Mitomycin C augmented glaucoma surgery: evolution of filtering bleb avascularity, transconjunctival oozing, and leaks

AIMS: To prospectively study the evolution of possible high risk features of conjunctival filtration blebs like avascularity, transconjunctival oozing (TCO), and leaks after mitomycin C (MMC) enhanced glaucoma surgery. METHODS: Single observer, 2 year prospective study on bleb characteristics of 125 eyes of 125 consecutive patients who had MMC augmented glaucoma surgery with initially successful filtration. MMC (0.2 mg/ml for 2 minutes in most cases) was applied on the area of the scleral flap before dissection. Glaucoma surgeries included were trabeculectomy, deep sclerectomy, and combined procedures. A dry fluorescein strip was applied on the avascular part of the bleb and observed for aqueous egress with flow (point leak, PL) or without (TCO). RESULTS: The mean time (95% CI) for observing bleb avascularity, TCO, and bleb leaks were 106 days (69 to 143), 208 days (155 to 261), and 609 days (559 to 659), respectively. Bleb leaks were observed in 17 eyes (13.6%)-15 (24.6%) in the trabeculectomy group and two (3.1%) in the deep sclerectomy group (p = 0.003). Kaplan-Meier survival analyses showed that the probability of observing bleb avascularity at sixth, 12th, and 24th month after surgery was 56%, 71%, and 73%, respectively. In eyes with avascular blebs, the probability of developing TCO and leaks was 77% and 1% at 6 months, 81% and 12% at 12 months, and 95% and 26% at 24 months, respectively. Cox's regression analyses and log rank tests showed that eyes with larger avascular blebs (>4 mm) were more likely to develop TCO (hazard ratio 3.77, p = 0.001) and delayed bleb leaks were more likely to be seen in eyes of the trabeculectomy group rather than the deep sclerectomy group (hazard ratio 0.06, p = 0.0006). CONCLUSIONS: MMC application over the area of scleral flap dissection during glaucoma surgery is associated with a high incidence of bleb avascularity, TCO, and delayed bleb leaks. Most eyes developed bleb avascularity within the first year after surgery. TCO will eventually be seen in all eyes with avascular blebs and the incidence of leaks gradually increases with time. This study shows that patients with eyes undergoing glaucoma surgery with MMC and avascular blebs should be monitored indefinitely.     

Intraoperative mitomycin-C without conjunctival and Tenon's capsule touch in primary trabeculectomy

OBJECTIVE: To verify whether intraoperative mitomycin C (MMC) without conjunctival and Tenon's touch is effective in inhibiting the development of thin, avascular blebs in eyes undergoing primary trabeculectomy. DESIGN: Noncomparative, interventional study. PARTICIPANTS: Fifteen eyes of 15 consecutive patients undergoing primary trabeculectomy. INTERVENTION: All eyes underwent trabeculectomy with intraoperative MMC (0.25 mg/ml for 3 minutes) without either conjunctival or Tenon's touch. Patients were examined 1 month, 3 months, 6 months, and 12 months after surgery. Intraocular pressure (IOP) and number of medications were evaluated at each examination. The appearance of the bleb was classified at the last examination into one of three groups: flat and vascularized; elevated but not avascular; or elevated, thin, and avascular. MAIN OUTCOME MEASURES: Intraocular pressure, number of antiglaucoma medications, and appearance of the bleb. RESULTS: Preoperative mean IOP was 30.57 +/- 10.92 mmHG: Statistically significant IOP reductions were observed 1 month, 3 months, 6 months, and 1 year after surgery (P < 0.01). Twelve months after surgery, the mean IOP was 14.92 +/- 6.53 mmHG: Five eyes (33.3%) showed an IOP less than 15 mmHg without antiglaucoma medication at the 12-month examination. The bleb was considered elevated, thin, and avascular in 12 of 15 eyes (80%) at the end of follow-up. CONCLUSIONS: Intraoperative MMC at 0.25 mg/ml for 3 minutes without either conjunctival or Tenon's touch was not effective in eliminating the development of thin, avascular blebs in eyes undergoing primary trabeculectomy.     

Determinants of bleb morphology in minimally invasive, clear-cornea micropenetrating glaucoma surgery with mitomycin C

PURPOSE: Antimetabolites, especially mitomycin C (MMC), increase the incidence of late bleb-related endophthalmitis in trabeculectomy. This is related to a higher incidence of avascular, thin, cystic, translucent blebs, which may be caused by a toxic effect on conjunctival tissue. An MMC dose-response study was carried out focusing on bleb morphology and function. PATIENTS AND METHODS: In a retrospective, comparative case series study, 2 successive groups of patients with complicated glaucoma were compared 2 years after a special, minimally invasive, filtering procedure (intrastromal holmium laser keratostomy). Preoperative local subconjunctival injections of a fixed MMC dose (4 microg) were used in group A, and lower MMC doses, calculated individually (1 or 2 microg), were used in group B. Bleb vascularity and morphology were evaluated by masked grading of photomicrographs. Bleb function was evaluated by intraocular pressure (IOP). RESULTS: Total bleb avascularity occurred in 63% of the blebs in group A and 0% in group B (P < 0.01). In eyes with IOP < or = 20 mmHg without medical treatment, the mean IOP was significantly lower in group 1 (8 vs 15 mm Hg, P < 0.002). A translucent cystic bleb without conjunctival stroma was observed in only 1 eye in group A. An optimal spongy stromal bleb was observed in all other eyes (96%) despite the different MMC doses. The numbers of complications in the 2 groups were nearly equal. CONCLUSIONS: Bleb avascularity after 4 microg MMC could be avoided by the use of 1 or 2 microg MMC on the basis of preoperative prognosticators for failure, but at the expense of some of the IOP-lowering effect. This indicates that the therapeutic index (clinical safety margin) of MMC seems to be narrow. An MMC dose-response relation was not observed for the thin, cystic, and translucent bleb. The low incidence of this bleb (4%) indicates that the operative technique, apart from the vascularity, may be the most essential determinant of bleb morphology.     

Midterm follow-up of necrotic bleb excision and advancement of the fornical conjunctiva

Mitomycin C has improved the success rate of glaucoma filtering surgery in patients at high risk for surgical failure. However chronic hypotony is marked by decreased vision and a late-onset leaking bleb after filtration surgery using mitomycin C. Bleb excision and conjunctival advancement is the method of choice to repair bleb leakage and chronic hypotony. Five eyes from five patients were received glaucoma filtration surgery with topical mitomycin C. All of the patients' blebs were avascular and transparent. The reasons for bleb excision were two spontaneous bleb leaks, two traumatic bleb leaks and one case of severe irritation. The mean follow-up period was 18.4 +/- 8.3 months (ten to 29 months). Cataract surgery was combined in one eye. Postoperative intraocular pressure (IOP) increased from 2.3 +/- 1.5 mmHg to 9.5 +/- 3.7 mmHg at nine months postoperatively in four eyes. It went from 28 mmHg to 40 mmHg in one patient with uveitis, for whom a second trabeculectomy with mitomycin C; 0.4 mg/ml for 3 minutes, was performed. After surgery, IOP decreased to 4 mmHg in three months. Postoperative visual acuity improved four snellen lines in three eyes. A partially avascular bleb recurred in three eyes, a corneal bleb in one eye and blepharoptosis, which disappeared spontaneously at four months postoperatively, in one eye. Necrotic bleb excision and advancement of fornical conjunctiva were useful methods to increase IOP and to improve visual acuity for the patient experiencing irritation symptoms, and for leaking blebs, and hypotonic maculopathy.     

干扰素α-2b与丝裂霉素C用于青光眼滤过术的临床对比研究

目的 评价干扰素α－２ｂ（ｉｎｔｅｒｆｅｒｏｎ α－２ｂ,ＩＦＮ α－２ｂ）与丝裂霉素Ｃ（ｍｉｔｏｍｙｃｉｎ Ｃ,ＭＭＣ）用于青光眼滤过术的临床疗效及应用价值。方法 采取随机对照临床试验研究方法,将４１例（６８只眼）晚期原发性开角型青光眼（ｐｒｉｍａｒｙ ｏｐｅｎ ａｎｇｌｅ ｇｌａｕｃｏｍａ,ＰＯＡＧ）患者分为两组。每组各有３４只眼,其中２７例为同一患者左右眼对照;患者年龄１５～４０岁,均为衩手     

环孢霉素A抗增殖作用的实验研究

目的 通过环孢霉素A(cyclosporine A,CsA)与丝裂霉素C(mytomycin C,MMC)进行对比研究,用免疫组织化学方法,探讨CsA在抗青光眼滤过性手术中的抗增殖作用。方法 25只50眼健康新西兰大白兔随机分为3组,均行小梁切除术。术中分别在Tenon's囊和巩膜之间放置浸有20g·L~(-1)CsA、0.2g·L~(-1)的MMC和生理盐水(normalsaline,NS)海绵片4min,用NS 100mL充分冲洗干净。分别在术后1、4、7、14和28d检查眼压、滤过泡、角膜和眼底情况,取滤过泡及周围组织作病理检查,并用免疫组织化学方法观察成纤维细胞的增殖情况。结果 CsA组和MMC组增殖细胞核抗原(proliferation cellnuclear antigen,PCNA)阳性细胞出现较晚,细胞总数低于NS组。CsA组和MMC组之间无明显差异;CsA组和MMC组眼压多控制在1.93kPa((1kPa=7.5mmHg))以下,形成功能性滤过泡;CsA无明显副作用,MMC组可见角膜混浊及前房反应。结论 CsA能抑制成纤维细胞的增殖,有助于功能性滤过泡的形成,有效控制术后眼压,和MMC组相比无明显差异,值得推广应用。     

曲古抑菌素A对兔眼滤过术后滤过泡作用的研究

目的：观察曲古抑菌素A( trichostatin A,TSA)作用于兔眼滤过术后滤过泡的形态变化,研究其对术后结膜瘢痕的抑制作用。
　　方法：兔眼滤过术中结膜下注射TSA、丝裂霉素C( MMC)、PBS,分别于术后3,7,14,21,28d应用Krofeld评分评价滤过泡的形态变化。
　　结果：TSA组14 d内滤过泡弥漫性隆起,28 d囊性泡形成。术后14,21 d TSA组滤过泡评分高于PBS组,具有统计学差异(P<0.05)。
　　结论：TSA能够抑制术后结膜瘢痕形成,延长滤过泡存在时间,保持滤过道通畅。     

Sodium hyaluronate eye drops prevent late-onset bleb leakage after trabeculectomy with mitomycin C

PURPOSE: To evaluate the efficacy of sodium hyaluronate eye drops for prevention of late-onset bleb leakage after trabeculectomy with mitomycin C (MMC). METHODS: Sixty-eight patients (68 eyes) who had trabeculectomy with MMC from March 1995 to February 2002 at the Marui Eye Clinic or the Department of Ophthalmology, Fukushima Medical University Hospital were examined in this study. Twenty-two were treated postoperatively with sodium hyaluronate eye drops (sodium hyaluronate group) and 46 eyes were not treated postoperatively (control group). The blebs were classified according to the avascular area, epithelial defect and degree of bleb wall leakage. Both groups were assigned classes (0, avascular or partial avascular bleb; 1, avascular or partial avascular bleb with an epithelial defect; 2, avascular or partial avascular bleb with oozing; 3, avascular or partial avascular bleb with a point of leakage). RESULTS: Follow-up duration ranged from 10 to 116 months (mean+/-SD, 57.6+/-30.5). The incidence of reclassification from class 1 to class 0 was significantly greater in the sodium hyaluronate group (four of six class 1 eyes improved to class 0 after application of sodium hyaluronate eye drops) than in the control group (zero of 10 eyes) (P=0.008). And, the incidence of reclassification from class 1 to class 2 or class 3 was significantly smaller in the sodium hyaluronate group (one of six eyes) than in the control group (nine of 10 eyes) (P=0.008). CONCLUSIONS: Sodium hyaluronate eye drops may prevent late-onset bleb leakage after trabeculectomy with MMC.     

Characteristics of filtering blebs after fornix-based trabeculectomy with a scleral tunnel

PURPOSE: To evaluate the characteristics of filtering blebs after fornix-based trabeculectomy with a scleral tunnel. PATIENTS AND METHODS: We studied 119 eyes of 149 patients who had undergone fornix-based trabeculectomy with mitomycin C as their primary surgery between 2000 and 2002 and in whom we could evaluate the characteristics of filtering blebs after a follow-up period of 6 months or more, and whose intraocular pressure at the evaluation time was 18 mmHg or less. We evaluated the width, depth, height, border, avascular area, conjunctival thickness, and late-onset bleb leak of the filtering blebs. RESULTS: The mean period of evaluation was 528 +/- 243 days (mean +/- standard deviation) after surgery, and the mean intraocular pressure at that time was 12.0 +/- 3.0 mmHg. Among these patients, 108 eyes (72.5%) had completely diffuse blebs and 90 eyes (60.4%) had completely vascular blebs. There was no apparent late-onset bleb leak. CONCLUSION: Fornix-based trabeculectomy with a scleral tunnel appears to be an effective method of developing diffuse, vascular and safe blebs with a low risk of late-onset bleb leak.     

Effects of intraoperative sponge mitomycin C and 5-fluorouracil on scar formation following strabismus surgery in rabbits

purpose?To investigate the influence of 5-fluorouracil (5-FU) and mitomycin C (MMC) on the postoperative adhesions following strabismus surgery in rabbits. methods?Twenty-one New Zealand white rabbits were used in this prospective, masked, controlled trial. Both eyes of 20 animals underwent 3-mm recession of the superior rectus muscle (SRM). In group I (10 animals), one eye of each animal received topical application of MMC (0.2?mg/ml) for 5 minutes and the other eye (control eye) was treated with balanced salt solution (BSS) using an intraoperative sponge. In group II (10 animals), a randomly chosen eye of each animal was treated with 5-FU soaked sponges (50?mg/ml) for 5 minutes and the fellow eye (control eye) with BSS. Two eyes of a rabbit were included as unoperated controls. Four weeks after the surgery, conjunctival vascularity and postoperative adhesions between the SRM Tenon's capsule (TC) and SRM sclera (scl) were assessed. Additionally, eyes were enucleated and evaluated histopathologically for evidence of scarring, granuloma formation, and muscle tissue changes under a light microscope. results?MMC-treated eyes had a higher rate of avascular conjunctiva compared to both controls and 5-FU-treated eyes. Mean adhesion scores, particularly between the SRM-scl, were lower in eyes treated with antiproliferative agents compared to controls. The difference was statistically significant in MMC-treated eyes for the adhesions between SRM-scl (p = 0.03). Histopathological examination revealed less scarring and granuloma formation in MMC- and 5-FU-treated eyes compared to their control eyes. conclusions?MMC, and to a lesser extent 5-FU, are shown to be effective in reducing postoperative scarring following strabismus surgery in rabbits. It seems reasonable to suggest that antimetabolites should be used for cases having an increased risk of postoperative adhesions.     

Filtering bleb functionality: a clinical, anterior segment optical coherence tomography and in vivo confocal microscopy study

PURPOSE: To provide a microscopic and macroscopic analysis by a clinical, in vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (AS-OCT) assessment of filtering blebs after glaucoma surgery. MATERIAL AND METHODS: We retrospectively analyzed 60 eyes of 48 glaucomatous patients by slit-lamp, IVCM, and AS-OCT examinations. Patients were divided into 2 groups: successful blebs (group 1, 16 patients, 27 eyes) were defined as a one-third reduction in preoperative intraocular pressure without antiglaucoma medications and failed blebs (group 2, 32 patients, 33 eyes) as a less than one-third reduction in preoperative intraocular pressure without therapy. The examinations were performed from 1 to 96 months postoperatively. RESULTS: Diffuse or cystic clinical patterns were indicative for good functionality whereas flat or encapsulation was indicative for poor functionality. When comparing successful with failed blebs, the IVCM analysis showed a greater number (P=0.014), density (P=0.009), and total area of epithelial microcysts (P=0.017) and a lower density of connective tissue (P=0.006). The AS-OCT analysis showed a lower degree of bleb wall reflectivity (P<0.001). A significant correlation was found between the clinical and AS-OCT parameters, particularly for the cystic (100%) and diffuse (74%) patterns. CONCLUSIONS: All IVCM parameters did correlate well with the bleb functionality whereas, among the AS-OCT parameters, only the bleb wall reflectivity was significantly related to the filtering capability. Clinical and AS-OCT bleb classification showed a significant degree of concordance. As a consequence, simultaneous approach by clinical, microscopic, and tomographic assessment improves the clinician's ability in the postsurgery understanding and management of blebs.     

Effects of intraoperative sponge mitomycin C and 5-fluorouracil on scar formation following strabismus surgery in rabbits

PURPOSE: To investigate the influence of 5-fluorouracil (5-FU) and mitomycin C (MMC) on the postoperative adhesions following strabismus surgery in rabbits. METHODS: Twenty-one New Zealand white rabbits were used in this prospective, masked, controlled trial. Both eyes of 20 animals underwent 3-mm recession of the superior rectus muscle (SRM). In group I (io animals), one eye of each animal received topical application of MMC (0.2 mg/ml) for 5 minutes and the other eye (control eye) was treated with balanced salt solution (BSS) using an intraoperative sponge. In group II (10 animals), a randomly chosen eye of each animal was treated with 5-FU soaked sponges (50 mg/ml) for 5 minutes and the fellow eye (control eye) with BSS. Two eyes of a rabbit were included as unoperated controls. Four weeks after the surgery, conjunctival vascularity and postoperative adhesions between the SRM Tenon's capsule (TC) and SRM sclera (scl) were assessed. Additionally, eyes were enucleated and evaluated histopathologically for evidence of scarring, granuloma formation, and muscle tissue changes under a light microscope. RESULTS: MMC-treated eyes had a higher rate of avascular conjunctiva compared to both controls and 5-FU-treated eyes. Mean adhesion scores, particularly between the SRM-scl, were lower in eyes treated with antiproliferative agents compared to controls. The difference was statistically significant in MMC-treated eyes for the adhesions between SRM-scl (p = 0.03). Histopathological examination revealed less scarring and granuloma formation in MMC- and 5-FU-treated eyes compared to their control eyes. CONCLUSIONS: MMC, and to a lesser extent 5-FU, are shown to be effective in reducing postoperative scarring following strabismus surgery in rabbits. It seems reasonable to suggest that antimetabolites should be used for cases having an increased risk of postoperative adhesions.     

眼前段相干光断层扫描仪和超声活体显微镜对青光眼滤过术后滤过泡的检测评价

目的 比较眼前段相干光断层扫描仪(SL-OCT)与超声活体显微镜(UBM)检测青光眼滤过术后滤过泡的效果.方法 比较研究.以Singh的方法,对53例(69只眼)青光眼滤过术后患者的功能性滤过泡进行检测,同时对受试患者分别进行SL-OCT与UBM检查,获取结膜下滤过泡内部形态结构图像,并对滤过泡进行归类分型;对两种检查方法所得结果进行比较,采用Fisher精确检验.结果 SL-OCT检测青光眼功能性滤过泡的形态和分型与Singh法所判定的功能性滤过泡对照,显示SL-OCT检测和识别功能性滤过泡的敏感性为92.7%(38/41),特异性为83.3%(20/24);而UBM检测和识别功能性滤过泡(Yamamoto分型)的敏感性为66.7%(30/45),特异性为75.0%(18/24).两组在识别功能性滤过泡的敏感性方面,差异有统计学意义(Fisher精确检验,P=0.003).结论 SL-OCT检测和识别青光眼滤过术后功能性滤过泡的敏感性和特异性优于UBM,四种滤过泡分型为判断功能性滤过泡提供了形态和结构方面的支持,可作为判断青光眼疗效和再次手术的重要客观依据.     

Correlation between the early morphological appearance of filtering blebs and outcome of trabeculectomy with mitomycin C

PURPOSE: To correlate the morphologic appearance of filtering blebs in the early postoperative period with the outcome of trabeculectomy with mitomycin C (MMC) during the first postoperative year. PATIENTS AND METHODS: In a prospective study, the morphologic appearance of filtering blebs after primary trabeculectomy with adjunctive MMC (0.1 mg/ml for 5 minutes intra-operatively) was classified; 49 eyes of 49 patients were examined preoperatively, 1 and 3 days, 1 and 2 weeks, 1, 3, 6, and 12 months postoperatively. Status of filtering bleb, intraocular pressure (IOP), and number of medications were recorded. RESULTS: One year after surgery all patients had IOP < or = 21; 6 patients received antiglaucoma medication. One eye required needling of the filtering bleb because of encapsulation. During the first postoperative year, eyes with conjunctival subepithelial micro cysts, observed in the first and the second postoperative week, had significantly lower mean IOP, than eyes without (11.1 mm Hg vs. 13.9 mm Hg; p:0.0043, ANOVA). Eyes with corkscrew vessels, observed in the first and the second postoperative week, had significantly higher mean IOP, than eyes without during the first postoperative year (13.4 mm Hg vs. 11.7 mm Hg; p:0.0141, ANOVA). CONCLUSION: Classification of filtering blebs after trabeculectomy with MMC may help to disclose patients with an increased failure risk.     

Clinical characteristics and leakage of functioning blebs after trabeculectomy with mitomycin-C in primary glaucoma patients

PURPOSES: To describe the clinical characteristics of functioning blebs in Japanese glaucoma patients after primary trabeculectomy with adjunctive mitomycin-C (MMC) and to correlate their associations with postoperative bleb leakage. DESIGN: A prospective, observational case series. PARTICIPANTS: One hundred sixty-two glaucoma patients who had undergone primary trabeculectomy with MMC at the University of Tokyo Hospital at least 3 months before were examined between December 1997 and February 1998. METHODS: A predesigned data form was completed at each visit. Ophthalmologic examinations included Goldmann applanation tonometry, slit-lamp examination, and Seidel tests with and without digital ocular pressure (DOP). MAIN OUTCOME MEASURES: Properties of the functioning bleb, including bleb appearance, thickness of bleb wall, dimensions of bleb and avascular area, and leakage status with and without DOP. RESULTS: Of 162 Japanese patients, 162 eyes with functioning blebs were included. There were no differences in bleb characteristics among the different types of primary glaucoma. With a long postoperative duration, blebs tended to be thinner (P = 0.024). With DOP, the leaking rate increased from 3.1% to 5.6%, and the oozing rate increased from 11.1% to 35.8% (P < 0.001). Logistic regression analysis indicated that the larger the avascular area, the more likely the bleb leaked without DOP (P = 0.016). When DOP was applied, leakage was more likely to occur in the blebs with a long postoperative duration (P = 0.002) or with a large avascular area (P < 0.001). CONCLUSIONS: The clinical characteristics of filtering blebs were similar in Japanese patients with different types of primary glaucoma. Blebs with a large avascular area were associated with a higher risk of bleb leakage. Attention to the increased chance of leakage induced by DOP is important, especially for blebs with a long postoperative duration. Ophthalmologists should be aware of late bleb-related complications in addition to bleb function.     

Remodelling the filtration bleb

AIMS: To report remodelling of enlarged dysmorphic filtration blebs with conjunctival compression sutures and autologous blood injection. METHODS: A retrospective analysis of consecutively recruited patients with enlarged and dysmorphic filtration blebs who were managed with conjunctival compression sutures and subconjunctival autologous blood injections. Under topical anaesthesia, conjunctival (8.0-9.0 Nylon or 8.0 Vicryl) compression sutures were placed either side of blebs that were not showing signs of spontaneous resolution. In each case up to 0.75 ml of autologous blood was then injected into the areas of the bleb to be flattened. Supplemental injections of autologous blood were given in clinic as required. RESULTS: In 11 eyes of 11 patients, conjunctival compression sutures were placed and autologous blood was injected, on average, 568 days following filtration surgery (range 41-2023). Supplemental autologous blood injections were required in eight patients, with three injections being given in one patient. In each case, the sutures were well tolerated and satisfactory compression of the conjunctiva was achieved. The highest intraocular pressure following injection was 25 mm Hg (mean 17.3, SD 4.2) and in none of the cases did blood enter the anterior chamber or parts of the filtration bleb bounded by the sutures. CONCLUSION: Conjunctival compression sutures with autologous blood provide a simple and effective means for remodelling the filtration bleb. The procedure can be performed under topical anaesthesia and does not hinder further bleb surgery, should this be required.     

Epiconjunctival Mitomycin-C Application for Early Failing Filtering Blebs

Abstract

Purpose: To evaluate the effectiveness of epiconjunctival Mitomycin-C (MMC) application in early failing filtering blebs. Design: Interventional case series. Participants: Patients with failing blebs and raised intraocular pressure (IOP) in the early (two weeks to one month) postoperative period following glaucoma filtering surgery. Methods: A retrospective analysis of records of failed blebs was done for the period of April 2011-March 2012. Patients who were subjected to three applications of MMC (0.04%) applied over the conjunctiva directly over the bleb at baseline (visit1), one week (visit 2) and at one month (visit 3) were included. Bleb characteristics were graded in a blinded fashion by one independent ophthalmologist, while IOP during follow-up visits were analyzed. Main Outcome Measures: Intraocular pressure, need for additional measure, or medications and bleb characteristics as graded by Indiana classification. Results: Ten eyes of nine patients with failing blebs received topical MMC, including included eight males and one female with a mean age of 52?±?18 years (trabeculectomy:combined surgery?=?5:5). Complete success was seen in eight of 10 eyes with a final mean IOP of 14?±?2.9?mm Hg at three months. Excluding the two eyes that required medications, IOP reduction of 9%–42% was seen at visit 2, 16–57% IOP reduction at visit 3, and 16–56% at three months’ follow-up. Of eight eyes, all eyes showed decrease in vascularity of the blebs, p?<?0.001. While the height of the blebs did not show significant increase, all had increase in the avascular area of the bleb. One eye developed spontaneously resolving adenoviral conjunctivitis without any sequelae. Conclusion: Three applications of epiconjunctival MMC may be a safe alternative for salvaging failing blebs in the early postoperative period. This may help maximize anti-fibrotic effect of MMC while minimizing complications by limiting the area of contact.     

Prolonged antiscarring effects of ilomastat and MMC after experimental glaucoma filtration surgery

PURPOSE: To determine the long-term antiscarring effect of ilomastat treatment after experimental glaucoma filtration surgery (GFS). METHODS: In a randomized, prospective, masked-observer study, 21 New Zealand White rabbits underwent modified GFS. The animals were allocated to receive either intraoperative mitomycin-C (MMC) at a concentration of 0.2 mg/mL or postoperative subconjunctival injections of either ilomastat or phosphate-buffered saline (PBS). Fifteen injections were given to each animal during the study period. The animals were killed 60 days after surgery. Bleb morphology and intraocular pressures were recorded. Tissue sections were immunohistochemically stained for signs of scarring. RESULTS: Ilomastat significantly improved surgical outcome compared with vehicle (P < 0.0163) and length of bleb survival was similar to the MMC group. The mean day of failure was 46.2 (range, 42-60) with ilomastat, 51.3 (range, 49-60) with MMC, and 16 (range, 15-21) with vehicle. IOP maintenance with ilomastat was similar to that in the MMC group. Histologically, minimal scar tissue was seen with MMC and ilomastat. MMC-treated tissue demonstrated subconjunctival hypocellularity associated with peripheral fibrosis. Ilomastat resulted in normal-appearing conjunctival morphology. CONCLUSIONS: Ilomastat successfully prolongs bleb survival. MMP inhibition may provide an additional, potentially safer method of controlling intraocular pressure, thus preventing failure of glaucoma surgery, and may also act as a potential adjuvant treatment when MMC alone is inadequate.     

Avastin抑制兔眼小梁切除术后滤过泡瘢痕化的作用

目的:探讨Avastin抑制兔眼小梁切除术后滤过泡纤维瘢痕形成的作用。方法:兔20只40眼随机分为3个不同剂量Avastin实验组、丝裂霉素C(MMC)对照组及空白对照组。对兔眼行常规小梁切除术,Avastin实验组于术毕及术后3,7d术区结膜下分别注射0.5,1及2mg Avastin;MMC对照组术中筋膜囊、巩膜瓣下放置0.2g/LMMC棉片。术后裂隙灯下观察滤过泡形态及角膜、前房等情况;术后7,14d摘除眼球,常规HE染色观察组织形态,在高倍视野中,通过滤过泡腔面在结膜中形成的面积百分比及滤过泡形成区在结膜中面积百分比,评价不同剂量Avastin结膜下注射对滤过泡形成及纤维化的影响。结果:术后7d各组结膜纤维结缔组织中均可见明显的滤过泡形成。术后14d仅注射2mg Avastin实验组及MMC对照组的结膜组织中可见明显滤过泡;1mg Avastin实验组见少量面积微小的滤过泡;0.5mg Avastin实验组及空白对照组滤过泡均消失,纤维组织增生明显。术后7d各组高倍视野下滤过泡腔面在结膜中形成的面积百分比及滤过泡形成区在结膜中面积百分比无明显差异。术后14d,2mg及1mg Avastin实验组滤过泡腔面积在结膜中形成的面积百分比分别为1.0%,0.8%,MMC组为0.9%。2mg及1mgAvastin实验组滤过泡形成区在结膜中面积百分比分别为26.1%,2.9%,MMC组为25.8%。2mg及1mgAvastin实验组的滤过泡腔面及形成区面积与结膜面积的百分比均明显高于空白对照组,单项方差分析结果分别为F=270.10,P=0.00;F=49.99,P=0.00;2mg Avastin实验组的上述滤过泡面积百分比与MMC组无差异。结论:结膜下注射Avastin可有效帮助滤过术后滤过泡的形成与维持,缓解滤过泡的纤维增生。     

苏拉明辅助用于兔小梁切除术中抗增殖作用的实验研究

目的探讨苏拉明辅助用于兔小梁切除术中的抗增殖效果。设计实验研究。研究对象新西兰白兔32只。方法32只兔双眼均行标准小梁切除术,并随机分为空白对照组、标准对照组、实验Ⅰ组、实验Ⅱ组,后3组术中巩膜瓣下分别应用03mg／ml丝裂霉素C、220mg／ml及250mg／ml苏拉明海绵片2min。术后第3、7、15、30d观察眼压及滤过泡形态并行HE染色和增殖细胞核抗原（PCNA）染色。主要指标眼压、滤过泡形态、组织病理染色。结果术后30天空白组和实验Ⅰ组功能滤过泡比率均较标准组低,实验Ⅱ组高于其它三组。PCNA染色阳性细胞核计数（四组分别为18．79±1．91,11．75±1．96,11．08±1．80,5．12±1．15）实验I组和标准组无统计学差异（P〉0．05）,两组均较空白组少,实验Ⅱ组最少（P〈0．05）。结论苏拉明辅助用于兔小梁切除术可维持功能性滤过泡,250mg／ml苏拉明抗增殖能力不低于0．3mg/ml丝裂霉素C,而副作用小。