Comparison of Efficacy and Safety of Bleb Needle Revision With and Without 5-Fluorouracil for Failing Trabeculectomy Bleb

Efficacy of Ab Interno Revision for Trabeculectomy Bleb Failure Using a Minimally Invasive Approach: A Prospective Study

PRCIS

Ab interno bleb revision using the Grover and Fellman spatula offers potential benefits in improved intraocular pressure control and spares the conjunctiva for enhanced bleb management.

PURPOSE

This study aimed to evaluate the safety and effectiveness of Ab-Interno Bleb Revision (AIBR) for treating failed trabeculectomy blebs.

METHODS

This noncomparative case series enrolled glaucoma patients with failed trabeculectomy blebs who underwent AIBR and were followed up for 1 year. Eligible patients received subconjunctival Mitomycin C 0.1 mL of 0.2 mg/mL (20 μg) 5 days before the AIBR, performed using the Grover and Fellman spatula. The primary outcome measures were intraocular pressure (IOP) and the usage of IOP-lowering medications 1 year after the procedure. Secondary outcomes included the procedure's failure rate and complications. Complete success was defined as achieving an IOP between 5 and 21 mm Hg without medication, while qualified success required additional medical treatment.

RESULTS

The study comprised 23 eyes from 23 patients, having a mean age of 59.66±14.93 years. Preoperatively, the mean IOP was 23.54±10.7 mm Hg, and the mean antiglaucoma medication requirement was 3.99±0.65, both significantly reduced to 15.7±6.9 mm Hg ( P =0.009) and 1.26±1.2 ( P <0.001) at 1 year, respectively. Overall, 19 eyes (82.6%) achieved success (complete success: 39.2%, qualified success: 43.4%), while in 4 (17.4%) patients, the procedure failed (IOP >21 mm Hg). 5 patients had transient hyphema, but there were no sight-threatening complications such as hypotony or choroidal detachment.

CONCLUSIONS

Ab-Interno Bleb Revision (AIBR) is a safe, effective, and minimally invasive intervention for managing failed trabeculectomy blebs. By eliminating the need to reopen the conjunctiva, this technique offers a promising alternative for the treatment of this challenging condition.

A modified trabeculectomy technique with direct filtration into the Tenon's capsule

OBJECTIVE

To report the surgical outcomes of a modified trabeculectomy technique involving implanting the Tenon's layer under the scleral flap.

DESIGN

Prospective, interventional case series.

PARTICIPANTS

51 eyes with medically uncontrolled glaucoma were enrolled for this study. A new trabeculectomy technique, the Tenon's filtration technique for trabeculectomy (TFT-LEC) was used in 26 eyes, while a conventional procedure, normal trabeculectomy (N-LEC), was used for 25 eyes.

METHODS

Intraocular pressure (IOP) control, the number of glaucoma medications, the need for additional interventions, and postoperative complications were assessed.

RESULTS

Twelve months postoperatively, the mean IOP was 13.5 ± 0.5 mmHg in the TFT-LEC group and 15.4 ± 0.5 mmHg in the N-LEC group (p = 0.13). The TFT-LEC group required an average of 1.3 ± 1.0 additional glaucoma medications (21 cases required only ripasudil) postoperatively, with no cases of bleb needling revision or reoperation. The N-LEC group required an average of 1.7 ± 1.5 glaucoma medications (p = 0.43) compared to TFT-LEC group, eight cases (32%) required bleb needling revision (p = 0.002), and one case (4%) of reoperation (p = 0.49). The complications in the TFT-LEC group included shallow anterior chamber in six (23 %) cases (p = 1.00) compared to N-LEC group, choroidal detachment in two (8%) cases (p = 0.42), and anterior chamber hemorrhage in seven (27%) cases (p = 0.29). None of these complications affected visual function.

CONCLUSIONS

This new technique involving implanting the Tenon's layer under the scleral flap may improve the postoperative outcomes of trabeculectomy.

Safety and Efficacy of the Rho-Kinase Inhibitor (Ripasudil) in Bleb Needling after Trabeculectomy: A Prospective Multicenter Study

Ripasudil, a rho-associated protein kinase inhibitor ophthalmic solution, shows a protective effect in preventing excessive scarring in vitro. This study aims to evaluate the safety and efficacy of ripasudil for glaucoma patients submitted to the needling procedure. In this prospective, multicenter, single-arm study, we included 20 eyes of 20 patients with glaucoma who underwent the needling procedure without antimetabolites. All patients administered ripasudil after needling for three months. The primary endpoint of this study was the safety of ripasudil in patients, and the secondary endpoint was the change in IOP at 12 weeks after the needling procedure. No serious complications were found in the patients. One eye experienced pruritus and conjunctival follicle, while another eye had conjunctival follicle. These complications were transient and resolved quickly after discontinuation of ripasudil. The mean preoperative IOP was 14.6 ± 4.6 mmHg, which decreased to 11.0 ± 4.7 mmHg (p = 0.0062) at 1 week postoperatively. The IOP reduction effect continued to 12 weeks (11.8 ± 3.1 mmHg; p = 0.0448). The administration of the ROCK inhibitor, ripasudil, after the needling procedure is safe and effective in maintaining IOP for 12 weeks.

A multicenter phase II study on the safety of rho-kinase inhibitor (ripasudil) with needling for the patients after trabeculectomy

Background

There is no established method of maintaining or reducing intra ocular pressure after the needling procedure for failing blebs post trabeculectomy. Regarding newer antihypertensive medications, ripasudil, which is a rho-associated protein kinase inhibitor ophthalmic solution, was able to prevent excessive scarring in vitro. This study aims to evaluate the safety of glaucoma patients submitted to the needling procedure and administered ripasudil for preventing scarring after the procedure. We also investigate the efficacy of ripasudil after needling for bleb failure through suppression of fibrosis to the bleb.

Methods

This study is a multicenter, open-label, single-arm, phase II trial to evaluate the safety and efficacy of ripasudil in glaucoma patients after the needling procedure. Forty patients who will undergo needling at least 3 months after trabeculectomy will be recruited in Hiroshima university hospital and Hiroshima eye clinic. All the patients will instill ripasudil two times per day for three months after the needling procedure. The primary endpoint is the safety of ripasudil.

Conclusions

We plan to establish the safety of ripasudil and to collect information involving the efficacy of ripasudil widely in this study.

Blood Reflux Through a PreserFlo MicroShunt Device After Needling

INTRODUCTION

To report a case of hyphema after a bleb needling revision in a PreserFlo MicroShunt implantation.

CASE DESCRIPTION

An 87-year-old man suffering from bilateral open angle glaucoma was referred to our hospital with a diagnosis of unsatisfactory intraocular pressure (IOP) control in the right eye, despite the maximally tolerated medical therapy. The patient underwent PreserFlo MicroShunt implantation in his right eye. About 2 months after the surgical procedure, the IOP was raised because of bleb failure for subconjunctival scarring. A needling revision was performed at the slit lamp. During the procedure blood reflux through a PreserFlo MicroShunt device from a filtering bleb to the anterior chamber was observed, causing an IOP rise. Treatment with oral acetazolamide, topical steroid, and antibiotic resulted in the complete resolution of the hyphema in 2 weeks and a significant lowering in IOP.

CONCLUSIONS

This is the first reported case of blood reflux to the anterior chamber through a PreserFlo MicroShunt implant after a needling procedure.

Novel Bacterial Cellulose Membrane to Reduce Fibrosis Following Trabeculectomy

PURPOSE

The aim was to evaluate the effectiveness of bacterial cellulose membrane (BCM) in preventing fibrosis in trabeculectomy and the biocompatibility of BCM with conjunctiva and sclera.

MATERIALS AND METHODS

Twenty-one eyes of 21 adult rabbits underwent fornix-based trabeculectomy. Standard surgery was done to control group (CG, n=7). Mitomycin-C (MMC) (0.3 mg/mL, 3 min) was applied to MMC group only (MMCG, n=7). BCM (~100 µm thick, 10×10 mm, single layer) was covered on the sclerotomy area before conjunctiva was closed in BCM group (BCMG, n=7). Intraocular pressures (IOP) were measured before, and 7, 14, 28, and 45 days after surgery (IOP-POD7, POD14, POD28, POD45). The IOP decrease were expressed as DIOP%-POD7, DIOP%-POD14, DIOP%-POD28, and DIOP%-POD45. The rabbits were sacrificed on the 45th day. Conjunctival vessel number, degrees of fibrosis, total inflammation, foreign body reaction, inflammatory cell types (B cells, T cells, plasma cells), macrophages, bleb spaces and the expression of α-smooth muscle actin were studied using histopathology and immunohistochemistry techniques. The groups were compared using nonparametric tests.

RESULTS

There was no statistically significant difference between the groups regarding baseline IOP and DIOP%-POD7 (P>0.05). While DIOP%-POD14, 28 and 45 were similar between BCMG and MMCG, they were significantly lower in CG (P<0.05). The lowest conjunctival vessel number was detected in the MMCG but the difference was not significant. There was no difference between BCMG and CG with regard to the numbers of B cells, T cells, and macrophages, however, these cells were significantly lower in MMCG (P<0.05). Five cases had mild and 2 cases had moderate foreign body reaction in the BCMG. There was mild to moderate inflammation in all BCM cases. While fibrosis and α-smooth muscle actin staining were higher in the CG (P<0.001), they were minimal in the BCM and MMCGs.

CONCLUSIONS

BCM showed good biocompatibility and provided better control of IOP with minimal fibrosis at the trabeculectomy site compared with the control group.

Reoperation Rates and Disease Costs for Primary Open-Angle Glaucoma Patients in the United States Treated with Incisional Glaucoma Surgery

PURPOSE

To evaluate the claims-based 5-year economic and reintervention burden for patients with primary open-angle glaucoma (POAG) after incisional glaucoma surgery in the United States.

DESIGN

Retrospective Medicare claims analysis.

PARTICIPANTS

One thousand nine hundred forty-five Medicare fee-for-service patients with POAG treated with trabeculectomy, tube shunt, or EX-PRESS shunt procedures from 2010 through 2011.

METHODS

Patients with POAG treated with incisional glaucoma surgery (trabeculectomy, tube shunt, or EX-PRESS shunt) from 2010 through 2011 were identified in the Medicare 5% Standard Analytical Files. Ten years of claims data for each patient (2005-2016) were evaluated for prior incisional surgeries and downstream procedures in the treated eye within 5 years of index. Patients' characteristics, downstream procedures, and POAG-related costs were evaluated. Proportions of patients with downstream procedures in the index eye indicating failure of the index surgery, glaucoma reoperations, nonfailure complications, interventions, or cataract surgery were assessed over 5 years of follow-up.

MAIN OUTCOME MEASURES

Cumulative rates of index surgery failure and glaucoma reoperations over 5 years after incisional glaucoma surgery.

RESULTS

Of 1945 patients, 223 underwent EX-PRESS shunt, 551 underwent tube shunt, and 1171 underwent trabeculectomy at index. Rates of failure, glaucoma reoperations, or nonfailure complications rose over 5 years after index for all patient subgroups. At 1 year, 15.1% of EX-PRESS shunt patients, 11.6% of tube shunt patients, and 8.8% of trabeculectomy patients had experienced failure based on postindex procedures. By 5 years follow-up, these rates were 31.5% of EX-PRESS shunt patients, 27.1% of tube shunt patients, and 23.5% of trabeculectomy patients. Five-year rates of glaucoma reoperations were 18.3%, 14.0%, and 15.1%, respectively. Among tube shunt and trabeculectomy patients with prior incisional surgery, the 5-year failure rates were 32.5% and 32.6%, and reoperations rates were 12.0% and 26.1%, respectively.

CONCLUSIONS

More than one-fourth of patients with POAG treated with incisional surgery underwent additional procedures to address index surgery failure within 5 years. Of these, more than half underwent additional incisional glaucoma surgery. These outcomes from clinical practice settings demonstrate that patients with POAG who require incisional surgery continue to need additional safe and effective surgical treatment options to manage their glaucoma.

Efficacy and safety of 5-fluorouracil in infrared monitor guided bleb revision

Purpose

Infrared monitor-guided bleb revision (IRGBR), an alternative needling system, visualizes anterior-segment tissues around the bleb not visible during needle revision after trabeculectomy. This study determined the safety and efficiency of 5-fluorouracil (5-FU) as an adjunctive anti-metabolite in IRGBR.

Methods

We retrospectively analyzed 43 consecutive eyes (40 patients; 14 eyes, primary open-angle; 29 eyes, secondary glaucoma) treated with IRGBR for failing filtering blebs. The patients were divided into two groups. The first one had IRGBR without adjunctive 5-FU subconjunctival injection, and the second one had IRGBR with 5-FU. We performed Kaplan-Meier survival analysis using log-rank tests after 2 years of follow-up and Cox proportional hazards regression model to analyze the dependence of the survival time on predictor variables. Two failure criteria were defined as the need for additional surgery for intraocular pressure (IOP) reduction and the IOP at two consecutive follow-up visits based on definition 1, IOP ≧22 mmHg and definition 2, IOP ≧17 mmHg.

Results

Thirty eyes (29 cases) underwent IRGBR with subconjunctival 5-FU injection (group A in the second term) and 13 eyes (11 cases) without 5-FU (group B in the first term). The success rates 24 months after IRGBR were 73.3 and 23.1%, respectively, in groups A and B based on the definition 1 failure and 56.7 and 7.7% based on the definition 2 failure. Complications included transient bleb leaks (group A, 3 eyes; group B, none) and choroidal detachment (group A, 1 eye; group B, none). No use of 5-FU and IOPs ≧10 mmHg 1 week after IRGBR were significant risk factors.

Conclusions

Adjunctive 5-FU in IRGBR achieved a better success rate for failing trabeculectomy blebs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01843-4.

Safety and Efficacy of Bleb Needling with Antimetabolite after Trabeculectomy Failure in Glaucoma Patients: A Systemic Review and Meta-Analysis

Background

Bleb needling with subconjunctival injection of antimetabolites had become a widely accepted approach for trabeculectomy failure. However, IOP reduction effects, success rates, and complications occurrence for this procedure showed great inconsistency among the different studies.

Methods

We conducted a literature search on PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. A random-effects model was performed on the extracted data based on the included studies. The intraocular pressure (IOP) and number of antiglaucomatous medications before and after the surgery were pooled for meta-analysis. The success and complication rates were estimated based on the results. Subgroup analysis, sensitivity analysis, and metaregression were applied to explore the origination of heterogeneity.

Results

Thirty-seven studies with a total of 2182 patients were finally included in our review. For the present meta-analysis, the overall effects of bleb needling at the last visit revealed a reduction in IOP of 9.74 mmHg (95% confidence interval (CI) [8.85, 10.63]), 45.9% (95% CI [39.0%, 53.0%]) for complete success rate, and 70.4% (95% CI [63.5%, 77.0%]) for qualified success rate. Application of mitomycin C (MMC) and 5-fluorouracil (5-Fu) during the procedure were efficacious for IOP control during the follow-up. Metaregression revealed that possible origination of heterogeneity was baseline IOP before bleb needling, revealing a trend that higher baseline IOP correlated with a greater IOP reduction results (p < 0.001). For safety profile, conjunctival haemorrhage (5.7%, 95% CI [2.5%, 10.1%]), hyphema (5.5%, 95% CI [3.0%, 8.7%]), and bleb leakage (5.0%, 95% CI [3.2%, 7.3%]) had the highest estimate of incidence. An increasing number of needling was the main risk factor for needling failure.

Conclusion

Bleb needling with antimetabolites could be considered an effective and safe procedure after trabeculectomy failure. After the process, patients will gain IOP control and reduce antiglaucomatous medications for at least six months with 5-Fu or MMC. Meanwhile, the overall estimates for complications were relatively low in the whole process.

Needling after trabeculectomy - does augmentation by anti-metabolites provide better outcomes and is Mitomycin C better than 5-Fluoruracil? A systematic review with network meta-analyses

PURPOSE

Favourable outcome after glaucoma surgery depends on proper control of the inflammatory response. Failing filtration bleb and consequently increased intraocular pressure is an important cause of continuous visual field deterioration after uncomplicated glaucoma surgery. The present systematic review and meta-analysis aimed to compare the effects of employing either Mitomycin C (MMC), 5-Fluoruracil (5-FU) or no anti-metabolite in needling revision of trabeculectomies.

METHODS

We performed a systematic literature search in PubMed, Cochrane and EMBASE to identify randomized and non-randomized trials published between year 2000 and March 2019 comparing the efficacy of needling filtering blebs when using no anti-fibrotic agent, MMC or 5-FU in patients with glaucoma. Efficacy was defined as intraocular pressure at 12 months or latest follow-up, rate of complications, rates of success and the number of re-needling cases. Comparisons were made using network meta-analyses.

RESULTS

We identified one randomized trial and five retrospective trials. Twelve months after needling revision of trabeculectomy, no significant difference was observed when comparing the effect of the use of MMC with 5-FU or without any use of anti-metabolite on intraocular pressure, complication rates, qualified success, complete success or number of re-needling cases.

CONCLUSION

We found no significant difference in the efficacy of using either MMC, 5-FU or no anti-metabolite in needling revision of trabeculectomies. The number of studies meeting our inclusion criteria was limited. Considering the design of studies, only one was randomized leading to an overall low quality of evidence on the subject matter. Further research is warranted.