Bleb Appearance Research Articles

Efficacy and Safety of the Subtenon Injection of 0.01% Mitomycin C-augmented Trabeculectomy.

Background Trabeculectomy, with the application of mitomycin C (MMC), has been the gold standard glaucoma-filtering surgery. The conventional method of applying MMC using soaked sponges does not ensure a controlled amount of delivery of MMC, and incidences of blebitis are reported to be associated with leftover sponges. This study aims to assess the safety and efficacy of a low dose (0.1 mg/ml) of MMC administered through subtenon injection during trabeculectomy combined with cataract extraction, addressing existing research gaps. Methods It is a prospective interventional study on patients who underwenttrabeculectomywith a subtenon injection of 0.1 mg/ml of MMC combined with cataract extraction and were followed up over six months. Efficacy was determined in terms of intraocular pressure (IOP) reduction; bleb architecture was graded using the Indiana Bleb Appearance Grading System (IBAGS) and success rate, and safety was commented upon in terms of complications. Results Thirty patients were enrolled, with the majority having primary open-angle glaucoma (63.33%), while 36.67% had primary angle-closure glaucoma. Baseline IOP was 31.40(±10.38) mmHg. It significantly reduced to 14.60(±3.75) mmHg on the first postoperative day, decreasing to 9.55(±1.57) mmHg by the sixth postoperative month (p=0.001). The percentage reduction in IOP was substantial, 69.57%, by the sixth postoperative visit. Bleb morphology assessment using IBAGS revealed significant improvements in bleb height and extent and a reduction in vascularity over the six-month follow-up (p=0.001), and no eyes had bleb encapsulation. Out of the total patients, 93.33% achieved controlled IOP without anti-glaucoma medications, while 6.67% required one medication for IOP control. Complications were minimal, with transient corneal edema in six patients and manageable postoperative hypotony in one case. Conclusion A subtenon injection of MMC during trabeculectomy effectively reduces IOP and promotes favorable bleb architecture, offering an effective and safer alternative to the conventional approach.

The Effects of Bevacizumab in Augmenting Trabeculectomy for Glaucoma : Systematic Review and Meta-Analysis

Introduction & Objectives : Anti-vascular endothelial growth factor (VEGF) agents have been used to slow the healing response and postoperative scar tissue formation. To determine the effectiveness of adding Anti VEGF bevacizumab to the results of trabeculectomy in glaucoma.
 Methods : Searches were conducted in a structured way using keywords across several data sources, including Pubmed, Proquest and Cochrane library. The keywords used for searching were “Bevacizumab”, “Trabeculectomy” and “Glaucoma”. The reviewed articles are Randomized Control Trial in english, conducted on humans in the last 15 years. The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
 Results : From a total of 353 articles, there were 6 studies with 362 eyes of 352 patients been evaluated for the effectiveness of bevacizumab addition to trabeculectomy. The primary outcome of all articles was the assessment of Intra Ocular Pressure (IOP). No significant difference in IOP was found between the subconjunctival bevacizumab + Mytomycin-c group and mytomycin-c alone group (MD 0.11 ; 95% CI -0.10 to 0.33), as well as subconjunctival comparison with mytomycin-c (MD 0.11 ; 95% CI -0.29 to 0.50). Similar results were also found in the intracameral and placebo groups (MD 0.08 ; -0.22 to 0.38). However, 3 articles reported significant differences in peripheral vascularity of the bleb both by the Moorfields Bleb Grading System and by the Indiana Bleb Appearance System.
 Conclusion : The addition of bevacizumab to trabeculectomy did not show any benefit in reducing IOP when compared with MMC. But it gives better peripheral vascularity of the bleb.

Antiprotozoal Activity of Benzoylthiourea Derivatives against Trypanosoma cruzi: Insights into Mechanism of Action.

For decades, only two nitroheterocyclic drugs have been used as therapeutic agents for Chagas disease. However, these drugs present limited effectiveness during the chronic phase, possess unfavorable pharmacokinetic properties, and induce severe adverse effects, resulting in low treatment adherence. A previous study reported that N-(cyclohexylcarbamothioyl) benzamide (BTU-1), N-(tert-butylcarbamothioyl) benzamide (BTU-2), and (4-bromo-N-(3-nitrophenyl) carbamothioyl benzamide (BTU-3) present selective antiprotozoal activity against all developmental forms of Trypanosoma cruzi Y strain. In this study, we investigated the mechanism of action of these compounds through microscopy and biochemical analyses. Transmission electron microscopy analysis showed nuclear disorganization, changes in the plasma membrane with the appearance of blebs and extracellular arrangements, intense vacuolization, mitochondrial swelling, and formation of myelin-like structures. Biochemical results showed changes in the mitochondrial membrane potential, reactive oxygen species content, lipid peroxidation, and plasma membrane fluidity. In addition, the formation of autophagic vacuoles was observed. These findings indicate that BTU-1, BTU-2, and BTU-3 induced profound morphological, ultrastructural, and biochemical alterations in epimastigote forms, triggering an autophagic-dependent cell death pathway.

Scar formation in the presence of mitomycin C and the anti-fibrotic antibody in a rabbit model of glaucoma microsurgery: A pilot study

PurposeThis study aimed to evaluate the utility of a rationally engineered antibody that directly blocks collagen fibrillogenesis to reduce scar tissue formation associated with subconjunctival glaucoma surgery. Material and methodsFourteen eyes of 7 adult rabbits underwent glaucoma filtering surgery using XEN 45 Gel Stent. The rabbits’ eyes were divided randomly into three treatment groups: (i) treated with the antibody, (ii) treated with mitomycin C, and (iii) treated with the antibody and mitomycin C. Following surgeries, the intraocular pressure and bleb appearance were evaluated in vivo. The rabbits were sacrificed 8 weeks after the surgery, and their eyes were harvested and processed for tissue analysis. Subsequently, tissue samples were analyzed microscopically for fibrotic tissue and cellular markers of inflammation. Moreover, the collagen-rich fibrotic tissue formed around the stents was analyzed using quantitative histology and infrared spectroscopy. The outcomes of this study were analyzed using the ANOVA test. ResultsThis study demonstrated no significant differences in intraocular pressure, bleb appearance, or presence of complications such as bleb leak among the treatment groups. In contrast, we observed significant differences among the subpopulations of collagen fibrils formed within scar neo-tissue. Based on the spectroscopic analyses, we determined that the relative content of mature collagen cross-links in the antibody-treated group was significantly reduced compared to other groups. ConclusionsDirect blocking of collagen fibrillogenesis with the anti-collagen antibody offers potentially beneficial effects that may reduce the negative impact of the subconjunctival scarring associated with glaucoma filtering surgery.

Deep learning for anterior segment OCT angiography automated denoising and vascular quantitative measurement

Anterior segment optical coherence tomography angiography (AS-OCTA) has superior advantages in objective assessment of anterior segment (AS) vessels. Resolving noise interference in image is necessary to optimize the application of AS-OCTA. The study aimed to explore an automated denoising algorithm based on deep learning (DL). The algorithm was built through 21,000 pairs of images, and tested with 30 healthy eyes, 47 preoperative eyes with glaucoma, and 30 eyes undergone trabeculectomy (Trab). The real pure noise images were acquired by artificial simulation of eye movements through AS-OCTA. The algorithm included deep convolutional generative adversarial network (DCGAN), Res-Unet and Otsu. ImageJ software quantified vessel density (VD) and vessel diameter index (VDI). Images after noise reduction had relatively satisfactory peak signal-to-noise ratio (PSNR) and structural similarity (SSIM). Indiana bleb appearance grading scale (IBAGS), Kronfeld grading system (KGS) and intraocular pressure (IOP) used for Trab analysis. The DL method was superior to the conventional methods (PSNR = 16.45, SSIM = 0.52, both P < 0.001), and the denoising reduced measurement error of VD and VDI (P < 0.001). The denoising methods enabled the differentiation of V2 in IBAGS from V0 and V1 (P < 0.001) or that of II in KGS from I (P = 0.020). VD and VDI could better reflect IOP after noise reduction (R2 increased from 0.25 to 0.63, 0.14 to 0.41, both P < 0.001). Our research offered a DL denoising algorithm which improved the quality of AS-OCTA and the accuracy of AS vessel analysis.

Filtering Bleb Characteristics in Combined Cataract Surgery with Ex-PRESS Implant vs. Non-Penetrating Deep Sclerectomy. A Prospective, Randomized, Multi-center Study

(1) Background: After filtering surgery, bleb morphology is an indicator of the factors that may determine the final intraocular pressure (IOP). The present study aimed to evaluate and compare filtering bleb characteristics after combined cataract and glaucoma surgery. (2) Methods: We conducted a prospective multi-center randomized trial. Eyes with glaucoma and cataract were randomly assigned to either phacoemulsification and filtration surgery with an EX-PRESS implant (Alcon) or non-penetrating deep sclerectomy (NPDS) with an ESNOPER implant (AJL). The bleb characteristics were assessed with the Moorfields bleb grading system at months 1 and 12 of follow-up, and the relationship with IOP was analyzed. (3) Results: There were significant changes in bleb appearance between the assessments at month 1 and month 12. The changes in bleb appearance were more evident in the EX-PRESS group. The central area in the EX-PRESS group decreased from 2.9 at month 1 to 2.4 at month 12 (p = 0.014). Bleb height in the EX-PRESS group decreased from 2.3 at month 1 to 1.8 at month 12 (p = 0.034). The vascularity of the central area in the NPDS group decreased from 1.8 at month 1 to 1.3 at month 12 (p = 0.02). The maximal bleb area was inversely related (r = −0.39; p = 0.03) to the IOP in the NPDS group at month 1. Vascularity in the central area was directly related (r = 0.39; p = 0.01) to a higher IOP in the EX-PRESS group at month 1. Vascularity in the central area (r = 0.56; p &lt; 0.001) and maximal area (r = 0.37; p = 0.012) at month 1 was directly related to a higher IOP in the EX-PRESS group at month 12. (4) Conclusions: More intense vascularity at month 1 was related to a higher final IOP in the EX-PRESS group. Larger blebs were associated with a lower IOP in the NPDS group.

Short-hairpin RNA-mediated suppression of cortactin may inhibit the migration and invasion abilities of endometrial cancer cells by reducing lamellipodia.

The prognosis of endometrial cancer (EC) is significantly affected by tumor infiltration and metastasis. Cortactin (CTTN) regulates infiltration and metastasis in other tumors. Studies on the role and mechanism of CTTN in EC are limited and further studies are needed. Quantitative PCR and immunohistochemistry were used to detect Ras-associated C3 botulinum toxin substrate 1 (Rac1) and CTTN in EC and normal tissues. The relationship between the expression of these two genes and their prognostic factors was analyzed. A CTTN-RNAi lentiviral system was constructed and transfected into EC cells. Migration and invasion were evaluated by scratch assay, transwell migration, and invasion assays. Pseudopodia formation was observed by immunofluorescence staining. Western blotting was performed to detect the expression of Rac1. The expression levels of Rac1 and CTTN in EC tissues were significantly higher than those in normal tissues. In the EC group, Rac1 and CTTN levels were correlated. The protein expression levels of Rac1 and CTTN were related to myometrial invasion and stage. After CTTN knockdown, the migration rate, invasiveness, and migratory ability of EC cells decreased significantly. Lamellipodia was observed to disappear with the appearance of blebs. Rac1 protein expression was decreased after CTTN knockdown. CTTN may promote the invasion and migration of EC by lamellipodia. This effect may be related to the regulation of Rac1 by CTTN.

Cell-surface contacts determine volume and mechanical properties of human embryonic kidney 293 T cells.

Alterations in the organization of the cytoskeleton precede the escape of adherent cells from the framework of cell-cell and cell-matrix interactions into suspension. With cytoskeletal dynamics being linked to cell mechanical properties, many studies elucidated this relationship under either native adherent or suspended conditions. In contrast, tethered cells that mimic the transition between both states have not been the focus of recent research. Using human embryonic kidney 293 T cells we investigated all three conditions in the light of alterations in cellular shape, volume, as well as mechanical properties and relate these findings to the level, structure, and intracellular localization of filamentous actin (F-actin). For cells adhered to a substrate, our data shows that seeding density affects cell size but does not alter their elastic properties. Removing surface contacts leads to cell stiffening that is accompanied by changes in cell shape, and a reduction in cellular volume but no alterations in F-actin density. Instead, we observe changes in the organization of F-actin indicated by the appearance of blebs in the semi-adherent state. In summary, our work reveals an interplay between molecular and mechanical alterations when cells detach from a surface that is mainly dominated by cell morphology.

Anti-proliferative and Apoptosis Inducing Effects of Gallic Acid on Human Acute Myeloid Leukaemia Cell Lines (HL-60)

Gallic acid (GA) comes from benzoic acid or, more specifically, 3,4,5-tryhydroxybenzoic, which derives from the phenolic acid of the non-flavonoid part of the polyphenol compound. It is found ubiquitously in various plants and fruits, such as grapes, gallnuts, pomegranates, and tea leaves [1]. Many scientific journals and articles reported on the pharmacological properties of the photochemical like GA, which has antioxidant properties, antimicrobial, anti-inflammatory, anticancer, cardioprotective, gastroprotective, and neuroprotective activity [2]. Moreover, the anticancer properties of GA have been recognised in several cancers, such as lung cancers, oesophageal cancer cells and leukaemia [3].&#x0D; &#x0D; The objective of this study is to examine the anti-proliferative and apoptosis inducing effects of GA on HL-60 cell lines. Six concentrations of GA were made using the stock solution of GA compound dissolved in dimethyl sulfide (DMSO). HL-60 cells were treated with concentrations of 100, 50, 25, 12.5, 6.25, and 3.125 µg/mL and was incubated at three incubation period which were 24, 48, and 72 hours. The quantitative measure was determined with cytotoxicity assay of 3- (4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay and was read by microplate reader at 570 nm. For qualitative measure was through staining with acridine orang (AO) and propidium iodide (PI) and observed the morphological changes of the treated cells.&#x0D; &#x0D; Results from the MTT assays show that GA has cytotoxicity effect on HL-60 cells especially for 72 hours incubation period. The maximal half inhibitory concentrations (IC50) value of GA decreases as incubation period increases. The IC50 of GA were 9.03, 6.76, and 3.65 µg/ml for 24-, 48-, and 72-hours incubation, respectively. The IC50 value of GA (p&lt;0.05) was significantly different for different incubation periods. The morphological changes were seen through the AO/PI staining with the appearance of the cell blebbing, early apoptosis, and late apoptosis.&#x0D; &#x0D; Figure 1 shows early apoptosis (EA), late apoptosis (LA), cell blebbing (CB), membrane loose (MB), nuclear fragmentation (NF), and apoptotic bodies (AB).&#x0D; &#x0D; These findings show that GA has potential as anti-proliferative and apoptosis inducing effects on HL-60 cells line. More research is needed to determine the pathways of apoptosis in HL-60 treated with GA.

Volumetric surveillance of brain aneurysms: Pitfalls of MRA.

Untreated brain aneurysms are usually surveilled with serial MR imaging and evaluated with 2D multiplanar measurements. The assessment of aneurysm growth may be more accurate with volumetric analysis. We evaluated the accuracy of a magnetic resonance angiography (MRA) segmentation pipeline for aneurysm volume measurement and surveillance. A pipeline to determine aneurysm volume was developed and tested on two aneurysm phantoms imaged with time-of flight (TOF) MRA and 3D rotational angiography (3DRA). The accuracy of the pipeline was then evaluated by reconstructing 10 aneurysms imaged with contrast enhanced-MRA (CE-MRA) and 3DRA. This calibrated and refined post-processing pipeline was subsequently used to analyse aneurysms from our prospectively acquired database. Volume changes above the threshold of error were considered true volume changes. The accuracy of these measurements was analysed. TOF-MRA reconstructions were not as accurate as CE-MRA reconstructions. When compared to 3DRA, CE-MRA underestimated aneurysm volume by 7.8% and did not accurately register the presence of blebs. Eighteen aneurysms (13 saccular and 5 fusiform) were analysed with the optimized 3D volume reconstruction pipeline, with a mean follow-up time of 11 months. Artifact accounted for 10.2% error in volume measurements using serial CE-MRA. When this margin of error was used to assess aneurysms volume in serial imaging with CE-MRA, only two fusiform aneurysms changed in volume. The variations in volume of these two fusiform aneurysms were caused by intra-mural and intrasaccular thrombosis. CE-MRA and TOF-MRA 3D volume reconstructions may not register minor morphological changes such as the appearance of blebs. CE-MRA underestimates volume by 7.8% compared to 3DRA. Serial CE-MRA volume measurements had a larger margin of error of approximately 10.2%. MRA-based volumetric measurements may not be appropriate for aneurysm surveillance.

Characteristic Assessment of Angiographies at Different Depths with AS-OCTA: Implication for Functions of Post-Trabeculectomy Filtering Bleb.

This study aimed to analyze the quantitative vascular biomarkers of filtering bleb function at different depths using anterior segment optical coherence tomography angiography (AS-OCTA). This cross-sectional study is registered on Clinicaltrails.gov (NCT 04515017). Forty-six eyes with primary open-angle glaucoma that had undergone trabeculectomy with mitomycin-C for more than six months were included. Vessel density (VD) and vessel diameter index (VDI) in the superficial layer (SL), Tenon’s layer (TL), and deep layer (DL) of the bleb were obtained. The VD and VDI were higher in the failure group (both p = 0.000). Significant correlations were found between the SL, TL, DL’s VDI, and IOP in the success group (p = 0.013, 0.016, 0.031, respectively). The VD of the TL and DL were related to IOP in the failure group (p = 0.012, 0.009). Tenon’s VD (TVD) and Tenon’s VDI (TVDI) correlated with IOP adjusting for TVD, TVDI, and the Indiana Bleb Appearance Grading Scale (IBAGS) (p = 0.009, 0.043) or Kenfeld grading system (KGS) (p = 0.011, 0.016). The area under curve (AUC) of the TVD, TVDI, IBAGS, and KGS to predict surgery failure were 0.960, 0.925, 0.770, and 0.850. AS-OCTA realized the quantitative evaluation of vessels, especially the invisible vascularity beneath the conjunctiva. TVD and TVDI as detected by AS-OCTA better reflected bleb function than conventional grading systems.

Forkhead domain inhibitory-6 attenuates subconjunctival fibrosis in rabbit model with trabeculectomy

Antiproliferative therapies are crucially important for improving the success rate of the glaucoma filtration surgeries. In this study, we investigated the potential efficacy of Forkhead Domain Inhibitory-6 (FDI-6) in inhibiting post-trabeculectomy subconjunctival fibrosis. In vitro, the effect of FDI-6 (10 μM) on fibrotic response and its underlying mechanism were investigated in rabbit tenon's fibroblasts (RTFs) treated with or without transforming growth factor-β1 (TGF-β1, 20 ng/mL). In vivo, FDI-6 (40 μM) was injected subconjunctivally to a rabbit trabeculectomy model. Intraocular pressure (IOP) changes were monitored within the 14-day period post-surgery. Bleb morphology and subepithelial fibrosis at the operating area were evaluated with slit lamp and confocal microscopic examinations and with histologic examinations. The results showed that, in cell culture studies, FDI-6 suppressed the proliferation, migration, collagen gel contraction and the expression levels of fibronectin (FN) and α-smooth muscle actin (α-SMA) in RTFs with TGF-β treatment by down-regulating the TGF-β1/Smad2/3 signaling pathway. In animal studies, the IOPs of the FDI-6-treated group were significantly lower than those of the saline-treated group after trabeculectomy. The FDI-6-treated eyes showed a better bleb appearance with fewer blood vessels compared to the saline-treated eyes. The analysis of confocal microscopy in vivo and histopathology revealed that subconjunctival fibrosis after trabeculectomy was significantly attenuated in the FDI-6-treated group compared to the controls. In conclusion, our studies indicate that FDI-6 exerts an inhibitory effect on subconjunctival fibrosis caused by trabeculectomy, holding potentials as a new antiproliferative agent used in anti-glaucoma filtration surgeries in the future.

Intraocular Pressure-Lowering Effects of Trabeculectomy Versus MicroShunt Insertion in Rabbit Eyes

PurposeTo compare the surgical results of PRESERFLO MicroShunt (MicroShunt) insertion and trabeculectomy in rabbit eyes.MethodsTrabeculectomy or MicroShunt insertion was performed on the eyes of Japanese white rabbits. Intraocular pressure (IOP) was measured on conscious rabbits using a rebound tonometer for up to 12 weeks after surgery. Filtering bleb appearance was evaluated. Scarring in the filtering bleb was assessed by immunohistochemical analyses. The change in mRNA expression in the conjunctiva was evaluated using RNA sequence analyses.ResultsThe preoperative IOP of the operative eye did not differ significantly between trabeculectomy (11.6 ± 1.0 mmHg, n = 10) and MicroShunt insertion (12.6 ± 1.3 mmHg, n = 10). In both groups, the IOP of the operative eye was significantly lower than that of the contralateral eye at one day postoperatively, which continued until 12 weeks after surgery. The peak differences in IOP were −8.4 ± 3.0 (trabeculectomy) and −8.1 ± 2.1 mmHg (MicroShunt) at two weeks after surgery; no significant differences were observed in IOP reduction between the groups. Appearance and immunohistochemical analyses of the filtering bleb showed no significant difference between the groups. Moreover, RNA sequence analysis results showed no difference between the groups in mRNA expression fluctuations.ConclusionsPostoperative IOP, bleb appearance, and immunohistochemical analysis results were similar in the trabeculectomy and MicroShunt groups, indicating that MicroShunt insertion is as effective as trabeculectomy in lowering IOP.Translational RelevanceComparison of surgical procedures using animal models has made it possible to predict clinical efficacy and safety.

Adjunctive modulation of wound healing during cataract surgery to promote survival of a previous trabeculectomy.

Trabeculectomy is a surgical treatment for glaucoma to lower intraocular pressure with high success rates; however, it is often associated with an increased rate of cataract formation. Cataract can cause symptoms such as glare in bright conditions, foggy vision, and difficulty in driving at night. Cataract extraction surgery is highly successful in improving vision, but it comes at a cost of trabeculectomy failure, with a reported risk of 30% to 40%. An additional intervention to promote trabeculectomy survival after cataract extraction is needed. This review encompassed all adjunctive therapies used at the time of cataract surgery to increase trabeculectomy survival rate. To investigate the effect of the adjunctive modulation of wound healing during cataract surgery on the survival of a previously functioning trabeculectomy. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 4); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov; and the WHO ICTRP. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 14 April 2021. We plannedto include all randomised controlled trials (RCTs)of participants who had a functioning trabeculectomy and were undergoing cataract surgery that compared any adjunctive therapy intended to modulate wound healing (such as 5-fluorouracil, mitomycin C, or anti-vascular endothelial growth factor (VEGF) therapy) with no adjuvant therapy. DATA COLLECTION AND ANALYSIS: We used standard methods expected by Cochrane. Our primary outcome wastrabeculectomy failure at 6 months and 12 months after cataract surgery. Secondary outcomes weremean intraocular pressure difference from pre-cataract surgery baseline to 6 to 18 months post-cataract surgery; number of medications required to control eye pressure compared to before cataract surgery; bleb appearance as measured by a summation score of the Moorfields bleb grading system or other equivalent numerical grading systems; visual field progression measured by difference in mean deviation from baseline; and any complications. We did not identify any RCTs of adjunctive modulation of wound healing during cataract surgery to promote survival of a previous trabeculectomy. There is a need for an RCT to investigate the role of adjuvant wound modulating therapy at the time of cataract surgery to promote survival of a functioning trabeculectomy.

Changes in the morphology of the hyperemic blebs in eyes undergone trabeculectomy with mitomycin C after injection of triamcinolone acetonide during one-year follow-up.

To track changes in the morphology of hyperemic blebs in eyes undergone trabeculectomy with mitomycin C 0.02% (MMC) after triamcinolone acetonide (TA) injection. A total of 30 eyes of 30 patients with localized or diffuse hyperemia after trabeculectomy with MMC were enrolled in this prospective interventional case series. Two milligrams of TA were injected at the site of maximal injection. Bleb morphology was graded using Indiana Bleb Appearance Grading Scale (IBAGS), and the Moorfields Bleb Grading System (MBGS) 1week, 1month, 3months, 6months, and 1year after injection. Failure was defined as intraocular pressure (IOP) more than predefined target IOP for each eye, need for an additional surgical procedure, IOP less than 6mmHg, and loss of Light Perception (LP) vision. A total of 27 patients completed a 1-year follow-up period and were included in the final analysis. The mean time interval from trabeculectomy to injection of TA was 5.98 ± 2.57weeks. The bleb height and vascularity in the IBAGS system decreased significantly after the intervention (p < 0.05), with an increase in bleb extension (p = 0.006). Using MBGS, the bleb area did not change significantly following TA injection (p = 0.056) but its height and vascularity significantly decreased in both central and peripheral areas and the surrounding conjunctiva (p = 0.032). The development of a mature cataract was the only complication that could be attributed to TA injection. Injection of TA in hyperemic failing blebs improves bleb morphology by decreasing vascularity and height while increasing the extent with an acceptable safety profile.

One-Year Randomized Comparison of Safety and Efficacy of Trabeculectomy with Mitomycin C Sub-Tenon Injection versus Mitomycin C-Infused Sponges

To compare the safety and efficacy of sub-Tenon injection of mitomycin C (MMC) with application of MMC-infused sponges during trabeculectomy. Single-center randomized clinical trial. A total of 56 eyes of 49 patients with open-angle glaucoma were included in this clinical trial. In this single-center randomized clinical trial, 56 eyes of 49 patients underwent trabeculectomy with MMC for primary open-angle glaucoma. Patients were randomized into 2 groups. The injection group received a sub-Tenon injection of 0.15 ml of 0.01% MMC diluted with preservative free lidocaine 2% (n= 27). In the sponges group, sponges soaked in 0.02% MMC were applied under the Tenon's capsule and the scleral flap for 2 minutes (n= 29). Intraocular pressure, endothelial cell count, best-corrected visual acuity, and number of intraocular pressure (IOP)-lowering medications were assessed before surgery and 1 week; 1, 3, and 6 months; and 1 year after surgery. Complete success was defined as IOP of 14 mmHg or less without medication. Bleb morphologic features were assessed using the Indiana Bleb Appearance Grading Scale bleb grading system. Intraocular pressure reduction was the primary outcome. Bleb morphologic features and endothelial cell counts (ECCs) were secondary outcomes. Mean IOP in the sponges group decreased from 30.5 ± 7.4 mmHg at baseline to 12.6 ± 5.9 mmHg at 1 year (P < 0.001); in the injection group, IOP decreased from 29.3 ± 6.8 mmHg at baseline to 12.7 ± 4.3 mmHg at 1 year (P < 0.001). No difference in IOP between the 2 groups was noted at any visit (P < 0.001). Surgical success was 81.5% and 82.8% in the injection and sponges groups, respectively, at 1 year. Mean ECC values were unchanged from baseline to 1 year after surgery for both groups (P= 0.444). Complication rates were similar in the 2 groups. Bleb morphologic features showed differences in the appearance and grading of the blebs between the 2 groups at 1 year, showing larger extent, lower height, and less vascularization in the injection group. Sub-Tenon injection of MMC during trabeculectomy seems to be as safe and as efficacious as conventional application of MMC with sponges at 1 year after surgery. Bleb morphologic features show notable differences that may suggest a better long-term outcome.

Analysis of bleb morphology after CLASS with ultrasound biomicroscopy and clinical grading scale.

Filtration in the area subjected to CO2 laser-assisted sclerectomy surgery (CLASS) is described using ultrasound biomicroscopy (UBM) and the clinical grading scale to evaluate the mechanism of intraocular pressure (IOP) reduction. Twenty-eight patients with open-angle glaucoma underwent CLASS. The Indiana Bleb Appearance Grading Scale evaluation was performed 1 month after surgery to determine bleb height, extent, vascularity, and leakage. UBM was used to describe and measure the surgical area. Bleb morphology, the size of the scleral lake, scleral route, and trabeculodescemetic membrane (TDM) thickness were examined. One month after CLASS, IOP significantly decreased from 20.46 ± 3.92 mmHg to 12.71 ± 2.99 mmHg, and the anterior chamber depth significantly more shallow, from 2.75 ± 0.36 mm to 2.61 ± 0.33 mm(p < 0.05). Shallow uplift occurred in 71.43% of the blebs, and 64.29% of the blebs were within 1 to 2 h; 82.15% showed mild or moderate vascular hyperemia, and the Seidel test was negative. UBM showed that all eyes had an intact TDM, with a mean thickness of 99.3 ± 22.2 μm; 21 eyes (75%) had L-type (low reflective). The scleral lake anteroposterior length, height, and transversal length were 2.247 ± 1.831 mm, 0.520 ± 0.234 mm, and 3.312 ± 0.423 mm, respectively. The TDM thickness and postoperative IOP were positively correlated, and the size of the scleral lake was not correlated with IOP reduction. Four eyes (14.29%) exhibited cyclodialysis. UBM examination indicated the aqueous humor drainage route. In the early stage after CLASS, subconjunctival and choroidal drainage routes might be the major mechanism underlying IOP reduction. Mild and moderate congestion of bleb blood vessels warrant attention to avoid early bleb scarring.

Surgical site characteristics after CLASS followed by ultrasound biomicroscopy and clinical grading scale: a 2-year follow-up.

This study describes the imaging of the filtering area in CO2 laser-assisted sclerectomy surgery (CLASS) using ultrasound biomicroscopy (UBM) combined with the Indiana Bleb Appearance Grading Scale (IBAGS) and evaluates the mechanism by which CLASS lowers the intraocular pressure (IOP). Twenty-eight cases (28 eyes) of primary open-angle glaucoma that could not be controlled by drugs underwent CLASS. At 1, 3, 6, 12, 18, and 24 months after surgery, IBAGS was used to evaluate the external morphology of the filtering blebs, and UBM was used to describe and measure their internal structure. During the early period after CLASS, most cases showed diffuse filtering blebs with a serious degree of congestion. At the end of follow-up, most cases did not present filtering blebs. All patients showed an intact and thin trabeculodescemetic membrane (TDM) with an average thickness of 0.094 ± 0.017 mm. The scleral reservoir size gradually decreased over time and tended to stabilize after 18 months. At 3 and 6 months after surgery, 53.57% of the patients had abnormalities in the TDM area, and after laser goniopuncture treatment, the scleral reservoir became slightly larger and the IOP decreased. The TDM thickness was not correlated with postoperative IOP, and the scleral reservoir size was negatively correlated with IOP. During the early phase after CLASS, the subconjunctival and suprachoroidal pathways may be the main mechanisms lowering IOP; over time, internal drainage pathways such as the intrascleral, trabecular-meshwork, and suprachoroidal pathways play greater roles in lowering IOP.

S2190 A Rare Presentation of Blue Rubber Bleb Nevus Syndrome in the Elderly

INTRODUCTION: Blue Rubber Bleb Nevus Syndrome (BRBNS) is a rare congenital condition consisting of venous malformations manifesting as blue blanchable rubbery blood filled sacks. BRBNS is often diagnosed in childhood to early adulthood, and can occasionally present with significant blood loss anemia requiring hospitalization and blood product transfusions. In the case below, we discuss a patient with no prior history of anemia who presented with suspected BRBNS associated GI bleeding manifesting in late adulthood. CASE DESCRIPTION/METHODS: 64 y/o female with hypertension and hypothyroidism, who presented to the ER with acute hematemesis, melena, and associated bilateral lower quadrant abdominal pain. The patient does not take any blood thinners nor NSAIDs. The physical exam was significant for epigastric tenderness and bilateral lower extremity pitting edema, but was otherwise largely unremarkable. The patient had no obvious rashes, hemangiomas, petechiae or skin lesions. Initial Hgb was 5.7 gm/dL with MCV 106 Femtoliters, PLTs 188,000 per mc/L. The PT, INR, renal function, and liver function tests were within normal limits. After 3 units of packed RBCs, her Hgb increased to 8.6 gm/dL. CT Abdomen/Pelvis w/ IV contrast: unremarkable. Upper endoscopy: A single vascular gastric abnormality consistent with arteriovascular malformation. Colonoscopy: Multiple venous malformations manifesting as blue blebs along the right-sided colon suggestive of BRBNS. No evidence of fresh or old blood. No biopsies were taken given concerns of possible profuse bleeding. Patient was discharged with outpatient follow up after hemoglobin stabilized. DISCUSSION: BRBNS is an autosomal dominant disease with venous malformations manifesting along the GI tract, skin, liver/spleen, kidneys, brain, retroperitoneum and other organs. The GI tract is the most common location, and often manifests as occult GI bleeding. BRBNS is often diagnosed during endoscopy with its characteristic blue blanching rubbery bleb appearance which distinguishes it from other vascular abnormalities. Biopsies of the blebs can aid in diagnosis. In the limited number of cases documented, the majority have been identified during childhood to early adulthood with rarely any cases presenting in late adulthood. Regardless of advanced age, BRBNS should remain in the differential for unexplained anemia or GI bleed when suspicious vascular lesions are encountered during endoscopy.

A Randomized Controlled Trial Comparing Subconjunctival Injection to Direct Scleral Application of Mitomycin C in Trabeculectomy

To compare the efficacy of intraoperative scleral application with subconjunctival injection of mitomycin C (MMC) in trabeculectomy. Prospective, randomized, interventional study. This study took place in a single clinical practice in an academic setting. Patients had medically uncontrolled glaucoma as indicated by high intraocular pressure (IOP), worsening visual field, or optic nerve head changes in whom primary trabeculectomy was indicated. Patients were older than 18 years with medically uncontrolled glaucoma and no history of incisional glaucoma surgery. Patients were randomized to MMC delivered by preoperative subconjunctival injection or by intraoperative direct scleral application using surgical sponges during trabeculectomy. Comprehensive eye examinations were conducted at 1day, 1week, 6weeks, 3months, and 6months postoperatively. Subconjunctival 5-fluorouracil injections were given postoperatively, as needed. The primary outcome was the proportion of patients who demonstrated IOP of <21mm Hg and ≥30% reduction in IOP from baseline. Secondary outcome measures included the number of IOP-lowering medications, bleb morphology using the Indiana Bleb Appearance Grading Scale, and complication rates. Participants (n= 100) were randomized into groups matched for baseline demographics, glaucoma status, and baseline IOP. At 6months, there were no significant differences between the injection (n= 38) and sponge (n= 40) groups in surgical success (P= .357), mean IOP (P= .707), number of glaucoma medications (P= 1.000), bleb height (P= .625), bleb extension (P= .216), bleb vascularity (P= .672), or complications rates. Both techniques of MMC delivery (subconjunctival injection and direct scleral application) resulted in comparable surgical outcomes and bleb morphologies.