Combined Baerveldt glaucoma drainage implant and trabeculectomy with mitomycin C for refractory glaucoma

PURPOSE: To describe the surgical technique and clinical outcomes of a procedure for refractory glaucoma, concurrent Baerveldt glaucoma implant (BGI) and trabeculectomy with mitomycin C. MATERIALS AND METHODS: Medical records of all patients who underwent combined Prolene-ligated BGI and trabeculectomy with mitomycin C were retrospectively reviewed. Main outcome measures were intraocular pressure (IOP), number of glaucoma medications, visual acuity, and complications. Kaplan-Meier survival analysis was used to determine success, defined as IOP < 22 mm Hg, no reoperation for glaucoma, and no loss of light perception vision. RESULTS: The mean +/- SD follow-up period for 38 eyes of 36 patients was 34 +/- 36 months (range, 3-121 months), during which 18 of 38 eyes (47%) required laser suture lysis of the Prolene suture. Intraocular pressure was reduced from a mean (+/- SD) preoperative value of 35.7 +/- 12.8 to 12.7 +/- 4.7 mm Hg at 1-year follow-up and 11.9 +/- 5.5 mm Hg at the last follow-up visit ( < 0.001). Number of medicines used for glaucoma was reduced from a mean +/- SD preoperative value of 2.5 +/- 0.9 to 0.5 +/- 0.6 at 1-year follow-up and 0.6 +/- 0.8 at the last follow-up visit ( < 0.001). LogMar visual acuity remained stable at mean of 1.15 +/- 0.85 preoperatively, compared with 1.14 +/- 1.05 at 1-year follow-up, but declined to 1.61 +/- 1.01 at the last follow-up visit, a loss of an average of four lines of vision ( = 0.004). Cumulative success was 91% at year 1, 86% at year 2, and 81% at year 3. Three eyes (8%) had suprachoroidal hemorrhages, one eye (3%) needed reoperation for an extruded implant, one (3%) eye had poor vision due to chronic hypotony, three eyes (8%) required additional glaucoma surgery during the postoperative period, and one eye (3%) needed revision of the implant for pressure control. CONCLUSIONS: Combined BGI and mitomycin C trabeculectomy provides excellent postoperative IOP control in patients with refractory glaucoma.     

Comparison of low-dose intraoperative mitomycin-C vs 5-fluorouracil in primary glaucoma surgery: a pilot study

BACKGROUND AND OBJECTIVE: This study was undertaken to compare the efficacy and safety of low-dose intraoperative application of mitomycin-C (MMC) with that of 5-fluorouracil (5-FU) in primary trabeculectomy. PATIENTS AND METHODS: A non-randomized prospective study was performed between August 1994 and November 1995. Thirty-two eyes of 16 consecutive patients who underwent trabeculectomy for uncontrolled glaucoma of various causes form the study group. The mean age was 46.8 +/- 9.9 years. The first eye received MMC (0.2, 0.4 mg/ml), fellow eye received 5-FU (50 mg/ml), for 1 minute intraoperatively. Bleb characteristics and intraocular pressure (IOP) control were analyzed. Success of surgery based on IOP control was measured by 3 different criteria: IOP less than 21 mm Hg; IOP less than 21 mm Hg with more than 30% reduction; and IOP less than 16 mm Hg with more than 30% reduction. RESULTS: Mean preoperative IOP was 31.4 +/-12.7 mm Hg in MMC group and 27.8+/- 8.8 mm Hg in 5-FU group. Mean follow-up in MMC group was 16.12 +/- 8.17 months; in 5-FU group 13.37 +/- 8.19 months. At last follow-up all 5-FU blebs were nonischemic, while 4 eyes in the MMC group showed nonischemic blebs, and 12 eyes had ischemic blebs. There was no statistically significant difference between MMC group and 5-FU group success rates with all 3 criteria. Success rates were: IOP less than 21 mm Hg; 100% in both groups; IOP less than 21 mm Hg with more than 30% reduction; MMC group 93.8%, 5-FU group 75%; less than 16 mm Hg with more than 30% reduction; MMC group 87.5%, 5-FU group 68.8%. CONCLUSIONS: Low-dose intraoperative MMC and 5-FU can provide control of IOP in primary trabeculectomy, 5-FU group showed more non-ischemic blebs.     

Trabeculectomy with mitomycin C in secondary glaucoma associated with Behçet disease

PURPOSE: To determine the outcome of initial trabeculectomy with mitomycin C (MMC) in the management of secondary glaucoma associated with Beh?et disease (BD) in a 1-year follow-up period. METHODS: Twenty-three eyes of 13 cases with secondary glaucoma associated with BD, were evaluated prospectively. They underwent primary trabeculectomy with MMC. The operative success was defined as an intraocular pressure (IOP) < or =20 mm Hg (+/- medical therapy) in the absence of phthisis and without the necessity of further surgery for glaucoma and success rates at the postoperative first day, first month, sixth month, and first year were determined. RESULTS: Success was achieved in all of the eyes (100%) at the postoperative first day and month, in 21 eyes (91.3%) at the postoperative sixth month and in 19 eyes (82.6%) at the postoperative first year. The mean preoperative IOP was 30.9+/-5.3 mm Hg under the mean 3.3+/-0.7 antiglaucoma medications but it reduced to 16.8+/-3.1 mm Hg under the mean 1.7+/-0.8 medications at the postoperative sixth month and 18.5+/-3.2 mm Hg under the mean 2.6+/-1.1 medications at the postoperative first year. CONCLUSIONS: Trabeculectomy with MMC provides reduction of IOP and the number of antiglaucoma medications in cases with secondary glaucoma associated with BD in a 1-year follow-up period.     

Surgical results and complications of mitomycin C-augmented trabeculectomy in refractory developmental glaucoma.

BACKGROUND AND OBJECTIVE: To evaluate the surgical results and complications of mitomycin C-augmented trabeculectomy in refractory developmental glaucoma. PATIENTS AND METHODS: The authors reviewed the charts of all patients of refractory developmental glaucoma who underwent mitomycin C-augmented trabeculectomy (0.4 mg/ml for 3 minutes) between September 1990 and August 1995. Thirty-eight eyes of 29 patients were included in the study; 34 eyes (89.5%) had refractory primary congenital glaucoma with documented failure of primary surgery, 2 eyes (5.3%) had Axenfeld-Rieger syndrome and 2 eyes (5.3%) had aniridia. The main outcome measures in this study were preoperative and postoperative intraocular pressures (IOPs),visual acuities, bleb characteristics, success rate, time of surgical failure, and complications. RESULTS: The IOP (mean +/- SD) reduced from a preoperative level of 32.6 +/- 11.8 mm Hg to 12.3 +/- 7.3 mm Hg (P <0.0001) with the percentage reduction in IOP being 56%. Kaplan-Meier survival analysis showed that the success probability at 18 months was 65%, which was maintained till 30 months of follow-up. The bleb was characterized by its large, elevated, avascular, transparent appearance in all the eyes. There were no intraoperative complications. The postoperative complications included hyphema (absorbed one week) in 8 eyes (21%), uncontrolled IOP in 8 eyes (21%), shallow anterior chamber in 3 eyes (7.9%), hypotony without visual loss in one eye (2.6%) and retinal detachment in 2 eyes (5.2%) which was surgically repaired successfully. Visual acuity was maintained in all cases after surgery. None of the patients developed mitomycin-C related late bleb-leakage or endophthalmitis. CONCLUSION: Treatment of refractory developmental glaucoma with mitomycin C-augmented trabeculectomy is effective and safe with an acceptable rate of complications.     

The filtering, clear-cornea diathermal keratostomy: a minor Danish multicenter study

PURPOSE: Is the new micropenetrating, clear-cornea procedure, intrastromal diathermal keratostomy (IDK), an alternative to the intricate "modern trabeculectomy"? METHODS: Prospective multicenter study. Four surgeons from 4 Danish eye departments attended an IDK course and subsequently decided when to start their consecutive IDK series. The data were analyzed centrally. Injection of preoperative, subconjunctival doses of mitomycin C (MMC) was recommended according to risk-of-failure. A total of 54 eyes from 48 patients with advanced and complicated glaucomas (mean age 65 y) and preoperative mean intraocular pressure (IOP) of 29 mm Hg were studied. RESULTS: At 10 months (range: 3 to 34 mo) the total success rate, employing traditional IOP success criteria (IOP< or =18 mm Hg and postoperative IOP decrease > or =30%), was 87% (47 of 54 eyes). In the 69% (37 of 54 eyes) without medication, the final IOP+/-SD was 11+/-3.5 mm Hg. Employing new IOP success criteria (IOP< or =15 mm Hg and postoperative IOP decrease> or =30%) for severe glaucoma (cup/disc ratio> or =0.8) and traditional criteria for moderate glaucoma (cup/disc ratio< or =0.7) the success rates were 76% and 80% and the mean postoperative IOP+/-SD were 10+/-2.5 mm Hg and 13+/-2.5 mm Hg, respectively. No serious complications (malignant glaucoma, endophthalmitis) were seen. The success rate for the most experienced and the less experienced surgeons, with risk-of-failure factors per eye of 1.3 and 1.2, was similar at 88% and 86%, respectively. The "knife time" for the experienced surgeon averaged 15 minutes (range: 10 to 20 min). The success rate (traditional criteria) after IDK revision with internal needling was 69%. CONCLUSIONS: MMC IDK seems to be simpler and quicker than the modern trabeculectomy, and with similar success rate and safety. Revision by internal needling is easy and efficient. Thus, MMC IDK may be a valid alternative and may also be recommended after failed MMC trabeculectomy, replacing shunting. Randomized, controlled studies are indicated.     

Effect of intraoperative intracameral 2% hydroxypropyl methylcellulose viscoelastic during trabeculectomy.

BACKGROUND AND OBJECTIVE: To evaluate the effect of intraoperative intracameral injection of 2% hydroxypropyl methylcellulose (HPMC) on anterior chamber depth and intraocular pressure (IOP) following trabeculectomy in eyes with uncontrolled primary open-angle glaucoma in a prospective randomized manner. PATIENTS AND METHODS: Thirty consecutive eyes with primary open-angle glaucoma scheduled for trabeculectomy were randomized to conventional trabeculectomy without HPMC injection (group I; n = 15) or to intracameral injection of 2% HPMC during trabeculectomy (group II; n = 15). All patients were observed serially on days 1, 3, 5, 7, and 14 and months 1, 3, and 6 postoperatively. The main outcome measure was restoration of anterior chamber depth to preoperative level with IOP of less than 21 mm Hg with no additional antiglaucoma medication or surgery. RESULTS: The anterior chamber depth decreased from 2.5 +/- 0.53 to 1.5 +/- 0.94 mm on postoperative day 1 in group I and increased slightly from 2.4 +/- 0.43 to 2.5 +/- 0.36 mm on postoperative day 1 in group II (P = .04). Overall, the IOP decreased to 5.0 +/- 2.8 mm Hg in group I (87% reduction) and 9.0 +/- 4.6 mm Hg in group II (70% reduction). Two eyes developed postoperative flat anterior chamber and related complications in group I, whereas none of the eyes in group II developed such complications. CONCLUSIONS: Intracameral injection of 2% HPMC during trabeculectomy helps to maintain anterior chamber depth and reduces incidence of complications related to shallow anterior chamber depth following trabeculectomy.     

Amniotic membrane transplantation in trabeculectomy with mitomycin C for refractory glaucoma

PURPOSE: To compare outcomes of trabeculectomy combined with mitomycin C (MMC) and amniotic membrane transplantation (AMT) with those of trabeculectomy with MMC alone in refractory glaucoma. METHODS: This prospective, randomized study included 37 eyes with refractory glaucoma at such high risks as neovascular, pseudophakic, and prior failure. Trabeculectomy with MMC and single-layer AMT under the scleral flap was performed in 19 eyes and trabeculectomy with MMC alone in 18 eyes. The outcome measures included intraocular pressure (IOP), number of antiglaucoma medications, and complications. All patients were followed for 12 months. RESULTS: Complete success (IOP <22 mm Hg without glaucoma medications) was seen in 15/16 (93.7%) study eyes and 9/15 (60%) control eyes at 6 months postoperatively (P=0.03), and in 12/15 (80%) and 6/15 (40%) at 12 months after surgery, respectively (P=0.03). IOP decreased from 45.6+/-12.7 mm Hg and 44.9+/-10.7 mm Hg preoperatively in study and control groups to 15.3+/-2.3 mm Hg and 21.3+/-3.8 mm Hg, respectively, at 12 months (P<0.0001). Early postoperative hypotony developed in 3 (16.7%) control eyes owing to excessive filtration but none of study eyes (P=0.1). Encapsulated bleb occurred in 7 (38.9%) control eyes but in 1 (5.3%) study eye (P=0.02). CONCLUSIONS: In refractory glaucoma, trabeculectomy combined with MMC and AMT compared to trabeculectomy with MMC alone has higher success rates, lower postoperative mean IOPs, and less complication rates.     

Surgical outcomes of traditional limbal-based versus fornix-based trabeculectomy with corneal valve.

BACKGROUND AND OBJECTIVE: To compare the safety and efficacy of fornix-based trabeculectomy with corneal valve to traditional limbal-based trabeculectomy with mitomycin C (MMC) in eyes with open-angle glaucoma. PATIENTS AND METHODS: In this retrospective, nonrandomized, comparative study, 42 eyes that underwent limbal-based trabeculectomy with MMC were compared with 32 eyes with fornix-based trabeculectomy with corneal valve with MMC. Success was defined as final intraocular pressure (IOP) of at least 20% less than preoperative IOP and between 5 and 22 mm Hg. mean IOPs were 23.5 +/- 12.2 and 11.5 +/- 5.3 mm Hg, respectively, in the limbal-based group and 24.8 +/- 11.1 and 11.7 +/- 2.5 mm Hg, respectively, in the fornix-based group (P < .001 and P = .85, respectively). The fornix-based group had significantly less hypotony (3% vs. 21%, P < .05). CONCLUSIONS: Fornix-based corneal valve trabeculectomy with posterior placement of MMC sponges provides IOP control comparable to limbal-based traditional trabeculectomy, with decreased incidence of hypotony.     

Trabeculectomy with mitomycin C combined with direct cauterization of peripheral iris in the management of neovascular glaucoma

PURPOSE: To determine the outcomes of trabeculectomy with mitomycin C (MMC) combined with direct cauterization of peripheral iris before iridectomy in the management of neovascular glaucoma (NVG), and to demonstrate the effect of this surgical technique on decreasing the incidence of intraoperative bleeding and early postoperative hyphema. METHODS: This prospective study was based on 72 eyes of 72 patients with NVG who underwent primary trabeculectomy with MMC combined with direct cauterization of peripheral iris before iridectomy. The patients were evaluated for intraoperative and early postoperative complications such as hyphema, and operative success rates. Operative success was defined as an intraocular pressure (IOP) < or =22 mm Hg (+/-medical therapy) in the absence of phthisis. The mean IOP and the mean number of antiglaucomatous medications at baseline and at the posttrabeculectomy sixth month were compared by paired Student t test. RESULTS: The mean preoperative IOP was 39.3+/-5.6 mm Hg (range, 29 to 60 mm Hg) whereas it was 20.02+/-4.3 mm Hg (range, 14 to 38 mm Hg) at the postoperative sixth month. The mean preoperative number of antiglaucoma medications was 3.2+/-0.4 (range, 2 to 4) but it reduced to 1.8+/-0.6 (range, 1 to 4) at the postoperative sixth month. These differences were statistically significant (P<0.00001). The IOP was < or =22 mm Hg (+/-medical therapy) in 69 eyes (95.8%) at the postoperative first week, in 62 eyes (86.1%) at the postoperative first month, in 60 eyes (83.3%) at the postoperative third month and in 48 eyes (66%) at the postoperative sixth month. Hyphema occurred in 15 eyes (20.8%) within the first week of the surgery. In 12 eyes it was transient; however, in 3 eyes irrigation of anterior chamber was required. CONCLUSIONS: Trabeculectomy with MMC combined with direct cauterization of peripheral iris decreases the incidence of both intraoperative bleeding, and early postoperative hyphema, and provides reduction of IOP and the number of antiglaucomatous medications in cases with NVG in a 6-month follow-up period.     

Intraocular pressure changes in the contralateral eye after trabeculectomy with mitomycin C

AIM: To assess intraocular pressure (IOP) changes of the contralateral eyes of eyes undergoing trabeculectomy with mitomycin C (MMC). METHODS: Non-comparative retrospective study of 24 consecutive patients who underwent trabeculectomy with MMC that led to more than 45% reduction in IOP. In the contralateral eyes, IOP before surgery was compared with IOP 1 day and 1 month after surgery. 11 fellow eyes were under topical hypotensive therapy while 13 contralateral eyes were not (12 contralateral eyes had previous filtering surgery and one had normal tension glaucoma). No patients had systemic ocular hypotensive therapy. RESULTS: Mean IOP in all contralateral eyes decreased from 15.5 (SD 5.5) mm Hg to 12.5 (3.8) mm Hg (p<0.01), and 13.0 (4.7) mm Hg (p<0.001) 1 day and 1 month after surgery, respectively. In the 11 fellow eyes under topical ocular hypotensive therapy mean IOP was reduced from 19.5 (4.0) mm Hg to 13.5 (2.2) mm Hg (p<0.01), and 16.5 (2.8) mm Hg (p<0.05) 1 day and 1 month after surgery, respectively. In the 13 fellow eyes not under topical ocular hypotensive therapy mean IOP was reduced from 12.1 (4.2) mm Hg to 11.6 (4.7) mm Hg (p not significant) and 9.8 (3.8) mm Hg (p0.01) 1 day and 1 month after surgery, respectively. CONCLUSIONS: In the present population, a month after trabeculectomy, mean IOP in the contralateral eyes decreased independently of whether these contralateral eyes were undergoing topical ocular hypotensive therapy or not.     

原发性开角型青光眼患者单侧小梁切除术后对侧眼眼压变化

目的　观察原发性开角型青光眼患者单眼行外路小梁切除术后对侧眼眼压变化趋势。方法　回顾性分析2016年12月至2021年1月于我院行单眼外路小梁切除术的37例原发性开角型青光眼患者资料,随访并记录患者术后1 d、2 d、3 d、1周、2周、1个月和3个月对侧未手术眼眼压,与术前基线眼压比较。结果　术后1 d、2 d、3 d及1周、2周、1个月和3个月患者对侧眼眼压分别由术前(16.38±4.25)mmHg（1 kPa=7.5 mmHg）升至（18.11±4.03）mmHg、(18.35±5.29)mmHg、（18.03±5.35）mmHg、（17.21±3.33）mmHg、(17.96±3.82)mmHg、（18.57±4.45）mmHg、(17.27±3.73)mmHg,差异均有统计学意义(均为P<0.05）。术后1 d患者对侧眼眼压开始升高,增幅最大出现在术后1个月［(3.36±4.56)mmHg(升高21%)］。术后3个月患者对侧眼眼压开始回归基线水平。相关性分析结果显示,术后不同时间点患者对侧眼眼压改变与年龄、性别均无相关性(均为P>0.05),与术前基线眼压均呈正相关（均为P<0.05）,术后随访期内有11例患者对侧眼眼压控制不佳（继续同术前用药,眼压≥21 mmHg）需要手术或加用降眼压药物。术后对侧眼眼压改变与术前降眼压药物使用时间相关。除术后1 d(P=0.31)外,术前持续用药患者与新用药患者术后其他时间点对侧眼眼压改变差异均有统计学意义(均为P<0.05)。结论　原发性开角型青光眼患者行单侧外路小梁切除术后,患者早期可能会出现对侧眼眼压升高,3个月后逐渐降低,恢复至术前基线水平。单侧小梁切除术后应加强未手术眼的眼压监测。     

Experience with the baerveldt glaucoma implant in the management of pediatric glaucoma

PURPOSE: To report the clinical outcome in 48 eyes of 48 children who received a Baerveldt glaucoma implant (BGI) for the management of pediatric glaucoma. DESIGN: Retrospective, noncomparative case series. METHODS: The medical records of all patients with pediatric glaucoma who underwent a BGI at two tertiary care referral centers in Los Angeles between 1990 and 1999 were reviewed. Intraocular pressure (IOP), intraoperative and postoperative complications, number of glaucoma medications, visual acuity, and pre- and postoperative corneal diameter and axial length were collected from patient records. Criteria for success were IOP between 6 and 21 mm Hg with or without glaucoma medications, no need for further glaucoma surgery, the absence of visually threatening complications, and some residual vision (minimum visual acuity of light perception). RESULTS: The study included 48 eyes from 48 patients aged 16 years and younger (mean age 4.1 years). Mean preoperative IOP was 31.2 +/- 25.7 mm Hg, and mean postoperative IOP was 16.4 +/- 4.9 mm Hg. Cumulative probability of success (based on the Kaplan-Meier survival curve) was 95% at 6 months, 90% at 1 year, 84% at 2 years, 74% at 36 months, and 58% at 48 months. On average, the BGIs were successful for a mean period of 5.6 years (67.7 months). Overall, 11 eyes failed, with the causes being uncontrolled IOP (eight eyes), retinal detachment (two eyes), and no light perception (one eye). CONCLUSIONS: Baerveldt glaucoma implants can be a safe and effective treatment modality for the management of pediatric glaucoma refractive to medical therapy.     

Incidence of presumed steroid response in contralateral eye of patients who underwent glaucoma filtration surgery

Purpose:The aim of this study was to report the incidence of presumed steroid response in contralateral eye of patients who underwent glaucoma filtration surgery.Methods:We reviewed records of 298 glaucoma patients (147 PACG [primary angle-closure glaucoma], 129 POAG [primary open-angle glaucoma], and 22 JOAG [juvenile open-angle glaucoma]) who underwent either trabeculectomy alone or trabeculectomy with cataract extraction. All patients received prednisolone acetate 1% eye drop postoperatively in the operated eye for up to 6 to 8 weeks. The contralateral eye received the same antiglaucoma medications as before. Information collected included age, sex, number of antiglaucoma medications in the fellow eye preoperatively, and VFI (visual field index). The preoperative intraocular pressure (IOP) in the contralateral eye was taken as the baseline. The maximum IOP recorded postoperatively up to a follow-up period of 6 to 8 weeks was noted. A steroid response was defined as rise in the IOP by ≥6 mmHg.Results:In this study, 298 eyes of 298 glaucoma patients were included. The mean age of patients was 60.1 ± 13.7 years. The mean number of antiglaucoma medications in the fellow eye pre-operatively was 2.4 ± 1.2. Mean preoperative and postoperative IOP in the fellow eye were 17.46 ± 7 and 19.37 ± 7.1 mmHg, respectively. Sixty-three eyes out of 298 eyes (21.14%) showed a rise in IOP by 6 mmHg. The maximum IOP difference noted was 15 mmHg. The average time interval to the defined steroid response was 16.13 days. The majority showed a steroid response within 19 days.Conclusion:Steroid response is a significant factor leading to elevated IOP postoperatively in the contralateral eye as well.     

Seven-year follow-up of combined cataract extraction and viscocanalostomy

PURPOSE: To investigate the long-term success and complications of phacoemulsification combined with viscocanalostomy (phacoviscocanalostomy) in eyes with coexisting cataract and medically uncontrolled glaucoma. SETTING: Department of Ophthalmology, Warrington Hospital, Warrington, United Kingdom. METHODS: A prospective nonrandomized study evaluated 165 consecutive eyes (114 patients) that had phacoviscocanalostomy. The main outcome measures were intraocular pressure (IOP), visual acuity, requirement for topical antiglaucoma medication, and the presence or absence of drainage blebs or bleb complications. RESULTS: The mean follow-up was 38.7 months +/- 19.3 (SD) (range 12 to 90 months). There was a statistically significant decrease in IOP, from 24.1 +/- 5.1 mm Hg preoperatively to 13.8 +/- 8.1 mm Hg 1 day after surgery (P<.001), 16.0 +/- 4.1 mm Hg at 5 years (P<.001), and at all evaluations to the last follow-up. The mean number of medications per eye decreased significantly from 2.5 +/- 0.9 before surgery to 0.1 +/- 0.5 at last follow-up (P<.001). At the final follow-up, IOP was reduced by 33.2% (16.2 mm Hg versus 24.1 mm Hg). Complete success, defined as an IOP reduction of more than 30% from preoperative level without medications, was achieved in 48.5% of eyes, with 42% of eyes having an IOP of less than 16 mm Hg. The percentage fall in IOP was linearly related to the preoperative IOP level (P<.001). No eye developed a trabeculectomy-type bleb, and there were no bleb-related complications. CONCLUSIONS: Phacoviscocanalostomy was safe and effective for the management of eyes with coexisting cataract and medically uncontrolled glaucoma. It provided a stable and sustained reduction in IOP with a minimum requirement for topical medication.     

Deep sclerectomy with collagen implant in one eye compared with trabeculectomy in the other eye of the same patient

PURPOSE: To study the efficacy and safety of deep sclerectomy with collagen implant in one eye versus trabeculectomy in the other eye of the same patient. METHODS: The authors conducted a nonrandomized prospective trial of 20 patients with medically uncontrolled primary and secondary open-angle glaucoma. Patients with bilateral medically uncontrolled glaucoma who had previously undergone trabeculectomy in one eye were selected for the study, and a deep sclerectomy with collagen implant was performed in the second medically uncontrolled glaucomatous eye. Trabeculectomy was studied retrospectively whereas deep sclerectomy with collagen implant was studied prospectively. Visual acuity, intraocular pressure, and slit-lamp examinations were performed before and after surgery, at 1 and 7 days, and at 1, 3, 6, 9, 12, 18, and 24 months. Visual fields were repeated every 6 months. RESULTS: The mean follow-up period for both groups was 24.3 +/- 19.1 months. The mean intraocular pressure at 24 months was 13.9 +/- 4.5 mm Hg for deep sclerectomy with collagen implant and 12.9 +/- 4.8 mm Hg for trabeculectomy. At 24 months, IOP was reduced by 39.7% in the deep sclerectomy with collagen implant group (13.8 mm Hg vs. 22.9 mm Hg), and by 55.9% in the trabeculectomy group (12.9 mm Hg vs. 29.3 mm Hg). Forty percent of the deep sclerectomy with collagen implant eyes and 45% of the trabeculectomy eyes achieved a pressure of less than 21 mm Hg without treatment (complete success rate). The deep sclerectomy with collagen implant group showed 50% less hyphema and choroidal detachment than the trabeculectomy group. CONCLUSIONS: Deep sclerectomy with collagen implant is another surgical treatment option in the management of glaucoma, showing pressure results comparable with trabeculectomy but with a lower rate of early postoperative complications.     

小梁切除联合羊膜移植治疗难治性青光眼

目的:探讨小梁切除联合羊膜移植术治疗难治性青光眼的疗效。方法:对16例(17只眼)难治性青光眼行小梁切除联合羊膜移植术。术后随访 3～24个月,平均11.2个月。结果:术前平均眼压为(39.72±7.26)mmHg(1mmHg=0.133kPa);术后3个月眼压降至(14.62±3.72)mmHg,差异有显著性意义(t=11.73 P<0.001)。术后早期均形成弥散的滤过泡。术后3个月随访中,17只眼有16只眼有功能性滤过泡;术后6个月随访中16只眼有14只眼有功能性滤过泡。术后前房反应轻,无其它并发症。结论:小梁切除联合羊膜移植术是治疗难治性青光眼的一种安全、有效方法。眼科学报2003;19:89-91。     

Trabeculectomy with mitomycin C in pseudophakic patients with open-angle glaucoma: outcomes and risk factors for failure

PURPOSE: To evaluate tonometric outcomes of trabeculectomy with mitomycin C in pseudophakic patients with open-angle glaucoma and associated risk factors for failure. DESIGN: Retrospective cohort study. METHODS: Seventy-three pseudophakic patients (89 eyes) with primary open-angle, normal-tension, exfoliative, or pigmentary glaucoma were recruited. Success rates were defined according to three criteria: (A) intraocular pressure (IOP) < or = 18 mm Hg and IOP reduction > or = 20%; (B) IOP < or = 15 mm Hg and IOP reduction > or = 25%; and (C) IOP < or = 12 mm Hg and IOP reduction > or = 30%. IOP, visual acuity, complications, and additional interventions were documented after surgery. Cox's proportional hazard regression analysis was used to identify risk factors for failure. RESULTS: Mean IOP (+/-SD) decreased from a preoperative value of 18.8 +/- 6.6 mm Hg to 10.2 +/- 5.1 mm Hg at one year and to 10.0 +/- 4.2 at two years (P < .001 for both). Average number of preoperative medications decreased from 3.0 +/- 1.1 to 0.5 +/- 1.0 at one year and to 0.5 +/- 0.9 at two years (P < .001 for both). For criteria A, B, and C, success rates (+/-SE) were 87% +/- 4%, 83% +/- 5%, and 76% +/- 5% at 1 year and 67% +/- 4%, 58% +/- 8%, and 50% +/- 7 at two years. Laser suture lysis was performed in 30 eyes, and 11% of those required a second glaucoma procedure. CONCLUSION: Increasing age, use of a limbus-based conjunctival flap, and performance of laser suture lysis were factors that were associated with a smaller risk of failure. Present findings indicate that trabeculectomy with mitomycin C provides acceptable long-term success rates in pseudophakic patients, with a low incidence of complications.     

Surgical outcomes of combined phacoemulsification and glaucoma drainage implant surgery for Asian patients with refractory glaucoma with cataract

PURPOSE: To examine the safety and efficacy of combined phacoemulsification and glaucoma drainage implant surgery in providing reduction of intraocular pressure (IOP) and visual rehabilitation in eyes with refractory glaucoma and cataract. DESIGN: Interventional case series. METHODS: A retrospective chart review was performed on all subjects who underwent combined phacoemulsification with intraocular lens implantation and glaucoma drainage implant surgery by a single surgeon at the National University Hospital, Singapore. The implants used were the 185 mm2 Ahmed glaucoma valve and the 350 mm2 Baerveldt glaucoma implant. In terms of IOP, a complete success was defined as IOP of between 6 to 21 mm Hg without medication, qualified success as IOP between 6 to 21 mm Hg with one or more medication, and failure as a sustained IOP of >21 mm Hg or <6 mm Hg with or without one or more medication on two or more visits. RESULTS: A total of 32 combined phacoemulsification and glaucoma implant surgeries in 32 patients was performed. All patients were of Asian origin, and the mean age was 58 +/- 16 years (range, 20-78 years). The Baerveldt glaucoma implant and Ahmed glaucoma valve implant were inserted in 16 eyes each. With a mean follow-up of 13 +/- 5 months (range 6 to 22 months), IOP was reduced from a mean of 28.0 +/- 11.5 mm Hg to 15.2 +/- 6.0 mm Hg postoperatively (P <.0001), whereas the number of antiglaucoma medications decreased from a mean of 2.4 +/- 1.4 to.3 +/-.7 (P <.0001) at last follow-up. Overall, there were 24 eyes (75%) that were classified as complete successes, 4 eyes (12.5%) that were qualified successes, and 4 eyes that failed (12.5%). Twenty-three eyes (72%) had improvement of visual acuity, while only one eye had a loss of more than 1 line of Snellen acuity. There was no case that encountered an intraoperative complication, and postoperative complications occurred in 12 eyes (38%), the most common of which was hypotony (in six eyes, 19%). CONCLUSION: For subjects with refractory glaucoma and cataract, combined phacoemulsification and glaucoma drainage implant surgery provide good visual rehabilitation and control of IOP, with low incidence of complications.     

Surgical outcomes of trabeculotomy combined with sinusotomy for juvenile glaucoma

PURPOSE: To evaluate the outcome of trabeculotomy combined with sinusotomy for juvenile glaucoma. METHODS: We studied 16 patients (25 eyes) (age range, 11-50 years) with juvenile glaucoma for a minimum follow-up period of 1 year. We performed combined trabeculotomy and sinusotomy surgery in 13 juvenile glaucoma patients (18 eyes), and trabeculotomy alone in 6 patients (7 eyes). RESULTS: The intraocular pressure (IOP) of the combined surgery group was 29.8 +/- 7.8 mm Hg before surgery and 15.6 +/- 3.0 mm Hg 1 year after surgery. The IOP of the trabeculotomy-alone group was 29.1 +/- 6.4 mm Hg before surgery and 15.4 +/- 2.4 mm Hg 1 year after surgery. A postoperative IOP spike that was higher than the preoperative IOP was recorded in 2 eyes of the combined surgery group and in 2 eyes of the trabeculotomy group. The combined surgery group consisted of 7 eyes with a previously failed glaucoma surgery, and 11 eyes having a first glaucoma surgery. The postoperative IOP in these 11 eyes was 15.5 +/- 2.8 mm Hg. CONCLUSION: Trabeculotomy is very effective in lowering the IOP in patients with juvenile glaucoma. Sinusotomy does not play an important role in tension control.     

A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma

PURPOSE: To compare endoscopic cyclophotocoagulation (ECP) and the Ahmed drainage implant in the treatment of refractory glaucoma. METHODS: Sixty-eight eyes of 68 patients with refractory glaucoma were prospectively assigned to either ECP or Ahmed tube shunt implantation. All procedures were performed by a single surgeon. Eyes that were included were pseudophakic with a history of at least one trabeculectomy with antimetabolite, an intraocular pressure (IOP) equal to or above 35 mm Hg on maximum tolerated medical therapy, and a visual acuity better than light perception. Exclusion criteria included eyes that had had previous glaucoma drainage device implantation or a cyclodestructive procedure. Success was defined as an IOP more than 6 mm Hg and less than 21 mm Hg, with or without topical anti-hypertensive therapy. RESULTS: The mean follow-up was 19.82 +/- 8.35 months and 21.29 +/- 6.42 months, for the Ahmed and ECP groups, respectively (P = 0.4). The preoperative IOP, 41.32 +/- 3.03 mm Hg (Ahmed) and 41.61 +/- 3.42 mm Hg (ECP) (P = 0.5), and the mean postoperative IOP, at 24 months follow-up, 14.73 +/- 6.44 mm Hg (Ahmed) and 14.07 +/- 7.21 mm Hg (ECP) (P = 0.7), were significantly different from baseline in both groups (P < 0.001). Kaplan-Meier survival curve analysis showed a probability of success at 24 months of 70.59% and 73.53% for the Ahmed and ECP groups, respectively (P = 0.7). Complications included choroidal detachment (Ahmed 17.64%, ECP 2.94%), shallow anterior chamber (Ahmed 17.64%, ECP 0.0%), and hyphema (Ahmed 14.7%, ECP 17.64%). CONCLUSION: There was no difference in the success rate between the Ahmed Glaucoma Valve and ECP in refractory glaucoma. The eyes that underwent Ahmed tube shunt implantation had more complications than those treated with ECP.