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Nagar AM, Maghsoudlou P, Wormald R, Barton K, Hysi P, Lim KS. Differences in the Surgical Outcomes of Glaucoma Surgery in Patients of African Caribbean Descent. Curr Eye Res 2022; 47:1567-1577. [PMID: 36214781 DOI: 10.1080/02713683.2022.2126859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE People of African Caribbean Descent (ACD) have a higher prevalence of glaucoma compared to people of European Descent (ED) and there is uncertainty if treatment outcomes are equivalent between the two groups. To assess surgical failure rates comparing ACD with ED focusing on trabeculectomy, aqueous shunt implantation, non-penetrating filtering surgery (NPFS), and minimally invasive glaucoma surgery (MIGS) by performing a systematic review in accordance with the PRISMA guidelines and to determine whether there is any evidence in to show a difference in success rates based on race. METHODS A systematic review of articles using the CENTRAL, Ovid MEDLINE, PubMed, EMBASE, and ClinicalTrials.gov databases was completed. Additional studies were identified by contacting clinical experts and searching bibliographies. All retrospective and prospective studies on trabeculectomy, aqueous shunt implantation, NPFS, and MIGS that included at least 20% ACD were included. Two review authors independently screened search results for eligibility and inclusion and extracted the data using pre-determined fields. RESULTS A total of 76 studies were identified for inclusion in the review. Glaucoma surgical outcomes in ACD appear to be poorer compared to ED overall, particularly for trabeculectomy. Data on NPFS are limited, but the studies completed thus far demonstrate surprisingly good results for ACD, particularly when compared to ED, who have significantly lower pre-operative IOPs. Evidence from studies investigating aqueous shunts does not suggest that ACD have poorer outcomes than ED. There is not enough data on MIGS to provide a significant conclusion. CONCLUSION In a population where trabeculectomy may no longer be the gold standard, sufficiently powered studies assessing surgical outcomes in aqueous shunts, NPFS, and MIGS are needed to guide clinicians.
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Affiliation(s)
- A M Nagar
- Department of Ophthalmology, St Thomas' Hospital, London, UK.,King's College London, London, UK
| | | | - R Wormald
- International Centre for Eye Health at the LSHTM and Institute of Ophthalmology UCL, London, UK
| | - K Barton
- Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
| | - P Hysi
- King's College London, London, UK
| | - K S Lim
- Department of Ophthalmology, St Thomas' Hospital, London, UK.,King's College London, London, UK
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Trabecular Microbypass Stent and Phacoemulsification in African American Patients With Open-angle Glaucoma: Outcomes and Effect of Prior Laser Trabeculoplasty. J Glaucoma 2021; 30:89-93. [PMID: 33351549 DOI: 10.1097/ijg.0000000000001692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/19/2020] [Indexed: 11/26/2022]
Abstract
PRECIS In African American patients with glaucoma, iStent/phacoemulsification lowered intraocular pressure and reduced glaucoma medication usage for up to 1 year, even in patients with prior selective laser trabeculoplasty (SLT). PURPOSE Currently, no studies have examined the outcomes of a trabecular microbypass stent and phacoemulsification in African American patients. Here, the authors investigate whether iStent/phacoemulsification decreases intraocular pressure (IOP) and/or medication usage in African American patients with glaucoma. They are also interested in whether prior SLT would affect outcomes of iStent/phacoemulsification. PATIENTS AND METHODS A multicenter, retrospective case series of eyes that underwent iStent/phacoemulsification between 2013 and 2017 with up to 1-year follow-up. Eyes with a confirmed diagnosis of glaucoma in African American patients were included. Eyes with neovascular glaucoma or closed angle glaucoma and eyes that underwent previous incisional glaucoma surgery were excluded. RESULTS Eighty-nine eyes were included in the study and data for 66 eyes were available at postoperative year 1 (POY1). IOP decreased from 18.3±5.7 mm Hg to 15.9±4.6 (P<0.001) and glaucoma medication usage decreased from 1.9±1.1 to 1.1±1.1 (P<0.001) at POY1. Eyes that underwent prior SLT experienced less of a decrease in IOP when compared with eyes without prior SLT, but IOP at POY1 was not significantly different between these groups. Both groups had a similar reduction in medication usage. The most common complications were IOP spikes on postoperative day 1 and microhyphemas. CONCLUSIONS In this cohort, there was a significant decrease in IOP and medication usage 1 year after iStent/phacoemulsification. iStent/phacoemulsification is an effective and safe treatment option in African American patients with glaucoma.
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Taubenslag KJ, Kammer JA. Outcomes Disparities between Black and White Populations in the Surgical Management of Glaucoma. Semin Ophthalmol 2016; 31:385-93. [DOI: 10.3109/08820538.2016.1154163] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Combined Phacoemulsification and Ahmed Glaucoma Drainage Implant Surgery for Patients With Refractory Glaucoma and Cataract. J Glaucoma 2016; 25:162-6. [PMID: 25264992 DOI: 10.1097/ijg.0000000000000141] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To examine the indications, safety, efficacy, and complications of combined phacoemulsification and Ahmed glaucoma drainage implant surgery. METHODS A retrospective case review of 35 eyes (31 patients) subjected to combined phacoemulsification and Ahmed glaucoma drainage implant surgery. Demographic characteristics of the study population, indications for combined surgery, and operative and postoperative complications were recorded. Visual acuity, intraocular pressure (IOP), and number of glaucoma medications were evaluated preoperatively and postoperatively. Complete success was defined as IOP ≤ 21 mm Hg without medication, qualified success if IOP ≤ 21 mm Hg with ≥ 1 medications, and failure if IOP>21 mm Hg or ≤ 5 mm Hg on ≥ 2 consecutive visits. RESULTS Mean follow-up was 29.5 months (range, 6 to 87 mo). The most common indication for combined surgery was a history of prior failed trabeculectomy (60%). Postoperative visual acuity improved in 30 of 35 eyes (85%) (P<0.01) regardless of the indication for combined surgery. IOP was reduced from a mean of 24.7 to 15.0 mm Hg at the last follow-up visit (P<0.01). The number of IOP-lowering medications was reduced from a median of 3.1 preoperatively to 1.7 at the last follow-up (P<0.01). Overall, there were 31 eyes (89%) classified as qualified success and 4 eyes (11%) as complete success. The most common postoperative complication was a hypertensive phase in 18 eyes (51%). CONCLUSIONS Combined phacoemulsification and Ahmed glaucoma drainage implant surgery seems to be a safe and effective surgical option, providing good visual rehabilitation and control of IOP for patients with refractory glaucoma and cataract.
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Chen DZ, Koh V, Sng C, Aquino MC, Chew P. Complications and outcomes of primary phacotrabeculectomy with mitomycin C in a multi-ethnic asian population. PLoS One 2015; 10:e0118852. [PMID: 25775362 PMCID: PMC4361399 DOI: 10.1371/journal.pone.0118852] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 01/17/2015] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To determine the occurrence of intraoperative and postoperative complications up to three years after primary phacotrabeculectomy with intraoperative use of Mitomycin C (MMC) in primary open angle (POAG) and primary angle closure glaucoma (PACG) patients, and the effect of postoperative complications on surgical outcome. METHODS Retrospective review of 160 consecutive patients with POAG (n = 105) and PACG (n = 55), who underwent primary phacotrabeculectomy with MMC at the National University Hospital, Singapore, from January 1, 2008 to December 31, 2010. Data was collected using a standardized form that included patient demographic information, ocular characteristics and postoperative complications, including hypotony (defined as intraocular pressure < 6 mmHg), shallow anterior chamber (AC) and hyphema. RESULTS The mean age ± standard deviation (SD) of patients was 68.2 ± 8.2 years. No patient lost light perception during duration of follow-up. 77% of the postoperative complications occurred within the first month only. The commonest complications were hypotony (n = 41, 25.6%), hyphema (n = 16, 10.0%) and shallow AC (n = 16, 10.0%). Five patients (3.1%) required reoperation for their complications. Early hypotony (defined as hypotony < 30 days postoperatively) was an independent risk factor for surgical failure (hazard ratio [HR], 5.1; 95% CI, 1.6-16.2; p = 0.01). Hypotony with another complication was also a risk factor for surgical failure (p < 0.02). CONCLUSIONS Hypotony, hyphema and shallow AC were the commonest postoperative complications in POAG and PACG patients after phacotrabeculectomy with MMC. Most complications were transient and self-limiting. Early hypotony within the first month was a significant risk factor for surgical failure.
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Affiliation(s)
- David Z. Chen
- Department of Ophthalmology, National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- * E-mail:
| | - Victor Koh
- Department of Ophthalmology, National University Health System, Singapore, Singapore
| | - Chelvin Sng
- Department of Ophthalmology, National University Health System, Singapore, Singapore
| | - Maria C. Aquino
- Department of Ophthalmology, National University Health System, Singapore, Singapore
| | - Paul Chew
- Department of Ophthalmology, National University Health System, Singapore, Singapore
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L Jung J, Isida-Llerandi CG, Lazcano-Gomez G, SooHoo JR, Kahook MY. Intraocular Pressure Control after Trabeculectomy, Phacotrabeculectomy and Phacoemulsification in a Hispanic Population. J Curr Glaucoma Pract 2014; 8:67-74. [PMID: 26997812 PMCID: PMC4741170 DOI: 10.5005/jp-journals-10008-1164] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/02/2014] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To compare the efficacy of different surgical strategies for intraocular pressure (IOP) control in Hispanic glaucoma patients with and without visually significant cataracts. DESIGN Comparative retrospective consecutive case series. METHODS The charts of 153 consecutive patients with primary open angle glaucoma who underwent either trabeculectomy alone (n = 51), phacotrabeculectomy (n = 51), or phacoemulsification alone (n = 51) were reviewed to compare IOP control, the number of glaucoma medications required postoperatively, and the inci dence of surgical complications. RESULTS Preoperative IOP was 17.5 ± 5.2 mm Hg in the trabe-culectomy group, 15.4 ± 4.5 mm Hg in the phacotrabeculectomy group and 13.9 ± 2.9 mm Hg in the phacoemulsification group (p < 0.001 for all comparisons). Mean IOP reduction from baseline was 4.2 ± 6.9 (24.6%) for the trabeculectomy group, 2.9 ± 5.0 (20.8%) for the phacotrabeculectomy group, and 0.9 ± 3.4 (6.5%) for the phacoemulsification group (p = 0.009). The number of IOP-lowering medications required postoperatively decreased significantly in all three groups (p = 0.001). The rate of early and late postoperative complications was similar between the trabeculectomy and phacotrabeculectomy groups and less for the phacoemulsification group. CONCLUSION Trabeculectomy and phacotrabeculectomy are both viable surgical options for managing open angle glau coma. Both resulted in similar rates of success, IOP reduction, decrease in use of IOP-lowering medications and post operative complication rates. Phacoemulsification alone had a lower success rate and greater need for postoperative IOP-lowering medications compared to trabeculectomy alone or phacotrabeculectomy. Phacoemulsification alone may be a reasonable option for patients with visually significant cataract and lower baseline IOP. How to cite this article: Jung JL, Isida-Llerandi CG, Lazcano-Gomez G, SooHoo JR, Kahook MY. Intraocular Pressure Control after Trabeculectomy, Phacotrabeculectomy and Phaco-emulsification in a Hispanic Population. J Curr Glaucoma Pract 2014;8(2):67-74.
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Affiliation(s)
- Jennifer L Jung
- Instructor, Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cristina G Isida-Llerandi
- Glaucoma Fellowship, Asociacion para evitar la ceguera en Mexico IAP, Vicente Garcia Torres 46, San Lucas Coyoacan, DF, Maxico
| | - Gabriel Lazcano-Gomez
- Glaucoma Associate Professor, Asociacion para evitarla ceguera en Mexico IAP, Vicente Garcia Torres 46, San Lucas Coyoacan, DF, Maxico
| | - Jeffrey R SooHoo
- Assistant Professor, Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Malik Y Kahook
- Professor, Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Zhao XJ, Yang XX, Fan YP, Li BH, Li Q. Comparison of Combined Phacoemulsification, Intraocular Lens Implantation, and Goniosynechialysis With Phacotrabeculectomy in the Treatment of Primary Angle-Closure Glaucoma and Cataract. Asia Pac J Ophthalmol (Phila) 2013; 2:286-90. [PMID: 26107030 DOI: 10.1097/apo.0b013e318299df62] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE This study aimed to compare the efficacy and safety of combined phacoemulsification, intraocular lens implantation, and goniosynechialysis with phacotrabeculectomy in the treatment of primary angle-closure glaucoma (PACG) and cataract. DESIGN A comparative case series. METHODS Sixty-five patients (65 eyes) with PACG and cataract from the Fifth Affiliated Hospital of Sun Yat-Sen University were enrolled for this study between October 2009 and July 2011. Of these, 33 underwent combined phacoemulsification, intraocular lens implantation, and goniosynechialysis (treatment group), and 32 underwent phacotrabeculectomy (control group). The effects on intraocular pressure, best-corrected visual acuity, anterior chamber angle, number of antiglaucoma medications, and complications were evaluated. RESULTS Both the treatment group and the control group had lowered intraocular pressure, reduced the use of antiglaucoma medications, and improved vision in patients with PACG and cataract. Complications were 8 (24.2%) of 33 in the treatment group and 12 (37.5%) of 32 in the control group. CONCLUSIONS Combined phacoemulsification, intraocular lens implantation, and goniosynechialysis appears to be a preferred method for the treatment of PACG and cataract because it seems to have the same efficacy as phacotrabeculectomy and has much less surgical complications.
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Affiliation(s)
- Xiao-Jing Zhao
- From the Departments of *Ophthalmology, and †Otolaryngology, the Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
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De Fendi LI, Arruda GV, Scott IU, Paula JS. Mitomycin C versus5-fluorouracil as an adjunctive treatment for trabeculectomy: a meta-analysis of randomized clinical trials. Clin Exp Ophthalmol 2013; 41:798-806. [DOI: 10.1111/ceo.12097] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Lígia I De Fendi
- Department of Ophthalmology; Otorhinolaryngology and Head and Neck Surgery; School of Medicine of Ribeirão Preto; University of São Paulo
- Department of Ophthalmology; School of Medicine of Marília; São Paulo Brazil
| | - Gustavo V Arruda
- Department of Radiotherapy; School of Medicine of Marília; São Paulo Brazil
| | - Ingrid U Scott
- Departments of Ophthalmology and Public Health Sciences; Penn State College of Medicine; Hershey Pennsylvania USA
| | - Jayter S Paula
- Department of Ophthalmology; Otorhinolaryngology and Head and Neck Surgery; School of Medicine of Ribeirão Preto; University of São Paulo
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Lin ZJ, Li Y, Cheng JW, Lu XH. Intraoperative Mitomycin C Versus Intraoperative 5-Fluorouracil for Trabeculectomy: A Systematic Review and Meta-Analysis. J Ocul Pharmacol Ther 2012; 28:166-73. [PMID: 22029538 DOI: 10.1089/jop.2011.0117] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Zhong-Jie Lin
- Department of Ophthalmology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - You Li
- Department of Ophthalmology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
- Department of Ophthalmology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jin-Wei Cheng
- Department of Ophthalmology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - Xiao-He Lu
- Department of Ophthalmology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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Mathalone N, Marmor S, Rahat MA, Lahat N, Oron Y, Geyer O. MMP expression in leaking filtering blebs and tears after glaucoma filtering surgery. Graefes Arch Clin Exp Ophthalmol 2011; 249:1047-55. [DOI: 10.1007/s00417-011-1658-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 01/08/2011] [Accepted: 02/18/2011] [Indexed: 11/28/2022] Open
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A Comparison of Corneal Endothelial Cell Changes After 1-Site and 2-Site Phacotrabeculectomy. Cornea 2008; 27:889-94. [PMID: 18724149 DOI: 10.1097/ico.0b013e31817618b0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
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.
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Affiliation(s)
- A Labbé
- Service d'Ophtalmologie III, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Paris, France.
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Abstract
Fluorouracil (5-fluorouracil, 5-FU) is a pyrimidine analogue that was originally known for its widespread use as an anticancer drug. The ability of 5-FU to reduce fibroblastic proliferation and subsequent scarring has made it an important adjunct in ocular and periorbital surgeries. It is used in primary glaucoma filtering surgeries and in reviving failing filtering blebs, in dacryocystorhinostomy, pterygium surgery, and in vitreoretinal surgery to prevent proliferative vitreoretinopathy. In addition, 5-FU is also gaining recognition in the treatment and surgical management of ocular surface malignancies like ocular surface squamous neoplasia; however, the specific action of the drug on highly proliferating cells limits its use in primary acquired melanosis of the conjunctiva. When applied topically, this drug has a low rate of sight-threatening adverse effects, is inexpensive, and is easy to administer, making it an important tool in enhancing the success rate in ophthalmic surgery and in reducing the recurrence of ocular surface neoplasia.
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Affiliation(s)
- Lekha M Abraham
- Glaucoma Services, South Australian Institute of Ophthalmology, Royal Adelaide Hospital, University of Adelaide, Australia
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Abstract
PURPOSE OF REVIEW This review analyzes the most relevant studies on current surgical strategies to treat glaucoma patients with cataracts. RECENT FINDINGS No clear evidence has confirmed better results with trabeculectomy alone compared with phacotrabeculectomy. Recent studies have reported successful outcomes combining deep sclerectomy and two-site phacoemulsification. The phacoemulsification cataract extraction will not vary the intraocular pressure of patients with previous deep sclerectomy. Mitomycin C proved to be effective in maintaining lower pressure levels with the combined surgery technique; however, 5-fluorouracil did not show any improvement. Minimally invasive cataract surgery reduces surgical trauma, making it possible to obtain better results with combined surgery and previous glaucoma surgery. SUMMARY The surgical strategy decision must be customized to every patient. Only filtering surgeries are recommended in glaucoma patients with incipient cataract. Combined surgical procedures are recommended for progressive or advanced glaucoma. Two-site phacotrabeculectomy with mitomycin C achieves better stabilized results; however, combined phacoemulsification with deep sclerectomy or viscocanalostomy achieves similar results with a lower rate of complications. These promising findings need more study to be confirmed.
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Affiliation(s)
- Carlos Verges
- Institut Universitari Dexeus, Universitat Autonoma de Barcelona, Barcelona, Spain.
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Paris G, Zhao M, Sponsel WE. Operative revision of non-functioning filtering blebs with 5-fluorouracil to regain intraocular pressure control. Clin Exp Ophthalmol 2004; 32:378-82. [PMID: 15281971 DOI: 10.1111/j.1442-9071.2004.00841.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the efficacy of extensive microsurgical needling revision of failed filtering blebs followed by serial 5-fluorouracil subconjunctival injections. METHODS Thirty-six eyes of 34 consecutive patients with progressive open-angle glaucoma refractory to topical therapy submitted to needling revision as a major procedure. All patients required multiple antiglaucoma medications preoperatively, and had completely flat or densely encapsulated filtering blebs. All patients underwent elaborate needling revision (limbus to superior rectus >8 mm diameter, >3 mm elevation, entry-site sutured with 8-0 vicryl and bleb reformed via paracentesis with viscoelastic) in the operating room, followed by serial 5-fluorouracil. The patients were followed for up to 6 months postoperatively. The main outcome measures were intraocular pressure (IOP) and the number of antiglaucoma medications used. RESULTS Thirty-one eyes (86%) maintained mean IOP below 15 mmHg postneedling without medication. Overall the mean IOP postneedling was >9 mmHg lower than medicated preoperative levels (P < 0.0001). IOP reduction in encapsulated blebs was marginally superior to that in flat blebs. CONCLUSIONS Extensive needling revision in the operating room is safe, straightforward, and produces reproducible restoration of filtering function.
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Affiliation(s)
- Gianmarco Paris
- Department of Ophthalmology, University of Texas Health Science Center, San Antonio, Texas 78229-3900, USA
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Yoon PS, Singh K. Update on antifibrotic use in glaucoma surgery, including use in trabeculectomy and glaucoma drainage implants and combined cataract and glaucoma surgery. Curr Opin Ophthalmol 2004; 15:141-6. [PMID: 15021227 DOI: 10.1097/00055735-200404000-00015] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW This paper summarizes the use of antifibrotic agents adjunctive to glaucoma surgery, reviews recently published studies that address current use of these antifibrotics, and reviews new methods of wound modulation. RECENT FINDINGS The use of antifibrotic agents, namely, 5-fluorouracil and mitomycin C, in conjunction with glaucoma surgery has resulted in lower postoperative intraocular pressures after trabeculectomy or combined cataract and glaucoma surgery. Mixed results have been seen when these agents are used with glaucoma drainage device surgery. The use of antifibrotic agents has also created and increased complications. Therefore, methods of antifibrotic use have become more refined and modified for specific circumstances. Promising new wound modulation agents, such as CAT-152, are currently under study. SUMMARY Antifibrotics are potent adjuncts to glaucoma surgery, but along with their beneficial use are risks that need to be considered. While we continue to look for more efficacious agents and methods to treat glaucoma, we must continue to modify techniques with the individual patient's best interest in mind.
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Affiliation(s)
- Patricia S Yoon
- Stanford University, School of Medicine, Stanford, California, USA.
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Chung AN, Aung T, Wang JC, Chew PTK. Surgical outcomes of combined phacoemulsification and glaucoma drainage implant surgery for Asian patients with refractory glaucoma with cataract. Am J Ophthalmol 2004; 137:294-300. [PMID: 14962420 DOI: 10.1016/j.ajo.2003.08.036] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2003] [Indexed: 11/23/2022]
Abstract
PURPOSE To examine the safety and efficacy of combined phacoemulsification and glaucoma drainage implant surgery in providing reduction of intraocular pressure (IOP) and visual rehabilitation in eyes with refractory glaucoma and cataract. DESIGN Interventional case series. METHODS A retrospective chart review was performed on all subjects who underwent combined phacoemulsification with intraocular lens implantation and glaucoma drainage implant surgery by a single surgeon at the National University Hospital, Singapore. The implants used were the 185 mm2 Ahmed glaucoma valve and the 350 mm2 Baerveldt glaucoma implant. In terms of IOP, a complete success was defined as IOP of between 6 to 21 mm Hg without medication, qualified success as IOP between 6 to 21 mm Hg with one or more medication, and failure as a sustained IOP of >21 mm Hg or <6 mm Hg with or without one or more medication on two or more visits. RESULTS A total of 32 combined phacoemulsification and glaucoma implant surgeries in 32 patients was performed. All patients were of Asian origin, and the mean age was 58 +/- 16 years (range, 20-78 years). The Baerveldt glaucoma implant and Ahmed glaucoma valve implant were inserted in 16 eyes each. With a mean follow-up of 13 +/- 5 months (range 6 to 22 months), IOP was reduced from a mean of 28.0 +/- 11.5 mm Hg to 15.2 +/- 6.0 mm Hg postoperatively (P <.0001), whereas the number of antiglaucoma medications decreased from a mean of 2.4 +/- 1.4 to.3 +/-.7 (P <.0001) at last follow-up. Overall, there were 24 eyes (75%) that were classified as complete successes, 4 eyes (12.5%) that were qualified successes, and 4 eyes that failed (12.5%). Twenty-three eyes (72%) had improvement of visual acuity, while only one eye had a loss of more than 1 line of Snellen acuity. There was no case that encountered an intraoperative complication, and postoperative complications occurred in 12 eyes (38%), the most common of which was hypotony (in six eyes, 19%). CONCLUSION For subjects with refractory glaucoma and cataract, combined phacoemulsification and glaucoma drainage implant surgery provide good visual rehabilitation and control of IOP, with low incidence of complications.
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Affiliation(s)
- Alejandro N Chung
- Department of Ophthalmology, National University Hospital, Singapore
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Abstract
When medical and laser therapy fail to control intraocular pressure, glaucoma filtration surgery needs to be performed. Glaucoma surgery is unique in that its success is linked to interruption of the wound-healing response in order to maintain patency of the new filtration pathway. In this article we will review the wound-healing pathway and the pharmacologic interventions that have been employed clinically and experimentally to interrupt wound healing, particularly steroids and the antifibrotic agents 5-fluorouracil and mitomycin C. A review of the published literature looking at use of these agents to enhance success as well as the associated complications are presented, critiqued, and interpreted in order to put the studies in proper perspective. Future directions and recommendations regarding use of these agents are available and an introduction to newer wound modulating agents such as anti-transforming growth factor beta 2 is presented.
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Affiliation(s)
- Paul J Lama
- Glaucoma Division, New Jersey Medical School, Newark 07103, USA
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Jampel HD, Friedman DS, Lubomski LH, Kempen JH, Quigley H, Congdon N, Levkovitch-Verbin H, Robinson KA, Bass EB. Effect of technique on intraocular pressure after combined cataract and glaucoma surgery: An evidence-based review. Ophthalmology 2002; 109:2215-24; quiz 2225, 2231. [PMID: 12466161 DOI: 10.1016/s0161-6420(02)01439-2] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TOPIC To analyze the literature pertaining to the techniques used in combined cataract and glaucoma surgery, including the technique of cataract extraction, the timing of the surgery (staged procedure versus combined procedure), the anatomic location of the operation, and the use of antifibrosis agents. CLINICAL RELEVANCE Cataract and glaucoma are both common conditions and are often present in the same patient. There is no agreement concerning the optimal surgical management of these disorders when they coexist. METHODS/LITERATURE REVIEWED Electronic searches of English language articles published since 1964 were conducted in Pub MED and CENTRAL, the Cochrane Collaboration's database. These were augmented by a hand search of six ophthalmology journals and the reference lists of a sample of studies included in the literature review. Evidence grades (A, strong; B, moderate; C, weak; I, insufficient) were assigned to the evidence that involved a direct comparison of alternative techniques. RESULTS The preponderance of evidence from the literature suggests a small (2-4 mmHg) benefit from the use of mitomycin-C (MMC), but not 5-fluorouracil (5-FU), in combined cataract and glaucoma surgery (evidence grade B). Two-site surgery provides slightly lower (1-3 mmHg) intraocular pressure (IOP) than one-site surgery (evidence grade C), and IOP is lowered more (1-3 mmHg) by phacoemulsification than by nuclear expression in combined procedures (evidence grade C). There is insufficient evidence to conclude either that staged or combined procedures give better results or that alternative glaucoma procedures are superior to trabeculectomy in combined procedures. CONCLUSIONS In the literature on surgical techniques and adjuvants used in the management of coexisting cataract and glaucoma, the strongest evidence of efficacy exists for using MMC, separating the incisions for cataract and glaucoma surgery, and removing the nucleus by phacoemulsification.
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Affiliation(s)
- Henry D Jampel
- Department of Ophthalmology, Johns Hopkins University, Baltimore, Maryland, USA
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Jampel HD, Friedman DS, Lubomski LH, Kempen JH, Quigley H, Congdon N, Levkovitch-Verbin H, Robinson KA, Bass EB. Methodologic rigor of clinical trials on surgical management of eyes with coexisting cataract and glaucoma. Ophthalmology 2002; 109:1892-901. [PMID: 12359611 DOI: 10.1016/s0161-6420(02)01084-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess the methodologic quality of published studies of the surgical management of coexisting cataract and glaucoma. DESIGN Literature review and analysis. METHOD We performed a systematic search of the literature to identify all English language articles pertaining to the surgical management of coexisting cataract and glaucoma in adults. Quality assessment was performed on all randomized controlled trials, nonrandomized controlled trials, and cohort studies. Overall quality scores and scores for individual methodologic domains were based on the evaluations of two experienced investigators who independently reviewed articles using an objective quality assessment form. MAIN OUTCOME MEASURES Quality in each of five domains (representativeness, bias and confounding, intervention description, outcomes and follow-up, and statistical quality and interpretation) measured as the percentage of methodologic criteria met by each study. RESULTS Thirty-six randomized controlled trials and 45 other studies were evaluated. The mean quality score for the randomized, controlled clinical trials was 63% (range, 11%-88%), and for the other studies the score was 45% (range, 3%-83%). The mean domain scores were 65% for description of therapy (range, 0%-100%), 62% for statistical analysis (range, 0%-100%), 58% for representativeness (range, 0%-94%), 49% for outcomes assessment (range, 0%-83%), and 30% for bias and confounding (range, 0%-83%). Twenty-five of the studies (31%) received a score of 0% in the bias and confounding domain for not randomizing patients, not masking the observers to treatment group, and not having equivalent groups at baseline. CONCLUSIONS Greater methodologic rigor and more detailed reporting of study results, particularly in the area of bias and confounding, could improve the quality of published clinical studies assessing the surgical management of coexisting cataract and glaucoma.
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Affiliation(s)
- Henry D Jampel
- Department of Ophthalmology, Johns Hopkins University, Baltimore, Maryland 21287-9205, USA
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Hoffman KB, Feldman RM, Budenz DL, Gedde SJ, Chacra GA, Schiffman JC. Combined cataract extraction and Baerveldt glaucoma drainage implant: indications and outcomes. Ophthalmology 2002; 109:1916-20. [PMID: 12359614 DOI: 10.1016/s0161-6420(02)01185-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To report the indications and outcomes of simultaneous cataract extraction (CE) and Baerveldt glaucoma drainage implant surgery. DESIGN Noncomparative, interventional, retrospective, consecutive case series. PARTICIPANTS Thirty-three eyes of 33 patients. INTERVENTION Combined phacoemulsification CE and Baerveldt glaucoma drainage implant (BGI) surgery at two tertiary care referral centers. MAIN OUTCOME MEASURES Visual acuity, intraocular pressure (IOP), and complications. RESULTS The study included 33 eyes of 33 patients followed for an average of 15.4 months (range, 3.0-46.9). The most common indication for combined CE and Baerveldt glaucoma drainage implant surgery was a history of prior failed trabeculectomy. Postoperative visual acuity at last follow-up was > or =20/40 in 12 of 33 patients (36%). IOP was reduced from a mean (+/- standard deviation) of 21 +/- 7.3 mmHg preoperatively to 13.1 +/- 3.5 mmHg at last follow-up visit ( P < 0.001). The number of antiglaucoma medications was reduced from a mean (+/- standard deviation) of 2.3 +/- 1.0 preoperatively to 0.7 +/- 1.1 at last follow-up (P < 0.001). Three eyes met our criteria for failure, and cumulative survival of the glaucoma surgery at 18 months was 89%. Intraoperative complications were all related to the cataract surgery, whereas early and late postoperative complications were related both to the CE and BGI surgery. CONCLUSIONS Combined CE and Baerveldt glaucoma drainage implant placement seems to be a safe and effective surgical option and may be preferred in certain clinical situations.
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Affiliation(s)
- Kara B Hoffman
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine, Miami, Florida 33136, USA
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Mwanza JC, Kabasele PM. Trabeculectomy with and without mitomycin-C in a black African population. Eur J Ophthalmol 2001; 11:261-3. [PMID: 11681505 DOI: 10.1177/112067210101100308] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the beneficial effects of intraoperative application of mitomycin-C during trabeculectomy in a black African population in Congo-Kinshasa. METHODS A prospective randomized study in 22 eyes (11 patients) with open-angle glaucoma. All patients underwent trabeculectomy with application of mitomycin-C (0.4 mg/ml for 2.5 min) under the scleral flap in the right eye and trabeculectomy alone in the left eye. Assessment of the clinical outcome included intraocular pressure, visual acuity, visual field and complications. The follow-up was 20 months. Success of the filtering surgery was defined as a final IOP of 21 mmHg or lower without antiglaucoma medications and no further glaucoma surgery necessary. RESULTS The success rate of trabeculectomy was 81.8% in eyes treated with mitomycin-C compared with 63.6% in eyes not receiving this drug. Rates of intraocular pressure reduction were 57.9% and 42.9% respectively. Complications occured in 36.3% of the eyes managed with mitomycin-C against 9% in the control eyes. CONCLUSIONS Mitomycin-C, as adjunctive treatment during trabeculectomy in black Africans, offers great benefit in lowering IOP, but with a substantial high risk of complications. These data need to be confirmed by further studies in this population.
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Affiliation(s)
- J C Mwanza
- Department of Ophthalmology, University Hospital of Kinshasa, Democratic Republic of Congo.
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