新生血管性青光眼联合手术治疗疗效观察

目的 探讨联合手术治疗新生血管性青光眼的疗效.方法 对3l例(31只眼)新生血管性青光眼患者采用联合手术治疗方法:标准小梁切除术,应用丝裂霉素C,羊膜植入,全视网膜冷凝术.结果 术后5～7 d眼压7～18 mmHg(平均12.5 mmHg),术后3个月(31只眼)眼压10～29 mmHg(平均13.5 mmHg),术后6个月(28只眼)眼压10～31 mmHg(平均17.5 mmHg),术后12个月(24只眼)眼压11-31mml-1g(平均17 mmHg);术后3个月(31只眼)眼压低于21mmHg为完全成功有25只眼,条件成功有4只眼,成功率93.5%;术后6个月(28只眼)完全成功有19只眼,条件成功有5只眼,成功率85.7%;术后12个月(24只眼)眼压完全成功有12只眼,条件成功有7只眼,成功率79.1%.术后6个月(28只眼)有功能性滤过泡14只眼,非功能性滤过泡14只眼;术后12个月(24只眼)有功能性滤过泡11只眼,非功能性滤过泡13只眼.术后3月(31只眼)虹膜新生血管消失24只眼,术后12个月(24只眼)虹膜新生血管消失18只眼.手术后并发症:前房出血有11只眼;有3只眼前房渗出;有6只眼有脉络膜脱离;元前房消失,有1只眼恶性青光眼.结论 对新生血管性青光眼行联合手术:标准小梁切除术,应用丝裂霉素C,植入羊膜,全视网膜冷凝术效果肯定,并发症少,安全有效.     

新生血管性青光眼联合手术治疗的临床观察

目的探讨联合手术治疗新生血管性青光眼（NVG）的疗效。方法对53例（53眼）NVG根据病情分3组采用联合手术的治疗方法。（1）A组23眼,先应用多波长氪激光行超广泛视网膜光凝术,光凝术后1～2周进行小梁切除术,术中应用丝裂霉素C（0．4mg／mL）棉片放置巩膜瓣下3～5rain。（2）B组17眼,先应用氪绿激光对虹膜面及房角新生血管直接光凝,2周后行小梁切除术,术中应用丝裂霉素c。（3）C组13眼,选用睫状体冷凝联合全周边视网膜冷凝术。结果6个月随访时：（1）A组成功率78．3％;平均眼压为（17．35±5．23）mmHg。（2）B组成功率为82．4％;平均眼压为（15．94±4．17）mmHg。（3）c组成功率为76．9％;平均眼压为（17．31±5．00）mmHg。结论针对不同程度的NVG要采用不同的治疗方法,并根据病情的发展随时调整治疗方案。     

次全视网膜冷凝联合抗代谢药物治疗新生血管性青光眼

目的： 探讨新生血管性青光眼尤其晚期病例的治疗方法。方法： 将 ４０ 例新生血管性青光眼随机分为次全视网膜冷凝 （ Ｓ Ｒ Ｃ）组 ２３ 例 （２３ 只眼）, 单纯用 Ｓ Ｒ Ｃ或联合抗青光眼手术, 对照组 １７ 例 （１７ 只眼） 行抗青光眼手术。两组术后均局部应用 ５— Ｆｕ 和地塞米松。术后随访 １ 月～５ 年, 平均 ６ 个月。结果： Ｓ Ｒ Ｃ组的治疗成功率 （７３９％ ） 高于对照组 （４１２％ ）, 差异有显著性 （ Ｐ＜ ００５）。结论：单纯次全视网膜冷凝术或联合抗青光眼手术及术后抗代谢药物的应用是一种治疗新生血管性青光眼的较有效的方法, 本方法特别适用于屈光间质混浊的晚期的病例。     

The critical role of the conjunctiva in glaucoma filtration surgery

This review considers the critical role of the conjunctiva in determining the success or failure of glaucoma filtration surgery. Glaucoma filtration surgery can be defined as an attempt to lower intraocular pressure (IOP) by the surgical formation of an artificial drainage pathway from the anterior chamber to the subconjunctival space. Many types of glaucoma filtration surgery have been developed since the first attempts almost 180 years ago. The wide range of new techniques and devices currently under investigation is testament to the limitations of current techniques and the need for improved therapeutic outcomes. Whilst great attention has been paid to surgical techniques and devices to create the drainage pathway, relatively little attention has been given to address the question of why drainage from such artificial pathways is often problematic. This is in contrast to normal drainage pathways which last a lifetime. Furthermore, the consequences of potential changes in aqueous humour properties induced by glaucoma filtration surgery have not been sufficiently addressed. The mechanisms by which aqueous fluid is drained from the subconjunctival space after filtration surgery have also received relatively little attention. We propose that factors such as the degree of tissue damage during surgery, the surrounding tissue reaction to any surgical implant, and the degree of disruption of normal aqueous properties, are all factors which influence the successful formation of long term drainage channels from the conjunctiva, and that these channels are the key to successful filtration surgery. In recent years it has been suggested that the rate of fluid drainage from the subconjunctival space is actually the determining factor in the resultant IOP reduction. Improved knowledge of aqueous humour induced changes in such drainage pathways has the potential to significantly improve the surgical management of glaucoma.We describe for the first time a novel type of drainage surgery which attempts to minimise surgical trauma to the overlying conjunctiva. The rationale is that a healthy conjunctiva allows drainage channels to form and less opportunity for inflammation and scar tissue formation which are a frequent cause of failure in glaucoma filtration surgery. Successful drainage over extended periods of time has been demonstrated in monkey and rabbit eyes. Long lasting drainage pathways were clearly associated with the presence of lymphatic drainage pathways. A new philosophy in glaucoma drainage surgery is proposed in which minimisation of surgical trauma to the conjunctiva and the encouragement of the development of conjunctival drainage pathways, particularly lymphatic pathways, are central pillars to a successful outcome in glaucoma filtration surgery.     

次全视网膜冷凝联合抗代谢药物治疗新生血管性青光眼

目的　探讨新生血管性青光眼尤其晚期病例的治疗方法。方法　将４０ 例新生血管性青光眼临床随机分为次全视网膜冷凝（ＳＲＣ） 组和对照组。前组２３ 例（２３ 只眼） 单纯用ＳＲＣ 或联合抗青光眼手术,后组１７ 例（１７ 只眼） 行抗青光眼手术。两组患者术后均局部应用５ － Ｆｕ 和地塞米松。术后随访１ ｍ ｏ ～５ａ ,平均６ ｍｏ 。结果　ＳＲＣ 组的治疗成功率（７３ ．９ ％ ） 高于对照组的成功率（４１ ．２ ％ ） ,两组有显著性差异（ Ｐ ＜ ０ ．０５） 。结论　单纯次全视网膜冷凝术或联合抗青光眼手术及术后抗代谢药物的应用是一种治疗新生血管性青光眼的较有效的方法,该方法特别适用于屈光间质混浊的、晚期的病例     

新生血管性青光眼手术探讨

目的 比较全视网膜冷凝术（ＰＲＣ）联合小梁切除,自体巩膜条引流术与前视网膜冷凝术（ＡＲＣ）联合小梁切除术对新生血管性青光眼的疗效。方法 ４２例随机分成Ａ,Ｂ两组,分别行ＡＲＣ联合小梁切除术和ＰＲＣ联合小梁切除,自体巩膜条引流术。结果 术后第１天,Ｂ组眼压明显高于Ａ组,而术后末期随访Ｂ组眼压下降及虹膜新生血管消退均优于Ａ组。     

Ex-PRESS青光眼引流器植入治疗新生血管性青光眼的疗效观察

目的：比较Ex－PRESS青光眼引流器植入术和小梁切除术治疗新生血管性青光眼的疗效和并发症情况。
　　方法：前瞻性随机对照临床试验研究,选择新生血管性青光眼34眼,排除前房浅的患者,随机分为两组。第一组（ A组）15眼行Ex－PRESS青光眼引流器植入术,术中应用丝裂霉素;第二组（ B组）19眼行小梁切除术,术中应用丝裂霉素。随访1 a,观察两种手术前后眼内压,视力变化,以及随访期间联合应用降眼压药物情况,并发症情况,结果进行统计学分析。
　　结果：两组治疗前后的平均眼压均有明显的下降（P＝0．01）。两组在治疗后1,4wk;6,12mo的眼压变化相似,没有明显差异（ P＝0．451）。两组1,4wk;6,12mo的最佳矫正视力与治疗前相比没有明显变化（ P＝0．832）。 Ex－PRESS青光眼引流器植入术组和小梁切除组成功率分别是66．7％和63．1％。小梁切除组8例患者出现了前房出血,Ex－PRESS青光眼引流器植入术组有3例患者发生了前房出血。术后早期小梁切除组6例患者发生了脉络膜脱离,Ex－PRESS青光眼引流器植入术组有3例患者出现了脉络膜脱离。
　　结论：Ex－PRESS青光眼引流器植入术治疗新生血管性青光眼相对简便、安全、微创、学习曲线短,患者痛苦小,并发症少,是治疗新生血管性青光眼的一种有效方法。     

新生血管性青光眼综合手术治疗疗效观察

目的 评价全视网膜冷凝术(PRC)联合小梁切除、自体巩膜条翻转固定引流，并应用丝裂霉素C(MMC)治疗新生血管性青光眼的效果。方法 回顾21例PRC联合小梁切除、自体巩膜条翻转固定引流，并应用MMC治疗新生血管性青光眼的病例。结果 术后随访4月～2年，18例眼压控制在1．46～2．6个kPa(10．94～19．55mmHg)。结论 PRC联合小梁切除、自体巩膜条翻转固定引流，并应用MMC治疗新生血管性青光眼疗效理想。     

The role of different VEGF isoforms in scar formation after glaucoma filtration surgery

Vascular endothelial growth factor (VEGF) plays an important role in both physiological and pathological angiogenesis. Our previous studies showed a differential role of VEGF isoforms in retinal physiological angiogenesis. We also demonstrated that non-selective inhibition of VEGF by bevacizumab had a beneficial effect on surgical outcome after glaucoma filtration surgery by reducing angiogenesis as well as fibrosis. However, the function of the VEGF isoforms in pathological angiogenesis and wound healing in the eye still remains unidentified. This study was designed to elucidate the differential roles of VEGF isoforms in scar formation after trabeculectomy. Furthermore, we also investigated whether pegaptanib (Macugen™, Pfizer), an aptamer which specifically blocks VEGF₁₆₅, could improve surgical outcome by reducing postoperative scarring. VEGF-R2 and neuropilin-1 (NRP-1) expression was analyzed in vitro by RT-PCR, and were found to be expressed at higher levels in human umbilical vein endothelial cells (HUVEC) as compared to Tenon fibroblasts (TF). The effect of the different VEGF isoforms (VEGF₁₂₁, VEGF₁₆₅ and VEGF₁₈₉) and pegaptanib on cell proliferation was determined via WST-1 assay. Endothelial cell proliferation was stimulated after addition of VEGF₁₂₁ and VEGF₁₆₅, whereas VEGF₁₂₁ and VEGF₁₈₉ increased fibroblast growth. These effects on proliferation were associated with an activation of the ERK pathway, as revealed using the TransAM c-Myc assay. Inhibition of the ERK pathway, by PD98059 administration, significantly reduced VEGF isoform induced cell growth. A dose-dependent reduction of endothelial cell proliferation was observed after pegaptanib administration, while only the highest dose was able to inhibit fibroblast growth. Next, the in vivo effect of pegaptanib was investigated in a rabbit model of trabeculectomy. The surgical outcome was evaluated by performing clinical investigations (IOP, bleb area, height and survival), as well as histomorphometric analyses of angiogenesis (CD31), inflammation (CD45) and fibrosis (Sirius Red). A single postoperative application of pegaptanib had a beneficial impact on surgical outcome, mainly by reducing angiogenesis, but not inflammation or collagen deposition. Repeated injections slightly improved surgical outcome, but again solely by reducing angiogenesis. In summary, our results revealed that the VEGF isoforms play a differential role in ocular wound healing: VEGF₁₆₅ and VEGF₁₂₁ predominantly affect blood vessel growth, whereas VEGF₁₈₉ is rather involved in fibrosis, an important process in wound healing.     

Nonpenetrating filtration surgery for glaucoma: control by surgery only

PURPOSE: To report on intraocular pressure (IOP) control by nonpenetrating filtration surgery without medical treatment in eyes with primary open-angle glaucoma (POAG). SETTING: Oxford Eye Center and St. John Eye Hospital, Johannesburg, South Africa. METHODS: This retrospective study evaluated IOP control by nonpenetrating filtration surgery in 46 patients (86 eyes) with POAG who had surgery between February 1992 and February 1998 (mean follow-up 46 months); 48 eyes were previously treated, and 38 were newly diagnosed, untreated eyes. Under a trapezoidal scleral flap, a deep sclerectomy and a fenestration in Schlemm's canal were created without penetrating the anterior chamber. Postoperatively, when IOP rose above 20 mm Hg, instead of adding medical treatment, the filtration site was revised to re-establish filtration. RESULTS: The mean drop in IOP was 50%, from a mean of 30.4 mm Hg preoperatively to a mean of 15.35 mm Hg postoperatively. After a mean period of successful filtration of 29.9 months, the filtration site was revised in 48 eyes (56%) to maintain the IOP below 21 mm Hg without medication. The reoperation rate was 4.7 times higher in previously treated patients than in untreated patients. CONCLUSIONS: Nonpenetrating filtration surgery in eyes with POAG was more rewarding in untreated patients than in medically treated patients. To control IOP without medication, revision of the filtration site is feasible and needed in the medium and long term.     

青光眼滤过手术成功要素的探讨

目的 探讨提高青光眼滤过手术成功率的措施。方法 采取6项措施：术前3天停用缩瞳剂，滴皮质类固醇滴眼液；仅做球周麻醉，不做结膜下注射，以减少出血机会；术后彻底止血，但避免重烧伤；制做三角形巩膜瓣；小梁切除位置在Schwalbe线之后0．5mm以内；术后早期进行眼球按摩。结果 86例113眼术后眼压均控制在正常水平，术后第1天前房即形成，随访仅1例2眼术后半月出现包裹性滤过泡；1例1眼术后10天缝线滑脱，经处理恢复正常，余所有病例未见并发症发生。结论 只要注意青光眼手术中的每个细节，是可以提高其手术成功率的。     

Vitreoretinal surgery in the treatment of neovascular glaucoma

PURPOSE: Neovascular glaucoma develops on a background of ischemic ocular pathologies, such as diabetic eye diseases or central retinal vein occlusion. Development of neovascular membranes in the chamber angle leads to elevated intraocular pressure. Since treatment by cyclodestructive therapy or drainage surgery often fails, we have examined intense antiproliferative surgery as a treatment for advanced neovascular glaucoma. PATIENTS AND METHODS: Thirty-two patients with neovascular glaucoma subsequent to central vein occlusion or advanced diabetic retinopathy underwent antiproliferative surgery, which comprised vitrectomy, panretinal laser treatment and direct laser coagulation of the ciliary processes, followed by silicone oil tamponade. Patients were followed for a minimum of 1 year and as long as 3 years. RESULTS: After one week following surgery the intraocular pressure (IOP) was normal, ranging from 8 to 21 mm#Hg, in 52% (15/29 eyes), after 3 months the IOP was normal in 50% (16/32 eyes), after 6 months the IOP was normal in 59% (16/27 eyes) and after 1 year the IOP was normal in 72% (18/25 eyes). Of the 10 eyes that lost all sight after the surgery, 7 eyes had a history of central vein occlusion. Hypotony was observed in 6% (2/32) of the eyes 3 months following surgery; after 6 months hypotony was present in 15% (4/27) of the eyes and after 1 year hypotony was present in 12% (3/25) of the eyes. CONCLUSIONS: The theoretical premise of our surgical intervention (antiproliferative surgery) is based on the assumption that laser treatment interrupts the self enhancing pathway of retinal ischemia, release of proliferative factors and increase in intraocular pressure. The silicone oil endotamponade prevents postoperative complications and supports the rapid regression of rubeosis iridis by separating the anterior from the posterior segment.     

Filtration surgery in the treatment of neovascular glaucoma

The disappointing visual acuity results following cyclocryotherapy for neovascular glaucoma have prompted us to consider filtration surgery as a reasonable alternative in the treatment of selected patients. All cases of surgically treated neovascular glaucoma were reviewed. There were 26 operations in 24 eyes with a follow-up ranging from six months to seven years and a mean of 22.8 months. Adequate pressure control was obtained in 16 of the 24 eyes (67%). In the eyes with successful control of intraocular pressure, vision was 20/400 or better in eight of the 16 eyes (50%). Four patients (17%) lost light perception. Approximately one half of the operations were trabeculectomies, and the others were posterior lip sclerectomies. There seemed to be no significant difference in the final intraocular pressure levels, number or degree of complications, or successes within the two subgroups. Panretinal photocoagulation, topical steroids, cycloplegics, and time for these measures to have their effect are important preoperative adjuncts to surgical treatment. We are encouraged by the long-term preservation of vision and control of intraocular pressure in many of these eyes.     

Flap selection in glaucoma filtration surgery

Glaucoma surgery requires the fashioning of conjunctival flaps with or without scleral flaps. The advantages and use of fornix-based conjunctival flaps are presented. Methods to decrease complications of limbal-based conjunctival flaps are discussed. The use of scleral flaps and their modification to assist in enhancing filtration and to prevent complications of filtering surgery is shown.     

Filtering valve implant surgery for eyes wtih neovascular glaucoma

We performed filtration surgery with a unidirectional, pressure-sensitive valve implant in 40 eyes with neovascular glaucoma. The device consisted of an open Supramid tube (outside diameter 0.58 mm, inside diameter 0.38 mm) sealed to a Silastic tube with a slit valve. The Supramid tube was inserted at the corneoscleral limbus 1 to 4 mm into the anterior chamber and the Silastic portion was located under a lamellar scleral flap. Twenty-seven of 40 eyes (68%) had a postoperative IOP less than or equal to 24 mm Hg with a mean follow-up of 13.8 months. Ten of these 27 eyes required postoperative medical therapy to achieve this level of IOP control. The glaucoma valve implant failed to return IOP to normal in 13 of the 40 eyes (32%), 11 of these as a consequence of scarring of the external bleb.     

Cataract after glaucoma filtration surgery

PURPOSE: We reviewed the evidence regarding cataract incidence and progression after glaucoma surgery. DESIGN: Evidence-based review of available literature. METHODS: We performed a systematic review of relevant studies published in English. RESULTS: Reports of visually significant cataract after glaucoma surgery are supported by data from randomized clinical trials and large case series. CONCLUSIONS: Patients undergoing glaucoma surgery are at increased risk for the development and progression of cataract.