Operative revision of non‐functioning filtering blebs with 5‐fluorouracil to regain intraocular pressure control
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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.Keywords:
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Refractory (planetary science)
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Suction blister
The main objective of this study was to determine if consistent intraocular pressure (IOP) measurements could be obtained from an in vivo Long Evans rat glaucoma model. An increase in IOP is the primary risk factor associated with glaucoma and reliable IOP measurements would validate our in vivo glaucoma model that we are inducing in rats. The study used nine Long Evans rats. Three rats severed as controls, three received surgery to induce glaucoma and three were administered PNU-282987 neuroprotective eye drops and then surgery to induce glaucoma. IOP measurements were obtained by tapping the retina of the rat eye through use of a Tono-Lab. Theoretically, IOP should have increased in six of the nine rats, since the surgery created scar tissue and decreased the efficiency of the aqueous drainage system of the eye. The results of this study were somewhat inconclusive in obtaining reliable IOP measurements but are promising. Significant differences were found between the experimental groups and internal controls as well as the control group. In order to claim significantly reliable results, there should not be statistical significance in the control group. This study recommends that future techniques used to obtain consistent IOP measurements should include, longer training periods, increase the number of IOP measurements taken at one time and disregard the first few readings until consistency is observed. This overall significance of this study reveals how future experiments may obtain reliable IOP measurements to validate the surgical procedure of inducing glaucoma.
Glaucoma surgery
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Achievement of target intraocular pressure is the goal of every efficient antiglaucoma therapy. Target intraocular pressure is the level of intraocular pressure which is associated with minimal likelihood of visual field or optic nerve lesion, or an existing lesion progression due to elevated intraocular pressure. Results of large clinical studies which have offered some new concepts on target intraocular pressure in the management of glaucoma are reviewed. An association between the curve of intraocular pressure decrease and glaucoma progression was demonstrated in these studies. Generally, a lower value of target intraocular pressure implies better protection from the loss of vision and visual field impairment in glaucoma patients. In advanced glaucoma, the greatest possible reduction from the initial intraocular pressure should be attempted. A 20% reduction from the initial intraocular pressure or decrease to < 18 mmHg in advanced glaucoma has been recognized as a favorable strategy to reach target intraocular pressure. In normal tension glaucoma, a lower value of target intraocular pressure is associated with a slower disease progression. In patients with initial glaucoma, 25% reduction from the initial intraocular pressure will slow down the disease progression by 45%. The value of target intraocular pressure depends on the pretreatment level of intraocular pressure, optic nerve condition, glaucoma disease state, rate of glaucoma progression, patient's age, and other risk factors for the development of glaucoma.
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To compare 6 month outcomes of bleb needling performed in the clinic vs. the operating room (OR) in adult glaucoma patients with failed bleb.A retrospective case series of 47 eyes from 41 glaucoma patients who received needling with mitomycin C (MMC) of scarred bleb from prior bleb-forming procedures in clinic (32 eyes) vs. the OR (15 eyes), including trabeculectomy (14 eyes), ExPress shunt (16 eyes), and ab-interno XEN gel stent (17 eyes). The primary outcome was needling success, defined as IOP ≤ 18 mmHg on 0 glaucoma medications without requiring an additional IOP lowering procedure within 6 months after needling.At 6 months, bleb needling success rate was similar when performed in the clinic vs. in the OR (28% vs. 20%, P = 0.54). Success rate was not statistically different in patients with prior trabeculectomy, ExPress shunt, and XEN gel stent (29% vs. 38% vs. 12%, P = 0.26). When comparing clinic vs. the OR needling procedures at 6 months, there was no difference in mean IOP (14.2 vs. 14.9 mmHg, P = 0.73), mean glaucoma medications (1.4 vs. 1.7, P = 0.69), additional IOP-lowering procedure rate (16% vs. 27%, P = 0.37), or complication rate (0% vs. 7%, P = 0.32).Bleb needling with MMC in clinic may be a safe and effective way to revise failed bleb after trabeculectomy, ExPress shunt, and XEN gel stent procedures when compared to needling in the OR.
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To study the effect of topical application of mitomycin C on enhancing the efficacy of needling in the management of bleb failure.Thirty-six eyes of 32 consecutive patients with an intraocular pressure over 21 mmHg, without bleb or with a thick, flat bleb after the second postoperative month after trabeculectomy, were included in the study. Needling with mitomycin C was performed in the other 18 eyes with bleb failure (group A) and needling without antimetabolite was performed in 18 eyes (group B). Topical application of mitomycin C (0.4 mg/mL) with a microsponge over the conjunctiva at the failed bleb for 5 minutes (group A) was performed; after irrigation, the needling procedure was the same in both groups. A 30-gauge needle was used to perforate the area of subconjunctival and subscleral fibrosis and to reestablish flow; conjunctival puncture was at least 7 mm away from the bleb and no sutures were taken after needling. Follow-up was performed for 1 year after needling.Overall, 55 needling procedures were performed; needling was done twice in 17 eyes in group B, whereas only 2 eyes needed more than 1 needling procedure in group A. The difference was statistically highly significant, and the mean follow-up was 8.9 ± 3.7 months. Mean intraocular pressure was 28.9 ± 4.2 mm Hg and 27.8 ± 4.7 mm Hg in group A and group B respectively before any intervention; this decreased to a mean of 19.8 ± 2.7 mm Hg and 20.5 ± 4.8 mm Hg respectively without medication after 6 months of last needling. Complications included diffuse corneal punctate epitheliopathy lasting for 2 to 3 weeks (2 eyes in group A), subconjunctival hemorrhage (3 eyes in each group), and hyphema (2 eyes in each group).Topical application of mitomycin C with needle revision seems to be an extremely effective way to revive failed filtration surgery. The incidence of complications related to mitomycin C was minimal.
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To evaluate the role of anterior segment optical coherence tomography (OCT) in describing the morphology and outcome of encapsulated filtering blebs after bleb needling.Prospective assessment of 9 patients - before, 2 days and 6 months after filtering bleb needling with 5-FU - using slit-lamp examination, Goldmann tonometry and OCT.Before the needling, the average internal height of the cyst was 1.3 +/- 0.8 mm. Two days after the needling procedure, the cyst collapsed in 5 patients. After 6 months, the average internal cyst height was 0.7 +/- 0.4 mm. All patients with a collapsed cyst at day 2 after needling had controlled regulated IOP without glaucoma medication.The preoperative internal height of the cyst does not correlate with the outcome of the needling. A collapsed cyst at day 2 after needling is an indicator of controlled intraocular pressure, whereas a prominent cyst after 6 months indicates poor function.
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Our concepts of open angle glaucoma originated largely from patients with symptoms of angle closure who almost always presented with high and severely damaging intraocular pressures. The elevated pressure constituted glaucoma as was clearly expressed some 150 years ago by Priestley Smith when he wrote “Glaucoma is characterized by one constant and essential symptom, increased tension of the eyeball. Let this physical condition be added to any eye, healthy or diseased, and straightaway it becomes glaucomatous. Let the excess of intraocular pressure be taken away from the glaucoma eye and whatever structural or morbid change may be left, glaucoma exists no longer”. This concept was challenged some 35 years ago by the first population studies, which showed that elevated intraocular pressure was indeed a risk factor for the prevalence of glaucoma and that there was a clear relationship between the prevalence and the height of the intraocular pressure. However, these studies also showed that glaucoma patients with perfectly normal, and occasionally even low pressures constituted a sizeable group and subsequently it appeared that in Japan they formed the majority of the disease. Populations, which were followed over long periods of time, demonstrated that a large group of people with elevated intraocular pressures did not appear to develop obvious glaucomatous damage. It has therefore become clear that elevated intraocular pressure does not constitute the disease and that there must be additional risk factors, which by themselves, or in combination with other risk factors including pressure, could be responsible for damage. In order to cling to our traditions we refer to these other factors as an increased susceptibility of the optic nerve (presumably to pressure) without knowing the true nature of the mechanism by which these factors influence the disease. Some of these risk factors, in addition to intraocular pressure, have been known or suspected for a long time. Ethnic origin, family history, age and myopia were among them. In the current Acta, Grodum and colleagues confirm, in the large population whom they screened for the disease, that age, intraocular pressure and myopia are such risk factors. They also show that the greater the myopia the greater the prevalence of glaucoma but that at high intraocular pressures the association with myopia is no longer evident. This apparent lack of association at high intraocular pressures does not necessarily indicate that the association ceases at these pressure levels but rather that the great prevalence of pressure induced damage at these high pressures masks the myopic contribution. There are almost certainly many other risk factors including the many vascular risk factors such as low perfusion pressures, vascular hypertension, shock-like states, intermittent dysrhythmias, vasospasm, vascular occlusive disease and therefore all the many risk factors for vascular diseases such as diabetes, obesity, smoking, sedentary life styles and elevations in homocysteine which may play a part. Some of these may interrelate with one another and others may be quite intermittent and difficult to identify between events. Some of these may have a low prevalence compared to the more major ones such as intraocular pressure and there is a danger that they might not be confirmed even by the large population studies unless they are specifically looked for. It is of course a truism that we can usually only see what we look for. The collaborative Normal Tension Glaucoma Study points out that risk factors which account for the prevalence of the disease, discussed above, may not be the same as those which determine the subsequent course of the disease. Glaucoma remains a complicated, multifactorial disease which requires both the meticulous studies of selected populations to identify the many possible risk factors, some currently probably not even suspected, followed by the large population based studies and costly clinical trials to confirm their significance. Until all the genes underlying the many risk factors are found and can be identified, and I suspect even long after that, the attempts to influence and understand the disease must go on in order to better the quality of life of our patients. Correspondence: Stephen Drance, MD, OCVancouver, BCCanadae-mail: [email protected]
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The prevalence of open angle glaucoma is disproportionately high in the African American population. Information about the effectiveness of anti-glaucoma medications in an exclusively African American population is lacking. We treated both eyes of 38 African American patients who have stable open angle glaucoma with either levobunolol b.i.d. or dipivefrin b.i.d. to evaluate the effectiveness of each drug in lowering intraocular pressure. Patients were treated for six weeks following a two week washout period. We measured intraocular pressure levels after one, three, and six weeks. Each medication produced a statistically significant decrease in intraocular pressure by week one. The mean pre-treatment pressure of 24.4 mmHg in the levobunolol was reduced to 17.0 mmHg by week six. The mean pre-treatment pressure of 25.4 mmHg in the dipivefrin treated group was reduced to 18.2 mmHg by week six. There was not a statistically significant difference in the pre-treatment or the final pressure between the two groups. Both levobunolol and dipivefrin produce a statistically significant decrease in intraocular pressure in African American patients with open angle glaucoma.
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