Procedimentos Minimamente Invasivos para Glaucoma: uma revisão atualizada da literatura / Minimally Invasive Glaucoma Surgery (MIGS): an updated literature review

RESUMO O glaucoma é considerado a maior causa de cegueira irreversível no mundo, e o aumento da pressão intraocular constitui seu principal fator de risco. Usualmente, a terapia inicial do glaucoma consiste na redução da pressão intraocular a partir da instilação de drogas hipotensoras tópicas, estando as cirurgias antiglaucomatosas reservadas, na maioria das vezes, para casos em que o controle da doença não é atingido clinicamente. Classicamente, o tratamento cirúrgico do glaucoma é realizado a partir dos procedimentos filtrantes: trabeculectomia e implante de dispositivos de drenagem. O acrônimo MIGS (do inglês minimally invasive glaucoma surgery, procedimentos minimamente invasivos para glaucoma) corresponde a um grupo de procedimentos cirúrgicos pouco invasivos, que propõem a redução pressórica de maneira mais segura e previsível, quando comparada às técnicas cirúrgicas antiglaucomatosas convencionais.

ABSTRACT Glaucoma is considered the biggest cause of irreversible blindness in the world and the increase in intraocular pressure is its main risk factor. Usually, the initial therapy for glaucoma consists of reducing IOP through the instillation of topical hypotensive drugs, with antiglaucoma surgeries being normally reserved for cases in which disease control is not clinically achieved. Classically, the surgical treatment of glaucoma is performed using filtering procedures: trabeculectomy; non-penetrating sclerotomy and glaucoma drainage devices. The acronym MIGS (Minimally Invasive Glaucoma Surgery) corresponds to a group of minimally invasive surgical procedures that provide a safer and more predictable pressure reduction when compared to conventional antiglaucoma surgical techniques.

Glaucoma drainage devices / Dispositivos de drenagem para glaucoma

ABSTRACT Glaucoma drainage devices are important therapeutic options for cases of refractory glaucoma, in which trabeculectomy with antimetabolites has shown high risk of failure. There are devices with different sizes, designs and materials, and several studies have been conducted to test their safety and effectiveness. Despite known complications, their use has progressively increased in recent years, and they are the primary surgical option, in some situations. The aim of this review is to discuss the importance, mechanisms, biomaterials, results and complications of glaucoma drainage devices.

RESUMO Os dispositivos de drenagem para glaucoma são importante opção terapêutica em casos de glaucomas refratários, nos quais a trabeculectomia com antimetabólitos tem alta chance de falência. Há dispositivos com diferentes tamanhos, desenhos e materiais, e muitos estudos foram realizados para testar sua segurança e eficácia. Apesar de suas conhecidas complicações, seu uso tem aumentado progressivamente nos últimos anos, inclusive como primeira opção cirúrgica, em algumas situações. O objetivo desta revisão foi discutir a importância, os mecanismos, os biomateriais, os resultados e as complicações dos dispositivos de drenagem para glaucoma.

Evaluación cualitativa de la ampolla de filtración / Qualitative evaluation of filtering blebs

Se realizó una búsqueda sobre la evaluación cualitativa de la ampolla de filtración. La ampolla conjuntival es la parte visible de la cirugía filtrante, y su morfología es un indicador de factores que pueden determinar el resultado hipotensor de la cirugía y las posibles complicaciones posoperatorias. Se han desarrollado diversos estudios que relacionan la evaluación clínica de su morfología y el control de la presión intraocular, y se han establecido varios sistemas de puntuación, entre ellas: Wuerzburg Bleb Classification Score, Moorfields Bleb Grading System, Indiana Bleb Appearance Grading Scale y métodos de imagen para evaluar el segmento anterior (biomicroscopia ultrasónica, Tomografía retinal de Heidenberg y tomografía de coherencia óptica). Estos métodos proporcionan una herramienta útil para el seguimiento de la cirugía filtrante y su documentación(AU)

A review was conducted on the qualitative evaluation of the filtering bleb. The conjunctival bleb is the visible part of filtration surgery, and its morphology is an indicator of factors which may determine the hypotensive result of surgery and the possible postoperative complications. Various studies have been conducted which relate the clinical evaluation of its morphology and intraocular pressure control. Several grading systems have thus been established: Wuerzburg Bleb Classification Score, Moorfields Bleb Grading System, Indiana Bleb Appearance Grading Scale and imaging methods to evaluate the anterior segment (ultrasound biomicroscopy, Heidenberg retinal tomography and optical coherence tomography). These methods are a useful tool for the follow-up of filtration surgery and its documentation(AU)

Implante Ex-PRESS mediante la técnica de Richard Hoffman / Ex-PRESS implantation by Richard Hoffman's technique

La cirugía filtrante es una opción de tratamiento encaminada a disminuir la presión intraocular una vez que no hay respuesta a las alternativas no quirúrgicas. En los últimos años ha experimentado una evolución sorprendente. Aparecen nuevos dispositivos que buscan obtener un control tensional con las mínimas complicaciones; entre estos, el implante Ex-PRESS ha demostrado una efectividad similar a la trabeculectomía, mientras que la variante técnica para su implantación, descrita por Richard Hoffmann, posibilita excelentes resultados con menos dificultades. Se presenta un paciente masculino de 51 años de edad, de raza blanca, con antecedente de glaucoma, con agudeza visual mejor corregida de 100 VAR y presión intraocular de 32 mmHg. Se realizó implante de dispositivo Ex-PRESS (modelo P-50) mediante la técnica modificada de Richard Hoffmann, asociada al uso de mitomicina C al 0,2 por ciento en el transoperatorio. A los dos años se lograron tensiones oculares de 17 mmHg y agudeza visual mejor corregida de 100 VAR(AU)

Filtration surgery is a therapeutic option aimed at reducing intraocular pressure when there is no response to non-surgical alternatives. Filtration surgery has developed remarkably in recent years. New devices have emerged geared to achieving pressure control with minimum complications. Among them, Ex-PRESS implantation has shown to be as effective as trabeculectomy, and the technique described by Richard Hoffman provides excellent results with fewer difficulties. A case is presented of a male white 51-year-old patient with a history of glaucoma, best corrected visual acuity 100 VAR, and intraocular pressure 32 mmHg. Implantation was performed of an Ex-PRESS (model P-50) device by modified Richard Hoffman's technique associated to 0.2 percent mitomycin C in the perioperative period. Two years after surgery, ocular tensions of 17 mmHg and a best corrected visual acuity of 100 VAR had been achieved(AU)

Evolução atípica de cisto de tenon após implante de válvula de Ahmed / Atypical evolution of tenon cyst after Ahmed valve implantation

Resumo Descrevemos o caso de um paciente portador de glaucoma secundário que evoluiu com cisto de tenon após implante de válvula de Ahmed. A despeito da conduta expectante inicial e das intervenções cirúrgicas posteriores, apenas com a utilização da ciclofotocoagulação transescleral com laser micropulsado a pressão intraocular atingiu valores aceitáveis.

Abstract We describe the case of a patient with secondary glaucoma who developed tenon cyst after Ahmed valve implantation. Despite the initial expectant management and subsequent surgical interventions, only with the micropulse transecleral cyclophotocoagulation did the intraocular pressure reach acceptable values.

Cicatrização por segunda intenção como alternativa terapêutica para blebite grave / Second intention healing as a therapeutic alternative for blebitis serious

As infecções relacionadas à ampola filtrante da cirurgia de trabeculectomia podem ser divididas em dois subgrupos: formas localizadas de infiltrado mucopurulento limitadas a ela (blebite) ou uma infecção que envolve todo o olho (endoftalmite). Neste último caso, podemos observar hipópio e células no vítreo anterior. De etiologia ainda pouco definida, sabe-se que o uso de antimetabólitos como a mitomicina aumenta o risco de formação de bolha cística avascular mais susceptível à infecção. Embora não haja consenso sobre o manejo da blebite, sugere-se o início imediato da antibioticoterapia e o monitoramento diário. As intervenções cirúrgicas geralmente consistem na remoção do tecido não saudável, seguido de avanço conjuntival ou falha intencional da ampola seguida do implante de um tubo. O objetivo deste estudo é relatar uma abordagem cirúrgica incomum em um caso de blebite grave. Não foram encontrados dados na literatura de Oftalmologia que pudessem sugerir um manejo expectante mantendo uma esclera exposta, sem prejuízo do desfecho final da cirurgia fistulizante. (AU)

Infections related to the filtering ampoule of trabeculectomy surgery can be divided into two subgroups: localized forms of mucopurulent infiltrate limited to it (blebitis) or an infection involving the entire eye (endophthalmitis). In the second case we can observe hypopyon and cells in the anterior vitreous. Of a still poorly defined etiology, the use of antimetabolites, such as mitomycin, is known to increase the risk of creating an avascular cystic bleb more susceptible to infection. Although there is no consensus on blebitis management, it is suggested to start antibiotic therapy immediately and monitor it daily. Surgical interventions usually consist of removing the unhealthy tissue followed by conjunctival advancement or intentional failure of the ampulla followed by tube implantation. The aim of this study is to report an unusual surgical approach in a severe blebitis case. No data were found in the Ophthalmology literature that could suggest an expectant management maintaining an exposed sclera without any prejudice to the final outcome of the fistulizing surgery.

Retinosquise peripapilar e descolamento seroso de retina neuro-sensorial após esclerectomia profunda não penetrante / Peripapillary retinoschisis and serous detachment of neurosensory retina after a non-penetrating deep sclerectomy

Resumo Relato de caso de um paciente de 46 anos com glaucoma juvenil de controle clínico insatisfatório, portador de retinosquise peripapilar que, após ser submetido à esclerectomia profunda não penetrante, evoluiu com descolamento seroso da retina neuro-sensorial. A associação entre retinosquise peripapilar e o descolamento seroso pós cirurgia filtrante é de ocorrência rara, tendo sido descrito apenas um caso na literatura. A partir deste relato temos por objetivo, além de enfatizar a raridade da associação, mostrar a importância de investigar retinosquise peripapilar em pacientes glaucomatosos, em especial se associada a camada de fibras nervosas, e a importância da explanação adequada aos pacientes de um possível descolamento seroso de retina no pós-operatório de cirurgia filtrante.

Abstract Case report of a 46-year-old patient with unsatisfactory clinical controlled juvenile glaucoma and peripapillary retinoschisis who, after being submitted to non-penetrating deep sclerectomy, evolved with serous detachment of the neurosensory retina. The association between peripapillary retinoschisis and serous detachment after filtering surgery is rare and only one case has been described in the literature. The purpose of this report is, besides to emphasize the rarity of the association, to show the importance of investigating peripapillary retinoschisis in glaucomatous patients, especially if associated with retinal nerve fiber layer, and the importance of adequate explanation to patients of possible serous detachment of retina in the postoperative of filtering surgery.

Use of compressive suture in the prevention and management of perioperative complications of glaucoma surgery / Uso da sutura compressiva na prevenção e manejo das complicações peroperatórias da cirurgia antiglaucomatosa

Abstract Purpose: To describe the use of compressive suture (CS) in the prevention and management of adverse events associated with glaucoma surgery. Methods: This was a descriptive, retrospective study based on information retrieved from the records of patients submitted to glaucoma surgery between 1999 and 2012 at a regional main public hospital and at a private ophthalmology clinic belonging to one of the authors. Only cases with adverse events treated with CS were eligible. Results: Compressive suture was successfully used to improve the closure of the anterior and/or lateral edge of the conjunctival flap, to limit the downward extension of filtering blebs, to prevent excessive filtration from the scleral flap edge in cases of difficult closure with conventional suture, and in patients submitted to trabeculotomy-trabeculectomy. Conclusion: Safe, low-cost and easy to perform, compressive suture is a useful tool for the prevention and management of adverse events associated with glaucoma surgery.

Resumo Objetivo: Descrever o uso de sutura compressiva (SC) na prevenção e no manejo de complicações associadas à cirurgia antiglaucomatosa. Métodos: Trata-se de um estudo descritivo, retrospectivo, baseado em informações obtidas dos registros de pacientes submetidos à cirurgia de glaucoma entre 1999 e 2012 em um hospital público de referência regional e em uma clínica oftalmológica privada de um dos autores. Somente casos com eventos adversos tratados com SC foram selecionados. Resultados: A SC foi usada com sucesso para proporcionar melhor vedação nas bordas anterior e/ou lateral do retalho conjuntival, para limitar a extensão descendente das bolhas filtrantes, para evitar a filtração excessiva da borda do retalho escleral em casos de fechamento difícil pela sutura convencional, e em pacientes submetidos à trabeculotomia - trabeculectomia. Conclusão: Trata-se de um procedimento de fácil realização, seguro e de baixo custo, bastante útil na abordagem de intercorrências e complicações durante a cirurgia antiglaucomatosa.

Anti-scarring effect of rapamycin in rabbits following glaucoma filtering surgery / 南方医科大学学报

OBJECTIVE@#To study the anti- scarring effect of rapamycin in rabbits receiving glaucoma filtering surgery.@*METHODS@#Ninety-six Chinchilla rabbits were randomized equally into 3 rapamycin treatment groups and one control group. All the rabbits underwent trabeculectomy, after which the rabbits in the 3 rapamycin groups were treated with eye drops containing 1%, 3%, or 5% rapamycin in the operated eyes, and those in the control groups were given castor oil 4 times a day. The intraocular pressure (IOP) and inflammatory reaction in the treated eyes were observed, and the PCNA-positive cells in the filtering bleb were detected using immunohistochemistry. RTFs isolated from the Tenon's capsule of the rabbits were cultured , and the expressions of caspase-3, caspase-8, and caspase-9 in the fibroblasts were detected after treatment with different concentrations of rapamycin.@*RESULTS@#The IOP was significantly lower in rapamycin-treated group than in the control group after the surgery ( < 0.05). The counts of the PCNA-positive cells were significantly lower in rapamycin-treated rabbits than in the control group ( < 0.05). Rapamycin treatment dose-dependently increased the expressions of caspase-3 and caspase- 9 at both the mRNA ( < 0.001) and protein ( < 0.001) levels without causing significant changes in the expressions of caspase-8.@*CONCLUSIONS@#Rapamycin can inhibit excessive proliferation of the fibroblasts in the filtering bleb to reduce scar formation after glaucoma filtration surgery in rabbits. Rapamycin also increases the expressions of caspase-3 and caspase-9 to induce apoptosis of the RTFs.

Resultados a corto plazo de la facotrabeculectomía por una vía en el Instituto Cubano de Oftalmología Ramón Pando Ferrer / Short-term outcomes of one-site phacotrabeculectomy at Ramón Pando Ferrer Cuban Institute of Ophthalmology

Objetivos: describir los resultados a corto plazo de la facotrabeculectomía por una vía. Métodos: se realizó un estudio descriptivo de series de casos en 19 ojos de 18 pacientes tratados con facotrabeculectomía por una vía y por un mismo cirujano del Departamento de Glaucoma del Instituto Cubano de Oftalmología Ramón Pando Ferrer, entre los meses de febrero y octubre del año 2016. Se controlaron las siguientes variables: edad, sexo, color de piel (blanco o negro), número de fármacos hipotensores, agudeza visual mejor corregida, presión intraocular, estadio de daño glaucomatoso, tipo de glaucoma y complicaciones posquirúrgicas con seguimiento durante tres meses. Resultados: la edad promedio de la muestra fue 69 ± 12 años, igual número de masculinos y femeninos. Predominó el glaucoma primario de ángulo abierto y el color de piel negra. En el preoperatorio la presión intraocular media fue 22,5 ± 5,9 mmHg; la agudeza visual mejor corregida 51,77 ± 31,89 VAR y el número de fármacos hipotensores 3,2 ± 0,5. A los tres meses posoperatorios la presión intraocular media fue 15,6 ± 4,3 mmHg (p< 0,05); la agudeza visual mejor corregida 71,15 ± 33,05 VAR y el número de fármacos hipotensores 0,7 ± 1 (p< 0,05). Las complicaciones posquirúrgicas fueron atalamia, desprendimiento coroideo y quiste de Tenon. Conclusiones: la facotrabeculectomía por una vía constituye una alternativa quirúrgica que ofrece a pacientes con glaucoma y catarata el control de la presión intraocular, la recuperación visual, la reducción del número de fármacos hipotensores oculares y mínimas complicaciones(AU)

Objectives: describe the short-term outcomes of one-site phacotrabeculectomy. Methods: a descriptive case-series study was conducted of 19 eyes of 18 patients treated with one-site phacotrabeculectomy by the same surgeon at the Glaucoma Department of Ramón Pando Ferrer Cuban Institute of Ophthalmology from February to October 2016. The variables evaluated were age, sex, skin color (black or white), number of hypotensive drugs, best corrected visual acuity, intraocular pressure, glaucomatous damage, glaucoma type and postsurgical complications during a three-month follow-up. Results: mean age of the sample was 69 ± 12 years, with an equal number of males and females. There was a predominance of primary open-angle glaucoma and black skin color. In the preoperative period mean intraocular pressure was 22.5 ± 5.9 mmHg, best corrected visual acuity was 51.77 ± 31.89 VAR, and the number of hypotensive drugs was 3.2 ± 0.5. Three months after surgery mean intraocular pressure was 15.6 ± 4.3 mmHg (p< 0.05), best corrected visual acuity was 71.15 ± 33.05 VAR and the number of hypotensive drugs was 0.7 ± 1 (p< 0.05). The postoperative complications were athalamia, choroidal detachment and Tenon cyst. Conclusions: one-site phacotrabeculectomy is a surgical alternative offering patients with glaucoma and cataract intraocular pressure control, visual recovery, a reduction in the number of hypotensive drugs, and minimal complications(AU)

Quarter-Shifted Microincisional Sutureless Vitrectomy in Patients with a Glaucoma Drainage Implant or Filtering Bleb

When vitrectomy is performed in eyes that have undergone glaucoma surgery, the site of sclerotomy often overlaps with the previous glaucoma operation site. It can lead to serious complications such as postoperative hypotony, leakage, and/or infection. Our technique involves modification of surgeon's position and two sclerotomy sites 45° away from the original position, with an infusion cannula inserted infranasally to avoid damage to the glaucoma drainage implant or filtering bleb. The modified approach was applied to seven eyes with various indications. Vitrectomy was successfully completed, and there were no sclerotomy site complications, leakage, or hypotony in any case. Good intraocular pressure control was maintained throughout the postoperative course in all cases.

Intravitreal Injection of Dexamethasone Implant during Cataract Surgery in Patients with Noninfectious Uveitis

PURPOSE: To investigate the efficacy and safety of intravitreal dexamethasone implant for controlling postoperative inflammation among uveitis patients undergoing cataract extraction. METHODS: Ten eyes with noninfectious uveitis underwent phacoemulsification with intraocular lens implantation followed by intravitreal injection of 0.7-mg dexamethasone implant (implant group) between February 2011 and January 2014. Twenty age- and gender-matched controls who received cataract surgery without implantation during the same period were recruited (non-implant group). Medical records of the subjects were retrospectively reviewed and 6-month postoperative clinical outcomes were compared between the 2 groups. RESULTS: The mean age was 42.30 +/- 15.81 years in the implant group and 45.65 +/- 13.63 years in the non-implant group. The 2 groups were similar in terms of age, gender, preoperative inflammatory status, and preoperative visual acuity (p = 0.552, 1.000, 0.133 and 0.767, respectively). After surgery, oral steroid was used in the non-implant group (8.8 +/- 1.5 mg/day on average) and the implant group (3.5 +/- 1.3 mg/day; p = 0.029). Visual acuity (log MAR) improved significantly in both groups (p = 0.789) with no significant difference between the 2 groups. Postoperative recurrence rates of uveitis were reduced more (40%) in the implant group than in the non-implant group (50%) but without significance (p = 0.709). Elevated intraocular pressure > or =25 mm Hg occurred in 3 eyes (30%) in the implant group and 4 eyes (20%) in the non-implant group (p = 0.657), of which 1 in each group required a filtering surgery. Otherwise, no significant complications developed in either group. CONCLUSIONS: Intravitreal dexamethasone implants help reduce conventional oral steroid dosage for controlling postoperative inflammation. Dexamethasone implants could be an effective and safe alternative to control the inflammation after cataract surgery in uveitis patients.

GM6001 suppresses scar formation after glaucoma filtration surgery in rabbits / 南方医科大学学报

<p><b>OBJECTIVE</b>To study the effect of matrix metalloproteinases inhibitor GM6001 in suppressing scar tissue formation in the filtering passage after glaucoma filtration surgery.</p><p><b>METHODS</b>Twenty-four pigmented rabbits (48 eyes) underwent trabeculectomy followed by subconjunctival injection of GM6001 in the right eye (treated eyes) and injection of PBS in the left eye (control) once a day. The intraocular pressure was monitored postoperatively and proliferating cell nuclear antigen (PCNA)- and α-smooth muscle actin (α-SMA)-positive cells in the filtering pathway were detected using immunohistochemistry.</p><p><b>RESULTS</b>On postoperative days 7, 14, 21, and 28, the intraocular pressure was significantly lower in the treated eyes (GM6001) than in the control eyes (P<0.01). The counts of PCNA- and α-SMA-positive cells were also significantly lowered in the treated than in the control eyes (P<0.01).</p><p><b>CONCLUSION</b>GM6001 can inhibit excessive proliferation of the fibroblasts in the filtering pathway to suppress scar tissue formation and prolong the existence of the functional filtration bleb in rabbits.</p>

A Case of Central Serous Chorioretinopathy after Glaucoma Filtering Surgery

PURPOSE: To report a case of central serous chorioretinopathy development after glaucoma filtering surgery and spontaneous resolution in a patient with a history of central serous chorioretinopathy in the contralateral eye. CASE SUMMARY: A 46-year-old male with a history of chronic uveitis in both eyes presented with uncontrolled intraocular pressure (IOP) in his left eye. Initial IOP was 34 mm Hg in his left eye. On preoperative evaluation, central serous chorioretinopathy, which was diagnosed in another clinic 1 month prior, was observed in his right eye. Slightly pale optic disc and retinal nerve fiber layer defects were noted in the left eye. However, macular abnormalities were not observed in the left eye. Trabeculectomy and peripheral iridectomy using mitomycin C were performed in the left eye. The patient was prescribed triamcinolone 8 mg daily for 4 days to reduce the post-surgical inflammation. On postoperative day 4, IOP in the left eye was 7 mm Hg and newly developed central serous chorioretinopathy was noted. On follow-up, IOP was maintained at 7-10 mm Hg and central serous chorioretinopathy disappeared 7 months postoperatively. CONCLUSIONS: When clinicians consider performing an ophthalmological procedure in a patient with a history of central serous chorioretinopathy in the contralateral eye, careful observation of central serous chorioretinopathy development is recommended.

A retrospective and consecutive study of viscocanalostomy versus trabeculectomy for primary congenital glaucoma / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Surgical interventions are the main treatment for primary congenital glaucoma (PCG). This study aimed to compare the efficacy and safety between viscocanalostomy and mitomycin C (MMC)-trabeculectomy in patients with PCG.</p><p><b>METHODS</b>A total number of 43 patients with PCG who underwent either viscocanalostomy (group 1) or MMC- trabeculectomy (group 2) between June 2003 and June 2008 were retrospectively reviewed. The patients' intraocular pressures (IOPs) were examined before surgery and on day 1, week 1, month 1, month 6, and month 12 post-operative. Mean horizontal corneal diameters, success rates, intra- and post-operative complications were compared between the two groups.</p><p><b>RESULTS</b>Pre-operative IOPs were (31.96 ± 3.90) mmHg in group 1 and (32.56 ± 4.00) mmHg in group 2. At the last visit, IOPs were (16.78 ± 2.20) mmHg and (15.77 ± 2.60) mmHg, respectively (P < 0.001); the complete success rates of group 1 and group 2 were 45.9% and 67.4%, respectively, and the difference was not statistically significant (P = 0.158). There were no major complications occurred in the two groups.</p><p><b>CONCLUSIONS</b>Both viscocanalostomy and trabeculectomy can lower IOP in PCG patients effectively. Although there was no major complications occurred in both groups, viscocanlostomy may decrease the probability of postoperative haemorrhage, hypotony, cataract, or choroid effusion.</p>

Effects of Prednisolone and Loteprednol Eyedrops on the Proliferation of Human Tenon's Capsule Fibroblasts

PURPOSE: To compare the effect of loteprednol etabonate (LE) with prednisolone acetate (PDA) drops on the proliferation of human Tenon's capsule fibroblasts (HTFBs). METHODS: Primarily cultured HTFBs were treated with serially diluted PDA and LE for 3 days. Cellular survival was determined by a rapid colorimetric assay using MTT. RT-PCR was performed to determine the relative expression of TGF-beta mRNA in response to LE and PDA. RESULTS: PDA inhibited proliferation of HTCF in a dose-dependent manner and LE inhibited significantly the proliferation of HTCF at the higher concentration of 50 microg/ml (p < 0.05). Compared to LE, PDA inhibited proliferation of HTCF significantly at each diluted concentration (p < 0.05). Expressions of TGF-beta were decreased as the concentration of both PDA and LE increased. PDA decreased expression of TGF-beta more significantly compared to LE at each concentration (p < 0.05). CONCLUSIONS: Although LE has offered promising anti-inflammatory efficacy with decreased impact on intraocular pressure, LE may be less effective than PDA in inhibiting fibroblast proliferation and may be not comparable to PDA in preventing excessive scarring after glaucoma filtering surgery.

Effect of poly(DL-lactide-co-glycolide) on scar formation after glaucoma filtration surgery / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Glaucoma filtering surgery (GFS) is the most common procedure performed in the treatment of glaucoma. Although antiscarring agents help prevent postsurgical scarring and improve glaucoma surgical outcomes, they may be associated with an increased incidence of severe and potentially blinding complications. Poly(DL-lactide-co-glycolide) (PDLLA/GA) is a bioresorbable polymer, which can be prepared with a large range of physical, mechanical, and biological properties and has been widely used in medicine, including as an absorbable suture and a drug carrier and especially as a scaffold in tissue engineering. This study aimed to evaluate the effect of PDLLA/GA on scar formation after glaucoma filtration surgery (GFS).</p><p><b>METHODS</b>Forty-eight New Zealand white rabbits were divided into two groups randomly and GFS was performed on the right eye of each. PDLLA/GA membranes were put under the sclera flap for evaluation. GFS with no membrane inserted served as control. Clinical evaluations of intraocular pressure (IOP) and the presence of a filtration bleb were performed at intervals (3 days, 1, 2, 4, 8, 12, 20, and 24 weeks) postoperatively. At each time point, three eyes per group were excised to observe histological changes such as inflammation and scar formation and the expression of collagen type IV, proliferating cell nuclear antigen (PCNA), matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of metalloproteinase-1 (TIMP-1). The expression of connective tissue growth factor (CTGF) mRNA was determined by reverse transcription-polymerase chain reaction.</p><p><b>RESULTS</b>The lower IOP level and an effective bleb were maintained for a long time after GFS in the PDLLA/GA group. The histological analysis showed less inflammation and scar formation, weaker expression of collagen type IV and PCNA, more intense MMP-9 and TIMP-1, slightly elevated ratio of MMP-9 and TIMP-1, and a smaller increase in CTGF mRNA postoperatively in the PDLLA/GA group but less than the control group (P < 0.05).</p><p><b>CONCLUSION</b>PDLLA/GA membranes may be promising for preventing fibrosis after GFS.</p>

Biomicroscopia ultrassônica na viscocanalostomia / Ultrasound biomicroscopy in viscocanalostomy

OBJETIVO: Estudar por biomicroscopia ultrassônica (UBM) de alta frequência as características anatômicas da viscocanalostomia, e a relação dessas características com a redução da pressão intraocular. MÉTODOS: Estudo transversal, que incluiu nove olhos (sete pacientes) submetidos à viscocanalostomia, e posteriormente examinados por UBM de alta frequência (80 MHz). Os parâmetros da UBM avaliados após um follow-up mínimo de seis meses foram: presença de espaço intraescleral, comprimento e altura máximos do espaço intraescleral, e a espessura mínima da membrana trabéculo-descemética (MTD) residual. O sucesso cirúrgico definiu-se como pressão intraocular (PIO) <22mmHg ou redução de 20% da PIO sem medicação tópica. Possíveis associações entre as variáveis da UBM e o resultado cirúrgico foram avaliados. RESULTADOS: O tempo médio entre a cirurgia e a realização da UBM foi de 15,5 ± 8,8 meses (6 - 29 meses). Verificou-se uma redução da PIO de 23,5 ± 6,9 mmHg (13,7-32,0) pré-operatória para 14,5 ± 2,4 mmHg (10,7-17,3) pós-operatória (p<0,05). Identificou-se a presença de espaço intraescleral em todos os olhos. A média do comprimento máximo do espaço intraescleral era 1,83 ± 0,51mm; a média da altura máxima do espaço intraescleral era 0,36 ± 0,17mm; e a média da espessura mínima da MTD era 0,14 ± 0,07mm. Não foram encontradas correlações significativas entre o valor da PIO pós-operatória e o comprimento do espaço intraescleral (r²=0,359), a altura do espaço intraescleral (r²=0,017) e a espessura da MTD (r²=0,003). CONCLUSÃO: Em pacientes submetidos à viscocanalostomia, a UBM após um follow-up mínimo de seis meses identificou o espaço intraescleral em todos os olhos. Não se encontrou qualquer correlação estatisticamente significativa entre os valores de PIO pós-operatória e as características anatômicas do espaço intraescleral.

PURPOSE: To evaluate by high frequency ultrasound biomicroscopy (UBM) the anatomical characteristics of viscocanalostomy and their relationship with the intraocular pressure (IOP) lowering. METHODS: A transversal study which included 9 eyes (7 patients) undergoing viscocanalostomy and examined by high frequency UBM (80 MHz). Several UBM variables were evaluated, including the presence of the intrascleral space, the maximum length and height of the intrascleral space and the minimum thickness of residual trabeculo-Descemet membrane (TDM). Surgical success was considered to be achieved when IOP was <22mmHg or the IOP was lowered 20% or more without the use of any medication. The possible association between UBM variables and the surgical outcome was determined. RESULTS: The mean time between surgery and the UBM examination was 15.5 ± 8.8 months (range 6-29). The mean IOP decreased from a preoperative value of 23.5 ± 6.9 mmHg (range 13.7-32.0) to 14.5 ± 2.4 mmHg (range 10.7-17.3) postoperative (p<0.05). The presence of an intrascleral space was a constant finding. The mean length of the intrascleral space was 1.83 ± 0.51mm, the mean height was 0,36 ± 0,17mm; and the mean TDM thickness was 0.14 ± 0.07mm. There were a poor correlation between the level of IOP at the time of UBM and the lenght of the intrascleral space (r²=0.359), the height of the intrascleral space (r²=0.017) or the thickness of the remaining TDM (r²=0.003). CONCLUSION: In patients undergoing viscocanalostomy, UBM examination after a minimum of 6-month follow-up period showed the presence of an intrascleral space in all patients. There was no statiscally significant relationship between the level of IOP and the anatomical characteristics of the intrascleral space.

Histopathologic Features of Triamcinolone Deposits in Refractory Steroid-Induced Glaucoma after Subtenon Triamcinolone Injection

PURPOSE: To report the removal of subtenon triamcinolone precipitates in patients with refractory steroid-induced glaucoma following subtenon triamcinolone injection. CASE SUMMARY: A 72-year-old male patient with diabetic retinopathy had cystoid macular edema in the right eye. The patient received a posterior subtenon injection of triamcinolone acetonide and developed intractable glaucoma one month after the injection in the right eye. Corticosteroid-deposit was excised three month after the injection. The intraocular pressure decreased to normal within one month after surgery and remained normal for seven months after surgery. A 42-year-old man with bilateral chronic recurrent anterior uveitis received a posterior subtenon triamcinolone acetonide injection in both eyes. The patient developed refractory steroid-induced glaucoma one month after the injection in the right eye. Corticosteroid-deposit was excised six months after the injection in the right eye. The patient's intraocular pressure decreased to normal within two weeks after surgery and remained normal. Light microscopy showed a fibrous capsule encapsulating an amorphous whitish material. The excised specimen with polarized light showed birefringence of triamcinolone crystals within an encapsulated cyst. CONCLUSIONS: Removal of subtenon triamcinolone acetonide precipitate may facilitate the management of patients developing increased intraocular pressure unresponsive to maximum tolerable medical therapy and should be considered before performing glaucoma filtration surgery.

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

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