Ologen implant versus mitomycin C for trabeculectomy: a systematic review and meta-analysis

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preserflo TM MicroShunt implantation combined with Ologen TM in primary and secondary glaucoma patients in a clinical setting

PURPOSE

This study aims to assess the effectiveness and safety of combining the Preserflo™ MicroShunt implant (MicroShunt) with a simultaneous Ologen™ implant in patients with glaucoma.

METHODS

We conducted a retrospective study on consecutive patients with medically uncontrolled glaucoma who underwent MicroShunt + Ologen implantation as a standalone procedure or in combination with phacoemulsification (combined procedure). Success was defined as achieving an intraocular pressure (IOP) of 6-15 mmHg at 18 months post surgery, with a preoperative IOP reduction of at least 20%, and without (complete success) or with (qualified success) the need for antiglaucoma medications. The primary endpoint was the success rate.

RESULTS

Forty-eight eyes from 47 patients were included, with 28 eyes (58.3%) undergoing the standalone procedure and 20 eyes (41.7%) undergoing the combined procedure. Overall, there was a significant reduction in preoperative IOP from 19.7 ± 5.8 mmHg to 11.4 ± 2.6 mmHg at 18 months ( P < 0.0001). In the standalone procedure group, preoperative IOP decreased from 21.5 ± 5.2 mmHg to 11.7 ± 2.5 mmHg ( P < 0.0001), and in the combined procedure group, preoperative IOP decreased from 17.1 ± 5.8 mmHg to 10.9 ± 2.7 mmHg ( P = 0.0002), with no significant difference between the two groups regarding final IOP. The mean number of antiglaucoma medications significantly decreased from 3.2 ± 1.1 to 0.3 ± 0.7 in the overall study population ( P < 0.0001). At 18 months, 40 eyes (83.3%) were classified as successful. Regarding safety, out of the total number of eyes, two (4.2%) experienced choroidal detachment without visual impairment, two (4.2%) had transient hyphema, one (2.1%) showed reactivation of a corneal herpetic ulcer, one (2.1%) had diplopia, and one (2.1%) exhibited a shallow anterior chamber during the first week.

CONCLUSION

The combination of Ologen™ and Preserflo™ MicroShunt, either alone or in conjunction with phacoemulsification, demonstrated a favorable profile in terms of IOP reduction and safety.

Efficacy and safety of deep sclerectomy with uveoscleral implant plus collagen matrix implant overcoming the superficial scleral flap in glaucoma surgery

AIM

To assess the efficacy and safety of non-penetrating deep sclerectomy (NPDS) with uveoscleral implant plus subconjunctival and intrascleral collagen matrix overcoming the superficial scleral flap lips (modified deep sclerectomy technique, DS) and minimal use of mitomycin C in glaucoma surgery.

METHODS

A retrospective review of 47 consecutive glaucoma patients who underwent NPDS with DS between January 2017 and May 2018. Best-corrected visual acuity, intraocular pressure (IOP), post-operative need for glaucoma medications, visual field mean deviation (MD), re-interventions, needling revisions and laser goniopuncture were noted. Absolute success was defined as IOP≤18 mm Hg without topical medication. Relative success was defined as the same criteria but with the addition of any antihypertensive medication. IOP over 18 mm Hg on two consecutive follow-up visits was considered as a failure.

RESULTS

Fifty-two eyes of 47 patients were evaluated. Mean preoperative IOP was 25.37±6.47 mm Hg, and decreased to 15.04±4.73 at 12mo and 12.21±4.1 at 24mo (all P<0.0001). Requirement for topical medications dropped from a mean of 3.06±0.25 per patient to 0.51±0.99 and 1.11±1.23 respectively after 12 and 24mo (all P<0.0001). No medications were required in 45.5% of patients after 24mo. Relative and absolute success rate at 24mo were 85.5%±5% and 48.5%±7.4%, respectively.

CONCLUSION

DS is a safe and effective non-penetrating glaucoma surgery variation. It aims to retain the patency of all pathways created for aqueous humor drainage: the intrascleral bleb, the supraciliary space and the open communication between intrascleral and subconjunctival compartments.

Comparison of surgical outcomes with and without Ologen collagen matrix augmentation during XEN gel stent implantation

Background

To compare the surgical outcomes and postoperative complications with and without Ologen collagen matrix augmentation during XEN gel stent implantation.

Methods

We retrospectively analyzed patients who underwent XEN gel stent implantation with an ab externo technique. The amount of intraocular pressure (IOP) reduction, percentage of postoperative complications and additional management, and surgical success defined as IOP reduction greater than 20% compared with the preoperative IOP measurement were compared between Ologen-augmented and non-augmented groups. Groups of patients who underwent XEN gel stent implantation alone and combined with phacoemulsification were analyzed separately.

Results

A total 103 eyes of 103 participants were included. Of those, 72 eyes underwent standalone XEN gel stent implantation: 42 eyes with Ologen augmentation (Oloxen group) and 30 eyes without Ologen augmentation (Xen group). Thirty-one eyes underwent XEN gel stent implantation with phacoemulsification: 19 eyes with Ologen augmentation (Phaco-Oloxen group) and 12 eyes without Ologen augmentation (PhacoXen group). The surgical success rate at six months postoperatively was not different between the Oloxen and Xen groups (56.4% vs 43.3%, P > 0.05) or between the Phaco-Oloxen group and PhacoXen group (57.9% vs 41.7%, P > 0.05). The prevalence of postoperative hypotony, 5-fluorouracil injections, use of anti-glaucoma medications, bleb needling, and additional glaucoma surgeries was not different between the Oloxen and Xen groups or between the Phaco-Oloxen and PhacoXen groups when assessed six months postoperatively.

Conclusions

All groups showed significant IOP reduction after XEN gel stent implantation, but there was no significant difference between the Ologen collagen matrix augmented and non-augmented groups in surgical outcomes.

The surgical management of glaucoma: A review

After a long period of little change, glaucoma surgery has experienced a dramatic rise in the number of possible procedures in the last two decades. Glaucoma filtering surgeries with mitomycin C and glaucoma drainage devices remain the standard of surgical care. Other newer surgeries, some of which are minimally or microinvasive glaucoma surgeries, target existing trabecular outflow, enhance suprachoroidal outflow, create subconjunctival blebs, or reduce aqueous production. Some require the implantation of a device such as the iStent, Hydrus, Ex-PRESS, XEN and PRESERFLO, whilst others do not-Trabectome, Kahook dual blade, Ab interno canaloplasty, gonioscopy-assisted transluminal trabeculotomy, OMNI and excimer laser trabeculotomy. Others are a less destructive variation of an established procedure, such as micropulse transscleral cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cycloplasty. Cataract surgery alone can be a significant glaucoma operation. These older and newer glaucoma surgeries, their mechanism of action, efficacy and complications are the subject of this review.

Use of Amniotic Membrane in MMC-Augmented Trabeculectomy: A Retrospective Comparative Study

Purpose

Amniotic membrane transplantation (AMT) has shown promising results as an antifibrotic agent in trabeculectomy. We aimed to evaluate the additional effect of AMT in MMC-augmented trabeculectomy.

Patients and Methods

This retrospective study analyzed the results of the first 12 postoperative months of glaucomatous eyes submitted to Moorfields Safer Surgery Trabeculectomy with MMC alone (non-AMT group) compared to MMC and AMT (AMT group). Both groups were compared in terms of intraocular pressure (IOP), number of antihypertensive medications and need for surgical reinterventions. Absolute and relative success rates 12 months after surgery were defined as IOP <18 mmHg, without and with the use of antihypertensive medications, respectively.

Results

The analysis included 51 eyes of 45 glaucoma patients (29 eyes in the non-AMT group and 22 in the AMT group). Mean IOP decreased from 24.72±5.11 mmHg and 26.86±10.62 mmHg preoperatively in non-AMT and AMT groups to 12.86±4.22 mmHg and 12.60±4.43 mmHg, respectively, at 12 months (p = 0.84). Postoperative number of medications decreased significantly in both groups. Absolute success was seen in 71% of non-AMT eyes and 55% of AMT eyes (p = 0.46), whereas relative success was obtained in 14% and 30%, respectively (p = 0.55). Reinterventions were needed in 28% of the eyes (11 bleb injection/needling and 4 Ahmed tube implantation) in the non-AMT group and in 27% of the AMT group (10 bleb injection/needling and 1 Ahmed tube implantation) (p = 0.89).

Conclusion

Trabeculectomy combined with MMC and AMT did not show better results than trabeculectomy with MMC alone.

Outcomes of bleb revision with ologen following filtering glaucoma surgery

PURPOSE

This study reports long-term outcomes of bleb revision with ologen™ Collagen Matrix (Aeon Astron Europe BV, the Netherlands) for the surgical management of various bleb-related issues including persistent bleb leaks with or without associated hypotony, bleb dysesthesia, overhanging blebs, or hypotony after filtering glaucoma surgery.

MATERIALS AND METHODS

A retrospective chart review was performed for patients who underwent ologen bleb revision from 2012 to 2019 at Glaucoma Associates of Texas.

RESULTS

The study included 23 eyes of 22 patients undergoing bleb revision with the ologen implant. Mean age was 74.0 ± 11.3 years, 16 (69.6%) were female, and 13 (56.5%) were White. Indications for bleb revision included bleb leak (78.3%), dysesthesia (13.0%), and hypotony from an overfiltering bleb (8.7%). Mean preoperative intraocular pressure was 6.8 ± 4.1 mmHg and the number of medications was 0.3 ± 0.9. Median follow-up was 24 months (range: 12-84 months); all patients had at least 12 months of follow-up. At 1 year, mean intraocular pressure was 10.9 ± 4.6 mmHg on 0.2 ± 0.5 medications, and at last follow-up, mean intraocular pressure was 10.4 ± 3.6 mmHg on 0.3 ± 0.7 medications. Bleb morphology remained low, diffuse, and posterior. One patient developed kissing choroidal effusions requiring surgical drainage with subsequent stabilization of intraocular pressure and bleb function, and three patients required additional surgery due to persistent leaks or bleb failure; there were no other vision-threatening complications.

CONCLUSIONS

Use of the ologen implant during surgical bleb revision is a useful surgical technique that confers long-term improvements in bleb morphology and stability of function.

Comparison of bleb morphology by anterior segment optical coherence tomography and clinical outcome after phacotrabeculectomy with mitomycin C or Ologen implant

Purpose:

To compare the bleb morphology by Anterior Segment Optical Coherence Tomography (ASOCT) and clinical outcome after Phacotrabeculectomy with either mitomycin C or Ologen implant.

Methods:

In a prospective interventional active controlled study, 93 patients aged 18 years and above underwent phacotrabeculectomy with either mitomycin C (53 eyes) or ologen implant (40 eyes), followed up for 12 months. The primary outcome measure was to note the evolution of bleb morphology by ASOCT in the two groups over 12 months. Secondary outcome measures were mean IOP, reduction in the need for anti-glaucoma medications, and complications seen in the two groups.

Results:

All parameters in the two groups were comparable preoperatively (P>0.05). Best corrected visual acuity at 12 months was 0.38±0.27 in mitomycin group and 0.31±0.23 in ologen group (P=0.151). Post-operative IOP at 12 months was 14.09±3.1mmHg (95%CI 13.22-14.97) in mitomycin group, and 13.25±2.5 mmHg (95%CI 12.40-14.30) in ologen group (P=0.254).The mean number of medications was 0.36±0.68 in mitomycin group and 0.38+/-0.70 in ologen group at 12 months (P=0.91). Overall success was achieved in 98.1 % of patients in mitomycin group and 90 % of patients in ologen group at 12 months. No major sight-threatening complications were noted in any group. AS-OCT imaging at 12 months showed multiform reflectivity with multiple large cystic spaces in both groups, with good IOP control.

Conclusion:

Phacotrabeculectomy using Mitomycin C and Ologen implant resulted in similar morphologic and functioning blebs at one year with comparable efficacy in controlling intraocular pressure.

Cross-linked hyaluronic acid viscoelastic scleral implant in trabeculectomy

Purpose:

Patients with glaucoma undergoing trabeculectomy develop bleb cicatrix causing poor postoperative intraocular pressure (IOP) control and low success rates. Several approaches have been explored over the years for better outcomes. This study assesses the safety, efficacy, and outcome of trabeculectomy with HealaFlow^® (Anteis S. A, Geneva, Switzerland), a high-molecular-weight cross-linked hyaluronic acid viscoelastic gel, and comparing it with the antimetabolite Mitomycin-C (MMC).

Methods:

A prospective, interventional, case-controlled study conducted at a tertiary care hospital in Southern India on 60 eyes of patients requiring trabeculectomy divided in two groups – HealaFlow scleral implant and adjuvant low-dose MMC (0.1 mg/mL). Postoperative IOP reduction along with bleb morphology was assessed over follow-up at 1 week, 1 month, 3 months, 6 months, and 12 months.

Results:

Preoperatively IOP in the two groups was statistically similar. Postoperative IOP on day 1 had statistically significant reduction in both groups with greater reduction in MMC group. However, by 12 months, the IOP reduction was statistically similar in both groups, i.e., 46.24% (to 11.04 ± 2.55 mmHg) and 54.47% (to 11.99 ± 3.37 mmHg) in HealaFlow^® group and MMC group, respectively (P > 0.05). The bleb morphologies were similar and complications were seen equally, which resolved by 4 weeks. A complete success rate of 89.29% and a qualified success rate of 10.71% were observed equally in both groups.

Conclusion:

Absorbable biosynthetic cross-linked hyaluronic acid and low-dose MMC are equally safe and efficacious in trabeculectomy with significant IOP reduction and good bleb morphology. Therefore, it is a novel substitute for MMC.

Outcome of Trabeculectomy with Collagen Matrix Implant versus Mitomycin C in Primary Glaucoma: A Comparative Study

Background:

Glaucoma is a serious vision-threatening condition appropriately called as the silent killer of sight. The effect of postoperative fibrosis on success of filtration surgeries requires modulation of the wound healing process.

Aim:

The aim of the study was to compare trabeculectomy augmented with collagen matrix implant with mitomycin C in primary glaucoma.

Materials and Methods:

This prospective, longitudinal, hospital-based, analytical, and interventional study was conducted on 36 eyes of 36 patients. Group 1 included 18 patients who underwent trabeculectomy combined with subconjunctival collagen matrix implant and Group 2 included 18 patients who underwent trabeculectomy augmented with intraoperative mitomycin C (0.04 mg/ml) for 2 min. Each patient underwent detailed ocular examination and comparison was drawn by recording intraocular pressure (IOP), bleb characteristics, and postoperative complications.

Results:

The cumulative success rates at the end of our study were similar in two groups, 94.44% in Group 1 and 88.89% in Group 2 (P = 1.000). The mean reduction in IOP at 24 weeks in Group 1 was 18.67 ± 7.59 mmHg and in Group 2 was 21.32 ± 5.84 mmHg. The reduction in IOP was similar between the two groups (P = 0.290). The mean fall in IOP was 56.46% in Group 1 and 64.70% in Group 2 at 24 weeks. Mean bleb score in Group 1 was 10.33 ± 1.23 and in Group 2 was 8.89 ± 1.41, and the difference was statistically significant (P = 0.002). Shallow anterior chamber, overfiltration, and hypotony were statistically higher in Group 2 than in Group 1 (P = 0.041, 0.041, and 0.046, respectively).

Conclusion:

Collagen matrix implant as an adjuvant to trabeculectomy is noble, safe, and effective option as compared to mitomycin C.

Ologen augmentation of Ahmed glaucoma drainage devices in pediatric glaucomas

Background

Limited data exists on the effectiveness of the collagen matrix, Ologen, on increasing Ahmed glaucoma valve (AGV) success in childhood glaucomas.

Methods

Ocular examination and surgical details of pediatric patients who underwent AGV placement ± Ologen augmentation between 2012 and 2020. Complete success was defined as intraocular pressure (IOP) between 5 and 20 mmHg without glaucoma medications and additional IOP-lowering surgeries. Qualified success was defined as above, except IOP control maintained with or without glaucoma medications.

Results

Twenty-two eyes of 16 patients underwent AGV placement of which 6 eyes had Ologen-augmentation (OAGV) and 16 eyes had conventional surgery (CAGV). Average age was 6.4 ± 5.1 years with 4.2 ± 2.5 follow-up years. There was no difference in age, number of previous surgeries, and preoperative IOP and glaucoma medications. At final follow-up, success rate was 100% (5 eyes complete, 6 eyes qualified) in the OAGV group compared to 31% (0 eyes complete, 5 eyes qualified) in the CAGV group. One and two-year survival rates were 100% for OAGV compared to 62 and 38% for CAGV. Postoperative IOP was significantly lower at 1-month and final follow-up (p = 0.02) as was the number of glaucoma medications at 3, 6, 12-months and final follow-up (p < 0.05) in the OAGV group.

Conclusions

Ologen-augmentation increased the success and survival rates of AGVs in childhood glaucomas. Further, Ologen mitigated the hypertensive phase and decreased medication dependency. Longer follow-up with a greater number of eyes is required to fully evaluate the effectiveness of OAGV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01827-4.

Prospective Evaluation of the First Mitomycin C Augmented Needle Revision in Patients With Failed Nonpenetrating Deep Sclerectomy

PRECIS

At 6 months the procedure achieved a 33.89% drop in intraocular pressure (IOP), had an overall success rate of 57.15%, and did not change the best-corrected visual acuity. Achieving <8 mm Hg of IOP the day after the procedure may be a prognostic success indicator.

PURPOSE

The purpose of this study was to evaluate the first mitomycin C (MMC)-augmented needle revision in patients with failed nonpenetrating deep sclerectomy (NPDS) and factors associated with its success.

MATERIALS AND METHODS

This prospective, nonrandomized comparative trial included 21 consecutive patients (21 eyes) who underwent their first MMC needling revision of failed NPDS blebs. The success was defined as absolute if the IOP decreased >20% from the preoperative value without antiglaucoma treatment and as qualified if that level was achieved with antiglaucoma medications. Preoperative and postoperative factors were evaluated for an association with postoperative success using Kaplan-Meier analysis.

RESULTS

A significant reduction in mean IOP from preoperative levels was evident at the end of the follow-up. The overall surgical success rate was 57.15%. On the basis of Kaplan-Meier survival analysis, we found that patients whose IOP on the following day of the procedure was <8 mm Hg had a higher success rate than those whose 1-day postoperative IOP was higher. These patients had a percentage of success of 100%, 84.6%, and 76.9% at 1-, 3-, and 6-month postoperative follow-up, respectively.

CONCLUSION

The IOP level on the first postoperative day could be considered a prognostic indicator of success in needling revision performed in failed NPDS.

Outcomes of trabeculectomy with polyvinylpyrrolidone collagen versus mitomycin in primary open angle glaucoma. 36-month follow-up

PURPOSE

Describe and compare the effects of intraoperative application of Polyvinylpyrrolidone Collagen (PVP) versus Mitomycin C (MMC) on the pattern of change in mean IOP reduction and mean number of medications over 36-months follow-up in patients with primary open angle glaucoma (POAG) undergoing trabeculectomy.

METHODS

Prospective, randomized, comparative study. Twenty-six eyes of 26 patients with POAG and no previous incisional glaucoma surgery underwent trabeculectomy and were randomized to PVP or MMC and completed a 36-month follow-up. Main outcome measures were IOP and number of glaucoma medications. Multivariate longitudinal analysis was performed by fitting a linear trend model adjusting for baseline response for the IOP outcome and a log-linear regression model with within-subject associations for the number of hypotensive medications outcome. Sensitivity analysis was performed to assess lower and higher order polynomial trends over time in IOP.

RESULTS

The univariate analysis revealed that the mean IOP reduction from baseline to 36 months was 7.62mmHg (3.05; 12.18) in the MMC group and 8.15mmHg (-0.64; 16.95) in the PVP group. Mean percentage IOP reduction from baseline was 37.09% (15.93; 58.17) and 36.08% (5.16; 67.20) in the PVP group. Mean change in number of medications from baseline to 36 months was -0.92 medications (-3.38; +1.54) for the MMC group and -1 medication (-3.12; +1.12) for the PVP group. Both groups had a statistically significant decline in mean IOP over the follow-up period (p<0.001) but there was no discernible difference between the two exposure groups in the rate of change in IOP (p=0.5975). Sensitivity analysis showed that a linear trend model is adequate to describe the IOP reduction over the follow-up period. Both groups had a statistically significant change in the number of hypotensive medications used between baseline and month 36 (p<0.05) but there was no discernible difference between exposure groups (p=0.2917). Both the PVP and MMC groups showed an initial reduction in number of medications until month 12 and a relatively linear increase towards month 36. A longer follow-up may be warranted to reveal differences in the number of medications between the two exposure groups. Postoperative complications were less frequent in the PVP group.

CONCLUSIONS

The use of PVP during trabeculectomy achieves and maintains a statistically significant IOP reduction from baseline to 36 months and decreases the number of glaucoma medications. Secondary outcome measures showed a lower incidence of adverse events in the PVP group.

[Trabeculectomy with Ologen® implant and bevacizumab]

BACKGROUND

Trabeculectomy is the most frequent form of glaucoma surgery. Despite the intraoperative use of antimetabolites, such as mitomycin C (MMC) postoperative scarring reactions can cause surgical failure. The subconjunctival placement of an Ologen® implant can avoid wound scarring. The additional application of bevacizumab should reduce angiogenesis and thereby scarring reactions and improve the surgical success rate.

METHODS

This was a retrospective single center study of patients with glaucoma after trabeculectomy with MMC. The operation was carried out either without an Ologen® implant (group 1), or with an Ologen® implant as an bevacizumab depot (group 2) or with an Ologen® implant and intrachamber injection of bevacizumab (group 3). The follow-up postoperative observation of intraocular pressure (IOP), complications, subsequent interventions and antiglaucoma treatment was performed for 12 months.

RESULTS

There were no significant differences between the groups with respect to IOP, complications, subsequent interventions and postoperative antiglaucoma treatment. The highest success rate (IOP after 12 months ≤15 mm Hg without treatment) was in group 1 (77.5%), followed by group 2 with 63.6% and group 3 with 57.1% (p = 0.34, χ²-test).

CONCLUSION

The highest success rate was achieved in group 1 with MMC but without an Ologen® implant or bevacizumab. In this study the additional use of Ologen® implants and bevacizumab in trabeculectomy was found to be a safe operation method but did not provide any additional benefits.

Efficacy and Safety of Argon Laser Peripheral Iridoplasty and Systemic Medical Therapy in Asian Patients with Acute Primary Angle Closure: A Meta-Analysis of Randomized Controlled Trials

PURPOSE

The purpose of this meta-analysis was to assess the percent reduction in the intraocular pressure (IOP) after argon laser peripheral iridoplasty (ALPI) and systemic medical therapy in patients with acute primary angle closure (APAC).

METHODS

We searched a number of electronic databases, including MEDLINE, EMBASE, PubMed, and Cochrane Library. We searched the electronic databases from the inception of the databases to August 2018. The primary outcomes included the IOP reduction (IOPR), percent reduction in IOP (IOPR%) from baseline to the endpoint and peripheral anterior synechiae (PAS). The secondary outcomes included the cup-to-disc ratio (CDR), mean endothelial count, and percent of patients requiring topical glaucoma medication. Summary weighted mean difference (WMD), odds ratio (OR), and 95% confidence intervals (CIs) were calculated.

RESULTS

Four eligible studies including 183 eyes (92 in the ALPI group and 91 in the medical therapy group) were identified. When comparing ALPI to medical therapy, the WMDs of the IOPR% were 30.03 (95% CI: 21.33 to 38.72, p < 0.00001) at 15 minutes, 27.39 (95% CI: 18.89 to 35.89, p < 0.00001) at 30 minutes, 18.15 (95% CI: 10.63 to 25.68, p < 0.00001) at 1 hour, and 12.91 (95% CI: 4.50 to 21.32, p=0.003) at 2 hours. There was no statistically significant difference between the two groups at 24 hours and at more than 6 months after therapy. Meanwhile, no significant difference was observed in the degree of PAS, CDR, mean endothelial count, and percent of patients requiring topical glaucoma medication after treatment between the two groups.

CONCLUSIONS

Both ALPI and systemic medications were effective with regard to decreasing the IOP. ALPI was more effective in lowering the IOP within the first two hours. Therefore, ALPI may be a better choice for rapidly lowering the IOP in patients with APAC within a short period.

Ologen implant versus mitomycin-C for trabeculectomy: A meta-analysis

AIM

To evaluate the efficacy and safety of trabeculectomy (Trab) with mitomycin-C (MMC) versus Trab with implant.

METHODS

Studies published in different languages were retrieved by systematically searching Embase, PubMed, Cochrane library, China Biology Medicine disc, and Google Scholar from 1966 to April 2018, as well as manually examining the references of the original articles. The outcome measures of efficacy covered intraocular pressure, glaucoma medications reductions, and success rate. Safety evaluation was measured by relative ratio of complications.

RESULTS

A total of 11 studies involving 443 participants were covered in this meta-analysis. The weighted mean difference (WMD) in the percentage of intraocular pressure (IOP) reduction (IOPR%) comparing Ologen group with MMC group was -3.69 (95% CI: -6.70 to -0.68) at 1 month, -2.69 (-5.17 to -0.21) at 3 months, -3.67 (-6.09 to -1.25)at 6 months, -3.24 (-6.08 to -0.41) at 12 months, 1.24 (-9.43 to 11.90) at 24 months, and 1.10 (-10.11 to 12.31) at 60 months, which showed that there was statistically significant difference at 1,3, 6, and12 months after the surgery. A significantly higher incidence of postsurgery hypotony (0.64 (95% Cl: 0.42 to 0.98)) and suture lysis (0.30 (95% CI: 0.10-0.93)) was observed in MMC group. However, there was no significant difference in the reduction in glaucoma medications, success rate, and incidence of other complications.Trab with 0.2 mg/mL MMC presented higher rates of complete success compared with Trab with 0.4 mg/mL MMC (P = .01).

CONCLUSION

Trab with MMC was associated with a higher IOP-lowering efficacy and a higher incidence of postsurgery hypotony and suture lysis in contrast to that of Trab with Ologen.

Efficacy of collagen matrix implant on adhesions in restrictive strabismus: An experimental study in a rabbit model

PURPOSE

To determine the efficacy of a biodegradable collagen matrix implant (Ologen, Aeon Astron Europe BV, Leiden, the Netherlands) in reducing adhesions in a rabbit model of restrictive strabismus.

METHODS

A prospective, masked-observer, controlled experimental study was performed. Sixty superior rectus muscles of 30 rabbits were resected and Marlex mesh was fixed beneath the resected muscle using nonabsorbable suture. Forty eyes underwent one of two different procedures; the resected muscle was wrapped with preserved human amniotic membrane (AM group) or Ologen (Ologen group). Randomly selected 20 eyes served as controls. Eyes were enucleated at 4 weeks after surgery to measure the severity of adhesion using a push pull gauge. Histopathological examination was performed.

RESULTS

At postoperative week four, the average tensile strength of the myoscleral adhesion was significantly lower in the Ologen group (151.8 ± 42.7 gram force) compared to controls (347.9 ± 68.6 gram force) and AM group (193.0 ± 44.3 gram force) (p < 0.001 and p = 0.045, respectively). Ologen group showed significantly lower degree of acute inflammation, chronic inflammation and rectus muscle fibrosis compared with controls (all p < 0.01). The degree of chronic inflammation was significantly lower in the Ologen group compared with AM group (p = 0.012).

CONCLUSION

Compared to amniotic membrane, Ologen is more effective in reducing mesh-related extraocular muscle adhesions in a rabbit model of restrictive strabismus.

Efficacy of Ologen matrix implant in Ahmed Glaucoma Valve Implantation

To determine the efficacy and safety of the Ologen collagen matrix adjunctive to Ahmed valve surgery. A randomized prospective multicentre clinical trial involving 58 patients that were followed for one year. Conventional surgery with Ahmed valve was performed in 31 eyes (Control group/CG) and in 27 Ologen (Ologen group/OG) was placed over the valve's plate. Baseline data: age, corneal thickness, intraocular pressure(IOP) and antiglaucoma medications.Postoperative data (days 1, 7 and months 1, 3, 6 and 12): IOP, antiglaucoma medications, visual acuity and complications were recorded. Frequency of hypertensive phase, complete and qualified success and survival rate were studied. No differences were found between CG and OG in the baseline data. The only difference between groups was a significantly lower IOP at day 1. No other differences were found in the follow-up between groups. Hypertensive phase (56%CG and 55%OG, p = 0,947), complete success 28,6%CG and 30,4%OG (p = 0,88) and qualified success 96,4% and 95,9%(p = 0,794). Survival rates at 1 year were 76,7%(CG) and 69,2%(OG)(p = 0,531). 38,7% of patients in the CG suffered some complication during follow-up and 61,5% in OG(p = 0,086). Ologen does not increase safety or efficacy in Ahmed valve surgery at one-year follow-up. This is the first study that shows no benefit of Ologen adjunctive to this surgery.

Use of a Collagen Matrix Implant as an Adjuvant in Combined Surgery Involving Phacoemulsification and Nonpenetrating Deep Sclerectomy

AIM

To assess the efficacy and safety of the Ologen collagen matrix as an adjuvant for combined phacoemulsification and nonpenetrating deep sclerectomy (Phaco-NPDS), in addition to mitomycin C (MMC).

MATERIALS AND METHODS

This was a longitudinal retrospective comparative study of eyes treated with Phaco-NPDS, with (group 1) or without (group 2) an Ologen collagen matrix implant, in addition to MMC. The main outcome measures were operative success [absolute success: intraocular pressure (IOP) <18 mm Hg and an at least 20% reduction from baseline without medication; relative success: IOP<18 mm Hg and at least 20% reduction from baseline IOP with or without medication], mean reductions (%) in IOP and medication use; number of postoperative reinterventions (goniopuncture, needling, reoperation), and number of complications.

RESULTS

The mean age of the study population (N=100) was 72.0±9.7 years. Groups 1 (n=51) and 2 (n=49) achieved absolute success rates of 72.5% and 55.1%, respectively (P=0.054), and relative success rates of 90.2% and 83.7%, respectively (P=0.251). From a similar baseline IOP (19.8 and 20.7 mm Hg in groups 1 and 2, respectively, P=0.527), eyes in group 1 achieved a significant lower 12-month IOP (11.7 vs. 14.5 mm Hg, respectively, P=0.002) and a lower rate of medication use (0.2 vs. 0.9, respectively, P<0.001). Eyes in group 2 presented with a higher rate of bleb failure (12.2% vs. 2.0%, P=0.028), leading to a higher rate of needling procedures (38.8% vs. 2.0%, P<0.001) during the postoperative period.

CONCLUSIONS

The adjunctive use of Ologen collagen matrix in addition to MMC during Phaco-NPDS was associated with a higher rate of absolute success, a lower mean IOP at 12 months, a lower rate of bleb failure, and a lower rate of postoperative bleb needling.

Five Years' Outcomes of Trabeculectomy with Cross-linked Sodium Hyaluronate Gel Implantation for Chinese Glaucoma Patients

Background:

Trabeculectomy is the most efficient surgical treatment. Prevention failure of bleb cicatrix would lead to unsatisfactory postoperative intraocular pressure (IOP) controlling and unsatisfactory success rate. The aim of this study was to evaluate the 5-year outcomes of trabeculectomy with a cross-linked sodium hyaluronate gel implantation for Chinese glaucoma patients.

Methods:

This is a prospective, case-controlled study. Patients who were to be applied first-time trabeculectomy in the Department of Ophthalmology of Peking University Third Hospital between 2010 and 2012 were included in the study. Totally, 60 eyes were randomly assigned to the trabeculectomy group (TA group) or the trabeculectomy with cross-linked sodium hyaluronate gel implantation group (TH group). Follow-up was finished at 1 week, 1 month, 3 months, 1 year, 3 years, and 5 years after the operation. The statistical index of demographic data, IOP, bleb shape, and any complications or medications or surgical procedures were recorded and assessed by SPSS 19.0 software through independent t-test, one-way analysis of variance (ANOVA) and Pearson's Chi-square test, respectively.

Results:

The baseline IOP was comparable between the two groups (t= −1.00, P= 0.32) while the postoperative IOP was significantly lower in the TH group at 1, 3 and 5 years' time points (P = 0.00, P= 0.01 and P = 0.01, respectively). According to the Indiana Bleb Appearance Grading Scale, the height and extent of bleb were better in the TH group at all follow-up time points (P < 0.05), however, the comparison of bleb vascularity showed no statistical difference (P > 0.05). TA group had a higher percentage of complications (13% vs. 3%) compared to TH group; however, there was no statistical difference in the comparison of each statistical item (P > 0.05, respectively). The complete success at 5 years was higher in the TH group than that in the TA group (78% vs. 54%, P = 0.03).

Conclusion:

Our results suggested that implantation of cross-linked sodium hyaluronate gel with trabeculectomy was more efficient and would improve the prognosis of glaucoma patients.

Trabeculectomy with subconjunctival collagen implant in Indian eyes: Long-term results

Purpose

To report long-term safety and efficacy of trabeculectomy with collagen implant in Indian population.

Methods

All cases of trabeculectomy with Ologen^® Collagen Matrix implant performed over a 7-year period from May 2008 through April 2015 at a tertiary referral institute were reviewed. A total of 30 eyes of 28 patients were included in the study with two patients undergoing bilateral trabeculectomy. Outcomes measured included intraocular pressure (IOP) control, number of antiglaucoma medications used, bleb morphology, and complications/reoperations.

Results

Trabeculectomy resulted in reduction in IOP from 36.46 to 11.65 mm Hg in the immediate postoperative period (day 1), a 68% decrease to 15.18 mm Hg at 84 months (58% decrease). The mean IOP reduction decreased over time from 63% in the first year to 55% after 5 years of follow-up. Fourteen eyes attained a follow-up of 5 years and eight eyes a follow-up of ≥7 years. No sight-threatening complication such as hypotony, bleb leak, and bleb-related endophthalmitis was observed in our series, and only intervention required was 5-fluorouracil needling in one case.

Conclusion

Ologen-augmented trabeculectomy is effective in controlling IOP over a long-term follow up from minimal 3 to maximal 7 years. No untoward events jeopardizing bleb safety were noted at any time. This modality is a viable alternative for patients with contraindications to use of antimetabolites.

Outcome of trabeculectomy with Ologen versus Mitomycin C: A comparative prospective study in Bangladesh

AIMS:

To compare the efficacy and safety of trabeculectomy with Ologen versus Mitomycin C in primary glaucoma.

MATERIALS AND METHODS:

This is a prospective study of patients aged 18 years and above, diagnosed with primary glaucoma randomised to having trabeculectomy with Ologen or Mitomycin C. The primary outcome measure was success of trabeculectomy defined as intraocular pressure >5 mmHg but ≤21 mmHg. Complete success was defined as intraocular pressure achieved without anti-glaucoma medication and qualified success was defined as intraocular pressure achieved with additional anti-glaucoma medication.

RESULTS:

At the end of 12 months follow-up, the postoperative mean intraocular pressure in the Ologen group was 12.8 ± 1.6 mmHg and 13.4 ± 2.2 mmHg in the Mitomycin C group. The Ologen group achieved complete success in 86.5% and qualified success in 13.5% of the patients, while the Mitomycin C group achieved complete and qualified success in 85.5% and 14.5%, respectively. There was no statistically significant difference in the success rate of both the groups ( p = 0.57). Furthermore, no significant intraocular pressure difference was noted between the two groups at the end of 12 months follow-up ( p = 0.14).

CONCLUSION:

Trabeculectomy augmented with Ologen appeared to be as successful and safe as trabeculectomy augmented with Mitomycin C, with no reported adverse reaction to Ologen.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of 1-year outcomes after Ahmed glaucoma valve implantation with and without Ologen adjuvant

Background

Many studies have investigated the clinical benefits of Ologen for trabeculectomy. However, its benefits for Ahmed glaucoma valve (AGV) implantation have not been investigated as extensively. The aim of this study was to compare the 1-year outcomes of AGV implantation with and without Ologen adjuvant for the treatment of refractory glaucoma.

Methods

This retrospective study included a total of 20 eyes of 20 glaucoma patients, who were followed for at least 1-year after undergoing AGV implantation. In 12 eyes of 12 patients, conventional AGV (CAGV) surgery was performed, while in 8 eyes of 8 patients, Ologen-augmented AGV (OAGV) implantation was performed. The outcomes were evaluated according to intraocular pressure (IOP) and the number of IOP-lowering medications. Complete success was defined as IOP ≤ 21 mmHg without medications throughout the 1-year follow-up period, and qualified success was defined as IOP ≤ 21 mmHg with or without medications throughout the 1-year follow-up period.

Results

The rate of complete success was significantly higher in the OAGV group (50.0%) than in the CAGV group (8.3%) (p = 0.035). There were no significant differences between the two groups in terms of qualified success or incidence of the early hypertensive phase. The IOP changes were similar between the groups within 1-year postoperatively, though the number of IOP-lowering medications was significantly lower in the OAGV group during the early hypertensive phase (p = 0.031, 0.031, and 0.025 at postoperative months 1, 2, and 3, respectively). When subjects were divided into groups according to the occurrence of the early hypertensive phase, the group with early hypertensive phase was more likely to use IOP-lowering medications at postoperative 6 months and 1 year (p = 0.002 and 0.005, respectively).

Conclusions

OAGV surgery shows encouraging results for patients with refractory glaucoma, specifically with respect to the achievement of complete success and the reduction of the number of IOP-lowering medications during the early hypertensive phase. Furthermore, our results suggest that occurrence of the early hypertensive phase is predictive of which patients will require IOP-lowering medications at postoperative 6 months and 1 year.

Is device-modified trabeculectomy better than classic surgery for treatment of glaucoma?

Several techniques have emerged as complement or replacement for trabeculectomy, the standard surgery for glaucoma. Device-modified trabeculectomy is a recently developed technique whose results compared to the classical technique have not been fully defined. To answer this question, we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We identified eight systematic reviews including 34 studies overall. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded device-modified trabeculectomy probably leads to greater overall success rate and may decrease intraocular pressure more than classical surgery. In addition, this technique would probably have a better safety profile than standard trabeculectomy.

Subconjunctival implantation of ologen Collagen Matrix to treat ocular hypotony after filtration glaucoma surgery

PurposeTo report the results of subconjunctival ologen Collagen Matrix implantation to manage ocular hypotony after filtration glaucoma surgery.Patients and methodsThis retrospective observational case series included 12 consecutive implantations of ologen in nine eyes of nine Japanese subjects (five men, four women; mean age±SD, 72.1±12.7 years) who underwent subconjunctival implantation of the device to treat hypotony after glaucoma filtration surgery. Demographic data and surgical results were collected by chart review.ResultsThe subjects included six patients who underwent trabeculectomy and three who underwent an EX-PRESS shunt surgery. The duration between the last glaucoma surgery and the initial ologen implantation was longer than 2 years in seven (78%) eyes. Bleb leakage in five (56%) eyes preoperatively stopped in all cases by 8 days after the device implantation. After the initial implantation, three (33.3%) eyes required a second implantation of ologen because of insufficient efficacy. After a mean follow-up of 12.6±6.8 months, the mean preoperative intraocular pressure (IOP) of 3.8±2.7 mmHg increased significantly (P=0.0001) to 9.0±3.2 mmHg; no eye required glaucoma medication to control the IOP. No vision-threatening complications developed in association with the treatment.ConclusionWhen conservative management failed, subconjunctival implantation of ologen Collagen Matrix in combination with bleb revision can be a useful therapeutic option for ocular hypotony after glaucoma filtration surgery.

Collagen matrix vs mitomycin-C in trabeculectomy and combined phacoemulsification and trabeculectomy: a randomized controlled trial

Background

Antifibrotic agents are commonly utilized to enhance the success rates of trabeculectomy. Novel approaches to further improve success rates and reduce the risks of complications are needed. The purpose of this study was to compare intraocular pressure (IOP)-lowering efficacy and safety of trabeculectomy or combined phacoemulsification and trabeculectomy with mitomycin-C (MMC) vs. Collagen Matrix (CM).

Methods

A prospective, multicenter, randomized controlled trial was performed. Ninety-five eyes of 94 patients with uncontrolled glaucoma despite medical therapy, without previous incisional glaucoma surgery underwent trabeculectomy (85 eyes) or combined phacoemulsification and trabeculectomy (10 eyes) and were randomized to MMC or CM. One eye of each subject was analyzed. Patients were followed for 24 months. The criteria for complete success were IOP >5 and ≤21 mmHg with at least a 20% reduction below medicated baseline without additional glaucoma surgery or medications. The main outcome measures were complete success rates at 24 months with Kaplan-Meier analysis and incidence of adverse events.

Results

The baseline IOPs were 20.4 ± 6.0 mmHg and 21.2 ± 6.1 (mean ± standard deviation, p = 0.49) on 3.2 ± 1.1 and 3.1 ± 1.0 medications (p = 0.53) compared to 11.8 ± 5.2 and 12.8 ± 3.7 (p = 0.36) on 0.5 ± 0.8 and 0.6 ± 1.0 medications (p = 0.63) at 2 years in the MMC and CM groups, respectively. Kaplan-Meier analysis demonstrated complete success rates were similar in both groups at 24 months: 38.4 ± 7.6% with MMC and 56.2 ± 7.9% with CM (mean ± standard error, p = 0.112, log rank test); however, a significantly higher incidence of failure due to persistent hypotony was observed with MMC (p = 0.002).

Conclusions

Use of the CM implant at the time of trabeculectomy or combined phacoemulsification and trabeculectomy is associated with similar complete success rates compared to adjunctive MMC; however, the risk of persistent hypotony is higher with MMC.

Trial registration

ClinicalTrials.gov registration number NCT01440751.

Registered 9/14/11

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-016-0393-z) contains supplementary material, which is available to authorized users.

Biodegradable collagen matrix implant versus mitomycin-C in trabeculectomy: five-year follow-up

Background

Clinical studies comparing trabeculectomy augmented with Ologen implant (OLO) versus trabeculectomy plus mitomycin-C (MMC) show contradictory results. To obtain long-term data, we report an extended 5-year follow-up trial evaluating the safety and efficacy of OLO as adjuvant compared to low-dosage MMC in trabeculectomy.

Methods

Forty glaucoma patients (40 eyes) assigned to trabeculectomy with MMC or Ologen. Primary outcome: target IOP at ≤21, ≤17 and ≤15 mmHg; complete and qualified success endpoint rates. Secondary outcomes: visual acuity (VA), mean deviation (MD), bleb evaluation, according to Moorfields Bleb Grading System (MBGS); spectral domain OCT (SD-OCT) bleb examination; number of glaucoma medications; frequency of postoperative complications.

Results

The mean preoperative IOP was 26.7(±5.2) in MMC and 27.3(±6.0) in OLO eyes. Mean 60-month percentage reduction in IOP was significant in both groups [40.9 (±14.2) and 42.1(±13.3) P = 0.01], with an endpoint value of 15.2 (±3.2) and 15.8 (±2.3) mmHg in MMC and OLO, respectively. Complete success rates at ≤ 21 mmHg target IOP were 65 % and 70 %, at ≤17 mm Hg 60 % and 55 %, and at the ≤15 mm Hg target IOP 35 % and 45 % in MMC and OLO, respectively.

The Kaplan–Meier curves did not differ both for complete and qualified success at any target IOP, with no significant endpoint intergroup difference at ≤ 15 mm Hg (log-rank P = 0.595).The intergroup MBGS scores differed due to reduced central and peripheral vascularity in MMC group (P = 0.027; P = 0.041).

SD-OCT analysis denied differences in bleb height between MMC vs OLO (140.5 ± 20.3 μ vs 129.2 ± 19.3 μ respectively; P =0.079).

Mean antiglaucoma medications were significantly reduced (P < 0.0005) from 2.5 (±0.3) to 1.2 (±0.4) in MMC and from 2.6 (±0.2) to 1.4 (±0.3) in OLO group, with no intergroup differences (P = 0.08).

Six (30 %) cystic thin avascular blebs without oozing were recorded in the MMC group and 2 (10 %) in the OLO group, without intergroup difference (P = 0.235).

Conclusions

Our extended follow-up results confirm that Ologen implant yields efficacy and long-term success rates quite similar to MMC, with at least equivalent safety.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-016-0198-0) contains supplementary material, which is available to authorized users.

Current and Future Techniques in Wound Healing Modulation after Glaucoma Filtering Surgeries

Filtering surgeries are frequently used for controlling intraocular pressure in glaucoma patients. The long-term success of operation is intimately influenced by the process of wound healing at the site of surgery. Indeed, if has not been anticipated and managed accordingly, filtering surgery in high-risk patients could end up in bleb failure. Several strategies have been developed so far to overcome excessive scarring after filtering surgery. The principal step involves meticulous tissue handling and modification of surgical technique, which can minimize the severity of wound healing response at the first place. However, this is usually insufficient, especially in those with high-risk criteria. Thus, several adjuvants have been tried to stifle the exuberant scarring after filtration surgery. Conventionally, corticosteroids and anti-fibrotic agents (including 5-fluorouracil and Mitomycin-C) have been used for over three decades with semi-acceptable outcomes. Blebs and bleb associated complications are catastrophic side effects of anti-fibrotic agents, which occasionally are encountered in a subset of patients. Therefore, research continues to find a safer, yet effective adjuvant for filtering surgery. Recent efforts have primarily focused on selective inhibition of growth factors that promote scarring during wound healing process. Currently, only anti-VEGF agents have gained widespread acceptance to be translated into routine clinical practice. Robust evidence for other agents is still lacking and future confirmative studies are warranted. In this review, we explain the importance of wound healing process during filtering surgery, and describe the conventional as well as potential future adjuvants for filtration surgeries.

Biocompatibility of a fish scale-derived artificial cornea: Cytotoxicity, cellular adhesion and phenotype, and in vivo immunogenicity

PURPOSE

To determine whether a fish scale-derived collagen matrix (FSCM) meets the basic criteria to serve as an artificial cornea, as determined with in vitro and in vivo tests.

METHODS

Primary corneal epithelial and stromal cells were obtained from human donor corneas and used to examine the (in)direct cytotoxicity effects of the scaffold. Cytotoxicity was assessed by an MTT assay, while cellular proliferation, corneal cell phenotype and adhesion markers were assessed using an EdU-assay and immunofluorescence. For in vivo-testing, FSCMs were implanted subcutaneously in rats. Ologen(®) Collagen Matrices were used as controls. A second implant was implanted as an immunological challenge. The FSCM was implanted in a corneal pocket of seven New Zealand White rabbits, and compared to sham surgery.

RESULTS

The FSCM was used as a scaffold to grow corneal epithelial and stromal cells, and displayed no cytotoxicity to these cells. Corneal epithelial cells displayed their normal phenotypical markers (CK3/12 and E-cadherin), as well as cell-matrix adhesion molecules: integrin-α6 and β4, laminin 332, and hemi-desmosomes. Corneal stromal cells similarly expressed adhesion molecules (integrin-α6 and β1). A subcutaneous implant of the FSCM in rats did not induce inflammation or sensitization; the response was comparable to the response against the Ologen(®) Collagen Matrix. Implantation of the FSCM in a corneal stromal pocket in rabbits led to a transparent cornea, healthy epithelium, and, on histology, hardly any infiltrating immune cells.

CONCLUSION

The FSCM allows excellent cell growth, is not immunogenic and is well-tolerated in the cornea, and thus meets the basic criteria to serve as a scaffold to reconstitute the cornea.

Device-modified trabeculectomy for glaucoma

BACKGROUND

Glaucoma is an optic neuropathy that leads to vision loss and blindness. It is the second most common cause of irreversible blindness worldwide. The main treatment for glaucoma aims to reduce intraocular pressure (IOP) in order to slow or prevent further vision loss. IOP can be lowered with medications, and laser or incisional surgeries. Trabeculectomy is the most common incisional surgical procedure to treat glaucoma. Device-modified trabeculectomy is intended to improve drainage of the aqueous humor to lower IOP. Trabeculectomy-modifying devices include Ex-PRESS, Ologen, amniotic membrane, expanded polytetrafluoroethylene (E-PTFE) membrane, Gelfilm and others. However, the effectiveness and safety of these devices are uncertain.

OBJECTIVES

To assess the relative effectiveness, primarily with respect to IOP control and safety, of the use of different devices as adjuncts to trabeculectomy compared with standard trabeculectomy in eyes with glaucoma.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2014, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to December 2014), EMBASE (January 1980 to December 2014), PubMed (1948 to December 2014), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 December 2014.

SELECTION CRITERIA

We included randomized controlled trials comparing devices used during trabeculectomy with trabeculectomy alone. We also included studies where antimetabolites were used in either or both treatment groups.

DATA COLLECTION AND ANALYSIS

We used standard procedures expected by Cochrane.

MAIN RESULTS

We found 33 studies that met our inclusion criteria, of which 30 were published as full-length journal articles and three as conference abstracts. Only five studies have been registered. The 33 studies included a total of 1542 participants with glaucoma, and compared five types of devices implanted during trabeculectomy versus trabeculectomy alone. Five studies reported the use of Ex-PRESS (386 participants), eight studies reported the use of Ologen (327 participants), 18 studies reported the use of amniotic membrane (726 participants), one study reported the use of E-PTFE (60 participants), and one study reported the use of Gelfilm (43 participants). These studies were conducted in North America, South America, Europe, Asia, and the Middle East. Planned participant follow-up periods ranged from three months to five years. The studies were reported poorly which limited our ability to judge risk of bias for many domains. Only two studies explicitly masked outcome assessment so, we rated 31 studies at high risk of detection bias.Low-quality evidence from three studies showed that use of Ex-PRESS compared with trabeculectomy alone may be associated with a slightly lower IOP at one year (mean difference (MD) -1.58 mm Hg, 95% confidence interval (CI) -2.74 to -0.42; 165 eyes). Cataract surgery and hyphema may be less frequent in the Ex-PRESS group than in the trabeculectomy-alone group (cataract surgery: risk ratio (RR) 0.32, 95% CI 0.14 to 0.74, 3 studies, low-quality evidence; hyphema: RR 0.33, 95% CI 0.12 to 0.94, 4 studies, low-quality evidence). The effect of whether Ex-PRESS prevents hypotony was uncertain (RR 0.92, 95% CI 0.63 to 1.33, 2 studies, very low-quality evidence). All these studies received funding from the device manufacturer.Very low-quality evidence from five studies suggests that use of Ologen compared with trabeculectomy alone is associated with slightly higher IOP at one year (MD 1.40 mm Hg, 95% CI -0.57 to 3.38; 177 eyes). The effect of Ologen on preventing hypotony was uncertain (RR 0.75, 95% CI 0.47 to 1.19, 5 studies, very low-quality evidence). Differences between the two treatment groups for other reported complications also were inconclusive.Low-quality evidence from nine studies suggests that use of amniotic membrane with trabeculectomy may be associated with lower IOP at one year compared with trabeculectomy alone (MD -3.92 mm Hg, 95% CI -5.41 to -2.42; 356 eyes). Low-quality evidence showed that use of amniotic membrane may prevent adverse events and complications, such as hypotony (RR 0.40, 95% CI 0.17 to 0.94, 5 studies, low-quality evidence).The report from the only E-PTFE study (60 eyes) showed no important differences for postoperative IOP at one year (MD -0.44 mm Hg, 95% CI -1.76 to 0.88) between the trabeculectomy + E-PTFE versus the trabeculectomy-alone groups. Hypotony was the only postoperative complication observed less frequently in the E-PTFE group compared to the trabeculectomy-alone group (RR 0.29, 95% CI 0.11 to 0.77).The one Gelfilm study reported uncertainty in the difference in IOP and complication rates between the two groups at one year; no further data were provided in the study report.

AUTHORS' CONCLUSIONS

Overall, the use of devices with standard trabeculectomy may help with greater IOP reduction at one-year follow-up than trabeculectomy alone; however, due to potential biases and imprecision in effect estimates, the quality of evidence is low. When we examined outcomes within subgroups based on the type of device used, our findings suggested that the use of an Ex-PRESS device or an amniotic membrane as an adjunct to trabeculectomy may be slightly more effective in reducing IOP at one year after surgery compared with trabeculectomy alone. The evidence that these devices are as safe as trabeculectomy alone is unclear. Due to various limitations in the design and conduct of the included studies, the applicability of this evidence synthesis to other populations or settings is uncertain. Further research is needed to determine the effectiveness and safety of other devices and in subgroup populations, such as people with different types of glaucoma, of various races and ethnicity, and with different lens types (e.g. phakic, pseudophakic).

Cyclodialysis-enhanced trabeculectomy with triple Ologen implantation

PURPOSE

To describe a novel technique of trabeculectomy combined with cyclodialysis and Ologen implantation at 3 sites in cases with high risk for failure of trabeculectomy.

METHODS

Six eyes of 6 patients who had high risk for failure of trabeculectomy underwent cyclodialysis-augmented trabeculectomy with Ologen implantation at 3 sites using the described technique.

RESULTS

All the eyes achieved target intraocular pressure, which was maintained until 1 year of follow-up. One eye required bleb needling at 6 weeks postoperative follow-up. None of the eyes had any other intraoperative or postoperative complications.

CONCLUSIONS

This novel technique of combining trabeculectomy with cyclodialysis augmented by Ologen placement at 3 locations appears to have encouraging short-term intraocular pressure control and may be adopted in eyes with risk factors for failure of conventional trabeculectomy.

Biodegradable 3D-Porous Collagen Matrix (Ologen) Compared with Mitomycin C for Treatment of Primary Open-Angle Glaucoma: Results at 5 Years

Purpose. To evaluate the effectiveness and safety of the Ologen as an aid for trabeculectomy performed for primary open-angle glaucoma compared with mitomycin C. Methods. In this prospective, randomized, parallel assignment, comparative study, 31 eyes of 21 primary open-angle glaucoma patients were allocated for trabeculectomy with the Ologen implant; another 32 eyes of 23 patients were treated with trabeculectomy augmented with mitomycin C. The patients were followed up for 5 years and evaluated for intraocular pressure, rate of success, status of the bleb, and adverse events. Result. The mean postoperative intraocular pressure was statistically different at 3 m, 6 m, 1 y, 3 y, and 5 y follow-up. The rates of both complete success (P = 0.017) and overall success (P = 0.031) in the Ologen group were significantly higher than those in the mitomycin C group. The difference of the bleb extent and vascularity was statistically significant in both groups. There was no significant difference in postoperative complication. Conclusions. Ologen provides higher rates of surgical success compared with mitomycin C for patients with primary open-angle glaucoma undergoing trabeculectomy. It may be a new, safe, simple, and effective therapeutic approach for treating primary open-angle glaucoma.

Comparison of Ahmed glaucoma valve implantation and trabeculectomy for glaucoma: a systematic review and meta-analysis

Objective

To compare the efficacy and safety of Ahmed glaucoma valve implantation (AGV) with trabeculectomy in the management of glaucoma patients.

Methods

A comprehensive literature search (PubMed, Embase, Google, and the Cochrane library) was performed, including a systematic review with meta-analysis of controlled clinical trials comparing AGV versus trabeculectomy. Efficacy estimates were the weighted mean differences (WMDs) for the percentage intraocular pressure reduction (IOPR %) from baseline to end-point, the reduction in glaucoma medications, and the odds ratios (ORs) for complete and qualified success rates. Safety estimates were the relative risks (RRs) for adverse events. All outcomes were reported with a 95% confidence interval (CI). Statistical analysis was performed using the RevMan 5.0 software.

Results

Six controlled clinical trials were included in this meta-analysis. There was no significant difference between the AGV and trabeculectomy in the IOPR% (WMD = -3.04, 95% CI: -8.36- 2.26; P = 0.26). The pooled ORs comparing AGV with trabeculectomy were 0.46 (0.22, 0.99) for the complete success rate (P = 0.05) and 0.97 (0.78–1.20) for the quantified success rate (P = 0.76). No significant difference in the reduction in glaucoma medicines was observed (WMD = 0.24; 95% CI: -0.27–0.76; P = 0.35). AGV was found to be associated with a significantly lower frequency of all adverse events (RR = 0.71; 95%CI: 1.14–0.97; p = 0.001) than trabeculectomy, while the most common complications did not differ significantly (all p> 0.05).

Conclusion

AGV was equivalent to trabeculectomy in reducing the IOP, the number of glaucoma medications, success rates, and rates of the most common complications. However, AGV was associated with a significantly lower frequency of overall adverse events.