Partial Tenon's capsule resection with adjunctive mitomycin C in Ahmed glaucoma valve implant surgery

AIM: To verify if partial intraoperative Tenon's capsule resection (PTCR) with adjunctive mitomycin C is effective in developing thin, avascular blebs in eyes undergoing Ahmed glaucoma valve insertion, and to assess the efficacy and safety of this procedure. METHODS: A multicentre, prospective, alternating case assignment, investigator unmasked, parallel group, comparative interventional study was conducted in four Latin American countries (Argentina, Brazil, Colombia, and Peru). Ahmed glaucoma valve implant insertion with PTCR (group A) and without PCTR (group B) was performed in neovascular glaucomatous eyes without previous surgery. Adjunctive mitomycin C (MMC) was used in both groups. Patients were examined 1 day, 10 days, 1 month, 2 months, 3 months, 6 months, and 1 year following the surgery. Intraocular pressure (IOP) and the appearance of the bleb were evaluated at each examination. Appearance of the bleb was classified at both the 1 month mark and last examinations into one of three groups: flat and vascularised; elevated avascular; or elevated and not avascular. RESULTS: 92 eyes from 92 patients were included in the study. The preoperative mean IOP was 50.0 (SD 10.5) mm Hg in group A and 48.4 (11.7) in group B (p>0.05). Statistically significant IOP reductions were observed at all periods of follow up. 12 months after surgery, the mean IOP was 17.2 (5.0) mm Hg in group A and 18.3 (8.7) mm Hg in group B (p>0.05). A hypertensive phase occurred in 40.0% in group A and in 46.8% in group B (p>0.05). At the 1 month and the final follow up, the blebs in all eyes were considered elevated and not avascular. The success rate (IOP0.05). Overall, 74.2% of the patients achieved an IOP 相似文献   

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.     

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.     

Suppression of avascular bleb formation by a thin biodegradable film in a rabbit filtration surgery with mitomycin C

Background

Avascularity of the bleb is regarded as a risk of bleb infection, which is the most serious complication after filtration surgery with mitomycin C (MMC). There is no perfect way to prevent avascular bleb formation. We hypothesized that keeping the conjunctiva away from direct exposure to aqueous filtration may suppress avascular bleb formation after filtration surgery with MMC. In order to prove our hypothesis, we investigated whether a thin biodegradable, honeycomb-patterned film (HPF) can reduce bleb avascularity in a rabbit model of filtration surgery with mitomycin C (MMC).

Methods

A fornix-based full-thickness filtration surgery was performed in one eye of each of five rabbits (control group). The same surgery with intraoperative MMC treatment was done in both eyes of six rabbits, with one eye receiving a 14-μm-thick HPF made from poly(L-lactide-co-ε-caprolactone), which was placed subconjunctivally over the filtration site with the honeycomb surface facing up. Intraocular pressure (IOP) measurements, bleb evaluations using ultrasound biomicroscopy (UBM), and in vivo confocal microscopy (IVCM) were performed periodically for 4?weeks postoperatively followed by histological examination.

Results

The postoperative IOP decrease and bleb survival were significantly greater in MMC-treated eyes than in control eyes, and were similar between MMC-only and MMC + HPF eyes. The avascular area in the bleb persisted for 4?weeks in MMC-only eyes. Postoperative IVCM showed morphological changes of the conjunctival epithelial cells (i.e., enlarged and variable in size and shape) and epithelial defects in MMC-only eyes, and significantly lower density of connective tissue and vascularity in the subepithelial space in MMC-only eyes compared to the control eyes. These IVCM findings agreed with those by UBM and histology. Bleb avascularity shown by clinical bleb appearance, IVCM and histology, conjunctival epithelial damage shown by IVCM and histology, and loose subepithelial connective tissue shown by UBM, IVCM, and histology were all reduced in MMC + HPF eyes compared to MMC-only eyes.

Conclusions

IVCM successfully showed the characteristic conjunctival damage in MMC-treated blebs. The concomitant use of a thin biodegradable HPF reduced avascularity and conjunctival damage in blebs, without compromising filtration in rabbits following filtration surgery with MMC.     

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.     

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.     

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.     

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.     

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.     

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

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

Comparative evaluation of outcomes of novel approach of subconjunctival Mitomycin C (MMC) injection at the end of trabeculectomy versus intraTenon injection of MMC prior to the initial conjunctival incision – A pilot study

Purpose:To describe a novel approach of subconjunctival injection of mitomycin C (MMC) at the end of trabeculectomy and compare it with intraTenon MMC injection.Methods:This pilot study included 40 eyes of 40 patients with uncontrolled primary and secondary glaucoma. Patients below18 years and failed trabeculectomy were excluded. Patients were randomly allocated into groups A and B (20 patients each). Group A patients received subconjunctival MMC injection in the superonasal quadrant at the end of standard trabeculectomy. Group B received an intraTenon MMC injection before the initial conjunctival incision. Outcome measures included intra-ocular pressure (IOP) reduction, bleb morphology, and complication rates. The complete success was defined as an IOP of ≤21 mmHg without antiglaucoma drugs.Results:The mean preoperative IOP of 46.00 ± 11.2 mmHg in group A and 43.05 ± 10.3 mmHg in group B reduced to 12.00 ± 2.41 mmHg (P ≤ 0.001) in group A and 13.65 ± 2.76 mmHg in group B (P ≤ 0.001) at last follow-up. Complete success was 95% and 75% in groups A and B, respectively, 19 months after surgery. Avascular microcystic blebs (70% of group A and 45% of group B) were more common than avascular white blebs (15% in group A and 35% in group B). No intraoperative complications were seen. Postoperative wound leak, hypotony, choroidal detachment, or endophthalmitis were not encountered in any group.Conclusion:A novel approach of subconjunctival MMC application during trabeculectomy is reported. Both approaches appear to be highly effective in reducing IOP in primary and secondary glaucoma with similar safety profiles and bleb morphology. Subconjunctival MMC yielded a greater success rate (95%) compared to the intraTenon MMC group (75%).     

Results of medical management and mitomycin C-augmented excisional bleb revision for encapsulated filtering blebs

BACKGROUND AND OBJECTIVE: To assess the outcome of medical management and mitomycin C (MMC)-augmented excisional bleb revision (EBR) for encapsulated filtering blebs. PATIENTS AND METHODS: The author conducted a retrospective study of 503 patients who had undergone trabeculectomy performed over a 5 year period, followed up for at least one year, in order to identify the encapsulated filtering blebs. Mitomycin C-augmented (0.4mg/ml for 3 minutes) EBR was performed in cases of failed medical therapy for managing encapsulated blebs consisting of antiglaucoma medications, topical steroids, and digital compression. RESULTS: An encapsulated bleb developed in 18 eyes (3.6%) of 503 patients. Identification of bleb encapsulation occurred at a mean follow-up time of 24.2 +/- 10.4 days after surgery. The mean intraocular pressure (IOP) at that point was 30.4 +/- 11.7 mmHg in the affected eyes. Fifteen (83.3%) of 18 eyes responded to conservative management and 3 eyes (16.7%) required MMC augmented EBR. The mean IOP reduced from 30.4 +/- 11.7 mmHg to 14.2 +/- 4.2 mmHg after a mean follow-up of 37.6 +/- 11.4 months in the conservative management group, while it reduced from 37.3 +/- 23.4 mmHg to 12.0 +/- 4.4 mmHg after a mean follow-up of 42 +/- 6 months in the surgically treated group. None of the surgically treated eyes developed MMC-related complications. CONCLUSION: Conservative management is very effective in the treatment of encapsulated filtering blebs. The intraoperative use of MMC is a safe and effective adjunct in EBR in cases where conservative management has failed.     

Trabeculectomy with or without mitomycin-C for paediatric glaucoma in aphakia and pseudophakia following congenital cataract surgery

PURPOSE: To evaluate the safety and efficacy of trabeculectomy with or without mitomycin-C (MMC) in the management of glaucoma in aphakia and pseudophakia following congenital cataract surgery. PATIENTS AND METHODS: All patients of glaucoma with aphakia or pseudophakia who underwent trabeculectomy with or without MMC from January 1989 to April 2000 were included. The medical records of 19 consecutive patients (23 eyes) were reviewed. Data collected from a retrospective chart review were analysed. Outcome measures were evaluated using Kaplan-Meier survival analysis. Pre- and postoperative intraocular pressures (IOPs), visual acuities, success rate, bleb characteristics, surgical failure and complications were the main outcome measures. Successful IOP control was defined as an IOP between 6 and 21 mmHg, without antiglaucoma medications, without further antiglaucoma surgery and without any sight-threatening complication. RESULTS: The mean age of patients was 8.8+/-5.5 years at the time of trabeculectomy with MMC compared to 11.0+/-12.4 years for trabeculectomy without MMC. Eight patients underwent trabeculectomy with MMC and 11 patients underwent trabeculectomy without MMC. There was no statistically significant difference between the two groups in terms of visual acuity, IOP, antiglaucoma medications, age at cataract surgery and at trabeculectomy. The IOP reduced from a preoperative level of 34.2+/-8.9 mmHg (range: 20-52) to a postoperative level of 18.4+/-12.2 mmHg (range: 2-60) with a mean follow-up of 24.2+/-17.9 months. The mean reduction in IOP in the MMC group was 15.5+/-17.3 and 16.3+/-13.8 mmHg in the other group (P = 0.967). Overall, complete success was achieved in 36.8%, qualified success in 21.1% and surgical failure in 42.1% of patients with a mean follow-up of 24.2+/-17.9 months. There was no difference in the success between the two groups at the last follow-up. One patient developed bleb-related endophthalmitis in both eyes following trabeculectomy with MMC. CONCLUSIONS: The success rate of trabeculectomy in glaucoma following congenital cataract surgery was 36.8% at the end of 3 years. The present study proves a poor success rate of trabeculectomy in a small series of aphakic Asian Indian patients even with the use of MMC.     

Hydrodissection of conjunctival flap during trabeculectomy in eyes with conjunctival scarring caused by trachoma

BACKGROUND AND OBJECTIVE: Conjunctival scarring caused by trachoma represents a substantial challenge even to the most experienced cataract/glaucoma surgeon. We describe a simple technique of hydrodissection of conjunctival flap during combined trabeculectomy and phacoemulsification in eyes with conjunctival scarring caused by trachoma, and discuss its impact on surgical outcome. PATIENTS AND METHODS: A prospective study was conducted in 10 Omani patients, aged 48 to 83 who underwent combined trabeculectomy and phacoemulsification with intraocular lens (IOL) implantation. The conjunctival flap was prepared after hydrodissection using a mixture of 1 mL of balanced salt solution (BSS) and 1 mL of lignocaine 2% with 1:200,000 adrenaline. Outcome measures that were evaluated were visual function, intraocular pressure (IOP) and bleb characteristics. Patients were followed-up postoperatively for a minimum period of 6 months. RESULTS: The mean age of patients was 60.4 years (48-83) and a functioning bleb after 6 months was seen in 8 (80%) cases. IOP < 20 mm of Hg (applanation tonometry) without antiglaucoma medications was found in 8 cases; 1 case required one antiglaucoma medication and 1 case required more than one antiglaucoma medication for control of IOP. The latter was reoperated for control of IOP. Nonprogression of visual field was found in 8 (80%) cases. CONCLUSION: Preparation of conjunctival flap by hydrodissection was found to be a simple modification of the conventional technique during combined trabeculectomy and phacoemulsification in trachomatous eyes. It reduced conjunctival dissection, use of cautery and possibility of button-holing of the conjunctiva during dissection in scarred eyes. The minimal tissue dissection involved in this procedure reduced wound healing and thereby increased chances of a functioning bleb, control of IOP and nonprogression of visual field compared to combined surgery employing a conventional method (nonhydrodissection method) of conjunctival flap dissection.     

Effects of thick Tenon's capsule on primary trabeculectomy with mitomycin-C

PURPOSE: To investigate the effects of thick Tenon's capsule on primary trabeculectomy with adjunctive mitomycin-C. METHODS: In this prospective interventional case series of 45 consecutive uncomplicated glaucoma patients, 45 eyes with thick Tenon's capsule underwent primary trabeculectomy with intraoperative mitomycin-C (0.4 mg/ml for 3 min). Success was defined as intraocular pressure (IOP) 相似文献   

薄壁囊状滤过泡的结膜瓣加固术

目的　探讨改良转移结膜瓣对矫正青光眼小梁切除术后薄壁囊状滤过泡的临床效果。方法　剪开滤过泡周围的结膜（保留原滤过泡）,游离转移上方或颞侧球结膜-筋膜组织,加固覆盖于经局部冷冻的变性囊状泡表面,转移结膜瓣的前缘固定缝合于周边角膜的槽状浅沟内。转移结膜瓣不够松弛时,在穹窿部做一减张性球结膜-筋膜组织切开。结果　46例（52只眼）术后随访6个月至4年,平均眼压由术前（4.25±1.33）mmHg（1mmHg=0.133kPa）提高至术后（12.98±5.70）mmHg,差异有显著性（t=3.26,P<0.01）。51只眼仍保留滤过功能,20只眼的结膜渗漏和6只眼的黄斑水肿消失,术后视力较术前有明显改善（χ     

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

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

Late needle revision of failed filtering bleb with adjunctive Mitomycin C

A 61-year-old man presented to our hospital with right eye pain and headache off and on for 1 month. He had twice trabeculectomy in the right eye 25 years ago without using antiglaucoma agents. Snellen visual acuity (VA) was 20/400 and intraocular pressure (IOP) was 52 mm Hg in his right eye. The slit-lamp examination of his right eye revealed corneal microcystic edema and two blebs were noted. The nasal upper bleb had thinner wall with obvious focal underlying uvea dark color and temporal upper bleb had relative thicker wall. Both blebs showed low lying and high vascularity. No pupillary block was present. Considering the risks of repeat trabeculectomy and drainage implant, needle revision was done on the temporal upper bleb.A mixture of lidocaine and mitomycin C (MMC) was prepared for a final MMC concentration of 0.07 mg/ml. After 15 minutes of subconjunctival injection of lidocaine-MMC mixture, the needle revision was done to disrupt any episcleral and scleral fibrosis. Restoration of aqueous drainage was considered to be the end point when the bleb height was restored. The right eye VA was 20/100 on postoperatively Day 1 and IOP was 8 mm Hg. The only minor complication was subconjunctival hemorrhage. The IOP was around 10-15 mm Hg without antiglaucoma agent during a 6-month follow-up. The temporal upper bleb remained moderate height without hypervascularity or cystic change and no corneal edema was noted.Bleb needling with adjunctive MMC is simple and safe. It should be considered in the management of failing or failed filtration blebs.     

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

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

针拨联合球结膜下注射丝裂霉素C治疗功能不良滤过泡

目的 探讨针拨联合丝裂霉素C(mitomycin C,MMC)球结膜下注射治疗青光眼患者小梁切除术后早期功能不良滤过泡的疗效.方法 对47例(50眼)小梁切除术后2～8周滤过泡功能不良青光眼患者行针拨联合MMC 0.2 mL(0.04 mg)结膜下注射,术后所有患者随访3～6个月,观察患者眼压、滤过泡形态和并发症.结果 小梁切除术后2～8周,低平、限局、肥厚、充血型滤过泡32眼、包囊型囊样滤过泡18眼.针拨联合MMC结膜下注射治疗后3～6个月,46眼的滤过泡转为功能性的,轻度膨隆弥散型31眼,多腔或薄壁型15眼,限局肥厚型或无滤过泡4眼.治疗前患眼的平均眼压为(28.5±6.5)mmHg(1 kPa=7.5 mmHg),随访3～6个月平均眼压为(16.3±2.9)mmHg,与注射前比较二者差异有统计学意义(P<0.05).46眼没有用抗青光眼药物或用一种抗青光眼药物眼压控制在21 mmHg以下,成功率占92%.治疗后视物模糊10眼,结膜下出血6眼,角膜上皮点状脱落2眼,无低眼压、伤口渗漏和前房变浅等并发症.结论 针拨联合MMC结膜下注射治疗小梁切除术后早期功能不良滤过泡是安全、有效、简单的方法.