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.

Trabéculo-sclérectomie non perforante avec mitomycine C, sans implant

PURPOSE

Since 1998 we have been conducting a prospective study of nonpenetrating deep trabeculectomy with chronic open-angle glaucoma to evaluate the efficiency of the technique.

MATERIAL AND METHODS

The study was carried out in 55 eyes of 41 patients who suffered from open-angle glaucoma. After performing a superior scleral flap, mitomycin diluted to 0.01% was applied for 3 minutes, then the 4 x 4-mm superficial scleral flap was dissected at two-thirds deepness until reaching the cornea. The Schlemm canal and the external trabecula were surgically removed and the two points of the Schlemm canal were catheterized with a trabeculotome to ensure that the ablation was well done. If it was not, it was completed by using a trabeculotome as a guide. Postoperatively, if the filtering bleb tended to decrease or ocular pressure began to increase, the operated trabecular region was reopened with Yag laser. The filtering bleb characteristics were correlated with the normalization of intraocular pressure in the first 30 cases.

RESULTS

Preoperative pressure without treatment was 32 mmHg. Postoperative intraocular pressure without treatment was 20 mmHg or less in 79% of the eyes after 4 months, 77.5% after 6 months, 75% after 8 months and 61% after 12 months. By adding a local hypotension treatment in monotherapy, a pressure of 20 mmHg or less was obtained in 79% of the cases after 12 months. No severe complications were observed. The presence of a filtering bleb is an important factor in the normalization of postoperative pressure (p=0.0048).

CONCLUSIONS

This surgical technique provides a substantial decrease in intraocular pressure and very few complications after 12 months of follow-up.

Comparison of long-term outcomes of selective laser trabeculoplasty versus argon laser trabeculoplasty in open-angle glaucoma

PURPOSE

To compare the long-term success rate of selective laser trabeculoplasty (SLT) versus argon laser trabeculoplasty (ALT).

DESIGN

Retrospective chart review.

PARTICIPANTS

One hundred ninety-five eyes of 195 patients with uncontrolled open-angle glaucoma (OAG), of which 154 eyes underwent ALT and 41 eyes underwent SLT and were followed up for a maximum of 5 years.

INTERVENTION

The SLT patients were treated with the frequency-doubled q-switched neodymium:yytrium-aluminum-garnet laser (532 nm). Approximately 50 to 55 nonoverlapping spots were placed over 180 degrees of the trabecular meshwork at energy levels ranging from 0.6 to 1.0 mJ per pulse. The ALT patients were treated with the argon blue-green laser with between 45 to 55 adjacent, nonoverlapping spots over 180 degrees of the trabecular meshwork at 470 to 1150 mW of energy per pulse.

MAIN OUTCOME MEASURES

The success rates were defined by criterion I and criterion II. Success by criterion I was defined as a decrease in intraocular pressure (IOP) of 3 mmHg or more with no additional medications, laser, or glaucoma surgery. Criterion II had the same requirements as criterion I, except that a 20% or more IOP reduction was required for success.

RESULTS

The mean follow-up time was 37.4+/-14.7 months for patients in the SLT group and 33.6+/-17.0 months for patients in the ALT group. The long-term success rate was not significantly different between the ALT and SLT groups by either criterion (Kaplan-Meier survival analysis log-rank P = 0.20 by criterion I and P = 0.12 by criterion II). When comparing patients with and without previous ALT, there was not a statistically significant difference in the patients treated with SLT by either criterion (log-rank P = 0.37 by criterion I and P = 0.39 by criterion II).

CONCLUSIONS

In eyes with primary OAG that are receiving maximally tolerated medical therapy, SLT was found to be as effective as ALT in lowering IOP over a 5-year period. However, long-term data reveal that many of the glaucoma patients treated with SLT and ALT required further medical or surgical intervention. Whether SLT has better long-term success than ALT in repeat laser trabeculoplasty treatments remains unclear.

Foldable acrylic versus rigid polymethylmethacrylate intraocular lens in combined phacoemulsification and trabeculectomy

BACKGROUND

Combined trabeculectomy and phacoemulsification is a widely accepted option in treating patients with glaucoma who also have cataracts. Implantation of a foldable intraocular lens (IOL) in cataract surgery has several theoretical advantages. We performed a study to determine the results of combined phacoemulsification and trabeculectomy with mitomycin C and implantation of either a foldable acrylic or rigid polymethylmethacrylate (PMMA) IOL.

METHODS

Review of the charts of 58 consecutive patients (60 eyes) who underwent combined phacotrabeculectomy for concomitant cataract and glaucoma at a university-affiliated hospital in Montreal between September 2001 and December 2002. Forty-one eyes received a foldable acrylic lens (3.2-mm-wide incision), and 19 eyes received a rigid PMMA lens (5.2-mm-wide incision). Outcome measures included visual acuity, intraocular pressure (IOP) and postoperative complications. The results in the two groups were compared.

RESULTS

There were no differences in baseline characteristics between the two groups. Earlier recovery of visual acuity was noted in the foldable IOL group than in the rigid IOL group (p = 0.013 for the difference at day 7). IOP control was similar in the two groups, as was the incidence of IOP spikes in the early postoperative period.

INTERPRETATION

The results suggest that combined phacotrabeculectomy with mitomycin C using a foldable acrylic IOL allows for good postoperative IOP control and earlier visual recovery than the same procedure with insertion of a rigid PMMA lens.

Primary viscocanalostomy versus trabeculectomy for primary open-angle glaucoma

PURPOSE

To compare the efficacy and safety of viscocanalostomy and trabeculectomy in patients with primary open-angle glaucoma (POAG).

SETTING

Department of Ophthalmology, Ankara Education and Research Hospital, Ankara, Turkey.

METHODS

In this prospective randomized trial, 50 eyes of 50 patients with medically uncontrolled POAG were randomized to have a trabeculectomy (25 eyes) or a viscocanalostomy (25 eyes). Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before surgery and 1 day, 1 week, 1, 3, and 6 months, and 1, 2, and 3 years postoperatively.

RESULTS

At 3 years, the mean IOP was 16.0 mmHg +/- 7.07 (SD) in the trabeculectomy group and 17.8 +/- 4.6 mmHg in the viscocanalostomy group (P=.694). Complete success (IOP 6 to 21 mm Hg without medication) was achieved in 66.2% of eyes at 6 months and 55.1% at 3 years in the trabeculectomy group and in 52.9% and 35.3%, respectively, in the viscocanalostomy group (P>.05). Qualified success (IOP 6 to 21 mmHg with medication) was achieved in 95.8% of eyes at 6 months and 79.2% at 3 years in the trabeculectomy group and in 90.7% and 73.9%, respectively, in the viscocanalostomy group (P>.05). Postoperative hypotony and cataract formation occurred more frequently in the trabeculectomy group than in the viscocanalostomy group (P=.002).

CONCLUSIONS

Primary trabeculectomy lowered IOP more than viscocanalostomy in POAG patients. However, the complication rate was lower in the viscocanalostomy group.

Effects of matrix metalloproteinase-3 gene transfer by electroporation in glaucoma filter surgery

To develop gene therapy that can be applied to glaucoma-filtering surgery, we studied effects of transfection of matrix metalloproteinase-3 (MMP-3) cDNA into rabbit conjunctiva by electroporation (EP) on changes of intraocular pressure (IOP) and bleb formation after glaucoma filtering surgery. pTracer-CMV2 vector containing MMP-3 cDNA was transfected into rabbit conjunctiva by EP and MMP-3 expression was studied by reverse transcription (RT)-PCR, zymography and western blot analysis. Three days after the EP transfection of MMP-3 cDNA or vector alone into rabbit conjunctiva, trabeculectomy was performed at the place of transfection in the presence or absence of 0.04% mitomycin C (MMC). Then changes in IOPs and bleb formation were compared with each other. Expression of MMP-3 was detected in conjunctiva until 30 days after transfection by EP. Trabeculectomy following MMP-3 transfection caused significantly longer survival of filtering bleb and decreased levels of IOP in comparison with controls (trabeculectomy alone or trabeculectomy following vector transfection), and these levels were almost identical to those of trabeculectomy with MMC. The present study indicates that EP is effective to transfect some genes that promote the filtering bleb formation in glaucoma surgery, such as MMP-3 gene, and this may be potentially applicable to glaucoma-filtering surgery in glaucoma patients.

Does the site of filtration influence the medium to long term intraocular pressure control following microtrabeculectomy in low risk eyes?

AIMS

To evaluate the influence of varying surgical site on the medium to long term intraocular pressure (IOP) control in patients undergoing unenhanced small flap trabeculectomy (microtrabeculectomy) in eyes at low risk of failure.

METHODS

A retrospective non-concurrent analysis was performed on two cohorts of patients who underwent unenhanced microtrabeculectomy at different sites by a single surgeon (SAV). The first cohort of eyes was part of a trial to study the astigmatic effect of microtrabeculectomy (results published elsewhere) and all had flaps centred at the 12 o'clock meridian (superior flaps). The second cohort consisted of eyes with flaps created on either side of the 12 o'clock-that is, superonasal in left eyes and superotemporal in right eyes. All case notes were reviewed for the preoperative and presenting IOPs, the number and duration of antiglaucoma medication use preoperatively and, postoperatively, any intraoperative, early, or late postoperative complications. All IOPs measured at 6 months and then yearly intervals were recorded. The baseline characteristics and IOPs at each follow up were compared between the eyes with the superonasal and superotemporal flaps of the non-12 o'clock group against those with superior flaps in the 12 o'clock group up to a maximum of 72 months. Survival was assessed by the site of microtrabeculectomy, with failure considered as any IOP above 22 and 15 mm Hg with or without medications.

RESULTS

All patients had a minimum follow up of 12 months and 12/17 patients in the 12 o'clock group and 17/28 in the non-12 o'clock group completed the full follow up of 72 months. The IOPs at all points in time were lower in the left eyes with superonasal flaps compared to both the superior and the superotemporal groups. This difference was statistically significant between the three groups to the end of 4 years (p = 0.001) and remains clinically significant thereafter with the mean last recorded IOPs of 15.9, 12.4 (p = 0.03), and 14.3 mm Hg in the superior, superonasal and superotemporal groups respectively, with a smaller mean number of drops in the non-12 o'clock group. Kaplan-Meier curves showed a significantly better outcome for the cutoff IOP of 15 mm Hg in the superonasal group (p = 0.003) compared with both the other groups.

CONCLUSION

Eyes with superonasal flaps achieve and maintain lower IOPs when compared with both the superior and superotemporal flaps. The results suggest that, when a low target IOP is desired, the site of surgery in an unenhanced filtering procedure should be superonasally sited.