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2.
Rev. bras. oftalmol ; 80(2): 91-95, Mar.-Apr. 2021. tab, graf
Article in Portuguese | LILACS | ID: biblio-1280107

ABSTRACT

RESUMO Objetivo: Avaliar os resultados da facotrabeculectomia em seguimento igual ou superior a 5 anos. Métodos: Estudo retrospectivo, de intervenção e analítico realizado no centro cirúrgico da clínica de olhos de Juazeiro do Norte com pacientes operados no período de 2006 a 2013. Foram envolvidos na investigação 34 olhos de 29 pacientes com catarata senil e glaucoma primário de ângulo aberto submetidos à facotrabeculectomia. Foi criado um escore de risco de dano glaucomatoso variando de 0 a 5 ao avaliar pressão intraocular, escavação do disco óptico, número de drogas hipotensoras utilizadas para o tratamento do glaucoma e a idade do paciente em anos. A amostra foi de conveniência e pareada. Foi utilizado o teste de Wilcoxon pareado para a verificação de diferenças entre médias. Foi aceito p< 0,05 para a rejeição da hipótese de nulidade. O estudo foi aprovado pelo comitê de ética da plataforma Brasil e segue a resolução 466 do Conselho Nacional de Saúde. Resultados: A média da acuidade visual foi significantemente maior após o seguimento de 5 anos (média pré-operatória 0,42 +/- 0,23 ver-sus média pós-operatória 0,62 +/- 0,29 - p=0,0031). A média dos escores de risco para dano glaucomatoso após 5 anos de seguimento foi significativamente menor quando comparado ao pré-operatório (media pré-operatória: 9,47 +/- 1,61 versus média pós-operatória 6,55 +/- 2,21) p < 0,0001, considerado extremamente significante. Conclusão: A facotrabeculectomia foi significantemente efetiva na melhora da acuidade visual e na redução do risco de dano glau-comatoso após seguimento pós-operatório igual ou superior a 5 anos.


ABSTRACT Objective: To evaluate the results of phacotrabeculectomy in a follow-up of five years or more. Methods: Retrospective, interventional and analytical study that was carried out in the surgical center of clínica de olhos do juazeiro with patients operated on from 2006 to 2013. 34 eyes of 29 patients with senile cataract and primary open-angle glaucoma, who underwent phacotrabeculectomy were involved in the investigation. A risk score for glaucomatous dam-age ranging from 0 to 5 when evaluating intraocular pressure, excavation of the optic disc, number of hypotensive drugs used to treat glaucoma and the patient's age in years. The sample was of convenience and paired. The paired Wilcoxon test was used to verify differences be-tween means. P <0.05 was accepted for the rejection of the null hypothesis. The study was approved by the ethics committee of the Brazil platform and follows the principles of resolu-tion 466 of the National Health Council. Results: The mean visual acuity was significantly higher after a five-year follow-up (preoperative average 0.42 +/- 0.23 versus postoperative average 0.62 +/- 0.29 - p = 0.0031). The average risk score for glaucomatous damage after five years of follow-up was significantly lower when compared to the preoperative (preoperative mean: 9.47 +/- 1.61 versus postoperative mean 6.55 +/- 2, 21) p <0.0001, considered extremely significant. Conclusion: Phacotrabeculectomy was significantly effective in improving visual acuity and reducing the risk of glaucomatous damage after a five-year postoperative follow-up.


Subject(s)
Humans , Male , Female , Aged , Aged, 80 and over , Cataract/complications , Trabeculectomy/methods , Glaucoma, Open-Angle/surgery , Phacoemulsification/methods , Visual Acuity , Visual Fields , Glaucoma, Open-Angle/complications , Retrospective Studies , Follow-Up Studies , Treatment Outcome , Combined Modality Therapy , Intraocular Pressure
3.
Rev. cuba. oftalmol ; 33(4): e988, oct.-dic. 2020. tab
Article in Spanish | LILACS, CUMED | ID: biblio-1156571

ABSTRACT

Objetivo: Describir los resultados visuales e hipotensores de la trabeculotomía gonioasistida modificada y determinar sus complicaciones. Métodos: Se realizó un estudio analítico de 30 ojos; 15 de ellos (15 pacientes) recibieron trabeculotomía gonioasistida modificada (grupo caso) y 15 ojos (15 pacientes) recibieron trabeculectomía con mitomicina C (control histórico). Resultados: Predominaron los pacientes masculinos. La edad promedio del grupo con trabeculectomía fue 64,2 ± 7,3 años; mientras la del grupo con trabeculotomía gonioasistida modificada fue 69,9 ± 4,8 años. La agudeza visual mejor corregida media preoperatoria fue menor en el grupo con trabeculectomía (95 VAR/100-80 vs. 97 VAR/100-90) y la presión intraocular media fue 26,0 mmHg/24,5-30,0) y 25,0 mmHg/22,5-27,0 respectivamente. Todos los pacientes con trabeculectomía recibieron 3 colirios hipotensores en el preoperatorio, mientras el 53,3 por ciento de los tratados con trabeculotomía gonioasistida modificada requirieron 3 colirios hipotensores. Al año, la agudeza visual mejor corregida media disminuyó en el grupo con trabeculectomía (90VAR/100-75), y se mantuvo en el grupo con trabeculotomía gonioasistida modificada (97VAR/100-90). En ambos grupos se produjo una caída significativa de la PIO promedio y más del 85 por ciento de los casos requirió uno o ningún colirio para su control. Conclusiones: El resultado visual, el poder hipotensor y las complicaciones quirúrgicas al año muestran la trabeculotomía gonioasistida modificada como una técnica útil y segura. Se requieren estudios a largo plazo para evaluar su efectividad futura(AU)


Objective: Describe results one year after modified gonioscopy-assisted trabeculotomy. Methods: An analytical study was conducted of 30 eyes, 15 of which (15 patients) underwent modified gonioscopy-assisted trabeculotomy (GATTm) (case group), and 15 trabeculotomy with mitomycin C (TBT) (historical control). Results: Male patients prevailed. Mean age was 64.2 ± 7.3 years for the TBT group and 69.9 ± 4.8 years for the GATTm group. In the TBT group mean preoperative best corrected visual acuity was lower (95 VAR/100-80 vs. 97VAR/100-90), whereas mean intraocular pressure was 26.0 mmHg/24.5-30.0 and 25.0 mmHg/22.5-27.0, respectively. All TBT patients received 3 hypotensive collyriums preoperative, while 53.3 percent of the GATTm patients required 3 hypotensive collyriums. At one year, mean best corrected visual acuity was lower in the TBT group (90VAR/100-75) and remained the same in the GATTm group (97VAR/100-90). A significant mean intraocular pressure reduction was observed in both groups and more than 85 percent of the cases required either one or no collyrium for their control. Conclusions: Visual result, hypotensive effect and surgical complications at one year are evidence that modified gonioscopy-assisted trabeculotomy is a safe, useful technique. Long-term studies are required to evaluate its future effectiveness(AU)


Subject(s)
Humans , Male , Middle Aged , Glaucoma/diagnosis , Mitomycin/therapeutic use , Intraocular Pressure , Trabeculectomy/methods
5.
Rev. cuba. oftalmol ; 33(4): e970, oct.-dic. 2020. graf
Article in Spanish | LILACS, CUMED | ID: biblio-1156586

ABSTRACT

Se presenta una paciente femenina, de 52 años de edad, con antecedentes de asma bronquial, miopía y glaucoma juvenil diagnosticado a los 22 años de edad. Le fueron realizadas dos trabeculectomías en el ojo izquierdo y una en el ojo derecho. En el año 2008 se le realizó cirugía de facoemulsificación más implante de lente intraocular en ambos ojos. La paciente acudió a nuestro Servicio hace un año, y refirió disminución progresiva de la visión. El examen oftalmológico reveló agudeza visual mejor corregida de 0,4 y presión intraocular de 30 y 23,5 mm/Hg para los respectivos ojos, con terapia hipotensora máxima tolerable. Al fondo de ojo se observó daño glaucomatoso avanzado, mayor en ojo izquierdo. Como opción de tratamiento se realizó ciclofotocoagulación transescleral en 2 cuadrantes del ojo derecho. A los 6 meses se constató presión intraocular de 30 y 18 mm/Hg, y se decidió el implante de la válvula de Baervelt en el temporal superior del ojo derecho. En el posoperatorio a los 7 días el examen oftalmológico arrojó presión intraocular de 5 mm/Hg, atalamia grado III y agudeza visual mejor corregida de 0,2. Se prescribió tratamiento con midriático ciclopléjico y antinflamatorios tópicos y sistémicos, y se logró a los 15 días mejoría del cuadro ocular. Se obtuvo buena agudeza visual y presión intraocular de 12 mmHg a los 3 meses del posoperatorio. El dispositivo del drenaje de Baerveldt es eficaz para lograr la reducción de la presión intraocular en el glaucoma refractario(AU)


A case is presented of a female 52-year-old patient with a history of bronchial asthma, myopia and juvenile glaucoma diagnosed at age 22. Two trabeculectomies were performed on the left eye and one on the right eye. In the year 2008 the patient underwent phacoemulsification surgery plus intraocular lens implantation in both eyes. She attended our service a year ago, reporting progressive vision reduction. Ophthalmological examination revealed best corrected visual acuity of 0.4 and intraocular pressure of 30 and 23.5 mm/Hg for either eye, with maximum tolerated hypotensive therapy. Funduscopy showed advanced glaucomatous damage, greater in the left eye. The treatment option selected was transcleral cyclophotocoagulation in two quadrants of the right eye. At 6 months intraocular pressure was 30 and 18 mm/Hg, and it was decided to implant a Baerveldt valve in the upper temporal quadrant of the right eye. Ophthalmological examination results at 7 days postoperative were intraocular pressure 5 mm/Hg, grade III athalamia and best corrected visual acuity 0.2. The treatment indicated was a cycloplegic mydriatic and topical and systemic anti-inflammatories. Ocular status improvement was achieved at 15 days. Satisfactory visual acuity and an intraocular pressure of 12 mm/Hg were obtained at 3 months postoperative. The Baerveldt drainage device is effective to achieve intraocular pressure reduction in refractory glaucoma(AU)


Subject(s)
Humans , Female , Middle Aged , Trabeculectomy/methods , Glaucoma/diagnosis , Phacoemulsification/methods , Lens Implantation, Intraocular/adverse effects , Vision, Ocular/physiology
6.
Rev. cuba. oftalmol ; 33(4): e914, oct.-dic. 2020. graf
Article in Spanish | LILACS, CUMED | ID: biblio-1156584

ABSTRACT

El tratamiento del glaucoma se realiza con el objetivo de disminuir los niveles de presión intraocular, único factor tratable hasta el momento, y debe ser individualizado. Se presenta un paciente masculino de 54 años de edad, de piel mestiza, intelectual, con antecedentes de aparente salud y diagnóstico de glaucoma desde hace 10 años. Se realizó trabeculectomía con antimetabolito (mitomicina C) en el ojo izquierdo en el año 2012 por daño glaucomatoso avanzado. En el año 2016 acudió a nuestra consulta y refirió mala visión y descontrol de la presión intraocular de ambos ojos. Se constataron cifras muy elevadas de presión intraocular en ambos ojos, superiores a 30 mmHg; en el ojo derecho la unidad de visión con su mejor corrección y un daño campimétrico muy avanzado limitado a una isla de visión central con caída hasta los 5° centrales, y el ojo izquierdo no alcanzaba la percepción luminosa. Después de combinar 3 líneas farmacológicas con la dosis máxima, los valores de la presión intraocular no eran protectores. Surgió la disyuntiva entre realizar una cirugía filtrante, temiendo al riesgo quirúrgico elevado y tratándose de un ojo único, o no practicar cirugía alguna y solo continuar con el tratamiento farmacológico a pesar de no conseguirse valores de presión intraocular meta. Se decidió realizar esclerectomía profunda no penetrante con antimetabolito (mitomicina C al 0,02 por ciento). No se presentaron complicaciones asociadas y se consiguió el descenso de la presión intraocular a 24 mmHg, por lo que al mes de la cirugía se realizó goniopuntura. Se obtuvo la presión intraocular objetivo, sin progresión del daño glaucomatoso y hubo conservación de la agudeza visual(AU)


Treatment for glaucoma is aimed at reducing the levels of intraocular pressure. This is the only factor that may be treated so far, and it should be individualized. A case is presented of a male 54-year-old mulatto patient, intellectual, with a history of apparently good health who was diagnosed with glaucoma ten years ago. Trabeculectomy with antimetabolite (mitomycin C) was performed on the patient's left eye in the year 2012 due to advanced glaucomatous damage. In the year 2016 the patient attended our service and reported poor vision and uncontrolled intraocular pressure in both eyes. Very high intraocular pressure values above 30 mmHg were confirmed in both eyes. In the right eye the vision unit with its best correction, and very advanced campimetric damage limited to a central vision island with a fall to 5° central, whereas the left eye did not achieve light perception. After combining 3 drug lines at their maximum dosage, intraocular pressure values were not protective. The dilemma arose whether to perform filtration surgery, fearing the high surgical risk, being as it was a single eye, or not to perform any surgery and just go on with the drug treatment despite not having achieved target intraocular pressure values. It was decided to perform non-penetrating deep sclerectomy with antimetabolite (0.02 percent mitomycin C). No associated complications occurred and intraocular pressured fell to 24 mmHg. Therefore, goniopuncture was performed one month after surgery. The target intraocular pressure was obtained without glaucomatous damage progression and visual acuity was preserved(AU)


Subject(s)
Humans , Male , Middle Aged , Trabeculectomy/methods , Mitomycin/therapeutic use , Intraocular Pressure/drug effects , Glaucoma/diagnosis , Glaucoma/therapy
7.
Rev. cuba. oftalmol ; 33(4): e917, oct.-dic. 2020. graf
Article in Spanish | LILACS, CUMED | ID: biblio-1156582

ABSTRACT

El glaucoma congénito primario constituye la forma más común de glaucoma infantil, el cual exige un diagnóstico precoz y un tratamiento quirúrgico relativamente urgente, ya que puede ocasionar graves secuelas morfológicas y funcionales. Se presenta la realización, por primera ocasión, de la trabéculo-trabeculectomía combinada en la República Democrática y Popular de Argelia. Se ejecutó en un paciente árabe, de un año de edad, a quien se le diagnosticó el glaucoma congénito primario II. Se evaluó el seguimiento posoperatorio con resultados satisfactorios, por lo que se consideró la trabéculo-trabeculectomía como el proceder quirúrgico efectivo y suficientemente seguro, el cual debe ser realizado por un personal calificado para poder admitirse como primera opción en el tratamiento quirúrgico del glaucoma congénito primario(AU)


Primary congenital glaucoma is the most common form of childhood glaucoma. This condition requires early diagnosis and relatively urgent surgical treatment, since it may leave serious morphological and functional sequelae. A description is provided of the first combined trabeculotomy-trabeculectomy performed in the People's Democratic Republic of Algeria. The operation was performed on a male one-year-old Arab patient diagnosed with primary congenital glaucoma II. Post-operative follow-up found satisfactory results, and trabeculotomy-trabeculectomy was thus considered to be an effective, sufficiently safe surgical procedure, which should be performed by qualified personnel to be accepted as the first surgical treatment option for primary congenital glaucoma(AU)


Subject(s)
Humans , Infant , Trabeculectomy/methods , Glaucoma/diagnostic imaging , Early Diagnosis
8.
Rev. cuba. oftalmol ; 33(4): e981, oct.-dic. 2020. graf
Article in Spanish | LILACS, CUMED | ID: biblio-1156581

ABSTRACT

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)


Subject(s)
Humans , Male , Middle Aged , Trabeculectomy/methods , Glaucoma/diagnosis , Mitomycin/adverse effects , Filtering Surgery/adverse effects , Intraocular Pressure
9.
Rev. cuba. oftalmol ; 33(2): e856, tab
Article in Spanish | LILACS, CUMED | ID: biblio-1139074

ABSTRACT

RESUMEN Objetivo: Determinar los resultados de la facotrabeculectomía por dos vías como tratamiento combinado de pacientes cubanos con glaucoma y catarata. Métodos: Se realizó un estudio observacional descriptivo longitudinal prospectivo en pacientes adultos cubanos tratados con facotrabeculectomía en el Servicio de Glaucoma del Instituto Cubano de Oftalmología "Ramón Pando Ferrer" entre junio del año 2016 y abril de 2017. El universo estuvo constituido por todos los pacientes operados con facotrabeculectomía por dos vías. La muestra la integraron pacientes operados por un mismo cirujano, quienes estuvieron de acuerdo con participar en la investigación. Se excluyeron aquellos con cirugía intraocular previa. Salieron del estudio los que no pudieron mantener el seguimiento en la institución. Se estudiaron las variables edad, sexo, color de la piel, agudeza visual mejor corregida, presión intraocular, número de medicamentos hipotensores oculares y complicaciones presentadas. El seguimiento fue por dos años con consultas al día siguiente, a los siete y a los treinta días; a los tres y a los seis meses; al año y a los dos años. Resultados: Se observaron 31 pacientes. La edad promedio fue de 70 años, con predominio del sexo femenino y el color de la piel no blanco; la agudeza visual mejor corregida preoperatoria media 0,58 y la posoperatoria 0,73. La presión intraocular media preoperatoria 22,04 mmHg y a los dos años 16,37 mmHg. La media de los medicamentos hipotensores preoperatorios fue 3,0 y 0,3 a los dos años. Las complicaciones más frecuentes resultaron la ruptura transquirúrgica de la cápsula posterior y la opacidad posquirúrgica de la cápsula posterior. Conclusiones: Con la facotrabeculectomía por dos vías disminuye la presión intraocular; mejora la agudeza visual mejor corregida y se reduce el número de fármacos hipotensores oculares al menos durante dos años. Las complicaciones asociadas a la técnica son mínimas(AU)


ABSTRACT Objective: Determine the results of two-site phacotrabeculectomy as combined therapy for Cuban patients with glaucoma and cataract. Methods: An observational prospective longitudinal descriptive study was conducted of Cuban patients undergoing phacotrabeculectomy at the Glaucoma Service of Ramón Pando Ferrer Cuban Institute of Ophthalmology from June 2016 to April 2017. The study universe was all the patients undergoing two-site phacotrabeculectomy. The sample was patients operated on by the same surgeon who consented to participate in the research. Patients with a history of intraocular surgery were excluded, as well as those who could not be followed up at the institution. The variables considered were age, sex, skin color, best corrected visual acuity, intraocular pressure, number of ocular hypotensive drugs, and complications developed. Follow-up extended for two years with visits on the next day, at seven and thirty days, at three and six months, and at one and two years. Results: Thirty-one patients were observed. Mean age was 70 years, with a predominance of the female sex and non-white skin color. Best corrected visual acuity was 0.58 preoperative and 0.73 postoperative. Mean preoperative intraocular pressure was 22.04 mmHg, whereas at two years it was 16.37 mmHg. Hypotensive drugs averaged 3.0 preoperative and 0.3 at two years. The most common complications were intraoperative posterior capsule rupture and postsurgical posterior capsule opacity. Conclusions: Two-site phacotrabeculectomy reduces intraocular pressure, improves best corrected visual acuity and lowers the number of ocular hypotensive drugs for at least two years. The complications associated to the technique are minimum(AU)


Subject(s)
Humans , Female , Aged , Cataract/etiology , Trabeculectomy/methods , Glaucoma/epidemiology , Combined Modality Therapy/methods , Phacoemulsification/methods , Epidemiology, Descriptive , Prospective Studies , Longitudinal Studies , Observational Studies as Topic
10.
Rev. cuba. oftalmol ; 32(3): e778, jul.-set. 2019.
Article in Spanish | LILACS, CUMED | ID: biblio-1099089

ABSTRACT

RESUMEN El tratamiento del glaucoma pediátrico es principalmente quirúrgico. En la actualidad se han creado alternativas para mejorar el éxito de las diferentes técnicas quirúrgicas relacionadas con el glaucoma pediátrico, donde se exige un tratamiento oportuno para poder controlar las presiones intraoculares y rehabilitar precozmente a estos pacientes, ya que muchos de ellos se encuentran en pleno desarrollo visual. De ahí la importancia de realizar una revisión de las principales técnicas quirúrgicas del glaucoma pediátrico(AU)


ABSTRACT Treatment of childhood glaucoma is mainly surgical. New alternatives are presently available to improve the success of the various surgical techniques for childhood glaucoma, a condition requiring timely treatment aimed at intraocular pressure control and quick rehabilitation of these patients, considering that many of them are in full visual development. Hence the importance of conducting a review of the main surgical techniques used for childhood glaucoma(AU)


Subject(s)
Humans , Child, Preschool , Child , Pediatrics , Trabeculectomy/methods , Glaucoma/diagnosis
11.
Rev. cuba. oftalmol ; 32(3): e770, jul.-set. 2019. tab
Article in Spanish | LILACS, CUMED | ID: biblio-1099085

ABSTRACT

RESUMEN Se realiza una actualización sobre el diagnóstico y tratamiento del glaucoma infantil primario, considerando la importancia que tiene un diagnóstico precoz y un tratamiento oportuno para obtener los mejores resultados posibles. Actualmente, a pesar del surgimiento de nuevos fármacos y de técnicas quirúrgicas para tratar esta afección, aún existen discrepancias sobre cómo debemos realizar el diagnóstico positivo; qué tratamiento o técnica quirúrgica emplear; cuándo y cuál sería la mejor. Cuando se trata de glaucoma pediátrico (primario o secundario), presente en etapas tan tempranas de la vida -incluso al nacimiento, donde la cirugía está indicada lo más precozmente posible, con la disyuntiva de cuáles medicamentos podemos emplear o no, por desconocimiento de qué efectos indeseables pudieran presentarse en estas edades y además, teniendo en cuenta que estos niños serán nuestros pacientes para toda la vida- es necesario conocer y repasar una vez más este tema. Se recomienda instruir a pediatras y oftalmólogos generales para lograr la remisión adecuada y precoz del niño a un centro especializado para su tratamiento quirúrgico, y mejorar así su pronóstico visual(AU)


ABSTRACT Updated information is provided about the diagnosis and treatment of primary childhood glaucoma, given the importance of early diagnosis and timely treatment to obtain the best possible results. Despite the emergence of new drugs and surgical techniques to treat this disorder, there is still controversy about how we should perform the positive diagnosis, what treatment or surgical technique should be used and when, and which would be the best. When childhood glaucoma (whether primary or secondary) presents at early stages of life - even at birth -, in which case surgery should be indicated as soon as possible, we are faced with the dilemma of what drugs we may or may not use, due to lack of knowledge about undesirable effects which could appear at these ages, and bearing in mind that these children will be our patients for a lifetime. It is thus necessary to be informed about this topic and go over it once again. It is recommended to instruct pediatricians and ophthalmologists to ensure timely, appropriate referral of the child patient to a specialized center where they will receive surgical treatment, thus improving their visual prognosis(AU)


Subject(s)
Humans , Infant , Child, Preschool , Tonometry, Ocular/methods , Trabeculectomy/methods , Ocular Hypertension/etiology , Early Diagnosis , Gonioscopy/methods
12.
Rev. bras. oftalmol ; 78(4): 274-277, July-Aug. 2019. tab, graf
Article in Portuguese | LILACS | ID: biblio-1042376

ABSTRACT

Resumo A matriz de colágeno Ologen TM é um novo agente antifibrótico composto por uma matriz porosa de atelocolageno tipo I e glicosaminoglicanos reticulados, que pode ser utilizado como uma alternativa para a modulação da cicatrização nas cirurgias. Por ser altamente poroso e biodegradável, este implante auxilia nos processos de reparação fisiológicos que ocorrem no tecido conjuntivo e epitelial da lesão, sem a formação de tecido fibrótico, o qual acarreta insucesso cirúrgico e elevação da PIO. A Trabeculectomia (TREC) é considerada a cirurgia padrão para o tratamento do glaucoma, no entanto as taxas de sucesso cirúrgico a médio e longo prazo estão relacionadas a cicatrização do sítio operatório, envolvendo principalmente o tecido conjuntival e tenoniano. O processo de cicatrização é divido em 4 fases principais: coagulativa, inflamatória, proliferativa e remodeladora, com uma série de cascatas químicas e fatores bioquímicos liberados na tentativa de restabelecer a hemostasia. Diversas pesquisas na literatura já demonstraram os efeitos benéficos na cicatrização ao utilizar a matriz de colágeno Ologen em cirurgias oftalmológicas, além das possíveis complicações. Os resultados dos atuais estudos com implante de Ologen para o tratamento de glaucoma são encorajadores e promissores. No entanto, ensaios clínicos randomizados futuros com seguimento a longo prazo são necessários para avaliarmos a segurança e a eficácia do novo implante na modulação da cicatrização, alcançando melhores taxas de sucesso cirúrgico.


Abstract The Ologen™ collagen matrix is a new antifibrotic agent composed of a porous matrix of type I atelocolagene and cross-linked glycosaminoglycans, which can be used as an alternative for the modulation of healing in surgeries. Because it is highly porous and biodegradable, this implant assists in the physiological repair processes that occur in the connective and epithelial tissue of the lesion without the formation of fibrotic tissue, which leads to surgical failure and IOP elevation. The Trabeculectomy (TREC) is considered the standard surgery for the treatment of glaucoma; however, the surgical success rates in the medium and long term are related to surgical site healing, mainly involving conjunctival and tenonian tissue. The healing process is divided into 4 main phases: coagulative, inflammatory, proliferative and remodeling, with a series of chemical cascades and biochemical factors released in an attempt to restore hemostasis. Since several researches in the literature have already demonstrated the beneficial effects on healing by using the Ologen collagen matrix in ophthalmic surgeries, in addition to possible complications. The results of current Ologen implant studies for the treatment of glaucoma are encouraging and promising. However, future randomized clinical trials with long-term follow-up are necessary to evaluate the safety and efficacy of the new implant in modulating healing, achieving better rates of surgical success.


Subject(s)
Humans , Male , Female , Adult , Middle Aged , Wound Healing , Trabeculectomy/methods , Mitomycin/therapeutic use , Absorbable Implants , Comparative Study , Glaucoma/surgery , Retrospective Studies
13.
Rev. cuba. oftalmol ; 31(3): 1-9, jul.-set. 2018. ilus
Article in Spanish | LILACS | ID: biblio-985575

ABSTRACT

En una enfermedad como el glaucoma, considerada la segunda causa de ceguera en Cuba y en el mundo, el tratamiento quirúrgico ha experimentado una evolución sorprendente y se buscan opciones más sencillas, eficaces y con un posoperatorio tranquilo. En el departamento de Glaucoma del Instituto Cubano de Oftalmología se comenzó a realizar una modificación de la trabeculotomía gonioasistida y es de interés presentarla mediante la evolución posoperatoria a corto plazo de un caso clínico. Se trata de un paciente de 72 años de edad, con catarata y glaucoma descompensado, a pesar del tratamiento médico. Se presenta con 50 VAR de visión y presión intraocular de 26 mmHg. Se realizó cirugía combinada: facoemulsificación y trabeculotomía gonioasistida modificada. Se lograron cifras de presión intraocular de 18 mmHg y agudeza visual mejor corregida de 100 VAR a los 6 meses posoperatorios(AU)


In a disease such as glaucoma, considered the second main cause of blindness both in Cuba and worldwide, surgical treatment has experienced surprising development, and simpler, more effective alternatives as well as a quiet postoperative period are constantly sought. At the glaucoma department of the Cuban Institute of Ophthalmology a modification has started to be performed of gonioscopy-assisted trabeculotomy. It would be interesting to present it by describing the short-term postoperative evolution of the clinical case of a 72-year-old male patient with cataract and decompensated glaucoma despite medical treatment. At presentation, the patient's vision was 50 VAR and intraocular pressure 26 mmHg. Combined surgery was performed: phacoemulsification and modified gonioscopy-assisted trabeculotomy. Six months after surgery, intraocular pressure was 18 mmHg and best corrected visual acuity was 100 VAR(AU)


Subject(s)
Humans , Male , Aged , Trabeculectomy/methods , Glaucoma/drug therapy , Minimally Invasive Surgical Procedures/adverse effects , Phacoemulsification/methods
14.
Rev. bras. oftalmol ; 77(4): 214-218, jul.-ago. 2018. tab, graf
Article in English | LILACS | ID: biblio-959101

ABSTRACT

ABSTRACT Objective: We describe the pressure lowering effect of micropulse laser trabeculoplasty (MLT) in patients with uncontrolled open angle glaucoma (OAG). Design: Retrospective case series. Methods: We retrospective reviewed 30 eyes with Open angle Glaucoma (OAG) at the Vista Clinic in Lima, Peru. A single session of MLT treatment was delivered using a 532 nm Frequency doubled Nd. YAG laser to 360º of the trabecular meshwork with a power of 1000 mW, 25 % of duty cycle, and 300 ms. of exposure. The intraocular pressure (IOP) was measured at baseline and at 1 day, 1 week, 3, 6 months post-treatment and were followed up for one last control. Results: The mean baseline IOP was 15.6 mmHg and in the last control was12.8 mmHg, mean follow up time of 19 months (+/- 10 SD). The mean reduction of IOP in the first day was 1.6 mmHg (± 2.6 SD) and 1.2 mmHg (± 3.3 SD) in the last follow up. The mean percentage of IOP reduction was 17.9% and 7 eyes (40%) had IOP reduction greater than 20%. No statistical difference in relation to demographics characteristics of the patients. The greatest reduction was achieved in the first day with a median of 2.00 (P 0.001). A tendency to achieve higher reduction of IOP in patients with higher baseline IOP was found, but was not statistical significant. No adverse reactions occurred. Conclusions: Micropulse laser trabeculoplasty can temporarily be effective in reducing the IOP in some patients with uncontrolled Open angle glaucoma and appears to be safe.


RESUMO Objetivo: Descrevemos o efeito redutor de pressão da trabeculoplastia com laser de micropulso (MLT) em pacientes com glaucoma de ângulo aberto (OAG) descontrolado. Design: Série de casos retrospectiva. Métodos: Foram revisados retrospectivamente 30 olhos com glaucoma de ângulo aberto (OAG) na Clínica Vista em Lima, Peru. Uma única sessão de tratamento com MLT foi administrada usando uma Nd de frequência duplicada de 532 nm. Laser YAG a 360 º da malha trabecular com uma potência de 1000 mW, 25% do ciclo de trabalho e 300 ms. de exposição. A pressão intra-ocular (PIO) foi medida no início e em 1 dia, 1 semana, 3, 6 meses após o tratamento e foram seguidos por um último controle. Resultados: A média da PIO basal foi de 15,6 mmHg e no último controle foi de 12,8 mmHg, com tempo médio de seguimento de 19 meses (+/- 10 DP). A redução média da PIO no primeiro dia foi de 1,6 mmHg (± 2,6 DP) e 1,2 mmHg (± 3,3 DP) no último seguimento. A porcentagem média de redução da PIO foi de 17,9% e 7 olhos (40%) tiveram redução da PIO superior a 20%. Nenhuma diferença estatística em relação às características demográficas dos pacientes. A maior redução foi obtida no primeiro dia com mediana de 2,00 (P 0,001). A tendência de atingir uma redução maior da PIO em pacientes com PIO basal mais alta foi encontrada, mas não foi estatisticamente significativa. Nenhuma reação adversa ocorreu. Conclusões: A trabeculoplastia a laser Micropulse pode ser temporariamente eficaz na redução da PIO em alguns pacientes com glaucoma de ângulo aberto descontrolado e parece ser segura.


Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Trabeculectomy/methods , Glaucoma, Open-Angle/surgery , Laser Therapy/methods , Peru , Medical Records , Retrospective Studies , Lasers, Semiconductor/therapeutic use , Intraocular Pressure
15.
Rev. bras. oftalmol ; 77(4): 180-183, jul.-ago. 2018. graf
Article in English | LILACS | ID: biblio-959097

ABSTRACT

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.


Subject(s)
Humans , Trabeculectomy/adverse effects , Glaucoma/surgery , Suture Techniques , Filtering Surgery/adverse effects , Trabeculectomy/methods , Medical Records , Retrospective Studies , Intraoperative Complications/prevention & control
16.
Rev. bras. oftalmol ; 77(1): 25-29, jan.-fev. 2018. tab, graf
Article in English | LILACS | ID: biblio-899108

ABSTRACT

Abstract Objective: The main purpose of this article is to compare the predictability of biometric results and final refractive outcomes expected in patients undergoing cataract surgery through phacoemulsification with and without associated trabeculectomy. Methods: Cataract patients who have undergone phacoemulsification surgery alone (control group) or associated with trabeculectomy (study group) screened. All surgeries were performed following standard protocol. For enrollment, biometrics calculated by IOL Master (Carl Zeiss Meditec, Inc.) biometry, refraction and intraocular pressure (IOP) before and after surgery were required. Data was compared between groups in addition to the correlation between variation of IOP and final refraction. Results: Thirty eyes per group were enrolled. Only prior IOP (p <0.001), IOP post-surgery (p = 0.01) and the difference in IOP (p <0.001) were statistically significant. Axial length, IOL diopter used, expected spherical refraction by biometrics and astigmatism pre- and post-surgery were similar in both groups (p=0.1; 0.4; 0.4; 0.5 and 0.3, respectively). Spherical predictability by biometrics within 0.25 diopters was noted in both the control group (range 0.06 ± 0.45) and study group (range 0.25 ± 0.97, p = 0.3). There was no statistical significance between groups for the difference between final cylinder and corneal astigmatism (p = 0.9), and the difference between axis of refractive and corneal astigmatism (p = 0.7). Conclusion: The biometric predictability in phacoemulsification surgery and the expected final refraction are significant, andare not modified by trabeculectomy in the combined surgeries.


Resumo Objetivo: Comparar a previsibilidade dos resultados refracionais e da biometria em pacientes submetidos à cirurgia de catarata por facoemulsificação com e sem trabeculectomia (Trec) associada. Métodos: Pacientes com catarata submetidos à cirurgia de facoemulsificação isolada (grupo controle) ou associada a Trec (catarata + glaucoma, grupo estudo) foram consecutivamente selecionados. Todas as cirurgias foram feitas seguindo protocolo padrão. Para inclusão, era necessário apresentar biometria calculada pelo biômetro IOL Master (Carl Zeiss, Meditec, Inc), refração e pressão intraocular (Pio) pré e pós-operatórios. Os dados foram comparados entre os grupos, além da correlação entre a variação da Pio e a refração final. Resultados: Foram incluídos 30 olhos por grupo. Na comparação, apenas a Pio prévia (p<0,001), Pio pós cirurgia (p=0,01) e a diferença de Pio pré-pós cirurgia (3,8 ± 4,4mmHg vs. 15,5 ± 9,3mmHg, grupos controle e estudo, respectivamente, p<0,001) foram estatisticamente significativos. Diâmetro axial, dioptria da Lio utilizada, dioptria esperada pela biometria e astigmatismo prévio e pós- cirurgia foram estatisticamente semelhantes entre os grupos (p=0,1; 0,4; 0,4; 0,5 e 0.3, respectivamente). Notou-se previsibilidade esférica pela biometria dentro de 0,25 dioptrias, tanto no grupo controle (variação de 0,06 ± 0,45), quanto no grupo estudo (variação de 0,25 ± 0,97, p=0,3). Não houve significância estatística entre os grupos para a diferença entre o cilindro final e o astigmatismo corneano em dioptrias (p=0,9), e diferença entre o eixo do astigmatismo refracional e corneano (p=0,7). Conclusão: A previsibilidade biométrica e a refração na cirurgia de facoemulsificação aferida pelo biômetro IOL Master é significativa, e não sãoalteradas na cirurgia combinada com trabeculectomia.


Subject(s)
Humans , Male , Female , Aged , Refraction, Ocular , Trabeculectomy/methods , Biometry , Phacoemulsification/methods , Postoperative Period , Cataract , Visual Acuity , Glaucoma , Treatment Outcome , Combined Modality Therapy , Lens Implantation, Intraocular , Intraocular Pressure
17.
Medwave ; 18(5): e7238, 2018.
Article in English, Spanish | LILACS | ID: biblio-915409

ABSTRACT

Resumen INTRODUCCIÓN: La derivación acuosa ha surgido como una técnica alternativa a la trabeculectomía, considerada la cirugía de elección en pacientes con glaucoma. Actualmente, se considera que la principal indicación de esta técnica es ante el fracaso de la trabeculectomía o en tipos de glaucoma que tienen alto riesgo de fracasar. La válvula Ahmed y el implante Baerveldt son las derivaciones acuosas más utilizadas. Sin embargo, no está claro cuáles son las diferencias entre estas dos alternativas. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud a nivel mundial, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyeron 10 estudios primarios, de los cuales dos son ensayos aleatorizados. Concluimos que la válvula Ahmed probablemente logra una menor disminución de la presión intraocular; podría lograr un menor éxito calificado y probablemente necesita más reintervenciones que el implante Baerveldt. Respecto al perfil de seguridad, la válvula Ahmed no se presenta claramente superior ni inferior al implante Baerveldt.


Abstract INTRODUCTION: Aqueous shunt has emerged as an alternative technique to trabeculectomy, considered the standard for glaucoma surgery. Currently, it is mainly indicated after failure of trabeculectomy or in glaucoma with high risk of failure. The Ahmed valve and the Baerveldt implant are the most commonly used aqueous shunts. However, it is not clear whether there are differences between them. METHODS.: o answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews including 10 studies overall, of which two were randomized trials. We concluded the Ahmed valve probably achieves a lower decrease in intraocular pressure, might lead to less qualified success and probably needs more reinterventions than the Baerveldt implant. Regarding safety profile, the Ahmed valve is not clearly superior or inferior to the Baerveldt implant.


Subject(s)
Humans , Trabeculectomy/methods , Glaucoma/surgery , Glaucoma Drainage Implants , Trabeculectomy/instrumentation , Randomized Controlled Trials as Topic , Databases, Factual , Treatment Outcome , Prosthesis Implantation/methods , Intraocular Pressure
18.
Medwave ; 18(8): e7389, 2018.
Article in English, Spanish | LILACS | ID: biblio-969324

ABSTRACT

INTRODUCCIÓN: La derivación acuosa ha surgido como una técnica alternativa a la trabeculectomía, la cual se considera el tratamiento estándar para cirugía de glaucoma. Actualmente, su principal indicación es en el glaucoma con trabeculectomía fallida o en algunos tipos de glaucoma con alto riesgo de fracaso. Sin embargo, aún existe controversia con respecto a su efectividad en comparación con la trabeculectomía. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyeron nueve estudios primarios, de los cuales, cuatro corresponden a ensayos aleatorizados. Concluimos que la derivación acuosa podría aumentar el éxito calificado en comparación con la trabeculectomía, pero que no está claro si tiene algún efecto sobre el resto de los desenlaces críticos para la toma de decisión, porque la certeza de la evidencia es muy baja.


INTRODUCTION: Aqueous shunt has emerged as an alternative technique to trabeculectomy, which is considered the standard treatment for glaucoma surgery. Currently, it is mainly indicated after failure of trabeculectomy or in some types of glaucoma with high risk of failure. However, there is still controversy regarding its effectiveness compared to trabeculectomy. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews including nine studies overall, of which four were randomized trials. We concluded that aqueous shunt might increase the qualified success compared to trabeculectomy, but it is not clear whether it has any effect on the rest of the critical outcomes for decision-making because the certainty of the evidence is very low.


Subject(s)
Humans , Trabeculectomy/methods , Glaucoma/surgery , Glaucoma Drainage Implants , Randomized Controlled Trials as Topic , Databases, Factual , Treatment Outcome
19.
Medwave ; 18(1): e7138, 2018.
Article in English, Spanish | LILACS | ID: biblio-909780

ABSTRACT

INTRODUCCIÓN: La trabeculectomía es considerada la intervención de elección en pacientes con glaucoma con indicación de manejo quirúrgico. Dentro de los factores asociados al fracaso de este tratamiento se encuentra la cicatrización postoperatoria. Para disminuir este factor se han usado distintos antimetabolitos, en particular el 5-fluorouracilo y la mitomicina C. Si bien ambos se consideran efectivos, no está claro si existen diferencias entre ambos en relación al éxito de la trabeculectomía y los efectos adversos. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis, preparamos tablas de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cuatro revisiones sistemáticas que en conjunto incluyen 17 estudios primarios, de los cuales, 12 corresponden a ensayos aleatorizados. Concluimos que el uso de mitomicina C podría lograr una mayor disminución de la presión intraocular e incrementar la tasa de éxito calificado en comparación con el 5-fluorouracilo. Sin embargo, su uso podría asociarse a una mayor incidencia de complicaciones.


INTRODUCTION: Trabeculectomy is considered the standard for glaucoma surgery. Postoperative scarring is one the factors associated with surgery failure. Different antimetabolites have been used in order to reduce this risk, particularly 5-fluorouracil and mitomycin C. Although both are considered effective, it is not clear if they are different in terms of success of trabeculectomy and adverse effects. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified four systematic reviews including 17 studies overall, of which 12 were randomized trials. We concluded mitomycin C might be more effective in reducing intraocular pressure and increasing qualified success compared to 5-fluorouracil. However, its use might be associated to a higher risk of complications.


Subject(s)
Humans , Trabeculectomy/methods , Glaucoma/surgery , Mitomycin/administration & dosage , Fluorouracil/administration & dosage , Randomized Controlled Trials as Topic , Cicatrix/prevention & control , Intraocular Pressure , Antimetabolites/administration & dosage
20.
Rev. cuba. oftalmol ; 30(4): 1-6, oct.-dic. 2017.
Article in Spanish | LILACS | ID: biblio-901390

ABSTRACT

La cirugía del glaucoma 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 está experimentando una evolución sorprendente. Aparecen nuevos dispositivos que buscan obtener un control tensional con las mínimas complicaciones. Actualmente se reserva el término minimally invasive glaucoma surgery para el grupo de técnicas quirúrgicas que favorecen el drenaje del humor acuoso vía ab-interno a través de la córnea clara y con las cuales con frecuencia se coloca un dispositivo biocompatible en el ángulo camerular. El Ex-PRESS, el Trabectome, el iStent y recientemente el Cypass (julio, 2016) son los únicos aprobados por la FDA. Pendiente de esto se encuentran el Hydruss y el XEN. Sin embargo, es necesario para la mayoría de ellos mostrar su éxito en el tiempo(AU)


Glaucoma surgery is a therapeutic alternative aimed at reducing the intraocular pressure when there is no response to non-surgical medical treatment. In the last few years, glaucoma surgery has remarkably evolved. New devices, capable of achieving pressure management with minor complications, have emerged. The term MIGS (minimally invasive glaucoma surgery) is reserved only for those techniques that favor aqueous humor drainage ab-interno approach through clear corneal incision and usually a biocompatible device is placed into the anterior chamber angle. The Ex-PRESS, Trabectome, iStent and recently Cypass (July 2016) are the only devices approved by the Food and Drug Enforcement Agency (FDA). Hydrus and Xen are still pending on approval. Nevertheless, it is required that most of them prove their success in the course of time(AU)


Subject(s)
Humans , Glaucoma Drainage Implants/adverse effects , Glaucoma/surgery , Trabeculectomy/methods
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