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Siewert S, Kischkel S, Brietzke A, Kinzel L, Lindner T, Hinze U, Chichkov B, Schmidt W, Stiehm M, Grabow N, Guthoff RF, Schmitz KP, Stahnke T. Development of a Novel Valve-Controlled Drug-Elutable Microstent for Microinvasive Glaucoma Surgery: In Vitro and Preclinical In Vivo Studies. Transl Vis Sci Technol 2023; 12:4. [PMID: 36857065 PMCID: PMC9987165 DOI: 10.1167/tvst.12.3.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Purpose Microinvasive glaucoma surgery (MIGS) has become an important treatment approach for primary open-angle glaucoma, although the safe and long-term effective lowering of intraocular pressure with currently available implants for MIGS is not yet achieved to a satisfactory extent. The study focusses on the development and in vitro and in vivo testing of a novel microstent for MIGS. Methods A silicone elastomer-based microstent was developed. Implants were manufactured using dip coating, fs-laser cutting, and spray coating. Within the current study no antifibrotic drug was loaded into the device. Sterilized microstents were analyzed in vitro regarding pressure-flow characteristics and biocompatibility. Six New Zealand white rabbits were implanted with a microstent draining the aqueous humor from the anterior chamber into the subconjunctival space. Drainage efficacy was evaluated using oculopressure tonometry as a transient glaucoma model. Noninvasive imaging was performed. Results Microstents were manufactured successfully and characterized in vitro. Implantation in vivo was successful for four animals with additional device fixation. Without additional fixation, dislocation of microstents was found in two animals. Safe and effective intraocular pressure reduction was observed for the four eyes with correctly implanted microstent during the 6-month trial period. Conclusions The described microstent represents an innovative treatment approach for MIGS. The incorporation of a selectively antifibrotic drug into the microstent drug-elutable coating will be addressed in future investigations. Translational Relevance The current preclinical study successfully provided proof of concept for our microstent for MIGS which is suitable for safe and effective intraocular pressure reduction and offers promising perspectives for the clinical management of glaucoma.
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Affiliation(s)
- Stefan Siewert
- Institute for ImplantTechnology and Biomaterials e.V., Rostock-Warnemünde, Germany
| | - Sabine Kischkel
- Institute for Biomedical Engineering, Rostock University Medical Center, Rostock, Germany
| | - Andreas Brietzke
- Institute for Biomedical Engineering, Rostock University Medical Center, Rostock, Germany
| | - Ludmila Kinzel
- Department of Ophthalmology, Rostock University Medical Center, Rostock, Germany
| | - Tobias Lindner
- Core Facility Multimodal Small Animal Imaging, Rostock University Medical Center, Rostock, Germany
| | - Ulf Hinze
- Institute of Quantum Optics, Faculty of Mathematics and Physics, Leibniz University Hannover, Hannover, Germany.,Laser nanoFab GmbH, Garbsen, Germany
| | - Boris Chichkov
- Institute of Quantum Optics, Faculty of Mathematics and Physics, Leibniz University Hannover, Hannover, Germany.,Laser nanoFab GmbH, Garbsen, Germany
| | - Wolfram Schmidt
- Institute for Biomedical Engineering, Rostock University Medical Center, Rostock, Germany
| | - Michael Stiehm
- Institute for ImplantTechnology and Biomaterials e.V., Rostock-Warnemünde, Germany
| | - Niels Grabow
- Institute for Biomedical Engineering, Rostock University Medical Center, Rostock, Germany
| | - Rudolf F Guthoff
- Department of Ophthalmology, Rostock University Medical Center, Rostock, Germany
| | - Klaus-Peter Schmitz
- Institute for ImplantTechnology and Biomaterials e.V., Rostock-Warnemünde, Germany.,Institute for Biomedical Engineering, Rostock University Medical Center, Rostock, Germany
| | - Thomas Stahnke
- Institute for ImplantTechnology and Biomaterials e.V., Rostock-Warnemünde, Germany.,Department of Ophthalmology, Rostock University Medical Center, Rostock, Germany
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Siggel R, Schroedl F, Dietlein T, Koch KR, Platzl C, Kaser-Eichberger A, Cursiefen C, Heindl LM. Absence of lymphatic vessels in non-functioning bleb capsules of glaucoma drainage devices. Histol Histopathol 2021; 35:1521-1531. [PMID: 33382078 DOI: 10.14670/hh-18-300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the presence and appearance of blood and lymphatic vessels in non-functioning bleb capsules of glaucoma drainage devices (GDD). MATERIALS AND METHODS Non-functioning (n=14) GDD-bleb capsules of 12 patients were analyzed by immunohistochemistry for blood vessels (CD31, vascular endothelium), lymphatic vessels (lymphatic vessel endothelial hyaluronan receptor-1 [LYVE-1] and podoplanin) and macrophages (CD68). RESULTS CD31+++ blood vessels and CD68+ macrophages were detected in the outer layer of all specimens. LYVE-1 immunoreactivity was registered in single non-endothelial cells in 8 out of 14 (57%) bleb capsule specimens. Podoplanin-immunoreactivity was detected in all cases, located in cells and profiles of the collagen tissue network of the outer and/or the inner capsule layer. However, a colocalization of LYVE-1 and podoplanin as evidence for lymphatic vessels was not detected. CONCLUSIONS We demonstrate the presence of blood-vessels but absence of lymphatic vessels in non-functioning bleb capsules after GDD-implantation. While the absence of lymphatic vessels might indicate a possible reason for drainage device failure, this needs to be confirmed in upcoming studies, including animal experiments.
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Affiliation(s)
- Robert Siggel
- Department of Ophthalmology, University of Cologne, Cologne, Germany.,Department of Ophthalmology, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Germany.
| | - Falk Schroedl
- Institute of Anatomy and Cell Biology, Paracelsus Medical University, Salzburg, Austria
| | - Thomas Dietlein
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Konrad R Koch
- Department of Ophthalmology, University of Cologne, Cologne, Germany
| | - Christian Platzl
- Institute of Anatomy and Cell Biology, Paracelsus Medical University, Salzburg, Austria
| | | | - Claus Cursiefen
- Department of Ophthalmology, University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMK), University of Cologne, Cologne, Germany
| | - Ludwig M Heindl
- Department of Ophthalmology, University of Cologne, Cologne, Germany
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Klapstova A, Horakova J, Tunak M, Shynkarenko A, Erben J, Hlavata J, Bulir P, Chvojka J. A PVDF electrospun antifibrotic composite for use as a glaucoma drainage implant. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 119:111637. [PMID: 33321675 DOI: 10.1016/j.msec.2020.111637] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
Glaucoma disease therapy frequently involves the application of a glaucoma implant. This approach is effective in terms of reducing the intraocular pressure via the filtering of intraocular fluid from the anterior chamber into the drainage pathways. The basic properties of such implants comprise of long-term stability and the filtering of fluids without the occurrence of undesirable blockages. This study describes the design and production of a novel material for the treatment of glaucoma disease that is based on electrospinning technology. Non-toxic, biocompatible and non-degradable polyvinylidenefluoride (PVDF) was selected as the implant material. The research investigated the resistance of this material to the growth of a fibroblast cell line without the use of antifibrotic agents such as mitomycin C. Three different types of PVDF were electrospun separately and mixed with polyethyleneoxide (PEO), following which the degree of cell growth resistance was evaluated. It was discovered that the fiber layers that contained PVDF blended with PEO evinced a statistically significant difference in metabolic activity compared to the PURE PVDF layers. Only small cell clusters formed on the layers that were resistant to cell fibrotization. As a result of the observed clustering, a new program was developed in MATLAB software for the determination of the number of cells involved in cluster formation, which then allowed for the determination of the spatial dependence between the cells in the form of a point pattern. The study describes a simple technique for the production of composite PVDF+PEO structures suitable for use in the field of glaucoma treatment.
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Affiliation(s)
- Andrea Klapstova
- Technical University of Liberec, Faculty of Textile Engineering, Department of Nonwovens and Nanofibrous Materials, Studentska 1402/2, 461 17 Liberec, Czech Republic.
| | - Jana Horakova
- Technical University of Liberec, Faculty of Textile Engineering, Department of Nonwovens and Nanofibrous Materials, Studentska 1402/2, 461 17 Liberec, Czech Republic
| | - Maros Tunak
- Technical University of Liberec, Faculty of Textile Engineering, Department of Textile Evaluation, Studentska 1402/2, 461 17 Liberec, Czech Republic
| | - Andrii Shynkarenko
- Technical University of Liberec, Faculty of Mechanical Engineering, Department of Manufacturing Systems and Automation, Studentska 1402/2, 461 17 Liberec, Czech Republic
| | - Jakub Erben
- Technical University of Liberec, Faculty of Textile Engineering, Department of Nonwovens and Nanofibrous Materials, Studentska 1402/2, 461 17 Liberec, Czech Republic
| | - Jana Hlavata
- Technical University of Liberec, Faculty of Textile Engineering, Department of Nonwovens and Nanofibrous Materials, Studentska 1402/2, 461 17 Liberec, Czech Republic
| | - Petr Bulir
- Liberec Regional Hospital, Department of Ophthalmology, Vzdusna 1360/6, 460 01 Liberec, Czech Republic
| | - Jiri Chvojka
- Technical University of Liberec, Faculty of Textile Engineering, Department of Nonwovens and Nanofibrous Materials, Studentska 1402/2, 461 17 Liberec, Czech Republic
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Martin G, Lübke J, Schefold S, Jordan JF, Schlunck G, Reinhard T, Kanokwijitsilp T, Prucker O, Rühe J, Anton A. Prevention of Ocular Tenon Adhesion to Sclera by a PDMAA Polymer to Improve Results after Glaucoma Surgery. Macromol Rapid Commun 2020; 41:e1900352. [DOI: 10.1002/marc.201900352] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/17/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Gottfried Martin
- Eye CenterMedical Center ‐ Faculty of MedicineUniversity of Freiburg Killianstraße 5 79106 Freiburg Germany
| | - Jan Lübke
- Eye CenterMedical Center ‐ Faculty of MedicineUniversity of Freiburg Killianstraße 5 79106 Freiburg Germany
| | - Suzanna Schefold
- Eye CenterMedical Center ‐ Faculty of MedicineUniversity of Freiburg Killianstraße 5 79106 Freiburg Germany
- Department of Microsystems Engineering (IMTEK)University of Freiburg Georges‐Köhler‐Allee 103 79110 Freiburg Germany
| | - Jens F. Jordan
- Eye CenterMedical Center ‐ Faculty of MedicineUniversity of Freiburg Killianstraße 5 79106 Freiburg Germany
- Praxisausübungsgemeinschaft Vobig & Jordan Hans‐Thoma‐Straße 24 60596 Frankfurt Germany
| | - Günther Schlunck
- Eye CenterMedical Center ‐ Faculty of MedicineUniversity of Freiburg Killianstraße 5 79106 Freiburg Germany
| | - Thomas Reinhard
- Eye CenterMedical Center ‐ Faculty of MedicineUniversity of Freiburg Killianstraße 5 79106 Freiburg Germany
| | - Thananthorn Kanokwijitsilp
- Department of Microsystems Engineering (IMTEK)University of Freiburg Georges‐Köhler‐Allee 103 79110 Freiburg Germany
| | - Oswald Prucker
- Department of Microsystems Engineering (IMTEK)University of Freiburg Georges‐Köhler‐Allee 103 79110 Freiburg Germany
| | - Jürgen Rühe
- Department of Microsystems Engineering (IMTEK)University of Freiburg Georges‐Köhler‐Allee 103 79110 Freiburg Germany
| | - Alexandra Anton
- Eye CenterMedical Center ‐ Faculty of MedicineUniversity of Freiburg Killianstraße 5 79106 Freiburg Germany
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Development of a biodegradable antifibrotic local drug delivery system for glaucoma microstents. Biosci Rep 2018; 38:BSR20180628. [PMID: 30061178 PMCID: PMC6117617 DOI: 10.1042/bsr20180628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/27/2018] [Accepted: 07/26/2018] [Indexed: 12/18/2022] Open
Abstract
To prevent implant failure due to fibrosis is a major objective in glaucoma research. The present study investigated the antifibrotic effects of paclitaxel (PTX), caffeic acid phenethyl ester (CAPE), and pirfenidone (PFD) coated microstent test specimens in a rat model. Test specimens based on a biodegradable blend of poly(4-hydroxybutyrate) biopolymer and atactic poly(3-hydroxybutyrate) (at.P(3HB)) were manufactured, equipped with local drug delivery (LDD) coatings, and implanted in the subcutaneous white fat depot. Postoperatively, test specimens were explanted and analyzed for residual drug content. Fat depots including the test specimens were histologically analyzed. In vitro drug release studies revealed an initial burst for LDD devices. In vivo, slow drug release of PTX was found, whereas it already completed 1 week postoperatively for CAPE and PFD LDD devices. Histological examinations revealed a massive cell infiltration in the periphery of the test specimens. Compact fibrotic capsules around the LDD devices were detectable at 4–36 weeks and least pronounced around PFD-coated specimens. Capsules stained positive for extracellular matrix (ECM) components. The presented model offers possibilities to investigate release kinetics and the antifibrotic potential of drugs in vivo as well as the identification of more effective agents for a novel generation of drug-eluting glaucoma microstents.
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Comparison of Six Different Silicones In Vitro for Application as Glaucoma Drainage Device. MATERIALS 2018; 11:ma11030341. [PMID: 29495462 PMCID: PMC5872920 DOI: 10.3390/ma11030341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/30/2018] [Accepted: 02/24/2018] [Indexed: 12/28/2022]
Abstract
Silicones are widely used in medical applications. In ophthalmology, glaucoma drainage devices are utilized if conservative therapies are not applicable or have failed. Long-term success of these devices is limited by failure to control intraocular pressure due to fibrous encapsulation. Therefore, different medical approved silicones were tested in vitro for cell adhesion, cell proliferation and viability of human Sclera (hSF) and human Tenon fibroblasts (hTF). The silicones were analysed also depending on the sample preparation according to the manufacturer's instructions. The surface quality was characterized with environmental scanning electron microscope (ESEM) and water contact angle measurements. All silicones showed homogeneous smooth and hydrophobic surfaces. Cell adhesion was significantly reduced on all silicones compared to the negative control. Proliferation index and cell viability were not influenced much. For development of a new glaucoma drainage device, the silicones Silbione LSR 4330 and Silbione LSR 4350, in this study, with low cell counts for hTF and low proliferation indices for hSF, and silicone Silastic MDX4-4210, with low cell counts for hSF and low proliferation indices for hTF, have shown the best results in vitro. Due to the high cell adhesion shown on Silicone LSR 40, 40,026, this material is unsuitable.
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Yoo TK, Han SH, Han J. Protective effects of biodegradable collagen implants on thinned sclera after strabismus surgery: a paired-eye study. J AAPOS 2017; 21:467-471.e1. [PMID: 29102674 DOI: 10.1016/j.jaapos.2017.07.217] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the efficacy of a biodegradable Ologen (Aeon Astron Europe BV, Leiden, The Netherlands) collagen matrix in reducing the blue color change due to exposed thinned sclera after strabismus surgery. METHODS Fourteen patients with intermittent exotropia undergoing symmetric bilateral lateral rectus recession surgery were included in this prospective, randomized, paired-eye controlled study. In each patient, Ologen was implanted at the original rectus insertion site in one randomly selected eye; the other eye underwent conventional surgery. Ologen was inserted under the conjunctiva without suturing, covering the muscle insertion site. Conjunctival color change was analyzed using computer-based image analysis immediately and 1 week, 1 month, and 3 months postoperatively. Slit-lamp photographs of each eye were evaluated using contrast limited adaptive histogram equalization (CLAHE), Canny edge, and the RGB (red-green-blue) model. Secondary outcomes were conjunctival and sclera thickness 3 months postoperatively determined by anterior segment optical coherence tomography. RESULTS Immediately and 1 week postoperatively all color models showed no significant differences between Ologen-implanted and control eyes. Three months postoperatively, Ologen-implanted eyes exhibited significantly lower CLAHE (P = 0.041) and RGB model blue color (P = 0.008) values than control eyes. Canny edge (P = 0.061) and RGB model red color (P = 0.152) values did not differ between eyes. Conjunctival stroma and episcleral complex thickness was greater in Ologen-implanted eyes than in controls (P = 0.001). CONCLUSIONS Blue color change was significantly less noticeable in Ologen-implanted eyes than in controls. Thus, Ologen implantation helps prevent visible blue sclera at the original rectus insertion site after lateral rectus recession.
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Affiliation(s)
- Tae Keun Yoo
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea
| | - Sueng-Han Han
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jinu Han
- Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, South Korea.
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Abstract
BACKGROUND Glaucoma is an optic neuropathy that leads to vision loss and blindness. It is the second most common cause of irreversible blindness worldwide. The main treatment for glaucoma aims to reduce intraocular pressure (IOP) in order to slow or prevent further vision loss. IOP can be lowered with medications, and laser or incisional surgeries. Trabeculectomy is the most common incisional surgical procedure to treat glaucoma. Device-modified trabeculectomy is intended to improve drainage of the aqueous humor to lower IOP. Trabeculectomy-modifying devices include Ex-PRESS, Ologen, amniotic membrane, expanded polytetrafluoroethylene (E-PTFE) membrane, Gelfilm and others. However, the effectiveness and safety of these devices are uncertain. OBJECTIVES To assess the relative effectiveness, primarily with respect to IOP control and safety, of the use of different devices as adjuncts to trabeculectomy compared with standard trabeculectomy in eyes with glaucoma. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2014), EMBASE (January 1980 to December 2014), PubMed (1948 to December 2014), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 December 2014. SELECTION CRITERIA We included randomized controlled trials comparing devices used during trabeculectomy with trabeculectomy alone. We also included studies where antimetabolites were used in either or both treatment groups. DATA COLLECTION AND ANALYSIS We used standard procedures expected by Cochrane. MAIN RESULTS We found 33 studies that met our inclusion criteria, of which 30 were published as full-length journal articles and three as conference abstracts. Only five studies have been registered. The 33 studies included a total of 1542 participants with glaucoma, and compared five types of devices implanted during trabeculectomy versus trabeculectomy alone. Five studies reported the use of Ex-PRESS (386 participants), eight studies reported the use of Ologen (327 participants), 18 studies reported the use of amniotic membrane (726 participants), one study reported the use of E-PTFE (60 participants), and one study reported the use of Gelfilm (43 participants). These studies were conducted in North America, South America, Europe, Asia, and the Middle East. Planned participant follow-up periods ranged from three months to five years. The studies were reported poorly which limited our ability to judge risk of bias for many domains. Only two studies explicitly masked outcome assessment so, we rated 31 studies at high risk of detection bias.Low-quality evidence from three studies showed that use of Ex-PRESS compared with trabeculectomy alone may be associated with a slightly lower IOP at one year (mean difference (MD) -1.58 mm Hg, 95% confidence interval (CI) -2.74 to -0.42; 165 eyes). Cataract surgery and hyphema may be less frequent in the Ex-PRESS group than in the trabeculectomy-alone group (cataract surgery: risk ratio (RR) 0.32, 95% CI 0.14 to 0.74, 3 studies, low-quality evidence; hyphema: RR 0.33, 95% CI 0.12 to 0.94, 4 studies, low-quality evidence). The effect of whether Ex-PRESS prevents hypotony was uncertain (RR 0.92, 95% CI 0.63 to 1.33, 2 studies, very low-quality evidence). All these studies received funding from the device manufacturer.Very low-quality evidence from five studies suggests that use of Ologen compared with trabeculectomy alone is associated with slightly higher IOP at one year (MD 1.40 mm Hg, 95% CI -0.57 to 3.38; 177 eyes). The effect of Ologen on preventing hypotony was uncertain (RR 0.75, 95% CI 0.47 to 1.19, 5 studies, very low-quality evidence). Differences between the two treatment groups for other reported complications also were inconclusive.Low-quality evidence from nine studies suggests that use of amniotic membrane with trabeculectomy may be associated with lower IOP at one year compared with trabeculectomy alone (MD -3.92 mm Hg, 95% CI -5.41 to -2.42; 356 eyes). Low-quality evidence showed that use of amniotic membrane may prevent adverse events and complications, such as hypotony (RR 0.40, 95% CI 0.17 to 0.94, 5 studies, low-quality evidence).The report from the only E-PTFE study (60 eyes) showed no important differences for postoperative IOP at one year (MD -0.44 mm Hg, 95% CI -1.76 to 0.88) between the trabeculectomy + E-PTFE versus the trabeculectomy-alone groups. Hypotony was the only postoperative complication observed less frequently in the E-PTFE group compared to the trabeculectomy-alone group (RR 0.29, 95% CI 0.11 to 0.77).The one Gelfilm study reported uncertainty in the difference in IOP and complication rates between the two groups at one year; no further data were provided in the study report. AUTHORS' CONCLUSIONS Overall, the use of devices with standard trabeculectomy may help with greater IOP reduction at one-year follow-up than trabeculectomy alone; however, due to potential biases and imprecision in effect estimates, the quality of evidence is low. When we examined outcomes within subgroups based on the type of device used, our findings suggested that the use of an Ex-PRESS device or an amniotic membrane as an adjunct to trabeculectomy may be slightly more effective in reducing IOP at one year after surgery compared with trabeculectomy alone. The evidence that these devices are as safe as trabeculectomy alone is unclear. Due to various limitations in the design and conduct of the included studies, the applicability of this evidence synthesis to other populations or settings is uncertain. Further research is needed to determine the effectiveness and safety of other devices and in subgroup populations, such as people with different types of glaucoma, of various races and ethnicity, and with different lens types (e.g. phakic, pseudophakic).
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Affiliation(s)
- Xue Wang
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetBaltimoreMarylandUSA21205
| | - Rabeea Khan
- UCLA ‐ Olive ViewInternal Medicine1445 Olive View DriveSylmarCaliforniaUSA91342
| | - Anne Coleman
- Jules Stein Eye Institute, UCLA100 Stein PlazaBox 957000Los AngelesCaliforniaUSACA 90095‐7000
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Zhang ML, Hirunyachote P, Jampel H. Combined surgery versus cataract surgery alone for eyes with cataract and glaucoma. Cochrane Database Syst Rev 2015; 2015:CD008671. [PMID: 26171900 PMCID: PMC4730948 DOI: 10.1002/14651858.cd008671.pub3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cataract and glaucoma are leading causes of blindness worldwide, and their co-existence is common in elderly people. Glaucoma surgery can accelerate cataract progression, and performing both surgeries may increase the rate of postoperative complications and compromise the success of either surgery. However, cataract surgery may independently lower intraocular pressure (IOP), which may allow for greater IOP control among patients with co-existing cataract and glaucoma. The decision between undergoing combined glaucoma and cataract surgery versus cataract surgery alone is complex. Therefore, it is important to compare the effectiveness of these two interventions to aid clinicians and patients in choosing the better treatment approach. OBJECTIVES To assess the relative effectiveness and safety of combined surgery versus cataract surgery (phacoemulsification) alone for co-existing cataract and glaucoma. The secondary objectives include cost analyses for different surgical techniques for co-existing cataract and glaucoma. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 10), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2014), EMBASE (January 1980 to October 2014), PubMed (January 1948 to October 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 3 October 2014.We checked the reference lists of the included trials to identify further relevant trials. We used the Science Citation Index to search for references to publications that cited the studies included in the review. We also contacted investigators and experts in the field to identify additional trials. SELECTION CRITERIA We included randomized controlled trials (RCTs) of participants who had open-angle, pseudoexfoliative, or pigmentary glaucoma and age-related cataract. The comparison of interest was combined cataract surgery (phacoemulsification) and any type of glaucoma surgery versus cataract surgery (phacoemulsification) alone. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, collected data, and judged risk of bias for included studies. We used standard methodological procedures expected by the Cochrane Collaboration. MAIN RESULTS We included nine RCTs, with a total of 655 participants (657 eyes), and follow-up periods ranging from 12 to 30 months. Seven trials were conducted in Europe, one in Canada and South Africa, and one in the United States. We graded the overall quality of the evidence as low due to observed inconsistency in study results, imprecision in effect estimates, and risks of bias in the included studies.Glaucoma surgery type varied among the studies: three studies used trabeculectomy, three studies used iStent® implants, one study used trabeculotomy, and two studies used trabecular aspiration. All of these studies found a statistically significant greater decrease in mean IOP postoperatively in the combined surgery group compared with cataract surgery alone; the mean difference (MD) was -1.62 mmHg (95% confidence interval (CI) -2.61 to -0.64; 489 eyes) among six studies with data at one year follow-up. No study reported the proportion of participants with a reduction in the number of medications used after surgery, but two studies found the mean number of medications used postoperatively at one year was about one less in the combined surgery group than the cataract surgery alone group (MD -0.69, 95% CI -1.28 to -0.10; 301 eyes). Five studies showed that participants in the combined surgery group were about 50% less likely compared with the cataract surgery alone group to use one or more IOP-lowering medications one year postoperatively (risk ratio (RR) 0.47, 95% CI 0.28 to 0.80; 453 eyes). None of the studies reported the mean change in visual acuity or visual fields. However, six studies reported no significant differences in visual acuity and two studies reported no significant differences in visual fields between the two intervention groups postoperatively (data not analyzable). The effect of combined surgery versus cataract surgery alone on the need for reoperation to control IOP at one year was uncertain (RR 1.13, 95% CI 0.15 to 8.25; 382 eyes). Also uncertain was whether eyes in the combined surgery group required more interventions for surgical complications than those in the cataract surgery alone group (RR 1.06, 95% CI 0.34 to 3.35; 382 eyes). No study reported any vision-related quality of life data or cost outcome. Complications were reported at 12 months (two studies), 12 to 18 months (one study), and two years (four studies) after surgery. Due to the small number of events reported across studies and treatment groups, the difference between groups was uncertain for all reported adverse events. AUTHORS' CONCLUSIONS There is low quality evidence that combined cataract and glaucoma surgery may result in better IOP control at one year compared with cataract surgery alone. The evidence was uncertain in terms of complications from the surgeries. Furthermore, this Cochrane review has highlighted the lack of data regarding important measures of the patient experience, such as visual field tests, quality of life measurements, and economic outcomes after surgery, and long-term outcomes (five years or more). Additional high-quality RCTs measuring clinically meaningful and patient-important outcomes are required to provide evidence to support treatment recommendations.
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Affiliation(s)
- Mingjuan Lisa Zhang
- Johns Hopkins University School of Medicine929 N. Wolfe St, Apt. 615BaltimoreMarylandUSA21205
| | | | - Henry Jampel
- Johns Hopkins University School of MedicineWilmer Eye Institute600 N. Wolfe StreetMaumenee B‐110BaltimoreMarylandUSA21287‐9205
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Hovakimyan M, Siewert S, Schmidt W, Sternberg K, Reske T, Stachs O, Guthoff R, Wree A, Witt M, Schmitz KP, Allemann R. Development of an Experimental Drug Eluting Suprachoroidal Microstent as Glaucoma Drainage Device. Transl Vis Sci Technol 2015; 4:14. [PMID: 26175960 DOI: 10.1167/tvst.4.3.14] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/28/2015] [Indexed: 12/26/2022] Open
Abstract
PURPOSE A novel glaucoma drainage device (GDD) with local drug delivery (LDD) system was created and characterized for safety and effectiveness after implantation into the suprachoroidal space (SCS) of rabbit eyes. METHODS Thin films of two different polymers, Poly(3-hydroxybutyrate) (P(3HB)) and Poly(4-hydroxybutyrate) (P(4HB)), containing the drugs mitomycin C (MitC) or paclitaxel (PTX) were attached to silicone-tubes to create LDD devices. The release kinetics of these drugs were explored in vitro using high performance liquid chromatography (HPLC). Twenty-four New Zealand white rabbits, randomly divided into eight groups, were implanted with different kinds of microstents into SCS. The intraocular pressure (IOP) was monitored noninvasively. After 6 weeks, rabbits were sacrificed and enucleated eyes were used for anterior segment optical coherence tomography (OCT), micro magnetic resonance imaging (MRI), and histology. RESULTS In vitro, faster drug release from both polymers was observed for MitC compared to PTX. Comparing polymers, the release from P(3HB) matrix was slower for both drugs. MRI and OCT showed all implants maintained a proper location. An effective IOP reduction was observed for up to 6 weeks in eyes with microstents combined with a drug-releasing LDD system. Overall, the surrounding tissue revealed mild-to-moderate inflammation. No pronounced fibrosis was observed in any of the groups. However, both drugs caused damage to the neighboring retina. CONCLUSIONS The suprachoroidal microstent reduced IOP with mild inflammation in rabbit eyes. To avoid negative effects on the retina, it is necessary to identify novel drugs with less cytotoxicity. Future studies are needed to explore the fibrotic process over the long-term. TRANSLATIONAL RELEVANCE The presented data serve as a proof of principle study for the concept of a suprachoroidal drug eluting microstent. Future device improvements will be focused on the design of LDD systems and the use of specific anti-inflammatory or antifibrotic agents with less cytotoxicity compared to MitC or PTX. Long-term animal studies using a reliable glaucoma model will be a further step towards clinical application and improvement of surgical glaucoma therapy.
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Affiliation(s)
- Marina Hovakimyan
- Institute for Biomedical Engineering Rostock University Medical Center, Rostock, Germany
| | - Stefan Siewert
- Institute for Biomedical Engineering Rostock University Medical Center, Rostock, Germany
| | - Wolfram Schmidt
- Institute for Biomedical Engineering Rostock University Medical Center, Rostock, Germany
| | - Katrin Sternberg
- Institute for Biomedical Engineering Rostock University Medical Center, Rostock, Germany
| | - Thomas Reske
- Institute for Biomedical Engineering Rostock University Medical Center, Rostock, Germany
| | - Oliver Stachs
- Department of Ophthalmology, Rostock University Medical Center, Rostock, Germany
| | - Rudolf Guthoff
- Institute for Biomedical Engineering Rostock University Medical Center, Rostock, Germany
| | - Andreas Wree
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
| | - Martin Witt
- Department of Anatomy, Rostock University Medical Center, Rostock, Germany
| | - Klaus-Peter Schmitz
- Institute for Biomedical Engineering Rostock University Medical Center, Rostock, Germany
| | - Reto Allemann
- Department of Ophthalmology, Rostock University Medical Center, Rostock, Germany
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Senthil S, Badakare A. Dynamic tube movement after reimplantation of Ahmed glaucoma valve in a child with glaucoma in aphakia. BMJ Case Rep 2014; 2014:bcr-2013-203197. [PMID: 24695662 DOI: 10.1136/bcr-2013-203197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 10-year-old girl underwent an Ahmed glaucoma valve (AGV) implantation as a primary procedure for glaucoma in aphakia due to congenital cataract surgery. Following an unintended accidental excision of AGV tube during bleb revision for hypertensive phase, AGV was explanted and a second AGV was implanted in the same quadrant after 2 weeks. This resulted in a rare complication of dynamic tube movement in the anterior chamber with tube corneal touch and localised corneal oedema. Excision of the offending unstable tube and placement of a paediatric AGV in a different quadrant led to resolution of this complication, stable vision and well-controlled intraocular pressure. This case highlights the possible causes of dynamic tube, related complications and its management. This case also highlights the importance of understanding the various physiological phases after glaucoma drainage device implantation and their appropriate management.
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Affiliation(s)
- Sirisha Senthil
- Department of Glaucoma, L V Prasad Eye Institute, Hyderabad, Andhra Pradesh, India
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12
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Allemann R, Stachs O, Falke K, Schmidt W, Siewert S, Sternberg K, Chichkov B, Wree A, Schmitz KP, Guthoff R. Neue Konzepte für druckgesteuerte Glaukomimplantate. Ophthalmologe 2013; 110:733-9. [DOI: 10.1007/s00347-013-2839-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Abstract
This paper describes methods for design, manufacturing and characterization of a micro-mechanical valve for a novel glaucoma implant. The implant is designed to drain aqueous humour from the anterior chamber of the eye into the suprachoroidal space in case of an elevated intraocular pressure (IOP). In contrast to any existing glaucoma drainage device (GDD), the valve mechanism is located in the anterior chamber and there, surrounded by aqueous humour, immune to fibrosis induced failure. For the prevention of hypotony the micro-mechanical valve is designed to open if the physiological pressure difference between the anterior chamber and the suprachoroidal space in the range of 0.8 mmHg to 3.7 mmHg is exceeded. In particular the work includes: (i) manufacturing and morphological characterization of polymer tubing, (ii) mechanical material testing as basis for (iii) the design of micro-mechanical valves using finite element analysis (FEA), (iv) manufacturing of microstent prototypes including micro-mechanical valves by femtosecond laser micromachining and (v) the experimental fluid-mechanical characterization of the manufactured microstent prototypes with regard to valve opening pressure. The considered materials polyurethane (PUR) and silicone (SIL) exhibit low elastic modulus and high extensibility. The unique valve design enables a low opening pressure of micro-mechanical valves. An ideal valve design for PUR and SIL with an experimentally determined opening pressure of 2 mmHg and 3.7 mmHg is identified. The presented valve approach is suitable for the inhibition of hypotony as a major limitation of today's GDD and will potentially improve the minimally invasive treatment of glaucoma.
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14
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Stahnke T, Löbler M, Kastner C, Stachs O, Wree A, Sternberg K, Schmitz KP, Guthoff R. Different fibroblast subpopulations of the eye: a therapeutic target to prevent postoperative fibrosis in glaucoma therapy. Exp Eye Res 2012; 100:88-97. [PMID: 22579993 DOI: 10.1016/j.exer.2012.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 04/20/2012] [Accepted: 04/23/2012] [Indexed: 12/17/2022]
Abstract
The aim of this study is the characterization of fibroblasts mainly responsible for fibrosis processes associated with trabeculectomy or microstent implantation for glaucoma therapy. Therefore we isolated human primary fibroblasts from choroidea, sclera, Tenon capsule, and orbital fat tissues. These fibroblast subpopulations were analysed in vitro for expression of the extracellular matrix components which are responsible for postoperative scarring in glaucoma therapy. For scarring the proteins of the collagen family are predominant and so we focused on the expression of collagen I, collagen III and collagen VI in every fibroblast subpopulation. Also, the extracellular matrix protein fibronectin which crosslinks collagen fibres or other extracellular matrix components and cell surfaces, was analyzed. Collagen I, III and VI were prominent in every fibroblast subpopulation. The highest amounts of collagen III were found in hCF and hOF, whereas the signal in hSF and hTF was negligible. Additionally, there is a link between scarring processes and proliferating potential of fibroblasts, in case of microstent implantation triggered through the infiltration of inflammatory cells. Thus we analyzed fibroblast subpopulations for the presence of TGF-β1 which is one of the most important cytokines involved in proliferation processes. TGF-β1 was prominent in all fibroblast subpopulations with lowest expression in hCF cultures. To prevent postoperative fibroblast proliferation we analyzed in vitro the proliferation-inhibitors paclitaxel and mitomycin C which are potential candidates in drug eluting drainage systems on ocular fibroblast subpopulations. These inhibitors arrest fibroblast proliferation and viability, being, however, not very specific and have a cytotoxic potential also on healthy tissues surrounding the microstent outflow area. Significant differences in protein synthesis of fibroblasts subpopulations which could be specific targets for inhibition may help to find out fibroblast specific inhibitors to prevent postoperative scarring and could prevent patients from secondary surgery after microstent implantation.
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Affiliation(s)
- Thomas Stahnke
- Department of Ophthalmology, University of Rostock, Doberaner Straße 140, D-18057 Rostock, Germany.
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15
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Suprachoroidal implant surgery in intractable glaucoma. Jpn J Ophthalmol 2011; 55:351-355. [DOI: 10.1007/s10384-011-0035-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 02/22/2011] [Indexed: 10/18/2022]
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16
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Lankaranian D, Razeghinejad MR, Prasad A, Fakhraie G, Freitas DJ, Ichhpujani P, Moster MR. Intermediate-term results of the Ex-PRESS miniature glaucoma implant under a scleral flap in previously operated eyes. Clin Exp Ophthalmol 2011; 39:421-8. [DOI: 10.1111/j.1442-9071.2010.02481.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Campbell RJ, Zhang YL, Campbell EDLP. New surgical technique for correcting tube-iris touch following glaucoma drainage implant surgery. Clin Exp Ophthalmol 2011; 39:572-5. [PMID: 21176043 DOI: 10.1111/j.1442-9071.2010.02484.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Glaucoma drainage implant surgery may be associated with a number of potential complications including tube malpositioning. This malpositioning may have serious sequelae such as corneal endothelial damage, chronic iritis, cataract formation or tube occlusion. Traditional management of tube malpositioning involves major surgical re-dissection and reinsertion of the tube. Alternatively, shortening of the tube within the anterior chamber can, in some circumstances, relieve tube contact with the endothelium or iris. However, these procedures are associated with important risks. We describe a new minimally invasive surgical technique for correcting posterior tube malpositioning that avoids the need to shorten the tube or re-dissect the conjunctiva. This technique is straightforward to perform and has successfully maintained proper drainage device tube position during more than 1 year of follow up.
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Affiliation(s)
- Robert J Campbell
- Department of Ophthalmology, Queen's University and Hotel Dieu Hospital, Kingston, Ontario, Canada.
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Abstract
The Trabectome provides a new perspective in angle surgery for open angle glaucoma. Through a 1.7 mm clear cornea tunnel, the juxtacanalicular meshwork is electroablated under gonioscopic control. Thereby, the collector channels in the outer wall of Schlemm's canal are uncovered and resistance to trabecular outflow is removed. From the literature and from our own experience, a pressure reduction by 30-35% can be achieved with a simultaneous reduction of eye drops by 50%. The Trabectome can conveniently be combined with phako-emulsification. Serious complications have not yet been reported. As the conjunctiva remains completely untouched, trabeculectomy, if necessary, could be performed without prognostic restrictions. With a realistic target pressure of approximately 16 mmHg, Trabectome surgery is indicated in patients with moderate optic nerve damage.
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Hong S, Lee JR, Choi JY, Choi J, Kim YD. Trabeculectomy With Biodegradable Collagen Material: A Report of Two Cases. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2010. [DOI: 10.3341/jkos.2010.51.6.912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Implantate. BIOMED ENG-BIOMED TE 2010. [DOI: 10.1515/bmt.2010.709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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21
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Guthoff R, Schmidt W, Buß D, Schultze C, Ruppin U, Stachs O, Sternberg K, Klee D, Chichkov B, Schmitz KP. Entwicklung eines Glaukommikrostents mit Drainage in den suprachoroidalen Raum. Ophthalmologe 2009; 106:805-12. [DOI: 10.1007/s00347-009-1929-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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