A prospective randomized trial comparing intraoperative 5-fluorouracil vs mitomycin C in primary trabeculectomy

Wound Modulations in Glaucoma Surgery: A Systematic Review

Excessive fibrosis and resultant poor control of intraocular pressure (IOP) reduce the efficacy of glaucoma surgeries. Historically, corticosteroids and anti-fibrotic agents, such as mitomycin C (MMC) and 5-fluorouracil (5-FU), have been used to mitigate post-surgical fibrosis, but these have unpredictable outcomes. Therefore, there is a need to develop novel treatments which provide increased effectiveness and specificity. This review aims to provide insight into the pathophysiology behind wound healing in glaucoma surgery, as well as the current and promising future wound healing agents that are less toxic and may provide better IOP control.

Minimally invasive micro sclerostomy (MIMS) procedure in the treatment of open-angle glaucoma

BACKGROUND

To evaluate the safety and efficacy of the Minimally Invasive Micro Sclerotomy (MIMS) procedure in the management of uncontrolled open-angle glaucoma.

METHODS

A prospective, open-label, single-arm clinical evaluation with intra-subject comparisons performed at the Ophthalmologic Center after S.V. Malayan, Yerevan, Armenia. Included were adults with primary open-angle glaucoma (OAG) (N = 114) or exfoliative glaucoma (N = 6) who were uncontrolled (IOP > 21) on tolerated topical medication. Mild (N = 7), moderate (N = 66) and severe (n = 47) cases were prospectively included without preselection. Following subconjunctival Mitomycin C, an ab-interno MIMS procedure was performed alone (N = 100) or combined with phacoemulsification (N = 20). Patients were followed for 52 weeks. Procedure-related complications and adverse events were recorded. Success criteria were defined as -5 < IOP ≤ 21mmHg OR a reduction in IOP of ≥ 20% from baseline with (qualified success) or without (complete success) hypotensive medications.

RESULTS

Mean patient age was 69 ± 10.1 years. The mean duration of the procedure was 2:01 ± 0:41 min:sec. Scleral drainage channels were achieved in all cases. No device malfunctions, intraoperative complications, or serious adverse events were reported. Iris plugging of the sclerostomy site and early spikes in IOP were the most common adverse events. The only reason for failure was final IOP > 21 mmHg on tolerated medication. At 52 weeks (n = 93), mean IOP decreased by 38% from baseline (P < 0.001), from 27.9 ± 3.7 to 17.5 ± 5.3 mmHg, a difference of 10.5 mmHg (95% CI: -11.7, -9.3). One-year qualified success was documented in 82.1% (95% CI: 72.9%,89.2%) of the patients and complete success, in 70.5% (60.3-79.4%). 60% (95 CI:49.4%,69.9%) of the patients achieved maximum IOP level of 14 mmHg or at least 30% reduction in IOP.

CONCLUSIONS

MIMS procedure is a relatively simple, short and safe minimally invasive bleb-forming procedure. Its efficacy, as found in this short-term evaluation, lends it suitable for mild and moderate uncontrolled open-angle glaucoma patients.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04503590 2019-05-29.

Effect of mitomycin C and 5-fluorouracil on wound healing in patients undergoing glaucoma surgery: A meta-analysis

Increased intraocular pressure (IOP) is a risk factor for glaucoma. One treatment option is trabeculectomy. Antimetabolic agents are used in the operation to decrease the post-operative scarring of the wound. The two most common medicines are Mitomycin C (MMC) and 5-Fluorouracil (5-FU). The aim of this research is to assess the effect of MMC on post-operation wound healing in comparison with 5-FU in addition to trabeculectomy. Well, we went through four common databases. Our language was limited to English during the study. The last time we looked at the e-databases was August 2023. Case control studies were performed where MMC resulted in better wound healing than 5-FU. Researchers selected a total of 1023 trials and eventually selected six trials for data analysis. Four hundred and ninety one cases of glaucoma were treated with trabeculectomy. Among them, 246 were given MMC and 245 were given 5-FU during operation. Six trials showed that there was no statistical difference between MMC and 5-FU in the incidence of post-operative wound leak in glaucoma patients who received trabeculectomy (OR, 1.21; 95% CI, 0.63-2.30 p = 0.57); Five trials demonstrated that MMC was associated with a reduced risk of post-operative corneal damage compared to 5-FU injection (OR, 0.18; 95% CI, 0.06-0.56 p = 0.003); In both trials, the incidence of post-operative bleeding was not significantly different from that of 5-FU injected in the MMC group (OR, 0.33; 95% CI, 0.05-2.16 p = 0.25). Our results indicate that MMC is superior to 5-FU in the reduction of post-operative corneal injury. Additional comparisons between MMC and 5-FU are required in order to increase the reliability and effectiveness of these findings.

Early Outcomes of Combined Phacoemulsification and Ab Interno Tanito Microhook Trabeculotomy in Open-Angle Glaucoma

PURPOSE

To study the early postoperative efficacy and safety of an Ab Interno microhook trabeculotomy (microLOT) combined with cataract surgery in patients with open-angle glaucoma.

METHODS

This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and mild-moderate open-angle glaucoma. One hundred fourteen patients were included for analysis. The patients were randomized to undergo microhook trabeculotomy with phacoemulsification (group 1) or phacoemulsification alone (group 2). All patients were evaluated on postoperative day 1, 15, and 30, as well as 3, 6, and 12 months postoperatively. A P value < 0.05 was considered statistically significant. Baseline and follow-up visits were compared to determine significant differences in the number of antiglaucoma medications (AGMs), intraocular pressure (IOP), and best-corrected visual acuity.

RESULTS

There were 57 patients in each group. The baseline characteristics were similar between the 2 groups, except the number of AGMs, which was greater in group 2. The mean preoperative IOP for group 1 (phaco-microLOT) was 26.5 mmHg ± 5.2 and group 2 (phaco-alone group) was 25.3 mmHg ± 3.1 which decreased to 12.5 mmHg ±3.6 (P < 0.001) and 20.0 mmHg ± 2.7(P < 0.001) at 12 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.48 (interquartile range [IQR], 0.30-0.60) preoperatively to 0.00 (0.00-0.18) postoperatively (P < 0001) in group 1 and improved from 0.30 (IQR, 0.30-0.48) to 0.00 (0.00-0.00) in group 2 (P < 0.001). In group 1, the mean (standard deviation [SD]) AGM used preoperatively was 0.6 (0.9) which was significantly reduced to 0.2 (0.5) at 12 months postoperatively, whereas in group 2, at 12 months, the mean (SD) AGM used was reduced from 1.4 (0.6) to 1.1 (0.9). In group 1, 90.3% of eyes achieved complete success at the end of 1 year. The most common complication was hyphema, noted in 4 patients with 1 eye requiring an anterior chamber washout.

CONCLUSION

Ab interno microhook trabeculotomy (microLOT) combined with phacoemulsification in patients with open-angle glaucoma is an efficacious procedure with relatively minimal complications.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Comparison of tube shunt implantation and trabeculectomy for glaucoma: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of tube shunt implantation with trabeculectomy in the treatment of patients with glaucoma.

METHODS

A systematic literature search was performed for studies comparing tube with trabeculectomy in patients with glaucoma (final search date: 27 February 2022). Comparisons between tube and trabeculectomy were grouped by the type of tube (Ahmed, Baerveldt, Ex-PRESS and XEN). The primary endpoints included intraocular pressure (IOP), IOP reduction (IOPR), IOPR percentage (IOPR%), complete success rate (CSR), qualified success rate (QSR) and adverse events (AEs).

RESULTS

Forty-nine studies were included in this meta-analysis and presented data for 3795 eyes (Ahmed: 670, Baerveldt: 561, Ex-PRESS: 473, XEN: 199, trabeculectomy: 1892). Ahmed and Ex-PRESS were similar to trabeculectomy in terms of IOP outcomes and success rate (Ahmed vs trabeculectomy: IOPR%: mean difference (MD)=1.34 (-5.35, 8.02), p=0.69; Ex-PRESS vs trabeculectomy: IOPR%: MD=0.12 (-3.07, 3.31), p=0.94). The IOP outcomes for Baerveldt were worse than those for trabeculectomy (IOPR%: MD=-7.51 (-10.68, -4.35), p<0.00001), but the QSR was higher. No significant difference was shown for the CSR. XEN was worse than trabeculectomy in terms of IOP outcomes (IOPR%: MD=-7.87 (-13.55, -2.18), p=0.007), while the success rate was similar. Ahmed and Ex-PRESS had a lower incidence of AEs than trabeculectomy. Baerveldt had a lower incidence of bleb leakage/wound leakage, hyphaema and hypotonic maculopathy than trabeculectomy but a higher incidence of concurrent cataracts, diplopia/strabismus and tube erosion. The incidence of AEs was similar for the XEN and trabeculectomy procedures.

CONCLUSION

Compared with trabeculectomy, both Ahmed and Ex-PRESS appear to be associated with similar ocular hypotensive effects and lower incidences of AEs. However, Baerveldt and XEN cannot achieve sufficient reductions in IOP outcomes similar to those of trabeculectomy.

PROSPERO REGISTRATION NUMBER

CRD42021257852.

Noncontact Conjunctiva: A Better Mitomycin C Application Site for Trabeculectomy

INTRODUCTION

Bleb scarring is the most important complication of trabeculectomy. Changing the application position of mitomycin C (MMC) during trabeculectomy might affect the surgery outcome. Our aim is to compare the effectiveness and safety of intraocular pressure (IOP) lowering in two different application sites of mitomycin in trabeculectomy.

METHODS

This retrospective trial compared the surgical outcomes of 177 eyes that underwent trabeculectomy with adjunctive mitomycin C. In 70 eyes, an MMC-soaked sponge was applied under the scleral flap without touching Tenon's capsule. In 107 eyes, an MMC-soaked sponge was applied under the scleral flap covered by Tenon's capsule. Outcome measures were the IOP, best-corrected visual acuity (BCVA), success rates, and incidence of complications.

RESULTS

Within both groups, a highly significant IOP reduction was seen during follow-up. The effectiveness in reducing IOP and the change in best-corrected visual acuity (BCVA) were similar between the two groups. Thin-walled blebs and postoperative hypotony were seen more often when MMC-soaked sponges were applied under the scleral flap covered by Tenon's capsule (P = 0.008 and P = 0.012, respectively). There was no significant difference in BCVA or other complications in either group.

CONCLUSION

Since the effectiveness of IOP reduction was similar between both groups and with a low incidence of thin-walled blebs and hypotony, the subscleral application without touching Tenon's capsule seems to be the safer application site of MMC during trabeculectomy.

Short-term Outcomes and Prognostic Factor of Cataract Combined Surgery with iStent Inject versus XEN

Purpose: To analyze the intraocular pressure (IOP) lowering effect, prognostic factors, and complications that occurred after iStent inject® or XEN® implantation in South Korea.Methods: We retrospectively analyzed 83 eyes with glaucoma who were followed-up for more than 6 months after iStent inject® or XEN® implantation alone or combination with cataract surgery. The success of surgery was defined as an IOP ≤21 mmHg and IOP reduction ≥20% from preoperative IOP.Results: The average IOP drop rate for 6 months after surgery was 33.80% for iStent inject® (group A, 24 eyes), 24.91% for XEN® (group B, 15 eyes), 20.47% for combined iStent inject® and cataract surgery (group A-1, 32 eyes), and 30.39% for combined XEN® and cataract surgery. The cumulative success rate of 6 months after surgery was 45.5% ± 11.2% for group A, 52.8% ± 15.4% for group B, 51.9% ± 9.0% for group A-1, and 83.3% ± 10.8% for group B-1. The difference in success rates between groups A and B was not statistically significant (p = 0.574), and also between groups A-1 and B-1 (p = 0.079).Conclusions: iStent inject® and XEN® both have a significant effect on lowering IOP, regardless of combining cataract surgery. XEN® implantation led to a statistically significant reduction in IOP lowering medications.

Assessing safety and success after using bevacizumab, 5-fluorouracil or placebo in primary trabeculectomy. A Prospective Randomized placebo controlled 1-Year Follow-up Study

PURPOSE

The aim of this study was to determine whether glaucoma patients after trabeculectomy could benefit more from subconjunctival injections of bevacizumab than 5-FU or placebo.

METHODS AND RESULTS

Fifty-one eyes of 51 patients were recruited for primary MMC (0.2mg/ml for 1 min) augmented trabeculectomy. 17 patients were randomly assigned to receive 1.25mg (0.05ml) of bevacizumab augmentation, 21 patients were assigned to receive 0.1ml of 50mg/ml 5-FU and 13 patients were assigned to a control group receiving a normal saline injection as a placebo. Initial recruitment included 58 patients, but seven patients had to be excluded from the study for various reasons. Postoperative follow up of IOP and bleb characteristics was carried out at 1 day, 1 week, 3 weeks, 6 weeks, 6 months and 1 year after surgery. All analyses where carried out by two masked clinicians. IOP reduction was statistically significant (P < 0.05) across all three groups between baseline visit and final 1-year postoperative visit. There was no significant difference of the final average IOP values between the three groups. Bleb evaluation was made using the Moorfields bleb grading system (MBGS) after 1 year follow up. Central bleb area was statistically greater in the Bevacizumab group when compared with the 5-FU group but not with the placebo group. The vascularity of the central bleb was significantly different between the groups with the Bevacizumab group showing the least vascularity. Vascularity of the peripheral bleb was also decreased in the Bevacizumab group when compared with the placebo group but not with the 5-FU group.

CONCLUSION

The 12-month IOP results showed no significant differences between the groups of patients after Bevacizumab, 5-FU or placebo to augment primary MMC enhanced trabeculectomy. However, by the analysis of bleb morphology there was a significant difference in terms of central bleb area and vascularity.

Results of fluorouracil-augmented Xen45 implantation in primary open-angle and pseudoexfoliation glaucoma

PURPOSE

To report the effectiveness and safety of 5-fluorouracil (5-FU)-augmented Xen45 implantation in primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PEXG).

METHODS

This single-center, retrospective chart review study included 29 eyes that underwent 5-FU-augmented Xen45 implantation. Main outcome measures were intraocular pressure (IOP) levels and number of glaucoma medications. Surgical success was defined as IOP ≤ 21 mmHg and ≥ 20% reduction from preoperative levels without (complete success) or with (qualified success) glaucoma medications and without further glaucoma surgery at last follow-up. All postoperative interventions and complications were also noted.

RESULTS

The mean age of the patients was 67.5 ± 10.3 years, and the mean follow-up time was 23.2 ± 12.6 months. Mean IOP was 24.5 ± 8.7 mmHg and decreased by 30.2% at 12 months, 24.9% at 24 months, and 31.7% at final visit (p < 0.001, p = 0.006, p > 0.001, respectively). Mean number of glaucoma medications decreased from 2.83 preoperatively to 0.71 at 12 months, 0.87 at 24 months, and 0.86 at final visit (p < 0.001). At final visit, the complete success rate was 48.3%, qualified success rate was 69%, and 62.1% of the eyes were free of glaucoma medications. Needling was performed in 7 eyes (24%). Adverse events included choroidal detachment in 5 eyes, hyphema in 2 eyes, and endophthalmitis in 1 eye.

CONCLUSION

5-FU-augmented Xen45 implantation in POAG and PEXG patients provided safe and effective IOP lowering with significant reduction of glaucoma medications up to 3 years.

Recent Advances in the Surgical Management of Glaucoma in Exfoliation Syndrome

Surgical and laser procedures traditionally used in the management of exfoliation glaucoma (XFG) include laser trabeculoplasty, trabeculectomy, and glaucoma drainage implant surgery. Having demonstrated similar safety and efficacy in XFG compared with primary open-angle glaucoma, trabeculectomy remains the most commonly performed surgery in XFG. Recent trends in practice patterns in developed nations demonstrate a shift towards glaucoma drainage implant surgery, which is currently the procedure of choice in XFG for many, particularly in developed nations. In addition, cataract surgery alone may significantly decrease intraocular pressure in patients with XFG, may prevent glaucoma development in patients with exfoliation syndrome, and is recommended to be performed early in the course of the disease. With the relatively recent introduction of nonpenetrating glaucoma surgery and the ongoing evolution of minimally invasive glaucoma surgery, several other surgical procedures have now become part of the glaucoma surgeon's armamentarium when treating XFG, including the Ex-PRESS shunt, deep sclerectomy, viscocanalostomy, Trabectome, as well as angle procedures. These techniques have demonstrated promising results in various types of glaucoma. More research is, however, needed to establish the safety and efficacy of these procedures in XFG.

Trabeculectomy offers better intraocular pressure reduction in intrapatient comparison to transscleral cyclophotocoagulation

PURPOSE

Both trabeculotomy (TE) as well as transscleral endodiode laser cyclophotocoagulation (CPC) are common approaches in glaucoma surgery. The purpose of this study was to perform an intraindividual comparison of these procedures carried out by the same surgeon in the same patient on the same day.

METHODS

An observational monocentric retrospective cohort study was conducted. Patients with a bilateral refractory open-angle glaucoma who underwent trabeculectomy in one eye and transscleral endodiode laser cyclophotocoagulation in the fellow eye simultaneously were included and followed up with over the course of 1 year.

RESULTS

Eighty-two eyes of 41 patients were included. Seventeen patients (41.5%) were men and 24 (58.5%) women. The mean age was 68.7 ± 9.5 years. The diagnosis comprised 33 (80.5%) patients with a primary open-angle glaucoma, five (12.2%) patients with pseudoexfoliation glaucoma, and three (7.3%) patients with pigment dispersion glaucoma. A reduction in intraocular pressure (IOP) was seen in both after TE (from 26.2 ± 13.2 to 10.6 ± 4.1 mmHg, 52 weeks post-treatment) as well as CPC (from 24.2 ± 9.9 to 15.0 ± 5.4 mmHg, 52 weeks post-treatment). In comparison to each other, TE was significantly more effective in lowering the IOP (10.6 ± 4.1 vs. 13.4 ± 5.0; p = 0.0030, 52 weeks post-treatment) and needed antiglaucomatous medications (0.45 ± 0.80 vs. 1.24 ± 1.13; p = 0.0009, 52 weeks post-treatment). Consistently, the achievement rate of an IOP ≤ 16 mmHg without antiglaucomatous medications was significantly higher in TE-treated eyes (65.8% vs. 31.6%; p = 0.0019). Re-interventions, including 10 secondary TEs, were commonly required in those eyes undergoing CPC, especially in younger patients.

CONCLUSIONS

Trabeculectomy was demonstrated to be more effective in reducing IOP in comparison to fellow eyes receiving CPC. In particular, in younger patients, an additional TE in the CPC-treated eyes was necessary. The outcome of those secondary TEs however was comparable to the primarily performed TEs. Our study thus supports the use of CPC as tool to control IOP, especially in the context of bilateral refractive glaucoma.

Efficacy and safety of the ab interno gelatin stent in severe pseudoexfoliation glaucoma compared to non-pseudoexfoliation glaucoma at 6 months

PURPOSE

To compare the efficacy and safety of the XEN45 Gel Stent surgery between patients with and without severe pseudoexfoliation glaucoma.

METHODS

In this retrospective, single-center, comparative chart review, records of 24 eyes of 23 patients with pseudoexfoliation glaucoma and 24 eyes of 23 patients with non-pseudoexfoliation glaucoma with severe glaucoma, defined as uncontrolled intraocular pressure on maximally tolerated medical therapy, were reviewed. All patients were treated with XEN45 Gel Stent surgery, in either a standalone procedure (84.8%) or combined with phacoemulsification (15.2%). Mean intraocular pressure, mean number of intraocular pressure-lowering medications, change in best-corrected visual acuity and needling or rescue surgery rates were assessed. Success was defined as at least 20% decrease in baseline intraocular pressure among treatment-free patients.

RESULTS

Patient characteristics were similar between the groups. At 6 months, intraocular pressure in the pseudoexfoliation glaucoma group decreased by 32% (24.3 ± 9 mmHg-14.8 ± 7 mmHg, p < 0.001), with comparable decrease in intraocular pressure in the non-pseudoexfoliation glaucoma group (22.6 ± 7 mmHg-16.7 ± 6 mmHg, p = 0.011). Similar rates of patients required topical anti-glaucoma therapy (29% vs 22%, p = 0.559), needling (54% vs 37%, p = 0.247), and rescue trabeculectomy (13% in both, p = 1.00) at the last follow-up. However, intraocular pressure decreased more in the pseudoexfoliation glaucoma group among treatment-free patients (-10.1 ± 8.0 mmHg vs -4.1 ± 8.1 mmHg, p = 0.043), and final intraocular pressure was lower in the pseudoexfoliation glaucoma group (12.2 ± 3.5 mmHg vs 15.8 ± 5.7 mmHg, p = 0.044).

CONCLUSIONS

The XEN45 Gel Stent implant demonstrated similar efficacy and safety among severe pseudoexfoliation glaucoma and non-pseudoexfoliation glaucoma patients. Greater magnitude of decreased intraocular pressure occurred among treatment-free pseudoexfoliation glaucoma patients.

Effect of subconjunctival Bevacizumab injection on the outcome of Ahmed glaucoma valve implantation: a randomized control trial

IMPORTANCE

The effect of subconjunctival Bevacizumab injection on the outcome of Ahmed glaucoma valve (AGV) implantation.

BACKGROUND

Evaluation of efficacy and safety of subconjunctival Bevacizumab injection adjunctive to AGV implantation.

DESIGN

Prospective and randomized clinical trial.

PARTICIPANTS

Fifty eyes of 50 patients with diagnosis of glaucoma that were candidate for AGV surgery were included.

METHODS

In 25 eyes, conventional AGV surgery (group 1) and in 25 eyes AGV surgery with subconjunctival Bevacizumab (group 2) was performed by block randomization MAIN OUTCOME MEASURES: The primary outcome measure was surgical success. Outcome measures were compared at postoperative month 3, 6 and 12.

RESULTS

Mean age of patients was 58.76 ± 12.11 and 51.36 ± 15.44 years in group 1 and 2 respectively (P = 0.06). Mean intraocular pressure (IOP) at baseline was 24.88 ± 7.62 mmHg in group 1 and 27.52 ± 8.57 mmHg in group 2 which decreased to15.4 ± 4.4 mmHg in group 1 and 13.42 ± 2.9 mmHg in group 2 (P < 0.00) at last follow up. Surgical success was defined in two level: postoperative IOP ≤ 21 mmHg with at least 20% reduction in IOP (Criterion A), either with no medication (complete success) or with no more than two medications (qualified success) and criterion B with the same definition but the IOP ≤ 18 mmHg The cumulative success according to criterion A and B was 77.8%, 72.2% in group 1 and 89.5% in group 2, respectively, at the end of follow-up.

CONCLUSIONS AND RELEVANCE

Subconjunctival injection of Bevacizumab adjunctive to AGV implantation leads to higher success rate compared with AGV alone in one year follow-up.

First-in-human phase I study of ISTH0036, an antisense oligonucleotide selectively targeting transforming growth factor beta 2 (TGF-β2), in subjects with open-angle glaucoma undergoing glaucoma filtration surgery

Purpose

To evaluate the safety and tolerability of intravitreal ISTH0036, an antisense oligonucleotide selectively targeting transforming growth factor beta 2 (TGF-β2), in patients with primary open angle glaucoma (POAG) undergoing trabeculectomy (TE; glaucoma filtration surgery).

Methods

In this prospective phase I trial glaucoma patients scheduled for TE with mitomycin C (MMC) received a single intravitreal injection of ISTH0036 at the end of surgery in escalating total doses of 6.75 μg, 22.5 μg, 67.5 μg or 225 μg, resulting in calculated intraocular ISTH0036 concentrations in the vitreous humor of approximately 0.3 μM, 1 μM, 3 μM or 10 μM after injection, respectively. Outcomes assessed included: type and frequency of adverse events (AEs), intraocular pressure (IOP), numbers of interventions post trabeculectomy, bleb survival, visual acuity, visual field, electroretinogram (ERG), slit lamp biomicroscopy and optic disc assessment.

Results

In total, 12 patients were treated in the 4 dose groups. Main ocular AEs observed were corneal erosion, corneal epithelium defect, or too high or too low IOP, among others. No AE was reported to be related to ISTH0036. All other safety-related analyses did not reveal any toxicities of concern, either. The mean medicated preoperative IOP at decision time-point for surgery was 27.3 mmHg +/- 12.6 mmHg (SD). Mean IOP (±SD) for dose levels 1, 2, 3, and 4 were at Day 43 9.8 mmHg ± 1.0 mmHg, 11.3 mmHg ± 6.7 mmHg, 5.5 mmHg ± 3.0 mmHg and 7.5 mmHg ± 2.3 mmHg SD; and at Day 85 9.7 mmHg ± 3.3 mmHg, 14.2 mmHg ± 6.5 mmHg, 5.8 mmHg ± 1.8 mmHg and 7.8 mmHg ± 0.6 mmHg, respectively. In contrast to IOP values for dose levels 1 and 2, IOP values for dose levels 3 and 4 persistently remained below 10 mmHg throughout the observation period.

Conclusion

This first-in-human trial demonstrates that intravitreal injection of ISTH0036 at the end of TE is safe. Regarding IOP control, single-dose ISTH0036 administration of 67.5 μg or 225 μg at the time of TE resulted in IOP values persistently < 10 mmHg over the three month postoperative observation period.

Glaucoma Surgery Outcome in Rwanda

PURPOSE

To assess long-term intraocular pressure (IOP) outcome after adult trabeculectomy surgery in Central Africa.

PATIENTS AND METHODS

All adult glaucoma patients who underwent trabeculectomy surgery in the Kabgayi Eye Unit, Rwanda between August 2003 and March 2008 were invited for a follow-up visit. Surgical and clinical data were collected from medical records. At the study visit, best-corrected visual acuity was measured and Goldmann applanation tonometry and biomicroscopy were done. Good IOP outcome was defined as both an IOP<21 mm Hg and achieving ≥30% reduction from the preoperative IOP. Considering first operated eyes, univariate and multivariate logistic regression was used to investigate risk factors for failure.

RESULTS

Of 163 individuals operated 3 had died, 118 (74%) participated. Preoperatively, the mean IOP was 31 mm Hg (SD=11; range, 12 to 60). At the time of the follow-up study visit the mean postoperative IOP was 13 mm Hg (SD=5; range, 4 to 35). Good IOP outcome was achieved in 132 eyes (84%). Univariate analysis suggested a protective effect against failure of use of antimetabolites [odds ratio (OR)=0.39; 95% confidence interval (CI), 0.14-1.11; P=0.07] and a decrease in success with length of follow-up (OR=3.57; 95% CI, 1.09-12.50; P=0.03). The latter remained borderline significant with multivariate analysis. Seven eyes went from previously better vision (at least hand movements) down to perception of light or no perception of light after trabeculectomy. Particularly a flat anterior chamber in the first postoperative week (OR=0.07; 95% CI, 0.01-0.49; P<0.001) and late hypotony (OR=0.04; 95% CI, 0.002-0.99; P=0.004) were significant risk factors for severe visual loss.

CONCLUSIONS

Trabeculectomy with antimetabolites is one of the best available options for glaucoma management in Africa. However, the IOP control reduced at a follow-up duration beyond 2 years, highlighting the importance of regular long-term follow-up.

The Long-term Outcome of Primary "Bleb-sparing, Epithelial Exchange" in Dysfunctional Filtering Blebs

OBJECTIVE

To evaluate the long-term outcome of epithelial peeling and conjunctival replacement as a primary procedure in dysfunctional filtering blebs, without excising the bleb.

MATERIALS AND METHODS

A prospective, observational case series involving 34 consecutive eyes, having prior operated trabeculectomy with a dysfunctional filtering bleb, that met the inclusion criteria and were reviewed for at least 12 months. The bleb epithelium was peeled off and replaced with the adjacent conjunctiva, without bleb excision. Patients were reviewed at 1 week, 1 and 3 months postoperatively, and thereafter every 6 months for best corrected visual acuity (BCVA), applanation tonometry, bleb morphology and leaks, the lens status, glaucoma medications, and any complications. ASOCT was performed preoperatively and at the last review. Complete success (primary outcome) was defined as an intraocular pressure (IOP) >6 and <18 mm Hg without any additional antiglaucoma medications at the last follow-up.

RESULTS

The average age of the patients was 36.6±20.7 years. The average time of follow-up was 23.9±6.1 months (range, 13 to 40 mo). The mean preoperative IOP was 5.8±4.2 mm Hg. Postoperatively, the IOP at 24 months was 12.6±3.9 mm Hg (P<0.0001). The bleb characteristics were graded according to the Indiana Bleb Appearance Grading Scale (IBAGS), which showed significant results in terms of the height (H), the vascularity (V), and Seidel (S) (P<0.0001). The preoperative and the postoperative BCVAs in logMAR were 0.51±0.26 and 0.37±0.21 (P=0.0001), respectively. Complete success was noted in 31/34 eyes (91.18%) and qualified success was noted in 3 eyes (8.82%). One patient developed a mild ptosis after bleb revision.

CONCLUSIONS

Epithelial peeling of the bleb with replacement by advancement, without bleb excision, maintains bleb function and resolves bleb dysfunction in the long term.

Changes in macular thickness after trabeculectomy with or without adjunctive 5-fluorouracil

Conflict of interest.

None of the authors have any conflict of interest to declare, financial or otherwise. No financial or other support was received for the study.

Background.

The aim of the study was to assess changes in macular thickness after trabeculectomy in respect to the use of 5-fluorouracil (5-FU) as well as to analyse possible associations between the postoperative changes in macular thickness and intraocular pressure (IOP).

Materials and methods.

The prospective observational study included 106 eyes (100 patients) with glaucoma who underwent trabeculectomy with or without 5-FU. Subsequently 5-FU needling was performed if failure of the filtrating bleb occurred. Macular thickness and the IOP were evaluated before, one week, and six months after the surgery. The mean and sectoral macular thickness was assessed using spectral domain optical coherence tomography.

Results.

The mean (±SD) IOP reduced from 27.71 (±6.88) mmHg at baseline to 18.3 (±8.1) mmHg one week (p < 0.001) and 15.1 (±7.6) mmHg six months (p < 0.001) after trabeculectomy. One week postoperatively, the mean macular thickness increased from 285.19 (±15.98) μm to 288.9 (±16.31) μm (p < 0.001); macular thickening was significant in all subfields (p < 0.001) and correlated positively with IOP reduction (rho = 0.312, p = 0.001 for central subfield). After six months, macula remained thicker only at the central and inner nasal subfields (p < 0.05). The changes in macular thickness were not affected by the use of 5-fluorouracil.

Conclusions.

Trabeculectomy may induce a slight macular thickening which is more pronounced in the early postoperative period. The IOP reduction plays an important role in this process and is associated with thicker postoperative macula. However, the use of adjunctive 5-FU has no influence on macular thickness after glaucoma surgery despite its potential hypotonic, inflammatory and cytotoxic effects.

A Pilot Study on Ocular Safety and Efficacy of Infliximab as an Antifibrotic Agent After Experimental Glaucoma Filtration Surgery

Introduction

Tumor necrosis factor-α (TNF-α) is a multifunctional, proinflammatory cytokine that mediates pleiotropic biological functions, especially inflammation and immunoregulation. We hypothesized that blocking TNF-α with a monoclonal antibody would decrease inflammation and subconjunctival scarring in an animal model of experimental filtration surgery.

Methods

In a randomized, prospective, masked-observer study, 30 New Zealand albino rabbits underwent glaucoma filtration surgery. The animals were allocated to receive either intraoperative application of infliximab (group A) or mitomycin C (MMC) at a concentration of 0.2 mg/ml (group B) or balanced salt solution (BSS, control) (group C). Different infliximab doses, namely 1.0, 2.0, 3.0, 4.0, 5.0 mg in 0.1 ml, were applied. Bleb survival and characteristics were evaluated over a 30-day period. The animals were killed on postoperative day 15 or 30. Histology of the operated eyes was performed to evaluate and grade the amount of scarring in each group. Cellular density was evaluated in each case.

Results

Infliximab did not appear to improve outcomes in this model of glaucoma filtration surgery. Bleb survival was significantly higher in the MMC group compared to the other groups (p < 0.001 for both comparisons). Vascularity was also significantly lower in the MMC group compared to the other groups (p = 0.018 for both comparisons). There was a significant decrease in cellular density in the MMC group compared to the control (p = 0.0352) and the infliximab group (p < 001).

Conclusion

Our results have shown that trabeculectomies in the infliximab group failed faster and displayed more scarring, compared to the control and MMC groups. This outcome suggests that the infliximab doses used in this pilot study resulted in a subconjunctival TNF-α concentration, which acted as a stimulator to fibroblasts.

A simple and effective protocol for fast isolation of human Tenon's fibroblasts from a single trabeculectomy biopsy - a comparison of cell behaviour in different culture media

Background

Human Tenon’s fibroblasts (HTFs) play a crucial role in wound healing. They cause postoperative scarring of the filtering bleb and are thus responsible for trabeculectomy failure. This study aimed to find an effective and fast protocol for HTF isolation from trabeculectomy biopsies. The protocol was compared with the commonly recommended HTF isolation procedure, which uses Dulbecco’s modified Eagle’s medium (DMEM). We used Eagle’s minimum essential medium (EMEM) enriched with fibroblast growth factor (FGF), which selectively promoted the proliferation of HTF cells. A secondary goal was to compare HTF morphology, metabolism and growth during parallel cultivation of the isolated cells in FGF-enriched EMEM and DMEM.

Results

Standard procedures for HTF isolation from tissue biopsies require a 20- to 30-day culture of the explants to obtain the first monolayer. Our protocol yielded the first monolayer after approx. 15 days. More importantly, the majority of the cells were fibroblasts with only individual epithelium-derived cells present. Using FGF-enriched EMEM allowed 1.3 × 10⁶ vimentin-positive fibroblasts to be obtained from a single biopsy within approx. 25 days. Using DMEM resulted in isolation failure and required exchange to FGF-enriched medium to recover the fibroblast culture. HTFs maintained in FGF-enriched EMEM also showed faster proliferation and a different type I collagen production ability compared to HTFs cultured in DMEM. Thus, FGF-enriched EMEM is recommended for fast propagation of HTFs unless the aim of the study is to assess the effect of a tested agent on proliferation ability or type I collagen production.

Conclusions

Our fast protocol for HTF isolation allows easy setup of cell banks by researchers under laboratory conditions and could be very useful during testing of novel ophthalmologic anti-fibrotic agents in vitro. Molecular analysis of HTFs isolated from patients with known treatment histories may provide valuable information on the effects of some medications taken before glaucoma surgery on the subsequent wound-healing process and potential for trabeculectomy failure.

Electronic supplementary material

The online version of this article (doi:10.1186/s11658-017-0034-4) contains supplementary material, which is available to authorized users.

The Effects of Bevacizumab in Augmenting Trabeculectomy for Glaucoma: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The aim of the study was to assess the effects of bevacizumab in augmenting trabeculectomy for glaucoma. We searched the databases of Cochrane Library, PubMed, Embase, CNKI, and VIP. All the databases were retrieved from the time databases established to September, 2015. The keywords we used were as follows: "bevacizumab," "anti-VEGF," "avastin," "trabeculectomy," "glaucoma," and so on. We used a method of the freedom word search and the MeSH search combined, which was recommended by Cochrane Systematic Review Manual 5.1.2. Randomized controlled trails (RCTs) of frequently used bevacizumab in trabeculectomy for glaucoma were included. Study selection, data extraction, quality assessment, and data analysis were performed according to the Cochrane standards. Eight randomized controlled trails involving 212 eyes in the experimental (bevacizumab or bevacizumab + mitomycin C) groups and 214 eyes in the control (mitomycin C or placebo) groups were selected. Compared with placebo, bevacizumab significantly increased the complete success rate [OR = 2.79, 95%CI, (1.47, 5.29), P = 0.002], what else, bevacizumab also significantly decreased the intraocular pressure (IOP) [MD = 3.07, 95% CI, (0.87, 5.27), P = 0.006] at the 6-month after trabeculectomy and the number of antiglaucoma medications [MD = 1.23, 95% CI, (0.66, 1.80), P < 0.0001]. Additionally, it also increased the risk of bleb leak [OR = 5.24, 95% CI, (1.30, 21.10), P = 0.02]. When compared with mitomycin C (MMC), bevacizumab significantly increased the rate of encysted blebs [OR = 4.62, 95% CI, (1.02, 20.91), P = 0.05]. However, there was no significantly difference between the bevacizumab + MMC groups and MMC groups whatever the items were. Bevacizumab was an effective way in trabeculectomy concerning the complete success rate, IOP, and anti-glaucoma medications reduction when compared with placebo; however, it increased the risk of bleb leakage. And it significantly increased the rate of encysted blebs compared with MMC.

Mitomycin C versus 5-Fluorouracil for wound healing in glaucoma surgery

BACKGROUND

Raised intraocular pressure is a risk factor for glaucoma. One treatment option is glaucoma drainage surgery (trabeculectomy). Antimetabolites are used during surgery to reduce postoperative scarring during wound healing. Two agents in common use are mitomycin C (MMC) and 5-Fluorouracil (5-FU).

OBJECTIVES

To assess the effects of MMC compared to 5-FU as an antimetabolite adjunct in trabeculectomy surgery.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015 Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2015), EMBASE (January 1980 to October 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 October 2015.

SELECTION CRITERIA

We included randomised controlled trials where wound healing had been modified with MMC compared to 5-FU.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and collected data. The primary outcome was failure of a functioning trabeculectomy one year after surgery. Secondary outcomes included mean intraocular pressure at one year. We considered three subgroups: high risk of trabeculectomy failure (people with previous glaucoma surgery, extracapsular cataract surgery, African origin and people with secondary glaucoma or congenital glaucoma); medium risk of trabeculectomy failure (people undergoing trabeculectomy with extracapsular cataract surgery) and low risk of trabeculectomy failure (people who have received no previous surgical eye intervention).

MAIN RESULTS

We identified 11 trials that enrolled 687 eyes of 679 participants. The studies were conducted in the United States, Europe, Asia and Africa. Five studies enrolled participants at low risk of trabeculectomy failure, five studies enrolled participants at high risk of failure, and one study enrolled people with both high and low risk of failure. None of the included trials enrolled participants with combined trabeculectomy/cataract surgery.We considered one study to be at low risk of bias in all domains, six studies to be at high risk of bias in one or more domains, and the remaining four studies to be at an unclear risk of bias in all domains.The risk of failure of trabeculectomy at one year after surgery was less in those participants who received MMC compared to those who received 5-FU, however the confidence intervals were wide and are compatible with no effect (risk ratio (RR) 0.54, 95% confidence interval (CI) 0.30 to 1.00; studies = 11; I(2) = 40%). There was no evidence for any difference between groups at high and low risk of failure (test for subgroup differences P = 0.69).On average, people treated with MMC had lower intraocular pressure at one year (mean difference (MD) -3.05 mmHg, 95% CI -4.60 to -1.50), but the studies were inconsistent (I(2) = 52%). The size of the effect was greater in the high-risk group (MD -4.18 mmHg, 95% CI -6.73 to -1.64) compared to the low-risk group (MD -1.72 mmHg, 95% CI -3.28 to -0.16), but again the test for interaction was not statistically significant (P = 0.11).Similar proportions of eyes treated with MMC lost 2 or more lines of visual acuity one year after surgery compared to 5-FU, but the confidence intervals were wide (RR 1.05, 95% CI 0.54 to 2.06).Adverse events occurred relatively rarely, and estimates of effect were generally imprecise. There was some evidence for less epitheliopathy in the MMC group (RR 0.23, 95% CI 0.11 to 0.47) and less hyphaema in the MMC group (RR 0.62, 95% CI 0.42 to 0.91).None of the studies reported quality of life.Overall, we graded the quality of the evidence as low largely because of risk of bias in the included studies and imprecision in the estimate of effect.

AUTHORS' CONCLUSIONS

We found low-quality evidence that MMC may be more effective in achieving long-term lower intraocular pressure than 5-FU. Further comparative research on MMC and 5-FU is needed to enhance reliability and validity of the results shown in this review. Furthermore, the development of new agents that control postoperative scar tissue formation without side effects would be valuable and is justified by the results of this review.

Pseudoexfoliation Syndrome and Pseudoexfoliation Glaucoma: A Review of the Literature with Updates on Surgical Management

Pseudoexfoliation syndrome (PES) is a systemic disorder caused by progressive accumulation of extracellular material over various tissues. PES usually determines increased intraocular pressure, changes in the anatomical aspects of the optic nerve, and visual field alterations leading to the diagnosis of pseudoexfoliation glaucoma (PEG). Use of topical medical treatment usually leads to poor results in terms of long-term follow-up but many surgical techniques, such as Argon Laser or Selective Laser Trabeculoplasty, have been proposed for the management of PEG affected patients. The present paper is a review on the pseudoexfoliation syndrome and pseudoexfoliation glaucoma with an update on surgical management.

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.

Prevalence and Prognosis of Pseudoexfoliation Glaucoma in Western India

PURPOSE

To investigate the prevalence and reconnoiter treatment modalities for Pseudoexfoliation Glaucoma (PXG) in subjects with Pseudoexfoliation Syndrome (PXF) in a rural scenario of western India.

DESIGN

A prospective prevalence study.

METHODS

Occurrence of PXG in 250 subjects with PXF was studied in the Department of Glaucoma, Shri Ganapati Netralaya, Jalna, India, from 2009 to 2011. The subject pool presented with PXF, having intraocular pressure (IOP) ≥ 20 mm of Hg, and evidencing optic nerve damage and abnormal visual fields were judiciously selected as PXG cohorts. A decision table is formulated to assist the physician in rendering medical or surgical treatment options.

RESULTS

The prevalence of PXG increased with increasing age at 30% (95% CI: 28.56-33.72) in the 60-year-old and older population. It was predominantly higher in cohorts involved in outdoor physical activities at 46% (95% CI: 41.24-52.38). The eminence and prevalence of nuclear cataract in subjects with PXG was 72 % (95% CI: 65.72-76.34). Visual impairment was highly prevalent in 75% (95% CI: 73.43-78.29) and 10% (95% CI: 6.87-13.21) cohorts with PXG and PXF respectively. In general, linear modelling IOP was 26.37±1.64 in subjects with PXG, which was managed to 16.50±1.32 after rendering our adapted treatment protocols.

CONCLUSIONS

Increased IOP, occludable angles, and glaucomatous optic neuropathy occur more frequently in the population with PXF. It is inferred that that treatment protocol of combined cataract and glaucoma surgery gives maximum reduction in IOP.

Achieving Target Pressures with Combined Surgery: Primary Patchless Ahmed Valve Combined with Phacoemulsification vs Primary Phacotrabeculectomy

PURPOSE

To evaluate the ability of phacoemulsification combined with either primary trabeculectomy (PT) or primary Ahmed glaucoma valve implantation (PAVI) to achieve target intraocular pressures (TIOP) in adults with primary open angle glaucoma.

MATERIALS AND METHODS

Chart review of 214 adult patients operated between January 2002 and June 2008 with a minimum follow-up of 6 months. Group 1 comprised 181 eyes of 166 patients undergoing PT while group 2 included 50 eyes of 49 patients in combination with primary AVI. Target lOPs were pre-determined for each patient and success was defined as an IOP at or lower than target with or without medications. An IOP above target, loss of light perception or need for additional procedures to lower IOP were considered a failure.

RESULTS

Mean preoperative IOP was 17.2 mm Hg in group 1 and 17.3 in group 2. Mean postoperative IOPs were 10.2 and 9.2 on day 1, 12.2 and 11.6 at year 1, and 10.7 in both groups at year 5. Survival rates in groups 1 and 2 were 96.7 vs 96% at 6 months, 89 vs 96% at 12 months, 83.5 vs 96% at 24 months and 79.4 vs 89.1% at 36, 48 and 72 months. Transient bleb leaks were more frequent in group 1 (26 eyes, 14.4 vs 0%, p = 0.001) and transient choroidal detachments were more frequent in group 2 (7 eyes, 3.9 vs 6 eyes, 12%, p = 0.038).

CONCLUSION

Midterm results for achieving target pressures using combined phacoemulsification with either PT or PAVI are comparable. The profile of complications is different for the two procedures. How to cite this article: Albis-Donado O, Sánchez-Noguera CC, Cárdenas-Gómez L, Castañeda-Diez R, Thomas R, Gil-Carrasco F. Achieving Target Pressures with Combined Surgery: Primary Patchless Ahmed Valve Combined with Phacoemulsification vs Primary Phacotrabeculectomy. J Curr Glaucoma Pract 2015;9(1):6-11.

Biodegradable Collagen Implants in Trabeculectomy

Subconjunctival and subscleral fibrosis are the major causes of failure of filtering surgery. Antiproliferative agents have been successfully used to improve the long-term success of this surgery. Recent advancement in the field of glaucoma surgery has been the use of bioengineered, biodegradable, porous collagen-glycosaminoglycan matrix implant in the subconjunctival and/or subscleral space to modify the wound-healing process and reduce scar formation, hence improving the surgical success without the need for anti-fibrotic agents. Biodegradable, collagen implants have shown favorable results when used with deep sclerectomy. There have been variable results regarding the success of trabeculectomy when combined with these implants. These implants also decrease the dose of mitomycin C required with trabeculectomy and hence, decrease the side effect associated with these drugs. The use of the biodegradable implants in glaucoma surgery is still evolving and further studies are needed to find the appropriate surgical technique, the ideal size and site of placement and determine their long-term impact on trabeculectomy outcomes and complications. How to cite this article: Ichhpujani P, Dada T, Bhartiya S. Biodegradable Collagen Implants in Trabeculectomy. J Curr Glaucoma Pract 2015;9(1):24-27.

Amniotic membrane transplantation in failed trabeculectomy

PURPOSE

To determine the efficacy and safety of amniotic membrane transplantation for trabeculectomy in patients with previous failed filtering blebs.

METHODS

A consecutive series of 19 eyes from 18 patients with 1 or more failed trabeculectomies were enrolled in this retrospective study. Trabeculectomy, with amniotic membrane positioned as a "graft" under the scleral flap, was performed, and the intraocular pressure (IOP), number of antiglaucoma medications, appearance of the filtering bleb, and intraoperative and postoperative complication data were retrospectively analyzed for a period of 24 months. Success was defined as IOP<21 mm Hg at the end of the follow-up period.

RESULTS

The median preoperative pressure was 29 mm Hg [interquartile range (IQR)=5 mm Hg], with an average of 2.8 glaucoma medications (range, 1 to 4). At 6 months postoperatively the median IOP was 18 mm Hg (IQR=1.75 mm Hg) with no further significant increases recorded, settling at 19 mm Hg (IQR=3.25 mm Hg) at the end of the 24-month follow-up. Success was achieved in all 19 cases (100%), and only 1 patient (5%) required postoperative antiglaucoma therapy to reach the target pressure. At 24 months after surgery, 18 of 19 (95%) amniotic membrane filtering blebs were functioning well without antiglaucoma therapy. No patients had severe intraoperative or postoperative complications.

CONCLUSIONS

Amniotic membrane transplantation in trabeculectomy seems to be a safe and useful procedure for improving the surgical outcome and maintaining low postoperative IOP in patients with a high risk of surgical failure.

Antimetabolites in cataract surgery to prevent failure of a previous trabeculectomy

BACKGROUND

Patients having cataract surgery have often earlier undergone a trabeculectomy for glaucoma. However, cataract surgery may be associated with failure of the previous glaucoma surgery and antimetabolites may be used with cataract surgery to prevent such failure. There is no systematic review on whether antimetabolites with cataract surgery prevent failure of a previous trabeculectomy.

OBJECTIVES

To assess the effects of antimetabolites with cataract surgery on functioning of a previous trabeculectomy.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2014), EMBASE (January 1980 to June 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to June 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 June 2014. We also searched the Science Citation Index database (July 2013) and reference lists of potentially relevant studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of antimetabolites with cataract surgery in people with a functioning trabeculectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the titles and abstracts from the electronic searches. Two review authors independently assessed relevant full-text articles and entered data.

MAIN RESULTS

We identified no RCTs to test the effectiveness of antimetabolites with cataract surgery in individuals with the intention of preventing failure of a previous trabeculectomy.

AUTHORS' CONCLUSIONS

There are no RCTs of antimetabolites with cataract surgery in people with a functioning trabeculectomy. Appropriately powered RCTs are needed of antimetabolites during cataract surgery in patients with a functioning trabeculectomy.

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.

[Long-term results after trabeculectomy with 5-fluorouracil]

PURPOSE

Trabeculectomy is among the first choice surgical treatments for glaucoma. Antimetabolites, especially mitomycin C, have improved the success rate. The aim of this study is to present the results of trabeculectomy with 5-fluorouracil (5-FU).

METHODS

A total of 71 consecutive trabeculectomies with 5-FU for decompensated glaucoma with at least 1 year follow-up data were retrospectively evaluated. The absolute (without therapy) and relative (with therapy) success rates for glaucoma medication were determined for intraocular pressure (IOP) levels of ≤ 21 mmHg, ≤ 18 mmHg, ≤ 15 mmHg and ≤ 12 mmHg respectively. Postoperative 5-FU administration rates, needling procedures and complications were recorded.

RESULTS

Sufficient follow-up data were available for a total of 55 patients. The average IOP was preoperatively 29.6 ± 7.3 mmHg (3 ± 1.4 active ingredients, partly acetazolamide), after 6 months 13.2 ± 4.1 mmHg and after 1 year 13.7 ± 4.3 mmHg. Complete success at 6 months postoperatively for the given pressure levels: were 92 %, 87 %, 79 % and 52% and at 1 year 87 %, 84 %, 51 % and 56%, respectively. Postoperative relative success for these pressure levels at 6 months were 96 %, 90 %, 81 % and 54% and at 1 year 96 %, 93 %, 58 % and 58%, respectively. Administrations of 5-FU postoperatively were no intervention (n=30 patients), subconjunctival 5-FU administration (n=25) and needling procedures (n=6). A temporary hypotension with a shallow anterior chamber was seen in 6 patients, cataract development in 5 patients and 1 patient developed corneal decompensation (multiple previous operations before trabeculectomy).

CONCLUSION

Trabeculectomy with intraoperative 5-FU administration showed very high success rates after 1 year. Serious complications were rarely seen. Intraoperative 5-FU administration can be considered as an alternative treatment to trabeculectomy with intraoperative use of mitomycin C.

Current variations of glaucoma filtration surgery

PURPOSE OF REVIEW

Trabeculectomy continues to be the most effective incisional surgery for uncontrolled glaucoma. Since its introduction by Cairns in 1968, the procedure has undergone numerous modifications. This article will summarize the current variations of glaucoma filtration surgery and evidence-based review of their potential advantages and disadvantages.

RECENT FINDINGS

Recent innovations in glaucoma filtration surgery have focused on wound modulation to enhance long-term surgical outcomes and the search for a small incision surgery with more predictable outcomes, lower complication rates, and rapid visual recovery. Amniotic membranes, antivascular endothelial growth factor agents, and tissue-engineered biodegradable implants are currently being investigated as alternatives to mitomycin C and 5-fluorouracil to reduce inflammation and subsequent bleb failure with fewer complications. The Ex-PRESS glaucoma filtration device appears promising with its unique feature of small-incision surgery, fewer intraoperative and postoperative complications, and its ability to lower intraocular pressure significantly, which appears to be comparable with standard trabeculectomy.

SUMMARY

Knowledge and surgical expertise in handling current variations of glaucoma filtration surgery are essential to offer an individualized approach with the overall goal of optimizing surgical outcomes and minimizing complications.

Interventions for late trabeculectomy bleb leak

BACKGROUND

Late trabeculectomy bleb leaks are a common complication after filtering glaucoma surgery. Although asymptomatic, late bleb leaks may lead to hypotony and are associated with bleb related infections.

OBJECTIVES

To assess the effects of interventions for late trabeculectomy bleb leak.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), MEDLINE (January 1946 to July 2012), EMBASE (January 1980 to July 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 18 July 2012.

SELECTION CRITERIA

We included randomised and quasi-randomised trials in which any treatments for eyes with late bleb leak (interventional and non-interventional) were compared with each other.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors when additional information was needed.

MAIN RESULTS

The review included one multicentre trial based in the USA with 30 eyes of 30 participants. The trial compared two surgical procedures (conjunctival advancement and amniotic membrane transplant) to cover a filtering bleb leak. Conjunctival advancement has been shown to be more effective in sealing filtering bleb leaks.

AUTHORS' CONCLUSIONS

Although a variety of treatments have been proposed for bleb leaks, there is no evidence of their comparative effectiveness.The evidence in this review was provided by a single trial that compared two surgical procedures (conjunctival advancement and amniotic membrane transplant). The trial did show a superiority of conjunctival advancement, which was regarded as standard treatment, to amniotic membrane transplantation. There is a need for more randomised trials to validate the findings of this single trial and provide more information on the different types of interventions, especially non-surgical treatments compared to surgical procedures. We recommend that any intervention should be compared to a standard procedure, which is to date conjunctival advancement.

Comparison of the use of 5-fluorouracil and bevacizumab in primary trabeculectomy: results at 1 year

BACKGROUND

The present study compared the effects of adjuvant bevacizumab and 5-fluorouracil on the efficacy and safety of trabeculectomy.

DESIGN

A nonrandomized, prospective, interventional case study.

PARTICIPANTS

A total of 62 patients in two groups undergoing primary trabeculectomy.

METHODS

In Group 1 (21 primary open-angle glaucoma, nine pseudoexfoliative glaucoma), trabeculectomy was performed with an adjuvant 5% solution of 5-fluorouracil administered for 4 min, intraoperatively. In Group 2 (21 primary open-angle glaucoma, 11 pseudoexfoliative glaucoma), trabeculectomy was enhanced with 1.25 mg of bevacizumab applied subconjunctivally immediately before and after surgery and again 1 and 7 days after surgery.

MAIN OUTCOME MEASURES

Intraocular pressure, best corrected visual acuity, visual field index, bleb morphology, cornel endothelial cell count.

RESULTS

Mean intraocular pressure was 28.0 ± 8.0 mmHg before 5-fluorouracil-augmented trabeculectomy and 27.8 ± 9.5 mmHg before bevacizumab-augmented trabeculectomy. After 12 months, mean intraocular pressure was 13.6 ± 4.4 mmHg in the 5-fluorouracil group and 14.7 ± 4.7 mmHg in the bevacizumab group. A 30% reduction of initial intraocular pressure was attained in 86.7% of patients in the 5-fluorouracil group and 78.1% of patients in the bevacizumab group at the end of follow up. No significant differences were noted between the two studied groups with respect to corneal endothelial density, visual field indices and postoperative complications.

CONCLUSIONS

The 12-month intraocular pressure results showed no significant differences between the two groups of patients after bevacizumab or 5-fluorouracil to augment trabeculectomy. However, to obtain successful intraocular pressure control more patients in bevacizumab group needed medical therapy.

Expanded indications for transconjunctival trabeculectomy flap suturing: postoperative choroidal effusion and dysesthesia

OBJECTIVE

To assess the efficacy of transconjunctival trabeculectomy flap suturing (TTFS) in improving choroidal effusions and bleb dysesthesia resulting from overfiltration after trabeculectomy.

DESIGN

Retrospective review.

PARTICIPANTS

The study involved 15 eyes of 15 patients.

METHODS

Patients underwent TTFS for choroidal effusions and bleb dysesthesia following trabeculectomy using mitomycin C. The scleral flap was sutured through the conjunctiva as an outpatient clinic procedure.

RESULTS

There were 11 patients who had choroidal effusions and 4 patients were identified with dysesthesia. The average duration of choroidal effusion prior to TTFS was 2.1 ± 2.3 months and 3 ± 2 months in the dysesthesia group. At the final follow-up (25 ± 17 months) the mean intraocular pressure improved from 4.1 ± 2.1 mm Hg before suturing to 8.1 ± 3.6 mm Hg (p < 0.007) for the patients with choroidal effusion and from 4.2 ± 0.6 mm Hg to 8. 7 ± 3.5 mm Hg (p = 0.05) for the patients with dysesthesia. In both groups, resolution of the signs and symptoms was achieved in all cases. The mean time to resolution of choroidal effusions was 5.5 ± 8.6 weeks and the mean time to resolution of dysesthesia was 2 ± 0.8 weeks. None of the patients had serious complications such as failure of the trabeculectomy or visual loss.

CONCLUSIONS

Transconjunctival suturing of the trabeculectomy scleral flap is a simple and effective surgical method for the treatment of cases of choroidal effusions or dysesthesia resulting from trabeculectomy.

Low-dose subconjunctival bevacizumab to augment trabeculectomy for glaucoma

Background:

The purpose of this study was to assess the effect of bevacizumab in maintaining intraocular pressure lowered by trabeculectomy in refractory open-angle glaucoma.

Methods:

Thirty-seven eyes from 37 patients referring to Nikoukari Ophthalmology University Hospital in Tabriz were enrolled in this randomized clinical trial. Seventeen patients were randomly assigned to receive bevacizumab augmentation after trabeculectomy, and 20 patients were assigned to a control group receiving a placebo injection of normal saline. Bevacizumab was injected subconjunctivally at a dose of 0.2 mg. Intraocular pressure was measured on eight occasions, ie, at baseline, 24 hours, 3 days, 7 days, 2 weeks, 1 month, 2 months, and 3 months after treatment.

Results:

Men constituted 81% of the participants, who were of mean age 67.5 years. Twenty-nine patients had secondary open-angle glaucoma, while eight patients had primary open-angle glaucoma. Intraocular pressure decreased from a mean of 28.4 mmHg at baseline to a mean of 12.1 mmHg during the first day and to 15.1 mmHg after 3 months. Adding bevacizumab to trabeculectomy was not found to affect intraocular pressure differently to placebo. Neither the results of repeated measurements analysis nor single comparison statistical tests were significant for a difference in efficacy of bevacizumab versus placebo.

Conclusion:

Subconjunctival bevacizumab 0.2 mg was not found to affect the trend in intraocular pressure more than placebo after trabeculectomy for open-angle glaucoma.

A watertight acrylic-free titanium recording chamber for electrophysiology in behaving monkeys

Neurophysiological recording in alert monkeys requires the creation of a permanent aperture in the skull for repeated insertion of microelectrodes. Most laboratories use polymethyl methacrylate to attach a recording chamber over the skull opening. Here, we describe a titanium chamber that fastens to the skull with screws, using no polymethyl methacrylate. The gap between the base of the chamber and the skull is filled with hydroxyapatite, forming a watertight gasket. As the chamber base osseointegates with the skull, the hydroxyapatite is replaced with bone. Rather than having a finite lifetime, the recording chamber becomes more firmly anchored the longer it is in place. It has a small footprint, low profile, and needs little maintenance to control infection. Toilette consists of occasional application of betadine to clean the scalp margin, followed by application of neomycin, polymyxin, and bacitracin ointment. Antibiotic is also placed inside the chamber to suppress bacterial proliferation. Thickening of the dura within the chamber can be prevented by regular application of mitocycin C and/or bevacizumab, an antibody against vascular endothelial growth factor. By conducting an e-mail survey, this protocol for chamber maintenance was compared with procedures used in 37 other vision research laboratories. Refinement of appliances and techniques used for recordings in awake monkeys promises to increase the pace of scientific discovery and to benefit animal welfare.

Augmenting trabeculectomy in glaucoma with subconjunctival mitomycin C versus subconjunctival 5-fluorouracil: a randomized clinical trial

Objective:

The aim of this study was to compare the efficacy of augmenting trabeculectomy with subconjunctival mitomycin C (TMMC) versus 5-fluorouracil (T5-FU) in lowering intraocular pressure (IOP).

Methods:

Forty eyes from 40 patients referred to the Nikoukari Ophthalmology University Hospital, Tabriz University of Medical Sciences, Tabriz, Iran, were enrolled in a randomized clinical trial. Patients with high-risk open angle glaucoma were allocated to receive either subconjunctival TMMC or T5-FU.

Results:

Mean overall preoperative IOP was 30.8 mmHg. Mean preoperative IOPs in the TMMC and T5-FU groups were 31.2 ± 9.8 and 30.6 ± 9.9 mmHg, respectively. Postoperatively, mean IOPs were 11.4.3 ± 4.9 and 13.6 ± 3.9 mmHg, respectively for TMMC and T5-FU groups after 6 months. In spite of some existing descriptive differences in IOP between the groups, statistical tests showed no difference in mean and median IOP. Three cases of hypotonia (IOP < 6 mmHg) and 1 case of epithelial keratitis were detected.

Conclusion:

TMMC and T5-FU appeared to have similar efficacy in lowering IOP.