Preoperative Preparation and Anesthesia for Trabeculectomy

Analysis of the impact of different schemes of preparation to trabeculectomy on the healing markers on the Tenon fibroblasts cultures

The aim of the study was to assess the influence of different regimes of patient's preparation before trabeculectomy on the markers of healing process in Tenon's fibroblast cultures.The studied group consisted of 66 patients with open angle glaucoma undergoing primary trabeculectomy. The patients were divided into 5 groups with different regimes of preparation before the surgery based on application or withdrawal of topical antiglaucoma medications and steroids (G1-patients using antiglaucoma drops until the day of the surgery; G2-patients using antiglaucoma drops until the day of the surgery and additionally dexamethasone for 4 weeks before surgery; G3-patients who stopped using antiglaucoma drops 4 weeks before the surgery and introduced dexamethasone for 4 weeks before surgery; G4-patients who stopped using antiglaucoma drops 4 weeks before the surgery; G5-control group, patients with newly diagnosed glaucoma in whom trabeculectomy was the first treatment option without medical treatment). During trabeculectomy the samples of Tenon's capsule were obtained. Tenon fibroblasts were isolated directly from the explants to test their proliferation ability and the level of released healing markers. Following factors typical of healing process were evaluated using commercially available ELISA kits: IL 1-β, IL-6, IL-8, VEGF-A, TGF-β1 and MMP-9. Concentrations of IL-1β, IL-6 and TGF-β1 were significantly higher in the group obtaining antiglaucoma drops. Additionally, in this group the fibroblasts revealed the highest proliferation potential, indicating the active healing process. The levels of IL-8, VEGF-A and MMP-9 were similar between the groups. Our study shows that for the best conjunctival anti-inflammatory control, the most influential factor is the withdrawal of antiglaucoma medications.

Advanced glaucoma. Clinical practice guideline

OBJECTIVE

To present an update clinical practice guideline that serve as a guide for the detection, evaluation and treatment of adults patients with advanced glaucoma.

METHODS

After defining the objectives and scope of the guide, the working group was formed and structured clinical questions were formulated following the PICO (Patient, Intervention, Comparison, Outcomes) format. Once all the existing clinical evidence had been independently evaluated with the AMSTAR 2 (Assessment of Multiple systematic Rewiews) and Cochrane "Risk of bias" tools by at least two reviewers, recommendations were formulated following the Scottish Intercollegiate methodology. Guideline Network (SIGN).

RESULTS

Recommendations with their corresponding levels of evidence that may be useful in the diagnosis, monitoring and treatment of adults patients with advanced glaucoma.

CONCLUSIONS

Despite the fact that for many of the questions the level of scientific evidence available is not very high, this clinical practice guideline offers an updated review of the different existing aspects related to the evaluation and management of advanced glaucoma.

Anesthesia for ophthalmic surgery: an educational review

PURPOSE

Selecting an anesthetic agent for ophthalmic surgery has crucial implications for the surgeon, anesthesiologist, and patient. This educational review explores the common classes of anesthesia used in ophthalmology. Additionally, we discuss the considerations unique to cataract, glaucoma, strabismus, orbital, oculoplastic, and ocular trauma surgeries.

METHODS

A comprehensive Embase search was performed using combinations of the subject headings "anesthesia", "eye surgery", "ophthalmology" and "cataract extraction", "glaucoma", "strabismus", "vitreoretinal surgery", "retina surgery", "eye injury", and "eyelid reconstruction".

RESULTS

Topical anesthetics are the most commonly used form of ocular anesthesia, used in both an office and surgical setting, and carry a minimal side effect profile. Notably, topical anesthetics offer analgesia, but do not provide akinesia or amnesia. Regional blocks, such as are sub-Tenon's, peribulbar, and retrobulbar blocks, are used when akinesia is required in addition to analgesia. Recently, sub-Tenon's blocks have recently gained popularity due to their improved safety profile compared to other regional blocks. General anesthesia is considered for long, complex surgery, surgery in patients with multiple comorbidities, surgery in young pediatric patients, or surgery in patients intolerant to local or regional anesthetic.

CONCLUSION

Anesthetizing the eye has rapidly evolved in recent years, supporting the safety, efficacy and comfort of ocular surgery. Since there are many viable options of anesthetics available for ophthalmic surgery, a robust understanding of the patients needs, the skill of the surgical team, and surgery-specific factors ought to be considered when creating an anesthetic plan for surgery.

Efficacy and Safety of the Preserflo Microshunt With Mitomycin C for the Treatment of Open Angle Glaucoma

PRCIS

The Preserflo Microshunt (PSM) is a safe and effective glaucoma microfiltering implant that significantly reduces the intraocular pressure (IOP), either alone or in combination with phacoemulsification, during the first year after surgery.

PURPOSE

The purpose of this study was to assess the safety and efficacy of the PSM for the treatment of open angle glaucoma with 0.2 mg/mL mitomycin C, either alone or in combination with cataract surgery.

METHODS

A retrospective, open-label study of 64 eyes with primary open angle glaucoma that underwent PSM implantation and were followed up for at least 9 months. Success was defined as IOP 6-17 mm Hg and a reduction of at least 20%, complete without hypotensive medication, and qualified with medication. Safety was assessed by the incidence of adverse events. Secondary endpoints included mean hypotensive medications, visual acuity, and incidence of needling and surgical revision.

RESULTS

A total of 51 eyes underwent PSM alone and 13 underwent PSM+phacoemulsification. In the overall population of the study, the mean IOP was significantly reduced from 22.03±0.7 mm Hg at baseline to 12.7±0.4 mm Hg at the final visit, P <0.0001 (mean follow-up: 11±1.4 mo). The IOP was significantly reduced in both groups ( P <0.0001). Ocular hypotensive medication was reduced significantly from 2.7±0.7 to 0.2±0.5 ( P <0.0001). No significant differences were found in IOP-lowering medication between groups (PSM alone, 0.2±0.08; PSM+phacoemulsification, 0.1±0.1; P =0.2). At the final visit, 70.3% were considered as complete success and 12.5% as qualified success. The most common adverse event was clinical hypotony (7.8%) followed by hyphema (4.7%), and anterior chamber reformation (1.6%). Overall, 1.6% required needling and 15.6% surgical revision to restore the flow.

CONCLUSION

Glaucoma surgery with the PSM and mitomycin C was efficacious and safe in the short term, either alone or in combination with cataract surgery, and may be considered a surgical option for lowering IOP in primary open angle glaucoma.

[Forms of anesthesia in ophthalmology]

The range of anesthesiological procedures in ophthalmology has not changed significantly over the last decades, with local anesthesia clearly coming to the fore. The development of minimally invasive surgical techniques requires significantly less analgesia and economic constraints to shorten operating times. The increasing proportion of outpatient ophthalmic surgery requires a short analgesia of the surgical area with as few complications as possible. Nevertheless, the selection of the procedures, which are described here in detail, must be made individually for each patient. General anesthesia continues to have its place, especially in cases of reduced compliance and difficult surgical conditions. The close cooperation between anesthetists and ophthalmic surgeons, e.g. for analgosedation in the outpatient area, can create a very pleasant surgical experience for the patient. An important goal should always be sufficient anxiolysis, analgesia and, in special operations, sufficient akinesia.

New anesthetic approach in glaucoma surgery: "Underbleb" subtenonian anesthesia and its influence in medium term outcome

PURPOSE

To present a new anterior subtenonian anesthesia approach in the area of the future filtration bleb and its influence on medium term surgical success.

MATERIAL AND METHODS

Retrospective study of 97 surgeries, deep sclerectomy (DE) or phaco-deep sclerectomy (PHACO-DS), were performed in patients with open angle glaucoma (OAG) comparing our modified "underbleb" subtenonian anesthesia (USA) (n=58) versus a control group under peribulbar anesthesia (PA) (n=38). Main outcomes were intraocular pressure (IOP), number of antiglaucomatous drugs and total and qualificated success, compared during 1, 3, 6, 12, 18 and 24 months follow up after glaucoma surgery.

RESULTS

Both groups were comparable in terms of age, gender, surgical technique, number of antiglaucoma drugs and preoperative IOP. The IOP in the USA group decreased as in PA control group without statistical significant differences except at 24 months, where the IOP was 2mm lower (14.83 ± 2.87 vs. 17.61 ± 4.27 (P=.009). This happened for both, DS and PHACO-DS surgeries. The number of postoperative drugs was lower at 3, 6, and 18 months but without statistically significant diferences. Total success rate at 24 months was higher in the USA group respect AP control group (62.5% vs. 51.6) as well as partial success (100% vs. 71%).

CONCLUSION

Our new USA anesthetic technique does not have a negative impact in DS medium-term surgical success, even it could contribute to a longer-term improvement.