Tiefe Sklerektomie mit Hyaluronatimplantat vs. Trabekulektomie

Outcomes of Deep Sclerectomy following Failed XEN Gel Stent Implantation in Open-Angle Glaucoma: A Prospective Study

Background: The purpose of this study is to evaluate the outcome of deep sclerectomy (DS) as a secondary procedure following failed ab-interno XEN gel stent implantation in patients with open-angle glaucoma. Methods: Prospective, single-center, non-randomized, interventional study. Consecutive eyes that underwent mitomycin C (MMC) augmented XEN gel stent surgery, with uncontrolled intraocular pressure (IOP) or signs of disease progression, were included to undergo MMC-augmented DS. Primary efficacy outcome was surgical success, defined as complete when the unmedicated IOP was 12 mmHg or less, or 15 mmHg or less and 20% lower than at the timing of XEN failure and defined as qualified when the IOP fulfilled the same conditions with fewer medications than before deep sclerectomy. Secondary measures were mean reduction in IOP and in the number of medications, and the rates of complications. Results: Seventeen eyes were enrolled with a mean age of 72.1 ± 8.2 years (66.7% women). The mean follow-up was 20.1 ± 4.9 months, with more than 12-month data available from 15 eyes. Following DS, IOP decreased significantly from 22.6 ± 5.3 mmHg to 12.3 ± 5.5 (45.6%; p < 0.001). Antiglaucoma medications dropped from 1.1 ± 0.9 to 0.3 ± 0.7. Complete success was obtained in 40% of eyes using the threshold of 12 mmHg or less and a 20% decrease of IOP, and in 60% using the 15 mmHg or less threshold. Adverse events were observed in 20% of eyes (bleb leakage (13.3%); hypotony (6.7%)). No cases of choroidal detachment or hypotony maculopathy were reported. Conclusions: Failed XEN gel stent implantation does not seem to negatively affect the safety and efficacy of subsequent deep sclerectomy surgery.

Efficacy and Safety of Trabeculectomy Versus Nonpenetrating Surgeries in Open-angle Glaucoma: A Meta-analysis

PURPOSE

The purpose of this study was to conduct a meta-analysis on the efficacy and safety of trabeculectomy (TE) and nonpenetrating glaucoma surgery (NPGS) techniques in patients with primary open-angle glaucoma, pseudoexfoliation glaucoma, pigmentary glaucoma, and normal-tension glaucoma.

METHODS

All studies were identified by searching electronic sources (PubMed, Medline, Scopus, and Embase) until February 5, 2018. Primary outcome was mean intraocular pressure (IOP) reduction at 6, 12, and 24 months. Complications, number of antiglaucomatous medications, and visual outcomes were also evaluated.

RESULTS

Twenty-one studies were included. Ten studies compared TE with deep sclerectomy (DS), 5 with viscocanalostomy (VC), 1 study with both DS and VC, and 5 with canaloplasty (CP). TE was superior to DS, VC, and CP in reducing IOP at 6 and 12 months, and to DS at 24 months. When comparing TE to VC and to CP at 24 months, there was no significant difference in IOP reduction. Hypotony, choroidals, anterior chamber shallowing or flattening, and cataract formation or progression were more associated with TE than with NPGSs. TE was more effective in reducing antiglaucomatous medications than VC and CP.

CONCLUSIONS

TE is more effective in reducing IOP. TE presents a higher risk of complications as compared with NPGS, except for hyphema.

[Non-penetrating glaucoma surgery]

Patients at high risk of developing complications (e.g. high myopia, aphakia, advanced visual field defects) benefit from non-penetrating glaucoma surgery (NPGS). Neovascular glaucoma, traumatic glaucoma or patients with a narrow angle (a scleral spur must at least be visible) are not suitable for NPGS. The aim of deep sclerectomy (DS) is mainly external subconjunctival drainage. Modified with mitomycin C and intrascleral implants, intraocular pressure (IOP) and success of DS are comparable to trabeculectomy. Viscocanalostomy and the further development to canaloplasty aim for blebless IOP control. Viscocanalostomy has an extremely low complication profile but only a slight reduction in IOP. Canaloplasty creates much more favourable results. Combined with phacoemulsification canaloplasty appears to lower IOP comparable to phacotrabeculectomy and demonstrates a more sustainable success compared to canaloplasty alone.

Clinical effect of improved viscocanalostomy for the treatment of primary congenital glaucoma

AIM

To evaluate the clinical effect of improved viscocanalostomy in patients with primary congenital glaucoma.

METHODS

Retrospective analysis of improved viscocanalostomy was performed on 51 eyes of 42 patients with primary congenital glaucoma. The outcome evaluation included postoperative intraocular pressure(IOP), corneal diameter, cup/disc ratio and complications. All patients were followed up at week 1, month 1, 3, 6 and 12.

RESULTS

The results revealed that postoperative IOP was decreased from (38.57±13.61)mmHg to (10.53±3.91)mmHg, (14.89±5.26)mmHg, (15.42±5.11)mmHg, (13.82±3.46)mmHg, (13.16±5.29)mmHg at follow-up time of 1 week, 1, 3, 6, 12 months (P<0.001). The postoperative corneal diameter was decreased significantly (P=0.002); The mean cup/dish ratio wasn't significantly different (P=0.148) before and after the surgery, the cup/dish ratio of successful surgery was evidently decreased (preoperative 0.7±0.2, postoperative 0.6±0.3, P=0.007), but the complications like as unformed anterior chamber were not observed. The mean follow-up period was 12 months.

CONCLUSION

Improved viscocanalostomy improves the clinical effects of the patients with primary congenital glaucoma, such as higher success rates, lower postoperative mean IOP and fewer complications.

Systematic overview of the efficacy of nonpenetrating glaucoma surgery in the treatment of open angle glaucoma

BACKGROUND

To evaluate the intraocular pressure (IOP)-lowering effects achieved by nonpenetrating glaucoma surgery (NPGS) and its modifications in patients with open angle glaucoma.

MATERIAL/METHODS

Randomized controlled trials evaluating patients with primary and secondary open angle glaucoma treated with NPGS were identified through systematic searches. The main outcome measures were the percentage IOP reduction and the complete success rate. Complete success was defined as target endpoint IOP (usually less than 21 mm Hg) without medications. The pooled estimates were calculated using the random effects model.

RESULTS

Both deep sclerectomy (DS) and viscocanalostomy (VCO) were less effective than trabeculectomy (TE) in lowering IOP, with the percentage IOP reductions at 2 years being 35.2% for DS, 30.2% for VCO, and 45.6% for TE. Intraoperative use of implants and mitomycin C (MMC) increased IOP-lowering effects of DS, with IOP reductions at 2 years of 41.1% and 41.7%, respectively. The complete success rates at 4 years were 35.4% for DS, and 22.7% for VCO, lower than that of TE (47.6%). The complete success rates of DS with implants and MMC of 64.6% and 52.1%, respectively, at 4 years, were greater than that of primary DS. NPGS caused major complications in fewer patients than did TE.

CONCLUSIONS

Primary deep sclerectomy and primary viscocanalostomy, which can significantly lower IOP, were associated with fewer complications than was TE. However, the IOP-lowering effects of both NPGS seem to be lower than that of primary TE. The efficacy of DS can be improved with the intraoperative use of implants and MMC.

SKGEL® implant versus T-Flux® implant in the contralateral eye in deep sclerectomy with phacoemulsification: long-term follow-up

Purpose:

To intraindividually compare the efficacy and safety of the SKGEL^® implant versus the T-Flux^® implant in deep sclerectomy.

Methods:

In a retrospective analysis 17 patients were identified who underwent combined phacoemulsification-deep sclerectomy and implantation of SKGEL^® in one eye and T-Flux^® in the contralateral eye.

Results:

In eyes with SKGEL^® the IOP decreased from 20.6+7.3 mm Hg to 14.8+5.3 mm Hg (-5.8 mm Hg or -28.1%), and in eyes with T-Flux^® from 19.9+7.2 mm Hg to 14.7+3.3 mm Hg (-5.2 mm Hg or -26.1%, no statistically significant difference, p >0.05). Antiglaucoma medications with either implant decreased from initially 2.0+0.8 to 0.3+0.7. A qualified success was found in 17/17 eyes with T-Flux^® and in 16/17 eyes with SKGEL^®. Complete success was achieved in 14/17 eyes with T-Flux^® and in 13/17 eyes with SKGEL^®.

Conclusions:

The IOP-lowering effect and safety of SKGEL^® and T-Flux^® seem to be comparable.

CO2, excimer and erbium:YAG laser in deep sclerectomy

PURPOSE

Deep sclerectomy is a non-penetrating filtering procedure that is not generally accepted, as tissue dissection is difficult and varying success rates have been reported. The purpose of the present study was to compare the use of CO2, excimer and erbium:YAG lasers in dissection of the deep corneoscleral lamella.

METHODS

In enucleated porcine eyes a superficial lamellar scleral flap of 5 x 5 mm was surgically dissected. The deep lamella was removed using a pulsed erbium:YAG, a CO2 or an excimer laser (10 eyes/group). All eyes were analysed histologically and 3 in each group by scanning electron microscopy (SEM).

RESULTS

It is feasible to ablate the deep corneoscleral lamella with the CO2, excimer and erbium:YAG lasers without perforating the anterior chamber. The following histology and SEM showed a smoother surface after dissection with the CO2 and excimer lasers compared to the erbium:YAG laser. There was no thermal damage after excimer laser treatment, compared to a damage zone of 10-30 mum using the erbium laser and one of 70-100 microm with the CO2 laser.

CONCLUSIONS

Excimer,erbium:YAG and CO2 lasers allow the microsurgical dissection of the deep lamella. The excimer and CO2 lasers achieve a more regular and smoother tissue surface. The excimer laser has the advantage to dissect without thermal tissue damage.

Long-term results of Erbium YAG-laser-assisted deep sclerectomy

PURPOSE

To evaluate the long-term results of Erbium YAG-laser-assisted deep sclerectomy (DS). In this procedure, the delicate dissection of a deep corneoscleral lamella is greatly simplified by using the Erbium YAG-laser.

METHODS

Data of 14 consecutive patients (10 male, four female, age 67.7+/-10.4 years), who underwent surgery from 1999 to 2000 were analysed retrospectively. The procedure was begun as a standard DS. The deep corneoscleral lamella was dissected with a pulsed Erbium YAG-laser (energy: 40-100 mJ, frequency: 5-10 Hz). Schlemm's canal was unroofed and the lamella thinned until aqueous percolated continuously through the membrane.

RESULTS

The mean follow-up time was 50.4+/-6.8 months. The mean preoperative intraocular pressure (IOP) was 37.7+/-10.5 mmHg. The mean postoperative IOP was 16.1+/-3.9 mmHg at 1 month, 15.1+/-4.3 mmHg at 3 months, 16.4+/-4.5 mmHg at 12 months, and 17.6+/-8.7 mmHg at 50.5 months. The complete success rates (IOP< or =21 mmHg+IOP reduction > or =20% without glaucoma medication) were 83.3% at 3 months and 50% at 12 and 50.5 months. Rates for qualified success (IOP< or =21 mmHg+IOP reduction > or =20% with glaucoma medication) were 91.7% at 3 months, 92.9% at 12 months, and 78.6% at 50.5 months. The number of glaucoma medications was reduced from 3.07+/-0.92 preoperatively to 1.14+/-1.41 at 50.5 months. A single case of anterior-chamber penetration, requiring iridectomy, was the only intraoperative complication.

CONCLUSIONS

Erbium YAG-laser-assisted DS has the advantage of a greatly simplified dissection, while offering a successful long-term IOP control comparable to conventional DS.

Klassifikation biomedizinischer Forschungsberichte als Grundlage evidenzbasierter Medizin in der Augenheilkunde

BACKGROUND

Evidence-based medicine requires careful appraisal of published data derived from experimental and clinical studies. Based on classification of biomedical research reports, evidence levels can be determined and recommendations for therapeutic decisions can be made.

METHODS

A classification system for clinical studies was developed. It was evaluated in classifying the reports published in Der Ophthalmologe during 2003-2004 (study design: descriptive cross-sectional study, case series).

RESULTS

In the 2-year interval, 70 longitudinal and 95 cross-sectional studies were published. The vast majority of the longitudinal studies were interventional cohort studies. Not considering case reports, 73% of the original articles were longitudinal prospective studies, 1% were retrospective (case-control) studies, and 26% were cross-sectional studies.

CONCLUSIONS

The study design of all published articles could be classified using the classification system. This classification system proves to be applicable in the context of clinical studies in ophthalmology and may be helpful in the process of critical appraisal of the literature and synthesis of clinical evidence and an evidence-based recommendation.

Deep sclerectomy with mitomycin C in failed trabeculectomy

AIM

To evaluate the success rate and complications associated with deep sclerectomy with mitomycin C (MMC) and a reticulated hyaluronic acid implant in previously failed trabeculectomy.

METHODS

This prospective study included 20 eyes with a previously failed trabeculectomy, which were treated with deep sclerectomy with 0.2 mg/ml MMC application under the conjunctiva and superficial scleral flap. Intraocular pressure (IOP), glaucoma medications, visual acuity, and complications were recorded preoperatively and 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively.

RESULTS

The mean preoperative IOP was 25.8+/-7.3 mmHg; the IOP significantly decreased to 14.6+/-3.2 mmHg 1 year postoperative. At each interval, the mean IOP was significantly lower than preoperatively (P=0.000). At 1 year, the complete success rate (IOP<or=21 mmHg untreated) was 65% and the qualified success rate (IOP<or=21 mmHg with and without medication) was 100%. 12 patients (60%) achieved an IOP<or=15 mmHg with and without medication. No shallow or flat anterior chamber, endophthalmitis, or leakage developed.

CONCLUSIONS

These data suggest that deep sclerectomy augmented with MMC is a safe surgical procedure that decreases IOP in eyes with a previously failed trabeculectomy.