Effect of trabeculectomy on ocular blood flow

BACKGROUND/AIM

Current evidence suggests that vascular insufficiencies in the optic nerve head play an important part in the pathogenesis of glaucomatous optic neuropathy. Trabeculectomy is the most common operative procedure for the treatment of medically uncontrolled glaucoma. This study was conducted to investigate whether trabeculectomy may improve ocular haemodynamics.

METHODS

30 patients with primary open angle glaucoma about to undergo trabeculectomy were included in the study. Patients were evaluated before surgery and at 2 and 10 weeks after trabeculectomy. Optic nerve head blood flow (OnhBF) was assessed with scanning laser Doppler flowmetry. Fundus pulsation amplitude (FPA) measurements were obtained with laser interferometry.

RESULTS

Because of the decrease in intraocular pressure there was a significant increase in ocular perfusion pressure (OPP) following trabeculectomy (18.5% (SD 12.0%) and 19.0% (17.1%) at 2 and 10 weeks postoperatively; p <0.001). A significant increase in OnhBF was observed after trabeculectomy (11.6% (16.4%) and 16.2% (20.2%) for each postoperative visit, respectively; p <0.001). FPA was also significantly higher compared with baseline values (17.2% (17.3%) and 17.4% (16.3%), respectively; p <0.001). A significant association between the increase in OPP and the increase in OnhBF and FPA was observed 10 weeks after surgery (r = 0.47; p = 0.009, and r = 0.50; p = 0.005, respectively).

CONCLUSION

The results of this study suggest that trabeculectomy improves ocular blood flow in patients with chronic open angle glaucoma.

Intraoperative 2-dimensional optical coherence tomography as a new tool for anterior segment surgery

We tested a 1310-nm optical coherence tomograph coupled with a beam splitter on the front lens of an operating microscope for intraoperative, noncontact visualization of anterior segment procedures. This new modification of optical coherence tomography technology allows intraoperative, high-resolution, cross-sectional imaging and pachymetry of the cornea and sclera during anterior segment surgery. It is particularly helpful for lamellar dissection techniques such as deep anterior lamellar keratoplasty and trabeculectomy.

Combined cataract and glaucoma surgery: endoscope-controlled erbium:YAG-laser goniotomy versus trabeculectomy

BACKGROUND

To compare endoscopic infrared laser trabecular ablation and trabeculectomy (both combined with cataract surgery) regarding intraocular pressure (IOP), visual acuity, anti-glaucomatous drugs and complications.

METHODS

Seventeen eyes of 14 patients [age 74.7+/-11.7 years (arithmetic mean +/- standard deviation)]-13 with primary open-angle glaucoma (POAG) and four with pseudoexfoliation glaucoma (PEXG)-underwent standard cataract surgery. After lens implantation, a probe (1.1 mm external diameter) with optic and laser fibres and an irrigation tube was introduced through the cataract incision. To perforate Schlemm's canal, 15-17 single pulses (16 mJ, 160 micros) were applied using a photo-ablative infrared laser (Er:YAG, lambda=2.94 microm). All eyes except one received antiglaucoma treatment. The control group treated with cataract surgery and trabeculectomy consisted of 17 eyes (13 POAG, four PEXG) of 15 patients (age 75.0+/-5.6 years), each eye received antiglaucoma treatment.

RESULTS

Mean follow-up was 3 years. The eyes treated with the endoscopic laser showed a mean preoperative IOP of 23.3+/-4.3 mmHg, which was reduced to 15.0+/-2.1 mmHg (mean IOP lowering 33.7%) after 3 years. Five eyes needed no medication for IOP-control after the procedure. Two eyes needed further surgery for IOP-control. In the control group, mean IOP was 24.5+/-2.6 mmHg in the beginning and 17.3+/-6.2 mmHg after 3 years, corresponding to a 33.3% lowering of IOP. Six eyes needed no medication, four eyes needed further surgery to lower IOP.

CONCLUSIONS

After 3 years follow-up of a small pilot group, combined endoscopic infrared laser surgery with cataract surgery seems to be a safe and effective way to lower IOP. It shows the same ability to lower IOP as combined cataract surgery with trabeculectomy. In addition, there are markedly less complications with the endoscope-controlled photo-ablative laser procedure.

[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.

[The long-term effect of phacoemulsification combined with trabeculectomy and intraoperative 5-fluorouracil in glaucoma patients]

OBJECTIVE

This study was designed to evaluate the long-term effect of phacoemulsification, lens implantation combined with trabeculectomy augmented with 5-Fluorouracil (phaco-trab-5-Fu) in Asian glaucoma patients with primary open-angle glaucoma (POAG) and primary angle-closure glaucoma (PACG).

METHODS

This retrospective study included 71 consecutive patients who underwent phaco-trab-5-Fu in Singapore National Eye Center between January 1996 and December 1998. Patients with follow-up time less than 6 months were excluded from the study.

RESULTS

The mean follow-up time was (53.1 +/- 20.9) months. Postoperative IOP was significantly lower than preoperation [(15.0 +/- 4.0) mmHg (1 mmHg = 0.133 kPa), (20.3 +/- 5.4) mmHg, respectively, P < 0.01]. Postoperative number of antiglaucoma medications was also significantly decreased than preoperation (P < 0.01). IOP of 1 to 5 years postoperation dropped significantly from that of preoperation (P < 0.01). Complete success (CS) rate of phaco-trab-5-Fu was 84.2%, 62.7%, 55.3% for 1, 3, 5 years, respectively. There were neither significant difference found in PACG group and POAG group, or in single-incision and separate-incision of CS rate. But mean IOP of last follow-up was significantly different between PACG and POAG [mean IOP (13.8 +/- 4.6) mmHg, (16.2 +/- 3.7) mmHg, respectively, P = 0.02]. According to LogMAR chart, mean preoperative visual acuity (VA) and postoperative VA were 0.75 +/- 0.40 and 0.46 +/- 0.46, respectively. Postoperative VA was significantly improved (P < 0.01). In visual field, MD were (-16.6 +/- 8.8) dB and (-17.6 +/- 10.1) dB at preoperation and postoperation, respectively. PSD were (6.2 +/- 2.9) dB and (6.5 +/- 3.2) dB correspondingly. There were no significant difference in both MD and PSD (P = 0.55, 0.64, respectively). One patient had early endophthalmitis and required vitrectomy. Two late-onset of hypotony were due to choroidal effusion and wound leak.

CONCLUSIONS

Phacoemulsification combined with trabeculectomy and 5-Fu could be a successful and safe treatment for patients with cataract and primary glaucoma in a long run. There is no difference in success rate in PACG and POAG, or in single incision or separate incision in such combined surgery.

Comparison of PMMA, foldable silicone and foldable acrylic hydrophobic intraocular lenses in combined phacoemulsification and trabeculectomy

PURPOSE

To compare the postoperative results of phacotrabeculectomy with implantation of PMMA, foldable silicone or foldable hydrofobic acrylic intraocular lens (IOL).

SETTING

Glaucoma unit, The Royal Liverpool University Hospital, Liverpool, United Kingdom.

METHODS

We studied a total of 124 eyes of three consecutive groups of patients with glaucoma and cataract that underwent phacotrabeculectomy with implantation of a PMMA (30 eyes), a foldable silicone (57 eyes) or a foldable acrylic (37 eyes) IOL. Postoperative Snellen visual acuity and intraocular pressure (IOP), and early and late complications were assessed. All data were analyzed by means of chi2 test, Fisher's exact test, ANOVA/MANOVA tests or a combination whenever appropriate.

RESULTS

In all three groups the early and late mean postoperative IOPs were significantly lower than the preoperative ones (p<0.001), with no intergroup differences (p=0.48). The number of eyes with early postoperative hypertension (IOP>25 mmHg) and hypotony (IOP<7 mmHg) was similar in the three groups (p=0.91 and p=0.92 respectively). All groups showed improvement in mean visual acuity (p<0.001), and the differences among the groups were not significant (p=0.79). By 9-12 months after surgery IOPs lower than 22 mmHg without glaucoma medication were found in 76.9% in the PMMA group, 76.6% in the silicone group and in 76.9% in the acrylic group. At the same interval, best visual acuity of 6/12 or better was attained in 80.8%, 83% and 80.8%, in the PMMA, silicone and acrylic groups respectively. The silicone group had significantly more postoperative fibrin reaction into the anterior chamber (p=0.01) and giant cell deposits on the IOL (p<0.0001) than the PMMA and the acrylic groups. The rate of Yag laser posterior capsulotomy was lower with the acrylic IOL (0%) than with the silicone (12.2%) or PMMA (13.3%) IOLs (p=0.08).

CONCLUSION

In patients with glaucoma and cataract, phacotrabeculectomy with PMMA, silicone or acrylic IOL was equally effective in lowering the IOP and improving visual acuity. However, incidence of fibrin reaction and lens deposits was higher in those eyes which received a silicone IOL. The PMMA and the acrylic groups did not differ with respect to postoperative complications, but those eyes with an acrylic IOL had a lower rate of posterior capsule opacification.

Pig eye trabeculectomy—a wet-lab teaching model

PURPOSE

A teaching model for trabeculectomy is described using pig eyes prepared in formalin.

METHOD

The model enables trainee surgeons to practice various aspects of tissue handling required for successful trabeculectomy including the construction of a fornix-based conjunctival flap, scleral flap with buried releasable sutures, and water-tight conjunctival closure.

RESULTS

Exposure to the necessary skills required to perform trabeculectomy surgery can be improved by the use of wet laboratory practice.

CONCLUSIONS

Trabeculectomy surgery experience is becoming more limited as fewer procedures are being performed due to the efficacy of recent medications. Wet laboratories will become an increasingly important aspect of a comprehensive ophthalmology training programme.

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.

Short term experience with "modern" trabeculectomy augmented with intraoperative antimetabolites

PURPOSE

Owing to its technical refinements, "modern" trabeculectomy aims to reduce the incidence and severity of early postoperative complications while increasing postop IOP success. The purpose of our study was to evaluate namely the safety of "modern" trabeculectomy, the quality of the filtration blebs, the influence on the quality of life and secondarily IOP reduction according to the surgical procedure whether augmented with peroperative application of antimetabolites or not.

MATERIAL-METHODS

Retrospective study including our 45 first consecutive procedures in 38 patients (mean age: 61.1 years) with medically uncontrolled various glaucomas. All procedures were performed according to a modified P. Khaw's protocol. Antimetabolites were applied peroperatively in 28/45 eyes (62.2%) with a history of previous filtering surgery (12/28 eyes) and/or advanced glaucomatous damage (22/28 eyes). Antimetabolites were not used in the 17/45 other eyes with lower surgical risk factors and higher target IOP, surgical procedure was not augmented with antimetabolites. Postoperative management included laser suture lysis, withdrawal of adjustable sutures and 5-FU injections when needed. Complete ocular examination was carried out preoperatively and postoperatively at day 1, 7, at 1, 2 and 3 months and every 3 months thereafter. All patients were questioned for symptoms associated with filtration bleb dysesthesia at the last visit.

RESULTS

The mean follow-up was 7.9 +/- 3.3 in the group without antimetbolites and 5.3 +/- 2.2 months in the group with antimetabolites (p < 0.05). Final mean IOP (+/-SD) was significantly lower in the group augmented with antimetabolites (11.2 +/- 4.5 mmHg) compared with the group without antimetabolites (14.9 +/- 3.7 mm Hg) (p < 0.05). Complete and qualified success were respectively 64.3% and 89.3% in the group with antimetabolites and 70.6% and 82.4% in the subgroup without antimetabolites (p > 0.05). 1st month postoperative complications were transient and minor. They occurred in 59% in the group without antimetabolites and in 68% in the subgroup augmented with antimetabolites. Complications had comparable frequency of distribution between the 2 subgroups (p > 0.05). 84% of the filtration blebs (30/45) were diffuse and mildly vascularized. Avascular blebs were noticed in 7 eyes (15.5%) and were not related with the intraoperative application of mitomycin C (p > 0.05). Subjective comfort was good to excellent in 42/45 eyes (93.3%). Mean final visual acuity was not altered compared with preop level (p > 0.05).

CONCLUSIONS

Our short term results suggest that the safety of "modern" trabeculectomy augmented with antimetabolites is comparable to those without intraoperative antimetabolites. Filtration blebs were very well tolerated in most patients. The peroperative use of antimetabolites precludes to appreciate if the success rates are due to the use of antimetabolites and/or the technique per se.

Needling-revision of failed filtering blebs

PURPOSE

To investigate the efficacy and safety of needling-revision of failed blebs after trabeculectomy.

METHODS

A retrospective chart review of 28 eyes of 28 patients who underwent a trabeculectomy with subsequent needling-revision between January 2002 and December 2003. The mean follow-up was 15 months after the first needling-revision. All interventions were conducted by the same surgeon. Absolute success was defined as an IOP <18 mmHg without medication or as an IOP reduction > 20% without medication if the preoperative IOP was < or = 21 mmHg. Relative success was defined as meeting these criteria with or without medication.

RESULTS

The mean interval between trabeculectomy and the first needling-revision was 5 months. Repeated needling-revision (up to 3 times) was performed as clinically necessary. In 90% of the needling-revisions 5-FU was used to prevent postoperative fibrosis. The mean +/- SD IOP before needling-revision and at the last follow-up was respectively 24.7 +/- 6 and 15.7 +/- 3 mmHg (p<0.001) Needling-revision was an absolute success in 39% (11/28) and a relative success in 68% (19/28). Minor complications attributed to needling-revision occurred in 32% including self reabsorbing subconjunctival bleeding (1), filamental (1) and punctate keratitis (1), transient choroidal effusion (3), wound leak (4) and hyphaema (2). Progression of cataract occurred in 1 patient. A serious complication occurred in 1 case (hypotony with persistent macular oedema).

CONCLUSIONS

Bleb needling-revision can prevent more invasive intervention in a significant number of patients with failed trabeculectomy blebs. Complications are similar to those seen after trabeculectomy.

[Current trends in glaucoma surgery]

The aim of this paper is presentation of new methods of laser and surgery treatment for glaucomatous patients, mainly no perforating operations: deep sclerectomy and viscocanalostomy and new modifications of known very well trabeculectomy.

[Effectiveness of the combined surgical treatment for glaucoma and cataract]

PURPOSE

There are currently some techniques of combined cataract and glaucoma treatment. They have been under debate for many years. We present efficacy of different techniques of combined cataract and glaucoma surgery

MATERIAL AND METHODS

50 patients (60 eyes, 21 male and 29 female), mean age 64.9+/-5.6 years enrolled in the study were divided into 3 groups in which the combined surgery were performed. Group 1: phacotrabeculectomy (20 patients, 27 eyes) (FT), group 2: phacoemulsification combined with deep nonperforative sclerectomy (20 patients, 23 eyes) (FS) and group 3: phacoemulsification combined with iridocleisis (10 patients, 10 eyes) (FW). Measure outcomes during 6 months of follow up were: value of postoperative intraocular pressure, visual acuity, pre and postoperative antiglaucoma medications ratio, intra and postoperative complications.

RESULTS

There were not differences in preoperative intraocular pressure (IOP) among group 1 and 2 Significantly higher IOP was assessed in group 3. Preoperative antiglaucoma medications ratio was the highest in group 3 (3.5 +/- 1.5) as compared with group 1 and 2, (2.0 +/- 1.5). Postoperatively mean value of IOP was significantly lower as compared with the value in preoperative period in each group. After 3 months of follow up the IOP lower than 20 mmHg was achieved in 81.5% eyes in group 1, 73.9% eyes in group 2 and in 40 % of eyes in group 3. Six months postoperatively the target IOP was decreased to 62.9% in group 1 and 65.2% in group 2 and slightly increased to 50% in group 3. Postoperative antiglaucoma medications ratio was higher in group 3 (2.0 +/- 1.0), as compared with group 1 and 2, (1.5 +/- 1.0). The best visual acuity after 6 month of follow up was achieved in group 2, (0.8 +/- 0.2). More severe intraoperative complications such as: anterior chamber bleeding as well as postoperative complications eg.: hypotension, inflammation were noticed particularly in group 1 and 3 and choroidal effusion only in group 1.

CONCLUSIONS

Efficacy in lowering of IOP after FT and FS is the highest within first 3 months postoperatively. In the late postoperative period the efficacy of these methods is significantly decreasing and additional conservative treatment has to be introduced. Interestingly, the efficacy of IOP normalization after FW in the late postoperative period increases. Most of intra and postoperative complications are link up on FT and FW techniques. Our results suggest that further investigations and preparing more adequate indications for surgical strategy among patients with combined cataract and glaucoma are needed.

[Simultaneous cataract and glaucoma surgery. Selection of trabeculectomy site]

PURPOSE

Analysis of the results of simultaneous surgery using phacotrabeculectomy technique and standard phacoemulsification and trabeculectomy from two separate incisions.

MATERIAL AND METHODS

Analyzed group included 41 patients /44 eyes/, aged 68 +/-18 years with combined glaucoma and cataract. In 28 operated eyeballs phacotrabeculectomy from single incision was performed and in 19 operated eyeballs phacotrabeculectomy and phacoemulsification from two separate incisions was used.

RESULTS

In both analyzed groups authors obtained reduction in intraocular pressure and transparent optical system. In group of patients operated on from two separate incisions three times more often anterior chamber had become shallower with conjoined choroidal detachment and two times more often hypotension below 10 mmHg and breakdown of blood - aqueous fluid barrier were observed. Blood in anterior chamber was observed in 1/5 of operated patients with equal frequency in both analyzed groups. In addition in three months follow-up patients from two separate incisions presented more elevated intraocular pressure and more often required additional pharmacological therapy.

CONCLUSIONS

Simultaneous cataract and glaucoma surgery effectively reduces elevated intraocular pressure and improves transparency of optical system. Phacotrabeculectomy is safer and gives fewer complications than standard operation from two separate incisions.

Deep Sclerectomy Versus Punch Trabeculectomy with or without Phacoemulsification

PURPOSE

To compare the efficacy of non-penetrating deep sclerectomy without implant with Crozafon-De Laage punch trabeculectomy, and to evaluate the effect of simultaneous temporal approach phacoemulsification on both techniques.

PATIENTS AND METHODS

SETTING

Department of Ophthalmology of the University of Palermo.

DESIGN

Prospective randomized clinical trial. Patients and intervention procedures: Sixty-five patients (65 eyes) with primary open angle glaucoma (POAG) or pseudoexfoliative glaucoma (PEXG): 32 eyes underwent non-penetrating deep sclerectomy (NPDS), 17 as single procedure and 15 combined with phacoemulsification (phaco-NPDS), and 33 eyes underwent punch trabeculectomy (PT), 18 single and 15 with phaco (phaco-PT). The patients were randomly assigned to each procedure. No adjuvants, such as Nd: YAG laser goniopuncture, laser suturelysis, and antimetabolites were used.

MAIN OUTCOME MEASURES

Postoperative complications, number of antiglaucoma medications, and IOP level were checked at each control. Complete success indicated the achievement of the target IOP without antiglaucoma medications, while qualified success indicated the same goal with or without medications. These categories were assessed at two target IOP levels, namely < or =21 mm Hg and < or =17 mm Hg in all four groups.

RESULTS

The mean follow-up period was 22.5 +/- 2.5 months. The mean preoperative IOP was 30.2 mm Hg in NPDS eyes, 26.8 in phaco-NPDS eyes, 32.1 in PT eyes, and 27.0 in phaco-PT ones, without significant intergroup difference. At the end point the mean IOP was 17.7 +/- 0.8, 15.7 +/- 0.9, 14.2 +/- 1.1, and 13.8 +/- 1.1 mm Hg respectively with postoperative IOP significantly lower (P = 0.005) than preoperative IOP in all groups. No difference was observed among groups at any observation time when simple and combined surgery were compared. Significant difference at the end point was found between NPDS and PT (P = 0.030). As for complete and qualified success with a < or =21 and < or =17 mm Hg target IOP no significant differences were noticed in all groups. Among postoperative complications, hypotony was significantly more frequent in both PT groups when compared with the NPDS groups. The same was true, but relating only to the single procedures, for shallow anterior chamber and choroidal detachment. The Kaplan-Meier cumulative survival curves relating to the qualified success rate in the four surgical groups for a < or =21 mm Hg target IOP (log rank, P = 0.564) and for a < or =17 mm Hg target IOP (log rank, P = 0.591) showed no significant intergroup differences. When the < or =21 mm Hg target IOP was considered, a mild positive trend in combined procedures (both phaco-NPDS and phaco-PT) was found in comparison with simple procedures. At lower IOP target (ie, < or =17 mm Hg) a better trend was found in favor of simple or combined PT procedure.

CONCLUSIONS

Both techniques, NPDS and PT, without enhancements (ie, implants or antimetabolites) control IOP efficaciously at our end point. Phacoemulsification combined with penetrating and non-penetrating procedures does not seem to interfere with final results. When a lower target IOP and probability of success over time are considered, PT, single or combined, exhibits a better trend. PT, therefore, could be more suitable for higher IOP levels or longer life expectancies.

Goniosurgery for Glaucoma Secondary to Chronic Anterior Uveitis

PURPOSE

To describe the preoperative prognostic factors that correlate with the surgical success of goniosurgery for glaucoma complicating chronic anterior uveitis and to describe the surgical technique.

METHODS

The medical records of 31 patients with 31 eyes with glaucoma secondary to chronic anterior uveitis for which 38 goniotomy procedures were performed were reviewed. Uveitis etiology, gender, age of onset of iritis, duration of iritis before recognition of glaucoma, duration of iritis and duration of glaucoma until initial goniosurgery, preoperative gonioscopic findings, lens status, surgical outcome, age at initial goniosurgery, duration of postoperative observation, lens status, preoperative and postoperative intraocular pressures, topical steroid, and glaucoma medication use were reviewed. Complete success was defined by an intraocular pressure (IOP) < or = 21 mm Hg, and qualified success as IOP < or = 21 mm Hg with use of glaucoma medications. The surgical technique used to perform the goniosurgery was reviewed.

RESULTS

Overall surgical success was achieved in 22 (71%) of 31 eyes. The mean age at surgery was 10.2 +/- 4.2 years (range, 4-21 years). All but 8 patients were female. Mean follow-up interval was 10.3 +/- 6.4 years (range, 1.5-22 years). Significant correlation was found between outcome and age at initial surgery, lens status, duration of glaucoma before goniosurgery, duration of iritis before glaucoma surgery, and hours of peripheral anterior synechia (PAS). The mean number of clock hours of preoperative (PAS) was 0.5 hours in eyes with success versus 2.5 hours in eyes with failure. Age of onset of iritis, duration of iritis before recognition of glaucoma, trabecular meshwork pigmentation (TM), TM opacification, and circumferential ciliary body band narrowing did not correlate with surgical outcome.

CONCLUSION

Goniosurgery is an effective treatment of glaucoma secondary to chronic anterior uveitis. The outcome of surgery was unfavorably influenced by older age, longer duration of glaucoma, and evidence of more advanced preoperative filtration angle abnormalities secondary to uveitis. Goniosurgery for this secondary glaucoma can be successfully performed utilizing the standard goniotomy technique.

Combined cyclectomy-trabeculectomy procedure for refractory glaucoma

A new surgical technique for cases of refractory glaucoma is described. The technique has been performed on 42 severely glaucomatous eyes. The technique consists of a partial excision of the ciliary body combined with a trabeculectomy to maintain an effective filtration by several passages. All excised material was verified as ciliary body by an ophthalmic pathologist. The follow-up period was 2 to 5 years. Intraocular pressure decreased after the operation and remained less than 20 mm Hg in 39 eyes. The visual acuity increased in 8 of 42 eyes and remained the same in 32 eyes. Complications were similar to those seen after trabeculectomy. This method is efficient for severely glaucomatous eyes that are difficult to manage with trabeculectomy alone.

[An experimental-and-morphological substantiation of non-perforating profound sclerectomy with trabeculosuturization]

The causes of ineffectiveness of primary non-penetrating profound sclerectomy were analyzed on the basis of filtration-zone biopsy materials obtained in repeatedly made antiglaucomatous procedures. The authors believe that the above ineffectiveness is preconditioned by inconsistency of the drainage-zone internal wall resulting from its dystrophic changes due to tissue ischemia, cell apoptosis, collagen changes with fiber's degradation and fibers' colliquative necrosis. It was demonstrated experimentally that the monofilament suture, when applied to the filtration zone, enhances the hypotensive effect of the non-penetrating procedure due to the ability of filtration canals (shaping around sutures) to dose the outflow of lachrymal fluid through the anterior chamber into the subscleral and subconjunctival spaces as well as by activation of the uveoscleral outflow paths.

Surgically-induced astigmatism following single-site phacotrabeculectomy, phacotrabeculotomy and advanced non-penetrating phacotrabeculectomy

We study surgically-induced astigmatism following three kinds of glaucoma surgeries combined with cataract surgery with 6 months of follow-up. The mean surgically-induced astigmatism at 6 months postoperatively was 1.92 +/- 1.87 diopters in phacotrabeculectomy (n = 45), 0.72 +/- 0.40 diopters in advanced non-penetrating phacotrabeculectomy (n = 40) and 0.76 +/- 0.47 diopters in phacotrabeculotomy (n = 49), which appeared to be stabilized by 3 months. Each group revealed a tendency of "with the wound" induced astigmatism. Phacotrabeculectomy could induce greater surgically-induced astigmatism than advanced non-penetrating phacotrabeculectomy and phacotrabeculotomy.

Five-year follow up of selective laser trabeculoplasty in Chinese eyes

PURPOSE

To study the effectiveness and safety of selective laser trabeculoplasty (SLT) on primary open-angle glaucoma and ocular hypertension in Chinese eyes.

METHODS

This was a prospective randomized controlled clinical study in which 58 eyes of 29 patients with primary open-angle glaucoma or ocular hypertension were included. One eye of each patient was randomized to receive SLT (Group 1) and the fellow eyes received medical treatment (Group 2). Patients were evaluated after laser treatment at 2 h, 1 day, 1 week, 2 weeks, 1 month, 3 months, 6 months, and then yearly.

RESULTS

All patients (13 male, 16 female) were Chinese. The mean age was 51.9 +/- 14.7 years. The mean baseline intraocular pressure was 26.8 +/- 5.6 mmHg in group 1 and 26.2 +/- 4.2 mmHg in group 2 (P = 0.62). The failure rate, defined as intraocular pressure >21 mmHg with maximal medications, was 17.2% in group 1 and 27.6% in group 2 at 5-year follow-up (P = 0.53). Eight eyes (27.6%) in group 1 required medications to control the intraocular pressure to below 21 mmHg. There was no statistically significant difference in the intraocular pressure reductions between the two groups at all time intervals (P > 0.05). The mean number of antiglaucoma medications was significantly lower in the SLT than the medical treatment group up to 5 years of follow up (P < 0.001). Transient post-SLT intraocular pressure spike >5 mmHg was observed in three eyes (10.3%).

CONCLUSION

With fewer medications, SLT gives similar intraocular pressure reduction to medical therapy alone in Chinese patients with primary open-angle glaucoma or ocular hypertension.