Correlation between morphologic appearance and function of filtering bleb in vivo.

PURPOSE: Efficacy and long-term success of trabeculectomy largely depends on the postoperative development of a functioning filtering bleb. This study was designed to observe histological changes in filtering blebs after trabeculectomy using in vivo confocal microscopy (IVCM), and to investigate the correlation between morphologic appearance and function of filtering blebs. METHODS: A total of 46 glaucoma patients who had received a trabeculectomy unilaterally in the past 1 to 60 months underwent slit-lamp examination, applanation tonometry, and in vivo confocal microscopy. Eyes were classified into 4 groups according to the morphologic appearance of the filtering bleb based on the Kronfled system: type I blebs (8 eyes), type II blebs (14 eyes), type III blebs (16 eyes), and type IV blebs (8 eyes). The IVCM images were analyzed for the number of intraepithelial microcysts, the density of subepithelial connective tissue and the presence of blood vessels. RESULTS: Type II blebs presented with numerous intraepithelial vacuolar microcysts, while several large intraepithelial microcysts were found in type I blebs. Subepithelial connective tissue was widely spaced in type I and II blebs. In contrast, type III and IV blebs showed few or no intraepithelial microcysts, and subepithelial connective tissue was densely distributed. Neovascularization was seen in 83.3% of failed blebs, whereas neovascularization was found in only 16.6% of successful blebs. CONCLUSION: Different types of blebs reveal various histological characteristics at the cellular level, which appear to be correlated with postoperative filtering function.

Interobserver variability of the Würzburg bleb classification score.

BACKGROUND: The Würzburg bleb classification score (WBCS) serves to assess filtering blebs in a standardized fashion. The purpose of this prospective masked agreement study was to evaluate the WBCS interobserver variability. METHODS: The WBCS provides a scheme to grade clinical bleb morphology. It evaluates the following parameters: vascularity, corkscrew vessels, encapsulation, microcysts and bleb height. Thus, 113 eyes of 104 consecutive patients at various times after surgery were examined (slit lamp biomicroscopy) by 3 ophthalmologists with each observer being unaware of the findings reported by the others. To calculate the interobserver variability of the WBCS, the interobserver consistency and absolute agreement were determined with an intraclass correlation coefficient (ICC) using a 2-way random model. RESULTS: The ICC values of a single rater's judgment were: vascularity +0.62, corkscrew vessels +0.67, encapsulation +0.63, bleb height +0.53, microcysts +0.52 and total score +0.74. The ICC values of the mean of all 3 raters were: +0.83 vascularity, +0.86 corkscrew vessels, +0.84 encapsulation, +0.77 bleb height, +0.76 microcysts and +0.90 total score. CONCLUSION: The WBCS is a bleb morphology score with high levels of interobserver consistency and absolute agreement in clinical practice.

Trabeculotomía-trabeculectomía combinada como tratamiento quirúrgico inicial del glaucoma congénito primario / Combined trabeculotomy-trabeculectomy as the initial surgical procedure of primary developmental glaucoma

Objetivo: Valorar los resultados quirúrgicos a largo plazo de la trabeculotomía-trabeculectomía combinada (TTC) como tratamiento preferente del glaucoma congénito primario. Métodos: Se seleccionaron 22 ojos de 14 pacientes consecutivos con glaucoma congénito primario en los que se empleó la TTC como procedimiento inicial entre 1981 y 2005. Se introdujo en una base de datos la información relacionada con la historia familiar, edad de inicio del glaucoma, síntomas y signos, integridad corneal, presión intraocular (PIO), gonioscopia, cirugía, complicaciones postoperatorias, agudeza visual, defecto de refracción, microscopia endotelial, longitud axial, campos visuales y estado final de la papila. El resultado de la presión intraocular fue evaluado usando el análisis de supervivencia Kaplan-Meier. Resultados: Las probabilidades acumuladas de éxito después de realizar una TTC como procedimiento inicial fueron del 95,5% a los 12 meses y del 78,2% a los 24 meses, manteniéndose esta proporción durante 15 años de seguimiento. Cuatro ojos (18,1%) requirieron más de un procedimiento debido a una PIO elevada persistente. Las complicaciones postoperatorias fueron raras. Al final del seguimiento, de 12 ojos de 8 pacientes cooperadores, la mejor agudeza visual corregida fue igual o mayor de 0,5 en el 75% (9 ojos). Conclusiones: La TTC como cirugía primaria ofrece una alta eficacia a largo plazo en el control de la PIO sin tratamiento farmacológico, mostrando mínimas complicaciones quirúrgicas y una baja incidencia de reintervenciones

Purpose: To evaluate the long-term outcome of trabeculotomy-trabeculectomy as the primary surgical treatment for primary congenital glaucoma. Methods: Twenty-two eyes of 14 consecutive patients with primary congenital glaucoma who underwent combined trabeculotomy-trabeculectomy as the initial procedure between 1981 and 2005 were selected for review. Records of ocular family history, age at onset of glaucoma, symptoms and signs, corneal integrity, intraocular pressure (IOP), gonioscopy, surgery, postoperative complications, visual acuity, refractive error, endothelial microscopy, axial length, visual fields and final status of the optic nerve head were entered into a computer database. The outcome, in terms of IOP obtained, was evaluated using Kaplan-Meier survival analysis. Results: Cumulative probabilities of success, after performing combined trabeculotomy-trabeculectomy as the initial operative procedure, were 95.5% after 12 months and 78.2% after 24 months, with this rate being maintained during 15 years of follow-up. Four eyes (18.1%) required more than one operative procedure because of persistent raised IOP. Postoperative complications were rare. At the time of the last follow-up, of 12 eyes from 8 co-operative patients, the final best spectacle-corrected visual acuity was 0.5 (20/40) or better, in 75% (9 eyes). Conclusion: Combined trabeculotomy-trabeculectomy as the primary surgical procedure offers long-term high efficacy in the control of IOP without medical treatment, is rarely associated with surgical complications, and a low need for re-operations (Arch Soc Esp Oftalmol 2008; 83: 479-486)

Comparison of two clinical Bleb grading systems.

PURPOSE: To evaluate 2 recently described grading systems for clinical grading of filtering surgery blebs: the Moorfields Bleb Grading System (MBGS) and the Indiana Bleb Appearance Grading Scale (IBAGS). DESIGN: Observational comparative study. PARTICIPANTS: Twenty-four glaucoma filtering blebs in 24 eyes of 17 patients. METHODS: Three observers in a prospective agreement study compared MBGS with IBAGS during slit-lamp examination. MAIN OUTCOME MEASURES: Comparison analyses were performed, including agreement, repeatability, and intraclass correlation coefficient (ICC). RESULTS: A wide range of bleb characteristics was represented in the cohort. Acceptable levels of intrasystem agreement were found in both systems: for IBAGS, overall agreement at the 0.5- and 1.0-unit levels were 80.6% and 97.6%, respectively, and for MBGS, these were 78.4% and 97.4% for morphologic and vascularity indices. Repeatability coefficients ranged from 0.5 to 1.4 for MBGS and 0.8 to 1.2 for IBAGS. The ICC values in the MBGS ranged from 0.18 to 0.72 for single measures and 0.39 to 0.88 for average measures. For IBAGS, the single-measure ICC values were between 0.06 and 0.53, and the average-measure ICC values were between 0.16 and 0.77. The MBGS ICC values for bleb size were higher than for IBAGS. CONCLUSIONS: Both methods are reproducible clinically and had generally high levels of interobserver agreement. Both have minor deficiencies that should be amenable to improvement. The MBGS performed similarly to the IBAGS for reproducibility, had higher ICC values for morphologic features, and captured extra vascularity data with probable clinical implications.

Trabeculectomía en el Hospital Bertha Calderón Roque durante el período enero 1988-diciembre 1989 / Trabeculectomy the Hopistal Bertha Calderon Roque during the period. january 1980-december 1989

Se realizó un estudio descriptivo transversal, retropectivo en pacientes operados por glaucoma de diferentes tipos, con el objetivo de conocer el comportamiento post-trabeculectomía efectuada en el Hospital Bertha Calderón Roque, en el período de enero 1988-diciembre 1989. La trabeculectomía representa el 8 porciento del total de las cirugías oftalmológicas en dicho centro. El 61.3 porciento fueron del sexo femenio. El 64 porciento de las cirugía se efectuaron en pacientes mayores de 40 años, pero también se destaca el grupo de 0-9años con el 19.3 porciento de los mismos. En relación a las complicaciones el 81.5 porciento de las cirugía fueron existosas. El 4.2 porciento se acompañó de uveitis (la que con medicamentos) un 4.2 porciento también presentó cámara plana aosciada a Hipotomía. El glaucoma de ángulo cerrado crónico simple aparecen como las principales causas de indicación para la trabeculectomía. El 68 porciento delos pacientes presentarón presión intraocular mayor de 41mm Hg. pre-operatoria. El 58.2 porciento de los pacientes presentaron una presión intraocular menor de 20mm Hg. con más de seis semanas de evolución. Le llegó a conclusiones y recomendaciones...