Risk Factor For Trabeculectomy Failure Research Articles

Ex-PRESS Implantation versus Trabeculectomy for Long-Term Maintenance in Patients with Open-Angle Glaucoma.

To compare the efficacy of Ex-PRESS implantation (EXP) with that of trabeculectomy (TLE) with mitomycin C for maintaining low target intraocular pressure (IOP) in patients with open-angle glaucoma. Patients were randomly assigned to receive EXP or TLE. Surgical success was defined according to three target mean IOP ranges (5 mmHg ≤ IOP ≤ 18 mmHg [criterion A], 5 mmHg ≤ IOP ≤ 15 mmHg [criterion B], and 5 mmHg ≤ IOP ≤ 12 mmHg [criterion C]) representing reductions of at least 20% below the baseline on two consecutive follow-up visits 3 months post-surgery, with or without antiglaucoma medication and without further glaucoma surgery. Participants were divided into three subgroups based on baseline mean deviation (MD) values: early (MD ≥ -6 dB), moderate (-6 dB > MD ≥ -12 dB), and advanced (-12 dB > MD). Survival rates were calculated by subgroup. A total of 73 patients, including 30 in the EXP group and 43 in the TLE group, were included in the study. No significant differences in baseline ocular or demographic characteristics were found between the two groups. No significant difference in IOP was noted every 6 months. After the 3-year follow-up, success rates were A) 60.0% and 60.2%, B) 45.7% and 58.1%, and C) 31.5% and 40.5% for the EXP and TLE groups, respectively. Moreover, there was no difference in success rate based on glaucoma level. Many glaucoma medications administered before surgery were associated with a higher failure rate in the TLE group but not in the EXP group. Both procedures resulted in similar IOP reductions and success rates for a low target IOP. The number of preoperative glaucoma medications was a risk factor for TLE failure.

Glaucoma Treatment Outcomes in Open Angle Glaucoma Patients of African Descent.

Open angle glaucoma (OAG), characterized by structural changes to the optic nerve head and retinal nerve fiber layer, is a progressive multifactorial optic neuropathy and a leading cause of irreversible blindness globally. Currently, intraocular pressure is the only modifiable risk factor; however, others have been identified, including genetics and race. Importantly, OAG is much more prevalent in persons of African descent (AD) compared with those of European descent (ED). OAG patients of AD are also known to have a more severe course of the disease, a finding potentially explained by structural and/or vascular differences within eye tissues. In addition, disparities in treatment outcomes have been identified in OAG patients of AD. Specifically, prostaglandin analogues have been suggested to be more effective in patients of AD than in those ED, while beta-adrenergic receptors have been suggested to be less effective, although the evidence is inconsistent. AD has also been identified as a risk factor for trabeculectomy failure while laser trabeculoplasty has been conversely found to be very effective in lowering intraocular pressure in patients of AD. Alternative surgical options, including Ex-Press shunt implantation, viscocanalostomy, and canaloplasty are promising in equivalence but require further research to evaluate disparity in outcome properly. In addition to treatment outcomes, social disparities affecting clinical care also exist for AD persons in the form of reduced adherence, access, and choice. Overall, data suggest the need for properly designed prospective trials with AD populations as a primary focus to identify the potential mechanisms driving disparities in treatment and address overall potential bias in glaucoma management.

Potential effects of angiogenesis-related factors on the severity of APAC and surgical outcomes of trabeculectomy

BackgroundEPO (erythropoietin) and PDGF (platelet derived growth factor) families are thought to be associated with angiogenesis under hypoxic condition. The sharp rise of intraocular pressure in acute primary angle closure (APAC) results in an inefficient supply of oxygen and nutrients. We aimed to measure the expression of EPO and PDGF family members in APAC eyes and demonstrate their associations with APAC’s surgical success rate.MethodsConcentrations of EPO, PDGF-AA, -BB, -CC and -DD collected in aqueous humor samples of 55 patients recruited were measured. Before operations, correlations between target proteins and IOP (intraocular pressure) were detected between APAC (acute primary angle closure) and cataract patients. Based on the post-operative follow-up, the effects of EPO and PDGF family members on the successful rate of trabeculectomy were tested.ResultsThe levels of EPO, PDGF-CC and -DD were significantly elevated in the APAC group compared to the cataract group. During the post-operative follow-up, EPO, PDGF-CC and -DD showed significant differences between the success and failure groups. In multivariable linear regression analyses, failed filtration surgery was more likely in APAC eyes with higher EPO level. The Kaplan-Meier survival plot suggested that the success rate in eyes with low EPO level was significantly higher than that in eyes with high EPO level.ConclusionThe levels of EPO, PDGF-CC and -DD were significantly elevated in failure group. EPO level correlated with preoperative IOP and numbers of eyedrops, and higher EPO level in aqueous humor is a risk factor for trabeculectomy failure. It can be a biomarker to estimate the severity of APAC and the success rate of surgery. The investigation of mechanism of EPO in APAC a may have potential clinical applications for the surgical treatment of APAC.

Imbalance of Matrix Metalloproteinases and Their Inhibitors Is Correlated With Trabeculectomy Outcomes in Acute Primary Angle Closure

To analyze matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs), and their molar ratios in the aqueous humor in previous acute primary angle closure (APAC) patients and their correlations with trabeculectomy outcomes. Prospective cohort study. Aqueous humor samples were collected from a total of 78 eyes, including 52 previous APAC eyes and 26 cataract eyes. TIMP-1, 2, 3, and 4 and MMP-1, 2, 3, 7, 8, 9, 12, and 13 analyte concentrations were measured using multiplexed immunoassay kits. Patient follow-up occurred at 1week and 1, 3, 6, 12, and 18months. In the previous APAC group, 11 MMP/TIMP molar ratios were significantly lower. APAC eyes were then followed for up to 18months after trabeculectomy and divided into success (37 eyes) and failure (15 eyes) groups. Five out of the 11 molar ratios were significantly lower in the failure group than in the success group. In multiple logistic regression analysis, failed filtration surgery was more likely in APAC eyes with lower MMP-2/TIMP-2 (P= .040, odds ratio= 44.499) and MMP-13/TIMP-1 (P= .034, odds ratio= 37.947) ratios. Previous APAC eyes were divided according to MMP-2/TIMP-2 and MMP-13/TIMP-1 ratios. Compared to eyes with high ratios, eyes with low MMP-2/TIMP-2 and MMP-13/TIMP-1 ratios had significantly higher failure rates. In previous APAC eyes, changes in MMP and TIMP levels resulted in MMP and TIMP imbalance. Lower MMP-2/TIMP-2 and MMP-13/TIMP-1 ratios in aqueous humor are risk factors for trabeculectomy failure. Modulating specific MMP/TIMP ratios may have potential clinical applications for filtration surgery.

Additive Effect of Risk Factors for Trabeculectomy Failure in Glaucoma Patients: A Risk-group From a Cohort Study.

The purpose of the study was to assess the role of significant risk factors and develop a risk-group category related to the trabeculectomy (Trab) failure. A retrospective cohort study was developed between January 2009 and June 2014. In total, 120 eyes included in this study had a glaucoma diagnosis and undergone to Trab with mitomycin. The main outcome measures were surgical success and failure rate. Multivariate (Cox proportional hazards regression model) analyses were used to examine the predictive value of significant factors. A risk-group category was build based on the number of significant risk factors for patients. The risk group category was tested using the Kaplan-Meier method and log-rank test. With a median follow-up of 33 months (3 to 72 mo), the complete surgical success in 1, 2, 3, and 4 years was 82%, 63.5%, 52%, and 27.6%, respectively. The probability of freedom from a complete surgical failure was 88%, 84.5%, 78%, and 70% in 1, 2, 3, and 4 years, respectively. Glaucoma type (P=0.008), previous ophthalmic surgery (P=0.04), glaucoma medication use ≥3 years (P=0.010) and 4 glaucoma medication use pre-Trab (P=0.038) were identified as risk factors for surgical failure. The probability of freedom of surgical failure in 3 years was 93%, 83%, and 37.6% (P=0.003), for low (no factors), intermediate (1 to 2 factors), and high-risk group (3 to 4 factors). Trab with mitomycin produces satisfactory intraocular pressure control over time. However, several risk factors influence the efficacy of the surgical procedure. Our data show that there seems to exist an additive effect among risk factors with similar pathophysiology.

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

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

Influence of high myopia on outcomes of trabeculectomy with mitomycin C in patients with primary open-angle glaucoma.

To determine the clinical characteristics and surgical outcomes of highly myopic (HM) eyes with an axial length (AL) of ≥26.0mm that underwent trabeculectomy with mitomycin C (MMC). This was a retrospective study of 63 eyes of 54 patients with primary open-angle glaucoma that underwent trabeculectomy with MMC. The characteristics and surgical outcomes of 19 HM eyes were compared with those of 44 non-HM eyes. Surgical success was defined as an high intraocular pressure (IOP) of ≤21mmHg (criterion A), ≤18mmHg (criterion B), or ≤15mmHg (criterion C), with a lower IOP cutoff of 6mmHg and a >20% reduction regardless of the use of antiglaucoma medication. Cox regression analyses were performed to evaluate the effect of each pretreatment and surgical factor on the success rate. Patients with HM eyes were significantly younger than those with non-HM eyes (mean age 64.1±9.9 vs. 69.1±9.5years; P<0.05). The 3-year qualified success rates for HM eyes and non-HM eyes did not differ significantly for the three criteria. Younger age [hazard ratio (HR) for a 1-year increase0.93, P<0.005], preoperative pseudophakia (HR3.88, P<0.005), and shorter AL (HR for a 1-mm increase0.72, P<0.05) were found to be significant risk factors for trabeculectomy failure based on an IOP of ≤15mmHg (criterion C). Age and pseudophakia also had significant effects on trabeculectomy failure based on criteria A and B, and the AL had a significant influence based on criterion A. In our patient cohort a longer AL was not a risk factor for trabeculectomy failure, but it may be a success factor for trabeculectomy with MMC.

Intraocular Pressure Outcomes and Risk Factors for Failure in the Collaborative Bleb-Related Infection Incidence and Treatment Study

To evaluate the efficacy and safety of trabeculectomy for patients with glaucoma who were enrolled in the Collaborative Bleb-related Infection Incidence and Treatment Study (CBIITS). Multicenter, prospective, cohort study. A total of 829 eyes in 829 patients with glaucoma who had undergone trabeculectomy alone or trabeculectomy combined with phacoemulsification at 34 clinical centers were examined in this study. Intraocular pressures (IOPs, in millimeters of mercury), risk factors for surgical failure, and surgical complications. The enrollment period was 2 years, and follow-up was conducted every 6 months for up to 5 years. Outcomes were measured at 6-month intervals. Four levels of success were defined by achievement of the following IOP: (A) 4<IOP<22, (B) 4<IOP<19, (C) 4<IOP<16, and (D) 4<IOP<13. The primary outcome was the qualified success rate according to the defined criteria. The secondary outcomes included IOP, risk factors for surgical failure, and surgical complications. Mean IOP and preoperative antiglaucoma medications were significantly decreased from 24.9±9.0 to 12.6±5.2 mmHg (P<0.0001) and from 2.8±1.0 to 1.2±1.3 mmHg (P<0.0001), respectively, 5 years after surgery. For criteria A, B, C, and D, the qualified success rates were 90.1%, 88.9%, 77.6%, and 57.7% at 1 year, respectively, and 71.9%, 66.7%, 50.1%, and 29.9% at 5 years, respectively. The third or subsequent trabeculectomy was less effective than the first and second trabeculectomies. Preoperative lens status and preoperative higher IOP were risk factors for trabeculectomy failure. The needling procedure and cataract surgery were associated with the risk of failure. The rates of postoperative hyphema, shallow anterior chamber, bleb leak, and choroidal detachment were 2.7%, 3.1%, 1.9%, and 7.2%, respectively, in our series. Trabeculectomy with mitomycin C is an effective and safe procedure for reducing IOP in the CBIITS. The number of previous glaucoma surgeries, preoperative lens status and IOP, the needling procedure, and cataract surgery after trabeculectomy influenced the success rate, as determined by the target IOP.

Trabeculectomy with antiproliferative agents in uveitic glaucoma.

To evaluate the outcome of trabeculectomy with antiproliferative agents in patients with uveitic glaucoma A retrospective chart review of 44 eyes of 44 patients with uveitic glaucoma who underwent trabeculectomy with mitomycin C or 5-fluorouracil. The authors defined complete success as an intraocular pressure of 21 mm Hg or lower without pressure-lowering medications, qualified success as an intraocular pressure of 21 mm Hg or lower with medications, and failure as an intraocular pressure of more than 21 mm Hg with medications, loss of light perception, or the need for reoperation. The cumulative probability of complete or qualified success was 78% at 1 year and 62% at 2 years. At 2 years, success rates were 39% in males and 71% in females (P = 0.02), 74% in white patients and 55% in black patients (P = 0.58), and 45% in patients with idiopathic uveitis and 74% in patients with sarcoid uveitis (P = 0.17). Sixteen of 31 (51.6%) phakic patients developed new cataracts or had progression of existing cataracts and required cataract extraction. Four of 16 eyes (25%) lost intraocular pressure control and needed repeat trabeculectomy after undergoing cataract surgery. Patients with uveitic glaucoma can have good outcomes after trabeculectomy with antiproliferative agents. Male gender was the only statistically significant risk factor for trabeculectomy failure. Cataract management in the presence of a filtering bleb poses a treatment dilemma between improvement of visual acuity and loss of intraocular pressure control.

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.

Aqueous humor uric acid and ascorbic acid concentrations and outcome of trabeculectomy.

To determine if there is an association between the surgical outcome of trabeculectomy and uric acid and ascorbic acid concentrations in the aqueous humor at the time of the procedure. Aqueous humor samples were collected from the eyes of 169 of 249 adult patients who underwent trabeculectomy alone for any type of glaucoma between April 1989 and July 1995. Postoperatively, all medical records were reviewed and outcomes were classified as successful, unsuccessful, or indeterminate. The ascorbic acid and uric acid concentrations were determined in masked fashion by high-pressure liquid chromatography. Factors associated with surgical outcome were determined. Uric acid concentration was higher in unsuccessful eyes (mean+/-SD, 0.21+/-0.08 mmol/L, n=26) than in successful eyes (0.15+/-0.09 mmol/L, n=91, 95% confidence interval for difference, 0.02-0.10 mmol/L). Ascorbic acid levels were not significantly different in the eyes with unsuccessful (1129.9+/-601.9 micromol/L) and successful (1334.3+/-511.0 micromol/L) surgery (95% confidence interval for difference, -475.2 to 66.4 micromol/L, P=.13) surgery. Other factors associated with failure were previous surgery and surgery performed at the inferior limbus. A multiple polytomous logistic regression analysis was performed, after excluding the small number of operations performed at the inferior limbus. The odds ratio for failure increased by a factor of 1.68 for every 1-mmol/L increase in uric acid (95% confidence interval, 1.16-2.43, P=.006). Uric acid levels were higher at the time of surgery in eyes that had unsuccessful outcomes than in those with successful outcomes. No significant difference in ascorbic acid levels was detectable. A higher uric acid level in the aqueous humor is a risk factor for trabeculectomy failure and might be tested as a prognostic indicator [corrected].

Results of Trabeculectomy with 0.3 mg/ml Mitomycin C Titrating Exposure Times Based on Risk Factors for Failure

To examine the efficacy of trabeculectomy with mitomycin C 0.3 mg/ml using titrated exposure times. A retrospective chart review of consecutive patients undergoing trabeculectomy in an academic referral glaucoma clinic was performed. All patients received trabeculectomies performed by one surgeon (M.B.S.). The study included 57 eyes of 57 patients using mitomycin C with exposure times titrated from one to five minutes based on risk factors for trabeculectomy failure. Surgical success was defined as a final intraocular pressure (IOP) of less than 21 mmHg with or without medications or a 25% reduction in IOP if preoperative IOP was 21 mmHg or less. Patients requiring repeat trabeculectomies were considered failures regardless of their final IOP. Patients receiving different mitomycin C exposure times were compared but statistical analysis was not used because these subgroups were not randomized. An overall surgical success rate of 84.2% was achieved at a mean follow-up of 11.9 months. The surgical success rate and percentage IOP reduction was similar between exposure time subgroups. Hypotonous maculopathy observed in three patients (5.3%). All cases of hypotonous maculopathy was occurred in the lower-risk patients receiving one to three minute exposure times to mitomycin C. We believe mitomycin C should be used sparingly if at all in patients at lower risk for trabeculectomy failure. This concentration of mitomycin C with four to five minute exposure times appears to be efficacious for patients with multiple risk factors for trabeculectomy failure.

Laser revision of failing filters

To evaluate the efficacy and safety of trabeculectomy for patients with glaucoma who were enrolled in the Collaborative Bleb-related Infection Incidence and Treatment Study (CBIITS).Multicenter, prospective, cohort study.A total of 829 eyes in 829 patients with glaucoma who had undergone trabeculectomy alone or trabeculectomy combined with phacoemulsification at 34 clinical centers were examined in this study.Intraocular pressures (IOPs, in millimeters of mercury), risk factors for surgical failure, and surgical complications.The enrollment period was 2 years, and follow-up was conducted every 6 months for up to 5 years. Outcomes were measured at 6-month intervals. Four levels of success were defined by achievement of the following IOP: (A) 4 < IOP < 22, (B) 4 < IOP < 19, (C) 4 < IOP < 16, and (D) 4 < IOP < 13. The primary outcome was the qualified success rate according to the defined criteria. The secondary outcomes included IOP, risk factors for surgical failure, and surgical complications.Mean IOP and preoperative antiglaucoma medications were significantly decreased from 24.9±9.0 to 12.6±5.2 mmHg (P < 0.0001) and from 2.8±1.0 to 1.2±1.3 mmHg (P < 0.0001), respectively, 5 years after surgery. For criteria A, B, C, and D, the qualified success rates were 90.1%, 88.9%, 77.6%, and 57.7% at 1 year, respectively, and 71.9%, 66.7%, 50.1%, and 29.9% at 5 years, respectively. The third or subsequent trabeculectomy was less effective than the first and second trabeculectomies. Preoperative lens status and preoperative higher IOP were risk factors for trabeculectomy failure. The needling procedure and cataract surgery were associated with the risk of failure. The rates of postoperative hyphema, shallow anterior chamber, bleb leak, and choroidal detachment were 2.7%, 3.1%, 1.9%, and 7.2%, respectively, in our series.Trabeculectomy with mitomycin C is an effective and safe procedure for reducing IOP in the CBIITS. The number of previous glaucoma surgeries, preoperative lens status and IOP, the needling procedure, and cataract surgery after trabeculectomy influenced the success rate, as determined by the target IOP.