The efficacy and safety of intraoperative and/or postoperative 5-fluorouracil in trabeculectomy and phacotrabeculectomy

Purpose : First, to assess the safety and efficacy of using 5‐fluorouracil (5‐FU) to improve trabeculectomy and phacotrabeculectomy success rates, and second, to assess the efficacy of intraoperative and reduced postoperative 5‐FU following trabeculectomy compared with a more intensive course of postoperative 5‐FU alone. Methods : In a retrospective, unmatched, non‐randomized consecutive series study, 186 eyes of 186 patients who had filtration surgery were followed for 2 years in four groups: 51 patients had undergone trabeculectomy surgery with postoperative 5‐FU, 51 had phacotrabeculectomy with postoperative 5‐FU, 56 had trabeculectomy with both intraoperative and postoperative 5‐FU, and 28 patients had trabeculectomy without antifibrotics. Results : At all times mean intraocular pressure (IOP) was reduced in all groups (P < 0.001 for each group). Success was defined as IOP < 16 mmHg and > 30% IOP reduction at the 2‐year follow up. It was achieved in 71% of the trabeculectomy patients with intraoperative and postoperative 5‐FU, 76% of the trabeculectomy group with only postoperative 5‐FU, 55% of the phacotrabeculectomy/ 5‐FU group, and in 29% of the trabeculectomy‐only eyes (between‐group differences P < 0.01). Success rates were not significantly different for the intraoperative and postoperative 5‐FU trabeculectomy versus the postoperative 5‐FU‐only eyes, but the former had fewer postoperative 5‐FU injections and corneal ulceration (P < 0.01 for both). Conclusions : 5‐Fluorouracil was safe and improved trabeculectomy survival. Intraoperative 5‐FU allowed fewer postoperative 5‐FU injections and fewer side‐effects without compromising success rates. Phacotrabeculectomy with postoperative 5‐FU had a lower surgical success rate than did trabeculectomy with 5‐FU and this was not statistically different from trabeculectomy without 5‐FU.     

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=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.     

Beta radiation as an adjunct to low-risk trabeculectomy

Purpose : To assess a single dose of intraoperative beta radiation used to enhance the success rate of trabeculectomy in a population of low‐risk glaucoma patients in whom antimetabolites might not be indicated. Methods : A prospective randomized trial of 65 eyes was designed, with 31 eyes receiving 750 rads of intraoperative beta radiation (group 1), and 34 eyes receiving no supplementation (group 2). Results : Mean follow‐up time was 24 months. Mean postoperative intraocular pressure was 12.2 mmHg in group 1, and 13.7 mmHg in group 2 (P = 0.16). Mean decrease in intraocular pressure was 10.3 mmHg in group 1, and 9.3 mmHg in group 2 (P = 0.49). The two groups were not significantly different in terms of surgical complications. Conclusion : For this population of low‐risk patients, there was no significant difference in outcome after applications of a single intraoperative dose of beta radiation.     

Intraoperative mitomycin versus postoperative 5-fluorouracil in high-risk glaucoma filtering surgery.

In a randomized clinical trial, the authors compared the use of postoperative subconjunctival injections of 5-fluorouracil (5-FU) in 19 eyes with a single intraoperative application of subconjunctival mitomycin (MMC) at the filtering site in 20 eyes at high risk for failure of glaucoma filtering surgery. Six months after surgery, intraocular pressures averaged 10.9 +/- 5.3 mmHg (mean +/- standard deviation) in the MMC-treated eyes versus 14.2 +/- 5.5 mmHg in the 5-FU-treated eyes (P = 0.08) and were less than or equal to 12 mmHg in 60.0% of MMC-treated eyes and 21.1% of 5-FU-treated eyes (P = 0.03). Mitomycin-treated eyes were receiving an average of 0.3 +/- 0.5 medications for intraocular pressure control, and 5-FU-treated eyes were receiving an average of 1.1 +/- 1.1 medications (P = 0.01). Drug-induced corneal epithelial defects were seen in nine 5-FU-treated eyes and in no MMC-treated eyes (P = 0.0004). These results suggest that intraoperative MMC may be a viable alternative to postoperative 5-FU, with lower overall intraocular pressures, decreased dependence on postoperative ocular antihypertensive medications, and decreased corneal toxicity.     

小梁切除术联合丝裂霉毒C治疗青光眼的临床疗效

目的:探讨小梁切除联合丝裂霉素C(mitomycin C,MMC)治疗青光眼的临床疗效。方法:原发性青光眼患者57例95眼随机分为两组,为小梁切除术联合MMC(T+MMC)组(31例54眼)和小梁切除术(T)组(26例41眼),术后随访4~6mo,观察其前房、滤过泡、眼压及并发症。结果:T+MMC组术后1d平均眼压为11.24±3.73mmH g,较术前眼压明显降低(P<0.01),与T组比较差异无统计学意义(P>0.05)。而末次随访平均眼压为16.15±3.62mmH g,与T组(18.79±5.27mmH g)比较具有统计学差异(P<0.05)。T+MMC组和T组功能性滤过泡形成率分别为94.44%和80.48%,组间差异具有显著统计学意义(P<0.01)。两组偶发前房出血、角膜水肿,均治愈。结论:采用小梁切除术联合MMC治疗青光眼,术后眼压控制及滤过泡形态维持均良好,并发症少。     

Seprafilm as a new antifibrotic agent following trabeculectomy in rabbit eyes

Purpose  To investigate the efficacy of Seprafilm (Genzyme, Framingham, MA, USA) in preventing postoperative adhesion between the conjunctiva and sclera after glaucoma filtering surgery. Methods  A subconjunctival pocket was created and Seprafilm was inserted into the pocket in nine rabbits (Seprafilm group), whereas in a second group, a subconjunctival pocket was created in nine rabbits but no Seprafilm was inserted (non-Seprafilm group). The postoperative adhesion force was measured 4 weeks after surgery. For the trabeculectomy study, trabeculectomy was performed and Seprafilm placed on the scleral flap in five rabbits (Seprafilm trabeculectomy group), whereas in a second group, trabeculectomy was performed in five rabbits but no Seprafilm was placed (non-Seprafilm trabeculectomy group). Filtering bleb formation and intraocular pressure (IOP) was evaluated on days 1, 3, 5, 7, 14, 21, and 28 following surgery. The eyes were enucleated for histologic evaluation 4 weeks after surgery. Results  The mean adhesive force between the conjunctiva and sclera in the Seprafilm group (125.6 ± 94.5 mmHg) was lower than that of the non-Seprafilm group (263.3 ± 79.3 mmHg) (P = 0.0041, unpaired t test). A more prominent bleb was observed in the Seprafilm trabeculectomy group than in the non-Seprafilm trabeculectomy group. Histologically, the subconjunctival space was larger in the Seprafilm trabeculectomy group than in the non-Seprafilm trabeculectomy group. Mean IOP was significantly lower in the Seprafilm trabeculectomy group (9.9 ± 0.6 mmHg) than in the non-Seprafilm trabeculectomy group (11.9 ± 0.7 mmHg) 4 weeks after surgery (P = 0.0044, unpaired t test). Conclusions  Seprafilm can reduce postoperative conjunctiva-sclera adhesion and may be a desirable antifibrotic agent for trabeculectomy in the early stages of wound repair.     

Fornix-based trabeculectomy using the 'anchoring' corneal suture technique

Aim: To assess the safety and efficacy of fornix‐based tra­beculectomy with the ‘anchoring’ corneal suture technique in Chinese patients. Methods: A retrospective non‐comparative case series of 66 eyes of 63 Chinese patients who underwent fornix‐based trabeculectomy combined with intraoperative mitomycin C (MMC) 0.4 mg/mL for 2?5 min were studied. Conjunctival wound closure of all eyes was with the anchoring corneal suture technique using a 9?0 nylon suture to prevent leakage at the corneolimbal interface. The success rate, with or without anti‐glaucoma medication, the complication rate and the longevity of the drainage blebs were analyzed. Results: At a mean follow‐up period of 447.36 ± 337.98 days, the mean intraocular pressure decreased from 26.83 ± 7.90 mmHg to 17.74 ± 8.74 mmHg (P < 0.001). The mean glaucoma medication decreased from 2.95 ± 0.98 preoperatively to 1.23 ± 1.41 postoperatively (P < 0.001). Thirty‐one eyes (47.0%) required no anti‐glaucoma medication postoperatively. Twenty eyes (30.3%) had qualified success postoperatively. Eight eyes (12.1%) had early wound leakage that resolved with conservative treatment. Three eyes (4.5%) required surgical repair. One eye (1.5%) had hypotonous maculopathy. No other major complications were encountered. Conclusion: Fornix‐based trabeculectomy with adjunctive mitomycin C employing the anchoring corneal suture technique appears to be both safe and effective in Chinese patients.     

原发性闭角型青光眼高眼压下复合式小梁切除术的疗效

目的：探讨高眼压下原发性闭角型青光眼采用复合式小梁切除术治疗的临床疗效。
　　方法：选取33例34眼原发性闭角型青光眼患者均实行复合式小梁切除术,其中A组：18例18眼患者经联合用药48~72 h后,眼压仍在35 mmHg以上,在高眼压下施行复合式小梁切除术;B组：15例16眼患者经过药物治疗后眼压降至21 mmHg以下,施行复合式小梁切除术。术后观察视力、眼压。
　　结果：患者34眼均顺利完成手术,未发生爆发性脉络膜出血等严重的并发症。术后随访6~18mo,两组患者手术前后视力均有明显改善,分别由术前0.02±0.01、0.04±0.02提高到0.2±0.06、0.3±0.07,差异有统计学意义( P<0.01);30眼眼压均控制在9~23mmHg,3眼联合降眼压药物后眼压控制正常,1眼滤过失败, A、B组患者术后眼压较术前明显降低,差异有统计学意义(P<0.01),基本降至正常,分别为17.9±9.1、15.4±8.4mmHg,两组患者术后眼压无统计学差异(P>0.05)。
　　结论：对于持续高眼压下的原发性闭角型青光眼,应果断考虑高眼压下施行复合式小梁切除术,以防视功能进一步损害甚至丧失。只要术前全面考虑,术中精心操作,术后仔细护理,持续高眼压下的原发性闭角型青光眼施行复合式小梁切除术是安全、有效的。     

Effect of postoperative subconjunctival 5-fluorourcil injections on the surgical outcome of trabeculectomy in the Japanese

A controlled study was carried out to evaluate the effect of postoperative subconjunctival 5-fluorouracil (5-FU) injections on the surgical outcomes of trabeculectomy in the Japanese (a total of 196 eyes in 157 patients). The eyes that had undergone trabeculectomy with postoperative 5-FU (5-FU group) included 36 eyes with primary open-angle glaucoma (POAG) and 17 with secondary glaucoma (SG) undergoing their first or second trabeculectomy. There were also 34 eyes with refractory glaucoma. The eyes that had had trabeculectomy without postoperative 5-FU (control group) included 46 POAG and 31 SG eyes undergoing their first or second trabeculectomy and 24 refractory glaucoma eyes. The surgical techniques and postoperative care were virtually identical between the two groups, except that the control group did not receive 5-FU. The results were analyzed by means of a life table method and a postoperative intraocular pressure (IOP) level equal to or less than 20 mmHg was adopted as the criterion for successful IOP control. In the 5-FU group, the success probability (%) at the 3-year follow-up was 93.9 ± 4.2 (SE) for POAG eyes, 93.8 ± 6.1 for SG eyes, and 86.7 ± 5.6 for refractory glaucoma eyes. In the control group, it was 55.0 ± 7.9, 37.2 ± 13.5, and 16.1 ± 7.4, respectively. The difference in success probability between the 5-FU and control groups was highly significant (P < 0.001 or 0.01). In the POAG and SG eyes, the mean postoperative IOP was significantly lower in the 5-FU group than in the control group. Except for the fact that the corneal epithelial defect and conjuntival wound leak were encountered significantly more frequently in the 5-FU group, there was no significant difference in the incidences of postoperative complications between the 5-FU and control groups. Postoperative subconjunctival 5-FU increased the success probability of the trabeculectomy operation.     

Success criteria and success rates in trabeculectomy with and without intraoperative antimetabolites using intensified postoperative care (IPC)

Purpose: To define the success rate of trabeculectomy for surgical treatment of glaucoma under intensified postoperative care (IPC) conditions in cases of severe visual field damage or progression of visual field loss. Methods: In a retrospective study, we evaluated the outcome of trabeculectomy in 99 eyes of 99 patients from October 1995 to June 1997. In 23 eyes, antimetabolites were used intraoperatively. Regarding intraocular pressure (IOP), success was defined as lowering the preoperative, maximally treated IOP by more than 20% in addition to a postoperative IOP level lower than 21 mmHg without using further glaucoma medication. Success rate was defined by stabilisation of visual acuity and visual field in addition to IOP reduction. Results: The postoperative IOP was 14.7 mmHg (±3.4 mmHg) following standard trabeculectomy (preoperative IOP 24.3±6.7 mmHg) and 15.8 mmHg (±4.9 mmHg) following trabeculec-tomy with intraoperative anti- metabolites (preoperative IOP 27.0±9.5 mmHg). The success rate concerning the IOP was 83% in standard trabeculectomy and 74% following trabeculectomy with intraoperative antimetabolites. The visual acuity showed stabilisation in 93% of cases following standard trabeculectomy and in 100% following trabeculectomy with intraoperative antimetabolites. The visual field showed stabilisation according to the Aulhorn criteria in 95% and 94% of cases following standard trabeculectomy and trabeculectomy with intraoperative antimetabolites, respectively. The total success rate using all criteria together was 76% following standard trabeculectomy and 74% following trabeculectomy with intraoperative antimetabolites. Conclusion: The overall outcome after trabeculectomy is good with appropriate follow-up and timely decisions for after- treatment to ensure good development of the filtering bleb. Received: 24 June 1999 Revised: 6 January 2000 Accepted: 18 January 2000     

Outcomes of primary phakic trabeculectomies without versus with 0.5- to 1-minute versus 3- to 5-minute mitomycin C

PURPOSE: To compare the intraocular pressure and hypotony outcomes of primary phakic trabeculectomies with no mitomycin C (MMC), shorter MMC, and longer MMC exposure.METHODS: We evaluated primary phakic trabeculectomies with no MMC (36 eyes of 36 patients), 0.5- to 1-minute MMC (50 eyes of 50 patients), and 3- to 5-minute MMC (38 eyes of 38 patients) at the concentration of 0.5 mg/ml. Successful trabeculectomy was defined as an intraocular pressure of 21 mm Hg or less without development of a marked visual acuity loss associated with prolonged hypotony (intraocular pressure < 6 mm Hg over 3 months) and without the need for additional surgery to control intraocular pressure or treat postoperative complications.RESULTS: The three groups were similar in demographics, preoperative intraocular pressure, and medical dependency. However, the incidence of hypotony during the postoperative periods of 3 to 12 months was significantly higher in the 3- to 5-minute MMC group (P < .05, chi-square test). Severe visual acuity loss associated with hypotony was also more frequently found in the 3- to 5-minute MMC group than in the 0.5- to 1-minute (P = .009, chi-square test) group or the control group (P = .014, chi-square test). In addition, the success probabilities were significantly different among the three groups (P = .001, Kaplan-Meier survival analysis with log-rank test) and were the highest in the 0.5- to 1-minute MMC group and the lowest in the 3- to 5-minute MMC group.CONCLUSION: Shorter application (0.5 to 1 minute) of MMC appears to be optimal for the successful outcome of primary phakic trabeculectomy compared with no MMC or longer application of MMC at a concentration of 0.5 mg/ml.     

白内障超声乳化术联合小梁切除术治疗青光眼合并白内障的临床疗效

目的:观察白内障超声乳化吸除及人工晶状体植入术联合小梁切除术治疗原发性闭角型青光眼(primary angle-closure gloucoma,PACG)合并白内障的临床疗效和安全性。方法:对49例59眼PACG合并白内障患者进行回顾性调查研究,其中急性闭角型青光眼(急性ACG)35眼,慢性闭角型青光眼(慢性ACG)24眼。患者均行白内障超声乳化吸除及人工晶状体植入术联合小梁切除术。观察患者术前及术后视力、眼压、中央前房深度、晶状体厚度、眼轴、术后用药情况及并发症。随访6～12mo。结果:(1)急性ACG组术前(n=35眼)平均眼压23.9±6.6mmHg,术后12mo时(n=28眼)平均眼压11.7±2.6mmHg(P<0.01)。慢性ACG组(n=24眼)术前平均眼压20.9±6.5mmHg,术后12mo时(n=19眼)平均眼压14.5士1.4mmHg(P<0.01)。急性ACG组术后眼压降低幅度为11.3±5.9mmHg,慢性ACG组为7.4±7.1mmHg,差异有统计学意义(P<0.05)。(2)PACG59眼术后末次复查时44眼(74.6%)视力较术前提高。(3)急性ACG组术前、术后中央前房深度分别为1.79±0.15,3.32±0.17mm,差异有统计学意义(P<0.01)。慢性ACG组术前、术后中央前房深度分别为1.84±0.19,3.37±0.20mm,差异有统计学意义(P<0.01)。(4)两组晶状体厚度/眼轴长度系数分别为2.26±0.16,2.14±0.13,差异有统计学意义(P<0.01)。(5)急性ACG组、慢性ACG组手术完全成功率分别为94.3%,87.5%,条件成功率分别为5.7%,8.3%。(6)全部患者术后有15眼(25.4%)发生轻或中度角膜内皮水肿,15眼(25.4%)发生前房纤维素渗出。结论:白内障超声乳化吸除及人工晶状体植入术联合小梁切除术是治疗PACG合并白内障的有效而安全的方法。急性ACG的疗效优于慢性ACG。     

Results of combined phacoemulsification and trabeculectomy with mitomycin C in pseudoexfoliation versus non-pseudoexfoliation glaucoma

Background This study was conducted to evaluate the rate of intraoperative and postoperative complications and the outcome of combined phacoemulsification (phaco) with posterior chamber (PC) intraocular lens (IOL) and trabeculectomy in patients with pseudoexfoliation (PXF) versus non-pseudoexfoliation (non-PXF) glaucoma. Methods One hundred and four eyes of 88 patients with combined phaco, PC IOL and trabeculectomy with mitomycin C (MMC) were included in the study. MMC 0.02% was applied for 1 min in all cases. Main outcome measures were rate of intraoperative and postoperative complications, intraocular pressure (IOP) and visual acuity (VA). Success rates were determined via Kaplan–Meier survival analysis. Surgical success for both groups was defined as IOP being less than 21 mmHg with no treatment or less than 16 with one topical pressure-reducing agent allowed. Results The PXF group included 55 (52.9%) eyes and the non-PXF group 49 (47.1%) eyes. Transition to extracapsular cataract extraction (ECCE) occurred in 12.7% of the PXF group, and in 6.1% of the non-PXF group (P=0.16). The occurrence of vitreous loss did not differ significantly between the groups. Patients of both groups had a significant IOP reduction after surgery (P=0.0001). At the end of postoperative follow-up, the success rate approached 83.6% in the PXF group and 83.7% in the non-PXF group. The most common postoperative complications were hyphema (14.5%) in the PXF group and fibrin (14.3%) in the non-PXF group. Conclusions Although transition to ECCE was more frequent in the PXF than in the non-PXF group, there was no significant difference in the rate of complications between PXF and non-PXF eyes. The Department of Ophthalmology, Kaplan Medical Center, Rehovot is affiliated to the School of Medicine, Hebrew University and Hadassah, Jerusalem, Israel.     

Effect of subconjunctival Bevacizumab injection on the outcome of Ahmed glaucoma valve implantation: a randomized control trial

Importance

The effect of subconjunctival Bevacizumab injection on the outcome of Ahmed glaucoma valve (AGV) implantation.

Background

Evaluation of efficacy and safety of subconjunctival Bevacizumab injection adjunctive to AGV implantation.

Design

Prospective and randomized clinical trial.

Participants

Fifty eyes of 50 patients with diagnosis of glaucoma that were candidate for AGV surgery were included.

Methods

In 25 eyes, conventional AGV surgery (group 1) and in 25 eyes AGV surgery with subconjunctival Bevacizumab (group 2) was performed by block randomization

Main Outcome Measures

The primary outcome measure was surgical success. Outcome measures were compared at postoperative month 3, 6 and 12.

Results

Mean age of patients was 58.76 ± 12.11 and 51.36 ± 15.44 years in group 1 and 2 respectively (P = 0.06). Mean intraocular pressure (IOP) at baseline was 24.88 ± 7.62 mmHg in group 1 and 27.52 ± 8.57 mmHg in group 2 which decreased to15.4 ± 4.4 mmHg in group 1 and 13.42 ± 2.9 mmHg in group 2 (P < 0.00) at last follow up. Surgical success was defined in two level: postoperative IOP ≤ 21 mmHg with at least 20% reduction in IOP (Criterion A), either with no medication (complete success) or with no more than two medications (qualified success) and criterion B with the same definition but the IOP ≤ 18 mmHg The cumulative success according to criterion A and B was 77.8%, 72.2% in group 1 and 89.5% in group 2, respectively, at the end of follow‐up.

Conclusions and Relevance

Subconjunctival injection of Bevacizumab adjunctive to AGV implantation leads to higher success rate compared with AGV alone in one year follow‐up.     

开角型青光眼小梁切除术中应用胶原蛋白基质与MMC的疗效比较

目的:观察开角型青光眼行小梁切除术中应用胶原蛋白基质与MMC的临床效果,评价两组术后有效性及安全性.方法:选取2015-01/2016-12于我院诊断为开角型青光眼的患者24例32眼,随机分为两组,行小梁切除术中应用胶原蛋白基质12例14眼为研究组;行小梁切除术中应用MMC 12例18眼为对照组.观察两组患者术后1d,1wk,1、3、6mo眼压、手术成功率、术后应用降眼压药物情况及手术并发症情况.结果:术后1d两组患者眼压均数差异有统计学差异(P<0.05).术后1wk,1mo两组患者眼压均数差异无统计学差异(P>0.05),术后3、6mo两组患者眼压均数差异性有计学意义(P<0.05).术后6mo两组患者手术成功率差异无统计学意义(P>0.05).两组患者术前眼压均值在术后1d有明显下降趋势,术后1wk~ 6mo眼压均数水平趋向平稳,术后3、6mo研究组平均眼压水平线较对照组低.术后6mo研究组有28%患者需要用降眼压眼液控制眼压,对照组有33%患者需要用降眼压眼液控制眼压,两组间比较无统计学意义(P>0.05).研究组与对照组术后1d并发症发生率比较无统计学意义(P>0.05).结论:开角型青光眼小梁切除术应用胶原蛋白基质的手术成功率与应用MMC的治疗效果相似,其降低眼压幅度较应用MMC明显,其避免术后发生低眼压、浅前房、结膜伤口渗漏并发症较应用MMC无明显优势.     

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.     

Bleb vascularity following post‐trabeculectomy subconjunctival bevacizumab: a pilot study

Background: To determine whether postoperative subconjunctival bevacizumab significantly alters bleb vascularity. Design: A randomized, prospective interventional study. Participants: Forty‐three eyes from 39 patients were recruited, with 21 eyes randomized to subconjunctival injections of 5‐fluorouracil, and 22 eyes to combined 5‐fluorouracil/bevacizumab. Methods: All patients who underwent uncomplicated primary antimetabolite augmented trabeculectomy who subsequently required postoperative subconjunctival 5‐fluorouracil injection within 4 weeks of surgery were eligible. Patients were randomized to receive subconjunctival 5‐fluorouracil only (7.5 mg/0.15 mL) or 5‐fluorouracil plus bevacizumab (1.25 mg/0.05 mL). Main Outcome Measures: Primary outcome was bleb vascularity with secondary endpoints including visual acuity, intraocular pressure, bleb morphology, complications and total numbers of 5‐fluorouracil injections were recorded at baseline, week 12 and 18 months. Results: At week 12, there was no significant difference between groups for visual acuity, intraocular pressure, bleb vascularity and morphology, or total number of 5‐fluorouracil injections. By 18 months, 47.4% of the 5‐fluorouracil/bevacizumab group exhibited central bleb avascularity compared with 21.1% of the 5‐fluorouracil group (Fisher's exact test, P = 0.17). Two bleb complications (one blebitis; one suture abscess) recorded in the 5‐fluorouracil/bevacizumab group. Conclusions: After a single combined injection, a trend for increased central bleb avascularity was observed, although this effect was not sufficient to reach statistical significance. This, in addition to the occurrence of two bleb‐related complications in the bevacizumab group, suggests the need for a larger clinical trial to further evaluate the safety and efficacy of bevacizumab as a modulating agent in glaucoma filtration surgery.     

Effect of different application depths of mitomycin-C in deep sclerectomy with collagen implant: a randomized controlled trial

Purpose: To evaluate effects of mitomycin‐C (MMC) in deep sclerectomy with collagen implant applied under the superficial scleral flap or under the deep scleral flap. Methods: Twenty‐five patients with primary or secondary open‐angle glaucoma and at high risk for postoperative cicatrization underwent deep sclerectomy and were randomly distributed to the two treatment arms. In the superficial MMC group (S‐MMC), MMC was applied under the superficial scleral flap using a soaked sponge for 60 s; in the deep MMC group (D‐MMC), MMC was applied under the deep scleral flap for 60 s before entering the Schlemm's canal. In both groups, remaining MMC was irrigated with 40 mL balanced salt solution. Patients were followed up for up to 2 years. The volume of filtering blebs was studied with ultrasound biomicroscopy at the last follow‐up visit. Results: Mean preoperative intraocular pressure (IOP) was 20.5 ± 8.9 mmHg for D‐MMC and 21.6 ± 6.6 mmHg for S‐MMC eyes (P = 0.67). The mean postoperative IOP was 5.3 ± 3.3 mmHg (D‐MMC) and 6.9 ± 4.8 mmHg (S‐MMC) at day 1 (P = 0.22) and 11.4 ± 6.3 mmHg (D‐MMC) versus 11.3 ± 4.6 mmHg (S‐MMC) at last follow up (P = 0.54). The mean number of medications per patient was reduced from 2.5 ± 0.5 to 0.4 ± 0.5 (D‐MMC) (P < 0.001) and from 2.5 ± 0.9 to 0.3 ± 0.4 (S‐MMC) (P < 0.001). Ultrasound biomicroscopy at 24 months showed mean intrascleral space volume of 1.97 ± 0.35 mm3 (D‐MMC) and 5.68 ± 0.42 mm3 (S‐MMC) (P < 0.05). Conclusion: No significant difference in efficacy and safety was found between the two groups at a mean of 19.2 months of follow up. Deep scleral application of MMC, however, seems to produce significantly smaller intrascleral blebs.     

Viscocanalostomy versus trabeculectomy in white adults affected by open-angle glaucoma: a 2-year randomized,controlled trial

PURPOSE: To compare the effectiveness and safety of viscocanalostomy and trabeculectomy in adults with uncontrolled open-angle glaucoma. DESIGN: Single-masked, parallel-group, prospective, randomized 24-month trial, with 90% power to detect a clinically important difference between groups. PARTICIPANTS: Fifty consecutive patients (50 eyes) with primary open-angle or pseudoexfoliative glaucoma. INTERVENTION: Eyes were assigned randomly to either viscocanalostomy (group 1) or trabeculectomy (group 2) with no intraoperative antifibrotics in the study eye. In group 1, no further intervention was allowed, whereas trabeculectomy eyes could receive subconjunctival 5-fluorouracil (5-FU) injections or laser suture lysis after surgery. MAIN OUTCOME MEASURES: Success rate based on intraocular pressure (IOP), visual acuity, discomfort, and other complications. RESULTS: At the end of the 24-month follow-up, IOP of 21 mmHg or less and more than 6 mmHg was achieved in 76% in group 1 (n = 19) and in 80% in group 2 (n = 20; log-rank P = 0.60); an IOP between 6 and 16 mmHg was obtained in 56% in group 1 (n = 14) and in 72% in group 2 (n = 18; log-rank P = 0.17; Kaplan-Meier cumulative probability of success). Complications of viscocanalostomy included one intraoperative conversion into trabeculectomy; microruptures in Descemet's membrane in five eyes; three cases of iris incarceration in the Decemet's window, two of which caused early failure of the procedure requiring reoperation; and a 1-mm to 2-mm transient self-resolving hyphema in three cases. Complications of trabeculectomy included one case of postoperative bleb bleeding with early transient IOP spike; one early hyphema; five cases of postoperative hypotony, two of which had a positive Seidel test from the conjunctival suture; three cases of transient choroidal detachment, two of which had shallow anterior chamber. No patient required reoperation. Two eyes required argon laser suture lysis, and nine underwent one or more 5-FU injections, which caused punctate keratopathy in three eyes. CONCLUSIONS: Viscocanalostomy is an effective IOP-lowering procedure in white adults affected by open-angle glaucoma. Trabeculectomy with postoperative 5-FU can probably provides lower IOPs but, with more numerous complications, greater discomfort, and more intensive postoperative management.     

Enhancement of the success rate in trabeculectomy: large-area mitomycin-C application

Background: To compare the effects of variable mitomycin‐C (MMC) applications during trabeculectomy on target intraocular pressure (IOP), number of antiglaucomatous therapy, bleb morphology and surgical complications. Methods: 66 glaucoma cases who underwent trabeculectomy combined with small‐area (Group 1) or large‐area (Group 2) MMC application were included. This study is a retrospective case series comparison. In Group 1, MMC had only been applied to the scleral flap area, whereas additional MMC applications were performed on upper temporal and nasal quadrant in Group 2. The cases with diabetes, narrow angle glaucoma, secondary glaucoma, history of previous ocular surgery and follow‐up period less than 2 years were exluded from the study. A routine ophthalmological examination was performed in all cases and IOP measurements, morphology and the function of the blebs, necessity for antiglaucomatous medications and complications at first month and second year were evaluated. Results: There were 32 cases (48.5%) in Group 1 and 34 cases (51.5%) in Group 2. The mean IOPs were 12.6 ± 5.5 and 10.8 ± 5.3 mmHg at first month (P > 0.05), whereas 14.4 ± 2.8 and 10.1 ± 2.6 mmHg at second year, respectively (P < 0.05). The mean number of medications were 3.3 ± 1.6 and 3.2 ± 0.2 preoperatively (P > 0.05), whereas 0.8 ± 1.2 and 0.26 ± 0.70 at second year (P < 0.05). The number of diffuse blebs was higher in Group 2 whereas the number of cystic blebs was higher in Group 1 (P > 0.05). There was no difference between two groups with regards to the number of eyes with hypotonia (P > 0.05). Conclusions: Large‐area MMC application seems to increase long‐term success without increasing the complication rates in trabeculectomy.