16 p = 0.25). Our results indicate that MMC is superior to 5-FU in the reduction of post-operative corneal injury. Additional comparisons between MMC and 5-FU are required in order to increase the reliability and effectiveness of these findings.

Treatment of filtration bleb dysfunction after glaucoma surgery by needle revision of filtration bleb combined with conbercept

Filtration surgery (Trabeculectomy) is the main treatment for glaucoma. The scarring of the filtration bleb and obstruction of the outflow of aqueous humor through the filtration channel are the main reasons of the surgery failure. The objective of this study was to determine the clinical efficacy of needle revision of filtration blebs combined with subconjunctival injection of conbercept on the functional bleb formation in glaucoma patients with eye pressure out of control after trabeculectomy. A total of 48 eyes with poor filtration bleb function after trabeculectomy for glaucoma were treated with needle revision of filtration bleb combined with subconjunctival injection of conbercept. After the treatment, the patients were followed up for 3 months during which visual acuity, intraocular pressure, slit lamp and ultrasound biomicroscope examinations were performed. Intraoperative and postoperative complications were recorded. The visual acuity and intraocular pressure were significantly improved after the needle revision of filtration blebs. Among the 48 eyes, 39 eyes still had functional blebs at the end of the follow-up period, and filtration blebs failed in 9 eyes 2 to 8 weeks after the removal of the needle. The survival rate of filtration blebs at 3 months after needle revision was (79.06 ± 3.42%), and 81.25% (39/48) of the eyes showed good formation rate of functional bleb at the last follow-up. Three months after needle revision, there was local scar formation in some filtration blebs. Part of the filtration blebs showed mild thickening of the local subconjunctival tissue, and the filtration bleb was slightly raised and diffuse, showing a multi-cavity and thin-walled shape in some blebs. Ultrasound biomicroscopy examination showed relative structural manifestations. Subconjunctival hemorrhage occurred in 43 patients during and after the operation. Low intraocular pressure occurred in 8 patients with the lowest pressure of 5 mm Hg. Choroidal edema was observed in 3 patients. Five patients had intraoperative conjunctival hemorrhage in the anterior chamber, and hyphema occurred. All complications were self-limited and resolved without surgical intervention. Needle revision of filtration bleb combined with anti-VEGF drugs is a safe and effective method for the treatment of filtration bleb dysfunction after surgery of glaucoma.

Risk factors for Baerveldt glaucoma drainage implantation for uveitic glaucoma

Uveitic glaucoma (UG) is sometimes intractable, including intricate interaction between intraocular pressure (IOP) elevation associated with inflammation and side effects of steroids. Based on the Tube Versus Trabeculectomy study in refractory glaucoma results in 2012, tube shunt surgeries have been performed for UG, but few reports have focused on UG. We retrospectively examined the surgical efficacy, complications, and risk factors in 62 eyes with UG that underwent Baerveldt glaucoma drainage device (BGD) implantation at Kumamoto University. The IOPs significantly dropped, and the mean number of glaucoma medications was reduced by more than two. Kaplan‒Meier survival curves were presented under 2 conditions: an IOP reduction of 20% and 6 ≤ IOP ≤ 18 mmHg (criterion A) or 6 ≤ IOP ≤ 15 mmHg (criterion B). In criterion A, the median survival times (MST) were 124 days (complete) and 997 days (qualified). In criterion B, the MST was 129 days (complete) and 867 days (qualified). The Cox hazard proportional model found that the hazard ratio was 0.170 for a history of cataract surgery (95% CI 0.0303-0.950) and 8.669 for systemic immunosuppressive therapy (95% CI 1.810-41.51). BGD implantation is effective for treating UG, but the presence of systemic treatment and the lens status should be considered.

Maculopathies in Glaucoma

In the presence of glaucoma, various changes in the macula can occur during the course of the disease itself or its treatment. Maculopathies that can be observed in glaucoma include cystoid macular edema, hypotony maculopathy, and microcystic macular edema. The following article discusses the pathophysiology, causes, course, clinical presentation, and treatment of these maculopathies.

Comparison of Outcomes Following Glaucoma Drainage Tube Surgery Between Primary and Secondary Glaucomas, and Between Phakic and Pseudophakic eyes

PURPOSE

To report outcomes of glaucoma drainage device (GDD) surgery based on primary or secondary glaucoma diagnosis and lens status.

DESIGN

Single-center, retrospective, consecutive cohort study.

METHODS

University of Florida patients aged 18 to 93 years who underwent nonvalved GDD surgery between 1996 and 2015 with a minimum of 1-year follow-up were examined. Of the 186 eyes of 186 patients enrolled, 108 had a primary glaucoma and 78 a secondary glaucoma diagnosis. Excluding 13 aphakic patients, 57 eyes were phakic and 116 pseudophakic. Mean intraocular pressure (IOP), mean number of medications, visual acuity (VA), surgical complications, and failure (IOP ≥18 mm Hg, IOP <6 mm Hg, reoperation for glaucoma, or loss of light perception) were the main outcome measures.

RESULTS

No significant difference was noted in mean IOP and mean medication use (12.8 ± 4.5 and 13.0 ± 6.6 mm Hg on 2.0 ± 1.2 and 1.5 ± 1.1 medication classes, respectively), mean VA (1.08 ± 0.98 and 0.94 ± 0.89, respectively), failure, or numbers of complications and reoperations (P > 0.05) between eyes with primary and secondary glaucomas at up to 5 years postoperatively. Comparison of phakic and pseudophakic eyes showed a statistically significant higher success rate for the pseudophakic patient group at the ≥18 mm Hg upper limit and <6 mm Hg lower limit (P = 0.01), and significantly fewer eyes required reoperation to lower IOP (6.9% vs 23%).

CONCLUSIONS

GDD surgery appears equally effective for secondary glaucomas as for primary glaucomas, and has a better outcome for pseudophakic eyes than phakic eyes.

Inhibitory Effects of Angiotensin II Receptor Blockade on Human Tenon Fibroblast Migration and Reactive Oxygen Species Production in Cell Culture

Purpose

We investigate the effect of angiotensin receptor blockade on the migration of human Tenon fibroblasts (HTF), using irbesartan, an angiotensin II receptor type 1 (AT1R) blocker (ARB) as a potential antifibrotic agent in glaucoma filtration surgery.

Methods

Confluent HTF cultures were scratched with a 1 mL pipette tip and treated with either irbesartan (10, 50, and 100 μg/mL) or angiotensin II (2 μg/mL). The extent of HTF migration up to 30 hours, and cell number and morphology at 72 hours was evaluated. To assess the effect on reactive oxygen species (ROS) level, HTF were treated with either irbesartan (10 μg/mL) or angiotensin II (2 μg/mL) for 24 hours after scratching, and then stained with dihydroethidium (DHE) before evaluation by confocal microscopy.

Results

Irbesartan inhibited HTF migration by 50% to 70% compared to controls (P < 0.05). Levels of ROS were almost completely attenuated by irbesartan (DHE fluorescence intensity of 5.68E-09) (P < 0.05). Irbesartan reduced cell numbers by 50% and induced morphologic changes with loss of pseudopods (P < 0.05). Conversely, angiotensin II increased cell numbers up to 4-fold while retaining cell viability.

Conclusions

Irbesartan inhibited HTF migration and ROS production. It also reduced cell numbers and altered HTF morphology. Angiotensin II increased cell number without altering morphology. This initial study warrants future investigations for further potential antifibrotic effects of this drug.

Translational Relevance

This in vitro study focused on investigations of irbesartan's effects on HTF migration, ROS production, as well as HTF cell numbers and morphology. It suggests a potential therapeutic strategy worth further exploration with a view towards postoperative wound healing modulation in glaucoma filtration surgery.

Late-onset Hypotony Maculopathy After Trabeculectomy in a Highly Myopic Patient With Juvenile Open-angle Glaucoma

Hypotony maculopathy is a sight-threatening complication after trabeculectomy. We report on a 34-year-old man with juvenile open-angle glaucoma and high myopia, who developed hypotony maculopathy 14 years after trabeculectomy without bleb leak. This represents the longest known period from trabeculectomy to the development of hypotony maculopathy without bleb leak. The possible mechanisms for the development of late-onset hypotony maculopathy in the highly myopic patient are progressive scleral thinning, reduced scleral rigidity, and scleral morphologic change with aging. These changes might weaken the biomechanical properties of sclera and then contribute to the collapse of the scleral wall during hypotony. This case serves as a reminder that hypotony maculopathy can happen up to 14 years after tabeculectomy even without bleb leak and hypotony should be avoided after trabeculectomy in highly myopic patients with juvenile open-angle glaucoma.

Revisiting the Role of the Myofibroblast in Socket Surgery: An Immunohistochemical Study

PURPOSE

To determine the impact of a single injection of various anti-inflammatory, antimitotic, and antiangiogenic agents on the cell count of myofibroblasts in an eviscerated socket.

METHODS

One eye from 15 skeletally mature New Zealand white rabbits was eviscerated, and the rabbits were divided into 5 groups. Each group of 3 rabbits received a 0.1 ml subconjunctival injection of a different agent. Group I received bevacizumab 25 mg/ml, group II received triamcinolone 40 mg/ml, group III received 5-fluorouracil 50 mg/ml, group IV received mitomycin-C 0.4 mg/ml, while group V was the control group and received no injections. The animals were euthanized 19 days after evisceration and conjunctival samples were submitted for histopathological examination. Monoclonal α-smooth muscle actin antibody was applied, and the mean of 5 readings of the number of myofibroblasts was recorded in each slide.

RESULTS

The mean count of myofibroblasts was highest for the control group and all groups achieved a statistically significant reduction in myofibroblast count compared with the control group. Sorting the means showed that Group IV (mitomycin-C) achieved the lowest mean value (p = 0.000006) followed by triamcinolone (p = 0.00048), while group I (bevacizumab) achieved the least reduction in myofibroblast count (p = 0.00148).

CONCLUSION

Until newer antimyofibroblast medications and antibodies are commercially available, a single injection of mitomycin-C or triamcinolone during surgery achieves the highest mean reduction of myofibroblast count.

Rho kinase inhibitor AMA0526 improves surgical outcome in a rabbit model of glaucoma filtration surgery

PURPOSE

First, to elucidate the effect of Rho kinase inhibitor, AMA0526, on Human Tenon Fibroblast (HTF) proliferation and transdifferentiation to myofibroblasts. Second, the effects of ROCK inhibition on the wound healing process and surgical outcome were investigated in a rabbit model of glaucoma filtration surgery.

METHODS

After exposure of HTF to AMA0526 (0.1-25 μM), a water-soluble tetrazolium salt-1 assay and caspase 3/7 activity assay were used to assess its effect on cell proliferation and to elucidate any toxic effects, respectively. Immunohistochemistry of α-smooth muscle actin expression was used to investigate fibroblast-to-myofibroblast differentiation induced by transforming growth factor-beta 1 (TGF-β1) in the presence or absence of the ROCK inhibitor. The effect of topical treatment was studied in a rabbit model of glaucoma filtration surgery. Treatment outcome was studied by performing intraocular pressure (IOP) measurements and clinical investigation of the bleb area and survival. Immunohistological analysis for inflammation (CD45), angiogenesis (CD31), and collagen I was performed at day 8, 14, and 30 after surgery (n=5/time point). Separate control groups treated with vehicle were used as control.

RESULTS

In vitro results showed that AMA0526 dose dependently inhibited proliferation of HTF (P<0.05) without the induction of caspase 3/7 activity. Incubation of HTF with the AMA0526 inhibited TGF-β1 induced fibroblast-to-myofibroblast differentiation. In the rabbit model, topical treatment significantly improved surgical outcome. Compared to vehicle-treated eyes, AMA0526 resulted in increased bleb area (P<0.0001) and prolonged survival (P=0.0025). IOP remained significantly lower throughout the course of the experiment in the AMA0526 group (P<0.0001). Histological evaluation revealed that blebs treated with the ROCK inhibitor were characterized by reduced inflammation, angiogenesis, and collagen deposition at the site of filtration surgery (P<0.05).

CONCLUSIONS

AMA0526 had profound effects on HTF proliferation and myofibroblast transition and improved glaucoma filtration surgery outcome by interfering at different levels of the wound healing process. Therefore, these data indicate that ROCK inhibitors may be considered as more physiological agents which specifically target the wound healing process to improve the outcome of glaucoma surgery.

The effect of bevacizumab on the outcome of trabeculectomy with 5-Fluorouracil

BACKGROUND

To evaluate the effect of bevacizumab in trabeculectomies with 5-fluorouracil (5-FU).

METHODS

Thirty-six patients with uncontrolled glaucoma were included. Twelve patients underwent trabeculectomies with intracameral and subconjunctival injections of bevacizumab (1.25 mg/0.05 mL) and subconjunctival injections of 5-FU (5.0 mg/0.5 mL). The control group underwent trabeculectomies with subconjunctival injections of only 5-FU (5.0 mg/0.5 mL). The outcome measures, including best-corrected visual acuity, intraocular pressure (IOP), number of IOP-lowering medications, the assessment of bleb, and surgical complications, were evaluated until postoperative 24 months.

RESULTS

At each follow-up visit, there were no statistically significant differences between the 2 groups with regard to all outcome measures (P>0.05). The cumulative probabilities of surgical success were 50% and 58.33% in trabeculectomy with bevacizumab and 5-FU and in trabeculectomy with 5-FU, respectively (P=0.68, log-rank test).

CONCLUSIONS

Bevacizumab may not exert significant additive effects in trabeculectomy when administered in conjunction with 5-FU.

Advanced glaucoma: management pearls

A significant proportion of glaucoma patients present late, particularly in the developing world, and unfortunately, in an advanced stage of the disease. They are at imminent danger of losing remaining vision, and may also be afflicted with various socioeconomic and health challenges. The encounter with such a patient is typically characterized by anxiety/fear and sometimes hopelessness from the patient's perspective. The physician may also feel that they are in a difficult position managing the patient's disease. When dealing with such cases, we suggest a holistic, individualized approach taking into account the 'biopsychosociospiritual' (BPSS) profile of each patient. The BPSS model takes into account relevant ocular as well as systemic biology (factors such as the mechanism of glaucoma, level of intraocular pressure [IOP], rate of progression, life expectancy, general health), psychological considerations (e.g., fear, depression), socio-economic factors and spiritual/cultural values and beliefs before being able to decide with the patient and their care partner(s) what treatment goals should be and how they can best be approached. Treatment for advanced glaucoma can be highly effective, and patients and their care partners should be informed that aggressive IOP lowering to the low teens or even single digits offers the best chance of protecting remaining vision. This can be achieved safely and effectively in most cases with trabeculectomy (including an antimetabolite), and in some cases with medical and/or laser therapy. Vision rehabilitation and psychosocial support should also be considered in order to optimize remaining vision, replace fear with hope as appropriate, and thus improve the overall quality of life.

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.

Intraoperative mitomycin C versus intraoperative 5-fluorouracil for trabeculectomy: a systematic review and meta-analysis

PURPOSE

The aim of this study was to assess the intraoperative application of mitomycin C (MMC) compared to 5-fluorouracil (5-FU) on the outcome of trabeculectomy and to examine the balance of risk and benefit.

METHODS

Pertinent studies were selected through systematic searches of major literature databases, including the Cochrane Library, PubMed, Embase, and Chinese Biomedicine Database. Internet searches of search engines, the professional associations' websites, and the manufacturers' databases were also performed. Clinical controlled trials comparing 5-FU with MMC in trabeculectomy were selected. The primary efficacy measure was the weighted mean difference (WMD) in percentage intraocular pressure reduction (IOPR%) at follow-up end point. The secondary efficacy measure was the relative risk (RR) for "qualified" (with or without medical therapy) success of trabeculectomy at follow-up end point. The third efficacy measure was RR for "complete" (without medical therapy) success of trabeculectomy at follow-up end point. The fourth efficacy measure was RR for adverse events, including wound leak, hypotony, endophalmitis, and shallow anterior chamber (AC). The pooled effects were calculated using the random effects model by RevMan version 5.0 software.

RESULTS

Eight studies enrolling a total of 536 patients were included in the meta-analysis. MMC was associated with significantly more IOPR% compared with 5-FU, with a WMD of 7.09 [95% confidence interval (CI) 1.47-12.70] at follow-up end point (P=0.01). MMC was comparable with 5-FU in qualified success rate, with a RR of 1.09 (0.99-1.20) at follow-up end point (P=0.09). MMC was comparable with 5-FU in complete success rate, with a RR of 1.17 (0.79- 1.75) at follow-up end point (P=0.43). Rates of adverse events did not differ significantly between 5-FU and MMC, with an RR of 0.71 (0.22-2.28) for bleb leakage, 1.40 (0.72-2.72) for hypotony, 1.63 (0.27-9.75) for endophthalmitis, and 0.95 (0.41-2.21) for shallow AC.

CONCLUSIONS

Intraoperative MMC is more effective in lowering IOP in trabeculectomy compared with intraoperative 5-FU, but is comparable with intraoperative 5-FU in both qualified and complete success rate. Intraoperative use of both agents may contribute equally to adverse events.

Phacoemulsification-deep sclerectomy modified by trabeculum microperforations and implantation of lens anterior capsule as autologous scleral implant

OBJECTIVE

To evaluate the efficacy and safety of Phacoemulsification-deep sclerectomy modified by trabeculum microperforations and anterior lens capsule as autologous scleral implant (mPDS) for open-angle glaucoma.

RESEARCH DESIGN AND METHOD

A case series study comprised 127 patients and 127 eyes after mPDS. The applied modification of deep sclerectomy consisted in creating microperforations within the posterior trabeculum and in fixing the anterior lens capsule, removed during phacoemulsification, in the scleral lake as an autologous intrascleral implant. Primary open-angle glaucoma without satisfying intraocular pressure (IOP) control (>or=21 mmHg) despite maximally tolerated medications or with progression of visual field and cataract was the indication for surgery. For statistical analyses paired Student's t-test, the Wilcoxon signed rank test and one-dimensional ANOVA with repeated measures were used; survival analysis was performed using the Kaplan-Meier method.

MAIN OUTCOME MEASURES

IOP, number of medications and best corrected visual acuity (BCVA) were examined. On the basis of the assessment of the anterior and posterior segments of the eye, the character and also the degree of intensification of postoperative complications were established. Follow-up examinations were performed on days 1 and 7, and at 1, 3, 6, 12, 18 and 24 months and thereafter every 6 months. The complete success rate was defined as IOP <or= 18 mmHg without, and the qualified success rate as IOP <or= 18 mmHg with and without antiglaucoma medications.

RESULTS

The mean follow-up was 32.2 +/- 9.1 months. Mean IOP decreased by 30.4%. Mean IOP decreased from 20.1 +/- 5.1 to 14.0 +/- 2.9 mmHg (p < 0.001). The mean number of medications was reduced from 2.2 +/- 0.7 to 0.6 +/- 0.8 (p < 0.001). Complete and qualified success rates were 74.4 % and 93.3 %, respectively. Mean logMAR of BCVA changed from 0.52 +/- 0.40 to 0.16 +/- 0.16 (p < 0.001). Subconjunctival 5-FU injections together with suturolysis because of bleb fibrosis were performed in 20 eyes, which represented 15.7% of the cases operated on. 5-FU-induced complications involved corneal epitheliopathy in nine eyes (7.1 % of cases) and irregular astigmatism in one eye (0.8% of cases). Among early complications the most frequent was transient hypotony observed in 55 eyes (41.7% of cases).

LIMITATIONS

The explanation of the role of the anterior capsule in the mechanism of mPDS requires inclusion into the study of histological observations of surgeries performed on an animal model as well as prospective ultrasound biomicroscopy (UBM) examinations performed in humans.

CONCLUSIONS

Phacoemulsification-deep sclerectomy modified by trabecular microperforations and anterior capsule as a scleral implant lead to an effective decrease in the IOP in medium-term follow-up. The profile of the observed complications indicates that it can be a safe procedure. However, a larger group of patients should be observed to confirm this.

Combined surgery for cataract and glaucoma: PDS with absorbable SK-gel implant compared with PDS with non-absorbable T-flux implant - medium-term results

OBJECTIVE

To compare the efficacy and safety of phacoemulsification - deep sclerectomy (PDS) with absorbable SK-gel or non-absorbable T-flux implantation.

RESEARCH DESIGN AND METHOD

The study involved eyes after PDS with SK-gel (32 eyes) and T-flux (20 eyes). Primary open angle glaucoma without satisfying intraocular pressure (IOP) control (> or =21 mmHg) despite maximally tolerated medication or with progression of the visual field and cataract was the indication for surgery. For statistical analyses, the Mann-Whitney U test, Student's t-test, pair sequence Wilcoxon test, and analysis of variance were used. Survival analysis was done using the Kaplan-Meier method.

MAIN OUTCOME MEASURES

The best corrected visual acuity (BCVA), IOP, anterior and posterior segments of the eye, and number of antiglaucoma medications were examined. Follow-up examinations were performed on days 1 and 7, and at 1, 3, 6, 12, 18 and 24 months. A complete success rate was defined as IOP < or =18 mmHg without and qualified success as IOP < or =18 mmHg with or without antiglaucoma medications.

RESULTS

After a 24-month follow-up, mean IOP decreased in the SK-gel group from 20.9 +/- 6.1 to 13.8 +/- 2.1 mmHg (P = 0.000012) and in the T-flux group from 21.1 +/- 6.2 to 14.1 +/- 1.9 mmHg (P = 0.000006). There was no statistically significant difference between the number of antiglaucoma medications used in either group (P = 0.389). Complete success rates were 69.8% and 61.3%, respectively (P = 0.064) and qualified success rates were 93.2% and 84.1%, respectively (P = 0.034). There were no significant differences in complications between the two groups.

LIMITATIONS

Despite the obtained statistical differences between the investigated groups in the scope of the qualified success rate, the result should not be treated as reliable from a clinical point of view. The influence of the kind of implant on the obtained result and the nature of the decompression space would require confirmation by ultrasound biomicroscopy (UBM), and by analysis of histological specimens but these were not performed. It should also be noted that the groups were not numerous.

CONCLUSIONS

In the case of SK-gel and T-flux application, PDS demonstrates similar efficacy and safety although the qualified success rate in the case of PDS with T-flux is significantly lower after a 24-month follow-up. The study does not indicate the cause of the observed changes but the nature of the intrascleral lake created by the implants used and its role in IOP regulation may be essential.

A phase III study of subconjunctival human anti-transforming growth factor beta(2) monoclonal antibody (CAT-152) to prevent scarring after first-time trabeculectomy

OBJECTIVE

To evaluate CAT-152 (lerdelimumab), a monoclonal antibody to transforming growth factor-beta2 (TGF-beta2), in preventing the progression of fibrosis in patients undergoing first-time trabeculectomy for primary open-angle (POAG) or chronic angle-closure glaucoma (CACG).

DESIGN

Randomized, double-masked, multicenter, placebo-controlled trial.

PARTICIPANTS

Individuals with a diagnosis of POAG, CACG, pseudoexfoliative glaucoma (PEXG), or pigmentary glaucoma (PG), with a recorded intraocular pressure (IOP) of more than 21 mmHg, visual field or optic disc changes characteristic of glaucoma, and taking the maximum tolerated dose of medication.

INTERVENTION

Patients received unilateral trabeculectomy with either 4 subconjunctival injections of CAT-152 (100 microg in 100 microl phosphate buffer) or 4 placebo injections, administered immediately before and on completion of trabeculectomy, and on the first day and at 1 week after surgery. Patients were followed up for 12 months after surgery.

MAIN OUTCOME MEASURES

The primary outcome measure was treatment success in the study eye (unmedicated IOP of 6-16 mmHg inclusive), at the 6- and 12-month follow-up. Secondary outcome measures were the incidence of postoperative intervention with 5-fluorouracil (5-FU); incidence of surgical failure; time to surgical failure; and incidence of vascularity, microcysts, and encapsulation or demarcation of the bleb site.

RESULTS

Of the 388 patients evaluated in the trial, 81% (n = 274) had either POAG or CACG, combined into a single set (POAG/CACG) analyzed by intent-to-treat (ITT) criteria. Separate ITT analyses were carried out for all participants (+PEXG/PG group), with similar results. The treatment success rate was 60% in the CAT-152 group and 68% in the placebo group (P = 0.23). No statistically significant differences emerged in the secondary end points. Patients requiring 5-FU for postsurgical management were more likely to be treatment failures (P = 0.0003). Patients with a primary diagnosis of PG (n = 49) had a higher success rate than those with other diagnoses (P = 0.0077). Administration of CAT-152 was not associated with an increased incidence of adverse events. The immunogenicity of CAT-152 was very low.

CONCLUSIONS

At the dose level and regimen studied, there was no difference between CAT-152 and placebo in preventing the failure of primary trabeculectomy. The safety profile of CAT-152 was similar to that of placebo.

AQ4, an antitumor anthracenedione, inhibits endothelial cell proliferation and vascular endothelial growth factor secretion: implications for the therapy of ocular neovascular disorders

Current clinical options for the treatment of neovascular disorders of the posterior segment of the eye have several drawbacks. Photocoagulation lasers can impair peripheral and night vision. Photodynamic therapies as well as intravitreal macromolecule injections (Macugen and Lucentis) require frequent, invasive administrations. Above all, only modest improvement in vision is achieved with any of the existing treatments. In order to overcome these limitations in the long run, this study investigated the antiangiogenic potential of AQ4, a low molecular weight anthracenedione. The results indicate that AQ4 enters the cell nucleus and inhibits proliferation of choroid-retina endothelial (RF/6A) cells and human retinal pigment epithelial (ARPE-19) cells under hypoxic (1% O(2)) as well as normoxic (21% O(2)) conditions. The IC(50) for these effects ranges from 5.5 to 6.9 muM. AQ4 does not affect the viability of non-dividing RF/6A or ARPE-19 cells up to 0.1 mM. Further, AQ4 (20 muM) reduces vascular endothelial growth factor (VEGF) protein secretion by about 50% in ARPE-19 cells under normoxia as well as hypoxia, possibly by reducing VEGF transcription. AQ4 arrests the growth of endothelial cells in S phase, consistent with interference of AQ4 with DNA replication. These results for the first time suggest that AQ4 can potentially alleviate the neovascularization of choroid/retina by a dual mechanism of inhibiting the proliferation of endothelial cells and by reducing mitogenic VEGF stimulus from retinal pigment epithelial cells.

[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.

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.

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.

Uses and complications of mitomycin C in ophthalmology

Mitomycin C is a chemotherapeutic agent that acts by inhibiting DNA synthesis. Its use and application in ophthalmology has been increasing in recent years because of its modulatory effects on wound healing. Current applications include pterygium surgery, glaucoma surgery, corneal refractive surgery, cicatricial eye disease, conjunctival neoplasia and allergic eye disease. Although it has been used successfully in these conditions, it has also been associated with significant complications. This article reviews the current trends and uses of mitomycin C in the eye and its reported complications.

The Clinical Applications of Fluorouracil in Ophthalmic Practice

Fluorouracil (5-fluorouracil, 5-FU) is a pyrimidine analogue that was originally known for its widespread use as an anticancer drug. The ability of 5-FU to reduce fibroblastic proliferation and subsequent scarring has made it an important adjunct in ocular and periorbital surgeries. It is used in primary glaucoma filtering surgeries and in reviving failing filtering blebs, in dacryocystorhinostomy, pterygium surgery, and in vitreoretinal surgery to prevent proliferative vitreoretinopathy. In addition, 5-FU is also gaining recognition in the treatment and surgical management of ocular surface malignancies like ocular surface squamous neoplasia; however, the specific action of the drug on highly proliferating cells limits its use in primary acquired melanosis of the conjunctiva. When applied topically, this drug has a low rate of sight-threatening adverse effects, is inexpensive, and is easy to administer, making it an important tool in enhancing the success rate in ophthalmic surgery and in reducing the recurrence of ocular surface neoplasia.

Trabeculectomy with brief exposure to mitomycin C

BACKGROUND

To evaluate the safety and efficacy of primary trabeculectomy with brief exposure (15 s) to mitomycin C (MMC) (0.4 mg/mL).

METHODS

Medical record review of all patients who underwent primary trabeculectomy with brief exposure to MMC at the Goldschleger Eye Institute in a 4-year period was performed.

RESULTS

Sixty-three patients (35 men, mean age of 55 years) underwent trabeculectomy with brief exposure to MMC. Intraocular pressure (IOP) decreased a mean +/- standard deviation of 17.9 +/- 9.6 mmHg from 30.4 +/- 9.5 mmHg preoperatively to 12.5 +/- 6.2 mmHg postoperatively after a mean follow up of 18.3 months (P < 0.001). Number of antiglaucoma medications decreased from 2.9 +/- 1.1 preoperatively to 0.2 +/- 0.4 postoperatively (P < 0.001, paired samples t-test). Complete success, defined as IOP < 18 mmHg without antiglaucoma medication, was achieved in 46 patients (73%) and qualified success, defined as IOP <or= 21 mmHg with or without antiglaucoma medications, was achieved in 59 patients (93.7%). Thirty-eight patients (60%) had a final IOP < 15 mmHg with no glaucoma medications at the end of follow up. Needle revision was required in four patients (6.3%) and repeated trabeculectomy was performed in three patients (4.8%). Four patients had an IOP of less than 6 mmHg at the end of follow-up period (three had final IOP of 5 mmHg and one of 4 mmHg); these patients had an average larger bleb size (2.8 +/- 1.3).

CONCLUSIONS

Trabeculectomy with brief (15 s) exposure to MMC 0.4 mg/mL is safe and effective in lowering IOP in this group of patients, and results in low rate of postoperative complications. Success is comparable to reported data with longer exposure durations to antimetabolites.

Mitomycin: clinical applications in ophthalmic practice

Mitomycin (mitomycin C; MMC) is an antibiotic isolated from Streptomyces caespitosus. The drug is a bioreductive alkylating agent that undergoes metabolic reductive activation, and has various oxygen tension-dependent cytotoxic effects on cells, including the cross-linking of DNA. It is widely used systemically for the treatment of malignancies, and has gained popularity as topical adjunctive therapy in ocular and adnexal surgery over the past 2 decades. In ophthalmic medicine, it is principally used to inhibit the wound healing response and reduce scarring of surgically fashioned ostia. Hence, it has been used as adjunctive therapy in various ocular surgeries, such as glaucoma filtering surgeries, dacryocystorhinostomy, corneal refractive surgery and surgeries for ocular cicatrisation. In addition, it has been used as an adjunct in the surgical management of pterygia, ocular surface squamous neoplasia, primary acquired melanosis with atypia and conjunctival melanoma. In many of these surgeries and ophthalmic pathologies, MMC showed a significant beneficial effect.

Pars plana insertion of glaucoma drainage devices for refractory glaucoma

BACKGROUND

Glaucoma drainage devices are more commonly inserted into the anterior chamber because of the relative ease of this method of insertion. However, in certain cases, posterior placement of the tube may be necessary or may be more desirable. The outcome of a series of patients with glaucoma drainage devices inserted into the pars plana was examined.

METHODS

Retrospective chart review of patients who underwent pars plana implantation of Molteno and Baerveldt glaucoma drainage devices at the Sydney Eye Hospital.

RESULTS

There were 33 cases reviewed. The mean follow-up period was 30.2 months. The mean final postoperative intraocular pressure was reduced to 13.4 +/- 4.4 mmHg (SD) from 33.06 +/- 8.47 mmHg preoperatively. The mean number of intraocular pressure-lowering medications in use postoperatively was 0.6 +/- 0.8, reduced from 3.6 +/- 1.27 medications in use preoperatively. Sixteen (48.5%) eyes were classified as complete successes, 14 (42.4%) eyes as qualified successes and three eyes (9%) as failures. Kaplan-Meier survival analysis for cumulative success (absence of failure) predicted 61.1% survival at 60 months. Complications included five cases of decompensation of corneas or corneal grafts, one case each of conjunctival wound dehiscence, large choroidal effusion, epiretinal membrane, Molteno plate extrusion and intraocular pressure unresponsive to medical therapy, and three cases of tube blockage.

CONCLUSIONS

In this series of patients, pars plana insertion of glaucoma drainage devices has been shown to be an effective alternative for selected cases where anterior chamber tube insertion is not possible or is not ideal.

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.