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The use of antimetabolites with trabeculectomy: a critical appraisal.
PURPOSE: To examine why most ophthalmologists routinely use mitomycin C or 5-fluorouracil (antimetabolites) in association with filtering surgery for glaucoma. METHODS: Critical analysis of seven medical, social and economic trends. RESULTS: The rapid acceptance of the adjunctive use of antimetabolites at the time of filtration surgery may be explained by reasons other than anticipated increase in the "success" of glaucoma surgery. CONCLUSION: The use of antimetabolites in conjuction with filtering glaucoma surgery may be at least partially a consequence of changing medical-social-economic factors, rather than solely a desire on the part of physicians to improve the "success" of glaucoma surgery. This may indicate a need to reevaluate the proper place of antimetabolites in association with filtration surgery.
Ultrasound biomicroscopic patterns after glaucoma surgery in congenital glaucoma.
OBJECTIVE: This study aimed to demonstrate specific morphologic patterns in congenital glaucoma after various surgical procedures by means of ultrasound biomicroscopy (UBM) and to investigate correlations between UBM morphology and the effectiveness of glaucoma surgery in reducing intraocular pressure. DESIGN: Observational case series. PARTICIPANTS AND INTERVENTIONS: Thirty four eyes of 18 consecutive patients, not older than 18 years, with congenital glaucoma and with a history of previous antiglaucomatous surgery underwent UBM examination of the anterior chamber angle in the treatment area and in an untreated region. MAIN OUTCOME MEASURES: The morphology of the anterior chamber angle region and the tissue reflectivity were analyzed. RESULTS: Specific UBM patterns of the anterior chamber angle in congenital glaucoma were observed after goniotomy, trabeculotomy, trabeculectomy, deep sclerectomy, and cyclodialysis. In the first months after surgery, a limited correlation was found between morphology and the success of filtering surgery. Adhesions of the iris or the ciliary processes to the trabeculectomy cleft were detected in 19 of 25 eyes after filtering procedures. CONCLUSIONS: In cases of cloudy cornea and unknown previous glaucoma surgery, UBM can be used to identify the type and localization of previous surgery in congenital glaucoma, thus assisting surgical planning for subsequent glaucoma management. The correlation between UBM morphology and the effectiveness of filtering surgery is less convincing than previously demonstrated in adults, possibly underlining the importance of individual nonsurgical factors for prognosis in congenital glaucoma.
[Modulation of wound healing in glaucoma filtration surgery].
Authors evaluate application of mitomycin C (0.2-0.4 mg/ml) on the sclera during glaucoma filtering surgery. Mean follow up was 19.5 months in the group of 67 patients (75 eyes). The most serious complication was an early endophthalmitis in 2 cases with the loss of residual visual field and vision, 1x hemophthalmus followed with development of traction retinal detachment, 1x hypotonic maculopathy, 1x traction retinal detachment for progression of diabetic proliferative vitreoretinopathy of neovascular glaucoma. Higher rate of complications was noted in the group of mitomycin C 0.4 mg/ml. Visual acuity was better one line Snellen optotypes in 3 cases, and worse in 26 cases. Intraocular pressure compensation up to 20 mmHg was reached in 32 cases without therapy (45.1%), in 28 cases therapy (39.6%), Intraocular pressure above 20 mm Hg was in 11 cases (15.4) and the data are not known in 4 cases (5.4%). Intraocular pressure was compensated after mitomycin C application in 84.7%.
[Encapsulated filtering blebs--incidence and methods of treatment].
Encapsulation of the filtering bleb occurs as a complication of glaucoma filtering surgery in 8.3-28% of all eyes filtered, often between 2-4 weeks after surgery. It has a characteristic clinical appearance--highly elevated localized bleb, prominent surface vessels and patent sclerostomies on gonioscopy. This study retrospectively reviewed the results of 100 filtering operations, performed in the Prof. Dr. I. Stankovitsh Eye Department, focused on the incidence, possible risk factors and management of encapsulated filtering blebs. Trabeculectomy was done in all patients with limbus-based conjunctival flap, rectangular scleral flap 4 x 4 mm, and sclerostomy 2 x 2 mm. Two or three interrupted 10-0 nylon sutures were used to tether the flap, the conjunctiva with Tenon's capsule was closed with a running suture. All eyes received topical dexamethasone drops, mydriatics-homatropin or tropicamide and antibiotic ointment for three weeks. Possible risk factors were considered: sex, age, other eye or systemic disease, type of glaucoma, previous ocular procedure and antiglaucoma medical therapy, early postoperative complications, postoperative and final intraocular pressure (IOP). All eycs with encapsulated filtering bleb were given topical beta-blocker initially and carbonic anhydrase inhibitor, and if IOP continued to be uncontrolled incisional surgical management was performed. Success was defined as IOP maintained at less than 22 mmHg, with or without medication. An encapsulated filtering bleb developed in 9% of eyes. Previous argon laser trabeculoplasty was associated with an increased frequency of bleb encapsulation. The mean postoperative IOP was 11.30 +/- 1.90. Encapsulation of filtering bleb was developing at mean time of 19.9 +/- 3.0 after surgery. Six eyes returned to IOP below 21 (mean IOP was 20.17 +/- 0.90) within 4 weeks, and 4 of them continued on a topical beta-blocker. Four eyes required incisional surgery. A week after surgery mean IOP was 18 mmHg. Haemophthalmus occurred after one incision performed in a patient suffering from diabetes mellitus. Late scarring of the filtering bleb was developed in 2 eyes. Seven months and 2 years after filtration surgery mean IOP was 21.30 +/- 4.00 mmHg. The cause of bleb encapsulation is not known. Male patients, surgical glove powder, topical corticosteroids, previous argon laser trabeculoplasty and beta-blockers are some of potential risk factors for the development of encapsulated filtering bleb. This study suggests the association between development of encapsulated bleb and previous argon laser trabeculoplasty--40% in the eyes with encapsulation and 18% in the eyes without encapsulation. The optimal management of bleb encapsulation has not been defined. In this study topical antiglaucoma therapy achieved IOP control and cyst's remodeling in 60% of cases. Forty percent of all cysts required incisional surgical management. Encapsulation of the filtering bleb is not an uncommon complication of glaucoma filtration surgery. It is important to examine postoperative eyes frequently during the first 2 months to detect this complication. Fortunately, most eyes have their IOPs controlled with antiglaucoma therapy.
Classification of filtering blebs in trabeculectomy: biomicroscopy and functionality.
The long-term success of filtering surgery is not dependent on surgical technique alone. The development of the filtering bleb in the postoperative period, in particular with regard to wound healing and subconjunctival scarring, is equally important. Morphologic changes of the developing filtering bleb after trabeculectomy can predict early failure even if the intraocular pressure is still normal. A basic understanding of wound healing processes and histologic changes of the developing filtering bleb are mandatory to interpret correctly the morphologic appearance of the developing filtering bleb. In clinical practice, follow-up of the filtering bleb according to a standardized morphologic classification may help to predict outcome and provide clues for the necessity and timing of further treatment.
Cataract extraction as a means of treating postfiltration hypotony maculopathy.
Hypotony maculopathy may arise after glaucoma filtering surgery. This can be treated by inducing inflammation and scarring within the filter, with the aim of increasing intraocular pressure (IOP) and promoting resolution of maculopathy. Cataract extraction can promote such inflammation. Phacoemulsification with posterior chamber intraocular lens (PC IOL) implantation was performed in two consecutive patients with postfiltration hypotony maculopathy and preexisting cataracts. After cataract extraction, improvement of IOP, visual acuity, maculopathy, and metamorphopsia occurred in both patients. Cataract extraction can be beneficial in the management of postfiltration hypotony maculopathy.
[The use of antimetabolites in glaucoma surgery].
The authors present, in the context of actual management of glaucoma, the role of antimetabolites in addition to glaucoma filtering surgery. The main reason of failure in filtration surgery is the excessive postoperative scarring response at the contact episclera-subconjunctiva. The antimetabolites inhibit the fibroblastic growth, therefore providing a great number of adequate filtering blebs. Indications, surgical techniques, complications and risks are also discussed.
New aspects in the surgical treatment of glaucoma.
With modern techniques and advances in materials and instruments, the outcome of glaucoma surgery has been improved. Early filtering surgery has become a definite option in open angle glaucoma, particularly as the complications of such surgery are minimal. Refractory cases of glaucoma are always problematic, but modifications to the routine surgical options such as silicone-tube implants, partial-thickness procedures, 5-fluorouracil, and cyclocryotherapy, have improved the outcome. This article reviews some of the current trends in glaucoma surgery.
Corneal endothelial permeability in protection glaucoma filter bleb with tissue plasminogen activator.
After glaucoma filtering surgery subconjunctival injection of human recombinant tissue plasminogen activator may promote the function of glaucoma filter bleb and increase outflow facility. It can also increase postoperative complications, such as corneal damage. The aim of our research was to determine corneal endothelial permeability (Pac) in subjects with glaucoma filter bleb protected by a plasminogen activator (Actilyse, Boehringer) when haemorrhagic clots obstructing a glaucoma filtering site had occurred. Two weeks, three months and six months after goniotrephining with scleral cover, in groups with and without subconjunctival injection of 25 mg human tissue plasminogen activator, Pac was calculated. In both groups, no significant differences in the level of Pac measured by fluorophotometry were found.
Collagen type I and III synthesis by Tenon's capsule fibroblasts in culture: individual patient characteristics and response to mitomycin C, 5-fluorouracil, and ascorbic acid.
PURPOSE: This study was performed to better understand the differences between patients in specific components of wound healing as it may pertain to glaucoma filtration surgery, including the use of antimetabolites. METHODS: Human Tenon's capsule fibroblasts were obtained at the time of glaucoma filtering surgery and established in individual cell cultures from 35 glaucoma patients. The dose-response to 5-fluorouracil (5FU) and mitomycin C (MMC) was determined. The individual cell lines were exposed to the antimetabolites and ascorbic acid with measurement of collagen type I and III production by an ELISA-type dot blot assay. These results were then statistically compared to the individual patient characteristics including age, race, previous surgery and medications, and type of glaucoma. RESULTS: 5-FU had little effect on collagen type I and III production or protein synthesis. MMC had an inhibitory effect on collagen secretion and total protein synthesis with increasing concentration. Photomicrographs of the cells after each treatment condition revealed characteristic morphologic changes when compared to controls. There was a large range of collagen type I and III production with correlation between the amounts of each collagen type secreted in response to the antimetabolites. However, there was no correlation with accepted risk factors for filtration failure. CONCLUSION: These antimetabolites act similarly on different cell lines in a nonspecific manner. The results suggest that the increased risk of filtration failure due to age, race, diagnosis, and previous conjunctival surgery is not due to differences in secretion of collagen types I and III by Tenon's capsule fibroblasts.
Utility of insufflation filters in laparoscopic surgery.
OBJECTIVES: To determine whether filters, regularly used as part of the insufflator tubing during laparoscopic surgery, trap microbial and particulate matter from CO2 tanks, thus preventing passage from one patient to another. METHODS: A total of 67 used filters were collected from 17 CO2 tanks and six insufflation machines at three local hospitals, and sterile unused filters were used as controls. The used filters were distributed equally and sequentially into three groups: Group I-viewed under a dissecting microscope for particulate matter; group II-examined by mass spectrometry for contamination with oils and other impurities; group III-incubated on sheep blood agar plates and evaluated for growth of microorganisms. RESULTS: Negative. Used filters were indistinguishable by all parameters from controls. CONCLUSIONS: This limited study suggests filters now used in laparoscopic surgery fail to trap microbes or particulate matter. The question remains whether tank waste is absent or these filters fail to trap waste matter.
The place of sodium hyaluronate in glaucoma surgery.
The advantages of sodium hyaluronate (Healon) in filtering surgery have been mostly theoretical, with no study of sufficient numbers to justify its use. The authors used sodium hyaluronate in 119 consecutive trabeculectomies. These were compared to a control group of 122 cases. The long-term intraocular pressure and visual acuity results between the two groups were indistinguishable. The only definite benefit noted with the use of sodium hyaluronate was the lower incidence of hyphemas. No side-effects were seen. Its ability to maintain a deep anterior chamber and encourage hemostasis makes sodium hyaluronate useful in teaching goniotomies as well as performing trabeculectomies in congenital glaucoma. Sodium hyaluronate can also be used to evacuate hyphemas and dissect adhesions with minimal trauma, and may be healthier for the corneal endothelium than air in anterior chamber reformations.
[Anti-allergic drugs inhibit the proliferation of human Tenon's capsule fibroblast and maintain the experimental filtering blebs on rabbit eyes].
PURPOSE: To examine whether tranilast and ketotifen fumarate inhibit the growth of human Tenon's capsule fibroblasts and maintain experimental filtering blebs on rabbit eyes. METHODS: Human Tenon's capsule fibroblasts were grown in Dulbecco's modified Eagle's medium with 10% fetal calf serum and growth was measured with 3-[4,5-dimethylthiazole-2-yl]-2,5-diphenyltetrazolium bromide (MTT) and direct counting of cell number. Production of collagen and transforming growth factor-beta 1 (TGF-beta 1) was measured with corresponding enzyme-linked immunosorbent assay (ELISA). In experimental filtering surgery performed on rabbit eyes, the effects of the topical drugs on intraocular pressure and on maintenance of the filtering blebs were observed. RESULTS: Both tranilast and ketotifen inhibited the growth of the fibroblasts and half-inhibitory concentrations were 200 microM and 70 microM, respectively. Low concentration (10 microM) of tranilast and ketotifen decreased the synthesis of collagen but neither drug had any obvious effect on TGF-beta 1 production. Both drugs prolonged the life of the experimental filtering bleb significantly [12.5 +/- 3.2 (mean +/- standard deviation) days, 13.9 +/- 3.4 days, respectively; control, 10.5 +/- 2.4 days]. CONCLUSION: Tranilast and ketotifen inhibited the growth of human Tenon's capsule proliferation and are capable of maintaining experimental filtering blebs in rabbit eyes.
[Perspectives in glaucoma surgery].
Trabeculectomy is still considered to be the gold standard in the surgical treatment of the open-angle glaucomas. The additional application of local antimetabolites has reduced the rate of early filtering bled fibrosis, but increased the rate of essential late-postoperative complications. Growth factor inhibition and photodynamic therapy may be an alternative local treatment to enhance the results in filtering surgery. Non-penetrating glaucoma surgery and ab-interno trabecular surgery have several conceptual advantages, e.g. the lack of overfiltration or the untouched conjunctiva in the ab-interno approach. Clinical studies of these and other new procedures including antiglaucomatous retinectomy and subchoroidal shunt systems are currently performed in order to evaluate their potential and limits in the clinical management of glaucoma.
[Vitrectomy for the treatment of expulsive hemorrhage].
PURPOSE: To evaluate the surgical outcome of vitrectomy in the treatment of expulsive hemorrhage associated with intraocular surgery. METHODS: We reviewed 12 eyes from 12 patients with expulsive hemorrhage, occurring after or during cataract extraction (4 eyes), phacoemulsification (2 eyes), glaucoma filtering surgery (4 eyes), or vitrectomy (2 eyes). Mean follow-up period was 21 months. RESULTS: The retina was reattached in 6 eyes (50%) after the initial surgery and ultimately in 9 eyes (75%). Three eyes, which failed to achieve retinal reattachment, resulted in phthisis bulbi. Final visual acuity was 0.1 or belter in 4 eyes and 0.01 to 0.09 in 4 eyes. The incidence of expulsive hemorrhage was 0% for cataract surgery, 0.57% for trabeculectomy, and 0.09% for vitrectomy at Toho University Sakura Hospital. CONCLUSION: In the treatment of expulsive hemorrhage, vitrectomy is an effective surgical procedure to improve the visual function.
Management of delayed massive suprachoroidal hemorrhage: a clinical retrospective study.
Suprachoroidal hemorrhages, both expulsive and delayed non-expulsive, are among the most devastating complications of intraocular surgery. We reviewed the charts of 13 patients with a delayed non-expulsive suprachoroidal hemorrhage (DNSCH) after cataract extraction (3 patients), glaucoma filtering surgery (6 patients), penetrating keratoplasty (3 patients), or vitrectomy (1 patient). All had large hemorrhagic choroidal detachments with nine eyes presenting kissing choroidal detachment, five eyes with associated retinal detachment, and one eye with intravitreous hemorrhage. All patients were treated with systemic corticosteroids before surgery. Eleven eyes underwent anterior drainage sclerotomy, followed by SF6 gas injection in eight eyes, and pars plana vitrectomy with silicon oil tamponade in three eyes. Mean follow-up was 22 months. These procedures gave good anatomical results in eleven cases and good visual results in nine. The results suggest that not all DNSCH need to be drained surgically but that, when surgical drainage is indicated, the use of gas to maintain internal tamponade appears to be beneficial.
Lack of corneal toxicity of interferon Alpha-2b administered subconjunctivally after sclerectomy.
PURPOSE: To evaluate the corneal toxicity of subconjunctival injection interferon alpha-2b at filtering bleb after sclerectomy in white rabbits. METHODS: Eight rabbits which had been performed sclerectomy were randomly divided into two groups. Each group consisted of four rabbits. Eight eyes in group 1 were subconjunctivally received interferon alpha-2b 5 x 10(5) IU/0.2 ml into filtering bleb from the edge of the filtering site immediately after operation and every postoperative day. The other eight eyes in group 2 were injected with 0.2 ml normal saline. All of the eyes underwent daily examination by slip-lamp microscopy and direct ophthalmoloscopy. Sodium fluorescein was used to assess corneal epithelial integrity. On day 3, 4, 7 and 14, every two rabbits (group 1 and 2 each, respectively) were killed and removed cornea immediately to take examination of the viability of corneal endothelium by dual staining with typan blue and alizanin red S. RESULTS: No sign of toxicity in corneal epithelium and endothelium were found following continuously injection interferon alpha-2b at filtering bleb 3-14 days totally for selected doses. CONCLUSION: Subconjunctivally administered interferon alpha-2b at filtering bleb after glaucoma filtering surgery may be a safe drug-applied method.