Trabeculectomy Failure Research Articles

Bleb Needling Procedure in Juvenile Open Angle Glaucoma (JOAG) for Failed Bleb in Trabeculectomy

Introduction : JOAG is less responsive to medications and often requires surgical therapy. The main choice of surgery is trabeculectomy. One of its success rates is determined by the formation of bleb. Failed bleb causes an increase in IOP. To repair the bleb, bleb needling can be performed as a simple procedure.
 Case Illustration : A 7-year-old boy came with a chief complaint of pain accompanied by redness of the left eye. The patient was diagnosed with JOAG and had underwent trabeculectomy with mitomycin-C (MMC) 3 months ago on the right eye and 2 months ago on the left eye with complete success surgery. On physical examination, intraocular pressure (IOP) was 12 mmHg / 29 mmHg with flat bleb on the left eye. Visual acuity on the right eye was 3/10 with cc C-2.00 X 0° ? 7/10 while on the left eye was light perception without possible refractive correction. Timolol maleate and latanoprost eye drops were given for 2 weeks but the IOP remained high. Therefore, the patient underwent bleb needling with 5- Fluorouracil (5-FU) on the left eye. Post-operatively, the IOP was 12 mmHg without antiglaucoma medication.
 Discussion : Failure of the trabeculectomy bleb can occur due to fibrotic proliferation as part of the wound healing response. Studies stated 5-FU bleb needling provide clinically significant IOP lowering and minimal complication. Reduced IOP post needling and formation of bleb indicate successful needling.
 Conclusion : Bleb is an important indicator of a success trabeculectomy surgery. Bleb needling with 5-FU could be considered as effective and safe procedure after trabeculectomy failure.

RE-TRABECULECTOMY + 5-FLUOROURACIL IN PRIMARY ANGLE CLOSURE GLAUCOMA PATIENTS AGGRAVATED BY CONSUMPTION OF SCHIZOAFFECTIVE DRUG

Introduction : PACG occurs when the anterior chamber angle is occluded by the iris thus reducing aqueous humor outflow. Most schizoaffective patients use anticholinergic drugs which may result in iridocorneal angle closure through deposition. This article reported a Re-Trabeculectomy + 5 FU surgery in PACG which was aggravated by the use of schizoaffective drugs
 Case Illustration : A 43 year old woman, underwent Re-Trabeculectomy + 5 FU on LE after increasing IOP and regularly took schizoaffective drugs. Tapering of schizoaffective therapy was done 1 month preoperatively. Patient presented with LE UCVA of 3/60 and LE IOP is 30.9 mmHg with three anti- glaucoma medications. LE examinations revealed VH1 AC, bayonet sign and cupping on funduscope, closed angle on gonioscope, nasal step defect on humphrey and diffuse RNFL thinning on OCT. On the first postoperative day LE IOP is 18.5 mmHg. The schizoaffective therapy was re-initiated from psychiatric and evaluation was done weekly
 Discussion : Re-trabeculectomy surgery have been done considering the failure of the first trabeculectomy and administration of 5-Fluorouracil as an anti-fibrosis. The benefits of reducing preoperative dose of schizoaffective drugs for a month due to having an anticholinergic effect and reduces IOP by 5 mmHg. Psychiatrists and ophthalmologists work together to try to administer basic schizoaffective drug doses and evaluate IOP to keep it under control.
 Conclusion : The re-operative action was carried out by adding anti-fibrosis and cooperating with psychiatry for postoperative tapering of schizoaffective drugs. Long-term use of antidepressant drugs and benzodiazepines increases PACG.

Ab-Interno Bleb Needling in A Failed Trabeculectomy: A Case Report

Introduction : Trabeculectomy remains a gold standard of glaucoma surgical management despite a steady rate of bleb failure due to conjunctival scarring. In this case, we report a case of a failed trabeculectomy managed with ab-interno bleb needling followed by antimetabolite injection of mitomycin C.
 Case Illustration : A 18-year-old male patient with a history of blurry vision in his right eye and vision loss in his left eye. The patient had previously undergone cataract surgery due to juvenile cataracts and developed persistent high intraocular pressure (IOP) in both of his eyes. A trabeculectomy was performed on his right eye six months prior to the examination; however, the IOP remained at 22 mmHg. Ocular examination revealed a shallow anterior chamber and flat conjunctival bleb. An ab-interno bleb needling technique was performed followed by antimetabolite injection of mitomycin C under local anesthesia in an operating theatre. Follow-up results showed a significant reduction of IOP on the first day (13.3 mmHg) and a week after surgery (18.5 mmHg), maintained by one anti-glaucoma eye drop.
 Discussion : Trabeculectomy filtration surgery has a high failure rate in younger patients due to a high risk of conjunctival scarring. The ab-interno needling approach with mitomycin C injection is a novel technique that can be performed and offers the advantage of increasing aqueous outflow through a direct opening of the trabecular meshwork from within the anterior chamber.
 Conclusion : This technique provides effective management of failed trabeculectomy to achieve intraocular pressure lowering effect and a corresponding decrease in the risk of progressive glaucomatous optic neuropathy.

Implantacja zastawki Ahmeda w trudnych przypadkach jaskry – technika i powikłania

Glaucoma drainage devices have an established position in the surgical treatment of glaucoma, and moreover their use has grown rapidly in recent years. The aim of the study is to discuss the technique and complications of Ahmed glaucoma valve implantation – one of the most frequently used filtering systems in the treatment of difficult cases of glaucoma. Ahmed glaucoma valve implantation is an effective and relatively safe surgical procedure. The effectiveness of the method, according to various literature reports, is estimated at approximately 45–64% in a 5-year follow-up. Traditionally, Ahmed glaucoma valve implantation has been reserved for the treatment of glaucoma refractory to multiple filtration surgical procedures. Currently, this procedure is recommended for patients with risk factors for failure of trabeculectomy with antimetabolites. The current literature shows the potential role of Ahmed glaucoma valve implantation also as a primary surgical option in selected glaucoma cases, for example in patients with a higher risk of infection.

Ab interno trabeculectomy revision with 5-flourouracil for failed trabeculectomy in advanced glaucoma: 3-year outcomes

ObjectiveTo describe the 3-year outcomes of patients who underwent ab interno trabeculectomy revision with a translimbal sclerostomy spatula augmented with 5-flourouracil. DesignRetrospective cohort study. ParticipantsIn this single-centre study, inclusion criteria included patients who were 18 years of age or older with advanced glaucoma who had undergone ab interno trabeculectomy revision with 5-flourouracil due to subconjunctival fibrosis and above-target intraocular pressure (IOP). Patients were required to have a minimum follow-up of 3 years. MethodsThe primary outcome measure was IOP. Secondary outcome measures included number of topical IOP-lowering medications, best-corrected distance visual acuity, visual field mean deviation, and postoperative complications. ResultsForty-one eyes of 41 patients met the criteria for inclusion. Survival analysis demonstrated success defined by criterion A (IOP <15 mm Hg and >20% reduction) in 44% of eyes without medication (complete success) and 71% of eyes with or without medication (qualified success) at 3-year follow-up. Complete and qualified successes defined by criterion B (IOP <12 mm Hg and >20% reduction) were achieved by 31% and 44% of eyes, respectively. Early complications included transient hypotony in 26 eyes (63%) and transient hyphema in 3 eyes (7.3%). No persistent complications were reported within the 3-year study period. ConclusionAb interno trabeculectomy revision can be an effective technique for achieving a low target IOP in patients with advanced glaucoma in up to 3-year follow-up.

Bilateral Glaucoma Drainage Device (GDD) Implantation in Steroid Induced Glaucoma

Objective: This study aims to report a case of Bilateral Glaucoma Drainage Device (GDD) implantation surgery in a patient with Steroid Induced Glaucoma. Case Presentation: A 18-year-old male patient with steroid-induced glaucoma and allergic conjunctivitis. The patient also complained about red eyes and itchy in both eyes and had been using steroid eye drops for 5 years. The patient also complained about headaches and blurry vision. The patient had undergone trabeculectomy surgery 5 months ago on the left eye. The visual acuity was 6/6 on the right eye and 6/7.5 on the left eye. His intraocular pressure (IOP) on the right eye was 24 mmHg, and his left eye was 23 mmHg with conjunctival left eye bleb, flat, and fibrosis. The patient then underwent a non-valve Virna’s GDD implant surgery on the right eye. On day two post-GDD, the IOP was 4 mmHg, and the COA was shallow, so reform the COA. At the first month follow-up, the patient's right eye pressure was still in normal condition with no complications, and then the plan was for left eye Virna’s GDD implantation surgery. At the first month follow-up after left eye GDD implantation, the visual acuity was 6/9 on the right eye and 6/24 on the left eye, with IOP RE 11mmHg and LE 16mmHg, from anterior segment deep anterior chamber, no plate exposed, no leakage, and tube not attached to the corneal endothelium. The patient's intraocular pressure was still in normal condition in both eyes, and no complications was found, although the patient was still using low-dose topical steroid eye drops. Conclusion: In steroid-induced glaucoma, after trabeculectomy failure, the implantation of GDD is the most effective option in controlling high IOP and slowing down glaucoma progressivity.

Letter to the Editor: Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery.

Letter to the Editor: Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery.

Response to Letter to the Editor: Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery.

Response to Letter to the Editor: Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery.

Selective Laser Trabeculoplasty-What Do We Know So Far? Review

Abstract Selective laser trabeculoplasty (SLT) has been used for lowering intraocular pressure (IOP) in patients with different types of glaucoma. It is a safe and effective procedure as initial or additional therapy when target IOP could not be achieved with medical therapy. SLT could specifically target pigmented cells in trabecular meshwork (TM) leaving nonpigmented cells unaffected, which may allow repeat treatments and thus has lower complication rate. It can be successfully used for IOP reduction in primary open angle glaucoma (POAG), normotensive glaucoma (NTG), pigmentary glaucoma (PG), pseudoexfoliation glaucoma (PXFG), primary angle closure glaucoma (PACG), silicone-oil-induced glaucoma, and high IOP after failed trabeculectomy. SLT could also be used in all stages of open agle glaucoma but failure of SLT in advanced glaucoma patients should go to immediate filtering surgery to avoid postoperative fibrosis. SLT reduces IOP fluctuation. IOP-lowering effect of SLT diminishes over time, but it can be repeated in order to achieve additional or recurrent IOP reduction. Higher baseline IOP up to a certain level is the strongest predictor of success after SLT.

Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery.

Repeat trabeculectomy is associated with similar postoperative intraocular pressure (IOP), a lower complication rate, and a lower need for medications when compared with Ahmed valve implantation (AVI) when performed after initially failed trabeculectomy. The goal of this study was to compare the efficacy of repeat trabeculectomies and AVI after an initial failed trabeculectomy. All studies that investigated the postoperative success of patients who underwent AVI or repeat trabeculectomy with mitomycin- C after a prior failed trabeculectomy with mitomycin- C found in PubMed, Cochrane Library, Scopus, and CINAHL were included. Mean preoperative and postoperative IOP, proportions of complete and qualified successes, and proportions of complications were extracted from each study. Meta-analyses were performed to compare the differences between the two surgical approaches. Methods of measuring complete and qualified success were too heterogeneous among the included studies to allow for meta-analysis. The literature search yielded 1305 studies, and 14 studies were included in the final analysis. Mean IOP was not significantly different between the two groups preoperatively and then after 1, 2, and 3 years. Mean number of medications between the two groups was similar preoperatively. After 1 and 2 years, the mean amount of glaucoma medications in the AVI group was approximately twice that of the trabeculectomy group; however, this relationship was only significant at 1 year of follow-up ( P = 0.042). In addition, the cumulative proportion of overall and sight-threatening complications was significantly higher in the AVI group. Repeat trabeculectomy with mitomycin- C and AVI may both be considered after failed primary trabeculectomy. However, our analysis suggests that repeat trabeculectomy may be the preferred method as it provides similar efficacy with fewer disadvantages.

SPARC-YAP/TAZ inhibition prevents the fibroblasts-myofibroblasts transformation

BackgroundFibrotic scar is a severe side effect of trabeculectomy, resulting in unsatisfactory outcomes for glaucoma surgery. Accumulating evidence showed human Tenon's fibroblasts (HTFs) play an important role in fibrosis formation. We previously reported that the aqueous level of secreted protein acidic and rich in cysteine (SPARC) was higher in the patients with primary angle closure glaucoma, which was associated with the failure of trabeculectomy. In this study, the potential effect and mechanism of SPARC in promoting fibrosis were explored by using HTFs. MethodsHTFs were employed in this study and examined under a phase-contrast microscope. Cell viability was determined by CCK-8. The expressions of SPARC-YAP/TAZ signaling and the fibrosis-related markers were examined with reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR), Western blot, and immunofluorescence, subcellular fractionation was conducted to further determined the variation of YAP and phosphorylated YAP. The differential gene expressions were analyzed with RNA sequencing (RNAseq), followed by Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses. ResultsExogenous SPARC induced HTFs-myofibroblast transformation, as evidenced by the increased expression of α-SMA, collagen I and fibronectin in both protein and mRNA levels. SPARC knockdown decreased the expressions of the above genes in TGF-β2-treated HTFs. KEGG analysis showed that the Hippo signaling pathway was mostly enriched. SPARC treatment increased the expressions of YAP, TAZ, CTGF and CYR61 as well as enhanced YAP translocation from cytoplasm to nucleus, and decreased the phosphorylation of YAP and LAST1/2, which was reversed by SPARC knockdown. Knockdown of YAP1 decreased the fibrosis-related markers, such as α-SMA, collagen I and Fibronectin, in SPARC-treated HTFs. ConclusionsSPARC induced HTFs-myofibroblast transformation via activating YAP/TAZ signaling. Targeting SPARC-YAP/TAZ axis in HTFs might provide a novel strategy for inhibiting fibrosis formation after trabeculectomy.

Clinical and Histopathological Effects of Intracameral Ranibizumab in Experimental Trabeculectomy.

Post-surgical scarring is a known cause of trabeculectomy failure. The aim of this study was to investigate the effectiveness of ranibizumab as an adjuvant anti-scarring agent in experimental trabeculectomy. Forty New Zealand white rabbits were randomised into four eye treatment groups: groups A (control), B (ranibizumab 0.5 mg/mL), C (mitomycin C [MMC] 0.4 mg/mL), and D (ranibizumab 0.5 mg/mL and MMC 0.4 mg/mL). Modified trabeculectomy was performed. Clinical parameters were assessed on post-operative days 1, 2, 3, 7, 14, and 21. Twenty rabbits were euthanised on day 7, and the other twenty were euthanised on day 21. Eye tissue samples were obtained from the rabbits and stained with haematoxylin and eosin (H&E). All treatment groups showed a significant difference in IOP reduction compared with group A (p < 0.05). Groups C and D showed a significant difference in bleb status on days 7 (p = 0.001) and 21 (p = 0.002) relative to group A. H&E staining showed significantly low fibrotic activity (p < 0.001) in group C on both days and inflammatory cell grade in group B on day 7 (p < 0.001). The grade for new vessel formation was significantly low in groups B and D on day 7 (p < 0.001) and in group D on day 21 (p = 0.007). Ranibizumab plays a role in reducing scarring, and a single application of the ranibizumab-MMC combination showed a moderate wound-modulating effect in the early post-operative phase.

The Outcomes of Trabeculectomy Surgery among Patients at Makkah Specialist Eye Hospital Bauchi Nigeria

Trabeculectomy remains the world’s gold standard and the main therapeutic intervention for controlling moderate to advanced glaucoma in Nigeria due to the expensive anti-glaucoma drugs as well as the unavailability of facilities to carry out minimal invasive glaucoma surgery (MIGS). There is still limited knowledge of the outcome of trabeculectomy surgery in northeastern, Nigeria. To determine the outcomes of trabeculectomy surgery regarding lowering post-operative Intra Ocular Pressure (IOP), preserved visual acuity (VA) as well as a preserved functional vision among glaucoma patients attending Makkah Specialist Eye Hospital Bauchi (MSEHB). A retrospective trabeculectomy surgery data search of operating theatre records was done to collect the outcomes from January 2021 to January 2023. Patients who have undergone trabeculectomy with a minimum follow-up of 6 months were included in the study. The criteria for a good outcome were post-operative IOP of less than 22mmHG or at least 30% reduction from pre-operative levels, and a preserved aided VA. A visiting consultant from the Ophthalmology Department of Federal Teaching Hospital Gombe performed the trabeculectomy surgeries. A total of fifty-two eyes of 50 patients having a postoperative follow-up of six months were included in the study. The mean age at presentation was 54.10(± 13.02) years. On the last day before surgery, the mean Snellen VA was 0.37(± 0.36) but became 0.40(± 0.36) post-operatively, p = 0.01, mean cup-to-disc ratio (CDR) was 0.86(± 0.12) but changed to 0.87(± 0.12) p = 0.79 at six months after surgery. Complete success, qualified success (with postoperative anti-glaucoma eyedrops), and failure of trabeculectomy (even with postoperative anti-glaucoma eyedrops) were 47(90.40%), 4(7.70%), and 1(1.90%), respectively. Based on the IOP, the complete success rate of trabeculectomy was 90.40%. The mean preoperative Snellen VA was improved by about half a line, six months after surgery and there was a significant reduction of IOP from its baseline. These outcomes will revolutionize our approach to the referral of suitable candidates for this surgical procedure as well as assure post-operative reserved vision.

Outcomes and risk factors for failure of trabeculectomy in glaucomatous patients in Southwest China: a 325 eyes analysis.

To evaluate the outcomes and elucidate the failure factors for trabeculectomy with mitomycin C (MMC) in Southwest Chinese patients. A retrospective correlational study was conducted on the glaucomatous patients who underwent initial trabeculectomy with MMC in Southwest Hospital and had been followed up for 1-3y. A complete success for surgery is defined as a postoperative intraocular pressure (IOP) >5 and ≤21 mm Hg and 20% reduction of IOP compared to preoperative, without IOP-lowering medications. A qualified success for surgery is defined as the abovementioned postoperative IOP with or without IOP-lowering medications. The primary outcomes were IOP, the number of IOP-lowering medications, and cumulative success rate. The secondary outcomes included best corrected visual acuity (BCVA), mean deviation (MD) of visual field, major complications, and risk factors for surgical failure. A total of 325 eyes of 261 glaucomatous patients had been included in our study. Both the mean IOP and the number of IOP-lowering medications were significantly decreased from 32.9±12.0 to 16.4±5.7 mm Hg (P<0.0001) and 3.0±0.9 to 0.9±1.0 (P<0.0001), respectively, at the last visit. The cumulative complete success rate and qualified success rate were 77.8% and 92.0% at 1-year follow-up, and 47.2% and 77.7% at 3-year follow up. There were no significant differences in surgical outcomes between primary angle-closure glaucoma (PACG) and primary open angle glaucoma (POAG). In PACG patients, the success rates of trabeculectomy were comparable with those of phacotrabeculectomy. Hypertension (HR=1.904, P=0.011), encapsulated bleb (HR=2.756, P<0.001), and more preoperative topical medications (HR=2.475, P=0.008) were risk factors for surgical failure. The qualified success rate of trabeculectomy with MMC in glaucomatous patients in the cohort is 92.0% at 1-year, and 77.7% at 3-year follow up. Hypertension, encapsulated bleb, and more preoperative topical medications are associated with surgical failure.

Factors influencing the effectiveness of trabeculectomy: following materials of the City Multidisciplinary Hospital No. 2

BACKGROUND: Despite the ever-expanding arsenal of IOP-lowering surgeries, trabeculectomy remains the most common procedure amongst them. Therefore, the identification of factors reducing its effectiveness and potentially being able to change the surgical treatment plan is of particular importance.&#x0D; AIM: To identify factors reducing trabeculectomy effectiveness.&#x0D; MATERIALS AND METHODS: The study group consisted of 443 consecutively enrolled patients who were operated in 20162020 in Saint Petersburg City Multidisciplinary Hospital No. 2 for primary open-angle decompensated glaucoma and then observed for 6 to 24 months. Using statistical research methods, factors that significantly affected the impact of the procedure were identified.&#x0D; RESULTS: The main predictors of trabeculectomy failure following the order of decreasing importance of established relations (p) were: loss of effectiveness of the preceding IOP-lowering procedure (р = 0.0001), dry eye syndrome (р = 0.013), number of drop instillations per day (р = 0.041), and excessive preservative load due to unnecessarily aggressive topical glaucoma treatment (р = 0.039). An obvious demonstration of excessive therapy is a simultaneous administration of four IOP-lowering medications. It also causes scarring of the procedure area, especially in patients previously operated for glaucoma. Null preservative load and prostaglandin monotherapy are associated with guaranteed complete success of trabeculectomy. Unlike the intensity of medical glaucoma treatment, its duration does not have such a significant impact on trabeculectomy outcomes (р = 0.270). Close to a significant one is the relationship between poor surgical outcomes and advanced stages of the disease (р = 0.052).&#x0D; CONCLUSIONS: The main factors affecting the effectiveness of trabeculectomy were failure of the previous IOP-lowering surgeries; concomitant dry eye syndrome, arising or being aggravated by unduly intense and prolonged pharmacological effects on the eye surface; as well as delayed appliance for surgical IOP normalization at advanced disease stages.

Efficacy and Safety of the Intraoperative Application of Mitomycin in Glaucoma Patients with Trabeculectomy: A Systematic Review and Meta-Analysis

What Is Known and Objective. The primary cause of trabeculectomy failure in glaucoma surgery is the imperfect formation of the filter bubble, which blocks the filtration effect. This systematic review and meta-analysis aimed to compare the effects and safety of mitomycin C (MMC) or no antimetabolite in trabeculectomies cases that require needling revision. Methods. We searched PubMed, Cochrane, and EMBASE to identify randomized trials published between the time the databases were built and May 31, 2022. To compare the effectiveness and safety of mitomycin with or without mitomycin in trabeculectomy, intraocular pressure (IOP), the surgical failure rate, and functional follicle formation were used as efficacy indicators, and the occurrence of postoperative complications was used as a safety indicator. Meta-analyses were performed for comparisons. Results and Discussion. After trabeculectomy, MMC was significantly better than a placebo at lowering postoperative IOP (MD = −11.31 mmHg, 95% CI −19.73 to −2.88 mmHg). MMC outperformed the control group in terms of filtering blebs formation (relative risk (RR) = 1.18, 95% CI: 1.09 to 1.27). The surgical failure rate was significantly lower with MMC compared to placebo (RR = 0.35, 95% CI: 0.22 to 0.58). No significant difference was observed between MMC and placebo in terms of hypotony, anterior chamber bleeding, filter bubble leakage, and endophthalmitis, apart from the shallow anterior chamber (RR: 1.51, 95% CI: 1.02 to 2.25). What Is New and Conclusion. The use of MMC in glaucoma trabeculectomy can increase the success rate of the procedure and provide significant patient benefits. However, it is important to be extremely careful and aware of complications such as shallow anterior chambers.

Clinical Outcomes of XEN45®-Stent Implantation after Failed Trabeculectomy: A Retrospective Single-Center Study.

The implantation of a collagen gel micro-stent (XEN45®) as a minimally invasive form of glaucoma surgery (MIGS) after a failed trabeculectomy (TE) may be an effective option with few risks. This study investigated the clinical outcome of XEN45® implantation after a failed TE, with follow-up data of up to 30 months. In this paper, we present a retrospective review of patients undergoing XEN45® implantation after a failed TE at the University Eye Hospital Bonn, Germany, from 2012 to 2020. In total, 14 eyes from 14 patients were included. The mean follow-up time was 20.4 months. The mean time duration between the failed TE and XEN45® implantation was 110 months. The mean intraocular pressure (IOP) decreased from 17.93 mmHg to 12.08 mmHg after one year. This value increased again to 17.63 mmHg at 24 months and 16.00 mmHg at 30 months. The number of glaucoma medications decreased from 3.2 to 0.71, 2.0, and 2.71 at 12, 24, and 30 months, respectively. XEN45® stent implantation after a failed TE did not lead to an effective long-term decrease in IOP and glaucoma medications in many patients in our cohort. Nevertheless, there were cases without the development of a failure event and complications, and others in whom further, more invasive surgery was delayed. XEN45® implantation in some failed trabeculectomy cases may, therefore, be a good option, especially in older patients with multiple comorbidities.

Comparison between Surgical Techniques Used for Revision of the Filter Bleb: A Randomized Controlled Clinical Trial

Introduction/Purpose: The aim of this study was to compare two surgical revision techniques in failed trabeculectomies after 6 months. Methods: Patients diagnosed with open-angle glaucoma who underwent trabeculectomy in at least one eye with uncontrolled intraocular pressure (IOP) after trabeculectomy performed at least 6 months before were enrolled in this prospective trial. All participants underwent a complete ophthalmological examination at baseline. Randomization was performed to one eye per patient to double-masked trabeculectomy revision or needling. Patients were examined on the first day, 7 days, 14 days, and then monthly until completing 1 year after surgical intervention. All follow-up visits included the following: patients reported ocular and systemic events, best-corrected visual acuity, IOP, slit-lamp examination, and optic disc evaluation for cup-to-disc ratio. Gonioscopy and stereoscopic optic disc photographs were taken at baseline and 12 months. After 1-year, the IOP and number of medications were compared between the groups. Absolute success criteria in the study were IOP <16 mm Hg, for 2 consecutive measurements without using a hypotensive medication. Results: Forty patients were included in this study. Among them, 38 completed 1-year follow-up (18 in revision group and 20 in needling group). The age ranged from 21 to 86 years, with a mean of 66.82 ± 13.44. At baseline, the average IOP was 21.64 ± 5.12 mm Hg (range from 14 to 38 mm Hg) in the entire group. All patients were using at least two classes of hypotensive eye drops, and 3 patients were using oral acetazolamide. The mean use of hypotensive eye drop medications was 3.11 ± 0.67 at the baseline for the entire group. In the present study, 58% of the patients presented complete success, 18% qualified success, and 24% failed in both groups. After 1-year treatment, both techniques were similar for IOP parameters and also for number of medications (p = 0.834 and p = 0.433, respectively). Regarding intra- or postoperative complications, one patient in each group needed a new surgical intervention, one in the needling group due to shallow anterior chamber and one in the revision group due to spontaneous Seidel sign, and one patient in the needling group underwent posterior revision due to fail. Conclusions: Both techniques were safe and effective for IOP control after 1 year of follow-up in patients who underwent to trabeculectomy more than 6 months before.

Uneventful Phacoemulsification after Trabeculectomy in Pseudoexfoliation Glaucoma versus Primary Open-Angle Glaucoma

Introduction: Conflicting results have been reported on phacoemulsification in the filtered eyes with open-angle glaucoma. In this study, we aim to compare the effect of phacoemulsification after trabeculectomy between pseudoexfoliation glaucoma (XFG) and primary open-angle glaucoma (POAG). Methods: Consecutive patients with XFG and POAG who underwent uneventful phacoemulsification after trabeculectomy with 5-fluorouracil (TRAB-PHACO group) were reviewed retrospectively and matched to patients who underwent trabeculectomy only (TRAB group). Comparisons were performed for IOP, medication numbers, and success rates. Surgical failure was defined as IOP >21 mm Hg or IOP ≤21 mm Hg with additional medication or glaucoma surgery. Survival analysis was investigated by Kaplan-Meier test and the factors influencing final success by multivariate logistic regression analysis. Results: The records of 204 patients were reviewed. In XFG, when compared with the baseline, increase in IOP became statistically significant at the at 24-month visit in the TRAB-PHACO group (p = 0.002), at the 6-month visit (p = 0.001) in the TRAB group and remained so throughout the follow-up. In the TRAB-PHACO group, increase of glaucoma medications was statistically significant only at the last visit (p = 0.001) in XFG, at the 6-month visit (p = 0.02) in POAG and remained so throughout the follow-up. Two glaucoma types did not differ statistically from one another in terms of survival analysis. In the TRAB group, the additional glaucoma surgery was more common in XFG compared to POAG (p = 0.02). The trabeculectomy failure after phacoemulsification was related with an IOP spike >25 mm Hg at postoperative first 24h (p = 0.04). Conclusions: In the filtered eyes with XFG, uneventful phacoemulsification may delay time-related worsening in IOP control and may decrease the additional glaucoma surgery need.

Glaucoma Drainage Device (GDD) Implantation in Post Trabeculectomy Patients

Objective: This study aims to report a case of Glaucoma Drainage Device (GDD) implant surgery in a patient who experienced an increase in Intraocular Pressure (IOP) after long term trabeculectomy. Case Presentation: A 58-year-old male patient came with complaint of blurred vision since two years ago. Patient did not complain of sore and red eyes. He was given 2 x 250 mg of Acetazolamide, 2 x 1 tablet of Aspar K, 2 x 1 right and left eye (RLE) of Latanoprost, and 2 x 1 RLE of Betaxolol HCl. The patient had glaucoma since 20 years ago and had undergone surgery in 2002 on the right eye and left eye surgery in 2004. His right eye intraocular pressure was 38 mmHg with conjungtival bleb (+) flat (+) minimal vascularity (+) horizontal extent 1-2 clock hours. Patient then underwent a GDD implant surgery on the right eye, IOP 8 mmHg post GDD. Three months after surgery, the visual acuity decrease into 6/120 ph 6/21, elevated IOP into 32 with prominent lens opacity, so the phacoemulsification was done to the right eye After the surgery, patient’s intraocular pressure was stable with better visual acuity. Conclusion: In trabeculectomy failure, implantation of the GDD is the safest and most effective option in eyes that have undergone previous intraocular surgery.