Supplemental transscleral diode laser cyclophotocoagulation after aqueous shunt placement in refractory glaucoma

OBJECTIVE: To assess the outcome of supplemental transscleral diode laser cyclophotocoagulation after aqueous tube shunt placement to obtain effective intraocular pressure (IOP) control. DESIGN: Retrospective non-comparative case series. PARTICIPANTS: Twenty-one eyes in 21 subjects with uncontrolled IOP despite the presence of an aqueous tube shunt and maximally tolerated glaucoma medications. INTERVENTION: Supplemental transscleral diode laser cyclophotocoagulation was performed. MAIN OUTCOME MEASURES: Reduction of intraocular pressure and reduction of glaucoma medications. RESULTS: Twelve adults and nine children underwent supplemental transscleral diode cyclophotocoagulation and were followed postoperatively for a mean of 26.9 +/- 13.4 (standard deviation [SD]) months (range, 7-58 months). Average IOP was significantly reduced from a preoperative level of 35.7 +/- 14.7 (SD) mmHg to a postoperative level of 13.6 +/- 7.1 (SD) mmHg (P < 0.001) with the mean number of medications significantly reduced to 1.5 +/- 1.3 (SD) (P < 0.001). Seven subjects (33%) had additional laser treatment to achieve IOP control. Six subjects who were therapy failures included three who developed no light perception in the setting of proliferative diabetic retinopathy, one subject with chronic angle-closure glaucoma who gradually developed no light perception after refusing further treatment or medication, and two subjects who developed retinal detachments. One child who was a qualified success underwent enucleation and debulking of an enlarging neurofibroma that caused significant proptosis and disfigurement. CONCLUSIONS: In cases of glaucoma that are uncontrolled despite a glaucoma aqueous tube shunt and multiple medications, adjunctive transscleral diode cyclophotocoagulation treatment(s) is a viable option to lower IOP.     

Long-term surgical outcomes of patients with glaucoma secondary to the iridocorneal endothelial syndrome

PURPOSE: To report the long-term outcomes of patients with iridocorneal endothelial (ICE) syndrome who required surgery for glaucoma. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-six patients with ICE syndrome who underwent surgery for glaucoma at one institution between January 1987 and January 2000. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), visual acuity, number of glaucoma medications, and further surgical interventions were measured. RESULTS: Five eyes had a trabeculectomy with an antifibrotic agent alone, seven eyes had a trabeculectomy with an antifibrotic agent and a subsequent glaucoma drainage implant (GDI), and 14 eyes had a GDI alone. In eyes that underwent a trabeculectomy with an antifibrotic agent, preoperative IOP was reduced from a mean of 38.8 +/- 10.5 mmHg on 2.3 +/- 0.8 glaucoma medications to a mean of 11.8 +/- 4.3 mmHg on 1.2 +/- 1.4 medications at last follow-up after surgery (83.8 +/- 40.3 months). In eyes that underwent GDI surgery, preoperative IOP was reduced from a mean of 35.2 +/- 13.0 mmHg on 2.0 +/- 1.3 glaucoma medications to a mean of 8.7 +/- 11.2 mmHg on 1.2 +/- 1.1 medications at last follow-up after surgery (50.5 +/- 40.7 months). Twenty-four eyes (92%) had an IOP less than 22 mmHg, and 22 eyes (85%) had visual acuity 20/400 or better at last follow-up (55.8 +/- 41.5 months). Mean number of glaucoma surgeries per patient over the follow-up period was 1.6 +/- 1.2. Trabeculectomy with antifibrotic agents had a survival of 73% at 1 year, 44% at 3 years, and 29% at 5 years. Glaucoma drainage implants had a survival of 71% at 1 year, 71% at 3 years, and 53% at 5 years. CONCLUSIONS: Glaucoma associated with ICE syndrome can be managed successfully surgically, although multiple procedures are often needed.     

Survival analysis for success of Molteno tube implants

AIM: To apply survival analysis in assessing the long term outcome of Molteno tube implantation and to identify risk factors for failure. METHODS: A retrospective, 10 year, consecutive case series study of 119 eyes that underwent implantation of a Molteno tube. The main outcome measures considered were intraocular pressure (IOP), visual acuity, and complications. RESULTS: A 30% or greater reduction in IOP was achieved in 68.9% of cases. However, the overall, "complete success" rate (IOP <22 mm Hg with no medications) after a mean (SD) follow up period of 43 (33) months (range 6-120) was only 33.6% despite a fall in mean (SD) IOP from 38.2 (8.2) mm Hg to 20.1 (11.0) mm Hg. The "qualified success" rate (IOP <22 mm Hg with or without medications) was 60.5%. Failure was most common in the first postoperative year but could occur after several years, the survival curve having an exponential shape. The only statistically significant risk factor for failure identified was pseudophakia, although eyes with neovascular glaucoma tended to fare poorly. Postoperative IOP tended to be lower after double plate than after single plate implantation. There was no significant difference in outcome based on age, sex, race, previous penetrating keratoplasty, or previous conjunctival surgery. CONCLUSIONS: In eyes at high risk of trabeculectomy failure, implantation of an aqueous shunt device should be considered. Pseudophakia should be considered an additional risk factor for failure. Early failure appeared relatively more common but long term follow up of all cases is recommended to ensure adequate management of late failures.     

Trabecular meshwork bypass tube shunt: initial case series

AIMS: This study describes a prospective consecutive case series of the initial six eyes of five patients undergoing implantation of the trabecular bypass tube shunt. METHODS: A prospective consecutive case series. The initial six eyes of five patients with uncontrolled open angle glaucoma who had never previously undergone ocular surgery. Implantation of the trabecular bypass tube shunt measuring 150 micro m outer diameter and 50 micro m inner diameter was performed with the distal end placed in Schlemm's canal and the proximal end in the anterior chamber. The main outcome measures were visual acuity, intraocular pressure, glaucoma medication use. RESULTS: The tube was successfully implanted in five of six eyes. In four eyes longer term follow up of 5-9 months showed no loss of visual acuity with decreased intraocular pressure from preoperative levels (mean 23.4-16.5 mm Hg) and reduced requirement of glaucoma medications (mean 3-0.5). In a subset of two eyes, there was no measured increase in aqueous flare or reduction of endothelial cell count. In one eye the tube was explanted because of presumed misplacement by excessive bleeding during surgery. Two eyes showed a diffuse bleb. CONCLUSIONS: This study reports the initial experience with a novel approach to surgical glaucoma therapy. This very small tube allows a direct communication to be established between the anterior chamber and Schlemm's canal, effecting a trabecular bypass. In this small number of eyes this procedure reduced intraocular pressure and the need for glaucoma medications without appreciable side effects.     

Phacoemulsification in patients with Baerveldt tube shunts

PURPOSE: To investigate the effects of phacoemulsification in glaucomatous eyes with functioning Baerveldt tube shunts. SETTING: Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA. METHODS: This retrospective analysis followed 9 eyes of 8 patients with functioning Baerveldt tube shunts who had clear corneal phacoemulsification. Intraocular pressure (IOP), number of glaucoma medications, corneal thickness, visual acuity, and additional glaucoma surgery were measured. RESULTS: The mean follow-up was 21 months +/- 3 (SD) (range 17 to 25 months). The mean change in IOP and the number of glaucoma medications used did not significantly change at 1 month (P>.19), 1 year (P>.17), or the last follow-up (P>.17). At the last examination, 2 eyes had IOP increases of 2 to 4 mm Hg, 3 eyes had no change, and 4 eyes had decreases of 4 to 7 mm Hg. Intraocular pressure increased in 1 eye at 8 months and required a tube shunt revision. No eye developed corneal decompensation. Visual acuity improved in 8 eyes; the mean improvement was 4 +/- 3 Snellen lines. CONCLUSION: In most cases, phacoemulsification in glaucomatous eyes with a functioning Baerveldt tube shunt improved vision and maintained control of IOP.     

Outcomes of sequential tube shunts in complicated glaucoma

OBJECTIVE: To evaluate intraocular pressure (IOP) control, change in visual acuity, and complications in eyes that have undergone a second glaucoma tube shunt procedure. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-two eyes of 22 patients that have undergone sequential tube implants for management of glaucoma. METHODS: Parameters analyzed included IOP, visual acuity, and number of hypotensive agent before each shunt procedure and at last follow-up visit. The overall IOP lowering effect attributable to each tube shunt was calculated. Any ocular complications after the second tube shunt were recorded. Success was defined as an IOP between 6 and 21 mm Hg and a 20% reduction in IOP from the second tube shunt procedure. Qualified successes met one of these two requirements at the last follow-up visit. Total failures did not meet any of the above criteria, required additional surgical intervention to lower IOP, or both. MAIN OUTCOME MEASURES: Intraocular pressure control, visual acuity preservation, and complications. RESULTS: At the last follow-up visit, the average percent reduction in IOP from both tube shunt procedures was 42+/-21%. The average percent IOP reduction from the second tube shunt was 33+/-17%. Eleven (50%) patients met the criteria for success, 8 (36.4%) patients were qualified successes, and 3 (13.6%) were failures. The median number of hypotensive agents decreased from two to one. Ten patients experienced new or worse pseudophakic bullous keratopathy after the second tube shunt, six of whom underwent penetrating keratoplasty. Thirteen (59%) patients maintained visual acuity within one line of their second tube shunt pre-operative Snellen visual acuity. Seven (32%) patients lost more than 2 lines, and one patient lost light perception. CONCLUSIONS: Although corneal morbidity is a common complication, a second tube shunt does not cause higher-than-expected rates of other complications associated with tube shunt surgery. Eyes that undergo a second tube shunt procedure can achieve pressure control, require fewer hypotensive agents, and may maintain stable visual acuity.     

Outcome of trabeculectomy with mitomycin-C in the iridocorneal endothelial syndrome

PURPOSE: Eyes with iridocorneal endothelial (ICE) syndrome have a high risk of failure in glaucoma filtering surgery failing. We investigated the efficacy of trabeculectomy with intraoperative mitomycin-C application in these patients. DESIGN: Retrospective nonrandomized comparative trial with historical controls. PARTICIPANTS AND CONTROLS: Ten patients with unilateral iridocorneal endothelial (ICE) syndrome were reviewed. Their intraocular pressures could not be controlled medically. In five eyes, this was the primary surgery performed. Five of the patients had undergone prior intraocular pressure-(IOP) lowering surgery that had failed at the time enrolled. Results were compared with previously published case series of similar patients treated with trabeculectomy alone or trabeculectomy and subconjunctival 5-fluorouracil injections. INTERVENTION: Intervention consisted of trabeculectomy with a limbus-based conjunctival flap and mitomycin-C application. The dosage of mitomycin-C was 0.4 mg/ml for 1 to 4 minutes (mean, 1.9 min). MAIN OUTCOME MEASURES: Adequate control of IOP (without medication lower than 21 mm Hg). RESULTS: In eight eyes the IOP remained well controlled (mean IOP, 12.1 mm Hg) over the entire length of available of follow-up (mean, 14.9 months). Two eyes required implantation of an aqueous tube shunt at 4 and 11 months, respectively, after trabeculectomy with mitomycin-C. One eye experienced visual loss of 3 Snellen lines because of hypotony maculopathy. CONCLUSIONS: Trabeculectomy with mitomycin-C application offers a reasonable intermediate-term success rate in ICE patients, who are otherwise at high risk for failure of filtering surgery.     

Shunt revision versus additional tube shunt implantation after failed tube shunt surgery in refractory glaucoma

PURPOSE: To compare tube shunt revision with additional tube shunt after failed tube shunt surgery. METHODS: We identified 281 patients who underwent a primary tube shunt procedure from 1985 to 1998 at Indiana University and reviewed 33 eyes of 33 patients that had failed and required further surgery. Shunt revision was performed in 12, whereas an additional shunt was placed in 21 eyes. Intraocular pressure, antiglaucoma medications, visual acuity, and complications were noted. Success was defined as at least a 25% reduction in intraocular pressure that was deemed clinically adequate. Qualified success was defined as a 25% intraocular pressure reduction but with additional medications or a significant reduction in medications with stable intraocular pressure for preoperative intraocular pressure less than 21 mm Hg. RESULTS: Preoperative intraocular pressures (mean +/- 95% confidence interval) for the revision and additional tube groups were 28.8 +/- 5.8 mm Hg and 29.8 +/- 2.7 mm Hg (P =.73), with an average follow-up period of 25.2 months (range, 3 to 108 months) and 34.8 months (range, 6 to 84 months), respectively. Final mean intraocular pressure was 25.3 +/- 6.7 mm Hg for the revision group and 17.7 +/- 3.4 mm Hg for the additional tube group (P =.037). Forty-two percent in the revision group versus 62% in the additional tube group achieved at least a qualified success (P =.30, Fisher exact test). Corneal edema was a common complication, especially in the additional tube group. Limitations of this study include the small sample sizes and the uneven distribution of neovascular glaucoma between the two groups (six of 12 in the revision group vs two of 21 in the additional tube group; P =.015, Fisher exact test). CONCLUSIONS: Our series showed that after failed tube shunt surgery, an additional tube shunt offers better intraocular pressure control than revision by excision of an encapsulated bleb.     

引流管植入联合羊膜移植和Molteno植入物治疗角膜移植术后青光眼的研究

目的：探讨房水引流管植入联合羊膜移植对角膜移植术后难治性青光眼的治疗作用。方法：应用α－糜蛋白酶行兔眼后房注射制备青光眼动物模型,把它们随机分为照组、单纯引流管植入组、引流管植入加羊膜移植组、引流管加羊膜支架植入联合羊膜移植组,观察眼内压、管周组织学改变、引流管周组织渗透性,并且比较各治疗组对难治性青光眼的疗效。临床上４１例（４２眼）穿透性角膜移植术后青光眼进行了房水引流管植入联合羊膜移植１２眼和     

Surgical repair of leaking filtering blebs

PURPOSE: To report the surgical management of leaking filtering blebs occurring after blebitis or persistent hypotony. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-two eyes of 20 patients with late bleb leak, blebitis or endophthalmitis, hypotony maculopathy, or bleb dysesthesia on presentation to the glaucoma service who required surgical bleb revision from 1990 through 1999. INTERVENTION: Pedicle flap, partial excision, and advancement or free conjunctival autologous graft techniques for surgical bleb revision. Type of bleb revision was dependent on the dimensions of the bleb and quality of surrounding conjunctiva. MAIN OUTCOME MEASURES: Preoperative and postoperative intraocular pressure (IOP), status of bleb leak, reoperation for glaucoma, or requirement for postrevision glaucoma medical therapy, with success defined as the need for two or fewer glaucoma medications after revision. RESULTS: Eighty-six percent (19/22) of eyes that underwent surgical bleb revision had resolution of leak and IOP control using two or fewer medications after one or more bleb revisions. The preoperative IOP (mean +/- standard deviation) was 3.7 +/- 2.6 mmHg (range, 0-8 mmHg). After an average follow-up of 21 months (range, 8-108 months), the IOP was 11.0 +/- 4.4 mmHg for patients taking 0.6 +/- 1.0 glaucoma medications. Eighteen percent (4/22) of eyes required two or more bleb revisions. In one eye, an IOP spike of 36 mmHg developed after revision, which required laser suture lysis on two occasions before the IOP was significantly lowered. The three failures were: one eye that required three or more medications for IOP control, a patient whose eye had a persistent leak after revision and who was not mentally competent to undergo repeat revision, and one eye that required combined glaucoma and cataract surgery after revision. CONCLUSIONS: Surgical bleb revision has a high success rate of closing late bleb leaks, maintaining glaucoma control, and preserving vision, with few postoperative complications. The appropriate surgical procedure for revision must be based on the individual clinical situation and can result in successful bleb revision.     

Ahmed青光眼阀治疗难治性青光眼的长期疗效

目的：评估Ahmed青光眼阀（Ahmed glaucoma valve,AGV）植入治疗难治性青光眼的长期疗效及并发症。 方法：回顾性分析13例13眼接受Ahmed青光眼阀植入,最短随访18mo的难治性青光眼患者。所有患者均在术前及术后1,3,6mo,1a及1a以后行全面的眼科检查,眼压测量,记录并发症及抗青光眼的药物需求。 结果：患者平均年龄27.3±16.0岁。所有患眼（100%）接受至少一次前置小切口手术。平均随访61.3±30.8mo。在少量药物的作用下,12mo时眼压由35.0±7.0mmHg降至18.2±7.9mmHg,96mo时降至17.0±4.1mmHg,76.9%患者需其他辅助治疗以达到预期的成功疗效。最常见的并发症包括包裹性囊肿8眼(61.5%),置管脱出4眼(308%)。 结论：包裹性囊肿是最常见的并发症,阻碍了Ahmed青光眼阀植入治疗难治性青光眼。虽然囊肿被抗纤维化药物切除,但没有抗青光眼药物的治疗,眼压仍旧不能很好控制。     

Outcome of Baerveldt glaucoma drainage implants for the treatment of uveitic glaucoma

OBJECTIVE: To evaluate the efficacy and safety of Baerveldt glaucoma drainage devices in the management of uveitic glaucoma. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-four eyes of 24 patients who underwent implantation of Baerveldt glaucoma drainage devices between 1996 and 2000 for the treatment of uveitic glaucoma refractory to medical therapy. INTERVENTION: Implantation of Baerveldt glaucoma drainage device. MAIN OUTCOME MEASURES: Control of intraocular pressure (IOP), number of glaucoma medications needed for adequate IOP control, visual acuity, complications associated with the surgery, and the effect of subsequent surgery on the ability of the device to control IOP. Success was defined as IOP >/=5 and 相似文献   

Long-term success of ahmed glaucoma valve in refractory glaucoma

AIM: To evaluate the long-term results and complications of ahmed glaucoma valve (AGV) implantation in refractory glaucoma. METHODS: A retrospective review of 13 patients (13 eyes) with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 18 months was performed. All patients underwent a complete ophthalmologic examination and intraocular pressure (IOP) measurement before surgery and at 1 month, 3 months, 6 months, 1 year after surgery and yearly afterwards. Complications and the number of antiglaucoma medications needed were recorded. RESULTS: Mean age was 27.3±16.0 years. All eyes (100%) had at least one prior incisional surgery. Mean follow-up was 61.3±30.8 months. IOP was reduced from a mean of 35.0 ±7.0mmHg to 18.2±7.9mmHg at 12 months and to 17.0±4.1mmHg at 96 months (P<0.05) with a lower number of medications from baseline, 76.9% patients required additional procedures to achieve the success criteria set by previously published series. The most common complications were encapculated cyst formation in eight eyes (61.5 %) and tube exposure in four eyes (30.8%). CONCLUSION: Encapsulated cyst formation was the most common complication which hindered succesful IOP control after AGV implant insertion for refractory glaucoma. Despite cyst excision with anti-fibrotic agents, successful IOP reduction was not achieved in 76.9% of the patients without antiglaucoma medication.     

Surgical outcomes of Ahmed glaucoma valve implantation in patients with glaucoma secondary to iridocorneal endothelial syndrome

ObjectivesTo evaluate the long-term outcome of patients with iridocorneal endothelial (ICE) syndrome who underwent Ahmed glaucoma valve implantation surgery for uncontrolled glaucoma.MethodsEighteen patients who suffered from unilateral ICE syndrome with uncontrolled glaucoma and subsequently underwent Ahmed aqueous shunt surgery at Zhongshan Ophthalmic Center between January 2008 and December 2016 were reviewed. Outcome measures included intraocular pressure (IOP), the use of glaucoma medications, visual acuity, further surgical interventions, and surgical complications.ResultsThe mean IOP was reduced from 34.8 ± 10.6 mmHg on 3.6 ± 0.5 medications to 17.4 ± 4.9 mmHg (t = 6.791, P = 0.000) on 1.6 ± 1.1 medications (Z = −3.545, P = 0.000) at the last follow-up (42.0 ± 19.3 months). Five eyes (27.8%) achieved complete success, nine (50.0%) achieved qualified success, and the remaining four (22.2%) were considered failures. Survival was 94.4% at 1 year, 88.1% at 2 years, and 73.5% at 3 years. Four cases displayed a flat anterior chamber and were treated with a single anterior chamber reformation surgery with no recurrence. No other complications related to the glaucoma drainage implants occurred in this series.ConclusionsAhmed glaucoma valve implantation appears to be a safe and effective method for treating glaucoma secondary to ICE syndrome. Postoperative shallow anterior chamber and hypotony may occur but responds well to the treatment. Early consideration may be given to aqueous shunt surgery in patients with glaucoma secondary to ICE syndrome when trabeculectomy fails.Subject terms: Glaucoma, Outcomes research     

Long-term results of Ahmed glaucoma valve implantation in Egyptian population

AIM: To evaluate the long-term results and complications of Ahmed glaucoma valve (AGV) implantation in a cohort of Egyptian patients. METHODS: A retrospective study of 124 eyes of 99 patients with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 5y was performed. All patients underwent complete ophthalmic examination and intraocular pressure (IOP) measurement before surgery and at 1d, weekly for the 1st month, 3, 6mo, and 1y after surgery and yearly afterward for 5y. IOP was measured by Goldmann applanation tonometry and/or Tono-Pen. Complications and the number of anti-glaucoma medications needed were recorded. Success was defined as IOP less than 21 mm Hg with or without anti-glaucoma medication and without additional glaucoma surgery. RESULTS: Mean age was 23.1±19.9y. All eyes had at least one prior glaucoma surgery. IOP was reduced from a mean of 37.2±6.8 to 19.2±5.2 mm Hg after 5y follow-up with a reduced number of medications from 2.64±0.59 to 1.81±0.4. Complete and qualified success rates were 31.5% and 46.0% respectively at the end of follow-up. The most common complications were encapsulated cyst formation in 51 eyes (41.1%), complicated cataract in 9 eyes (7.25%), recessed tube in 8 eyes (6.45%), tube exposure in 6 eyes (4.8%) and corneal touch in 6 eyes (4.8%). Other complications included extruded AGV, endophthalmitis and persistent hypotony. Each of them was recorded in only 2 eyes (1.6%). CONCLUSION: Although refractory glaucoma is a difficult problem to manage, AGV is effective and relatively safe procedure in treating refractory glaucoma in Egyptian patients with long-term follow-up. Encapsulated cyst formation was the most common complication, which limits successful IOP control after AGV implantation. However, effective complications management can improve the rate of success.     

【In Press】 Long-term results of Ahmed glaucoma valve implantation in Egyptian population

AIM: To evaluate the long-term results and complications of Ahmed glaucoma valve (AGV) implantation in a cohort of Egyptian patients. METHODS: A retrospective study of 124 eyes of 99 patients with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 5y was performed. All patients underwent complete ophthalmic examination and intraocular pressure (IOP) measurement before surgery and at 1d, weekly for the 1, 3, 6mo, and 1y after surgery and yearly afterward for 5y. IOP was measured by Goldmann applanation tonometry and/or Tono-Pen. Complications and the number of anti-glaucoma medications needed were recorded. Success was defined as IOP less than 21 mm Hg with or without anti-glaucoma medication and without additional glaucoma surgery. RESULTS: Mean age was 23.1±19.9y. All eyes had at least one prior glaucoma surgery. IOP was reduced from a mean of 37.2±6.8 mm Hg to 19.2±5.2 mm Hg after 5y follow-up with a reduced number of medications from 2.64±0.59 to 1.81±0.4. Complete and qualified success rates were 31.5% and 46.0% respectively at the end of follow-up. The most common complications were encapsulated cyst formation in 51 eyes (41.1%), complicated cataract in 9 eyes (7.25%), recessed tube in 8 eyes (6.45%), tube exposure in 6 eyes (4.8%) and corneal touch in 6 eyes (4.8%). Other complications included extruded AGV, endophthalmitis and persistent hypotony. Each of them was recorded in only 2 eyes (1.6%). CONCLUSION: Although refractory glaucoma is a difficult problem to manage, AGV is effective and relatively safe procedure in treating refractory glaucoma in Egyptian patients with long-term follow-up. Encapsulated cyst formation was the most common complication, which limits successful IOP control after AGV implantation. However, effective complications management can improve the rate of success.     

Clinical experience of e-PTFE membrane implant surgery for refractory glaucoma

AIMS: To evaluate the clinical efficacy of membrane tube implant made of expanded polytetrafluoroethylene (e-PTFE, Gore-Tex) membrane and silicone tube in treating refractory glaucoma. METHODS: A retrospective chart review was performed on 43 eyes of 40 patients who underwent glaucoma tube shunt implant surgery using double layered e-PTFE membrane and silicone tube to treat refractory glaucoma. The surgeries were performed from May 1991 to September 1995, and the subjects were patients with terminal glaucoma without useful vision on the study eye. RESULTS: The mean follow up period was 32.9 months. The Kaplan-Meier survival for intraocular pressure (IOP) control (IOP between 6 and 21mm Hg without significant complication) was 80.9% at 1 year, 73.9% at 2 years, and 62.2% at 3 years after surgery. After excluding three eyes of three patients who were dropped within 3 months after surgery and did not have any serious complication or problem in IOP control, the average preoperative IOP was 42.5 (SD 14.6) mm Hg and IOP on the last visit was 17.3 (10.2) mm Hg (p = 0.000, n = 40). The number of antiglaucoma medications before surgery (2.2 (0.6)) was reduced to 0.5 (0.8) on the last visit (p = 0.000). The IOP was controlled within the range of 6-21 mm Hg in 26 eyes (65.0%). In the remaining 14 eyes (35%), we could not control the IOP or additional surgery was needed to control the IOP or to treat severe complications. Two cases of endophthalmitis and three of phthisis were found as serious complications. The other complications were similar to those of other commercially available glaucoma implants. CONCLUSION: A comparable clinical result was obtained with this new implant as with the other commercially available implants. This implant with a thin and non-rigid reservoir has a potential to reduce some complications associated with the large volume and rigid consistency of the other implants, although it is not yet proved. This membrane tube implant may be considered as another substitute in the surgery of refractory glaucoma.     

Trabeculectomy with internal tube shunt: a novel glaucoma surgery

PURPOSE: To describe a pilot study that evaluates the efficacy and mechanism of action of a new glaucoma operation, trabeculectomy with internal tube shunt. METHODS: Twenty-three patients underwent the new operation in one eye for open angle glaucoma. Under a scleral flap, a deep sclerectomy was performed, resulting in an intrascleral lake. Laterally, on both sides, a small silicone tube was placed between the intrascleral lake and the suprachoroidal space. A trabeculectomy stoma and a peripheral iridectomy permitted easy access of aqueous to the tube. Postoperative and preoperative results were analyzed and also compared with results of 45 eyes that underwent a conventional trabeculectomy. RESULTS: After a mean follow-up time of 324 days, the mean postoperative IOP was 13.8 mm Hg compared with a preoperative value of 25.4 mm Hg. The mean number of postoperative medications was only 1.1 compared with a preoperative value of 3.0. No significant change in outflow facility was seen. The bleb size was very small. In comparison, in conventional trabeculectomy eyes, the outflow facility and bleb size were significantly larger. CONCLUSION: Trabeculectomy with internal tube shunt is very effective in lowering IOP. It is postulated to work, to a large extent, by allowing access of the aqueous humor to the suprachoroidal space where the protein colloid osmotic pressure of uveal blood causes its absorption. This new procedure offers many advantages over other filter procedures and tube shunts.     

Endoscopic laser cyclophotocoagulation in pediatric glaucoma with corneal opacities.

INTRODUCTION: Endoscopic diode cycloablation (ECP) has shown modest efficacy for the management of pediatric glaucomas. Eyes with pediatric glaucoma and corneal opacities pose obstacles to intraocular surgery. We examined the role of ECP in lowering intraocular pressure (IOP) as well as that of endoscopy in facilitating tube shunt placement in these eyes. METHODS: Retrospective chart review of 12 eyes (11 patients) with glaucoma and corneal opacities from 12/99 to 9/05. ECP was performed for IOP control with success defined as postoperative IOP < or =21 mm Hg, with or without medications and without procedure-related complications. Success of ECP, repeat ECP, and endoscopically guided tube shunt placement was studied. RESULTS: Diagnoses included the following: Peters/anterior segment dysgenesis in nine eyes and corneal scar/failed corneal graft in three. Patients included eight females and three males with median age 3 years (0.5 to 10.3) at treatment. Median number of prior surgeries was three; median time to failure was 7.8 months (0.3 to 38). Ten eyes had prior external cycloablation(s). Success of first ECP (mean 6.1 clock hours) was 2/12 (17%), with Kaplan-Meier median survival 12 months. Two treatment failures had repeat ECP, and both failed. Four treatment failures had subsequent tube shunt surgery (three with endoscopic assistance), and all were successful at median follow-up of 33 months (11 to 63). Baseline IOP was 36.8 +/- 11 mm Hg before ECP versus 28.2 +/- 16 mm Hg after first treatment (p = 0.07). Procedure-related complications included chorioretinal detachment in one eye. CONCLUSIONS: ECP had limited success in children with refractory glaucoma. However, with anatomic limitations, endoscopy itself was valuable in facilitating subsequent successful tube shunt surgery.     

Risk factors for failure of 5-fluorouracil needling revision for failed conjunctival filtration blebs

PURPOSE: To investigate the risk factors for failure of 5-fluorouracil (5-FU) needling revision, a useful procedure for restoring a failed filtration bleb. DESIGN: Interventional case series.METHODS: Retrospectively conducted study. SETTING: Institutional. STUDY POPULATION: Sixty-four eyes of 64 consecutive glaucoma patients that underwent 5-FU needling revisions for failed filtering bleb following either trabeculectomy or phaco-trabeculectomy with or without adjunctive mitomycin C (MMC). OBSERVATION PROCEDURES: Goldmann applanation tonometry, Kaplan-Meier survival analysis, and Cox proportional hazards regression analysis. MAIN OUTCOME MEASURES: Successful outcome of the initial 5-FU needling revision, arbitrarily defined as target intraocular pressure (IOP) control with not more than two topical glaucoma medications and no additional 5-FU needling or other surgical procedures, was analyzed by Kaplan-Meier survival analysis, and risk factors for failure of the initial 5-FU needling revision were analyzed by Cox proportional hazards regression analysis. RESULTS: The cumulative success rate of the initial 5-FU needling revision was 45% at 1 year, 33% at 2 years, and 28% at 4 years. Failure of the initial 5-FU revision correlated significantly with preneedling IOP > 30 mm Hg (P =.0003), lack of MMC use during the previous filtration surgery (P =.013), and IOP >10 mm Hg immediately following needling revision (P =.0012) according to Cox's proportional hazards regression analysis.CONCLUSIONS: Pre-needling IOP > 30 mm Hg, lack of MMC use during the previous filtration surgery, and IOP > 10 mm Hg immediately after needling were found to be significant risk factors for failure of the initial 5-FU needling procedure. Therefore, it is important to monitor IOP closely following needling revision in those patients with such risk factors. They are more likely to require additional therapeutic interventions, including repeat needling revisions.