National survey of antimetabolite use in glaucoma surgery in the United Kingdom

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.

History, presence, and future of mitomycin C in glaucoma filtration surgery

PURPOSE OF REVIEW

Mitomycin C (MMC) is an alkylating agent with extraordinary ability to crosslink DNA, preventing DNA synthesis. By this virtue, MMC is an important antitumor drug. In addition, MMC has become the gold standard medication for glaucoma filtration surgery (GFS). This eye surgery creates a passage for drainage of aqueous humor (AqH) out of the eye into the sub-Tenon's space with the aim of lowering the intraocular pressure. A major cause of failure of this operation is fibrosis and scarring in the sub-Tenon's space, which will restrict AqH outflow. Intraoperative application of MMC during GFS has increased GFS success rate, presumably mainly by reducing fibrosis after GFS. However, still 10% of glaucoma surgeries fail within the first year.

RECENT FINDINGS

In this review, we evaluate risks and benefits of MMC as an adjuvant for GFS. In addition, we discuss possible improvements of its use by adjusting dose and method of administration.

SUMMARY

One way of improving GFS outcome is to prolong MMC delivery by using a drug delivery system.

National survey of intraoperative mitomycin C use during trabeculectomy surgery in the UK

PURPOSE

Mitomycin C is a routinely used antimetabolite which effectively limits the scarring process. Conventionally, the intra-operative technique of MMC delivery during trabeculectomy is the direct application of the soaked sponges. The aim of this study is to evaluate the current practice of delivering MMC during trabeculectomy and to see the practices related to a retained MMC swab during trabeculectomy in the UK.

METHODS

An electronic questionnaire of 8 questions regarding the intraoperative use of MMC during trabeculectomy surgery was emailed to 69 ophthalmologist members of the UK and Eire glaucoma society (UKEGS) through email in July 2019.

RESULTS

97.2% of the surveyed glaucoma surgeons said they use MMC during trabeculectomy routinely, while 2.9% said they never use MMC for trabeculectomy. In reply to a question 'Have you ever had a retained MMC-soaked sponge/fragment of sponge', 11.76% replied 'yes', 88.24% said 'No'. In response to what technique was employed at the time of retained MMC sponges, all the respondents said they had employed the same technique of 'multiple individual sponges'. 47.1% surgeons said they use multiple individual sponges on being asked what technique they currently employ for delivering MMC during trabeculectomy surgery, while 14.7% surgeons use multiple sponges linked with a 'necklace suture' and 5.9% inject MMC.

CONCLUSION

Our survey suggests the intra-operative MMC use in the UK is high and that unintentional MMC-soaked swab retention does occur, albeit rarely. A preference of using the MMC-soaked swabs as a delivery method of MMC is seen in our survey.

Learning from the past: Mitomycin C use in trabeculectomy and its application in bleb-forming minimally invasive glaucoma surgery

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.

Bleb Needling with Mitomycin C as Adjunctive Therapy in Failing Blebs: A Retrospective Study

PURPOSE

To evaluate the effects and complications related to use of mitomycin C (MMC) as an adjunctive therapy in bleb needling.

METHODS

Retrospective review of the records of patients affected by open-angle glaucoma who underwent a bleb revision as a treatment for failed trabeculectomy. All subjects underwent surgery with a fornix-based approach to incision. Full baseline data for each patient included a comprehensive ocular and medical history, the patient's Snellen visual acuity test results, and Goldmann applanation tonometry test results. Data were reported following observations occurring at 6, 12, 18, 24, and 30 months. In addition, the number and timing of needling with or without MMC subconjunctival injections and any short- and long-term complications were observed.

RESULTS

We included 101 patients, 56 (55.4%) male and 45 (44.6%) female. The mean age was 69.81 ± 16.19 years (range 28-92). Statistically significant effects of needling and needling and MMC (p values <0.05) in the decrease in intraocular pressure were observed. Three (2.9%) patients presented hypotony at the last follow-up visit. No other complications were observed.

CONCLUSIONS

Needling bleb revision augmented with the use of MMC appears to be a more useful tool in the management of failing bleb.

Bleb-associated endophthalmitis: Proportion, presentation, management and outcomes in Victoria, Australia

IMPORTANCE

Bleb-associated endophthalmitis is a potentially vision-threatening complication of trabeculectomy. With improvements in surgical technique and changing patterns of intraoperative antimetabolite use, a re-evaluation of the incidence of bleb-associated endophthalmitis is warranted.

BACKGROUND

To investigate changes in the incidence, presentation, management and outcomes of bleb-associated endophthalmitis between 1997 and 2015 in Victoria, Australia.

DESIGN

A retrospective cohort analysis.

PARTICIPANTS

Consecutive cases of bleb-associated endophthalmitis managed at the Royal Victorian Eye and Ear Hospital (RVEEH) between 1997 and 2015.

METHODS

Medical record review of consecutive cases of bleb-associated endophthalmitis and statistical analysis were performed.

MAIN OUTCOME MEASURES

Visual acuity, including loss of light perception, intraocular pressure, and need for further surgery.

RESULTS

Sixty-seven eyes with bleb-associated endophthalmitis (BAE) were identified. Of these, 41 had trabeculectomy performed in Victoria during the study period, over which time 11 129 trabeculectomies were performed. The proportion of BAE was stable over time (0.4%). The mean age at presentation was 73.7 ± 12.1 years old and the majority of patients were Caucasian (79.1%). The mean duration between glaucoma filtration surgery and the development of bleb-associated endophthalmitis was 3 years (Interquartile Range = 0.4-6.0 years). The cultures were positive in 71.6% of cases. Approximately 1 in 8 patients required enucleation. The final visual acuity was poor with a Snellen Visual Acuity (VA) of 6/60 or worse in two-thirds of patients.

CONCLUSIONS AND RELEVANCE

Bleb-associated endophthalmitis is an uncommon complication following glaucoma filtration surgery. The proportion has remained stable over time. Visual outcomes remain poor.

Short-term change in higher-order aberrations after mitomycin-C-augmented trabeculectomy

PURPOSE

To investigate the changes in ocular higher-order aberrations (HOA) after trabeculectomy using mitomycin-C (MMC).

METHODS

We retrospectively reviewed data for 63 eyes from 63 glaucoma patients who had undergone MMC augmented trabeculectomy. We measured intraocular pressure (IOP), refractive errors, anterior chamber depth (ACD), and HOA before surgery and 1, 2, and 4 weeks postoperatively. The patients were divided into two groups on the basis of preoperative lens status: phakic and pseudophakic group. We used a paired t test to compare preoperative and postoperative HOA values. Regression analysis was used to compare higher-order total (HOT) change and factors including ACD and age.

RESULTS

For entire eye aberrations, coma-like and total HOT were significantly increased postoperatively at 1 week (P = 0.029, P = 0.005, respectively), but not after 2 or 4 weeks in the phakic group and were not significant at any time in the pseudophakic group. Corneal HOA were significantly increased postoperatively after 1, 2 weeks, but not after 4 weeks in the phakic group and were not significant in the pseudophakic group. For internal optics aberrations, HOA were significantly increased postoperatively at 1, 2, and 4 weeks in the phakic group, but were not significant at any time in the pseudophakic group. However, HOT aberration change showed no correlation with age, ACD, IOP change in either group.

CONCLUSION

Following trabeculectomy, HOA changes were significantly increased postoperatively at 1, 2 weeks in the phakic group. Therefore, visual complaint-related HOA changes after trabeculectomy may be more profound in phakic patients.

Understanding practice patterns of glaucoma sub-specialists in India

AIM

To obtain information on the prevailing practice patterns of glaucoma specialists in India.

METHODS

Glaucoma specialists attending the Annual Conference of the Glaucoma Society of India (GSI) were surveyed. This survey, conducted in 2013, was based on an interactive audience response system.

RESULTS

The information was obtained from 146 glaucoma specialists. Approximately half (n=83; 57%) had ≥10y of experience in managing glaucoma and were in institutional practice (n=74, 51%). Goldmann applanation tonometry was preferred by 103 (72%) specialists whilst n=25 (17.4%) used non-contact tonometer. Indentation gonioscopy was favoured by two-thirds (n=90, 66%) whereas stereoscopic optic disc examination and visual fields using Humphrey perimeter was performed by a majority of the specialists surveyed (n=115, 86% and n=114; 83% respectively). Nearly three quarter specialists (n=96; 72%) preferred optical coherence tomography for imaging. The primary choice for treatment of angle closure disease and primary open angle glaucoma was laser (iridotomy, n=117; 93%) and medical management (prostaglandin analogue, n=104; 78%), respectively. Approximately only a third of the specialists surveyed (n=37; 28%) were performing both trabeculectomy and implantation of a glaucoma drainage device and about half (n=64; 47%) were not operating on congenital glaucoma at all.

CONCLUSION

This survey has found conformance with preferred practice patterns in several areas of diagnosis and management of glaucoma, but there was diversity in a few areas. The information is a significant step towards improvement of glaucoma care in India, including planning for future strategies.

Prevalent practice patterns in glaucoma: Poll of Indian ophthalmologists at a national conference

Purpose:

The aim of this study is to explore and compare the prevailing practice patterns in the diagnosis and management of glaucoma among subspecialists and general ophthalmologists in India.

Materials and Methods:

This is an interactive audience response system (ARS) based poll of ophthalmologists attending the annual conference of the Glaucoma Society of India in 2013.

Results:

The information was obtained from 379 ophthalmologists (146 glaucoma specialists, 54 nonglaucoma subspecialists, and 179 general ophthalmologists). The majority of polled ophthalmologists (236; 62%) had 10 or more years of experience in ophthalmology. The glaucoma specialists differed from nonglaucomatologists in their preference for Goldmann applanation tonometer (P < 0.01), four-mirror gonioscope (P < 0.01), Humphrey perimeter (P < 0.01), laser peripheral iridotomy in primary angle closure disease (P = 0.03), postiridotomy gonioscopy (P < 0.01), and usage of antifibrotic agents during filtering surgery (P < 0.01). Optical coherence tomography was the most preferred imaging modality and was utilized more often by the subspecialists than general ophthalmologists. The ophthalmologists also differed in their choice of antiglaucoma medications. More glaucoma specialists were performing surgery on children with congenital glaucoma (P < 0.01), implanting glaucoma drainage devices (P < 0.01), and using scientific journals to upgrade knowledge (P = 0.03) than the other ophthalmologists.

Conclusions:

This poll is the first of its kind in India, in its usage of the ARS, and in comparing the practice patterns of care for glaucoma among subspecialists and general ophthalmologists. It has revealed substantial diversity in a few areas among those who did and did not receive specialty training in glaucoma.

A review of the efficacy of mitomycin C in glaucoma filtration surgery

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.

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

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.

Amniotic membrane transplantation in failed trabeculectomy

PURPOSE

To determine the efficacy and safety of amniotic membrane transplantation for trabeculectomy in patients with previous failed filtering blebs.

METHODS

A consecutive series of 19 eyes from 18 patients with 1 or more failed trabeculectomies were enrolled in this retrospective study. Trabeculectomy, with amniotic membrane positioned as a "graft" under the scleral flap, was performed, and the intraocular pressure (IOP), number of antiglaucoma medications, appearance of the filtering bleb, and intraoperative and postoperative complication data were retrospectively analyzed for a period of 24 months. Success was defined as IOP<21 mm Hg at the end of the follow-up period.

RESULTS

The median preoperative pressure was 29 mm Hg [interquartile range (IQR)=5 mm Hg], with an average of 2.8 glaucoma medications (range, 1 to 4). At 6 months postoperatively the median IOP was 18 mm Hg (IQR=1.75 mm Hg) with no further significant increases recorded, settling at 19 mm Hg (IQR=3.25 mm Hg) at the end of the 24-month follow-up. Success was achieved in all 19 cases (100%), and only 1 patient (5%) required postoperative antiglaucoma therapy to reach the target pressure. At 24 months after surgery, 18 of 19 (95%) amniotic membrane filtering blebs were functioning well without antiglaucoma therapy. No patients had severe intraoperative or postoperative complications.

CONCLUSIONS

Amniotic membrane transplantation in trabeculectomy seems to be a safe and useful procedure for improving the surgical outcome and maintaining low postoperative IOP in patients with a high risk of surgical failure.

[Long-term results after trabeculectomy with 5-fluorouracil]

PURPOSE

Trabeculectomy is among the first choice surgical treatments for glaucoma. Antimetabolites, especially mitomycin C, have improved the success rate. The aim of this study is to present the results of trabeculectomy with 5-fluorouracil (5-FU).

METHODS

A total of 71 consecutive trabeculectomies with 5-FU for decompensated glaucoma with at least 1 year follow-up data were retrospectively evaluated. The absolute (without therapy) and relative (with therapy) success rates for glaucoma medication were determined for intraocular pressure (IOP) levels of ≤ 21 mmHg, ≤ 18 mmHg, ≤ 15 mmHg and ≤ 12 mmHg respectively. Postoperative 5-FU administration rates, needling procedures and complications were recorded.

RESULTS

Sufficient follow-up data were available for a total of 55 patients. The average IOP was preoperatively 29.6 ± 7.3 mmHg (3 ± 1.4 active ingredients, partly acetazolamide), after 6 months 13.2 ± 4.1 mmHg and after 1 year 13.7 ± 4.3 mmHg. Complete success at 6 months postoperatively for the given pressure levels: were 92 %, 87 %, 79 % and 52% and at 1 year 87 %, 84 %, 51 % and 56%, respectively. Postoperative relative success for these pressure levels at 6 months were 96 %, 90 %, 81 % and 54% and at 1 year 96 %, 93 %, 58 % and 58%, respectively. Administrations of 5-FU postoperatively were no intervention (n=30 patients), subconjunctival 5-FU administration (n=25) and needling procedures (n=6). A temporary hypotension with a shallow anterior chamber was seen in 6 patients, cataract development in 5 patients and 1 patient developed corneal decompensation (multiple previous operations before trabeculectomy).

CONCLUSION

Trabeculectomy with intraoperative 5-FU administration showed very high success rates after 1 year. Serious complications were rarely seen. Intraoperative 5-FU administration can be considered as an alternative treatment to trabeculectomy with intraoperative use of mitomycin C.

Trabeculectomy in the 21st century: a multicenter analysis

OBJECTIVE

To evaluate the efficacy and safety of current trabeculectomy surgery in the United Kingdom.

DESIGN

Cross-sectional, multicenter, retrospective follow-up.

PARTICIPANTS

A total of 428 eyes of 395 patients.

METHODS

Consecutive trabeculectomy cases with open-angle glaucoma and no previous incisional glaucoma surgery from 9 glaucoma units were evaluated retrospectively. Follow-up was a minimum of 2 years.

MAIN OUTCOME MEASURES

Surgical success, intraocular pressure (IOP), visual acuity, complications, and interventions. Success was stratified according to IOP, use of hypotensive medications, bleb needling, and resuturing/revision for hypotony. Reoperation for glaucoma and loss of perception of light were classified as failures.

RESULTS

Antifibrotics were used in 400 cases (93%): mitomycin C (MMC) in 271 (63%), 5-fluorouracil (5-FU) in 129 (30%), and no antifibrotic in 28 (7%). At 2 years, IOP (mean ± standard deviation) was 12.4 ± 4 mmHg, and 342 patients (80%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP without IOP-lowering medication, whereas 374 patients (87%) achieved an IOP ≤ 21 mmHg and 20% reduction of preoperative IOP overall. An IOP ≤18 mmHg and 20% reduction of preoperative IOP were achieved by 337 trabeculectomies (78%) without IOP-lowering treatment and by 367 trabeculectomies (86%) including hypotensive medication. Postoperative treatments included suture manipulation in 184 patients (43%), resuturing or revision for hypotony in 30 patients (7%), bleb needling in 71 patients (17%), and cataract extraction in 111 of 363 patients (31%). Subconjunctival 5-FU injection was performed postoperatively in 119 patients (28%). Visual loss of >2 Snellen lines occurred in 24 of 428 patients (5.6%). A total of 31 of the 428 patients (7.2%) had late-onset hypotony (IOP <6 mmHg after 6 months). In 3 of these, visual acuity decreased by >2 Snellen lines. Bleb leaks were observed in 59 cases (14%), 56 (95%) of which occurred within 3 months. Two patients developed blebitis. Bleb-related endophthalmitis developed in 1 patient within 1 month postoperatively and in 1 patient at 3 years. There was an endophthalmitis associated with subsequent cataract surgery.

CONCLUSIONS

This survey shows that good trabeculectomy outcomes with low rates of surgical complications can be achieved, but intensive proactive postoperative care is required.

Wound modulation after filtration surgery

Filtration surgery is the standard invasive procedure for the management of intraocular pressure in advanced glaucoma. The key to a successful outcome is to modulate the normal wound healing cascade that leads to closure of the newly created aqueous outflow pathway. Antifibrotic agents such as mitomycin C and 5-fluorouracil have been increasingly used to modulate the wound healing process and increase surgical success. Although these agents have proven efficacy, they also increase the risk of complications. Efforts have centered on the identification of novel agents and techniques that can influence wound modulation without these complications. We detail new agents and methods under investigation to control wound healing after filtration surgery.

Subscleral trabeculectomy with mitomycin-C versus ologen for treatment of glaucoma

PURPOSE

To compare the results of subscleral trabeculectomy (SST) augmented with mitomycin-C (MMC) versus Ologen™ implant regarding intraocular pressure (IOP) control and incidence of complications.

METHODS

Sixty eyes of 60 patients, who planned to undergo SST, were divided into 2 groups. Group I eyes (included thirty eyes) were operated upon with SST augmented with intraoperative MMC. Group II eyes (included 30 eyes) were operated upon with SST using an Ologen implant. IOP and bleb status, as well as reporting postoperative complications, were followed up.

RESULTS

The follow-up period was 12 months. At 12 months postoperatively, the mean IOP was 19.33±3.22 mmHg in group I, and 19.87±4.17 mmHg in group II, with no significant difference between groups. One case in each group had hyphema, and 4 cases in group I and 2 cases in group II had shallow anterior chamber. One case in group I and no cases in group II had blebitis. There was no significant difference regarding the complications between both groups.

CONCLUSION

We conclude that the use of the Ologen implant in SST is comparable to the use of MMC with advantage of avoiding the potential dangerous complications related to MMC use in the early (12 months) follow-up period.

Comparison of needle revision with subconjunctival bevacizumab and 5-fluorouracil injection of failed trabeculectomy blebs

PURPOSE

To evaluate the efficacy and complications of bevacizumab versus 5-fluorouracil (5-FU)-augmented bleb needling of failed filtration blebs following trabeculectomy.

METHODS

Twenty-seven eyes of 27 patients with bleb failure were included. Patients were randomly assigned to receive either 5-FU or bevacizumab. Needling was performed in the operating room under sterile conditions. After the needling procedure, a viscoelastic material was injected subconjunctivally around the bleb area to avoid the entrance of 5-FU or bevacizumab into the anterior chamber. Bevacizumab (1.25 mg/0.1 mL) was injected into 12 eyes and 5-FU injected into 15 eyes subconjunctivally. All of the patients were controlled weekly until a filtration bleb was maintained. Intraocular pressure (IOP), bleb appearance, and complications were noted in each group. Success was defined as absolute if the IOP 21 mmHg or less without any medication or surgical intervention at last visit, and qualified if the IOP 21 mmHg or less with topical antiglaucomatous medications. The patients were followed from 11 to 26 (median, 17) months.

RESULTS

The IOP decreased, from 31.2±3.2 mmHg to 16.1±2.1 mmHg, in the bevacizumab group on the first postoperative day. The IOP was within normal limits in 1 (8.3%) patient without medication and controlled with topical antiglaucomatous drops in 2 (16.7%) patients. The total success rate was 25% at the time of the last visit. Success was not achieved in 9 (75%) eyes. The IOP was 32.0±4.6 mmHg preoperatively and 12.2±2.6 mmHg on the first postoperative day in the 5-FU injected patients. The total success rate was 80%; 8 (53.3%) eyes showed absolute success, whereas 4 (26.7%) eyes showed a qualified success. A statistically significant difference between groups in terms of success rates was observed (P=0.04).

CONCLUSIONS

Subconjunctival 5-FU application is a more effective therapy than bevacizumab application for needling procedures in failed trabeculectomy blebs.

Comparison of the outcome of repeat trabeculectomy with adjunctive mitomycin C and initial trabeculectomy

Purpose

To compare the efficacy and safety of repeat and initial trabeculectomy with mitomycine C (MMC).

Methods

Eighty seven patients, who had underwent repeat (repeat group) or initial (initial group) trabeculectomy with MMC, were enrolled in this prospective trial. Postoperative outcome measures included the amount of decrease in intraocular pressure (IOP), the number of anti-glaucoma medications, and the complications. The success of trabeculectomy was defined on the basis of three definitions which were: IOP ≤18 mmHg (definition 1), IOP ≤21 mmHg (definition 2), and the amount of decrease in IOP from baseline ≥30% (definition 3). Success was further defined as "complete" when these criteria were obtained without any anti-glaucoma medications and "qualified" with or without medical therapy and no further surgical procedures.

Results

Fifty nine eyes underwent initial and 28 eyes underwent repeat trabeculectomy. The mean follow-up period was 19.1 ± 5.9 months. Complete success rates were significantly greater in the initial trabeculectomy group (p = 0.02 for definition 1, p = 0.038 for definition 2, p = 0.003 for definition 3). A higher proportion of eyes in the initial group achieved qualified success relative to the group A eyes, but the differences were not statistically significant (p = 0.33 for definition 1, p = 0.99 for definition 2, p = 0.24 for definition 3). The mean number of antiglaucomatous medications at the last examination was 1.2 ± 1.2 in repeat group and 0.7 ± 1.1 in initial group (p = 0.01). The number of complications during the follow up period did not differ significantly between the two groups (p = 0.65).

Conclusions

Repeat trabeculectomy with MMC has high success and low complication rates in patients with previously failed trabeculectomy in spite of the need of higher number of anti-glaucoma medications.

Attitudes of consultant ophthalmologists in the UK to initial management of glaucoma patients presenting with severe visual field loss: a national survey

BACKGROUND

Recent National Institute of Clinical Excellence guidance suggests primary surgery should be offered to patients presenting with glaucoma with severe visual field loss. We undertook a survey of UK consultant ophthalmologists to determine if this represents current practice and explore attitudes towards managing patients with advanced glaucoma at presentation.

DESIGN

Questionnaire evaluation study.

PARTICIPANTS

All consultant ophthalmologists currently practicing in the UK.

METHODS

A single-page questionnaire was posted to all consultants (n = 910) currently practicing in the UK along with a pre-paid return envelope. A second questionnaire was sent to non-responders (n = 459).

MAIN OUTCOME MEASURES

Questionnaire responses.

RESULTS

626 responses were received representing 68.8% of the population surveyed. 152 (24%) volunteered a specialist interest in glaucoma. Consensus opinion for both glaucoma specialists (64.9%) and non-glaucoma specialists (62.4%) was to start with primary medical therapy, most commonly citing surgical risk as the primary reason (23% and 22%, respectively) for this approach. Most felt the highest intraocular pressure measurement during follow up (measured in clinic) was the most important variable for prevention of further visual loss (60% of glaucoma specialists and 55% of non-glaucoma specialists). Eighty-three per cent of all responders suggested they would change their practice if evidence supporting primary surgery as a safe and more effective approach existed.

CONCLUSIONS

Recent National Institute of Clinical Excellence guidance does not reflect the current management approach of UK ophthalmologists. The primary concern was related to potential complications of surgery although most practitioners would be willing to change their practice if evidence existed supporting primary surgery in patients presenting with advanced glaucoma.

The increasingly iatrogenic indications for mitomycin C trabeculectomy over 10 years

OBJECTIVE

The success of trabeculectomy can be adversely affected by certain risk factors. In these cases, the outcome can be improved by the intraoperative use of mitomycin C (MMC). We aimed to investigate the impression that this operation was being performed more often in our unit and that the risk factors were changing.

DESIGN

Retrospective review.

PARTICIPANTS

The study involved 107 MMC trabeculectomies during the 2 separate study periods.

METHODS

Operating theatre logbooks were used to identify patients who had undergone MMC trabeculectomy during 2 separate periods of 32 months, 10 years apart. Patient characteristics, the indication for surgery (previously failed trabeculectomy; aphakic/pseudophakic glaucoma; uveitic, developmental, or rubeotic glaucoma; post-vitreoretinal (VR) surgery glaucoma; postkeratoplasty glaucoma; and other), and follow-up data regarding intraocular pressure control were recorded.

RESULTS

In the later period, 71 MMC trabeculectomies were performed, compared with 36 in the earlier period, a significant rise (p < or = 0.05). The most obvious change in indication was an increase for postkeratoplasty and post-VR surgery glaucoma, which accounted for 77.1% of the additional operations. Intraocular pressure control at 1 year following surgery was good, particularly in the later period, with 88.8% controlled with the addition of topical medication where necessary. Complications in both periods were rare.

CONCLUSIONS

The frequency of MMC trabeculectomies has doubled over a 10-year period in our unit. Postkeratoplasty and post-VR surgery glaucomas are increasingly contributing to the caseload of complex glaucoma in our hospital. These cases may be managed effectively with MMC trabeculectomy.

The singapore 5-Fluorouracil trabeculectomy study: effects on intraocular pressure control and disease progression at 3 years

PURPOSE

To report 3-year results of a randomized, controlled trial comparing the use of a single application of 5-fluorouracil (5-FU) with placebo in trabeculectomy surgery.

DESIGN

Prospective, randomized, double-blinded treatment trial.

PARTICIPANTS

Two hundred forty-three Asian patients with primary open-angle or primary angle-closure glaucoma undergoing primary trabeculectomy.

METHODS

One eye of each patient was randomized to receive either intraoperative 5-FU or normal saline (placebo) during trabeculectomy.

MAIN OUTCOME MEASURES

Primary outcome measure was the level of intraocular pressure (IOP). Secondary outcomes were progression of visual field loss, rates of adverse events, and interventions after surgery.

RESULTS

Of the 288 eligible patients, 243 were enrolled and 228 completed 3 years follow-up; 120 patients received 5-FU and 123 received placebo. Trial failure, according to predefined IOP criteria, was lower in the 5-FU group compared with the placebo group, although the difference was only significant with a failure criterion of IOP >17 mmHg (P = 0.0154). There was no significant difference in progression of optic disc and/or visual field loss over 36 months between 5-FU and placebo (relative risk [RR], 0.67; 95% confidence interval [CI], 0.34-1.31; P = 0.239). Uveitis occurred more often in the 5-FU-treated group (14/115 [12%] vs 5/120 [4%]; P = 0.032).

CONCLUSIONS

This is the first masked, prospective, randomized trial reporting the effect of adjunctive 5-FU in trabeculectomy surgery in an East Asian population. The trial shows that an increased success rate can be achieved for several years after a single intraoperative treatment with 5-FU. We conclude that 5-FU is relatively safe and can be routinely used in low-risk East Asian patients.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

The effect of the randomized trial of patching regimens for treatment of moderate amblyopia on pediatric ophthalmologists: 3-year outcome

PURPOSE

To investigate whether the recommendations of the randomized trial of patching regimens for treatment of moderate amblyopia in children have been adopted by pediatric ophthalmologists 3 years after publication.

METHODS

An identical questionnaire to that emailed 3 years ago (6 months after publication of the randomized trial) was emailed to 560 members of the American Association for Pediatric Ophthalmology and Strabismus.

RESULTS

One hundred seven (20%) responses were received. Fifty-five percent of respondents had decreased their prescribed patching regimens at least sometimes as compared with 28% (p = 0.0005) in 2003. There was no significant increase in the prescription of near visual tasks or only 2 hour patching regimens.

CONCLUSIONS

Our study suggests that pediatric ophthalmologists may be prescribing fewer patching hours in 2006 in comparison to 2003. However, the majority of ophthalmologists are still reluctant to patch for only 2 hours, and there has not been a significant increase in prescribing near visual tasks during patching.

[Wound healing modulation in glaucoma surgery]

The wound healing response is one of the major determinants of filtering surgery success. Over the last two decades, antifibrotic agents, 5-fluorouracil (5-FU) and mitomycin C (MMC), have modified the prognosis of filtering surgery, particularly in patients at high risk for failure. Nevertheless, these agents are associated with severe complications. In order to maximize their benefits and minimize the rate of complications, the use of these powerful treatments has to be carefully evaluated in relation to patient risk factors for scarring. The choice of an antifibrotic agent, mode, dose and duration of application should be made with complete knowledge of the different effects of these treatments and adapted for each patient after an exhaustive preoperative evaluation.

Frequency of bleb manipulations after trabeculectomy surgery

AIM

To quantify the type and frequency of postoperative bleb manipulations undertaken after modern glaucoma surgery.

METHODS

Bleb manipulations were recorded after trabeculectomy surgery on 119 consecutive patients with at least 1 year of follow-up. The type of intervention and time after surgery were recorded. Statistical analysis identified success rates at various intraocular pressure (IOP) cut-off definitions and identified factors that increased the risk for bleb manipulation.

RESULTS

In all, 78.2% of trabeculectomies were followed by some form of bleb manipulation. Almost 49% of blebs underwent massage and a similar number required at least one suture removal, 31.1% required at least one 5-fluorouracil (5-FU) injection and 25.2% required at least one needling and 5-FU injection. The median time to the first intervention for massage, suture removal, 5-FU injection, and needling and 5-FU injection were 1, 14, 14 and 43 days, respectively. IOP measurements were higher at all follow-up time points in the intervention group. Failure to achieve specific IOP target pressures was also generally poorer in the 5-FU, and needling and 5-FU intervention groups.

CONCLUSIONS

Postoperative intervention is a frequent occurrence after modern glaucoma surgery. This requires intensive postoperative follow-up and is a labour-intensive undertaking. Despite interventions in our group of patients, IOP in the intervention group was always higher than in the group that required no intervention.

Trabeculectomy with brief exposure to mitomycin C

BACKGROUND

To evaluate the safety and efficacy of primary trabeculectomy with brief exposure (15 s) to mitomycin C (MMC) (0.4 mg/mL).

METHODS

Medical record review of all patients who underwent primary trabeculectomy with brief exposure to MMC at the Goldschleger Eye Institute in a 4-year period was performed.

RESULTS

Sixty-three patients (35 men, mean age of 55 years) underwent trabeculectomy with brief exposure to MMC. Intraocular pressure (IOP) decreased a mean +/- standard deviation of 17.9 +/- 9.6 mmHg from 30.4 +/- 9.5 mmHg preoperatively to 12.5 +/- 6.2 mmHg postoperatively after a mean follow up of 18.3 months (P < 0.001). Number of antiglaucoma medications decreased from 2.9 +/- 1.1 preoperatively to 0.2 +/- 0.4 postoperatively (P < 0.001, paired samples t-test). Complete success, defined as IOP < 18 mmHg without antiglaucoma medication, was achieved in 46 patients (73%) and qualified success, defined as IOP <or= 21 mmHg with or without antiglaucoma medications, was achieved in 59 patients (93.7%). Thirty-eight patients (60%) had a final IOP < 15 mmHg with no glaucoma medications at the end of follow up. Needle revision was required in four patients (6.3%) and repeated trabeculectomy was performed in three patients (4.8%). Four patients had an IOP of less than 6 mmHg at the end of follow-up period (three had final IOP of 5 mmHg and one of 4 mmHg); these patients had an average larger bleb size (2.8 +/- 1.3).

CONCLUSIONS

Trabeculectomy with brief (15 s) exposure to MMC 0.4 mg/mL is safe and effective in lowering IOP in this group of patients, and results in low rate of postoperative complications. Success is comparable to reported data with longer exposure durations to antimetabolites.

South-East Scotland trabeculectomy survey

AIM

Assessment of trabeculectomy in South-East Scotland (SESTS) with comparison to National Survey of Trabeculectomy (NST) and outcomes of consultant and trainee surgery.

METHOD

A retrospective study of 304 consecutive, primary trabeculectomies, in two Scottish centres (Edinburgh and Dunfermline) with two glaucoma specialists and higher surgical trainees, was performed. The study group had primary open angle glaucoma (65.5%), pseudoexfoliation (6.9%), normal tension glaucoma (7.6%), pigment dispersion syndrome (1.6%), and other complicated glaucoma (18.4%). All patients underwent trabeculectomy by the glaucoma specialist (57.6%) and higher surgical trainee (42.4%) with close scrubbed supervision.

RESULTS

Compared to the NST, the waiting time for surgery (<3 months) was significantly less in the SESTS (P<0.001). There was also significantly more use of intraoperative antimetabolites (P<0.01), bleb intervention (P<0.001), and a higher rate of early complications (P<0.025). There was no significant difference in outcome at intraocular pressure (IOP)<2/3 listing IOP (qualified and unqualified) between the SESTS and the NST. Significantly, more patients achieved an unqualified success of IOP<21 mmHg (P<0.01) and an unqualified success of IOP<16 mmHg in the SESTS than the NST (P<0.05). At 1 year post surgery, visual loss of greater than one Snellen line was more common in the NST (P<0.01) as was the use of anti-glaucoma medication (P<0.001). Trainee cases returned to theatre more frequently (P<0.025) and merited more bleb intervention (P<0.01) than consultant cases, but the long-term outcome was similar.

CONCLUSION

Our study highlights significant changes in the practice and outcome of trabeculectomy compared to the national survey conducted a decade ago.

Recent advances in trabeculectomy technique

PURPOSE OF REVIEW

Trabeculectomy is an effective operation for lowering intraocular pressure. However, success is limited by complications such as infection, hypotony, and scarring.

RECENT FINDINGS

These complications, which are increased by antifibrotic use, can be reduced with attention to surgical technique. We highlight the benefit of sub-Tenon anaesthesia, careful choice of the surgical site, fashioning of the scleral flap to produce diffuse aqueous flow, and better intraocular pressure control, maintenance of intraocular pressure, a formed anterior chamber, with outflow control during surgery using an infusion, optimal method of antimetabolites application, new adjustable sutures, and corneal-conjunctival closure techniques.

SUMMARY

These techniques reduce hypotony, producing a diffuse noncystic bleb with long-term pressure control.