Postoperative Subconjunctival 5-fluorouracil Injections Research Articles

Sturge-Weber syndrome coexisting with polydactyly: a case report

BackgroundSturge-Weber syndrome (SWS) is a sporadic congenital disorder, characterized by unilateral facial nevus flammeus associated with ipsilateral glaucoma, choroidal angioma and leptomeningeal hemangiomas. SWS can comorbid with other disorders in some patients, however, there has been no prior described case of SWS and polydactyly occurring in the same patient.Case presentationA 15-year-old girl with diagnosis of SWS presented to our hospital. She had bilateral glaucoma and extensive port-wine stains distributing in bilateral faces, left neck and left upper limb. Meanwhile, the patient was noted to demonstrate the superfluous digit attaching on the left thumb and was diagnosed as polydactyly. Trabeculectomy, with intraoperative application of mitomycin C and postoperative subconjunctival injections of 5-fluorouracil, was successful in controlling the intraocular pressure in both eyes.ConclusionsWe report a case with bilateral SWS coexisting with unilateral polydactyly, which, to our knowledge, has not been recognized previously and adds further evidence to the existing literature. In view of the rare concurrence of SWS and polydactyly, the etiology is unclear and further investigation is required to explore the underlying pathogenesis.

Effectiveness of Needling Revision with Mitomycin-C for Failing Blebs

This surgical technique study was designed to evaluate the efficacy of surgical needling revision using Mitomycin-C to restore filtering function in scarred or encapsulated filtering blebs, and thereby minimize reliance on adjunctive medications. Twenty-eight eyes of 23 consecutive patients were studied, all having undergone operating room based bleb revisions for inadequate IOP-control during 2008-10. The standard needling procedure was performed as described with our previous data set, now using a 1-minute intra-bleb cannulation of 0.6 ml of 0.4 mg/ml MMC rather than multiple postoperative subconjunctival 5-fluorouracil injections. Outcome measures were IOP, number of antiglaucoma medications, and acuity. Both mean IOP reduction and decrease in anti-glaucoma medications at all four measured time intervals (1 week, 1 month, 2 months, 6 months) post-operatively were highly significant (p<0.0001). IOP was reduced from a mean of 27.2 ± 10.6 mmHg pre-op to 15 ± 7.8 mmHg 6 months post-op (Δ -45%), with 86% of eyes requiring glaucoma medication prior to the procedure and only 16% thereafter. At six months, 60% of eyes had IOP ≤15 mmHg without medications, and 76% ≤18 mmHg. Visual acuity was stable or improved in 69% of cases. Mitomycin-C augmented needling revision appears to be a reasonably safe and reliable option for restoring bleb function in glaucomatous eyes with failed filters.

5-Fluorouracil as chemoadjuvant for primary pterygium surgery: preliminary report.

To investigate the safety and efficacy of intraoperative application of 5-fluorouracil as an adjuvant in primary pterygium surgery and to evaluate the effect of postoperative subconjunctival 5-fluorouracil injections on the recurrent pterygium. Of 25 consecutive white patients, 28 eyes with primary pterygium underwent pterygium excision with intraoperative application of 5-fluorouracil (25 mg/mL for 3 minutes). The superior and inferior conjunctiva was approximated to cover the scleral bed within 1 mm of the limbus. Recurrence of pterygium was defined as postoperative fibrovascular growth more than 1 mm onto the cornea. Eyes with recurrence less than 2 mm were treated with subconjunctival 5-fluorouracil injections. After a mean follow-up of 14.1 +/- 3.9 months (mean +/- standard deviation), 7 recurrences (25%) were observed. All recurrences were detected within 12 months. In 4 of 7 recurrences, the fibrovascular growths were less than 2 mm. We, therefore, performed subconjunctival 5-fluorouracil injections. In 3 (75%) of 4 recurrences, the fibrovascular growths became atrophic. No serious complications were observed during and after the surgery. However, superficial punctate keratitis, pain, and hyperemia were detected in all patients in the early postoperative period. As a result, of 28 eyes, 4 (14%) had unacceptable cosmetic results and growing recurrences. This study suggests that intraoperative applications of 5-fluorouracil is both efficient and safe in the treatment of primary pterygium. Additionally, postoperative subconjunctival 5-fluorouracil injections may prevent the progression of fibrovascular tissue.

Prognosis and risk factors for early postoperative wound leaks after trabeculectomy with and without 5-Fluorouracil

PURPOSE: To evaluate the prognosis of patients who develop early postoperative wound leaks after trabeculectomy, to determine risk factors for these leaks, and to document adverse outcomes. DESIGN: Multicenter randomized clinical trial. METHODS: Two-hundred thirteen patients with previous cataract surgery or failed filtering surgery were randomized to either trabeculectomy (standard group) or trabeculectomy with postoperative subconjunctival 5-fluorouracil injections (5-FU group). Masked measurements of intraocular pressure were performed throughout 5 years of follow-up. Failure was defined as a reoperation to control intraocular pressure or an intraocular pressure greater than 21 mm Hg with or without medication at or after the 1-year examination. An early postoperative wound leak was defined as one that developed within 2 weeks postoperatively, determined by daily topical fluorescein testing. RESULTS: At 1 year (5 years), the success rate for the 5-FU group was 80% (54%) in eyes without a leak, and 60% (28%) in those with a leak. The 1-year (5-year) success rate in the standard group was 50% (24%) in those without a leak and 44% (15%) with a leak. ( P = .018, log-rank test, adjusted for treatment). Leaks were more common in the 5-FU group, 34/105 (32%), than in the standard treatment group, 22/108 (20%), ( P = .066, χ 2). More eyes with one-layer conjunctiva-Tenon capsule closure developed leaks 40/115 (35%) than those with two-layer closure 16/95 (17%) ( P = .006, χ 2). More eyes with a trabeculectomy located inferiorly 29/76 (38%) developed leaks than those done superiorly 27/137 (20%) ( P = .006, χ 2). Patients with leaks were older (66 years) than those without leaks (60 years) ( P = .011, t test). CONCLUSION: An early postoperative wound leak was a risk factor for trabeculectomy failure. We recommend that trabeculectomy be performed in a superior location with a two-layer closure.

Randomized, controlled study of low-dose 5-fluorouracil in primary trabeculectomy

PURPOSE: To report a randomized clinical trial of postoperative subconjunctival injections of low-dose 5-fluorouracil in patients undergoing primary trabeculectomy. METHODS: In a prospective, randomized clinical trial, 40 eyes of 40 patients were randomized to the low-dose 5-fluorouracil group and received three subconjunctival injections of 5 mg each over 11 postoperative days, and 40 eyes of 40 patients were randomized to trabeculectomy without 5-fluorouracil. RESULTS: Mean (±SD) preoperative and 1-year postoperative intraocular pressures in the 5-fluorouracil group were 26.9 (±9.5) and 15.3 (±5.8) mm Hg, respectively. In the control group these were 25.9 (±8.1) mm Hg, and 15.8 (±5.1) mm Hg, respectively. The patients who received 5-fluorouracil had a mean reduction in intraocular pressure of 11.5 (±9.1) mm Hg at a median follow-up of 52.3 weeks. The control group had a mean reduction in intraocular pressure of 10.2 (±8.7) mm Hg at a median follow-up of 52.6 weeks. These differences were not statistically significant. CONCLUSIONS: Three postoperative subconjunctival 5-fluorouracil injections of 5 mg each after trabeculectomy in eyes at low risk for failure had no statistically or clinically significant effect on reduction of intraocular pressure with 1-year follow-up. Enhancement of success in this group of patients may require a larger total dose of 5-fluorouracil.

Five-year Follow-up of the Fluorouracil Filtering Surgery Study

To determine the efficacy and safety of subconjunctival 5- fluorouracil injections after trabeculectomy in patients with poor prognoses, to determine risk factors for surgical failure and to examine the relationship of intraocular pressure and visual function. In this multicenter clinical trial, 213 patients with previous cataract surgery or previous failed filtering surgery were randomly assigned to receive either trabeculectomy alone or trabeculectomy with postoperative subconjunctival 5-fluorouracil injections. Measurements of intraocular pressure, visual acuity, and visual fields were performed throughout the five years, with the clinician masked to the treatment group. Failure was defined as a reoperation to control intraocular pressure or an intraocular pressure greater than 21 mm Hg at or after the first-year examination. Fifty-four (51%) of the 105 eyes in the 5-fluorouracil group and 80 (74%) of the 108 eyes in the standard filtering surgery group were classified as failures (P < .001, Mantel-Cox survival analysis). Risk factors for failure include high intraocular pressure, a short time interval after the last procedure involving a conjunctival incision, the number of procedures with conjunctival incisions, and Hispanic ethnicity. Patients in both treatment groups with controlled intraocular pressures were more likely to maintain visual acuity. Patients in the 5-fluorouracil group had a higher risk of late-onset bleb leaks (9% nine of 105) than those in the standard filtering surgery group (2% two of 108) (P = .032, Fisher's exact test). We recommend the use of subconjunctival 5-fluorouracil after trabeculectomy in eyes after previous cataract surgery or unsuccessful filtering surgery, but caution against its routine use in patients with good prognoses.

Sturge-Weber Syndrome: Management of Glaucoma With Combined Trabeculotomy-Trabeculectomy

ABSTRACT We reviewed the records of 16 patients (19 eyes) with Sturge-Weber syndrome (SWS). Scleral pigmentation was present in 12 (63.2%) of these eyes; nevus of Ota in two (10.6%). Combined trabeculotomy-trabeculectomy was performed in 18 eyes. After a mean follow up of 42 months (range, 1 to 8 years), intraocular pressure was controlled (=≤ 22 mm Hg) in 11 eyes (61.1%), and visual acuity was better than 6/60 in eight. Intraoperative hyphema occurred in four eyes (22.2%); vitreous loss in three (16.7%). Postoperative choroidal detachment occurred in three eyes (16.7%); vitreous hemorrhage in one (5.6%). In all of the cases of repeat surgery (three eyes), postoperative subconjunctival injections of 5-fluorouracil resulted in a diffuse filtering bleb. We conclude that combined trabeculotomy-trabeculectomy is a promising treatment for patients with SWS with glaucoma.

Young Patient Trabeculectomy: Assessment of Risk Factors for Failure

Various risk factors for failure of glaucoma filtering surgery, including young age, have been suggested. A retrospective study of 113 trabeculectomies in 113 patients, ranging in age between 11 and 49 years (mean, 33.3 +/- 10.5 years), was carried out to determine the influence of these risk factors in young patients. A successful outcome (intraocular pressure [IOP] < or = 21 mmHg without antiglaucoma treatment), assessed by life-table analysis, was achieved in 54% of trabeculectomies after 38 months (mean follow-up, 36.7 +/- 29.7 months). Previous ocular surgery (e.g., glaucoma filtering, cataract, or conjunctival surgery) and previous laser therapy (i.e., argon laser trabeculoplasty and YAG laser iridotomy) both significantly reduced the success rate. An IOP greater than 40 mmHg during the course of the disease was found to adversely affect the outcome. No direct correlation between success rate and age and no racial difference were demonstrated. Success rates for specific diagnoses were not significantly different. Postoperative subconjunctival injections of 5-fluorouracil (5-FU) did not significantly improve the success rate. A Cox regression analysis of various prognostic variables identified previous cataract surgery (hazard ratio, 4.4), argon laser trabeculoplasty (hazard ratio, 3.4), previous glaucoma filtering surgery (hazard ratio, 2.5), nonfiltering glaucoma surgery (hazard ratio, 2.2) and IOP greater than 40 mmHg (hazard ratio, 2.4) to be the major risk factors for glaucoma filtering surgery failure. A majority (74%) of the patients in our series had at least one of these risk factors, thus explaining why young patients, in general, have lower success rates for trabeculectomy.

Surgical Management of Post-traumatic Angle Recession Glaucoma

The purpose of this study is to compare the results of three different drainage procedures performed for uncontrolled post-traumatic angle recession glaucoma. A retrospective analysis was undertaken of 87 drainage procedures performed on 65 patients over an 8-year period. The results of trabeculectomy (47 procedures), Molteno single-plate implantation (20 procedures), and trabeculectomy combined with antimetabolite (20 procedures) were compared. Of those treated with antimetabolite, 11 received postoperative subconjunctival injections of 5-fluorouracil and 9 received an intraoperative application of 0.02% mitomycin C to the trabeculectomy site. In the group undergoing trabeculectomy with antimetabolite therapy, the intraocular pressure (IOP) drop was significantly greater, the percentage of successful cases at 3 and 6 months postoperatively was significantly higher, and the number of postoperative glaucoma medications was significantly lower than the other two groups. No statistically significant differences were found between the groups undergoing trabeculectomy without antimetabolite therapy and Molteno implantation. Of concern were three cases of late bleb infection in the group that received postoperative antimetabolite therapy. In medically uncontrolled post-traumatic angle recession glaucoma, trabeculectomy with antimetabolite therapy is the most effective surgical procedure. However, late bleb infection is a significant risk.

Hypotonous Maculopathy After Trabeculectomy With Subconjunctival 5-Fluorouracil

Long-term success in trabeculectomy has been enhanced in recent years by postoperative subconjunctival 5-fluorouracil injections and intraoperative mitomycin C applications. During 1990 and 1991, after trabeculectomy with a small scleral flap (2 x 3 mm) augmented by antimetabolite therapy, hypotonous maculopathy developed in eight eyes of six patients. The maculopathy was characterized by loss in visual acuity, retinal striae, and choroidal folds without evidence of vascular leakage. The average loss in visual acuity was four Snellen lines. Visual acuity did not return to preoperative levels even when the hypotony could be reversed. Reversing the hypotony with various strategies aimed at stimulating subconjunctival scarring has been relatively ineffective. During that same period, an additional seven eyes in six patients had prolonged hypotony but without development of maculopathy. Features common to patients who developed maculopathy included age (mean age, 46 years; range, 32 to 60 years) and myopia (mean, -7.5 diopters; range, -0.75 to -11.75 diopters). The patients with hypotony but no maculopathy were older (mean age, 73 years; range, 63 to 82 years) and were closer to emmetropia (mean, -1.11 diopters; range, +1.50 to -9.00 diopters). The means of the ages and refractive errors were statistically significantly different in the two groups (P = .007 and .04, respectively). Trabeculectomy with adjunctive antifibrosis therapy should be used with caution in young myopic patients.

Intraoperative Mitomycin versus Postoperative 5-Fluorouracil in High-risk Glaucoma Filtering Surgery

In a randomized clinical trial, the authors compared the use of postoperative subconjunctival injections of 5-fluorouracil (5-FU) in 19 eyes with a single intraoperative application of subconjunctival mitomycin (MMC) at the filtering site in 20 eyes at high risk for failure of glaucoma filtering surgery. Six months after surgery, intraocular pressures averaged 10.9 +/- 5.3 mmHg (mean +/- standard deviation) in the MMC-treated eyes versus 14.2 +/- 5.5 mmHg in the 5-FU-treated eyes (P = 0.08) and were less than or equal to 12 mmHg in 60.0% of MMC-treated eyes and 21.1% of 5-FU-treated eyes (P = 0.03). Mitomycin-treated eyes were receiving an average of 0.3 +/- 0.5 medications for intraocular pressure control, and 5-FU-treated eyes were receiving an average of 1.1 +/- 1.1 medications (P = 0.01). Drug-induced corneal epithelial defects were seen in nine 5-FU-treated eyes and in no MMC-treated eyes (P = 0.0004). These results suggest that intraoperative MMC may be a viable alternative to postoperative 5-FU, with lower overall intraocular pressures, decreased dependence on postoperative ocular antihypertensive medications, and decreased corneal toxicity.

5-Fluorouracil after Trabeculectomy and the Iridocorneal Endothelial Syndrome

Nine patients (nine eyes) with iridocorneal endothelial (ICE) syndrome underwent trabeculectomy and received postoperative subconjunctival injections of 5-fluorouracil (5-FU) to enhance bleb formation (total 5-FU dose, 30-105 mg; mean, 53.8 mg). Eight eyes had undergone prior unsuccessful trabeculectomy. Four eyes had intraocular pressure (IOP) less than or equal to 21 mmHg on zero to two glaucoma medications after 6 to 54 months of follow-up (mean, 25.3 months). Five eyes required repeat surgery within 2 to 13 months and were considered failures. All five eyes that failed received a Molteno drainage implant. Progressive endothelial proliferation may explain late onset bleb failure and the relative ineffectiveness of 5-FU in this condition.