Late needling of flat filtering blebs with adjunctive mitomycin C: efficacy and safety for the corneal endothelium

An Atypical Case of Severe Toxicity, Anterior Chamber Inflammation, and Transient Subretinal Fluid Formation Induced by the Subconjunctival Injection of 5-FU

PURPOSE

To report an atypical presentation of severe toxicity, anterior chamber (AC) inflammation, and transient parafoveal formation of subretinal fluid induced by the subconjunctival injection of 5-fluorouracil (5-FU).

METHODS

Case presentation.

RESULTS

Seven weeks after trabeculectomy, a 40-year-old white male had a subconjunctival injection of 5-FU. Within minutes after the injection, the lens turned grey and then total white. Initially, AC was clear, and 20 min later, a severe AC reaction was detected. The patient was prescribed hourly dexamethasone eye drops and tropicamide eye drops twice daily. Two days post-injection, vision improved, AC reaction was minimal, and there was whitish fibrinous material on the anterior surface of the lens, extending up to the pupillary margin. Minimal posterior synechiae were observed, and upon dilation, the remainder of the anterior surface of the lens appeared completely clear, indicating that only the portion of the lens not covered by the iris exhibited fibrinous material and deposits. One week post-injection, vision worsened due to severe corneal toxicity. The dimensions of the whitish fibrinous material on the anterior lens capsule decreased, and macular scans revealed parafoveal subretinal fluid. Two weeks later, vision significantly improved, and the dimensions of the whitish fibrinous material on the anterior lens capsule were further decreased. The subretinal fluid had completely resolved.

CONCLUSION

We describe a rare case of severe toxicity, AC inflammation, and transient parafoveal subretinal fluid formation caused by the 5-FU. This was treated with topical steroid treatment, and eventually some level of lens opacification persisted despite significant clearance of the AC inflammation.

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.

Safety and Efficacy of the Rho-Kinase Inhibitor (Ripasudil) in Bleb Needling after Trabeculectomy: A Prospective Multicenter Study

Ripasudil, a rho-associated protein kinase inhibitor ophthalmic solution, shows a protective effect in preventing excessive scarring in vitro. This study aims to evaluate the safety and efficacy of ripasudil for glaucoma patients submitted to the needling procedure. In this prospective, multicenter, single-arm study, we included 20 eyes of 20 patients with glaucoma who underwent the needling procedure without antimetabolites. All patients administered ripasudil after needling for three months. The primary endpoint of this study was the safety of ripasudil in patients, and the secondary endpoint was the change in IOP at 12 weeks after the needling procedure. No serious complications were found in the patients. One eye experienced pruritus and conjunctival follicle, while another eye had conjunctival follicle. These complications were transient and resolved quickly after discontinuation of ripasudil. The mean preoperative IOP was 14.6 ± 4.6 mmHg, which decreased to 11.0 ± 4.7 mmHg (p = 0.0062) at 1 week postoperatively. The IOP reduction effect continued to 12 weeks (11.8 ± 3.1 mmHg; p = 0.0448). The administration of the ROCK inhibitor, ripasudil, after the needling procedure is safe and effective in maintaining IOP for 12 weeks.

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.

A multicenter phase II study on the safety of rho-kinase inhibitor (ripasudil) with needling for the patients after trabeculectomy

Background

There is no established method of maintaining or reducing intra ocular pressure after the needling procedure for failing blebs post trabeculectomy. Regarding newer antihypertensive medications, ripasudil, which is a rho-associated protein kinase inhibitor ophthalmic solution, was able to prevent excessive scarring in vitro. This study aims to evaluate the safety of glaucoma patients submitted to the needling procedure and administered ripasudil for preventing scarring after the procedure. We also investigate the efficacy of ripasudil after needling for bleb failure through suppression of fibrosis to the bleb.

Methods

This study is a multicenter, open-label, single-arm, phase II trial to evaluate the safety and efficacy of ripasudil in glaucoma patients after the needling procedure. Forty patients who will undergo needling at least 3 months after trabeculectomy will be recruited in Hiroshima university hospital and Hiroshima eye clinic. All the patients will instill ripasudil two times per day for three months after the needling procedure. The primary endpoint is the safety of ripasudil.

Conclusions

We plan to establish the safety of ripasudil and to collect information involving the efficacy of ripasudil widely in this study.

Clinicopathological features of corneal invasion by filtering bleb

PURPOSE

To describe the clinicopathological characteristics and explore the possible etiology of cornea invasion by filtering bleb (CIFB) after filtering surgery.

METHODS

We reviewed 22 patients treated for CIFB between March 2005 and March 2022. The patients were followed up for more than 1 year. Slit-lamp examination, optical coherence tomography (OCT), ultrasound biomicroscopy, and histopathological examination were performed to observe the morphology of the bleb and depth of corneal invasion. Depending on the severity of the lesion, treatments consisting of local massage, acupuncture separation, or surgical resection were administered.

RESULTS

The mean age of the patients was 56.3 ± 8.8 years. All patients underwent filtering surgery in the moderate or advanced stage of glaucoma. The filtering bleb was closely connected with the cornea, and its posterior boundary was locally adhered. Forward displacement of the internal opening of the filtering bleb was found in 4 of 7 surgically treated patients. OCT and pathological examination showed that the filtering blebs invaded the corneal stroma. Removal of the adhesion of the posterior boundary of the filtering bleb by different treatment methods successfully improved the patients' conditions.

CONCLUSION

Filtering blebs can invade the corneal stroma. Adhesion of the posterior boundary and forward displacement of the internal opening of the filtering bleb are the possible causes of CIFB. Removal of the adhesion of the posterior boundary of the filtering bleb can halt the progression of CIFB.

The Japan Glaucoma Society guidelines for glaucoma 5th edition

We are pleased to bring you the 5th edition of the Glaucoma Clinical Practice Guidelines. Clinical practice guidelines are based on evidence (scientific grounds). It is a document that presents the treatment that is the most appropriate for the patient. "Glaucoma Clinical Guidelines" was first published in 2003. This was the first guideline for glaucoma treatment in Japan. The principle of glaucoma treatment is to lower intraocular pressure. Means for lowering intraocular pressure includes drugs, lasers, and surgery; Glaucoma is a disease that should be considered as a complex syndrome rather than a single condition. Therefore, the actual medical treatment is not as simple as one word. This time we set the Clinical Questionnaire with a focus on glaucoma treatment. We hope that you will take advantage of the 5th edition.

Blood Reflux Through a PreserFlo MicroShunt Device After Needling

INTRODUCTION

To report a case of hyphema after a bleb needling revision in a PreserFlo MicroShunt implantation.

CASE DESCRIPTION

An 87-year-old man suffering from bilateral open angle glaucoma was referred to our hospital with a diagnosis of unsatisfactory intraocular pressure (IOP) control in the right eye, despite the maximally tolerated medical therapy. The patient underwent PreserFlo MicroShunt implantation in his right eye. About 2 months after the surgical procedure, the IOP was raised because of bleb failure for subconjunctival scarring. A needling revision was performed at the slit lamp. During the procedure blood reflux through a PreserFlo MicroShunt device from a filtering bleb to the anterior chamber was observed, causing an IOP rise. Treatment with oral acetazolamide, topical steroid, and antibiotic resulted in the complete resolution of the hyphema in 2 weeks and a significant lowering in IOP.

CONCLUSIONS

This is the first reported case of blood reflux to the anterior chamber through a PreserFlo MicroShunt implant after a needling procedure.

History, presence, and future of mitomycin C in glaucoma filtration surgery

PURPOSE OF REVIEW

Mitomycin C (MMC) is an alkylating agent with extraordinary ability to crosslink DNA, preventing DNA synthesis. By this virtue, MMC is an important antitumor drug. In addition, MMC has become the gold standard medication for glaucoma filtration surgery (GFS). This eye surgery creates a passage for drainage of aqueous humor (AqH) out of the eye into the sub-Tenon's space with the aim of lowering the intraocular pressure. A major cause of failure of this operation is fibrosis and scarring in the sub-Tenon's space, which will restrict AqH outflow. Intraoperative application of MMC during GFS has increased GFS success rate, presumably mainly by reducing fibrosis after GFS. However, still 10% of glaucoma surgeries fail within the first year.

RECENT FINDINGS

In this review, we evaluate risks and benefits of MMC as an adjuvant for GFS. In addition, we discuss possible improvements of its use by adjusting dose and method of administration.

SUMMARY

One way of improving GFS outcome is to prolong MMC delivery by using a drug delivery system.

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.].

The Effects of Glaucoma and Glaucoma Therapies on Corneal Endothelial Cell Density

A healthy corneal endothelium is required for corneal clarity. Both the glaucoma disease state and its various forms of treatment can have adverse effects on the corneal endothelium. Both the presence of glaucoma and the magnitude of intraocular pressure elevation are related to endothelial cell loss (ECL). Topical medical therapy, laser procedures, and both traditional surgeries-trabeculectomy and tube-shunts-and newer minimally invasive glaucoma surgeries have variable effects on ECL. This review will summarize the reported effects of glaucoma and its treatment on ECL. Concerns for corneal endothelial cell health should be part of the decision-making process when planning glaucoma therapy for lowering intraocular pressure, with added caution in case of planned device implantation in eyes with preexisting ECL and low endothelial cell density at high risk for corneal endothelial decompensation.

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.

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.

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.

One-Year Results of Stab Incision Glaucoma Surgery and Radiofrequency-Assisted Stab Incision in Management of Open-Angle Glaucoma

PURPOSE

The aim of the study is to evaluate the surgical outcome of stab incision glaucoma surgery (SIGS) and compare it with radiofrequency-assisted stab incision in the treatment of uncontrolled open-angle glaucoma.

PATIENTS AND METHODS

A prospective, interventional study included 50 eyes who were assigned into two equal groups: Group A underwent stab incision procedure with preoperative subconjunctival (SC) mitomycin-C (MMC) and Group B underwent radiofrequency-assisted technique without MMC. Intraoperative and postoperative complications, visual acuity, intraocular pressure (IOP), and bleb status were evaluated up to 12 months.

RESULTS

Mean preoperative IOP in Group A was 26.96 ± 2.42 reduced to 13.43 ± 2.31 while in Group B was 27.20 ± 3.57 reduced to 15.48 ± 3.68 mmHg (P < 0.001) with a mean reduction of 50.61% ± 8.42% and 43.56% ± 12.83%, 12 months postoperatively in Groups A and B, respectively. Non-basal peripheral iridectomy was the most encountered intraoperative complication in 8 eyes (32%) and 9 eyes (36%) and hypotony was the most reported postoperative complication in 5 eyes (20%) and 9 eyes (36%) in Groups A and B, respectively. Flat bleb area had been reported at the end of follow-up time in 3 eyes (13%) and 7 eyes (30%) in Groups A and B, respectively. Complete success rate was 52.2% and 28.6% while qualified success rate was 28.8% and 42.9% in Groups A and B, respectively.

CONCLUSION

SIGS with SC MMC is an effective and safe procedure in IOP lowering, while radiofrequency-assisted stab incision had high incidence of subconjunctival scarring and ostium closure.

Bleb Needling with Mitomycin C as Adjunctive Therapy in Failing Blebs: A Retrospective Study

PURPOSE

To evaluate the effects and complications related to use of mitomycin C (MMC) as an adjunctive therapy in bleb needling.

METHODS

Retrospective review of the records of patients affected by open-angle glaucoma who underwent a bleb revision as a treatment for failed trabeculectomy. All subjects underwent surgery with a fornix-based approach to incision. Full baseline data for each patient included a comprehensive ocular and medical history, the patient's Snellen visual acuity test results, and Goldmann applanation tonometry test results. Data were reported following observations occurring at 6, 12, 18, 24, and 30 months. In addition, the number and timing of needling with or without MMC subconjunctival injections and any short- and long-term complications were observed.

RESULTS

We included 101 patients, 56 (55.4%) male and 45 (44.6%) female. The mean age was 69.81 ± 16.19 years (range 28-92). Statistically significant effects of needling and needling and MMC (p values <0.05) in the decrease in intraocular pressure were observed. Three (2.9%) patients presented hypotony at the last follow-up visit. No other complications were observed.

CONCLUSIONS

Needling bleb revision augmented with the use of MMC appears to be a more useful tool in the management of failing bleb.

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.

Long-term outcome of mitomycin C-augmented needle revision of trabeculectomy blebs for late trabeculectomy failure

OBJECTIVES

To describe the 3-year outcomes of mitomycin C (MMC)-augmented bleb needling procedures following late trabeculectomy failure.

METHODS

A retrospective, observational chart review of 44 eyes that underwent MMC-augmented bleb needling following late trabeculectomy failure. The primary outcome measure was IOP at 3 years post-operatively. Secondary outcome measures were the number of topical glaucoma medications and success rate at 3 years. Success was defined on the basis of IOP (≤21 mmHg and ≥5 mmHg with a reduction of ≥ 20% from pre-operative baseline), need for ocular hypotensive medications, and need for further laser or surgical intervention.

RESULTS

Mean IOP was reduced from 19.8 mmHg preoperatively to 13.9 mmHg (29.5% reduction) at 3 years. By the 3-year time point, 26 eyes (59.1%) had met one or more of the criteria for failure. A lower immediate post-operative IOP was found to be associated with greater likelihood of success.

CONCLUSIONS

Bleb needling augmented with MMC can achieve a significant reduction in IOP in eyes with late trabeculectomy failure. By 3 years however, 59% of eyes were classified as failures, with half requiring further glaucoma surgery or laser. Patients undergoing this procedure should therefore be warned of the likelihood of requiring further intervention, and a repeat antimetabolite-augmented trabeculectomy or glaucoma tube shunt surgery in the first instance can be considered instead.

Rescue of failing or failed trabeculectomy blebs with slit-lamp needling and adjunctive mitomycin C in Indian eyes

Purpose:

The aim of this study is to investigate the efficacy and safety of needling-revision augmented with a high dose of mitomycin C (MMC) in failing or failed blebs after trabeculectomy in Indian eyes.

Methods:

Prospective, noncomparative, interventional study. All patients (>18 years) who had raised intraocular pressure (IOP) following trabeculectomy (>6 weeks and <2 years), who had a flat bleb, bleb encapsulation, and/or required antiglaucoma medication (AGM) for IOP control were eligible for inclusion. MMC was injected subconjunctivally at least ½ hour before the needling procedure was carried out at the slit lamp in the outpatient's clinic.

Results:

Thirty-nine eyes of 38 patients were included. The median follow-up was 20 months and time interval between trabeculectomy and needle revision was 113 days. Initially, in all cases, aqueous flow was re-established with a raised bleb; 7 eyes required repeat needling. IOP decreased from median 24 mmHg (Q1 21, Q3 27, interquartile range [IQR] 6, range 18–35) preneedling to median 14 mmHg (Q1 10, Q3 16, IQR 6, range 6–18) postneedling at last follow-up (P < 0.0001, 95% confidence interval [CI]: 8.2–13.0). The use of AGM reduced from median 1 (Q1 0, Q3 3, IQR 3, range 0–4) preneedling to median 0 postneedling (P < 0.0001, 95% CI: 1–2). Complete success was seen in 28 eyes (71.8%, 95% CI: 71.1%–96.4%); another 5 eyes (12.8%) were controlled with AGM (qualified success) with overall success of 84.6%. Most complications were transient in nature with resolution within 1 week. One patient developed hypotony, and another developed a late bleb leak.

Conclusion:

Needling revision augmented with high-dose MMC, at the slit lamp, effectively rescues failing or failed filtration, and appears to be safe.

Ab Interno Trabeculectomy With the Trabectome as a Valuable Therapeutic Option for Failed Filtering Blebs

PURPOSE

Uncontrolled intraocular pressure (IOP) after glaucoma filtration surgery is a challenging problem in the management of glaucoma patients. The Trabectome is a device for selective electroablation of the trabecular meshwork through a clear cornea incision without affecting the conjunctiva. Minimally invasive glaucoma surgery using the Trabectome is safe and effective as primary glaucoma surgery. Here we investigate the results of ab interno trabeculectomy with the Trabectome for IOP control in patients with a failed filtering bleb.

METHODS

A total of 60 eyes of 60 consecutive patients with primary open-angle glaucoma (POAG) or pseudoexfoliative glaucoma (PXG) were enrolled in this single center observational study. Trabectome surgery was performed alone or in combination with phacoemulsification by 2 experienced surgeons. IOP readings and number of IOP lowering medication as primary outcome parameters were taken by an independent examiner. Intraoperative and postoperative medication were recorded systematically.

RESULTS

Mean IOP before surgery was 24.5±3.5 mm Hg and decreased to 15.7±3.4 (-36%) after mean follow-up of 415 days. The number of necessary IOP lowering medication dropped from 2.1±1.3 to 1.8±1.2 (14% reduction from baseline). A total of 25% (n=15) of cases reported here needed additional surgery after 517 days (range: 6 to 1563 d). No major complications were observed. After mean follow-up, we found a qualified success rate for PXG of 87% and 50% for POAG as revealed by the Kaplan-Meier analysis according to the definitions for success in advanced glaucoma cases according to the World Glaucoma Association (40% reduction from baseline IOP and maximum IOP of 15 mm Hg).

DISCUSSION

Trabectome surgery for uncontrolled IOP after trabeculectomy is safe and effective especially in PXG patients. Given the demanding subgroup of patients studied here, it is not surprising that success rates are lower compared with previous studies investigating the Trabectome for primary glaucoma surgery. The number of necessary IOP lowering medication drops at first, but seems to reach preoperative values after 20 months of follow-up. Trabectome surgery should be considered as a valuable escape procedure for patients with failed filtering blebs and uncontrolled IOP.

Transconjunctival Revision With Mitomycin-C Following Failed Trabeculectomy

PURPOSE

To evaluate the efficacy of transconjunctival revision (TCR) with mitomycin-C (MMC) following failed trabeculectomy.

MATERIALS AND METHODS

The medical records of 27 patients (27 eyes) who underwent TCR with subconjunctival injection of MMC by a single surgeon between September 2001 and August 2013 were retrospectively reviewed. The same surgical protocol was followed for all patients. Revision was performed using a microvitreoretinal blade through a small conjunctival incision. Main outcome measures included visual acuity, intraocular pressure (IOP), and number of glaucoma medications. Failure was defined as an IOP<5 or >14 mm Hg, loss of light perception, or need for additional glaucoma surgery.

RESULTS

Mean interval between trabeculectomy and TCR was 56.4±57.2 months. Mean preoperative IOP was 21.9±6.8 mm Hg using 4.0±1.2 glaucoma medications. Fifteen (55.6%) patients met success criteria. At most recent follow-up, mean IOP and number of glaucoma medications for successful patients were 9.7±3.8 mm Hg and 0.6±1.1, respectively. Kaplan-Meier analysis revealed 1-, 2-, and 3-year success rates of 62%, 58%, and 53%, respectively. Three additional patients achieved success after undergoing a second TCR, and 1 patient achieved success after a third TCR. Postoperative complications included transient choroidal effusion (n=8), shallow anterior chamber requiring reformation (n=5), 5-fluorouracil-related corneal epitheliopathy (n=10), and bleb leak (n=1).

CONCLUSIONS

TCR with adjunctive MMC is a safe and effective procedure following failure of a trabeculectomy. More than 1 revision may be necessary to achieve long-term IOP reduction.

Same-site surgical revision of failed trabeculectomy blebs with mitomycin C augmentation: long-term follow-up

PurposeTo determine the long-term outcomes of same-site revision of failed filtering blebs with mitomycin C application.Patients and methodsNoncomparative retrospective case series of 45 eyes of 39 patients. Main outcome measures were surgical success (≤21, ≤18, and ≤16 mm Hg reduction in intraocular pressure (IOP)). Other outcome measures included best-corrected visual acuity (VA), visual field loss, number of glaucoma medications, need for further interventions, time from surgery to recommencement of medications or interventions, and complications.ResultsMean follow-up was 126±59.6 months (range 16-227 months). The overall success proportion at last follow-up was 96% for IOP ≤21 mm Hg (criterion 1), 91% for IOP ≤18 mm Hg (criterion 2), and 84% for IOP ≤16 mm Hg (criterion 3). Absolute success at last follow-up was 64%, 38%, and 33% for criteria 1, 2, and 3, respectively. Mean baseline IOP was reduced from 24.2±5.5 to 12.4±5.5 mm Hg at last follow-up. Ten eyes (22%) had early and 3 (7%) eyes had late complications. None of these complications resulted in visual loss or surgery failure. Nine eyes (20%) required further glaucoma surgery. Nine eyes (20%) required further glaucoma laser.ConclusionsSame-site, augmented, bleb revision is a safe and effective technique to control IOP and prevent further visual loss in patients with failed trabeculectomies.

Intraoperative Injection vs Sponge-applied Mitomycin C during Trabeculectomy: One-year Study

AIM

To determine the safety and efficacy of intraoperative injection of mitomycin C (MMC) against conventional sponge-applied MMC during trabeculectomy.

MATERIALS AND METHODS

This study was a retrospective, comparative case series. Thirty eyes with primary open-angle glaucoma underwent consecutive trabeculectomies with MMC injection (injection group), and thirty eyes with sponge-applied MMC were as controls (sponge group). Data were collected preoperatively and postoperatively at 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year after surgery. Demographic data, applanation intraocular pressure (IOP), best-corrected visual acuity (VA), number of glaucoma medications, postoperative interventions, postoperative complications, and number of visits within 3 months were recorded. In order to stratify data, proportion of eyes achieving >30% IOP reduction from baseline with or without glaucoma medications was calculated and defined as surgical success.

RESULTS

Mean IOP reduction at 1 year was significant in both the injection and sponge groups from baseline (46.8 and 37.8% respectively). The injection group had overall lower postoperative IOP and comparable complete treatment success, defined as achieving >30% IOP reduction without glaucoma medications (p = 0.941). The number of postoperative visits within 3 months and the proportion of eyes needing 5-fluorouracil (5-FU) intervention were significantly lower in the injection group (p = 0.03, p = 0.04 respectively).

CONCLUSION

Injection of MMC was as safe and effective as sponge application with comparable estimated complete treatment success, less need for visits within 3 months, and 5-FU intervention.

CLINICAL SIGNIFICANCE

Surgeons may consider intraopera-tive injection of MMC in appropriate patient cohorts given comparable safety and efficacy and several advantages over traditional sponge application. Further study in a prospective, larger, long-term manner is necessary to assess this modality.How to cite this article: Khouri AS, Huang G, Huang LY. Intraoperative Injection vs Sponge-applied Mitomycin C during Trabeculectomy: One-year Study. J Curr Glaucoma Pract 2017;11(3):101-106.

Outcomes for Ab Interno Bleb Revision With a Novel Translimbal Sclerostomy Spatula

PURPOSE

To report outcomes for a novel ab interno bleb revision technique and spatula.

PATIENTS AND METHODS

This is a retrospective chart review.

RESULTS

A total of 21 eyes of 21 patients underwent ab interno bleb revision with the Grover-Fellman biplanar sclerostomy spatula. Mitomycin C was given at least 1 week preoperation. The mean age of the patients and blebs were 67 and 6.75 years, respectively. The mean follow-up is 10.6 months (range: 3 to 17 mo). Mean preoperative intraocular pressure (IOP) (SD) was 21.9 (9.1) mm Hg on 3.7 (1.2) glaucoma medications. At 12 months follow-up, the mean IOP was 12.1 mm Hg on 0.86 medications. Four eyes failed due to uncontrolled IOP needing a tube shunt. One eye failed due to uncontrolled IOP but was lost to follow-up before a tube shunt could be performed. All failures occurred within 3 months. Two eyes had an IOP of <5 mm Hg after 1 month with no evidence of hypotony maculopathy. These cases resolved after 3 months without surgical intervention. All successful cases had blebs that were low, diffuse, and posterior.

CONCLUSIONS

After a failed filtration surgery, a low-diffuse bleb was reestablished by pretreating with subconjunctival mitomycin C followed by ab interno bleb revision with the Grover-Fellman biplanar sclerostomy spatula, decreasing further more invasive glaucoma procedures.

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.

Prospective study comparing mitomycin C or bevacizumab as adjuvant in trabeculectomy revision by needling

PURPOSE

To compare the use of mitomycin C (MMC) or bevacizumab (BEV) as adjunctive in the needling revision of failed trabeculectomy blebs.

METHODS

Glaucoma patients with failed trabeculectomy were included. Cystic blebs were excluded. All procedures were performed by the same surgeon at the operating room under peribulbar blockade. Rate of success, intraocular pressure (IOP), and number of antiglaucoma drugs in use were compared before and after the procedures. The IOP was measured postoperatively at days 1, 30, 90, and 180. Absolute success was defined as IOP ≤18 mm Hg, without any complication or use of any antiglaucomatous drugs. Qualified success was the same criteria, but with the use of any antiglaucomatous drugs.

RESULTS

Twenty-nine eyes of 29 patients were included: 15 eyes with MMC and 14 eyes with BEV. There was no statistical difference in the IOP reduction between the groups (MMC 32.6 ± 16.1% vs BEV 30.1 ± 12.0%, p = 0.6). The BEV group showed similar reduction in the number of antiglaucoma drugs compared to the MMC group (p = 0.6). Absolute success was found in 28.5% of the BEV group and in 6.6% of patients with MMC. Qualified success was found in 64.3% and 73.4%, respectively, both limited to 180 days.

CONCLUSIONS

In this selected and limited group of patients, bevacizumab can be considered as an alternative to MMC in the needling revision of failed trabeculectomy. Studies with a larger number of patients and longer follow-up are needed to confirm the hypothesis suggested here.

Targeting a low-teen intraocular pressure by trabeculectomy with a fornix-based conjunctival flap: continuous Japanese case series by a single surgeon

PURPOSE

To examine the medium-term outcomes of fornix-based trabeculectomy (TLE) performed by a single surgeon and to analyze outcome in 3 glaucoma subtypes.

METHODS

Consecutive prospective case series study to examine the 6-month outcome of 106 eyes [primary open-angle glaucoma (OAG), exfoliation glaucoma (XFG), and inflammatory glaucoma (ING)] that underwent TLE with mitomycin C performed by a single surgeon from September 2009 to September 2010 at Tokyo University Hospital. Main outcome measure was survival rates of targeted intraocular pressure (IOP) after TLE. Postoperative complications and procedures were analyzed according to glaucoma subtypes. Life table analyses were then made according to 2 criteria of failure: (1) IOP was >12 mm Hg with or without the use of topical glaucoma medications after 2 consecutive measurements or another surgery was needed; and (2) IOP was >15 mm Hg.

RESULTS

A total of 106 eyes, which consisted of 67 OAG eyes, 23 XFG eyes, 16 ING eyes, were analyzed for 6 months after TLE. Four eyes were reoperated. During and after hospitalization, complications were equally observed and procedures were equally performed in all of the 3 groups. For the first definition, cumulative survival rates at 6 months after surgery in OAG, XFG, and ING cases were 76.0%, 73.9%, and 62.5%, respectively. For the second definition, cumulative survival rates in OAG, XFG, and ING cases were 88.0%, 78.3%, and 68.8%, respectively.

CONCLUSIONS

Six-month outcome of TLE with a fornix-based conjunctival incision by a single surgeon that targeted an IOP<12 mm Hg was not different among 3 types of glaucoma.

Wound Healing Modulation in Glaucoma Filtration Surgery-Conventional Practices and New Perspectives: The Role of Antifibrotic Agents (Part I)

Glaucoma filtration surgery is regularly performed for the treatment of glaucoma and trabeculectomy is often regarded as the ‘gold standard' glaucoma operation. The biggest risk of failure of the operation is bleb scarring. The advent of anti-fibrotic agents, such as mitomycin C (MMC) and 5-fluorouracil (5FU) has vastly prolonged the longevity of the bleb, but concerns remain regarding the potential increase in postoperative complications. More selective therapeutic targets have therefore been explored. One of these is vascular endothelial growth factor (VEGF) inhibition. Vascular endothelial growth factor inhi bition has a role not only in sub conjunctival angiogenesis inhi bition but also it has direct anti-fibrotic properties. Newer phar macological compounds and materials have also been developed in recent years in attempt to modulate the wound healing in different ways after glaucoma surgery. These include physical barriers to scarring and vehicles for sustained release of pharmacological agents, and early promising results have been demonstrated. This two-part review will provide a discussion of the application of anti-fibrotic agents in glaucoma filtration surgery and evaluate the newer agents that have been developed.

How to cite this article: Fan Gaskin JC, Nguyen DQ, Ang GS, O'Connor J, Crowston JG. Wound Healing Modulation in Glaucoma Filtration Surgery–Conventional Practices and New Pers pectives: The Role of Antifibrotic Agents (Part I). J Curr Glaucoma Pract 2014;8(2):37-45.

[Modern filtration surgery. An update]

Preoperative treatment with steroids and nonsteroidal anti-inflammatory drugs increases the success of filtration surgery. Surgery with the patient under subconjunctival anesthesia is safe. Intraoperative application of mitomycin C is state of the art and enhances success rates. Perioperative use of bevacizumab seems to attenuate postoperative fibrosis. Postoperative hypotension is avoided by stable fixation of the scleral flap followed by stepwise controlled suturelysis or release. Transconjunctival flap suturing allows fast and simple treatment of overfiltration. The shorter the time lag between trabeculectomy and subsequent cataract surgery the higher the probability of bleb failure will be. The number of antiglaucomatous drugs and severity of glaucomatous damage before surgery correlate with the probability of failure and blindness.

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.

Efficacy of repeated 5-fluorouracil needling for failing and failed filtering surgeries based on simple gonioscopic examination

Purpose

To evaluate the success rate of a modified bleb needling technique in eyes with previous glaucoma surgery that had elevated intraocular pressure.

Methods

A retrospective study of 24 eyes of 24 patients that underwent repeated bleb needling performed for failing and failed blebs on slit lamp with 5-fluorouracil (5-FU) injections on demand. This was performed after gonioscopic examination to define levels of filtration block.

Results

There was significant reduction of mean IOP from 36.91 mmHg to 14.73 mmHg at the final follow-up (P < 0.001). The overall success rate was 92%.

Conclusion

Repeated needling with adjunctive 5-FU proved a highly effective, safe alternative to revive filtration surgery rather than another medication or surgery.