[Encapsulated filtering blebs--incidence and methods of treatment]. / Inkapsulisano filtraciono jastuce--ucestalost i metodi lecenja.

Encapsulation of the filtering bleb occurs as a complication of glaucoma filtering surgery in 8.3-28% of all eyes filtered, often between 2-4 weeks after surgery. It has a characteristic clinical appearance--highly elevated localized bleb, prominent surface vessels and patent sclerostomies on gonioscopy. This study retrospectively reviewed the results of 100 filtering operations, performed in the Prof. Dr. I. Stankovitsh Eye Department, focused on the incidence, possible risk factors and management of encapsulated filtering blebs. Trabeculectomy was done in all patients with limbus-based conjunctival flap, rectangular scleral flap 4 x 4 mm, and sclerostomy 2 x 2 mm. Two or three interrupted 10-0 nylon sutures were used to tether the flap, the conjunctiva with Tenon's capsule was closed with a running suture. All eyes received topical dexamethasone drops, mydriatics-homatropin or tropicamide and antibiotic ointment for three weeks. Possible risk factors were considered: sex, age, other eye or systemic disease, type of glaucoma, previous ocular procedure and antiglaucoma medical therapy, early postoperative complications, postoperative and final intraocular pressure (IOP). All eycs with encapsulated filtering bleb were given topical beta-blocker initially and carbonic anhydrase inhibitor, and if IOP continued to be uncontrolled incisional surgical management was performed. Success was defined as IOP maintained at less than 22 mmHg, with or without medication. An encapsulated filtering bleb developed in 9% of eyes. Previous argon laser trabeculoplasty was associated with an increased frequency of bleb encapsulation. The mean postoperative IOP was 11.30 +/- 1.90. Encapsulation of filtering bleb was developing at mean time of 19.9 +/- 3.0 after surgery. Six eyes returned to IOP below 21 (mean IOP was 20.17 +/- 0.90) within 4 weeks, and 4 of them continued on a topical beta-blocker. Four eyes required incisional surgery. A week after surgery mean IOP was 18 mmHg. Haemophthalmus occurred after one incision performed in a patient suffering from diabetes mellitus. Late scarring of the filtering bleb was developed in 2 eyes. Seven months and 2 years after filtration surgery mean IOP was 21.30 +/- 4.00 mmHg. The cause of bleb encapsulation is not known. Male patients, surgical glove powder, topical corticosteroids, previous argon laser trabeculoplasty and beta-blockers are some of potential risk factors for the development of encapsulated filtering bleb. This study suggests the association between development of encapsulated bleb and previous argon laser trabeculoplasty--40% in the eyes with encapsulation and 18% in the eyes without encapsulation. The optimal management of bleb encapsulation has not been defined. In this study topical antiglaucoma therapy achieved IOP control and cyst's remodeling in 60% of cases. Forty percent of all cysts required incisional surgical management. Encapsulation of the filtering bleb is not an uncommon complication of glaucoma filtration surgery. It is important to examine postoperative eyes frequently during the first 2 months to detect this complication. Fortunately, most eyes have their IOPs controlled with antiglaucoma therapy.

[5-fluorouracil in the treatment of postoperative glaucoma]. / Pet-fluorouracil u lecenju postoperacionog glaukoma.

INTRODUCTION: Standard filtering surgery in postoperative glaucoma in aphakic and pseudophakic eyes and eyes after failed filtering surgery is successful in 50% cases. The main cause of failure filtering surgery is scarring of the filtering bleb-fibroblastic proliferation at the subconjunctival episcleral interface [1, 2]. The use of antimetabolites such as 5-fluorouracil and Mitomycin C inhibits fibroblast proliferation and increases the success rate of filtering surgery, especially in postoperative glaucoma [3-6]. The exact dosage and frequency of administration to maximize success and minimize complications of treatment has not yet been determined [7]. METHODS: Fifteen patients (15 eyes) with medically uncontrolled postoperative glaucomas were included in the study. Clinical data are summarised in Table 1. All patients after standard trabeculectomy received 5 mg of 0.3 ml 5-fluorouracil subconjunctivally each day for 7 days. The mean 5-fluorouracil dose was 25.1 mg. Topical corticosteroid and cycloplegic eye drops were also instilled in all 15 eyes for 4 weeks after surgery. RESULTS: Successful control of IOP was achieved after a 5-fluorouracil filtering procedure in 13 of 15 eyes (86.6%), with a mean follow-up of 11.4 months. Two patients (13.4%) with uncontrolled glaucoma required cyclokryocoagulation in addition to antiglaucoma medications. Transscleral fibrosa and internal occlusive membrane were the primary cause of failure of filtration fistulas. Only one patient in the group of successful control of IOP required topical 0.5% Timolol (Table 1). Mean value of postoperative IOP was 13.53 mmHg. Most of the early complications such as corneal epitheliopathy, corneal epithelial defects and shallow anterior chamber, resolved without irreversible damage. Two eyes had transient maculopathy and choroidal detachment. There were no late complications, except progression of cataracta in one eye (Table 2). DISCUSSION: Our success rate in 5-fluorouracil treatment in postoperative glaucoma was 86.6%. The results of Fluorouracil Filtering Surgery Study Group revealed failure in 28% of eyes with 5-fluorouracil treatment compared to 60% of eyes in standard group without fluorouracil. We achieved better results in shorter follow-up. Short term complications related to 5-fluorouracil treatment such as corneal epithelipathy, recovered well with time. Long term complications caused by thin and cystic blebs: endophthalmitis, iridocyclitis, late bleb leaks, bleb encapsulated, were not recorded in our series. By comparing the results reported here with those previously reported [8-10] it looks like that certain long term complications can be reduced by adjusting the dose according to the clinical response. Weinrab et al. [10] reported similar successful surgical outcomes in refractory glaucoma, but these results cannot be compared directly, because of likely differences in such factors, as are the indications of surgical criteria for selection of specific surgical procedures, surgical technique and postoperative care. Some clinical reports have shown that Mitomycin C contributes to the increased success of filtering surgery in high risk glaucoma [11, 12], but 5-fluorouracil is still the golden standard among other antimetabolites.

[Repeat argon laser trabeculoplasty in the treatment of primary open-angle glaucoma]. / Ponovljena trabekuloplastika argonskim laserom u lecenju primarnih glaukoma otvorenog ugla.

Twenty-one eyes of eighteen patients with clinically uncontrolled open angle glaucoma, 3 to 49 months after the initial laser treatment underwent repeat argon laser trabeculoplasty. Retreatment was successful in eleven eyes (52%). Ten eyes (48%) has marked increases in intraocular pressure, necessitating urgent filtering surgery. Repeat argon laser trabeculoplasty was effective for these patients who show a prolonged response to their initial treatment.

Draining implant for neovascular glaucoma.

We treated 12 eyes with advanced neovascular glaucoma with a modification of drainage implant surgery. All 12 eyes had rubeosis iridis and severe pain and nine had undergone previous glaucoma surgery. After follow-up periods of two to 24 months (mean, 11.3 months), nine of 12 eyes had intraocular pressures of less than 24 mm Hg (mean preoperative value, 49.5 +/- 8.2 mm Hg; mean postoperative value, 22.2 +/- 12.9 mm Hg). Surgery was unsuccessful in three eyes, in two because the anterior chamber remained flat postoperatively and in one because a large hyphema blocked the tube 15 months postoperatively. Our procedure, which uses a Y-shaped Teflon tube, is easy to perform, is well tolerated by the eye, and is associated with a low risk of serious complications.