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The article reviews the results of using optical coherence tomography (OCT) - a non-invasive non-contact examination method for obtaining a tomographic slice image of the site of glaucoma surgery. The method helped reveal the functional relationships between the newly created outflow pathways and various parameters of the filtering bleb such as its linear dimensions, wall structure, presence of microcysts, position of drainage, etc. Due to its high resolution and noninvasiveness, OCT can be reliably used to examine the structure of aqueous outflow pathways in different postoperative periods with accuracy close to morphometric. The amount of data that had been obtained with the method has allowed the creation of new classifications and clarification of OCT-relevant prognostic signs for glaucoma surgery site.В обзоре обобщены результаты применения оптической когерентной томографии (ОКТ) - бесконтактного объективного неинвазивного метода исследования, позволяющего получить картину томографического среза зоны хирургического вмешательства антиглаукомной операции. С помощью данного метода была выявлена взаимосвязь 'работоспособности' созданных путей оттока и различных характеристик фильтрационной подушки, таких как линейные размеры, структура стенки, наличие микрокист, положение дренажного устройства и др. За счет высокого разрешения и неинвазивности ОКТ позволяет с большой достоверностью оценить структурные особенности путей оттока в различные сроки после оперативного вмешательства на уровне, близком к морфологическому. К настоящему моменту объем знаний, полученный в результате подобных исследований, позволил создать новые классификации и прогностически значимые ОКТ-признаки зоны хирургического вмешательства антиглаукомной операции.

Purpose Evaluating the anterior chamber angle (ACA) and filtering bleb following phacotrabeculectomy by using anterior segment optical coherence tomography (AS-OCT). Patients and methods This is a retrospective study that included 30 eyes of 30 patients with cataract and glaucoma of both sexes and aged from 42 to 72 years. Patients attended the Ophthalmology Department of Minia University Hospital between June 2016 and November 2017. The duration of follow-up was 6 months. The patient’s underwent preoperative clinical and AS-OCT examination, followed by phacotrabeculectomy, and then postoperative AS-OCT to evaluate the angle and the filtering bleb. Results A total of eight patients were diagnosed with primary open-angle glaucoma and 22 with primary closed-angle glaucoma. Overall, eight (26.7%) eyes had closed angle in two quadrants: six (20%) eyes with closed superior and inferior quadrants and two (6.7%) eyes with closed nasal and temporal quadrants. Closed ACAs in three quadrants of the eye, the superior, nasal, and temporal quadrants, were found in six (20%) eyes. Closed ACAs in the four quadrants of the eyes were observed in eight (26.7%) eyes. Cystic blebs are highly elevated and hyporeflective (30% of cases). Diffuse blebs are moderately elevated with moderate reflectivity (50% of cases). Flat blebs are low with hyperreflectivity (20% of cases). Conclusion AS-OCT is an optimistic tool to investigate the filtering blebs. It was able to detect angle changes preoperatively and postoperatively and show the features of the bleb that are not properly detected by the slit lamp examination. It has the advantage over ultrasound biomicroscopy in being a noncontact, noninvasive procedure, allowing early postoperative examination.

To determine whether thermography can be used to evaluate bleb function.The surface temperatures of filtering blebs from 39 eyes of 33 post-trabeculectomy patients were measured using thermography. We introduced a new parameter: the temperature decrease in the filtering bleb (TDB) where TDB = (mean temperature of the temporal and nasal bulbar conjunctiva)-(temperature of the filtering bleb). The eyes were classified into good and poor intraocular pressure (IOP) control groups according to the patients' postoperative IOP. The morphological appearance of the filtering blebs were classified by slit-lamp images according to the Indiana Bleb Appearance Grading Scale. The differences in TDB were analysed statistically.Mean overall scores were as follows. The TDB were 0.54 (SD 0.20) degrees C and 0.21 (SD 0.18) degrees C for the good and poor IOP control groups, respectively. The difference between the TDB of the two IOP control groups was significant (p0.0001), but there was no significant relationship between morphological classification and TDB.Thermographic measurements suggest that functional blebs have lower temperatures than non-functional blebs, and their morphological appearances are not affected by their temperature. Thermography may be useful for the evaluation of bleb function.

But. - Une reprise tardive de la bulle de filtration est parfois necessaire en cas de fragilisation de la conjonctive, en raison d'un risque de blebite, voire d'endophtalmie, ou en presence d'une bulle exuberante qui provoque une gene fonctionnelle intense. Le but de cette etude est d'apprecier le retentissement d'une refection de bulle sur la pression intra-oculaire. Patients et methode. - Nous avons analyse l'evolution de 46 refections chirurgicales de bulle de filtration (43 patients, âge moyen 67,9 ans ± 12,2 ans, 30 femmes, 13 hommes). La reprise chirurgicale a ete effectuee en moyenne 38,5 mois ± 45,2 apres la chirurgie initiale (25 trabeculectomies dont 8 avec mitomycine, 8 avec 5-fluoro-uracile et 9 sans adjuvant et 21 trabeculectomies non perforantes dont 5 avec mitomycine, 15 avec 5-fluoro-uracile et 1 sans adjuvant), car il existait une fragilisation de la bulle avec signe de Seidel (dans 56,52 % des cas), une gene fonctionnelle trop importante (17,40 %) ou une bulle exuberante (26,08 %). La technique a consiste en une resection complete et large de la zone fragilisee (en preservant le tissu spongieux en regard de la zone de filtration) associe a un abaissement au limbe de la conjonctive saine en regard. Resultats. - Les pressions intra-oculaires moyennes avant refection de bulle et apres un de recul 24,3 mois ± 17,9 apres la refection etaient respectivement de 10,52 mmHg ± 4,46 et 14,08 mmHg ± 4,12. La remontee tensionnelle moyenne a donc ete de 3,56 mmHg ± 4,3 (p < 0,001), et une reprise d'un traitement hypotonisant a ete necessaire dans 26 % des cas pour garder un niveau pressionnel cible. La pression est restee stable uniquement dans 15,2%. La gene fonctionnelle a ete amelioree dans tous les cas, ainsi que la solidite de la bulle. Conclusion. - La refection chirurgicale de la bulle doit etre realisee en cas de fragilite importante de la bulle de filtration en raison du risque d'endophtalmie tardive, mais elle entraine une remonte tensionnelle moderee, et ne doit donc pas etre realisee a la moindre gene fonctionnelle.

Evaluation von Needlings und 5-Fluorouracil- (5-FU-)Injektionen spater als 4 Monate nach vorausgehender filtrierender Operation. Retrospektive Analyse von 17 Augen von 14 Patienten, bei denen mindestens ≥4 Monate nach Trabekulektomie (TE) mit Mitomycin C (MMC) ein Sickerkissen-Needling mit 5-FU-Injektionen durchgefuhrt wurde (1 Operateur). Absoluter Erfolg wurde definiert als Drucksenkung >30% des Ausgangswerts ohne Therapie. Bei POWG musste zusatzlich ein IOD ≤18 mmHg vorliegen. Die durchschnittliche Nachbeobachtungszeit betrug 8,1 Monate (3–24 Monate). Durchschnittlich 31,3 Monate (4–108 Monate) nach TE wurden 1–4 Needlings (O 1,6) mit 1–5 5-FU-Injektionen (O 3,1) nach klinischen Erfordernissen kombiniert. Der Ausgangs-IOD betrug durchschnittlich 25 mmHg (±SD 6,02, Median 25 mmHg). Post Needling und 5-FU-Injektionen lag der IOD bei der letzten Kontrolle im Mittel bei 13,64 mmHg (±SD 5,2, Median 13 mmHg) (p

But Le but de cette etude etait d’evaluer l’apport de l’OCT-Visante® dans le suivi des patients operes de chirurgie filtrante. Patients et methodes Dans cette etude retrospective, 38 bulles de filtration de 31 patients operes de trabeculectomie (4 yeux) ou de sclerectomie profonde non perforante (SPNP) (34 yeux) ont ete analysees. Dans 11 cas, de la mitomycine C (MMC) a ete utilisee durant l’intervention. Parmi les patients operes de SPNP, un implant de collagene (Aquaflow®, Staar Surgical AG) a ete mis en place dans le lit scleral dans 8 yeux, et 7 yeux ont necessite la realisation d’une goniopuncture lors du suivi postoperatoire. Chaque patient a eu un examen ophtalmologique complet avec une evaluation morphologique de la bulle au biomicroscope et une mesure de la PIO, et un examen par OCT-Visante®. Resultats Le site de trabeculectomie, la membrane trabeculo-descemetique (SPNP), le volet conjonctival, le volet scleral, l’iris et les rapports de ces structures entre elles ont pu etre analysees. Les bulles fonctionnelles presentaient un tissu conjonctival hyporeflectif inhomogene ainsi qu’une voie de passage pour l’humeur aqueuse, sous le volet scleral, de la chambre anterieure vers l’espace sous-conjonctival. Cette voie de passage etait egalement observee dans les bulles non fonctionnelles encapsulees. Les bulles non fonctionnelles plates et encapsulees presentaient un tissu conjonctival hyperreflectif et dense. Dans le cas particulier des bulles non fonctionnelles plates, il n’existait pas de voie de passage pour l’humeur aqueuse sous le volet scleral. Conclusion L’OCT-Visante® est une technique d’exploration simple, non invasive permettant d’etudier avec une bonne resolution les modifications morphologiques qui surviennent au sein des yeux operes de chirurgie filtrante.

Background We investigated the outcome of 23-gauge transconjunctival pars plana vitrectomy (23G PPV) for the treatment of vitreoretinal disorder in patients with prior trabeculectomy. Methods We retrospectively reviewed medical records of 23G PPV in 11 eyes that had functioning filtering blebs after trabeculectomy. The main outcome measures were the visual acuity, intraocular pressure (IOP) and subconjunctival fluid height in bleb by anterior segment optical coherence tomography (OCT) before and after the surgery. Results Eyes that had 23G PPV showed improvement of visual acuity after the surgery (P =0.003). Mean IOP was 13.82 mmHg before 23G PPV and 15.82 mmHg at 6 months postoperatively, which was statistically insignificant (P = 0.758). The bleb was observed before and after surgery using anterior segment OCT, and the difference in subconjunctival fluid was not statistically significant (P =0.172). Conclusions 23G PPV did not adversely affect bleb function in eyes with prior trabeculectomy.

To evaluate a surgical technique to revise a failed filtering bleb using subconjunctival 5-Fluorouracil with a combined ab-externo and ab-interno approach.This study is a retrospective review of the outcome of 77 consecutive bleb revisions, with greater than 6-month follow-up, performed by a single glaucoma surgeon (MW). All eyes had previously functioning filtering blebs with currently inadequately controlled intraocular pressures (IOP) prior to the bleb revisions. All surgery was performed in the operating room, using a retrobulbar injection and a microscope. Visco-elastic was injected into the anterior chamber. 5-Fluorouracil (0.1 mL; 50 mg/ml) was infiltrated around the bleb. A 30-gauge needle was used to lyse subconjunctival fibrosis and episcleral scar tissue binding down the scleral flap, and elevate the scleral flap. Through an inferior paracentesis, a cyclodialysis spatula was used to confirm and enlarge the communication with the subconjunctival space. The main outcome measurements were IOP and number of glaucoma medications. A successful outcome was defined as a 20% reduction from baseline IOP and a maximum IOP of 18 mm Hg, with or without medications, and a minimal follow-up of 6 months.52% of patients achieved success after one revision with an average follow-up of 29.6 +/- 14.4 months. In successful cases, the mean IOP decreased from 22.7 +/- 4.5 mm Hg to 11.3 +/- 3.5 mm Hg and medications were reduced from an average of 2.2 +/- 1.1 to 0.4 +/- 0.7. Kaplan-Meier survival analysis calculated a success of 77% at 1 year, 68% at 2 years, and 58% at 3 years.In failed filtering blebs, needle revision with 5-Fluorouracil and a combined ab-externo and ab-interno approach results in high success and low complication rates. The outcome of this procedure compares favorably with previously reported revision techniques.

Purpose To present a case of repeated graft dislocation after Descemet stripping automated endothelial keratoplasty (DSAEK) in a post-trabeculectomy eye and to suggest a simple postoperative maneuver to minimize this occurrence. Methods A 61-year-old woman presented to our cornea clinic with pseudophakic bullous keratopathy in her left eye 13 years after a trabeculectomy had been performed. After the DSAEK was performed, repeated graft dislocations were observed. When air was seen in the filtering bleb in the immediate postoperative period, it was assumed that it had escaped from the air bubble remaining in the anterior chamber at the end of the surgery. The patient was thus placed in the Trendelenburg position immediately after performing a rebubbling procedure to retain the air bubble in the anterior chamber and away from the filtering bleb. Results The corneal graft remained centered and clear at postoperative day 1 and remained so at the last follow-up visit 8 months after the surgery had taken place. The patient's intraocular pressure was well controlled with a functional filtering bleb. Conclusions Postoperative Trendelenburg positioning is an easily applied maneuver that may promote graft adherence after performing a DSAEK in eyes that have undergone glaucoma surgery.

To evaluate the efficacy of topical autologous serum application to stop aqueous oozing or point-leak through filtering bleb after trabeculectomy.A total of 21 consecutive eyes with oozing and 21 eyes with a point-leak through a functional bleb after trabeculectomy with 5-fluorouracil or mitomycin C were enrolled in this randomized, case-control study. In eyes randomly assigned to the serum group, an antibiotic and the autologous serum, which was sterilely diluted to 20% with physiological saline, were topically applied four times a day for up to 12 weeks. In eyes assigned to the control group, the antibiotic alone was applied according to the same protocol. Intraocular pressure (IOP) and the presence of oozing or a point-leak were tested before and every 2 weeks after starting the treatments.In the serum and control groups, oozing stopped in 62.5 and 0% of eyes, respectively (P=0.003), and point-leaks stopped in 27.3 and 18.2%, respectively (P0.9). IOP significantly increased from 10.0+/-3.2 (mean+/-standard deviation) to 11.8+/-3.3 mmHg in eyes in which oozing stopped (P=0.066), and from 11.4+/-2.7 to 15.4+/-2.3 mmHg in eyes in which a point-leak stopped (P=0.042).Autologous serum application was significantly effective to stop aqueous oozing but not point-leaks. Stopping oozing or point-leaks was significantly associated with an increase in IOP.

Purpose: To describe the use of a motorized milling drill to perform nonpenetrating glaucoma surgery and to assess its safety. Setting: Instituto Oftalmologico de Alicante, Miguel Hernandez University, School of Medicine, Alicante, Spain. Methods: This prospective noncomparative study included 16 eyes (13 patients) diagnosed with primary open-angle glaucoma. The eyes were divided into 2 groups. Group 1 (8 eyes) had a milling procedure, and Group 2 (8 eyes) had combined phacoemulsification and milling. A fornix-based conjunctival flap was created, and then the milling procedure was performed using a notched hemispherical metallic tip. Evolution of intraocular pressure (IOP), visual outcomes, and the development of intraoperative and postoperative complications were evaluated. Results: The mean age of the patients was 67.9 years ± 10.9 (SD) (range 50 to 80 years). In Group 1, the mean IOP preoperatively was 27.6 ± 10.1 mm Hg (range 18 to 50 mm Hg) and after 6 months, 15.8 ± 5.2 mm Hg (range 12 to 24 mm Hg). The mean IOP reduction 6 months postoperatively was 15.4 ± 10.6 mm Hg, a 55.7% decrease from preoperatively. In Group 2, the mean IOP preoperatively was 21.7 ± 4.6 mm Hg (range 13 to 30 mm Hg), and after 6 months, 16.2 ± 3.4 mm Hg (range 13 to 23 mm Hg). The mean reduction in IOP at 6 months was 5.5 ± 2.8 mm Hg, a decrease of 25.3% from the preoperative value. In Group 1 at 6 months, 5 eyes (62.5%) had a diffuse filtering bleb and 3 (37.5%), localized filtration. In Group 2, 7 eyes (87.5%) had a diffuse filtering bleb and 1 (12.5%) had fibrosis of the bleb and reduction of filtration. Conclusion: The motorized milling drill can be safely used to mill and refine the remaining scleral thickness, eliminating the rupture of trabeculo-Descemet's membrane.

To evaluate subconjunctival mitomycin C (MMC) injection efficacy and safety in patients with failing glaucoma non-penetrating filtering blebs.Twenty-eight eyes were consecutively recruited for this study. Only one eye for each patient was randomly selected. All the recruited patients had glaucoma and uncontrolled intraocular pressure after a non-penetrating filtering glaucoma surgery and/or a pathological aspect of the filtering bleb (i.e., vascularized and/or encysted). One or more MMC injections were performed under the conjunctiva closed to the bleb to improve filtration. Local effects and complications of subconjunctival MMC injections were analyzed.Out of the 28 patients, 21 (75%) had MMC also applied intraoperatively. The mean postoperative IOP before MMC injections was 17 +/- 6.6 mmHg. The final IOP after MMC injections was 13.9 +/- 2.9 mmHg after a mean follow-up of 6 months. A total of 67 subconjunctival MMC injections were performed with a mean of 2.9 (ranging from 1 to 5) injections per patient. The only complication found to be possibly related to MMC injections was two cases of corneal Dellen.From these preliminary results, subconjunctival MMC injections in selected cases appear to be not only safe but also effective in promoting further the postoperative IOP drop.

Background: Although widely accepted, pars plana vitrectomy is difficult to perform when patients have a large filtering bleb. We describe technical details of 25-gauge transcorneal vitrectomy and the clinical outcomes. Methods: We performed 25-gauge transcorneal vitrectomy on seven eyes of seven patients (female: male, 4:3; age, 39 to 77 years; mean, 66.1 years) between January 2005 and February 2007. Phacoemulsification via a corneal incision was followed by continuous curvilinear capsulorrhexis (CCC) of the posterior capsule. We used a notched contact lens to perform 25-gauge transcorneal vitrectomy. Results: Four patients with idiopathic ERM and three with secondary ERM were treated by 25-gauge vitrectomy. Postoperative visual acuity was good in most of them and the cell density of the corneal endothelium was maintained. Conclusion: These advantages of this procedure are that the conjunctiva and ocular surface can be completely maintained and vitreous incarceration can be avoided. Thus, 25-gauge vitrectomy might be particularly suitable for treating glaucoma with a filtering bleb. (158 words/200 words), Retina, 31(1), pp.181-183; 2011

Objectives: To analyze and assess compatibility of trabeculectomy filtering bleb characteristics and appearances using biomicroscopy, anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM). Materials and Methods: Twenty-eight eyes of 28 patients who underwent glaucoma filtering surgery with mitomycin C in our clinic between 2009 and 2013 were evaluated. Morphological appearances of the blebs on slit-lamp biomicroscopy were defined according to the Moorfields bleb classification system. For the internal tissue assessment of blebs, AS-OCT and IVCM were performed. Bleb biometric parameters such as length, height and bleb wall thickness were assessed by AS-OCT; conjunctival epithelial-stromal cyst, structural network of conjunctival stroma and vascularisation were examined with IVCM. The relation between biomicroscopic morphological staging and bleb characteristics detected on AS-OCT and IVCM were assessed. Results: The mean age of the 28 patients (16 male, 12 female) was 57.2±15.9 (19 to 79) years. The mean time elapsed between surgery and examination was 29.2±19.2 (6 to 68) months. According to biomicroscopic appearance, 17 (60.7%) blebs were functional (13 diffuse, 4 microcystic), whereas 11 (39.3%) blebs were non-functional (9 flat, 2 encapsulated). In the comparison of non-functional and functional blebs, functional blebs were found to be superior in terms of biometric parameters on AS-OCT assessment (p

Purpose. To determine the feasibility of using 25-gauge microincision vitrectomy surgery (25GMIVS) to treat vitreoretinal disease in glaucomatous eyes which have previously undergone trabeculectomy (TLE).Methods. A consecutive, interventional case series. We performed 25GMIVS in 15 glaucomatous eyes that had undergone TLE. Follow-up period was 11.5 months.Results. 25GMIVS was successfully used and led to improvement in visual acuity (P<0.01). We performed 25GMIVS for proliferative diabetic retinopathy with neovascular glaucoma in 53% of eyes (8 of 15). Although 3 eyes needed further TLE following 25GMIVS, final IOP was below 21 mmHg in all eyes except one eye (93%) and was comparable to pre-25GMIVS IOP (P=0.20) without an increase in the number of glaucoma medications (P=0.14).Conclusions. 25GMIVS is a feasible treatment for vitreoretinal disease in eyes with preexisting TLE, effective in both significantly improving BCVA and preserving the filtering bleb, while not excluding further glaucoma surgery.

Purpose: The purpose of this study was to compare the aqueous humor outflow using three type of implants after deep sclerectomy. A numeric imaging system with ICG and fluorescein angiography was used. The evolution over time was recorded, while filtration and outflow facility were measured. Material and Methods: Numeric imaging system with ICG and fluorescein angiography were performed before and after deep sclerectomy at regular intervals after surgery. Both resorbable (collagen) and non-resorbable (hema) intrascleral devices have been tested in eight rabbits. The resorbtion time of the collagen implants has been monitored using UBM technique. The outflow facility was measured with the technique of anterior chamber canulation and constant pressure method. Results: The resorbable collagen implants could be observed with UBM and angiography during the first six weeks postoperatively. The image of the non-resorbable Hema implant remained clearly visible over time. New drainage vessels were observed around the filtering bleb. The filtration significantly increased as the outflow facility improved after surgery, while the intraocular pressure remained stable over time. Conclusion: This conjunction of UBM, angiography and outflow measurement allowed us to study and compare three types of implants used as space maintainer after deep sclerectomy, and analyse their effect on the aqueous filtration and outflow facility.

Blebs fail when the conditions necessary for their continued existence cease to exist. They need a steady flow of aqueous humor to maintain a passageway at the outer edge of the scleral fistula and to distend the interstitial space within the bleb or else connective tissue cells in the episclera and Tenon's capsule may bridge across and fill in those spaces. Initial bleb survival is aided when the flow of aqueous maintains sufficient tissue turgor pressure to collapse the conjunctival and Tenon's capsule blood vessels and when the aqueous is free of inflammatory cells or flare. Under such conditions there is little source of serum-derived growth factors to stimulate fibrosis or vascularization but an adequate nutrient supply to the cells in the bleb. 16

To evaluate the effectiveness of excisional revision of filtering blebs for hypotony or leakage when more conservative measures have failed.Retrospective review of all patients who underwent excisional revision of a filtering bleb for hypotony (intraocular pressure [IOP]5 mm Hg) or leakage during a 3 year period. The revision consisted of excision of the avascular bleb, mobilization of the surrounding conjunctiva, and suturing of the conjunctiva at the limbus.Sixteen patients were included in the study. The average age was 66.3 +/- 14.8 years (range, 39-83). Revision followed trabeculectomy in 11 cases, combined phacoemulsification-trabeculectomy in three cases, and inadvertent blebs in two cases. Five cases had bleb leaks without hypotony, four cases had hypotony alone, and seven cases had both hypotony and a bleb leak. Average follow-up after bleb revision was 25 +/- 11 months (range, 9-43). Average IOP increased from 3.8 +/- 5.6 mm Hg (range, 0-22) to 11.9 +/- 4.1 mm Hg (range, 3-18), with an average of 1.1 +/- 1.1 medication (range, 0-3). The IOP at the last visit was15 mm Hg in all but two patients, with 10 of the 16 patients requiring medications. At the last follow-up examination, visual acuity had improvedor = two lines in nine patients and was reduced two lines in one patient. Five patients had early postoperative limbal wound leaks; resuturing was required in one case.Excisional bleb revision is an effective technique to correct hypotony or leakage after filtering surgery when other methods have failed. Intraocular pressure control is often maintained with the use of medications.

Purpose: Based on our previous report that showed enhanced transfer of mitomycin C to the sclera and the conjunctiva by dissolving the agent into a reversible thermo-setting gel, we conducted a study to investigate the efficacy of mitomycin C gel in the rabbit. Methods: We subconjunctivally injected 0.1 mL of the mitomycin C gel solution containing several different amounts of the agent. Trephination was performed in the injected region 24 hours later. Intraocular pressure measurement, photography, and ultrasound biomicroscopic examination of the filtering bleb were conducted 1, 2, and 4 weeks postoperatively. Results: The gel containing 3.0 μg or more mitomycin C significantly enhanced bleb formation and reduction in the intraocular pressure. Conclusions: The reversible thermo-setting gel seems to help the filtering bleb to survive in the rabbit and deserves further investigation as a new method of mitomycin C application.

* PURPOSE: To investigate the effect of compression sutures on filtering bleb cellularity in rabbit eyes. * METHODS: Six New Zealand rabbits had bilateral filtering surgery. In the study eye, on postoperative day 1 4 a 1 0-0 nylon suture was placed that compressed the bleb. Five-bromo-2'-deoxyuridine (BrdU) was injected intravenously on days 15, 16, and 18. On day 21 histologie sections of the blebs were obtained. The total cell count was compared to the number of actively dividing cells (marked by anti-BrdU antibody). * RESULTS: Study eyes had higher total cell counts (/"=.004) on postoperative day 21, but the proportion of proliferating cells was not significantly different (P=. II). * CONCLUSION: In rabbit eyes, bleb compression sutures were associated with more cellular components in the bleb compared to control eyes, but did not induce a higher level of cellular proliferation. [Ophthalmic Surg Lasers 1998;30:2 16-220.]

Ilias Georgalas, Dimitris Papaconstantinou, Ioannis Tservakis, Chrysanthi Koutsandrea, Ioannis Ladas“G.Gennimatas” Hospital of Athens, NHS, Athens, GreeceAbstract: We report a case of a patient with age-related macular degeneration, who had undergone trabeculectomy nine years earlier, and developed severe hypotony and bleb leak after treatment with intravitreal injections of ranibizumab. Although the incident is rare, in patients with longstanding filtering blebs, who need treatment with antivascular endothelial growth factors, close follow-up may be advocated, since the occurrence of bleb rupture could lead to permanent vision loss.Keywords: trabeculectomy, ranibizumab, age-related macular degeneration

Background Pathogenesis of giant papillary conjunctivitis is still elusive and many hypotheses are being proposed to explain the irritative symptoms associated with it. The research data available to date shows that mechanical, immunological and allergic components are involved in this to various extents. We report a rare cause of giant papillary conjunctivitis which was induced by a large filtering bleb following trabeculectomy surgery for glaucoma. Method A 30-year-old female, operated for glaucoma filtering surgery in her right eye 15 years back, presented with ocular irritation. Clinical evaluation revealed two giant papillae on the superior tarsal conjunctiva which coincided with the large filtering bleb with its peripheral extension. The fellow eye was normal and no association with any allergic disorders was noted. Result The patient responded symptomatically to the topical application of anti-inflammatory and anti-allergic medications. The giant papillae decreased considerably in size but the diffuse papillary response persisted. Conclusion Though multiple etiological factors have been proposed for the giant papillary conjunctivitis, only a single case report is available where a filtering bleb is the causative factor. The mechanical irritation caused by the large-sized bleb seems to be the provoking agent in our case taking into consideration the position of the papillae that coincides with the peripheral extension of the bleb.

A 24-year-old male was referred for unilateral visual loss and papilloedema. Eight years previously he had suffered a penetrating injury to the affected eye and 6 months prior to presentation a blunt contusive injury. Examination revealed a post-traumatic cystic bleb and signs of hypotonic papilloedema and maculopathy. Filtering blebs may therefore occur as a complication of trauma and be symptomatic over long periods of time.

Hintergrund Zuweilen besteht bei glaukomatosen Patienten, die einer Trabekulektomie unterzogen worden waren, keine Korrelation zwischen dem Erscheinungsbild des Filterkissens und dem Augeninnendruck. Da die Ultraschallbiomikroskopie eine hohe Auflosung der Strukturen des vorderen Augensegments erlaubt, wurden mit ihr Filterkissen von Patienten untersucht, die einer Trabekulektomie unterzogen worden waren. Patienten und Methoden Bei 46 Augen von 46 Patienten wurde nach Trabekulektomie eine Ultraschallbiomikroskopie (50 Mhz) des Filterkissens durchgefuhrt. In zwei Gruppen mit einem postoperativen Augeninnendruck kleiner oder groser als 16 mmHg wurden Hohe des Filterkissens, Darstellbarkeit des Skleralappens und Binnenstruktur verglichen. Ergebnisse Es war moglich, longitudinale und transversale Schnitte der Filterkissen zu erhalten und deren Hohe, Struktur und Reflektivitat zu bestimmen. Filterkissen mit niedriger Reflektivitat und einem gut darstellbaren Skleralappen waren mit einem niedrigen postoperativen Augeninnendruck korreliert, wahrend die Hohe des Filterkissens keinen Zusammenhang mit dem postoperativen Augeninnendruck erkennen lies. Schlusfolgerungen Die Ultraschallbiomikroskopie ermoglicht eine prazise In-vivo-Darstellung des Filterkissens, erlaubt Ruckschlusse auf Mechanismen, die der Filtration von Filterkissen zugrunde liegen. Background Sometimes in glaucomatous patients treated with trabeculectomy there is not a correlation between bleb shape and intraocular pressure. So we studied the functional anatomy of the filtering bleb by a ultrasound biomicroscope, using high frequency (50 Mhz) probe, which provides high resolution images of filtering blebs. Materials and Methods A total of 46 filtering blebs of 46 patients after trabeculectomy were analyzed by ultrasound biomicroscopy (50 Mhz). Dimensions, shapes and structure of blebs were evaluated in 2 groups of patients. Results It was possible to obtain longitudinal or transverse images of filtering blebs, to measure the height, to evaluate the reflectivity inside and to follow the route under the scleral flap. Blebs with lower reflectivity and a visible route under the scleral flap had a lower intraocular pressure while the height was not important for a good intraocular pressure. Conclusions So ultrasound biomicroscopy can be a useful method to study filtering blebs and also to explain the mechanisms of filtering structures in patients who underwent trabeculectomy.

The utility of needle bleb revision with bevacizumab in a patient with a failing bleb following trabeculectomy is explored. The patient had previously failed needle bleb revision with mitomycin C. After needling and injection of 1 mg of bevacizumab, the bleb was noted to be more diffuse with a decrease in surface neovascularization. Bevacizumab may be an effective medication for rescuing failing filtering blebs that exhibit neovascularization. [Ophthalmic Surg Lasers Imaging 2006;37:148-150.]

Background : Needling may become necessary when filtering blebs fail due to scarring or encapsulation. Our goal was to calculate the medium term success rate of the needling procedure. Methods : The results of 90 needling procedures performed on 58 eyes were analyzed. 52 eyes required one single needling (group 1) after simple trabeculectomy, whereas 19 eyes had to have double needling (group 2) and 3 eyes had to be needled 3 times (group 3). These figures do not include a 4th group of eyes which had been needled after repeated and complicated surgery. Success rates were calculated at t 1 = 0-1 day, t 2 = 1-4 weeks, t 3 = 4-8 weeks, t 4 = 3-5 months and t 5 =>6 months after the treatment. Results : The mean lOP (n = 90) was 29 ± 6 mm Hg preoperatively, 15 ± 10 10 mmHg at t 1 , 23 ± 9 mmHg at t2, 20 ± 7 mm Hg at t3, 17 ± 5 at and 17 ± 3 at t 5 . The overall success rates were 80% (t 1 ), 45% (t 2 ), 37% (t 3 ), 35% (t 4 ) and 31% (t 5 ). The corresponding success rates were 74%, 36%, 32%, 28% and 26% for group 1, 89%, 52%, 37%, 37% and 31% for group 2. 67% at all times for group 3 and 100%, 69%, 54%, 54% and 45% for group 4. Conclusions : In one third of all cases the needling is effective for more than 6 months. A complicated pressure lowering surgery does not necessarily diminish the effectiveness of a needling procedure. Re-needlings are as successful as the first one.

Background: Glaucoma is one of the most common causes of blindness in the world. This aspect is well known for the developed countries, however in Africa blindness mainly occurs due to cataract, trachoma and onchocercosis. Glaucoma is not mentioned enough. Patients present with severe findings after a long-lasting history of disease. Patients and Methods: In our project experienced surgeons and young medical doctors have been practising regularly in Cameroon since 2001. By means of support from the "Komitee zur Verhutung von Blindheit" and medical industries we keep in contact with a local ophthalmologist. During the consultation of hundreds of patients we have often seen highly advanced glaucoma cases. Results: The medical therapy of glaucoma and also the surgical procedures are limited - modern antiglaucomatosa are not available. We achieved sufficient regulation of intraocular pressure after trabeculectomy with or without cataract surgery in many cases. The success rate was decreased by severe scar reactions especially in young black people. In advanced glaucoma cases and oculus ultimus we also used the old techniques of iridencleisis. There was a good postoperative regulation of eye pressure, but sometimes we saw a giant filtering bleb after this iris-mutilating procedure. Conclusions: Glaucoma is a very complex problem, also in Cameroon. Although the diagnostic possibilities are limited, the therapeutic spectrum is differentiated. The introduction of a robust laser for cyclophotocoagulation would be a useful alternative.

A fundamental shift in philosophical direction is occurring in glaucoma surgery. This shift is toward restoring or exploiting of existing outflow pathways in hopes of avoiding the long-term complications of current incisional glaucoma therapy. The Trabectome and the iStent are two FDA-approved surgical therapies that increase trabecular outflow to lower IOP without the creation of a filtering bleb. The Trabectome surgery requires a Trabectome surgical unit, disposable single-use handpiece, and direct surgical gonioscope. The iStent requires an iStent pre-loaded on an applicator and a direct surgical gonioscope. Early results of both surgeries are comparable in terms of degree of technical difficulty, and both create postoperative IOPs in the mid to upper teens with decreased medical burden. These techniques are intended to integrate into cataract surgery to further minimize additional risks of these surgeries in mild to moderate disease state glaucoma patients.

Non penetrating surgical procedures involving Schlemm canal represent a new challenge in glaucoma surgery. While allowing good IOP control this technics avoids major complications known with Trabeculectomy and avoids the need for a subconjunctival filtering bleb which shunts aqueous to nonphysiological routes. Viscocanalostomy is characterized by the enlargement of Schlemm’s canal with viscoelastic near the surgical margins, in order to enhance aqueous egress through the ostia of the canal and then out of the eye via aqueous collector channels. Since the first description of Viscocanalostomy by Stegman several improvements have been made in the technic of the procedure resulting finally in the 360 ° catheterization of the Schlemm’s canal, a procedure called Canaloplasty. The technic, personal and published results, advantages and disadvantages of these procedures will be discussed.

PURPOSE To evaluate the filtering bleb function after trabeculectomy using a new ocular surface thermography device. METHODS Thirty-five eyes of 35 patients after trabeculectomy were included in this prospective study. The filtering bleb function was tested with a new ocular surface-oriented, infrared radiation thermographic device in a noncontact manner (TG 1000). The eyes were classified into poorly controlled and well-controlled intraocular pressure (IOP) groups according to the patients' postoperative IOP. According to Kawasaki and colleagues, the mean temperature decrease in the filtering bleb (TDB) for evaluating bleb function was used, where TDB=(mean temperature of the temporal and nasal bulbar conjunctiva)-(mean temperature of the filtering bleb). Furthermore, the filtering bleb was evaluated during 10 seconds of eye opening and a new parameter was introduced, the TB10sec. TDB and TB10sec were analyzed statistically. RESULTS The TDB was 0.911°C (±0.467) and the TB10sec was -1.027°C (±0.312) in the well-controlled IOP group. The TDB was 0.599°C (±0.499), and the TB10sec was -0.623°C (±0.265) in the poorly controlled IOP group, respectively. The difference in TDB (P=0.045), as well as that of TB10sec (P

The problem of cataract management in the patients of glaucoma who have undergone fltering surgery is a challenging proposition for any surgeon, as the surgery can lead to several complications in the already compromised eye. As glaucoma requires lifelong management, the development of cataract is a significant concern because its treatment may lead to loss of intraocular pressure (IOP) control. This review aims to highlight the intra- and postoperative measures that may increase the chances of bleb survival following cataract surgery. How to cite this article: Dada T, Bhartiya S, Baig NB. Cataract Surgery in Eyes with Previous Glaucoma Surgery: Pearls and Pitfalls. J Current Glau Prac 2013;7(3):99-105.

Hintergrund: Ein erhöhter intraokularer Druck (IOD) wird als einer der bedeutendsten okulären Risikofaktoren für einen Glaukomschaden betrachtet. Zur Drucksenkung kann eine fistulierende Glaukomoperationen durchgeführt werden. Die dadurch gebildeten Sickerkissen vernarben jedoch oftmals und eine Revisionsoperation muss folgen. Die Revision der gedeckten Sklerotomie stellt einen minimalinvasiven, gut durchzuführenden Eingriff dar. Um der erhöhten Vernarbungstendenz entgegenzuwirken, wird bei der Revision der Antimetabolit Mitomycin C intraoperativ verwendet. Methoden: In einer retrospektiven klinischen Untersuchung wurden 40 Augen (37 Patienten), die alle eine Revision nach einer gedeckten Sklerotomie erhielten, untersucht. Alle Revisionsoperationen erfolgten durch Reaktivierung der Fistulation und unter intraoperativer Mitomycin-Applikation (0,02 % für 3 min). Überprüft wurden im postoperativen Verlauf der IOD, die Vernarbungsrate und mögliche Komplikationen für einen Beobachtungszeitraum von einem Jahr. Ergebnisse: Ein Revisionseingriff war im Durchschnitt nach 14,7 ± 14 Monate nach der primären gedeckten Sklerotomie erforderlich. Der IOD lag vor der Revision im Durchschnitt bei 27,0 ± 5,4 mmHg. 4 Tage postoperativ im Durchschnitt 9,8 ± 5,8 mmHg ohne zusätzliche Glaukommedikamente. Im weiteren Verlauf betrug der IOD 18,4 ± 7,5 mmHg nach 4 Wochen, 18,0 ± 4,4 mmHg nach 3 Monaten, 16,6 ± 4,8 mmHg nach 6 Monaten und 17,5 ± 4,4 mmHg nach einem Jahr. 13 Patienten (32,5 %) mussten im Durchschnitt 4,2 ± 2,9 Monate nach der Revisionsoperation wiederholt operiert werden (CPC, Needling, erneute Revision, gedeckte Sklerotomie an neuer Stelle). Als Komplikationen traten ein kurzzeitiges positives Seidelphänomen (32,5%), eine Hypotonie (IOD ≤ 5 mmHg) in 30% und eine Aderhautamotio in 15% der Fälle auf. Die Komplikationen bildeten sich alle im Laufe von höchstens 4 Wochen wieder zurück. Schlussfolgerung: Bei 17% der Patienten konnte ein absoluter Erfolg (IOD ≤ 21 mmHg ohne antiglaukomatöse Medikamente) und bei 56% ein relativer Erfolg (IOD ≤ 21 mmHg mit antiglaukomatösen Medikamente) durch die Revisionsoperation erzielt werden bei einer geringen Komplikationsrate., Backround: Scarring of the filtering bleb is one of the most significant postoperative complications after glaucoma filtration surgery. Subsequent elevation of the intraocular pressure [IOP] requires a revision of the fistula in most of the cases. Revision of the scarred filtering bleb after covered sclerotomy is a minimal invasive procedure. To prevent subsequent scarring Mitomycin C is used intraoperatively. Methods: In a retrospective clinical investigation 40 eyes (37 patients) were examined. In each case revision of covered sclerotomy combined with intraoperative Mitomycin C application (0,02% 3 minutes) was performed by removing cicatricial tissue and thereby reactivating the fistulization. Postoperatively IOP, scarring and complications were observed for a period of one year . Results: Revision of the covered sclerotomy was carried out 14,7 ± 14 months on average after the covered sclerotomy had been undertaken. Intraocular pressure before reoperation was 27,0 ± 5,4 mmHg on average. IOP was reduced postoperatively to 9,8 ± 5,8 mmHg on average 4 days after surgery, 18,4 ± 7,5 mmHg on average after 4 weeks, 18,0 ± 4,4 mmHg on average after 3 months, 16,6 ± 4,8 mmHg on average after 6 months and 17,5 ± 4,4 mmHg on average after one year. In 13 cases (32,5 %) further antiglaucomatous surgery (cyclophotocoagulation, needling, repeated revision, covered sclerotomy at a new place) was required 4,2 ± 2,9 months on average after the first revision. As short-term complications bleb-fistulization (positive Seidel phenomenon) was observed in 32,5% of the examined cases, hypotony (IOP ≤ 5 mmHg) in 30% and amotio choroideae in 15%. All these complications, however, regressed within 4 weeks, at the latest. Conclusion: After the revision of covered sclerotomy 17% of the cases showed absolute success (IOP ≤ 21 mmHg without antiglaucomatous medicine) and 56% of the cases relative success (IOP ≤ 21 mmHg with antiglaucomatous medicine). The intra- and postoperative complication rate was low.

Soll die Phakoemulsifikation mit einem fistulierenden Eingriff kombiniert werden, ist der „self-sealing“-Effekt des Sklera-Cornea-Tunnels unerwunscht. Eine radiare Durchtrennung der inneren Lamelle des Phako-Kanals hebt meist den selbstdichtenden Effekt auf und fuhrt zu Kammerwasserfistulation und Sickerkissenbildung. Ergebnisse von 51 mit dieser kombinierten Operationsmethode versorgten Patienten (51 Augen), die uber einen Zeitraum von 5 bis 11 Monaten kontrolliert wurden, liegen vor. Neben Augendruckmessungen und biomikroskopischer, einschlieslich gonioskopischer Begutachtung erfolgten Gesichtsfelduntersuchungen sowie Sehscharfen- und Astigmatismusbestimmungen. Aufgetretene Komplikationen und Auffalligkeiten wurden dokumentiert und analysiert. Die Auswertung erfolgte unter Berucksichtigung der primaren Operationsindikation Katarakt oder Glaukom. Obwohl der Beobachtungszeitraum fur eine abschliesende Beurteilung zu kurz ist, erlauben es die bisher erarbeiteten Ergebnisse diese Methode der kombinierten Katarakt- und fistulierenden Glaukomoperation als erfolgversprechend anzusehen. If the phacoemulsification is combined with a filtering operation, the self-sealing of the sclerocorneal tunnel is an undesired effect. A radial incision of the inner lamina of the phaco-tunnel will usually eliminate the sealing effect and will lead to fistulation and development of a filtering bleb. 51 patients (51 eyes) underwent this combined cataract and glaucoma surgery and were carefully surveyed during a period of 5–11 months. These results are available. Eyepressure measurement, slit-lamp microscope examination (including gonioscopy), perimetry, visual acuity and astigmatism have been taken. Complications and other conspicious circumstances were documented and analysed. The evaluation was made taking the primary indication of either cataract or glaucoma into consideration. Although the follow-up time for a conclusive statement is too short, our study shows that this method of glaucoma-triple-procedure can be applied successfully.

Self-sealing sclerocomeal tunnel incisions with an external frown entry are widely used for implantation of poly(methyl methacrylate) intraocular lenses. Although safe and effective, these incisions have certain drawbacks. We developed a wound construction in which a straight external incision is used in conjunction with a tension-free, infinity-type suture. Out of 100 consecutive cases, only two did not seal satisfactorily at the conclusion of surgery but were tight upon placement of re-enforcing sutures. Postoperatively, the valve remained tight in all cases; there were no cases of hypotony, filtering bleb, flat chamber, or pupil capture or endophthalmitis indicating transient leakage. Flattening in the vertical and steepening in the horizontal meridian were minor and nonprogressive.

* BACKGROUND AND OBJECTIVE: To determine the status of filtering bleb function following pars plana vitrectomy. * PATIENTS AND METHODS: The authors retrospectively reviewed patients with functioning filtering blebs undergoing pars plana vitrectomy. * RESULTS: Twenty-three eyes with functioning filtering blebs underwent pars plana vitrectomy. Postoperatively, 7/23 (30%) of the eyes had moderate (5 to 20 mm Hg) intraocular pressure (IOP), 8/23 of the eyes had IOP persistently greater than 20 mm Hg, and 7/23 of the eyes had IOP of less than 5 mm Hg. One of 7 eyes that underwent vitrectomy within 6 weeks after trabeculectomy maintained bleb function, whereas 6 of 16 eyes that underwent trabeculectomy 6 weeks or later maintained bleb function. Loss of bleb function occurred in the early postoperative period in the majority of the patients. Prior antimetabolite therapy was not associated with preservation of bleb function. * CONCLUSION: There is a substantial risk of bleb failure following vitrectomy, which is in part related to the often severe nature of the diseases requiring vitreoretinal surgery. [Ophthalmic Surg Lasers 1996;27:367-373.]

* BACKGROUND AND OBJECTIVE: Cataract extraction in filtered eyes often leads to decreased outflow and, eventually, to bleb failure. The authors describe a surgical technique that promotes preservation of the filtering bleb. * PATIENTS AND METHODS: The authors retrospectively reviewed 19 eyes of 19 consecutive patients who underwent corneal incision phacoemulsification and simultaneous internal revision of the previous filtering bleb. * RESULTS: The mean follow-up time was 13.6 ± 7.6 months. Visual acuity improved in all patients (89.4% achieved 20/40 or better). No significant difference was noted between preoperative and postoperative intraocular pressures and astigmatism. The bleb was preserved in 89.4% of the eyes at the time of the last follow-up. * CONCLUSIONS: This surgical technique proved to be safe and yielded good results. [Ophthalmic Surg Lasers 1996;27:361-366.]

Purpose: This study evaluated the feasibility of anterior segment optical coherence tomography (OCT) and ultrasound biomicroscopy (UBM) for the imaging of EX-PRESS® implant. Materials and Methods: This nonrandomized comparative case series was performed at the Department of Ophthalmology of the University Hospital of Heraklion, Crete, Greece. The Ellex Eye Cubed (40 MHz) UBM and the Zeiss Visante OCT systems were used. The filtering bleb morphology (BL), aqueous outflow (AS), and tube position (TB) were evaluated by two independent observers using a quality scale of 1 (worst) to 4 (best). Data were also collected on corneal and iris clearance from the tip of the tube (CC and IC, respectively). Data from both the devices were statistically analyzed. P < 0.05 was considered as statistically significant. Results: Ten eyes of 10 patients (6 males) with EX-PRESS® implant were examined. TB, AS, and BL scores using UBM were 2.40 ± 0.39, 3.45 ± 0.72, and 2.45 ± 0.64, respectively. TB, AS, and BL scores for OCT were 3.35 ± 0.41, 1.55 ± 0.43, and 2.55 ± 0.55, respectively. AS was significantly higher with UBM whereas the opposite was true for TB. Differences in BL between OCT and UBM were not statistically significant (P > 0.05). Conclusion: Imaging of the EX-PRESS® implant is feasible with both UBM and OCT. Both modalities allow visualization of the position of the implant tube in relation to the iris or cornea and delineate the internal structure of the filtering bleb.

Purpose The aim of this study was to evaluate the relationship between filtering bleb parameters (height, extent) and the wideness of the aqueous drainage route beneath the scleral flap using ultrasound biomicroscopy (UBM) in patients who have undergone trabeculectomy with and without mitomycin-C (MMC). Design This was a prospective interventional observation uncontrolled study. Patients and methods A total of 30 patients undergoing 30 glaucoma filtering surgeries were assessed for at least 6 months using UBM to evaluate the bleb reflectivity, the visibility of the route under the scleral flap, the bleb height, and the extent in correlation with the mean intraocular pressure. Patients were divided into two groups: group A included 15 eyes in which trabeculectomy was performed without MMC and group B included 15 eyes in which trabeculectomy was performed with MMC (0.4%) applied for 2 min. Results The reflectivity inside the filtering bleb showed a significant correlation with the maximal width of the aqueous drainage route and the maximal height and the extent of the bleb. Furthermore, the bleb function was significantly associated with its UBM image in eyes trabeculectomized with adjunctive MMC. Conclusion The study concluded that the internal structure of the bleb can be a more sensitive predictor of the outcome of filtering surgery.

A combined Phaco-Trabeculectomy will often not have the same result as both procedures separately. The IOP lowering effect of a combined procedure is usually less than that of Trabeculectomy alone. Likewise, post-operative fluctuations of the anterior chamber depth after a combined procedure will influence the post-operative refraction, especially in the early post-operative period and/or if additional procedures (e.g. needling) are necessary to rescue a failing bleb. Therefore, most surgeons will prefer to stage both procedures. Since cataract surgery might compromise an existing filtering bleb, it is recommended to perform Phaco first if the IOP is not too elevated. If the glaucoma is at risk to deteriorate in the short term, filtering surgery should be performed first. It is advisable to wait 6 months between the cataract and glaucoma surgery.

Trabeculectomy is the most commonly used surgical procedure for managing medically uncontrolled glaucoma. It reduces intraocular pressure (IOP) by creating an artificial drainage pathway of the aqueous humor from the anterior chamber to the subconjunctival space, forming a filtering bleb. Aqueous humor in the subconjunctival space may then exit by multiple pathways including transconjunctival filtration and absorption through the episcleral veins (Fig. 1).

PURPOSE The authors conducted a morphology analysis of filtering blebs with anterior segment optical coherence tomography (AS-OCT) in patients shortly after trabeculectomy to find further criteria for success or failure of a filtering bleb. METHODS Thirty-seven patients (43 eyes) who had recently (