Partial-thickness Scleral Flap Research Articles

Asymptomatic chronic hypotony due to subclinical choroidal effusion after blunt trauma

Objective: To present a case report of asymptomatic post-traumatic chronic hypotony in which the cause was undetected until phacoemulsification.
 Methodology: Case report.
 Results: A 55-year-old female’s left eye suffered blunt trauma causing hyphema and iritis, which were successfully managed; however, up to a year after, the intraocular pressure (IOP) ranged from 3 to 5 mmHg and the anterior chamber remained very shallow (Van Herick grade 4) with the lens–iris diaphragm pushed anteriorly with difficulty assessing the angles for recession or clefts . Visual acuity was initially 20/20 upon resolution of the hyphema but worsened to 20/40 a year after, presumably due to a developing cataract. Periodic dilated fundus examinations revealed no hypotony maculopathy or choroidal effusions. Prior to phacoemulsification, ultrasound biomicroscopy (UBM) revealed 360 degrees of mild peripheral choroidal effusions. During phacoemulsification, after intraocular lens insertion, direct gonioscopy revealed a supero-nasal cyclodialysis cleft (2 clock hours) and this was repaired intraoperatively with direct cyclopexy through a partial thickness scleral flap. Postoperatively, the vision improved to 20/20 without correction and the IOP normalized to 16 to 18 mmHg.
 Conclusion: Chronic hypotony post-trauma may be asymptomatic and the cause may not be clinically evident and may be detected by UBM (choroidal effusion). In our case, the proximate aetiology (cyclodialysis cleft) of the effusion was only observed intraoperatively after phacoemulsification for which cyclopexy was performed which increased the IOP to physiologic levels.

Efficacy of ciliary sulcus suture fixation of intraocular lens through reverse partial-thickness scleral flap

Efficacy of ciliary sulcus suture fixation of intraocular lens through reverse partial-thickness scleral flap

Aqueous shunts with mitomycin C versus aqueous shunts alone for glaucoma.

Glaucoma affects more than 70 million people worldwide, with about 10% being bilaterally blind, making it the leading cause of irreversible blindness globally. In patients with advanced glaucoma or those who have failed medical treatment without achieving adequate intraocular pressure (IOP) control, trabeculectomy (glaucoma filtration surgery where an ostium is created into the anterior chamber from underneath a partial thickness scleral flap to allow for aqueous flow out of the anterior chamber intointo the subconjunctival space forming a filtering bleb) and aqueous shunt surgery for more complex and refractory cases remain the mainstay therapies. Proliferation of fibrous tissue around an implanted aqueous shunt may block the diffusion of aqueous humour. Mitomycin C (MMC) is one of two commonly used adjunct antifibrotic agents used during aqueous shunt surgery to prevent proliferation of fibrous tissue. However, the effectiveness and safety of the use of intraoperative MMC during aqueous shunt surgery has not been established. To evaluate the effectiveness and safety of MMC versus no MMC used during aqueous shunt surgery for reducing IOP in primary and secondary glaucoma. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 2); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 13 February 2018. We included randomized controlled trials (RCTs) in which one group of participants received MMC during aqueous shunt surgery and another group did not. We did not exclude studies based on outcomes. Two review authors independently reviewed titles and abstracts from the literature searches. We obtained full-text reports of potentially relevant studies and assessed them for inclusion. Two review authors independently extracted data related to study characteristics, risk of bias, and outcomes. We used standard methodological procedures expected by Cochrane. We included five RCTs, with a total of 333 eyes with glaucoma randomized, and identified two ongoing trials. All included trials examined the effect of MMC versus no MMC when used during aqueous shunt surgery for glaucoma. The trials included participants with different types of uncontrolled glaucoma. One study was conducted in China, one in Saudi Arabia, two in the USA, and one study was a multicenter study conducted in Brazil, Canada, Scotland, and USA. We assessed all trials as having overall unclear risk of bias due to incomplete reporting of study methods and outcomes; two of the five trials were reported only as conference abstracts.None of the included trials reported mean decrease from baseline in IOP; however, all five trials reported mean IOP at 12 months post-surgery. At 12 months, the effect of MMC on mean IOP compared with no MMC was unclear based on a meta-analysis of trials (mean difference -0.12 mmHg, 95% CI -2.16 to 2.41; low-certainty evidence). Two trial did not report sufficient information to include in meta-analysis, but reported that mean IOP was lower in the MMC group compared with the no MMC group at 12 months.None of the included trials reported mean change from baseline in visual acuity; however, one trial reported lower mean LogMAR values (better vision) in the MMC group than in the no MMC group at 12 months post-surgery. None of the included studies reported the proportion of participants with stable best-corrected visual acuity. Three trials reported that loss of vision was not significantly different between groups (no data available for meta-analysis).None of the included studies reported the proportion of participants with a postoperative hypertensive phase, which is defined as IOP > 21 mmHg within 3 months after surgery. Two trials reported adverse events (choroidal effusion, corneal edema, flat anterior chamber, and retinal detachment); however, due to small numbers of events and sample sizes, no clear difference between MMC and placebo groups was observed. We found insufficient evidence in this review to suggest MMC provides any postoperative benefit for glaucoma patients who undergo aqueous shunt surgery. Data across all five included trials were sparse and the reporting of study methods required to assess bias was inadequate. Future RCTs of this intervention should report methods in sufficient detail to permit assessment of potential bias and estimate target sample sizes based on clinically meaningful effect sizes.

Autologous Partial-thickness Scleral Flap and Donor Corneal Graft in Management of Tube Erosion of Glaucoma Drainage Device.

To evaluate the outcomes of autologous limbus-hinged partial-thickness scleral flap and half-moon-shaped split-thickness donor corneal allograft in management of tube erosion of glaucoma drainage device. Consecutive patients who had undergone a limbus-hinged partial-thickness scleral flap and half-moon-shaped split-thickness corneal graft were reviewed. Primary outcome was surgical success of coverage of the exposed tube without complications or additional surgeries. Secondary outcomes were visual acuity (VA), intraocular pressure, number of glaucoma medications, surgical complications, and additional surgeries. From March 1, 2016 to August 30, 2017 (18 mo), 8 consecutive cases (7 patients) of tube erosions were included for analysis. Mean follow-up and age were 16.6±5.4 months and 74.4±15.2 years, respectively. Mean number of intraocular surgeries was 4.8±1.6 (range: 3 to 6 surgeries) and intraocular glaucoma surgeries was 2.9±1.7 (range: 1 to 6 surgeries) before tube erosion. There were no intraoperative or postoperative complications or recurrence of tube erosion in any patient. Differences between the preoperative and postoperative number of medications (2.6±1.8, 2.9±1.8, respectively; P=0.171) and intraocular pressure (12.9±6.9, 10.8±3.5 mm Hg, respectively; P=0.209) were not statistically significant. Preoperative and 3-month postoperative VA were identical in all eyes except in 1 eye that the VA improved from 20/300 to 20/70 after repair. Combination of limbus-hinged partial-thickness scleral flap and half-moon-shaped split-thickness corneal allograft is a viable surgical option to repair tube erosion.

Prospective evaluation of CO2 laser-assisted sclerectomy surgery (CLASS) with Mitomycin C.

Our purpose was to evaluate the clinical safety and efficacy of CO2 laser-assisted sclerectomy surgery (CLASS) with Mitomycin C (MMC) in open angle glaucoma (OAG). This was a prospective, uncontrolled, interventional case series. All subjects underwent CLASS procedure by a single surgeon. After the dissection of a partial thickness scleral flap, topical MMC 0.2mg/ml was applied to the sclera and the conjunctiva for 3min. The CO2 laser with a beam-manipulating system was used to ablate the scleral tissue and expose the Schlemm's canal area. Primary outcomes: intraocular pressure (IOP) change, number of IOP-lowering medicaments change. Adverse events were evaluated as secondary outcomes. Twenty-one eyes of 21 patients underwent the CLASS procedure. Thirteen were primary OAG (62%), two normal pressure glaucoma (10%), three exfoliative glaucoma (14%) and three others secondary OAG. With a mean (SD) follow-up of 15.3 (5.9) months, the IOP changed from 25.4 (6.7) mmHg at baseline to 10.9 (3.4) mmHg al the last visit. Mean reduction of IOP was -14.5mmHg (95% CI, -17.7 to -11.2, P < 0.001). The median (IQR) number of IOP-lowering medication decreased from 3 (3-3) at baseline to 1 (0-1) at the last visit (P < 0.001). Visual acuity did not change significantly. Adverse events: five eyes (24%) developed iris adhesion to the filtration area that was successfully managed with office-based procedures. In one case (5%), CLASS was converted to trabeculectomy due to intraoperative perforation of the ablated area. There was one case of hypotony maculopathy successfully treated with placement of additional transconjunctival scleral flap sutures. The CLASS procedure with MMC is clinically safe and effective maintaining a large reduction in IOP and in the number of IOP-lowering medications with a mean follow-up of 15months. Iris adhesion at the filtrating area warrants further evaluation and possibly reflects the surgeon's learning curve.

Surgical Treatment for Tube Erosion after Ahmed Valve Implantation

Purpose: To report serial cases of patients who received surgical treatment for tube erosion after Ahmed valve implantation. Methods: In this retrospective and longitudinal study, surgical outcomes of reconstruction for tube erosion after Ahmed valve implantation were evaluated. Tube erosion occurred in 7 of 125 eyes (121 patients) at 60.5 ± 67.5 months (2 to 196 months). To prevent recurrence of tube erosion, the tube was repositioned backward in 4 eyes. Scleral allograft was used in all cases. Partial thickness scleral flap, collagen matrix implant, or bovine pericardium was used to cover the exposed tube in selected cases. In eyes with large conjunctival defects or severe adhesions between surrounding conjunctiva and episclera, rotational conjunctival flap, conjunctival autograft, or amniotic membrane graft was used to reconstruct the ocular surface. Results: Three of 7 eyes (42.9%) with tube erosion were successfully repaired by the first surgical treatment. No recurrence of tube erosion was found after the second and the fourth surgical procedure in 3 and 1 eyes, respectively. There was no case of explantation of the Ahmed valve in our series. Tube erosion recurred in 1 of the 4 eyes in which tube-repositioning was required and in 3 of the 5 eyes in which a partial thickness scleral flap was made to cover a tube. One eye experienced recurrent tube erosion in a relatively short-term interval and was repaired successfully using both collagen matrix implantation and amniotic membrane transplantation. Conclusions: Tube erosion after Ahmed valve implantation was successfully treated by various methods including tube repositioning, partial thickness scleral flap combined with scleral allograft, biodegradable collagen implant, pericardial graft, and/or amniotic membrane transplantation. J Korean Ophthalmol Soc 2016;57(3):453-460

Use of a 24 gauge intravenous cannula for minimally invasive trabeculectomy

We describe an innovative technique for performing standardized low cost glaucoma filtration surgery using a polytetrafluoroethylene (PTFE) intravenous cannula. The trocar of a 24 gauge (24G) PTFE intravenous cannula was used to create a trabeculectomy ostium and its tube was inserted under a partial thickness scleral flap in 2 patients with advanced glaucomatous optic neuropathy, in whom intraocular pressure (IOP) was not controlled on maximal tolerable hypotensive therapy. Postoperatively, IOP of the operated eyes at 3, 6 and 9 months’ follow-up ranged from 12 to 15 mmHg with a well formed anterior chamber and a diffuse bleb.

Randomized, Prospective, Comparative Trial of EX-PRESS Glaucoma Filtration Device versus Trabeculectomy (XVT Study)

To compare the clinical outcomes of the EX-PRESS glaucoma filtration device placed under a partial-thickness scleral flap with trabeculectomy. Randomized, prospective, multicenter trial. A total of 120 eyes in 120 subjects were analyzed, including 59 eyes treated with EX-PRESS and 61 eyes treated with trabeculectomy. Both the EX-PRESS and the trabeculectomy groups were treated intraoperatively with mitomycin C and followed postoperatively for 2 years. Surgical success was defined as 5 mm Hg ≤ intraocular pressure ≤ 18 mm Hg, with or without medications, without further glaucoma surgery. Mean intraocular pressure was significantly reduced compared with baseline in both groups (P < 0.001). Average intraocular pressure and number of medications were similar in both groups during follow-up, with mean intraocular pressure at 2 years after surgery of 14.7 ± 4.6 mm Hg and 14.6 ± 7.1 mm Hg in the EX-PRESS and trabeculectomy groups, respectively (P = 0.927). At 2 years after surgery, the success rate was 83% and 79% in the EX-PRESS and trabeculectomy groups, respectively (P = 0.563). Although visual acuity (logMAR) was significantly decreased on day 1 in both groups, the vision was not significantly different compared with baseline at 1 month after EX-PRESS implant (P = 0.285) and 3 months after trabeculectomy (P = 0.255). The variance of early postoperative intraocular pressure values was similar between groups on the first postoperative day but higher after trabeculectomy compared with EX-PRESS implant on day 7 (P = 0.003). The total number of postoperative complications was higher after trabeculectomy than after EX-PRESS implantation (P = 0.013). Mean intraocular pressures, medication use, and surgical success were similar at 2 years after treatment with the EX-PRESS device and trabeculectomy. Vision recovery between groups was also similar throughout the study, although return to baseline vision was more rapid in the EX-PRESS group. Intraocular pressure variation was lower during the early postoperative period, and postoperative complications were less common after EX-PRESS implantation compared with trabeculectomy.

Advances in Glaucoma Treatment and Management: Surgery

Ever since the first glaucoma surgery in 1856, the goal has been to decrease intraocular pressure (IOP), the only modifiable risk and prognostic factor for glaucoma. Over the years, reduction of IOP has been achieved by surgical manipulation of the aqueous inflow or outflow pathways. The glaucoma surgeries that have been developed to affect the inflow pathway have involved the destruction of the ciliary body, the tissue that makes the aqueous, whereas those that affect the aqueous outflow pathway involve either internal or external filtration. With internal filtration, the outflow pathways are manipulated so that they function better; with external filtration, the eye’s natural outflow pathways are bypassed. After the introduction of prostaglandin analogue medications in 1996, the frequency of all types of glaucoma surgery decreased, including the most common type, argon laser trabeculoplasty. In early 2000, a new type of laser surgery, selective trabeculoplasty, was developed and was reported to be less destructive than argon laser trabeculoplasty. 1 Since then, the frequency of laser trabeculoplasty procedures has gradually increased to pre‐prostaglandin-analogue levels (personal communication, H. Dunbar Hoskins, Jr, MD, Center for Quality Eye Care, June 6, 2011). The most frequently used intraocular surgery for glaucoma has been the trabeculectomy, which involves the creation of a partial-thickness scleral flap over a sclerectomy into the anterior chamber. Although this type of external filtration has been regarded as safer than the prior full-thickness sclerectomy, which does not have a partial-thickness flap limiting the flow of aqueous out of the eye, several new surgeries have been developed with the goal of improving on or replacing the trabeculectomy. Thus, in many new-device trials, the standard with which the new device or surgery is compared is a trabeculectomy. Since many of these studies have limitations, of which clinicians should be aware, the goal of this article is to review some of the most recent advances in incisional glaucoma surgery. In a literature review of trabeculectomies, Rotchford and King 2 identified 100 studies published between 2000 and 2005. Only 31 were randomized clinical trials; 53 were retrospective series. The best evidence for supporting clinical decisions is from randomized clinical trials, which involve the random assignment of patients to one procedure or another, an approach that prevents unknown biases from changing or affecting the results. Without randomization, it is difficult to know whether one procedure is better than another. In the 100 studies, there were 92 distinct IOP-related definitions of success, making it very difficult to compare the results of the studies, in which success rates ranged between 36% and 98% after 3 years of follow-up. Such a wide range of expectations for success makes it very difficult for a surgeon to obtain consent from a patient. The drive to create a better or different surgical procedure to lower IOP arises not only from the limited success rates of trabeculectomies but also from the short- and long-term risks of endophthalmitis (ocular infection) and ocular hypotony (too low IOP) after trabeculectomy. Unfortunately, 99 of the 100 studies did not report information on either visual function or optic nerve progression parameters. Although lowering of IOP is often used as a surrogate treatment goal for glaucoma management, the ultimate goal is to preserve visual function. Without information on visual function before and after surgery or across surgical groups, assessment of the success of the surgery is limited to IOP and thus does not capture the whole story.

Fibrin Glue–Assisted Fixation of Decentered Posterior Chamber Intraocular Lens

To report the feasibility and outcome of the technique of glue-assisted fixation of decentered posterior chamber intraocular lens (PCIOL) in the posterior chamber using the same IOL. The procedure was performed in three eyes having decentered PCIOL with inadequate capsular rim to support the IOL. The haptics were exteriorized under a partial thickness scleral flap at 1.5 mm behind the limbus and placed into a partial thickness scleral pocket and fixed with fibrin glue. No suture was placed at any site. On day 1 and at 6 weeks, the IOLs were well centered. There was no significant anterior or posterior segment inflammation, and the intraocular pressure was normal. Fibrin glue-assisted fixation of PCIOL is a feasible technique with good outcome in eyes with decentered IOL with inadequate capsular support.

Surgical outcomes of the Ex-PRESS glaucoma filtration device in African American and white glaucoma patients

PurposeTo compare the surgical outcomes of the Ex-PRESS glaucoma filtration device in African American and white glaucoma patients.DesignRetrospective comparative case series.MethodsThis was a comparative case series of 36 eyes of 36 African Americans and 43 eyes of 43 whites that underwent placement of the Ex-PRESS glaucoma filtration device under a partial-thickness scleral flap for uncontrolled glaucoma. All eyes received intraoperative mitomycin C. The primary outcome measures were intraocular pressure (IOP), number of postoperative glaucoma medications, and surgical success. Surgical success was defined as IOP between 5 and 18 mm Hg, with or without glaucoma medications, without further glaucoma surgery, or loss of light perception vision.ResultsAverage follow-up was 31.9 ± 9.8 (range, 14.6–47) months for African Americans and 30.7 ± 8.6 (range, 14.3–47) months for whites. At 33 months, surgical success was 80.0% in the African American group and 83.3% in the white group (P = 1.00). Reasons for surgical failure included increased IOP (3 eyes, 3.8%), persistent hypotony with maculopathy (1 eye, 1.3%), and further surgery (4 eyes, 5.06%). Compared with preoperative values, the mean postoperative IOP and number of glaucoma medications were significantly reduced in both groups, and no statistical difference was observed between the two groups at 33 months. Postoperative complications were similar in the two groups.ConclusionsSimilar surgical outcomes were observed in African American and white glaucoma patients after implantation of the Ex-PRESS glaucoma filtration device. This latest modification of glaucoma filtration surgery may be a better surgical option for African Americans given its potential advantages of no tissue removal, predictable outcomes related to consistent lumen size and controlled flow, fewer postoperative complications, and overall reduced inflammation.

Use of Ultrasound Biomicroscopy to Predict Long-Term Outcome of Sub-Tenon Needle Revision of Failed Trabeculectomy Blebs: A Pilot Study

To evaluate the role of ultrasound biomicroscopy (UBM) in predicting the long-term outcome of sub-Tenon needling revision of failed trabeculectomy blebs. Adult patients with a failed trabeculectomy bleb and unsatisfactory intraocular pressure (IOP) control were recruited. The aqueous flow under the partial thickness scleral flap was looked for and the blebs classified on UBM as scleral route patent (SRP) or scleral route occluded (SRO). All blebs underwent needling revision with injection of 5 mg/0.1 mL 5-fluorouracil. Survival of the revision procedure at the end of 2 years follow-up with regards to the baseline UBM characterization of the bleb was noted. Successful outcome was defined as IOP <22.0 mmHg and/or 30% reduction of baseline IOP with or without medication. A total of 13 eyes had SRP and 5 eyes had SRO blebs on UBM. Only SRP blebs survived the needling procedure by the end of 2 years. Of the 13 SRP blebs, 10 blebs survived (76.9%). Needling had failed in all 5 SRO blebs. The overall success rate was 55.6% at 2 years. There was no difference in age, IOP, and time from initial trabeculectomy between the failed and successful group. The outcome correlated significantly to the patency of the scleral route assessed by UBM (p=0.07). Ultrasound biomicroscopy characterization of failed blebs appears to help in predicting the outcome of needle revision. In SRO blebs, it may be better to plan a full bleb revision rather than needling alone. Ultrasound biomicroscopy may help in avoiding an unnecessary needling procedure in SRO blebs where it is likely to fail.

Surgical Outcomes of Different Ahmed Glaucoma Valve Implantation Methods between Scleral Graft and Scleral Flap

PurposeTo compare the surgical outcomes of the two different methods used for Ahmed Glaucoma Valve (AGV) implantation between the donor scleral graft method and the partial-thickness scleral flap method.MethodsWe retrospectively reviewed medical records of 28 eyes of 26 patients diagnosed as neovascular glaucoma followed by AGV implantation. Based on the surgical method, the included eyes were divided into two groups. In the graft group (n = 18), the drainage tube was inserted into the anterior chamber, and then covered with preserved donor sclera. In the flap group (n = 10), the drainage tube was inserted under the partial-thickness scleral flap, and then covered with the flap. We compared the postoperative intraocular pressure (IOP), surgical success rates, and postoperative complications between the two groups.ResultsPostoperative IOP was not significantly different between the two groups (p = 0.967, 0.495 at 12 months, 24 months, respectively, by the Mann-Whitney U-test). The mean success periods were 53.1 ± 10.1 months in the graft group versus 50.9 ± 9.4 months in the flap group (p = 0.882 by log rank test), and cumulative success rates were 77.8% and 80.0% at one year, respectively. However, tube migration occurred more frequently in the flap group than in the graft group (p = 0.037 by Fisher's exact test).ConclusionsIn AGV surgery for neovascular glaucoma, the scleral graft method may be associated with relatively less complication about tube migration than the scleral flap method. The surgical results, however, were not statistically different.

Femtosecond-Assisted Descemet Stripping Automated Endothelial Keratoplasty With Fibrin Glue-Assisted Sutureless Posterior Chamber Lens Implantation

We report a surgical technique for managing postsurgical aphakia with endothelial decompensation. The technique comprises femtosecond laser-assisted Descemet stripping automated endothelial keratoplasty (DSAEK) with fibrin glue-assisted sutureless posterior chamber intraocular lens (IOL) implantation-"glued IOL". Three eyes (of 3 patients) underwent the technique. The donor lenticules were created on a 60-kHz femtosecond laser platform (Intralase; Abott Medical Optics, Santa Ana, CA). Two partial-thickness scleral flaps and sclerotomies were made in host. After this, the Descemet was scored and stripped. A 3-piece 6.5-mm posterior chamber IOL was inserted, and its haptics were externalized through the sclerotomies. The haptics were then tucked into intrascleral pockets. The donor lenticule was inserted into the anterior chamber and unfolded. Air tamponade and pull suture manipulations were used to stabilize and center it. The partial-thickness scleral flaps were apposed with fibrin glue. The uncorrected and best-corrected visual acuities improved in all cases. There were no donor dislocations. The average donor endothelial cell loss was 27.7% at 6 months. Our series suggests that there is a benefit of glued IOL with DSAEK in such scenarios. It also has potential benefits as a combined procedure with DSAEK in comparison to anterior chamber IOL because it does not reduce the anterior chamber volume, does not require intact iris tissue, and unlike suture-fixated IOL, does not have knot slippage or pseudophakodonesis.

Ex-PRESS Miniature Glaucoma Device Implanted Under a Scleral Flap Alone or Combined With Phacoemulsification Cataract Surgery

Our purpose was to evaluate the clinical outcomes of the Ex-PRESS miniature glaucoma device placed under a partial-thickness scleral flap as a single procedure or combined with phacoemulsification cataract surgery. This was a comparative consecutive case series of 345 eyes: 231 eyes treated with Ex-PRESS implant under scleral flap alone and 114 eyes treated with Ex-PRESS implant under scleral flap combined with phacoemulsification (both groups were treated intraoperatively with mitomycin C). The patients were followed for 25.7+/-11.1 (range, 1 to 46.2) months (Ex-PRESS alone) and 21.9+/-12.5 (range, 1.9 to 46.2) months (combined cases). At 3 years after surgery, surgical success was 94.8% and 95.6% in the Ex-PRESS and combined groups, respectively (P=0.948). Compared with baseline values, the postoperative intraocular pressure (IOP) and number of glaucoma medications were significantly lowered in both groups. The change from baseline IOP was significantly greater after Ex-PRESS implant alone compared with combined surgery (P<0.001). The most common device-related complication was obstruction of the tube (6 eyes), which was treated successfully with Nd:YAG laser in all 6 eyes. The use of the Ex-PRESS implant under a scleral flap was effective for lowering IOP both alone and combined with cataract surgery. The most common device-related complication was tube blockage, which was treated with the Nd:YAG laser.

Novel surgical procedures in glaucoma: advances in penetrating glaucoma surgery

Despite late modifications and enhancements, traditional penetrating glaucoma surgery is not without complications and is reserved for patients in whom pharmacologic treatment and/or laser trabeculoplasty do not suffice to control the intraocular pressure. This article critically reviews recent advances in penetrating glaucoma surgery with particular attention paid to two novel surgical approaches: ab interno trabeculectomy with the Trabectome and implantation of the Ex-PRESS shunt. Ab interno trabeculectomy (Trabectome) achieves a sustained 30% reduction in intraocular pressure by focally ablating and cauterizing the trabecular meshwork/inner wall of Schlemm's canal. It has a remarkable safety profile with respect to early hypotonous or infectious complications as it does not generate a bleb, but it can be associated with early postoperative intraocular pressure spikes that may necessitate additional glaucoma surgery. The Ex-PRESS shunt is more commonly implanted under a partial thickness scleral flap, and appears to have similar efficacy to standard trabeculectomy offering some advantages with respect to the rate of early complications related to hypotony. Penetrating glaucoma surgery will continue to evolve. As prospective randomized clinical trials become available, we will determine the exact role of these surgical techniques in the glaucoma surgical armamentarium.

Comparison of Trabeculectomy With Ex-PRESS Miniature Glaucoma Device Implanted Under Scleral Flap

To evaluate the Ex-PRESS miniature implant (Model R 50) placed under partial-thickness scleral flap compared with standard trabeculectomy. In this retrospective comparative series of 100 eyes, we compared 50 eyes in 49 patients treated with the Ex-PRESS miniature glaucoma implant under a scleral flap with 50 matched control eyes in 47 patients treated with trabeculectomy. Success was defined as intraocular pressure (IOP) > or =5 mm Hg and < or =21 mm Hg, with or without glaucoma medications, without further glaucoma surgery or removal of implant. Early postoperative hypotony was defined as IOP <5 mm Hg during the first postoperative week. The average follow-up was 10.8 months (range 3.5 to 18) for the Ex-PRESS group and 11.2 months (range 3 to 15) for the trabeculectomy group. Although the mean IOP was significantly higher in the early postoperative period in the Ex-PRESS group compared with the trabeculectomy group, the reduction of IOP was similar in both groups after 3 months. The number of postoperative glaucoma medications in both groups was not significantly different. Kaplan-Meier survival curve analysis showed no significant difference in success between the 2 groups (P=0.594). Early postoperative hypotony and choroidal effusion were significantly more frequent after trabeculectomy compared with Ex-PRESS implant under scleral flap (P<0.001). The Ex-PRESS implant under a scleral flap had similar IOP-lowering efficacy with a lower rate of early hypotony compared with trabeculectomy.

Scleral window surgery and topical mitomycin C for nanophthalmic uveal effusion complicated by renal failure: case report

To describe the case of a 16-year-old patient with nanophthalmic uveal effusion associated with renal failure that was treated with scleral window surgery and topical administration of mitomycin C (MMC). Case report. Total uveal effusion was restored in the nanophthalmic eyes. Partial-thickness scleral flap with deep sclerostomy was performed and topical MMC was administered to one quadrant of the equatorial sclera. The subretinal fluid resorbed gradually. Topical MMC might relieve the blocked transscleral outflow of intraocular fluid in the small area of a sclerostomy in young patients with nanophthalmos or in patients with renal failure in whom uveal effusion occurs repeatedly.

Evaluation of efficacy and safety of daunorubicin in glaucoma filtering surgery

To evaluate the intraocular pressure (IOP)-lowering effect and ocular side effects of daunorubicin (DNR) in drug-modulated trabeculectomy. A prospective pilot study was conducted in which 21 Asian patients of Indian origin with high risk factors for failure of trabeculectomy were recruited. An approval from research ethics committee and an informed consent from every patient included in the study were obtained. DNR, an antimetabolite with known antifibroblastic action was used intraoperatively. A limbus-based conjunctival flap followed by conventional trabeculectomy was performed in all eyes. During trabeculectomy, a cellulose sponge soaked in 0.2 mg/ml DNR was applied for 3 min at the proposed site of trabeculectomy before preparation of the partial thickness scleral flap. A regular follow-up was carried out for 1 year where parameters including visual acuity, IOP by applanation tonometry, and slit lamp examination were performed on each visit. An IOP of 21 mmHg or less was taken as criteria for success. Following DNR trabeculectomy, the IOP was lowered from baseline preoperative value of 36.19+/-5.9 to 16.05+/-2.52 mmHg at the end of 1 year. Success rate of 81% (17 out of 21 patients) was noted. None of the patients developed corneal epithelial toxicity, hypotony maculopathy, or choroidal detachment. The authors feel that intraoperative daunorubicin is safe and effective in lowering IOP in high-risk surgical cases of glaucoma. However, a much larger cohort study over a considerable number of years will eventually demonstrate its safety.

False Passage: A Complication of 360° Suture Trabeculotomy

F c s t he use of suture material to perform trabeculotomy as first described by Smith in 1960. The technique as subsequently refined by Beck and Lynch in 1995 hen they presented a series of 26 eyes undergoing 60° trabeculotomy using a single length of 6-O olypropylene suture. In this new modification, a suure fragment is passed through the entire length of chlemm’s canal via a partial thickness scleral flap. nce passed, the 2 free ends of the suture are pulled, pening all 360° of the angle as the suture tears into he anterior chamber. The potential advantage of this echnique is the ability to open the entire angle hrough only one incision during a single surgical rocedure. By contrast, conventional trabeculotomy ith metal trabeculotomes is only able to open onehird to one-half of the angle circumference at a single ession and would require at least 2 separate incisions o complete for 360° angle surgery. This report decribes a potential complication of suture trabecuotomy; false passage into the subscleral (suprachoroial) space.