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De Francesco T, Armstrong JJ, Hussein IM, Costa VP, Ahmed IIK. Mitomycin C 0.2 mg/ml vs. Mitomycin C 0.4mg/ml during the implantation of an ab externo SIBS microshunt: A mega-analysis. Ophthalmol Glaucoma 2024:S2589-4196(24)00085-1. [PMID: 38851392 DOI: 10.1016/j.ogla.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/18/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024]
Abstract
PURPOSE To compare the effectiveness and adverse event profile of standalone SIBS microshunt implantation with adjunct MMC 0.2 mg/ml and MMC 0.4 mg/ml. DESIGN Mega-analysis using individual patient data from international prospective and retrospective clinical studies. STUDY POPULATION Patients with glaucoma who underwent implantation of a SIBS microshunt with MMC as a standalone procedure. METHODS A comparison of eyes that received MMC 0.2 mg/ml or 0.4 mg/ml MAIN OUTCOMES MEASURES: Primary outcome was complete success defined as the proportion of eyes at one year with all of the following: (1) no two consecutive IOPs > 17 mmHg; (2) no clinical hypotony (3) ≥20% IOP reduction from baseline and (4) no use of glaucoma medications. Secondary outcomes included IOP thresholds of 12 mmHg,14 mm Hg and 21mmHg, median IOP, number of medications, risk factors for failure, interventions, adverse events, and reoperations. RESULTS At 1 year, the complete success rate was significantly higher (71.3% vs 50.46%, p<0.001) and the median IOP significantly lower (13.0 vs. 14.2 mmHg, p<0.05) in the MMC 0.4 mg/ml group. MMC 0.2 mg/ml was found to be a significant risk factor for failure (HR 1.75 95%CI 1.14 to 2.67). Needling and surgical revision occurred at a lower rate in the MMC 0.4 mg/ml group (7% vs. 18.8%, p= 0.002 and 4.3% vs.13.7% p= 0.0087, respectively). Adverse events occurred at a similar frequency in both groups (26.6% MMC 0.2 mg/ml vs. 29.6% MMC 0.4 mg/ml, p=0.46), most of which were early and transient. CONCLUSION SIBS microshunt implantation with MMC 0.4 mg/ml resulted in a higher success rate with greater IOP reduction compared to MMC 0.2 mg/ml. Higher MMC concentration was not associated with increased serious adverse events.
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Affiliation(s)
- Ticiana De Francesco
- John A. Moran Eye Center, University of Utah, Salt Lake City, USA; University of Campinas, Campinas, Brazil; Clinica de Olhos De Francesco, Fortaleza, Brazil; Hospital de Olhos Leiria de Andrade, Fortaleza, Brazil.
| | - James J Armstrong
- Department of Ophthalmology, Schulich School of Medicine, Western University, London, Canada
| | - Isra M Hussein
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, Canada
| | | | - Iqbal Ike K Ahmed
- John A. Moran Eye Center, University of Utah, Salt Lake City, USA; Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Canada; Prism Eye Institute, Mississauga, Canada
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Schlenker MB, Armstrong JJ, De Francesco T, Ahmed IIK. All Consecutive Ab Externo SIBS Microshunt Implantations With Mitomycin C: One-Year Outcomes and Risk Factors for Failure. Am J Ophthalmol 2023; 255:125-140. [PMID: 37352909 DOI: 10.1016/j.ajo.2023.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/28/2023] [Accepted: 06/07/2023] [Indexed: 06/25/2023]
Abstract
PURPOSE To present the effectiveness, risk factors for surgical failure, and adverse events over 12 months in a consecutive diverse cohort of glaucoma patients who underwent solo or combined ab externo SIBS microshunt with mitomycin C (MMC) with or without previous subconjunctival surgery. DESIGN Retrospective, consecutive, interventional case series. METHODS Consecutive glaucomatous eyes on maximally tolerated medical therapy received ab externo SIBS microshunt with MMC implantation as a solo or combined procedure with phacoemulsification from July 2015 to January 2020. The primary outcome was the proportion of eyes at 12-months with the following: (1) no 2 consecutive intraocular pressures (IOPs) >17 mm Hg or clinical hypotony, without (complete success) or with (qualified success) glaucoma medications; and (2) ≥20% reduction from baseline IOP. Secondary outcomes included upper IOP thresholds of 14 and 21 mm Hg with and without a 20% IOP reduction from baseline, median IOP, medications, risk factors for failure, postoperative interventions, complications, and reoperations. RESULTS A total of 436 eyes underwent surgery; 86 (20%) combined with phacoemulsification, 127 (29%) in eyes with refractory glaucoma, and 234 (51%) stand-alone procedures in non-refractory eyes. Complete success (6-17 mm Hg with no medications) was achieved in 64.0% of combined eyes, 58.1% of refractory eyes, and 74.8% of stand-alone non-refractory eyes; and qualified success rates (6-17 mm Hg with medications) were 90.7%, 84.7%, and 92.4% of eyes, respectively. At 12 months, 67% of eyes were medication free. Significant risk factors for failure included combined procedures in refractory eyes (hazard ratio [HR] = 3.2; 95% CI = 1.4-7.4), receiving <0.4 mg/mL of MMC (HR = 2.2; 95% CI = 1.6-3.1), refractory eyes (HR = 1.7; 95% CI = 1.2-2.5), combined procedures (HR = 1.6; 95% CI = 1.0-2.5), and each additional baseline medication class (HR = 1.3; 95% CI = 1.1-1.5). Postoperative complications occurred in 31% of eyes, and more often in those receiving ≥0.4 mg/mL MMC (odds ratio [OR] = 2.2, 95% CI 1.2-3.8). Needling occurred in 12% of eyes, with significantly higher frequency in refractory eyes (23%) and combined procedures (13%) compared to stand-alone (7%; P < .001). Revisions and reoperations occurred in 4% and 1.4% of eyes, respectively. CONCLUSIONS The 1-year follow-up data from this large and diverse cohort support promising rates of qualified and complete surgical success with decreased medication burden and few postoperative complications and interventions. Combined phacoemulsification, refractory glaucoma, and receiving <0.4mg/mL MMC were associated with reduced surgical success rates.
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Affiliation(s)
- Matthew B Schlenker
- From the Department of Ophthalmology and Vision Sciences (M.B.S., J.J.A.,I.I.K.A.), University of Toronto, Toronto, Ontario, Canada; Prism Eye Institute (M.B.S., J.J.A., I.I.K.A.), Mississauga, Ontario, Canada; John A. Moran Eye Center (M.B.S., T.D.F., I.I.K.A.), University of Utah, Salt Lake City, Utah, USA.
| | - James J Armstrong
- From the Department of Ophthalmology and Vision Sciences (M.B.S., J.J.A.,I.I.K.A.), University of Toronto, Toronto, Ontario, Canada; Prism Eye Institute (M.B.S., J.J.A., I.I.K.A.), Mississauga, Ontario, Canada
| | - Ticiana De Francesco
- John A. Moran Eye Center (M.B.S., T.D.F., I.I.K.A.), University of Utah, Salt Lake City, Utah, USA; Hospital de Olhos Leiria de Andrade (T.D.F.), Fortaleza, Ceará, Brazil
| | - Iqbal Ike K Ahmed
- From the Department of Ophthalmology and Vision Sciences (M.B.S., J.J.A.,I.I.K.A.), University of Toronto, Toronto, Ontario, Canada; Prism Eye Institute (M.B.S., J.J.A., I.I.K.A.), Mississauga, Ontario, Canada; John A. Moran Eye Center (M.B.S., T.D.F., I.I.K.A.), University of Utah, Salt Lake City, Utah, USA
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Liao Y, Liu Y, Gao X, Ren J, Lin H, Liu Y, Huang W, Zuo C, Lin M. Noncontact Conjunctiva: A Better Mitomycin C Application Site for Trabeculectomy. Ophthalmol Ther 2023; 12:1723-1735. [PMID: 37027100 PMCID: PMC10164217 DOI: 10.1007/s40123-023-00706-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/21/2023] [Indexed: 04/08/2023] Open
Abstract
INTRODUCTION Bleb scarring is the most important complication of trabeculectomy. Changing the application position of mitomycin C (MMC) during trabeculectomy might affect the surgery outcome. Our aim is to compare the effectiveness and safety of intraocular pressure (IOP) lowering in two different application sites of mitomycin in trabeculectomy. METHODS This retrospective trial compared the surgical outcomes of 177 eyes that underwent trabeculectomy with adjunctive mitomycin C. In 70 eyes, an MMC-soaked sponge was applied under the scleral flap without touching Tenon's capsule. In 107 eyes, an MMC-soaked sponge was applied under the scleral flap covered by Tenon's capsule. Outcome measures were the IOP, best-corrected visual acuity (BCVA), success rates, and incidence of complications. RESULTS Within both groups, a highly significant IOP reduction was seen during follow-up. The effectiveness in reducing IOP and the change in best-corrected visual acuity (BCVA) were similar between the two groups. Thin-walled blebs and postoperative hypotony were seen more often when MMC-soaked sponges were applied under the scleral flap covered by Tenon's capsule (P = 0.008 and P = 0.012, respectively). There was no significant difference in BCVA or other complications in either group. CONCLUSION Since the effectiveness of IOP reduction was similar between both groups and with a low incidence of thin-walled blebs and hypotony, the subscleral application without touching Tenon's capsule seems to be the safer application site of MMC during trabeculectomy.
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Affiliation(s)
- Yunru Liao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China
- Department of Ophthalmology, Sun Yat-sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yafen Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China
| | - Xinbo Gao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China
| | - Jiawei Ren
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China
| | - Huishan Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China
| | - Yao Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China
| | - Wei Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China
| | - Chengguo Zuo
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China.
| | - Mingkai Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, No.7 Jinsui Road, Tianhe District, Guangzhou, 510060, China.
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Systematic Preserflo MicroShunt Intraluminal Stenting for Hypotony Prevention in Highly Myopic Patients: A Comparative Study. J Clin Med 2023; 12:jcm12041677. [PMID: 36836212 PMCID: PMC9959075 DOI: 10.3390/jcm12041677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/12/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Transient hypotony is the most common early complication after Preserflo MicroShunt (PMS) implantation. High myopia is a risk factor for the development of postoperative hypotony-related complications; therefore, it is advisable that PMS implantation in patients should be performed while employing hypotony preventive measures. The aim of this study is to compare the frequency of postoperative hypotony and hypotony-related complications in high-risk myopic patients after PMS implantation with and without intraluminal 10.0 nylon suture stenting. This is a retrospective, case-control, comparative study of 42 eyes with primary open-angle glaucoma (POAG) and severe myopia that underwent PMS implantation. A total of 21 eyes underwent a non-stented PMS implantation (nsPMS), while in the remaining eyes (21 eyes), PMS was implanted with an intraluminal suture (isPMS group). Hypotony occurred in six (28.57%) eyes in the nsPMS group and none in the isPMS group. Choroidal detachment occurred in three eyes in the nsPMS group; two of them were associated with the shallow anterior chamber and one was associated with macular folds. At 6 months after surgery, the mean IOP was 12.1 ± 3.16 mmHg and 13.43 ± 5.22 mmHg (p = 0.41) in the nsPMS and isPMS group, respectively. PMS intraluminal stenting is an effective measure to prevent early postoperative hypotony in POAG highly myopic patients.
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Zhang X, Song Y, Liebmann J, Weinreb RN. A Modified Technique in Applying Sponge Soaked with Mitomycin C in Trabeculectomy. Asia Pac J Ophthalmol (Phila) 2021; 10:548-552. [PMID: 34608066 PMCID: PMC8673849 DOI: 10.1097/apo.0000000000000438] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/24/2021] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Trabeculectomy with adjunctive use of Mitomycin C (MMC) has been a benchmark for glaucoma filtration surgery for decades. However, there are many variations in the ways that the sponges soaked with MMC are applied during the trabeculectomy surgery. We herein describe our way of placing the MMC-soaked sponges to improve the safety and efficacy of the trabeculectomy. The sponges are placed vertically and posteriorly with the long side of the sponge perpendicular to the limbus, not parallel. This will reduce the size of the conjunctival wound at the limbus to preserve more virgin conjunctiva that can be used for repeated trabeculectomy when needed. This will also facilitate a more posteriorly directed flow of aqueous drainage that, in turn, may increase the success rate of the trabeculectomy. We have obtained encouraging results in our practice, and further large-scale randomized studies seem warranted.
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Affiliation(s)
- Xiulan Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China
| | - Yunhe Song
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, China
| | - Jeffery Liebmann
- Bernard and Shirlee Brown Glaucoma Research Laboratory, Edward S. Harkness Eye Institute, Department of Ophthalmology, Columbia University Medical Center, New York, NY, USA
| | - Robert N. Weinreb
- Shiley Eye Institute, Hamilton Glaucoma Center and Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA, USA
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Mudhol R, Bansal R. Cross-linked hyaluronic acid viscoelastic scleral implant in trabeculectomy. Indian J Ophthalmol 2021; 69:1135-1141. [PMID: 33913846 PMCID: PMC8186654 DOI: 10.4103/ijo.ijo_2462_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: Patients with glaucoma undergoing trabeculectomy develop bleb cicatrix causing poor postoperative intraocular pressure (IOP) control and low success rates. Several approaches have been explored over the years for better outcomes. This study assesses the safety, efficacy, and outcome of trabeculectomy with HealaFlow® (Anteis S. A, Geneva, Switzerland), a high-molecular-weight cross-linked hyaluronic acid viscoelastic gel, and comparing it with the antimetabolite Mitomycin-C (MMC). Methods: A prospective, interventional, case-controlled study conducted at a tertiary care hospital in Southern India on 60 eyes of patients requiring trabeculectomy divided in two groups – HealaFlow scleral implant and adjuvant low-dose MMC (0.1 mg/mL). Postoperative IOP reduction along with bleb morphology was assessed over follow-up at 1 week, 1 month, 3 months, 6 months, and 12 months. Results: Preoperatively IOP in the two groups was statistically similar. Postoperative IOP on day 1 had statistically significant reduction in both groups with greater reduction in MMC group. However, by 12 months, the IOP reduction was statistically similar in both groups, i.e., 46.24% (to 11.04 ± 2.55 mmHg) and 54.47% (to 11.99 ± 3.37 mmHg) in HealaFlow® group and MMC group, respectively (P > 0.05). The bleb morphologies were similar and complications were seen equally, which resolved by 4 weeks. A complete success rate of 89.29% and a qualified success rate of 10.71% were observed equally in both groups. Conclusion: Absorbable biosynthetic cross-linked hyaluronic acid and low-dose MMC are equally safe and efficacious in trabeculectomy with significant IOP reduction and good bleb morphology. Therefore, it is a novel substitute for MMC.
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Affiliation(s)
- Rekha Mudhol
- Department of Ophthalmology, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
| | - Rolika Bansal
- Department of Ophthalmology, KLE Academy of Higher Education and Research, Belagavi, Karnataka, India
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Alagöz N, Taskoparan S, Altan AC, Solmaz B, Basgil Pasaoglu I, Basarır B, Cubuk MO, Yasar T. Pressure restoration and visual recovery time in hypotony after trabeculectomy. Int Ophthalmol 2021; 41:3183-3190. [PMID: 34009519 DOI: 10.1007/s10792-021-01883-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To asses the course of intraocular pressure (IOP) restoration and visual acuity (VA) recovery in eyes with hypotony after trabeculectomy. METHODS Medical charts of patients undergoing trabeculectomy between January 2017 and June 2019 were reviewed. Cases with hypotony (IOP < 5 mmHg) due to over-filtration in the early postoperative period were assessed retrospectively. Primary outcome measures included change in IOP and VA in the postoperative period and percentage of eyes with hypotony on each follow-up. RESULTS Thirty-five eyes of 31 patients (23 male, 8 female) were included. The mean follow-up was 18.3 ± 6.9 months. The mean IOP was 3.0 ± 3.2, 9.2 ± 6.2, 9.4 ± 5.6, 9.4 ± 4.0, 10.9 ± 3.6 and 10.2 ± 3.3 mmHg at week 1, months 1, 3, 6, 12 and last follow-up, respectively. Out of 35 hypotonic eyes, 8 (22.8%) had prolonged hypotony at month 1, 4 (11.4%) at month 3, 1 (2.9%) at month 6. The decrease in VA continued to be significant at months 1 and 3 (p = 0.015, p = 0.036, respectively) and returned to baseline after the sixth month (p > 0.524). CONCLUSIONS In eyes with early hypotony after trabeculectomy while low IOP recovers at first month, it takes longer for the visual restoration. The postoperative month 1 appears to be decisive for recovery of hypotony.
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Affiliation(s)
- Neşe Alagöz
- Beyoğlu Eye Training and Research Hospital, University of Health Sciences, Bereketzade Camii Sok., No 2 Beyoğlu, Istanbul, Turkey.
| | - Sariye Taskoparan
- Beyoğlu Eye Training and Research Hospital, University of Health Sciences, Bereketzade Camii Sok., No 2 Beyoğlu, Istanbul, Turkey
| | - Ayse Cigdem Altan
- Beyoğlu Eye Training and Research Hospital, University of Health Sciences, Bereketzade Camii Sok., No 2 Beyoğlu, Istanbul, Turkey
| | - Banu Solmaz
- Beyoğlu Eye Training and Research Hospital, University of Health Sciences, Bereketzade Camii Sok., No 2 Beyoğlu, Istanbul, Turkey
| | - Isıl Basgil Pasaoglu
- Beyoğlu Eye Training and Research Hospital, University of Health Sciences, Bereketzade Camii Sok., No 2 Beyoğlu, Istanbul, Turkey
| | - Berna Basarır
- Beyoğlu Eye Training and Research Hospital, University of Health Sciences, Bereketzade Camii Sok., No 2 Beyoğlu, Istanbul, Turkey
| | - Mehmet Ozgur Cubuk
- Beyoğlu Eye Training and Research Hospital, University of Health Sciences, Bereketzade Camii Sok., No 2 Beyoğlu, Istanbul, Turkey.,Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Tekin Yasar
- Beyoğlu Eye Training and Research Hospital, University of Health Sciences, Bereketzade Camii Sok., No 2 Beyoğlu, Istanbul, Turkey
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Comparison of the Efficacy and Safety of Trabeculectomy with Mitomycin C According to Concentration: A Prospective Randomized Clinical Trial. J Clin Med 2020; 10:jcm10010059. [PMID: 33375313 PMCID: PMC7796253 DOI: 10.3390/jcm10010059] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/14/2020] [Accepted: 12/23/2020] [Indexed: 12/02/2022] Open
Abstract
(1) Background: Mitomycin C (MMC) is commonly used during trabeculectomy. However, there is no consensus on which concentration should be used. We aimed to compare the efficacy and safety of 0.2 mg/mL and 0.4 mg/mL of MMC in eyes undergoing trabeculectomy. (2) Methods: Thirty-six eyes (36 glaucoma patients) were randomized to undergo a trabeculectomy with 0.2 mg/mL or 0.4 mg/mL of MMC. The success rate was evaluated according to three criteria: (A) intraocular pressure (IOP) ≤ 18 mmHg and IOP reduction ≥ 20%; (B) IOP ≤ 15 mmHg and IOP reduction ≥ 25%; (C) IOP ≤ 12 mmHg and IOP reduction ≥ 30%. Cox’s proportional hazard model was used to identify the predictive factors for failure. Immunohistochemical procedures for matrix metalloproteinase (MMP) were performed on Tenon’s tissue. Bleb morphology was evaluated. Safety was assessed based on the incidence of complications. (3) Results: Of the 36 eyes, 19 underwent trabeculectomy with 0.2 mg/mL of MMC and 17 with 0.4 mg/mL. The success rates were 75%, 67%, and 47% at 6 months for criteria A, B, and C, respectively. There were no significant differences between the two groups. High MMP-9 staining and low preoperative IOP were associated with failure (hazard ratio (HR), 5.556; p = 0.033, and HR, 0.936; p = 0.033). Complications included hypotony in two eyes (6%), hyphema in one eye (3%), and choroidal detachment in one eye (3%). (4) Conclusions: Trabeculectomy with 0.2 mg/mL and 0.4 mg/mL of MMC showed similar IOP-control effects to those recorded in previous studies, along with a low rate of complications. There was no significant difference in efficacy or safety between the 0.2 mg/mL and 0.4 mg/mL MMC groups.
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Shimokawa S, Nakao S, Murakami Y, Ikeda Y, Sonoda KH. Serous retinal detachment accompanied by pachychoroid in hypotony maculopathy after trabeculectomy for diabetic neovascular glaucoma. Am J Ophthalmol Case Rep 2020; 18:100682. [PMID: 32280809 PMCID: PMC7139135 DOI: 10.1016/j.ajoc.2020.100682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/28/2020] [Indexed: 11/16/2022] Open
Abstract
Purpose Two diabetic case reports of serous retinal detachment (SRD) accompanied by pachychoroid in hypotony maculopathy after trabeculectomy for neovascular glaucoma (NVG). Observations Case 1: A 66-year-old female with stage 3 NVG and decreased vision acuity in the left eye. After trabeculectomy, postoperative laser suture lysis (LSL) resulted in development of hypotony maculopathy, followed by pachychoroid and SRD. Injection of C3F8 gas in the anterior chamber was unsuccessful and transconjunctival scleral re-suturing was performed. Intraocular pressure (IOP) consequently increased and SRD improved. Case 2: A 60-year-old man with stage 2 NVG and decreased vision acuity in the right eye. Trabeculectomy was uneventful, but postoperative LSL also resulted in development of hypotony maculopathy followed by pachychroid and SRD. Intravitreal bevacizumab injection had no effect and transconjunctival flap re-suturing was performed. IOP consequently increased and SRD improved. Conclusions SRD accompanied by pachychoroid was observed in hypotony maculopathy in diabetic cases. VEGF-independent exudative change in hypotony maculopathy may be due to hydrostatic pressure elevation in choroidal blood vessels based on Starling's hypothesis with the consequent breakdown of retinal pigment epithelium barrier in diabetic patients.
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Affiliation(s)
- Sakurako Shimokawa
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shintaro Nakao
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yusuke Murakami
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Ikeda
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Ophthalmology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Koh-Hei Sonoda
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Bell K, de Padua Soares Bezerra B, Mofokeng M, Montesano G, Nongpiur ME, Marti MV, Lawlor M. Learning from the past: Mitomycin C use in trabeculectomy and its application in bleb-forming minimally invasive glaucoma surgery. Surv Ophthalmol 2020; 66:109-123. [PMID: 32450159 DOI: 10.1016/j.survophthal.2020.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/26/2022]
Abstract
Trabeculectomy has been performed since the mid-1960s and remains the gold standard for glaucoma surgery. Newer surgical options have evolved, collectively referred to as minimally invasive glaucoma surgeries. Despite producing large intraocular pressure decreases, full-thickness procedures into the subconjunctival space may be limited by fibrosis. Mitomycin C (MMC) and 5-fluorouracil have been in use with trabeculectomy with good evidence of significantly increased success at the cost, however, of an increased risk of complications. Off-label MMC application can be found in almost all clinical trials, including in combination with minimally invasive glaucoma surgeries. We explore current evidence for MMC use in trabeculectomy and how this may differ for minimally invasive glaucoma surgery devices and analyze the range of agents and doses that are used. Although we found that most studies could not show any correlation between MMC dosage and the surgical outcome, the success rates with the Xen® microshunt seemed to be higher when using 20 mcg of MMC than when using 10 mcg. Certain important methodological considerations make this hard to confirm definitively, and other factors such as placement of the device may play a more substantial role. For the PreserFlo® microshunt, preliminary data suggest higher success rates with higher MMC dosage at the cost of higher device-related adverse events and reoperations. Although the ideal dose still needs to be established, it seems very likely that MMC provides significant improvement in outcomes in bleb-forming minimally invasive glaucoma procedures.
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Affiliation(s)
- Katharina Bell
- Experimental and Translational Ophthalmology, Department of Ophthalmology, Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rhineland-Palatinate, Germany.
| | | | | | - Giovanni Montesano
- University of Milan - ASST Santi Paolo e Carlo, Milan, Italy; City, University of London - Optometry and Visual Sciences, London, United Kingdom; NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London, United Kingdom
| | | | | | - Mitchell Lawlor
- Save Sight Institute, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Sydney Eye Hospital, Macquarie St, Sydney, Australia
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Historical Considerations and Innovations in the Perioperative Use of Mitomycin C for Glaucoma Filtration Surgery and Bleb Revisions. J Glaucoma 2020; 29:226-235. [DOI: 10.1097/ijg.0000000000001438] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sharpe R, Pham G, Chang P. Comparison of Ab Interno XEN Gelatin Stent vs Trabeculectomy with Mitomycin C: A Retrospective Study. J Curr Glaucoma Pract 2020; 14:87-92. [PMID: 33867756 PMCID: PMC8028032 DOI: 10.5005/jp-journals-10078-1287] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim To compare outcomes of ab interno XEN gelatin stent (Allergan, Dublin, Ireland) implantation vs trabeculectomy with mitomycin C (MMC). Materials and methods A retrospective review was conducted of eyes that underwent standalone XEN implantation or trabeculectomy with MMC at a single institution from 2014 to 2019. Intraocular pressure (IOP), visual acuity, glaucoma medications, complications, and postoperative interventions were evaluated. The primary endpoint was the reduction in IOP at 6 months postoperatively. Secondary endpoints included the incidence of postoperative intervention and complications. Results One hundred and seventy-nine eyes were included who underwent XEN (n = 90) or trabeculectomy (n = 89). The mean age was 74.5 ± 7.6 and 68.1 ± 8.2 years old for the XEN and trab groups, respectively (p < 0.001). Baseline IOP for XEN was 17.8 ± 6.0 vs 20.4 ± 9.0 mm Hg for the trab group (p = 0.03). At 6 months, mean IOP for XEN group was 13.5 ± 5.9 mm Hg, representing a 24.1% IOP reduction from baseline (p < 0.001) while mean for trab group was 10.8 ± 4.8 representing a 47% IOP reduction from baseline (p < 0.001). The mean IOP was 2.7 mm Hg lower in trab compared to the XEN group at 6 months (p < 0.003). The number of medications was reduced in both groups from 2.9 ± 1.1 and 3.1 ± 0.9 to 1.1 ± 2.3 and 0.8 ± 1.4 by 6 months postoperatively for XEN and trab groups, respectively (p < 0.001). Complication rates were low for both groups. The needling rate was 30% in XEN vs 7.9% in the trab group (p < 0.001), and 46.1% of eyes in the trab group underwent laser suture lysis. Additionally, IOP reduction and complication rates were similar following XEN in eyes receiving <40 or ≥40 μg of MMC. Conclusion XEN implantation produces a substantial reduction in IOP with a favorable safety profile comparable to trabeculectomy. Careful postoperative bleb management is critical to obtain optimum outcomes, and higher MMC doses appear safe and may reduce needling rates. Clinical significance This study confirms the safety and efficacy of XEN gelatin stent implantation in comparison to trabeculectomy with MMC. How to cite this article Sharpe R, Pham G, Chang P. Comparison of Ab Interno XEN Gelatin Stent vs Trabeculectomy with Mitomycin C: A Retrospective Study. J Curr Glaucoma Pract 2020;14(3):87–92.
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Affiliation(s)
- Robert Sharpe
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA
| | - Gina Pham
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Chang
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas, USA
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Huang H, Bao WJ, Yamamoto T, Kawase K, Sawada A. Postoperative outcome of three different procedures for childhood glaucoma. Clin Ophthalmol 2018; 13:1-7. [PMID: 30587913 PMCID: PMC6301729 DOI: 10.2147/opth.s186929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the long-term postoperative outcome of three surgical procedures for childhood glaucoma. Patients and methods In this retrospective study, the patients were divided into a goniotomy group, a trabeculotomy group, and a filtering surgery group, based on the initial surgical procedure. Failure was defined as an IOP ≥21 mmHg with medication at two consecutive visits. A Kaplan–Meier analysis was applied to calculate the probability of success. Additional metrics included IOP, number of additional operations, eye drop scores, and visual acuity. Results We studied 40 eyes of 25 patients, 21 eyes of 15 patients, and 12 eyes of 7 patients in the goniotomy, trabeculotomy, and filtering surgery groups, respectively. The 10- and 20-year probability of success was 65.2% and 65.2%, 42.2% and NA (no data for 20 years), and 91.7% and 80.2% for the goniotomy, trabeculotomy, and filtering surgery groups, respectively. Conclusion All three procedures maintained an IOP of less than 21 mmHg for up to 10 years in 65.2%, 42.2%, and 91.7% of childhood glaucoma cases.
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Affiliation(s)
- Hailong Huang
- Department of Ophthalmology, Gifu University Graduate School of Medicine, Gifu, Japan,
| | - Wenjun J Bao
- Department of Ophthalmology, Gifu University Graduate School of Medicine, Gifu, Japan,
| | - Tetsuya Yamamoto
- Department of Ophthalmology, Gifu University Graduate School of Medicine, Gifu, Japan,
| | - Kazuhide Kawase
- Department of Ophthalmology, Gifu University Graduate School of Medicine, Gifu, Japan,
| | - Akira Sawada
- Department of Ophthalmology, Gifu University Graduate School of Medicine, Gifu, Japan,
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Martini E, Laffi GL, Sprovieri C, Scorolli L. Low-Dosage Mitomycin C as an Adjunct to Trabeculectomy. A Prospective Controlled Study. Eur J Ophthalmol 2018; 7:40-8. [PMID: 9101194 DOI: 10.1177/112067219700700108] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To assess the advantages and adverse effects of intraoperative low-dose Mitomycin C in filtering glaucoma surgery. METHODS Sixty eyes of 48 patients undergoing surgery for uncontrolled glaucoma were randomized to two groups: one underwent standard trabeculectomy, the other had trabeculectomy with intraoperative application of 0.1 mg/ml mitomycin C. Follow-up was at least one year. RESULTS The success rate (IOP < 18 mmHg) was 96.6% in the mitomycin C group and 73.3% in the control group. Mean IOP at one year of successful cases was 11.1 +/- 3.1 mmHg in the mitomycin C group and 16.4 +/- 6.1 mmHg in controls (p < 0.0001). Two patients in the mitomycin C group (6.6%) and six (20%) in the control group needed antiglaucomatous drugs to keep IOP below 18 mmHg. CONCLUSIONS Mitomycin C is a useful adjunct to glaucoma surgery. Adverse effects at the dosage used are mainly due to hypotony and are preventable with two-layer suture. Low-dose mitomycin C may be useful in standard primary trabeculectomy.
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Affiliation(s)
- E Martini
- Department of Physiopathologic Optics, University of Bologna, Italy
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Al Habash A, Aljasim LA, Owaidhah O, Edward DP. A review of the efficacy of mitomycin C in glaucoma filtration surgery. Clin Ophthalmol 2015; 9:1945-51. [PMID: 26527859 PMCID: PMC4621205 DOI: 10.2147/opth.s80111] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Ahmed Al Habash
- King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia ; Department of Ophthalmology, University of Dammam, Dammam, Saudi Arabia
| | - Leyla Ali Aljasim
- King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Ohoud Owaidhah
- King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Deepak P Edward
- King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia ; Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Thomas M, Vajaranant TS, Aref AA. Hypotony Maculopathy: Clinical Presentation and Therapeutic Methods. Ophthalmol Ther 2015; 4:79-88. [PMID: 26253854 PMCID: PMC4675727 DOI: 10.1007/s40123-015-0037-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Indexed: 11/26/2022] Open
Abstract
Introduction
Hypotony maculopathy is ocular hypotony complicated by papilledema and/or folding of the retina and choroid in the posterior pole. Our objective was to examine the current literature regarding hypotony maculopathy and treatment methods. Methods A systematic review of the English-language literature was conducted by performing a broad search of PubMed from 1972 through 2015 using the keywords hypotony maculopathy and hypotony. Additional articles were identified from bibliographies of relevant articles. Results Hypotony maculopathy was infrequent before the introduction of antimetabolite agents in glaucoma-filtering surgery, and the incidence of this entity is now up to 20%. Risk factors for developing hypotony maculopathy include male gender, young age, myopia, and primary filtering surgery. Correctly identifying the etiology of hypotony is essential for successful treatment. Treatment of hypotony maculopathy includes procedures to elevate the intraocular pressure, thus reversing the collapse of the scleral wall and chorioretinal wrinkling. Conclusion This review discusses the definition, clinical presentation, pathophysiology, incidence and risk factors, prevention and treatment of hypotony maculopathy.
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Affiliation(s)
- Merina Thomas
- University of Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois Hospital and Health System, Chicago, IL, USA
| | - Thasarat S Vajaranant
- University of Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois Hospital and Health System, Chicago, IL, USA
| | - Ahmad A Aref
- University of Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois Hospital and Health System, Chicago, IL, USA.
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Evaluating the long-term efficacy of short-duration 0.1 mg/ml and 0.2 mg/ml MMC in primary trabeculectomy for primary adult glaucoma. Graefes Arch Clin Exp Ophthalmol 2015; 253:1153-9. [PMID: 25940554 DOI: 10.1007/s00417-015-3028-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 03/20/2015] [Accepted: 04/20/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To evaluate safety and efficacy of 0.1 mg/ml versus 0.2 mg/ml mitomycin-C (MMC), applied for 1 min subconjunctivally, during trabeculectomy for primary adult glaucoma in previously un-operated eyes. MATERIALS AND METHODS This is a randomised controlled, non-inferior, clinical trial consisting of 50 consecutive POAG or CPACG patients uncontrolled on maximal hypotensive therapy, meeting all inclusion criteria. Patients were randomized into two groups and underwent a standard limbus-based trabeculectomy with MMC: Group I, 0.1 mg/ml and Group II, 0.2 mg/ml. The pre-operative and post-operative intraocular pressure (IOP), bleb morphology, and visual acuity were recorded every 6 months for 2 years. Complete success (primary outcome) was defined as IOP ≤ 15 mmHg without any additional medications at the end of 2 years. RESULTS The average age of patients was 62.6 ± 9.8 years and 61.2 ± 8.1 years in Group 1 and 2, respectively; p = 0.57. The mean preoperative IOP was 22.5 ± 1.4 mmHg and 23.3 ± 1.8 mmHg; p = 0.10. The mean IOP at 2 years was 11.1 ± 1.6 mmHg and 10.8 ± 2.8 mmHg, a mean reduction in IOP of 50.6 ± 1.23 %, and 53.7 ± 2.25 % in Group I and II, respectively. The complete success was 92.0 % and 91.7 % in the two groups, respectively (p = 0.99), and there was one failure (Group II, post trauma). A wider bleb extent and larger areas of thin, transparent conjunctiva over the bleb were seen with the 0.2 mg/ml MMC group (p < 0.001) and in PACG eyes; p < 0.04. CONCLUSION A 1-min subconjunctival application of low dose 0.1 mg/ml MMC is non-inferior to 0.2 mg/ml and is probably a safer alternative, as thinning of the bleb is significantly less frequent in the long term.
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Investigation of efficacy of mitomycin-C, sodium hyaluronate and human amniotic fluid in preventing epidural fibrosis and adhesion using a rat laminectomy model. Asian Spine J 2013; 7:253-9. [PMID: 24353840 PMCID: PMC3863649 DOI: 10.4184/asj.2013.7.4.253] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 09/22/2012] [Accepted: 09/24/2012] [Indexed: 12/15/2022] Open
Abstract
Study Design A retrospective study. Purpose The aim of this study was to evalute the effects of mitomycin-C, sodium hyaluronate and human amniotic fluid on preventing spinal epidural fibrosis. Overview of Literature The role of scar tissue in pain formation is not exactly known, but it is reported that scar tissue causes adhesions between anatomic structures. Intensive fibrotic tissue compresses on anatomic structures and increases the sensitivity of the nerve root for recurrent herniation and lateral spinal stenosis via limiting movements of the root. Also, neuronal atrophy and axonal degeneration occur under scar tissue. Methods The study design included 4 groups of rats: group 1 was the control group, groups 2, 3, and 4 receieved antifibrotic agents, mitomycin-C (group 2), sodium hyaluronate (group 3), and human amniotic fluid (group 4). Midline incision for all animals were done on L5 for total laminectomy. Four weeks after the surgery, the rats were sacrificed and specimens were stained with hematoxylin-eosin and photos of the slides were taken for quantitive assesment of the scar tissue. Results There was no significant scar tissue in the experimental animals of groups 2, 3, and 4. It was found that there was no significant difference between drug groups, but there was a statistically significant difference between the drug groups and the control group. Conclusions This experimental study shows that implantation of mitomycin-C, sodium hyaluronate and human amniotic fluid reduces epidural fibrosis and adhesions after spinal laminectomy in rat models. Further studies in humans are needed to determine the complications of the agents researched.
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Huang CY, Tseng HY, Wu KY. Mid-term outcome of trabeculectomy with adjunctive mitomycin C in glaucoma patients. Taiwan J Ophthalmol 2013. [DOI: 10.1016/j.tjo.2012.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Kudo T, Takeuchi K, Ebina YI, Nakazawa M. Inhibitory effects of trehalose on malignant melanoma cell growth: implications for a novel topical anticancer agent on the ocular surface. ISRN OPHTHALMOLOGY 2012; 2012:968493. [PMID: 24558596 PMCID: PMC3914279 DOI: 10.5402/2012/968493] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 10/18/2012] [Indexed: 12/02/2022]
Abstract
Purpose. To investigate the inhibitory effects of trehalose on malignant melanoma cell growth. Methods. We cultured human malignant melanoma cells in a medium containing trehalose (control/2.5%/5.0%/7.5%/10.0%) and used the MTT assay to evaluate the growth activities. Subsequently, trehalose was topically instilled on subconjunctivally inoculated melanoma cells in F334/NJcl-rmu/rmu rats, followed by a histopathological evaluation of tumor growth. Using flow cytometry, we compared the distribution of the cell cycle, rate of apoptotic cells, and intracellular factors related to the cell cycle in cultured melanoma cells after trehalose treatment. Results. The MTT study showed that proliferation of melanoma cells was significantly inhibited by ≧ 5% of trehalose concentrations in the culture media. Subconjunctivally inoculated melanoma cell masses were significantly smaller in eyes administered trehalose as compared to controls. Flow cytometry analyses demonstrated that the trehalose groups had increased rates of G2/M phase cells and apoptotic cells in the cell culture. These cells also exhibited increased expressions of cell-cycle inhibitory factors. Conclusions. The current results show trehalose inhibits malignant melanoma cell growth by inducing G2/M cell cycle arrest and apoptosis, suggesting trehalose as a potential candidate for a topical agent to inhibit proliferation of malignant tumor cells of the ocular surface.
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Affiliation(s)
- Takashi Kudo
- Department of Opthalmology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki 036-8562, Japan
| | - Kimio Takeuchi
- Department of Opthalmology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki 036-8562, Japan
| | - Yu-Ichi Ebina
- Department of Opthalmology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki 036-8562, Japan
| | - Mitsuru Nakazawa
- Department of Opthalmology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki 036-8562, Japan
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Jampel HD, Solus JF, Tracey PA, Gilbert DL, Loyd TL, Jefferys JL, Quigley HA. Outcomes and bleb-related complications of trabeculectomy. Ophthalmology 2012; 119:712-22. [PMID: 22244944 DOI: 10.1016/j.ophtha.2011.09.049] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 09/11/2011] [Accepted: 09/26/2011] [Indexed: 12/01/2022] Open
Abstract
PURPOSE To determine rates of success and complications of trabeculectomy surgery. DESIGN Case series. PARTICIPANTS Consecutive patients undergoing trabeculectomy by 2 surgeons between May 2000 and October 2008. INTERVENTION By using the Wilmer Institute's billing database, we identified all patients at least 12 years of age coded as having undergone trabeculectomy between May 2000 and October 2008 by 1 of 2 glaucoma surgeons and whose surgery was not combined with another operation. From the chart, we abstracted demographic information on the patients and clinical characteristics of the eyes. The Kaplan-Meier product-limit method and Cox proportional hazard models were used to look at success rates and characteristics associated with inadequate intraocular pressure (IOP) reduction. Complications were tabulated. MAIN OUTCOME MEASURES (1) Success rate of trabeculectomy, as determined by the achievement of each of 4 different IOP goals, with or without IOP-lowering medications; and (2) incidence of surgical complications. RESULTS During the study period, 797 eyes of 634 persons underwent trabeculectomy without concurrent surgery. The success rates 4 years after surgery, with or without the use of IOP-lowering eye drops, were 70%, 72%, 60%, and 44%, for achievement of target IOP, ≤18 mmHg and ≥20% IOP reduction, ≤15 mmHg and ≥25% reduction, and ≤12 mmHg and ≥30% reduction, respectively. Increased chance of success was associated with European-derived race; use of mitomycin C (MMC); higher concentrations of MMC, when used; and higher preoperative IOP. Age and previous intraocular surgery were not associated with surgical success. Complications included worsening lens opacity in 242 of 443 phakic eyes (55%), loss of ≥3 lines of acuity (Snellen) in 161 eyes (21%), surgery for bleb-related problems in 70 eyes (8.8%), and infection occurring >6 weeks after surgery in 27 eyes (3.4%). A total of 101 eyes of 94 patients had at least 1 subsequent operation for inadequate IOP control. CONCLUSIONS Trabeculectomy surgery performed by 2 experienced glaucoma specialists achieved target IOP at 4 years in 70% of those operated and was associated with progressive cataract and small risks of bleb-related complications. These results are comparable to those reported in smaller series.
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Affiliation(s)
- Henry D Jampel
- Glaucoma Service and Dana Center for Preventive Ophthalmology, Wilmer Ophthalmological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Lima VC, Prata TS, Castro DPE, Castro LC, De Moraes CGV, Mattox C, Rosen RB, Liebmann JM, Ritch R. Macular changes detected by Fourier-domain optical coherence tomography in patients with hypotony without clinical maculopathy. Acta Ophthalmol 2011; 89:e274-7. [PMID: 19906084 DOI: 10.1111/j.1755-3768.2009.01719.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate macular changes in eyes with postoperative hypotony without clinical maculopathy using high-resolution Fourier-domain optical coherence tomography (FD-OCT). METHODS Fourteen eyes of 12 patients with postoperative intraocular pressure (IOP) £ 6 mmHg for at least 4 weeks but with no detectable clinical features associated with hypotony maculopathy were imaged by FD-OCT prospectively. Images were analysed by two retina specialists masked to clinical findings. RESULTS Most patients were female (83%) and myopic (75%) with a mean age of 65 ± 17 [standard deviation (SD)] years (range 2–86 years). Mean central corneal thickness was 519 ± 34 lm [95% confidence interval (CI) 502–537] and mean IOP before surgery was 20 ± 8 mmHg (95% CI 15–24). During the period of hypotony (mean 15 ± 6 weeks), the average mean IOP was 4 ± 1 mmHg (95% CI 3–5). Abnormal FD-OCT findings (retinal folds and ⁄ or intraretinal fluid) were present in eight eyes. These patients had a higher rate of visual symptoms (75% versus 17%), visual acuity loss (‡ 2 lines; 63% versus 17%) and increased mean foveal thickness (250 ± 26 versus 210 ± 12 lm; p < 0.01, Mann–Whitney U-test) compared with those with normal FD-OCT. CONCLUSION FD-OCT identified subclinical macular abnormalities in over half of the eyes with postoperative hypotony. These findings were accompanied by visual disturbances and central macular thickening. FD-OCT can be an important diagnostic tool for this disorder when clinical features are absent.
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Affiliation(s)
- Verônica C Lima
- Retina Service, New York Eye and Ear Infirmary, New York, NY 10003, USA
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Choi YJ, Rhee DJ, Choi KR. Treatment Outcome of Phacotrabeculectomy and Trabeculectomy in Patients with Cataracts and Glaucoma. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2011. [DOI: 10.3341/jkos.2011.52.11.1308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Yun Jeong Choi
- Department of Ophthalmology, Institute of Ophthalmology and Optometry, Ewha Womans University Medical Center, Seoul, Korea
| | - Douglas J. Rhee
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Kyu-Ryong Choi
- Department of Ophthalmology, Institute of Ophthalmology and Optometry, Ewha Womans University Medical Center, Seoul, Korea
- Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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Takeuchi K, Nakazawa M, Ebina Y, Sato K, Metoki T, Miyagawa Y, Ito T. Inhibitory effects of trehalose on fibroblast proliferation and implications for ocular surgery. Exp Eye Res 2010; 91:567-77. [PMID: 20650271 DOI: 10.1016/j.exer.2010.07.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 06/04/2010] [Accepted: 07/05/2010] [Indexed: 02/06/2023]
Abstract
Trehalose is a disaccharide which plays an important role in preserving cells from completely dehydrated circumstances. In this study, we investigated effects of trehalose on proliferative activity of fibroblasts and epithelial cells both in vitro and in vivo. As in vitro assessment, normal human dermal fibroblasts and normal human epidermal keratinocytes were cultured in media containing various concentrations of trehalose. Growth activities of cells were evaluated with MTT assay and diff-quick™ staining. Expressions of vimentin and α smooth muscle actin (α-SMA) changed by trehalose were semiquantitatively measured by Western blot. As an in vivo study, 5% or 10% trehalose was topically instilled onto rabbit eyes after simple conjunctival incision or trabeculectomy. Condition of the surgical wound was evaluated by morphologically and immunohistochemically using isolectin B4 and antibodies specific for vimentin and α-SMA. Intraocular pressures (IOPs) after trabeculectomy were compared between eyes treated with trehalose and 0.04% mitomycin C (MMC). Results obtained by in vitro experiments showed that growth activities of cultured fibroblasts and keratinocytes were inhibited by trehalose in a dose-dependent manner. Fibroblasts were strongly inhibited by trehalose concentrations ≧ 5% of trehalose, whereas keratinocytes were less inhibited compared to fibroblasts. Expressions of vimentin and α-SMA were reduced by trehalose. With in vivo experiments, postoperative application of trehalose resulted in less firm adhesion between conjunctiva and sclera compared to controls. Immunohistochemical studies showed reduced staining of isolectin B4, vimentin and α-SMA in conjunctival wounds treated by topical trehalose. Also, after trabeculectomy, IOP remained in a low range during instillation of topical trehalose solution. We concluded that trehalose has inhibitory effects on proliferation of fibroblasts and vascular tissues, partially due to inhibition of transformation of fibroblasts into myofibroblasts in wound tissues. The present results imply that trehalose can be a potential agent for preventing postoperative fibrous scar formation after ocular surgery such as glaucoma filtration surgery.
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Affiliation(s)
- Kimio Takeuchi
- Department of Ophthalmology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
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Su C, Yao C, Lu S, Zhang A, Cao X, Teng G, Zang F. Study on the optimal concentration of topical mitomycin-C in preventing postlaminectomy epidural adhesion. Eur J Pharmacol 2010; 640:63-7. [PMID: 20450905 DOI: 10.1016/j.ejphar.2010.04.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 04/01/2010] [Accepted: 04/23/2010] [Indexed: 11/18/2022]
Abstract
There is increasing evidence that topical application of mitomycin-C can be beneficial in reducing epidural scar adhesion. However, the ideal concentration of mitomycin-C is unknown. The purpose of this study was to verify its efficacy for preventing epidural adhesion and the immediate electrophysiological responses caused by it in a laminectomy model. Seventy rats underwent laminectomy at L-1 and L-2. Cotton pads soaked with saline and various concentrations of mitomycin-C (0.1 mg/ml, 0.3 mg/ml, 0.5 mg/ml and 0.7 mg/ml) were applied to the exposed dura for 5 min. Spine somatosensory evoked potentials (SSEP) were monitored in preoperative and the immediate electrophysiological responses of mitomycin-C used. Four weeks postlaminectomy the rats were killed. The area of epidural scar tissue and degree of epidural adhesion were determined by 7.0 T Micro MR imaging. Macroscopic evaluations were performed according to the Rydell standard. The results showed that severe epidural adhesion was formed in the saline group and no dural adherence or incomplete adhesions were found in the mitomycin-C group. The Rydell classification and the degree of epidural adhesion and the area of the scar in 0.5 mg/ml group and 0.7 mg/ml mitomycin-C group revealed a significant decrease compared with the control group and 0.1 mg/ml group and 0.3 mg/ml mitomycin-C group. The spine sensory evoked potentials did not alter obviously in both preoperative and the immediate electrophysiological responses of mitomycin-C used. In conclusion, locally applied mitomycin-C in a concentration of 0.5 mg/ml and 0.7 mg/ml mitomycin-C may be the optimal concentration in preventing postlaminectomy epidural adhesion.
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Affiliation(s)
- Changhui Su
- Department of Orthopedics Surgery, the First Affiliated Hospital of Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, Jiangsu Province, China
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Mizoguchi T, Kuroda S, Terauchi H, Nagata M. Trabeculotomy combined with phacoemulsification and implantation of intraocular lens for primary open-angle glaucoma. Semin Ophthalmol 2009; 16:162-7. [PMID: 15513436 DOI: 10.1076/soph.16.3.162.4195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Retrospective study examined the surgical effects of lowering intraocular pressure of trabeculotomy combined with phacoemulsification and implantation of an intraocular lens. Included in the retrospective study were 96 eyes of 64 patients with primary open-angle glaucoma. Preoperative mean IOP was 25.6 mmHg. At final examination, the IOP was well-controlled at 21 mmHg or lower without medications in 32 of 96 eyes. In another 62 eyes, the IOP was well-controlled with antiglaucoma medications. The postoperative IOPs were in the high teens after surgery. The life table analysis using Kaplan-Meier methods showed that the success probability after phacoemulsification and implantation of intraocular lens, combined with trabeculotomy (PIT)-I and PIT-II, were 93.9% and 82.6% at 4 years, respectively. Postoperative visual acuity improved by more than two lines in 79 of the 96 eyes. In no case was the visual acuity decreased by more than two lines. Deterioration of the visual field was found in 4 eyes. There were no complications such as shallow anterior chamber, choroidal detachment, malignant glaucoma, hypotonic maculopathy, and endophthalmitis. This triple procedure should be performed in the early stages of glaucoma. Trabeculotomy is thought to relieve the resistance to aqueous outflow by mechanical cleavage of the trabecular meshwork and the inner layer of Schlemm's canal. This technique leads to aqueous outflow the from the opening of the internal trabecular meshwork to the collector channel. For this reason trabeculotomy was developed by a number of surgeons. Recently, however, trabeculotomy has not been selected for those patients with advanced stages of primary open-angle glaucoma because of the disadvantages such as transient intraocular pressure (IOP) elevation several days after surgery and somewhat higher levels (18 mmHg) of postoperative intraocular pressure (Fig. 1). To avoid the IOP spike (transient IOP elevation) after trabeculotomy, we reported previously that the new technique of trabeculotomy combined with outer sclerectomy was a useful surgical option. The results of our previous study indicated that the postoprative intraocular pressure levels after combined trabeculotomy and outer sclerectomy were significantly lower than that of trabeculotomy alone. On the other hand, trabeculotomy with mitomycin C is currently the standard filtration procedure for glaucoma. This technique, however causes severe postoperative complication such as hypotonic maculopathy, bleb leakage and late bleb infection. The major advantages of trabeculotomy preclude these severe complications resulting from creating progressive filtration of aqueous humor from the anterior chamber to the subconjunctival space. The recent advance of small-incision phacoemulsification procedure prompted phacoemulsification and implantation of intraocular lens and trabeculotomy. The theoretical advantages of smaller scleral, conjunctival incision, reduced stimuli to wound healing, and inflammation, could improve long-term IOP control in patients with glaucoma. Therefore several reports have been published on the surgical outcomes of combined trabeculotomy and modern phacoemulsification. These reports suggested that the combined trabeculotomy and a small-incision with intraocular lens implantation is effective in controlling IOP in patients with glaucoma.
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Morales J, Kelleher PJ, Campbell D, Crosson CE. Effects of daunomycin implants on filtering surgery outcomes in rabbits. Curr Eye Res 2009. [DOI: 10.1080/02713689808951267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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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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Nuyts RMMA, Holley GP, Edelhauser HF. Effects of Mitomycin C on the Corneal Endothelium. ACTA ACUST UNITED AC 2008. [DOI: 10.3109/15569529509037552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Maruyama K, Shirato S. Efficacy and safety of transconjunctival scleral flap resuturing for hypotony after glaucoma filtering surgery. Graefes Arch Clin Exp Ophthalmol 2008; 246:1751-6. [PMID: 18751993 DOI: 10.1007/s00417-008-0924-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 07/23/2008] [Accepted: 07/26/2008] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND To evaluate the efficacy and safety of transconjunctival scleral flap resuturing for the management of hypotony-associated excess filtration after glaucoma filtering surgery. METHODS Fifty-six eyes of 55 patients with hypotony maculopathy and/or choroidal detachment caused by excess filtration after glaucoma filtering surgery underwent transconjunctival scleral flap resuturing directly through the conjunctiva, using a 10-0 nylon suture with a round tapered needle. Intraocular pressure (IOP) after suture, best-corrected visual acuity, rate of resolution of hypotony maculopathy and choroidal detachment, rate of complication, and rate of supplemental surgical treatment were assessed. RESULTS IOP (mean +/- SD) was 2.9 +/- 1.4 mmHg before suture, and elevated significantly to 7.3 +/- 4.5 mmHg at 1 week after suture, 7.2 +/- 3.5 mmHg at 1 month, 8.4 +/- 4.1 mmHg at 1 year, and 8.1 +/- 3.5 mmHg at the last follow-up (mean of 23 months). The best-corrected visual acuity was improved. Hypotony maculopathy was resolved in 92% and choroidal detachment in 100% of the patients. None of the patients required supplemental surgical treatment, because transconjunctival scleral flap resuturing failed to increase IOP. Suture removal was performed in 14 eyes that showed high IOP after suture. Of these eyes, six required needle revision and one required surgical bleb revision. In two eyes, aqueous humor leak after suture was controlled by wearing contact lenses. No bleb-associated infection was observed. CONCLUSION Even though additional treatments such as repeated suture, suture removal, and needle revison were necessary in some cases, transconjunctival scleral flap resuturing is a simple and minimally invasive procedure that improves hypotony after glaucoma filtering surgery, with no serious complication.
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Affiliation(s)
- Katsuhiko Maruyama
- Department of Ophthalmology, Tokyo Medical University, 6-7-1, Nishi-shinjuku, Shinjuku, Tokyo, 160-0023, Japan.
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Wellik SR, Schiffman JC, Budenz DL, Greenfield DS. Relationship between central corneal thickness and hypotony-related complications after glaucoma surgery. Ophthalmic Surg Lasers Imaging Retina 2008; 39:281-7. [PMID: 18717432 DOI: 10.3928/15428877-20080701-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To examine the hypothesis that patients with increased central corneal thickness may have an overestimation of Goldmann applanation tension and a predisposition to hypotony-related complications. PATIENTS AND METHODS A case-control analysis of patients with an intraocular pressure of 7 mm Hg or less on two consecutive postoperative visits following glaucoma filtration or drainage implant surgery was performed. Forward stepwise multiple logistic regression was used to determine the model that best predicted hypotony-related complications defined as choroidal effusion or hypotony maculopathy. RESULTS Forty-three eyes (17 with hypotony-related complications and 26 controls) of 43 patients were enrolled. Eyes with pseudophakia (P = .006) and lower postoperative intraocular pressure (P = .013) were significantly more likely to develop hypotony-related complications. Mean central corneal thickness was similar in eyes with hypotony-related complications (519 +/- 32 microm) and controls (525 +/- 37 microm) and was not a significant predictor of hypotony-related complications in the multivariate model (P = .90). CONCLUSION Increased central corneal thickness does not represent a risk factor for hypotony-related complications following glaucoma surgery.
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Affiliation(s)
- Sarah R Wellik
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Palm Beach Gardens, FL 33418, USA
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Ortolan EP, Bustamante TF, Takegawa BK, Mendonça FA, Rodrigues AM, Mendes ÉF. THERAPEUTIC OPTION FOR CHILDREN WITH ESOPHAGEAL CAUSTIC STENOSIS. Dig Endosc 2008. [DOI: 10.1111/j.1443-1661.2008.00794.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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nol M, Akta Z, Hasanreisolu B. Enhancement of the success rate in trabeculectomy: large-area mitomycin-C application. Clin Exp Ophthalmol 2008; 36:316-22. [DOI: 10.1111/j.1442-9071.2008.01736.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ahn JH, Jang MH, Lee JH. Results of Trabeculectomy Using Modified Scleral Flap Suture Technique in Comparison with Standard Trabeculectomy. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2008. [DOI: 10.3341/jkos.2008.49.6.925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jung Hyun Ahn
- Department of Ophthalmology, Dankook University College of Medicine, Cheonan, Korea
| | - Moo Hwan Jang
- Department of Ophthalmology, Dankook University College of Medicine, Cheonan, Korea
| | - Jong-Hoon Lee
- Department of Ophthalmology, Dankook University College of Medicine, Cheonan, Korea
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Sisto D, Vetrugno M, Trabucco T, Cantatore F, Ruggeri G, Sborgia C. The role of antimetabolites in filtration surgery for neovascular glaucoma: intermediate-term follow-up. ACTA ACUST UNITED AC 2007; 85:267-71. [PMID: 17488455 DOI: 10.1111/j.1600-0420.2006.00810.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Dario Sisto
- Department of Ophthalmology and Otorhinolaryngology, University of Bari, Bari, Italy
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Abstract
Hypotony maculopathy, first described in 1954 by Dellaporta, usually occurs after antiglaucomatous surgery or after perforating eye injuries; it is characterized by hypotony associated with fundus abnormalities, including papilloedema, vascular tortuosity and chorioretinal folds. In hypotony maculopathy, the scleral wall collapses inward, resulting in redundancy of the choroid and retina, leading to chorioretinal wrinkling. As the antero-posterior diameter of the vitreous cavity decreases, the very thick perivofeal retina surrounding the very thin foveal retina is thrown into radial folds around the fovea. It has been reported that hypotony maculopathy occurs in up to 20% of cases of glaucoma filtering surgery and has become more common after the introduction of antimetabolites. Young age, myopia, primary filtering surgery, systemic illnesses and elevated preoperative intraocular pressure (IOP) have been found to be associated with hypotony maculopathy. Hypotony maculopathy is treated with procedures designed to elevate IOP, which may reverse the inward scleral bowing and improve visual acuity. The successful treatment of hypotony maculopathy depends on the correct identification of its cause. Once the cause is detected, treatment should be employed as soon as possible because delayed normalization of the IOP may result in permanent macular chorioretinal changes and poor vision. This review will explore the definition, mechanisms, clinical findings and treatment of hypotony maculopathy.
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Affiliation(s)
- Vital Paulino Costa
- Glaucoma Service, Department of Ophthalmology, University of Campinas, São Paulo, Brazil.
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Fukuchi T, Suda K, Nakatsue T, Hara H, Abe H. Midterm Results and the Problems of Nonpenetrating Lamellar Trabeculectomy with Mitomycin C for Japanese Glaucoma Patients. Jpn J Ophthalmol 2007; 51:34-40. [PMID: 17295138 DOI: 10.1007/s10384-006-0381-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Accepted: 06/23/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE To present midterm results and problems pertaining to nonpenetrating lamellar trabeculectomy (NPT) with mitomycin C (MMC) for Japanese glaucoma patients. METHODS Thirty-nine patients (39 eyes) with primary open-angle glaucoma or normal-tension glaucoma underwent NPT. The results were compared with those in patients treated by penetrating trabeculectomy (PT) with MMC. In addition, the NPT patients were classified into two groups (group A, 24 patients treated between April 1998 and April 1999; group B, 21 patients treated from May 1999 onward), and the results were compared. RESULTS The average intraocular pressure (IOP) was 12.6 +/- 2.8 mmHg with NPT and 12.4 +/- 3.0 mmHg with PT. No statistical differences between NPT and PT were identified with respect to IOP at any time after surgery. A life-table analysis showed that the probability of success (good IOP control) was 37.2% with NPT and 62.5% with PT. No significant difference was detected in postoperative IOP change or in the probability of success between NPT groups A and B. CONCLUSIONS While postoperative IOP is similar between PT and NPT, the probability of success is better with PT than with NPT. Postoperative laser treatment after NPT is effective but sometimes has a negative influence on IOP control.
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Affiliation(s)
- Takeo Fukuchi
- Division of Ophthalmology and Visual Science, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
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Mehta JS, Maurino V, Patel H, Kirwin J, Murdoch IE. Immediate postoperative intraocular pressure measurements after trabeculectomy with releasable sutures. Clin Exp Ophthalmol 2007; 34:778-82. [PMID: 17073901 DOI: 10.1111/j.1442-9071.2006.01307.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND To assess the practicality of same-day intraocular pressure (IOP) review following trabeculectomy with releasable sutures. It is a prospective observational case series study. METHODS 40 eyes of patients undergoing inpatient trabeculectomy for glaucoma optic neuropathy. IOP measurement at 2, 4, 8, 12 and 24 h following trabeculectomy with releasable sutures. Slit-lamp microscopy documenting surgical complications. RESULTS Three patients required intervention within the first 24 h and four patients at 24 h because of raised IOP. Investigating pressure outcomes of low (<8 mmHg) and high (>21 mmHg) the sensitivity and specificity of IOP assessments at 2, 4, 8 and 12 h were compared with a 'gold standard' of IOP at 24 h postoperatively. False negative results persist at time periods for low IOP and are absent for high IOP only at 8 h postoperatively. There is a marked change in IOP over the first 24-h period in some patients, both from high to low and from low to high levels. CONCLUSIONS Same-day review of trabeculectomy is not a practical proposition as a policy for a unit with present operative techniques. Indeed the finding of transient high pressures during the first 24 h in some cases suggests that in those patients for whom there is concern (mainly those with severe disc cupping at the time of surgery) at least one IOP check during the first 24 h postoperatively may be warranted in addition to the 24-h postoperative check.
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Chan CK, Lee S, Sangani P, Lin LW, Lin MS, Lin SC. Primary Trabeculectomy Surgery Performed by Residents at a County Hospital. J Glaucoma 2007; 16:52-6. [PMID: 17224750 DOI: 10.1097/01.ijg.0000243473.59084.dd] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of trabeculectomies performed by ophthalmology residents at a metropolitan county hospital, under the supervision of attending physicians. METHODS A retrospective analysis of resident-performed trabeculectomies at the San Francisco General Hospital from the period of 1994 to 2004 was performed. The preoperative and postoperative ocular data of 50 eyes in 35 patients were evaluated. Of the 50 cases, 47 procedures were performed as primary trabeculectomies and 3 were revisions of trabeculectomies. RESULTS The average follow-up period was 28.9+/-17.6 months with an intraocular pressure (IOP) decrease from 23.2+/-9.4 mm Hg preoperatively to 11.3+/-4.4 mm Hg at last follow-up, for a mean reduction of 11.9+/-10.5 mm Hg (51.6%) (P<0.0001). Follow-up periods ranged from 3 months to over 6 years. The number of medications required decreased from 3.2+/-1.1 to 0.6+/-0.1 (P<0.0001). Success, defined by a postoperative IOP < or =21 mm Hg or a decreased postoperative IOP of at least 25% from preoperative pressure if the preoperative IOP was already < or =21 mm Hg, was observed in 42 eyes (84%) at last follow-up. Best-corrected visual acuity was stable or improved in 22 eyes (44%) and was noted to decrease 2 or more Snellen lines in 28 eyes (56%). Notable complications included 3 cases (6%) of persistent hypotony (IOP<5), 1 case (2%) of late endophthalmitis, and 1 case (2%) of phthisis. Seven eyes (14%) required subsequent penetrating glaucoma procedures due to bleb failure. CONCLUSIONS Results of this study suggest that the outcomes of trabeculectomies performed by residents at a county hospital can have a high success rate, comparable with previous studies in the literature. Rates of complications are overall similar to those found in the published literature.
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Affiliation(s)
- Candy K Chan
- Department of Ophthalmology, The Beckman Vision Center, University of California, San Francisco, CA 94143, USA
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Moreno-Montañés J, Palop JA, García-Gómez P, Heras H, Cristóbal JA. Intraocular lens opacification after nonpenetrating glaucoma surgery with mitomycin-C. J Cataract Refract Surg 2006; 33:139-41. [PMID: 17189810 DOI: 10.1016/j.jcrs.2006.07.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Accepted: 07/05/2006] [Indexed: 10/23/2022]
Abstract
A 58-year-old woman had successful phacoemulsification with intraocular lens (IOL) implantation in January 2001. Two years later, nonpenetrating glaucoma surgery with mitomycin-C (MMC) 0.02% was performed for uncontrolled glaucoma. Two months later, opacification of the anterior IOL surface was observed. The IOL was removed and a hydrophobic acrylic AcrySof IOL (Alcon) implanted. The opacified IOL was studied by flame atomic absorption spectrometry, which showed the presence of calcium carbonate. A new IOL of the same model was placed in an aqueous solution with calcium carbonate and basic pH, and the same opacification developed. We hypothesize that the change in aqueous humor pH after glaucoma surgery and the characteristics of the IOL precipitated deposition of calcium.
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Affiliation(s)
- Javier Moreno-Montañés
- Department of Ophthalmology, Clínica Universitaria de Navarra, Universidad de Navarra, Pamplona, Spain.
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Abstract
Mitomycin (mitomycin C; MMC) is an antibiotic isolated from Streptomyces caespitosus. The drug is a bioreductive alkylating agent that undergoes metabolic reductive activation, and has various oxygen tension-dependent cytotoxic effects on cells, including the cross-linking of DNA. It is widely used systemically for the treatment of malignancies, and has gained popularity as topical adjunctive therapy in ocular and adnexal surgery over the past 2 decades. In ophthalmic medicine, it is principally used to inhibit the wound healing response and reduce scarring of surgically fashioned ostia. Hence, it has been used as adjunctive therapy in various ocular surgeries, such as glaucoma filtering surgeries, dacryocystorhinostomy, corneal refractive surgery and surgeries for ocular cicatrisation. In addition, it has been used as an adjunct in the surgical management of pterygia, ocular surface squamous neoplasia, primary acquired melanosis with atypia and conjunctival melanoma. In many of these surgeries and ophthalmic pathologies, MMC showed a significant beneficial effect.
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Affiliation(s)
- Lekha M Abraham
- Department of Ophthalmology and Visual Sciences, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
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Shigeeda T, Tomidokoro A, Chen YN, Shirato S, Araie M. Long-term follow-up of initial trabeculectomy with mitomycin C for primary open-angle glaucoma in Japanese patients. J Glaucoma 2006; 15:195-9. [PMID: 16778640 DOI: 10.1097/01.ijg.0000212202.57029.45] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [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 intraocular pressure (IOP) control and postoperative complications after initial trabeculectomy with use of mitomycin C (MMC) in patients with primary open-angle glaucoma (POAG). PATIENTS AND METHODS A retrospective review was conducted of a consecutive series of 123 eyes (87 patients) with POAG who underwent initial trabeculectomy with MMC and had at least 4 years of follow-up. All patients underwent standard trabeculectomy with 0.04% MMC applied intraoperatively for 3 minutes. The long-term outcomes (IOP control and bleb leak, long-standing hypotony, bleb-related infections) were analyzed with the Kaplan-Meier life-table method on the basis of three definitions of successful IOP control (defined as IOP <18 mmHg (definition 1), IOP <16 mmHg (definition 2), and IOP decrease of by > or =30% and <21 mmHg (definition 3)). RESULTS The mean follow-up time was 6.8+/-1.4 (mean+/-SD) years. The cumulative survival rates were 67.0+/-4.6%, 44.5+/-5.4%, and 74.1+/-4.2%, respectively, based on definitions 1, 2, and 3, 8 years postoperatively by life-table analysis. At 8 years, bleb leak occurred in 7.9+/-2.6% of eyes, long-standing hypotony in 8.3+/-2.5%, and bleb-related infections in 5.9+/-2.4%. CONCLUSION Long-term outcome after initial trabeculectomy with MMC in Japanese POAG patients is comparable with that reported in other populations and with that after trabeculectomy with 5-fluorouracil.
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Affiliation(s)
- Takashi Shigeeda
- Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
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Park SW, Koo BS, Park YH, Jin YD, Rha KS. Effect of topical mitomycin C for antrostomy in rabbit with sinusitis. Eur Arch Otorhinolaryngol 2006; 263:917-23. [PMID: 16786365 DOI: 10.1007/s00405-006-0083-1] [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] [Received: 08/23/2005] [Accepted: 04/06/2006] [Indexed: 10/24/2022]
Abstract
The aim of this study is to evaluate if mitomycin C (MMC), applied topically at the site of maxillary antrostomy in experimentally inflamed maxillary sinuses, may reduce postoperative ostial stenosis without any harmful effect. Twenty-four rabbits with experimentally induced maxillary sinusitis underwent maxillary antrostomy bilaterally. MMC at a concentration of 0.4 or 1 mg/ml was applied at the site of antrostomy on the right whilst the antrostomy site on the left served as the control. Half of each MMC concentration group of animals were killed after 3 weeks, and the remaining half after 6 weeks. For every rabbit, the areas of antrostomies were measured and mucosal specimens around the ostia were obtained for microscopic evaluation at the time of antrostomy and killing. Within each MMC concentration group, MMC-treated antrostomies were significantly wider than those of the controls (P < 0.05), even after 6 weeks. However, comparison of the areas of MMC-treated antrostomies between the two MMC concentration groups did not show any significant difference (P > 0.05). No systemic side effect or permanent mucosal damage was detected. These results suggest that postoperative topical MMC at a concentration of 0.4 mg/ml can be used to prolong the patency of maxillary antrostomy in an inflammed sinus.
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Affiliation(s)
- Seok-Won Park
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Dongguk University, Goyang, South Korea
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Mietz H, Krieglstein GK. Postoperative application of mitomycin c improves the complete success rate of primary trabeculectomy: a prospective, randomized trial. Graefes Arch Clin Exp Ophthalmol 2006; 244:1429-36. [PMID: 16598468 DOI: 10.1007/s00417-005-0217-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2005] [Revised: 11/02/2005] [Accepted: 11/16/2005] [Indexed: 10/24/2022] Open
Abstract
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.
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Affiliation(s)
- Holger Mietz
- Aschaffenburg Eye Clinic, Aschaffenburg, Germany.
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Kessing SV, Flesner P, Jensen PK. Determinants of Bleb Morphology in Minimally Invasive, Clear-Cornea Micropenetrating Glaucoma Surgery with Mitomycin C. J Glaucoma 2006; 15:84-90. [PMID: 16633219 DOI: 10.1097/00061198-200604000-00002] [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]
Abstract
PURPOSE Antimetabolites, especially mitomycin C (MMC), increase the incidence of late bleb-related endophthalmitis in trabeculectomy. This is related to a higher incidence of avascular, thin, cystic, translucent blebs, which may be caused by a toxic effect on conjunctival tissue. An MMC dose-response study was carried out focusing on bleb morphology and function. PATIENTS AND METHODS In a retrospective, comparative case series study, 2 successive groups of patients with complicated glaucoma were compared 2 years after a special, minimally invasive, filtering procedure (intrastromal holmium laser keratostomy). Preoperative local subconjunctival injections of a fixed MMC dose (4 microg) were used in group A, and lower MMC doses, calculated individually (1 or 2 microg), were used in group B. Bleb vascularity and morphology were evaluated by masked grading of photomicrographs. Bleb function was evaluated by intraocular pressure (IOP). RESULTS Total bleb avascularity occurred in 63% of the blebs in group A and 0% in group B (P < 0.01). In eyes with IOP < or = 20 mmHg without medical treatment, the mean IOP was significantly lower in group 1 (8 vs 15 mm Hg, P < 0.002). A translucent cystic bleb without conjunctival stroma was observed in only 1 eye in group A. An optimal spongy stromal bleb was observed in all other eyes (96%) despite the different MMC doses. The numbers of complications in the 2 groups were nearly equal. CONCLUSIONS Bleb avascularity after 4 microg MMC could be avoided by the use of 1 or 2 microg MMC on the basis of preoperative prognosticators for failure, but at the expense of some of the IOP-lowering effect. This indicates that the therapeutic index (clinical safety margin) of MMC seems to be narrow. An MMC dose-response relation was not observed for the thin, cystic, and translucent bleb. The low incidence of this bleb (4%) indicates that the operative technique, apart from the vascularity, may be the most essential determinant of bleb morphology.
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Affiliation(s)
- Svend Vedel Kessing
- Glaucoma Clinic, Eye Department, Copenhagen University Hospital, Rigshospitalet, Denmark.
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Chen PL, Chen WY, Lu DW. Evaluation of mitomycin C in reducing postoperative adhesions in strabismus surgery. J Ocul Pharmacol Ther 2005; 21:406-10. [PMID: 16245968 DOI: 10.1089/jop.2005.21.406] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
AIMS The aim of this study was to evaluate the efficacy of mitomycin C in reducing postoperative adhesions following strabismus surgery. METHODS This study was a prospective, single-center, interventional case series. We randomized 14 patients with restrictive strabismus to the mitomycin C group (7 patients) or to the control group (7 patients). We used mitomycin C intraoperatively for 5 min at a concentration of 0.2 mg/mL in the mitomycin group after adhesion release. We compared postoperative results using the forced duction test. RESULTS Compared to the control group, the mitomycin C group exhibited a better range of passive duction at all postoperative follow-up times; however, mitomycin C did not completely eliminate the problem of postoperative adhesions. Patients receiving mitomycin C did not report any complications during this study. CONCLUSIONS The intraoperative application of mitomycin C is a safe and effective adjunct to surgery in the treatment of restrictive strabismus.
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Affiliation(s)
- Po-Liang Chen
- Department of Ophthalmology, Tri-Service General Hospital, Taipei, Taiwan, Republic of China.
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Maquet JA, Dios E, Aragón J, Bailez C, Ussa F, Laguna N. Protocol for mitomycin C use in glaucoma surgery. ACTA ACUST UNITED AC 2005; 83:196-200. [PMID: 15799732 DOI: 10.1111/j.1600-0420.2005.00437.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the results of a protocol described for mitomycin C (MMC) use in trabeculectomy or combined surgery (phacoemulsification and trabeculectomy). METHODS A total of 143 eyes (60 trabeculectomies and 83 combined surgeries) of 124 patients were divided into four groups: group 1 (without MMC); group 2 (with 0.1 mg/ml MMC); group 3 (with 0.2 mg/ml MMC), and group 4 (with 0.4 mg/ml MMC). Two-minute MMC was used in every case in groups 2, 3 and 4. The results were analysed after 1 year of follow-up. Intraocular pressure (IOP) and complications were evaluated. Successful IOP control was defined when IOP was <21 mmHg and <16 mmHg if advanced glaucoma was present, always without additional medical treatment. RESULTS Mean preoperative IOP decreased from 24.60 mmHg (SD 1.40 mmHg) to 13.47 mmHg (SD 0.37 mmHg) (p < 0.00001), 12 months postoperatively. Control in IOP was achieved in 79.02% of eyes. No significant differences were found in final mean IOP values (p > 0.196) or in postoperative complications (p > 0.120) in groups 2, 3 and 4. CONCLUSION With the protocol described, a selection of concentration of MMC has been made in different clinical forms of glaucoma. No significant differences in IOP control and postoperative complications were noticed among the groups.
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Affiliation(s)
- J A Maquet
- Department of Ophthalmology, University Hospital, University of Valladolid, Valladolid, Spain.
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Ilbay K, Etus V, Yildiz K, Ilbay G, Ceylan S. Topical application of mitomycin C prevents epineural scar formation in rats. Neurosurg Rev 2004; 28:148-53. [PMID: 15580369 DOI: 10.1007/s10143-004-0370-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2004] [Revised: 08/20/2004] [Accepted: 10/11/2004] [Indexed: 01/24/2023]
Abstract
The role of topically applied mitomycin C in preventing postoperative perineural fibrosis was examined by gross anatomical dissection and histological analysis in rats. The sciatic nerve was exposed bilaterally in 24 Wistar adult male rats, and an abrasion injury was produced on the exposed surface of the biceps femoris muscle in all animals. In the experimental group, cotton pads soaked with mitomycin C (0.5 mg/ml) were placed around the nerves for 5 min, whereas cotton pads soaked with saline were applied to the control group. Four weeks after surgery, the neurolysis sites were evaluated by blinded surgical dissection. Perineural adhesions were graded using a numerical grading scheme. The scar tissue formation index was also calculated, and a grading was made according to the number of fibroblasts/fibrocytes counted around the epineurium in histological evaluation. Mitomycin C-treated nerves showed significantly less perineural adhesions than controls. Quantification of the dense connective tissue surrounding the nerves revealed a statistically significant reduction around nerves treated with mitomycin C, and the number of fibroblast/fibrocytes was also significantly reduced. Application of topical mitomycin C might be effective in preventing epineural scar formation after neurolysis of peripheral nerves.
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Affiliation(s)
- Konuralp Ilbay
- Department of Neurosurgery, Kocaeli University Medical School, Derince, Turkey.
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