Needle Revision Research Articles

The role of primary needle revision after Ahmed glaucoma valve (AGV) implantation.

To evaluate the efficacy and safety of primary needle revision after Ahmed Glaucoma Valve (AGV) implantation in comparison with glaucoma medication use. In this interventional case series, 23 eyes of 23 patients who underwent AGV implantation were enrolled. Needle revision was performed when the intraocular pressure was higher than the target pressure before glaucoma medications. Using a 30-gauge needle, the Tenon's capsule over the plate was incised and the bleb was reformed. Patients were examined on a postoperative day one, weekly (for four weeks), and every 1-3months. Two criteria were used to define cumulative success as a minimum 20% reduction in IOP and 5 <IOP ≤ 21mmHg (Criteria A) or 5 <IOP ≤ 18mmHg (Criteria B) without (Complete success) or with (Qualified success) glaucoma medication. In this pilot study, we enrolled 23 patients with a mean age of 53.8 ± 12.4years (25-78years) who underwent AGV implantation and a one-year follow-up period. The mean number of primary needle revision was 2.2 ± 1.6 (1-6). One year postoperatively, the cumulative success rate was 91.4% and 86.9% based on Criteria A and B, respectively. The average of preoperative IOP was 28.26 ± 8.86mmHg (range 15-46mmHg), reaching 13.78 ± 3.54mmHg (range 8-20) at the end of the one-year follow-up. (P < 0.001) The mean preoperative medication significantly decreased from a median of 4 (range 3-4) at baseline to 2 (range 1-4) after the one-year follow-up (P < 0.001). One patient experienced leakage over the plate, which was successfully treated via conservative management. This pilot study showed that primary needle revision is a safe and effective method for controlling IOP after AGV implantation with a lower need for medication.

XEN Gel Stent in the management of primary open-angle glaucoma

PurposeTo assess the efficacy and safety of the XEN Gel Stent in patients with primary open-angle glaucoma.Materials and methodsTwenty eyes of 17 patients (6 males, 11 females) with primary open-angle glaucoma were implanted with XEN Gel Stent. The following data were ascertained in each participant at baseline and at 1, 3, 6, 9 and 12 months following implanting procedure: intraocular pressure, number of anti-glaucoma medications, retinal sensitivity (PS 24/2 w/w), pattern electroretinogram (ISCEV standard), as well as the number of complications.ResultsThe mean intraocular pressure reduction in a 1-year follow-up was 18% (21.56 vs. 17.69 mmHg, p < 0.001). The mean number of anti-glaucoma medications was reduced from 3.2 to 1.6 (p = 0.001). The PERG parameters at baseline and at 12 months postoperatively included a stable amplitude of P50 (2.55 µV vs. 2.65 µV, p = 0.024) and N95 (3.45 µV vs. 3.38 µV, p = ns) waves. The delta N95 and delta P50 amplitudes remained stable over the follow-up period (p = ns). The mean deviation (MD) of PS 24/2 was − 6.54 dB vs. − 8.43 dB, p = ns, whereas the pattern standard deviation (PSD) was 6.18 dB vs. 6.91 dB, p = ns. Transient hypotony within the first postoperative week occurred in 18 eyes (90%), whereas hyphema occurred in two eyes (10%). Needle revision of a filtration bleb was performed in five eyes (25%).ConclusionsThe XEN Gel Stent enables significant reduction in intraocular pressure with very low complication rates. It ensures a stabilization of the retinal function as established with the PERG.

Impact of Phacoemulsification Combined with XEN Gel Stent Implantation on Corneal Endothelial Cell Density: 2-Year Results

Corneal integrity has long been a preoccupation of glaucoma surgeons considering glaucoma drainage device surgery or antimetabolite-enhanced trabeculectomy. Despite having demonstrated a good safety profile and significant intraocular pressure-lowering capacities, the impact of XEN gel stents on endothelial density was never specifically investigated. The purpose of this study is to assess the effect of XEN gel stents on central endothelial cell density (ECD) over 24 months. To achieve this, we compared the effect on ECD of combined XEN surgery with that of a standard phacoemulsification procedure. This was an investigator-initiated, retrospective study, conducted at a single tertiary glaucoma center. Patients with primary or secondary open-angle glaucoma who underwent XEN implantation combined with phacoemulsification between January 2015 and June 2016 were retrospectively enrolled. Patients who had undergone standalone phacoemulsification over the same period of time were enrolled to form the control group of this comparative study. The primary outcome measure was the ECD. Patients who had undergone standalone XEN implantation and patients for whom both a baseline and 24-month ECD could not be obtained were excluded from the analysis. Percentages of ECD reductions were calculated for each studied eye, and the mean of ECD reductions was calculated for each group as well as for subgroups. Thirty-two eyes of 23 patients (mean age=76.0±7.9 y, 60% female) underwent standalone phacoemulsification (n=15) or combined XEN surgery (n=17) and had an ECD both at baseline and 24-month postoperatively. Mean baseline ECDs were 2568±491 versus 2379±335 cells/mm, respectively (P=0.21). In the combined XEN surgery group, 58.8% of eyes (n=10) required at least 1 mitomycin C (MMC)-enhanced needling revision to maintain their target intraocular pressure. In the standalone phacoemulsification group, ECD decreased by a mean 14.5%, from 2567.7±491.2 to 2196.1±591.9 cell/mm (P=0.072). In the combined XEN surgery group, ECD decreased by a mean 14.3%, from 2378.8±334.7 to 2039.6±451.1 cell/mm (P=0.018). The difference in percentage reduction of ECD between the 2 groups was not statistically significant (P=0.226). Within the combined XEN surgery group, the ECD decreased by a mean of 15.4% in patients who did not undergo needling revisions and by 13.1% in patients who underwent the MMC-augmented procedure (P=0.485). In the 3 patients who underwent >1 needling revision, a 21.3% reduction in ECD was observed, but the difference was not statistically significant (P=0.653). Neither the time of the first needling (P=0.452), the patients' age (P=0.285), or sex (P=0.308) was statistically associated with ECD loss. The present study demonstrated that the XEN gel implant combined with phacoemulsification produces 24-month ECD loss of a similar magnitude to that observed following standalone phacoemulsification. MMC-augmented needling revisions do not appear to have an impact on ECD.

Efficacy of Needling Revision After XEN Gel Stent Implantation: A Prospective Study

The XEN gel stent is currently the only minimally invasive glaucoma surgical device that targets the subconjunctival outflow pathway through an ab interno placement. It has demonstrated a significant intraocular pressure (IOP)-lowering potential and a favorable safety profile compared with traditional filtering surgery. However, despite a less invasive approach, the presence of a filtering bleb inevitably implies some risk of complications. The most commonly reported bleb-related complication, with rates as high as 45%, is bleb fibrosis associated with raised IOP. To restore filtration in those failing blebs, needling revision is considered the procedure of choice. In this study, we present the results of mitomycin C-augmented needling after XEN implantation. This was a prospective, interventional study, conducted at a single tertiary glaucoma center. Fifty-one eyes of 51 patients with raised IOP associated with either a fibrotic or shallow bleb or increased vascularity following XEN gel stent implantation at the investigation site between January 2015 and June 2016 were enrolled in this study. Patients with other identified causes of filtration failure (stent malposition, internal ostium obstruction, retained viscoelastic) were excluded. Included patients who underwent mitomycin C-augmented needling revision, and follow-up examinations were conducted at 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months. The primary outcome was the magnitude of IOP reduction following needling revision at the last follow-up visit. Secondary outcome measures were the number of needling procedures carried out in all patients, the rate of patients requiring further filtering surgery following needling revision, and the rate of intraoperative and postoperative complications associated with needling revisions. The average age was 74.4±9.6 years; 66.7% (n=34) were female individuals. Primary open-angle glaucoma was the most common diagnosis (n=21, 41.2%). A total of 78 needling procedures were performed over the 24-month follow-up. Overall 20 of 51 eyes (39.2%) required >1 needling revision, and 14 eyes (24.5%) eventually required reoperation to maintain IOP within their desired target range. Before XEN implantation, mean preoperative IOP was 22.3±8.2 mm Hg and decreased to 14.1±8.0 mm Hg at day 1 postoperatively (-36.8%). The last measured IOP before the first needling revision was on average 23.6±8.9 mm Hg, which reduced to a mean 12.1±4.2 mm Hg at the first postrevision appointment (-48.7%). At the last follow-up appointment, on average 17.0±7.0 months after the first needling, the mean IOP was 14.3±4.1 mm Hg (-35.9% and -39.4% from preoperative and prerevision baselines, respectively). Complications associated with needling revisions were partial amputation of the XEN implant during needling (n=2, 3.9%), hypotony with choroidal detachment (n=1, 2%), and failure to achieve target IOP requiring subsequent surgery (n=14, 27.5%). No association was found between any of the recorded characteristics and the number of needling revisions performed or their outcomes. The present study shows that needling revision following XEN gel stent implantation is a relatively safe and efficient intervention to restore filtration in failing blebs, with a significant and durable IOP-reduction potential.

The efficacy of bleb needling revision with 5-fluorouracil in encapsulated bleb after unsuccessful trabeculectomy

Objectives: To investigate the efficacy of the bleb needling revision (BNR) procedure with the adjunctive use of 5-Fluorouracil (5-FU) in encapsulated bleb after unsuccessful trabeculectomy. Methods: We reviewed 16 eyes of 15 subjects who underwent BNR procedure due to encapsulated bleb after unsuccessful trabeculectomy. Demographic data, type of glaucoma, intraocular pressure (IOP) values of pre-BNR, IOP values of post-BNR at first day, first week and first month, follow up time and complications were recorded from patients’ files, retrospectively. Results: The mean follow up time was 53.1 ± 26.4 weeks. The average time between previous unsuccessful trabeculectomy and BNR was 11.12 ± 8.79 weeks. The mean IOP of pre-BNR was 26.0 ± 4.4 mmHg and significantly decreased to 12.4 ± 5.0 mmHg post-BNR at the first day (p &amp;lt; 0.001). The mean IOP values of post-BNR at the first week was 13.3 ± 4.9 mmHg and at the first month was 14.8 ± 4.8 mmHg. According to the mean IOP of pre-BNR, the mean IOP values of post-BNR at the first week and at the first month were significantly lower (p &amp;lt; 0.001 and p &amp;lt; 0.001, respectively). Seven (44%) eyes were achieved success and eight (50%) eyes were achieved qualified success. One (6%) eye was classified as the failure. Conclusion: The bleb needling revision procedure with the adjunctive use of 5-FU in encapsulated bleb after unsuccessful trabeculectomy is a simple, useful and repeatable method to restore the dysfunctional bleb.

Outcome of needle revisions with subconjunctival 5-fluorouracil in filtration blebs

Outcome of needle revisions with subconjunctival 5-fluorouracil in filtration blebs

Needle revision outcomes after glaucoma filtering surgery: survival analysis and predictive factors.

To evaluate the efficacy and safety of needle revision and examine factors predictive of failure. In total, 157 eyes of 131 patients that underwent needle revision augmented with either 5-fluorouracil or betamethasone for trabeculectomy failure were included in this retrospective study. Complete failure was defined as additional glaucoma surgery, ciliodestructive procedures, loss of light perception, sight-threatening complications, hypotony maculopathy, and surgical bleb revision. Success was defined as intraocular pressure ⩽ 18 (criterion A), ⩽15 (criterion B), and ⩽12 mmHg (criterion C) reached with (qualified) or without (complete) medications, and absence of any criteria of complete failure. The median (interquartile range) follow-up was 25.0 (41.0) months. Complete failure rates were 19%, 26%, and 31% at 1, 2, and 3 years, respectively. For criterion A, qualified and complete success rates were, respectively, 77% and 69% at 1 year, 66% and 51% at 2 years, and 60% and 47% at 3 years. For criterion B, qualified and complete success rates were, respectively, 67% and 61% at 1 year, 48% and 42% at 2 years, and 44% and 39% at 3 years. For criterion C, qualified and complete success rates were, respectively, 43% and 41% at 1 year, 27% and 25% at 2 years, and 24% and 23% at 3 years. High baseline intraocular pressure and primary surgery were associated with higher and lower risks of complete failure, respectively. Needle revision is an effective and safe procedure to rescue failing trabeculectomy postponing or avoiding further glaucoma surgery. Eyes with low target intraocular pressure may have poor long-term outcomes.

1-year outcomes of the Xen45 glaucoma implant.

To describe the 12-month outcomes of the Xen45 glaucoma stent. Non-comparative retrospective study of all cases who underwent Xen glaucoma surgery in April 2017 or earlier and completed 12 months of follow-up. The primary outcome measures were intraocular pressure (IOP) reduction and number of glaucoma medications at 12 months postoperatively. The secondary outcome measures were surgical complications and the success rate of surgery at 1 year. Success rate was defined according to the multiple IOP thresholds of 15 mmHg, 18 mmHg, and 21 mmHg with all requiring a drop of 20% and no additional glaucoma surgery. Revision or needling of the Xen conjunctival bleb was not considered to constitute a surgical failure. Sixty-eight eyes were included in the study. Mean IOP dropped from 22.1 mmHg preoperatively to 14.8 mmHg at 12 months, a 33% drop (p < 0.0001). Mean number of glaucoma medications reduced from 2.9 preoperatively to 1.1 at 12 months (p < 0.0001). In total, 54.4% of cases were back on glaucoma medications by 12 months. Success rate varied from 32.4% when defined as IOP ≤ 15 mmHg and ≥ 6 mmHg and ≥ 20% reduction without medications to 70.6% when defined as IOP ≤ 21 mmHg and ≥ 6 mmHg and ≥ 20% reduction with or without medications. Thirty cases (44.1%) required bleb needling or surgical revision. The Xen45 is effective at reducing IOP and glaucoma medication use at 12 months postoperatively. Patients considering this procedure should be warned that by 12 months postoperatively there is a significant chance of requiring postoperative bleb intervention and glaucoma drops.

Cataract extraction after deep sclerectomy and its effect on intraocular pressure control.

To estimate the incidence and predisposing factors for cataract extraction (CE) after Deep Sclerectomy (DS) with Mitomycin-C (MMC) and its effect on intraocular pressure (IOP) control. Retrospective study of phakic eyes which had DS with MMC performed over a 5-year period. 179 eyes of 179 patients were included. Mean age at time of DS was 68.6 ± 9.7 years and mean follow-up was 89.4 ± 29.4 months. 63 eyes had CE and the probability of CE following DS was 0% at 1, 11.6% at 3, 21.0% at 5 and 33.2% at 7 years, with a 50% probability (median survival time) of 10 years. Age was association with increased risk for CE (Hazard ratio 1.05, 95% CI: 1.03-1.08, p < 0.0001). Mean IOP had increased from 11 mmHg to 15 mmHg in the first 3 months and remained higher up to a year (p < 0.001). There was no difference in the probability of maintaining an IOP < 16 mmHg without additional medications or needle revision (p = 0.05,Log-rank test). 20/47 eyes that failed were from the CE group, of which 14 (22.2%) failed prior to CE. Number of eyes on glaucoma medications before CE was 6 (mean edications 0.2 ± 0.5 m) and by last follow-up, 9 eyes were on medications (mean medications 0.2 ± 0.7). Post-CE needle revision was performed on 4 eyes. The probability of CE after DS is low, with a gradual increase with time. Increasing age was found to be a statistically significant risk factor. There was a modest increase in IOP after CE and increase use of glaucoma medications.

Standalone Ab Interno Gelatin Stent versus Trabeculectomy: Postoperative Interventions, Visual Outcomes, and Visits

To evaluate postoperative interventions, visual outcomes, and number of postoperative office visits after standalone ab interno gelatin microstent implantation with mitomycin C (MMC) vs. trabeculectomy with MMC. International, multicenter, retrospective cohort study. A total of 354 eyes of 293 patients, including 185 microstent eyes and 169 trabeculectomy eyes. Consecutive eyes with uncontrolled glaucoma underwent microstent or trabeculectomy surgery from January 1, 2011, through July 31, 2015, at 4 academic ophthalmology centers: Toronto, Canada; Frankfurt, Germany; Salzburg, Austria; and Leuven, Belgium. Assessed outcomes included (1) in-clinic interventions, (2) transconjunctival needle revision (TCNR), (3) postoperative visits at 1 and 3 months, (4) >2 lines vision loss at last follow-up, (5) complete visual recovery, and (6) >0.5 or >1 diopter (D) of surgically induced astigmatism. Ninety-five (51.4%) of the microstent eyes and 105 (62.1%) of the trabeculectomy eyes underwent an intervention by last follow-up (log-rank P= 0.0004). The most common intervention was TCNR, followed by laser suture lysis. Seventy-eight (42.2%) microstent eyes and 55 (32.5%) trabeculectomy eyes received TCNR (adjusted hazard ratio [HR], 1.73 [95% confidence interval (CI), 1.10-2.71]): 128 total TCNRs in the microstent group and 95 in the trabeculectomy group. Predictors for TCNR included prior laser peripheral iridotomy and diabetes. Microstent eyes had on average 1.00 (standard deviation 2.32) fewer visits compared with trabeculectomy eyes in the first month (P < 0.001), adjusted for baseline characteristics. The percentage of eyes that had lost >2 lines of vision at last follow-up or reoperation was 12.4% (95% CI, 8.0%-18.7%) and was 21.9% (95% CI, 15.3%-30.1%) adjusted (P= 0.0383). A higher proportion of microstent eyes regained their baseline preoperative visual acuity compared with trabeculectomy eyes (log-rank P= 0.0250; adjusted HR, 1.46 [95% CI, 1.10-2.00]). Altogether, 25.3% (95% CI, 15.3%-38.9%) of microstent eyes and 40.7% (95% CI, 27.7%-55.3%) of trabeculectomy eyes had > 0.5 D surgically induced astigmatism on an adjusted basis; 8.0% (95% CI, 3.2%-18.6%) vs. 17.3% (95% CI, 8.9%-9.8%) had >1 D. Microstent eyes had more TCNRs (though fewer in-clinic interventions), fewer postoperative visits, and less vision loss, and experienced less surgically induced astigmatism, than trabeculectomy eyes. Overall, the postoperative course was less intensive for the microstent, except for more TCNRs.

ReGAE 12: preventing glaucoma blindness in the Caribbean through implementation of the Moorfields Safer Surgery System and skills transfer from the UK to Trinidad and Tobago.

ObjectiveThe objective of the study was to present evidence of successful skills transfer of the Moorfields Safer Surgery System (MSSS) from the UK to Trinidad and Tobago and the safety and efficacy of this technique.MethodsHospital-based retrospective, consecutive, non-comparative case series study of 33 eyes (24 African-Caribbean patients; 16 male patients) with primary open-angle glaucoma undergoing trabeculectomy + mitomycin C (MSSS) by a single surgeon with UK Glaucoma Fellowship training. The clinical outcome measures included intraocular pressure (IOP), bleb morphology, postsurgical interventions, postoperative complications, and best-corrected visual acuity (BCVA) at the final follow-up.ResultsAll patients were self-identified as African-Caribbean. The median age was 56 years (range 34–79 years). The mean preoperative IOP on maximum tolerated medical treatment was 22.4 mmHg (SD=5.9 mmHg). With or without medication, IOP was ≤21 mmHg in 92.6% at 1 year and 87.5% at 5 years. At 1 year, IOP was ≤18 mmHg in 78%, ≤15 mmHg in 73% and ≤14 mmHg in 52%. Removal of scleral flap releasable suture(s) was performed in 84%, 5-fluorouracil injection(s) in 88% and bleb needling revision in 38%. The most common complication was early transient bleb leak (52%). No patient developed endophthalmitis, hypotony maculopathy, suprachoroidal hemorrhage, or malignant glaucoma. At the final follow-up, 91% had excellent or satisfactory bleb morphology, and 73% had equal or better BCVA.ConclusionSkills transfer between different geographical and economic regions contributes to the prevention of avoidable blindness through disease control – one of the core strategies of the World Health Organization’s Vision 2020 initiative. In the Caribbean (Trinidad and Tobago), the MSSS was utilized by a surgeon with Glaucoma Fellowship training and achieved outcomes similar to best-published data. This success can be reproduced in other geographic locations.

Long-term outcome of mitomycin C-augmented needle revision of trabeculectomy blebs for late trabeculectomy failure.

To describe the 3-year outcomes of mitomycin C (MMC)-augmented bleb needling procedures following late trabeculectomy failure. A retrospective, observational chart review of 44 eyes that underwent MMC-augmented bleb needling following late trabeculectomy failure. The primary outcome measure was IOP at 3 years post-operatively. Secondary outcome measures were the number of topical glaucoma medications and success rate at 3 years. Success was defined on the basis of IOP (≤21 mmHg and ≥5 mmHg with a reduction of ≥ 20% from pre-operative baseline), need for ocular hypotensive medications, and need for further laser or surgical intervention. Mean IOP was reduced from 19.8 mmHg preoperatively to 13.9 mmHg (29.5% reduction) at 3 years. By the 3-year time point, 26 eyes (59.1%) had met one or more of the criteria for failure. A lower immediate post-operative IOP was found to be associated with greater likelihood of success. Bleb needling augmented with MMC can achieve a significant reduction in IOP in eyes with late trabeculectomy failure. By 3 years however, 59% of eyes were classified as failures, with half requiring further glaucoma surgery or laser. Patients undergoing this procedure should therefore be warned of the likelihood of requiring further intervention, and a repeat antimetabolite-augmented trabeculectomy or glaucoma tube shunt surgery in the first instance can be considered instead.

Two-year Results After Deep Sclerectomy With Nonabsorbable Uveoscleral Implant (Esnoper-Clip): Surgical Area Analysis Using Anterior Segment Optical Coherence Tomography.

To report 2-year results of deep sclerectomy (DS) with mitomycin C and the uveoscleral implant Esnoper-Clip (AJL Ophthalmics, Álava, Spain), a nonabsorbable hema implant, and the morphologic analysis of the surgical area with anterior segment optical coherence tomography (AS-OCT). In total, 41 eyes of 41 patients with medically uncontrolled open angle glaucoma who underwent DS with the uveoscleral implant were included in this prospective interventional study. Patients were recruited and selected sequentially. All patients were followed at least for 12 months and 36 of them for 24 months. Absolute success was defined as intraocular pressure (IOP)≤18 mm Hg and ≥20% of IOP reduction without topical medication. Relative success was defined with the same criteria but with the addition of any antihypertensive medication. Primary outcomes were IOP decrease in the postoperative stage. Secondary outcomes were number of medication, best-corrected visual acuity changes, rate of goniopuncture, needle revision, and AS-OCT analysis of the bleb area. AS-OCT analysis, using Visante OCT, was performed at 1, 12, and 24 months. Absolute success rate was 68.3% at 12 months and 61.1% at 2 years. Relative success was 78.0% and 71.4%, at 12 and 24 months, respectively. A significant IOP decrease was observed, from 27.3±6.3 to 14.9±4.4 mm Hg at 12 months and 15.3±5.2 mm Hg at 24 months (P<0.001). There was also a significant reduction in the number of medications, dropping from a mean of 2.5 to 0.28 one year and 0.36 two years after the surgery (P<0.001). Main postoperative complications were transient: 4 eyes with seidel phenomenon at 24 hours (10.3%), 3 hyphema (7.7%), and 1 choroidal detachment (2.6%). Mean intrascleral space height, measured by AS-OCT, was 0.78 mm and it showed a significant positive correlation with IOP at 12 months. Neodymium-doped yttrium aluminium garnet laser goniopuncture was performed in 25 eyes (61%) at 12 months and in 27 (66.8%) by 24 months. DS with the uveoscleral implant is a safe and effective procedure to lower IOP in open angle glaucoma patients. IOP reduction is maintained over 2 years and is correlated to the postoperative height of the intrascleral bleb. Supraciliary implantation reduces intrascleral lake dependency, being a simultaneous drainage alternative to the subconjunctival pathway.

Deep sclerectomy for uveitic glaucoma: long-term outcomes.

PurposeTo report long-term outcomes of deep sclerectomy (DS) in eyes with raised intraocular pressure (IOP) and glaucoma secondary to uveitis.Patients and methodsRetrospective consecutive case series of 43 eyes of 43 patients with uveitic glaucoma. Mitomycin C (MMC) 0.2-0.4 mg/ml was applied sub-conjunctivally prior to scleral flap dissection for 2-3 min in 35 eyes (81%). Combined phacoemulsification and DS was done in 4 cases (9%).ResultsMean follow-up was 68.5±33.5 months. In total, 23 eyes (53.5%) had previous intraocular surgery. Pre-operative IOP was 33.6±12.0 mm Hg. Mean IOP at one, three and five years after surgery was 15.5±5.0 mm Hg, 16.9±6.7 mm Hg and 16.4±5.2 mm Hg, respectively.The probability of IOP <22 and <19 mm Hg was 69 and 62% at 3 years and 60 and 51% at 5 years, respectively. This included eyes that had undergone needle revision and/or laser goniopuncture within that period but had not needed glaucoma medication or further glaucoma procedures. The overall number of glaucoma medications decreased from 3.0±1.2 to 0.8±1.2 by last follow-up (P<0.001). Serious complications included hypotony with macular folds in two eyes and occlusion of the trabeculo-Descemet's membrane (TDM) by iris in two eyes. Recurrence of uveitis was observed in 16 eyes. Seven eyes (16.3%) had subsequent procedures including trabeculectomy with MMC in one eye, DS with MMC in two eyes and Baerveldt tube implantation in five eyes.ConclusionsDS is a safe and effective procedure to lower IOP in uveitic glaucoma. However, as with other glaucoma procedures, a significant proportion of patients will require another IOP-lowering procedure in the long-term.

Revision after filtration surgery

In contrast to all other glaucoma surgeries, filtration surgery is associated with biomicroscopically visible wound healing, which enables the surgeon to perform revision surgeries if necessary. The aim of this review is to provide general considerations and to give astructured overview about bleb revisions after trabeculectomy. The different revision techniques are explained in detail and in the context of perioperative management. Preoperative preparation and modifications of the surgical techniques reduce the incidence of postoperative revisions. The site of the fibrosis defines the revision technique (bleb needling, needle revision, bleb revision with reopening). The increased percolation rate of aqueous humor in postoperative hypotony contributes to fibrosis and may lead to maculopathy, choroidal effusion, and suprachoroidal hemorrhage. Discontinuing administration of local medication and pretreatment with steroids without preservative for at least one week prior to surgery increase surgical success of trabeculectomy and reduce the incidence of postoperative revisions. Postoperative management after filtration surgery should be performed after consulting the surgeon. The primary endpoint of trabeculectomy is an intraocular pressure between 8 and 12mmHg without local antiglaucomatous medication. In postoperative hypotony revisions should be done earlier and based on the pathological findings.

The relationship of bleb morphology and the outcome of needle revision with 5-fluorouracil in failing filtering bleb.

To investigate the risk factors for failure of needling revision with 5-fluorouracil (5-FU) and to identify the correlation of outcomes of needling revision and the morphological features of dysfunctional filtration blebs using Moorfields bleb grading system.This retrospective, nonrandomized, comparative case–control study included 41 consecutive patients (41 eyes) who underwent 5-FU needling revision for failed or failing filtration blebs between July 2012 and August 2014 in Chang Gung Memorial Hospital, a referral center in Taiwan. The main outcome measures were the bleb survival and the correlation factors of bleb morphology before revision. The secondary outcome measure was the identification of any study factor associated with bleb failure.Forty-one eyes of 41 patients were included in this study. The most frequent glaucoma diagnoses were 10 cases (24%) of neovascular glaucoma and 8 cases (19%) of chronic open-angle glaucoma. Survival of bleb at 6, 12, and 24 months was 42%, 39%, and 23%. Fourteen cases (34%) maintained overall success at the last follow-up, with an average follow-up of 22.7 ± 9.4 months (range: 12–48 months). The central bleb area and height were significantly different between the successful needling group and the failed needling group (P = 0.03 and 0.04, respectively). Further trend test confirmed that smaller central bleb extension and flatter height were associated with a higher chance of failure (P = 0.02 and 0.02, respectively). Time from initial trabeculectomy to needling of less than 4 months and higher intraocular pressure (IOP) in the first postoperative week also led to significantly higher risk for failure (P = 0.01 and 0.03, respectively).A small central area and the flat height of dysfunctional blebs were more likely to fail after the needle revision. Cautious case selections, taking account of the time from the initial filtering surgery and postoperative IOP, may improve the surgical outcome.

A New Method for Revision of Encapsulated Blebs after Trabeculectomy: Combination of Standard Bleb Needling with Transconjunctival Scleral Flap Sutures Prevents Early Postoperative Hypotony.

PurposeA simple needling procedure is the standard method for restoring the function of an encapsulated bleb after trabeculectomy. However, postoperative hypotony represents a possible hazard. This study describes a new surgical approach for treating encapsulated blebs with reduced risk of early postoperative hypotony: bleb needling combined with transconjunctival sutures tightening the scleral flap directly.MethodsThe study included two groups of 23 patients with failing bleb following trabeculectomy: “Group 1” underwent simple needling revision of the filtering bleb and served as a control group, while “Group 2” received needling revision with additional transconjunctival scleral flap sutures, if intraoperatively the intraocular pressure was estimated to be very low. Intraocular pressure (IOP), postoperative management and complications were analyzed over a follow-up period of 4 weeks postoperatively. Results were compared using t-test or Mann-Whitney U-tests.ResultsAdverse effects occurred with a higher frequency after sole needling of the bleb (5 cases of choroidal effusion and 1 case of choroidal hemorrhage) than after the combined method with additional scleral sutures (1 case of choroidal effusion). The IOP on the first postoperative day was significantly lower in group 1, with 9.43 ± 9.01 mm Hg vs. 16.43 ± 8.35 mm Hg in group 2 (P = 0.01). Ten patients with ocular hypotony (IOD of 5 mmHg or lower) were found in group 1 and only two in group 2. One week and one month after surgery the intraocular pressure was similar in both groups (P>0.05).ConclusionsThis new needling technique with additional transconjunctival scleral flap sutures appears to reduce postoperative hypotony, and may thus protect from further complications, such as subchoroidal hemorrhage.

Needle revision with subconjunctival injection of 5-fluorouracil for failed filtering blebs after trabeculectomy

Needle revision with subconjunctival injection of 5-fluorouracil for failed filtering blebs after trabeculectomy

Outcomes: Trabeculectomy Bleb Needle Revision With 5-Fluorouracil.

To evaluate outcomes of trabeculectomy bleb needle revision with 5-fluorouracil augmentation performed in the operating theater. Retrospective study of all patients undergoing trabeculectomy bleb needle revisions in the operating theater performed by a single surgeon in a metropolitan hospital in Australia. A total of 51 needle revisions were performed on 33 eyes over a mean follow-up time of 1.81±1.56 years. A total of 29% achieved intraocular pressure (IOP) ≤20 mm Hg off all glaucoma medications, and an additional 39% achieved qualified success with the addition of glaucoma medications, giving overall success of 68%. Analyzing success rate for target IOP≤16 mm Hg, 24% achieved target off all glaucoma medications, 35% achieved qualified success with the addition of glaucoma medications, giving an overall success rate of 59%. There was a statistically significant improvement in IOP, as compared with preoperative levels, at all timepoints postoperatively (P<0.05). However, number of glaucoma medications remained unchanged (P>0.05) contributing to the high percentage of qualified successes. Visual acuity remained unchanged and there were no major postoperative complications. The Kaplan-Meier survival shows a survival rate of 60% with IOP≤20 mm Hg and 40% for IOP≤16 mm Hg at 5 years. Trabeculectomy needle revision is a useful option for the management of elevated IOP in the presence of a failed or failing trabeculectomy bleb. However, as with trabeculectomy, there tends to be a failure rate over time. This often leads to reinstitution of glaucoma medications and/or further needle revisions to maintain IOPs at target level. The procedure itself is minimally invasive with an acceptable safety profile.

Long term outcome of 5-Fluorouracil(5-FU) augmented bleb needling revision of failed and failing filtration blebs.

Purpose: To evaluate the long term outcome of 5-Fluorouracil (5-FU) augmented bleb needling revision of failed and failing filtration blebs based on survival analysis and to identify risk factors for failure, indicators for success and complications.Methods: This was a prospective, interventional case series with survival analysis. 32 eyes of 32 patients underwent bleb needling augmented with 5-FU and were then followed up. Statistical analysis was done to assess the association between study factors and time to failure. Main outcome measures were reduction in IOP (&lt;21 mm of Hg), number of antiglaucoma medications (AGM’s), complications and factors associated with outcome including indicators for success. Results: At one year followup 9 (28. 13%) eyes had IOP &lt;21 mmHg without the use of any antiglaucoma medications. 13 eyes (40. 63%) had qualified success with mean IOP &lt;21 mm Hg after 1 or multiple needlings but with the help of one or more AGM’s (1. 2±0. 4). 10 cases (31. 25%) failed and had to undergo repeat Trabeculectomy or shunt surgery. In the cases which achieved overall success, complete and qualified together (n = 22) the baseline IOP pre needling was 26. 7±8. 2 mmHg which was reduced to 13. 6±4. 6 mmHg at the end of the minimum follow up period of 1 year. The median interval between the “index” filtration surgery and the first (or only) needling procedure was 7. 5 months (Range 3 months to 4 years). Overall reduction in mean number of topical AGM’s was from 2. 68±0. 82 to 0. 82±0. 34. Overall cross sectional success rate at 1 year follow up (complete and qualified) was 68. 76%(n=32) and the overall cross-sectional success rate (complete and qualified) at the 3 year follow up period was 66. 91%(n=24) and 65. 82%(n=16) at 5 year follow up. Strong evidence was found for association between pre needling IOP &gt;28 mm of Hg and failure and immediate attainment of low IOP &lt;11 mmHg and longer survival. None of the other proposed factors were identified as having statistically significant effect. Conclusions: This long term study shows that bleb needling augmented with 5-FU is a safe and effective method by which a significant number of failed or failing filtration blebs can be rescued. Attaining an immediate reduction in IOP &lt;11 mmHg seems to be a favorable factor with respect to reasonably long-term efficacy.