Evaluation the adjunctive use of combined bevacizumab and mitomycinc to trabeculectomy in management of recurrent pediatric glaucoma

The Use of Ologen Implant in Childhood Glaucoma Surgeries: A Review

PURPOSE

This study assesses the effectiveness and safety of using Ologen implants (Aeon Astron Europe BV, Leiden, The Netherlands) as an adjunctive therapy in childhood glaucoma surgeries.

METHODS

We systematically reviewed the existing literature across various electronic databases to examine the effectiveness and safety of Ologen implants in childhood glaucoma surgeries.

RESULTS

Our analysis encompassed 14 studies on the use of Ologen implants in childhood glaucoma. Among these, seven were prospective, five were retrospective, and two did not specify their study design. Success rates varied depending on the type of surgery and the included childhood glaucoma subtype. The success rates for Ologen implants-augmented surgeries were as follows: 33.3-70% for trabeculectomy, 50-81% for combined trabeculotomy-trabeculectomy procedure, 33%-87% for glaucoma drainage device, and 60% in deep sclerectomy.

CONCLUSION

Ologen implant has a potential role in mitigating postoperative fibrosis and enhancing success rates in various childhood glaucoma surgeries. However, the existing literature is limited. Future comparative prospective studies with larger cohorts are needed.

Efficacy of anti-vascular endothelial growth factor and mitomycin C on wound healing after trabeculectomy in glaucoma patients: A meta-analysis

Trabeculectomy is the main surgical treatment for glaucoma, but scar formation during wound healing may lead to surgical failure. In this study, we evaluated the efficacy of anti-vascular endothelial growth factor (anti-VEGF) and mitomycin C (MMC) on wound healing after glaucoma surgery. We have been looking for Pubmed, Embase and other databases. The last time we looked at an electronic database was August 2023. A case control study was conducted to compare the use of anti-VEGF and mitomycin C for the treatment of glaucoma. We used the Cochrane standard methodology for collecting and analysing the data. Based on the criteria of inclusion, we have determined 369 related papers and selected seven eligible trials for data analysis. Three hundred and twenty-six cases were treated with trabeculectomy, of which 166 were injected with anti-VEGF and 160 were given MMC for trabeculectomy. In six trials, anti-VEGF and MMC were not found to have any statistical significance on postoperative wound leakage after surgery (OR, 1.55; 95% CI, 0.71, 3.35 p = 0.27). The three trials showed that anti-VEGF and MMC did not differ in terms of reducing postoperative wound hypotony after surgery (OR, 0.78; 95% CI, 0.20, 3.11 p = 0.73). Five trials demonstrated that anti-VEGF and MMC were not associated with a lower incidence of shallow anterior chamber (OR, 1.17; 95% CI, 0.5, 2.76 p = 0.71). There is no significant difference in the effect of anti-VEGF and MMC on wound healing after glaucoma surgery. A multicentre randomized controlled trial with a larger sample size is needed to confirm this study.

The PAUL® glaucoma implant: 1-year results of a novel glaucoma drainage device in a paediatric cohort

PURPOSE

The PAUL® glaucoma implant (PGI) is a novel glaucoma drainage device, which has not been previously reported in paediatric glaucoma management. This study aims to evaluate the safety and effectiveness of the PGI in a paediatric cohort.

METHODS

A retrospective evaluation of 25 cases of paediatric PGI surgery (age 8 months to 16 years) was performed at Manchester Royal Eye Hospital between September 2019 and July 2020. Primary outcome measures included failure (intraocular pressure (IOP) > 21 mmHg or < 20% reduction of IOP, removal of the implant, further glaucoma intervention or visual loss. Secondary outcomes included mean IOP, mean number of medications, logMAR visual acuity and complications.

RESULTS

Eleven eyes (48%) had a complete success and achieved an unmedicated IOP < 21 mmHg, and 21 eyes (84%) had a qualified success (with or without medications). Four failures were observed, 2 due to hypotony and 2 underwent further surgery (gonioscopy-assisted transluminal trabeculotomy). The mean preop IOP was 30.9 ± 5.9 mmHg (n = 25), falling to 13.5 ± 6.8 mmHg at 1 month, 17.9 ± 7.2 mmHg at 3 months, 13.4 ± 5.1 mmHg at 6 months, 13.2 ± 4.9 mmHg at 12 months and 11.8 ± 4.6 mmHg at 24 months. The mean change in IOP from the preoperative visit to the last visit was a reduction of 19.1 ± 7.7 mmHg. A significant reduction in the number of medications and IOP was demonstrated after PGI (p < 0.0001). Nine patients required removal of the intraluminal Prolene stent from the PGI for further pressure lowering.

CONCLUSION

The one- to two-year results demonstrate paediatric PGI has high qualified success rates and effectively reduces IOP and the need for glaucoma medical therapy.

Surgical interventions for primary congenital glaucoma

BACKGROUND

Primary congenital glaucoma (PCG) is an optic neuropathy with high intraocular pressure (IOP) that manifests within the first few years of a child's life and is not associated with other systemic or ocular abnormalities. PCG results in considerable morbidity even in high-income countries.

OBJECTIVES

To compare the effectiveness and safety of different surgical techniques for PCG.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2020, Issue 4); Ovid MEDLINE; Embase.com; PubMed; metaRegister of Controlled Trials (mRCT) (last searched 23 June 2014); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 27 April 2020.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs comparing different surgical interventions in children under five years of age with PCG.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology.

MAIN RESULTS

We included 16 trials (13 RCTs and three quasi-RCTs) with 587 eyes in 446 children. Eleven (69%) trials were conducted in Egypt and the Middle East, three in India, and two in the USA. All included trials involved children younger than five years of age, with follow-up ranging from six to 80 months. The interventions compared varied across trials. Three trials (on 68 children) compared combined trabeculotomy and trabeculectomy (CTT) with trabeculotomy. Meta-analysis of these trials suggests there may be little to no evidence of a difference between groups in mean IOP (mean difference (MD) 0.27 mmHg, 95% confidence interval (CI) -0.74 to 1.29; 88 eyes; 2 studies) and surgical success (risk ratio (RR) 1.01, 95% CI 0.90 to 1.14; 102 eyes; 3 studies) at one year postoperatively. We assessed the certainty of evidence as very low for these outcomes, downgrading for risk of bias (-1) and imprecision (-2). Hyphema was the most common adverse outcome in both groups (no meta-analysis due to considerable heterogeneity; I² = 83%). Two trials (on 39 children) compared viscotrabeculotomy to conventional trabeculotomy. Meta-analysis of 42 eyes suggests there is no evidence of between groups difference in mean IOP (MD -1.64, 95% CI -5.94 to 2.66) and surgical success (RR 1.11, 95% CI 0.70 to 1.78) at six months postoperatively. We assessed the certainty of evidence as very low, downgrading for risk of bias and imprecision due to small sample size. Hyphema was the most common adverse outcome (38% in viscotrabeculotomy and 28% in conventional trabeculotomy), with no evidence of difference difference (RR 1.33, 95% CI 0.63 to 2.83). Two trials (on 95 children) compared microcatheter-assisted 360-degree circumferential trabeculotomy to conventional trabeculotomy. Meta-analysis of two trials suggests that mean IOP may be lower in the microcatheter group at six months (MD -2.44, 95% CI -3.69 to -1.19; 100 eyes) and at 12 months (MD -1.77, 95% CI -2.92 to -0.63; 99 eyes); and surgical success was more likely to be achieved in the microcatheter group compared to the conventional trabeculotomy group (RR 1.59, 95% CI 1.14 to 2.21; 60 eyes; 1 trial at 6 months; RR 1.54, 95% CI 1.20 to 1.97; 99 eyes; 2 trials at 12 months). We assessed the certainty of evidence for these outcomes as moderate due to small sample size. Hyphema was the most common adverse outcome (40% in the microcatheter group and 17% in the conventional trabeculotomy group), with greater likelihood of occurring in the microcatheter group (RR 2.25, 95% CI 1.25 to 4.04); the evidence was of moderate certainty due to small sample size (-1). Of the nine remaining trials, no two trials compared the same two surgical interventions: one trial compared CTT versus CTT with sclerectomy; three trials compared various suturing techniques and adjuvant use including mitomycin C, collagen implant in CTT; one trial compared CTT versus Ahmed valve implant in previously failed surgeries; one trial compared CTT with trabeculectomy; one trial compared trabeculotomy to goniotomy; and two trials compared different types of goniotomy. No trials reported quality of life or economic data. Many of the included trials had limitations in study design, implementation, and reporting, therefore the reliability and applicability of the evidence remains unclear.

AUTHORS' CONCLUSIONS

The evidence suggests that there may be little to no evidence of difference between CTT and routine conventional trabeculotomy, or between viscotrabeculotomy and routine conventional trabeculotomy. A 360-degree circumferential trabeculotomy may show greater surgical success than conventional trabeculotomy. Considering the rarity of the disease, future research would benefit from a multicenter, possibly international trial, involving parents of children with PCG and with a follow-up of at least one year.

A Mitomycin C-Sparing Novel Technique for Subscleral Trabeculectomy in Primary Congenital Glaucoma

Purpose

To evaluate the safety and efficacy of a novel modified subscleral trabeculectomy technique in management of primary congenital glaucoma.

Methods

This study included 25 infants diagnosed of having bilateral primary congenital glaucoma. For each patient, one eye was assigned to undergo subscleral trabeculectomy with trimming of the edges of the scleral bed (group I), while the contralateral eye underwent subscleral trabeculectomy with application of mitomycin C (0.4 mg/ml for 3 min) (group II). All the patients were followed up for a period of 14 ± 3 months (range 13-22 months).

Results

25 eyes were included in each group. Patients' mean age was 2.5 ± 0.5 months (range 1.8-6.5 months). The mean preoperative intraocular pressure was 31 ± 4.9 mmHg and 32.1 ± 4.0 mmHg in group I and II, respectively. The mean postoperative intraocular pressure was 9.0 ± 1.0, 11.0 ± 3.2, 12.5 ± 0.9, 13.0 ± 2.9, and 15.5 ± 1.5 mm Hg in group I and was 10.3 ± 1.2, 12.0 ± 2.5, 13.5 ± 1.7, 15.0 ± 1.5, and 17.1 ± 2.8 mm Hg in group II at the first week and 1, 3, 6, and 12 months, respectively. There was no statistically significant difference between the mean intraocular pressure values recorded at both groups preoperatively and at each follow-up visit. Failure necessitating further surgical interventions was recorded in 4 eyes (16%) in group I as compared to 3 eyes (12%) in group II (P > 0.05). Postoperative complications included mild hyphema, which occurred in one eye (4%) in group I and 2 eyes (8%) in group II, and shallow anterior chamber in 3 eyes (12%) in group I and in 2 eyes (8%) in group II. One eye (4%) in group I developed drawn-up pupil. Choroidal effusion developed in one eye (4%) at each group.

Conclusion

Trimming the edges of the scleral bed adjacent to the sclera flap is a safe and effective surgical step which can be added to the subscleral trabeculectomy procedure to effectively control the intraocular pressure in patients with primary congenital glaucoma, sparing them the hazards associated with mitomycin C application.

[Monocentric, Retrospective, Comparative Study of the Safety and Effectiveness of Wound Modulation with Bevacizumab after Combined Cataract Surgery with Implantation of the CyPass Stent]

BACKGROUND

Because of the known positive effect of bevacizumab (Avastin^®) on wound modulation in trabeculectomy, a retrospective study evaluated the safety and efficacy of wound modulation with Avastin following combined cataract surgery with CyPass stent.

METHOD

Retrospectively, the pre-, intra- and postoperative data (after three and six months) were collected from 484 eyes after combined surgery (n = 187 without Avastin, n = 297 with Avastin). The safety criteria were intraoperative complications and postoperative slit-lamp microscopic findings. Efficacy criteria were intraocular pressure (IOP) and number of IOP-lowering drugs.

RESULTS

With respect to age and sex distribution, early postoperative fibrin reaction, intraocular pressure and reduction in medication, the two groups (with and without Avastin) did not differ statistically significantly. However, iris tissue reactions were statistically significantly more frequently observed three months postoperatively in the control group than in the Avastin group (chi square test: p = 0.02, n = 47/128); there is a slight trend after six months towards less iris tissue reaction in the Avastin group (chi square test: p = 0.15, n = 45/125). Other trends in favour of the Avastin group were identified within the failure rate (2% compared to 6% at three months (chi square test: p = 0.103, n = 50/130) and 4 to 10% at six months (chi square test: p = 0.106, n = 50/130) and within the proportion of eyes without supplemental hypotensive medication, with 86 vs. 74% and 68 vs. 56% (chi square test: three months: p = 0.053; six months: p = 0.12; n = 50/130). In addition, 85% of the eyes in the Avastin group reached the postoperative pressure threshold of ≤ 21 mmHg without supplemental hypotensive medication three months postoperatively and 65% after six months compared to 74% (chi square test: p = 0.099, n = 50/130) and 54% (chi square test: p = 0.11, n = 50/130) in the control group.

CONCLUSION

The postoperative injection of Avastin into the anterior chamber is safe, reduces iris tissue reactions and improves efficacy up to six months postoperatively to a clinically limited extent.

Trabeculectomy with Ologen implant versus mitomycin C in congenital glaucoma secondary to Sturge Weber Syndrome

AIM

To compare the efficacy and safety of collagen matrix implant [Ologen (OLO) implant] versus mitomycin C (MMC) with subscleral trabeculectomy (SST) for the surgical treatment of congenital glaucoma (CG) in Sturge-Weber Syndrome (SWS).

METHODS

A prospective comparative randomized study of 20 eyes of 16 patients with CG associated with SWS was divided into two groups. The first group (MMC Group) included 10 eyes that were subjected to SST with MMC. The second group (OLO Group) included 10 eyes that were subjected to trabeculectomy with a collagen matrix implant (OLO implant). Postoperative evaluation included intraocular pressure (IOP) level, bleb evaluation, complications, and the need for further medication or surgical intervention.

RESULTS

The mean preoperative IOP was 29±3.16 mm Hg in MMC and 29.8±3.08 mm Hg in OLO eyes. Mean 12-month percentage reduction in IOP was significant in both groups (57.9% and 56.3%). At the end of the 12 postoperative follow-up month, in the MMC Group, 80% of eyes achieved the complete success, 20% of eyes had qualified success with no failed surgery in comparison to OLO Group which 70% of eyes achieved the complete success, 20% of eyes had qualified success with 10% failed surgery. In terms of complications, the MMC Group had a higher rate of complications than the OLO Group in the form of thin polycystic bleb in 6 eyes (60%), blebitis in only one eye (10%) treated with topical antibiotics, shallow anterior chamber in two eyes (20%).

CONCLUSION

This study proves that the use of a collagen matrix implant yields equally effective results as MMC when combined with trabeculectomy for the treatment of CG in SWS. Furthermore, OLO implantation is safe and has low incidences of complications.

Retrospective observation on trabeculectomy of primary congenital glaucoma by applying biological amniotic membranes soaked with 5-fluorouracil

PURPOSE

To report our experience on treatment of primary congenital glaucoma with trabeculectomy in combination with biological amniotic membranes soaked with 5-fluorouracil.

METHODS

This is a retrospective study. Thirty primary congenital glaucoma (PCG) patients (41 eyes) were treated with trabeculectomy in combination with biological amniotic membranes soaked with 5-fluorouracil before operation and followed up for 2.75 ± 1.35 years in average ranging from 1.2 to 5.3 years (Group A). In addition, 22 PCG patients (32 eyes) treated with mitomycin C-trabeculectomy were selected as control and followed up for 2.3 ± 1.25 years in average ranging from 1.4 to 5.1 years (Group B).

RESULTS

Patients in Group A were 4.74 ± 2.13 years old. After treatment, their mean intraocular pressure decreased from preoperative 38.8 ± 11.3-17.6 ± 8.2 mmHg at 12 months of postoperation (P = 0.0000). At 12 months of follow-up, the intraocular pressure was less than 13 mmHg in 8 eyes (19.5%), between 17 and 13 mmHg in 15 eyes (36.6%), between 21 and 17 mmHg in 12 eyes (29.3%) and more than 21 mmHg in 6 eyes (14.6%). The overall success rate was 85.4%, and total complication rate was 17.1%. By comparison, the overall success rate and total complication rate were 87.5 and 34.4%, respectively, at 12 months of follow-up for patients in Group B. Although the overall success rate was not significantly different between Groups A and B (P = 0.1203) at the end of follow-up, the total complication rate was significantly decreased in Group A (P = 0.0419).

CONCLUSION

Application of trabeculectomy in combination with biological amniotic membranes soaked with 5-fluorouracil can be an effective surgical treatment method for primary congenital glaucoma patients.