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

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

Five-year results of deep sclerectomy with collagen implant.

PURPOSE: To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI), a nonpenetrating filtration procedure. SETTING: Glaucoma Unit, Department of Ophthalmology, H?pital Ophtalmique Jules Gonin, University of Lausanne, Lausanne, Switzerland. METHODS: This nonrandomized prospective trial comprised 105 eyes of 105 patients with medically uncontrolled primary or secondary open-angle glaucoma. Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before and after surgery at 1 and 7 days and 1, 3, 6, 9, 12, 18, 24, 30, 36, 48, 54, 60, and 66 months. Visual field examinations were repeated every 6 months. A qualified success was defined as IOP below 21 mm Hg with or without medication. A complete success was defined as IOP lower than 21 mm Hg without medication. RESULTS: The mean follow-up was 43.2 months +/- 14.3 (SD). The mean IOP was 26.8 +/- 7 mm Hg preoperatively, 5.1 +/- 3 mm Hg 1 day postoperatively, and 11.8 +/- 3 mm Hg 60 months postoperatively. At 60 months, the qualified success rate was 94.8% and the complete success rate, 61.9%. The IOP was lower than 21 mm Hg with medication in 32.1% of patients at 60 months; 48 patients (45.7%) had an IOP of 15 mm Hg or lower without medication. No patient developed a shallow or flat anterior chamber, endophthalmitis, or surgery-induced cataract. However, 23 (21.9%) had progression of a preexisting senile cataract. Injections of 5-fluorouracil were given to 25 patients (23.8%) who had DSCI to salvage encysted blebs. The mean number of medications per patient was reduced from 2.30 +/- 0.76 to 0.49 +/- 0.72. CONCLUSION: Deep sclerectomy with collagen implant provided reasonable IOP over a long-term follow-up with few immediate postoperative complications.     

Comparative study between deep sclerectomy with and without collagen implant: long term follow up

AIM: To identify the value of using collagen implant in deep sclerectomy. METHODS: A prospective randomised trial of 104 eyes (104 patients) with medically uncontrolled primary and secondary open angle glaucoma. All patients had deep sclerectomy (DS), half of them with and the other half without a collagen implant (CI) sutured in the scleral bed. The main outcome measures were intraocular pressure (IOP), visual acuity, number of treatments preoperative and postoperative, and Nd:YAG goniopunctures. RESULTS: Mean follow up period was 44.5 (SD 21) months for the DS group and 43.9 (SD 14) months for the deep sclerectomy with a collagen implant (DSCI) group. The mean preoperative IOP was 23.3 (SD 7.2) mm Hg for the DS group and 25.6 (SD 4.9) mm Hg for the DSCI group. The mean IOP at the first postoperative day was 6.1 (SD 4.21) mm Hg for the DS group and 5.1 (SD 3.3) mm Hg for the DSCI group. At 48 months IOP was reduced by 40% (14 versus 23.3 mm Hg) for the DS group and by 50% (12.7 versus 25.6 mm Hg) for the DSCI group. Complete success rate, defined as IOP lower than 21 mm Hg without medication, was 34.6% (18/52 patients) at 48 months for the DS group, and 63.4% (33/52 patients) for the DSCI group. Qualified success rate; patients who achieved IOP below 21 mm Hg with or without medication, was 78.8% (41/52 patients) at 48 months and 94% (49/52 patients) for the DSCI group. The mean number of medications was reduced from 2.1 (SD 0.8) to 1.0 (SD 1) after DS, and was reduced from 2.2 (SD 0.7) to 0.4 (SD 0.6) in the DSCI group (p = 0.001) CONCLUSION: The use of a collagen implant in DS enhances the success rates and lowers the need for postoperative medication.     

Deep sclerectomy with collagen implant in patients with glaucoma and high myopia

PURPOSE: To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI), a nonpenetrating filtration procedure, in patients with glaucoma and high myopia. SETTING: Glaucoma Unit, H?pital Ophtalmique Jules Gonin, Lausanne, Switzerland. METHODS: This nonrandomized prospective trial comprised 21 eyes of 21 highly myopic patients with medically uncontrolled primary or secondary open-angle glaucoma. Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before as well as 1 and 7 days and 1, 3, 6, 9, 12, 18, 24, 30, 36, 42, 48, 54, 60, and 66 months postoperatively. Visual field examinations were repeated every 6 months. Exclusion criteria were known allergy to collagen, advanced lens opacity, and eye surgery or laser trabeculoplasty fewer than 6 months before enrollment. RESULTS: The mean follow-up was 44.0 months +/- 17.1 (SD). The mean preoperative IOP of 26.4 +/- 5.9 mm Hg dropped to 10.4 +/- 6.1 mm Hg at 48 months. Eighty-one percent of patients achieved an IOP below 21 mm Hg with or without medication at 48 months. Thirty-eight percent had an IOP below 21 mm Hg without medication. The mean number of medications per patient was reduced from 2.30 +/- 0.85 to 0.86 +/- 0.91. CONCLUSIONS: Deep sclerectomy with collagen implant provided reasonable control of IOP in patients with glaucoma and high myopia over a long-term follow-up. There were relatively few postoperative complications.     

Tiefe Sklerektomie mit Hyaluronatimplantat vs. Trabekulektomie

BACKGROUND: It was investigated whether a very low target pressure could be achieved by modification of deep sclerectomy without losing the advantages of non penetrating surgery in comparison to conventional filtration surgery. PATIENTS AND METHODS: A total of 22 eyes from 22 patients with advanced open angle glaucoma were randomly assigned to receive a deep sclerectomy or a trabeculectomy. Both groups received 0.02% mitomycin C under the conjunctiva prior to preparation of the scleral flap. In the deep sclerectomy group at least parts of the outer trabecular meshwork were removed until an apparent filtration was achieved. A dry cross-linked hyaluronate served as an implant. In the other group a classical trabeculectomy was performed. RESULTS: The median intraocular pressure 12 months post-operation was 11.5 mm Hg in the deep sclerectomy group compared to 11 mm Hg in the trabeculectomy group; the median of the relative IOP reduction was -47% in the deep sclerectomy group, and -57% in the trabeculectomy group. The best corrected visual acuity was unchanged 12 months postoperatively in both groups. DISCUSSION: As a more aggressive IOP-lowering procedure (intended filtration, use of antimetabolites) deep sclerectomy proved to be as effective as trabeculectomy. Nevertheless, the advantages of the more difficult surgical procedure concerning visual acuity, complications and surgical interventions were lost postoperatively.     

Long-term results of deep sclerectomy with collagen implant

PURPOSE: To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI). SETTING: Glaucoma Unit, Department of Ophthalmology, H?pital Ophtalmique Jules Gonin, University of Lausanne, Lausanne, Switzerland. METHODS: This nonrandomized prospective trial comprised 105 eyes of 105 patients with medically uncontrolled primary and secondary open-angle glaucoma. Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before surgery and after surgery at 1 and 7 days, and 1, 3, 6, 9, 12, 18, 24, 30, 36, 48, 54, 60, 66, 72, 78, 84, 90, and 96 months. Visual field examinations were repeated every 6 months. RESULTS: Mean follow-up period was 64 months +/- 26.6 (SD). Mean preoperative IOP was 26.8 +/- 7.7 mm Hg, and mean postoperative IOP was 5.2 +/- 3.35 mm Hg at day 1 and 12 +/- 3 mm Hg at month 78. At 96 months, the qualified success rate (ie, patients who achieved IOP <21 mm Hg with and without medication) was 91%, and the complete success rate (ie, IOP <21 mm Hg without medication) was 57%. At 96 months, 34% of patients had an IOP <21 mm Hg with medication. Fifty-one patients (49%) achieved an IOP < or =15 mm Hg without medication. Neodymium:YAG goniopuncture was performed in 54 patients (51%); mean time of goniopuncture performance was 21 months, and mean IOP before goniopuncture was 20 mm Hg, dropping to 11 mm Hg after goniopuncture. No shallow or flat anterior chamber, endophthalmitis, or surgery-induced cataract was observed. However, 26 patients (25%) showed a progression of preexisting senile cataract (mean time 26 months; range 18 to 37 months). Injections of 5-fluorouracil were administered to 25 patients (23%) who underwent DSCI to salvage encysted blebs. Mean number of medications per patient was reduced from 2.3 +/- 0.7 to 0.5 +/- 0.7 (signed rank P<.0001). CONCLUSION: Deep sclerectomy with collagen implant appears to provide stable and reasonable control of IOP at long-term follow-up with few immediate postoperative complications.     

Conversion from trabeculectomy to deep sclerectomy. Prospective study of the first 44 cases

PURPOSE: To evaluate the outcomes of conversion from trabeculectomy to deep sclerectomy with placement of a drainage implant. SETTING: Department of Ophthalmology, Hospital of Buskerud, Drammen, Norway. METHODS: Deep sclerectomy was performed in 41 patients (44 eyes) from November 1999 to January 2002. An absorbable implant (AquaFlow((R)), Staar Surgical) and a nonabsorbable implant (T.Flux((R)), IOLTech Laboratories) were used in 75% and 25% of eyes, respectively. Patients with open-angle glaucoma who needed filtering surgery were enrolled consecutively in a prospective study. Patients with 2 or more previous filtering surgeries or neovascular glaucoma were excluded, as were children. Of the original 48 eyes, accidental perforation of the trabeculo-Descemet's membrane occurred in 8.3%; these eyes were excluded from the study. The severity of optic nerve damage was considered in the decision to start therapy. An intraocular pressure (IOP) above 22 mm Hg was always treated. RESULTS: After a mean follow-up of 12.9 months +/- 7.1 (SD), 61.4% of eyes were controlled without therapy. When eyes with previous surgery were excluded, the rate increased to 66.7% after a mean follow-up of 13.8 +/- 7.2 months. The mean IOP preoperatively and after 12 months was 27.9 +/- 6.9 mm Hg and 14.6 +/- 3.5 mm Hg, respectively (P<.001). The mean number of medications decreased from 3.4 +/- 1.0 preoperatively to 0.6 +/- 1.1 12 months postoperatively (P<.001). A reoperation was required in 2 cases (4.5%). There were no complications related to hypotony or other significant complications. CONCLUSIONS: This study shows that conversion from trabeculectomy to deep sclerectomy with placement of an implant is safe. The postoperative IOP reduction was acceptable, and no significant complications occurred.     

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.     

Deep sclerectomy with mitomycin C in failed trabeculectomy

AIM: To evaluate the success rate and complications associated with deep sclerectomy with mitomycin C (MMC) and a reticulated hyaluronic acid implant in previously failed trabeculectomy. METHODS: This prospective study included 20 eyes with a previously failed trabeculectomy, which were treated with deep sclerectomy with 0.2 mg/ml MMC application under the conjunctiva and superficial scleral flap. Intraocular pressure (IOP), glaucoma medications, visual acuity, and complications were recorded preoperatively and 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. RESULTS: The mean preoperative IOP was 25.8+/-7.3 mmHg; the IOP significantly decreased to 14.6+/-3.2 mmHg 1 year postoperative. At each interval, the mean IOP was significantly lower than preoperatively (P=0.000). At 1 year, the complete success rate (IOP相似文献   

Laser-assisted deep sclerectomy

PURPOSE: To study the clinical effectiveness of deep sclerectomy using the erbium:YAG (Er:YAG) laser in patients with open-angle glaucoma (OAG). SETTING: Department of Ophthalmology, Institut Universitari Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain. METHODS: This nonrandomized prospective clinical study was performed in 46 consecutive eyes with OAG. Seventeen patients had not received any treatment for glaucoma. Eight had received 1 medication; 14, 2 medications; and 7, 3 medications. The mean duration of treatment was 18.3 months +/- 9.4 (SD). After mitomycin-C 0.02% was administered for 2 minutes, a superficial 4.0 mm x 4.0 mm scleral flap was created and a deep 3.0 mm x 3.0 mm scleral ablation was performed with the Er:YAG laser. Schlemm's canal was removed, and the cornea was dissected to Descemet's membrane until aqueous humor percolated. The scleral flap and conjunctiva were closed. Postoperative follow-up examinations were done at 1, 3, and 7 days, 2, 3, and 4 weeks, and then every 3 months up to 15 months. RESULTS: The mean preoperative intraocular pressure (IOP) was 28.3 +/- 6.1 mm Hg. The mean postoperative IOP was 14.1 +/- 3.5 mm Hg at 24 hours, 16.3 +/- 4.2 mm Hg at 3 months, and 15.3 +/- 2.7 mm Hg at 15 months (P <.001). There were no statistically significant differences in IOP by sex or age. There was a statistically significant difference between patients receiving no medication and those who received more than 2 medications and a treatment period longer than 1 year preoperatively (P <.006). The presence of a filtering bleb was associated with a longer period of decreased IOP (P <.007). The success rate (IOP < or =18 mm Hg without medication) was 93.47% at 1 month and 84.78% at 15 months. The number of complications was significantly lower than in previous reports of trabeculectomy. One patient lost 2 lines of visual acuity because of cystoid macular edema. CONCLUSIONS: Deep sclerectomy using the Er:YAG laser was safe and effective in eyes with OAG. More studies are needed to analyze the mechanism of lowering IOP.     

Viscocanalostomy for primary open-angle glaucoma: the Gross Pankow experience

PURPOSE: To assess the pressure-lowering effect and postoperative complications of the viscocanalostomy nonpenetrating filtering procedure. SETTING: A private practice ophthalmic surgery referral center. METHODS: Fifty-six eyes of 41 patients with medically uncontrolled primary open-angle glaucoma had a viscocanalostomy. After a superficial scleral flap was raised, a deep sclerectomy was performed in the scleral bed with deroofing of Schlemm's canal and preparation of a window of Descemet's membrane. The ostia of Schlemm's canal were probed and stretched with sodium hyaluronate 1.4% (Healon GV(R)), and the scleral flap and conjunctiva were sutured. Examinations were performed before surgery and 1, 3, and 14 days and 1, 3, 6, and 12 months postoperatively. RESULTS: Mean preoperative intraocular pressure (IOP) was 28.1 mm Hg +/- 7.4 (SD) with a mean of 2.4 +/- 0.7 medications. Mean postoperative IOP was 18.6 +/- 7.5 mm Hg with 0 medications at 1 day, 17.4 +/- 5.2 mm Hg with 0.1 medications at 3 days, 19.1 +/- 4. 3 mm Hg with 0.1 medications at 14 days, 19.4 +/- 4.3 mm Hg with 0.4 medications at 1 month, 18.3 +/- 3.6 mm Hg with 0.6 medications at 3 months, 18.0 +/- 2.6 mm Hg with 0.6 medications at 6 months, and 17. 8 +/- 3.8 mm Hg with 0.7 medications at 1 year. After 1 year, IOP was lower than 21 mm Hg without medication in 36% of patients and lower than 21 mm Hg with medication in 79%. Five patients (9%) required a second operation for pressure control. The following postoperative complications occurred: hyphema (2%); postoperative hypotony less than 10 mm Hg (2%); positive Seidel test (17%); further surgery to lower IOP (12%). Cataract surgery was performed in 1 patient (2%) at 4 months. Despite an attempt to close the scleral flap watertight, 26 patients had evidence of subconjunctival drainage (conjunctival microcysts or filtration bleb) at 1 year. CONCLUSION: Viscocanalostomy lowered IOP and reduced the need for pressure-controlling medications with a low postoperative complication rate. The high success rates of earlier publications were not reproduced.     

Ultrasound biomicroscopy of eyes undergoing deep sclerectomy with collagen implant.

AIMS--To assess the intraocular pressure (IOP) lowering mechanism of deep sclerectomy with collagen implant (DSCI), a non-penetrating glaucoma surgery. METHODS--Nine eyes of nine patients with medically uncontrolled open angle glaucoma underwent DSCI. Ultrasound biomicroscopy (UBM) of the sclerectomy site was performed 1 month after surgery. The following factors were assessed: length and height of collagen implant, and thickness of the residual trabeculocorneal membrane. RESULTS--Postoperative IOP decreased significantly in all nine eyes from a preoperative mean value of 25.8 (SD 4.8) mm Hg to a postoperative (1 month) mean value of 11.3 (6.3) mm Hg (p = 0.001). In all nine eyes, UBM at 1 month after surgery showed a subconjunctival filtration through the thin trabeculocorneal membrane and through the scleral flap around the collagen implant. In four cases, a hypoechoic area in the suprachoroidal space was observed and might represent ciliary body detachment or be due to suprachoroidal drainage of aqueous humour through the thin deep scleral wall. At 1 month after surgery the mean trabeculocorneal membrane thickness was 110.1 (16.8) microns, and the mean length and height of the collagen implant were 2.3 (0.1) mm and 1.1 (0.1) mm respectively. CONCLUSION--DSCI lowered IOP by allowing aqueous filtration through a thin trabeculocorneal membrane to the subconjunctival space and, eventually, to the suprachoroidal space.     

小梁切除联合羊膜植入和巩膜瓣松解缝线术治疗难治性青光眼

目的　探讨小梁切除联合羊膜植入和巩膜瓣松解缝线术治疗难治性青光眼的疗效。方法　对完成追踪观察的 5 8例 (6 7只眼 )难治性青光眼患者施行小梁切除术 ,术中巩膜瓣下及结膜瓣下植入新鲜或贮存羊膜 ,联合应用巩膜瓣松解缝线术控制房水渗漏量。结果　术后随访 5～ 38个月 ,平均 19 5个月 ,其中≥ 12个月者占 79 1%。术后 12个月时 ,新生血管性青光眼的眼压由术前 (43 86± 7 12 )mmHg(1mmHg=0 133kPa)降至 (19 6 3± 2 5 7)mmHg(t=4 96 ,P <0 0 0 1) ,人工晶状体植入术后青光眼的眼压由术前 (40 31± 4 79)mmHg降至 (18 0 9± 2 2 1)mmHg(t=3 5 4 ,P <0 0 5 ) ,无晶状体性青光眼的眼压由术前 (37 94± 5 6 3)mmHg降至 (2 0 14± 3 15 )mmHg (t=5 12 ,P <0 0 5 ) ,青少年型青光眼的眼压由术前 (32 4 8± 3 98)mmHg降至 (16 5 4± 1 84 )mmHg(t=4 2 3,P <0 0 1) ,葡萄膜炎性青光眼的眼压由术前 (36 0 1± 4 13)mmHg降至 (18 11± 3 4 0 )mmHg(t=4 4 7,P <0 0 1) ,滤过性手术失败的青光眼眼压由术前 (34 4 3± 5 2 8)mmHg降至 (18 31± 1 5 2 )mmHg(t=2 0 5 ,P <0 0 5 ) ;患者手术前、后眼压比较 ,差异均有显著意义。功能性滤过泡形成率为 80 6 %。无排斥反应和严重并发症。结论     

Intraocular pressure on the first postoperative day as a prognostic indicator in phacoemulsification combined with deep sclerectomy

PURPOSE: To study the intraocular pressure (IOP) as a prognostic indicator on the first day after combined phacoemulsification and nonpenetrating deep sclerectomy. SETTING: Ramón y Cajal Hospital, Madrid, Spain. METHODS: This retrospective study included 70 eyes of 70 patients who had combined phacoemulsification-nonpenetrating deep sclerectomy with a reticulated hyaluronic acid implant. Visual acuity, IOP, and slitlamp examinations were performed preoperatively and 1 and 7 days and 1, 3, 6, 12, and 24 months postoperatively. A split point of 9.0 mm Hg on the first postoperative day was used. Success probability analysis was performed using a Kaplan-Meier survival curve. The need for medication and postoperative neodymium:YAG goniopuncture was also recorded. RESULTS: The mean preoperative IOP was 22.5 mm Hg +/- 5.2 (SD). The mean postoperative IOP was 11.6 +/-8.1 mm Hg, 16.4 +/- 4.7 mm Hg, and 17.0 +/- 5.3 SD mm Hg at 1 day, 12 months, and 24 months, respectively. A greater success rate was observed in terms of survival (P = .006, log rank test) in patients with an IOP of 9 mm Hg or less on the first postoperative day; these patients also had a significantly reduced need for glaucoma treatment (P = .015) and goniopuncture (P = .009). CONCLUSION: An IOP of 9 mm Hg or less on the first postoperative day might serve as a positive prognostic indicator in combined phacoemulsification with deep sclerectomy.     

Implantation of a miniature glaucoma device under a scleral flap

PURPOSE: To test the safety and efficacy of the Ex-PRESS miniature glaucoma device when it is implanted under a scleral flap instead of under the conjunctiva as it was originally suggested. PATIENTS AND METHODS: Between November 2000 and February 2003, the Ex-PRESS implant was inserted in 24 eyes of 23 patients with severe open angle glaucoma. Sixteen eyes of the 24 (66%) had had previous failed filtering surgery. The remaining 8 eyes (33%) were high risk for failures cases. A 5 x 5 mm limbal-based, 50% depth, scleral flap was raised into clear cornea. The Ex-PRESS implant was inserted into the anterior chamber under the scleral flap at the limbus. The scleral flap was securely sutured back, as is done in trabeculectomy operations. RESULTS: The intraocular pressure was significantly reduced from 27.2 +/- 7.1 mm Hg pre-operatively to 14.5 +/- 5.0 mm Hg at 12 months (n = 21) and 14.2 +/- 4.2 mm Hg at 24 months (n = 8). Postoperatively, only two patients needed anti-glaucoma medications to keep the IOP below 21 mm Hg. CONCLUSIONS: The Ex-PRESS device was found to be safe and effective with few complications when it is implanted under a scleral flap even in the high-risk patients studied.     

Influence of deep scleral flap size on intraocular pressure after deep sclerectomy

PURPOSE: To study the effect of several morphometric characteristics of the deep scleral flap on intraocular pressure (IOP) control after deep sclerectomy. METHODS: The authors conducted a nonrandomized prospective study of 56 eyes of 51 patients who underwent deep sclerectomy alone or combined with phacoemulsification. A reticulated hyaluronic acid implant was used in all cases. The surface, volume, and weight of the dissected deep scleral flap were measured and recorded. The correlation between these parameters and the postoperative IOP was evaluated at 6 and 12 months postoperatively. RESULTS: Forty-nine eyes (87.50%) achieved an IOP of 21 mmHg or less without treatment, and the need for medication was decreased significantly (p<0.001) at 12 months postoperatively. The authors found a significant inverse correlation between the mean postoperative IOP at 6 months and the surface, volume, and weight of the deep scleral flap, but not at 12 months postoperatively. CONCLUSIONS: Greater weight, surface area, and volume of the deep scleral flap dissected during deep sclerectomy achieve significantly lower postoperative IOPs in the early postoperative period.     

非穿透性小梁手术联合透明质酸植入物治疗开角型青光眼

目的探讨非穿透性小梁手术(non-penetratingtrabecularsurgery,NPTS)联合网状透明质酸植入物的临床疗效.方法对25例(27只眼)原发性开角型青光眼(primaryopenangleglaucoma,POAG)患者进行NPTS联合透明质酸植入物治疗.术后观察眼压、眼内组织反应情况、滤过泡形态,并对手术区域进行超声生物显微镜(ultrasoundbiomicroscopy,UBM)和前房角镜检查.随访时间3.0～10.4个月,平均(6.61±2.47)个月.结果患者术前眼压平均(26.36±9.02)mmHg(1mmHg=0.133kPa),术后3个月眼压平均(14.18±3.51)mmHg,差异有显著性(t=6.875,P<0.05).术后无需药物治疗而眼压≤21mmHg者占56.0%,需局部应用药物治疗或术区行残存小梁网激光穿刺治疗眼压≤21mmHg者占44.0%.术前局部应用降眼压药平均(2.96±1.43)种,术后减至(0.77±1.07)种,差异有显著性(t=4.716,P<0.05).所有患者术前、后视力差异均无显著性(χ2=0.33,P=0.564).27只眼中,6只眼术后眼压≥21mmHg,4只眼有轻微前房出血;无前房变浅、炎症、脉络膜脱离等并发症发生.UBM检查结果显示所有患眼在巩膜瓣下均形成一内含植入物的透明液性间腔,透明质酸植入物在术后3个月开始降解,其透明性间腔逐渐缩小,部分患者结膜下伴有滤过泡形成.前房角镜检查显示患眼术区小梁网明显变薄及有透明间腔样改变者23只眼,4只眼术区呈半透明样脱色改变.结论NPTS联合透明质酸植入物能有效降低眼压、减少局部应用抗青光眼药物的种类和剂量,无穿透性小梁手术常见的严重并发症发生,术后视力变化不明显,是一种治疗POAG的有效方法.     

Deep sclerectomy with collagen implant: medium term results

AIMS—To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI), a new non-penetrating filtration procedure.
METHODS—Non-randomised prospective trial involving consecutive patients. 100 eyes of 100 patients with medically uncontrolled primary and secondary open angle glaucoma. A superficial scleral flap was raised and a deep sclerectomy was performed in the scleral bed. Schlemm's canal was opened and dissection of the cornea was performed up to Descemet's membrane, at which point aqueous percolated through the remaining trabeculo-Descemet's membrane. A collagen implant was sutured radially in the scleral bed. Visual acuity, intraocular pressure (IOP) measurements, and slit lamp examinations were performed before surgery and after surgery at 1 and 7 days, and 1, 3, 6, 9, 12, 18, 24, 30, and 36 months.
RESULTS—The mean follow up period was 17.8 (SD 8.7) months. The mean preoperative IOP was 27.8 (8.6) mm Hg; the mean postoperative IOP was 5.7 (4.0) at day 1, 11.2 (4.6) at month 1, 14.0 (3.5) at month 12, and 13.0 (3.8) at month 36. Complete success rate, defined as an IOP lower than 21 mm Hg without medication, was 44.6% at 36 months. Qualified success rate, defined as an IOP lower than 21 mm Hg with medication, was 97.7% at 36 months. Early postoperative complications included hyphaema in seven patients, wound leak in 10 patients, and subtle choroidal detachment in 11 patients. Goniopuncture was performed in 41 of the patients, and 5-fluorouracil injections were made in 23 patients; cataract progression occurred in seven patients. When comparing the different types of open angle glaucoma, no difference was found in terms of reduction in IOP, number of patients requiring antiglaucoma medications, or success rate.
CONCLUSIONS—Deep sclerectomy with collagen implant appears to provide reasonable control of IOP at medium term follow up, with few immediate postoperative complications.

Keywords: deep sclerectomy; glaucoma surgery; collagen implant     

Non-penetrating deep sclerectomy and collagen implant surgery in glaucoma patients with advanced field loss

Purpose: The aim of the study was to determine the medium term intraocular pressure (IOP) lowering effects and the potential complications of non-penetrating deep sclerectomy and collagen implant (DSCI) surgery in glaucoma patients. Patients and methods: 54 eyes of 52 patients with medically uncontrolled open angle glaucoma with advanced field loss underwent DSCI under topical anaesthesia. Follow-up period was 24 months. Results: The mean preoperative IOP was 24.7 ± 6.2 mmHg and decreased to 15.1 ± 4.0 mmHg at 24 months (p = 0.0068). During the follow- up period, 36 of 54 eyes (66%) received no topical antiglaucomatous medications. In 18 eyes, monotherapy with topical beta blockers (Betaxolol HCl) was added to the regimen. At last visit , only two patients (3.8%) had IOP greater than 18 mmHg. We did not detect any additional optic disc changes, visual field or visual acuity defects postoperatively. Detailed slit-lampexamination revealed no anterior segment complications regarding the probablecomplications of trabeculectomy. None of the patients developed surgery relatedcataract. As a complication, we diagnosed one case of self-limited, shallow choroidal detachment. Conclusion: DSCI appears to provide considerable medium term IOP decrease with few postoperative complications without deteriorating visual acuity. Owing to our medium term results, we believe that DSCI could be a valuable alternative to trabeculectomy especially in cases of advanced medically uncontrolled open angle glaucoma.     

Deep sclerectomy with collagen implant: initial experience

OBJECTIVE: To evaluate complications of deep sclerectomy with collagen implant (DSCI), a recently introduced nonpenetrating glaucoma-filtering surgical technique. PATIENTS AND METHODS: 30 eyes of 23 patients with open-angle glaucoma were included in this prospective, noncomparative, interventional case series. In all eyes, preoperative intraocular pressure (IOP) was lowered inadequately by topical antiglaucomatous medications. After undergoing DSCI, the patients were followed prospectively. If necessary, the procedure was combined with cataract surgery or mitomycin C application. RESULTS: In 27 (90%) of 30 eyes, DSCI could be performed. In 3 (10%) of 30 eyes, DSCI had to be transformed intraoperatively into a trabeculectomy because of a large trabecular penetration. Microperforations without further consequences occurred in 2 (7%) of 30 eyes. The mean follow-up was 6.6 +/- 3.8 months. IOP dropped from 26.0 +/- 6.7 to 13.6 +/- 4.7 mm Hg (p < 0.05). Medical glaucomatous treatment was reduced from 2.3 +/- 3.8 to 0.3 +/- 0.6 (p < 0.05). In cases without cataract, visual acuity decreased from 0.7 +/- 0.3 to 0.66 +/- 0.4 at the last visit (p > 0.1). Postoperative complications included Seidel (1/27, 4%), encapsulated bleb (4/27, 15%), astigmatism (1/27, 4%), iris capture (2/27, 7%), microhyphema (3/27, 11%) and peripheral anterior synechiae (4/27, 15%). Fifteen (56%) of the 27 eyes needed the following postoperative procedures: laser goniopuncture (8/27, 30%), needling of the filtering bleb (4/27, 15%), surgical revision in the operating theater (3/27, 11%). All 3 eyes where trabeculectomy was performed instead of DSCI had a favorable course. CONCLUSIONS: During the evaluation period, complications occurred in about half of the cases. None of the complications was severe or irreversible. Target pressure and a reduction in drug treatment could be achieved in all of the patients.