Primary viscocanalostomy versus trabeculectomy for primary open-angle glaucoma: three-year prospective randomized clinical trial

PURPOSE: To compare the efficacy and safety of viscocanalostomy and trabeculectomy in patients with primary open-angle glaucoma (POAG). SETTING: Department of Ophthalmology, Ankara Education and Research Hospital, Ankara, Turkey. METHODS: In this prospective randomized trial, 50 eyes of 50 patients with medically uncontrolled POAG were randomized to have a trabeculectomy (25 eyes) or a viscocanalostomy (25 eyes). Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before surgery and 1 day, 1 week, 1, 3, and 6 months, and 1, 2, and 3 years postoperatively. RESULTS: At 3 years, the mean IOP was 16.0 mmHg +/- 7.07 (SD) in the trabeculectomy group and 17.8 +/- 4.6 mmHg in the viscocanalostomy group (P=.694). Complete success (IOP 6 to 21 mm Hg without medication) was achieved in 66.2% of eyes at 6 months and 55.1% at 3 years in the trabeculectomy group and in 52.9% and 35.3%, respectively, in the viscocanalostomy group (P>.05). Qualified success (IOP 6 to 21 mmHg with medication) was achieved in 95.8% of eyes at 6 months and 79.2% at 3 years in the trabeculectomy group and in 90.7% and 73.9%, respectively, in the viscocanalostomy group (P>.05). Postoperative hypotony and cataract formation occurred more frequently in the trabeculectomy group than in the viscocanalostomy group (P=.002). CONCLUSIONS: Primary trabeculectomy lowered IOP more than viscocanalostomy in POAG patients. However, the complication rate was lower in the viscocanalostomy group.     

Combined cataract and glaucoma surgery: endoscope-controlled erbium:YAG-laser goniotomy versus trabeculectomy

Background To compare endoscopic infrared laser trabecular ablation and trabeculectomy (both combined with cataract surgery) regarding intraocular pressure (IOP), visual acuity, antiglaucomatous drugs and complications.Methods Seventeen eyes of 14 patients [age 74.7±11.7 years (arithmetic mean ± standard deviation)]—13 with primary open-angle glaucoma (POAG) and four with pseudoexfoliation glaucoma (PEXG)—underwent standard cataract surgery. After lens implantation, a probe (1.1 mm external diameter) with optic and laser fibres and an irrigation tube was introduced through the cataract incision. To perforate Schlemms canal, 15–17 single pulses (16 mJ, 160 s) were applied using a photoablative infrared laser (Er:YAG, =2.94 m). All eyes except one received antiglaucoma treatment. The control group treated with cataract surgery and trabeculectomy consisted of 17 eyes (13 POAG, four PEXG) of 15 patients (age 75.0±5.6 years), each eye received antiglaucoma treatment.Results Mean follow-up was 3 years. The eyes treated with the endoscopic laser showed a mean preoperative IOP of 23.3±4.3 mmHg, which was reduced to 15.0±2.1 mmHg (mean IOP lowering 33.7%) after 3 years. Five eyes needed no medication for IOP-control after the procedure. Two eyes needed further surgery for IOP-control. In the control group, mean IOP was 24.5±2.6 mmHg in the beginning and 17.3±6.2 mmHg after 3 years, corresponding to a 33.3% lowering of IOP. Six eyes needed no medication, four eyes needed further surgery to lower IOP.Conclusions After 3 years follow-up of a small pilot group, combined endoscopic infrared laser surgery with cataract surgery seems to be a safe and effective way to lower IOP. It shows the same ability to lower IOP as combined cataract surgery with trabeculectomy. In addition, there are markedly less complications with the endoscope-controlled photoablative laser procedure.The authors have no proprietary interest in the techniques used. This study was presented in part at the 101st meeting of the Deutsche Ophthalmologische Gesellschaft (DOG), Berlin, 2003.     

Ab interno gel implant in patients with primary open angle glaucoma and pseudoexfoliation glaucoma

Purpose

To compare efficacy and safety results of an ab interno gel implant in patients with pseudoexfoliation glaucoma (PXG) and primary open angle glaucoma (POAG).

Methods

Retrospective analysis of the medical records of 110 consecutive eyes with open angle glaucoma who had received a XEN45 gel implant between March 2014 and June 2015. Intraocular pressure course, number of glaucoma medications, the need for additional intervention (including needling) and complications were evaluated until 12?months postoperatively.

Results

Data of 67 eyes with POAG and 43 eyes with PXG were analyzed. At 12?months postoperatively, the mean IOP had significantly decreased by 54.0% from preoperatively 31.85?±?8.5?mmHg to 13.99?±?2.6?mmHg in the POAG group, (p?=?0.000; Wilcoxon test), and by 55.2% from 31.63?±?9.0?mmHg to 13.28?±?3.1?mmHg in the PXG group (p?=?0.000; Wilcoxon test). The mean number of anti-glaucoma medications had significantly decreased from 3.25?±?0.8 at baseline to 0.3?±?0.7 medications at 12?months postoperatively in POAG eyes (p?=?0.000; Wilcoxon test), and from 3.05?±?1.0 to 0.3?±?0.6 medications in PXG eyes (p?=?0.000; Wilcoxon test). Hypotony (IOP?≤?6?mmHg) was observed in 2 POAG eyes (3.0%) and in 5 PXG eyes (11.7%) at 1?month but normalized in all eyes at 12?months postoperatively. Severe complications were not observed. No statistically significant differences were found between PXG eyes and POAG eyes.

Conclusion

Our data indicate that the XEN45 gel implant provides significant and comparable reduction in IOP and anti-glaucoma medication during the one-year follow-up period in POAG as well as PXG eyes. This suggests that it may be a noteworthy alternative to traditional filtering procedures in patients with POAG and PXG respectively.

     

Trabeculectomy in uveitis Are antimetabolites necessary at the first procedure?

A retrospective study was undertaken analysing the results of trabeculectomy without antimetabolites in 33 eyes with uveitis compared to 33 eyes with primary open angle glaucoma (POAG). Both groups were matched for surgeon with a median follow-up of 19 months (range 2-44 months) for the uveitis group and 24 months (range 6-92 months) for the POAG group. The overall one and two year success (IOP ± 21 mmHg with or without medication) was 92% and 83% respectively for the uveitis group and 96% for both years for the POAG group (p = 0.241, Mantel-Haenszel test). These results indicate that the success of trabeculectomy in patients with inflammatory glaucoma compares well with that of the POAG group. In the absence of other risk factors, primary trabeculectomy without the use of antimetabolites should be considered as the first choice of surgical treatment for raised intraocular pressure in patients with intraocular inflammatory disease.     

改良的黏弹剂Schlemm管切开术治疗原发性开角型青光眼的临床研究

目的观察改良的黏弹剂Schlemm管切开术（VCO）和小梁切除术（TE）治疗原发性开角型青光眼的疗效和安全性。方法采用前瞻性随机对照方法,对100例（100只眼）药物控制眼压不理想的原发性开角型青光眼患者,随机分为改良VCO组50例（50只眼）,TE组50例（50只眼）,术后平均随访28个月。结果手术后1个月,改良VCO组和TE组患者的平均眼压分别为（11．22±4．34）和（12．35±3．79）mmHg（1mmHg=0．133kPa）,手术成功率（术后未用任何降眼压药物眼压〈21mmHg）均为98．0％;手术后12个月,两组的平均眼压分别为（14．50±3．22）和（16．58±4．73）mmHg,手术成功率分别为87．5％和70．0％,两组差异有统计学意义（P〈0．05）;手术后24个月,两组的平均眼压分别为16．0和15．4mmHg,手术成功率分别为76．1％和67．3％,两组差异无统计学意义（P〉0．05）;早期并发症如浅前房、脉络膜脱离、囊样滤过泡等以TE组明显多于改良VCO组,两组差异有统计学意义（P〈0．01）。结论在治疗原发性开角型青光眼方面,改良VCO组的成功率较TE组高．术后早期并发症相对较少.     

Results of a filtering procedure in low tension glaucoma

Twenty-six eyes of twenty patients with established low tension glaucoma, who had either a double flap Scheie filtering operation or a trabeculectomy, were followed over a period ranging from one to ten years, with a median of three years. These 26 eyes include two second eyes that served as a contralateral control eye until the visual field deteriorated. All 26 eyes showed progression of visual field defects preoperatively, while postoperatively only 2 eyes showed further progression. Of the 16 nonoperated contralateral eyes, 7 showed progression of visual field defects over the same follow-up period. Two of these 7 eyes had to be operated during the study-period. The difference in progression between the operated and the non-operated eyes was significant (P<0.01). The diltering procedure provided a reduction in IOP of 20% or more in 21 of 26 eyes. There was a significant difference in the mean intraocular pressure (IOP) between the operated and the non-operated contralateral eye of 6.8 mmHg (37%) at one year postoperatively. The diurnal variation decreased highly significantly from 4.3 to 2.1 mmHg (P<0.001). It is concluded that filtering surgery in low tension glaucoma may result not only in a significant lowering of IOP, but is also effective in slowing further deterioration of the visual fields.Supported in part by a grant from De Rotterdamse Vereniging Blindenbelangen.Presented in part by N. de Jong at the 180th Meeting of the Netherlands Ophthalmological Society, Apeldoorn, March 1986.     

Long-term follow-up of initial trabeculectomy with mitomycin C for primary open-angle glaucoma in Japanese patients

PURPOSE: To determine the long-term intraocular pressure (IOP) control and postoperative complications after initial trabeculectomy with use of mitomycin C (MMC) in patients with primary open-angle glaucoma (POAG). PATIENTS AND METHODS: A retrospective review was conducted of a consecutive series of 123 eyes (87 patients) with POAG who underwent initial trabeculectomy with MMC and had at least 4 years of follow-up. All patients underwent standard trabeculectomy with 0.04% MMC applied intraoperatively for 3 minutes. The long-term outcomes (IOP control and bleb leak, long-standing hypotony, bleb-related infections) were analyzed with the Kaplan-Meier life-table method on the basis of three definitions of successful IOP control (defined as IOP <18 mmHg (definition 1), IOP <16 mmHg (definition 2), and IOP decrease of by > or =30% and <21 mmHg (definition 3)). RESULTS: The mean follow-up time was 6.8+/-1.4 (mean+/-SD) years. The cumulative survival rates were 67.0+/-4.6%, 44.5+/-5.4%, and 74.1+/-4.2%, respectively, based on definitions 1, 2, and 3, 8 years postoperatively by life-table analysis. At 8 years, bleb leak occurred in 7.9+/-2.6% of eyes, long-standing hypotony in 8.3+/-2.5%, and bleb-related infections in 5.9+/-2.4%. CONCLUSION: Long-term outcome after initial trabeculectomy with MMC in Japanese POAG patients is comparable with that reported in other populations and with that after trabeculectomy with 5-fluorouracil.     

青光眼非穿透性小梁切除术的临床研究

目的分析非穿透性小梁切除术对开角型青光眼的手术效果,手术并发症及其房水引流机制。方法POAG组男22例(24眼),女24例(26眼),共46例(50眼)行NPT手术,PACG组男22例(24眼),女26例(27眼),共48例(52眼)行小梁切除术。比较两组术后眼压及并发症,随访3～18月。结果POAG组术中有4眼发生小梁-后弹力层微穿孔(8％),术后 2月眼压<21mmHg(1mmHg=0.133kPa)有44眼(88％),有2眼发生浅前房,6眼眼压升高,无前房出血,11眼结膜形成滤过手术典型滤过泡,28眼结膜疏松,无滤过泡形成,PACG组术后2月有38眼眼压<21mmHg(73％),并发症发生14眼(27％),其中浅前房5眼,前房出血4眼,脉络膜脱离2眼,黄斑部囊样水肿3眼,均有明显的结膜滤过泡形成。术后随访3-18月,眼压下降幅度POAG组44.5％,PACG组29.6％。结论NPT是一种降眼压效果较好并发症较少的青光眼滤过性手术疗法。     

Effects of trabeculectomy on posture-induced intraocular pressure changes over time

Introduction

To determine whether trabeculectomy affects postural-induced changes in intraocular pressure (IOP), and whether it is maintained.

Methods

Thirty-six eyes of 36 patients with open-angle glaucoma who were scheduled for their initial trabeculectomy with adjunctive mitomycin C were prospectively examined. The IOP was measured in the sitting and the lateral decubitus position with an ICare rebound tonometer before, and 1, 3, and 12?months after trabeculectomy.

Results

Twenty-nine eyes of 29 patients completed this study. The mean baseline IOP measured with the ICare tonometer was 17.4?±?4.9?mmHg in the sitting position and 21.3?±?5.6?mmHg in the lateral decubitus position (p?p?p?=?0.004 respectively). This decrease in the degree of posture-dependent IOP change was maintained at +1.7?±?2.2?mmHg at 1 year postoperatively (p?Conclusions Our results indicate that trabeculectomy not only reduces the IOP but also reduces the degree of posture-induced changes in the IOP. Our findings also speculate that measuring the postural IOP changes after trabeculectomy might provide a clue on the functioning of a filtering bleb.     

The role of needle revision and 5-fluorouracil application over the filtration site in the management of bleb failure after trabeculectomy: a prospective study

Fifty-three eyes of 49 consecutive patients with an intraocular pressure (IOP) over 21 mmHg; without bleb or with a thick, flat bleb after the second postoperative week following trabeculectomy were included in the study. Needle revision was performed with a 26-gauge tuberculin syringe containing 5 mg (0.2 ml) 5-FU in a period of 2 weeks to 10 months postoperatively after unsuccessful digital massage and/or laser suture-lysis. 5-FU injection was not performed when a bleb formation was observed during needling. In case of no bleb formation, 5-FU was injected subconjunctivally over the scleral flap area and repeated a maximum of six times until a functioning bleb was maintained. Needle revision was successful in 14 of 53 eyes (26.4%) as an initial procedure and nine (16.9%) eyes maintained success. Forty-four eyes (83.1%) had 5-FU injection since needle revision did not provide bleb formation (39 eyes) or did not maintain initial success (five eyes). Mean IOP was 27.8±4.7 mmHg (range, 22–41) before any intervention and decreased to 20.5±4.8 mmHg (range, 8–35) after a mean follow-up of 25.1 months and the difference was statistically significant (p<0.001). Mean IOP after needle revision in 14 patients was 18.9±4.9 mmHg (range, 8–29) and 16.3±3.7 mmHg in nine out of 14 patients that maintaned success. Mean IOP after the last 5-FU injection was 21.4±4.6 mmHg (range, 1335 mmHg). The mean number of 5-FU injections was 2.4 (range, 1 – 6). During a mean follow-up of 25.1 months (range, 1–48 months), three eyes (5.7%) had diffuse corneal punctate epitheliopathy lasting for 3–4 weeks and subconjunctival hemorrhage was seen in nine eyes (17%). Needle revision and/or subconjunctival injection of 5-FU over the bleb area is a safe, relatively efficient approach with a low rate of complications to overcome the early and mid term bleb failure after trabeculectomy.