Nonpenetrating deep sclerectomy: a 6-year retrospective study.

PURPOSE: Nonpenetrating trabeculectomy, also called nonpenetrating deep sclerectomy (NPDS), is a filtering surgery where the internal wall of Schlemm's canal is excised, allowing subconjunctival filtration without actually entering the anterior chamber. This, technique was developed to minimize the complications of trabeculectomy. The authors investigated its safety and efficacy in a retrospective noncomparative study. METHODS: A total of 258 eyes (179 patients, mean age 61.4 +/- 11.56 years) with uncontrolled open angle glaucoma with prior medical therapy were treated. NPDS with a biocompatible collagen device (157 eyes) sutured to deep scleral bed or with the use of a 5-fluorouracil sponge (90 eyes) were analyzed. The main outcome measure was postoperative intraocular pressure (IOP) with an average follow-up of 54.4 +/- 17.07 months (range 1-85). Efficacy was determined 1 month, 3 months, and every 6 months after the procedure for 6 years. RESULTS: Mean preoperative IOP was 24.47 +/- 5.92 mmHg. Mean postoperative IOP was 14.44 +/- 5.31 mmHg (average lowering of the IOP was 38.94 +/- 23.81%) at 1 month, 15.16 +/- 4.57 mmHg (35.73 +/- 21.35%) at 3 months, 15.87 +/- 4.24 mmHg (32.45 +/- 20.52%) at 6 months, 16.32 +/- 4.53 mmHg (29.96 +/- 23.69%) at 12 months, 17.12 +/- 4.45 mmHg (26.51 +/- 23.93%) at 18 months, 16.77 +/- 4.44 mmHg (28.18 +/- 21.73%) at 24 months, 16.43 +/- 4.15 mmHg (28.89 +/- 23.69%) at 30 months, 16.34 +/- 4.12 mmHg (30.05 +/- 21.61%) at 36 months, 16.16 +/- 4.01 mmHg (30.06 +/- 22.55%) at 42 months, 15.71 +/- 3.74 mmHg (32.49 +/- 19.08%) at 48 months, 15.61 +/- 3.48 mmHg (31.26 +/- 21.01%) after 5 years, and 15.81 +/- 3.79 mmHg (33.73 +/- 20.9%) after 6 years. YAG goniopuncture was performed in 47.3% of cases with a mean follow-up of 12 +/- 13 months. These goniopunctures were effective in lowering IOP after a long-term follow-up (24 months). Additional 5-fluorouracil injections were used in 7% of cases. Visual field (Octopus or Humphrey mean defect and corrected loss variance or loss variance) was not modified (p < 0.01). Number of preoperative glaucoma medications was 2.01 +/- 0.58 and number of postoperative glaucoma medications was 0.85 +/- 0.92. Complications were peroperative microperforations in 27 eyes (10.5%), shallow anterior chamber in 2 eyes, hyphema in 2 eyes (0.8%), cataract in 5 eyes (2%), and dellen in 1 eye (0.4%). No cases of endophthalmitis or choroidal detachment were found. After surgery, 23 eyes (8.9%) required a new filtering surgical procedure, and diode laser cyclophotocoagulation was necessary in 2 eyes (0.8%). The probability success rate, defined as an IOP lower than 21 mmHg, was 66.46% (Kaplan Meier) at 60 months off all glaucoma medications and 80.32% with medical or new surgical treatment. CONCLUSIONS: NPDS appears to be an effective and safe filtering procedure for lowering IOP and could be an alternative to trabeculectomy in open angle glaucoma with the advantage of having fewer complications.

[Scoring system for chronic open glaucoma]. / Evaluation du glaucome chronique à angle ouvert par un score de gradation: analyse préliminaire.

PURPOSE: The aim of this study was to evaluate a scoring system for chronic open-angle glaucoma. We devised an empirical scoring system grading severity of the disease and correlated this with treatment. MATERIAL: and methods: Ninety patients were evaluated on 11 parameters: 1) Family history of glaucoma: blindness (2), yes (1) no (1); 2) Age: infantile (4), juvenile (4); 3) Race: Caucasian (0), Asian (1), Afro-Caribbean (2); 4) Myopia: 0-6 diopters (1), 6-12 diopters (2),>12 diopters (3); 5) Pigment dispersion or pseudoexfoliation (1); 6) Intraocular pressure without treatment:>30 mmHg (4); 25-30 mmHg (3), 20-25 mmHg (2); 7) Corneal central thickness:<500 micro m (3),>500 micro m (0); 8) Optic disc appearance: suspect (1), pathological (4); 9) Visual field defect: early (1), moderate (3), advanced (5); 10) Vascular risk factors: yes (1), no (0); 11) Loss of eyesight in one eye due to glaucoma (4). Scoring values were 2-34. We correlated this score with patient treatment: medical or surgical, number of glaucoma medications. RESULTS: Patients were divided into three groups: group 1 (36 patients), score 0-8; group 2 (24 patients), score 9-13; group 3 (30 patients), score above 13. Distribution between patients treated with medicine (mean number of medications) and patients with filtering surgery was: group 1, medical treatment with 1.63+/-0.73 medications, surgery 4/36; group 2, medical treatment with 2.00+/-0.7 medications, surgery 17/24 and group 3, medical treatment with 2.12+/-0.67 medications, surgery 27/30. In group 1, 88% of the patients did not have filtering surgery, but 90% of the patients in group 3 had filtering surgery. CONCLUSION: This scoring system seems to be an easy and practical tool to evaluate chronic open-angle glaucoma, which could also be used to evaluate target pressure. Other studies are necessary to validate this scoring system.

Non-penetrating deep sclerectomy (NPDS) with or without collagen device (CD) in primary open-angle glaucoma: middle-term retrospective study.

The purpose of this study is to evaluate the middle-term tonometric results of a new filtering procedure, the nonpenetrating deep sclerectomy with or without collagen device, in primary open-angle glaucoma. This technic aims to eliminate or minimize the complications of classical trabeculectomy. METHOD: This procedure was carried out by Koslov and colleagues. This is performed under a limbal-based conjunctival flap and a superfical scleral flap, the ablation of a deep scleral flap taking away the external wall of Schlemm's canal, only living in place the Descemet membrane. One must obtain a visible filtration across the opened Schlemm's canal and Descemet membrane. To improve the aqueous filtration, a cylindric collagen device, made from porcine scleral tissue, biocompatible, known for its high water content, is fixed in the deep scleral bed with a 10/0 nylon suture. This device provides a support for the elimination route of aqueous humor and acts like a sponge, carrying the liquid by capillary action. It is sterilized by irradiation. Full guarantee against viral contamination is provided. This procedure ends in one suture (10/0 nylon) of superficial scleral flap and conjunctival closing suture. When NPDS is performed without CD a sponge of 5FU is used and the superficial scleral flap is not sutured. RETROSPECTIVE STUDY: Our material included 111 patients, 148 eyes in CD group; 43 patients, 55 eyes in the group without CD. The average follow-up was 13.3 +/- 5.8 months in the CD group, 7.2 +/- 3.5 months in the group without CD. All patients presented a POAG without risk factors of bleb failure. RESULTS: The delta average IOP before the operation and at the end of the follow-up period was 7.2 +/- 6.3 mmHg in the CD group; 8.3 +/- 7.6 mmHg in the group without CD (no significant difference). The probability-success rate with the Kaplan-Meier method (IOP < or = 20 mmHg) was, in the CD group, at 18 months, 68% and 69% in the group without CD, without medical treatment. With monotherapy, the success rate was 85% in the CD group, 74% in the group without CD (p < or = 0.05). PROSPECTIVE STUDY: Afterwards, we have conducted a prospective study comparing two groups of patients with POAG without risk factors of bleb failure, operated with and without collagen device, without 5FU in the second group. Our material included 31 patients, 31 eyes, one eye for each patient, two surgeons; 17 eyes in the CD group, 14 eyes in the group without CD. The average age was 65.8 +/- 8.2 years in the first group; 64.1 +/- 10.3 in the second group. The average follow-up was 11 months in both groups. RESULTS: delta average IOP was 8.3 +/- 5.8 in the CD group; 12.3 +/- 6 in the group without CD (p < 0.05). The probability-success rate without treatment at 12 months: 58% in the first group, 90% in the second group (p < 0.05) and with monotherapy: 80% and 90% (N.S.). In both studies, in both groups, except microperforations, more frequent in the prospective group without CD, no complications of the trabeculectomy were observed. The mean change in visual acuity was inferior to 0.1 at the end of the follow-up. A postoperative rise in IOP can occur. It can be due to an internal obstruction (goniosynechiae or bad filtration). It can be treated with Nd-Yag laser. It can also be due to external obstruction, treated by 5FU injections into the bleb. The success of these procedures were similar in the whole group. CONCLUSION: Non penetrating deep sclerectomy can be considered as an excellent alternative to trabeculectomy in open and wide angles. It does not modify visual acuity. It carries away less complications than trabeculectomy and the use of antimitotic agents is safer. Collagen device does not seem, at middle-term, to improve tonometric results.

[Non-penetrating deep sclerectomy combined with a collagen implant in primary open-angle glaucoma. Medium-term retrospective results]. / La sclérectomie profonde non perforante associée à la pose d'un implant de collagène dans le glaucome primitif à angle ouvert. Résultats rétrospectifs à moyen terme.

PURPOSE: To evaluate the middle term tonometric results of a new filtering procedure, the non penetrating deep sclerectomy with collagen device, in primary open-angle glaucoma. This technique aims to eliminate or minimize the complications of classical trabeculectomy. MATERIAL AND METHOD: This procedure has been developed by Koslov et al. Under a limbal-base conjunctival flap and a superficial scleral flap, the ablation of a deep scleral flap takes away the external wall of Schlemm's canal, leaving only the Descemet membrane. A visible filtration across the opened Schlemm's canal and Descemet membrane is obtained. To improve the aqueous filtration, a cylindric collagen device, made from biocompatible porcine scleral tissue, known for its high water content, is fixed in the deep scleral bed with a 10/0 nylon suture. This device provides a support for the elimination route of aqueous humor and acts like a sponge, carrying the liquid by capillary action. It is sterilized by irradiation. Full guarantee against viral contamination is provided. This procedure ends in one suture (40/0 nylon) of superficial scleral flap and conjunctival closing suture. We conducted a retrospective study. Our material included 159 patients (92 males, 65 females), 2/9 eyes. The mean age was 65 years (11-91). The mean follow-up : 8 months (3-20). The types of glaucoma were: POAG: 183 eyes; juvenile POAG: 18 eyes: pigmentary glaucoma: 11 eyes; capsular glaucoma: 7 eyes, 58 eyes (40 patients) presented one or several risk factors of failure for filtering surgery. RESULTS: The mean pre-operative IOP was 24 mmHg +/- 6.60; 15.7 +/- 5.30 at the end of the follow-up (delta average IOP: 9.1 +/- 7.1). The probability success rate (IOP < or = 20 mmHg), according to the Kaplan-Meier Method, was 89% at six months, 75.6% at 16 months. With monotherapy with beta blockers, 79% at 16 months. It was better in the without risk factors group. The mean change in visual acuity was inferior to 0.1 at the end of the follow-up. Except several hyphemas, no complications of the trabeculectomy were observed. The reelevation of IOP was due to an internal obstruction (goniosynechiae or bad filtration), it was treated with Nd-Yag laser with a 2/3 of success rate. External obstruction was treated by 5FU injections into the bleb. CONCLUSION: Non penetrating deep sclerectomy with collagen device can be an excellent alternative to trabeculectomy in open and wide angles. It does not modify visual actuity. It carries less complications than trabeculectomy and the use of antimitotic agents is safer.

X-PERT NCT advanced logic tonometer valuation.

The air pulsed automatic tonometer X-PERT NCT has been tested in hospitals on glaucomatous patients. This new technique avoids direct contact with the patient's eyes and therefore avoids any risk of contamination. The population studied consisted of 118 eyes of 60 patients whose intraocular pressure (I.O.P.) is measured by applanation with the Goldmann tonometer and then by the air pulsed tonometer. The average I.O.P. obtained by Goldmann tonometer is 17.5 +/- 5 mmHg while by X-PERT tonometer, the average I.O.P. is 17.4 +/- 1.5 mmHg. Statistical analysis of these data showed a very good correlation (r = 0.969) in the two methods of measurement.

Daunorubicin versus 5-fluoro-uracil in surgical treatment of primary open angle glaucoma: a prospective study.

In a prospective randomized study, we compare the results at 20 months of 5 Fluoro-Uracil and Daunorubicin filtering surgery in two groups of 25 patients with primary open-angle glaucoma. For the first group of 14 eyes, 10 injections of 5FU are done and only one subconjunctival preoperative injection of Daunorubicin in the second group of 13 eyes. 5FU group consists of 13 patients: 9 males, 4 females. The mean age is 52.3 +/- 18.4 years. The mean follow-up is 6.9 +/- 7 months. Daunorubicin group consists of 12 patients: 9 males, 3 females. The mean age is 50.2 +/- 21.4 years. The mean follow-up is 7.3 +/- 7 months. By Kaplan-Meier method, the probability success rate is 79 per 100 with 5FU and 68 per 100 with Daunorubicin. After 5FU procedure, the most disturbing complication is related to the decrease in IOP during the first postoperative days: flat anterior chamber (9 eyes) (7 eyes after Daunorubicin), choroïdal detachment (6 eyes) (2 eyes after Daunorubicin), cataract (3 eyes in the two groups). After Daunorubicin, corneal complications are less frequent: corneal ulcer (2 eyes) (3 eyes after 5FU), corneal dystrophy (1 eye in the two groups). Transient chemosis and local palpebral oedema are constant after Daunorubicin. We compared the IOP reduction rate and visual function loss in the two groups.

[Trabeculectomy and trabeculo-retraction in the treatment of chronic primary open-angle glaucoma. Long-term tonometric results]. / Trabéculectomies et trabéculorétractions dans le traitement du glaucome chronique primitif à angle ouvert. Résultats tonométriques à long terme.

The long term tonometric results of laser (Argon Laser Trabeculoplasty) and surgical (Trabeculectomy and combined-surgery) treatment in Primitive Chronic Open Angle Glaucoma are analysed on 184 eyes by a retrospective study. Three groups of patients are compared: group I: 81 trabeculoplasties followed 4 years, group II: 75 trabeculectomies followed 5 years, group III: 28 combined-surgery (intra-capsular cataract extraction without implantation combined with a trabeculectomy) followed 5 years. For the three groups, reduce of IOP is noted after 6 months but seems less important after 30 months. Instantaneous results curves show a success rate of 80 to 100% (of which 10 to 20% with additional medical treatment). But cumulative failures rates are higher: more than 50% at 4 years for group I and group II, and only 29% at 5 years for group III. These results are confirmed by actuarial curves: group I: probability success rate of 65% at 4 years group II: probability success rate of 49% at 5 years group III: probability success rate of 73% at 5 years. The comparison of group I and II by actuarial curves is not statistically significant (Logrank test: chi 2 = 0.05). We had discussed the advantage of a new prospective randomised study.

[Medium-term tonometric results of trabeculectomies performed after trabeculoretraction using an argon laser in chronic primary open-angle glaucoma]. / Résultats tonométriques à moyen terme des trabéculectomies effectuées après trabéculorétraction au laser à l'argon dans le glaucome chronique primitif à angle ouvert.

Following unsuccessful Argon Laser Trabeculoplasty (ALT), 93 eyes were tracked for periods of 6 to 42 (mean: 24 months). The total failure rate of 20% is similar to the generally known failure rate of the trabeculectomies. However, failures are more frequent (37%) when trabeculectomy is performed between the second and third month after ALT. This may suggest not to operate on too soon after ALT or to perform filtering surgery with 5 Fluoro-uracil.

[Treatment of chronic primary open-angle glaucoma. Long-term functional results]. / Traitement du glaucome primitif chronique à angle ouvert. Résultats fonctionnels à long terme.

The functional results of the treatment of primary open angle glaucoma (POAG) were analysed. A retrospective study was undertaken on 437 eyes from 282 patients (137 women, 145 men) followed in Saint Joseph's Hospital (Paris). The mean follow-up was 9.7 years (4-22 years). 265 eyes received only medical treatment, 83 eyes argon laser trabeculoplasty (ALT) and 89 eyes surgery (66 trabeculectomies - 23 cataract-glaucoma combined operations). At least twice a year, intraocular pressure (IOP), visual acuity (VA) and mean total visual capability (TVC) on the Friedmann analyser were recorded on a computer. The severity gradient (SG) was calculated from the evolution gradient of TVC versus IOP with time for each group (medical, ALT, surgery) before and after treatment. Medical SG was not significantly different from ALT SG or surgery SG (trabeculectomy or combined surgery). For each group, SG before treatment was not significantly different from SG after treatment. For tonometric failures after ALT or surgery, SG before treatment was not different from SG after treatment. Nevertheless, after trabeculectomy, in the cases of clear tonometric success (IOP less than or equal to 16 mmHg), SG was significantly improved (p less than 0.001). On the other hand, no positive influence was noted on visual field evolution in cases of a commonly admitted good tonometric control (IOP less than or equal to 21 mmHg). Visual acuity loss after trabeculectomy was greatest during the first year (6/20). The cataractogenic role of trabeculectomy was statistically confirmed. The incidence of cataract at 5 years was 46%. This cataractogenic effect occurred significantly more after 55 years. We discuss tonometric effect on TVC evolution.(ABSTRACT TRUNCATED AT 250 WORDS)

[Argon laser trabeculoretraction in chronic open-angle glaucoma with normal pressure. A prospective study on the tonometric and perimetric effect]. / Trabéculorétraction au laser à l'argon dans le glaucome chronique à angle ouvert à pression normale. Une étude prospective sur l'effet tonométrique et périmétrique.

A prospective randomised study was undertaken on sixty eyes, thirty five patients, (27 women, 8 men) followed in the Saint-Joseph hospital of Paris, with low tension glaucoma (LTG). The thirty five patients were selected at random and had either an argon laser trabeculoplasty (ALT) or received only vascular medications (medial). The first group (ALT) included 29 eyes. The second group (medical) included 31 eyes. The two groups were comparable: mean age, men/women distribution, mean intraocular pressure, mean C/D ratio, mean total visual capability (TVC) with the friedmann analyser. The mean follow up for the two groups was seven years. Nevertheless for the ALT group the mean follow up after ALT was four years. We compared for the two groups: --the aspect of the mean intraocular pressure (IOP) curve with time, --the evolution gradient of visual capabilities with time. For the ALT group we compared: --the mean IOP and 24 hours diurnal curves before and after laser treatment and the evolution gradient of visual capabilities before and after laser treatment. The introduction of ALT in the treatment of LTG had neither tonometric effect nor effect on the slope of visual field damage. We concluded that ALT is not recommended in LTG, but not that the IOP should not be reduced in this form of glaucoma.

[Glaucoma: detection and therapeutic indications]. / Glaucome: dépistage et indications thérapeutiques.

Glaucoma screening requires a good knowledge of the epidemiology and risk factors of this disease. So, we measure the intraocular pressure, analyse the visual field and examin the optic nerve head by ophtalmoscopy. Other investigations have been described, allowing early treatment. Some medications are active on aqueous humor production, others on outflow but side effects are often observed. Laser therapy is an alternative to surgery.