Limbus-based Conjunctival Flap Research Articles

Fornix-based versus limbal-based conjunctival trabeculectomy flaps for glaucoma.

Glaucoma is one of the leading largely preventable causes of blindness in the world. It is usually addressed first medically with topical intraocular pressure-lowering drops or by laser trabeculoplasty. In cases where such treatment fails, glaucoma-filtering surgery such as trabeculectomy, is commonly considered. Surgeons can differ in their technique when performing trabeculectomy, for example, the choice of the type of the conjunctival flap (fornix- or limbal-based). In a fornix-based flap, the surgical wound is performed at the corneal limbus; while in a limbal-based flap, the incision is further away. Many studies in the literature compare fornix- and limbal-based trabeculectomy with respect to outcomes and complications. To assess the comparative effectiveness of fornix- versus limbal-based conjunctival flaps in trabeculectomy for adult glaucoma, with a specific focus on intraocular pressure (IOP) control and complication rates (adverse effects). We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 3); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 23 March 2021. There were no restrictions to language or year of publication. We included RCTs comparing the benefits and complications of fornix- versus limbal-based trabeculectomy for glaucoma, irrespective of glaucoma type, publication status, and language. We excluded studies on children less than 18 years of age, since wound healing is different in this age group and the rate of bleb scarring postoperatively is high. We used standard methodological procedures as per Cochrane criteria. MAIN RESULTS: We did not identify any new eligible studies for this review update. As presented in the originalreview, we included six trials with a total of 361 participants. Two studies were conducted in the USA and one each in Germany, Greece, India, and Saudi Arabia. The participants of four trials had open-angle glaucoma; one study included participants with primary open-angle or primary closed-angle glaucoma, and one study did not specify the type of glaucoma. Three studies used a combined procedure (phacotrabeculectomy). Trabeculectomy with mitomycin C (MMC) was performed in four studies, and trabeculectomy with 5-fluorouracil (5-FU) was performed in only one study. None of the included trials reported trabeculectomy failure at 24 months. Only one trial reported the failure rate of trabeculectomy as a late complication. Failure was higher among participants randomised to the limbal-based surgery: 1/50 eyes failed trabeculectomy in the fornix group compared with 3/50 in the limbal group (Peto odds ratio 0.36, 95% confidence interval (CI) 0.05 to 2.61)); therefore we are very uncertain as to the relative effect of the two procedures on failure rate. Four studies including 252 participants provided measures of mean IOP at 12 months. In the fornix-based surgeries, mean IOP ranged from 12.5 to 15.5 mmHg and similar results were noted in limbal-based surgeries with mean IOP ranging from 11.7 to 15.1 mmHg without significant difference. Mean difference was 0.44 mmHg (95% CI -0.45 to 1.33; 247 eyes) and 0.86 mmHg, (95% CI -0.52 to 2.24; 139 eyes) at 12 and 24 months of follow-up, respectively. Neither of these pooled analyses showed a statistically significant difference in IOP between groups (moderate certainty evidence). One trial reported number of anti-glaucoma medications at 24 months of follow-up with no difference noted between surgical groups. However, three trials reported the mean number of anti-glaucoma medications at 12 months of follow-up without significant difference in the mean number of postoperative IOP-lowering medications between the two surgical techniques. Mean difference was 0.02, (95% CI -0.15 to 0.19) at 12 months of follow-up (high certainty evidence). Because of the small numbers of events and total participants, the risk of many reported adverse events was uncertain and those that were found to be statistically significant may have been due to chance. For risk of bias assessment: although all six trials were randomised selection bias was mostly unclear, with unclear random sequence generation in four of the six studies and unclear allocation concealment in five of the six studies. Attrition bias was encountered in only one trial which also suffered from reporting bias. All other trials had an unclear risk of reporting bias as there was no access to study protocols. All included trials were judged to have high risk of detection bias due to lack of masking of the outcomes. Trabeculectomy is quite a standard procedure and unlikely to induce bias due to surgeon 'performance', hence performance bias was not evaluated. The main result of this review was that there was uncertainty as to the difference between fornix- and limbal-based trabeculectomy surgeries due to the small number of events and confidence intervals that cross the null. This also applied to postoperative complications, but without any impact on long-term failure rate between the two surgical techniques.

The impact of conjunctival flap method and drainage cannula diameter on bleb survival in the rabbit model.

PurposeTo examine the effect of cannula diameter and conjunctival flap method on bleb survival in rabbits undergoing cannula-based glaucoma filtration surgery (GFS).MethodsTwelve New Zealand White rabbits underwent GFS in both eyes. The twenty-four eyes were divided into four groups. Two of the four groups (N = 12) received limbus-based conjunctival flaps (LBCF), and the other two (N = 12) received fornix-based conjunctival flaps (FBCF). Six FBCF rabbit eyes were implanted with 22-gauge drainage tubes, and the other six were implanted with 26-gauge tubes. Likewise, six LBCF rabbits received 22-gauge drainage tubes and six received 26-gauge tubes. Filtration blebs were evaluated every three days by a masked observer. Bleb failure was defined as the primary endpoint in this study and was recorded after two consecutive flat bleb evaluations.ResultsGroup 1 (LBCF, 22- gauge cannula) had a mean bleb survival time (Mean ± SD) of 18.7 ± 2.9 days. Group 2 (LBCF, 26-gauge cannula) also had a mean bleb survival time of 18.7 ± 2.9 days. Group 3 (FBCF, 22-gauge cannula) had a mean bleb survival time of 19.2 ± 3.8 days. Group 4 (FBCF, 26-gauge cannula) had a mean bleb survival time of 19.7 ± 4.1 days. A 2-way analysis of variance showed that neither surgical approach nor cannula gauge made a statistically significant difference in bleb survival time (P = 0.634 and P = 0.874). Additionally, there was no significant interaction between cannula gauge and conjunctival flap approach (P = 0.874), suggesting that there was not a combination of drainage gauge and conjunctival flap method that produced superior bleb survival.ConclusionLimbus and fornix-based conjunctival flaps are equally effective in promoting bleb survival using both 22 and 26-gauge cannulas in the rabbit model. The 26-gauge drainage tube may be preferred because its smaller size facilitates the implantation process, reducing the risk of corneal contact.

Efficacy of autologous conjunctival flap on repairing the late-onset filtering bleb leakage.

To evaluate the effectiveness of autologous conjunctival flap surgery for repairing the late-onset filtering bleb leakage after trabeculectomy. This study retrospectively reviewed 106 eyes from 106 patients with late-onset filtering bleb leakage after trabeculectomy who received autologous conjunctival flap surgery at the Zhongshan Ophthalmic Centre from 2005 to 2015. The basic information was recorded, and the interval time between trabeculectomy and autologous conjunctival flap surgery as well as related risk factors, intraocular pressure (IOP), anterior chamber depth (ACD) and best corrected visual acuity (BCVA) were analysed. Moreover, 41 patients who completed the 1-year follow up were analysed to determine the IOP and BCVA changes and long-term success rates. The 50 male and 56 female subjects (average age 39.13±17.96y) included 47 (44.34%) and 33 (31.13%) cases of primary open angle and primary angle-closure glaucoma. The mean interval between trabeculectomy and repair surgery was 60.60±56.92 (3-264)mo. The mean mitomycin (MMC) concentration during trabeculectomy was 0.27±0.04 (0.12-0.4) mg/mL in the fornix-based conjunctival flap group (68 patients) and 0.28±0.04 (0.20-0.33) mg/mL in the limbal-based conjunctival flap group (11 patients). After bleb leakage, the patients' vision remained stable while the IOP decreased from 10.25±4.76 (3-20.86) to 9.44±4.33 (2-21) mm Hg (P<0.01). In the 41 analysed patients, the IOP was controlled at 15.68±5.11 (7-40) mm Hg in the 1st year after autologous conjunctival flap surgery and recurrence was not observed, for a long-term success rate of 100%. Autologous conjunctival flap repairing surgery is an effective technique for sealing filtering bleb leakages and controlling IOP postoperatively.

Role of trabeculectomy in advanced glaucoma: Whether we stand to consider it a bane or a boon today?

To elucidate the role of trabeculectomy in advanced glaucoma. Only patients with primary open-angle glaucoma were selected. All patients who had cup-disc ratio of 0.9 or a near-total cupping were given a trial of aggressive maximum medical therapy for IOP control for at least 4weeks. Target IOP was defined as≤12mmHg. Patients who showed progression were included in the study. A total of 10 patients were selected. Trabeculectomy was performed using limbal-based conjunctival flap. Patients were followed up for a period of 2years for visual acuity, intraocular pressure, visual fields, slit-lamp biomicroscopy and bleb morphology. Mean preoperative intraocular pressure on five drugs was 21.7±3.8mmHg (range 18-27mmHg) on maximum medical therapy. Mean post-operative intraocular pressure was 11±1.78mmHg (range 9-13mmHg) and 11±1.92mmHg (range 9-14mmHg) at 1 month and 6months post-operatively, respectively. Post-operatively, the visual acuity remained stable in 17 patients. It dropped by 1 Snellen line in 2 patients and 2 Snellen lines in 1 patient, respectively, over a period of 6months and later improved to 6/6P following cataract surgery. There was no defined visual field progression in any of the 20 patients. Besides being a cost-effective alternative to medical management, trabeculectomy not only provides a better IOP control but also has a high safety profile when performed by an experienced surgeon.

Fornix-Based Versus Limbal-Based Conjunctival Trabeculectomy Flaps for Glaucoma: Findings From a Cochrane Systematic Review

To compare effectiveness of fornix- and limbal-based conjunctival flaps in trabeculectomy surgery. Systematic review. Setting: CENTRAL, MEDLINE, LILACS, ISRCTN registry, ClinicalTrials.gov, WHO, and ICTRP were searched to identify eligible randomized controlled trials (RCTs). RCTs in which benefits and complications of fornix- vs limbal-based trabeculectomy for glaucoma were compared in adult glaucoma patients. We followed Cochrane methodology for data extraction. Proportion of failed trabeculectomies at 24months, defined as the need for repeat surgery or uncontrolled intraocular pressure (IOP) >22mm Hg, despite topical/systemic medications. The review included 6 trials with a total of 361 participants, showing no difference in effectiveness between fornix-based vs limbal-based trabeculectomy surgery, although with a high level of uncertainty owing to low event rates. In the fornix-based and limbal-based surgery, mean IOP at 12months was similar, with ranges of 12.5-15.5mm Hg and 11.7-15.1mm Hg, respectively. Mean difference was 0.44mm Hg (95% CI-0.45 to 1.33) and 0.86mm Hg (95% CI-0.52 to 2.24) at 12 and 24months of follow-up, respectively. Mean number of postoperative glaucoma medications was similar between the 2 groups. Mean difference was 0.02 (95% CI-0.15 to 0.19) at 12months. As far as postoperative complications, an increased risk of shallow anterior chamber was observed in the limbal-based group. Similar efficacy of trabeculectomy surgery with respect to bleb failure or IOP control was observed in both types of conjunctival flap incisions. A significant difference was detected in the risk of postoperative shallow anterior chamber, which was increased in the limbal-based group.

Prospective observation of filtration blebs in high-risk eyes with limbal-based conjunctival flap

ObjectiveTo evaluate time-dependent changes in filtering bleb parameters using 3-dimensional anterior segment optical coherence tomography (3-D AS-OCT) in high-risk eyes after a limbal-based trabeculectomy procedure. DesignProspective, observational study. ParticipantsTwenty-three patients who underwent uncombined limbal-based trabeculectomy surgery and who also had a history of prior intraocular surgery. MethodsOf 23 eyes, 15 eyes were followed for 1 year without additional glaucoma surgeries, and their bleb parameters were measured 0.5, 3, 6, and 12 months after the trabeculectomy using 3-dimensional anterior segment optical coherence tomography. The correlations of these parameters to other clinical data were investigated. ResultsStatistical analysis showed significant changes in the bleb wall thickness (0.7 ± 0.4 mm vs 0.4 ± 0.2 mm; p = 0.007) and fluid cavity height (0.3 ± 0.2 mm vs 0.7 ± 0.4 mm; p = 0.005) between 0.5 and 3 months only. The width of the filtration openings at 0.5 months after trabeculectomy (2.1 ± 1.0 mm) was significantly associated with the intraocular pressure at 12 months (15.1 ± 5.7 mm Hg; R2 = 0.37, t = −2.65, and p = 0.021). ConclusionsThe width of the filtration opening in the early stage may be a prognostic factor for long-term intraocular pressure control.

Trabeculectomy and Combined Phacoemulsification-Trabeculectomy: Outcomes and Risk Factors for Failure in Primary Angle Closure Glaucoma.

To evaluate tonometric outcomes of patients with primary angle closure glaucoma (PACG) who have undergone trabeculectomy with mitomycin C (MMC) with and without concurrent phacoemulsification and to identify risk factors for postoperative failure. Retrospective cohort study of 44 eyes of 33 phakic patients who underwent trabeculectomy with MMC with or without combined phacoemulsification for PACG. The primary endpoint was qualified tonometric success at 12 months according to predefined criteria. LogMAR visual acuity, number of glaucoma medications, and postoperative complications were also evaluated. Cox proportional hazard regression analysis was performed to identify potential risk factors for trabeculectomy failure. Mean intraocular pressure (IOP) decreased from 21.3±7.9 to 12.2±3.9 mm Hg at 12 months (P<0.001) in all patients. A significant reduction in mean number of glaucoma medications (P<0.001) was also seen. There was no change in logMAR visual acuity (P=0.39) after 12 months. There were no significant intergroup differences in mean IOP (P=0.42), number of glaucoma medications (P=0.85), or logMAR visual acuity (P=0.42) between the trabeculectomy versus combined surgery groups after 12 months. Increased age, greater baseline IOP, limbus-based conjunctival flaps, and MMC duration >1 minute were associated with decreased risk of surgical failure. Concurrent phacoemulsification at the time of trabeculectomy did not alter tonometric success or rate of complications. In phakic patients with PACG, trabeculectomy with MMC significantly reduces IOP and number of glaucoma medications at 12 months without change in visual acuity. However, success rates are modest when based on more demanding tonometric criteria.

Persistent hypotony after trabeculectomy: incidence and associated factors in the Collaborative Bleb-Related Infection Incidence and Treatment Study.

To investigate the incidence of and factors associated with persistent hypotony after trabeculectomy with mitomycin C in the Collaborative Bleb-Related Infection Incidence and Treatment Study (CBIITS), a 5-year prospective multicenter study. A total of 955 eyes of 955 patients who underwent trabeculectomy with mitomycin C were studied. Surgical failure was defined as insufficient intraocular pressure (IOP) reduction (IOP>21mmHg or <20% IOP reduction, or further glaucoma surgeries), loss of light perception, or persistent hypotony (IOP≤5mmHg persisting for >6months). Factors associated with persistent hypotony in eyes with sufficient IOP reduction were determined by survival analysis and logistic regression analysis. The cumulative probabilities of surgical success and persistent hypotony at 5years were 62.0±1.7% (±standard error) and 7.7±0.9%, respectively. In 685 eyes with sufficient IOP reduction, preoperative IOP (mmHg), limbus-based conjunctival flap, or choroidal detachment that occurred within 6months of the surgery were significant risk factors for persistent hypotony [Cox proportional hazards regression model: hazard ratio, 0.95, 2.27, 3.24; 95% confidence interval (CI), 0.91-0.98, 1.21-4.23, 1.51-6.95; P=0.005, 0.01, 0.003, respectively]. Bleb infection and final visual acuity (logarithm of the minimal angle of resolution) were significantly associated with persistent hypotony (logistic regression: odds ratio, 8.74, 1.37; 95% CI, 1.89-40.4, 1.03-1.82; P=0.006, 0.029, respectively). In the CBIITS, eyes with successful IOP reduction, a limbus-based conjunctival flap, lower preoperative IOP, and choroidal detachment that occurred within 6months of the surgery were identified as risk factors for persistent hypotony.

Fornix-based versus limbal-based conjunctival trabeculectomy flaps for glaucoma.

Fornix-based versus limbal-based conjunctival trabeculectomy flaps for glaucoma.

Treatment with sodium hyaluronate eye drops in a patient who had early-onset bleb leakage after trabeculectomy with mitomycin C

We present the case of a 47-year-old man who had bilateral proliferative diabetic retinopathy and neovascular glaucoma. Schirmer I test revealed tear secretions of 5 mm and 3 mm in the right and left eyes, respectively. Tear breakup times in the right and left eyes were 7 and 8 seconds, respectively. The ocular surface staining in both eyes was scored as Grade 1 as per the Oxford scheme. Retinal photocoagulation was performed for correction of the proliferative diabetic retinopathy and rubeosis iridis, which resolved with treatment. However, the intraocular pressure in the left eye could not be adequately controlled. Therefore, trabeculectomy with mitomycin C using limbal-based conjunctival flap was performed. Three hours after the surgery, the patient developed a large and diffuse filtering bleb, but no leakage occurred from the conjunctival scar. However, on the first postoperative day, leakage was noted and the conjunctiva was at the leakage point. The leakage resolved transiently, but recurred the next day. Severe keratoconjunctival epithelial failure was detected, and the patient was administrated 0.1% sodium hyaluronate eye drops six times daily. The epithelial failure improved, and many microcysts were detected on the bleb surface where the epithelial failure improved. The leakage resolved 2 days after initiation of the sodium hyaluronate eye drops. The microcysts disappeared and the bleb surface became smooth 1 month later.

One-site versus two-site phacotrabeculectomy: a prospective randomized study.

PurposeThe purpose of this study is to compare the efficacy and safety of one-site and two-site combined phacotrabeculectomy with foldable posterior chamber intraocular lens implantation.MethodsThirty-four patients (41 eyes) with glaucoma and cataract were randomly assigned to undergo either a one-site (22 eyes) or a two-site (19 eyes) combined procedure. One-site approach consisted of a standard superior phacotrabeculectomy with a limbus-based conjunctival flap, while two-site approach consisted of a clear cornea phacoemulsification and a separate superior trabeculectomy with a limbus-based conjunctival flap.ResultsMean follow-up period was 54 months (standard deviation [SD] 2.3). Mean preoperative intraocular pressure (IOP) in the one-site group was 21.3 mmHg (SD 2.8) and in the two-site group was 21.8 mmHg (SD 3.0) (P>0.1). Mean postoperative IOP significantly decreased in both groups compared to the preoperative level and was 15.6 mmHg (SD 3.5) in the one-site group and 14.9 mmHg (SD 2.7) in the two-site group. Three months later, the difference between the two groups was not statistically significant (P=0.058). The one-site group required significantly more medications than the two-site group (P=0.03). Best-corrected visual acuity (BCVA) improved similarly in both groups, but there was less postoperative (induced) astigmatism in the two-site group in a marginal statistical level (P=0.058). Intra- and postoperative complications were comparable in the two groups.ConclusionBoth techniques yielded similar results concerning final BCVA and IOP reduction. However, the two-site group had less induced astigmatism and a better postoperative IOP control with less required postoperative antiglaucoma medications compared to the one-site group.

Fornix-based versus limbal-based conjunctival flaps in trabeculectomy with mitomycin C in high-risk patients.

PurposeTo compare the surgical outcomes of limbal-based and fornix-based trabeculectomy in eyes with a history of ocular incisional surgery.MethodsTwenty-six eyes underwent limbal-based trabeculectomy (group LB), and were condition matched with 26 eyes that received fornix-based trabeculectomy (group FB). Surgical failure was recorded retrospectively if the intraocular pressure value was either ≥21, ≥18, and ≥15 mmHg (conditions A, B, and C, respectively) or <4 mmHg or if the patient required additional glaucoma surgery. Kaplan–Meier survival curve analysis was used to assess surgical failure.ResultsFor condition A, the 2 year surgical success probabilities were 75.0% and 63.9% in groups FB and LB, respectively (P=0.124). The corresponding values were 55.0% and 61.7% (P=0.638) in condition B, and 55.0% and 57.0% (P=0.454) in condition C. The rates of bleb leakage, hypotony, choroidal detachment, and bleb-related infection were 11.5%, 26.9%, 50.0%, and 7.7% in group LB, respectively. The corresponding values in group FB were 30.8%, 23.1%, 46.2%, and 0.0%, which were not statistically different between the two groups.ConclusionNo significant differences in surgical outcomes were observed between limbal-based and fornix-based trabeculectomy for patients with a history of incisional ocular surgeries.

In Vivo Confocal Microscopy and Ultrasound Biomicroscopy Study of Filtering Blebs after Trabeculectomy

To evaluate morphological features of filtering blebs after trabeculectomy with limbus-based versus fornix-based conjunctival flaps (LBCF and FBCF, respectively) using in vivo confocal microscopy (IVCM) and ultrasound biomicroscopy (UBM). Seventy-five eyes of 62 patients with glaucoma were recruited. Thirty-eight eyes of 31 patients received trabeculectomy with LBCF and 37 eyes of 34 patients received trabeculectomy with FBCF. Successful bleb was defined as postoperative intraocular pressure (IOP) ≤15 mm Hg and IOP reduction ≥20% without antiglaucoma medication. Microcyst number, density of subepithelial connective tissue, and vascularity of subepithelial tissue were evaluated by IVCM. Bleb reflectivity, the route under the scleral flap, bleb height, and height of fluid-filled space were examined by UBM. On the basis of IOP criteria, 79% (30 of 38 blebs) of the LBCF group and 70% (26 of 37 blebs) of the FBCF group were defined as successful blebs (P=0.28). Compared with the successful FBCF group, the successful LBCF group had a larger microcyst number (P<0.001), lower density of subepithelial connective tissue (P=0.046), greater avascularity of subepithelial tissue (P=0.024), and higher height of fluid-filled space (P=0.017). No morphological differences between LBCF and FBCF groups were found in failed blebs. Morphological features of successful blebs in IVCM and UBM were different between blebs with LBCF and FBCF. Type of conjunctival flaps should be considered when estimating the bleb function based on bleb morphology examined with these imaging devices.

Changing trends in the incidence of bleb-related infection in trabeculectomy

AimTo investigate the incidence of late onset bleb-related infection (BRI) following Mitomycin C (MMC) augmented trabeculectomy procedures at a single institution.MethodsThis was a retrospective case series analysis of late onset...

Effect of trabeculectomy on ocular and corneal higher order aberrations

To examine the effect of trabeculectomy on ocular and corneal higher order wavefront aberrations. Trabeculectomy with a limbal-based conjunctival flap was performed in 13 patients (13 eyes). Ocular and corneal higher order aberrations were measured using a wavefront analyzer before and after surgery. The higher order aberrations for a 4-mm pupil diameter were expanded into Zernike's polynomials. Coma aberration, spherical aberration, and total higher order aberrations were evaluated as root mean square values. Mean intraocular pressure was significantly reduced from 15.5±3.1mmHg preoperatively to 7.5±3.5 and 7.2±4.4mmHg at 1 and 3months after surgery, respectively. The mean spherical equivalent refractive error was not changed by the surgery. Mean vector powers for surgically induced refractive changes at 1 and 3months postoperatively were 1.29±0.69 and 1.30±0.89 diopters, respectively. Corneal coma-like, spherical-like, and total higher order aberrations were not significantly changed by surgery. Trabeculectomy significantly increased ocular coma-like (P=0.0021) and total (P=0.0019) higher-order aberrations at 1month, but not at 3months postoperatively. Ocular coma-like and total aberrations were significantly increased at 1month after trabeculectomy with a limbal-based conjunctival flap, but they had returned to normal levels by 3months.

Bleb Morphology of Fornix-Based Versus Limbus-Based Conjunctival Flaps in Trabeculectomy with Mitomycin C

Bleb Morphology of Fornix-Based Versus Limbus-Based Conjunctival Flaps in Trabeculectomy with Mitomycin C

Conjunctival vasculature patterns influencing the filtering bleb shape following trabeculectomy with limbal-based conjunctival flaps

To investigate the correlation between conjunctival vasculature factors and two types of functional bleb shape, cystic and diffuse, formed after trabeculectomy with limbal-based conjunctival flaps. Eighty-five eyes of glaucoma patients were consecutively enrolled. After 6 months, functioning blebs were classified as either cystic or diffuse. For each bleb type, the presence of neovascularized vessels in the dissected area (NVc) or the nondissected area (NVi), an avascular area (AVA), or a posterior tarsal artery (PTA) feeding the conjunctiva was analyzed. In 62 eyes with functioning blebs, there were 54 cystic and eight diffuse blebs. AVA was present in 96.3% of the cystic and 25.0% of the diffuse blebs. NVc was present in 100% of the cystic and 62.5% of the diffuse blebs, and NVi in 96.3% of the cystic and 12.5% of the diffuse blebs. A PTA was present in 87.5% of the diffuse blebs, but in only 3.7% of the cystic blebs. AVA, NVi, and NVc were significantly more frequent in cystic blebs, whereas a PTA was more frequent in diffuse blebs. The presence of a PTA in the blebs was negatively related to the presence of AVA, NVc, or NVi. Avoidance of damage to the PTA during conjunctival dissection might facilitate the formation of a diffuse filtration bleb. The conjunctival vasculature should be considered to avoid cystic avascular bleb formation in trabeculectomy with limbal-based flaps.

Résultats à moyen terme de la phacotrabéculectomie en deux sites avec microtrabéculectomie ajustable

To evaluate the midterm effects of two-site phacotrabeculectomy with limbal-based conjunctival flap and microincisinal trabeculectomy with adjustable sutures. and method: The charts of 115 patients (188 eyes) were retrospectively reviewed. Patients had a mean age of 74.7 years and were all operated by the same surgeon between 2001 and 2003. The surgery consisted of a clear cornea phacoemulsification and a microtrabeculectomy with limbal-based conjunctival flap. The number of sutures on the scleral flap was adjusted according to the filtration. The mean preoperative IOP was 17.7 +/- 3.94 mmHg, and the mean number of antiglaucomatous medications was 2.05 +/- 0.86. The last postoperative IOP was 13.2 +/- 2.81 mmHg with a mean of 0.8 +/- 0.8 medications. Mean follow-up was 29.8 months (1-7 years). Visual acuity improved by at least two lines in 154 eyes (81%), stabilized (+/- 1 line) in 33 eyes (17.37%), and worsened of more than two lines in one eye (1.63%). Early postoperative complications were seven Seidels (3.68%), one shallow anterior chamber (0.55%), three chorioretinal detachments (1.58%), six hyphemas (3.15%), one iris incarceration (0.55%), and eight corneal edemas (4.21%). Late complications were five cases of bleb fibrosis despite needling and 5-FU injection. We had no cases of wipe-out syndrome. Our study shows the effectiveness of this special phacotrabeculectomy technique on IOP control and visual acuity improvement, with low complication incidence compared to classical phacotrabeculectomies.

The Effect of Paclitaxel on Conjunctival Wound Healing

To compare the effects of mitomycin C (MMC) and paclitaxel entrapped within Carbopol 980 hydrogel (CH) on conjunctival wound healing. Twenty rabbits were randomized into 2 groups. In group 1, limbal-based conjunctival flaps were created in both eyes. In this stage, eyes were randomized for 4 different processes. In process 1, a dry cellulose sponge soaked with 0.2 mg/mL of MMC was applied to the scleral surface. A cellulose sponge soaked with balanced saline solution was applied in the same manner in process 2. In process 3, paclitaxel 1 mg/mL entrapped within CH was placed between the conjunctiva and sclera. In process 4, CH without paclitaxel was applied in the same manner. The conjunctiva was then sutured. All procedures were applied in the same manner in both eyes of animals in group 2. Eyes from group 1 were sampled at the seventh day, and the sampling was also carried out in group 2 on day 14. The inflammatory response and fibrosis were evaluated with light microscopy. Among 4 different processes, lower cell counts and fibrosis scores were found in eyes treated with MMC and paclitaxel compared with balanced saline solution and CH groups (P<0.05). There was no difference between eyes treated with MMC and paclitaxel in terms of these histopathologic parameters (P>0.05). Paclitaxel was shown to provide MMC-like antifibrotic effects during conjunctival wound healing, particularly when delivered with CH and might be a promising alternative as an adjunctive antimetabolite in glaucoma filtration surgery.

Randomized Comparison of 1-Site and 2-Site Phacotrabeculectomy with 3-Year Follow-up

To compare intraocular pressure (IOP) control and other clinical outcomes after 1-site fornix-based and 2-site limbus-based phacotrabeculectomy. Prospective randomized controlled trial. A total of 90 eyes of 76 patients with cataract and glaucoma were treated. Forty-four eyes were assigned randomly to receive a 1-site phacotrabeculectomy with a fornix-based conjunctival flap, and 46 eyes were assigned randomly to receive a 2-site phacotrabeculectomy with a limbus-based conjunctival flap. All operations were performed with mitomycin C. Intraocular pressure and number of antiglaucoma medications were recorded at baseline and during a 3-year follow-up period. Mean preoperative IOP was 20.1+/-3.8 mmHg in the 1-site group and 19.5+/-5.3 mmHg in the 2-site group (P = 0.56) using a mean of 2.3+/-0.9 and 2.5+/-0.9 antiglaucoma medications, respectively (P = 0.27). After 3 years of follow-up, the mean IOP was 12.6+/-4.8 mmHg in the 1-site group and 11.7+/-4.0 mmHg in the 2-site group (P = 0.40), receiving a mean of 0.3+/-0.7 and 0.4+/-0.9 medications, respectively (P = 0.59). At the end of the study, 73% of 1-site eyes and 78.4% of 2-site eyes had IOPs of less than 18 mmHg while receiving no antiglaucoma medications (P = 0.59). Visual acuity was similar for both groups at 3 months after surgery. There were no significant differences in the need for digital pressure, postoperative bleb needling with 5-fluorouracil, or number of postoperative visits. There were 2 major complications in each group during follow-up. Early leaks of the conjunctival wound closure occurred in 6 eyes in the 1-site group and in 0 eyes in the 2-site group (P = 0.03). Operating time (in minutes) was less in the 1-site surgery group (P<0.0001). Day one postoperative IOP was higher in the 2-site group (P = 0.0.01). One-site fornix-based and 2-site limbus-based phacotrabeculectomy were similarly effective in lowering IOP and reducing the need for antiglaucoma medications over a 3-year follow-up period.