经角巩膜隧道不作放射状切开的青光眼小梁切除术

目的：讨论经角膜巩膜隧道所行的穿透性小梁切除术治疗青光眼。方法：最近有学报道了五种不同类型的经角膜巩膜隧道小梁切除术，术中不需行放射状巩膜切开。其中三种术式通过与标准Cairns小梁切除术进行比较作对照研究。结果：与标准Cairns小梁切除术相比，经角巩膜隧道所行的小梁切除术术后并发症发生率明显降低，而手术成功率则不低于标准凯恩斯小梁切除术。结论：非放射状巩膜切开经角巩膜隧道小梁切除术较标准Cairns小梁切除术安全性好，而手术成功率相当。     

TWENTY-TWO CASES OF CLEAR CORNEA TRABECULECTOMY

The essential feature of clear cornea trabeculectomy is the use of a corneal approach, to create an intrascleral cleft communicating freely with the anterior chamber, without disturbing fenon's tissue and conjunctiva. In this small series the procedure produced diffuse thick walled blebs with normalisation of intraocular pressure without medication in 11 eyes This relatively poor result may be due to lack of the specialised instruments used by Cairns The technique deserves further investigation.     

Twenty-two cases of clear cornea trabeculectomy

The essential feature of clear cornea trabeculectomy is the use of a corneal approach, to create an intrascleral cleft communicating freely with the anterior chamber, without disturbing Tenon's tissue and conjunctiva. In this small series the procedure produced diffuse thick walled blebs with normalisation of intraocular pressure without medication in 11 eyes. This relatively poor result may be due to lack of the specialised instruments used by Cairns. The technique deserves further investigation.     

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

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

Otago Glaucoma Surgery Outcome Study: long‐term results of 841 trabeculectomies

Background: To describe the long‐term outcomes of trabeculectomies performed at Dunedin Hospital and followed in the Otago Glaucoma Surgery Outcome Study. Methods: Prospective non‐comparative case series of 841 eyes of 607 patients who had first trabeculectomies for primary open‐ or closed‐angle glaucoma at Dunedin Hospital between 1976 and 2005 and followed for a mean of 7.5 years (standard deviation 6.0). Results: The probability of a trabeculectomy controlling the intraocular pressure at 21 mmHg or less at 1, 10 and 20 years was 0.96 (95% confidence interval [CI] 0.95, 0.97), 0.86 (95% CI 0.83, 0.89) and 0.79 (95% CI 0.74, 0.83), respectively. Visual acuity was maintained or improved between preoperative assessment and final follow up in 68% of cases. The probability of not being blind following trabeculectomy at 1, 10 and 20 years was 0.98 (95% CI 0.96, 0.98), 0.83 (95% CI 0.80, 0.87) and 0.70 (95% CI 0.64, 0.76), respectively. The proportion of those with glaucomatous field loss increased during follow up from 16% (44/283) at 0–5 years to 50% (10/20) for those with 21 or more years of follow up. A repeat drainage procedure was required in 65 eyes (8%) (56 Molteno implant insertions and 9 repeat trabeculectomies). Conclusions: Intraocular pressure was well controlled by trabeculectomy; however, a steady decline in intraocular pressure control, visual acuity and visual field occurred during follow up.     

青光眼白内障联合手术治疗青光眼合并白内障

目的　探讨3种不同切口三联手术治疗青光眼合并白内障的效果。方法　将2 4例(2 6眼)青光眼合并白内障分为3组:11眼采用常规巩膜瓣下小梁切除联合白内障囊外摘出人工晶状体植入术;9眼采用小切口隧道式巩膜瓣小梁切除联合超声乳化吸出及后房人工晶状体植入术;6眼采用透明角膜切口超声乳化联合后房人工晶状体植入术及房角分离术。观察术后视力、眼压及并发症。结果　随访3月,术后平均眼压(15 . 12±3 . 42 )mmHg(1mmHg =0 .13 3kPa) ,与术前平均眼压(2 6 .5 0±4 .92 )mmHg比较有了明显下降,差异有显著性意义(t =0 . 897,P <0 .0 0 1) ;视力明显提高;并发症有角膜水肿(19. 2 3 % )及后囊浑浊(11. 5 3 % )。结论　青光眼白内障联合手术(三联手术)是治疗白内障合并青光眼的一种有效的方法。     

Glaucoma and cataract: combined operation or trabeculectomy first and cataract extraction later?

BACKGROUND: The aim of this retrospective study is to evaluate the difference in postoperative intraocular pressure (IOP) control, number of antiglaucoma medications and visual acuity (VA) between combined phacoemulsification and trabeculectomy (Glaucoma triple) surgery and two-stage procedures with trabeculectomy first and cataract extraction later. PATIENTS AND METHODS: Two groups of glaucoma patients were assessed: In group 150 consecutive patients undergoing combined phacoemulsification and trabeculectomy were enrolled. In group two, 51 consecutive patients were included, that had undergone trabeculectomy first and cataract surgery later. The mean interval between the two procedures was 3.2 years, 35/51 patients (71%) underwent conventional extracapsular cataract extraction, the other 16 patients (29%) had phacoemusification via clear cornea incision. RESULTS: One year postoperative both groups revealed a significant IOP reduction. IOP-reduction was significantly better in the two-stage group one year after trabeculectomy (12.8 +/- 4.0 mm Hg) and one year after cataract extraction (14.0 +/- 2.8 mm Hg) as compared to the combined surgery group (15.3 +/- 4.0 mm Hg). Kaplan-Meier survival analysis revealed a 90% success-rate 12 months after trabeculectomy only as compared to 65% success-rate in the combined surgery group. The number of antiglaucoma medications was significantly reduced in both groups. One year after cataract surgery no difference in VA could be seen between the two groups. CONCLUSIONS: If medically uncontrolled glaucoma with advanced optic nerve head changes in patients with coexisting glaucoma and cataracts is the main indication for surgery, a two-stage procedure (i.e. trabeculectomy first, cataract extraction later) yields better long-term IOP control. If glaucoma is medically controlled with a simple regimen, conjunctiva-sparing cataract surgery may be the treatment of choice. In all other cases of coexisting glaucoma and cataract combined phacoemulsification and trabeculectomy (Glaucoma triple) is preferrable, either performed through a single incision or as two separate procedures in the same session (i.e. trabeculectomy from above, phacoemulsifiaction via clear cornea from temporal).     

Mini-trabeculectomy without radial incisions

PURPOSE: To describe a new modification of Cairns trabeculectomy. METHODS: Surgical adjustment includes a small, 3-mm, fornix-based conjunctival flap, a circumferential scleral incision at a distance of only 1 mm from the corneoscleral limbus, and a sclerocorneal tunnel without scleral radial incisions. RESULT: Among the various clinical and technical advantages of the procedure is the possibility of performing more operations through the superior limbus rather than reverting to an inferior trabeculectomy or implantation of an aqueous shunt. CONCLUSION: The reduced surgical area and manipulations of the current procedure appear to offer advantages over the standard approach.     

脉络膜上腔引流术治疗晚期新生血管性青光眼

目的探讨应用脉络膜上腔引流术治疗晚期新生血管性青光眼的疗效。方法选用了10例(10眼)晚期新生血管性青光眼,采用其他技术失败的病例,行小梁切除联合脉络膜上腔引流术。结果手术前后对比观察及术后随访6～24月结果表明,虽然视功能术前术后无明显变化,但术后角膜透明,水肿消失,虹膜红变明显减少、消失,无需降压治疗,眼压在正常范围内。结论该术式通过双渠道眼外引流,有效地控制眼压,是一种安全有效的方法。     

A comparative study of small incision trabeculectomy avoiding tenon's capsule with conventional trabeculectomy

BACKGROUND AND OBJECTIVE: The purpose of this study was to compare the results of small incision trabeculectomy (SIT) avoiding Tenon's capsule vis-à-vis conventional trabeculectomy, and find a safe, effective alternative to conventional trabeculectomy with or without pharmacological wound modulation. PATIENTS AND METHODS: A controlled prospective study was conducted on 80 consecutive open-angle glaucoma patients requiring glaucoma filtration surgery. They were divided into two groups: Group I (n = 40): patients undergoing conventional trabeculectomy; and Group II (n = 40): patients undergoing limbal approach SIT. Patients were followed up serially for a minimum of 12 months and their intraocular pressure was monitored. Success of the procedure was defined as an intraocular pressure (IOP) <22 mm Hg with no additional antiglaucoma medication or surgery, and achieving at least a 30% reduction from the initial IOP at which optic disc cupping and/or visual field changes occurred. RESULTS: A significant fall (P <0.0001) in the final mean IOP was present in both groups at all time intervals in comparison to their preoperative values. The final mean intraocular pressure achieved with conventional trabeculectomy was 18.90 +/- 4.86 mm Hg versus 16.60 +/- 5.93 mm Hg with SIT. The final success rate of 90% was obtained with SIT vs 80% with conventional trabeculectomy. No major complications were encountered with either procedure although complications such as shallow anterior chamber and progression of cataractogenesis were seen more often in patients undergoing conventional trabeculectomy. CONCLUSION: Small incision trabeculectomy avoiding Tenon's capsule is a low-cost and safe alternative to conventional trabeculectomy that effectively reduces IOP in 90% of cases. The use of a small 2.5 mm limbal incision, which obviates the dissection of Tenon's capsule and absence of any major complication, suggests that this procedure be used more often in glaucomatous eyes needing filtering surgery.     

Ipsilateral rotational autokeratoplasty for the management of corneal opacities

PURPOSE/BACKGROUND: Penetrating keratoplasty is the logical solution for the management of corneal opacities. In situations such as in Papua New Guinea, where donor corneal tissue is scarce and corneal opacities are plenty, an alternative procedure for the management of corneal opacities in the form of ipsilateral rotational autokeratoplasty was considered. METHODS: In the present prospective study, ipsilateral rotational autokeratoplasty was performed in 17 eyes over a 2 year period in a general hospital.The patient's cornea was trephined eccentrically and the corneal opacity was dialed out of the visual axis and was replaced by clear peripheral cornea. RESULTS: Most opacities were leucomata (76.4%). The average size of the opacity was 5.1 mm and the corneal button size was 7 mm.A final visual acuity of 6/18 or better was obtained in 64.7% of cases (at 12 months). No significant postoperative complications were encountered. No complex formula was needed to calculate the size of the button and, by simply adding 3 mm to the pupillary diameter in standard illumination, one could make an estimation of the graft diameter. CONCLUSIONS: Rotational autokeratoplasty has a definite role in places where donor corneal tissue is scarce, in patients in whom long-term steroids are a risk or in situations where follow up of patients is difficult. Rejection is a theoretical impossibility, but late endothelial failure could occur, requiring regrafting. Rotational autokeratoplasty should be seriously considered as an alternative to conventional penetrating keratoplasty.     

Congenital Glaucoma from Sturge-Weber Syndrome: A Modified Surgical Approach

Sturge-Weber syndrome (SWS) is a rare congenital neurocutaneous disorder that causes congenital glaucoma. Previous experiences have shown that drainage procedures are often required to control associated glaucoma. The conventional surgical approach in trabeculectomy carries a significant risk of intraoperative expulsive hemorrhage. Here, we describe a modified approach of the conventional trabeculectomy technique, which may lower the risk of expulsive hemorrhage. A viscoelastic device was employed to maintain a steady intraocular pressure throughout the procedure. Details of the surgical technique and material used are described. One patient with congenital glaucoma associated with SWS underwent a successful trabeculectomy using the modified technique. Postoperative intraocular pressure was successfully reduced and no intraoperative complications occurred. We describe a successful case of trabeculectomy in a SWS case where a modified technique was applied.     

Fornix vs limbal-based trabeculectomy with mitomycin C

PURPOSE: To compare the effectiveness of limbus- and fornix-based conjunctival flaps in patients undergoing trabeculectomy with mitomycin-C augmentation. METHODS: A retrospective review of the records of 71 consecutive eyes of 59 patients who underwent trabeculectomy with mitomycin C. All the patients had at least 6 months of follow-up. The first 35 eyes underwent surgery with a limbal-based flap, whereas all subsequent surgeries were by fornix-based procedures. RESULTS: No significant difference was detected between the groups with regard to patient demographics, preoperative visual field and intraocular pressure parameters, postoperative intraocular pressures at day 1, months 1, 3, and 6 postoperatively, need for intervention, need for supplementary glaucoma medication, and final visual acuity. There were four cases of overdrainage and hypotony in the limbal-based group, whereas none occurred in the fornix-based group. In all 83% percent of eyes in the limbal-based group achieved intraocular pressures off medication of less than 18 mmHg, whereas 94% of the fornix based group obtained such IOP control. One patient in the limbal-based group developed late postoperative endophthalmitis. CONCLUSION: Trabeculectomy with MMC augmentation is a safe and effective procedure for reduction of IOP and visual rehabilitation whether a fornix- or a limbal-based conjunctival flap is utilised. In this series, there was a greater risk of excessive drainage with subsequent hypotonous complications when surgery was undertaken by a limbal-based procedure.     

A comparative study of trabeculectomy and the new clear‐cornea filtering procedure,intrastromal diathermal keratostomy (IDK)

Purpose: For the first time to compare the 1‐year success rates of trabeculectomy and the new clear‐cornea filtering procedure, intrastromal diathermal keratostomy (IDK). Methods: Prospective clinical observational study including 99 consecutively operated eyes (69 patients) with well‐established primary open‐angle glaucoma referred for filtering operation. We compared the change in intraocular pressure (IOP), number of anti‐glaucomatous medication, complications and reoperations after 1 year. Seventy‐four eyes were operated with trabeculectomy, and 25 with IDK. Complete success was defined as IOP ≤18 mmHg, IOP lowered ≥30%, no medication and no reoperation. Qualified success was defined as IOP ≤18 mmHg, and IOP lowered ≥30% with or without medication or reoperation. Results: Intraocular pressure pre‐ and postoperatively in the trabeculectomy group was 25.3 and 14.1 mmHg versus 23.8 and 15.8 mmHg in the IDK group. The number of medications pre‐ and postoperatively in the trabeculectomy group was 3.1 and 0.5 versus 3.2 and 1.3 in the IDK group. Forty‐four (59%) of the eyes in the trabeculectomy group met the complete success criteria compared with 5 (20%) in the IDK group (p < 0.01). Sixty‐eight (92%) in the trabeculectomy group and 16 (64%) in the IDK fulfilled the qualified success criteria (p < 0.01). Conclusion: Both the complete and qualified 1‐year success rates of IDK are significantly lower compared with the success rates of trabeculectomy. The IDK does not reduce the IOP as much as the procedure of trabeculectomy, and it carries a higher frequency of reoperations and more medication postoperatively. Thus, our prospective data do not support the procedure of IDK as ‘the gold standard’ for filtering surgery in patients with open‐angle glaucoma.     

Otago glaucoma surgery outcome study: long-term results of trabeculectomy--1976 to 1995.

OBJECTIVE: To provide data on the long-term results of trabeculectomy performed in the province of Otago, New Zealand. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: A total of 289 eyes of 193 patients (excluding 4 eyes lost to follow-up soon after operation); all trabeculectomies performed for the first time on cases of primary glaucoma from 1976 through 1995. INTERVENTION: Standard Cairns trabeculectomy. MAIN OUTCOME MEASURES: Intraocular pressure, visual acuity, visual field damage. RESULTS: Trabeculectomy was effective in controlling intraocular pressure at a level of 21 mmHg or less, with probabilities of 0.93 (95% confidence interval [CI], 0.90-0.97), 0.87 (95% CI, 0.82-0.93), and 0.85 (95% CI, 0.77-0.92) at 5, 10, and 15 years, respectively, after surgery. The mean visual acuity improved from 20/60 to 20/40 immediately after trabeculectomy but then declined steadily over the postoperative years. The decline in visual acuity led to blindness in 47 eyes. The Kaplan-Meier estimated probability of retaining useful vision (visual acuity > 20/400 and visual field > 5 degrees radius) in the overall group was 0.87 (95% CI, 0.79-0.91), 0.72 (95% CI, 0.60-0.79), and 0.6 (95% CI, 0.43-0.69) at 5, 10, and 15 years, respectively, after surgery. Those eyes that had good preoperative visual acuity (visual acuity > or = 20/30) had a significantly better chance of retaining useful vision (P = 0.02). CONCLUSIONS: The intraocular pressure was well controlled by trabeculectomy, but a steady long-term decline in visual acuity and visual field occurred, decreasing the probability of an eye retaining useful vision up to the time of death to approximately 0.6.     

Further experience with trabeculectomy.

Trabeculectomies performed on 33 eyes were compared to 28 standard filtering procedures done at the same institution during a 4 year period. The success rates in the two groups of patients whether white or black were statistically comparable, 92% in the trabeculectomy group and 77% in the standard filtering surgical group. Only cases of phakic open angle glaucoma, chronic angle closure and combined mechanism glaucoma were considered. Cases of secondary glaucoma, previous surgical failure and aphakic nonpupillary block glaucoma did uniformly poorly. When trabeculectomy was performed with "enhanced cyclodialysis" early results in a few cases were successful. The incidence of flat anterior chamber and cataracts with permanent reduction in visual acuity was significantly less in the trabeculectomy group than in the standard filtering procedure group. These results support previous studies which support trabeculectomy as successful as standard filtering procedures with the advantage of having fewer permanent serious complications.     

Tube versus Trabekulektomie (TVT)-Studie

Epibulbar glaucoma drainage devices have been only slightly modified since their introduction more than 40 years ago. Having been used primarily in only difficult cases with a poor prognosis (and therefore with poor clinical results) the recently published trabeculectomy versus tube study (TVT) led to a change in our understanding of these devices. In this study epibulbar glaucoma drainage devices (here the Baerveldt device) were employed for early implantation (in some cases as primary glaucoma surgery intervention). Being sceptically monitored the results over the first 5 year clearly showed an almost equal or even better outcome in comparison to trabeculectomy. Despite these good results a critical evaluation seems mandatory mainly because of the unsolved problems concerning late complications. Late tube erosion with subsequent blebitis and enophthalmitis as well as late base plate encapsulation need to be mentioned here. The latter leads to thick fibrous tissue around the base plate resulting in an increase of intraocular pressure (IOP). Late corneal decompensation is also a late complication the pathomechanism of which is only poorly understood. Solving and treating such late complications are often troublesome and time consuming. Future experiments should lead to development of new drainage implant designs and the bulk material should be enhanced and optimized to increase clinical surgical results.     

【In Press】Comparison of surgical outcome of trabeculectomy and phacotrabeculectomy in Chinese glaucoma patients

Our study retrospectively reviewed the surgical outcomes up to 3mo of 38 consecutive Chinese glaucoma patients who underwent trabeculectomy (n=18) or phacotrabeculectomy (n=20). Baseline age, visual acuity, and intraocular pressure were comparable. Intraocular pressure from post-operative 1d to 3mo were similar between 2 groups. Complete success was achieved in 65% of phacotrabeculectomy, and 66.7% of trabeculectomy cases; while failure occurred in 16.7% of phacotrabeculectomy, and 10% of trabeculectomy cases at 3mo. Phacotrabeculectomy group consistently showed better improvement in visual acuity. Diffuse blebs occurred in 40% of phacotrabeculectomy and 72% of trabeculectomy eyes; and flat blebs in 30% of phacotrabeculectomy, but none after trabeculectomy. There was more hypotony (6% vs 0.06%) after phacotrabeculectomy. To conclude, phacotrabeculectomy and trabeculectomy demonstrated comparable intraocular pressure control up to 3mo post-operatively. However, phacotrabeculectomy patients had better visual acuity improvement. Nonetheless, more diffuse bleb and less hypotony were present following trabeculectomy.     

Adjustability of refractive effect for corneal ring segments

PURPOSE: To evaluate the safety and efficacy of adjustability of the refractive effect of intrastromal corneal ring segments (ICRS, Intacs). METHODS: Data from four patients who had their initial Intacs removed and exchanged for new Intacs of different thickness sizes during a United States Food and Drug Adminstration Phase II clinical trial were evaluated with regard to segment size, reasons for exchange, duration within the cornea before exchange procedure, loss or change of spectacle-corrected visual acuity, change of uncorrected visual acuity, manifest refraction, cycloplegic refraction, topography after exchange, and stability of refraction. RESULTS: The exchange procedure was performed in two patients due to undercorrection and in two for overcorrection. The length of time the segments remained in the cornea after initial surgery varied from 6 to 15 months (mean, 10.25 +/- 4.03 mo). The most recent examination occurred between 4 to 18 months (mean, 10.0 +/- 6.32 mo) following the exchange procedure and showed improved uncorrected visual acuity with a range from 20/16 to 20/20 and a gain of 2 to 7 lines of uncorrected visual acuity compared to baseline. No eyes lost any lines of spectacle-corrected visual acuity following the exchange procedure and all preserved their preoperative spectacle-corrected visual acuity of 20/16. The intended refractive correction was achieved in the first few days of the exchange procedure and remained stable. CONCLUSION: In these four eyes that were over- or undercorrected after initial Intacs placement, segment thickness sizes were exchanged after 6, 8, 12, and 15 months without complication and with final uncorrected visual acuities of 20/16 to 20/20.