Needle Revision of Filtering Blebs:

Ab interno trabeculectomy revision with 5-flourouracil for failed trabeculectomy in advanced glaucoma: 3-year outcomes

OBJECTIVE

To describe the 3-year outcomes of patients who underwent ab interno trabeculectomy revision with a translimbal sclerostomy spatula augmented with 5-flourouracil.

DESIGN

Retrospective cohort study.

PARTICIPANTS

In this single-centre study, inclusion criteria included patients who were 18 years of age or older with advanced glaucoma who had undergone ab interno trabeculectomy revision with 5-flourouracil due to subconjunctival fibrosis and above-target intraocular pressure (IOP). Patients were required to have a minimum follow-up of 3 years.

METHODS

The primary outcome measure was IOP. Secondary outcome measures included number of topical IOP-lowering medications, best-corrected distance visual acuity, visual field mean deviation, and postoperative complications.

RESULTS

Forty-one eyes of 41 patients met the criteria for inclusion. Survival analysis demonstrated success defined by criterion A (IOP <15 mm Hg and >20% reduction) in 44% of eyes without medication (complete success) and 71% of eyes with or without medication (qualified success) at 3-year follow-up. Complete and qualified successes defined by criterion B (IOP <12 mm Hg and >20% reduction) were achieved by 31% and 44% of eyes, respectively. Early complications included transient hypotony in 26 eyes (63%) and transient hyphema in 3 eyes (7.3%). No persistent complications were reported within the 3-year study period.

CONCLUSION

Ab interno trabeculectomy revision can be an effective technique for achieving a low target IOP in patients with advanced glaucoma in up to 3-year follow-up.

Effectiveness and Safety of Xen Gel Stent in Glaucoma Surgery: A Systematic Review of the Literature

Although topical medical therapy and selective-laser-trabeculoplasty represent the treatments of choice to reduce intraocular pressure, many patients do not achieve adequate glaucoma control; therefore, they require further options and eventually surgery. Trabeculectomy is still considered the gold standard, but the surgical management of glaucoma has undergone continuous advances in recent years, XEN-gel-stent has been introduced as a safer and less traumatic means of lowering intraocular pressure (IOP) in patients with open-angle glaucoma (OAG). This study aimed to review the effectiveness and safety of clinical data on XEN-stent in OAG patients with a Synthesis-Without-Meta-analysis (SWiM) methodology. A total of 339 studies were identified following a literature search adhering to PRISMA guidelines and, after evaluation, 96 studies are discussed. XEN63 and XEN45 device data were collected both short and long term. In addition, this document has evaluated different aspects related to the XEN implant, including: its role compared to trabeculectomy; the impact of mitomycin-C dose on clinical outcomes; postoperative management of the device; and the identification of potential factors that might predict its clinical outcomes. Finally, current challenges and future perspectives of XEN stent, such as its use in fragile or high myopia patients, were discussed.

Comparison between Surgical Techniques Used for Revision of the Filter Bleb: A Randomized Controlled Clinical Trial

INTRODUCTION/PURPOSE

The aim of this study was to compare two surgical revision techniques in failed trabeculectomies after 6 months.

METHODS

Patients diagnosed with open-angle glaucoma who underwent trabeculectomy in at least one eye with uncontrolled intraocular pressure (IOP) after trabeculectomy performed at least 6 months before were enrolled in this prospective trial. All participants underwent a complete ophthalmological examination at baseline. Randomization was performed to one eye per patient to double-masked trabeculectomy revision or needling. Patients were examined on the first day, 7 days, 14 days, and then monthly until completing 1 year after surgical intervention. All follow-up visits included the following: patients reported ocular and systemic events, best-corrected visual acuity, IOP, slit-lamp examination, and optic disc evaluation for cup-to-disc ratio. Gonioscopy and stereoscopic optic disc photographs were taken at baseline and 12 months. After 1-year, the IOP and number of medications were compared between the groups. Absolute success criteria in the study were IOP <16 mm Hg, for 2 consecutive measurements without using a hypotensive medication.

RESULTS

Forty patients were included in this study. Among them, 38 completed 1-year follow-up (18 in revision group and 20 in needling group). The age ranged from 21 to 86 years, with a mean of 66.82 ± 13.44. At baseline, the average IOP was 21.64 ± 5.12 mm Hg (range from 14 to 38 mm Hg) in the entire group. All patients were using at least two classes of hypotensive eye drops, and 3 patients were using oral acetazolamide. The mean use of hypotensive eye drop medications was 3.11 ± 0.67 at the baseline for the entire group. In the present study, 58% of the patients presented complete success, 18% qualified success, and 24% failed in both groups. After 1-year treatment, both techniques were similar for IOP parameters and also for number of medications (p = 0.834 and p = 0.433, respectively). Regarding intra- or postoperative complications, one patient in each group needed a new surgical intervention, one in the needling group due to shallow anterior chamber and one in the revision group due to spontaneous Seidel sign, and one patient in the needling group underwent posterior revision due to fail.

CONCLUSIONS

Both techniques were safe and effective for IOP control after 1 year of follow-up in patients who underwent to trabeculectomy more than 6 months before.

Effect of the rho-kinase inhibitor ripasudil in needling with mitomycin C for the failure of filtering bleb after trabeculectomy: a cross-sectional study

Background

Rho-kinase inhibitors can inhibit fibrosis after glaucoma surgery. This study aimed to evaluate the effect of rho-kinase inhibitor after needling procedure with mitomycin C for the failure of filtering bleb with trabeculectomy.

Methods

This retrospective single-center study examined the effects of rho-kinase inhibitor after the needling procedure. We included 27 eyes of 27 patients with glaucoma who underwent needling procedure using mitomycin C and were subsequently treated with ripasudil—a rho-associated protein kinase inhibitor (ripasudil group)—or without ripasudil (control group). The ripasudil and control groups were compared in terms of intraocular pressure (IOP) and the number of antiglaucoma medications. Success at 12 months after the needling procedure was defined as a > 20% decrease in IOP from the preoperative period without surgical reintervention.

Results

At 12 months after the needling procedure, the mean IOP decreased from 16.9 ± 4.5 to 12.6 ± 1.1 mmHg in the control group and from 16.0 ± 5.3 to 12.2 ± 1.2 mmHg in the ripasudil group (p = 0.77). The 12-month success rates were 60.00% and 56.25% in the control and ripasudil groups (p = 0.98), respectively. In the preoperative period, the numbers of antiglaucoma drugs were 0.27 ± 0.46 and 0.92 ± 0.91 in the control and ripasudil groups (p = 0.022), respectively, and at 12 months after the needling procedure, they were 1.07 ± 1.44 and 0.73 ± 1.10 (p = 0.52), respectively.

Conclusions

Treatment with ripasudil (a rho-associated protein kinase inhibitor) after the needling procedure with mitomycin C did not show better results than treatment with the mitomycin C needling procedure alone at 12 months after the procedure.

Impact of Primary Needling on the XEN Implant Clinical Outcomes: A Real-Life Retrospective Study

Purpose

To assess the effectiveness and safety of primary-needling in eyes who underwent a XEN45 implant.

Methods

Retrospective and single center study. Consecutive patients with early-to-moderate open-angle glaucoma (OAG) or ocular hypertension, who underwent XEN45 surgery, either alone or combined with phacoemulsification, and had at least a valid 12-month post-operative visit, were included in the study. Primary needling was performed by using a 30-gauge needle without viscoelastic. Subjects were divided in two groups: Eyes who underwent XEN+primary-needling (needling) and those who underwent XEN without primary-needling (no-needling). The primary end-point was the mean change in IOP from baseline to the last follow-up visit.

Results

Sixty-three eyes, 19 (30.2%) in the needling group and 44 (69.8%) in the no-needling one, were included in the study. There were not significant differences in mean IOP lowering between needling and no-needling groups at month-12 (mean difference −2.5±5.3 mm Hg, p=0.0926). No significant differences in mean reduction of ocular-hypotensive medications were observed between needling and no-needling groups, p=0.8690. At month-12, 50 (80.6%) had blebs considered as functioning, with no difference between groups, p = 0.5631. At month-12, 59 (93.7%) eyes were classified as success, with no significant differences between needling (17/19) and no-needling (42/44) groups, p=0.3754. Secondary needling was performed in 8 (12.7%) eyes, without differences between groups (p=0.6333).

Conclusion

Primary needling, at the time of surgery, was a safe procedure in OAG patients who underwent a XEN implant, although it was not associated with a lower postoperative IOP or less ocular hypotensive medications.

PreserFlo® MicroShunt: An Overview of This Minimally Invasive Device for Open-Angle Glaucoma

For moderate-to-severe glaucoma, trabeculectomy remains the “gold standard” intraocular pressure (IOP)-lowering treatment; nonetheless, this method requires extensive post-operative maintenance. Microinvasive glaucoma surgery (MIGS) treatments are designed to lessen intra- and post-operative care burden while offering an acceptable IOP decrease for individuals with mild to moderate glaucoma. The PreserFlo® MicroShunt (previously InnFocus MicroShunt) is an 8.5 mm glaucoma drainage device manufactured from poly(styrene-block-isobutylene-block-styrene) (SIBS), an extremely biocompatible and bioinert material. The lumen is narrow enough to prevent hypotony, but big enough to avoid being obstructed by sloughed cells or pigment. The device is implanted ab externo, as a stand-alone procedure or in conjunction with cataract surgery, with intraoperative mitomycin C, and a bleb is produced under the conjunctiva and Tenon’s capsule. The MicroShunt was CE-marked in 2012 and designed for primary open-angle glaucoma, the IOP of which remains uncontrolled after maximally tolerated topical treatment. Several clinical trials evaluating the MicroShunt’s long-term safety and effectiveness have been conducted, highlighting the effectiveness of the device over time, along with a tolerable safety profile. The present review aims to gather evidence of PreserFlo’s effectiveness and safety results almost 10 years after its introduction, and furthermore, to compare it with other MIGS and with the gold-standard trabeculectomy for glaucoma management.

The Optimization of an Anti-VEGF Therapeutic Regimen for Neovascular Glaucoma

This study investigates the safety and efficacy of conbercept injection through different routes for neovascular glaucoma (NVG) treatment, in which seventy-four patients (81 eyes) with NVG caused by ischemia retinopathy had participated. Patients were divided into three stages according to the progression of NVG and were randomly assigned to receive intracameral or intravitreal conbercept injection. After conbercept injection, patients experienced improved best-corrected visual acuity (BCVA), good intraocular pressure (IOP) control, and neovascularization of Iris (NVI) regression. In stage III, patients required trabeculectomy with mitomycin C plus pan-retinal photocoagulation (PRP) to achieve complete NVI regression. Compared to the intravitreal group, the intracameral group had significantly lower IOP in 2 days in stage III and 1 day in stages I and II after injection, complete NVI regression before PRP in stages I and II, and better NVI regression in stage III. The rates of hyphema after trabeculectomy and malfunction filtering bleb suffering needle bleb revision were lower in the intracameral group, but only the hyphema rate was significantly different. Injections through different routes are all safe. We recommend intravitreal injections for patients in stages I and II, but for stage III, intracameral injection is better, and trabeculectomy with mitomycin C should be conducted within 2 days after injection to maximally reduce the risk of perioperative hyphema.

Trial Registration:ClinicalTrials.gov, identifier NCT03154892.

Factors affecting the early and mid-term success of needling for early failure of filtering bleb

Purpose:

The purpose of this study is to evaluate the factors affecting the success of needling surgery for early filtering bleb failure after trabeculectomy.

Methods:

Patients who underwent a single needling surgery within 3 months after trabeculectomy were retrospectively evaluated. Glaucoma type, intraocular pressure (IOP), and medical treatments before trabeculectomy; the presence of hypotony after trabeculectomy; bleb type; IOP before needling; lens status; complications; IOP after 1, 6, and 12 months; and medical treatments after needling were recorded. Risk factors were evaluated for complete success at 1, 6, and 12 months after needling.

Results:

Thirty-three eyes of 33 patients were analyzed. The mean IOP after needling at 1, 6, and 12 months was 16.09 ± 3.70, 15.64 ± 2.68, and 15.79 ± 2.61 mmHg, respectively. The mean age of the patients was 53.97 (25–79) years. The mean IOP after needling at 1, 6, and 12 months was 16.09 ± 3.70, 15.64 ± 2.68, and 15.79 ± 2.61 mmHg, respectively. The pre-needling IOP and IOP decrease on the first day affected the complete and qualified success at 1, 6, and 12 months, but the glaucoma type, presence of hypotony after trabeculectomy, lens status, interval between trabeculectomy and needling, and bleb type were not found to affect success. In the receiver operating curve analysis, the pre-needling IOP value was found to be significant in determining complete success. Complete success at 1 month was more likely when the pre-needling IOP cutoff value was <24.5 mmHg.

Conclusion:

According to the results of single needling surgery performed within 3 months after trabeculectomy, the pre-needling IOP and IOP decrease with needling were found to be factors affecting success. Regardless of the time between the primary trabeculectomy and needling, effective needling will be successful before the IOP rises to high levels. Keeping the IOP at low values with medical treatment until the needling process is performed will have a positive effect on success.

A case of endophthalmitis following needling procedure after PRESERFLO® Micro Shunt implantation

PURPOSE

To report a case of endophthalmitis following bleb needling in a patient previously implanted with a PRESERFLO^® MicroShunt.

METHODS

Case report.

RESULTS

A 40-year-old woman with bilateral malformative glaucoma repeatedly operated on in childhood underwent PRESERFLO^® MicroShunt implantation in her right eye and six needling revisions (NRs) and a surgical revision due to unsatisfactory intraocular pressure (IOP) control due to bleb encapsulation. About 3 months after the surgical revision the bleb encapsulation relapsed and she underwent a further NR with betamethasone. About 4 days after the last NR, she experienced visual acuity reduction and was therefore advised to come immediately to the hospital for an unscheduled visit, showing up with hypopyon and diffuse vitreous haze. A clinical diagnosis of endophthalmitis (later confirmed by bacteria culture tests) was made and she was treated with pars-plana vitrectomy with silicone oil and intravitreal antibiotics. Preoperative visual function was luckily completely restored.

CONCLUSIONS

Endophthalmitis can occur after NR in an eye with PRESERFLO^® MicroShunt implant which therefore does not prevent reflux of bacteria from a filtering bleb to the anterior chamber.

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.

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.

Long-Term Outcomes from an Intraoperative Bleb Needling Procedure Augmented with Continuous Infusion

PURPOSE

To investigate long-term outcomes of a modified bleb needling technique performed in the operating room in controlling intraocular pressure (IOP) and to report risk factors for procedure failure.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

One hundred six eyes of 98 consecutive patients undergoing intraoperative bleb needling with a continuous infusion of balanced salt solution at the Wilmer Eye Institute, Johns Hopkins Hospital, in the setting of a failed trabeculectomy or express shunt, between May 2011 and December 2015.

METHODS

Postoperative data were collected between May 2011 and August 2019. Success was defined as achieving a previously determined target IOP regardless of (qualified success) or without (complete success) glaucoma medications. Patients who underwent additional glaucoma surgery were censored in the survival analysis.

MAIN OUTCOME MEASURES

Primary outcome measures included IOP, attainment of target IOP, and number of glaucoma medications used at different time points pre- and post-operatively.

RESULTS

Needling was performed in 106 eyes at an average of 4.3 years from the time of trabeculectomy (standard deviation [SD], 6.5 years) and an average baseline IOP of 20.7 mmHg (SD, 7.2 mmHg). Further glaucoma surgery was required for 33 eyes. We observed a 70% qualified success rate with a mean IOP lowering of 25% (95% confidence interval [CI], 13.8%-36.4%) at 1 year after surgery and a 52% qualified success rate and 44.3% reduction in IOP (95% CI, 34.9%-53.6%) at 5 years after surgery. Nearly half and a third of the eyes did not require medications after 1 and 5 years, respectively. The average medication reduction was 0.8 at year 1 (95% CI, 0.5-1.1) and 0.4 at year 5 (95% CI, -0.2 to 1.0). Postoperative complications were uncommon. Poorer outcomes were not associated with the age of the bleb but were more likely in Black patients.

CONCLUSIONS

Reductions in IOP were maintained in most patients over the long term using a modified bleb needling technique, despite an average time from trabeculectomy of over 4 years. No significant adverse events were observed. Bleb needling may defer or avoid more invasive procedures such as tube-shunts or repeat trabeculectomy.

Characteristics of the Filtering Bleb and the Agreement between Glaucoma Specialist and Anterior Segment-Optical Coherence Tomography Assessment

INTRODUCTION

This study aimed to evaluate the characteristics of the filtering bleb in failed late trabeculectomy and the agreement between glaucoma specialist assessment and anterior segment-optical coherence tomography (AS-OCT) system assessment in terms of the presence of subconjunctival fluid in the filtering bleb.

METHODS

Patients with a diagnosis of glaucoma who were scheduled to undergo trabeculectomy in at least one eye and with uncontrolled intraocular pressure (IOP) were enrolled. All participants underwent a complete ophthalmological examination. The presence of fluid under the filtering bleb was first evaluated by a glaucoma specialist using biomicroscopy evaluation and then using the OCT 1000 AS-OCT Version 3.0.1.8 (Carl Zeiss Meditec, Dublin, CA, USA) system. A Kappa statistical test was used to evaluate the agreement between AS-OCT and the examiner. The correlation between conjunctiva and tenon thickness and clinical parameters was also assessed.

RESULTS

Forty eyes of 40 patients were evaluated in this study. The ages ranged from 21 to 86 years, with a mean of 66.55 ± 12.33. The average IOP was 21.20 ± 4.44 mm Hg (range 14-38 mm Hg) in the entire group. The mean thickness of the conjunctiva and tenon was 302.03 ± 406.76 µm (range 251-1,616 µm). There was a significant negative correlation between the mean thickness of the conjunctiva and tenon and IOP (p = 0.045; confidence interval = -0.558, 0.024). Additionally, there was a significant negative correlation between the mean thickness of the conjunctiva and tenon, and the number of medications used at baseline (p = 0.043; confidence interval = -0.538, 0.051). There was significant negative correlation between the horizontal measurement of the bleb and the use of glaucoma medications (p = 0.017; confidence interval = -0.560, 0.004). A total of 26 patients were determined to have fluid by the examiner (glaucoma expert), and the presence of fluid in AS was confirmed in 19 patients by AS-OCT. Of the 14 patients who were determined to have an absence of fluid, this was confirmed by AS-OCT in 7 patients (Kappa = 0.231; agreement of 65.00%).

CONCLUSION

There is fair agreement between glaucoma specialist assessment and AS-OCT assessment in terms of the presence of fluid in trabeculectomy. Our findings highlight the importance of AS-OCT in some patients before deciding upon a new intervention.

Development of an Infrared Monitor-Guided Bleb Revision Procedure

The needle revision procedure to address failing filtering blebs is a blind technique that might easily damage the scleral flap, conjunctiva, and choroid. We propose a new surgical procedure, infrared monitor-guided bleb revision, to perform bleb revision minimally invasively and effectively, and demonstrate the procedure in a patient. We developed the guided procedure with the infrared monitor to observe the bleb interior with greater contrast. Under the monitor, we dissect the hard fibrotic tissue with a bleb knife and, if necessary, remove adhesions using a needle and vitreous forceps. Finally, 5-fluorouracil is injected into the subconjunctiva. We have performed bleb revisions safely with clear visualization of the scleral flap using an infrared light. In the current case, the patient had good intraocular pressure control for about 1 year. The new infrared monitor-guided bleb revision procedure facilitates successful bleb revisions without damage to the underlying structures.

Needling with 5-fluorouracil for encapsulated blebs after Ahmed glaucoma valve implantation

Objective: To evaluate the efficacy of 5-fluorouracil (5-FU) needling of encapsulated blebs (EBs) after Ahmed glaucoma valve (AGV) implantation in patients with medically uncontrolled secondary glaucoma. Methods: Thirty-eight eyes of 37 patients who underwent AGV implantation due to secondary glaucoma with EB were recruited in this retrospective non-randomized study. 5-FU needling (0.1 mL of 50 mg/mL) was performed for the restore of the aqueous outflow. Success after needling was defined as last intraocular pressure (IOP) ≤21 mmHg or ≥6 mmHg (with or without the use of antiglaucoma medication) without loss of light perception. Results: The mean follow-up time was 14.5 ± 8.5 (5-36) months after needling. The mean interval between the AGV implantation and the needling was 10.2 ± 7.5 (2-32) weeks. Patients were examined after needling at the 2nd hour, 1st week, 1st month, 3rd month, 6th month, and at the final visit. The success rates were 84.2%, 94.7%, 94.7%, 86.8%, 83.3%, and 71.1%, respectively. The Kaplan-Meier survival analysis revealed 96.4%, 77.4%, and 60.3% cumulative predictive success rates for the 6th, 12th, and 24th months, respectively. The mean IOP before needling was 28 ± 8.4 mmHg. At the final visit, the mean IOP was 18.1 ± 7.5 mmHg (p ≤ 0.001). Complications after needling included Seidel without hypotony (three eyes, 7.9%), hyphema (one eye, 2.6%), and decompression retinopathy (one eye, 2.6%). Neovascular glaucoma was the only factor that affected efficacy of treatment negatively (p = 0.003). Conclusions: Bleb needling with 5-FU seems to be a safe and effective method in patients with EB formation after AGV implantation in secondary glaucoma cases.

Needle revision outcomes after glaucoma filtering surgery: survival analysis and predictive factors

Purpose:

To evaluate the efficacy and safety of needle revision and examine factors predictive of failure.

Methods:

In total, 157 eyes of 131 patients that underwent needle revision augmented with either 5-fluorouracil or betamethasone for trabeculectomy failure were included in this retrospective study. Complete failure was defined as additional glaucoma surgery, ciliodestructive procedures, loss of light perception, sight-threatening complications, hypotony maculopathy, and surgical bleb revision. Success was defined as intraocular pressure ⩽ 18 (criterion A), ⩽15 (criterion B), and ⩽12 mmHg (criterion C) reached with (qualified) or without (complete) medications, and absence of any criteria of complete failure.

Results:

The median (interquartile range) follow-up was 25.0 (41.0) months. Complete failure rates were 19%, 26%, and 31% at 1, 2, and 3 years, respectively. For criterion A, qualified and complete success rates were, respectively, 77% and 69% at 1 year, 66% and 51% at 2 years, and 60% and 47% at 3 years. For criterion B, qualified and complete success rates were, respectively, 67% and 61% at 1 year, 48% and 42% at 2 years, and 44% and 39% at 3 years. For criterion C, qualified and complete success rates were, respectively, 43% and 41% at 1 year, 27% and 25% at 2 years, and 24% and 23% at 3 years. High baseline intraocular pressure and primary surgery were associated with higher and lower risks of complete failure, respectively.

Conclusion:

Needle revision is an effective and safe procedure to rescue failing trabeculectomy postponing or avoiding further glaucoma surgery. Eyes with low target intraocular pressure may have poor long-term outcomes.

Four-year results of a minimally invasive transscleral glaucoma gel stent implantation in a prospective multi-centre study

Importance

The transscleral XEN Glaucoma Gel Microstent (XEN‐GGM, Allergan Plc., Parsippany, New Jersey) is implanted by a minimally invasive ab interno technique.

Background

The present study aims to assess the long‐term clinical outcomes in patients after XEN‐GGM implantation.

Design

This prospective, non‐randomized, multi‐centred study was conducted in three countries (Austria, Canada and Germany).

Participants

Sixty‐four consecutive eyes of 64 patients with open angle glaucoma received the XEN‐GGM (63 μm) without Mitomycin C. Thirty‐five (55%) were solo procedures, and 29 (45%) were combined with cataract surgery.

Methods

Visits were planned at baseline, 6 months, 1, 2, 3 and 4 years postoperatively.

Main Outcome Measures

The main outcome measures were mean intraocular pressure (IOP), mean number of IOP lowering medication. Secondary outcome parameters were: visual acuity, visual fields and complete surgical failure (defined as presence of a secondary IOP lowering procedure or loss of light perception) at 4 years, postoperatively.

Results

Mean best‐medicated baseline IOP was 22.5 ± 4.2 mmHg and decreased significantly to 13.4 ± 3.1 mmHg 4 years postoperatively (−40%, n = 34, P < 0.001). Mean number of IOP lowering medication decreased significantly from 2.4 ± 1.3 preoperatively to 1.2 ± 1.3 (−50%, n = 34, P < 0.001) postoperatively. Visual field mean deviation showed no significant change between preoperative and postoperative examinations. Complete surgical failure rate per year was 10%.

Conclusions and Relevance

The XEN‐GGM resulted in lower IOP and a reduction in medications from baseline over 4 years of follow‐up. There was no detectable decrease in visual fields over the study. The surgical failure rate is comparable to other filtration surgeries.

Evolution of Glaucoma Surgery in the Last 25 Years

Glaucoma is a chronic neurodegenerative optic nerve disease. Treatment is intended to prevent the development and progression of optic nerve damage by lowering intraocular pressure (IOP). Current therapy options include topical/systemic drugs that increase aqueous humor outflow or decrease its production, laser therapy that targets the trabecular meshwork and ciliary body, and incisional surgery. Trabeculectomy as well as glaucoma drainage devices are often performed, given their high efficacy in lowering IOP. However, the significant risk profile with potential sight-threatening complications has motivated glaucoma experts to create alternative surgeries to treat glaucoma. Minimally invasive glaucoma surgery (MIGS) is defined by: micro-invasive approach, minimal tissue trauma, high safety profile, and rapid recovery. The new devices might promote an earlier transition from medical/laser therapy to surgery, and therefore decrease the side effects associated with long-term use of topical medications as well as deal with the limited adherence of patients to their regimens. This review presents the surgical options available for glaucoma patients and their evolution over the past 25 years.

Transconjunctival Revision With Mitomycin-C Following Failed Trabeculectomy

PURPOSE

To evaluate the efficacy of transconjunctival revision (TCR) with mitomycin-C (MMC) following failed trabeculectomy.

MATERIALS AND METHODS

The medical records of 27 patients (27 eyes) who underwent TCR with subconjunctival injection of MMC by a single surgeon between September 2001 and August 2013 were retrospectively reviewed. The same surgical protocol was followed for all patients. Revision was performed using a microvitreoretinal blade through a small conjunctival incision. Main outcome measures included visual acuity, intraocular pressure (IOP), and number of glaucoma medications. Failure was defined as an IOP<5 or >14 mm Hg, loss of light perception, or need for additional glaucoma surgery.

RESULTS

Mean interval between trabeculectomy and TCR was 56.4±57.2 months. Mean preoperative IOP was 21.9±6.8 mm Hg using 4.0±1.2 glaucoma medications. Fifteen (55.6%) patients met success criteria. At most recent follow-up, mean IOP and number of glaucoma medications for successful patients were 9.7±3.8 mm Hg and 0.6±1.1, respectively. Kaplan-Meier analysis revealed 1-, 2-, and 3-year success rates of 62%, 58%, and 53%, respectively. Three additional patients achieved success after undergoing a second TCR, and 1 patient achieved success after a third TCR. Postoperative complications included transient choroidal effusion (n=8), shallow anterior chamber requiring reformation (n=5), 5-fluorouracil-related corneal epitheliopathy (n=10), and bleb leak (n=1).

CONCLUSIONS

TCR with adjunctive MMC is a safe and effective procedure following failure of a trabeculectomy. More than 1 revision may be necessary to achieve long-term IOP reduction.

Needle Revision With 5-fluorouracil for the Treatment of Ahmed Glaucoma Valve Filtering Blebs: 5-Fluoruracil Needling Revision can be a Useful and Safe Tool in the Management of Failing Ahmed Glaucoma Valve Filtering Blebs

PURPOSE

To determine the outcome of needling with adjunctive 5-fluorouracil (5-FU) in patients with a failing Ahmed glaucoma valve (AGV) implant, and to identify predictors of long-term intraocular pressure (IOP) control.

METHODS

A prospective observational study was performed on consecutive patients with medically uncontrolled primary open-angle glaucoma (POAG) with AGV encapsulation or fibrosis and inadequate IOP control. Bleb needling with 5-FU injection (0.1 mL of 50 mg/mL) was performed at the slit-lamp. Patients were examined 1 week following the needling, and then at months 1, 3, and 6. Subsequent follow-up visits were scheduled at 6-month intervals for at least 2 years. Needling with 5-FU was repeated no more than twice during the first 3 months of the follow-up. Procedure outcome was determined on the basis of the recorded IOP levels.

RESULTS

Thirty-six patients with an encapsulated or fibrotic AGV underwent 67procedures (mean 1.86 ± 0.83). Complete success, defined as IOP ≤ 18 mm Hg without medications, was obtained in 25% at 24 months of observation. The cumulative proportion of cases achieving either qualified (ie, IOP ≤ 18 mm Hg with medications) or complete success at 24 months of observation was 72.2%. In a univariate Cox proportional hazards model, age was the only variable that independently influenced the risk of failing 5-FU needling revision. Fourteen eyes (38.8%) had a documented complication.

CONCLUSIONS

Needling over the plate of an AGV supplemented with 5-FU is an effective and safe choice in a significant proportion of POAG patients with elevated IOP due to encapsulation or fibrosis.

Outcomes of Bleb Revision With Mitomycin C After Ex-PRESS Shunt Surgery

PURPOSE

Investigate efficacy and safety of bleb revision using mitomycin C after Ex-PRESS shunt surgery.

PATIENTS AND METHODS

We performed chart reviews of 36 consecutive eyes from 34 patients with previous Ex-PRESS shunt surgery who underwent subsequent bleb revision with mitomycin C. The mean follow-up time was 13.5 months. The primary outcome measure was surgical success. Secondary outcomes included visual acuity, intraocular pressure, number of medications, and complications.

RESULTS

Twenty-four eyes had open-angle glaucoma (61.1%). Mean time from Ex-PRESS to bleb revision was 8.8 months. Complete success rate for the immediate 3-month postoperative period was 94.4% and qualified success rate was 97.2%. Complete and qualified success rates for the entire follow-up period were 40% and 65.7%, respectively. Visual acuity remained stable throughout the study period, and at 1 year, average intraocular pressure was 14.7 mm Hg on an average of 1.7 medications. No major complications were reported.

CONCLUSIONS

Bleb revision in eyes with an Ex-PRESS shunt is a safe and efficacious procedure. The surgical outcomes are within the range of published outcomes for bleb needling after trabeculectomy. Further research with larger sample size and longer follow-up is needed to confirm these results.

Results From a Modified Bleb Needling Procedure With Continuous Infusion Performed in the Operating Room

PURPOSE

Needling of a scarred trabeculectomy bleb is often performed in the office using a slit-lamp microscope as an alternative to additional surgery to lower intraocular pressure (IOP). However, the success rate in an office setting is highly variable, with reported success rates as low as 13%. We report a retrospective assessment of an intraoperative needling technique for reviving failed blebs.

DESIGN

A retrospective chart review.

PARTICIPANTS

Patients undergoing the intraoperative modified bleb revision technique in the setting of a failed trabeculectomy due to scarring at the Wilmer Eye Institute, Johns Hopkins Hospital between August 16, 2010 and August 29, 2012.

METHODS

Patients with uncontrolled IOP were operated on using a modified bleb needling technique. In this technique, a 25-G infusion cannula is placed in the anterior chamber and fibrotic adhesions within the bleb are lysed with a 25-G needle. The continuous infusion of balanced salt solution from the anterior chamber causes bleb elevation, which helps to guide the endpoint of lysis for the procedure. A subconjunctival injection of 5-fluorouracil is given at the conclusion of each case.

MAIN OUTCOME MEASURES

IOP reduction and number of glaucoma medications at postoperative day 1, week 1, month 1, month 3, month 6, and month 12.

RESULTS

A total of 33 eyes of 30 patients were included. At the visit before the procedure, the mean (±SD) IOP was 22.1±9.2 (range, 11 to 58) and subjects were using an average of 2.3±1.4 (range, 0 to 4) glaucoma medications. The mean IOP reduction was 8.7 mm Hg [95% confidence interval (CI), 5.6-11.8] at postoperative day 1, 8.1 mm Hg (95% CI, 4.0-12.3) at week 1, 8.9 mm Hg (95% CI, 5.3-12.5) at month 1, 8.1 mm Hg (95% CI, 4.2-12.0) at month 3, 8.2 mm Hg (95% CI, 3.9-12.5) at month 6, and 6.2 mm Hg (95% CI, 3.6-8.7) at month 12. IOP was reduced about 30% to 40% compared with baseline at each time point (P<0.05). The average reduction in medications used was 1.7 at day 1, 1.0 at month 1, 1.2 at month 3, 1.5 at month 6, and 0.5 at month 12. Seven patients underwent repeat needling. Overall, 64% of subjects maintained IOP at or below their target after 12 months.

CONCLUSIONS

A modified bleb needling procedure performed in the operating room can successfully lower IOP in the setting of a previous trabeculectomy in over 60% of subjects a year after the procedure.

Outcomes: Trabeculectomy Bleb Needle Revision With 5-Fluorouracil

PURPOSE

To evaluate outcomes of trabeculectomy bleb needle revision with 5-fluorouracil augmentation performed in the operating theater.

METHODS

Retrospective study of all patients undergoing trabeculectomy bleb needle revisions in the operating theater performed by a single surgeon in a metropolitan hospital in Australia. A total of 51 needle revisions were performed on 33 eyes over a mean follow-up time of 1.81±1.56 years.

RESULTS

A total of 29% achieved intraocular pressure (IOP) ≤20 mm Hg off all glaucoma medications, and an additional 39% achieved qualified success with the addition of glaucoma medications, giving overall success of 68%. Analyzing success rate for target IOP≤16 mm Hg, 24% achieved target off all glaucoma medications, 35% achieved qualified success with the addition of glaucoma medications, giving an overall success rate of 59%. There was a statistically significant improvement in IOP, as compared with preoperative levels, at all timepoints postoperatively (P<0.05). However, number of glaucoma medications remained unchanged (P>0.05) contributing to the high percentage of qualified successes. Visual acuity remained unchanged and there were no major postoperative complications. The Kaplan-Meier survival shows a survival rate of 60% with IOP≤20 mm Hg and 40% for IOP≤16 mm Hg at 5 years.

CONCLUSIONS

Trabeculectomy needle revision is a useful option for the management of elevated IOP in the presence of a failed or failing trabeculectomy bleb. However, as with trabeculectomy, there tends to be a failure rate over time. This often leads to reinstitution of glaucoma medications and/or further needle revisions to maintain IOPs at target level. The procedure itself is minimally invasive with an acceptable safety profile.

Anatomic and physiologic rationale to be applied in accessing the suprachoroidal space for management of glaucoma

This review examines the anatomic and physiologic rationale for accessing the suprachoroidal space in the management of glaucoma. The potential benefits and limitations of past and present attempts to tap into the intraocular pressure-lowering effects of the suprachoroidal space are highlighted.

FINANCIAL DISCLOSURE

The author has no financial or proprietary interest in any material or method mentioned.

Effects of topical bevacizumab application on early bleb failure after trabeculectomy: observational case series

Background

The aim of this study was to evaluate the influence of topical bevacizumab on the formation and function of filtering blebs in eyes with early bleb failure after antiglaucoma surgery.

Methods

Of all patients who underwent mitomycin-augmented trabeculectomy for glaucoma in the Department of Ophthalmology at the Medical University in Lublin, Poland, between March 2009 and March 2010, a total of 21 eyes from 20 patients with injected filtration bleb 9.8 ± 4.7 days after surgery were included in this observational case series. All patients were treated with standard steroid therapy and topical bevacizumab 5 mg/mL five times a day for 20.9 ± 9.8 days. Patients were followed up every other day, and a full eye examination was performed 14, 30, 60, and 180 days after initiation of treatment. Blebs were evaluated for vascularity by slit-lamp examination with concomitant photographic documentation and intraocular pressure measurement.

Results

Elevated functional bleb with significantly reduced vascularity was present in 16 eyes, and was flat and nonfunctional in five eyes. Intraocular pressure in all eyes decreased from a mean of 26.6 ± 9.6 mmHg before surgery to 14.6 ± 7.7 mmHg and 15.8 ± 8.3 mmHg at 2 and 6 months after surgery, respectively. Filtration bleb leak was noted in three eyes while on treatment with bevacizumab.

Conclusion

Topical application of bevacizumab might favor functional bleb formation after trabeculectomy in eyes with a high risk of failure.

A Potential Application of Canaloplasty in Glaucoma Gene Therapy

Canaloplasty, a recently developed non-penetrating glaucoma surgical approach, may restore physiological outflow routes in primary open-angle glaucoma with less risk of severe postoperative complications than trabeculectomy. Since the inner wall of Schlemm's canal (SC) is directly in contact with the trabecular meshwork (TM) for 360 degrees and the catheter device used in canaloplasty allows viscoelastic to be injected into the entire length of SC, canaloplasty might also be used to perform SC/TM-targeted delivery of transgene vectors for glaucoma gene therapy. This hypothesized new method for transgene delivery may give the transgene access to the entire inner wall of SC and the whole juxtacanalicular region of the TM and allow the transgene to be expressed in both the TM and SC without affecting the cornea, iris and ciliary body. Further, this strategy might have a greater trabecular outflow resistance-decreasing effect than either the genetic or surgical approach alone.

Expanded indications for transconjunctival trabeculectomy flap suturing: postoperative choroidal effusion and dysesthesia

OBJECTIVE

To assess the efficacy of transconjunctival trabeculectomy flap suturing (TTFS) in improving choroidal effusions and bleb dysesthesia resulting from overfiltration after trabeculectomy.

DESIGN

Retrospective review.

PARTICIPANTS

The study involved 15 eyes of 15 patients.

METHODS

Patients underwent TTFS for choroidal effusions and bleb dysesthesia following trabeculectomy using mitomycin C. The scleral flap was sutured through the conjunctiva as an outpatient clinic procedure.

RESULTS

There were 11 patients who had choroidal effusions and 4 patients were identified with dysesthesia. The average duration of choroidal effusion prior to TTFS was 2.1 ± 2.3 months and 3 ± 2 months in the dysesthesia group. At the final follow-up (25 ± 17 months) the mean intraocular pressure improved from 4.1 ± 2.1 mm Hg before suturing to 8.1 ± 3.6 mm Hg (p < 0.007) for the patients with choroidal effusion and from 4.2 ± 0.6 mm Hg to 8. 7 ± 3.5 mm Hg (p = 0.05) for the patients with dysesthesia. In both groups, resolution of the signs and symptoms was achieved in all cases. The mean time to resolution of choroidal effusions was 5.5 ± 8.6 weeks and the mean time to resolution of dysesthesia was 2 ± 0.8 weeks. None of the patients had serious complications such as failure of the trabeculectomy or visual loss.

CONCLUSIONS

Transconjunctival suturing of the trabeculectomy scleral flap is a simple and effective surgical method for the treatment of cases of choroidal effusions or dysesthesia resulting from trabeculectomy.

Five-year results of 5-fluorouracil augmented needling revision of failing blebs

BACKGROUND AND OBJECTIVE

To report the 5-year intraocular pressure (IOP) outcomes of patients requiring a 5-fluorouracil (5-FU) needling revision compared to a matched sample.

PATIENTS AND METHODS

Forty eyes receiving 5-FU bleb needling revision were matched to 40 patients not needled. IOP was recorded preoperatively and annually to 5 years. The main outcome measure was surgical success: IOP control without medications or surgery.

RESULTS

Thirty-two patients with 5-FU needling revision (80.0%) required anti-glaucoma medication postoperatively versus 28 control patients (70%) (P > .05). Thirty-two patients with 5-FU needling revision were complete or qualified successes compared to 36 control patients (P = .34). Eight patients with 5-FU needling revision (20%) had a reoperation versus 4 control patients (10%) (P > .05).

CONCLUSION

5-FU needling revision can produce long-term IOP control levels similar to those who did not require the procedure. No statistically significant differences between the two groups was seen in either the use of medications or further surgery.

Needling augmented with topical application of mitomycin C for management of bleb failure

PURPOSE

To study the effect of topical application of mitomycin C on enhancing the efficacy of needling in the management of bleb failure.

PATIENTS AND METHODS

Thirty-six eyes of 32 consecutive patients with an intraocular pressure over 21 mmHg, without bleb or with a thick, flat bleb after the second postoperative month after trabeculectomy, were included in the study. Needling with mitomycin C was performed in the other 18 eyes with bleb failure (group A) and needling without antimetabolite was performed in 18 eyes (group B). Topical application of mitomycin C (0.4 mg/mL) with a microsponge over the conjunctiva at the failed bleb for 5 minutes (group A) was performed; after irrigation, the needling procedure was the same in both groups. A 30-gauge needle was used to perforate the area of subconjunctival and subscleral fibrosis and to reestablish flow; conjunctival puncture was at least 7 mm away from the bleb and no sutures were taken after needling. Follow-up was performed for 1 year after needling.

RESULTS

Overall, 55 needling procedures were performed; needling was done twice in 17 eyes in group B, whereas only 2 eyes needed more than 1 needling procedure in group A. The difference was statistically highly significant, and the mean follow-up was 8.9 ± 3.7 months. Mean intraocular pressure was 28.9 ± 4.2 mm Hg and 27.8 ± 4.7 mm Hg in group A and group B respectively before any intervention; this decreased to a mean of 19.8 ± 2.7 mm Hg and 20.5 ± 4.8 mm Hg respectively without medication after 6 months of last needling. Complications included diffuse corneal punctate epitheliopathy lasting for 2 to 3 weeks (2 eyes in group A), subconjunctival hemorrhage (3 eyes in each group), and hyphema (2 eyes in each group).

CONCLUSIONS

Topical application of mitomycin C with needle revision seems to be an extremely effective way to revive failed filtration surgery. The incidence of complications related to mitomycin C was minimal.

Glaucoma surgery

Glaucoma is a potentially blinding condition that cannot be easily defined. There are various types of glaucoma which may vary in symptoms from none at all to sudden pain and redness. There is a characteristic optic neuropathy, or damage to the optic nerve, which results in progressive loss of visual field. The most important risk factor is an increase in the intraocular pressure (IOP) secondary to a reduction in the drainage of aqueous fluid from the drainage pathways in the eye, the filtration angle (Kanski 2007, Allingham et al 2011).