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.     

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.     

Late-onset transconjunctival oozing and point leak of aqueous humor from filtering bleb after trabeculectomy

PURPOSE: To estimate the prevalence and identify factors related to late-onset transconjunctival aqueous oozing and point leak from functioning blebs after trabeculectomy with 5-fluorouracil (5-FU) or mitomycin C. DESIGN: Cross-sectional study. METHODS: SETTING: The study took place at the outpatient clinic of the Department of Ophthalmology, University of Tokyo Graduate School of Medicine (Tokyo, Japan). Four hundred three consecutive patients (403 eyes) with functional blebs at least 3 months after previously performed trabeculectomy were examined between December 1997 and February 1998. The Seidel test was performed with extended observation up to 15 seconds. Oozing was identified as transconjunctival aqueous egress without interruption of the conjunctival tissue or aqueous stream on the bleb wall. Logistic regression analyses of oozing and point leak in 331 eyes with an avascular area were performed using independent variables, including age, gender, glaucoma diagnosis, prior incisional surgery, antimetabolite use, combined cataract surgery, postoperative follow-up period, intraocular pressure (IOP), concurrent glaucoma therapy, bleb size, and avascular area size. RESULTS: Of 403 eyes, 48 eyes (11.9%) had oozing and 8 eyes (2.0%) had point leak. Intraocular pressure was significantly lower and an avascular area was more frequent in eyes with oozing or leak than in eyes without (P <.001). Logistic regression analysis revealed that oozing was significantly more common after use of 5-FU than mitomycin C (P =.024), whereas point leak was associated with a larger avascular area (P =.045). CONCLUSIONS: After trabeculectomy with antimetabolites, transconjunctival oozing is much more frequent than point leak. Oozing was significantly associated with the use of 5-FU and point leak with a larger avascular area in the bleb.     

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.     

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。     

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.     

无结膜瓣小梁切除术的临床评价

目的评价无结膜瓣小梁切除术治疗原发性青光眼的临床疗效。方法68例（68眼）原发性青光眼随机分为两组,A组行无结膜瓣小梁切除术;B组行复合式小梁切除术。观察比较术后眼压变化、并发症和滤过泡情况。结果术后随访12个月,A组平均眼压为（15．3±3．5）mmHg,B组平均眼压为（15．9±3．6）mmHg,（P〉0．05）。术后1周内低眼压浅前房,A组5．6％、B组9．4％;脉络膜脱离A组2．8％、B组6．3％;滤过泡渗漏A组5．6％、B组6．3％。结论无结膜瓣小梁切除术对原发性青光眼疗效良好。     

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.     

小梁切除术后远期泪膜和眼表上皮改变及其影响因素研究

目的 探讨青光眼患者小梁切除术后远期泪膜和眼表上皮的情况及其影响因素.方法 对103例(139只眼)小梁切除术后6个月以上的患者进行眼表泪膜检查和结膜印迹细胞学检查,分析术后远期薄壁滤过泡的发生率与术中使用丝裂霉素C(MMC)的关系,分析术后远期泪膜和眼表上皮改变与术中使用MMC及术后滤过泡形态的相关关系.结果 小梁切除术后患眼与正常对照组相比,泪膜破裂时间缩短,眼表活体染色增多,结膜上皮鳞状化生改变明显.高浓度MMC组术后薄壁滤过泡的发生率明显高于低浓度MMC组和空白对照组.术后远期眼表上皮杯状细胞密度(GCD)与术中MMC的使用及术后滤过泡的形态呈负相关.结论 小梁切除术后远期患眼存在干眼表现.术中使用高浓度MMC可增加术后远期薄壁滤过泡的发生率.术后远期结膜上皮杯状细胞密度的降低与MMC的使用及隆起于眼表的滤过泡有关.     

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.     

Phacoemulsification in eyes with functioning filtering blebs: a prospective study

OBJECTIVE: To evaluate the effect of phacoemulsification on intraocular pressure (IOP) control in eyes with a previous functioning filtering bleb and no glaucoma medication. DESIGN: Prospective, nonrandomized comparative (self-controlled) trial. PARTICIPANTS: Forty-seven patients (49 eyes) who underwent phacoemulsification after successful trabeculectomy, with at least 12 months of follow-up. INTERVENTION: Clear corneal phacoemulsification and implantation of a foldable intraocular lens in eyes that underwent a previous successful trabeculectomy. The time between both procedures was always greater than 1 year. MAIN OUTCOME MEASURES: Preoperative and postoperative IOP, the number of glaucoma medications, bleb appearance, and visual acuity were recorded at each follow-up examination. Success was defined as no need for glaucoma medications, bleb needling, or further glaucoma surgery for IOP control after phacoemulsification. Preoperative and intraoperative factors were evaluated for an association with postoperative failure using Kaplan-Meier survival analysis. RESULTS: The mean (+/- standard deviation) IOP before phacoemulsification was 12.24 (+/- 4.68) mmHg, and it increased 3.94, 3.76, 1.39, 2.04, and 1.57 mmHg on the first postoperative day, after 1, 6, and 12 months, and at the last visit, respectively. At each interval, the mean IOP was significantly higher than the preoperative value (P = 0.000, 0.000, 0.049, 0.01, and 0.01, respectively). Nevertheless, the mean IOP after phacoemulsification was always lower than before trabeculectomy (P = 0.000). At the last visit, glaucoma medication was required in 17 eyes (34.7%). The success rates after phacoemulsification were 83.6%, 68.2%, and 55.7% at 6 months and 1 and 2 years, respectively (Kaplan-Meier survival analysis). The number of glaucoma medications used increased at all follow-up visits (P < 0.005). Bleb size decreased after phacoemulsification (P = 0.000). An IOP before phacoemulsification of greater than 10 mmHg was associated with postoperative failure (P = 0.002). Similarly, bleb failure and the need for glaucoma medication were associated with higher IOPs before phacoemulsification. CONCLUSIONS: Phacoemulsification significantly increased IOP and the number of glaucoma medications in eyes with preexisting functioning filtering blebs. Eyes with higher IOPs before phacoemulsification had worsened postoperative IOP control and bleb failure.     

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.     

人羊膜与丝裂霉素C用于青光眼小梁切除术的临床对比研究

目的 :探讨羊膜与丝裂霉素C (MMC)应用于小梁切除术的临床疗效。方法 :采用随机对照的方法 ,施行同一标准的小梁切除术 ,将 2 6例 (4 2眼 )闭角型青光眼患者分为羊膜组和MMC组各 2 1眼。前者施行小梁切除术联合巩膜瓣下羊膜植入术 ,后者在术中一次性应用MMC ,浓度为 0 2 5mg/ml ,共 5分钟。随访 6个月。结果 :手术成功率 :羊膜组的累积完全成功率和条件成功率分别为 86 2 3 %和 96 68% ,MMC组的累积完全成功率和条件成功率分别为 5 8 79%和 79 5 6% (P <0 0 1)。功能性滤过泡的累积存活率羊膜组为 86 2 6% ,MMC组为 5 1 3 3 % ,两组之间有显著性差异 (P <0 0 1)。术后视力 :MMC组术后视力下降者 10眼 (4 7 6% ) ,羊膜组则只有 2眼 (11 8% )。两组间差异有显著性 (P <0 0 5 )。并后并发症 :羊膜对眼部的副作用小 ,引起的并发症主要有术后浅前房 ;MMC引起的眼部并发症主要有薄壁滤过泡、术后浅前房、滤过泡渗漏、前房出血、持续性低眼压、低眼压性黄斑病变等。结论 :羊膜应用于小梁切除术可有效地防止滤过泡的瘢痕组织形成 ,并能有效长期保留功能性滤泡 ,且并发症较MMC少     

Penetration of topically applied fluorescein into eyes with avascular filtering bleb after trabeculectomy

PURPOSE: To evaluate intraocular penetration of topical fluorescein in eyes with avascular blebs after trabeculectomy. DESIGN: Case control study. METHODS: The study included 11 eyes with open-angle glaucoma and functioning avascular blebs, six of which were treated with topical anti-glaucomatous medications and had no history of surgery, 15 with open-angle glaucoma, and untreated eyes suspected of having open-angle glaucoma. The fluorescein concentration in the superior peripheral and central corneal stroma and anterior chamber was determined 30 and 60 minutes after fluorescein instillation. RESULTS: The fluorescein concentration in the superior cornea was significantly higher in eyes with blebs or those topically treated than in untreated eyes (P <.01); there was no significant difference in the central cornea. The fluorescein concentration in the anterior chamber was much higher in eyes with blebs than in those that were untreated or topically treated (P <.001). CONCLUSION: The presence of avascular filtering blebs greatly enhances intraocular penetration of topically instilled fluorescein.     

MMC与5-FU联合可调整缝线的小梁切除术治疗青光眼的疗效比较

目的：对比分析青光眼患者联合可调整缝线的小梁切除术中使用丝裂霉素C(mitomycin C,MMC)与5-氟尿嘧啶(5-fluorouracil,5-FU)的临床预后及并发症。

方法：回顾性病例系列研究。选取本院2016-06/2017-10的71例71眼青光眼(包括原发性开角型青光眼和原发性慢性闭角型青光眼)患者,分为两组,其中MMC组36例,5-FU组35例,均给予联合可调整缝线的小梁切除术,分别使用MMC、5-FU抗瘢痕治疗,术后随访6mo,比较两组患者的临床眼压控制疗效、滤过泡形态及并发症发生率。

结果：MMC组患者术后眼压控制低于5-FU组,差异有统计学意义(P<0.05),MMC组总手术成功率与5-FU组比较,差异无统计学意义(P>0.05),MMC组功能性滤过泡形成率高于5-FU组,MMC组非功能性滤过泡形成率低于5-FU组,差异有统计学意义(P<0.05),MMC组与5-FU组并发症发生率差异无统计学意义(P>0.05)。

结论：MMC及5-FU作为抗瘢痕药均能提高青光眼小梁切除手术的成功率,MMC能将眼压降到更低,形成功能性滤过泡方面MMC优于5-FU,根据患者制定个性化的手术方案MMC与5-FU的并发症发生率无明显差异,使用5-FU时需术后多次分离滤过泡及结膜下再次注射5-FU。     

Bleb reduction and bleb repair after trabeculectomy

OBJECTIVE: To describe methods and outcomes for repair of bleb-related complications of trabeculectomy surgery. DESIGN: Retrospective, consecutive, noncomparative case series. PARTICIPANTS: Thirty-one persons having bleb revision by two surgeons at the Wilmer Institute from 1994 to the present. INTERVENTION: One of two types of revision surgery was performed: bleb reduction to decrease symptoms from large blebs or bleb repair to improve hypotony, using conjunctival rotation flap or free conjunctival autograft. MAIN OUTCOME MEASURES: Visual acuity, intraocular pressure (IOP), reported symptoms, complications, and number of glaucoma medications at the final visit. RESULTS: The mean time from trabeculectomy to bleb revision was 4.4 years. Bleb reduction was performed because of symptomatic, high blebs in 11 eyes of 11 persons. Bleb repair was performed to end bleb leakage in 13 eyes of 13 persons and to increase IOP in 8 eyes of 7 persons with hypotony. Median visual acuity improved from 20/50 before revision to 20/30 at most recent follow-up. Mean IOP increased after treatment from 7.7+/-4.9 to 12.4+/-4.0 mmHg (P < 0.001). Symptoms that caused the revision surgery were eliminated in all cases. None of these eyes has lost IOP control, none has required repeat trabeculectomy, and only 2 of the 32 (6%) require topical glaucoma medication. More than one revision procedure was required in 8 of 32 (25%) eyes. CONCLUSIONS: Surgical bleb revisions for complications after trabeculectomy surgery are safe and effective. Bleb reduction for large, symptomatic blebs or bleb repair for leaking blebs and hypotony did not lead to loss of IOP control.     

Trabeculectomy with large area mitomycin-C application as a first-line treatment in advanced glaucoma:retrospective review

AIM:To evaluate the outcomes of trabeculectomy with large area mitomycin-C (MMC) application as a first line treatment in advanced glaucoma.METHODS:The records of 55 patients with severe visual field defects undergoing trabeculectomy were retrospectively reviewed. The patients were classified as first-line therapy to either early trabeculectomy (initial trabeculectomy-Group 1) or long term medical therapy followed by trabeculectomy (primary trabeculectomy-Group 2). Trabeculectomy was performed with large-area MMC application. Intraocular pressure (IOP) values, visual acuities, mean deviations, morphology and function of the blebs, necessity for anti-glaucomatous medications and surgical complications were reported.RESULTS:There were 20 eyes of 18 patients in Group 1 and 37 eyes of 37 patients in Group 2. The mean preoperative IOPs in Groups 1 and 2 were 40.2±10.0mmHg (27-68mmHg) and 29.0±4.4mmHg (21-41mmHg), respectively (P=0.001). Average preoperative mean deviations (MD) in Groups 1 and 2 were 17.4±2.8dB (13.3-23dB) and 17.9±2.4 dB (13.7-23.2dB), respectively (P=0.441). Postoperative IOPs significantly decreased and were comparable in both Groups. The mean number of medications was significantly higher in Group 2 (P=0.005). No cystic bleb formation was observed in Group 1, whereas 4 patients from Group 2 (10.8 %) developed cystic bleb (P=0.040). No visually devastating complication has occurred in both Groups.CONCLUSION:Initial trabeculectomy with large area MMC application might be applied in patients with advanced glaucoma with low complication rates. Long-term topically applied anti-glaucomatous medications seem to increase the risk of cystic bleb formation.     

Long-term follow-up of initial 5-fluorouracil trabeculectomy in primary open-angle glaucoma in Japanese patients.

PURPOSE: To evaluate the long-term efficacy and safety of initial trabeculectomy with subconjunctival 5-fluorouracil in Japanese patients with primary open-angle glaucoma. SUBJECTS AND METHODS: Clinical records of 117 eyes from 117 patients with records of up to 14 years were retrospectively analyzed using the appropriate statistical methods. RESULTS: The mean follow-up period was 6.2 +/- 3.6 years. Criteria for successful intraocular pressure control and success probability by Kaplan-Meier method at 12 years were intraocular pressure < 21 mm Hg without medication plus a 30% or more reduction in intraocular pressure, 50.4 +/- 5.2% (SE) 38.2 +/- 5.3%; and intraocular pressure < 16 mm Hg without medication plus a 30% or more reduction in intraocular pressure, 45.9 +/- 5.1% (36.5 +/- 5.2%). Cox multiple regression analysis showed that a younger age was associated with a higher success probability (P <0.01). Eyes with lower postoperative intraocular pressure tended to show more positive value of the MD slope (P = 0.0669), whereas 7% of successfully treated eyes showed a negative postoperative MD slope (P < 0.1). The probabilities for developing bleb leaks and bleb-related infections in eyes with a functioning bleb were 28.9 +/- 12.5% and 13.0 +/- 10.4% at 12 years. CONCLUSION: Trabeculectomy with 5-fluorouracil as an initial surgery in Japanese patients with primary open-angle glaucoma was effective for long-term control of glaucoma. However, the probability of late-onset bleb-related complications was not low in eyes with a functioning bleb, stressing the importance of constant care regarding bleb status.     

Estudio del epitelio conjuntival de las ampollas filtrantes mediante citología de impresión

PurposeTo study the ocular surface in filtering blebs using impression cytology, comparing the bleb side and areas outside the bleb edges.MethodsTwelve filtering blebs of 8 patients were included: 4 cases of trabeculectomy without mitomycin C (MMC), 6 cases of trabeculectomy with MMC, and 2 cases of non-penetrating glaucoma surgery. Impression cytology specimens were taken from filtering blebs as well as outside the bleb area. A classification scale from 0 to 3 was used to describe the distribution of epithelial cells and the density of goblet cells. Grade 0 indicated cohesive epithelial cells and abundant goblet cells; and the grade 3 indicated loss of epithelial cohesion and absence of goblet cells.ResultsThe mean grade of cytology in filtering blebs was 2.4 ± 0.9, and in the outside bleb area of 0.8 ± 0.3 (P<.001). These differences were independent of the use of MMC (P=.48). The large majority (83%) of filtering blebs showed a decrease in epithelial cohesion and absence of goblet cells. Outside the bleb area, 100% of the cases had cohesive epithelial cells with different grades of goblet cells.ConclusionThe conjunctival epithelium overlying the filtering blebs showed significant changes that consisted of increased intercellular spaces and loss of goblet cells. These increased intercellular spaces could explain the trans-epithelial pathway of aqueous humor. The least amount of mucin due to loss of goblet cells could contribute to increase the risk of infection in filtering blebs.     

Enhancement of the success rate in trabeculectomy: large-area mitomycin-C application

Background: To compare the effects of variable mitomycin‐C (MMC) applications during trabeculectomy on target intraocular pressure (IOP), number of antiglaucomatous therapy, bleb morphology and surgical complications. Methods: 66 glaucoma cases who underwent trabeculectomy combined with small‐area (Group 1) or large‐area (Group 2) MMC application were included. This study is a retrospective case series comparison. In Group 1, MMC had only been applied to the scleral flap area, whereas additional MMC applications were performed on upper temporal and nasal quadrant in Group 2. The cases with diabetes, narrow angle glaucoma, secondary glaucoma, history of previous ocular surgery and follow‐up period less than 2 years were exluded from the study. A routine ophthalmological examination was performed in all cases and IOP measurements, morphology and the function of the blebs, necessity for antiglaucomatous medications and complications at first month and second year were evaluated. Results: There were 32 cases (48.5%) in Group 1 and 34 cases (51.5%) in Group 2. The mean IOPs were 12.6 ± 5.5 and 10.8 ± 5.3 mmHg at first month (P > 0.05), whereas 14.4 ± 2.8 and 10.1 ± 2.6 mmHg at second year, respectively (P < 0.05). The mean number of medications were 3.3 ± 1.6 and 3.2 ± 0.2 preoperatively (P > 0.05), whereas 0.8 ± 1.2 and 0.26 ± 0.70 at second year (P < 0.05). The number of diffuse blebs was higher in Group 2 whereas the number of cystic blebs was higher in Group 1 (P > 0.05). There was no difference between two groups with regards to the number of eyes with hypotonia (P > 0.05). Conclusions: Large‐area MMC application seems to increase long‐term success without increasing the complication rates in trabeculectomy.