Releasable Sutures Research Articles

Flap and suture manipulation after trabeculectomy with adjustable sutures: titration of flow and intraocular pressure in guarded filtration surgery.

To describe the intraocular pressure (IOP) changes resulting from scleral flap suture and scleral flap manipulation in an experimental model of conventional guarded filtration surgery. Experimental study. Trabeculectomy operations were performed with adjustable sutures on 5 donor human eyes connected to a constant flow infusion and a real-time IOP monitoring system. Three different manipulations: posterior lip massage, suture adjustment using special forceps, and suture release, were tested on the completed operation site. The success in lowering IOP to the target range of 7 to 15 mm Hg within 5 interventions, the time to reach equilibrium IOP, and the frequency of undesired outcomes. Posterior lip massage, suture release, and suture adjustment lowered the IOP after stabilization to the target range in less than 5 interventions in 9%, 14%, and 100% respectively (P < 0.001). The median time for IOP to stabilize at the new level after each intervention after correction for the flow rates used was 36.3 minutes for massage, 8.5 minutes for releasable sutures, and 3.7 minutes for adjustment of sutures (P < 0.001). These results suggest that suture adjustment may be superior to both posterior lip massage and releasable sutures for managing IOP in the early phase following glaucoma surgery. Following clinical interventions that result in loss of anterior chamber volume, IOP checks should be made at least 40 minutes post-intervention or at a later time afterwards if there is a clinical risk of low aqueous production. Manipulation of the scleral flap and associated sutures may only lower the IOP for minutes to hours if the suture tension is not decreased.

Mitomycin C Primary Trabeculectomy with Releasable Sutures in Primary Glaucoma

Purpose: To evaluate the effects of mitomycin C and a releasable suture technique on outcomes of primary trabeculectomy in primary glaucoma patients. Methods: A prospective analysis of patients who underwent primary trabeculectomy with a mitomycin C concentration of 0.2 mg/mL for 2 minutes. For closing the scleral flap, releasable sutures were used in 18 patients (17 eyes), Group 1, or permanent sutures in 18 patients (20 eyes), Group 2. Clinical outcome factors including postoperative intraocular pressure (IOP), visual acuity, and incidence of complications were determined. Results: The mean follow-up periods were 8.1 ± 1.3 months in Group 1 and 8.3 ± 1.3 months in Group 2. The postoperative reduction in IOP was highly significant ( P < .0001) at all time intervals in both groups. In all measurement of IOP before the second week, mean IOP in Group 2 was found significantly lower than the mean IOP in Group 1 ( P = .01). No statistically significant differences were found between the groups at later mean IOP measurements. At the last visit, the complete success rate was 88.8% in Group 1 and 85.0% in Group 2. No serious complications such as hypotonous maculopathy were observed in any patient. Conclusion: Primary trabeculectomy with mitomycin C in eyes with primary glaucoma showed effective IOP pressure reduction. There were no cases of serious complications. In the early postoperative period IOP was controlled better in the releasable suture group.

SURGICAL MANAGEMENT OF COEXISTING GLAUCOMA AND CATARACT

As longevity increases among the elderly, the challenge of managing coexisting glaucoma and cataract is becoming ever more frequent. Modern surgical techniques for cataract removal (e.g., small incision phacoemulsification and temporal clear corneal incision) spare conjunctiva and minimize disruption of the anterior chamber angle. Postoperative bleb titration with releasable scleral flap sutures and antifibrotic medications increases the chance for successful aqueous filtration. These advances have made us reconsider the choice for performing cataract extraction and trabeculectomy together or in sequential steps (staged surgery) for eyes with coexisting cataract and glaucoma. There are many issues (Table 1) to consider in the surgical treatment of coexisting glaucoma and cataract including medication compliance, side effects, and cost. The severity of glaucomatous visual field loss and optic nerve damage and the level of intraocular pressure (IOP) influence the surgical decision. The possibility of further optic nerve damage from a postoperative IOP spike must be addressed. The type of glaucoma and the preoperative state of the conjunctiva and anterior segment also influence the decision-making process. Cataract extraction presents extra hazards in the glaucomatous eye relating to poor pupillary dilation caused by miotic use and diminished zonular integrity in eyes with exfoliation syndrome. The surgical approach for cataract extraction is also important. Large incision extracapsular cataract extraction (ECCE) or scleral tunnel phacoemulsification cause limbal and conjunctival scarring that may have an impact on the success of future glaucoma surgery. This can be avoided by using a clear corneal incision for removal of the cataract. In previous years, combined cataract and filtration surgery has gained favor over procedures. Combined surgery is convenient for the patient because two procedures are done during a single operation. It also diminishes the likelihood of a postoperative IOP spike, which is common when cataract surgery is performed alone. 18 This trend has resulted in more eyes with glaucoma who are destined for cataract extraction having a trabeculectomy added secondarily. Nevertheless, combined surgery risks more intraoperative and postoperative complications than either operation separately, slower visual recovery than cataract surgery alone, and lower chance of developing a filtration bleb. In this article we review the available information on the surgical management of eyes with coexisting cataract and glaucoma and present a rationale for a return to sequential or staged surgery. We approach each patient with glaucoma and cataract by considering the status of the patient's glaucoma and the patient's need for improved vision. Whatever procedures are selected, the ultimate goals should be an adequate IOP and improved quality of life by improving vision and decreasing the need for antiglaucoma medications.

Long term results of glaucoma surgery among participants in an east African population survey

AIMTo evaluate the long term results of glaucoma surgery among people in East Africa.METHODSParticipants in a population based survey of eye disease prevalence were offered glaucoma surgery using standardised criteria....

Phacotrabeculectomy With "Smile" Incision, Punch, and Single Releasable Suture

To describe and prospectively evaluate a technique of phacotrabeculectomy consisting of a "smile" wound, corneal punch, and tight closure of the scleral flap with a single releasable suture. A cohort of 25 patients underwent this procedure performed by a single surgeon. The surgical technique is described and the first year of follow-up is evaluated. Mean intraocular pressure (IOP) was 25.4 mm Hg preoperatively and 16.2 mm Hg at a mean follow-up of 10.2 months (a fall of 36%). Incidence of immediate postoperative complications was low, especially those related to hypotony (wound leak, shallow anterior chamber, fibrinous uveitis). There was a 50% incidence of postoperative IOP spikes of greater than 26 mm Hg. Three cases were deemed partial failures at 1 year (IOP < 21 mm Hg on medical treatment), and three cases were complete failures (IOP > 21 mm Hg or further surgery required). The tight scleral flap and routine release of the releasable suture on the third postoperative day reduce immediate postoperative complications compared with other studies, with the exception of IOP spikes. The lack of aqueous flow in the immediate postoperative phase may be a factor in the failure rate, which is higher than expected.

Late Removal of Releasable Sutures After Trabeculectomy or Combined Trabeculectomy With Cataract Extraction Supplemented With Antifibrotics

Releasable scleral flap sutures have been effectively used in trabeculectomy. The suggested time for suture removal is within the first two postoperative weeks. The authors wished to determine whether the use of intraoperative antifibrotics alters the time of suture removal and the results of surgery. The charts of 324 patients (388 eyes) undergoing trabeculectomy and 141 patients (174 eyes) undergoing combined trabeculectomy with cataract extraction with a minimum follow-up of 12 months were retrospectively reviewed. All eyes received intraoperative antifibrotics; mitomycin C in 534 eyes and 5-fluorouracil in 29 eyes. Two releasable scleral flap sutures were used in all of the eyes. The removal time of at least one of the two releasable sutures was later than 21 days postoperatively in 89 eyes of 83 patients with trabeculectomy (22.9%) and in 58 eyes of 55 patients with combined surgery (33.3%). The suture removal was deferred in 39 eyes because of an early complication such as hypotony (intraocular pressure (IOP) < or = 5 mm Hg), bleb leak, or shallow or flat anterior chamber. There was no complication in the other 108 eyes, but suture removal was delayed until the IOP was more than 10 mm Hg. Immediate IOP reduction was (mean +/- standard deviation) 6.3 +/- 2.8 mm Hg when suture removal was performed beyond 3 weeks. There was a decreased response as the postoperative time until suture removal increases (r = -0.57). No serious complication associated with late suture removal was noted during the follow-up period (mean +/- standard deviation, 19.8 +/- 10.1 months). Intraoperative pharmacologic modulation of wound healing in trabeculectomy and combined trabeculectomy with cataract extraction extends the period that releasable suture removal is clinically effective. However the response decreases with a longer interval to releasable suture removal.

Comparative Results of Combined Procedures for Glaucoma and Cataract: I. Extracapsular Cataract Extraction Versus Phacoemulsification and Foldable Versus Rigid Intraocular Lenses

The refinements of small-incision cataract surgery by phacoemulsification with foldable intraocular lens (IOL) implantation have recently permitted new options for combined trabeculectomy with cataract extraction. The objectives of this study were to compare the long-term intraocular pressure (IOP) control and visual outcome between trabeculectomies combined with extracapsular cataract extraction (ECCE) versus those with phacoemulsification, and to analyze these same factors for foldable versus rigid IOLs. The authors retrospectively reviewed the charts of 311 patients (397 eyes) who underwent combined trabeculectomy with cataract extraction and posterior chamber IOL implantation. In all of the surgeries, releasable scleral flap sutures were used. The mean follow-up was 22.9 +/- 15.1 months, with a minimum follow-up of 12 months. Trabeculectomy combined with phacoemulsification had a lower postoperative complication rate and was more effective than trabeculectomy combined with ECCE in reducing IOP to less than 20 mm Hg with or without medication (95% vs 82%) and in improving vision to levels of 20/40 or better (71% vs 52%) (P < .001). Regarding IOLs, foldable silicone lenses were found to be an effective alternative to polymethylmethacrylate lenses in combined surgeries in terms of a controlled IOP of less than 20 mm Hg (97% vs 97%) and visual recovery to 20/40 or better (78% vs 63%). The combination of trabeculectomy with releasable scleral flap sutures and small incision cataract surgery with foldable IOL implantation has improved postoperative IOP control and visual rehabilitation.

Surgical management of coincident cataract and glaucoma

Surgical management of coincident cataract and glaucoma has become very common for ophthalmic surgeons. As the medical options continue to improve, many patients with glaucoma do not require surgical intervention until the time of cataract extraction. Therefore, combined glaucoma procedures are becoming increasingly common. With the advent of small-incision phacoemulsification and trabeculectomy with releasable sutures and antimetabolites, techniques have improved considerably in the recent decade. This article discusses many of the important topics as they relate to this subject. It is not a comprehensive review, but rather discusses the literature over the scanning period of this periodical.

A Placebo-controlled, Double-masked Evaluation of Mitomycin C in Combined Glaucoma and Cataract Procedures

This study was performed to determine if adjunctive use of mitomycin C (MMC) would increase the success of combined phacoemulsification, intraocular lens implantation, and trabeculectomy surgery with releasable sutures. Seventy-two eyes with cataract and glaucoma, requiring surgery for decreased vision, uncontrolled intraocular pressure, or to obtain a better view of the optic nerve, were randomized to receive a 2.5-minute subconjunctival exposure to either MMC (0.5 mg/ml) or placebo balanced salt solution. Postoperative evaluations at 3, 6, and 12 months were performed by a masked observer who recorded visual acuity, intraocular pressure, glaucoma medications, presence of filtering blebs, and complications. Endothelial cell counts were measured before and 3 months after surgery. The MMC group had significantly greater reduction in mean intraocular pressure through the first 12 months of follow-up (7.05-7.65 mmHg versus 2.62-3.84 mmHg; P = 0.001-0.028). In addition, through the first 6 months of follow-up, the MMC group required significantly fewer medications (0.4-0.5 versus 1.1-1.2; P = 0.002-0.004). Requirements for additional glaucoma surgery were less in the MMC group (4/ 36) than in the placebo group (7/35) (P = 0.301). Filtering blebs were significantly larger at 6 and 12 months (P = 0.002 and P = 0.001, respectively), and would leaks were more common (P = 0.101) in the MMC group. The mean decrease in endothelial cell count at month 3 was slightly, although not significantly, greater in the MMC treatment group (206.9 versus 91.3 cells/mm2* P = 0.377). The increased success of the glaucoma procedure in the MMC group together with relatively minor toxicity, suggests its use is beneficial in combined glaucoma-cataract surgery.

Clear Corneal Graft Overlying the Seton Tube to Facilitate Laser Suture Lysis

To reduce hypotony and shallowing of the anterior chamber after seton implantation. The silicone tube is ligated with an 8-0 nylon suture and a clear corneal graft placed over the tube to facilitate postoperative laser suture lysis. Laser suture lysis has been performed in 34 cases to date with a follow-up period of up to 26 months. No severe complications occurred after laser suture lysis. This technique provides another option to increase drainage postoperatively without the risk of releasable sutures or instrumentation within the eye.

Endophthalmitis Following Trabeculectomy With Releasable Sutures

Releasable sutures are used in glaucoma filtering surgery to titrate the degree of aqueous humor outflow to avoid early postoperative hypotony and its associated complications. 1 The technique involves externalizing scleral flap sutures through the peripheral cornea, which allows for their removal at a later time when increased aqueous humor outflow is desired. We report, to our knowledge, the first case of postoperative endophthalmitis following trabeculectomy with releasable sutures. Report of a Case. A 67-year-old white man with primary openangle glaucoma had a trabeculectomy with intraoperative application of mitomycin C (0.3 mg/mL, 3-minute exposure) in the right eye. The scleral flap was secured with 2 releasable sutures that were externalized through the cornea, per the technique of Cohen and Osher. 2 The free corneal ends of the sutures were buried so that only a small loop of suture remained exposed. Postoperatively, the intraocular pressure stabilized at 4 to 8 mm

Endophthalmitis Associated With a Releasable Suture

Releasable sutures are used to titrate bleb function after trabeculectomy. Intraocular infection is considered a potential risk of a releasable suture because the exposed suture end might provide a wick for bacteria to enter the eye. We report the first case of endophthalmitis associated with a releasable suture after a trabeculectomy. Report of a Case. An 81-year-old woman was referred to us for evaluation of uncontrolled, open-angle glaucoma. Despite undergoing argon laser trabeculoplasty and using maximum tolerated glaucoma medications, her visual field continued to deteriorate and her intraocular pressure varied between 14 and 22 mm Hg. Her visual acuity was 20/40 OD and 20/20 OS. She underwent a trabeculectomy and was administered 0.4 mg/mL intraoperative mitomycin C in the left eye. A limbus-based, conjunctival flap was made superonasally. A partial-thickness, scleral flap was dissected. A piece of cellulose sponge (Weck-Cel, Xomed-Treace, Jacksonville, Fla) soaked in mitomycin C was placed under

No-stitch phacotrabeculectomy

Purpose: To describe and evaluate no-stitch trabeculectomy combined with phacoemulsification and intraocular lens implantation.Setting: Arnold Cataract Center, Springfield, Missouri.Methods: Results of two groups that had combined phacoemulsification/trabeculectomy were compared. One group had a standard, “two-stitch” phacotrabeculectomy in which the scleral tunnel incision was secured with sutures. In the no-stitch group, no scleral “flap” was created. The scleral tunnel (pocket) was left intact over the trabeculectomy, and no sutures were used to close the scleral incision. One episcleral suture was used to secure the conjunctiva at the limbus.Results: Mean intraocular pressure (IOP) reduction in the no-stitch group (n = 66) was 9.7 mm Hg; 88% of eyes required no glaucoma medication after a mean of 13.2 months. At the last examination, 95% had an IOP of 21 mm Hg or less and 73%, 16 mm Hg or less. A detectable bleb was present in 92%. These results, comparable to those of the two-stitch group, were consistent in eyes followed over 2 years.Conclusion: No-stitch phacotrabeculectomy is a simple, safe, effective way to combine phacoemulsification and trabeculectomy that might lead to better filtration without the risks of other techniques (e.g., releasable sutures, suturelysis, antimetabolite therapy).

Releasable "U" Suture for Trabeculectomy Surgery

Overfiltration after glaucoma surgery can lead to significant complications. Tight suturing of the trabeculectomy flap reduces this problem but can lead to higher pressure and poor drainage of aqueous. Releasable sutures often leave irritating exposed suture ends. We describe a simple two-arm releasable suture technique that leaves no exposed suture ends until one arm of the suture is removed. Good control of postoperative pressure with few complications was achieved in 28 cases using this technique, which allows manipulation at the slit lamp of the trabeculectomy flap, obviating laser lysis of the sutures.

Trabeculectomy with releasable sutures.

To determine whether the use of releasable scleral-flap sutures affects the success rate and the incidence of complications following trabeculectomy. A retrospective chart review of a consecutive series of trabeculectomies. A university-based referral practice. Two hundred fifty-eight consecutive patients (274 eyes) undergoing trabeculectomy because of uncontrolled glaucoma. During the first year, 124 patients (128 eyes) underwent trabeculectomies with permanent scleral-flap sutures. During the second year, 134 patients (146 eyes) underwent trabeculectomies with releasable scleral-flap sutures. Incidence of flat and shallow anterior chamber, incidence of operations to drain choroidal detachment and to re-form anterior chamber, and long-term control of intraocular pressure. In the group with permanent sutures, 42 eyes (32.8%) had clinically detectable shallowing of the anterior chamber in the early postoperative period. In contrast, a shallow anterior chamber was noted in 21 eyes (14.4%) in the group with releasable sutures (P = .0003). Flat anterior chamber, defined as iridocorneal apposition to the pupil margin, occurred in 11 eyes with permanent sutures (8.6%) but in only two eyes (1.4%) with releasable sutures (P = .0078). Surgical intervention to drain suprachoroidal fluid and re-form the anterior chamber was required in eight eyes with permanent sutures (6.2%) but in only one eye with releasable sutures (0.7%) (P = .014). At 1-year follow-up, the two groups were similar in terms of intraocular pressure and the need for ocular hypotensive medications. Releasable scleral-flap sutures reduce the incidence of shallow and flat anterior chamber after trabeculectomy without compromising long-term control of intraocular pressure.

Hypotony Maculopathy Following the Use of Topical Mitomycin C in Glaucoma Filtration Surgery

ABSTRACT Intraoperative mitomycin C has been shown to be highly effective in increasing the success rate of glaucoma filtration surgery. Between October 1991 and June 1992, 169 eyes of 156 patients underwent filtration procedures with intraoperative mitomycin C. In the postoperative period, five eyes (2.9%) developed hypotony maculopathy, characterized by disc edema, vascular tortuosity, and chorioretinal folds in the macular area. Cryotherapy was applied to three eyes, and was effective in reversing the hypotony in two of them. However, the visual prognosis was poor: after a mean follow up of 5.3 months (range, 3.5 to 8 months), visual acuity returned to preoperative levels in one case. Hypotony maculopathy may develop after glaucoma filtration surgery with intraoperative mitomycin C. We suggest restricting the indication of its adjunctive use to eyes with poor surgical prognosis or those in which a very low intraocular pressure is desired. The use of extra sutures (which can be sectioned by laser) or releasable sutures to prevent excessive filtration in the postoperative period also is advisable.

A Releasable Scleral-Flap Tamponade Suture for Guarded Filtration Surgery

Postoperative complications of filtering surgery are generally associated with overfiltration. We describe a technique that employs an externalized releasable suture in partial-thickness filtering surgery. This suture acts as a tamponade on the anterior surface of the scleral flap, assisting in maintenance of anterior-chamber depth during the early postoperative period. After using this technique, anterior-chamber depths preoperatively and 1 day after surgery were compared in 35 phakic patients. A mean (+/- SD) decrease in anterior chamber depth of 4.6% +/- 12% was found on the first postoperative day. One patient had iridocorneal apposition. The mean intraocular pressure 1 day after surgery was 7.0 +/- 7.0 mm Hg, with one patent having an intraocular pressure of 28 mm Hg. This "tamponade suture" appears to be useful in maintaining the anterior chamber depth in the early postoperative period while permitting satisfactory filtration.

The Use of Releasable Sutures in Molteno Glaucoma Implant Procedures to Reduce Postoperative Hypotony

We used releasable sutures to minimize immediate postoperative hypotony and flat anterior chamber in 19 cases of refractory glaucoma requiring insertion of a single-plate Molteno implant in a one-stage procedure. A slip knot using 7-0 nylon suture was fashioned around the Molteno tube under a lamellar scleral flap. In 18 of the 19 eyes, anterior chamber depth was normal immediately after surgery.

Comparative evaluation of trabeculectomy with releasable suture versus subconjunctival mitomycin C in post keratoplasty glaucoma

Aim: The aim of the study was to compare the efficacy of trabeculectomy with releasable suture (RS) and trabeculectomy with mitomycin C (MMC) in post keratoplasty glaucoma (PKG). Methods: This observational study was conducted for the patients who developed refractory PKG. Patients who underwent trabeculectomy with RS and with MMC 0.2mg/ml for 2 minutes under the sclera flap were randomly divided into two groups as group I and II respectively. Postoperative follow up of all patients was complete till 6 months for intraocular pressure (IOP) and complications if any. The criteria for surgical success and failure were defined as complete success if final IOP 21 mm Hg with more than one medications. Results: A total of 52 eyes of 52 patients were included with 26 eyes in each group. Most frequent indication for PK was corneal opacity 25(48.07%). The preoperative mean IOP was 42.11 ± 5.90mmHg and 46.38 ± 8.51mmHg on three AGM in group I and group II respectively. The mean IOP was lowered after both the procedures significantly at all the postoperative follow ups (P=0.000). In group I, the IOP stabilized to 13.12 ± 5.23mmHg by two weeks and remained same till three months with further mild rise in IOP to 17.13 ± 4.28mmHg at six months. In group II, the IOP decreased to 11.27 ± 4.35mmHg on Ist POD and it stabilized at around 22mmHg at two weeks and remained same till six months of follow up. Conclusion: IOP control in trabeculectomy with RS was very good till three months as compared to trabeculectomy augmented by MMC with comparable results at six months of follow up.

Types of Glaucoma and recent trends applied in treatment: Observations from a Glaucoma Training Workshop in the Gambia

To determine types of glaucoma seen and the recent trends applied in treatment, a retrospective non-comparative case-series study was conducted in the Eye Unit of the Royal Victoria Hospital, Banjul, The Gambia. The records of the 88 patients(145 eyes) seen during the glaucoma training workshop(organised by Prof.James Standefer, a clinical ophthalmologist from Minneapolis, U.S.A.) which held between 3rd and 14th of September, 2001, were analysed for types of glaucoma and treatment given. All but one patient who was a baby underwent the following tests: visual acuity measurement using the illiterate E-Chart with multiple optotypes; tonometry using the Schiotz tonometer with the 5.5g weight; oblique flashlight test; Van Herrick's estimation of the angle depth; pupillary reactions to light; Slitlamp biomicroscopy; gonioscopy using the 4-mirror pressure gonioprism; fundoscopy using the +78D Volk lens and confrontational visual field analysis. 27 eyes did not have definite glaucoma. Out of the remaining 118 eyes, 65(55.08%) had POAG;17(14.41%)ACG out of which 8 were CACG and 2 acute ACG. 8 eyes had pseudoexfoliation of the lens capsule with or without glaucoma. In the frail and elderly, guttae Timoptol 0.5% was given once daily. 27 eyes had trabeculectomy; all were with releasable sutures and intraoperative application of 5-Fluorouracil. 3 eyes had laser trabeculoplasty and 5, diode laser transscleral cyclophotocoagulation. POAG was the commonest type of glaucoma seen. Pseudoexfoliation of the lens capsule with or without glaucoma and ACG are not very rare in The Gambia. In the frail and elderly, guttae Timoptol 0.5% was given once daily and none at all in painless glaucoma-blind eyes. Trabeculectomy with releasable sutures and intraoperative application of 5-FU has a very satisfactory pressure-lowering effect. glaucoma; treatment; the Gambia.