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Lim R. The surgical management of glaucoma: A review. Clin Exp Ophthalmol 2022; 50:213-231. [PMID: 35037376 DOI: 10.1111/ceo.14028] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/20/2021] [Accepted: 11/28/2021] [Indexed: 01/26/2023]
Abstract
After a long period of little change, glaucoma surgery has experienced a dramatic rise in the number of possible procedures in the last two decades. Glaucoma filtering surgeries with mitomycin C and glaucoma drainage devices remain the standard of surgical care. Other newer surgeries, some of which are minimally or microinvasive glaucoma surgeries, target existing trabecular outflow, enhance suprachoroidal outflow, create subconjunctival blebs, or reduce aqueous production. Some require the implantation of a device such as the iStent, Hydrus, Ex-PRESS, XEN and PRESERFLO, whilst others do not-Trabectome, Kahook dual blade, Ab interno canaloplasty, gonioscopy-assisted transluminal trabeculotomy, OMNI and excimer laser trabeculotomy. Others are a less destructive variation of an established procedure, such as micropulse transscleral cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cycloplasty. Cataract surgery alone can be a significant glaucoma operation. These older and newer glaucoma surgeries, their mechanism of action, efficacy and complications are the subject of this review.
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Affiliation(s)
- Ridia Lim
- Department of Ophthalmology, Sydney Eye Hospital, Sydney, Australia.,Save Sight Institute, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Khaw PT, Bouremel Y, Brocchini S, Henein C. The control of conjunctival fibrosis as a paradigm for the prevention of ocular fibrosis-related blindness. "Fibrosis has many friends". Eye (Lond) 2020; 34:2163-2174. [PMID: 32587389 DOI: 10.1038/s41433-020-1031-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 05/19/2020] [Accepted: 06/09/2020] [Indexed: 12/27/2022] Open
Abstract
The processes involved in ocular fibrosis after disease or ocular tissue injury, including surgery play an important part in the development or failure of treatment of most blinding diseases. Ocular fibrosis is one of the biggest areas of unmet need in ophthalmology. Effective anti-scarring therapies could potentially revolutionise the management of many diseases like glaucoma worldwide. The response of a quiescent or activated conjunctiva to glaucoma surgery and aqueous flow with different stimulatory components and the response to different interventions and future therapeutics is a paradigm for scarring prevention in other parts of the eye and orbit. Evolution in our understanding of molecular and cellular mechanisms in ocular fibrosis is leading to the introduction of new and re-purposed therapeutic agents, targeting a wide range of key processes. This review provides current and futures perspectives on different approaches to conjunctival fibrosis following glaucoma surgery and highlights the challenges faced in implementing these therapies with maximal effect and minimal side effects.
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Affiliation(s)
- Peng Tee Khaw
- National Institute of Health Research Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK. .,UCL Institute of Ophthalmology, London, UK.
| | - Yann Bouremel
- National Institute of Health Research Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK.,UCL Institute of Ophthalmology, London, UK.,UCL School of Pharmacy, London, UK
| | - Stephen Brocchini
- National Institute of Health Research Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK.,UCL Institute of Ophthalmology, London, UK.,UCL School of Pharmacy, London, UK
| | - Christin Henein
- National Institute of Health Research Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK.,UCL Institute of Ophthalmology, London, UK.,UCL School of Pharmacy, London, UK
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Zada M, Pattamatta U, White A. Modulation of Fibroblasts in Conjunctival Wound Healing. Ophthalmology 2017; 125:179-192. [PMID: 29079272 DOI: 10.1016/j.ophtha.2017.08.028] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/18/2017] [Accepted: 08/21/2017] [Indexed: 12/20/2022] Open
Abstract
Modulating conjunctival wound healing has the potential to improve outcomes after glaucoma filtration surgery and for several ocular disorders, including ocular cicatrial pemphigoid, vernal keratoconjunctivitis, and pterygium. Although anti-inflammatories and antimetabolites have been used with success, these nonspecific agents are not without their complications. The search for novel and more targeted means to control conjunctival fibrosis without such limitations has brought much attention to the regulation of fibroblast proliferation, differentiation, extracellular matrix production, and apoptosis. This review provides an update on where we stand with current antifibrotic agents and outlines the strategies that novel agents use, as they evolve from the bench to the bedside.
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Affiliation(s)
- Mark Zada
- Glaucoma Cell Biology Group, The Westmead Institute for Medical Research, NSW, Australia; Discipline of Ophthalmology, Sydney Medical School, University of Sydney, NSW, Australia.
| | - Ushasree Pattamatta
- Glaucoma Cell Biology Group, The Westmead Institute for Medical Research, NSW, Australia; Discipline of Ophthalmology, Sydney Medical School, University of Sydney, NSW, Australia
| | - Andrew White
- Glaucoma Cell Biology Group, The Westmead Institute for Medical Research, NSW, Australia; Discipline of Ophthalmology, Sydney Medical School, University of Sydney, NSW, Australia; Save Sight Institute, University of Sydney, NSW, Australia
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Binibrahim IH, Bergström AK. The role of trabeculectomy in enhancing glaucoma patient's quality of life. Oman J Ophthalmol 2017; 10:150-154. [PMID: 29118488 PMCID: PMC5657155 DOI: 10.4103/ojo.ojo_61_2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE Is to control intraocular pressure (IOP) (up to 21 mmHg), to decrease medical treatment after trabeculectomy and to slow down or stop progression and deterioration in visual fields in glaucoma patients. METHODS A retrospective study. The charts of all trabeculectomies done in the Department of Ophthalmology at the Skåne University Hospital, Sweden during 2010 were retrospectively evaluated. The study was performed during fall 2012, so the longest follow-up is almost 2 years. RESULTS In total, 38 patients (21 males and 17 females) underwent trabeculectomy. The IOP was measured in both visits (pre- and post-operative); with a difference of -15.49 mmHg (-50.09%) respectively, showing a very highly statistical significance (P < 0.001). The amount of antiglaucoma drops was measured before and after the trabeculectomy, of average 3.5 drops and 1.2 drops, respectively. Showing a -2.30 difference (-66.41%), illustrating a very highly statistical significant value (P < 0.001). From 36 patients, 17 patients (45%) took Diamox before trabeculectomy, whereas 19 patients (50%) did not. After the trabeculectomy, only 1 patient (3%) took Diamox and 35 patients (92%) stopped taking Diamox, showing a very highly significant statistical value (P < 0.001). The visual field was measured for 13 patients showing a difference of -13.22 (-21.86%) before and after the trabeculectomy. CONCLUSION Trabeculectomy showed very high statistical significant results regarding IOP reduction and decrease in the amount of topical and systemic antiglaucoma medications.
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Affiliation(s)
| | - Anders K. Bergström
- Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Gothenburg, Sweden
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Rodriguez-Agirretxe I, Garcia I, Soria J, Suarez TM, Acera A. Custom RT-qPCR-array for glaucoma filtering surgery prognosis. PLoS One 2017; 12:e0174559. [PMID: 28358901 PMCID: PMC5373565 DOI: 10.1371/journal.pone.0174559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 03/11/2017] [Indexed: 12/27/2022] Open
Abstract
Excessive subconjunctival scarring is the main reason of failure of glaucoma filtration surgery. We analyzed conjunctival and systemic gene expression patterns after non penetrating deep sclerectomy (NPDS). To find expression patterns related to surgical failure and their correlation with the clinical outcomes. This study consisted of two consecutive stages. The first was a prospective analysis of wound-healing gene expression profile of six patients after NPDS. Conjunctival samples and peripheral blood samples were collected before and 15, 90,180, and 360 days after surgery. In the second stage, we conducted a retrospective analysis correlating the late conjunctival gene expression and the outcome of the NPDS for 11 patients. We developed a RT-qPCR Array for 88 key genes associated to wound healing. RT-qPCR Array analysis of conjunctiva samples showed statistically significant differences in 29/88 genes in the early stages after surgery, 20/88 genes between 90 and 180 days after surgery, and only 2/88 genes one year after surgery. In the blood samples, the most important changes occurred in 12/88 genes in the first 15 days after surgery. Correspondence analyses (COA) revealed significant differences between the expression of 20/88 genes in patients with surgical success and failure one year after surgery. Different expression patterns of mediators of the bleb wound healing were identified. Examination of such patterns might be used in surgery prognosis. RT-qPCR Array provides a powerful tool for investigation of differential gene expression wound healing after glaucoma surgery.
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Affiliation(s)
- Iñaki Rodriguez-Agirretxe
- Instituto Clínico Quirúrgico de Oftalmología, Bilbao, Spain
- Hospital Universitario Donostia, San Sebastian, Spain
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Abstract
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.
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Outcomes of same-site re-operation with minimal use of mitomycin in failed trabeculectomy. Int Ophthalmol 2013; 34:501-4. [PMID: 23942810 DOI: 10.1007/s10792-013-9840-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
Abstract
To evaluate efficacy and safety of same site re-operation in eyes with failed trabeculectomy. A retrospective, noncomparative, interventional case series. We reviewed the medical records of 35 eyes of 35 patients who underwent same-site re-operation for failed trabeculectomy. The surgery involved a fornix-based peritomy at the same site as the previous trabeculectomy with application of 0.2 mg/mL mitomycin for 1 min. Primary outcome measures were intraocular pressure (IOP) control and number of antiglaucoma medications at last follow-up. Success rates were defined according to criteria (A) IOP ≤ 21 mmHg or (B) IOP ≤ 18 mmHg, with or without antiglaucoma medication. The mean age of the patients was 43.3 ± 18.0 years and 62.9 % were male. The mean follow-up was 13.6 ± 12.0 months (range 6-49 months). At final follow-up, mean baseline IOP was reduced from 27.2 ± 8.0 to 16.6 ± 7.5 mmHg (p < 0001). The mean number of antiglaucoma medications was reduced from 2.8 ± 0.8 to 1.0 ± 1.3 (p < 0001). This study supports the efficacy and safety of same-site re-operation with minimal use of mitomycin C for management of failed filtering blebs following trabeculectomy.
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De Fendi LI, Arruda GV, Scott IU, Paula JS. Mitomycin C versus5-fluorouracil as an adjunctive treatment for trabeculectomy: a meta-analysis of randomized clinical trials. Clin Exp Ophthalmol 2013; 41:798-806. [DOI: 10.1111/ceo.12097] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Lígia I De Fendi
- Department of Ophthalmology; Otorhinolaryngology and Head and Neck Surgery; School of Medicine of Ribeirão Preto; University of São Paulo
- Department of Ophthalmology; School of Medicine of Marília; São Paulo Brazil
| | - Gustavo V Arruda
- Department of Radiotherapy; School of Medicine of Marília; São Paulo Brazil
| | - Ingrid U Scott
- Departments of Ophthalmology and Public Health Sciences; Penn State College of Medicine; Hershey Pennsylvania USA
| | - Jayter S Paula
- Department of Ophthalmology; Otorhinolaryngology and Head and Neck Surgery; School of Medicine of Ribeirão Preto; University of São Paulo
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Seibold LK, Sherwood MB, Kahook MY. Wound modulation after filtration surgery. Surv Ophthalmol 2013; 57:530-50. [PMID: 23068975 DOI: 10.1016/j.survophthal.2012.01.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 01/02/2012] [Accepted: 01/19/2012] [Indexed: 01/26/2023]
Abstract
Filtration surgery is the standard invasive procedure for the management of intraocular pressure in advanced glaucoma. The key to a successful outcome is to modulate the normal wound healing cascade that leads to closure of the newly created aqueous outflow pathway. Antifibrotic agents such as mitomycin C and 5-fluorouracil have been increasingly used to modulate the wound healing process and increase surgical success. Although these agents have proven efficacy, they also increase the risk of complications. Efforts have centered on the identification of novel agents and techniques that can influence wound modulation without these complications. We detail new agents and methods under investigation to control wound healing after filtration surgery.
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Affiliation(s)
- Leonard K Seibold
- Rocky Mountain Lions Eye Institute, Department of Ophthalmology, University of Colorado at Denver, Aurora, Colorado, USA
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Stavrakas P, Georgopoulos G, Milia M, Papaconstantinou D, Bafa M, Stavrakas E, Moschos M. The use of amniotic membrane in trabeculectomy for the treatment of primary open-angle glaucoma: a prospective study. Clin Ophthalmol 2012; 6:205-12. [PMID: 22347791 PMCID: PMC3280101 DOI: 10.2147/opth.s27187] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Panagiotis Stavrakas
- Department of Ophthalmology, University of Athens Medical School, General Hospital of Athens (Geniko Kratiko Hospital), Athens, Greece
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Shahid H, Salmon JF. Use of 5-Fluorouracil Injections to Reduce the Risk of Trabeculectomy Bleb Failure After Cataract Surgery. J Ocul Pharmacol Ther 2010; 26:119-23. [PMID: 20148657 DOI: 10.1089/jop.2009.0067] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Humma Shahid
- Oxford Eye Hospital, West Wing, Oxford Radcliffe Hospitals NHS Trust, Oxford, United Kingdom
| | - John F. Salmon
- Oxford Eye Hospital, West Wing, Oxford Radcliffe Hospitals NHS Trust, Oxford, United Kingdom
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Stavrou P, Misson GP, Rowson NJ, Murray PI. Trabeculectomy in uveitis Are antimetabolites necessary at the first procedure? Ocul Immunol Inflamm 2009; 3:209-16. [DOI: 10.3109/09273949509069114] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Wong TT, Khaw PT, Aung T, Foster PJ, Htoon HM, Oen FTS, Gazzard G, Husain R, Devereux JG, Minassian D, Tan SB, Chew PTK, Seah SKL. The singapore 5-Fluorouracil trabeculectomy study: effects on intraocular pressure control and disease progression at 3 years. Ophthalmology 2009; 116:175-84. [PMID: 19187822 DOI: 10.1016/j.ophtha.2008.09.049] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 09/08/2008] [Accepted: 09/26/2008] [Indexed: 10/21/2022] Open
Abstract
PURPOSE To report 3-year results of a randomized, controlled trial comparing the use of a single application of 5-fluorouracil (5-FU) with placebo in trabeculectomy surgery. DESIGN Prospective, randomized, double-blinded treatment trial. PARTICIPANTS Two hundred forty-three Asian patients with primary open-angle or primary angle-closure glaucoma undergoing primary trabeculectomy. METHODS One eye of each patient was randomized to receive either intraoperative 5-FU or normal saline (placebo) during trabeculectomy. MAIN OUTCOME MEASURES Primary outcome measure was the level of intraocular pressure (IOP). Secondary outcomes were progression of visual field loss, rates of adverse events, and interventions after surgery. RESULTS Of the 288 eligible patients, 243 were enrolled and 228 completed 3 years follow-up; 120 patients received 5-FU and 123 received placebo. Trial failure, according to predefined IOP criteria, was lower in the 5-FU group compared with the placebo group, although the difference was only significant with a failure criterion of IOP >17 mmHg (P = 0.0154). There was no significant difference in progression of optic disc and/or visual field loss over 36 months between 5-FU and placebo (relative risk [RR], 0.67; 95% confidence interval [CI], 0.34-1.31; P = 0.239). Uveitis occurred more often in the 5-FU-treated group (14/115 [12%] vs 5/120 [4%]; P = 0.032). CONCLUSIONS This is the first masked, prospective, randomized trial reporting the effect of adjunctive 5-FU in trabeculectomy surgery in an East Asian population. The trial shows that an increased success rate can be achieved for several years after a single intraoperative treatment with 5-FU. We conclude that 5-FU is relatively safe and can be routinely used in low-risk East Asian patients. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Tina T Wong
- Singapore National Eye Center, Singapore and Singapore Eye Research Institute, Singapore.
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Zarkovic A, Chow K, Mora JS. Comparison of 90-s versus 5-min intraoperative 5-fluorouracil in trabeculectomy. Int Ophthalmol 2009; 30:31-9. [PMID: 19137263 DOI: 10.1007/s10792-008-9287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 12/18/2008] [Indexed: 10/21/2022]
Abstract
To compare the relative efficacy of trabeculectomy surgery with 90-s and 5-min intraoperative exposure time to 5-fluorouracil. This was a retrospective, non-randomized comparative study. 41 eyes of 33 consecutive patients in the study group were compared to 40 eyes of 30 consecutive patients in the historical control group. Both groups were exposed to 5-fluorouracil (50 mg/ml) during trabeculectomy surgery. The exposure time was 90 s for the study group and 5 min for the control group. Three criteria were used to define surgical success: IOP (intraocular pressure) less than 21 mmHg; IOP less than 21 mmHg with more than 30% reduction in pressure; and IOP less than 15 mmHg with more than 30% reduction. The number of antiglaucoma medications, visual acuity, complications, and interventions were recorded at regular intervals. Mean preoperative IOP was 21.6 +/- 4.8 in the 90-s group and 21.2 +/- 4.9 in the 5-min group. Mean follow-up was 28.2 +/- 5.1 months in the 90-s group and 48.0 +/- 4.9 months in the 5-min group. During the first 30 postoperative months, there were no statistically significant differences in IOP and requirement for antiglaucoma medications between the two groups. The 90-s group had shorter survival rates using the 1st success criteria, but no significant difference was detected when the more stringent 2nd and 3rd criteria were applied. Choroidal effusions were significantly less common in the 90-s group (P = 0.0076). The results of this small study suggest that a 90-s application of 5-fluorouracil may be as effective as a 5-min one in trabeculectomy.
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Affiliation(s)
- Andrea Zarkovic
- Department of Ophthalmology, Greenlane Clinical Centre, Auckland, New Zealand.
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Khaw PT, Clarke J. Antifibrotic Agents in Glaucoma Surgery. Ophthalmology 2009. [DOI: 10.1016/b978-0-323-04332-8.00211-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abdul Karim MN, Bhatt UK, Sivaprasad S. Intraoperative 5-Fluorouracil for glaucoma surgery. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [DOI: 10.1002/14651858.cd006926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Fontana H, Nouri-Mahdavi K, Lumba J, Ralli M, Caprioli J. Trabeculectomy with Mitomycin C. Ophthalmology 2006; 113:930-6. [PMID: 16647135 DOI: 10.1016/j.ophtha.2006.01.062] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Revised: 12/14/2005] [Accepted: 01/08/2006] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To evaluate long-term tonometric outcomes of trabeculectomy with adjunctive mitomycin C (MMC) and its efficacy in achieving a range of intraocular pressures (IOP) in phakic patients with open-angle glaucoma. DESIGN Retrospective cohort study. METHODS Three levels of success were defined by these criteria: (A) IOP < or =18 mmHg and IOP reduction of 20%; (B) IOP < or =15 mmHg and IOP reduction of 25%; and (C) IOP < or =12 and IOP reduction of 30%. Kaplan-Meier survival analyses were used to assess outcomes. Cox's proportional hazard regression analysis was used to identify risk factors for failure. PARTICIPANTS Two hundred twenty-five phakic patients (292 eyes) with open-angle glaucoma, > or =40 years of age at time of trabeculectomy. MAIN OUTCOME MEASURES The primary outcome was qualified success rate (with or without medications) according to the defined criteria. Secondary outcomes include IOP level and number of medications at 1 and 3 years after surgery, postoperative complications, and need for further glaucoma surgery. RESULTS Mean IOP (+/-standard deviation) decreased from 18.8 mmHg (+/-6.1 mmHg) before surgery to 11.3 mmHg (+/-4.5 mmHg) at 1 year and 11.1 mmHg (+/-4.2 mmHg) at 3 years (P<0.001 for both). The mean number of medications decreased from 2.8 (+/-1.0) to 0.4 (+/-0.7) at 1 year and 0.7 (+/-1.0) at 3 years (P<0.001 for both). The success rates were 85%, 84%, and 79% at 1 year for criteria A, B, and C, respectively; and 62%, 56%, and 46% for these criteria, respectively, at 3 years. Postoperative laser suture lysis was associated with a higher rate of failure for criteria B and C (P<0.001 for both), the hazard ratio (HR) was 1.7 for criteria B and 2.0 for criteria C. Prior argon laser trabeculoplasty was associated with higher risk of failure for criteria C (HR = 1.6; P = 0.05). CONCLUSIONS Trabeculectomy with MMC effectively reduces IOP in phakic open-angle glaucoma, but long-term low IOPs are achieved in only half of the cases. Laser suture lysis after trabeculectomy and prior argon laser trabeculoplasty are associated with a higher risk of failure when low IOPs are required.
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Affiliation(s)
- Hector Fontana
- Glaucoma Division, Jules Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California 90095, USA
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Siriwardena D, Edmunds B, Wormald RPL, Khaw PT. National survey of antimetabolite use in glaucoma surgery in the United Kingdom. Br J Ophthalmol 2004; 88:873-6. [PMID: 15205228 PMCID: PMC1772249 DOI: 10.1136/bjo.2003.034256] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To assess the pattern of use of antimetabolites in trabeculectomy surgery by all consultant ophthalmologists in the United Kingdom. METHODS A postal questionnaire of 12 questions regarding antimetabolite use in trabeculectomy surgery was sent to all 749 consultant ophthalmologists in the United Kingdom. The consultants were asked to estimate the number of trabeculectomies they performed per year, how often they used 5-fluorouracil (5-FU) in primary and redo surgery, their usual method of administration of 5-FU, how often they used mitomycin (MMC) in primary and redo surgery, and their usual dosage regimen of MMC. Factors that influenced the decision to use or not use antimetabolites were also assessed. RESULTS The response rate of consultants returning the questionnaire was 82% (615 out of 749); 87% (533) of these consultants perform trabeculectomy surgery. Of these 533 consultants, 98 (18%) never use an antimetabolite. Most consultants (82%) use antimetabolites, but use them infrequently (only 9% using antimetabolites in more than half their cases). The preferred antimetabolite is 5-FU rather than MMC. Of the 435 consultants performing trabeculectomy surgery and using antimetabolites, 402 (93%) use 5-FU and 179 (41%) use MMC. Various factors influenced the decision to use or not use an antimetabolite, but experience of complications associated with their use was a factor for 34% of consultants. CONCLUSION The use of antimetabolites, particularly MMC, in the United Kingdom is much less than in America or Japan, where trabeculectomy with MMC is the surgical procedure preferred by glaucoma specialists.
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Affiliation(s)
- D Siriwardena
- Wound Healing Unit, Institute of Ophthalmology and Moorfields Eye Hospital, 11-43 Bath Street, London EC1V 9EL, UK.
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Abstract
Primary open-angle glaucoma is a progressive optic neuropathy and, perhaps, the most common form of glaucoma. Because the disease is treatable, and because the visual impairment caused by glaucoma is irreversible, early detection is essential. Early diagnosis depends on examination of the optic disc, retinal nerve fibre layer, and visual field. New imaging and psychophysical tests can improve both detection and monitoring of the progression of the disease. Recently completed long-term clinical trials provide convincing evidence that lowering intraocular pressure prevents progression at both the early and late stages of the disease. The degree of protection is related to the degree to which intraocular pressure is lowered. Improvements in therapy consist of more effective and better-tolerated drugs to lower intraocular pressure, and more effective surgical procedures. New treatments to directly treat and protect the retinal ganglion cells that are damaged in glaucoma are also in development.
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Affiliation(s)
- Robert N Weinreb
- Hamilton Glaucoma Center and Department of Ophthalmology, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0946, USA.
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Spinks RL, Baker SN, Jackson A, Khaw PT, Lemon RN. Problem of dural scarring in recording from awake, behaving monkeys: a solution using 5-fluorouracil. J Neurophysiol 2003; 90:1324-32. [PMID: 12904511 DOI: 10.1152/jn.00169.2003] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In studies using single neuron recordings from awake, behaving monkeys, it is necessary to make repeated transdural penetrations using fragile microelectrodes. The tough connective tissue that accumulates after the dura mater is first exposed is often problematic because of electrode breakage and the mechanical stress to the underlying brain tissue caused by excessive dimpling during penetration. We describe the use of an antimitotic compound, 5-fluorouracil (5FU) to control the growth of this connective tissue. 5FU can be safely applied for short periods to the exposed dural tissue on a regular basis provided that it is thoroughly rinsed after application. The advantages of using 5FU are fourfold: first, it depresses fibroblast division and minimizes dural growth and scar tissue formation so that penetrations are easier with less electrode damage or breakage. Second, the frequency of surgical procedures required to remove this tissue are greatly reduced, which benefits both the experiment animal and the experiment. Third, 5FU reduces vascularization of the tissue so that its removal is far easier and without significant blood loss. Finally, 5FU seems to inhibit bacterial infections within the recording chamber. In macaque motor cortex, we performed a quantitative study of electrophysiological data recorded from monkeys with and without 5FU treatment. No significant deleterious side effects produced by 5FU could be detected. Likewise, histological examination of cortical tissue underlying treated dura did not reveal any obvious signs of damage by 5FU. We recommend this approach, with the appropriate safety precautions, to all those neurophysiologists using transdural microelectrode methods in chronically prepared experimental animals. It is also possible that this technique may be useful in other situations where there is dural scarring after surgical intervention or injury.
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Affiliation(s)
- R L Spinks
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, United Kingdom
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Abstract
When medical and laser therapy fail to control intraocular pressure, glaucoma filtration surgery needs to be performed. Glaucoma surgery is unique in that its success is linked to interruption of the wound-healing response in order to maintain patency of the new filtration pathway. In this article we will review the wound-healing pathway and the pharmacologic interventions that have been employed clinically and experimentally to interrupt wound healing, particularly steroids and the antifibrotic agents 5-fluorouracil and mitomycin C. A review of the published literature looking at use of these agents to enhance success as well as the associated complications are presented, critiqued, and interpreted in order to put the studies in proper perspective. Future directions and recommendations regarding use of these agents are available and an introduction to newer wound modulating agents such as anti-transforming growth factor beta 2 is presented.
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Affiliation(s)
- Paul J Lama
- Glaucoma Division, New Jersey Medical School, Newark 07103, USA
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24
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Mandal AK, Bagga H, Nutheti R, Gothwal VK, Nanda AK. Trabeculectomy with or without mitomycin-C for paediatric glaucoma in aphakia and pseudophakia following congenital cataract surgery. Eye (Lond) 2003; 17:53-62. [PMID: 12579171 DOI: 10.1038/sj.eye.6700180] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of trabeculectomy with or without mitomycin-C (MMC) in the management of glaucoma in aphakia and pseudophakia following congenital cataract surgery. PATIENTS AND METHODS All patients of glaucoma with aphakia or pseudophakia who underwent trabeculectomy with or without MMC from January 1989 to April 2000 were included. The medical records of 19 consecutive patients (23 eyes) were reviewed. Data collected from a retrospective chart review were analysed. Outcome measures were evaluated using Kaplan-Meier survival analysis. Pre- and postoperative intraocular pressures (IOPs), visual acuities, success rate, bleb characteristics, surgical failure and complications were the main outcome measures. Successful IOP control was defined as an IOP between 6 and 21 mmHg, without antiglaucoma medications, without further antiglaucoma surgery and without any sight-threatening complication. RESULTS The mean age of patients was 8.8+/-5.5 years at the time of trabeculectomy with MMC compared to 11.0+/-12.4 years for trabeculectomy without MMC. Eight patients underwent trabeculectomy with MMC and 11 patients underwent trabeculectomy without MMC. There was no statistically significant difference between the two groups in terms of visual acuity, IOP, antiglaucoma medications, age at cataract surgery and at trabeculectomy. The IOP reduced from a preoperative level of 34.2+/-8.9 mmHg (range: 20-52) to a postoperative level of 18.4+/-12.2 mmHg (range: 2-60) with a mean follow-up of 24.2+/-17.9 months. The mean reduction in IOP in the MMC group was 15.5+/-17.3 and 16.3+/-13.8 mmHg in the other group (P = 0.967). Overall, complete success was achieved in 36.8%, qualified success in 21.1% and surgical failure in 42.1% of patients with a mean follow-up of 24.2+/-17.9 months. There was no difference in the success between the two groups at the last follow-up. One patient developed bleb-related endophthalmitis in both eyes following trabeculectomy with MMC. CONCLUSIONS The success rate of trabeculectomy in glaucoma following congenital cataract surgery was 36.8% at the end of 3 years. The present study proves a poor success rate of trabeculectomy in a small series of aphakic Asian Indian patients even with the use of MMC.
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Affiliation(s)
- A K Mandal
- Jasti V Ramanamma Children's Eye Care Center, LV Prasad Eye Institute, Hyderabad, India.
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Suzuki R, Dickens CJ, Iwach AG, Hoskins HD, Hetherington J, Juster RP, Wong PC, Klufas MT, Leong CJ, Nguyen N. Long-term follow-up of initially successful trabeculectomy with 5-fluorouracil injections. Ophthalmology 2002; 109:1921-4. [PMID: 12359615 DOI: 10.1016/s0161-6420(02)01186-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To study the long-term results (1-14 years) of trabeculectomies with 5-fluorouracil injections that were successful at 1 year. DESIGN A retrospective noncomparative case series. INTERVENTION/PARTICIPANTS: We identified 87 patients (87 eyes) who had trabeculectomies with 5-fluorouracil injections from 1984 to 1989 that were successful at 1 year and had a follow-up range of 1.0 to 14.7 years (mean, 8.1, standard deviation of 4.4 years). All patients had previously failed glaucoma surgery (66.7%), cataract surgery (47.1%), or other diagnoses making them at high risk for failure. MAIN OUTCOME MEASURES Successful control of intraocular pressure (IOP) was defined as IOP less than 21 mmHg or a reduction of 33% if preoperative pressure was less than 21 mmHg. Statistical analysis was performed using Kaplan-Meier life table analysis. RESULTS If an eye is considered successful by IOP at 1 year, the probability of successful control is 61% at 5 years, 44% at 10 years, and 41% at 14 years. CONCLUSIONS Despite successful IOP control at 1 year, trabeculectomies with 5-fluorouracil injections show a continual loss of IOP control over time.
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Affiliation(s)
- Ricardo Suzuki
- Glaucoma Research and Education Group, San Francisco, California 94102, USA
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26
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Abstract
AIMS To report remodelling of enlarged dysmorphic filtration blebs with conjunctival compression sutures and autologous blood injection. METHODS A retrospective analysis of consecutively recruited patients with enlarged and dysmorphic filtration blebs who were managed with conjunctival compression sutures and subconjunctival autologous blood injections. Under topical anaesthesia, conjunctival (8.0-9.0 Nylon or 8.0 Vicryl) compression sutures were placed either side of blebs that were not showing signs of spontaneous resolution. In each case up to 0.75 ml of autologous blood was then injected into the areas of the bleb to be flattened. Supplemental injections of autologous blood were given in clinic as required. RESULTS In 11 eyes of 11 patients, conjunctival compression sutures were placed and autologous blood was injected, on average, 568 days following filtration surgery (range 41-2023). Supplemental autologous blood injections were required in eight patients, with three injections being given in one patient. In each case, the sutures were well tolerated and satisfactory compression of the conjunctiva was achieved. The highest intraocular pressure following injection was 25 mm Hg (mean 17.3, SD 4.2) and in none of the cases did blood enter the anterior chamber or parts of the filtration bleb bounded by the sutures. CONCLUSION Conjunctival compression sutures with autologous blood provide a simple and effective means for remodelling the filtration bleb. The procedure can be performed under topical anaesthesia and does not hinder further bleb surgery, should this be required.
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Affiliation(s)
- J E Morgan
- Department of Ophthalmology, University Hospital of Wales, Heath Park, Cardiff CF4 4XW, UK.
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Leyland M, Bloom P, Zinicola E, McAlister J, Rassam S, Migdal C. Single intraoperative application of 5-Fluorouracil versus placebo in low-risk trabeculectomy surgery: a randomized trial. J Glaucoma 2001; 10:452-7. [PMID: 11740214 DOI: 10.1097/00061198-200112000-00003] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Trabeculectomy is the procedure of choice for the surgical control of glaucoma, and is often augmented by intraoperative 5-fluorouracil application to reduce scarring. This study aims to assess the validity of this technique with a randomized placebo-controlled trial. METHODS Patients without risk factors for bleb failure other than previous drop use who were undergoing trabeculectomy surgery as their first ocular procedure were randomized to receive fluorouracil or placebo. The main outcome measures were intraocular pressure and bleb morphology. RESULTS Results from 40 eyes of 36 patients are presented; 23 eyes were treated with fluorouracil, and 17 eyes were treated with placebo. Mean intraocular pressure at 1 year and at the final follow-up examination was significantly lower than preoperatively, but was not different between fluorouracil and placebo groups. Kaplan-Meier survival analysis also failed to show any difference, though there was a trend toward better survival of an intraocular pressure of 16 mm Hg or lower. Bleb morphology was examined postoperatively in 24 patients, with no differences found between fluorouracil and placebo groups. CONCLUSIONS No significant difference was found in trabeculectomy outcome between fluorouracil-treated and placebo-treated eyes. The study was too small to state definitively that no such difference exists, but suggests that any treatment effect is likely to be small.
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Affiliation(s)
- M Leyland
- Moorfields Eye Hospital, Western Eye Hospital, and Institute of Ophthalmology, London, United Kingdom
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28
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Affiliation(s)
- P T Khaw
- Department of Pathology, Moorfields Eye Hospital and Institute of Ophthalmology, London, United Kingdom
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29
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Susanna R, Costa VP, Malta RF, Barboza WL, Vasconcellos JP. Intraoperative mitomycin-C without conjunctival and Tenon's capsule touch in primary trabeculectomy. Ophthalmology 2001; 108:1039-42. [PMID: 11382626 DOI: 10.1016/s0161-6420(01)00573-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To verify whether intraoperative mitomycin C (MMC) without conjunctival and Tenon's touch is effective in inhibiting the development of thin, avascular blebs in eyes undergoing primary trabeculectomy. DESIGN Noncomparative, interventional study. PARTICIPANTS Fifteen eyes of 15 consecutive patients undergoing primary trabeculectomy. INTERVENTION All eyes underwent trabeculectomy with intraoperative MMC (0.25 mg/ml for 3 minutes) without either conjunctival or Tenon's touch. Patients were examined 1 month, 3 months, 6 months, and 12 months after surgery. Intraocular pressure (IOP) and number of medications were evaluated at each examination. The appearance of the bleb was classified at the last examination into one of three groups: flat and vascularized; elevated but not avascular; or elevated, thin, and avascular. MAIN OUTCOME MEASURES Intraocular pressure, number of antiglaucoma medications, and appearance of the bleb. RESULTS Preoperative mean IOP was 30.57 +/- 10.92 mmHG: Statistically significant IOP reductions were observed 1 month, 3 months, 6 months, and 1 year after surgery (P < 0.01). Twelve months after surgery, the mean IOP was 14.92 +/- 6.53 mmHG: Five eyes (33.3%) showed an IOP less than 15 mmHg without antiglaucoma medication at the 12-month examination. The bleb was considered elevated, thin, and avascular in 12 of 15 eyes (80%) at the end of follow-up. CONCLUSIONS Intraoperative MMC at 0.25 mg/ml for 3 minutes without either conjunctival or Tenon's touch was not effective in eliminating the development of thin, avascular blebs in eyes undergoing primary trabeculectomy.
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Affiliation(s)
- R Susanna
- Department of Ophthalmology, Glaucoma Service, University of São Paulo, São Paulo, Brazil.
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30
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Khaw PT, Chang L, Wong TT, Mead A, Daniels JT, Cordeiro MF. Modulation of wound healing after glaucoma surgery. Curr Opin Ophthalmol 2001; 12:143-8. [PMID: 11224722 DOI: 10.1097/00055735-200104000-00011] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The healing process after glaucoma filtration is the main determinant of surgical failure and, even more important, the final intraocular pressure. The ability to fully control wound healing may ultimately give us the ability to set the intraocular pressure in the low teens for all patients undergoing glaucoma filtration surgery. The authors review the changes in how to use antimetabolites to improve safety, and many of the exciting new areas of progress, including growth factor neutralization and future molecular therapies to control wound healing.
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Affiliation(s)
- P T Khaw
- Wound Healing Research Unit, Department of Pathology, Institute of Ophthalmology and Moorfields Eye Hospital, London, England
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31
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Singh K, Mehta K, Shaikh NM, Tsai JC, Moster MR, Budenz DL, Greenfield DS, Chen PP, Cohen JS, Baerveldt GS, Shaikh S. Trabeculectomy with intraoperative mitomycin C versus 5-fluorouracil. Prospective randomized clinical trial. Ophthalmology 2000; 107:2305-9. [PMID: 11097613 DOI: 10.1016/s0161-6420(00)00391-2] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate the relative efficacy and safety of 5-fluorouracil (5-FU) and mitomycin C (MMC) when used as adjuncts with primary trabeculectomy in eyes not at high risk for failure. DESIGN Prospective multicenter, randomized clinical trial. PARTICIPANTS One hundred thirteen patients with primary open-angle, pseudoexfoliative, pigmentary, or angle-closure glaucoma undergoing primary trabeculectomy were recruited. METHODS One eye of each patient was randomized to receive either 5-FU (50 mg/ml for 5 minutes) or MMC (0.4 mg/ml for 2 minutes). MAIN OUTCOME MEASURES Intraocular pressure (IOP), visual acuity, complications, and interventions were documented at fixed intervals after surgery. The study also examined progression of visual field loss, long-term complications, and bleb appearance 3 years after surgery. RESULTS Of the 108 patients with complete perioperative information, 54 eyes received 5-FU and 54 received MMC. The proportion of patients reaching different predefined target IOPs after surgery was slightly higher in the MMC group than in the 5-FU group. This difference was less than 25%, which would have been necessary to achieve statistical significance with a power of 0.8 and the sample size used. Likewise, there was no statistically significant difference between the groups with regard to mean preoperative IOP, complications, or interventions. Mean postoperative follow-up was 309 and 330 days in the 5-FU and MMC groups, respectively (P = 0.593). CONCLUSIONS 5-Fluorouracil and MMC were found to be equally safe and effective adjuncts to primary trabeculectomy in the short- and medium-term postoperative periods.
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Affiliation(s)
- K Singh
- Stanford University School of Medicine, Stanford, California, USA.
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32
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Towler HM, McCluskey P, Shaer B, Lightman S. Long-term follow-up of trabeculectomy with intraoperative 5-fluorouracil for uveitis-related glaucoma. Ophthalmology 2000; 107:1822-8. [PMID: 11013180 DOI: 10.1016/s0161-6420(00)00351-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To determine the effect of intraoperative application of 5-fluorouracil (5-FU) on the long-term outcome of trabeculectomy in uveitis-related glaucoma. DESIGN An open, prospective, noncomparative case study to evaluate the use of intraoperative application for 5 minutes of 25 mg/ml 5-FU in primary trabeculectomy for uveitis-related glaucoma. PARTICIPANTS Fifty eyes of 43 consecutive patients were enrolled in the study. METHODS Data were recorded prospectively on specifically designed forms at visits every 3 months after surgery. MAIN OUTCOME MEASURES The intraocular pressure, need for additional medication, and the need for repeat surgery were the criteria that determined the outcome of surgery. RESULTS No significant intraoperative, postoperative, or late complications of 5-FU administration were noted. Successful filtration was achieved in 82% of eyes at 1 and 2 years after surgery. The success rate was 67% at 5 years. Failure was significantly more common and occurred earlier in patients of black ethnic origin. No deleterious effect on control of uveitis in relation to surgical intervention was observed. CONCLUSIONS Intraoperative application of 5-FU appears to be a long-term, safe, and effective adjunct to trabeculectomy in uveitis-related glaucoma.
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Affiliation(s)
- H M Towler
- Department of Clinical Ophthalmology, Institute of Ophthalmology, Moorfields Eye Hospital, London, England UK
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33
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Rothman RF, Liebmann JM, Ritch R. Low-dose 5-fluorouracil trabeculectomy as initial surgery in uncomplicated glaucoma: long-term followup. Ophthalmology 2000; 107:1184-90. [PMID: 10857841 DOI: 10.1016/s0161-6420(00)00085-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To compare the effectiveness of trabeculectomy with adjunctive, low-dose, subconjunctival 5-fluorouracil (5-FU) to trabeculectomy alone in patients with uncomplicated glaucoma undergoing their first incisional surgical procedure. DESIGN Retrospective, nonrandomized comparative trial. PARTICIPANTS Consecutive series of 52 patients and 74 control subjects. INTERVENTION Trabeculectomy was performed in all patients. Study patients received adjunctive, subconjunctival injections of 5-FU up to 14 days from the date of surgery. MAIN OUTCOME MEASURES Intraocular pressure, number of postoperative antiglaucoma medications, interventions, and complications were evaluated. RESULTS Mean followup for all patients was 58.1 +/- 44.1 months (range, 1.1-159.9 months). Mean followup for successful eyes was 55.9 +/- 47.1 months (range, 7.6-159.9 months). The cumulative 5-year success (intraocular pressure [IOP] < or = 21 mmHg) was 77.8% in the 5-FU group and 62.2% in the control group (P = 0.02, Wilcoxon test. Complete success (IOP < or = 21 mmHg without medications) at 5 years was lower in both the 5-FU group (72.3%) and the control group (51.3%). Postoperative mean IOP at 5 years for all successful patients was lower in eyes receiving 5-FU (10.7 +/- 3.6 mmHg vs. 16.0 +/- 6.1 mmHg [P = 0.02, t-test]). For those patients considered to be complete successes, there was no difference in IOP between the two groups of patients at any evaluated time interval. Patients in the 5-FU group were using 0.7 +/- 1.1 medications at final followup compared with 1.8 +/- 1.4 medications in the control group (P = < 0.0001, t test). Bleb-related ocular infection occurred in 6.3% of patients and was more common in patients receiving 5-FU than controls (6 of 52 vs 2 of 74, respectively; P = 0.05, Fischer's exact test). CONCLUSIONS Adjunctive, low-dose 5-FU at the time of initial surgery in uncomplicated glaucoma improves long-term IOP control and reduces the need for postoperative, antiglaucoma therapy. Eyes receiving 5-FU are at greater risk of developing late bleb-related ocular infection.
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Affiliation(s)
- R F Rothman
- Department of Ophthalmology, The New York Eye and Ear Infirmary, New York, USA
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Sidoti PA, Belmonte SJ, Liebmann JM, Ritch R. Trabeculectomy with mitomycin-C in the treatment of pediatric glaucomas. Ophthalmology 2000; 107:422-9. [PMID: 10711876 DOI: 10.1016/s0161-6420(99)00130-x] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
PURPOSE To evaluate the effectiveness and safety of trabeculectomy with mitomycin-C (MMC) in the management of childhood glaucomas. DESIGN Retrospective, noncomparative case series. PARTICIPANTS All patients less than 18 years of age who underwent trabeculectomy with MMC from June 1991 through October 1997 were included. METHODS The medical records of 29 consecutive patients (29 eyes) were reviewed. Data collected during routine patient follow-up were analyzed. Surgical outcome was evaluated using Kaplan-Meier life-table analysis. MAIN OUTCOME MEASURES Clinical outcome assessment included intraocular pressure (IOP) control, visual acuity, and identification of complications. Successful IOP control was defined as 5 mmHg < or = final IOP < or = 21 mmHg, with or without antiglaucoma medications and without further glaucoma surgery or loss of light perception. Outcomes for the group of patients with primary infantile glaucoma were compared with those for the group with secondary glaucomas. RESULTS Mean patient age was 6.4 +/- 4.4 years (range, 0.2-15.3 years). A variety of primary and secondary glaucomas were represented. Mitomycin-C (0.5 mg/ml) on a surgical sponge was applied to the episcleral surface for an average of 3.8 +/- 1.0 minutes (range, 1.5-5.0 minutes). Mean follow-up time for patients categorized as successes was 25.1 +/- 16.0 months (range, 5.5-59.7 months). The 12-, 24-, and 36-month life-table success rates for IOP control were 82%, 59%, and 59% respectively. There was no difference between the primary infantile glaucoma group and the secondary glaucoma group with respect to length of follow-up, rate of successful IOP control, and incidence of complications. Five patients (17%) experienced late bleb-related infection (BRI) at an average of 27.9 +/- 18.1 months (range, 5.4-55.5 months) after surgery. Other complications included hyphema, retinal detachment, late-onset bleb leak, flat anterior chamber, chronic hypotony, decompression retinopathy, suture abscess, and phthisis. CONCLUSIONS Trabeculectomy with MMC may be useful in the management of childhood glaucomas in which goniotomy, trabeculotomy, or both have failed. However, the high incidence of BRI in this series over an extended follow-up interval dictates caution in using MMC as an adjunct in pediatric trabeculectomy.
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Affiliation(s)
- P A Sidoti
- Department of Ophthalmology, The New York Eye and Ear Infirmary, New York 10003, USA.
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35
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Jemec B, Linge C, Grobbelaar AO, Smith PJ, Sanders R, McGrouther DA. The effect of 5-fluorouracil on Dupuytren fibroblast proliferation and differentiation. CHIRURGIE DE LA MAIN 2000; 19:15-22. [PMID: 10777424 DOI: 10.1016/s1297-3203(00)73455-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Dupuytren's disease is a proliferative disease with contractile properties, prone to recur after surgery. Intra-operatively applied 5-fluorouracil has been used to avoid scar problems in the eye after glaucoma filtration surgery and was therefore investigated as a means to inhibit proliferation and myofibroblast differentiation in Dupuytren fibroblasts in vitro. METHOD Primary cell lines were obtained by explants from Dupuytren's tissue (n = 6), non-diseased palmar fascia from patients with Dupuytren's disease (n = 3) and carpal ligament from patients undergoing carpal tunnel release (n = 3). The effect of 5-fluorouracil on proliferation was assessed by cell counting. Myofibroblast differentiation, an intergral part of Dupuytren's contracture, was investigated by staining for alpha smooth muscle actin, a marker for contractile cells, using immunohisto-chemical methods. RESULTS A single exposure to 5-fluorouracil caused a sustained inhibition of proliferation in Dupuytren's and non-diseased fascia cultures, whilst the effect on carpal ligament cultures was transient. Untreated Dupuytren's fibroblasts exhibited the highest myofibroblast differentiation, whilst differentiation in non-diseased fascia cultures was shown to be proportional to cell density and virtually non-existent in carpal ligament cultures. After 5-fluorouracil exposure, the differentiation was significantly reduced in Dupuytren's fibroblasts cultures, reduced at high cell densities in non-diseased fascia and unchanged in carpal ligament cell cultures. DISCUSSION 5-fluorouracil inhibits both proliferation and myofibroblast differentiation in Dupuytren's cell cultures and may have a potential use as an adjuvant treatment to Dupuytren surgery in order to reduce the rate of recurrence and contracture.
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Affiliation(s)
- B Jemec
- Restoration of Appearance and Function Trust, Northwood, Middlesex, UK
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36
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Wilkins MR, Occleston NL, Kotecha A, Waters L, Khaw PT. Sponge delivery variables and tissue levels of 5-fluorouracil. Br J Ophthalmol 2000; 84:92-7. [PMID: 10611106 PMCID: PMC1723231 DOI: 10.1136/bjo.84.1.92] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To study how the delivery of 5-fluorouracil (5-FU) to ocular tissues is affected by altering delivery variables. METHOD Sponge(s) soaked in radiolabelled 5-FU were placed between the conjunctiva and sclera of pig eyes. Application time, sponge size, sponge make (Altomed, Weck, Merocel), and 5-FU concentration were varied. Conjunctival and scleral tissue levels were determined in samples taken from the application site. RESULTS Dose-response curves for scleral and conjunctival 5-FU levels against application time showed increasing tissue levels that reached a plateau after 2-3 minutes. Application beyond 3 minutes did not increase tissue levels. There was no difference in tissue levels between 7x4 and 3. 5x2 mm sponges. Altomed sponges produced 5-FU tissue levels that were twice as high as those obtained with Weck-cell (p<0.01) or Merocel (p<0.02) sponges. Changing the 5-FU concentration from 25 mg/ml to 6.25 mg/ml reduced the conjunctival concentration by a factor of 3.5 (p<0.003). CONCLUSION Application time up to 3 minutes, sponge make, and 5-FU concentration can have a large effect on the tissue delivery of 5-FU. Application time beyond 3 minutes, using 3.5x2 mm or 7x4 mm sponges, and replacing sponges every minute did not have a significant effect on tissue levels. This study models the effect that different variables can have on the ocular tissue levels of an antimetabolite applied intraoperatively.
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Affiliation(s)
- M R Wilkins
- Wound Healing Research Unit, Department of Pathology, Institute of Ophthalmology, London
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37
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Donoso R, Rodríguez A. Combined versus sequential phacotrabeculectomy with intraoperative 5-fluorouracil. J Cataract Refract Surg 2000; 26:71-4. [PMID: 10646149 DOI: 10.1016/s0886-3350(99)00334-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine and compare the intraocular pressure (IOP) lowering effects of single-incision combined phacoemulsification and trabeculectomy with phacoemulsification done after previous trabeculectomy, both with an intraoperative dose of 5-fluorouracil (5-FU). SETTING Hospital Del Salvador Ophthalmology Service, Clínica Oftalmológica Pasteur, Santiago, Chile. METHODS The effects on IOP after phacoemulsification in eyes with previous trabeculectomy using intraoperative 5-fluorouracil (5-FU) (Group 1, n = 18) were compared with those in a matched group of eyes having combined phacoemulsification and trabeculectomy, also with intraoperative 5-FU (Group 2, n = 22). The mean postoperative IOPs and survival curves for IOP values less than 20 mm Hg and 15 mm Hg or less were determined in both groups. Data were retrospectively collected. Comparisons were made with the paired Student t test, and survival curves were compared using log-rank analysis. RESULTS Mean postoperative IOP without medications was 12.6 mm Hg in Group 1 and 12.2 mm Hg in Group 2 (P = .64). Group 2 had a significant postoperative decrease in IOP (P = .0575); Group 1 did not have a significant increase or decrease. There was no significant difference in the survival curves between groups using arbitrarily defined failure criteria: (1) IOP greater than 15 mm Hg or (2) IOP equal to or greater than 20 mm Hg, both without medication (log-rank analysis, P = .333 and P = 1.00, respectively). CONCLUSION Combined cataract and glaucoma surgery with intraoperative 5-FU was associated with good long-term IOP control similar to that after phacoemulsification with intraoperative 5-FU in eyes with previous trabeculectomy.
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Affiliation(s)
- R Donoso
- University of Chile, Santiago, Chile
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Stavrou P, Murray PI. Long-term follow-up of trabeculectomy without antimetabolites in patients with uveitis. Am J Ophthalmol 1999; 128:434-9. [PMID: 10577584 DOI: 10.1016/s0002-9394(99)00185-3] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the long-term success rate after trabeculectomy without antimetabolites in patients with uveitis. METHODS Review of data from all patients with uveitis who underwent trabeculectomy for uncontrolled intraocular pressure secondary to intraocular inflammation between May 1990 and December 1994. Results were compared with those from a group of patients with primary open-angle glaucoma matched for sex and surgeon. RESULTS The uveitis group consisted of 32 eyes (20 patients). Maximum control of intraocular inflammation was achieved for a minimum of 2 months before surgery. Mean (+/-SD) age was 40.0 +/- 12.5 years (range, 14 to 67 years), with a median (+/-SE) follow-up of 53.0 +/- 1.8 months (range, 33 to 84 months). The primary open-angle glaucoma group consisted of 33 eyes (23 patients), with a mean age of 62.0 +/- 13.7 years (range, 26 to 81 years) and a median follow-up of 63.0 +/- 12.0 months (range, 34 to 299 months). The overall 5-year success rate (intraocular pressure < or =21 mm Hg with or without topical medication) for the uveitis group was 78% compared with 82% for the primary open-angle glaucoma group (P = .7). The absolute 5-year success rate (intraocular pressure < or =21 mm Hg with no medication) for the uveitis group was 53% compared with 67% for the primary open-angle glaucoma group (P = .87). CONCLUSIONS In the absence of other risk factors, such as Afro-Caribbean race and previous intraocular surgery, and with adequate preoperative control of inflammation, trabeculectomy without antimetabolites may be considered the primary surgical procedure for increased intraocular pressure in patients with uveitis.
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Affiliation(s)
- P Stavrou
- Birmingham and Midland Eye Centre, United Kingdom
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Mietz H, Raschka B, Krieglstein GK. Risk factors for failures of trabeculectomies performed without antimetabolites. Br J Ophthalmol 1999; 83:814-21. [PMID: 10381669 PMCID: PMC1723106 DOI: 10.1136/bjo.83.7.814] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To assess the risk profile for the failure of trabeculectomies in a large group of patients who were selected to be operated on without the use of antimetabolites. This was done in an effort to find subgroups of patients who may not need antimetabolites for primary procedures. METHODS Consecutive patients scheduled for routine trabeculectomies were operated during a 4 year period and were followed up for at least 6 months postoperatively. Patients were regularly examined in the glaucoma unit and by their local ophthalmologists. Pre- and postoperative data were evaluated and success rates determined. RESULTS 709 eyes of 566 patients were operated on; 534 eyes of 534 patients (94.4%) were finally evaluated. The mean follow up was 27.9 (SD 13.6) months with a range of 6-62 months. Success rates for complete surgical success ranged from 59% in the best group with pigmentary dispersion syndrome to 0% in the worst group with neovascular glaucoma. Success rates of patients with POAG, pseudoexfoliation, chronic angle closure, pigmentary dispersion syndrome, and dysgenetic glaucoma were similar. Failure rates ranged from 11% in the best group (pseudoexfoliation) to 80% in the worst group (neovascular glaucoma). Failure rates were high in complicated forms of glaucoma such as traumatic (30%), buphthalmus (40%), and uveitic (50%). For repeat trabeculectomies, the failure rate was 49% (20 of 41 eyes). The mean time until failure ranged from 2.7 months (traumatic) to 15.5 months (pigmentary dispersion syndrome) and was 4.9 months for repeat trabeculectomies. CONCLUSION Trabeculectomy performed in selected groups of patients has a favourable outcome without the use of antimetabolites. It may be possible to avoid antimetabolites in these groups of patients for primary procedures.
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Affiliation(s)
- H Mietz
- Department of Ophthalmology, University of Cologne, Cologne, Germany
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Mandal AK, Prasad K, Naduvilath TJ. Surgical Results and Complications of Mitomycin C-Augmented Trabeculectomy in Refractory Developmental Glaucoma. Ophthalmic Surg Lasers Imaging Retina 1999. [DOI: 10.3928/1542-8877-19990601-11] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wong JS, Yip L, Tan C, Chew P. Trabeculectomy survival with and without intra-operative 5-fluorouracil application in an Asian population. AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY 1998; 26:283-8. [PMID: 9843255 DOI: 10.1111/j.1442-9071.1998.tb01331.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To define and compare the trabeculectomy survival with regard to intra-ocular pressure (IOP) control without further surgery or anti-glaucoma medication n an Asian population. METHODS A retrospective review of two consecutive groups of patients who had trabeculectomy surgery in a university eye department setting. The first group of patients (group A) did not receive any adjunctive 5-fluorouracil (5-FU), while the second group (group B) had intra-operative sponge application of 5-FU. Only the first trabeculectomy of patients who had bilateral trabeculectomy and the first trabeculectomy performed in patients who had repeated surgery was analysed. Combined procedures were excluded. Survival analysis was performed using the Kaplan-Meier product limit method. RESULTS Eighty-nine patients (51 in group A and 38 in group B) were studied, with a mean follow up of 37.5 and 27.0 months, respectively (P = 0.014). There were no statistical differences in age, gender, mean pretreatment IOP, pre-operative medication, proportion of patients with previous ocular surgery, or proportion of primary compared with secondary glaucoma between the two groups. The probability of trabeculectomy survival (IOP < 22 mmHg without additional medication/surgery) at 12 and 36 months was 54.3 and 36.4%, respectively, in group A and 75.8 and 65.8%, respectively, in group B. The differences in survival were significant (P = 0.006, log rank test). CONCLUSIONS Our experience with trabeculectomy survival in the Asian population showed poorer success when compared with Caucasian populations reported by other investigators. The survival of trabeculectomy surgery was improved significantly with intra-operative 5-FU. There may be justification for advocating a more liberal use of intra-operative 5-FU in such a population.
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Affiliation(s)
- J S Wong
- Department of Ophthalmology, National University Hospital Singapore and Singapore National Eye Centre, Singapore
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Watts P, Karia N, McAllister J. Is the single use of intraoperative 5-fluorouracil in filtering surgery for high-risk cases enough? Eye (Lond) 1998; 12 ( Pt 3a):374-8. [PMID: 9775234 DOI: 10.1038/eye.1998.89] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To study the efficacy of the adjunctive use of a single intraoperative application of 5-fluorouracil (5FU) in eyes with poor prognoses for a successful outcome with a trabeculectomy. METHOD Twenty-four patients (25 eyes) with a mean age of 63.7 +/- 14.7 years (range 27-86 years) and a history of one or more risk factors (age < 50 years, more than 3 years on topical medication, a previous failed filter, previous cataract surgery, uveitis, neovascular glaucoma) underwent trabeculectomy with the intraoperative application of 5FU on a sponge (25 mg/ml) for 5 min. The average follow-up was 10.1 +/- 5.5 months. RESULTS The mean pre-operative intraocular pressure (IOP) was 24.7 +/- 6.2 mmHg and the mean post-operative IOP was 13.9 +/- 3.5 mmHg. Success, defined as an IOP within desired target levels for a particular eye, in the presence of a functioning filter, without supplementary medical therapy, was achieved in 56.5% of cases. CONCLUSIONS Our results of successful filters in this group of patients with moderate- to high-risk characteristics approach similar figures quoted for trabeculectomies without the adjunctive use of intraoperative 5FU in eyes with poor prognoses with a similar length of follow-up. Though the numbers are small there is a trend that indicates that the intraoperative application of a single dose of 5FU alone may not be sufficient in eyes with moderate- to high-risk characteristics of failure of a trabeculectomy.
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Affiliation(s)
- P Watts
- Prince Charles Eye Unit, King Edward VII Hospital, Windsor, UK
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Sidoti PA, Choi JC, Morinelli EN, Lee PP, Baerveldt G, Minckler DS, Heuer DK. Trabeculectomy With Intraoperative 5-Fluorouracil. Ophthalmic Surg Lasers Imaging Retina 1998. [DOI: 10.3928/1542-8877-19980701-05] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chang MR, Cheng Q, Lee DA. Basic science and clinical aspects of wound healing in glaucoma filtering surgery. J Ocul Pharmacol Ther 1998; 14:75-95. [PMID: 9493785 DOI: 10.1089/jop.1998.14.75] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Success of glaucoma filtration surgery is influenced by the wound healing response. Attention has been focused on pharmacological agents to control a process that leads to excessive scarring and eventual failure of glaucoma filtration surgery. Several agents, including 5-fluorouracil and mitomycin C, as well as other antiproliferative drugs will be discussed. Newer antifibrotic agents and novel drug delivery systems are under development in tissue culture and animal models in an effort to improve efficacy and safety. This article summarizes current treatment modalities and future prospects to prevent excessive wound healing and improve the success of glaucoma filtration surgery.
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Affiliation(s)
- M R Chang
- Jules Stein Eye Institute, Department of Opthalmology, UCLA School of Medicine, Los Angeles, California 90095-7004, USA
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Pappas RM, Higginbotham EJ, Choe HS. Advances in Laser Sclerostomy: How Far Have We Come? Ophthalmic Surg Lasers Imaging Retina 1997. [DOI: 10.3928/1542-8877-19970901-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lachkar Y, Leyland M, Bloom P, Migdal C. Trabeculectomy with intraoperative sponge 5-fluorouracil in Afro-Caribbeans. Br J Ophthalmol 1997; 81:555-8. [PMID: 9290368 PMCID: PMC1722259 DOI: 10.1136/bjo.81.7.555] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM To study the efficacy and safety of intraoperative 5-fluorouracil (5-FU) in Afro-Caribbean patients. METHODS The results of trabeculectomy in 18 eyes of 18 Afro-Caribbean patients in whom a sponge soaked in 25 mg/ml solution of 5-FU was applied between Tenon's capsule and sclera for 5 minutes before excision of the trabecula were compared with 16 eyes of 16 Afro-Caribbean patients matched for age, quantity, and duration of preoperative medications, who underwent trabeculectomy without 5-FU. RESULTS The mean postoperative intraocular pressure (IOP) at 1 month was 15.6 (SD 6.1) mm Hg in the 5-FU group and 18.0 (5.2) mm Hg in the control group (p = 0.15). There was no significant difference in the IOP at 6, 12, 15, 18, and 24 months in the two groups. Success rate at 18 months defined as an IOP less than or equal to 21 mm Hg with no adjunctive medication was 56% in the 5-FU group and 55% in the control group. No major complications were noted in either group. CONCLUSION Intraoperative sponge 5-FU alone is safe but does not appear to decrease the risk of failure of trabeculectomy in Afro-Caribbeans.
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Mora JS, Sprunger DT, Helveston EM, Evan AP. Intraoperative sponge 5-fluorouracil to reduce postoperative scarring in strabismus surgery. J AAPOS 1997; 1:92-7. [PMID: 10875084 DOI: 10.1016/s1091-8531(97)90005-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION To determine whether 5-fluorouracil is effective in reducing scarring after strabismus surgery we used rectus muscle surgery in experimental animals to compare a single intraoperative dose of 5-fluorouracil with mitomycin C and to compare results in similarly treated controls not receiving these antimetabolites. METHODS Muscle resections were performed on eight rabbits (16 eyes). Four eyes had 5-fluorouracil (50 mg/ml), and four eyes received mitomycin C (0.2 mg/ml), each of which was applied during surgery on an ophthalmic sponge for 5 minutes. Eight eyes served as controls. Six weeks after surgery conjunctival vascularity, muscle length-tension curves, muscle disinsertion force, and the histologic degree of scarring were assessed. RESULTS The mitomycin C-treated eyes clearly had more conjunctival avascularity and a lower disinsertion force. Both treated groups had flatter length-tension curves and less scarring on histologic examination than the control eyes. CONCLUSIONS Antifibroproliferative therapy with intraoperative sponge 5-fluorouracil appears as effective as, and is possibly safer than, mitomycin C. It may be a useful adjunct in recurrent strabismus surgery or in other situations where a risk of excessive postoperative scarring exists.
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Affiliation(s)
- J S Mora
- Department of Ophthalmology, Indiana University, Indianapolis 46202-5175, USA
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Singh K, Egbert PR, Byrd S, Budenz DL, Williams AS, Decker JH, Dadzie P. Trabeculectomy with intraoperative 5-fluorouracil vs mitomycin C. Am J Ophthalmol 1997; 123:48-53. [PMID: 9186096 DOI: 10.1016/s0002-9394(14)70991-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare the effectiveness of intraoperative 5-fluorouracil (5-FU) and mitomycin C used adjunctively with trabeculectomy in a black West African population. METHODS Eighty-five consecutive eyes of 85 black patients undergoing primary trabeculectomy for open-angle glaucoma were prospectively randomly assigned to receive either 5-FU (50 mg/ml for 5 minutes) or mitomycin C (0.5 mg/ml for 3 1/2 minutes) intraoperatively by soaked sponge. RESULTS Of the 81 eyes with at least a 3-month postoperative follow-up, 41 of 44 (93.2%) in the mitomycin C group and 27 of 37 (73.0%) in the 5-FU group had a final intraocular pressure of less than 21 mm Hg (P = .01). Twenty-eight of 44 eyes (63.6%) in the mitomycin C group and 18 of 37 (51.4%) in the 5-FU group had a final intraocular pressure of less than 15 mm Hg (P = .26). Mean postoperative intraocular pressure was 13.7 mm Hg in the mitomycin C group and 16.3 mm Hg in the 5-FU group (P = .05). There were no differences between the two groups in mean age, preoperative intraocular pressure, postoperative visual acuity, and complications. Mean follow-up was 10.0 +/- 4.41 months (range, 4 to 19 months). CONCLUSIONS The adjunctive use of mitomycin C with trabeculectomy is equally safe and more efficacious compared to 5-FU in this West African population. Use of mitomycin C in this study was not associated with a statistically significantly greater proportion of patients achieving low intraocular pressure (less than 15 mm Hg) compared to 5-FU.
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Affiliation(s)
- K Singh
- Department of Ophthalmology, Stanford University Medical Center, CA 94305-5308, USA.
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Iwach AG, Hoskins HD, Mora JS, Dickens CJ, Drake MV, Gaffney MM, Nguyen N, Wong PC, Tran H, Ma AS. Update on the Subconjunctival THC:YAG (Holmium) Laser Sclerostomy Ab Externo Clinical Trial: A 4-Year Report. Ophthalmic Surg Lasers Imaging Retina 1996. [DOI: 10.3928/1542-8877-19961001-03] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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