Correlation between the early morphological appearance of filtering blebs and outcome of trabeculectomy with mitomycin C

PURPOSE: To correlate the morphologic appearance of filtering blebs in the early postoperative period with the outcome of trabeculectomy with mitomycin C (MMC) during the first postoperative year. PATIENTS AND METHODS: In a prospective study, the morphologic appearance of filtering blebs after primary trabeculectomy with adjunctive MMC (0.1 mg/ml for 5 minutes intra-operatively) was classified; 49 eyes of 49 patients were examined preoperatively, 1 and 3 days, 1 and 2 weeks, 1, 3, 6, and 12 months postoperatively. Status of filtering bleb, intraocular pressure (IOP), and number of medications were recorded. RESULTS: One year after surgery all patients had IOP < or = 21; 6 patients received antiglaucoma medication. One eye required needling of the filtering bleb because of encapsulation. During the first postoperative year, eyes with conjunctival subepithelial micro cysts, observed in the first and the second postoperative week, had significantly lower mean IOP, than eyes without (11.1 mm Hg vs. 13.9 mm Hg; p:0.0043, ANOVA). Eyes with corkscrew vessels, observed in the first and the second postoperative week, had significantly higher mean IOP, than eyes without during the first postoperative year (13.4 mm Hg vs. 11.7 mm Hg; p:0.0141, ANOVA). CONCLUSION: Classification of filtering blebs after trabeculectomy with MMC may help to disclose patients with an increased failure risk.     

针刺分离联合滤泡内5-氟尿嘧啶注射治疗青光眼阀术后的盘周包裹

目的分析对Ahmed青光眼阀（AGV）植入术后盘周包裹致眼压升高的患者,采用针刺分离联合盘周滤泡内注射5-氟尿嘧啶（5-Fu）的治疗效果。方法对23例（25只眼）AGV植入术后1个月至1年眼压升高、滤泡包裹失败的患者,采用针刺分离滤泡周围纤维瘢痕,然后滤泡内注射5-Fu约10 mg,隔日1次共3～11次,分析治疗后眼压情况及治疗后的眼部并发症。结果治疗结束时,平均治疗（8.2±5.1）次。25只眼中有22只眼眼压〈21 mm Hg;治疗后3个月时,当时治疗有效的22只眼中11只眼眼压〈21 mm Hg,7只眼加用1～2种抗青光眼药物眼压〈21 mm Hg;治疗后6个月时,7只眼眼压〈21 mm Hg,8只眼加用1～2种抗青光眼药物眼压〈21 mm Hg,另5只眼加用3种以上抗青光眼药物眼压仍〉21 mm Hg。并发症：治疗后常见并发症有滤泡结膜出血、角膜上皮损伤、滤过泡损伤等,其中1只眼发生引流管脱出前房的严重并发症。结论 AGV植入术后盘周包裹致眼压升高的患者采用针刺分离联合滤泡内注射5-Fu治疗简单、安全、有效,在其他有创性治疗前以及某些病例加用药物治疗前,可首先考虑该方法。     

针拨联合球结膜下注射丝裂霉素C治疗功能不良滤过泡

目的 探讨针拨联合丝裂霉素C(mitomycin C,MMC)球结膜下注射治疗青光眼患者小梁切除术后早期功能不良滤过泡的疗效.方法 对47例(50眼)小梁切除术后2～8周滤过泡功能不良青光眼患者行针拨联合MMC 0.2 mL(0.04 mg)结膜下注射,术后所有患者随访3～6个月,观察患者眼压、滤过泡形态和并发症.结果 小梁切除术后2～8周,低平、限局、肥厚、充血型滤过泡32眼、包囊型囊样滤过泡18眼.针拨联合MMC结膜下注射治疗后3～6个月,46眼的滤过泡转为功能性的,轻度膨隆弥散型31眼,多腔或薄壁型15眼,限局肥厚型或无滤过泡4眼.治疗前患眼的平均眼压为(28.5±6.5)mmHg(1 kPa=7.5 mmHg),随访3～6个月平均眼压为(16.3±2.9)mmHg,与注射前比较二者差异有统计学意义(P<0.05).46眼没有用抗青光眼药物或用一种抗青光眼药物眼压控制在21 mmHg以下,成功率占92%.治疗后视物模糊10眼,结膜下出血6眼,角膜上皮点状脱落2眼,无低眼压、伤口渗漏和前房变浅等并发症.结论 针拨联合MMC结膜下注射治疗小梁切除术后早期功能不良滤过泡是安全、有效、简单的方法.     

Slit-lamp needle revision of failed filtering blebs using high-dose mitomycin C

PURPOSE: To investigate the efficacy of bleb needle revision with high-dose mitomycin C in reviving failed filtering blebs after 1 year. PATIENTS AND METHODS: We reviewed the charts of 44 patients with one eye that had undergone bleb needle revision with a mixture of 0.1 mL of mitomycin (0.4 mg/mL) mixed with 0.1 mL of non-preserved 1% lidocaine. At least 12 months of follow-up were required. A successful bleb needle revision was defined as one that did not require a subsequent needling, glaucoma surgery, or medication to reach an intraocular pressure (IOP) greater than 4 mm Hg but less than 22 mm Hg. A qualified success was defined as a successful bleb needle revision that required subsequent needling or medication. RESULTS: The bleb needle revision with high-dose mitomycin was a success or qualified success after 12 months in 28 patients or 64% (95% confidence interval, 50% to 78%). The baseline IOP in these patients was 26.7 +/- 8.2 mm Hg (range 15 to 48 mm Hg) using an average of 1.5 +/- 1.5 glaucoma medications. The IOP after 1 year was 13.6 +/- 4.0 (range 6 to 21 mm Hg) with an average of 0.5 +/- 0.8 medications. Of 44 patients, 17 (39%) were successes and 11 (25%) were qualified successes. CONCLUSION: Bleb needle revision with high-dose MMC was effective in reducing the IOP in 64% of eyes with a failed filtering bleb with minimal long-term complications.     

针刺分离联合5-FU治疗青光眼术后早期滤过泡功能不良

目的探讨对于青光眼术后早期功能不良的滤过泡采用针刺分离联合结膜下注射5-FU的治疗效果。方法青光眼滤过术后3月内25眼功能不良的滤过泡采用针刺分离滤过泡周围纤维瘢痕,联合结膜下注射5-FU 5mg/次,隔日1次,最多5次,分析治疗后眼压和滤过泡形态的变化及治疗后的眼部并发症。结果 25眼中,21眼眼压控制在21mmHg以下,其中18眼在15mmHg以下;滤过泡形态：有19眼表现为功能性滤过泡;并发症：常见并发症有结膜下出血、角膜上皮损伤、滤过泡损伤等。结论对于青光眼术后早期功能不良的滤过泡采用针刺分离联合结膜下注射5-FU是安全、有效的。     

针拨联合丝裂霉素C结膜下注射治疗抗青光眼术后失败滤过泡

目的:观察利用针拨联合丝裂霉素C结膜下注射治疗抗青光眼术后失败滤过泡的效果。方法:对抗青光眼小梁手术后3~22wk失败滤过泡34例(35眼)用针拨联合丝裂霉素C滤过泡旁注射,并随访6mo以上,观察滤过泡重新形成和眼压下降情况。结果:成功29例(29眼),手术前平均眼压为23.74±6.2mmHg,手术后眼压平均为13±4.3mmHg。其中3例(3眼)重复针拨、注射。随访期结束后统计针拨前后眼压具有显著性差异,Kaplan-Meier生存分析2a滤过泡成功率82.9%±6.4%。针拨术中有4眼前房出血,2眼低眼压,未见丝裂霉素的其它毒性反应。结论:针拨联合丝裂霉素C结膜下注射可以重新建立功能性滤过泡,有效地控制眼压,减少青光眼患者再次手术的痛苦。它是挽救抗青光眼术后失败滤过泡的一种良好的方法,具有毒性小、安全可重复的特点。     

薄壁囊状滤过泡的结膜瓣加固术

目的　探讨改良转移结膜瓣对矫正青光眼小梁切除术后薄壁囊状滤过泡的临床效果。方法　剪开滤过泡周围的结膜（保留原滤过泡）,游离转移上方或颞侧球结膜-筋膜组织,加固覆盖于经局部冷冻的变性囊状泡表面,转移结膜瓣的前缘固定缝合于周边角膜的槽状浅沟内。转移结膜瓣不够松弛时,在穹窿部做一减张性球结膜-筋膜组织切开。结果　46例（52只眼）术后随访6个月至4年,平均眼压由术前（4.25±1.33）mmHg（1mmHg=0.133kPa）提高至术后（12.98±5.70）mmHg,差异有显著性（t=3.26,P<0.01）。51只眼仍保留滤过功能,20只眼的结膜渗漏和6只眼的黄斑水肿消失,术后视力较术前有明显改善（χ     

抗青光眼术中应用C3F8的滤过泡形态学实验研究

目的：研究C3F8气体引起滤过泡的性状、功能、结构变化，探讨C3F8气体辅助应用于抗青光眼滤过术中的作用机理。方法：通过动物实验研究，观察C3F8气体辅助应用于兔眼小梁切除术后3天、1周、2周、3周、4周滤过泡的性状、功能和眼压，并进行病理组织学检查。结果：①眼压：C3F8气体组和单纯小梁切除术组术后3天、2周、3周的眼压差异均有统计学意义；C3F8组和MMC组术后3天的眼压差异有统计学意义；②滤过泡大小：C3F8气体组和单纯小梁切除术组术后3天差异有统计学意义；C3F8气体组五个时期比较，其中术后3天和1周、3天和2周、3天和3周、1周和2周、1周和3周的差异均有统计学意义。③有功能滤过泡的数量：C3F8气体组和MMC组术后3天均为100％；单纯小梁切除术组术后2周无；而C3F8气体组术后4周仍有25％的有功能的滤过泡。④结膜下间隙：光镜检查发现，C3F8气体组和MMC组结膜下均有较大的结膜下间隙，与单纯小梁切除术组之间差异均有统计学意义。结论：小梁切除术中辅助应用C3F8气体可以保持巨大的结膜下间隙，改善滤过泡的形态和体积，提高滤过泡的存活率；且比单纯小梁切除术能更有效的降低眼压。     

超声乳化白内障吸除术对功能性滤过泡形态和功能的影响

目的 评价超声乳化白内障吸除术对小梁切除术后有功能性滤过泡的患者的眼压及滤过泡形态的影响,并分析可能造成手术后眼压升高的危险因素.方法 前瞻性系列病例研究.选择2005年11月到2006年10月于我院就诊,需要行超声乳化白内障吸除术的具有功能性滤过泡的全部患者,完成2年随访的共20人(共25只眼).记录超声乳化白内障吸除术前及术后1、3、6、12、24个月的眼压和抗青光眼药物的使用情况;手术前、术后1个月及术后2年进行超声活体显微镜(UBM)检查.Kaplan-Meier法计算生存率,并结合UBM形态学测最结果分析造成超声乳化白内障吸除术后眼压升高的危险因素.对于患者手术前后的眼压及UBM的相关测量值进行配对t检验.声乳化白内障吸除术前后患者的眼压及抗青光眼的药物种类进行配对t检验.结果 超声乳化白内障吸除术前及术后各随访时间点的眼压分别为(15.8±5.1)、(13.7±3.6)、(13.6±3.3)、(14.4±4.1)、(14.2±3.6)、(13.8±3.5)mm Hg(1 mm Hg=0.133 kPa)(t=2.933,3.186,2.275,2.262,3.173;P=0.007,0.004,0.021,0.033,0.004).超声乳化白内障吸除术前后使用的抗青光眼药物数量分别为每眼(0.2±0.6)和(0.3±0.7)种,差异无统计学意义(t=-1.440,P=0.265).Log-rank分析超声乳化白内障吸除术后眼压升高的危险因素有手术前眼压高于15 mm Hg(P=0.042),手术后短期内出现滤过泡的高度下降大于10%和滤过泡的内反射增强.结论 对曾经进行过小梁切除术并有功能性滤过泡的患者进行超声乳化白内障吸除术,长期随访发现眼压控制良好,超声乳化白内障吸除术对外滤过功能无影响.超声乳化白内障吸除术前眼压高于15 mm Hg,术后短期出现滤过泡的明显变小和内反射增强是眼压升高的危险因素.     

Comparison of low-dose intraoperative mitomycin-C vs 5-fluorouracil in primary glaucoma surgery: a pilot study

BACKGROUND AND OBJECTIVE: This study was undertaken to compare the efficacy and safety of low-dose intraoperative application of mitomycin-C (MMC) with that of 5-fluorouracil (5-FU) in primary trabeculectomy. PATIENTS AND METHODS: A non-randomized prospective study was performed between August 1994 and November 1995. Thirty-two eyes of 16 consecutive patients who underwent trabeculectomy for uncontrolled glaucoma of various causes form the study group. The mean age was 46.8 +/- 9.9 years. The first eye received MMC (0.2, 0.4 mg/ml), fellow eye received 5-FU (50 mg/ml), for 1 minute intraoperatively. Bleb characteristics and intraocular pressure (IOP) control were analyzed. Success of surgery based on IOP control was measured by 3 different criteria: IOP less than 21 mm Hg; IOP less than 21 mm Hg with more than 30% reduction; and IOP less than 16 mm Hg with more than 30% reduction. RESULTS: Mean preoperative IOP was 31.4 +/-12.7 mm Hg in MMC group and 27.8+/- 8.8 mm Hg in 5-FU group. Mean follow-up in MMC group was 16.12 +/- 8.17 months; in 5-FU group 13.37 +/- 8.19 months. At last follow-up all 5-FU blebs were nonischemic, while 4 eyes in the MMC group showed nonischemic blebs, and 12 eyes had ischemic blebs. There was no statistically significant difference between MMC group and 5-FU group success rates with all 3 criteria. Success rates were: IOP less than 21 mm Hg; 100% in both groups; IOP less than 21 mm Hg with more than 30% reduction; MMC group 93.8%, 5-FU group 75%; less than 16 mm Hg with more than 30% reduction; MMC group 87.5%, 5-FU group 68.8%. CONCLUSIONS: Low-dose intraoperative MMC and 5-FU can provide control of IOP in primary trabeculectomy, 5-FU group showed more non-ischemic blebs.     

Treatment of encapsulated blebs with slitlamp needling and subconjunctival interferon injection

 Purpose: To investigate the efficacy and safety of slit-lamp needle revision with subconjunctival interferon injection in eyes with encapsulated blebs.   Methods: We reviewed a series of 25 cases (27 eyes) in which primary needling with 5×10⁵ IFN α-2b injection was performed for bleb encapsulation and analysed the results over a follow-up period of at least 12 months. Results: The mean time to development of encapsulated blebs after the surgery was 23.85 ± 10.66 days (9 to 60 days). The mean IOP decreased significantly from 22.51 ± 5.30 mm Hg at diagnosis of encapsulated blebs to 17.26±7.72 mmHg at the last visit (P = 0.009). Of the 27 eyes, 15 (55.56%) achieved a successful result, 10 (37.04%) were qualified for success and the remaining 2 (7.4%) were considered as failure. The qualified success group took 1.70 ± 0.67 antiglaucoma medications. No serious complications were detected. Conclusion: The needling procedure associated with subconjuctival injection of IFN α-2b is a safe and effective method in treating encapsulated blebs.     

Needle revision of failed filtering blebs using 5-Fluorouracil and a combined ab-externo and ab-interno approach

PURPOSE: To evaluate a surgical technique to revise a failed filtering bleb using subconjunctival 5-Fluorouracil with a combined ab-externo and ab-interno approach. PATIENTS AND METHODS: This study is a retrospective review of the outcome of 77 consecutive bleb revisions, with greater than 6-month follow-up, performed by a single glaucoma surgeon (MW). All eyes had previously functioning filtering blebs with currently inadequately controlled intraocular pressures (IOP) prior to the bleb revisions. All surgery was performed in the operating room, using a retrobulbar injection and a microscope. Visco-elastic was injected into the anterior chamber. 5-Fluorouracil (0.1 mL; 50 mg/ml) was infiltrated around the bleb. A 30-gauge needle was used to lyse subconjunctival fibrosis and episcleral scar tissue binding down the scleral flap, and elevate the scleral flap. Through an inferior paracentesis, a cyclodialysis spatula was used to confirm and enlarge the communication with the subconjunctival space. The main outcome measurements were IOP and number of glaucoma medications. A successful outcome was defined as a 20% reduction from baseline IOP and a maximum IOP of 18 mm Hg, with or without medications, and a minimal follow-up of 6 months. RESULTS: 52% of patients achieved success after one revision with an average follow-up of 29.6 +/- 14.4 months. In successful cases, the mean IOP decreased from 22.7 +/- 4.5 mm Hg to 11.3 +/- 3.5 mm Hg and medications were reduced from an average of 2.2 +/- 1.1 to 0.4 +/- 0.7. Kaplan-Meier survival analysis calculated a success of 77% at 1 year, 68% at 2 years, and 58% at 3 years. CONCLUSIONS: In failed filtering blebs, needle revision with 5-Fluorouracil and a combined ab-externo and ab-interno approach results in high success and low complication rates. The outcome of this procedure compares favorably with previously reported revision techniques.     

Ex-PRESS青光眼引流器植入术后无功能滤过泡的处理

目的：探讨针刺分离联合结膜下注射5-氟尿嘧啶(5-FU)对Ex-PRESS青光眼引流器植入术后的早期功能不良滤过泡的效果和安全性。

方法：回顾性分析在我院行针刺分离联合结膜下注射5-FU治疗Ex-PRESS青光眼引流器植入术后3mo内因滤过泡功能不良而眼压升高患者18例23眼的病例资料,所有患者均随访至治疗后6mo,统计分析治疗前后眼压和滤过泡形态的变化及治疗的相关并发症。

结果：治疗前眼压平均为(24.13±2.94)mmHg(1mmHg=0.133kPa),治疗后即刻、1、3、6mo的眼压分别为15.13±4.93、14.98±5.12、15.18±3.77、15.54±5.07mmHg,治疗后各时间点眼压与治疗前比较,差异均有统计学意义(P<0.05)。随访至治疗后6mo功能滤过泡形成率和治疗的总成功率均为83%。4眼(18%)治疗失败。治疗后常见并发症主要是滤泡结膜下出血、角膜上皮损伤,无严重并发症发生。

结论：采用针刺分离并结膜下注射5-FU治疗Ex-PRESS青光眼引流器植入术后早期功能不良滤过泡的患者是一种方便、安全、有效的方法。     

难治性青光眼早期功能不良滤过泡处理的临床观察

目的：观察难治性青光眼小梁切除术后早期功能不良滤过泡的处理方法、治疗效果,探讨有效、安全的早期功能不良滤过泡处理方法。

方法：收集我院2006-01/2012-01诊断为难治性青光眼且行小梁切除术后出现早期功能不良滤过泡(或倾向)者20例20眼于小梁切除术后3～8d进行治疗,治疗方法包括：眼球按摩、断(或拆除)巩膜缝线后再行眼球按摩、钝针头针拨分离滤过泡或联合结膜下注射5-氟尿嘧啶(5-FU)。所有患者术中曾用过抗代谢药丝裂霉素C(MMC, 0.3g/L)。随访6mo。

结果：经眼球按摩后有9眼获得功能滤过泡,联合钝针头针拨分离滤过泡治疗后有5眼为功能滤过泡,4眼经联合5-FU结膜下注射后为功能滤过泡,其综合成功率达90%。治疗前平均眼压24.61±5.4mmHg(1mmHg=0.133kPa),随访6mo结束时平均眼压为15.20±4.8mmHg,治疗前后眼压差异有显著统计学意义(P<0.01)。操作中和操作后未见任何并发症。

结论：难治性青光眼病情复杂,小梁切除术后极易出现早期功能不良滤过泡(或倾向),我们提倡尽早处理,综合眼球按摩、断(或拆除)巩膜缝线、钝针头针拨分离滤过泡或联合结膜下注射5-FU更安全有效,可很大程度上挽救早期濒临失败的滤过泡,提高手术成功率。     

Clinical study on interferon treatment of early scarring in filtering bleb

 Purpose: To investigate the effectiveness of needle revision combined with subconjuctival injection of interferon α-2b in reversing early scarring of filtering blebs following trabeculectomy surgery. Methods: Twenty-five  glaucoma patients (31 eyes) who presented with scarred or encapsulated filtering bleb after glaucoma surgery underwent needle revision in combination with subconjuctival injection of interferon α-2b, and were followed for 12 months. Intraocular pressure (IOP) and filtering bleb morphology were observed post treatment. Results: The mean time until scarring occurred was 21.0±7.4 days. The average time between recognition of bleb scarring and completion of needle revision was 2.2±0.8 days. The time interval between surgery and needle revision was inversely correlated with the time until needle revision (r = -0.694, P < 0.001). The mean IOPs before and after needle revision were 24.2±2.7mmHg and 19.6±3.8mmHg, respectively (t = 5.916,P < 0.001). At the 12-month follow-up visit, 18 eyes (58.1%) achieved complete success in IOP control, and 6 eyes (19.4%) had conditional success. The overall success rate for needling was thus 77.4%. Subconjunctival hemorrhage was observed in 4 eyes during the needle revision procedure. Punctate staining was found in the corneal epithelium of 2 eyes. Shallow  nterior chamber (Grade I or II) was identified in 5 eyes.  Conclusion: Slit-lamp needle revision combined with subconjunctival injection of interferon α-2b may be efficacious in the treatment of early scarring of filtering blebs, is easy and safe to perform, and may be considered for more widespread application.     

Determinants of bleb morphology in minimally invasive, clear-cornea micropenetrating glaucoma surgery with mitomycin C

PURPOSE: Antimetabolites, especially mitomycin C (MMC), increase the incidence of late bleb-related endophthalmitis in trabeculectomy. This is related to a higher incidence of avascular, thin, cystic, translucent blebs, which may be caused by a toxic effect on conjunctival tissue. An MMC dose-response study was carried out focusing on bleb morphology and function. PATIENTS AND METHODS: In a retrospective, comparative case series study, 2 successive groups of patients with complicated glaucoma were compared 2 years after a special, minimally invasive, filtering procedure (intrastromal holmium laser keratostomy). Preoperative local subconjunctival injections of a fixed MMC dose (4 microg) were used in group A, and lower MMC doses, calculated individually (1 or 2 microg), were used in group B. Bleb vascularity and morphology were evaluated by masked grading of photomicrographs. Bleb function was evaluated by intraocular pressure (IOP). RESULTS: Total bleb avascularity occurred in 63% of the blebs in group A and 0% in group B (P < 0.01). In eyes with IOP < or = 20 mmHg without medical treatment, the mean IOP was significantly lower in group 1 (8 vs 15 mm Hg, P < 0.002). A translucent cystic bleb without conjunctival stroma was observed in only 1 eye in group A. An optimal spongy stromal bleb was observed in all other eyes (96%) despite the different MMC doses. The numbers of complications in the 2 groups were nearly equal. CONCLUSIONS: Bleb avascularity after 4 microg MMC could be avoided by the use of 1 or 2 microg MMC on the basis of preoperative prognosticators for failure, but at the expense of some of the IOP-lowering effect. This indicates that the therapeutic index (clinical safety margin) of MMC seems to be narrow. An MMC dose-response relation was not observed for the thin, cystic, and translucent bleb. The low incidence of this bleb (4%) indicates that the operative technique, apart from the vascularity, may be the most essential determinant of bleb morphology.     

Wound modulation after trabeculectomy by different formulations of antimetabolites in rabbits.

A prospective, randomized study was performed to examine the effects of subconjunctival retention of 5-fluorouracil (5-FU) microparticles or 5-FU microparticles combined with mitomycin-C (MMC) on the success of trabeculectomy procedure in 32 New Zealand white rabbits. Drug-loaded microparticles were prepared using a biodegradable polymer, 50:50 ploy (D,L-lactide-co-glycolide) (50:50, PLG, MW 9000), by an oil-in-oil emulsification/solvent extraction technique. Each rabbit underwent trabeculectomy on both eyes, then one of the 5-FU and/or MMC preparations was placed at the site of the filtering surgery intraoperatively in the right eye, while the left eye was used as a control. The rabbits were randomly allocated to one of four treatment groups: group 1 rabbits received 5% 5-FU microparticles 10 mg; group 2 rabbits received 10% 5-FU microparticles 10 mg; group 3 rabbits received 10% 5-FU microparticles 5 mg and MMC 0.01 mg (5-FU/MMC); and group 4 rabbits received MMC 0.02 mg. Postoperatively, intraocularpressure (IOP), bleb survival, complications and IOP dynamics were compared during a follow-up period of 42 days. The results showed that IOPs were significantly lower in the eyes that received groups 3 and 4 treatments, while the eyes that received low concentrations of 5-FU microparticles resulted in no difference in IOPs as compared with those of controls. At 42 days, blebs were present in 100% of the eyes treated with 5-FU/MMC and MMC, but 0% of the eyes treated with 5-FU microparticles. The blebs in the eyes treated with MMC 0.02 mg were thinner, and significant complications (endophthalmitis, transient corneal opacification and neovascularization) occurred. In addition, the IOP dynamics study revealed that the eyes treated with 5-FU/MMC and MMC resulted in less IOP spikings after intravenous infusion of 0.9% NaCl solution. Our study suggested that the use of 5-FU microparticles in promoting the success of trabeculectomy in rabbits is dose-dependent, and its effect is less potent than a single intraoperative application of MMC.     

Operative revision of non-functioning filtering blebs with 5-fluorouracil to regain intraocular pressure control

PURPOSE: To determine the efficacy of extensive microsurgical needling revision of failed filtering blebs followed by serial 5-fluorouracil subconjunctival injections. METHODS: Thirty-six eyes of 34 consecutive patients with progressive open-angle glaucoma refractory to topical therapy submitted to needling revision as a major procedure. All patients required multiple antiglaucoma medications preoperatively, and had completely flat or densely encapsulated filtering blebs. All patients underwent elaborate needling revision (limbus to superior rectus >8 mm diameter, >3 mm elevation, entry-site sutured with 8-0 vicryl and bleb reformed via paracentesis with viscoelastic) in the operating room, followed by serial 5-fluorouracil. The patients were followed for up to 6 months postoperatively. The main outcome measures were intraocular pressure (IOP) and the number of antiglaucoma medications used. RESULTS: Thirty-one eyes (86%) maintained mean IOP below 15 mmHg postneedling without medication. Overall the mean IOP postneedling was >9 mmHg lower than medicated preoperative levels (P < 0.0001). IOP reduction in encapsulated blebs was marginally superior to that in flat blebs. CONCLUSIONS: Extensive needling revision in the operating room is safe, straightforward, and produces reproducible restoration of filtering function.     

Long-term follow up of surgical repair of late bleb leaks after glaucoma filtering surgery

PURPOSE: To study the long-term outcomes of surgical revision of leaking blebs after trabeculectomy and identify possible risk factors for failure. PATIENT AND METHODS: A retrospective, nonrandomized, noncomparative interventional study of 34 eyes with late bleb leaks after trabeculectomy that underwent bleb excision with conjunctival advancement. The primary outcome measure was successful repair and control of intraocular pressure (IOP). The other measures evaluated included change in visual acuity from baseline and complications such as recurrence of bleb leak, endophthalmitis or the need for additional antiglaucoma medication to control IOP. RESULTS: After a mean follow up of 36.2+/-23 months, the mean IOP at the last visit was 14.5+/-7.6 mm Hg. IOP in 58.8% of eyes was controlled without medication. Complications included early leaks (7/34), late recurrent or persistent leaks (1/34), and endophthalmitis (1/34). In all, 41.2% patients required additional medication at the last visit. Survival analysis at 22 months the probability of total and qualified success was 52% and 72%, respectively. However, this dropped to 10% and 15%, respectively, at 5 years. The probability of total and qualified success further dropped to 2.5% and 5% at 5 years when the IOP cut-off was lowered from 21 to 15 mm Hg. Cox regression analysis failed to identify risk factors for bleb failure. CONCLUSIONS: Surgical bleb revision seems to be effective in treating late bleb leaks with few postoperative complications. However, patients should be followed carefully as late failure of bleb function beyond 2 years is a significant possibility.     

Intraoperative mitomycin-C without conjunctival and Tenon's capsule touch in primary trabeculectomy

OBJECTIVE: To verify whether intraoperative mitomycin C (MMC) without conjunctival and Tenon's touch is effective in inhibiting the development of thin, avascular blebs in eyes undergoing primary trabeculectomy. DESIGN: Noncomparative, interventional study. PARTICIPANTS: Fifteen eyes of 15 consecutive patients undergoing primary trabeculectomy. INTERVENTION: All eyes underwent trabeculectomy with intraoperative MMC (0.25 mg/ml for 3 minutes) without either conjunctival or Tenon's touch. Patients were examined 1 month, 3 months, 6 months, and 12 months after surgery. Intraocular pressure (IOP) and number of medications were evaluated at each examination. The appearance of the bleb was classified at the last examination into one of three groups: flat and vascularized; elevated but not avascular; or elevated, thin, and avascular. MAIN OUTCOME MEASURES: Intraocular pressure, number of antiglaucoma medications, and appearance of the bleb. RESULTS: Preoperative mean IOP was 30.57 +/- 10.92 mmHG: Statistically significant IOP reductions were observed 1 month, 3 months, 6 months, and 1 year after surgery (P < 0.01). Twelve months after surgery, the mean IOP was 14.92 +/- 6.53 mmHG: Five eyes (33.3%) showed an IOP less than 15 mmHg without antiglaucoma medication at the 12-month examination. The bleb was considered elevated, thin, and avascular in 12 of 15 eyes (80%) at the end of follow-up. CONCLUSIONS: Intraoperative MMC at 0.25 mg/ml for 3 minutes without either conjunctival or Tenon's touch was not effective in eliminating the development of thin, avascular blebs in eyes undergoing primary trabeculectomy.