[Permeability of rabbit uveal vessels following filtering surgery. 2. Effect of anti-inflammatory drugs].
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Filtering surgery in childhood glaucoma.
A review of 38 eyes of 24 patients receiving filtration surgery for childhood glaucoma is presented. A total of 54 procedures were performed, including both thermal sclerostomies and trabeculectomies. Successful control of intraocular pressure was obtained in 20 eyes (52%). Average follow-up time was four years, two months. Filtration surgery is seen as a useful technique in the treatment of childhood glaucoma when goniotomy fails. It also is useful in those conditions where the success rate of goniotomy is expected to be low.
Adolescent↗
[Implant in filtering surgery. (Part III) Drainage mechanism after filtration].
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[Permeability of the uveal vessels in the rabbit after experimental filtering surgery].
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Animals↗
[Mitomycin C in glaucoma surgery].
Glaucoma filtering surgery fails because of scarring of the filtering bleb. Fibroblasts proliferation from the episclera and Tenon capsule play an important role in the scarring process. The use of antimetabolites in glaucoma filtering surgery have a beneficial effect on the lowering of intraocular pressure especially in eye at poor surgery prognosis. They inhibit the fibroblasts proliferation and subsequent scarring of filtering bleb. 5 fluorouracil improves chance of success with filtering surgery but the necessity of multiple subconjunctival injections has many disadvantages including discomfort for the patient and ocular surface problems such as corneal defect and conjunctival wound leak. Mitomycin C with its focal applications limits the toxic effects to tissue directly exposed to the drug. A single intra-operative application leads to a more hypotensive effect with less corneal complications which are two major advantages of this treatment (Kitazawa and al.): Success rate at one year without medical treatment: 88% with MMC-40% with 5 FU. Different tissue culture studies as well as clinical studies demonstrate that the antiproliferative effect of MMC is 100 times more powerful than 5 fluorouracil. Mitomycin C might probably interfere with other steps in the wound healing process. Mitomycin C seems to be a better treatment than 5 fluorouracil. Nevertheless long term randomized prospective human studies are necessary to confirm it.
Adult↗
The use of bioerodible polymers and daunorubicin in glaucoma filtration surgery.
PURPOSE: Glaucoma filtering surgery usually fails from postoperative fibroblast proliferation, collagen deposition, and subsequent sclerostomy or bleb scarring. Daunorubicin inhibits fibroblast proliferation in vivo and in vitro. The authors studied the effect of a sustained subconjunctival release of daunorubicin by way of a bioerodible polymer on the success of glaucoma filtration surgery in a rabbit model. METHODS: Daunorubicin was incorporated into the copolymer by compression molding. The resultant implant measured 3.0 mm in diameter, 1.0 mm in thickness, and 8.0 mg in weight. A posterior lip sclerectomy was performed in both eyes of 23 rabbits by the same surgeon. One eye was randomized to receive the disc with daunorubicin, whereas the fellow eye received a blank disk as a control. The appropriate polymer disk then was placed on the scleral surface immediately posterior to the sclerostomy site and the conjunctiva was closed. Intraocular pressures and slit-lamp biomicroscopy were recorded preoperatively, then every other day after surgery for 31 days. Intraocular pressure, bleb survival, and complications were evaluated. RESULTS: The decrease in intraocular pressure from baseline was significantly greater in the daunorubicin eyes than in the control eyes during postoperative days 5 through 25. Bleb survival was significantly longer in the daunorubicin eyes than in the control eyes (bleb failure in 91% of control eyes versus 22% of treatment eyes by day 13). There were no statistically significant differences between the daunorubicin-treated and control eyes regarding corneal clouding, lens clarity, cataract formation, or conjunctival injection. However, conjunctival erosions occurred in four daunorubicin-treated eyes. Histopathologic examination was performed 2 weeks after surgery on the eyes of three randomly selected rabbits. CONCLUSION: Daunorubicin in a bioerodible delivery system may potentially be a useful adjunct to glaucoma filtering surgery and requires further evaluation.
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[5-fluorouracil in the treatment of postoperative glaucoma].
INTRODUCTION: Standard filtering surgery in postoperative glaucoma in aphakic and pseudophakic eyes and eyes after failed filtering surgery is successful in 50% cases. The main cause of failure filtering surgery is scarring of the filtering bleb-fibroblastic proliferation at the subconjunctival episcleral interface [1, 2]. The use of antimetabolites such as 5-fluorouracil and Mitomycin C inhibits fibroblast proliferation and increases the success rate of filtering surgery, especially in postoperative glaucoma [3-6]. The exact dosage and frequency of administration to maximize success and minimize complications of treatment has not yet been determined [7]. METHODS: Fifteen patients (15 eyes) with medically uncontrolled postoperative glaucomas were included in the study. Clinical data are summarised in Table 1. All patients after standard trabeculectomy received 5 mg of 0.3 ml 5-fluorouracil subconjunctivally each day for 7 days. The mean 5-fluorouracil dose was 25.1 mg. Topical corticosteroid and cycloplegic eye drops were also instilled in all 15 eyes for 4 weeks after surgery. RESULTS: Successful control of IOP was achieved after a 5-fluorouracil filtering procedure in 13 of 15 eyes (86.6%), with a mean follow-up of 11.4 months. Two patients (13.4%) with uncontrolled glaucoma required cyclokryocoagulation in addition to antiglaucoma medications. Transscleral fibrosa and internal occlusive membrane were the primary cause of failure of filtration fistulas. Only one patient in the group of successful control of IOP required topical 0.5% Timolol (Table 1). Mean value of postoperative IOP was 13.53 mmHg. Most of the early complications such as corneal epitheliopathy, corneal epithelial defects and shallow anterior chamber, resolved without irreversible damage. Two eyes had transient maculopathy and choroidal detachment. There were no late complications, except progression of cataracta in one eye (Table 2). DISCUSSION: Our success rate in 5-fluorouracil treatment in postoperative glaucoma was 86.6%. The results of Fluorouracil Filtering Surgery Study Group revealed failure in 28% of eyes with 5-fluorouracil treatment compared to 60% of eyes in standard group without fluorouracil. We achieved better results in shorter follow-up. Short term complications related to 5-fluorouracil treatment such as corneal epithelipathy, recovered well with time. Long term complications caused by thin and cystic blebs: endophthalmitis, iridocyclitis, late bleb leaks, bleb encapsulated, were not recorded in our series. By comparing the results reported here with those previously reported [8-10] it looks like that certain long term complications can be reduced by adjusting the dose according to the clinical response. Weinrab et al. [10] reported similar successful surgical outcomes in refractory glaucoma, but these results cannot be compared directly, because of likely differences in such factors, as are the indications of surgical criteria for selection of specific surgical procedures, surgical technique and postoperative care. Some clinical reports have shown that Mitomycin C contributes to the increased success of filtering surgery in high risk glaucoma [11, 12], but 5-fluorouracil is still the golden standard among other antimetabolites.
Adult↗
A releasable scleral-flap tamponade suture for guarded filtration surgery.
Postoperative complications of filtering surgery are generally associated with overfiltration. We describe a technique that employs an externalized releasable suture in partial-thickness filtering surgery. This suture acts as a tamponade on the anterior surface of the scleral flap, assisting in maintenance of anterior-chamber depth during the early postoperative period. After using this technique, anterior-chamber depths preoperatively and 1 day after surgery were compared in 35 phakic patients. A mean (+/- SD) decrease in anterior chamber depth of 4.6% +/- 12% was found on the first postoperative day. One patient had iridocorneal apposition. The mean intraocular pressure 1 day after surgery was 7.0 +/- 7.0 mm Hg, with one patent having an intraocular pressure of 28 mm Hg. This "tamponade suture" appears to be useful in maintaining the anterior chamber depth in the early postoperative period while permitting satisfactory filtration.
Adult↗
Endophthalmitis caused by nutrient variant streptococci after filtering bleb surgery.
Late-onset endophthalmitis after filtering bleb surgery is most often caused by streptococci. We report the first case of endophthalmitis caused by nutrient variant streptococci (NVS), which probably originated from the oral cavity. This patient's vision improved from light perception to 20/80 with intravitreal and systemic antibiotic administration. In late-onset endophthalmitis, NVS can be pathogenic; the laboratory must be alerted to culture specifically for this fastidious bacterium.
Anti-Bacterial Agents↗
[Are filtering interventions in glaucoma patients with extensive visual field defects associated with a higher functional risk?].
BACKGROUND: We evaluated the prevalence of the loss of visual acuity due to loss of the central portion of the visual field and foveolar fixation in the first week after glaucoma filtering surgery. PATIENTS AND METHODS: We included 408 patients, in whom glaucoma filtering surgery was performed between January 1993 and April 1997 at the University Eye Clinic in Tübingen and who had completed 1-year follow-up examinations. The retrospective evaluation included preoperative, intraoperative and postoperative data. We excluded all patients who did not complete 1-year follow-up examinations (12 +/- 3 months), who have died during the 1-year follow-up, who had combined glaucoma and cataract surgery or in whom the Molteno implant procedure was performed. RESULTS: A total of 404 patients (99.3%) did not suffer loss of the central visual field and foveolar fixation in the first week after glaucoma filtering surgery. In 11 cases, loss of visual acuity > 2 dB was due to progressive lens opacification. One patient suffered from postoperative progression of his age-related maculopathy. In one patient (0.2%) progression of a preexisting relative central scotoma occurred immediately after the operation. Two patients (0.5%) suffered from loss of fixation and the central visual field immediately after glaucoma filtering surgery. CONCLUSIONS: Loss of the central visual field and central fixation immediately after glaucoma filtering surgery is a rare complication. Therefore, glaucoma filtering surgery can also be recommended for patients with advanced visual field defects.
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Young patient trabeculectomy. Assessment of risk factors for failure.
BACKGROUND: Various risk factors for failure of glaucoma filtering surgery, including young age, have been suggested. METHODS: A retrospective study of 113 trabeculectomies in 113 patients, ranging in age between 11 and 49 years (mean, 33.3 +/- 10.5 years), was carried out to determine the influence of these risk factors in young patients. RESULTS: A successful outcome (intraocular pressure [IOP] < or = 21 mmHg without antiglaucoma treatment), assessed by life-table analysis, was achieved in 54% of trabeculectomies after 38 months (mean follow-up, 36.7 +/- 29.7 months). Previous ocular surgery (e.g., glaucoma filtering, cataract, or conjunctival surgery) and previous laser therapy (i.e., argon laser trabeculoplasty and YAG laser iridotomy) both significantly reduced the success rate. An IOP greater than 40 mmHg during the course of the disease was found to adversely affect the outcome. No direct correlation between success rate and age and no racial difference were demonstrated. Success rates for specific diagnoses were not significantly different. Postoperative subconjunctival injections of 5-fluorouracil (5-FU) did not significantly improve the success rate. A Cox regression analysis of various prognostic variables identified previous cataract surgery (hazard ratio, 4.4), argon laser trabeculoplasty (hazard ratio, 3.4), previous glaucoma filtering surgery (hazard ratio, 2.5), nonfiltering glaucoma surgery (hazard ratio, 2.2) and IOP greater than 40 mmHg (hazard ratio, 2.4) to be the major risk factors for glaucoma filtering surgery failure. CONCLUSION: A majority (74%) of the patients in our series had at least one of these risk factors, thus explaining why young patients, in general, have lower success rates for trabeculectomy.
Adolescent↗
GGRGDSPCA peptide: a new antiscarring agent on glaucoma filtration surgery.
BACKGROUND AND OBJECTIVE: GGRGDSPCA synthetic peptide competes for integrin receptor in scar formation after glaucoma filtering surgery in a rabbit model. The purpose of this study was to evaluate the use of this peptide and compare it with mitomycin on glaucoma filtering surgery. MATERIALS AND METHODS: Posterior sclerectomy was performed in both eyes of 17 rabbits. The right eye received GGRGDSPCA (p605) at 0, 4, 8, 12, and 16 days after. Nine left eyes received saline as a control; the remaining 8 eyes received mitomycin C at 0.5 mg/mL intraoperative. Intraocular pressures and biomicroscopy were evaluated as well as bleb function. RESULTS: Intraocular pressure decreased significantly in both the peptide and mitomycin treated eyes in comparison with the saline group (P = 0.0003). Pressure was similar in both groups. The blebs showed filtrating function in a functional analysis at day 21 and 41 in the mitomycin cases as well as in the peptide group. Histologic analysis performed in both peptide and mitomycin groups showed inhibitory effect in fibrocellular and collagen organization with bleb formation. CONCLUSIONS: The p605 peptide showed to be similar to mitomycin C in controlling and improving glaucoma filtering surgery in rabbits. This alternative may potentially be useful for similar purposes in humans for the control of glaucoma and improvement of filtering surgery.
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[External trabecular excision--alternative to filtering glaucoma operation in patients with open angle glaucoma].
BACKGROUND: Postoperative complications concerning glaucoma filtering surgery (trabeculectomy, goniotrepanation) often include hypotonia that may lead to athalamia or choroidal detachment, which are difficult to handle. Cystic non filtering blebs are due to postinflammatory reactions, and may limit the success of filtering surgery. Aim of the study was to compare the success and the complications of a new operating technique, which will be described, with those of usual glaucoma filtering surgery. PATIENTS AND METHODS: In 24 open angle glaucoma patients with mean intraocular pressure of 28.12 mm Hg (+/- 8.6) we performed external trabecular excision in 25 eyes since June 1997. Preoperative visual acuity and peak intraocular pressure were compared retrospectively in all eyes with the values of the first postoperative day, in 22 eyes after one month and in 17 eyes after 3 months. RESULTS: Intraocular pressure measured between 0 mm Hg and 16 mm Hg on the first postoperative day (7.64 mm Hg +/- 4.3), after one month between 10 mm Hg and 30 mm Hg (17.81 mm Hg +/- 5.5) and after 3 months between 9 mm Hg and 26 mm Hg (15.29 mm Hg +/- 4.2). After 1 month 10 of 22 (45%) and after 3 months 7 of 17 eyes (42%) required antiglaucomatous drugs; 3 eyes needed gonitrepanation (2 weeks, 1 month, 3 months after ETE). Concerning postoperative complications, we observed 6 choroidal detachments, once erythrocoytes in the anterior chamber, twice hyphemata, twice inflammatory reaction in the anterior chamber, two flat anterior chambers and twice a positive seidel test. CONCLUSION: Complications after ETE are similar to those after filtering surgery. Postoperative intraocular pressure dip after ETE in most eyes was not as pronounced as after goniotrepanation or trabeculectomy, and postoperative complications were all reversible. 45% of the eyes again needed antiglaucomatous drugs after one month and 42% after 3 months. A prospective long-term study has to verify the success respectively the complications of ETE.
Adult↗
[5-fluorouracil injection treatment after fistulating glaucoma operations].
BACKGROUND: Since 1984 subconjunctival 5-Fluorouracil injections have been applied with success after filtering surgery. It was the purpose of this retrospective study to find out whether the results justify this treatment in view of all side effects. MATERIALS AND METHODS: Between 2/1991 and 1/1993 twenty-nine eyes of 11 female and 16 male patients with high-risk glaucoma (unsuccessful previous filtering surgery and a high risk of scarring) were treated with subconjunctival injections of 5-Fluorouracil after filtering surgery in the University Eye Hospital Düsseldorf. The mean age of the patients was 58 (11-84) years and the mean follow-up period was 16 (4-24) months. The mean amount of injected 5-Fluorouracil was 43 (5-85) mg. Glaucoma was regarded as controlled when intraocular pressure levels were reduced by more than 20% of the preoperative level and stayed consistently below 21 mm Hg. RESULTS: 26 (89.6%) of the eyes had controlled intraocular pressure during the follow-up period. Two eyes were controlled only after additional cyclocrycoagulation, and 1 glaucoma has remained uncontrolled. Postoperatively we observed fistulas of the conjunctiva in 24% of the eyes and 69% of the eyes had corneal epithelial breakdown problems. It is unlikely that subconjunctival injections of 5-Fluorouracil work only by inhibiting scarring of the filtration bleb. Long-lasting e-vacuo-symptoms in single cases with no functioning bleb at all as well as scarred blebs in 9 of 26 eyes with controlled glaucoma must be interpreted as a probable sign of 5-Fluorouracil toxicity on the ciliary epithelium. CONCLUSIONS: Subconjunctival injections of 5-Fluorouracil after filtering surgery are helpful to control high-risk glaucoma, but there are several disadvantages of this treatment as fistulas of the conjunctiva, corneal surface problems, discomfort for the patient, difficult follow-up and a potential toxicity on the ciliary epithelium that may be pronounced in some cases. Therefore, subconjunctival injections of 5-Fluorouracil after filtering surgery are a useful means for eyes with a high risk of scarring. However, 5-Fluorouracil should not be applied for primary normal glaucoma surgery.
Adolescent↗
Post-operative inflammation following deep sclerectomy with collagen implant versus standard trabeculectomy.
BACKGROUND: An investigation was carried out to compare post-operative inflammation following deep sclerectomy with collagen implant (DSCI) versus standard trabeculectomy. METHODS: In this prospective randomized study, 46 eyes of 46 Caucasian patients with medically uncontrolled chronic open-angle glaucoma and without previous glaucoma surgery underwent filtering surgery. Twenty-four eyes underwent DSCI. Twenty-two eyes underwent standard trabeculectomy. Pre- and post-operative flare, measured using laser flare photometry, were compared between the two groups. RESULTS: In both groups, the mean anterior chamber flare increased on the first post-operative day, then decreased progressively. DSCI was associated with lower flare measurements post-operatively. The difference was statistically significant up to 1 month post-operatively: 16.3 +/- 7.8 vs 72.5 +/- 38.9 (P < 0.001) at 1 day, 7.8 +/- 4.6 vs 44.7 +/- 29.2 (P < 0.001) at 1 week, 5.9 +/- 1.6 vs 7.0 +/- 2.8 (P = 0.012) at 1 month, 6.4 +/- 1.8 vs 6.5 +/- 1.9 (P = 0.77) at 2 months, 5.9 +/- 1.8 vs 6.1 +/- 1.6 (P = 0.65) at 3 months. CONCLUSION: Surgically induced inflammation can be reduced with DSCI. This may be due to the lack of iridectomy, irrigation, and penetration of the anterior chamber. Eyes at increased risk of post-operative inflammation, such as those with uveitic or traumatic glaucoma, may benefit from this procedure. Further studies are needed to evaluate the long-term functional and anatomical outcomes of DSCI.
Aged↗
Exudative macular degeneration and intravitreal triamcinolone: 18 month follow up.
PURPOSE: To evaluate the safety and efficacy of intravitreal triamcinolone after 18 months of follow up in patients with age-related macular degeneration and subfoveal or juxtafoveal choroidal neovascularization considered unsuitable for laser photocoagulation. METHODS: Thirty eyes of 28 patients, referred from general eye clinics as well as the private clinic of one of the authors to a hospital-based retinal out-patient clinic, were treated with an intravitreal injection of triamcinolone (4 mg). The primary outcome measure was the proportion of eyes with loss of six or more lines on a Bailey-Lovie Chart. The incidence of adverse events associated with treatment was also observed. RESULTS: Of the 20 eyes with initial visual acuity (VA) of 6/60 or better, the vision was maintained (+/-1 Bailey-Lovie lines) in 11 eyes (55%), while six eyes (30%) suffered severe visual loss (six or more lines). The VA improved by five to six lines in three of 10 eyes with initial vision of 3/60 or worse. Three of four eyes receiving a second injection suffered either progressive cataract or elevated intra-ocular pressure (IOP) requiring cataract surgery and/or filtering surgery. One of 26 eyes (3%) receiving a single injection showed progression of cataract and elevation of IOP within 6 weeks of treatment and required anti-glaucoma medication for 6 weeks. Progression of nuclear sclerosis 8-12 months after treatment was observed in six of 26 eyes (23%) receiving a single injection. CONCLUSIONS: The results of the present study suggest that a single intravitreal injection of 4 mg triamcinolone is reasonably well tolerated by the human eye. The rate of development of severe visual loss was less than reported for historical controls. Because the results are preliminary and uncontrolled, the treatment should not be used routinely until its benefit to patients is established by a prospective, randomized controlled study.
Aged↗
Filtering bleb encapsulation increased by steroid injection.
In an attempt to enhance its pressure-lowering and fibroblast inhibiting effects, we administered 0.15 cc of 24 mg/ml dexamethasone, intra-Tenon's, directly over the fistula site following 16 consecutive filtering surgeries. The encapsulation rate in these eyes was 56% (9/15), as compared with 10% (2/20) in a retrospectively matched group of eyes that had undergone filtering surgery with dexamethasone given subconjunctivally 180 degrees away from the filter site. The effective concentration of dexamethasone achieved by the injections at the filter site apparently did not maintain the fibroblast inhibitory drug level and, in fact, supported fibroblastic growth, resulting in increased encapsulation. Because of the increased encapsulation rate and the lack of any demonstrable benefit associated with it, we do not recommend intralesional dexamethasone in filtering surgery. Commercial topical steroids with their lower concentrations also may act to promote rather than inhibit fibroblast growth. Prolonged steroid use after filtering surgery beyond the inflammatory phase of wound healing (about 2 weeks) may increase fibrosis in the area of the filter, resulting in a thick-walled bleb with few microcysts, one form of which is frank encapsulation. Thus, we recommend that topical steroids routinely be stopped by the third postoperative week if the level of inflammation permits.
Adult↗
Response of filtered eyes to digital ocular pressure.
PURPOSE: To examine the effect of digital ocular pressure (DOP) on the intraocular pressure (IOP) of eyes 3 months or longer after successful glaucoma filtering surgery. METHODS: Fifteen patients participated in this study. Each had one eye with a successful filtering operation (IOP < or = 21 mmHg without medications) and a fellow eye that was not operated on, which served as a control. The authors measured IOP in both eyes before and serially after DOP until return to baseline or for 3 hours to determine the amounts and durations of reductions. The authors monitored changes of bleb morphology and searched for complications. RESULTS: Digital ocular pressure 3 months or more after successful filtering surgery reduced IOP by approximately 50% of baseline. The time after DOP for 50% of eyes to have intraocular pressure return to within 2 mmHg of baseline was 95 minutes; 40% recovered within 20 minutes and 30% had not recovered by 3 hours. Eyes with localized blebs recovered faster than did eyes with diffuse blebs. Transient shallowing of the anterior chamber developed in one eye. Otherwise, there were no adverse effects. Time since surgery and baseline IOP were not correlated with response. Fellow eyes had minimal response to DOP and recovered within 30 minutes. CONCLUSION: This study shows that a substantial, transient decrease of IOP after DOP occurs in glaucomatous eyes with a well-functioning bleb 3 months to 6 years after filtering surgery. The duration exceeds 90 minutes in more than 50% of the eyes tested and 180 minutes in more than 30% of the eyes tested.
Filtering Surgery↗