Postoperative 5-fluorouracil versus intraoperative mitomycin C in high-risk glaucoma filtering surgery: extended follow up

Purpose: To compare the long‐term efficacy and safety of postoperative subconjunctival 5‐fluorouracil (5‐FU) injections with that of intraoperative mitomycin C (MMC) in eyes at high risk for failure of trabeculectomy. Methods: In a retrospective, non‐randomized comparative trial, 36 eyes of 36 consecutive patients at high risk for failure of trabeculectomy underwent glaucoma filtering surgery with either postoperative subconjunctival 5‐FU injections (19 eyes) or intraoperative application of MMC (17 eyes). Intraocular pressure, number of postoperative antiglaucoma medications, postoperative visual acuity, interventions, and complications were evaluated. Results: Overall success (intraocular pressure ≤21 mmHg) at 1 year was 73.6% in the 5‐FU group and 82.3% in the MMC group. The cumulative 4‐year success was 52.6% in the 5‐FU group and 60.5% in the MMC group (P = 0.6). At 4‐year follow up, mean ± SD intraocular pressures were 17.58 ± 4.01 mmHg in the 5‐FU group and 13.33 ± 3.36 mmHg in the MMC group (P = 0.01). There was no significant difference in the number of post­operative medications (P = 0.84), appearance of blebs (P = 0.20), final visual acuity (P = 1.00), and complications (P > 0.05) between the groups. Conclusions: These results suggest that both postoperative 5‐FU injections and intraoperative MMC application have long‐term success in high‐risk patients. However, MMC results in a greater decrease in intraocular pressure than 5‐FU.     

Intraocular pressure outcome in primary 5FU phacotrabeculectomies compared with 5FU trabeculectomies

PURPOSE: Combined surgery for glaucoma and cataract may not achieve as low intraocular pressure (IOP) as compared with trabeculectomy alone. The aim of this study was to assess the IOP control of 5-fluorouracil (5FU) phacotrabeculectomies compared with 5-fluorouracil trabeculectomies. METHODS: A retrospective, nonrandomized study of consecutive primary 5FU phacotrabeculectomies and primary 5FU trabeculectomies. The main outcome measures were preoperative and postoperative IOP, number of medications, visual acuity, and complications. RESULTS: Forty-five 5FU phacotrabeculectomies and 47 5FU trabeculectomies were performed with a mean follow-up of 43.1 and 36.6 months, respectively. The absolute success rate as defined as an IOP equal to or less than 16 mm Hg on no glaucoma drops was 62.2% for the phacotrabeculectomy group and 63.8% for the trabeculectomy group. These success rates were not statistically significantly different (log-rank test P = 0.81 for absolute success and P = 0.29 for relative success). The magnitude of the treatment effect was found to be significantly greater in the T group compared with the PT group (a 44.6% reduction in IOP in the T group compared with a 31.2% reduction in the PT group). The phacotrabectomy group underwent significantly more postoperative 5FU injections compared with the trabeculectomy group (P = 0.008). CONCLUSIONS: 5FU phacotrabeculectomy seems to be a safe and effective treatment option in terms of IOP control. Patients with both coexistent glaucoma and cataract could be considered for combined surgery.     

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

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

Phacotrabeculectomy in Treatment of Primary Angle-closure Glaucoma and Primary Open-angle Glaucoma

Purpose To evaluate the surgical outcome of combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy (phacotrabeculectomy) in patients with primary angle-closure glaucoma (PACG) or primary open-angle glaucoma (POAG).Methods The records of 57 consecutive patients (65 eyes) with PACG or POAG that were treated with phacotrabeculectomy were reviewed retrospectively. There were 31 eyes with PACG and 34 with POAG. The mean follow-up period was 21.0 ± 8.3 months. The visual acuity, intraocular pressure (IOP), number of medications, and complications were evaluated.Results The mean IOP and the number of glaucoma medications decreased significantly after phacotrabeculectomy in both groups. The mean IOP reduction was significantly greater in eyes with PACG (P < 0.05). The absolute success rates were 87.1% and 70.6% in PACG and POAG, respectively. The difference in the success rates was not significant (P = 0.297). The early postoperative complication rates were similar in both groups.Conclusions Phacotrabeculectomy results in greater IOP reduction in eyes with PACG than in those with POAG, but the overall success rates were not significantly different. Jpn J Ophthalmol 2004;48:408–411 © Japanese Ophthalmological Society 2004     

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

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

Stratus optical coherence tomography study of filtering blebs after primary trabeculectomy with a fornix‐based conjunctival flap

Purpose: To investigate the relationship between filtering bleb function and Stratus optical coherence tomography (OCT) images. Methods: We studied 72 eyes of 65 consecutive patients who had a fornix‐based conjunctival flap in primary trabeculectomy with mitomycin C (MMC). Filtering blebs with various types of glaucoma were examined using Stratus OCT. Success rates were defined as intraocular pressure (IOP) ≤ 15 mmHg and IOP reduction ≥ 25% without medication or additional surgery. Success rates among classified groups were compared using Kaplan–Meier survival curves and the log‐rank test. Results: Blebs were classified into three different categories on the basis of the following Stratus OCT patterns: cystoid type (multiple cysts inside the bleb; 17 eyes), diffuse type (low to high reflective areas that were mixed inside the bleb; 31 eyes) and layer type (medium to high reflective layer inside the bleb; 24 eyes). Success rates in the cystoid‐, diffuse‐ and layer‐type blebs were 94%, 97% and 75% (P = 0.02), respectively. Conclusion: In trabeculectomy with MMC and a fornix‐based conjunctival flap, there is a significant association between the success rates and the postoperative Stratus OCT findings of filtering blebs.     

Comparison of trabeculectomy with Ex-PRESS miniature glaucoma device implanted under scleral flap

PURPOSE: To evaluate the Ex-PRESS miniature implant (Model R 50) placed under partial-thickness scleral flap compared with standard trabeculectomy. METHODS: In this retrospective comparative series of 100 eyes, we compared 50 eyes in 49 patients treated with the Ex-PRESS miniature glaucoma implant under a scleral flap with 50 matched control eyes in 47 patients treated with trabeculectomy. Success was defined as intraocular pressure (IOP) > or =5 mm Hg and < or =21 mm Hg, with or without glaucoma medications, without further glaucoma surgery or removal of implant. Early postoperative hypotony was defined as IOP <5 mm Hg during the first postoperative week. RESULTS: The average follow-up was 10.8 months (range 3.5 to 18) for the Ex-PRESS group and 11.2 months (range 3 to 15) for the trabeculectomy group. Although the mean IOP was significantly higher in the early postoperative period in the Ex-PRESS group compared with the trabeculectomy group, the reduction of IOP was similar in both groups after 3 months. The number of postoperative glaucoma medications in both groups was not significantly different. Kaplan-Meier survival curve analysis showed no significant difference in success between the 2 groups (P=0.594). Early postoperative hypotony and choroidal effusion were significantly more frequent after trabeculectomy compared with Ex-PRESS implant under scleral flap (P<0.001). CONCLUSIONS: The Ex-PRESS implant under a scleral flap had similar IOP-lowering efficacy with a lower rate of early hypotony compared with trabeculectomy.     

Comparison of phacotrabeculectomy and sequential surgery in the treatment of chronic angle-closure glaucoma coexisted with cataract

AIM: To compare the safety and effectiveness of phacotrabeculectomy versus sequential surgery in chronic angle-closure glaucoma (CACG) with coexisting cataract. METHODS: One hundred and sixty-two CACG patients (162 eyes) were retrospectively analyzed. Of them, 87 patients (87 eyes) in group A had underwent phacotrabeculectomy with intraocular lens (IOL) implantation, and 75 patients (75 eyes) in group B had underwent sequential surgery with IOL implanted. Best-corrected visual acuity (BCVA), intraocular pressure (IOP), complications and anterior chamber angle (ACA) were measured. RESULTS: Demographic characteristics of the two groups were similar. A mean follow-up period was 15±6mo (range 13 to 24mo), a mean IOP of 16.61±6.43 mm Hg in group A and 15.80±5.35 mm Hg in group B (P=0.84) at the last follow up. The Kaplan-Meier analysis revealed that the cumulative probability of success in both groups was similar (P=0.61). Anterior uveitis and hypotony were the most common complications in group A, whereas group B experienced shallow anterior chamber with trabeculectomy. With the exception of anterior uveitis, no complications occurred to 11 trabeculectomized eyes. All postoperative measurements of anterior chamber showed statistically significant differences in each group according to the preoperative data (P<0.05). However, fewer changes occurred in group B than in group A. CONCLUSION: Phacotrabeculectomy and sequential surgery exhibit similar IOP reduction, visual recovery, and complications when treating CACG patients with cataract. However, for a wider ACA, phacotrabeculectomy has demonstrated higher effectiveness than sequential surgery.     

Non-penetrating glaucoma surgery augmented with mitomycin C or 5-fluorouracil in eyes at high risk of failure of filtration surgery: long-term results

PURPOSE: To investigate the long-term efficacy and safety of non-penetrating glaucoma surgery (NPGS) augmented with mitomycin C (MMC) or 5-fluorouracil (5FU) in eyes at high risk of failure of glaucoma filtration surgery. METHODS: Prospective study of all eyes, undergoing NPGS with 0.04% MMC (1 to 2 min topical or 0.04 mL subconjunctival injection into the superior fornix) or 5FU (25 mg/mL topically for 5 min). Complete success was an intraocular pressure (IOP)or=20% drop in IOP or a reduction of at least two medications. RESULTS: Twenty-three eyes of 22 patients with a mean follow up of 41.4 months were reviewed. Fifteen eyes had failed trabeculectomy and seven had uveitic glaucoma. Mean preoperative IOP reduced from 25.8+/-7.8 to 15.4+/-4.9 mmHg at final visit, a mean change of 41%. Median number of preoperative medications decreased from 3 to 0 postoperatively. Cumulative probability of success was 100% at 2 years, 94% at 3 years and 85% at 4 years. No patient developed any long-term complications. Complete success was achieved in 11 eyes and qualified success in 10 eyes. Two eyes failed and required further surgery. CONCLUSION: NPGS augmented with small-volume MMC/5FU provides good long-term IOP control in eyes at high risk of failure with a lower incidence of complications compared with augmented trabeculectomy and eliminates the need for postoperative bleb or suture manipulation.     

Outcome of repeat trabeculectomy with mitomycin C in isolation or combined with phacoemulsification

Purpose:To evaluate the effectiveness of repeat trabeculectomy with Mitomycin C (MMC) in isolation or combined with phacoemulsification, and to identify risk factors for failure over 1 year.Methods:Retrospective review of 113 eyes of 113 patients (49 primary open angle, 27 primary angle closure, 37 secondary glaucoma) who underwent repeat trabeculectomy with MMC (isolated trabeculectomy 75 and phacotrabeculectomy 38). The primary outcome measure was intraocular pressure (IOP) at 1 year follow-up. Three IOP criteria were chosen to measure success A) IOP ≤21 mmHg and ≥20% reduction from baseline. B) IOP ≤17 mmHg and ≥20% reduction from baseline. C) IOP ≤14 mmHg.Results:Mean IOP decreased from 24.5 ± 8.8 mmHg to 16.4 ± 7.6 mmHg 1 year after repeat trabeculectomy. The mean number of medications reduced from 2.9 ± 1.0 to 0.6 ± 1.0. Complete success with trabeculectomy versus phacotrabeculectomy for criterion A was 60% vs 55.3%, criterion B 54.7% vs 50.0% and criterion C 40.0% vs 28.9%. IOP ≤14 mmHg was more likely with trabeculectomy than phacotrabeculectomy (P = 0.047). On regression analysis, duration between surgeries ≤4 years (P = 0.018) and secondary glaucoma (P = 0.046) were identified as risk factors for surgical failure with criterion A. Younger age (P = 0.042), fornix based flap (P = 0.058), and phacotrabeculectomy (P = 0.042) for criterion C.Conclusion:Repeat trabeculectomy with MMC is successful at lowering IOP and decreasing number of antiglaucoma medications. Low IOP levels are less likely with phacotrabeculectomy.     

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

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

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.     

Phacotrabeculectomy versus two-stage operation: a matched study

BACKGROUND AND OBJECTIVE: To evaluate the efficacy and safety of phacoemulsification and foldable intraocular lens, combined with trabeculectomy (phacotrabeculectomy) in patients with coexisting cataract and glaucoma. PATIENTS AND METHODS: A total of 53 consecutive eyes which underwent phacotrabeculectomy and posterior chamber intraocular lens (PCIOL) were matched and compared with 53 eyes that had trabeculectomy followed by phacoemulsification and posterior chamber intraocular lens (mean interval 3.2 month). The 2 groups were first matched by diagnostic group and subsequently for the closest possible match with other successive variables, including age, gender, race and preoperative glaucoma medications. Mean intraocular pressure (IOP) reduction, visual acuity, antiglaucoma medications, and surgical success as well as complications were compared in both groups. RESULTS: Mean IOP reduction was 14.5+/-4.1 mmHg in the two-stage group compared to 15.1+/-3.9 in the phacotrabeculectomy group at 6 months follow-up (P<0.1) and 13.8+/-3.9 and 14.6+/-3.7 respectively at 1 year (P<0.1).Visual acuity and complications were comparable. CONCLUSION: Phacotrabeculectomy provides IOP control statistically comparable to two-stage surgery with earlier visual rehabilitation.     

开角型青光眼小梁切除术中应用胶原蛋白基质与MMC的疗效比较

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

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

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

Combined Phacoemulsification, Intraocular Lens Implantation and Trabeculectomy for Chronic Angle Closure Glaucoma

Purpose: To investigate the results of combined phacoemulsification, intraocular lens implantation and trabeculectomy in Asian patients with chronic angle closure glaucoma (CACG). Methods: This was a retrospective non-comparative case series of 55 consecutive patients (57 eyes) who underwent phacoemulsification, posterior chamber intraocular lens implantation and trabeculectomy for CACG at the Singapore National Eye Centre between 1997–1998. The surgical outcome was assessed in terms of intraocular pressure (IOP), the incidence of complications and the visual acuity at last follow-up. Success was defined as final IOP 21 mmHg without medication and qualified success as final IOP 21 mmHg with medication. Patients with final IOP > 21 mmHg who required further glaucoma surgery, lost light perception or became pthisical, were classified as failures. The eyes were further categorized into two groups according to whether single-site or separate-sitesurgery was performed. The outcome was also compared among eyes in which per-operative antimetabolites were applied to the trabeculectomy site and those without antimetabolites. Results: The mean follow up was 22.0 ± 5.6 months (mean ± SD). Success was achieved in 46 (81%) eyes, qualified success in 10 (17%) eyes, and failure in 1 (2%) eye. In terms of IOP outcome, the success rate was similar in the two surgical groups (single-site or separate-site).There was no significant difference in IOP outcome among eyes in which per-operative antimetabolites were used and eyes with no per-operativeantimetabolites use. Forty-one eyes (72%) had 6/12 or better vision. There were no cases of intraoperative complications and the incidence of postoperative complications was low. Conclusions: Combined phacoemulsification, intraocular lens implantation and trabeculectomy is associated with good intraocular pressure control and visual outcome in patients with CACG.     

Phacotrabeculectomy with mitomycin C in patients with uveitis

PURPOSE: To evaluate the safety and efficacy of combined phacoemulsification, intraocular lens implantation, and trabeculectomy with mitomycin C for the management of uveitic complications. DESIGN: Retrospective case-control study. METHODS: We conducted a retrospective review of the records of 23 consecutive eyes with chronic noninfectious uveitis (uveitic group) and 43 nonuveitic eyes (control group) that had received primary phacotrabeculectomy. Mitomycin C was used in all the uveitic eyes. Considering the high preoperative intraocular pressure (IOP) of the uveitic group, nonuveitic eyes that had a preoperative IOP of >or=20 mm Hg or that had been given two or more medications were included in the control group. All patients were followed for at least one year. The main outcome measures were postoperative vision, IOP control, complications, and acute uveitis relapse rates. RESULTS: Visual outcome of the uveitic group was similar to the control group. In the uveitic group, the success rate of IOP control (91.3% at one year, 84.8% at two years) was favorable but was significantly lower than in the control group (P = .0423). Complications were comparable between the groups. Primary surgical failure in the uveitic group was associated with the postoperative acute uveitis attack. In the uveitic group, the acute uveitis attack rate showed no change after surgery (P = .283). CONCLUSION: With adequate inflammation suppression, phacotrabeculectomy with mitomycin C is an effective and safe therapeutic option for the management of secondary cataract and glaucoma in uveitic eyes. A lower surgical success rate of the uveitic group might be attributable to the postoperative inflammation recurrence.     

Long-term evaluation of trabeculectomy in primary open angle glaucoma and chronic primary angle closure glaucoma in an Asian population

Purpose: A retrospective cohort study was undertaken to evaluate and compare the long‐term results of trabeculectomy in primary open angle glaucoma (POAG) and chronic primary angle closure glaucoma (CPACG) in an Asian population. Methods: Yearly diurnal measurements of intraocular pressure (IOP), best‐corrected visual acuity, optic disc and visual field records of patients having primary adult glaucomas who had undergone trabeculectomy, without anti­mitotic agents, with a minimum of 5 years follow up were evaluated. Only one eye of each patient was studied. The success rates for IOP control in POAG and CPACG were statistically analysed. Results: Sixty‐four eyes of 64 patients were studied. The overall probability of success of trabeculectomy in controlling IOP to ≤21 mmHg with or without additional topical antiglaucoma medication was 0.94 and 0.88 at 5 and 10 years, respectively. There was no statistically significant difference in the qualified and absolute success rates for IOP control between POAG and CPACG eyes (log rank test P= 0.6, 0.88, respectively). Twelve of 38 CPACG eyes had a two‐line decrease in visual acuity as compared to four of 26 POAG eyes (P = 0.17). Progression or development of a cataract was the most common cause of visual decline. Conclusions: Trabeculectomy without antimetabolite use appears to be efficacious in lowering IOP and in visual field preservation over a period of 10 years in both POAG and CPACG. Development/progression of cataract especially in eyes with chronic angle closure glaucoma after trabeculectomy must be considered an important issue.     

The Clinical Outcomes of Three Surgical Managements on Primary Angle-closure Glaucoma

Purpose: To investigate the efficacy of trabeculectomy, phacotrabeculectomy and phaco-emulsification in the management of primary angle closure glaucoma (PACG). Methods: A prospective observational study was performed in 88 chronic PACG patients (97 eyes) who were divided into three groups following defined indications to receive different surgical interventions. The indications and clinical outcomes were evaluated. The mean follow-up was (17.7±4.9) months. Results: Success rate in trabeculectomy, phacotrabeculectomy and phacoemulsification group was 81.08%, 78.57‰ and 81.25‰, respectively. The anterior chamber depth was deeper and the angle was wider postoperatively vs. preoperatively both in phaco-trabeculectomy and phacoemulsification group. No obvious changes were seen in trabeculectomy group. The coefficient of outflow facility of aqueous humor (C values) significantly increased in three groups postoperatively (P < 0.01). No severe intra-operative complications were found and the incidence of postoperative complications was low. Five eyes sustained hypotony 3±1.87 months in trabeculectomy group and 1 eye happened malignant glaucoma in phacotrabeculectomy group. The visual acuity in patients with phacotrabeculectomy plus intraocular lens implantation and those only with phacoemulsification plus intraocular lens implantation were improved 78.57% and 93.74%, respectively. No significant improvement was found in trabeculectomy group (χ2 = 47.10, P < 0.001). Conclusion: Three surgical interventions were beneficial to manage PACG and with co-existing cataract. The indication choosing was suggested according to visual acuity, angle closure circumference, cataract, medication requirements and optic nerve damage. Phacotrabeculectomy was recommended for angle closed ≥180° circumference while phacoemulsification for angle closed < 180°.     

A randomised,prospective study comparing trabeculectomy augmented with antimetabolites with a viscocanalostomy technique for the management of open angle glaucoma uncontrolled by medical therapy

AIMS: To compare trabeculectomy with viscocanalostomy for the control of intraocular pressure (IOP) in open angle glaucoma (OAG) uncontrolled by medical therapy. METHODS: 48 patients (50 eyes) with uncontrolled OAG were randomised to either trabeculectomy (25 eyes) or a viscocanalostomy technique (25 eyes). Preoperatively, eyes were graded in terms of risk factors for drainage failure. Those undergoing trabeculectomy were given intraoperative antimetabolites (5-fluorouracil 25 mg/ml (5-FU), mitomycin C (MMC) 0.2 mg/ml and 0.4 mg/ml) according to a standard protocol. Antimetabolites were not used intraoperatively in eyes undergoing viscocanalostomy, but they were randomised to the use of viscoelastic (Healonid GV) for intraoperative intracanalicular injection. RESULTS: There were no significant differences between the groups in age, sex, type of OAG, preoperative medications, risk factors for drainage failure, and preoperative IOP. Mean follow up was 19 months (range 6-24 months). It was 12 months or longer in all eyes, except one lost to follow up at 6 months. At 12 months, complete success (IOP <21 mm Hg without antiglaucoma medications) was seen in all eyes undergoing trabeculectomy (100%), but in only 64% of eyes undergoing viscocanalostomy (p<0.001). The mean IOP was lower at 12 months (p<0.001) with trabeculectomy and the number of eyes with IOPs of 15 mm Hg or less was greater (p<0.05). The mean IOP at 12 months was lower in eyes that had undergone viscocanalostomy using intraoperative intracanalicular Healonid GV injection compared to those where only balanced saline solution had been used (p<0.01). However, in terms of complete success there was no difference between the viscocanalostomy groups (p<0.1). With the exception of measurements at 1 week, visual recovery (logMAR acuity) was similar and laser flare and cell values showed little differences between the groups. Corneal topography and keratometry at 12 months were little different from preoperative values. Postoperative interventions (subconjunctival 5-FU and needling procedures) were similar between the groups. Transient complications such as early bleb leak and hyphaema were more common in the trabeculectomy group (p<0.05). Postoperative cataract formation was more common after trabeculectomy (p<0.05). CONCLUSIONS: IOP control appears to be better with trabeculectomy. Viscocanalostomy is associated with fewer postoperative complications, although significant complications permanently impairing vision did not occur with either technique.