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Purpose: Evaluate the intraocular pressure (IOP) control in combined Ahmed Glaucoma Valve (AGV) implantation and trabeculectomy revision with adjunctive antimetabolite compared with AGV alone in patients who failed prior trabeculectomy., Methods: Consecutive cases of combined AGV implantation and trabeculectomy revision with adjunctive antimetabolite (combined group) after January 3, 2014 were case-matched to cases of AGV implantation alone (AGV-alone group) before January 3, 2014. Primary outcome measures were qualified success with stratified IOP targets based on criteria: (A) IOP≤18 mm Hg and 20% IOP reduction; (B) IOP≤15 mm Hg and 25% IOP reduction; (C) IOP≤12 mm Hg and 30% IOP reduction, and hypertensive phase (HP) rate. Secondary outcome measures were 1-year postoperative IOP and number of glaucoma medications and complications., Results: Twenty eyes (20 patients) in each group were included. Cumulative success for combined group and AGV-alone group at 1-year were: 74.0% versus 59.2% (criterion A, P=0.221), 61.9% versus 49.5% (B, P=0.183), and 54.2% versus 30.0% (C, P=0.033), respectively. In total, 50% (10 eyes) in the AGV-alone group developed HP compared with 15% (3 eyes) in the combined group (P=0.041). At 1-year follow-up, combined group had statistically significantly lower IOP than AGV-alone group (10.1±4.4, 13.3±2.9 mm Hg, respectively; P=0.028). There were no cases of bleb-related infections, choroidal effusion or hemorrhage, persistent hypotony, or hypotony maculopathy in either group., Conclusions: Combining AGV implantation with trabeculectomy revision with antimetabolite was associated with better tonometric success compared with AGV implantation alone in patients with previously failed trabeculectomy, particularly when a low IOP target (≤12 mm Hg) is required. Revised trabeculectomy may provide complimentary outflow facility to AGV.

Purpose: To determine the outcome of needling with adjunctive 5-fluorouracil (5-FU) in patients with a failing Ahmed glaucoma valve (AGV) implant, and to identify predictors of long-term intraocular pressure (IOP) control., Methods: A prospective observational study was performed on consecutive patients with medically uncontrolled primary open-angle glaucoma (POAG) with AGV encapsulation or fibrosis and inadequate IOP control. Bleb needling with 5-FU injection (0.1 mL of 50 mg/mL) was performed at the slit-lamp. Patients were examined 1 week following the needling, and then at months 1, 3, and 6. Subsequent follow-up visits were scheduled at 6-month intervals for at least 2 years. Needling with 5-FU was repeated no more than twice during the first 3 months of the follow-up. Procedure outcome was determined on the basis of the recorded IOP levels., Results: Thirty-six patients with an encapsulated or fibrotic AGV underwent 67procedures (mean 1.86 ± 0.83). Complete success, defined as IOP ≤ 18 mm Hg without medications, was obtained in 25% at 24 months of observation. The cumulative proportion of cases achieving either qualified (ie, IOP ≤ 18 mm Hg with medications) or complete success at 24 months of observation was 72.2%. In a univariate Cox proportional hazards model, age was the only variable that independently influenced the risk of failing 5-FU needling revision. Fourteen eyes (38.8%) had a documented complication., Conclusions: Needling over the plate of an AGV supplemented with 5-FU is an effective and safe choice in a significant proportion of POAG patients with elevated IOP due to encapsulation or fibrosis.

Purpose: To evaluate outcomes of trabeculectomy bleb needle revision with 5-fluorouracil augmentation performed in the operating theater., Methods: Retrospective study of all patients undergoing trabeculectomy bleb needle revisions in the operating theater performed by a single surgeon in a metropolitan hospital in Australia. A total of 51 needle revisions were performed on 33 eyes over a mean follow-up time of 1.81±1.56 years., Results: A total of 29% achieved intraocular pressure (IOP) ≤20 mm Hg off all glaucoma medications, and an additional 39% achieved qualified success with the addition of glaucoma medications, giving overall success of 68%. Analyzing success rate for target IOP≤16 mm Hg, 24% achieved target off all glaucoma medications, 35% achieved qualified success with the addition of glaucoma medications, giving an overall success rate of 59%. There was a statistically significant improvement in IOP, as compared with preoperative levels, at all timepoints postoperatively (P<0.05). However, number of glaucoma medications remained unchanged (P>0.05) contributing to the high percentage of qualified successes. Visual acuity remained unchanged and there were no major postoperative complications. The Kaplan-Meier survival shows a survival rate of 60% with IOP≤20 mm Hg and 40% for IOP≤16 mm Hg at 5 years., Conclusions: Trabeculectomy needle revision is a useful option for the management of elevated IOP in the presence of a failed or failing trabeculectomy bleb. However, as with trabeculectomy, there tends to be a failure rate over time. This often leads to reinstitution of glaucoma medications and/or further needle revisions to maintain IOPs at target level. The procedure itself is minimally invasive with an acceptable safety profile.

Current techniques for the delivery of antimetabolites, such as mitomycin C, tend to be very variable among surgeons and risk uncontrolled contact with the conjunctivae, which may result in delayed wound healing, wound dehiscence, and wound leakage postoperatively. We describe a novel technique which appear to allow a more precise and reproducible delivery of antimetabolite to the target area with minimal contact with the conjunctival edge. The technique involves the injection of an antimetabolite-soaked wick into the subconjunctival space posterior to the scleral flap using an intraocular lens injector system.

Purpose: To describe the outcome of surgical bleb revision for late-onset bleb leaks after trabeculectomy., Patients and Methods: Appropriate cases were identified. Qualified and complete success required intraocular pressure of 21 mm Hg or less with and without glaucoma medication use, respectively. Bleb survival was determined using Kaplan-Meier survival analysis, and overall success rate was defined as qualified success at last follow-up. Preoperative and postoperative ocular parameters were compared using the signed-rank test. Age, sex, ethnicity, time between leak and revision, and surgeon type (attending vs. surgeons in training) were entered into a logistic regression analysis to assess the impact on surgical outcome., Results: Seventy-eight eyes of 75 patients were included. The overall rate of successful bleb revision was 77%, and qualified and complete success at 24 months was 71% and 34%, respectively. Postoperative complications included early and late bleb leaks in 6% and 9% of the eyes, respectively; bleb-related infections in 4% of the eyes; and the need for additional glaucoma surgery in 10% of the eyes. There was no difference in preoperative and postoperative visual acuity (P=0.34) but there was an increase in intraocular pressure (P<0.0001) and the number of medications used (P<0.0001). The number of eyes that did not require glaucoma medication decreased (P=0.002). None of the variables examined had a significant impact on successful surgical outcome., Conclusion: Bleb revision showed a high success rate. About two-thirds of eyes required medication, 10% of eyes required additional glaucoma surgery, and there was a low risk for bleb-related infection following bleb revision.

Purpose: To compare the long-term efficacy and safety of intraoperative 5-fluorouracil (5-FU) versus mitomycin-C (MMC) used adjunctively with primary trabeculectomy in a Black West African population., Design: Retrospective comparative study supplemented with cross-sectional follow-up data., Methods: Review of 68 eyes of 68 Black West African subjects that underwent primary trabeculectomy with the use of intraoperative 5-FU or MMC between January 1, 1988 and January 1, 2002 and had at least 3 years postoperative follow-up. Postoperative outcome measures included intraocular pressure (IOP) control, number of glaucoma medications, visual acuity, and complications., Results: Thirty-eight of sixty-eight eyes received 5-FU and 30 received MMC. Mean postoperative follow-up was 7.5 and 6.5 years in the 5-FU and MMC groups, respectively (P=0.17). A higher proportion of eyes in the MMC group achieved "qualified" (with or without medical therapy) success with varying IOP targets relative to the 5-FU group, but the differences were not statistically significant. "Complete" (without medical therapy) postoperative success was greater in the MMC group with a significantly higher proportion achieving an IOP <21 mm Hg (P=0.02). MMC use was also associated with a lower likelihood of receiving IOP-lowering medications postoperatively (P=0.01). Baseline demographic characteristics, preoperative and postoperative IOP, visual acuity, and complications did not differ significantly between the 2 groups., Conclusions: Intraoperative MMC use is associated with a lower likelihood of requiring postoperative medications and a greater likelihood of achieving IOP lowering without medications relative to the use of 5-FU in a Black West African population.

Purpose: To investigate the effects of reduction of intraocular pressure (IOP) by surgical intervention on the frequency of disc hemorrhages in eyes with primary open-angle glaucoma (POAG) and normal-tension glaucoma (NTG)., Design: Retrospective study., Methods: We studied 99 eyes of 99 patients with POAG and 50 eyes of 50 patients with NTG, who underwent trabeculectomy with adjunctive mitomycin C (MMC) and were followed regularly at 1 to 3-month intervals at the Glaucoma Service of Gifu University Hospital. We applied Kaplan-Meier life-table analysis for the detection of disc hemorrhages before and after trabeculectomy., Results: Trabeculectomy significantly reduced IOP (in POAG: 19.6 +/- 4.4 down to 11.1 +/- 4.2 mm Hg; in NTG: 15.3 +/- 1.5 down to 11.3 +/- 4.5 mm Hg; mean +/- SD). Life-table analysis revealed that the final cumulative probability of detecting a disc hemorrhage after surgery in POAG was 5.5 +/- 2.2% (calculated probability +/- SE) and was significantly lower than that (33.4 +/- 7.8%) before surgery (P < 0.0001, log-rank test). Likewise, the final probability after surgery in NTG was 23.1 +/- 6.3% and was significantly lower than that (42.1 +/- 8.8%) before surgery (P = 0.0063, log-rank test)., Conclusions: IOP reduction via surgical intervention significantly decreases the frequency of disc hemorrhages in open-angle glaucoma patients.

Purpose: Antimetabolites, especially mitomycin C (MMC), increase the incidence of late bleb-related endophthalmitis in trabeculectomy. This is related to a higher incidence of avascular, thin, cystic, translucent blebs, which may be caused by a toxic effect on conjunctival tissue. An MMC dose-response study was carried out focusing on bleb morphology and function., Patients and Methods: In a retrospective, comparative case series study, 2 successive groups of patients with complicated glaucoma were compared 2 years after a special, minimally invasive, filtering procedure (intrastromal holmium laser keratostomy). Preoperative local subconjunctival injections of a fixed MMC dose (4 microg) were used in group A, and lower MMC doses, calculated individually (1 or 2 microg), were used in group B. Bleb vascularity and morphology were evaluated by masked grading of photomicrographs. Bleb function was evaluated by intraocular pressure (IOP)., Results: Total bleb avascularity occurred in 63% of the blebs in group A and 0% in group B (P < 0.01). In eyes with IOP < or = 20 mmHg without medical treatment, the mean IOP was significantly lower in group 1 (8 vs 15 mm Hg, P < 0.002). A translucent cystic bleb without conjunctival stroma was observed in only 1 eye in group A. An optimal spongy stromal bleb was observed in all other eyes (96%) despite the different MMC doses. The numbers of complications in the 2 groups were nearly equal., Conclusions: Bleb avascularity after 4 microg MMC could be avoided by the use of 1 or 2 microg MMC on the basis of preoperative prognosticators for failure, but at the expense of some of the IOP-lowering effect. This indicates that the therapeutic index (clinical safety margin) of MMC seems to be narrow. An MMC dose-response relation was not observed for the thin, cystic, and translucent bleb. The low incidence of this bleb (4%) indicates that the operative technique, apart from the vascularity, may be the most essential determinant of bleb morphology.

Purpose: To study the long-term effectiveness and factors involved in successful needling of failed filtration blebs with mitomycin C (MMC)., Materials and Methods: We conducted a prospective, nonrandomized comparative trial that included 34 consecutive patients (34 eyes) who underwent mitomycin C needling of a failed filtering bleb after trabeculectomy followed by a 0.01 mL injection of mitomycin C (0.2 mg/ml). The success of the needling revision was defined as absolute if the intraocular pressure (IOP) was < 21 mm Hg without antiglaucoma medications and qualified if the IOP was < 21 mm Hg with antiglaucoma medications. Preoperative and perioperative factors were evaluated for an association with postoperative success using Kaplan-Meier survival analysis., Results: The mean follow-up was 14.2 +/- 9.8 months. The mean preoperative IOP was 25.5 +/- 4.4 mm Hg, which decreased to 11.1, 13.4, 15.8, 16.7, 14.9, 14.1, 13.9, and 13 on postoperative day 1, postoperative week 1, and after 1, 3, 6, 9, 12, and 24 months, respectively (P = 0.001 for each comparison). At the final visit, success was absolute in 15 eyes (44.1%) and qualified in 14 eyes (41.2%). The success rates were 90% and 75% at 1 and 2 years, respectively. The success of the needling procedure was highly correlated with glaucoma filtration surgery performed less than 4 months previously (Kaplan-Meier analysis, log-rank test P = 0.006)., Conclusions: Mitomycin C needling revision appears to have a high long-term success rate. Surgery performed less than 4 months previously contributes to the success of the initial mitomycin C needling procedure.

Aim: To audit medium-term results of trabeculectomy at a tertiary referral unit in east Africa., Methods: A retrospective review of the files of all patients who underwent trabeculectomy surgery at our hospital during the year 2001., Results: One hundred fifty-seven patients were included. Mean age was 61 years (SD = 12). Thirty-one patients (20%) were women; 120 of 145 (83%) eyes had cup/disc ratios of 0.8 or greater preoperatively. Intraoperative 5-fluorouracil (5FU) was used in 57 cases (36%). Mean follow-up was 8 months (0-28, SD = 7). Mean intraocular pressures (IOP) was 25 mm Hg (6-70, SD = 10) preoperatively, 11 mm Hg (0-32, SD = 5) at 2 weeks postoperatively, and 13 mm Hg (0-42, SD = 6) at latest follow-up. One hundred fifteen patients (73%) had intraocular pressure of 15 mm Hg or less at latest follow-up and 141 (90%) had intraocular pressure of 21 mm Hg or less. Twenty (13%) had restarted antiglaucoma medication during the follow-up period. Thirty-seven of 148 (25%) lost 2 lines of Snellen acuity or equivalent between preoperative measurement and latest follow-up. Early postoperative complications (usually leaking bleb or shallow anterior chamber with hypotony) occurred in 18 patients (12%) and this was associated with postoperative loss of 2 or more lines of Snellen acuity (OR = 1.11 95% CI 1.02-1.22, P= 0.02). Patients having had 5FU had lower (t = 3.11, P= 0.02) mean intraocular pressure at 2-month follow-up (12 mm Hg, SD = 5) than those who did not receive it (16 mm Hg, SD = 6) but there was no significant difference at later follow-ups. Men (mean 14 mm Hg, SD = 6) had higher (t = 2.71, P= 0.01) intraocular pressures at latest follow-up than women (mean 11 mm Hg, SD = 3)., Conclusions: The results of surgery compare well with other reported series. 5FU did not demonstrate significant benefit in terms of intraocular pressure lowering beyond 2 months postoperatively. Early postoperative hypotony should be avoided. The gender difference in intraocular pressure results has not previously been reported and deserves further investigation.

Purpose: Trabeculectomy is the procedure of choice for the surgical control of glaucoma, and is often augmented by intraoperative 5-fluorouracil application to reduce scarring. This study aims to assess the validity of this technique with a randomized placebo-controlled trial., Methods: Patients without risk factors for bleb failure other than previous drop use who were undergoing trabeculectomy surgery as their first ocular procedure were randomized to receive fluorouracil or placebo. The main outcome measures were intraocular pressure and bleb morphology., Results: Results from 40 eyes of 36 patients are presented; 23 eyes were treated with fluorouracil, and 17 eyes were treated with placebo. Mean intraocular pressure at 1 year and at the final follow-up examination was significantly lower than preoperatively, but was not different between fluorouracil and placebo groups. Kaplan-Meier survival analysis also failed to show any difference, though there was a trend toward better survival of an intraocular pressure of 16 mm Hg or lower. Bleb morphology was examined postoperatively in 24 patients, with no differences found between fluorouracil and placebo groups., Conclusions: No significant difference was found in trabeculectomy outcome between fluorouracil-treated and placebo-treated eyes. The study was too small to state definitively that no such difference exists, but suggests that any treatment effect is likely to be small.

Purpose: To evaluate the safety and efficacy of fornix-based conjunctival flap versus limbal-based flap in initial trabeculectomy with postoperative 5-fluorouracil., Methods: 29 patients (58 eyes) with bilateral primary open-angle glaucoma (POAG) were included in the study. Patients were randomly assigned to have a fornix-based conjunctival flap in one eye and a limbal-based flap in the other, followed by subconjunctival injection of 5-fluorouracil., Results: Mean intraocular pressure (IOP) 2 years after treatment was 12.9 +/- 12.25 mmHg in eyes with fornix-based conjunctival flaps and 13.1 +/- 16.81 mmHg in eyes with limbal-based conjunctival flaps. At 4 years, mean IOP was 14.7 +/- 9.61 mmHg in eyes with fornix-based conjunctival flaps and 15.1 +/- 7.29 mmHg in eyes with limbal-based conjunctival flaps. Cumulative success at 4 years (IOP < 21 mmHg) was 89.6% in eyes with fornix-based conjunctival flaps versus 86.2% in eyes with limbal-based conjunctival flaps with medications. Cystic leaking blebs occurred in two cases, both with limbal-based flaps., Conclusion: The efficacy of limbal- and fornix-based conjunctival flaps in initial trabeculectomy with postoperative 5-fluorouracil was not significantly different; however, in this study cystic leaking blebs were encountered only in eyes with limbal-based conjunctival flaps.

Purpose: This study was conducted to review outcomes in eyes following primary trabeculectomy supplemented intraoperatively with 5-fluorouracil (5-FU) or lower dose mitomycin-C (MMC)., Patients and Methods: We retrospectively reviewed the medical records of 73 eyes of 63 patients with progressive, far advanced open angle glaucoma who had undergone initial trabeculectomy with intraoperative application of 5-FU, 50 mg/mL for 5 min (N = 37), or MMC, 200 micrograms/mL for 3-5 min (N = 36), and with at least 12 months follow-up., Results: Mean preoperative intraocular pressures (IOPs) in the MMC and 5-FU groups were 24.3 +/- 7.6 and 24.6 +/- 9.3 mm Hg, respectively. Postoperatively, IOPs were similar at 6-month interval follow-up examinations in the MMC and 5-FU groups. At an average follow-up of 20.9 months, mean final visit postoperative IOPs were 10.2 +/- 3.6 (p < 0.001) and 9.7 +/- 3.4 mm Hg (p < 0.001) in the MMC and 5-FU groups, respectively, requiring an average of 0.25 and 0.22 antiglaucoma medications per eye, respectively. Interval follow-up complications were similar between groups and included four bleb leaks in the MMC group, and three bleb leaks in the 5-FU group. Visual acuity remained stable in 71 of 73 eyes., Conclusions: Both antifibrosis agents provide good intermediate term IOP control and may be appropriate for use in those eyes requiring final "target" IOPs in the low teens or single digits.