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Glaucoma drainage devices: pros and cons.

Glaucoma drainage devices are an option in the management of complicated glaucomas that carry a high risk of failure from conventional filtering surgery. Examples include the glaucomas associated with aphakia or pseudophakia, neovascular glaucoma, and glaucomas associated with trauma, uveitis, epithelial downgrowth, iridocorneal endothelial syndrome, vitreoretinal disorders, and penetrating keratoplasty. Modifications in the various implant designs have been developed to limit the occurrence of postsurgical complications such as hypotony, serous and hemorrhagic choroidal detachment, tube and plate avulsion, tube exposure, and corneal endothelial damage.

Equipment Design↗

S-nitrosoglutathione photolysis as a novel therapy for antifibrosis in filtration surgery.

PURPOSE: To determine whether a novel peroxynitrite-based photosensitizer S-nitrosoglutathione (GSNO) can produce specific in vitro light-induced cell death of both standard animal lung and human Tenon's capsule (TC) fibroblasts and to compare this effect with that produced by the established photodynamic porphyrin precursor 5-aminolevulinic acid (ALA). METHODS: V79-4 Chinese hamster lung and human TC fibroblasts were established in tissue culture. GSNO, together with its radioactive tritiated and fluorescent dansylated derivatives, were synthesized. The labeled molecules were prepared to determine the time course of uptake into the fibroblasts. Uptake was monitored by scintillation counting for the tritiated GSNO and confocal fluorescence microscopy for the dansylated GSNO. The uptake of ALA and biosynthesis of its photosensitive product were determined by fluorescence emission spectroscopy of a separate set of fibroblasts. Once uptake was established, both cell lines were incubated with varying concentrations of GSNO or ALA as a function of time (0, 4, or 24 hours) before light exposure (200 msec pulsed visible light, 0.068 W per pulse, for 10 minutes at a distance of 10 cm). After 10 minutes of irradiation, the cells were washed and exposed to fresh tissue culture medium. The effect of the treatment was determined 24 hours later by measuring cell viability. RESULTS: A 2-minute drug treatment time (0 hours incubation) with GSNO, followed by 10 minutes of irradiation, resulted in approximately 78% of fibroblast cell death at the lowest concentration of GSNO used compared with the control, which was exposed to light, but no GSNO. The higher concentrations of GSNO, or longer drug treatment times before irradiation, did not statistically increase cell death. Maximal cell death was thus obtained using the lowest GSNO concentration (50 mM) and drug treatment time (2 minutes). In contrast, the well-established photosensitizer ALA killed only approximately 4% of cells at the lowest concentration and drug treatment time tested. At drug treatment times of 4 hours and less, increased concentrations of ALA did not produce cell death of more statistical significance. It was not until 24 hours of drug treatment that comparable amounts of cell death were produced by ALA and GSNO. In all experiments similar results were obtained with the animal lung and human TC fibroblasts, suggesting that the source of the fibroblast had no effect on the outcome. The differences in treatment effects between GSNO and ALA were statistically significant under all conditions tested. CONCLUSIONS: GSNO is able to cause light-specific cell death of human TC fibroblasts at drug treatment times (2 minutes) and irradiation times (10 minutes) that would be compatible with its use in glaucoma filtering surgery. This in vitro performance was superior to that of the well-established photosensitizer ALA, which required treatment times longer than 4 hours to approach the light-specific cell death produced by only 2 minutes of GSNO treatment.

Aminolevulinic Acid↗

Transient, profound cataract associated with intracameral 5-fluorouracil.

PURPOSE: To report a transient cataract after bleb needling and subconjunctival injection of 5-fluorouracil. DESIGN: Observational case report. METHODS: A 51-year-old man had an encapsulated bleb after filtering surgery. The bleb was needled, and 5 mg of 5-fluorouracil was injected adjacent to the bleb. RESULTS: Within 5 minutes, vision fell to finger counting at 1 foot owing to anterior lens capsule opacification. The next day, acuity and lens clarity had returned to their preneedling status. Best-corrected acuity 7 months later was 20/15. CONCLUSION: Entry of 5-fluorouracil into the anterior chamber after bleb needling can cause transient lens opacification. Recently, intracameral 5-fluorouracil was reported as a new treatment for epithelial ingrowth. Given the transient cataract observed in this case, the use of 5-fluorouracil for epithelial ingrowth should be considered with caution for phakic patients.

Antimetabolites, Antineoplastic↗

A major review of antimetabolites in glaucoma therapy.

Antimetabolites have been used in combination with filtering surgery to improve surgical results for more than 10 years. Based on research published since the introduction of antimetabolites right up to date, we discuss the various forms of antimetabolites that have been used, including drugs and irradiation. Among the drugs used, mitomycin C and 5-fluorouracil are the most prominent. We discuss the background of these agents, the progress in the use of antimetabolites and the research done on these drugs. These agents have been used both intra-operatively and perioperatively. We discuss the indications for their use, their mode of action, the techniques of usage, their variations as well as the complications and the treatment of complications.

Antimetabolites↗

[Interferon-alpha 2b inhibits proliferation of human tenon capsule fibroblasts].

PURPOSE: To evaluate the potential effect of interferon-alpha 2b(IFN alpha-2b) as antifibrotic treatment after glaucoma filtering surgery. METHODS: The MTT method was used to study the inhibitory effect of IFN alpha-2b on human Tenon capsule fibroblasts in vitro. The antimetabolites including 5-fluorouracil (5-FU), homoharringtonine(H.H) and mitomycin C(MMC) were also assessed. RESULTS: The IC50 values of IFN alpha-2b, 5-FU, H.H and MMC on fibroblasts at 48 hours were 60.578 mg/L, 5.447 mg/L, 0.531 mg/L, 1.329 mg/L respectively. CONCLUSION: The effect of IFN alpha-2b to inhibit proliferation of fibroblast was less than that of antimetabolites. Further investigation of other aspects of suppress(suppress) wound healing as a possible antifibrotic agent should be deserved.

Antimetabolites↗

The effects of compression sutures on filtering blebs in rabbit eyes.

PURPOSE: To investigate the effect of compression sutures on filtering bleb cellularity in rabbit eyes. METHODS: Six New Zealand rabbits had bilateral filtering surgery. In the study eye, on postoperative day 14 a 10-0 nylon suture was placed that compressed the bleb. Five-bromo-2'-deoxyuridine (BrdU) was injected intravenously on days 15, 16, and 18. On day 21 histologic sections of the blebs were obtained. The total cell count was compared to the number of actively dividing cells (marked by anti-BrdU antibody). RESULTS: Study eyes had higher total cell counts (P = .004) on postoperative day 21, but the proportion of proliferating cells was not significantly different (P = .11). CONCLUSION: In rabbit eyes, bleb compression sutures were associated with more cellular components in the bleb compared to control eyes, but did not induce a higher level of cellular proliferation.

Animals↗

Periocular accumulation of timolol and betaxolol in glaucoma patients under long-term therapy.

PURPOSE: To determine if betaxolol or timolol is present in measurable concentration in the Tenon capsule in patients under long-term topical therapy. METHODS: Small (1-cc) specimens of Tenon capsule were removed at the time of filtering surgery from 15 glaucoma patients under long-term preoperative topical therapy, nine of whom had been treated with timolol and six of whom had been receiving betaxolol. Methanol extracts of these tissue samples were analyzed quantitatively for the presence of either beta-adrenergic antagonist by high-performance liquid chromatography. RESULTS: Drug was detected in every specimen. A mean total of 2.6 (range, 0.1-30.0) microg of betaxolol was detected per 1-cc specimen. CONCLUSION: Timolol and betaxolol penetrate the conjunctiva and accumulate in the Tenon capsule. In patients under long-term therapy, the periocular tissue can accumulate a greater quantity of beta-antagonist than is present in a daily dosage of applied eyedrops, manyfold higher than the maximal intraocular concentration.

Adrenergic beta-Antagonists↗

Recurrent bleb infections.

AIM: To report the patient characteristics, causative organisms, and clinical outcomes in patients with recurrent bleb related ocular infections. METHODS: The medical records of all patients diagnosed with bleb related ocular infection at the New York Eye and Ear Infirmary over a 10 year period were reviewed. Recurrent bleb infection was defined as at least two episodes of bleb purulence with or without associated intraocular inflammation separated by a quiescent period of at least 3 months. RESULTS: Recurrent bleb infections developed in 12 eyes of 12 patients (10 men, two women) a mean of 16.3 (SD 17.9) months (range 3-51 months) after the initial infection. Two patients developed a third episode 3 and 20 months, respectively, after the second infection, yielding a total of 14 recurrent infection episodes. Recurrent infection developed after trabeculectomy in 11 eyes (adjunctive 5-fluorouracil, nine eyes; mitomycin C, one eye; no antifibrosis agent, one eye) and following cataract extraction with inadvertent bleb formation in one eye. Four (36.4%) of the filtered eyes had undergone trabeculectomy at the inferior limbus. The mean follow up time from filtering surgery to the first bleb related infection was 28 months for the nine patients treated with 5-fluorouracil and 14 months for the single patient treated with mitomycin C. 11 (78.6%) cases had a documented bleb leak in the 4 week period before or at the time of recurrent infection. Topical, prophylactic antibiotics had been used in 7/14 (50%) cases. The same organism was cultured from the initial and recurrent infections in 2/14 (14.3%) cases. CONCLUSION: Eyes that have been successfully treated for bleb related infection remain at risk for recurrent infection. No apparent correlation exists between organisms responsible for the initial and recurrent infections. The increased rate of recurrent bleb related infection in patients receiving adjunctive 5-fluorouracil compared to mitomycin C may have been related to the longer follow up of the 5-fluorouracil eyes.

Adult↗

[Non-penetrating deep sclerectomy combined with a collagen implant in primary open-angle glaucoma. Medium-term retrospective results].

PURPOSE: To evaluate the middle term tonometric results of a new filtering procedure, the non penetrating deep sclerectomy with collagen device, in primary open-angle glaucoma. This technique aims to eliminate or minimize the complications of classical trabeculectomy. MATERIAL AND METHOD: This procedure has been developed by Koslov et al. Under a limbal-base conjunctival flap and a superficial scleral flap, the ablation of a deep scleral flap takes away the external wall of Schlemm's canal, leaving only the Descemet membrane. A visible filtration across the opened Schlemm's canal and Descemet membrane is obtained. To improve the aqueous filtration, a cylindric collagen device, made from biocompatible porcine scleral tissue, known for its high water content, is fixed in the deep scleral bed with a 10/0 nylon suture. This device provides a support for the elimination route of aqueous humor and acts like a sponge, carrying the liquid by capillary action. It is sterilized by irradiation. Full guarantee against viral contamination is provided. This procedure ends in one suture (40/0 nylon) of superficial scleral flap and conjunctival closing suture. We conducted a retrospective study. Our material included 159 patients (92 males, 65 females), 2/9 eyes. The mean age was 65 years (11-91). The mean follow-up : 8 months (3-20). The types of glaucoma were: POAG: 183 eyes; juvenile POAG: 18 eyes: pigmentary glaucoma: 11 eyes; capsular glaucoma: 7 eyes, 58 eyes (40 patients) presented one or several risk factors of failure for filtering surgery. RESULTS: The mean pre-operative IOP was 24 mmHg +/- 6.60; 15.7 +/- 5.30 at the end of the follow-up (delta average IOP: 9.1 +/- 7.1). The probability success rate (IOP < or = 20 mmHg), according to the Kaplan-Meier Method, was 89% at six months, 75.6% at 16 months. With monotherapy with beta blockers, 79% at 16 months. It was better in the without risk factors group. The mean change in visual acuity was inferior to 0.1 at the end of the follow-up. Except several hyphemas, no complications of the trabeculectomy were observed. The reelevation of IOP was due to an internal obstruction (goniosynechiae or bad filtration), it was treated with Nd-Yag laser with a 2/3 of success rate. External obstruction was treated by 5FU injections into the bleb. CONCLUSION: Non penetrating deep sclerectomy with collagen device can be an excellent alternative to trabeculectomy in open and wide angles. It does not modify visual actuity. It carries less complications than trabeculectomy and the use of antimitotic agents is safer.

Adolescent↗

[External sclerostomy using the THC:YAG Holmium laser in the treatment of glaucoma].

Ab externo THC:YAG Holmium laser sclerostomy is an interesting alternative to standard full thickness filtering surgery. We report our retrospective experience over a total number of 38 sclerostomies between march 1993 and september 1994 on 32 patients (33 eyes) with primary or secondary glaucomas composed of 17 phakic and 16 aphakic and/or pseudophakic eyes. The mean patient age is 62.9 years (range: 10 to 90 years). The mean follow-up time is 7.5 months (1 to 18 months). We used a long pulsed (300 microsec) laser emitting in the near infrared (2.1 microns). A conjunctival stab incision was made 12 mm away from the sclerostomy site to allow entry of a 22 G probe which delivers energy at a right angle to the long axis of the fiber. We used 100 mJ per pulse laser energy delivered at a rate of 5 impacts per second. The mean delivered energy to produce a functional sclerostomy was 16.1 J. All patients received subconjunctival injections of 5 Fluorouracil (mean number of injections: 7.4). Criteria for success included an IOP of 22 mmH or less with or without additional medical treatment and a decrease of at least 30% of IOP when the preoperative IOP was 22 mmHg or less. The mean preoperative IOP was 35.8 mmHg (21 to 54 mmHg). By 3 months, the mean IOP of the 14 eyes over 19 successfully controlled was 15.2 mmHg (8 to 22 mmHg) with additional medical treatment in 3 cases. By 6 months, 11 eyes over 11 successfully controlled was 14.1 mmHg (6 to 21 mmHg) with additional medical treatment in 3 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

Effectiveness and complications of mitomycin C use during pediatric glaucoma surgery.

PURPOSE: To examine the safety of mitomycin C (MMC) use in pediatric glaucoma surgery. DESIGN: Retrospective interventional case series. PARTICIPANTS: One hundred eighty pediatric glaucoma patients younger than 7 years of age (254 eyes) who underwent glaucoma surgery and were followed for at least 1 year participated. INTERVENTIONS: Surgeries consisted of trabeculectomy or combined trabeculotomy-trabeculectomy with adjunctive use of MMC. MAIN OUTCOME MEASURES: Control of intraocular pressure (IOP) and occurrence of complications were measured. An IOP below 21 mmHg without any additional medical or surgical treatment was considered a success. RESULTS: Primary congenital glaucoma was present in 98% of the patients. Sixty percent had a trabeculectomy, and 40% had a trabeculotomy-trabeculectomy. The combined surgery was performed mostly in infants up to 1 year of age. Complications were cystic bleb (19), bleb leak (4), retinal detachment (3), flat anterior chamber (3), cataract (2), and endophthalmitis (1). Children younger than 2 years of age had fewer complications but higher failure rates. The combined procedure in infants up to 2 years of age was moderately more successful (57%) than trabeculectomy alone (39%). Minimal complications seen in this group were more likely related to young age than to the type of surgery. Complications increased with time after surgery, with most occurring 2 years or more after surgery. CONCLUSIONS: Success of MMC-augmented glaucoma filtering surgery increased with age, as did the complication rate. Serious complications were uncommon in the authors' group of pediatric patients up to now. However, complications related to bleb thinning increased with time after surgery, and additional problems can be anticipated with longer follow-up.

Chemotherapy, Adjuvant↗

Axial length decrease accompanying successful glaucoma filtration surgery.

OBJECTIVE: To evaluate change in axial length measurement after successful glaucoma filtering surgery. DESIGN: Retrospective consecutive case series. PARTICIPANTS: Sixty-two patients with phakia who underwent primary trabeculectomy. INTERVENTION: The A-scan biometry of ocular axial length before and after trabeculectomy. MAIN OUTCOME MEASURES: Changes in ocular axial length measurement after successful trabeculectomy were analyzed. RESULTS: The mean decrease in axial length measurement was 0.423 mm (range, -2.8 to +0.5 mm). Regression analysis yielded a statistically significant association between decrease in axial length measurement and age (P = 0.0001) and post-trabeculectomy intraocular pressure decrease greater than 30 mmHg (P = 0.01). Analysis of variance revealed a significant association between decrease in axial length measurement and use of antimetabolite (P = 0.005). Pseudophakic axial length measurements increased an average of 0.275 mm compared to the axial length after trabeculectomy and before cataract surgery. CONCLUSIONS: Axial length measurement decreased in 32 of 62 eyes after successful initial trabeculectomy. A decrease in axial length measurement may have an influence on intraocular lens calculations. Therefore, the authors recommend that an axial length measurement be obtained on phakic eyes before an initial trabeculectomy to reduce the risk of an inaccurate intraocular lens power calculation based on post-trabeculectomy axial length measurements.

Adult↗

Molteno implant surgery for advanced glaucoma.

PURPOSE: The use of adjunctive antimitotics with conventional filtering surgery appears to have decreased the need for Molteno implants in glaucomas with a poor prognosis. We review the current status, results and complications of Molteno implants. METHODS: Review of the literature and practical experience from two university departments of ophthalmology. RESULTS: Improvements in the design and surgical techniques for Molteno implants have decreased the incidence of over filtration, but this and other complications continue to pose problems. Increased success rates may be possible if antimitotics are used with Molteno implants. CONCLUSION: Molteno implants continue to be an option when conventional filtration with or without antimitotics has failed; they continue to be regarded as a last resort for filtration. The use of antimitotics to increase the success rate of Molteno implants is not proven, but merits further investigation.

Conjunctiva↗

Photodynamic therapy for antifibrosis in a rabbit model of filtration surgery.

BACKGROUND AND OBJECTIVE: The purpose of this pilot study was to investigate the use of photodynamic therapy (PDT) using tin ethyl etiopurpurin (SnET2) as an adjunctive antifibrotic therapy for filtering surgery in a rabbit model. MATERIALS AND METHODS: The pharmacokinetics of SnET2 were established by intravenous (1 mg/kg) and subconjunctival (25, 50, or 75 micrograms) injections and compared with controls. Intravenous and subconjunctival SnET2 injections were given prior to posterior lip sclerectomies followed by postoperative laser irradiation (664 +/- 7 nm; 100 mW/cm2; 30 J/cm2). Antifibrotic efficacy was established by clinical response and histologic examination. RESULTS: After subconjunctival injections, large areas of avascular conjunctiva were produced and filtering bleb survival was prolonged. No effect was found for intravenously administered photosensitizer followed by light irradiation. CONCLUSIONS: PDT may be an alternative antifibrotic therapy for filtration surgery that does not use chemotherapeutic agents or ionizing radiation. Multiple parameters (light, drug dose, irradiation area) may be manipulated to improve predictability of the antifibrotic effect.

Animals↗

Retinal dialysis.

Analysis of 196 patients with retinal dialysis indicated that unilateral nasal and superior dialyses almost invariably were produced by trauma (87.5%). A traumatic cause is proposed for unilateral inferotemporal dialyses, which also had an inordinately high rate of trauma (56%). Bilateral retinal dialyses, making up 14% of all cases, had a much lower incidence of trauma. A nongenetic, developmental anomaly at the ora serrata may account for some bilateral cases. In all types of dialyses, women acknowledged trauma less frequently than men, which probably reflects a sociologic tendency for women to deny physical abuse. Twelve percent of dialysis patients had ocular hypertension exceeding 22 mm Hg and 16% had angle recessions. Successful detachment surgery normalized the intraocular pressure in most cases without additional filtering surgery or medications.

Adolescent↗

Late onset endophthalmitis associated with filtering blebs.

A consecutive series of 71 cases of late onset endophthalmitis (defined as onset of symptoms at least 2 weeks after surgery) were reviewed to determine the association of this entity with glaucoma surgery filtering blebs and to identify any predisposing factors. Sixteen cases were associated with filtering blebs and two with inadvertent blebs following cataract surgery. Onset of endophthalmitis ranged from 24 days to 20 years after surgery (mean, 6.9 years). Possible contributing factors included trauma, vitreous wicks, and bleb leak. Twelve cases were culture-positive, with 5 cases of Staphylococcus epidermidis; 2, Staphylococcus aureus; 4, Streptococcus; and 1, Pseudomonas. There were no cases of Hemophilus. The more virulent organisms were generally associated with a poor visual outcome. The organisms recovered in this series were similar to those found in postoperative endophthalmitis not associated with filtering blebs.

Adult↗

Use of digital compression following glaucoma surgery.

A survey of American glaucoma specialists showed that digital compression of the globe following filtering surgery for glaucoma is used extensively. Consensus regarding the method and timing of "massage" is lacking, as are controlled clinical studies supporting its assumed benefits.

Glaucoma↗

Pressure control in glaucoma patients after cataract surgery with intraocular lens.

In a retrospective study 97 patients with glaucoma and 16 with ocular hypertension were examined with regard to intraocular pressure (IOP) after extracapsular cataract extraction with implantation of a posterior chamber lens. During the follow-up 39 cases dropped out but 63 glaucoma patients and 11 patients with ocular hypertension were followed for three years. Compared to preoperative IOP 59% of the patients treated previously with Argon laser trabeculoplasty (ALT) had an IOP rise of > 10 mm Hg the day after surgery. The corresponding proportion among medically treated patients was 34% (P = 0.01). A pressure rise of > 10 mm Hg was less frequent among patients treated with one drug than among those treated with two or three (P = 0.05). During follow-up eight patients had a pressure rise which could not be controlled medically and they had to undergo additional ALT or surgery. All eight had been treated with ALT or with glaucoma filtering surgery prior to the cataract operation. After three years observation of 63 of the glaucoma patients, 63% were having less medical therapy than preoperatively, 30% an equal amount and 7% more; 49% (31 of 63) were still without any therapy. In the group of patients who preoperatively were only treated medically, no definite increase in therapy was needed in the long term.

Aged↗