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PubMed2001

The use of antimetabolites with trabeculectomy: a critical appraisal.

PURPOSE: To examine why most ophthalmologists routinely use mitomycin C or 5-fluorouracil (antimetabolites) in association with filtering surgery for glaucoma. METHODS: Critical analysis of seven medical, social and economic trends. RESULTS: The rapid acceptance of the adjunctive use of antimetabolites at the time of filtration surgery may be explained by reasons other than anticipated increase in the "success" of glaucoma surgery. CONCLUSION: The use of antimetabolites in conjuction with filtering glaucoma surgery may be at least partially a consequence of changing medical-social-economic factors, rather than solely a desire on the part of physicians to improve the "success" of glaucoma surgery. This may indicate a need to reevaluate the proper place of antimetabolites in association with filtration surgery.

Antimetabolites↗

PubMed2000

Ultrasound biomicroscopic patterns after glaucoma surgery in congenital glaucoma.

OBJECTIVE: This study aimed to demonstrate specific morphologic patterns in congenital glaucoma after various surgical procedures by means of ultrasound biomicroscopy (UBM) and to investigate correlations between UBM morphology and the effectiveness of glaucoma surgery in reducing intraocular pressure. DESIGN: Observational case series. PARTICIPANTS AND INTERVENTIONS: Thirty four eyes of 18 consecutive patients, not older than 18 years, with congenital glaucoma and with a history of previous antiglaucomatous surgery underwent UBM examination of the anterior chamber angle in the treatment area and in an untreated region. MAIN OUTCOME MEASURES: The morphology of the anterior chamber angle region and the tissue reflectivity were analyzed. RESULTS: Specific UBM patterns of the anterior chamber angle in congenital glaucoma were observed after goniotomy, trabeculotomy, trabeculectomy, deep sclerectomy, and cyclodialysis. In the first months after surgery, a limited correlation was found between morphology and the success of filtering surgery. Adhesions of the iris or the ciliary processes to the trabeculectomy cleft were detected in 19 of 25 eyes after filtering procedures. CONCLUSIONS: In cases of cloudy cornea and unknown previous glaucoma surgery, UBM can be used to identify the type and localization of previous surgery in congenital glaucoma, thus assisting surgical planning for subsequent glaucoma management. The correlation between UBM morphology and the effectiveness of filtering surgery is less convincing than previously demonstrated in adults, possibly underlining the importance of individual nonsurgical factors for prognosis in congenital glaucoma.

Adolescent↗

PubMed2005

Resident glaucoma surgical training in United States residency programs.

PURPOSE: To determine current trends in resident glaucoma surgical training throughout the United States. METHODS: A comprehensive survey was sent to the residency director of all 121 ACGME-accredited ophthalmology training programs in the United States. RESULTS: The mean and median number of glaucoma procedures a resident will complete by the end of their training is 8.6 and 8 respectively for trabeculectomy, 5.3 and 4 for combined trabeculectomy/phacoemulsification, and 3.6 and 2 for tube-shunts. One percent of residents will gain experience as primary surgeon on trabeculectomies during their first year, 32% during their second year, and 67% during their third year. Seventy-five percent of residents are taught more than one trabeculectomy technique by more than one staff surgeon. Eighty-four percent of residents are taught glaucoma surgery almost exclusively by fellowship-trained glaucoma surgeons. Eighty-two percent of residents use antimetabolites (mitomycin C or 5-FU) as an adjunct to trabeculectomy most or all of the time. More than 96% of resident tube-shunt procedures use Ahmed, Baerveldt, or Molteno devices. Eighty percent of residents do not perform any pediatric glaucoma surgeries. Sixty-two percent of residents rotate out of their main facility to perform glaucoma surgery. CONCLUSIONS: Residents are being exposed to glaucoma surgery early in their residency training. Most are performing a variety of different procedures and techniques, and are taught by fellowship-trained surgeons. Residents gain very little exposure to pediatric glaucoma surgery. All programs reported compliance with minimum RRC requirements for glaucoma filtering surgery.

Clinical Competence↗

PubMed1998

[Modulation of wound healing in glaucoma filtration surgery].

Authors evaluate application of mitomycin C (0.2-0.4 mg/ml) on the sclera during glaucoma filtering surgery. Mean follow up was 19.5 months in the group of 67 patients (75 eyes). The most serious complication was an early endophthalmitis in 2 cases with the loss of residual visual field and vision, 1x hemophthalmus followed with development of traction retinal detachment, 1x hypotonic maculopathy, 1x traction retinal detachment for progression of diabetic proliferative vitreoretinopathy of neovascular glaucoma. Higher rate of complications was noted in the group of mitomycin C 0.4 mg/ml. Visual acuity was better one line Snellen optotypes in 3 cases, and worse in 26 cases. Intraocular pressure compensation up to 20 mmHg was reached in 32 cases without therapy (45.1%), in 28 cases therapy (39.6%), Intraocular pressure above 20 mm Hg was in 11 cases (15.4) and the data are not known in 4 cases (5.4%). Intraocular pressure was compensated after mitomycin C application in 84.7%.

Administration, Topical↗

PubMed2005

Nosocomial postoperative endophthalmitis: a 14-year review.

BACKGROUND: The objective of this study was to evaluate the incidence, predisposing surgery, management and final visual outcome of postoperative endophthalmitis over a 14-year period at one institute. METHODS: This retrospective study reviewed all intraocular operations performed between 1 January 1991 and 31 August 2004 at Chang Gung Memorial Hospital, Kaohsiung Medical Center, to determine the incidence of nosocomial postoperative endophthalmitis and the characteristics of patients who developed this condition. RESULTS: The overall incidence of postoperative endophthalmitis after intraocular surgery was 0.19% (56 out of 30,219). Postoperative endophthalmitis developed in 56 eyes in 56 patients during the study period. The condition developed after cataract surgery in 46 eyes, after penetrating keratoplasty in 6 eyes, after filtering surgery in 2 eyes, after secondary intraocular lens implant in 1 eye, and after vitrectomy in 1 eye. Postoperative endophthalmitis was culture-positive in 31 cases (55%). The most frequent organism isolated was coagulase-negative Staphylococcus. Factors associated with better visual acuity outcomes included low virulence of isolated pathogen, initial visual acuity of counting fingers or better, and history of cataract surgery compared with other intraocular surgery. CONCLUSION: The overall incidence of endophthalmitis after intraocular surgery was 0.19%. The results of this 14-year review from a local medical center may serve as a source of comparison for other centers and future studies.

Adult↗

PubMedDate not supplied

[Encapsulated filtering blebs--incidence and methods of treatment].

Encapsulation of the filtering bleb occurs as a complication of glaucoma filtering surgery in 8.3-28% of all eyes filtered, often between 2-4 weeks after surgery. It has a characteristic clinical appearance--highly elevated localized bleb, prominent surface vessels and patent sclerostomies on gonioscopy. This study retrospectively reviewed the results of 100 filtering operations, performed in the Prof. Dr. I. Stankovitsh Eye Department, focused on the incidence, possible risk factors and management of encapsulated filtering blebs. Trabeculectomy was done in all patients with limbus-based conjunctival flap, rectangular scleral flap 4 x 4 mm, and sclerostomy 2 x 2 mm. Two or three interrupted 10-0 nylon sutures were used to tether the flap, the conjunctiva with Tenon's capsule was closed with a running suture. All eyes received topical dexamethasone drops, mydriatics-homatropin or tropicamide and antibiotic ointment for three weeks. Possible risk factors were considered: sex, age, other eye or systemic disease, type of glaucoma, previous ocular procedure and antiglaucoma medical therapy, early postoperative complications, postoperative and final intraocular pressure (IOP). All eycs with encapsulated filtering bleb were given topical beta-blocker initially and carbonic anhydrase inhibitor, and if IOP continued to be uncontrolled incisional surgical management was performed. Success was defined as IOP maintained at less than 22 mmHg, with or without medication. An encapsulated filtering bleb developed in 9% of eyes. Previous argon laser trabeculoplasty was associated with an increased frequency of bleb encapsulation. The mean postoperative IOP was 11.30 +/- 1.90. Encapsulation of filtering bleb was developing at mean time of 19.9 +/- 3.0 after surgery. Six eyes returned to IOP below 21 (mean IOP was 20.17 +/- 0.90) within 4 weeks, and 4 of them continued on a topical beta-blocker. Four eyes required incisional surgery. A week after surgery mean IOP was 18 mmHg. Haemophthalmus occurred after one incision performed in a patient suffering from diabetes mellitus. Late scarring of the filtering bleb was developed in 2 eyes. Seven months and 2 years after filtration surgery mean IOP was 21.30 +/- 4.00 mmHg. The cause of bleb encapsulation is not known. Male patients, surgical glove powder, topical corticosteroids, previous argon laser trabeculoplasty and beta-blockers are some of potential risk factors for the development of encapsulated filtering bleb. This study suggests the association between development of encapsulated bleb and previous argon laser trabeculoplasty--40% in the eyes with encapsulation and 18% in the eyes without encapsulation. The optimal management of bleb encapsulation has not been defined. In this study topical antiglaucoma therapy achieved IOP control and cyst's remodeling in 60% of cases. Forty percent of all cysts required incisional surgical management. Encapsulation of the filtering bleb is not an uncommon complication of glaucoma filtration surgery. It is important to examine postoperative eyes frequently during the first 2 months to detect this complication. Fortunately, most eyes have their IOPs controlled with antiglaucoma therapy.

Adrenergic beta-Antagonists↗

PubMed1998

Classification of filtering blebs in trabeculectomy: biomicroscopy and functionality.

The long-term success of filtering surgery is not dependent on surgical technique alone. The development of the filtering bleb in the postoperative period, in particular with regard to wound healing and subconjunctival scarring, is equally important. Morphologic changes of the developing filtering bleb after trabeculectomy can predict early failure even if the intraocular pressure is still normal. A basic understanding of wound healing processes and histologic changes of the developing filtering bleb are mandatory to interpret correctly the morphologic appearance of the developing filtering bleb. In clinical practice, follow-up of the filtering bleb according to a standardized morphologic classification may help to predict outcome and provide clues for the necessity and timing of further treatment.

Aqueous Humor↗

PubMed1997

Cataract extraction as a means of treating postfiltration hypotony maculopathy.

Hypotony maculopathy may arise after glaucoma filtering surgery. This can be treated by inducing inflammation and scarring within the filter, with the aim of increasing intraocular pressure (IOP) and promoting resolution of maculopathy. Cataract extraction can promote such inflammation. Phacoemulsification with posterior chamber intraocular lens (PC IOL) implantation was performed in two consecutive patients with postfiltration hypotony maculopathy and preexisting cataracts. After cataract extraction, improvement of IOP, visual acuity, maculopathy, and metamorphopsia occurred in both patients. Cataract extraction can be beneficial in the management of postfiltration hypotony maculopathy.

Cataract Extraction↗

PubMedDate not supplied

[The use of antimetabolites in glaucoma surgery].

The authors present, in the context of actual management of glaucoma, the role of antimetabolites in addition to glaucoma filtering surgery. The main reason of failure in filtration surgery is the excessive postoperative scarring response at the contact episclera-subconjunctiva. The antimetabolites inhibit the fibroblastic growth, therefore providing a great number of adequate filtering blebs. Indications, surgical techniques, complications and risks are also discussed.

Adult↗

PubMed1991

New aspects in the surgical treatment of glaucoma.

With modern techniques and advances in materials and instruments, the outcome of glaucoma surgery has been improved. Early filtering surgery has become a definite option in open angle glaucoma, particularly as the complications of such surgery are minimal. Refractory cases of glaucoma are always problematic, but modifications to the routine surgical options such as silicone-tube implants, partial-thickness procedures, 5-fluorouracil, and cyclocryotherapy, have improved the outcome. This article reviews some of the current trends in glaucoma surgery.

Combined Modality Therapy↗

PubMed2005

Changes in axial length following trabeculectomy and glaucoma drainage device surgery.

AIM: This study examines the changes in axial length (AL) after trabeculectomy and glaucoma drainage device (GDD) surgery and enabled an equation to be derived allowing prediction of AL change after filtering surgery. METHODS: This was a prospective, interventional case series from the Glaucoma Service of the Doheny Eye Institute. PATIENT POPULATION: One eye of 39 patients undergoing trabeculectomy and 22 undergoing Baerveldt tube shunt implantation for uncontrolled glaucoma. INTERVENTION: These patients had AL measurements by non-contact, partial coherence interferometry preoperatively, at 1 week, 1 month, and >3 months after surgery. MAIN OUTCOME MEASURES: Axial length and intraocular pressure were compared at preoperative and postoperative visits. Postoperative intraocular pressure (IOP) was categorised as hypotonous (0-4 mm Hg), low (5-9), normal (10-17), and high (18 or more). RESULTS: There was a statistically significant reduction in IOP after 3 months of -12.8 (SD 1.5) mm Hg following trabeculectomy (p<0.001), and -10.7 (1.9) mm Hg after GDD (p<0.001). There was a statistically significant reduction in AL, which was similar after trabeculectomy and GDD at all time points (p<0.001), of -0.15 (0.03) and -0.21 (0.04) mm (1 week), -0.18 (0.02) and -0.10 (0.02) mm (1 month), and -0.16 (0.03) and -0.15 (0.03) mm (3 months). At 3 months or later the AL reduction was related to postoperative IOP and to the amount of IOP reduction (p<0.05, stepwise multiple regression). 10.2% (4/39) of trabeculectomy patients had hypotony after 3 months, with a mean AL reduction (-0.39 (0.11)) that was statistically significantly lower (p<0.01) than the other trabeculectomy eyes (-0.14 (0.15)). CONCLUSIONS: There is a small but statistically significant decrease in AL after both trabeculectomy and GDD surgery, greater in eyes that are hypotonous after surgery. The authors suggest that AL reduction can be predicted after 3 months by the formula: AL reduction (mm) = -199+0.006 x IOP reduction+0.008 x final IOP.

Aged↗

PubMed1995

Corneal endothelial permeability in protection glaucoma filter bleb with tissue plasminogen activator.

After glaucoma filtering surgery subconjunctival injection of human recombinant tissue plasminogen activator may promote the function of glaucoma filter bleb and increase outflow facility. It can also increase postoperative complications, such as corneal damage. The aim of our research was to determine corneal endothelial permeability (Pac) in subjects with glaucoma filter bleb protected by a plasminogen activator (Actilyse, Boehringer) when haemorrhagic clots obstructing a glaucoma filtering site had occurred. Two weeks, three months and six months after goniotrephining with scleral cover, in groups with and without subconjunctival injection of 25 mg human tissue plasminogen activator, Pac was calculated. In both groups, no significant differences in the level of Pac measured by fluorophotometry were found.

Aged↗

PubMed1999

Collagen type I and III synthesis by Tenon's capsule fibroblasts in culture: individual patient characteristics and response to mitomycin C, 5-fluorouracil, and ascorbic acid.

PURPOSE: This study was performed to better understand the differences between patients in specific components of wound healing as it may pertain to glaucoma filtration surgery, including the use of antimetabolites. METHODS: Human Tenon's capsule fibroblasts were obtained at the time of glaucoma filtering surgery and established in individual cell cultures from 35 glaucoma patients. The dose-response to 5-fluorouracil (5FU) and mitomycin C (MMC) was determined. The individual cell lines were exposed to the antimetabolites and ascorbic acid with measurement of collagen type I and III production by an ELISA-type dot blot assay. These results were then statistically compared to the individual patient characteristics including age, race, previous surgery and medications, and type of glaucoma. RESULTS: 5-FU had little effect on collagen type I and III production or protein synthesis. MMC had an inhibitory effect on collagen secretion and total protein synthesis with increasing concentration. Photomicrographs of the cells after each treatment condition revealed characteristic morphologic changes when compared to controls. There was a large range of collagen type I and III production with correlation between the amounts of each collagen type secreted in response to the antimetabolites. However, there was no correlation with accepted risk factors for filtration failure. CONCLUSION: These antimetabolites act similarly on different cell lines in a nonspecific manner. The results suggest that the increased risk of filtration failure due to age, race, diagnosis, and previous conjunctival surgery is not due to differences in secretion of collagen types I and III by Tenon's capsule fibroblasts.

Adolescent↗

PubMed1998

Utility of insufflation filters in laparoscopic surgery.

OBJECTIVES: To determine whether filters, regularly used as part of the insufflator tubing during laparoscopic surgery, trap microbial and particulate matter from CO2 tanks, thus preventing passage from one patient to another. METHODS: A total of 67 used filters were collected from 17 CO2 tanks and six insufflation machines at three local hospitals, and sterile unused filters were used as controls. The used filters were distributed equally and sequentially into three groups: Group I-viewed under a dissecting microscope for particulate matter; group II-examined by mass spectrometry for contamination with oils and other impurities; group III-incubated on sheep blood agar plates and evaluated for growth of microorganisms. RESULTS: Negative. Used filters were indistinguishable by all parameters from controls. CONCLUSIONS: This limited study suggests filters now used in laparoscopic surgery fail to trap microbes or particulate matter. The question remains whether tank waste is absent or these filters fail to trap waste matter.

Bacteria↗

PubMed2005

[Use of water drinking test after non-penetrating deep sclerectomy].

INTRODUCTION: Recent studies have demonstrated that the intraocular pressure peak obtained after water-drinking test is similar to the one after diurnal intraocular pressure curve. The aim of this study is to assess the intraocular pressure peaks, the amplitude of variation of intraocular pressure after the water-drinking test in patients submitted to a non penetrating deep sclerectomy, evaluating its capacity to avoid large intraocular pressure fluctuations in post-operative period. METHOD: Ninety-seven eyes of ninety-seven patients were enrolled and divided in 5 groups: group I--20 non-glaucomatous individuals, group II--21 glaucomatous patients with no treatment, group III--15 glaucomatous patients under medical treatment (timolol 0.5% + dorzolamide in fixed combination), group IV--21 glaucomatous patients after non penetrating deep sclerectomy, and group V--20 glaucomatous patients after trabeculectomy. The water-drinking test was then applied to everyone and the authors have compared and analyzed the results, concerning the initial intraocular pressure, intraocular pressure peaks and intraocular pressure amplitude of variation. RESULTS: Mean age (+/- standard deviation) was 58.9 +/- 13.4 years. Mean initial intraocular pressure, mean intraocular peak and mean amplitude were, respectively: in group I: 13.9/15.8/1.9; in group II: 17.5/26.0/8.4; in group III: 14.2/18.6 4.3; in group IV: 12.3/14.1/1.7; in group V: 10.0/11.6/1.6. There was no statistical difference, concerning the intraocular pressure amplitude of variation, among the following groups: I, IV and V. DISCUSSION AND CONCLUSION: The intraocular pressure variations after the water-drinking test are similar in non-glaucomatous individuals and in patients submitted to a penetrating filtering surgery, (trabeculectomy) or a non penetrating technique (deep sclerectomy). The water-drinking test demonstrated that these two filtering procedures are safe and efficient in avoiding intraocular pressure peaks and large fluctuations in glaucomatous patients.

Drinking↗

PubMed2003

Effects of octreotide acetate and amniotic membrane on wound healing in experimental glaucoma surgery.

Wound healing affects the success of glaucoma filtering surgery. Antimetabolites and antifibrotic agents are used in the modulation of surgical trauma. This study is performed to evaluate the effects of amniotic membrane and octreotide acetate on wound healing. Thirty pigmented rabbits were divided into three groups each including 10 animals. Trabeculectomy and topical postoperative prednisolone sodium phosphate four times daily for 7 days were applied to one eye of all the rabbits. After trabeculectomy, octreotide 10 microg three times daily applied topically to the octreotide group for 14 days and amniotic membrane transplantation was performed by suturing amniotic membrane between scleral flap and sclera to the amniotic membrane group. The operated eyes of the rabbits were enucleated on the 14th day of the operation and histopathological specimens were obtained from the bleb sites and they were evaluated by light microscope. Fibroblast and macrophage number per cm2 were counted and the average values were calculated. Compared with the control group, the fibroblasts and macrophages significantly decreased in the other two groups (p < 0.0001, p < 0.0001, respectively). The mean number of fibroblasts was lower than those of the control and amniotic membrane groups (p < 0.0001, p < 0.0001, respectively). Similarly the mean macrophage number was significantly lower in the octreotide group versus the control and amniotic membrane groups (p < 0.0001, p < 0.01, respectively). Octreotide administration and amniotic membrane transplantation might be alternative treatments in modulating the wound healing after trabeculectomy.

Amnion↗

PubMed1986

The place of sodium hyaluronate in glaucoma surgery.

The advantages of sodium hyaluronate (Healon) in filtering surgery have been mostly theoretical, with no study of sufficient numbers to justify its use. The authors used sodium hyaluronate in 119 consecutive trabeculectomies. These were compared to a control group of 122 cases. The long-term intraocular pressure and visual acuity results between the two groups were indistinguishable. The only definite benefit noted with the use of sodium hyaluronate was the lower incidence of hyphemas. No side-effects were seen. Its ability to maintain a deep anterior chamber and encourage hemostasis makes sodium hyaluronate useful in teaching goniotomies as well as performing trabeculectomies in congenital glaucoma. Sodium hyaluronate can also be used to evacuate hyphemas and dissect adhesions with minimal trauma, and may be healthier for the corneal endothelium than air in anterior chamber reformations.

Aged↗

PubMed2002

[Anti-allergic drugs inhibit the proliferation of human Tenon's capsule fibroblast and maintain the experimental filtering blebs on rabbit eyes].

PURPOSE: To examine whether tranilast and ketotifen fumarate inhibit the growth of human Tenon's capsule fibroblasts and maintain experimental filtering blebs on rabbit eyes. METHODS: Human Tenon's capsule fibroblasts were grown in Dulbecco's modified Eagle's medium with 10% fetal calf serum and growth was measured with 3-[4,5-dimethylthiazole-2-yl]-2,5-diphenyltetrazolium bromide (MTT) and direct counting of cell number. Production of collagen and transforming growth factor-beta 1 (TGF-beta 1) was measured with corresponding enzyme-linked immunosorbent assay (ELISA). In experimental filtering surgery performed on rabbit eyes, the effects of the topical drugs on intraocular pressure and on maintenance of the filtering blebs were observed. RESULTS: Both tranilast and ketotifen inhibited the growth of the fibroblasts and half-inhibitory concentrations were 200 microM and 70 microM, respectively. Low concentration (10 microM) of tranilast and ketotifen decreased the synthesis of collagen but neither drug had any obvious effect on TGF-beta 1 production. Both drugs prolonged the life of the experimental filtering bleb significantly [12.5 +/- 3.2 (mean +/- standard deviation) days, 13.9 +/- 3.4 days, respectively; control, 10.5 +/- 2.4 days]. CONCLUSION: Tranilast and ketotifen inhibited the growth of human Tenon's capsule proliferation and are capable of maintaining experimental filtering blebs in rabbit eyes.

Animals↗