Trabeculectomy with mitomycin C for refractory glaucoma in blacks

A comparative study on surgical outcomes of trabeculectomy with and without anti-metabolites in juvenile open-angle glaucoma

Purpose

To compare the surgical outcomes of trabeculectomy with and without anti-metabolites in patients with juvenile open-angle glaucoma (JOAG).

Methods

This retrospective comparative case series included 98 eyes of 66 patients with JOAG who underwent either trabeculectomy without anti-metabolites (group A, n = 53 eyes) or with anti-metabolites (group B, n = 45 eyes) with a minimum of 2 years follow-up. The main outcome measures were intra-ocular pressure (IOP), number of glaucoma medications, visual acuity, additional surgical interventions, surgical complications, and risk factors for failure. Surgical failure was defined as IOP >18 mmHg or failure to reduce IOP by <30% from the baseline value or IOP ≤5 mmHg or re-operation for refractory glaucoma or a complication or loss of light perception vision.

Results

The mean post-operative IOP reduced significantly from baseline at all post-operative visits until 6 months and thereafter. The cumulative probability of failure at 2 years was 28.7% in group A [95% confidence interval (CI) = 17.6-44.8%] and 29.1% in group B (95% CI = 17.1-46.7%) (P = 0.78). Surgical complications occurred in 18 eyes (34%) in group A and 19 eyes (42%) in group B. Re-operations for glaucoma or complications were performed in two eyes (3.8%) in group A and two eyes (4.4%) in group B. Cox-hazard regression model revealed male gender (HR = 0.29; P = 0.008), baseline high IOP (HR = 0.95; P = 0.002), and an increased number of pre-operative glaucoma medications (HR = 2.08; P = 0.010) as significant factors associated with failure.

Conclusion

: Our study results on trabeculectomy in JOAG revealed a success of 71% in both groups at 2 years follow-up. There was no significant difference in success or failure rates between the two groups. The risk factors for poor surgical outcome in JOAG were male gender, baseline high IOP, and an increased number of glaucoma medications.

Acute Attack of Glaucoma after Scleral Melting and Iris Blockage of the Surgical Ostium: A Case Report of a Complication Derived from a Mitomycin C Supplemented Trabeculectomy

Aim

To describe a case of an acute attack of glaucoma due to scleral melting in the area where a trabeculectomy was previously done. This condition resulted from the blockage of the surgical opening due to an iris prolapse in an eye that was previously supplemented with mitomycin C (MMC) during a filtering surgery and bleb needling revision.

Case description

A 74-year-old Mexican female with a prior glaucoma diagnosis who assisted to an appointment presenting an acute ocular hypertensive crisis after several months of adequately controlled intraocular pressure (IOP). Ocular hypertension had been regulated after undergoing a trabeculectomy and bleb needling revision; both supplemented with MMC. The severe IOP increase occurred due to uveal tissue blockage in the filtering site, related to melting of the sclera in the same area. The patient was successfully treated through the use of a scleral patch graft and the implantation of an Ahmed valve.

Conclusion

An acute attack of glaucoma associated with scleromalacia after trabeculectomy and needling has not been previously reported and is currently attributed to MMC supplementation. Nevertheless, the use of a scleral patch graft and further glaucoma surgery seems to be an efficient way to treat this condition.

Clinical significance

Even though this complication was appropriately managed with this patient, we want to prevent further cases like this through the judicious and careful use of MMC.

How to cite this article

Paczka JA, Ponce-Horta AM, Tornero-Jimenez A. Acute Attack of Glaucoma after Scleral Melting and Iris Blockage of the Surgical Ostium: A Case Report of a Complication derived from a Mitomycin C Supplemented Trabeculectomy. J Curr Glaucoma Pract 2022;16(3):199-204.

[Classification, diagnosis and treatment of juvenile glaucoma]

Juvenile open-angle glaucoma is a disease with complex pathogenesis affecting young people of working age that can lead to disability. The article describes modern concepts of diagnosis, classification and approaches to the treatment of juvenile glaucoma with special attention paid to the differential diagnostic criteria of juvenile open-angle glaucoma and congenital glaucoma.

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.

Does TRABECULECTOMY meet the 10-10-10 challenge in PACG, POAG, JOAG and Secondary glaucomas?

PURPOSE

Evaluation of the intraocular pressure (IOP) lowering efficacy of trabeculectomies over > 10 years and their ability to stabilize glaucomatous optic neuropathy.

METHODS

In total, 181 eyes (136 patients), which underwent trabeculectomy (10 min surgery) at least 10 years prior and were on regular follow-up, were evaluated. Qualified/complete success was taken as criteria A: IOP ≤ 12 mmHg, B: IOP ≤ 15 mmHg and C: IOP ≤ 18 mmHg, with all > 5 mmHg, with/without medications. Target IOP in advanced glaucoma is about 10 mmHg, therefore trabeculectomy 10-10-10 challenge!

RESULTS

The mean age of patients was 46.32 ± 11.50 years. Absolute success was 50.27%, 54.14% and 59.66% according to criteria A, B and C at last follow-up, while qualified success was 70.11%, 81.77% and 96.13%. An IOP of ≤ 12 mmHg was noted in 34, 64.15%, PACG eyes, 14, 73.68%, POAG, 15, 65.22%, JOAG and 64, 74.42%, secondary glaucoma eyes. The reduction in IOP overall was 64.83 ± 16.80% at last review and was 59.47 ± 16.07% in PACG, 62.40 ± 17.72% in POAG, 71.89 ± 8.50% in JOAG and 67.74 ± 18.10% in secondary glaucoma eyes. "Target" IOP was achieved in 97.29% of early glaucoma, 85.71% moderate glaucoma and 70% severe glaucoma eyes. 97.24% of patients were perimetrically stable. 2.21% of eyes post-trabeculectomy had a shallow anterior chamber needing surgical intervention. Visual acuity was maintained or better in 93.92% of patients, with a cataract surgery performed in 6.63% eyes. A repeat trabeculectomy was performed in 3.31% of eyes.

CONCLUSION

Trabeculectomy 10-10-10 is achievable in the long term, with few complications or repeat surgical interventions in the majority of POAG, PACG, JOAG and secondary glaucomas. Therefore, trabeculectomy should not be relegated to a last resort, but should be undertaken as soon as possible, if medical therapy is inadequate, unaffordable or compliance is an issue.

Assessing the Status of Filtering Blebs at 5 Year Post- Trabeculectomy

BACKGROUND:

Glaucoma is a common cause of blindness in the world as well as in Vietnam. It is treated by many different methods but trabeculectomy is still the most popular and highly effective surgical method to treat this condition.

AIM:

To analyze the status of 5 years filtering blebs following trabeculectomy and to explore multiple factors associated with filtering blebs.

METHODS:

This is a retrospective, cross-sectional descriptive study. Eyes had been performed trabeculectomy for 5 years were included in these results. The filtering blebs were assessed using slit lamp and OCT. the OCT captured bleb area to evaluate fluid subconjunctival spaces, thickness and height of bleb and to evaluate the related factors

RESULTS:

A group of 106 primary glaucoma eyes of 97 patients (88 patients with 1 eye, 9 patients 2 eyes) had been performed trabeculectomy for 5 years were taken OCT anterior image. The proportion of female patients is 1.5 times that of male patients. IOP was controlled with or without topical medication in all eyes. The filtering bleb had a high echo reflection, which accounted for 42.5%, the average echo reflection was 38.6%, the low echo reflection response of 18.9%. 66% of the eyes had the aqueous space under the conjunctiva, 65.1% have the aqueous space under sclera flap, the average height of the bleb on OCT was 0.4 mm ± 0.3 mm. Young patients often have a higher rate of bleb fibrosis and loss of function than older patients

CONCLUSION:

OCT is capable of assessing the function of bleb. After 5 years of trabeculectomy, on the OCT image, most cases of blebs are maintaining drainage function.

Observational Outcomes of Initial Trabeculectomy With Mitomycin C in Patients of African Descent vs Patients of European Descent: Five-Year Results

Importance

There is evidence that patients of African descent (AD) experience higher surgical failure rate after trabeculectomy without antimetabolites.

Objective

To compare outcomes of initial trabeculectomy with mitomycin C in AD patients with those of patients of European descent (ED) and to identify prognostic factors for failure.

Design, Setting, and Participants

In this retrospective matched cohort study, 135 eyes of 105 AD patients were matched with 135 eyes of 117 ED patients by age (within 5 years), surgeon, lens status, and follow-up time (within 1 year) from a single tertiary academic center.

Interventions

Initial trabeculectomy with mitomycin C.

Main Outcomes and Measures

Criteria A, B, and C defined qualified success rates as final intraocular pressure of 18 mm Hg or less, 15 mm Hg or less, and 12 mm Hg or less, respectively, in addition to 20% or more, 25% or more, and 30% or more reduction of intraocular pressure or reduction of 2 or more medications. Kaplan-Meier survival curves were compared with log-rank test in AD and ED patients, and Cox proportional hazard models were used to estimate the influence of race/ethnicity on surgical success accounting for confounding variables.

Results

Of the 105 AD patients, 56 (53.3%) were female, and the mean (SD) age was 67.5 (10.4) years; of the 117 ED patients, 64 (54.7%) were female, and the mean (SD) age was 68.2 (10.0) years. For AD patients compared with ED patients, the qualified success rates at 5 years for criteria A were 61% and 67%, respectively (difference, 7.3%; 95% CI, 4.4-10.4); for criteria B, 43% and 60% (difference, 17.6%; 95% CI, 15.2-20.0); and for criteria C, 25% and 40% (difference, 15.8%; 95% CI, 11.1-20.5). On multivariable Cox regression analyses, AD was associated with higher failure rate with criteria B and C for qualified success and with all criteria for complete success (ie, no need for medications). Incidence of bleb leaks was higher in the AD group (29 vs 11 eyes; P = .002). Additionally, AD patients required additional glaucoma surgeries more often than ED patients (47 vs 26 eyes; P = .004).

Conclusions and Relevance

African descent was associated with higher failure rates and higher incidence of bleb leaks after initial trabeculectomy with mitomycin C compared with European descent. If this is subsequently shown to be a cause and effect, the findings need to be considered when surgical treatment of glaucoma is contemplated in AD patients.

Conjunctival Fibrosis after Application of Mitomycin C: An Animal Experimental Study

Mitomycin C (MMC) is widely used as an antimetabolite to minimize scarring of filtering blebs. Its effectiveness has been demonstrated in several clinical studies. The drug's mechanism of action is attributed to its antiproliferative effect on the subconjunctival cells, reducing the wound healing response. We placed sponges soaked with various concentrations of MMC, from 0.05 to 1.0 mg/ml, under the conjunctiva of 18 rabbits. Four weeks later, there was marked concentration-dependent scarring of the substantia proppria of the conjunctiva. Macrophages were more numerous in treated eyes, as determined by immunohistochemistry. The reason for MMC-related fibrosis in this animal model is not clear but may be related to the substances toxic effects. Whether it is only present in rabbits remains to be clarified.

Viscocanalostomy with Mitomycin-C: A Preliminary Study

Purpose

To compare the results of viscocanalostomy with and without mitomycin-C (MMC).

Methods

Retrospective results of 15 standard viscocanalostomy (VCO) operations (Group 1) were compared with the prospective results of 15 VCO operations performed with intraoperative adjunctive MMC (Group 2). MMC (0.2 mg/mL) was applied over and under the superficial scleral flap for 3 minutes in Group 2 before the deep flap was prepared. Each patient was followed up for at least 1 year, and results of examinations in the first 12 months were used in the statistical comparison of the two groups. Surgical success was defined as intraocular pressure (IOP) ≤ 18 mmHg.

Results

Pr eoperative mean intraocular pressures (IOP) in Group 1 and Group 2 wer e 35.3±11.0 and 39.1±8.9, respectively. Mean IOP levels at the 12th month were 14.4±2.6 and 11.9±4.0, respectively, showing a significant decrease in both groups (p<0.001). Postoperative IOP course appeared to be lower in the MMC group, however, the difference was not statistically significant (p=0.554). Complete success rates without medications were 40% in Group 1 and 67% in Group 2. No significant difference was found between the two groups in terms of early and late postoperative complications, pre- and postoperative number of antiglaucoma medications, and surgical success rates at the end of the study period (p>0.05 for all). A significant difference was verified between the two groups of eyes considering the conjunctival bleb types, as low-lying, localized blebs were the most frequent type in Group 1 and thin-walled, avascular blebs were more predominant in the MMC group (p=0.004).

Conclusions

Intraoperative adjunctive MMC use might improve the long-term results of viscocanalostomy by facilitating subconjunctival filtration and might widen the indication range of the technique.

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.

Intraocular Pressure Control after Implantation of an Ahmed Glaucoma Valve in Eyes with a Failed Trabeculectomy

AIM

To evaluate the results of Ahmed glaucoma valve (AGV) in eyes with a failed trabeculectomy.

MATERIALS AND METHODS

This retrospective study evaluated 61 eyes with a failed trabeculectomy that underwent implantation of an AGV due to uncontrolled intraocular pressure (IOP) on maximal medical therapy. Success was defined as IOP ≤ 21 mm Hg (criterion 1) or 20% reduction in IOP (criterion 2) with or without antiglaucoma medications. Persistent hypotony, loss of light perception, and reoperation for IOP control were defined as failure.

RESULTS

Mean preoperative IOP and mean lOPs at 6, 12, and 24 months were 21.93 ± 6.32 mm Hg (n = 61), 14.15 ± 4.33 mm Hg (n = 59), 13.21 ± 4.44 mm Hg (n = 56), and 13.60 ± 3.27 mm Hg (n = 25) respectively. Mean number of antiglaucoma medications preoperatively and at 6, 12, and 24 months was 3.95 ± 0.85, 2.19 ± 1.38, 2.48 ± 1.44, and 2.40 ± 1.32 respectively. The reductions in the number of medications and IOP measurements were statistically significant at all time intervals (p < 0.001, Wilcoxon signed rank test). According to criterion 1, the Kaplan-Meier survival curve disclosed success rates of 75% at 12 and 24 months. According to criterion 2, the success rates were 57% at 12 months and 55% at 24 months. The most frequent complications were hypertensive phase (18%) and shallow anterior chamber (16.4%).

CONCLUSION

The AGV may effectively reduce IOP in eyes that had a failed trabeculectomy.

CLINICAL SIGNIFICANCE

The AGV is an alternative in eyes with a failed trabeculectomy.

HOW TO CITE THIS ARTICLE

Schimiti RB, Abe RY, Tavares CM, Vasconcellos JPC, Costa VP. Intraocular Pressure Control after Implantation of an Ahmed Glaucoma Valve in Eyes with a Failed Trabeculectomy. J Curr Glaucoma Pract 2016;10(3):97-103.

Conjunctival Advancement With Subconjunctival Amniotic Membrane Draping Technique for Leaking Cystic Blebs

PURPOSE

To describe the successful use of a technique involving amniotic membrane graft for the repair of leaking cystic blebs following mitomycin C (MMC) trabeculectomy.

PATIENTS AND METHODS

A retrospective review of 17 eyes of 16 patients who had undergone trabeculectomy with MMC or combined cataract phacoemulsification and trabeculectomy with MMC and presented with leaky cystic blebs with or without hypotony was conducted. All patients were treated with amniotic membrane graft over the leaking area with conjunctival advancement without excision of the cystic bleb and had a minimum of 1-year follow-up. Success was defined as a final intraocular pressure (IOP) ≥ 6 and ≤ 21 mm Hg without glaucoma medications. Qualified success that met the above criteria, however, required the use of glaucoma medication for optimal IOP control. Failure was defined as any patient with persistent bleb leak requiring additional procedures and/or the presence of hypotony (IOP<6 mm Hg ± clinical evidence of hypotony maculopathy).

RESULTS

Seventeen of the 17 eyes had complete resolution of bleb leak at last follow-up. Total success rate was 15 of the 17 patients, or 88%. Eleven eyes (64.7%) met criteria for complete success. Four eyes (23.5%) required glaucoma medications after the procedure and met criteria for qualified success. Two eyes (11.8%) met criteria for failure, as they presented with a pinpoint limbal leak requiring a suture at the slit lamp in the postoperative period. Mean IOP increased from 5.7 ± 2.8 mm Hg preoperatively to 13.1 ± 3.4 mm Hg at most recent follow-up (P<0.000007). LogMAR visual acuity likewise improved from 0.7 ± 0.8 preoperatively to 0.1 ± 0.1 LogMAR units at most recent follow-up (P<0.030). Mean follow-up time was 21.4 ± 7.3 months.

CONCLUSIONS

The technique of amniotic membrane bleb draping with conjunctival advancement successfully restored bleb function, while facilitating fast resolution and stabilization of IOP and visual acuity.

A review of the efficacy of mitomycin C in glaucoma filtration surgery

The success of trabeculectomy, which is considered the gold standard in the surgical treatment of glaucoma, depends on the wound healing response. The introduction of antiproliferative agents such as mitomycin C (MMC) has increased the success rates of trabeculectomy. However, complications due to these agents can be challenging to manage. Hence, it is important to determine the most efficacious dose and duration of exposure. Multiple studies suggest that many factors, including but not limited to MMC preparation, different concentrations, different exposure times, and method of application may affect success rate, and these factors were reviewed in this article. We concluded that lower concentrations of MMC that are prepared and applied in a standardized fashion, such as that using the Mitosol(®) kit (for 2-3 minutes) during trabeculectomy, could potentially provide trabeculectomy success rates similar to that reported with off-label preparations, and that such a treatment regime could result in in lower complication rates than higher doses of MMC.

Outcomes of trabeculectomy in juvenile open angle glaucoma

Purpose:

This study was aimed at reporting the outcomes of trabeculectomy in primary juvenile open angle glaucoma (JOAG).

Design:

This study was a retrospective noncomparative case series.

Materials and Methods:

We included 60 eyes of 41 JOAG patients who underwent primary trabeculectomy without mitomycin-C (MMC) between 1995 and 2007. The primary outcome was success, defined as complete, if intraocular pressure (IOP) was >5 and ≤21 mmHg without medications or qualified if IOP was >5 and ≤21 mmHg with or without antiglaucoma medications. Secondary outcome measures were mean and percentage IOP reduction, complications, and risk factors for the failure of trabeculectomy.

Results:

The mean (±standard deviation) age at presentation was 24.1 ± 6.8 years (range, 12–35). Mean follow-up was 67 ± 41 months (range, 12–156). At 1 year, the probability of complete success was 92% (n = 56, 95% CI: 81–96%), at 3 years it was 89% (n = 47, 95% CI: 78–95%), and at the end of 5 years, it was 80% (n = 34, 95% CI: 65–89%). The probability of qualified success was 100% (n = 60) at 1 year, 98% (n = 51, 95% CI: 87–100%) at 3 years, and 96% (n = 36, 95% CI: 84–99%) at the end of 5 years. The mean IOP reduced from 35 ± 10 to 13 ± 2.5 mmHg (P < 0.001) after trabeculectomy. There was no serious postoperative complication. Young age was the only significant risk factor associated with the failure (odds ratio = 0.89, P = 0.03).

Conclusion:

Primary trabeculectomy without MMC has good success rates in JOAG.

Long-term outcomes and risk factors for failure with the EX-press glaucoma drainage device

PURPOSE

To report on the long-term outcomes and risk factors for failure with the EX-PRESS shunt implanted under a scleral flap.

SETTINGS

Eye Department, University of Ancona, Ancona, Italy and the Oxford Eye Center, University of Witwatersrand, Johannesburg, South Africa.

METHODS

The medical records of glaucoma patients who underwent consecutive EX-PRESS implantations under a scleral flap between 2000 and 2009 were reviewed. The operations were performed by two experienced surgeons using an identical surgical technique. The potential risk factors for failure that were analysed included age, sex, race, glaucoma type, previous antiglaucoma medications, previous glaucoma surgeries, diabetes, and smoking. Complete success was defined as postoperative intraocular pressure (IOP) 5 mm Hg>IOP<18 mm Hg without antiglaucoma medications. Qualified success was defined as 5 mm Hg>IOP<18 mm Hg with or without antiglaucoma medications.

RESULTS

Two hundred and forty-eight eyes of 211 consecutive patients were included. The mean IOP was reduced from 27.63 ± 8.26 mm Hg preoperatively (n=248) to 13.95 ± 2.70 mm Hg at 5 years (n=95). The mean follow-up was 3.46 ± 1.76 years. Complete and qualified success rates decreased gradually from 83% and 85% at 1 year to 57% and 63% at 5 years follow-up, respectively. The risk factors for failure were diabetes, non-Caucasian race, and previous glaucoma surgery. Complete success rates of diabetic patients and non-Caucasian patients decreased from 63% and 75% at 1 year to 42% and 40% at 5 years follow-up, respectively.

CONCLUSIONS

EX-PRESS success rates decrease over time but compare favourably with trabeculectomy literature data. The main identifiable risk factors for failure are diabetes, non-Caucasian race, and previous glaucoma surgery.

Surgical outcomes of the Ex-PRESS glaucoma filtration device in African American and white glaucoma patients

Purpose

To compare the surgical outcomes of the Ex-PRESS glaucoma filtration device in African American and white glaucoma patients.

Design

Retrospective comparative case series.

Methods

This was a comparative case series of 36 eyes of 36 African Americans and 43 eyes of 43 whites that underwent placement of the Ex-PRESS glaucoma filtration device under a partial-thickness scleral flap for uncontrolled glaucoma. All eyes received intraoperative mitomycin C. The primary outcome measures were intraocular pressure (IOP), number of postoperative glaucoma medications, and surgical success. Surgical success was defined as IOP between 5 and 18 mm Hg, with or without glaucoma medications, without further glaucoma surgery, or loss of light perception vision.

Results

Average follow-up was 31.9 ± 9.8 (range, 14.6–47) months for African Americans and 30.7 ± 8.6 (range, 14.3–47) months for whites. At 33 months, surgical success was 80.0% in the African American group and 83.3% in the white group (P = 1.00). Reasons for surgical failure included increased IOP (3 eyes, 3.8%), persistent hypotony with maculopathy (1 eye, 1.3%), and further surgery (4 eyes, 5.06%). Compared with preoperative values, the mean postoperative IOP and number of glaucoma medications were significantly reduced in both groups, and no statistical difference was observed between the two groups at 33 months. Postoperative complications were similar in the two groups.

Conclusions

Similar surgical outcomes were observed in African American and white glaucoma patients after implantation of the Ex-PRESS glaucoma filtration device. This latest modification of glaucoma filtration surgery may be a better surgical option for African Americans given its potential advantages of no tissue removal, predictable outcomes related to consistent lumen size and controlled flow, fewer postoperative complications, and overall reduced inflammation.

The use of amniotic membrane in trabeculectomy for the treatment of primary open-angle glaucoma: a prospective study

BACKGROUND

To investigate the effectiveness of amniotic membrane transplantation (AMT) on improving the outcomes of trabeculectomy in primary open-angle glaucoma (POAG).

METHODS

Fifty-nine eyes affected by primary open-angle glaucoma were enrolled in this prospective randomized study. Thirty-two eyes underwent amnion-shielded trabeculectomy (study group) and 27 eyes underwent trabeculectomy without any antimetabolites (control group). Success was defined as intraocular pressure (IOP) <21 mmHg without any medications at 24 months follow-up. The two groups were compared in terms of IOP, bleb morphology, bleb survival and risk of failure, glaucoma medications, and complications.

RESULTS

There was no statistically significant difference in terms of postoperative IOP between the two groups and at 24 months median IOP was 15.5 mmHg for the AMT group and 16 mmHg for the control group. IOP postoperative reduction was 8 mmHg for the AMT group versus 6 mmHg for the non AMT group (P = 0.276). Two patients from the study group developed IOP >21 mmHg in contrast to seven patients from the classic trabeculectomy group. The study group had 61.0% less risk of developing IOP >21 mmHg (P = 0.203). No major complications in the AMT group were observed. AMT blebs were diffuse with mild vascularization.

CONCLUSION

In patients with POAG, AMT showed favorable effects on bleb survival, however data failed to provide firm evidence that AMT could be used as a routine procedure in trabeculectomy.

Comparison of the outcome of repeat trabeculectomy with adjunctive mitomycin C and initial trabeculectomy

Purpose

To compare the efficacy and safety of repeat and initial trabeculectomy with mitomycine C (MMC).

Methods

Eighty seven patients, who had underwent repeat (repeat group) or initial (initial group) trabeculectomy with MMC, were enrolled in this prospective trial. Postoperative outcome measures included the amount of decrease in intraocular pressure (IOP), the number of anti-glaucoma medications, and the complications. The success of trabeculectomy was defined on the basis of three definitions which were: IOP ≤18 mmHg (definition 1), IOP ≤21 mmHg (definition 2), and the amount of decrease in IOP from baseline ≥30% (definition 3). Success was further defined as "complete" when these criteria were obtained without any anti-glaucoma medications and "qualified" with or without medical therapy and no further surgical procedures.

Results

Fifty nine eyes underwent initial and 28 eyes underwent repeat trabeculectomy. The mean follow-up period was 19.1 ± 5.9 months. Complete success rates were significantly greater in the initial trabeculectomy group (p = 0.02 for definition 1, p = 0.038 for definition 2, p = 0.003 for definition 3). A higher proportion of eyes in the initial group achieved qualified success relative to the group A eyes, but the differences were not statistically significant (p = 0.33 for definition 1, p = 0.99 for definition 2, p = 0.24 for definition 3). The mean number of antiglaucomatous medications at the last examination was 1.2 ± 1.2 in repeat group and 0.7 ± 1.1 in initial group (p = 0.01). The number of complications during the follow up period did not differ significantly between the two groups (p = 0.65).

Conclusions

Repeat trabeculectomy with MMC has high success and low complication rates in patients with previously failed trabeculectomy in spite of the need of higher number of anti-glaucoma medications.

[Wound healing modulation in glaucoma surgery]

The wound healing response is one of the major determinants of filtering surgery success. Over the last two decades, antifibrotic agents, 5-fluorouracil (5-FU) and mitomycin C (MMC), have modified the prognosis of filtering surgery, particularly in patients at high risk for failure. Nevertheless, these agents are associated with severe complications. In order to maximize their benefits and minimize the rate of complications, the use of these powerful treatments has to be carefully evaluated in relation to patient risk factors for scarring. The choice of an antifibrotic agent, mode, dose and duration of application should be made with complete knowledge of the different effects of these treatments and adapted for each patient after an exhaustive preoperative evaluation.

The role of antimetabolites in filtration surgery for neovascular glaucoma: intermediate-term follow-up

PURPOSE

To compare the intermediate-term efficacy of 5-fluorouracil (5-FU) and Mitomycin C (MMC) as adjunctive antimetabolites in neovascular glaucoma (NVG) filtration surgery.

METHODS

Forty consecutive eyes of 40 patients with NVG refractory to medical therapy were randomized to receive antimetabolite-augmented trabeculectomy. Eighteen eyes received postoperative 5-FU (5-FU group) and 22 eyes received intraoperative, low-dose (0.2 mg/ml) MMC for 2 mins (MMC group). The main outcome measure was intraocular pressure (IOP). Surgical success was defined as IOP < 21 mmHg with topical treatment (qualified success) or without topical treatment (complete success). Surgical failure was defined as IOP > or = 21 mmHg, despite postoperative topical treatment, and by postoperative blindness.

RESULTS

The mean follow-up period was 35.8 +/- 22.6 months in the 5-FU group and 18.6 +/- 17.2 months in the MMC group. This difference was not significant. Mean IOP decreased from 40.4 +/- 10.3 mmHg to 14.7 +/- 3.4 mmHg (p < 0.0001) in the 5-FU group and from 42 +/- 11.3 mmHg to 22.9 +/- 13.3 mmHg (p = 0.0006) in the MMC group; however, the difference between the 5-FU and MMC groups was not significant at any point. The success rate in the 5-FU group was 55.5% (44.4% complete, 11.1% qualified), compared with 54.5% (9.1% complete, 45.4% qualified) in the MMC group. This difference was not significant.

CONCLUSIONS

The percentage of patients who achieved postoperative IOP < 21 mmHg was similar in both groups, although a larger proportion of patients treated with MMC-augmented trabeculectomy required topical treatment in comparison with the 5-FU group.

[Dosage and kinetics of MMC release of a collagen implant used as a delivery device in glaucoma surgery in the rabbit eye]

PURPOSE

To determine the absorption and the release of mitomycin-C from a collagen implant and tissue impregnation in the anterior structures of the rabbit eye.

METHODS

Determining the quantity of mitomycin-C that a collagen implant can absorb with the difference between dry and soaked weight. Mitomycin-C release was measured in vitro using spectrophotometry. The measurement was repeated using a bioassay. Ocular tissue impregnation was determined in 12 eyes of six rabbits. Sclera, implant, aqueous, and ciliary body specimens were collected for concentration measurement using HPLC from 1 to 6 h after surgery.

RESULTS

The mean mitomycin-C quantity absorbed in the implant was 3.22+/-0.2 microg. In vitro release was 0.13 mg/ml after 10 min and 0.05 microg/ml at 6 h. The bioassay showed almost no antifibrotic activity in sclera. In vivo release of mitomycin-C was high from the first to the sixth hour.

CONCLUSION

After filtering surgery, mitomycin-C in the collagen implant is clearly released and ocular tissues are effectively impregnated.

Synergistic effects of combined cytotoxic and apoptosis-inducing drugs on Tenon's capsule fibroblasts in vitro and in vivo

BACKGROUND

Highly toxic antimetabolites have gained access to routine clinical use to modulate and reduce the amount of postoperative scarring following glaucomatous filtering procedures. It could be speculated that by combining two different antiproliferative substances with different mechanisms of action total amounts of the substances could be decreased and side effects reduced.

METHODS

Twenty-two substances were tested that had antiproliferative effects by acting cytotoxically, inhibiting growth factors, or inducing apoptosis. With combinations of each two substances, cell culture experiments using 3T3 and human Tenon's capsule fibroblasts were performed evaluating cell toxicity, proliferation and migration, the extent of free radicals, and the amount of apoptosis (TUNEL, electron microscopy). The five most potent combinations were used in an animal experiment with rabbits performing filtering procedures. The extent of episcleral scarring was evaluated by histopathology.

RESULTS

The results of the various assays revealed consistently strong effects in 5 of the 462 combinations. Of these five combinations, two were highly effective in the rabbit model. Substances with strong effects when applied in combination included staurosporine, mitomycin, and CD95L.

CONCLUSIONS

We found synergistic effects in assays that evaluated different aspects of cell function. The amount of scarring in an animal experiment was inhibited to a level comparable with a high single dose of mitomycin. Combination therapy of two antiproliferative acting substances may be a promising concept.

Rescue of failed filtering blebs with ab interno trephination

We evaluated the effectiveness of ab interno automated trephination as a technique for rescuing failed mature filtering blebs. A retrospective chart review of 40 failed blebs of 38 patients who had a posttrephination follow-up period of at least 3 months was done. With success defined as intraocular pressure (IOP) <21 mm Hg and at least a 20% reduction from baseline on the same or fewer number of pretrephination medications, 30/40 eyes (75%) fit these criteria over the entire course of follow-up. Among all 40 eyes, there was a significant reduction of IOP from pretrephination to 3 months (P<.001). The percentage of patients requiring 2 or more medications declined from 90% pretrephination to 21% at 3 months (P<.0001), and was stable thereafter. Some patients were able to eliminate all medications. Patients who did not meet the criteria of success regained successful IOP control with other modalities of management. Complications were few. We believe that ab interno trephination is an excellent option for rescuing selected failed filtering blebs.

Postoperative application of mitomycin c improves the complete success rate of primary trabeculectomy: a prospective, randomized trial

BACKGROUND

The intraoperative application of mitomycin c for primary trabeculectomy is associated with potentially sight-threatening side-effects. This study was performed to evaluate the pressure-lowering effect of postoperative application of mitomycin c for primary trabeculectomy and to evaluate the complications of this new technique.

MATERIALS AND METHODS

A randomized, prospective clinical trial with 52 consecutive patients scheduled for glaucoma surgery in one large surgical center was performed. Patients underwent routine trabeculectomy. In group 1, mitomycin c (0.05 mg/ml) was applied topically to the filtering bleb for 5 min on the 3 days after surgery (postoperative application). In group 2, no mitomycin c was applied (controls). The IOP values, visual acuity, number of antiglaucomatous medications and complications were evaluated.

RESULTS

Follow-up was evaluated up to 24 months for all patients. The mean intraocular pressure decreased from 31.1 to 15.4 mmHg in group 1 and from 24.8 to 15.6 mmHg in group 2 (P=0.79; t-test). The average number of medications decreased from 2.5 and 2.4 to 0.4 and 0.6 (P=0.53; t-test) in groups 1 and 2, respectively. No cases of hypotony maculopathy occurred. An individual decrease of more than 25% of the IOP was present in 84.6% in group 1 and in 53.8% in group 2 (P<0.017). Survival analysis for eyes with a complete surgical success revealed a better outcome of eyes in group 1 as compared to the eyes in group 2 (P<0.013; log-rank test).

CONCLUSIONS

To our knowledge, this is the first prospective, randomized clinical trial to evaluate the efficacy of postoperative mitomycin c application in primary trabeculectomy. The application of mitomycin significantly reduced the IOP while not increasing the rate of complications.

Deep sclerectomy and low dose mitomycin C: a randomised prospective trial in west Africa

AIM

To study the efficacy and safety of deep sclerectomy (DS) augmented with intraoperative low dose mitomycin C (MMC) in a west African population.

METHODS

Prospective, randomised, controlled trial. Trial participants were Nigerian patients with medically uncontrolled primary open angle glaucoma undergoing primary surgery at Maja Hospital, Lagos, Nigeria. 39 eyes of 39 patients undergoing DS were randomised into receiving intraoperative MMC 0.25 mg/ml for 2 minutes at the end of procedure (DS-MMC) and a control group (DS-noMMC).

RESULTS

There were 21 patients in the DS-noMMC and 18 in the DS-MMC group with no difference in the preoperative characteristics of the groups. Mean follow up was 16.4 (SD 11.3) months. The probability of maintaining an intraocular pressure less than 18 mm Hg with or without additional medications (95% confidence intervals) at 1 year was 70% (47-92%, 95%) and 79% (57-100%), and at 18 months was 35% (8-62%) and 38% (7-69%) for the DS-noMMC and DS-MMC groups, respectively, with no difference in success rates (p = 0.6). An IOP of less than 18 mm Hg without additional medication was maintained in 65% (41-89%) and 73% (49-96%) at 1 year and 24% (8-48%) and 13% (13-46%) at 18 months for the DS-noMMC and DS-MMC groups, respectively (p = 0.5). There were no serious complications related to the procedure.

CONCLUSIONS

The success rates of DS in black west African glaucoma patients, as performed in this study, were low. The study did not achieve sufficient power to detect whether low dose intraoperative MMC application can increase success rates of DS.

What is practical in glaucoma management?

This article addresses some important issues in the detection and management of glaucoma using examples from the developing world, particularly drawing on experiences and research in sub-Saharan Africa.

A review of trabeculectomy in East Asian people—the influence of race

Glaucoma is the leading cause of irreversible blindness worldwide. East Asians account for approximately half of all glaucoma sufferers. It is likely that trabeculectomy will be needed for many of these people as the intraocular pressure is to be maintained at a satisfactorily low level. The eyes of East Asian people differ in some aspects from those of other races. This review describes the natural history of the eye after trabeculectomy in East Asians.

Long-term evaluation of trabeculectomy in primary open angle glaucoma and chronic primary angle closure glaucoma in an Asian population

PURPOSE

A retrospective cohort study was undertaken to evaluate and compare the long-term results of trabeculectomy in primary open angle glaucoma (POAG) and chronic primary angle closure glaucoma (CPACG) in an Asian population.

METHODS

Yearly diurnal measurements of intraocular pressure (IOP), best-corrected visual acuity, optic disc and visual field records of patients having primary adult glaucomas who had undergone trabeculectomy, without anti-mitotic agents, with a minimum of 5 years follow up were evaluated. Only one eye of each patient was studied. The success rates for IOP control in POAG and CPACG were statistically analysed.

RESULTS

Sixty-four eyes of 64 patients were studied. The overall probability of success of trabeculectomy in controlling IOP to < or = 21 mmHg with or without additional topical antiglaucoma medication was 0.94 and 0.88 at 5 and 10 years, respectively. There was no statistically significant difference in the qualified and absolute success rates for IOP control between POAG and CPACG eyes (log rank test P= 0.6, 0.88, respectively). Twelve of 38 CPACG eyes had a two-line decrease in visual acuity as compared to four of 26 POAG eyes (P = 0.17). Progression or development of a cataract was the most common cause of visual decline.

CONCLUSIONS

Trabeculectomy without antimetabolite use appears to be efficacious in lowering IOP and in visual field preservation over a period of 10 years in both POAG and CPACG. Development/progression of cataract especially in eyes with chronic angle closure glaucoma after trabeculectomy must be considered an important issue.

Gene therapy using p21WAF-1/Cip-1 to modulate wound healing after glaucoma trabeculectomy surgery in a primate model of ocular hypertension

Glaucoma is a common eye disease associated with elevated intraocular pressure (IOP). Lowering IOP is the only acceptable therapy for glaucoma and slows progression of the disease. Filtration surgery, which introduces a guarded ostomy through the sclera into the anterior chamber of the eye to allow the escape of aqueous humor, is the most reliable method for effective IOP lowering. Success of this surgery is limited by scarring of the ostomy, so this procedure is often accompanied by the use of antimetabolites, such as mitomycin C (MMC), to block the wound healing response. Although effective in preventing scarring, antimetabolites also yield unwanted side effects, such as hypotony and tissue degeneration due to cellular destruction. This study presents an alternative to antimetabolites by using gene therapy to introduce the human gene for p21(WAF-1/cip-1) (p21) to cause cell cycle arrest of surrounding cells rather than their destruction. In this procedure, p21 was delivered using a recombinant adenovirus to ocular hypertensive monkey eyes. These eyes then underwent filtration surgery. Results show that eyes treated with p21 exhibited open surgical ostomies by both functional and histological criteria, and did not display any side effects seen in control animals that were treated with MMC.

Intraoperative 5-fluorouracil application during primary trabeculectomy in Nigeria: a comparative study

PURPOSE

To investigate the effect on intraocular pressure (IOP) of intraoperative 5-fluorouracil (5-FU) application during primary trabeculectomy in a West African population.

METHODS

Retrospective case note search of operating theatre records for primary trabeculectomy between 1996 and 2000 in an eye hospital in Lagos, Nigeria. For statistical analysis, patients were divided into group that received intraoperative 5-FU (50 mg/ml for 5 min) and a control group that received no intraoperative antimetabolites. Patients with a follow-up of less than 6 months were excluded. For life-table analysis, only one eye from each patient was included to maintain independent analysis.

RESULTS

A total of 154 eyes of 101 patients were included in the study. Average follow-up was 17 +/- 2.18 (95% confidence interval) months. No significant difference was found between the groups for age, sex, preoperative medication, and follow-ups. Comparison of survival curves by the log-rank test showed that the probability of maintaining an IOP of 20 mm Hg or less at 18 months was 76% in the 5-FU group and 79% in the controls (P= 0.55). However, the probability of maintaining an IOP 14 mmHg or less was significantly greater in the 5-FU group (64%) than in the controls (39%, P=0.018). Visual acuity loss of more than two Snellen-chart lines was observed in six eyes (7.9%) of the 5-FU group and in four eyes (5.1%) of the control group and this difference was not significant (P=0.49, Fisher exact test). Complication rates were similar in each group.

CONCLUSIONS

In this population, intraoperative 5-FU application during trabeculectomy appears to improve probability of maintaining an intraocular pressure of 14 mmHg or less with no additional deleterious effects on the eye.

Effects of thick Tenon's capsule on primary trabeculectomy with mitomycin-C

PURPOSE

To investigate the effects of thick Tenon's capsule on primary trabeculectomy with adjunctive mitomycin-C.

METHODS

In this prospective interventional case series of 45 consecutive uncomplicated glaucoma patients, 45 eyes with thick Tenon's capsule underwent primary trabeculectomy with intraoperative mitomycin-C (0.4 mg/ml for 3 min). Success was defined as intraocular pressure (IOP) <or= 21 mmHg with (qualified) or without (complete) medications.

RESULTS

The mean follow-up period was 22.55 months. The mean preoperative IOP and number of medications were 28.91 +/- 7.06 mmHg and 1.68 +/- 0.73, respectively. The postoperative IOPs and the number of medications at all intervals were significantly lower than preoperative levels (p < 0.01 for each interval). The mean IOP was 11.03 +/- 3.93 mmHg (12.17 +/- 4.98 mmHg) at 24 months (12 months). Kaplan-Meier survival analysis revealed a qualified success rate of 93.1% (95.6%) after 24 months (12 months). During follow-up of the 45 eyes, 38 (84.4%) developed avascular thin-walled bleb, seven eyes (15.6%) had hypotony (IOP < 6 mmHg), 14 eyes (31.1%) had a shallow anterior chamber, and one eye (2.2%) had endophthalmitis.

CONCLUSIONS

The use of mitomycin-C is associated with high success rates and good IOP control even in the presence of thick Tenon's capsule. However, thick Tenon's capsule does not seem to eliminate the development of complications in eyes undergoing primary trabeculectomy with mitomycin-C.

Primary open-angle glaucoma in blacks: a review

Glaucoma is one of the leading causes of blindness worldwide. Primary open-angle glaucoma (POAG) is the most prevalent form of glaucoma and has a particularly devastating impact in blacks. In the black American population, POAG prevalence is estimated to be six times as high in certain age groups compared to whites. POAG is more likely to result in irreversible blindness, appears approximately 10 years earlier and progresses more rapidly in blacks than in whites. Racial differences in optic disk parameters have been reported and show that blacks have larger optic disks than whites. This finding is robust and may account for the reported differences in other optic disk parameters. The existence of racial differences in intraocular pressure remains to be demonstrated, as conflicting findings are reported in the literature. Intraocular pressure may actually be underestimated in blacks, perhaps because they have thinner corneas. The prevalence of diabetes and hypertension is higher in blacks than in whites, and although no causal relationship has been established between POAG and each of these systemic diseases, some reports suggest that they often occur together, perhaps through an indirect relationship with intraocular pressure. Compounding the problem, there is evidence that blacks are less responsive to both drug and surgical treatment for POAG. Finally, they often have reduced accessibility to treatment and are less aware of the risks of having POAG. This article provides a comprehensive review of the current knowledge pertaining to POAG in blacks.

Review of recent publications of the Advanced Glaucoma Intervention Study

PURPOSE OF REVIEW

This review summarizes and evaluates the published reports of the Advanced Glaucoma Intervention Study (AGIS) in the years 2001 and 2002. AGIS evaluated two treatment sequences in medically uncontrolled open-angle glaucoma. Notable initial findings of AGIS included the presence of a race-treatment interaction for the treatment sequences of argon laser trabeculoplasty and trabeculectomy, and that lower intraocular pressures were associated with a reduced progression of visual field damage.

RECENT FINDINGS

More recent findings of AGIS include (1). confirmation and quantification of an increased risk of cataract formation following trabeculectomy; (2). identification of risk factors for failure of argon laser trabeculoplasty and trabeculectomy, and the impact of complications on the success of these treatments; and (3). further delineation of a differential response to surgical treatment between black and white patients.

SUMMARY

AGIS publications in 2001 and 2002 provide new information regarding the complications and outcomes of surgically treated open-angle glaucoma.

Modifying subsceral fluid pressure in an experimental model of mitomycin-C diffusion

BACKGROUND

Episcleral application of mitomycin-C (MMC) during glaucoma filtration surgery hinders the post-operative wound healing. Diffusion through the sclera might result in a toxic effect on the ciliary body resulting in reduced aqueous humor production leading to post-operative hypotony. We developed an experimental model to investigate the influence of intraocular pressure on the diffusion of MMC through the sclera and in subscleral compartments.

METHODS

Scleral quadrants of 10 human donor eyes were mounted on PMMA tubes filled with saline imitating the intraocular volume. By height variation of a coupled infusion line different intraocular pressures were simulated (0, 8, 23 and 80 mmHg). Additionally the model included a subscleral sponge to mimic the compartment of the ciliary body. The episcleral sides of the scleral quadrants were exposed for 1 min to sponges soaked with 200 microg ml(-1) MMC. An 8-mm-diameter scleral disk was punched out with a trephine and horizontally dissected with a kryotome. The MMC concentrations of scleral layers, epi-and subscleral sponges and the fluid within the tubes were analysed by means of high-performance liquid chromatography.

RESULTS

The MMC concentration gradually declined from the episcleral sponge (165 microg ml(-1)) to the superficial (3.3 microg ml(-1)) and deep scleral layers (1.2 microg ml(-1)), and to the subscleral sponge (0.2 microg ml(-1)). We were able to detect very small concentrations of MMC in the fluid within the PMMA tubes (0.01 microg ml(-1)).

CONCLUSION

We developed a new experimental in vitro model for investigating transscleral MMC diffusion. The different simulated intraocular pressures had no effect on the concentration gradient through the investigated compartments of our model.

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

PURPOSE

To compare the safety and efficacy of intraoperative 5-fluorouracil (5-FU) or Intraoperative mitomycin C (MMC) in eyes undergoing primary trabeculectomy.

DESIGN

Prospective double-masked randomized clinical trial.

METHODS

One hundred fifteen eyes of 103 patients with uncontrolled intraocular pressure (IOP) despite maximally tolerated medical therapy or laser were prospectively randomized in a double-masked fashion to one of two treatment groups in a single institution setting. Subject's eyes underwent primary trabeculectomy with either topical 5-FU (50 mg/ml for 5 minutes) or topical MMC (0.2 mg/ml for 2 minutes). Primary outcome measures included the number of eyes achieving target pressures of 21, 18, 15, and 12 mm Hg at 6 and 12 months postoperatively. Secondary outcome measures included IOP, best-corrected visual acuity, complications, and interventions.

RESULTS

Of the 115 eyes, 57 received 5-FU while 58 received MMC. A target IOP of 21 mm Hg at 6 months was achieved in 53 of 56 (95%) eyes in the 5-FU group and 54 of 57 (95%) eyes in the MMC group (P = 1.00). At 12 months, 45 of 48 (94%) eyes in the 5-FU group met a target IOP of 21 mm Hg while 48 of 54 (89%) eyes in the MMC group did (P =.49). The most common complications in each group were persistent choroidal effusions and bleb leak.

CONCLUSION

Our study suggests that intraoperative topical 5-FU is at least as effective as intraoperative topical MMC in reducing IOP of eyes undergoing primary trabeculectomy.

Intraoperative episcleral versus postoperative topical application of mitomycin-C for trabeculectomies

OBJECTIVE

To assess the efficacy of a new application technique of mitomycin-C to enhance the outcome of filtering surgery in cases of complicated glaucoma.

DESIGN

Randomized clinical trial.

PARTICIPANTS

Fifty consecutive patients scheduled for glaucoma surgery in one large surgical center.

INTERVENTION

Patients underwent routine trabeculectomy. In group 1, mitomycin-C (0.05 mg/ml) was applied topically to the filtering bleb on days 1, 2, and 3 after surgery (postoperative application). In group 2, mitomycin-C (0.2 mg/ml) was applied by means of to a sponge during surgery (intraoperative application).

MAIN OUTCOME MEASURES

Preoperative and postoperative intraocular pressure (IOP) values, visual acuity, the need for antiglaucoma medication, previous surgical procedures, and the need for further surgical interventions were monitored.

RESULTS

Sufficient follow-up data were available from 24 of 25 patients in each of the two groups. The follow-up ranged from 12 to 28 months and was evaluated at 12 months for all patients. The mean IOP decreased from 27.3 to 15.5 mmHg in group 1 and from 29.0 to 17.5 mmHg in group 2. The average number of medications decreased from 2.3 and 2.4 to 0.9 and 0.8 (P = 0.68; t test) in groups 1 and 2, respectively, at the 12-month visit. Hypotony was more frequent in group 2, in which the only case of hypotony maculopathy occurred. There was a tendency of more eyes with lower IOP values in this group. The rate of loss of visual acuity of more than 2 lines was higher in group 2. Failures were more frequent in group 2 (7 of 24) compared with group 1 (1 of 24) (P = 0.04, chi-square test).

CONCLUSIONS

To our knowledge, this is the first prospective, randomized clinical study to evaluate the efficacy of this different technique of mitomycin-C application. The postoperative application of mitomycin-C was effective, having few failures. This application of mitomycin-C may be associated with a lower rate of complications when used in eyes with complicated forms of glaucoma.

Glaucoma in West Africa: a neglected problem

Glaucoma in sub-Saharan Africa is a devastating disease which has not been fully addressed by the global ophthalmology community. The key issue is the lack of a satisfactory treatment.

Activity of dissolved mitomycin C after different methods of long-term storage

PURPOSE

The cytostatic substance mitomycin C (MMC) is used in trabeculectomy to enhance the success rate in problematic cases and is usually dissolved immediately before application, but only approximately 1% of the substance is needed for treatment. The authors evaluated different methods of long-time storage of MMC for a period of 6 months.

METHODS

MMC in concentrations of 0.02, 0.05, 0.1, 0.2, and 0.4 mg/mL was prepared at the local pharmaceutical department and stored at +22 degrees C (room temperature), +4 degrees C (refrigerator), -20 degrees C (freezer compartment), and -196 degrees C (liquid N2). The activity of MMC was evaluated with a microagar diffusion method (bioassay) after 30 minutes, and 1, 3, 7, 14, 30, 90, and 180 days for the different concentrations and storage methods.

RESULTS

There was no difference in the long-term stability of the investigated MMC concentrations. Ninety percent of the initial activity was preserved after storage at +22 degrees C for 1 week, -20 degrees C for 1 month, or +4 degrees C for 3 months. At 6 months the activities were 16%, 48%, and 78% of the initial values, respectively. The activity of MMC stored at -196 degrees C is not reduced after storage for 6 months.

CONCLUSIONS

Dissolved MMC can be stored in the refrigerator for up to 3 months without significant loss of activity. Storage at room temperature is not recommended. Costs of trabeculectomy can be reduced by storage of reconstituted solutions rather than dissolving MMC before each glaucoma surgery.

Randomized controlled clinical trial of beta irradiation as an adjunct to trabeculectomy in open-angle glaucoma

OBJECTIVE

To assess the effect of a single intraoperative application of 750 cGy of beta irradiation on the outcome of trabeculectomy for uncontrolled open-angle glaucoma.

DESIGN

A prospective, randomized, double-blind, placebo-controlled clinical trial.

PARTICIPANTS

Sixty-one eyes of 61 Caucasian patients at low risk of filtering surgery failure, with poorly controlled primary or secondary open-angle glaucoma undergoing routine trabeculectomy.

METHOD

Patients were randomly assigned to control or beta irradiation groups. All patients underwent standard trabeculectomy with fornix-based conjunctival incision. Eyes assigned to beta irradiation received 750 cGy of beta irradiation directly over the sclerostomy site on completion of conjunctival suturing. An identical but inactive applicator was applied to control eyes, delivering no radiation. Both operator and patient remained masked to the assignment for the 12-month follow-up period.

MAIN OUTCOME MEASURES

The main outcome measure was intraocular pressure (IOP) control. Complete success of IOP control was defined as an IOP less than 21 mmHg at 12 months without need for additional medication. Qualified success was defined as an IOP less than 21 mmHg at 12 months where additional medication was required.

RESULTS

Complete success of IOP control was achieved in 19 (86%) control eyes and 35 (90%) irradiated eyes (P = 1.0). Qualified success of IOP control was achieved in 21 (95%) control eyes and 39 (100%) irradiated eyes at 12 months follow-up (P = 1.0)

CONCLUSIONS

We experienced a very high success rate of filtration surgery in this select population without adjunctive irradiation. Our sample size was too small to show any improvement in success with use of beta irradiation in this group. Other studies would have to be done to determine whether it may have measurable benefit in cases with a high risk of filtration failure.