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Purpose: To evaluate the efficacy and safety of needle revision and examine factors predictive of failure., Methods: In total, 157 eyes of 131 patients that underwent needle revision augmented with either 5-fluorouracil or betamethasone for trabeculectomy failure were included in this retrospective study. Complete failure was defined as additional glaucoma surgery, ciliodestructive procedures, loss of light perception, sight-threatening complications, hypotony maculopathy, and surgical bleb revision. Success was defined as intraocular pressure ⩽ 18 (criterion A), ⩽15 (criterion B), and ⩽12 mmHg (criterion C) reached with (qualified) or without (complete) medications, and absence of any criteria of complete failure., Results: The median (interquartile range) follow-up was 25.0 (41.0) months. Complete failure rates were 19%, 26%, and 31% at 1, 2, and 3 years, respectively. For criterion A, qualified and complete success rates were, respectively, 77% and 69% at 1 year, 66% and 51% at 2 years, and 60% and 47% at 3 years. For criterion B, qualified and complete success rates were, respectively, 67% and 61% at 1 year, 48% and 42% at 2 years, and 44% and 39% at 3 years. For criterion C, qualified and complete success rates were, respectively, 43% and 41% at 1 year, 27% and 25% at 2 years, and 24% and 23% at 3 years. High baseline intraocular pressure and primary surgery were associated with higher and lower risks of complete failure, respectively., Conclusion: Needle revision is an effective and safe procedure to rescue failing trabeculectomy postponing or avoiding further glaucoma surgery. Eyes with low target intraocular pressure may have poor long-term outcomes.

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.

Aims: To evaluate, describe and quantify the diversity in postoperative antimetabolite administration and bleb needling practices among glaucoma specialists performing trabeculectomy surgery within the UK and Ireland., Methods: A cross-sectional online survey was distributed to all consultant glaucoma specialists who are on the United Kingdom and Eire Glaucoma Society (UKEGS) contact list. Participants were asked specific questions about their current practices for post-trabeculectomy antimetabolite administration followed by questions directly related to bleb needling procedures., Results: 60 (83%) of UKEGS glaucoma subspecialty consultants completed the survey. 70% of respondents administered 5-fluorouracil (5-FU) in their clinic room while 30% used a separate treatment room. Doses of 5-FU varied considerably but 70% used 5 mg as standard. Techniques used to reduce corneal toxicity included precipitation with amethocaine (44%) or benoxinate (14%), saline wash (14%) and modified injection technique (8%). Topical antibiotics and/or betadine were used to prevent infection following 5-FU injection in just over 50%. Bleb needling was exclusively performed in operating theatre by 56% of respondents and solely at the slit lamp in the clinic room by 12%. A further 30% used a combination of both theatre and outpatient clinic rooms. Anti-metabolites used were 5-FU (72%) and mitomycin C (22%) with 12% using either of the two substances., Conclusions: There is a significantly wide variety of current practices for antimetabolite administration and bleb needling within the UK and Ireland. This may be influenced by a glaucoma surgeon's specific experience and audit results as well as particular clinical set-up, availability of antimetabolite and clinic room space., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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.

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.

To determine whether primary trabeculectomies performed in a UK district general hospital, specifically without making use of mitomycin-C augmentation but with selective use of the low potency anti-metabolite 5-fluorouracil, produce an acceptable long-term intraocular pressure (IOP)-lowering effect for an unselected patient group. Retrospective analysis of the outcomes of all the trabeculectomies (53 eyes) performed by a single surgeon in a UK district hospital with or without 5-fluorouracil enhancement. The mean follow-up period was 5.04 years. Mean IOP preoperatively was 26.4 mm Hg while postoperatively the mean was ≤14.9 at all the time periods examined. Intraoperative complications occurred in two eyes (3.8 %) including one suprachoroidal haemorrhage and one hyphema. Postoperative complications that occurred during the follow-up period included choroidal effusions in seven patients (13 %), early postoperative bleb leak in four patients (8 %) and immediate postoperative hypotony not requiring intervention in 18 patients (34 %). Five patients (9 %) developed postoperative hyphema (all <30 % anterior chamber height) and one patient (1.9 %) developed blebitis and endophthalmitis. None of our patients developed hypotony maculopathy. When trabeculectomy is performed on unselected patients attending a UK district general hospital, selective 5-fluorouracil augmentation is probably all that is required to obtain acceptable surgical outcomes.

Filtration surgery is the standard invasive procedure for the management of intraocular pressure in advanced glaucoma. The key to a successful outcome is to modulate the normal wound healing cascade that leads to closure of the newly created aqueous outflow pathway. Antifibrotic agents such as mitomycin C and 5-fluorouracil have been increasingly used to modulate the wound healing process and increase surgical success. Although these agents have proven efficacy, they also increase the risk of complications. Efforts have centered on the identification of novel agents and techniques that can influence wound modulation without these complications. We detail new agents and methods under investigation to control wound healing after filtration surgery., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Subconjunctival absorption of aqueous humor is an essential part of glaucoma filtration surgery. Mitomycin C (MMC) and 5-fluorouracil have been used to reduce postoperative episcleral fibrosis and scar formation in the filtering bleb area for more than two decades. Both antimetabolites have also been frequently injected before needling revision of failing filtering blebs. Recently, MMC was tried also in tube surgery and nonpenetrating filtering surgery, but its usefulness in these applications has not yet been determined. The main complications and side effects of antimetabolite-enhanced filtration surgery comprise development of thin-walled cystic blebs, late bleb leaks, bleb infections, endophthalmitis, chronic hypotony, hypotony maculopathy and corneal epithelial toxicity. Besides MMC and 5-fluorouracil, several other agents were proposed for decreasing episcleral healing after glaucoma filtering surgery. Only few were evaluated in randomized clinical trials, and none became generally accepted or widely used., (Copyright © 2012 S. Karger AG, Basel.)

Purpose: To assess the success of needling in failed filtration blebs and the potential benefit of using either 5-fluorouracil (5-FU) or mitomycin C (MMC)., Methods: In this retrospective, comparative observational case series, 107 eyes that underwent needle revision with either 5-FU or MMC between July 2003 and May 2008 at Wills Eye Institute were selected. Exclusion criteria included follow-up less than 1 month and a history of glaucoma drainage device. Intraocular pressure (IOP) and number of glaucoma medications were recorded preoperatively and postoperatively. Success was defined as >20% decrease in IOP if glaucoma medications were resumed or <10% decrease in IOP if medications were not resumed post needling or fewer medications than pre needling., Results: Sixty-five patients received 5-FU and 42 patients received MMC for needling. Mean IOP changed from 23.9 mmHg to 13.8 mmHg in the MMC group and from 23.3 mmHg to 13.02 mmHg in the 5-FU group (both p<0.001). Mean glaucoma medications changed from 1.7 to 0.7 in the MMC group and 2.0 to 0.8 in the 5-FU group (both p<0.001) at the end of follow-up. After a mean follow-up of 14.5 months, overall survival was 49.5%. Mean time to failure was 7.7 months. There was a moderately weak association between survival and the immediate postoperative IOP (r=0.262, p=0.01). In comparing MMC and 5-FU, there was no statistically significant difference in survival rate (p=0.267)., Conclusions: Bleb needling may be a safe and effective means of prolonging bleb survival. The only factor associated with success was the immediate postoperative IOP. There was no apparent difference between the use of 5-FU and MMC in this population. A prospective study may provide further confirmation of this finding.

Blebs resulting from glaucoma filtration surgery tend to result in lower intraocular pressure and to be associated with fewer complications when they are diffuse and spread over the globe rather than localized to the area over the scleral flap. One way to achieve this type of bleb morphology is by applying the antimetabolite to a larger area than the one usually used in the past, in which the antimetabolite was placed only over the area of the scleral flap. In this article, the authors present a safe and inexpensive technique, which consists of using sponges with long, colored tails. This allows applying antimetabolite as far under the Tenon's capsule as desired without the risk of losing the sponges in the sub-Tenon's space., (Copyright 2010, SLACK Incorporated.)

Risks that glaucoma medications pose to the fetus and neonate must be balanced against the risk of vision loss in the mother. There is no high level evidence for harmful effects on the fetus and neonate of medications used to treat glaucoma. All topical and systemic glaucoma medication should be avoided during the first trimester of pregnancy. Systemic carbonic anhydrase inhibitors, topical prostaglandin analogues and antimetabolites during surgery should be avoided absolutely. Some topical medications are deemed compatible with lactation by the American Academy of Pediatrics, however, caution should still be practiced.

Purpose: To assess the changes in optic nerve head (ONH) structure and visual field (VF) sensitivity over time in a cohort of patients with glaucoma after trabeculectomy., Methods: The MoreFlow Medical Research Council 5-Fluorouracil (5-FU) study was an 80-month prospective randomized controlled trial of per-operative 5-FU versus placebo on the outcomes of primary trabeculectomy. Before surgery, patients had ONH imaging with a retinal tomograph and full-threshold visual field testing. After surgery, ONH imaging was performed annually and VF testing at 4-month intervals. This analysis included only patients with a minimum of 3 years' postoperative ONH and VF data. ONH images were analyzed by linear regression of sector rim area (RA) over time with change defined as a significant slope >1% of baseline RA per year in any sector. VFs were analyzed with point-wise linear regression analysis (PLRA) techniques with the stringent three-omitting criteria used. Eyes were classed as progressing or not based on analysis with either technique. Patients' median IOP level, intervisit IOP fluctuation, and percentage reduction in IOP over the follow-up period were also determined., Results: Two hundred fifty eyes of 250 patients were suitable for analysis. Of these, 70 (28%) eyes were deemed to show glaucoma progression approximately 5 years after surgery: 20 eyes by ONH alone, 35 by VF alone, and 15 by both methods. Of the 15 shown to be progressing by both ONH and VF analysis, only 7 (3% total cohort) showed congruity in the location of change. Eyes showing changes in both ONH and VF sensitivity had slightly higher median follow-up IOP (median IOP [interquartile range; IQR] nonprogressors 14.0 mm Hg [11.8-16.0 mm Hg], progressors 15.1 mm Hg [12.7-17.0 mm Hg]; Mann-Whitney U test [MWU]; P = 0.03) and lower degrees of IOP reduction from baseline (percentage IOP reduction [IQR]: nonprogressors -38.4% [-51.8% to -26.4%]; progressors -31.4% [-43.1% to -21.5%]; MWU P = 0.01) compared with eyes showing no progression., Conclusions: The study demonstrates that approximately one third of eyes continued to show progression of glaucoma at five years after trabeculectomy, as determined by trend-based analysis of ONH structural changes and VF sensitivity over time. The study suggests that the degree of IOP reduction after trabeculectomy may play an important role in the progression of glaucoma as detected by both functional and structural methods.

Purpose: To evaluate the effects of radial conjunctival incision during fornix-based trabeculectomy, and conjunctival scarring associated with previous ocular surgeries, for the restriction of bleb formation., Methods: Digital photo-slit lamp images of filtering blebs, which had undergone fornix-based trabeculectomy with mitomycin C previously, were analysed. The area and the height of the bleb in the conjunctivae with radial incision (Ain and Hin, respectively) were compared with the area and the height of the bleb in the conjunctivae without radial incision (Ano and Hno, respectively). We compared the parameters of bleb area (total bleb area, Ain and Ano) and bleb height (the bleb height at the centre of the scleral flap; Hc, Hin and Hno) in eyes without previous ocular surgeries, with those in eyes that underwent previous ocular surgeries., Results: The study population consisted of 51 eyes. The Ano and the Hno were significantly larger than the Ain (p < 0.001) and the Hin (p < 0.001) respectively. Subgroup analyses in eyes without previous ocular surgeries and eyes with phacoemulsification cataract surgery also showed that the Ano was significantly larger than the Ain. However, there was no significant difference between the Ano and the Ain in eyes with previous trabeculectomy. A comparison of bleb formation between eyes without previous ocular surgeries and eyes with cataract surgery showed no significant differences in each of the bleb area and bleb height parameters. By contrast, the total bleb area (p = 0.021), the Ano (p = 0.017) and the Hc (p = 0.045) were significantly smaller in eyes with previous trabeculectomy than in eyes without previous ocular surgeries., Conclusions: Our data demonstrate that bleb formation depends on radial conjunctival incision during fornix-based trabeculectomy and surgical conjunctival scarring from previous trabeculectomy.

Objective: To compare the long-term efficacy of intraoperative 5-fluorouracil (5-FU) and mitomycin C (MMC) in primary trabeculectomy., Design: Comparative case series and extension of a prospective, randomized controlled trial., Participants: One hundred fifteen eyes of 103 subjects undergoing primary trabeculectomy with either intraoperative 5-FU or MMC., Methods: This study is an extension of a 12-month, prospective, double-masked, randomized trial that previously was reported. Subjects were randomized to receive either intraoperative 5-FU (50 mg/ml for 5 minutes) or MMC (0.2 mg/ml for 2 minutes) during primary trabeculectomy. Follow-up data were collected from patient medical records after informed consent was obtained from the study patient. Attempts were made to contact subjects who had been lost to follow-up, and some consented to reexamination., Main Outcome Measures: The primary measure was Kaplan-Meier survival function, with failure defined as intraocular pressure (IOP) of more than 21 mmHg or less than 6 mmHg on 2 consecutive visits, less than 20% reduction from baseline IOP, loss of light perception vision, or additional glaucoma surgery to lower IOP (except bleb revision). Secondary measures included IOP, number of glaucoma medications, visual acuity, additional surgeries, and number and type of complications., Results: Mean follow up was 53.4+/-31.4 months (interquartile range, 34-82 months) in the 5-FU group and 45.3+/-28.0 months (interquartile range, 19-70 months) in the MMC group (P = 0.15, t test). Kaplan-Meier success was 0.83 at 3 years and 0.76 at 5 years in the 5-FU group and 0.79 at 3 years and 0.66 at 5 years in the MMC group (P = 0.18, log-rank test). Bleb leakage was the most common complication in each group and developed in approximately 4% of subjects in each group per year (P = 0.33, log-rank test)., Conclusions: There were no significant differences between topical 5-FU and topical MMC in reducing IOP of eyes undergoing primary trabeculectomy. Both antifibrosis agents may contribute to the development of bleb leakage., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose: To assess the long-term success rate and to determine factors that predict survival after 5-fluorouracil-augmented needling revision of poorly functioning trabeculectomy blebs., Design: Prospective observational cohort study., Participants: Eighty-one consecutive patients undergoing bleb needling., Methods: Survival analysis was performed after a minimum of 2 years' follow-up. Cox proportional hazards regression analysis was used to test the association between survival and study variables, including bleb morphology., Main Outcome Measures: Intraocular pressure (IOP) reduction by >20% and to 20% and to

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.

Purpose: The purpose of this study was to evaluate the concept of targeting mediators of the scarring process at multiple points across the course of bleb failure, in order to prolong bleb survival., Methods: There were three linked parts to the experiment. In the first part, a cannula glaucoma filtration surgery (GFS) was performed on 32 New Zealand White (NZW) rabbits, and bleb survival was assessed for six different regimens plus controls by grading bleb height and width. For the second part of the study, the same GFS surgery was performed on an additional 10 NZW rabbits. Two additional filtering blebs were treated with balanced saline solution (BSS), two received mitomycin-C (MMC) (0.4 mg/mL), and for the remaining six, a sequential regimen was given consisting of 200 mmol/L mannose-6-phosphate (M-6-P) solution at the time of surgery, followed by subconjunctival injections of antibody to connective tissue growth factor at days 2 and 4, and Ilomastat, a broad-spectrum matrix metalloproteinase inhibitor, at days 7, 12, and 20 postoperatively. Bleb survival was again assessed. In the final part of the experiment, blebs treated with either BSS, MMC, or the above sequential multitreatment regimen were examined histologically at 14 days postoperatively in three additional NZW rabbits., Results: All six individual therapies selected resulted in some improvement of bleb survival compared to BSS control. Blebs treated with the new sequential, multitreatment protocol survived an average of 29 days (regression slope, P < .0001 compared to control), those receiving BSS an average of 17 days, and those treated with MMC (0.4 mg/mL) an average of 36 days. The sequential, multitreatment regimen was significantly superior to any of the six monotherapies for time to zero analysis (flattening) of the bleb (P < .002). Histologic examination of the bleb tissues showed a markedly less epithelial thinning, subepithelial collagen thinning, and goblet cell loss in the multitreatment group, when compared with the MMC blebs., Conclusions: In a rabbit model of GFS, a sequential, targeted, multitreatment approach prolonged bleb survival compared to BSS controls and decreased bleb tissue morphological changes when compared to those treated with MMC. It is not known whether these findings can be reproduced in humans, and further work is needed to determine an optimum regimen and timing of therapeutic delivery.

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.

Background/aim: In this study we compared the two groups of glaucoma patients who had underwent trabeculectomy, with or without intraoperative application of antimetabolite 5-Fluorouracile (5 FU)., Methods: We followed up 50 glaucoma patients (group I) in a four-years period after trabeculectomy alone (antimetabolites were not applied), and 50 patients in whom antimetabolite 5 FU was applied (group II). We followed up intraocular pressure (IOP), visual acuity (VA), lens transparency, optic disc changes, visual fields (VF perimetry). The IOP at the time of the surgery, and the period of the treatment before the surgery were the important data for the follow-up., Results: The results that we got in the first group were: in 8 patients (16%) there was no change of VA, and of optic disc with a mild VF deterioration; in 18 patients (33%) the worsening of VA by 1 Snellen line (3 years after the surgery) with no change of the disc and a mild VF progressing; in 10 patients (20%) VA decreased by 2 Snellen lines with the progressive VF changes and cataract appearance, (cataract and VA worsening appeared mainly 3 years after the surgery); in 6 patients (12%) by 3 Snellen lines, and in 4 patients (8%) by 4 Snellen lines. In 4 patients (8%), the highest worsening of VA--(0.2) and the best (0.9) at the time of the surgery were observed. The VA ranging from 0.4-0.6 at the time of the surgery yielded the longest preservation of vision. In the group II (5 FU applied intra-operatively): in 5 patients (10%) there was no change of VA and of optic disc with a mild VF deterioration; in 20 patients (40%) the worsening of VA by 1 Snellen line, with no change of the disc and a mild VF progressing. In 14 patients (28%) VA decreased by 2 Snellen lines with the progressive VF changes and cataract appearance; in 7 patients (14%) by 3 Snellen lines, and in 4 patints (8%) by 4 Snellen lines., Conclusion: All of the checked parameters were better in the group II of the patients, (5 FU applied intraoperatively). Also, in the group of the patients with the longest treatment before the surgery and with the good VA, and in the patients with the shorter treatment and with the bad VA, the quickest progression of the vision losts was observed. The best preservation of VA was recordered in the patients with a mild IOP, and in those who had not been treated more than 1 or 2 years with the drops before the surgery. The VA ranging from 0.4-0.6 at the time of the surgery allowed the longest preservation of vision.

Purpose: To probe the results of trabeculectomy with human amniotic membrane (HAM) or mitomycin(MMC) in the treatment of glaucoma., Methods: In a randomized control clinical trial, 48 eyes of 28 glaucoma patients were divided into two groups, each group has 24 eyes, and each group was divided into two sub-groups according to the age. The former was underwent trabeculectomy with HAM transplanted, the later was administrated intra operatively with MMC, 0.2-0.4mg/ml, for 2-4 minutes, the follow-up was 6 months., Results: The operation success rate of both groups was higher than the standard trabeculectomy, and the difference between the two groups was not significant. Complications induced by HAM were mainly shallow anterior chamber, whereas by MMC were thin wall bleb, bleb leaking, persistent hypotony and hypotonous maculopathy., Conclusion: Application properly HAM or MMC can improved the operation success rate, maintain the functional bleb long time and decreased the complications.

Purpose: To investigate the anti-fibroplastic effect of the preserved human amniotic membrane by transplanting on animals in glaucomatous surgery., Methods: Trabeculectomy were performed on 48 eyes of 24 rabbits which were divided into 3 groups: group A was treated with the amniotic transplantation under sclerotic flap, group B was performed trabeculectomy using MMC (0.25mg/ml) under sclerotic flap and group C played the role of control which had surgery only. postoperative examinations including the intraocular pressure (IOP) , filtering bleb, reaction of the anterior chamber and complications were performed on 1, 2, 3, 7, 14, 28, 60 days after surgery respectively. A rabbit selected randomly in the three groups was killed in 1, 2, 3, 4, 8 week after operation and extirpated the eyeball to observe the time of decomposition of the amniotic membrane in pathologic tissue slice, counted the number of fibroblast and inflammatory cells with computer and compare their difference., Results: There were not significant difference of IOP among the three groups except observed on the first day after operations (P > 0.05); Comparing with group B and group C, the complications of group A ( amniotic membrane) didn't increased. The duration of the existing time of the filtering blebs was about 1 month. The decomposed time of the amniotic membrane was about 3-4 weeks, after 4 weeks it was substituted by fibroblast and inflammatory cells. The number of fibroblast counted by computer showed significant difference between group A (0.0205+/-0.01235) and group C (0.0673+/-0.03830) (P=0.017 < 0.05), and no obvious difference with group B. The inflammatory cells of group A (0.4402+/-0.1708) increased greatly in comparison with group B (0.0407+/-0213) and group C (0.0294+/-08876); (t=5.67, P=0.002 < 0.05, t=4.81, P=0.004 < 0.05 respectively)., Conclusion: The decomposed time of the amniotic membrane is about 3-4 weeks in trabeculectomy. Amniotic membrane has a restraint effect on fibroblast and it can enhance the effect of surgery to lower the IOP in trabeculectomy as well as has less complication. The inflammation reaction in the operation area of the group A is heavier than the others which may be caused by repellent reaction between different species.

Purpose: Owing to its technical refinements, "modern" trabeculectomy aims to reduce the incidence and severity of early postoperative complications while increasing postop IOP success. The purpose of our study was to evaluate namely the safety of "modern" trabeculectomy, the quality of the filtration blebs, the influence on the quality of life and secondarily IOP reduction according to the surgical procedure whether augmented with peroperative application of antimetabolites or not., Material-Methods: Retrospective study including our 45 first consecutive procedures in 38 patients (mean age: 61.1 years) with medically uncontrolled various glaucomas. All procedures were performed according to a modified P. Khaw's protocol. Antimetabolites were applied peroperatively in 28/45 eyes (62.2%) with a history of previous filtering surgery (12/28 eyes) and/or advanced glaucomatous damage (22/28 eyes). Antimetabolites were not used in the 17/45 other eyes with lower surgical risk factors and higher target IOP, surgical procedure was not augmented with antimetabolites. Postoperative management included laser suture lysis, withdrawal of adjustable sutures and 5-FU injections when needed. Complete ocular examination was carried out preoperatively and postoperatively at day 1, 7, at 1, 2 and 3 months and every 3 months thereafter. All patients were questioned for symptoms associated with filtration bleb dysesthesia at the last visit., Results: The mean follow-up was 7.9 +/- 3.3 in the group without antimetbolites and 5.3 +/- 2.2 months in the group with antimetabolites (p < 0.05). Final mean IOP (+/-SD) was significantly lower in the group augmented with antimetabolites (11.2 +/- 4.5 mmHg) compared with the group without antimetabolites (14.9 +/- 3.7 mm Hg) (p < 0.05). Complete and qualified success were respectively 64.3% and 89.3% in the group with antimetabolites and 70.6% and 82.4% in the subgroup without antimetabolites (p > 0.05). 1st month postoperative complications were transient and minor. They occurred in 59% in the group without antimetabolites and in 68% in the subgroup augmented with antimetabolites. Complications had comparable frequency of distribution between the 2 subgroups (p > 0.05). 84% of the filtration blebs (30/45) were diffuse and mildly vascularized. Avascular blebs were noticed in 7 eyes (15.5%) and were not related with the intraoperative application of mitomycin C (p > 0.05). Subjective comfort was good to excellent in 42/45 eyes (93.3%). Mean final visual acuity was not altered compared with preop level (p > 0.05)., Conclusions: Our short term results suggest that the safety of "modern" trabeculectomy augmented with antimetabolites is comparable to those without intraoperative antimetabolites. Filtration blebs were very well tolerated in most patients. The peroperative use of antimetabolites precludes to appreciate if the success rates are due to the use of antimetabolites and/or the technique per se.

Purpose: 5-FU is an antimetabolite which increases efficacy of deep sclerectomy by inhibiting subconjuctival fibrosis and fibroblast proliferation. The objective of the study was to analyze glaucoma patients who had undergone sclerectomy and in a post-surgery period required subconjuctival 5-FU injections., Material and Methods: Out of 120 patients who had undergone deep sclerectomy between January through November 2004, 17 were included in the study since they required subconjuctival 5-FU injections in a post-operative period. The analysis comprised of: (1) indications for antimetabolite administration; (2) time that elapsed from the surgery to the first antimetabolite administration; (3) mean dosage; (4) complications observed; and (5) initial evaluation of the treatment., Results: In 13 patients (76.4%), the indication for 5-FU application was persistent intraocular pressure exceeding 15 mmHg; in one patient (5.8%), the 5-FU treatment was started due to an abrupt increase of the pressure from hypotony; in 6 subjects (35.2%), it was the thickening and vascular dilatation in the filtering bleb; in one subject (5.8%) encapsulated filtering bleb. Mean time of administering 5-FU was between the 2nd and 3rd week following surgery. Mean number of injections applied was 3.7 (18.5 mg 5-FU). The following complications were encountered: corneal superficial punctuate keratopathy (6 subjects), choroidal detachment (1 person), irregular astigmatism (1 person). In most cases IOP was well controlled by the end of the follow-up period (< or = 15 mmHg)., Conclusions: 5-FU is safe and does not increase the perioperative risk, and has turned out to be effective in most cases of increased scarring in the filtering bleb site.

We evaluated the change of corneal endothelium after trabeculectomy with mitomycin-C soaking (0.2 mg/ml, 2.4 +/- 1.2 minutes) and the effect of viscoelastic material in reducing this change. In randomly selected cases, 0.05 ml of sodium hyaluronate(Healon) was injected into anterior chamber (Healon group, n = 20), and same amount of balanced salt solution was injected in the other eyes (Control, n = 18) at the beginning of surgery. There were no differences in clinical variables and specular microscopy result between 2 groups before surgery. After surgery, the change of endothelial cells were significantly reduced in Healon group (cell density; -2.5 +/- 1.6%, variability of cell area; 5.8 +/- 2.5%, and percentage of hexagonal cell; -2.2 +/- 0.7%) compared to control group (-7.7 +/- 6.0%, 8.9 +/- 4.4%, and -4.8 +/- 3.5% respectively, p < 0.01). In trabeculectomy with mitomycin-C, the damage to the corneal endothelium was reduced significantly by injecting the viscoelastic material without significant complication.

A retrospective study was conducted at the Hospital Sultanah Aminah Johor Bahru to determine the outcome of trabeculectomy surgeries over a period of 4 years. One hundred and two eyes were followed up to a maximum of 63 months (mean 34.2 months). The 2-year survival rates for plain trabeculectomies, 5-Fluorouracil augmented trabeculectomies and Mitomycin-C augmented trabeculectomies were 52.9%, 27.3% and 60.5% respectively. The commonest complications noted were cataract formation (25%) and hyphaema (11%). Mitomycin-C induced complications were rarely seen. At last follow-up, 54% of eyes had intraocular pressures below 21 mmHg without medication, while 34% of eyes had intraocular pressures below 21 mmHg with medication. Vitreous at the trabeculectomy site was a statistically significant predictor of operative failure.

Purpose: To compare the safety and efficacy of intraoperative 5-fluorouracil (5-FU) or Intraoperative mitomycin C (MMC) in eyes undergoing primary trabeculectomy., Design: Prospective double-masked randomized clinical trial., Methods: One hundred fifteen eyes of 103 patients with uncontrolled intraocular pressure (IOP) despite maximally tolerated medical therapy or laser were prospectively randomized in a double-masked fashion to one of two treatment groups in a single institution setting. Subject's eyes underwent primary trabeculectomy with either topical 5-FU (50 mg/ml for 5 minutes) or topical MMC (0.2 mg/ml for 2 minutes). Primary outcome measures included the number of eyes achieving target pressures of 21, 18, 15, and 12 mm Hg at 6 and 12 months postoperatively. Secondary outcome measures included IOP, best-corrected visual acuity, complications, and interventions., Results: Of the 115 eyes, 57 received 5-FU while 58 received MMC. A target IOP of 21 mm Hg at 6 months was achieved in 53 of 56 (95%) eyes in the 5-FU group and 54 of 57 (95%) eyes in the MMC group (P = 1.00). At 12 months, 45 of 48 (94%) eyes in the 5-FU group met a target IOP of 21 mm Hg while 48 of 54 (89%) eyes in the MMC group did (P =.49). The most common complications in each group were persistent choroidal effusions and bleb leak., Conclusion: Our study suggests that intraoperative topical 5-FU is at least as effective as intraoperative topical MMC in reducing IOP of eyes undergoing primary trabeculectomy.

Purpose: To study the long-term results (1-14 years) of trabeculectomies with 5-fluorouracil injections that were successful at 1 year., Design: A retrospective noncomparative case series. INTERVENTION/PARTICIPANTS: We identified 87 patients (87 eyes) who had trabeculectomies with 5-fluorouracil injections from 1984 to 1989 that were successful at 1 year and had a follow-up range of 1.0 to 14.7 years (mean, 8.1, standard deviation of 4.4 years). All patients had previously failed glaucoma surgery (66.7%), cataract surgery (47.1%), or other diagnoses making them at high risk for failure., Main Outcome Measures: Successful control of intraocular pressure (IOP) was defined as IOP less than 21 mmHg or a reduction of 33% if preoperative pressure was less than 21 mmHg. Statistical analysis was performed using Kaplan-Meier life table analysis., Results: If an eye is considered successful by IOP at 1 year, the probability of successful control is 61% at 5 years, 44% at 10 years, and 41% at 14 years., Conclusions: Despite successful IOP control at 1 year, trabeculectomies with 5-fluorouracil injections show a continual loss of IOP control over time.

Background: 5-Fluorouracil, an antimetabolic agent, improves the success rate of trabeculectomies by inhibiting subconjunctival fibrosis. However, complications may be associated with early postoperative use. We investigated the outcome of needling revision with delayed subconjunctival 5-fluorouracil in failing filtering blebs after a trabeculectomy in patients with medically poorly controlled glaucoma., Methods: We performed needling revision with subconjunctival 5-fluorouracil injection 5.0 +/- 4.0 weeks after trabeculectomy with failing filtering blebs in 25 eyes of 24 patients. The diagnoses of these patients were primary angle-closure glaucoma (4), primary open-angle glaucoma (4), post-cornea-graft glaucoma (8), traumatic glaucoma (5), neovascular glaucoma (3) and pseudophakic glaucoma (1)., Results: Total success was achieved in 21 eyes (84%) including complete success in 10 (40%) and qualified success in 11 (44%) after 3.2 +/- 1.2 needling revisions over an average 8.3 +/- 7.0-month follow-up period from the last needling revision. The mean intraocular pressure was 16.0 +/- 8.4 mmHg in the last visit compared with 26.0 +/- 8.1 mmHg before the procedure. Major complications were transient hypotony (1), transient corneal epithelial defect (13) and hyphema (3)., Conclusions: This study supports the efficacy and safety of the delayed use of 5-fluorouracil with needling revision for managing failing filtering blebs following a trabeculectomy.

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.

Drainage devices are routinely placed in the eyes of patients with glaucoma to reduce intraocular pressure (IOP) by providing controlled outflow of fluid (aqueous humor) via a filtering bleb. However, the natural wound healing response often interferes with fluid outflow by thickening the walls of the bleb over time, so that these devices rarely remain functional for more than 5 years. We investigated the use of controlled release of an antimetabolite, 5-fluorouracil (5-FU), within glaucoma drains to determine if the wound healing response could be reduced and the useful life span of the device increased. Collagen plugs containing 1.125 mg of 5-FU were placed in the silicone tubes of modified Baerveldt glaucoma drains. Eight drains with 5-FU and eight drains without 5-FU were implanted in one eye each of 16 New Zealand white rabbits: the contralateral eyes served as unoperated controls. Results were evaluated in terms of IOP, fibrous capsule thickness, macrophage density. and presence of type III collagen surrounding the drain plate, 3 and 6 months after implantation. In general, eyes implanted with antimetabolite-containing drains demonstrated significantly lower values for all evaluated parameters at 3 months and lower or equal values at 6 months, compared with the eyes not receiving 5-FU and the unoperated controls, indicating improved IOP-lowering function, reduced bleb wall thickness, and earlier achievement of a steady-state wound healing response. All eyes remained healthy throughout the 6-month duration of the study with no cytotoxicity complications in any of the eyes. Thus, biodegradable plugs placed within the silicone tubes of glaucoma drains can safely deliver 5-FU to filtering blebs over time, which could prolong the functional life of the bleb by decreasing the thickness of the anterior fibrous capsule and permitting sufficient fluid outflow to reduce IOP to physiological levels.

Purpose: There is a considerable body of literature relating to trabeculectomy; however, there are no data representative of the national experience of trabeculectomy in the United Kingdom (UK). The Department of Health funded a national survey of trabeculectomy to establish current practice patterns and the outcome of trabeculectomy in the National Health Service (NHS). In this paper we report variations in surgical technique and the national success rate of trabeculectomy., Methods: A cross-sectional survey was carried out of consultant ophthalmologists performing trabeculectomy in the NHS. Participants recruited their four most recent consecutive first-time trabeculectomy cases according to study eligibility criteria and data were collected by self-administered questionnaire., Follow-Up: 1 year post-trabeculectomy. Main outcome measure of success: final intraocular pressure (IOP) less than two-thirds the pre-operative IOP. Secondary outcome measures of success: final IOP less than 21 mmHg and visual field stability. Success was further defined as unqualified (excluding patients on anti-glaucoma medications at final follow-up) or qualified (including patients on anti-glaucoma medications at final follow-up). The relationship between variables characterising consultants' practice and main outcome measure was examined by chi-square test., Results: Clinical outcome data were available for 1240 (85.3%) cases. There were wide variations in operative technique. The mean post-operative IOP was 14.4 mmHg (95% CI 14.2-14.7), which is a mean reduction of 11.8 mmHg (95% CI 11.4-12.2). An unqualified success, in terms of the main outcome measure, was achieved in 66.6% of patients and a qualified success in 71.0% of cases. An unqualified success, in terms of a final IOP less than 21 mmHg, was achieved in 84.0% of cases and a qualified success in 92.0%. Visual fields were stable in 84.2%. Outcome was not related to consultants' specialist interest, level of activity, type of hospital or region., Conclusions: The success rates reported in this paper represent the national experience of first-time trabeculectomy for open angle glaucoma in the UK. The national success rate at 1 year compares favourably with many studies in the literature. This survey provides valid and clinically relevant measures of success for the production of guidelines and standards for audit at regional, local and individual level and a baseline for the comparison of new therapies.

The healing process after glaucoma filtration is the main determinant of surgical failure and, even more important, the final intraocular pressure. The ability to fully control wound healing may ultimately give us the ability to set the intraocular pressure in the low teens for all patients undergoing glaucoma filtration surgery. The authors review the changes in how to use antimetabolites to improve safety, and many of the exciting new areas of progress, including growth factor neutralization and future molecular therapies to control wound healing.

Purpose: To report a randomized clinical trial of postoperative subconjunctival injections of low-dose 5-fluorouracil in patients undergoing primary trabeculectomy., Methods: In a prospective, randomized clinical trial, 40 eyes of 40 patients were randomized to the low-dose 5-fluorouracil group and received three subconjunctival injections of 5 mg each over 11 postoperative days, and 40 eyes of 40 patients were randomized to trabeculectomy without 5-fluorouracil., Results: Mean (+/-SD) preoperative and 1-year postoperative intraocular pressures in the 5-fluorouracil group were 26.9 (+/-9.5) and 15.3 (+/-5.8) mm Hg, respectively. In the control group these were 25.9 (+/-8.1) mm Hg, and 15.8 (+/-5.1) mm Hg, respectively. The patients who received 5-fluorouracil had a mean reduction in intraocular pressure of 11.5 (+/-9.1) mm Hg at a median follow-up of 52.3 weeks. The control group had a mean reduction in intraocular pressure of 10.2 (+/-8.7) mm Hg at a median follow-up of 52.6 weeks. These differences were not statistically significant., Conclusions: Three postoperative subconjunctival 5-fluorouracil injections of 5 mg each after trabeculectomy in eyes at low risk for failure had no statistically or clinically significant effect on reduction of intraocular pressure with 1-year follow-up. Enhancement of success in this group of patients may require a larger total dose of 5-fluorouracil.

Purpose: To determine the effect of intraoperative application of 5-fluorouracil (5-FU) on the long-term outcome of trabeculectomy in uveitis-related glaucoma., Design: An open, prospective, noncomparative case study to evaluate the use of intraoperative application for 5 minutes of 25 mg/ml 5-FU in primary trabeculectomy for uveitis-related glaucoma., Participants: Fifty eyes of 43 consecutive patients were enrolled in the study., Methods: Data were recorded prospectively on specifically designed forms at visits every 3 months after surgery., Main Outcome Measures: The intraocular pressure, need for additional medication, and the need for repeat surgery were the criteria that determined the outcome of surgery., Results: No significant intraoperative, postoperative, or late complications of 5-FU administration were noted. Successful filtration was achieved in 82% of eyes at 1 and 2 years after surgery. The success rate was 67% at 5 years. Failure was significantly more common and occurred earlier in patients of black ethnic origin. No deleterious effect on control of uveitis in relation to surgical intervention was observed., Conclusions: Intraoperative application of 5-FU appears to be a long-term, safe, and effective adjunct to trabeculectomy in uveitis-related glaucoma.

Purpose: To evaluate the efficacy and safety of augmented trabeculectomy with 5-fluorouracil (5-FU) and mitomycin C (MMC) compared to 5-FU only for the treatment of pediatric glaucoma., Patients and Methods: In a prospective randomized clinical trial, 8 children (12 eyes) with pediatric glaucoma, either congenital or secondary to: lens aspiration, Sturge-Weber syndrome, or steroids underwent augmented trabeculectomy. Six patients (8 eyes) underwent augmented trabeculectomy with 5-FU plus MMC and 2 patients (4 eyes) underwent augmented trabeculectomy with 5-FU only., Main Outcome Measures: Between-group comparison of postoperative parameters: change in intraocular pressure (IOP), dependence on antiglaucoma medication, number of 5-FU injections, cup-disc ratio, corneal diameter, drug-induced complications., Results: In the 5-FU/MMC group, 7/8 eyes showed good control of postoperative IOP (9-16 mm Hg), which was independent of antiglaucoma therapy; only 2 injections of 5-FU were needed. By contrast, in the 5-FU group, no control of the postoperative IOP (21-23 mm Hg) was achieved in 4/4 eyes, and these patients remained dependent on antiglaucoma medication; up to 6 injections of 5-FU were used. There was no deterioration in the cup-disc ratio or the corneal diameter in either group. Results were maintained on follow-up (23-27 months). No significant drug-induced complications were noted., Conclusion: Augmented trabeculectomy with adjunctive 5-FU/MMC may be an option for the control of pediatric glaucoma in patients with a poor surgical prognosis.

Background and Objective: This study was undertaken to compare the efficacy and safety of low-dose intraoperative application of mitomycin-C (MMC) with that of 5-fluorouracil (5-FU) in primary trabeculectomy., Patients and Methods: A non-randomized prospective study was performed between August 1994 and November 1995. Thirty-two eyes of 16 consecutive patients who underwent trabeculectomy for uncontrolled glaucoma of various causes form the study group. The mean age was 46.8 +/- 9.9 years. The first eye received MMC (0.2, 0.4 mg/ml), fellow eye received 5-FU (50 mg/ml), for 1 minute intraoperatively. Bleb characteristics and intraocular pressure (IOP) control were analyzed. Success of surgery based on IOP control was measured by 3 different criteria: IOP less than 21 mm Hg; IOP less than 21 mm Hg with more than 30% reduction; and IOP less than 16 mm Hg with more than 30% reduction., Results: Mean preoperative IOP was 31.4 +/-12.7 mm Hg in MMC group and 27.8+/- 8.8 mm Hg in 5-FU group. Mean follow-up in MMC group was 16.12 +/- 8.17 months; in 5-FU group 13.37 +/- 8.19 months. At last follow-up all 5-FU blebs were nonischemic, while 4 eyes in the MMC group showed nonischemic blebs, and 12 eyes had ischemic blebs. There was no statistically significant difference between MMC group and 5-FU group success rates with all 3 criteria. Success rates were: IOP less than 21 mm Hg; 100% in both groups; IOP less than 21 mm Hg with more than 30% reduction; MMC group 93.8%, 5-FU group 75%; less than 16 mm Hg with more than 30% reduction; MMC group 87.5%, 5-FU group 68.8%., Conclusions: Low-dose intraoperative MMC and 5-FU can provide control of IOP in primary trabeculectomy, 5-FU group showed more non-ischemic blebs.

Antimetabolites have been used in combination with filtering surgery to improve surgical results for more than 10 years. Based on research published since the introduction of antimetabolites right up to date, we discuss the various forms of antimetabolites that have been used, including drugs and irradiation. Among the drugs used, mitomycin C and 5-fluorouracil are the most prominent. We discuss the background of these agents, the progress in the use of antimetabolites and the research done on these drugs. These agents have been used both intra-operatively and perioperatively. We discuss the indications for their use, their mode of action, the techniques of usage, their variations as well as the complications and the treatment of complications.

Many adjunctive therapies have been proposed to increase the success and prevent or reduce the incidence of complications associated with filtering surgery. Intraoperative or postoperative use of an antimetabolite has found a place as adjunctive therapy for eyes with otherwise pour prognosis following glaucoma filtering surgery.

Purpose: To define and compare the trabeculectomy survival with regard to intra-ocular pressure (IOP) control without further surgery or anti-glaucoma medication n an Asian population., Methods: A retrospective review of two consecutive groups of patients who had trabeculectomy surgery in a university eye department setting. The first group of patients (group A) did not receive any adjunctive 5-fluorouracil (5-FU), while the second group (group B) had intra-operative sponge application of 5-FU. Only the first trabeculectomy of patients who had bilateral trabeculectomy and the first trabeculectomy performed in patients who had repeated surgery was analysed. Combined procedures were excluded. Survival analysis was performed using the Kaplan-Meier product limit method., Results: Eighty-nine patients (51 in group A and 38 in group B) were studied, with a mean follow up of 37.5 and 27.0 months, respectively (P = 0.014). There were no statistical differences in age, gender, mean pretreatment IOP, pre-operative medication, proportion of patients with previous ocular surgery, or proportion of primary compared with secondary glaucoma between the two groups. The probability of trabeculectomy survival (IOP < 22 mmHg without additional medication/surgery) at 12 and 36 months was 54.3 and 36.4%, respectively, in group A and 75.8 and 65.8%, respectively, in group B. The differences in survival were significant (P = 0.006, log rank test)., Conclusions: Our experience with trabeculectomy survival in the Asian population showed poorer success when compared with Caucasian populations reported by other investigators. The survival of trabeculectomy surgery was improved significantly with intra-operative 5-FU. There may be justification for advocating a more liberal use of intra-operative 5-FU in such a population.

The authors evaluate the results of preoperative 5-minute administration of 5-fluorouracil (5-FU), 50 mg/ml, during trabeculectomy on 11 high risk eyes of children with primary and secondary glaucoma. The mean age of the patients was 7.3 years, the average follow-up period 8.9 months (6-12 months). The intraocular pressure (i.o.p) of 11 eyes before surgery varied between 23 and 46 torr, average 31.5 torr, after treatment it was 13 to 28 torr, average 18.4 torr. The mean drop of IOP was 41.6%. In 7 eyes during the last assessment of IOP < 21 torr with a drop of more than 30%. The remaining 4 eyes have a was IOP between 25 and 28 torr with a reduction of 19-39%. Serious postoperative complications comprised four times marked hypotonia with a shallow anterior chamber, twice choroidal ablation and once macular oedema associated with transient deterioration of vision. In view of the limited therapeutic possibilities of high risk types of glaucoma in children postoperative administration of 5-FU is a promising alternative for the reduction of IOP.

The efficacy of combined surgery for the treatment of concurrent glaucoma and cataract has long been under scrutiny. Comparisons between sequential surgery and combined procedures have shown mixed results, and current guidelines have been drawn for the indication of combined surgery. The evolution of combined triple surgery--cataract extraction, intraocular lens implantation, and filtering procedure--has evolved from planned extracapsular cataract extraction to small-incision phacoemulsification. The improvements of phacoemulsification over extracapsular surgery have naturally given rise to improvements in the results of combined procedures; good outcomes in both intraocular pressure control and visual acuity have been reported along with low complication rates. The techniques of combined phacoemulsification-trabeculectomy are under continual development as new sutureless incisions, filtration procedures, and antimetabolite use are studied. The results of numerous studies show that the combined procedure is an effective method of treatment of glaucoma and cataract. This review examines various recent aspects of the combined procedure, phacoemulsification-trabeculectomy, antimetabolites, results and complications, as well as current developments of new techniques. In addition, we review studies on combined cataract extraction and trabeculectomy, including older literature on planned extracapsular extraction plus trabeculectomy as well as newer studies on phacoemulsification-trabeculectomy.

The refinements of small incision cataract surgery by phacoemulsification with foldable intraocular lens implantation and the pharmacologic modulation of wound healing have brought new options for the combined procedure. Phacoemulsification combined with filtering surgery has the potential advantage of requiring a smaller conjunctival and scleral incision, which may reduce inflammation and bleb scarring with the possibility of enhanced bleb formation and long-term intraocular pressure control. The smaller phacoemulsification incision also helps to reduce postoperative astigmatism and improve visual results. Following combined phacoemulsification and filtering surgery, a larger area of undisturbed or virginal tissue in the conjunctiva and at the limbus is spared for further glaucoma surgeries or revision if the initial procedure fails. The risk of suprachoroidal hemorrhage during phacoemulsification in this susceptible group of patients is minimized by maintaining a closed chamber during the procedure.

Combined phacoemulsification and trabeculectomy has become a common procedure in the management of coincident cataract and glaucoma. As the medical options to treat glaucoma continue to improve, more patients may not require surgical intervention until the time of cataract extraction. Current techniques using small-incision phacoemulsification and trabeculectomy with antimetabolites have vastly improved the results of combined glaucoma surgery. This article discusses many of the important issues as they relate to this subject. This is not a comprehensive review, but rather a discussion of the literature in the scanning period of this issue.

Purpose: To assess the outcome of trabeculectomy supplemented with intraoperative 5-Fluorouracil (5 FU) application in glaucoma patients., Methods: A prospective non-randomized case series of 76 eyes of 76 consecutive patients who underwent trabeculectomy with intraoperative sponge 5 FU (25 mg/ml). Minimum follow-up was 6 months. There were 31 eyes in the low-risk group and 45 eyes in the high-risk group. The reduction in intraocular pressure (IOP) and any treatment complications were noted., Results: The mean preoperative IOP was 28+/-7.72 mm Hg. The mean final postoperative IOP was 16.8+/-6.1 mm Hg. The average number of glaucoma medications required dropped from 1.8+/-0.8 preoperatively to 0.4+/-0.8 after the operation (p<0.001). Cumulative success rates (IOP less than 21 mm Hg) for all eyes were 93% and 81% at 6 and 12 months, respectively. There was no difference in outcome between the low- and high-risk groups if criteria for success were an IOP of less than 21 mm Hg or an IOP of less than 21 mm Hg and an IOP reduction of 30%. However, if success is defined as an IOP of 15 mm Hg or less and a 30% fall in IOP, then the low-risk group had significantly longer survival times than the high-risk group (p=0.033, log-rank test). Transient punctate keratitis and corneal epithelial defect were each observed in only 1 eye. Other serious complications include rapid progression of cataract in 2 eyes, endophthalmitis in 1 eye and hypotonic maculopathy after subsequent cataract extraction in 1 eye., Conclusion: Single dose intraoperative 5 FU appears to be a safe and useful adjunct to trabeculectomy. IOPs in the low teens were achieved in a greater proportion of low-risk eyes than high-risk eyes.

Purpose: Needling revision is an accepted method of management of poorly functioning trabeculectomy blebs. The authors present the outcome of the analogous needling revision of poorly functioning filtering blebs over glaucoma drainage device (GDD) reservoirs., Methods: Review of 20 patients (21 eyes) who underwent needling to the bleb overlying the GDD reservoir, with or without adjunctive 5-fluorouracil injection., Results: In the nine eyes (43%) that were considered successes (defined as intraocular pressure [IOP] less than or equal to 21 mmHg and decrease in IOP greater than or equal to 20% with no additional medication or glaucoma surgery), the mean IOP fell from 28.3 +/- 6.4 mmHg to 13.9 +/- 2.7 mmHg at last follow-up, after a mean of 1.7 needlings (range, 1-3 needlings) with mean follow-up of 14.6 months (range, 5-35 months [corrected]). Needling success was associated with larger GDD surface area (mean, 267 +/- 95 mm2 vs. 179 +/- 79 mm2 in eyes needled unsuccessfully, P = 0.04) and use of Baerveldt implants (six of eight eyes needled successfully). Minor complications were few. Endophthalmitis developed in one patient (5% of all eyes) after needling., Conclusions: Needling revision can be useful in the management of poorly functioning GDD blebs, although the risk for severe complications exists.

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.