Needling Revision of Trabeculectomies

Wound modulation in glaucoma surgery: The role of anti-scarring agents

Filtration surgery is one of the most frequently performed surgeries in the management of glaucoma, and trabeculectomy is considered the gold standard surgical technique for the same. Though trabeculectomy has been reported to have an excellent initial success rate, about 30% of them fail in 3 years, and nearly 50% of them fail in 5 years. The most significant risk of failure still seems to be wound scarring, especially episcleral fibrosis, leading to bleb failure. As a result, it is essential to explore the role of anti-scarring agents, including mitomycin C, and 5-fluorouracil in wound modulation and improving the bleb survival rate. Since these agents are widely used in trabeculectomy, it is crucial to understand the various modes of application, advantages, and adverse effects of these agents. On an evidence-based approach, all these points have been highlighted in this review article. In addition, the newer agents available for wound modulation and their scope for practical application are discussed.

Ab interno trabeculectomy revision with 5-flourouracil for failed trabeculectomy in advanced glaucoma: 3-year outcomes

OBJECTIVE

To describe the 3-year outcomes of patients who underwent ab interno trabeculectomy revision with a translimbal sclerostomy spatula augmented with 5-flourouracil.

DESIGN

Retrospective cohort study.

PARTICIPANTS

In this single-centre study, inclusion criteria included patients who were 18 years of age or older with advanced glaucoma who had undergone ab interno trabeculectomy revision with 5-flourouracil due to subconjunctival fibrosis and above-target intraocular pressure (IOP). Patients were required to have a minimum follow-up of 3 years.

METHODS

The primary outcome measure was IOP. Secondary outcome measures included number of topical IOP-lowering medications, best-corrected distance visual acuity, visual field mean deviation, and postoperative complications.

RESULTS

Forty-one eyes of 41 patients met the criteria for inclusion. Survival analysis demonstrated success defined by criterion A (IOP <15 mm Hg and >20% reduction) in 44% of eyes without medication (complete success) and 71% of eyes with or without medication (qualified success) at 3-year follow-up. Complete and qualified successes defined by criterion B (IOP <12 mm Hg and >20% reduction) were achieved by 31% and 44% of eyes, respectively. Early complications included transient hypotony in 26 eyes (63%) and transient hyphema in 3 eyes (7.3%). No persistent complications were reported within the 3-year study period.

CONCLUSION

Ab interno trabeculectomy revision can be an effective technique for achieving a low target IOP in patients with advanced glaucoma in up to 3-year follow-up.

Treatment of filtration bleb dysfunction after glaucoma surgery by needle revision of filtration bleb combined with conbercept

Filtration surgery (Trabeculectomy) is the main treatment for glaucoma. The scarring of the filtration bleb and obstruction of the outflow of aqueous humor through the filtration channel are the main reasons of the surgery failure. The objective of this study was to determine the clinical efficacy of needle revision of filtration blebs combined with subconjunctival injection of conbercept on the functional bleb formation in glaucoma patients with eye pressure out of control after trabeculectomy. A total of 48 eyes with poor filtration bleb function after trabeculectomy for glaucoma were treated with needle revision of filtration bleb combined with subconjunctival injection of conbercept. After the treatment, the patients were followed up for 3 months during which visual acuity, intraocular pressure, slit lamp and ultrasound biomicroscope examinations were performed. Intraoperative and postoperative complications were recorded. The visual acuity and intraocular pressure were significantly improved after the needle revision of filtration blebs. Among the 48 eyes, 39 eyes still had functional blebs at the end of the follow-up period, and filtration blebs failed in 9 eyes 2 to 8 weeks after the removal of the needle. The survival rate of filtration blebs at 3 months after needle revision was (79.06 ± 3.42%), and 81.25% (39/48) of the eyes showed good formation rate of functional bleb at the last follow-up. Three months after needle revision, there was local scar formation in some filtration blebs. Part of the filtration blebs showed mild thickening of the local subconjunctival tissue, and the filtration bleb was slightly raised and diffuse, showing a multi-cavity and thin-walled shape in some blebs. Ultrasound biomicroscopy examination showed relative structural manifestations. Subconjunctival hemorrhage occurred in 43 patients during and after the operation. Low intraocular pressure occurred in 8 patients with the lowest pressure of 5 mm Hg. Choroidal edema was observed in 3 patients. Five patients had intraoperative conjunctival hemorrhage in the anterior chamber, and hyphema occurred. All complications were self-limited and resolved without surgical intervention. Needle revision of filtration bleb combined with anti-VEGF drugs is a safe and effective method for the treatment of filtration bleb dysfunction after surgery of glaucoma.

Comparison between Surgical Techniques Used for Revision of the Filter Bleb: A Randomized Controlled Clinical Trial

INTRODUCTION/PURPOSE

The aim of this study was to compare two surgical revision techniques in failed trabeculectomies after 6 months.

METHODS

Patients diagnosed with open-angle glaucoma who underwent trabeculectomy in at least one eye with uncontrolled intraocular pressure (IOP) after trabeculectomy performed at least 6 months before were enrolled in this prospective trial. All participants underwent a complete ophthalmological examination at baseline. Randomization was performed to one eye per patient to double-masked trabeculectomy revision or needling. Patients were examined on the first day, 7 days, 14 days, and then monthly until completing 1 year after surgical intervention. All follow-up visits included the following: patients reported ocular and systemic events, best-corrected visual acuity, IOP, slit-lamp examination, and optic disc evaluation for cup-to-disc ratio. Gonioscopy and stereoscopic optic disc photographs were taken at baseline and 12 months. After 1-year, the IOP and number of medications were compared between the groups. Absolute success criteria in the study were IOP <16 mm Hg, for 2 consecutive measurements without using a hypotensive medication.

RESULTS

Forty patients were included in this study. Among them, 38 completed 1-year follow-up (18 in revision group and 20 in needling group). The age ranged from 21 to 86 years, with a mean of 66.82 ± 13.44. At baseline, the average IOP was 21.64 ± 5.12 mm Hg (range from 14 to 38 mm Hg) in the entire group. All patients were using at least two classes of hypotensive eye drops, and 3 patients were using oral acetazolamide. The mean use of hypotensive eye drop medications was 3.11 ± 0.67 at the baseline for the entire group. In the present study, 58% of the patients presented complete success, 18% qualified success, and 24% failed in both groups. After 1-year treatment, both techniques were similar for IOP parameters and also for number of medications (p = 0.834 and p = 0.433, respectively). Regarding intra- or postoperative complications, one patient in each group needed a new surgical intervention, one in the needling group due to shallow anterior chamber and one in the revision group due to spontaneous Seidel sign, and one patient in the needling group underwent posterior revision due to fail.

CONCLUSIONS

Both techniques were safe and effective for IOP control after 1 year of follow-up in patients who underwent to trabeculectomy more than 6 months before.

Intraocular Pressure and Medication Changes Associated with Xen Gel Stent: A Systematic Review of the Literature

The Xen gel stent (Allergan Inc, an AbbVie company; Dublin, Ireland) was conceived as an option for patients requiring modest IOP reduction but for whom trabeculectomy was not yet indicated. As with any glaucoma surgery, establishing criteria for patient selection and identifying factors that contribute to a high likelihood of success are important. To help guide clinical decision-making, a systematic review of published studies on the gel stent was performed, with the goal of understanding postoperative outcomes based on clinical and patient factors. Results were organized around a series of pertinent clinical questions based on scenarios encountered in clinical practice. Criteria for including studies were intentionally broad, with the objective of simulating the diverse population of glaucoma patients encountered in real-world practice. Outcomes for IOP and medication reduction postoperatively were assessed in various analyses, including in eyes with various glaucoma types and severity; in eyes naïve to surgery as well as those with a history of prior incisional glaucoma surgery; and when surgery was performed as a standalone procedure or at the time of cataract surgery. The results of each of the various analyses were consistent in demonstrating that successful gel stent surgery achieved a postoperative IOP of approximately 14.0 mm Hg and reduction to fewer than 1 glaucoma medication. Additional data are shown on outcomes by method of implant (ab interno vs ab externo); intraoperative use of antifibrotics; and rates of needling in published studies.

Reintervention rate in glaucoma filtering surgery: A systematic review and meta-analysis

PURPOSE

Reintervention rate is an important factor impacting on patients, surgeons, and society. To date, only a few studies have focused on this topic. For this reason, a systematic review and meta-analysis was undertaken to assess the reintervention rate after glaucoma filtering surgery.

MATERIALS AND METHODS

Prospective studies reporting the reintervention rate after glaucoma filtering surgery and with at least 12 months of follow-up were systematically searched on PubMed, Medline and Embase databases. The primary outcome was the total reintervention rate following surgery. Secondary outcomes were: the rate of manipulation, in-clinic and in-operating room reintervention; the reintervention rate for intraocular pressure (IOP) control and for complications; demographic, clinical and surgical variables associated with reintervention rate.

RESULTS

Ninety-three studies with a total of 8345 eyes were eligible. The total reintervention rate was 1.84 (95% CI 1.57-2.13), with a lower rate for Baerveldt (0.53, 95% CI 0.29-0.83) and Preserflo (0.60, 95% CI 0.15-1.29), and a higher rate for Xen (4.26, 95% CI 2.59-6.31). The manipulation rate was 0.99 (95% CI 0.77-1.23), the in-clinic reintervention rate was 0.08 (95% CI 0.05-0.12) and the in-operating room reintervention rate was 0.28 (95% CI 0.22-0.35). The reintervention rate for IOP control was 1.26 (95% CI 1.04-1.51) and the reintervention rate for complications was 0.27 (95% CI 0.21-0.35).

CONCLUSIONS

All types of surgery presented a total reintervention rate similar to the overall findings, except studies on Baerveldt and Preserflo Microshunt, with a lower rate, and Xen, with a higher rate. None of the variables evaluated were found to be directly associated with the explored outcomes.

Surgeon Experience as a Risk Factor for Short-Term Failure for Ab Interno Gelatin Microstent: A Canadian Multicenter Propensity-Matched Study

PURPOSE

To compare the efficacy and safety of early versus later ab interno gelatin microstent placement with mitomycin C.

DESIGN

Canada-wide, multicenter, retrospective propensity score-matched cohort study.

PARTICIPANTS

Two hundred seventy eyes (135 early cases and 135 later cases) with no prior incisional surgery.

METHODS

Surgeons' first 20 patients (early cases group), from 6 glaucoma surgeons across 4 Canadian sites, were matched 1:1 to patients with the closest propensity score from the later (21+) patients (later cases group).

MAIN OUTCOME MEASURES

Primary outcome was hazard ratio (HR) of failure of the early versus later cases groups, with failure defined as IOP of less than 6 mmHg with more than 2 lines of vision loss or more than 17 mmHg with no medications (complete success) on 2 consecutive visits despite in-clinic maneuvers (including needling) more than 1 month after surgery. Secondary outcomes were HRs for failure, defined as IOP outside the range of 6 to 14 mmHg and 6 to 21 mmHg with and without allowing for medications (qualified success), interventions, complications, and reoperations.

RESULTS

Hazard ratio of failure for early versus later cases groups was 1.38 (95% confidence interval [CI], 0.97-1.96) for the IOP range of 6 to 17 mmHg, 1.29 (95% CI, 0.90-1.84) for 6 to 14 mmHg, and 1.48 (95% CI, 1.03-2.13) for 6 to 21 mmHg without medication and 0.95 (95% CI, 0.55-1.64), 0.95 (95% CI, 0.61-1.48), and 0.95 (95% CI, 0.52-1.75) for the same IOP ranges allowing for medications. Needling rates were 43.0% (early cases group) and 41.5% (later cases group). Complication rates after 1 month occurred in 9.6% (early cases group) and 11.1% (later cases group; P = 0.69). Reoperation rates were 14.8% (early cases group) and 8.1% (later cases group; P = 0.08).

CONCLUSIONS

There is some evidence for improved success in the later cases group. Similar needling rates, similar complication rates, and a slightly higher reoperation rate were found for the early cases group. The results suggest that this procedure can be adopted by existing surgeons with current training regimens, although they may see an improvement in their success outcomes over time.

Factors affecting the early and mid-term success of needling for early failure of filtering bleb

Purpose:

The purpose of this study is to evaluate the factors affecting the success of needling surgery for early filtering bleb failure after trabeculectomy.

Methods:

Patients who underwent a single needling surgery within 3 months after trabeculectomy were retrospectively evaluated. Glaucoma type, intraocular pressure (IOP), and medical treatments before trabeculectomy; the presence of hypotony after trabeculectomy; bleb type; IOP before needling; lens status; complications; IOP after 1, 6, and 12 months; and medical treatments after needling were recorded. Risk factors were evaluated for complete success at 1, 6, and 12 months after needling.

Results:

Thirty-three eyes of 33 patients were analyzed. The mean IOP after needling at 1, 6, and 12 months was 16.09 ± 3.70, 15.64 ± 2.68, and 15.79 ± 2.61 mmHg, respectively. The mean age of the patients was 53.97 (25–79) years. The mean IOP after needling at 1, 6, and 12 months was 16.09 ± 3.70, 15.64 ± 2.68, and 15.79 ± 2.61 mmHg, respectively. The pre-needling IOP and IOP decrease on the first day affected the complete and qualified success at 1, 6, and 12 months, but the glaucoma type, presence of hypotony after trabeculectomy, lens status, interval between trabeculectomy and needling, and bleb type were not found to affect success. In the receiver operating curve analysis, the pre-needling IOP value was found to be significant in determining complete success. Complete success at 1 month was more likely when the pre-needling IOP cutoff value was <24.5 mmHg.

Conclusion:

According to the results of single needling surgery performed within 3 months after trabeculectomy, the pre-needling IOP and IOP decrease with needling were found to be factors affecting success. Regardless of the time between the primary trabeculectomy and needling, effective needling will be successful before the IOP rises to high levels. Keeping the IOP at low values with medical treatment until the needling process is performed will have a positive effect on success.

Primary Needling of the Ab Interno Gelatin Microstent Reduces Postoperative Needling and Follow-up Requirements

PURPOSE

To evaluate the effect of primary needling at the time of ab interno gelatin microstent insertion on postoperative needling rates.

DESIGN

Retrospective, interventional cohort study.

PARTICIPANTS

Eighty-six eyes of 74 patients with no prior incisional surgery.

METHODS

Consecutive eyes with open-angle glaucoma refractory to medical treatment that underwent ab interno gelatin microstent insertion (XEN; Allergan Inc.) with or without primary needling.

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of eyes requiring postoperative needling. Secondary outcome measures included the mean reduction in intraocular pressure (IOP), topical glaucoma medication use, complications, reoperations, and number of follow-up clinic visits over 12 months.

RESULTS

Fifty-one eyes (42 patients, median age 74 years) underwent XEN surgery with primary needling at the time of surgery, and 35 eyes (32 patients, median age 73 years) underwent XEN surgery without routine primary needling. Eyes that received routine primary needling had an 84.8% lower rate of postoperative needling (3.9% vs. 25.7%, P = 0.003) and required fewer postoperative clinic visits (P = 0.043). Median IOP was 18.0 mmHg (interquartile range [IQR], 13.0-23.0) on 3.0 (IQR, 2.0-3.0) classes of topical medications at baseline. At 12 months, the median IOP was 11.0 mmHg (IQR, 9.0-14.0) in the primary needling group and 11 mmHg (IQR, 10.0-14.0) when primary needling was not routinely performed. Both groups demonstrated a high safety profile. In total, 5 eyes required further glaucoma surgery with insertion of a glaucoma drainage device.

CONCLUSIONS

Primary needling at the time of XEN gel stent insertion is associated with a significant reduction in the need for postoperative needling and postoperative clinic visits. This modification provides a predictable postoperative course with a significant and sustained reduction in both IOP and glaucoma medication requirements with less intense postoperative management.

Outcome of Bleb Needling With 5-Fluorouracil in Failed Filtering Procedures in Pediatric Glaucoma

PURPOSE

To determine the surgical outcomes of bleb needling and the risk factors of failure of needling after failed filtration surgeries in patients with pediatric glaucoma.

METHODS

The medical records of patients who underwent needling with 5-fluorouracil following filtering surgeries (trabeculectomy, combined trabeculectomy, and trabeculotomy) between January 2012 and December 2016 were retrospectively reviewed. At the 1-year follow-up visit, complete success and qualified success were defined as an intraocular pressure (IOP) of less than 18 mm Hg with and without antiglaucoma medication, respectively.

RESULTS

Forty-five eyes that underwent needling and fulfilled the study criteria were included in the analysis. The mean age at needling was 9.6 years. The mean time interval between filtration surgery and the first needling procedure was 57.3 days. Thirty-eight of 45 eyes (84.4%) had undergone needling within 3 months after the primary surgery. Cumulative success was achieved in 35 eyes (77.7%) after needling (complete success in 22 eyes and qualified success in 13 eyes). Mean follow-up after needling was 18.9 months. The mean IOP before and after needling was 31.7 ± 9.45 and 16.6 ± 5.68 mm Hg, respectively (P < .00001). Steroid-induced glaucoma (P = .01), high IOP prior to the first filtration surgery (P = .01), and an inability to achieve low IOP (< 9 mm Hg, P = .04) immediately after needling were significant risk factors associated with failure.

CONCLUSIONS

Bleb needling is an efficient method for lowering IOP after a failed trabeculectomy or combined trabeculectomy and trabeculotomy in the pediatric population. [J Pediatr Ophthalmol Strabismus. 2021;58(2):118-125.].

Efficacy and safety of 5-fluorouracil in infrared monitor guided bleb revision

Purpose

Infrared monitor-guided bleb revision (IRGBR), an alternative needling system, visualizes anterior-segment tissues around the bleb not visible during needle revision after trabeculectomy. This study determined the safety and efficiency of 5-fluorouracil (5-FU) as an adjunctive anti-metabolite in IRGBR.

Methods

We retrospectively analyzed 43 consecutive eyes (40 patients; 14 eyes, primary open-angle; 29 eyes, secondary glaucoma) treated with IRGBR for failing filtering blebs. The patients were divided into two groups. The first one had IRGBR without adjunctive 5-FU subconjunctival injection, and the second one had IRGBR with 5-FU. We performed Kaplan-Meier survival analysis using log-rank tests after 2 years of follow-up and Cox proportional hazards regression model to analyze the dependence of the survival time on predictor variables. Two failure criteria were defined as the need for additional surgery for intraocular pressure (IOP) reduction and the IOP at two consecutive follow-up visits based on definition 1, IOP ≧22 mmHg and definition 2, IOP ≧17 mmHg.

Results

Thirty eyes (29 cases) underwent IRGBR with subconjunctival 5-FU injection (group A in the second term) and 13 eyes (11 cases) without 5-FU (group B in the first term). The success rates 24 months after IRGBR were 73.3 and 23.1%, respectively, in groups A and B based on the definition 1 failure and 56.7 and 7.7% based on the definition 2 failure. Complications included transient bleb leaks (group A, 3 eyes; group B, none) and choroidal detachment (group A, 1 eye; group B, none). No use of 5-FU and IOPs ≧10 mmHg 1 week after IRGBR were significant risk factors.

Conclusions

Adjunctive 5-FU in IRGBR achieved a better success rate for failing trabeculectomy blebs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01843-4.

Prospective Evaluation of the First Mitomycin C Augmented Needle Revision in Patients With Failed Nonpenetrating Deep Sclerectomy

PRECIS

At 6 months the procedure achieved a 33.89% drop in intraocular pressure (IOP), had an overall success rate of 57.15%, and did not change the best-corrected visual acuity. Achieving <8 mm Hg of IOP the day after the procedure may be a prognostic success indicator.

PURPOSE

The purpose of this study was to evaluate the first mitomycin C (MMC)-augmented needle revision in patients with failed nonpenetrating deep sclerectomy (NPDS) and factors associated with its success.

MATERIALS AND METHODS

This prospective, nonrandomized comparative trial included 21 consecutive patients (21 eyes) who underwent their first MMC needling revision of failed NPDS blebs. The success was defined as absolute if the IOP decreased >20% from the preoperative value without antiglaucoma treatment and as qualified if that level was achieved with antiglaucoma medications. Preoperative and postoperative factors were evaluated for an association with postoperative success using Kaplan-Meier analysis.

RESULTS

A significant reduction in mean IOP from preoperative levels was evident at the end of the follow-up. The overall surgical success rate was 57.15%. On the basis of Kaplan-Meier survival analysis, we found that patients whose IOP on the following day of the procedure was <8 mm Hg had a higher success rate than those whose 1-day postoperative IOP was higher. These patients had a percentage of success of 100%, 84.6%, and 76.9% at 1-, 3-, and 6-month postoperative follow-up, respectively.

CONCLUSION

The IOP level on the first postoperative day could be considered a prognostic indicator of success in needling revision performed in failed NPDS.

Safety and Efficacy of Bleb Needling with Antimetabolite after Trabeculectomy Failure in Glaucoma Patients: A Systemic Review and Meta-Analysis

Background

Bleb needling with subconjunctival injection of antimetabolites had become a widely accepted approach for trabeculectomy failure. However, IOP reduction effects, success rates, and complications occurrence for this procedure showed great inconsistency among the different studies.

Methods

We conducted a literature search on PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. A random-effects model was performed on the extracted data based on the included studies. The intraocular pressure (IOP) and number of antiglaucomatous medications before and after the surgery were pooled for meta-analysis. The success and complication rates were estimated based on the results. Subgroup analysis, sensitivity analysis, and metaregression were applied to explore the origination of heterogeneity.

Results

Thirty-seven studies with a total of 2182 patients were finally included in our review. For the present meta-analysis, the overall effects of bleb needling at the last visit revealed a reduction in IOP of 9.74 mmHg (95% confidence interval (CI) [8.85, 10.63]), 45.9% (95% CI [39.0%, 53.0%]) for complete success rate, and 70.4% (95% CI [63.5%, 77.0%]) for qualified success rate. Application of mitomycin C (MMC) and 5-fluorouracil (5-Fu) during the procedure were efficacious for IOP control during the follow-up. Metaregression revealed that possible origination of heterogeneity was baseline IOP before bleb needling, revealing a trend that higher baseline IOP correlated with a greater IOP reduction results (p < 0.001). For safety profile, conjunctival haemorrhage (5.7%, 95% CI [2.5%, 10.1%]), hyphema (5.5%, 95% CI [3.0%, 8.7%]), and bleb leakage (5.0%, 95% CI [3.2%, 7.3%]) had the highest estimate of incidence. An increasing number of needling was the main risk factor for needling failure.

Conclusion

Bleb needling with antimetabolites could be considered an effective and safe procedure after trabeculectomy failure. After the process, patients will gain IOP control and reduce antiglaucomatous medications for at least six months with 5-Fu or MMC. Meanwhile, the overall estimates for complications were relatively low in the whole process.

Needling after XEN gel implant: What's the efficacy? A 1-year analysis

PURPOSE

To analyse the long-term efficacy and safety of bleb needling in glaucoma patients previously submitted to XEN implantation.

METHODS

Retrospective, observational study. Charts from patients who underwent XEN gel implant surgery between October 2015 and December 2017 were reviewed. Needling protocol involves use of Mitomycin C 0.2 mg/mL in an operating room. Primary outcome was defined as intraocular pressure (IOP) lowering efficacy at 12 months post-operative. Complete success was defined as a decrease in IOP > 20% and overall value <18 mmHg. Secondary outcomes included safety parameters (both intra and post-operative). Exploratory analysis of predictive factors for success were performed. Statistical analysis was performed using SPSS version 24.

RESULTS

About 94 charts were reviewed, with 18 patients (19%) having undergone needle revision. This salvage procedure was performed after 3.3 ± 3.4 months, achieving a mean IOP reduction of 8.3 ± 8.4 mmHg at 12 months after the procedure (pre-needling: 24.0 ± 5.2 mmHg vs 12th month: 13.5 ± 5.9 mmHg, p < 0.0001). Accordingly, success was achieved in 72% (complete success in 61% of cases). Among predictive factors, there was a higher tendency for success in patients on two types of medications or fewer pre-operatively, cases of standalone XEN surgery and patients with a higher IOP difference pre-needling - day 1. No vision-threatening complications were recorded.

CONCLUSION

XEN salvage procedure with mitomycin C is a valid option in early bleb failure. This single intervention had a long-lasting effect on bleb survival, with almost two-thirds achieving long term significant drop-free IOP reduction.

Long-Term Outcomes from an Intraoperative Bleb Needling Procedure Augmented with Continuous Infusion

PURPOSE

To investigate long-term outcomes of a modified bleb needling technique performed in the operating room in controlling intraocular pressure (IOP) and to report risk factors for procedure failure.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

One hundred six eyes of 98 consecutive patients undergoing intraoperative bleb needling with a continuous infusion of balanced salt solution at the Wilmer Eye Institute, Johns Hopkins Hospital, in the setting of a failed trabeculectomy or express shunt, between May 2011 and December 2015.

METHODS

Postoperative data were collected between May 2011 and August 2019. Success was defined as achieving a previously determined target IOP regardless of (qualified success) or without (complete success) glaucoma medications. Patients who underwent additional glaucoma surgery were censored in the survival analysis.

MAIN OUTCOME MEASURES

Primary outcome measures included IOP, attainment of target IOP, and number of glaucoma medications used at different time points pre- and post-operatively.

RESULTS

Needling was performed in 106 eyes at an average of 4.3 years from the time of trabeculectomy (standard deviation [SD], 6.5 years) and an average baseline IOP of 20.7 mmHg (SD, 7.2 mmHg). Further glaucoma surgery was required for 33 eyes. We observed a 70% qualified success rate with a mean IOP lowering of 25% (95% confidence interval [CI], 13.8%-36.4%) at 1 year after surgery and a 52% qualified success rate and 44.3% reduction in IOP (95% CI, 34.9%-53.6%) at 5 years after surgery. Nearly half and a third of the eyes did not require medications after 1 and 5 years, respectively. The average medication reduction was 0.8 at year 1 (95% CI, 0.5-1.1) and 0.4 at year 5 (95% CI, -0.2 to 1.0). Postoperative complications were uncommon. Poorer outcomes were not associated with the age of the bleb but were more likely in Black patients.

CONCLUSIONS

Reductions in IOP were maintained in most patients over the long term using a modified bleb needling technique, despite an average time from trabeculectomy of over 4 years. No significant adverse events were observed. Bleb needling may defer or avoid more invasive procedures such as tube-shunts or repeat trabeculectomy.

Needling revision with marking maneuver to locate the scleral flap

PURPOSE

To report a variation of the classical needle revision maneuver with an external marking of the scleral flap, augmented with mitomycin C (MMC) in failed non penetrating deep sclerectomy (NPDS).

METHOD

This observational prospective pilot study included five consecutive patients who underwent an MMC needling revision of failed NPDS with the external marking of the scleral flap. All participants underwent a complete ophthalmologic examination and data were collected preoperatively as well as 1 day, 1 week and 1 month after the surgery. The surgical site was also evaluated during the procedure.

RESULTS

A significant reduction of IOP and antiglaucomatous medication from preoperative levels was detected at the end of the follow-up period. Regarding the surgical site, we succeed in locating the scleral flap and observing the bleb formation in all cases. No significant subconjunctival bleeding was detected.

CONCLUSION

This variation of the classical needling technique seems to improve intrasurgical visualization and reduces complications, which might lead to an improvement in surgical success.

Characteristics of the Filtering Bleb and the Agreement between Glaucoma Specialist and Anterior Segment-Optical Coherence Tomography Assessment

INTRODUCTION

This study aimed to evaluate the characteristics of the filtering bleb in failed late trabeculectomy and the agreement between glaucoma specialist assessment and anterior segment-optical coherence tomography (AS-OCT) system assessment in terms of the presence of subconjunctival fluid in the filtering bleb.

METHODS

Patients with a diagnosis of glaucoma who were scheduled to undergo trabeculectomy in at least one eye and with uncontrolled intraocular pressure (IOP) were enrolled. All participants underwent a complete ophthalmological examination. The presence of fluid under the filtering bleb was first evaluated by a glaucoma specialist using biomicroscopy evaluation and then using the OCT 1000 AS-OCT Version 3.0.1.8 (Carl Zeiss Meditec, Dublin, CA, USA) system. A Kappa statistical test was used to evaluate the agreement between AS-OCT and the examiner. The correlation between conjunctiva and tenon thickness and clinical parameters was also assessed.

RESULTS

Forty eyes of 40 patients were evaluated in this study. The ages ranged from 21 to 86 years, with a mean of 66.55 ± 12.33. The average IOP was 21.20 ± 4.44 mm Hg (range 14-38 mm Hg) in the entire group. The mean thickness of the conjunctiva and tenon was 302.03 ± 406.76 µm (range 251-1,616 µm). There was a significant negative correlation between the mean thickness of the conjunctiva and tenon and IOP (p = 0.045; confidence interval = -0.558, 0.024). Additionally, there was a significant negative correlation between the mean thickness of the conjunctiva and tenon, and the number of medications used at baseline (p = 0.043; confidence interval = -0.538, 0.051). There was significant negative correlation between the horizontal measurement of the bleb and the use of glaucoma medications (p = 0.017; confidence interval = -0.560, 0.004). A total of 26 patients were determined to have fluid by the examiner (glaucoma expert), and the presence of fluid in AS was confirmed in 19 patients by AS-OCT. Of the 14 patients who were determined to have an absence of fluid, this was confirmed by AS-OCT in 7 patients (Kappa = 0.231; agreement of 65.00%).

CONCLUSION

There is fair agreement between glaucoma specialist assessment and AS-OCT assessment in terms of the presence of fluid in trabeculectomy. Our findings highlight the importance of AS-OCT in some patients before deciding upon a new intervention.

Anatomical and physiological considerations in scleral lens wear: Conjunctiva and sclera

While scleral lenses have been fitted using diagnostic lenses or impression moulding techniques for over a century, recent advances in anterior segment imaging such as optical coherence tomography and corneo-scleral profilometry have significantly improved the current understanding of the anatomy of the anterior eye including the morphometry of the conjunctiva, sclera, and corneo-scleral junction, as well as the ocular surface shape and elevation. These technological advances in ocular imaging along with continual improvements and innovations in scleral lens design and manufacturing have led to a global increase in scleral lens prescribing. This review provides a comprehensive overview of the conjunctiva and sclera in the context of modern scleral lens practice, including anatomical variations in healthy and diseased eyes, the physiological impact of scleral lens wear, potential fitting challenges, and current approaches to lens modifications in order to minimise lens-induced complications and adverse ocular effects. Specific topics requiring further research are also discussed.

Measures to prevent the risks associated with exposure to cytostatic drugs in glaucoma filtering surgery

INTRODUCTION

The use of cytostatic drugs such as Mitomycin C and 5-Fluorouracil is well-known in glaucoma filtering surgery, as well as the management of its complications. However, there is a lack of information regarding the preventive measures to be taken by the professional that handles these types of substances.

OBJECTIVE

Raise awareness among professionals of the risks associated with the use of cytostatic drugs without adequate prevention measures.

RESULTS

Review of the available literature and legislation on preventive measures in the management of cytostatic drugs in the medical and ophthalmological field.

CONCLUSIONS

The prevention and awareness of the risks of the qualified professionals that handle these substances is the most important measure to prevent the possible risks. Coordination is necessary with the Occupational Health teams of the Hospital, as well as the professionals and staff involved in the different phases of the process, from the preparation in Hospital Pharmacy to its elimination.

Comparison of Efficacy and Safety of Bleb Needle Revision With and Without 5-Fluorouracil for Failing Trabeculectomy Bleb

PRéCIS:: Bleb needle revision with and without 5-FU showed similar success rates over the course of a long-term follow-up. A greater total number of needle revisions was identified as a risk factor for procedural failure.

PURPOSE

The purpose of the study was to investigate the efficacy and safety of bleb needle revision with adjunctive 5-fluorouracil (5-FU) subconjunctival injection in large-scaled patients with failing trabeculectomy bleb.

MATERIALS AND METHODS

A retrospective chart review was performed on a total of 113 eyes of 106 subjects who had undergone trabeculectomy followed by needle revision and been followed up for at least 6 months. The subjects were divided into 2 groups according to whether they had also undergone concurrent adjunctive 5-FU subconjunctival injection. Two definitions of failure were derived irrespective of IOP-lowering medication use and were assessed at each follow-up visit: (1) IOP>21 mm Hg or >85% of preoperative IOP or reoperation for glaucoma, (2) IOP>18 mm Hg or >80% of preoperative IOP or reoperation for glaucoma.

RESULTS

A total of 78 eyes of 73 subjects underwent the simple needle revision procedure and 35 eyes of 33 subjects underwent needle revision with subconjunctival 5-FU injection. There was no significant adverse event for either group and no significant IOP difference in any of the observational periods between them (P=0.867). There was also no statistically significant difference in the total number of IOP-lowering medications between the groups (P=0.199). The success rate at 24 months after the first needle revision was 45.6% (95% CI: 33.7, 56.7) in simple revision group and 44.6% (95% CI: 27.7, 60.2) in 5-FU needle revision group by failure 1, 36.3% (95% CI: 25.4, 47.2) and 32.9% (95% CI: 18.0, 48.6) by failure 2, respectively. A greater total number of needle revisions was the significant risk factors for needle revision failure (HR=2.25 and P=0.001 according to failure 2).

CONCLUSIONS

Bleb needle revision with 5-FU subconjunctival injection is a safe procedure for failing trabeculectomy bleb. Bleb needle revision with and without 5-FU were equally likely to succeed.

Needling With 5-Fluorouracil (5-FU) After XEN Gel Stent Implantation: 6-Month Outcomes

PURPOSE

The purpose of this study was to evaluate frequency, safety, and efficacy of needling in patients that underwent XEN Gel Stent implantation.

METHODS

Retrospective case review of 19 eyes of 57 consecutive patients (61 eyes) with primary open-angle glaucoma or pseudoexfoliative glaucoma that previously underwent implantation of XEN45 alone or in combination with cataract surgery followed by needling procedure with 5-FU. Success was defined at 2 IOP levels: ≤21 mm Hg and ≤15 mm Hg, with or without additional glaucoma medications. Treatment failure was defined as IOP>21 mm Hg or <5 mm Hg, need for additional glaucoma surgery or loss of light perception.

RESULTS

Totally 19 of 61 eyes that underwent XEN gel implantation had subsequent needling and were included. Preneedling IOP was 26.2±9.5 and postneedling IOP at last follow-up 15.4±3.7 mm Hg (P=0.0001). Overall success rates of 17 (90%) and 13 eyes (69%) were observed at the ≤21 mm Hg and ≤15 mm Hg level, respectively. Preneedling and postneedling visual acuity and number of medications remained unchanged (P>0.05). Two eyes (10%) were categorized as treatment failures. No major complications occurred. Mean follow-up was 203.8±142.2 (range, 22 to 456) days.

CONCLUSIONS

Needling revision following XEN gel stent implantation showed a good IOP-lowering effect without significant increase in number of antiglaucoma medications, decrease in visual acuity, nor any major complications. Further studies with long-term follow-up and a larger number of patients are needed to fully assess the safety and efficacy of this procedure.

XEN® Gel Stent in Medically Refractory Open-Angle Glaucoma: Results and Observations After One Year of Use in the United States

Introduction

The purpose of this study was to evaluate intraocular pressure (IOP) lowering and safety of XEN^® stent in medically refractory, progressive, open-angle glaucoma (OAG).

Methods

Forty-seven eyes of 42 patients were treated with XEN^® stent alone or combined with phacoemulsification.

Results

Mean IOP decreased from 22.34 ± 7.34 mmHg to 12.91 ± 4.21, 12.95 ± 4.36, 13.49 ± 3.91, and 13.36 ± 3.63 mmHg at 1, 3, 6, and 12 months (95% confidence interval [CI] [20.24, 24.44], [11.71, 14.12], [11.63, 14.27], [12.36, 14.62], and [12.10, 14.62]), respectively. Mean number of medications decreased from 2.96 ± 1.20 (95% CI [2.62, 3.30]) at baseline to 0.75 ± 1.27 (95% CI [0.31, 1.19]) at 1 year. At 1 year (n = 32), complete success was achieved in 68.8% (n = 22/32) (i.e., IOP reduction ≥ 20% and IOP < 18 mmHg without medication or any secondary glaucoma intervention). Qualified success was achieved in 90.6% (n = 29/32) (i.e., IOP reduction of ≥ 20% and IOP < 18 mmHg with and without medication or any secondary glaucoma intervention). Eleven eyes had not yet reached 12 months. Two patients (three eyes) died before 1 year; one patient (one eye) was lost to follow up. Adverse events: localized choroidal hemorrhage in one eye; hypotony (IOP < 6 mmHg) at day 1 in 10 eyes, with full resolution by 2 weeks. No persistent hypotony or maculopathy occurred. Stent erosion with removal occurred in two eyes. Fourteen eyes (29.8%) underwent needling. One patient required trabeculectomy.

Conclusions

XEN^® stent is effective and relatively safe surgery for medically refractory, progressive, OAG out to 1 year. Intraocular pressure and medications were significantly reduced.

Two-Year Outcomes of XEN Gel Stent Surgery in Patients with Open-Angle Glaucoma

PURPOSE

To evaluate the 2-year treatment outcomes of the XEN gel stent (Allergan, Inc, Irvine, CA) in glaucoma patients.

DESIGN

Prospective, single-center interventional study.

PARTICIPANTS

One hundred forty-nine eyes of 113 patients with open-angle glaucoma.

METHODS

Consecutive eyes with uncontrolled intraocular pressure (IOP) or signs of disease progression despite medical treatment were included to undergo either standalone XEN implantation or combined XEN implantation plus phacoemulsification surgery, both with mitomycin C injections.

MAIN OUTCOME MEASURES

Primary efficacy outcome was success, defined as complete when the unmedicated IOP was 12 mmHg or less, 15 mmHg or less, or 18 mmHg or less and 20% lower than at baseline over the 2-year period and defined as qualified when the IOP fulfilled the same conditions with fewer medications than at baseline. Secondary measures were mean reduction in IOP and in the number of medications and the rates of reoperations.

RESULTS

One hundred nine eyes (84 patients; mean age, 74.3 years) underwent XEN plus phacoemulsification surgery and 40 eyes (29 patients; mean age, 74.7 years) underwent standalone XEN surgery. Overall, 129 eyes (86.6%; 96 eyes of 75 XEN plus phacoemulsification patients and 33 eyes of 24 XEN standalone surgery patients) completed the study. Mean medicated IOP was 20.0±7.5 mmHg at baseline and 14.1±3.7 mmHg at 2 years (P < 0.01), a 29.3% IOP reduction. Mean number of medications dropped from 2.0±1.3 before surgery to 0.6±0.9 at 2 years (P < 0.001). Complete success was achieved in 18.2% of eyes using the 12 mmHg or less and 20% reduction criteria and in 44.4% using the 15 mmHg or less threshold. Needling with mitomycin C was performed in 58 eyes (45%). In all, 11.4% underwent reoperations.

CONCLUSIONS

After 2 years, XEN gel stent surgery achieved a clinically and statistically significant reduction both in IOP and the number of antiglaucoma medications, while requiring a high rate of needling interventions.

Outcomes of Wider Area Bleb Revision Using Bleb Knife With Adjunctive Mitomycin C

PRECIS

Wider area bleb revision using bleb knife with adjunctive mitomycin C (MMC) had a good success rate, according to strict success criteria, except in patients with neovascular glaucoma (NVG).

PURPOSE

We determined the efficacy of wider area bleb revision after filtering surgery using bleb knife with adjunctive MMC.

PATIENTS AND METHODS

In this retrospective single-center study, we analyzed 86 patients with glaucoma (46 primary open-angle, 18 exfoliations, 13 secondary, and 9 neovascular) after bleb revision using bleb knife with adjunctive MMC after a minimum follow-up of 6 months. A Kaplan-Meier survival analysis with log-rank tests and Cox proportional hazards regression analyses were performed. The main outcome measure was a successful initial bleb revision using bleb knife with adjunctive MMC, arbitrarily defined as intraocular pressure (IOP) control <15 mm Hg without any IOP-lowering medication, additional bleb revision, or glaucoma surgery.

RESULTS

The mean time since the initial filtering surgery was 243.8 days, and the mean prebleb revision IOP was 22.0±4.8 mm Hg. The total cumulative success rate of the bleb revision using bleb knife with MMC was 49% at 6 months and 30% at 1 year. Patients with primary open-angle glaucoma had the best success rate (64% at 6 mo and 40% at 1 y). Log-rank tests revealed that patients with NVG had the worst prognosis (P<0.01). NVG was the only significant risk factor identified for short survival time (odds ratio, 167.10; 95% confidence interval, 1.78-15620.44; P=0.027).

CONCLUSION

Wider area bleb revision using bleb knife with adjunctive MMC had a good success rate, according to strict success criteria, except in patients with NVG.

Needle revision outcomes after glaucoma filtering surgery: survival analysis and predictive factors

Purpose:

To evaluate the efficacy and safety of needle revision and examine factors predictive of failure.

Methods:

In total, 157 eyes of 131 patients that underwent needle revision augmented with either 5-fluorouracil or betamethasone for trabeculectomy failure were included in this retrospective study. Complete failure was defined as additional glaucoma surgery, ciliodestructive procedures, loss of light perception, sight-threatening complications, hypotony maculopathy, and surgical bleb revision. Success was defined as intraocular pressure ⩽ 18 (criterion A), ⩽15 (criterion B), and ⩽12 mmHg (criterion C) reached with (qualified) or without (complete) medications, and absence of any criteria of complete failure.

Results:

The median (interquartile range) follow-up was 25.0 (41.0) months. Complete failure rates were 19%, 26%, and 31% at 1, 2, and 3 years, respectively. For criterion A, qualified and complete success rates were, respectively, 77% and 69% at 1 year, 66% and 51% at 2 years, and 60% and 47% at 3 years. For criterion B, qualified and complete success rates were, respectively, 67% and 61% at 1 year, 48% and 42% at 2 years, and 44% and 39% at 3 years. For criterion C, qualified and complete success rates were, respectively, 43% and 41% at 1 year, 27% and 25% at 2 years, and 24% and 23% at 3 years. High baseline intraocular pressure and primary surgery were associated with higher and lower risks of complete failure, respectively.

Conclusion:

Needle revision is an effective and safe procedure to rescue failing trabeculectomy postponing or avoiding further glaucoma surgery. Eyes with low target intraocular pressure may have poor long-term outcomes.

Identifying the predictors of needling after XEN gel implant

PURPOSE

To identify factors associated with probability of needling after XEN implant.

METHODS

Analysis of data from prospective case series of patients with standalone XEN implant or combined XEN + cataract. Primary outcome was to determine whether postoperative day 1 and week 1 intraocular pressure (IOP), type of glaucoma, and glaucoma severity affected probability and number of needling interventions required.

RESULTS

A total of 149 eyes of 113 patients were included in the analysis. In the XEN alone group, mean IOP at day 1 and week 1 was 9.70 ± 5.43 and 10.33 ± 4.41 mmHg, respectively. Eyes with lower IOP on day 1 were less likely to require needling (Odds ratio; OR, 1.14; 95% CI, 1.02-1.28; p = 0.02). A similar association (OR, 1.15; 95% CI, 1.06-1.26; p = 0.001) was observed between day 1 IOP in and number of needling interventions. In the XEN + cataract group, mean IOPs at day 1 and week 1 were 13.75 ± 7.52 and 11.81 ± 5.36 mmHg, respectively. No significant association was noted between early postoperative IOP and probability or number of needling in this group. With IOP > 20 mmHg the probability of needling was ~ 80%. This number decreased to 35% if day 1 IOP was < 10 mmHg.

CONCLUSION

Postoperative day 1 IOP is a predictor for needling in patients undergoing standalone XEN implantation. These results suggest that surgeons should not wait too long to intervene via needling if IOP in the early postoperative period is in the high teens or above. Type or severity of glaucoma did not influence the probability of needling or number of needling interventions required.

Objective documentation of anterior chamber depth following trabeculectomy and its correlation with intraocular pressure and bleb functionality

The purpose of this study was to objectively evaluate the anterior chamber depth (ACD) after trabeculectomy and to correlate its variations with the intraocular pressure (IOP) and bleb functionality.Fifty eyes (46 patients) were included in this prospective study. ACD was documented with the use of a non-contact optical device (IOL Master-Carl Zeiss Meditec) and IOP was measured with the Goldmann applanation tonometer.Ophthalmological examination, IOP, and ACD measurements were performed before surgery, the day after and weekly thereafter.Linear regression Analysis between the 2 variables was performed and correlation coefficients were estimated. A 2-tailed t test was used and a P value < .05 was considered as statistically significant.Correlation coefficients between ACD and IOP, during the follow-up period, resulted in a moderate to strong positive relationship (r = 0.2-0.7), which since the 1st week resulted statistically significant at 5%.Twenty seven eyes (54%) needed at least 1 needling procedure. Considering each group separately, until the 3rd post-op week, the correlation coefficients in the needling group resulted higher than those in the non-needling group. Furthermore, in the needling group, the relationship between ACD and IOP, for the 1st, 2nd, 3, and 4th week was statistically significant at 5%.The objective documentation of the ACD in the early post-trabeculectomy period presents a moderate to strong positive correlation with the IOP.Furthermore, the brisk deepening of the ACD during the first 2 to 4 post-operative weeks is strongly correlated with the increase of the IOP and early signs of bleb encapsulation.

Treatment Outcomes of Mitomycin C-Augmented Trabeculectomy, Sub-Tenon Injection versus Soaked Sponges, after 3 Years of Follow-up: A Randomized Clinical Trial

PURPOSE

To report the 3-year outcome of trabeculectomy with mitomycin C (MMC)-soaked sponges versus intra-Tenon injection of MMC in eyes with uncontrolled primary open-angle glaucoma.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Eighty-two consecutive patients with uncontrolled primary open-angle glaucoma.

METHODS

Participants were randomized either to intra-Tenon injection of 0.1 ml of 0.01% MMC (TI group) or 0.02% subconjunctival application of MMC-soaked sponges (TS group). Patients were followed up for 3 years after surgery. The data for 73 eyes were included in the final analysis.

MAIN OUTCOME MEASURES

The primary outcome measure was the surgical success, defined as intraocular pressure (IOP) more than 5 mmHg and <21 mmHg, and IOP reduction of 20% or more from baseline, no reoperation for glaucoma, and no loss of light perception vision. Secondary outcome measures were IOP, glaucoma medications, best-corrected visual acuity (VA), bleb morphologic features according to the Indiana Bleb Appearance Grading Scale, complications, and endothelial cell count changes.

RESULTS

The cumulative probability of success at 3-year follow-up was 72.2% in the TI group and 65.1% in the TS group (P = 0.30). Uncontrolled IOP was the most common reason for failure. The mean preoperative IOP was 22.4±4.6 mmHg with an average of 3.1±1.0 medications. At 3 years, final IOP was 15.3±3.7 mmHg in the TI group and 16.4±3.5 mmHg in the TS group (P = 0.55). Mean glaucoma number of medications was 0.9±1.1 and 1.1±1.1 in the TI and TS groups, respectively (P = 0.54). Blebs tended to be more diffuse (P = 0.032), less vascularized (P = 0.013), and more shallow (P = 0.012) after intra-Tenon injection. Visual outcomes and endothelial cell changes were similar in both groups (P = 0.47 and P = 0.94, respectively).

CONCLUSIONS

Although the success rate and IOP reduction were comparable with both techniques, bleb morphologic parameters were more favorable after intra-Tenon injection of 0.1 ml of 0.01% MMC.

Comparison of intensity, phase retardation, and local birefringence images for filtering blebs using polarization-sensitive optical coherence tomography

Polarization-sensitive optical coherence tomography (PS-OCT) allows the recording of depth-resolved polarimetric measurements. It has been reported that phase retardation and local birefringence images can noninvasively detect fibrotic area in blebs after glaucoma surgery. Evaluation of scar fibrosis in blebs is important not only for predicting bleb function, but also for planning revision trabeculectomy. Herein, we characterize the intensity, phase retardation, and local birefringence images of blebs using PS-OCT. A total of 85 blebs from 85 patients who had undergone trabeculectomy were examined. Both phase retardation and local birefringence images detected fibrotic changes in blebs after glaucoma surgery. Phase retardation images detected slight fibrotic change during the early stage after surgery, whereas local birefringence images showed localized fibrotic tissue. There are two main patterns of local birefringence image changes in blebs: plate-like birefringence changes and diffuse changes. The area of plate-like birefringence change was significantly larger in poorly functioning blebs and is thus correlated with bleb function. These data suggest that the plate-like fibrotic change evaluation by PS-OCT may be useful not only for noninvasive evaluation of fibrotic scar tissue in blebs, but also for developing strategies for revision trabeculectomy.

Factors predicting the success of trabeculectomy bleb enhancement with needling

BACKGROUND

Bleb needling is widely used to restore flow and lower intraocular pressure (IOP) in a failing trabeculectomy. We aimed to measure the safety and efficacy of needling in a large cohort and identify factors that were associated with success and failure.

METHODS

This retrospective audit included all patients who underwent needling at Addenbrooke's Hospital, Cambridge over a 10-year period. Data were available on 91 patients (98% of patients identified), including 191 needlings on 96 eyes. Success was defined as IOP below 21 mm Hg or 16 mm Hg or 13 mm Hg consistently, without reoperation or glaucoma medication. Risk factors for failure were assessed by Cox proportional hazard regression and Kaplan-Meier curves.

RESULTS

Success defined as IOP <16 mm Hg was 66.6% at 12 months and 53% at 3 years and success defined as IOP <21 mm Hg was 77.1% at 12 months and 73.1% at 3 years. Failure after needling was most common in the first 6 months. Factors that predicted failure were flat or fibrotic blebs (non-functional) and no longer injected, while success was predicted by achieving a low IOP immediately after needling. No significant complications were identified.

CONCLUSION

Needling was most successful soon after trabeculectomy, but resuscitation of a long-failed trabeculectomy had lower likelihood of success. The safety and efficacy compare favourably with alternative treatment approaches.

Trabeculectomy bleb needling and antimetabolite administration practices in the UK: a glaucoma specialist national survey

AIMS

To evaluate, describe and quantify the diversity in postoperative antimetabolite administration and bleb needling practices among glaucoma specialists performing trabeculectomy surgery within the UK and Ireland.

METHODS

A cross-sectional online survey was distributed to all consultant glaucoma specialists who are on the United Kingdom and Eire Glaucoma Society (UKEGS) contact list. Participants were asked specific questions about their current practices for post-trabeculectomy antimetabolite administration followed by questions directly related to bleb needling procedures.

RESULTS

60 (83%) of UKEGS glaucoma subspecialty consultants completed the survey. 70% of respondents administered 5-fluorouracil (5-FU) in their clinic room while 30% used a separate treatment room. Doses of 5-FU varied considerably but 70% used 5 mg as standard. Techniques used to reduce corneal toxicity included precipitation with amethocaine (44%) or benoxinate (14%), saline wash (14%) and modified injection technique (8%). Topical antibiotics and/or betadine were used to prevent infection following 5-FU injection in just over 50%. Bleb needling was exclusively performed in operating theatre by 56% of respondents and solely at the slit lamp in the clinic room by 12%. A further 30% used a combination of both theatre and outpatient clinic rooms. Anti-metabolites used were 5-FU (72%) and mitomycin C (22%) with 12% using either of the two substances.

CONCLUSIONS

There is a significantly wide variety of current practices for antimetabolite administration and bleb needling within the UK and Ireland. This may be influenced by a glaucoma surgeon's specific experience and audit results as well as particular clinical set-up, availability of antimetabolite and clinic room space.

Posterior Surgical Revision of Failed Fornix-based Trabeculectomy

PURPOSE

To evaluate outcomes after revision of failed fornix-based trabeculectomy using a posterior conjunctival incision and mitomycin C.

METHODS

Cases were identified using Current Procedural Terminology codes. Information from clinical records was analyzed retrospectively. Complete success was defined as intraocular pressure (IOP) ≤16 mm Hg with no glaucoma medications and IOP reduction of >20% from preoperative levels. Qualified success was defined as IOP≤16 with or without medications and IOP reduction of >20%. Secondary outcomes included IOP, number of glaucoma medications used, visual acuity, and complications.

RESULTS

Sixty eyes of 56 patients underwent surgical revision of failed trabeculectomy. The complete success rate at 1 year was 43.7%, declining to 41.7% at 2 years and all time points up to 5 years; qualified success rates were 68.9% at 1 year and at all subsequent time points. Mean IOP declined from 21.2±7.7 (SD) mm Hg preoperatively to 10.9±4.3 mm Hg at 1 year, to 10.5±3.8 mm Hg at 2 years, and to 9.9±4.6 mm Hg at 3 years. The mean number of glaucoma medications used fell from 2.5±0.5 preoperatively to 1.0±0.4 at 1 year, 0.9±0.4 at 2 years, and 0.9±0.4 at 3 years. Complications included bleb leak in 3 eyes (5.0%), hypotony with choroidal detachment in 3 eyes (5.0%) and hyphema in 1 eye (1.7%). Eight eyes required additional glaucoma surgery.

CONCLUSIONS

Surgical bleb revision with mitomycin C using a posterior incision in cases of failed fornix-based trabeculectomy can provide effective control of IOP. This conjunctiva-sparing procedure should be considered as a viable alternative to a tube shunt or repeat trabeculectomy.

Revision of trabeculectomy filtering blebs with mitomycin C: Long term results

Aim:

The aim of the study is to assess the outcomes of transconjunctival mitomycin C (MMC)-augmented revision in eyes with failed trabeculectomy.

Materials and Methods:

This is a retrospective, noncomparative case series. One hundred and twenty-one eyes of 113 consecutive glaucoma patients with previously failed trabeculectomy who underwent transconjunctival revision with at least 12 months of follow-up were initially included in the study. The success was determined on the basis of intraocular pressure (IOP) alone. The main outcome measures were IOP, best-corrected distance visual acuity, complications, bleb appearance, lens status, visual field progression, and time between primary trabeculectomy and MMC revision. The main purpose of the study was to determine the efficacy of a single MMC-augmented needle revision.

Results:

Mean follow-up was 2.3 years. Twelve months after revision, IOP had declined from 26.1 ± 8.4 mmHg to 14.1 ± 4.8 mmHg (P < 0.05) and remained 16.0 ± 5.6 mmHg at 24 months, 15.7 ± 5.8 mmHg at 48 months, and 15.2 ± 4.0 mmHg at 60 months. Complete success was achieved in 53% of cases, 84% achieved qualified success, and 16% were classified as failures 12 months after revision. Early complications developed in 45 of the initial 121 eyes (37.2%).

Conclusions:

Transconjunctival MMC-augmented revision appears to be a safe and useful tool in reducing IOP and re-establishing filtration after trabeculectomy failure. This simple procedure has a high rate of success and helps avoid other surgical interventions which are more destructive for the conjunctiva.

Revision of encapsulated blebs after trabeculectomy: Long-term comparison of standard bleb needling and modified needling procedure combined with transconjunctival scleral flap sutures

PURPOSE

To compare two surgical approaches for treating encapsulated blebs after trabeculectomy with mitomycin C, in terms of the development of intraocular pressure and progression of glaucoma in a long-term follow up: 1. bleb needling alone vs. 2. a combined approach of needling with additional transconjunctival scleral flap sutures, to prevent early ocular hypotony.

METHODS

Forty-six patients with failing blebs after trabeculectomy with mitomycin C were enrolled in this study. Patients received either needling revision alone (group 1; n = 23) or a combined needling with additional transconjuctival flap sutures, if intraoperatively the intraocular pressure was estimated to be low (group 2; n = 23). Intraocular pressure (IOP), visual acuity, visual fields, and optic nerve head configuration by means of Heidelberg Retina Tomograph (HRT®) were analysed over time. Results from both groups were compared using Mann-Whitney U-test for single timepoints.

RESULTS

IOP did not differ significantly between the two groups during follow-up at three months (P = 0.13), six months (P = 0.12), one year (P = 0.92) and two years (P = 0.57) after surgery. Furthermore, there was no significant difference in the course of glaucoma concerning the optic nerve anatomy between the two groups (Rim Area Change in the Moorfields Regression Analysis of HRT®) till two years after surgery (P = 0.289). No functional impairment in visual acuity and visual fields was found in the groups of the study.

CONCLUSIONS

Single needling procedure is a standard successful method for restoring the function of encapsulated blebs. Postoperative hypotony represents a possible hazard, which can be minimized by additional transconjunctival flap sutures. Long-term results suggest that this modification is equally effective in lowering the IOP and preventing the progression of glaucoma as the standard needling procedure. To our knowledge this is the first study to investigate the long-term effect of tranconjunctival sutures for the prevention of hypotony.

The relationship of bleb morphology and the outcome of needle revision with 5-fluorouracil in failing filtering bleb

To investigate the risk factors for failure of needling revision with 5-fluorouracil (5-FU) and to identify the correlation of outcomes of needling revision and the morphological features of dysfunctional filtration blebs using Moorfields bleb grading system.This retrospective, nonrandomized, comparative case-control study included 41 consecutive patients (41 eyes) who underwent 5-FU needling revision for failed or failing filtration blebs between July 2012 and August 2014 in Chang Gung Memorial Hospital, a referral center in Taiwan. The main outcome measures were the bleb survival and the correlation factors of bleb morphology before revision. The secondary outcome measure was the identification of any study factor associated with bleb failure.Forty-one eyes of 41 patients were included in this study. The most frequent glaucoma diagnoses were 10 cases (24%) of neovascular glaucoma and 8 cases (19%) of chronic open-angle glaucoma. Survival of bleb at 6, 12, and 24 months was 42%, 39%, and 23%. Fourteen cases (34%) maintained overall success at the last follow-up, with an average follow-up of 22.7 ± 9.4 months (range: 12-48 months). The central bleb area and height were significantly different between the successful needling group and the failed needling group (P = 0.03 and 0.04, respectively). Further trend test confirmed that smaller central bleb extension and flatter height were associated with a higher chance of failure (P = 0.02 and 0.02, respectively). Time from initial trabeculectomy to needling of less than 4 months and higher intraocular pressure (IOP) in the first postoperative week also led to significantly higher risk for failure (P = 0.01 and 0.03, respectively).A small central area and the flat height of dysfunctional blebs were more likely to fail after the needle revision. Cautious case selections, taking account of the time from the initial filtering surgery and postoperative IOP, may improve the surgical outcome.

Results From a Modified Bleb Needling Procedure With Continuous Infusion Performed in the Operating Room

PURPOSE

Needling of a scarred trabeculectomy bleb is often performed in the office using a slit-lamp microscope as an alternative to additional surgery to lower intraocular pressure (IOP). However, the success rate in an office setting is highly variable, with reported success rates as low as 13%. We report a retrospective assessment of an intraoperative needling technique for reviving failed blebs.

DESIGN

A retrospective chart review.

PARTICIPANTS

Patients undergoing the intraoperative modified bleb revision technique in the setting of a failed trabeculectomy due to scarring at the Wilmer Eye Institute, Johns Hopkins Hospital between August 16, 2010 and August 29, 2012.

METHODS

Patients with uncontrolled IOP were operated on using a modified bleb needling technique. In this technique, a 25-G infusion cannula is placed in the anterior chamber and fibrotic adhesions within the bleb are lysed with a 25-G needle. The continuous infusion of balanced salt solution from the anterior chamber causes bleb elevation, which helps to guide the endpoint of lysis for the procedure. A subconjunctival injection of 5-fluorouracil is given at the conclusion of each case.

MAIN OUTCOME MEASURES

IOP reduction and number of glaucoma medications at postoperative day 1, week 1, month 1, month 3, month 6, and month 12.

RESULTS

A total of 33 eyes of 30 patients were included. At the visit before the procedure, the mean (±SD) IOP was 22.1±9.2 (range, 11 to 58) and subjects were using an average of 2.3±1.4 (range, 0 to 4) glaucoma medications. The mean IOP reduction was 8.7 mm Hg [95% confidence interval (CI), 5.6-11.8] at postoperative day 1, 8.1 mm Hg (95% CI, 4.0-12.3) at week 1, 8.9 mm Hg (95% CI, 5.3-12.5) at month 1, 8.1 mm Hg (95% CI, 4.2-12.0) at month 3, 8.2 mm Hg (95% CI, 3.9-12.5) at month 6, and 6.2 mm Hg (95% CI, 3.6-8.7) at month 12. IOP was reduced about 30% to 40% compared with baseline at each time point (P<0.05). The average reduction in medications used was 1.7 at day 1, 1.0 at month 1, 1.2 at month 3, 1.5 at month 6, and 0.5 at month 12. Seven patients underwent repeat needling. Overall, 64% of subjects maintained IOP at or below their target after 12 months.

CONCLUSIONS

A modified bleb needling procedure performed in the operating room can successfully lower IOP in the setting of a previous trabeculectomy in over 60% of subjects a year after the procedure.

A New Method for Revision of Encapsulated Blebs after Trabeculectomy: Combination of Standard Bleb Needling with Transconjunctival Scleral Flap Sutures Prevents Early Postoperative Hypotony

Purpose

A simple needling procedure is the standard method for restoring the function of an encapsulated bleb after trabeculectomy. However, postoperative hypotony represents a possible hazard. This study describes a new surgical approach for treating encapsulated blebs with reduced risk of early postoperative hypotony: bleb needling combined with transconjunctival sutures tightening the scleral flap directly.

Methods

The study included two groups of 23 patients with failing bleb following trabeculectomy: “Group 1” underwent simple needling revision of the filtering bleb and served as a control group, while “Group 2” received needling revision with additional transconjunctival scleral flap sutures, if intraoperatively the intraocular pressure was estimated to be very low. Intraocular pressure (IOP), postoperative management and complications were analyzed over a follow-up period of 4 weeks postoperatively. Results were compared using t-test or Mann-Whitney U-tests.

Results

Adverse effects occurred with a higher frequency after sole needling of the bleb (5 cases of choroidal effusion and 1 case of choroidal hemorrhage) than after the combined method with additional scleral sutures (1 case of choroidal effusion). The IOP on the first postoperative day was significantly lower in group 1, with 9.43 ± 9.01 mm Hg vs. 16.43 ± 8.35 mm Hg in group 2 (P = 0.01). Ten patients with ocular hypotony (IOD of 5 mmHg or lower) were found in group 1 and only two in group 2. One week and one month after surgery the intraocular pressure was similar in both groups (P>0.05).

Conclusions

This new needling technique with additional transconjunctival scleral flap sutures appears to reduce postoperative hypotony, and may thus protect from further complications, such as subchoroidal hemorrhage.

Intraoperative Optical Coherence Tomography Guided Bleb Needling

Two patients with history of trabeculectomy presented with uncontrolled intraocular pressure (IOP) postoperatively. The first patient had a flat and vasularized bleb 10 weeks after the surgery, and the second subject developed encapsulated bleb 3 months postoperatively. Both patients were taken to the operating room and intraoperative optical coherence tomography (OCT) guided bleb needling was performed to restore aqueous egress into the subconjunctival space. Postoperatively, IOP of the operated eyes ranged 14-18 mmHg at week 6 and month 3. None of the eyes had any intraoperative or postoperative complications. This novel application of the intraoperative OCT for bleb needling facilitates precision surgery under direct visualization and reduces the risk of complications.

Bleb needling outcomes for failed trabeculectomy blebs in Asian eyes: a 2-year follow up

AIM

To describe the outcomes of bleb needling in primary glaucoma in an Asian tertiary eye centre over a 2y period. To compare the success rates between primary angle-closure glaucoma (PACG) and primary open angle glaucoma (POAG). Lastly, to identify factors associated with success of bleb needling.

METHODS

This was a retrospective review of 227 patients who underwent bleb needling between June 2009 and June 2011 in Singapore National Eye Centre. The 5-fluorouracil (5-FU) augmented bleb needling was performed either at the slit lamp or in the operating theatre. Repeat bleb needlings were performed as necessary. Complete success was defined as maintenance of intraocular pressure (IOP) ≥6 mm Hg and ≤21 mm Hg, in the absence of further surgery or use of antiglaucoma medication. Qualified success met the above criteria with or without use of antiglaucoma medications.

RESULTS

One hundred and seventy-five eyes completed the two-year follow up. Sixty-nine percent of participants had POAG and 31% had PACG. The mean interval between filtering surgery and bleb needling was 299.9±616.4d for POAG and 167.1±272.2d for PACG. Mean needling attempts were 1.9±1.4 and 2±1.6 for POAG and PACG respectively. In general, there was a statistically significant reduction of IOP ranging from 21.9% to 26.8% from month 1 through to month 24. The complete success rates at month 6 were 70.0% for POAG and 65.7% for PACG. At month 12, this decreased to 62.2% for POAG and PACG and at month 24, 57.9% for POAG and 63.0% for PACG respectively. The qualified success rates at month 6 for POAG and PACG were 23.8% and 29.9% respectively, 32.2% and 29.2% at month 12, and 34.7% and 29.6% at month 24. The success rates between POAG and PACG were not significantly different (P>0.05 for complete and qualified success at months 6, 12 and 24). An increased number of needlings and higher pre-needling IOP were associated with failure.

CONCLUSION

The 5-FU augmented bleb needling within one year of trabeculectomy in Asian eyes can provide clinically significant IOP lowering of more than 20% for 2y. POAG and PACG had similar complete success rates (58% and 63% respectively). Factors associated with greater risk of procedure failure included increased number of needlings and higher pre-needling IOP. Asian eyes have a greater propensity for scarring but bleb needling, if performed in a timely manner can rescue bleb function.

Needle bleb revision with bevacizumab and mitomycin C compared with mitomycin C alone for failing filtration blebs

PURPOSE

To report the 6-month comparative outcomes and bleb morphology for needle revision with bevacizumab and mitomycin C (MMC) versus MMC alone of failed trabeculectomy and ExPRESS shunt blebs.

METHODS

Patients undergoing bleb needle revision procedures were enrolled in this study. All patients received a subconjunctival injection of 0.1 mL MMC (0.4 mg/mL) mixed with 0.1 mL preservative-free lidocaine (1%) at the beginning of the procedure. The patients were randomized into 2 cohorts assigned to receive either 1.0 mg (0.04 mL of 25 mg/mL) subconjunctival bevacizumab (treatment group) or 0.04 mL of balanced salt solution (control group) injected in an identical manner posterior to the bleb after the bleb needling. Success was defined as ≥20% reduction in intraocular pressure (IOP) without any IOP-lowering medications. Qualified success was defined as ≥20% reduction of IOP with IOP-lowering medications. Failure was defined as IOP>21 mm Hg, IOP reduction <20%, or need for additional surgery. Bleb morphology was classified using the Indiana Bleb Appearance Grading Scale.

RESULTS

Six months postoperatively, in treatment group (n=29), 57% of patients achieved complete success, and 43% failed. In control group (n=29), 41% of patients achieved complete success, 7% achieved qualified success, and 52% failed. The difference in success rates between the 2 groups was not statistically significant (P=0.35). At 6 months, the mean IOP was 11.52 in treatment group and 12.83 in control group (P=0.45); patients in treatment group were on a mean of 0.16 medications as compared with 0.58 medications in control group (P=0.058). For bleb morphology of treatment group compared with control group, the blebs had less vascularity (0.76 vs. 1.20, respectively, on a scale of 0 to 4, P<0.05) and greater extent (2.68 vs. 2.36, on a scale of 0 to 3, P=0.022) in treatment group.

CONCLUSIONS

There was no significant difference between the success rates and IOPs at postoperative month 6 between treatment and control groups. Postoperative blebs in the treatment group were less vascular and had greater extent.

Early transconjunctival needling revision with 5-fluorouracil versus medical treatment in encapsulated blebs: a 12-month prospective study

OBJECTIVE

To compare the efficacy of transconjunctival needling revision with 5-fluorouracil versus medical treatment in glaucomatous eyes with uncontrolled intraocular pressure due to encapsulated bleb after trabeculectomy.

METHODS

Prospective, randomized, interventional study. A total of 40 eyes in 39 patients with elevated intraocular pressure and encapsulated blebs diagnosed at a maximum five months after primary trabeculectomy with mitomycin C were included. The eyes were randomized to either transconjunctival needling revision with 5- fluorouracil or medical treatment (hypotensive eyedrops). A maximum of two transconjunctival needling revisions per patient was allowed in the needling arm. All patients underwent follow-up for 12 months. Successful treatment was defined as an intraocular pressure ≤ 18 mmHg and a 20% reduction from baseline at the final follow-up. Clinicaltrial.gov: NCT01887223.

RESULTS

Mean intraocular pressure at the final 12-month follow-up was lower in the transconjunctival needling revision group compared to the medical treatment group. Similar numbers of eyes reached the criteria for treatment success in both the transconjunctival needling revision group and the medical treatment group.

CONCLUSIONS

Despite similar success rates in eyes randomized to transconjunctival needling revision with 5-fluorouracil compared to eyes receiving medical treatment, there was a significantly lower mean intraocular pressure at 12 months after transconjunctival needling revision.

Combined ab externo and ab interno revision of failed filtering blebs with adjunctive mitomycin C

PURPOSE

To report the results of combined ab externo and ab interno revision with mitomycin C (MMC) of failed filtering blebs in glaucoma patients.

METHODS

Glaucoma patients with a failed trabeculectomy who had undergone internal and external revision with MMC in the last 6 years with at least 12 months of follow-up were considered. All study patients followed the same protocol in the operating room: injection of 0.2 mL of MMC (0.4 mg/mL) 2 cm lateral from the bleb followed by internal revision with an iris spatula and external revision with a 26-G × ½" needle. Success was defined as an intraocular pressure (IOP) ≥6 mm Hg and ≤18 mm Hg with (qualified) or without (absolute) any ocular hypotensive drugs.

RESULTS

The study included 25 eyes of 22 glaucoma patients. Mean age was 65.2 ± 10.5 years. Mean follow-up was 26.9 ± 10.3 months. The IOP was reduced from 24.5 ± 6.0 mm Hg preoperatively to 10.0 ± 3.3 mm Hg at the last visit (p<0.001). The number of ocular hypotensive medications was reduced from 1.8 ± 1.0 to 0.2 ± 0.6 (p<0.001). There was no change in visual acuity (0.83 ± 0.75 vs 0.83 ± 0.74, p = 0.7). Three patients developed choroidal detachment, another eye had a transient hypotony with maculopathy, and 2 patients developed cataract. Absolute success was achieved in 80% of eyes, and qualified success in 16% of eyes.

CONCLUSIONS

Combined ab externo and ab interno revision with MMC can be an effective technique to revitalize failed filtering blebs in glaucoma patients with minimal complications.