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PubMed2001

[When should glaucoma be surgically treated?].

The medical treatment of primary open angle glaucoma has progressively become more and more efficient and safe, and surgery is therefore mostly restricted to failure of and intolerance to antiglaucoma eyedrops. Glaucoma surgery may thus cause severe complications and a high risk of failure has tempered its prognostic. Nevertheless, when efficacious, glaucoma surgery definitively resolves two major pitfalls of medical treatment: patient compliance and eyedrops tolerance. Moreover, new surgical developments of surgery have come from the new technique of non-penetrating deep sclerectomy, which is actually an external trabeculectomy involving removal of the area of maximal resistance to aqueous outflow. This procedure has a very low risk of complications, much lower than that of standard trabeculectomy, but its efficacy is still controversial. Whatever the technique chosen for filtering surgery, antimetabolites may be used in order to limit the risk of postoperative fibrosis, but they also expose to specific, sometimes sight-threatening, complications. Therefore, the most important--and also the most difficult--choice for treating glaucoma patients still remains the best timing for surgery, either excessive, useless, and aggressive medical treatment, or systematic primary surgery.

Glaucoma↗

PubMed1995

Early clinical experience with the Baerveldt implant in complicated glaucomas.

PURPOSE: To evaluate our early experience with the Baerveldt implant in patients with complicated glaucoma. METHODS: We reviewed the charts of all patients with more than six months of follow-up after placement of a Baerveldt implant at LSU Eye Center. Surgery was considered a success if intraocular pressure was 21 mm Hg or less (with or without antiglaucoma medications) at the last postoperative visit, except when further glaucoma surgery had been performed or when loss of light perception occurred. RESULTS: Fifty eyes (50 patients) were divided into six diagnostic groups, with mean follow-up times of 16.1 to 19.2 months. Success was achieved in 36 of 50 patients (72%): 26 of 35 (74%) patients with aphakia or pseudophakia, nine of 12 (75%) patients with previously failed filtering surgery, three of seven patients with neovascular glaucoma, all three patients under the age of 13 years, nine of 13 (69%) patients who underwent penetrating keratoplasty, and four of five phakic patients. Overall, visual acuity improved or remained within one line of the preoperative acuity in 32 (64%) patients. The most frequently observed short- and long-term complications were serous choroidal effusion associated with hypotony in 13 (26%) patients and corneal graft failure in six of 13 (46%) corneal transplant patients, respectively. CONCLUSION: Within the study follow-up time, the Baerveldt implant appeared to be safe and effective, with success rates for intraocular pressure control similar to those reported in a recent retrospective study of the Molteno implant.

Adult↗

PubMed1998

An ultrasound biomicroscopic study of eyes after deep sclerectomy with collagen implant.

OBJECTIVE: This study aimed to assess the natural history of eyes after deep sclerectomy with collagen implant (DSCI), a nonperforating glaucoma-filtering surgery. DESIGN: The design was a prospective, longitudinal, observational, and nonrandomized study. PARTICIPANTS: Forty-five eyes of 41 patients with medically uncontrolled open-angle glaucoma were studied. INTERVENTION: Deep sclerectomy with collagen implant was performed. MAIN OUTCOME MEASURES: Ultrasound biomicroscopy (UBM) of the sclerectomy site was performed 1, 2, 3, 6, 9, 12, and 18 months after surgery. The following parameters were assessed: length and height of the collagen implant, thickness of the residual trabeculodescemetic membrane, and bleb appearance. RESULTS: Mean intraocular pressure decreased from a preoperative value of 26.3 +/- 3.5 mmHg (mean +/- standard deviation) to a postoperative value of 16.6 +/- 3.1 mmHg (mean +/- standard deviation) at 18 months (P < 0.001). The UBM findings showed a subconjunctival filtration with a nonperforated thin trabeculodescemetic membrane. In 23 eyes (51%), a hypoechoic area in the suprachoroidal space was observed. The thickness of the trabeculodescemetic membrane was stable throughout the study with a mean value of 0.13 mm +/- 0.02 (mean +/- standard deviation) at 18 months. The collagen implant dissolved slowly within 6 to 9 months, leaving a tunnel in the sclera. CONCLUSIONS: The UBM findings are consistent with intraocular pressure lowering by aqueous filtration through the thin remaining trabeculodescemetic membrane to an area under the scleral flap, which was maintained open by the collagen implant. The authors speculate that aqueous humor then reached the subconjunctival space and, eventually, was filtered through the thin scleral wall into the suprachoroidal space. Complete resorption of the collagen implant occurred between 6 and 9 months after surgery.

Aged↗

PubMed2001

[Prognostic outcome of leaking filtering blebs reconstruction with rotational conjunctival flaps].

PURPOSE: Late bleb leaks may follow months to years after filtering surgery especially with the use of antimetabolites. Complications related to beb leaks may lead to a decrease in visual acuity through complicated hypotony or ocular infection. Our retrospective study reports the anatomical and functional results of bleb reconstruction involving the resection of the bleb associated with the covering of the trabeculectomy site with a rotational conjunctival flap. MATERIAL: and methods: Twelve eyes of eleven patients with filtering bleb leaks occurring 3 months to 5 years after successful trabeculectomy (58.3% with adjunct of antimetabolites) underwent bleb surgical reconstruction between november 1995 and June 1999 and were followed until March 2000. Surgical bleb reconstruction was indicated because of persistent or a recurring bleb leak despite conservative medical treatment and blood bleb injections in seven cases. Complications associated with bleb leaks were chronical hypotony (9 cases), athalamy (1 case), hypotony maculopathy (1 case), and endophtalmitis with athalamy (1 case). Three patients had normal IOP but a bleb leak responsible for epiphora. All eyes were treated surgically through bleb excision and conjunctival closure was performed by rotational conjunctival flap. RESULTS: Mean (+/- SD) preoperative IOP was 5.1+/-3.5mmHg (range: 2 to 14mmHg). Mean (+/- SD) postoperative IOP evaluated before any other operation for uncontrolled IOP was 12.7+/-3.1mmHg (range: 6 to 15mmHg). Mean follow-up was 26.7+/-16.9 months (range: 9 to 64 months). All the complications related to the bleb leak resolved after bleb reconstruction. Surgery definively stopped the leak in 10 cases (83.3%) and allowed IOP control without treatment in 50.0% of the cases. Chronic recurring bleb leaks without hypotony occurred in two eyes and required surgery with conjunctival graft which led to a refractory increase in IOP responsible for loss of vision in one case. CONCLUSION: Bleb resection associated with the covering of the trabeculectomy site with a rotational conjunctival flap is a safe and effective procedure for the treatment of a late bleb leak and its complications. In most of the cases (83.3%), long-term IOP control can be expected without, medical treatment in 50% of the cases. Patients must be aware of the possibility of a recurring Seidel; however, the incidence of this complication remains low.

Adult↗

PubMed1992

Promotion of glaucoma filter bleb with tissue plasminogen activator after sclerectomy under a clot.

Since 1987 we have performed, with good results, glaucoma filtering surgery in which the limbo-scleral fistula was closed by an autogenic full blood clot (sclerectomy under a clot). In 8 patients with advanced stages of glaucoma simplex, 1-3 days after sclerectomy under a clot with rise IOP, 25 micrograms of tissue plasminogen activator (tPA) was injected subconjunctivally. Two weeks after surgery normalization of IOP below 15 mmHg and normal outflow facility in all tPA treated eyes were obtained. No increase in early post-operative complications, such as hemorrhage or corneal haze, was attributable to tPA use. In early period after sclerectomy under a clot, when blockage of outflow appears, the use of tPA can cause the re-creation of filtering tract.

Blood Coagulation↗

PubMed1991

Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery.

The authors reviewed the incidence of hospital-linked postoperative endophthalmitis at the Bascom Palmer Eye Institute between January 1, 1984 and June 30, 1989. After 30,002 intraocular surgical procedures, the following incidence of culture-proven endophthalmitis was observed: (1) extracapsular cataract extraction (ECCE) with or without intraocular lens (IOL) implantation--0.072% (17 of 23,625 cases); (2) pars plana vitrectomy--0.051% (1 of 1974 cases); (3) penetrating keratoplasty (PKP)--0.11% (2 of 1783 cases); (4) secondary IOL--0.30% (3 of 988 cases); and (5) glaucoma filtering surgery--0.061% (1 of 1632 cases). A statistically significant (P = 0.038, Fisher's exact test, two-tailed) increased incidence of endophthalmitis occurred in diabetic (0.163%, 6 of 3686 cases) compared with nondiabetic (0.055%, 11 of 19,939 cases) patients undergoing ECCE with or without IOL implantation. The authors also reviewed the incidence of postoperative endophthalmitis after intracapsular cataract extraction (ICCE) with and without IOL and observed an incidence of 0.093% (7 of 7552) in cases operated on between September 1, 1976 and December 31, 1982.

Aged↗

PubMed1995

Laser therapy for open-angle glaucoma.

Management of open-angle glaucoma is complex and consists of medications, laser therapy, and conventional surgery. Laser therapy is a vital component of management, with the most common procedure being a trabeculoplasty, which reduces intraocular pressure by increasing aqueous outflow. This review discusses the indications, contraindications, and specific techniques for laser trabeculoplasty. The use of holmium sclerostomy is also discussed. With recent advances in laser and fiberoptic technology, sclerostomy is proving to be a simpler procedure than conventional filtering surgery, while providing comparable effectiveness.

Glaucoma, Open-Angle↗

PubMed1999

A randomized phase II trial of interferon-alpha2b versus 5-fluorouracil after trabeculectomy.

PURPOSE: The aim of the present study was to investigate the safety and potential efficacy of subconjunctival interferon-alpha2b (IFN-alpha), either alone or in combination with 5-fluorouracil (5-FU), in reducing the risk of failure of glaucoma surgery METHODS: A prospective, masked randomized phase II study was undertaken in which patients received three subconjunctival injections per week for 3-4 weeks postoperatively. Three treatments were compared: (i) IFN-alpha (1 x 10(6)IU per dose); (ii) 5-FU (5 mg per dose); and (iii) alternating IFN-alpha and 5-FU (BOTH). The primary outcome measures were: (i) rate of successful control of intra-ocular pressure without further surgery; and (ii) the incidence of side effects. RESULTS: Fifty-seven patients undergoing glaucoma surgery with an increased risk of failure were evaluated, including 23 patients (40%) undergoing trabeculectomy combined with extracapsular cataract extraction as well as other conventional high-risk groups. With 53 patients (93%) completing 2 years follow up,there was no significant difference in success rates among the three groups. Intra-ocular pressure was controlled without further surgery in 79% of patients (95% confidence interval (CI): 61, 97%) receiving IFN-alpha, in 89% of patients (76, 100%) receiving 5-FU and in 89% of patients (76, 100% receiving BOTH. Side effects were similar among the three groups. CONCLUSIONS: These results are consistent with a beneficial effect of IFN-alpha2b given either alone or in combination with 5-FU after glaucoma filtering surgery. However, the lack of a clear and substantial benefit over conventional anti-fibrotic therapy does not support the further clinical evaluation of these treatments.

Adult↗

PubMed1996

Comparative study of the efficacy of argon laser trabeculoplasty for exfoliation and primary open-angle glaucoma.

PURPOSE: To investigate the efficacy of argon laser trabeculoplasty (ALT) for the treatment of primary open-angle glaucoma (POAG) and of glaucoma associated with exfoliation syndrome (EXF). METHODS: Review of > 200 charts from patients treated with ALT between 1981 and 1987 identified 66 POAG and 29 EXF eyes that underwent initial 180 degrees treatment. Variables including baseline intraocular pressure (IOP), age, sex, angle pigmentation, and follow-up IOP were studied with numerous statistical analyses. Multiple failure modes were used to define failure rate. All POAG and EXF patients were white. RESULTS: The baseline pre-ALT IOP was 23.2 +/- 6.1 mm Hg for the POAG group and 25.8 +/- 5.9 mm Hg for the EXF group (p < .06). Mean follow-up time was 27 +/- 22 months for POAG eyes and 23 +/- 20 months for EXF eyes. Using failure mode 4 (glaucoma surgery, third laser, IOP < or = 22 mm Hg, or two consecutive IOPs > 85% of original baseline IOP), the 1-year failure rates were 40% (POAG) and 18% (EXF), and the 3-year rates were 58% (POAG) and 47% (EXF), p < 0.89 by log-rank test. A Cox proportional hazards model controlling for baseline IOP, age, sex, and angle pigmentation demonstrated that exfoliation status did not affect progression to filtering surgery (p > 0.60). CONCLUSION: Using multiple failure modes, the results suggest that the success rate of ALT in exfoliation glaucoma tends to decrease over time, but then stabilizes at this reduced value at a level similar to that of POAG. By 3 years, there is a substantial failure rate in both POAG eyes and EXF eyes. Although the initial response to ALT in EXF patients is greater, the long-term outcome is similar for both groups.

Exfoliation Syndrome↗

PubMed1999

Endocapsular hematoma: report of a case following glaucoma surgery in a pseudophakic eye.

The authors describe a case of an endocapsular hematoma that occurred in a 69-year-old pseudophakic diabetic male following mitomycin C (MMC) augmented trabeculectomy for neovascular glaucoma (NVG). The clinical course of the patient is described, and the unique features of this case are presented and discussed. The endocapsular hematoma absorbed in 6 weeks with conservative management. The patient regained the preoperative visual acuity of 20/30, and his intraocular pressure was controlled without any glaucoma medication. The iris neovascularization regressed. This case is the first report of an endocapsular hematoma following glaucoma filtering surgery in a pseudophakic eye with neovascular glaucoma.

Aged↗

PubMed2004

Surgical strategies in patients with combined cataract and glaucoma.

PURPOSE OF REVIEW: In the elderly population, the combined presence of cataract and glaucoma is a frequent condition. In this situation, several surgical options are possible: cataract surgery only and later maybe trabeculectomy, trabeculectomy only and later maybe cataract surgery, or combined cataract and glaucoma surgery. This review compares the different surgical options on the basis of their achievable postoperative intraocular pressure (IOP) level and success and complication rates. RECENT FINDINGS: The impression of better IOP regulation with trabeculectomy than with phacotrabeculectomy has been recently confirmed by an evidence-based review. Contrary to this finding, the success of deep sclerectomy or trabeculotomy does not seem to be compromised by simultaneous phacoemulsification. In eyes with previous glaucoma-filtering surgery, cataract surgery with clear corneal incision has no effect on mean IOP but increases the 3-year failure probability. For phacotrabeculectomy, moderate evidence of a beneficial effect of MMC on IOP regulation and only weak evidence for separating the incisions has been recently reported by another evidence-based review. SUMMARY: The choice of the preferred surgical method depends on the target pressure, the amount of glaucomatous damage, and the grade of visual disturbance caused by the cataract. Phacotrabeculectomy combined with mitomycin C achieves the best IOP lowering of all types of combined cataract and glaucoma surgery currently possible but is associated with potentially sight-threatening complications. In the absence of a low target pressure, phacotrabeculotomy or the combination of phacoemulsification with viscocanalostomy or deep sclerectomy may be the therapy of choice.

Cataract↗

PubMed2002

Tenon's traction sutures: an aid for trabeculectomy and aqueous drainage device implantation.

PURPOSE: To describe a surgical technique to improve visualization and surgical access for trabeculectomy and implantation of aqueous drainage devices. MATERIALS AND METHODS: After the corneal traction suture (6-0 polygalactin; S-29 needle) is placed, a second suture is passed through Tenon's capsule alone, either at the anterior edge of a limbus-based conjunctival flap for trabeculectomy or at the incisional edge of a fornix-based conjunctival flap for drainage implant surgery. RESULTS: The incision for limbus-based peritomies must be posterior enough to take advantage of the posterior thickening of Tenon's capsule when placing the traction suture. The use of traction sutures enhances visualization and limbal surgical access for trabeculectomy. They also enhance posterior ocular surface visualization and aid placement of scleral fixation sutures for securing the explants of aqueous drainage devices. CONCLUSIONS: Tenon's traction sutures are an aid to visualization and to surgical access during glaucoma filtering surgery.

Connective Tissue↗

PubMed1992

Trabeculectomy with 5-fluorouracil subsequent to circular buckling operation and cataract extraction.

Six patients, each with one eye that had previously undergone circular buckling surgery for the repair of retinal detachment before or followed by cataract extraction with or without intraocular lens implantation, underwent trabeculectomy with 5-fluorouracil (5-FU) for intractable glaucoma. Surgery was done through scarred subconjunctival tissues that were excised partially. The total doses of 5-FU ranged from 65 to 100mg (mean +/- standard deviation, 84.2 +/- 13.2mg) Eight to 47 months later, intraocular pressures were 18mmHg in five eyes, two of which were not receiving hypotensive medications. In the sixth eye, the intraocular pressure was 26mmHg with maximum hypotensive treatment. Intraocular pressures in the six eyes were significantly lower postoperatively than preoperatively (P < .05). This preliminary study suggests that filtering surgery with 5-FU may be beneficial after intraocular operations even in eyes where it is done through postoperative scarred subconjunctival tissues.

Adult↗

PubMed2005

Trabeculectomy and optic nerve head topography.

The objective of the present study was to evaluate changes in optic nerve head parameters, measured by confocal laser tomography, before and after trabeculectomy in order to identify outcome measures for the management of glaucoma. The optic nerve head of 22 eyes (22 patients) was analyzed by confocal laser tomography with the Heidelberg retinal tomogram (HRT) before and after trabeculectomy. The median time between the first HRT and surgery was 4.6 months (mean: 7.7 +/- 8.3) and the median time between surgery and the second HRT was 10.8 months (mean: 12.0 +/- 6.8). The patients were divided into two groups, i.e., those with the highest (group A) and lowest (group B) intraocular pressure (IOP) change after surgery. Differences in the 12 standard topographic parameters before and after surgery for each group were evaluated by the Wilcoxon signed rank test and the differences in these parameters between the two groups were compared by the Mann-Whitney rank sum test. Multiple regression analysis was used to evaluate the influence of the change in IOP (DeltaIOP and DeltaIOP%) and the changes in the other parameters. There were significant differences in the HRT measures before and after surgery in group A only for cup volume. In group B, no parameter was statistically different. The changes in group A were not significantly different than those in group B for any parameter (P > 0.004, Bonferroni correction for multiple comparisons). DeltaIOP and DeltaIOP% had a statistically significant effect on Delta cup disk area, Delta cup volume and Delta mean cup depth. Changes in cup shape size were influenced significantly only by DeltaIOP. Some optic disc parameters measured by HRT presented a significant improvement after filtering surgery, depending on the amount of IOP reduction. Long-term studies are needed to determine the usefulness of these findings as outcome measures in the management of glaucoma.

Adult↗

PubMed1997

Prospective study of ab externo erbium:YAG laser sclerostomy in humans.

PURPOSE: To evaluate the efficacy of ab externo erbium:YAG (Er:YAG) laser sclerostomy in controlling intraocular pressure in eyes with uncontrolled glaucoma. METHODS: We performed ab externo laser sclerostomy on eyes of 26 patients. Mean +/- SD postoperative follow-up was 11.4 +/- 0.9 months. Complete success was defined as intraocular pressure below 22 mm Hg with no adjunct medication; qualified success was defined as intraocular pressure below 22 mm Hg with medication. RESULTS: In all eyes, ab externo Er:YAG laser sclerostomy achieved a functioning fistula with a prominent filtering bleb. Twelve eyes had had neodymium:YAG (Nd:YAG) laser iridotomy at the site of laser sclerostomy 2 weeks before filtering surgery; 14 eyes had surgical iridectomy at the site of laser sclerostomy. Mean preoperative intraocular pressure of 30.7 +/- 7.3 mm Hg (range, 17.0 to 48.0 mm Hg) was significantly (P < .05) reduced to 18.3 +/- 1.0 mm Hg (range, 0 to 25.0 mm Hg) at 2 weeks postoperatively. thereafter, marked regression was noted: at 1 month postoperatively, intraocular pressure was 20.1 +/- 9.5 mm Hg (range, 4.0 to 44.0 mm Hg); half-life of complete success was 25 days; of qualified success, 56 days; and of a functioning filtering bleb, 36 days. CONCLUSIONS: Ab externo Er:YAG laser sclerostomy reliably created successful full-thickness fistulae with prominent filtering blebs in human glaucomatous eyes. However, a transient phase of ocular hypotony caused by aqueous overfiltration, followed by an ongoing rate of fistula patency failure, renders Er:YAG laser sclerostomy, as performed in this study, unsuitable for long-term pressure control.

Adult↗

PubMed2000

Amniotic membrane transplantation or conjunctival limbal autograft for limbal stem cell deficiency induced by 5-fluorouracil in glaucoma surgeries.

PURPOSE: To determine if human amniotic membrane transplantation or limbal stem cell transplantation is effective to restore the corneal surface with partial or total limbal stem cell deficiency, respectively, caused by 5-fluorouracil (5-FU) toxicity after glaucoma surgeries. METHODS: Partial and total limbal stem cell deficiency was confirmed by impression cytology as the cause of reduced vision and corneal surface breakdown in a 69-year-old man and a 67-year-old man, respectively, who both had received a total of 105 mg 5-FU injections. Amniotic membrane transplantation or conjunctival limbal autograft was performed for corneal surface reconstruction, respectively. RESULTS: For a period of 15 months of follow-up, the visual acuity improved, and their corneal surfaces remained avascular, smooth, and without recurrence of limbal stem cell deficiency. CONCLUSION: Limbal stem cell deficiency can occur as a late complication for patients receiving 5-FU after glaucoma filtering surgeries. Partial limbal stem cell deficiency can be treated with amniotic membrane transplantation alone, whereas limbal transplantation must be considered as an alternative for total limbal stem cell deficiency to restore the corneal surface integrity and vision.

Aged↗

PubMed1993

Indications and technique for reopening closed filtering blebs using the Nd:YAG laser--a review and case series.

We reviewed the results of Nd:YAG laser treatment used with gonioscopy to reopen the internal sclerostomy in 10 consecutive patients with failing filtering blebs in whom the sclerostomy had become occluded internally with a membrane or iris after filtering surgery. Sixteen to 50 applications of 6- to 6.9-millijoules Nd:YAG laser irradiation were directed to the internal sclerostomy site. In 6 of the 10 patients, filtration was successfully reestablished, initially reducing the mean intraocular pressure (IOP) from 26.5 mm Hg (range, 20 to 40 mm Hg) to 8.6 mm Hg (range, 5 to 16 mm Hg), with an average IOP of 13.5 mm Hg at 7 months after the laser treatment. Nine of the patients were on significantly fewer glaucoma medications. We conclude that the YAG laser can be successfully used to reopen the fistula by the internal approach in carefully-selected patients who previously have had well-established filtering blebs. Identification of these suitable candidates involves careful gonioscopy.

Adult↗

PubMed1996

The effects of subconjunctival verapamil on filtering blebs in rabbits.

BACKGROUND AND OBJECTIVE: Verapamil is a calcium antagonist that has been shown to modulate wound healing through multiple mechanisms. The wound modulating effects of verapamil were studied in a rabbit model of filtering surgery. MATERIALS AND METHODS: Twenty New Zealand albino rabbits underwent a fistulizing procedure, with either verapamil or saline injected subconjunctivally daily for 6 days following surgery. The animals were sacrificed at 20 days after the fistulizing procedure. The effectiveness of verapamil in modulating wound healing was evaluated by bleb patency testing, histology, measurement of scar thickness, and counts of bromodeoxyuridine (BrdU)-labeled cells at the sclerostomy site. RESULTS: The group treated with verapamil had a 44 percent patency rate compared with 10 percent in the control group (P < .05), a mean scar thickness of 195.96 +/- 68 mu m compared with 313.55 +/- 110.4 mu m in the control group (P < .02), and a mean BrdU-labeled cell count of 15.5 +/- 14.7 compared with 26.3 +/- 17.0 in the control group (P < .002). CONCLUSION: Verapamil was effective in reducing scar formation at the sclerostomy site. At the doses administered, verapamil appeared to modulate wound healing in filtering blebs in the rabbit model. Further studies are needed to determine the dose-response and the efficacy of the drug in nonhuman primates.

Animals↗