Early results with scleral flap by Preziosi's operation (author's transl)

The antiglaucomatous Preziosi operation leads within some months in a relatively high percentage of cases to a cataract necessary operation. The main cause for the seems to be a flat anterior chamber lasting several days. Posterior synechaie are frequent. Two out of 55 patients developed an infection of the filtration bleb. By additional preparation of a scleral flap over the sclerectomy complications were obviously rarer, and the regulation of the pressure was very good. There was no difference if the operation was done with or without scleral flap. High pressures during the first days after operation normalize themselves spontaneously or by massage of the eye ball, and have no significance the prognosis. In the cases with scleral flap the filtration blebs show good vascularisation, only in a few cases we saw cystic areas without vessels within filtration blebs with good vascularisation. Moreover the anterior chamber is formed much quicker and complications such as cataract are rare.     

Tight scleral flap trabeculectomy with postoperative laser suture lysis

Thirty eyes of 30 patients underwent tight scleral flap trabeculectomy. Of these eyes, 22 underwent laser lysis of the scleral flap sutures, whereas eight eyes did not require such treatment because of low intraocular pressure and active filtering blebs. In the 22 eyes treated, preoperative intraocular pressure was 32.6 +/- 8.3 mm Hg, whereas postoperative and pre-laser intraocular pressure was 29.3 +/- 7.4 mm Hg. Immediately after laser suture lysis, intraocular pressure dropped by 22.7 +/- 9.4 mm Hg (P less than .01) to 6.6 +/- 7.0 mm Hg, with elevation of the conjunctival bleb in all eyes treated. After a mean follow-up of 14.4 months, intraocular pressure was controlled (less than or equal to 18 mm Hg) in 20 of the 22 eyes treated (91%). The only major complication was a single case of anterior chamber flattening with intraocular lens touching the corneal endothelium. Combination of tight scleral flap trabeculectomy with subsequent postoperative laser suture lysis is a safe and effective method for low-level intraocular pressure control. This technique seems to combine the advantages of full-thickness filtration and trabeculectomy by achieving relatively low intraocular pressures while minimizing complications caused by excessive aqueous runoff.     

Histological examination on disks obtained by goniotrephining with scleral flap (author's transl)]

Histological examination with serial sections of 26 disks obtained by goniotrephining with scleral flap showed in three cases only lamellas and Descemet's membrane. Twenty-three disks contained trabecular meshwork, fourteen of these Schlemm's canal. In three disks excision reaches as far as the ciliary muscle. In three of the twenty-six eyes the intra-ocular pressure was not regulated after the operation. It seems that in goniotrephining with scleral flap the opening of Schlemm's canal has no important influence on the postoperative regulation of the final intra-ocular pressure.     

Surgical outcomes of different Ahmed Glaucoma Valve implantation methods between scleral graft and scleral flap

Purpose

To compare the surgical outcomes of the two different methods used for Ahmed Glaucoma Valve (AGV) implantation between the donor scleral graft method and the partial-thickness scleral flap method.

Methods

We retrospectively reviewed medical records of 28 eyes of 26 patients diagnosed as neovascular glaucoma followed by AGV implantation. Based on the surgical method, the included eyes were divided into two groups. In the graft group (n = 18), the drainage tube was inserted into the anterior chamber, and then covered with preserved donor sclera. In the flap group (n = 10), the drainage tube was inserted under the partial-thickness scleral flap, and then covered with the flap. We compared the postoperative intraocular pressure (IOP), surgical success rates, and postoperative complications between the two groups.

Results

Postoperative IOP was not significantly different between the two groups (p = 0.967, 0.495 at 12 months, 24 months, respectively, by the Mann-Whitney U-test). The mean success periods were 53.1 ± 10.1 months in the graft group versus 50.9 ± 9.4 months in the flap group (p = 0.882 by log rank test), and cumulative success rates were 77.8% and 80.0% at one year, respectively. However, tube migration occurred more frequently in the flap group than in the graft group (p = 0.037 by Fisher''s exact test).

Conclusions

In AGV surgery for neovascular glaucoma, the scleral graft method may be associated with relatively less complication about tube migration than the scleral flap method. The surgical results, however, were not statistically different.     

隧道刀制作双层巩膜瓣的青光眼小梁切除术后疗效观察

目的：：探讨隧道刀制作双层巩膜瓣并切除层间巩膜瓣的青光眼小梁切除术的临床疗效。方法：采用随机分组方法,将46例60眼青光眼患者分为治疗组24例32眼和对照组22例28眼。前者用隧道刀制作双层巩膜瓣,浅层巩膜瓣大小约为5mm×5.5mm,1/3巩膜厚度,瓣下再做一大小约3.5mm×4mm的巩膜瓣,1/3巩膜厚度,切除中间层的巩膜瓣,切除2mm×2mm小梁组织,常规行虹膜周边切除,可调节缝线缝合浅层巩膜瓣,缝合球筋膜、球结膜;后者行常规青光眼小梁切除术。结果：术后随访1a,治疗组视力明显优于对照组,两组比较差异有统计学意义(P<0.05)。两组患者术后眼压均明显低于术前眼压。术后1,3 mo时,两组患者的眼压比较差异无统计学意义(P>0.05),但术后6,12mo检查发现,治疗组患者的眼压明显低于对照组,差异有统计学意义(P<0.05)。术后1a治疗组和对照组的累积完全成功率分别为90.63％和75％,两组的累积条件成功率分别为96.88％和89.29％,两组比较差异有统计学意义(均P<0.05)。结论：隧道刀制作双层巩膜瓣并切除层间巩膜瓣的小梁切除术降眼压效果好,巩膜瓣厚薄均匀、表面光滑,滤过泡功能维持时间长,术后并发症少,适用于多种类型的青光眼,值得临床推广。     

自体巩膜条翻转引流青光眼滤过术

目的 为防止青光眼滤过术后房水引流不畅和术后浅前房。方法 我们设计并开展了自体巩膜条翻转引流术,在常规小梁切除术的巩膜瓣后,再做一板层巩膜条,翻转后植入巩膜瓣下,两侧做密闭缝合。结果 治疗７８只眼术后早期观察前房形成良好,眼压正常。随访２年,１只眼滤过泡消失,手术失败。７７只眼滤过泡保持功能滤过泡,眼压正常。结论 自体巩膜条翻转引流术对长期保持滤过功能及防止并发症有良好的效果。     

保留直肌止端巩膜瓣的羟基磷灰石义眼台植入术的临床对照研究

目的观察保留直肌止端巩膜瓣的羟基磷灰石义眼台植入和常规眼球摘除联合羟基磷灰石义眼台植入两种术式的治疗效果。方法对36例眼球摘除的患者随机采用保留直肌止端巩膜瓣和常规眼球摘除联合眶内羟基磷灰石义眼台植入，观察两种手术方法术后反应，并发症以及义眼片的活动度。结果保留直肌止端巩膜瓣的羟基磷灰石义眼台植入较之常规眼球摘除联合羟基磷灰石义眼台植入：术后反应轻，义眼片活动度好。一例发生结膜切口裂开，未发生义眼台暴露。结论保留直肌止端巩膜瓣的眼球摘除联合羟基磷灰石义眼台植入术不损伤肌肉，手术后反应轻微，义眼片活动度佳，并发症少。     

同种异体巩膜瓣移植治疗前巩膜葡萄肿

目的探讨异体巩膜瓣移植治疗病理性前巩膜葡萄肿的临床疗效。方法对玻璃体切除术后的前巩膜葡萄肿3例（3眼）和前巩膜葡萄肿穿孔伴化脓性眼内炎1例（1眼）施行同种异体巩膜瓣移植,随访5～24个月。观察视力、巩膜植片、视网膜、眼压及其并发症等。结果3例玻璃体切除后的前巩膜葡萄肿,巩膜移植术后视力均同术前;巩膜植片表面可见血管网,植片无溶解,视网膜均在位,眼压控制在正常范围。1例前巩膜葡萄肿穿孔伴化脓性眼内炎,巩膜移植术后视力由术后光感／光定位不准恢复至0．05,玻璃体腔硅油填充,视网膜在位。巩膜植片周围被纤维组织包裹,略呈弧形隆起,并有新生血管长人,形成加厚的“新巩膜”。结论同种异体巩膜瓣移植治疗病理性前巩膜葡萄肿,能修补菲薄或穿孔的巩膜,且无排斥反应;能有效维持眼压,尽可能挽救患者的视力。     

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.     

Tight versus loose scleral flap closure in trabeculectomy surgery

Thirty-two consecutive trabeculectomy patients were randomized to receive a tight scleral flap closure (15 eyes) with postoperative laser suture lysis, or a loose scleral flap closure (18 eyes) to determine differences in the surgical results. Three months postoperatively no statistical difference in intraocular pressure (loose closure 15.1 ± 3.3 mm Hg, tight closure 15.0 ± 3.6 mm Hg,p > 0.05) or number of glaucoma medicines (loose closure 1.6, tight closure 1.3,p > 0.05) existed between treatment groups. In the early postoperative period, no statistical difference between groups was observed in the anterior chamber depth, visual acuity or intraocular pressure (p > 0.05). Laser suture lysis was performed without complication in nine patients with a statistically significant reduction in intraocular pressure (p < 0.01). This study suggests, by the technique used, that no obvious benefit exists in using a tight versus a loose scleral flap closure when performing a trabeculectomy.     

层间巩膜瓣切除联合小梁巩膜条转移治疗青光眼疗效观察

目的探讨层间巩膜瓣切除联合小梁巩膜条转移治疗青光眼的疗效。方法收集2010年5月至2011年2月在我院眼科住院治疗的青光眼患者42例(51眼),分为治疗组(21例26眼)与对照组(21例25眼)。治疗组采用层间巩膜瓣切除联合小梁巩膜条转移术,对照组采用常规小梁切除术。术后观察两组视力、眼压、滤过泡情况及并发症。采用SPSS17.0软件进行统计学处理。结果术后两组视力均较术前有所改善,治疗组改善更为明显。治疗组手术后眼压明显下降,至随访12个月时眼压为(14.46±1.92)mmHg(1kPa=7.5mmHg)。对照组手术后眼压亦明显下降,至随访12个月时眼压为(19.27±1.76)mm-Hg,差异有统计学意义(P<0.05)。术后12个月治疗组功能性滤过泡发生率所占比例为88.5%,对照组为60.0%,差异有统计学意义(P<0.05)。治疗组26眼中7眼出现浅前房,对照组仅3眼术后出现浅前房。治疗组Ⅰ级前房积血3眼,对照组Ⅰ级前房积血3眼,术后3～5d可完全吸收。治疗组5眼出现低眼压,对照组3眼出现低眼压,术后8d内眼压缓慢回升。结论层间巩膜瓣切除联合小梁巩膜条转移操作相对简单,手术安全,远期降眼压效果明显,值得临床推广应用。     

Long-term observations after trephination with scleral flap in glaucoma with threatened point of fixation

Follow-up examinations 2 months to 9 years after a filtering operation with scleral flap with successful pressure regulation could be carried out in 26 patients with 29 eyes in which a threat to the point of fixation due to glaucoma was present. In the majority of the cases, it was possible to stabilize visual acuity and visual field by the operation. In the remaining cases, there was a slow melting away of the residual visual field without correlation with lens or macular changes or underlying internal conditions.     

Glaucoma triple procedure comprising trabeculotomy with a fornix-based scleral flap

A new triple surgery procedure was applied to 20 primary open-angle glaucomatous (POAG) eyes. This technique comprises trabeculotomy with narrow (2–3 mm) fornix-based scleral flap, combined with extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC-IOL) implantation. As to surgical results, at two years postsurgery 53% (9/17) of the eyes were controlled under 21 mm Hg without medication, 35% (6/17) with topical medication alone. Eighteen (90%) eyes showed improved visual acuity of two or more Snellen lines. No serious postoperative complications occurred. There was no significant difference in postoperative astigmatism as compared with ordinary ECCE and PC-IOL surgery. Trabeculotomy with fornix-based scleral flap offers the advantage of simple and safe surgery when combined with ECCE and PC-IOL implantation.Abbreviations POAG primary open-angle glaucomatous - ECCE extracapsular cataract extraction - PC-IOL posterior chamber intraocular lens - IOP intraocular pressure     

Block resection with scleral flap rotation in ciliary body melanoma

The aim was to present a case of ciliary body melanoma treated with block resection and scleral flap rotation. 49-year old woman with ciliary body melanoma and extrascleral extension appeared in our clinic. Block resection of ciliary body melanoma and scleral flap rotation was performed and additional ruthenium brachytherapy was applied. There was no complications during surgery and follow-up. Described method can be recommended for openings in the sclera, which need emergency surgery.     

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.     

Polyglactin sutures versus nylon sutures for scleral flap suturing in trabeculectomy

BACKGROUND AND OBJECTIVES: To note the effect on filtration function of using polyglactin sutures for scleral flap suturing in trabeculectomy. PATIENTS AND METHODS: Polyglactin sutures were compared with nylon sutures to secure the scleral flap of trabeculectomy in 30 consecutive eyes. Parameters studied were intraocular pressure, central anterior chamber depth, and bleb score in this randomized prospective study. RESULTS: Observations regarding intraocular pressure, central anterior chamber depth and bleb score in the early postoperative period were comparable in the 2 groups. The results at 12 months follow-up reveal a lower mean IOP (P < 0.05) and a higher mean bleb score (P < 0.05) in the group with polyglactin sutures. Success rate (defined as IOP < 21 mm Hg) at 12 months was 100% with use of polyglactin sutures compared to 80% with nylon sutures. CONCLUSIONS: Polyglactin sutures can be used as an alternative to nylon sutures for scleral flap suturing in trabeculectomy, with the possible additional benefit of better long-term filtration function.     

Combined trephining with scleral flap (Elliot-Fronimopoulos) and intracapsular cataract extraction (author's transl)]

68 eyes of 51 non-selected patients on which a combined cataract extraction and Elliot's trephining with scleral flap (Fronimopoulos) had been performed between 1972 and september 1976, were re-examined between 6 and 48 months following operation. Postoperative complications were rare: there was one persistent shallow anterior chamber following excessive filtration, one increase of tension floowing a block of the trephine canal by vitreous, and one increase of tension following too tight suturing of the scleral flap which necessitated re-operation. Tension was compensated without therapy in 42 eyes (61,7%) and with local therapy in 24 eyes (35,3%). Only in 2 eyes (3%) normal intra-ocular pressure was not achieved. Altogether 97% of the eyes were compensated, some with additional local therapy. The combined cataract extraction and Elliot's trephining with scleral flap (Fronimopoulos) is an effective and low risk technique that is recommended in cases of cataract with raised intraocular pressure not controlled by medical treatment.     

Transconjunctival suturing of the scleral flap for overfiltration with hypotony maculopathy after trabeculectomy

Objective: To assess the efficacy of transconjunctival suturing of the scleral flap in improving hypotony maculopathy resulting from overfiltration after trabeculectomy.Design: Retrospective review.Participants: 35 eyes of 33 patients.Methods: Patients underwent transconjunctival scleral flap suturing for hypotony maculopathy following trabeculectomy using mitomycin C. The scleral flap was sutured through the conjunctiva as an outpatient clinic procedure using a spatulated needle with a 10-0 nylon suture.Results: The average age of the patients was 67.5 (SD 4.80, range 39-83) years, and 52% patients were male. The average duration of hypotony prior to transconjunctival suturing of the flap was 108.0 (SD 68.3) days. The median intraocular pressure (IOP) before suturing was 3 mm Hg, and the median IOP 6 months after the procedure was 9 mm Hg (p < 0.0001). The median best-corrected visual acuity (BCVA) before transconjunctival suturing of the scleral flap was 20/100, and the median BCVA 6 months after the procedure was 20/30 (p < 0.0001). Compared with visual acuity before suturing the average gain in BCVA was 4.9 (SD 0.8) lines.Conclusions: Transconjunctival suturing of the trabeculectomy scleral flap is an effective treatment to raise IOP and improve visual loss from hypotony maculopathy after trabeculectomy with overfiltering blebs.     

Resuturing the scleral flap through conjunctiva for treatment of excess filtration

PURPOSE: To elevate the intraocular pressure (IOP) in eyes with persistent hypotony caused by excess filtration after trabeculectomy. DESIGN: Interventional case series. METHODS: The scleral flap was sutured directly through the conjunctival flap using a round, tapered needle with a 10-0 nylon suture. This procedure has been performed in 10 eyes. RESULTS: The IOP elevated from 2.6 (+/- 1.0) mm Hg to 8.8 (+/- 3.7) mm Hg in 1 week and has been maintained between 6 to 14 mm Hg during the follow-up. Hypotony maculopathy has disappeared in nine eyes. The suture was buried in the conjunctiva spontaneously in 1 week in all cases. No complications developed. CONCLUSIONS: Suturing the scleral flap directly through the conjunctival flap is a simple and effective modality to treat the hypotony caused by excess filtration after trabeculectomy.     

Clinical results of fornix-based trabeculectomy with a scleral tunnel

PURPOSE: To evaluate retrospectivery the efficacy and safety of fornix-based trabeculectomy with a scleral tunnel. PATIENTS AND METHODS: We studied the records of 204 eyes of 156 patients who underwent fornix-based trabeculectomy with mitomycin C as their primary surgery between 2000 and 2002 and had a follow-up period of 6 months or more. A 3.5 or 4 mm rectangular double scleral flap incision was made and a scleral tunnel was fashioned by removing the second flap to allow the aqueous to flow into the fornix side. RESULTS: The mean intraocular pressure was significantly decreased from 22.2 +/- 7.8 (mean +/- standard deviation) mmHg to 12.4 +/- 3.9 mmHg 2 years after surgery (p < 0.0001). When the target pressure was defined as 15 mmHg, the 2-year survival rate using the Kaplan-Meier survival analysis was 69.1 %. Early wound leakages occurred in 16 eyes (7.8%) and additional sutures were needed on 13 eyes. The visual acuity of 22 eyes (11.0%) decreased by at least 2 lines. CONCLUSION: Although there are some complications specific to trabeculectomy, fornix-based trabeculectomy with a scleral tunnel appears to be an effective method of decreasing intraocular pressure.