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Purpose: To evaluate the effects of bevacizumab in 3 different application methods, subconjunctival injection (SCI), hyaluronic acid retardant (HAR), and eye drop (ED), on attenuating scar formation in the filtering bleb. Methods: Trabeculectomy (TRAB) was performed on New Zealand rabbits. TRAB rabbits were intervened with bevacizumab SCI, HAR, ED, or mitomycin C, respectively. Intraocular pressure (IOP) of 1, 7, 14, and 28 days after TRAB was recorded, and the bleb survival rate was analyzed. Bleb height, area, and vascularization were evaluated using anterior segment optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) at 7, 14 and 28 days after surgery. A histopathology examination of the bleb tissue was performed. The expression levels of vascular endothelial growth factor (VEGF)-A, interleukin (IL)-1α, tumor necrosis factor-alpha (TNF-α), transforming growth factor-β1 (TGF-β1), and α-smooth muscle actin (α-SMA) were measured by Western blot. Results: Bevacizumab significantly reduced postoperative IOP and increased the survival of the filtering bleb, especially in the ED group. Less vascularization was shown in the SCI, HAR, and ED groups. Histopathological results showed the fewest levels of scarring and fibrosis in the ED group. The local VEGF-A, IL-1α, and TNF-α expression levels after bevacizumab ED were decreased, combined with suppression of TGF-β1 and α-SMA. Conclusions: Postoperative use of bevacizumab EDs was an effective application method for improving surgical outcomes after TRAB in rabbits. It might be effective in preventing scarring of the filtering bleb by antivascularization and anti-inflammation. [ABSTRACT FROM AUTHOR]

AIM: To investigate the expression level of inflammatory factors of aqueous humor before trabeculectomy in binocular chronic primary angle-closure glaucoma(CPACG)and its correlation with postoperative filtration bleb and intraocular pressure.METHODS: A total of 15 cases(30 eyes)with binocular CPACG who admitted to the Affiliated Eye Hospital of Nanjing Medical University from September to December 2021 and received trabeculectomy were selected. The surgery interval between two eyes was 7d, and the preoperative expression levels of monocyte chemoattractant protein-1(MCP-1), interleukin-17(IL-17), transforming growth factor-β(TGF-β), and interferon-γ(IFN-γ)of the aqueous humor in both eyes were respectively detected by enzyme-linked immunosorbent assay(ELISA). Furthermore, the intraocular pressure(IOP)and the morphology of filtering blebs at 1mo after surgery were measured.RESULTS: The concentrations of MCP-1, IL-17, TGF-β, and IFN-γ in aqueous humor from the first eye before surgery were 330.4±46.2, 357.3±46.9, 2347.5±363.8 and 527.7±101.6pg/mL respectively, and those concentrations in aqueous humor from the fellow eye were 298.2±40.7, 309.1±53.5, 1938.3±426.0 and 628.2±104.9pg/mL respectively. The preoperative expression levels of inflammatory factors of aqueous humor in both eyes were statistically significant(P≤0.05). Furthermore, the expression levels of IL-17 and TGF-β in the aqueous humor of patients with CPACG correlated with IOP and the height of filtering blebs at 1mo after surgery(P

Abstract Purpose To describe the clinicopathological characteristics and explore the possible etiology of cornea invasion by filtering bleb (CIFB) after filtering surgery. Methods We reviewed 22 patients treated for CIFB between March 2005 and March 2022. The patients were followed up for more than 1 year. Slit-lamp examination, optical coherence tomography (OCT), ultrasound biomicroscopy, and histopathological examination were performed to observe the morphology of the bleb and depth of corneal invasion. Depending on the severity of the lesion, treatments consisting of local massage, acupuncture separation, or surgical resection were administered. Results The mean age of the patients was 56.3 ± 8.8 years. All patients underwent filtering surgery in the moderate or advanced stage of glaucoma. The filtering bleb was closely connected with the cornea, and its posterior boundary was locally adhered. Forward displacement of the internal opening of the filtering bleb was found in 4 of 7 surgically treated patients. OCT and pathological examination showed that the filtering blebs invaded the corneal stroma. Removal of the adhesion of the posterior boundary of the filtering bleb by different treatment methods successfully improved the patients’ conditions. Conclusion Filtering blebs can invade the corneal stroma. Adhesion of the posterior boundary and forward displacement of the internal opening of the filtering bleb are the possible causes of CIFB. Removal of the adhesion of the posterior boundary of the filtering bleb can halt the progression of CIFB.

Introduction/Purpose: The aim of this study was to compare two surgical revision techniques in failed trabeculectomies after 6 months. Methods: Patients diagnosed with open-angle glaucoma who underwent trabeculectomy in at least one eye with uncontrolled intraocular pressure (IOP) after trabeculectomy performed at least 6 months before were enrolled in this prospective trial. All participants underwent a complete ophthalmological examination at baseline. Randomization was performed to one eye per patient to double-masked trabeculectomy revision or needling. Patients were examined on the first day, 7 days, 14 days, and then monthly until completing 1 year after surgical intervention. All follow-up visits included the following: patients reported ocular and systemic events, best-corrected visual acuity, IOP, slit-lamp examination, and optic disc evaluation for cup-to-disc ratio. Gonioscopy and stereoscopic optic disc photographs were taken at baseline and 12 months. After 1-year, the IOP and number of medications were compared between the groups. Absolute success criteria in the study were IOP <16 mm Hg, for 2 consecutive measurements without using a hypotensive medication. Results: Forty patients were included in this study. Among them, 38 completed 1-year follow-up (18 in revision group and 20 in needling group). The age ranged from 21 to 86 years, with a mean of 66.82 ± 13.44. At baseline, the average IOP was 21.64 ± 5.12 mm Hg (range from 14 to 38 mm Hg) in the entire group. All patients were using at least two classes of hypotensive eye drops, and 3 patients were using oral acetazolamide. The mean use of hypotensive eye drop medications was 3.11 ± 0.67 at the baseline for the entire group. In the present study, 58% of the patients presented complete success, 18% qualified success, and 24% failed in both groups. After 1-year treatment, both techniques were similar for IOP parameters and also for number of medications (p = 0.834 and p = 0.433, respectively). Regarding intra- or postoperative complications, one patient in each group needed a new surgical intervention, one in the needling group due to shallow anterior chamber and one in the revision group due to spontaneous Seidel sign, and one patient in the needling group underwent posterior revision due to fail. Conclusions: Both techniques were safe and effective for IOP control after 1 year of follow-up in patients who underwent to trabeculectomy more than 6 months before. [ABSTRACT FROM AUTHOR]

Purpose: To describe the clinicopathological characteristics and explore the possible etiology of cornea invasion by filtering bleb (CIFB) after filtering surgery. Methods: We reviewed 22 patients treated for CIFB between March 2005 and March 2022. The patients were followed up for more than 1 year. Slit-lamp examination, optical coherence tomography (OCT), ultrasound biomicroscopy, and histopathological examination were performed to observe the morphology of the bleb and depth of corneal invasion. Depending on the severity of the lesion, treatments consisting of local massage, acupuncture separation, or surgical resection were administered. Results: The mean age of the patients was 56.3 ± 8.8 years. All patients underwent filtering surgery in the moderate or advanced stage of glaucoma. The filtering bleb was closely connected with the cornea, and its posterior boundary was locally adhered. Forward displacement of the internal opening of the filtering bleb was found in 4 of 7 surgically treated patients. OCT and pathological examination showed that the filtering blebs invaded the corneal stroma. Removal of the adhesion of the posterior boundary of the filtering bleb by different treatment methods successfully improved the patients' conditions. Conclusion: Filtering blebs can invade the corneal stroma. Adhesion of the posterior boundary and forward displacement of the internal opening of the filtering bleb are the possible causes of CIFB. Removal of the adhesion of the posterior boundary of the filtering bleb can halt the progression of CIFB. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to report a technique for the removal of dislocated polymethyl methacrylate (PMMA) intraocular lenses (IOLs) in glaucomatous eyes. Methods: Dislocated PMMA IOLs were removed from the inferior sclerocorneal incision, and sutureless intrascleral fixation of each IOL was performed to preserve the intact superior conjunctiva and sclera for future trabeculectomy or to maintain a functional filtering bleb of trabeculectomy. Results: In two cases, the condition of the bleb did not change, while the intraocular pressure improved or did not change after the procedures. IOL fixation was stable with no complications, such as tilt, decentration, or extrication of the IOL haptics. Conclusion: This procedure of preserving the superior conjunctiva and sclera can maintain the function of the bleb, superior cornea and sclera and may contribute to the success of future trabeculectomy. [ABSTRACT FROM AUTHOR]

This study aimed to analyze the quantitative vascular biomarkers of filtering bleb function at different depths using anterior segment optical coherence tomography angiography (AS-OCTA). This cross-sectional study is registered on Clinicaltrails.gov (NCT 04515017). Forty-six eyes with primary open-angle glaucoma that had undergone trabeculectomy with mitomycin-C for more than six months were included. Vessel density (VD) and vessel diameter index (VDI) in the superficial layer (SL), Tenon's layer (TL), and deep layer (DL) of the bleb were obtained. The VD and VDI were higher in the failure group (both p = 0.000). Significant correlations were found between the SL, TL, DL's VDI, and IOP in the success group (p = 0.013, 0.016, 0.031, respectively). The VD of the TL and DL were related to IOP in the failure group (p = 0.012, 0.009). Tenon's VD (TVD) and Tenon's VDI (TVDI) correlated with IOP adjusting for TVD, TVDI, and the Indiana Bleb Appearance Grading Scale (IBAGS) (p = 0.009, 0.043) or Kenfeld grading system (KGS) (p = 0.011, 0.016). The area under curve (AUC) of the TVD, TVDI, IBAGS, and KGS to predict surgery failure were 0.960, 0.925, 0.770, and 0.850. AS-OCTA realized the quantitative evaluation of vessels, especially the invisible vascularity beneath the conjunctiva. TVD and TVDI as detected by AS-OCTA better reflected bleb function than conventional grading systems. [ABSTRACT FROM AUTHOR]

Aim: To test the effect of pharmacological mydriasis on intraocular pressure (IOP) in eyes with functioning blebs compared with normal eyes. Patients and Methods: The cross-sectional study included 39 eyes, of which 19 eyes had filtering trabeculectomy blebs (group A), and 20 eyes with no previous surgeries (group B). IOP was measured using the Goldmann applanation tonometer before, and 30 min after the application of tropicamide 1% eye drops. Results: In group A eyes, the IOP level changed from 13.68 ± 3.4 mmHg before pupillary dilatation, to achieve a level of 11.95 ± 3.03 mmHg following mydriasis, with an average IOP drop of 1.73 mmHg (p < 0.0001). On the other hand, the pre-dilatation IOP in group B eyes was 15.9 ± 3.00 mmHg, had increased after mydriasis to 18.4 ± 2.9 mmHg, with an average rise of 2.5 mmHg (p < 0.0001). The difference in IOP change following mydriasis between both groups was significant (p < 0.0001). Conclusion: Surprisingly, pharmacological pupillary dilatation resulted in a reduction of IOP in eyes with successful trabeculectomy, which is different from the usual effect of raising the IOP as in the control group. This effect has not been previously studied. [ABSTRACT FROM AUTHOR]

INTRODUCTION[|]This study used ultrasound biomicroscopy (UBM) imaging to evaluate the anterior segment structure and surgical area of patients with open angle glaucoma following a trabeculectomy procedure.[¤]METHODS[|]Consecutive patients with primary open angle or pseudoexfoliative glaucoma who underwent a trabeculectomy were included. UBM was used to examine the anatomical parameters of anterior chamber depth, anterior chamber angle, angle opening distance at 500 µm (AOD500), trabecular ciliary process distance (TCPD), iris ciliary process distance, scleral ciliary process angle (SCPA), and ciliary process thickness, as well as the internal ostium opening, ostium-iris distance, and scleral flap dimensions. Bleb morphologies were evaluated qualitatively using the Yamamoto classification and quantitatively according to the presence of drainage from the medial, lateral, and posterior borders.[¤]RESULTS[|]Twenty-five eyes of 23 patients (4 female, 19 male) were included in the study. The TCPD and SCPA measurements were significantly greater in the postoperative third month (1.04+-0.12 mm vs 1.09+-0.16 mm, p

Background: To evaluate the outcome of Descemet's stripping automated endothelial keratoplasty (DSAEK) with "blocking air" in the filtering bleb in patients with previous trabeculectomy., Methods: In total, 299 eyes in 283 patients who underwent DSAEK were retrospectively reviewed. Endothelial graft adhesion, intraocular pressure (IOP), and air volume in the anterior chamber with (group A) or without (group B) a filtering bleb were compared between the groups. Group A was divided into two subgroups according to the presence (group A1) or absence (group A2) of air in the filtering bleb; the same three factors were compared between the subgroups., Results: The graft detachment rate was significantly higher in group A (14.3%) than in group B (6.5%) (p = 0.04). IOP was significantly lower in group A than in group B before surgery (p = 0.01), at the end of surgery (p = 0.04), at three hours (p < 0.001), and one week postoperatively (p = 0.02). The graft detachment rate did not significantly differ between groups A1 and A2. There were no differences in IOP at each follow-up time, whereas there was a statistically significant increase in IOP from the preoperative measurement to the end of surgery in group A1 (21.0±7.0 mmHg) compared with group A2 (14.2±8.6 mmHg) (p = 0.02)., Conclusions: The presence of blocking air in the filtering bleb helps ensure increased IOP during the early postoperative period but had no significant effect on graft detachment rates., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board of Hiroshima University issued approval E-709. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Iwakawa et al.)

Optical coherence tomography (OCT) is a noncontact method that provides two-dimensional (three-dimensional for some models) highresolution images of the anterior eye segment, with an axial resolution in the range from 3 to 20 µm. Two OCT diagnostics platforms are available: time-domain and spectral OCT. OCT provides a qualitative and quantitative assessment of the most important structures involved in the glaucoma pathogenesis: the state of the optic nerve head, the thickness of the nerve fiber layer, the anterior chamber angle and the trabecular apparatus. The OCT advantage is the ability to visualize surgically formed outflow tracts in the early postoperative period after antiglaucoma surgery. The OCT studies of the antiglaucomatous surgery zone are presented in detail in the literature, namely, the assessment of such biometric parameters of filtering bleb (FB) as wall thickness and reflectivity, radial length and height. According to the literature, the presence of a multi-layer filtration cushion 6 months after the operation indicates a favorable prognosis for the duration of the hypotensive effect of the operation. Such signs as low reflectivity of the filtration cushion wall and the presence of episcleral fluid are in most cases associated with a successful outcome of trabeculectomy. OCT studies of a filtration cushion after trabeculectomy make it much easier to choose an area for revision and nidling. In addition, OCT is used to assess anatomical features in the field of surgical intervention with drains and drainage devices. Currently OCT is widely implemented at the prehospital stage, however, engineers did not stop at the achieved level and carried out the integration of spectral OCT with an operating microscope. The possibilities of intraoperative imaging with cataract phacoemulsification (FEC) and trabeculectomy, implantation of the Ahmed valve, reconstruction of the anterior chamber angle, revision of the filtration bag and nidlinge are described in the literature. Conclusion. OCT is a very valuable method of intravital imaging of the antiglaucoma operation zone. It allows assessing the level of retention of intraocular fluid, determining the functional activity, the location of drains and drainage devices both in the early and late postoperative period.

Introduction: This study aimed to evaluate the characteristics of the filtering bleb in failed late trabeculectomy and the agreement between glaucoma specialist assessment and anterior segment-optical coherence tomography (AS-OCT) system assessment in terms of the presence of subconjunctival fluid in the filtering bleb. Methods: Patients with a diagnosis of glaucoma who were scheduled to undergo trabeculectomy in at least one eye and with uncontrolled intraocular pressure (IOP) were enrolled. All participants underwent a complete ophthalmological examination. The presence of fluid under the filtering bleb was first evaluated by a glaucoma specialist using biomicroscopy evaluation and then using the OCT 1000 AS-OCT Version 3.0.1.8 (Carl Zeiss Meditec, Dublin, CA, USA) system. A Kappa statistical test was used to evaluate the agreement between AS-OCT and the examiner. The correlation between conjunctiva and tenon thickness and clinical parameters was also assessed. Results: Forty eyes of 40 patients were evaluated in this study. The ages ranged from 21 to 86 years, with a mean of 66.55 ± 12.33. The average IOP was 21.20 ± 4.44 mm Hg (range 14–38 mm Hg) in the entire group. The mean thickness of the conjunctiva and tenon was 302.03 ± 406.76 µm (range 251–1,616 µm). There was a significant negative correlation between the mean thickness of the conjunctiva and tenon and IOP (p = 0.045; confidence interval = −0.558, 0.024). Additionally, there was a significant negative correlation between the mean thickness of the conjunctiva and tenon, and the number of medications used at baseline (p = 0.043; confidence interval = −0.538, 0.051). There was significant negative correlation between the horizontal measurement of the bleb and the use of glaucoma medications (p = 0.017; confidence interval = −0.560, 0.004). A total of 26 patients were determined to have fluid by the examiner (glaucoma expert), and the presence of fluid in AS was confirmed in 19 patients by AS-OCT. Of the 14 patients who were determined to have an absence of fluid, this was confirmed by AS-OCT in 7 patients (Kappa = 0.231; agreement of 65.00%). Conclusion: There is fair agreement between glaucoma specialist assessment and AS-OCT assessment in terms of the presence of fluid in trabeculectomy. Our findings highlight the importance of AS-OCT in some patients before deciding upon a new intervention. [ABSTRACT FROM AUTHOR]

Importance To analyse the preoperative conjunctival thickness in glaucomatous patients undergoing filtration surgery (FS), using optical coherence tomography (OCT). Background: The conjunctival status represents one of the most critical determinants of the FS outcome. Design Retrospective study. Participants: Sixty‐seven patients candidate to FS for uncontrolled glaucoma were enrolled. Methods: OCT was performed at the superior bulbar conjunctiva before FS, and at bleb site at the last follow‐up (LF‐up) after surgery. Main Outcome Measures: Preoperative full, epithelial, and stromal conjunctival thickness (FCT, CET, CST) and reflectivity (CR), and LF‐up bleb‐wall thickness (BT), reflectivity (BR) and intraocular pressure (IOP), were the major outcomes. The relations between preoperative parameters and LF‐up‐IOP, BT and BR were calculated. Results: FS was completely successful in 23 patients (group 1), successful with medications in 22 (group 2), and failed in 22 (group 3). FCT, CET and CST were lower, whereas CR higher, in group 3 compared to groups 1 and 2 (P <.05); BT was lower (P <.001), whereas BR higher (P <.05) in group 3 compared to group 1. FCT and CST were predictors of FS outcome with lower thickness associated with increased odds of failure (odds ratio 0.922, P =.08; 0.941, P =.025). LF‐up‐IOP inversely correlated with FCT and CST (r = −0.447, P =.003; r = −0.408, P =.007), whereas positively correlated with CR (r = 0.789, P <.001). Conclusions and Relevance: Preoperative conjunctival thickness and reflectivity show significant correlations with the FS outcome, both in terms of IOP and bleb‐wall features. Therefore, they may be proposed as predictive imaging biomarkers to estimate the risk of filtration failure. [ABSTRACT FROM AUTHOR]

AIM: To study the role of ultrasound biomicroscopy (UBM) in the assessment of the bleb function after trabeculectomy with mitomycin C (MMC). METHODS: This was a cross-sectional study including all cases had undergone trabeculectomy with MMC 0.2 mg/mL for 3min. Participants were recruited from the follow-up cases at Department of Ophthalmology, Tanta University in the period from August 2015 to August 2016. Full history taking and ophthalmological examination were performed. Intraocular pressure (IOP) was measured using Goldmann applanation tonometry and the history of prescribed postoperative antiglaucoma medications was recorded. Accordingly, the trabeculectomy blebs were divided clinically into successful blebs when the IOP post-operative was ≤18 mm Hg without medications. Scanning examination of the filtering bleb using UBM examination was performed at the period from 2 to 36mo after trabeculectomy (13.6±9.7mo). RESULTS: This study included 33 trabeculectomy filtering blebs of 25 patients (9 males and 16 females). The mean age of patients was 53.2±14.2y (range 25-71y). We had 20 eyes with complete success, 9 eyes with qualified success, and 4 eyes with failure after trabeculectomy with MMC. The blebs were classified into successful blebs (IOP ≤18 mm Hg without antiglaucoma medications), others were classified into qualified successful and failed blebs. There was a significant correlation between certain UBM findings (intra-bleb reflectivity, draining sub-scleral tract, bleb height, and intrableb fluid cysts) and cases with different grades of clinical functional success (P

Animal models are useful in glaucoma research to study tissue response to wound healing. Smaller animals such as rats offer additional advantages in terms of availability of detection antibodies and microarrays with cheaper maintenance costs. In this study, we describe a glaucoma filtering surgery (GFS) model in adult Sprague-Dawley rats by performing a sclerostomy using a 26-G needle and additionally placing a silicone tube (27 G) connecting the anterior chamber to the subconjunctival space to maintain a patent fistula for the flow of aqueous humor, thus providing a more definitive bleb. This technique will be useful in identifying and modifying newer targets in the wound healing process in order to improve surgical outcomes following GFS. [ABSTRACT FROM AUTHOR]

Purpose: Using a bleb‐grading system clinically facilitates long‐term follow‐up of patients with previous glaucoma surgery. Clinical evaluation of these patients can be challenging for untrained ophthalmologists. Morphological bleb configuration might influence planning of follow‐up visits in glaucoma patients due to different and individual prognosis after trabeculectomy. In this study, we compared the MaBAGS (Mainz Bleb Appearance Grading System), a classification system for filtering blebs with other classification systems (MBGS/Moorfields Bleb Grading System, IBAGS/Indiana Bleb Appearance Grading Scale) in reference to usability and reliability and compare it to grading by bleb photographs. Methods: Forty‐two eyes of 31 patients after trabeculectomy were included. Three observers, two senior and one junior observer, graded all blebs using MaBAGS, MBGS and IBAGS during slit‐lamp examination. Bleb photographs were reviewed at least 4 weeks after clinical examination. Statistical analysis was performed to determine agreement between the observers using intraclass correlation coefficients. Results: With MaBAGS, excellent and good levels of agreement were found for vascularity indices, Seidel test and transparency. Parameters for area and height yielded moderate agreement, while indices for conjunctival mobility and microcysts failed to show satisfying levels of agreement. Using MBGS resulted in excellent and good interobserver consistency for parameters regarding subconjunctival blood, Seidel test, and central and peripheral vascularity. Height and nonbleb vascularity reached moderate levels of agreement. Agreement for area parameters was low. With IBAGS, good levels of agreement were found for height and vascularity, and moderate for extent. In all grading systems, consistency was considerably better between the two experienced observers compared to the inexperienced grader. Conclusions: MaBAGS shows good reproducibility. Using such a grading system improves precision of the description of a highly variable clinical finding. The reliability of grading by slit‐lamp examination exceeds that of grading on photographs. [ABSTRACT FROM AUTHOR]

Objectives: This study used ultrasound biomicroscopy (UBM) imaging to evaluate the anterior segment structure and surgical area of patients with open angle glaucoma following a trabeculectomy procedure. Methods: Consecutive patients with primary open angle or pseudoexfoliative glaucoma who underwent a trabeculectomy were included. UBM was used to examine the anatomical parameters of anterior chamber depth, anterior chamber angle, angle opening distance at 500 µm (AOD500), trabecular ciliary process distance (TCPD), iris ciliary process distance, scleral ciliary process angle (SCPA), and ciliary process thickness, as well as the internal ostium opening, ostium-iris distance, and scleral flap dimensions. Bleb morphologies were evaluated qualitatively using the Yamamoto classification and quantitatively according to the presence of drainage from the medial, lateral, and posterior borders. Results: Twenty-five eyes of 23 patients (4 female, 19 male) were included in the study. The TCPD and SCPA measurements were significantly greater in the postoperative third month (1.04±0.12 mm vs 1.09±0.16 mm, p<0.05; 58.6±3.9° vs 60.8±3.8°, p<0.05, respectively). Cases with a longer ostium-iris distance had a significantly greater AOD500, TCPD, and SCPA (p<0.05). Bleb drainage and morphological classification were correlated (p=0.001). Conclusion: UBM is a sound and efficient method to investigate anterior segment variations and the surgical bleb following a trabeculectomy. TCPD and SCPA values increased after surgery. [ABSTRACT FROM AUTHOR]

Importance: Management of cystic bleb leak is difficult. It would be essential to look for a method to strengthen the original pathological conjunctiva and reverse bleb leak. Background: To evaluate the long‐term efficacy and safety of collagen crosslinking in patients with leaking cystic bleb. Design Prospective interventional case series at a university‐based hospital. Participants: Twelve eyes in 12 subjects with late‐onset bleb leak from cystic bleb, without indications for prompt surgical interventions were included. Methods: The subjects underwent crosslinking with 0.1% riboflavin application to bleb surface, followed by ultraviolet irradiation for 30 minutes. The subjects were followed up at baseline and at 1 week, 1 month, 3 months, 6 months post‐treatment and then every 6 months afterwards. Main Outcome Measures: Interval from treatment to cessation of bleb leak, recurrence rate of bleb leak and side effects of treatment. Results: The mean follow‐up after crosslinking was 29.33 ± 12.45 months. Bleb leak subsided in 11 (92%) of 12 patients after a single session of crosslinking, after 1 to 8 weeks (median 3 weeks). Time to leak cessation was significantly correlated with the number of prior glaucoma interventions (R = .71, P = .014). Bleb wall at 3 months was significantly thicker than at baseline (0.70 ± 0.67 vs 0.81 ± 0.62 mm, P = .008). None of the patients experienced any complications. Conclusions and Relevance: Crosslinking achieves resolution of cystic bleb leak which lasts for at least 12 months, without the need of subsequent surgical interventions. Crosslinking is a simple, non‐invasive treatment for bleb leak. It aims to restore the integrity of conjunctiva. [ABSTRACT FROM AUTHOR]

Filtering bleb scarring is the main cause of glaucoma filtration surgery failure. Subconjunctival injection of antimetabolites, such as mitomycin and 5-fluorouracil, is widely used clinically to reduce the incidence of scarring, which improves the success rate of the surgery. However, accompanied side effects such as cytotoxicity should not be ignored. Secreted protein acidic and rich in cysteine (SPARC) as a matricellular protein is widely distributed in the eyes, which plays an important role in the process of wound repairing and tissue remodeling. The expression of SPARC is significantly elevated in the mouse model of subconjunctival scarring. Researches suggest that SPARC participates in and regulate the formation of bleb scarring through multiple pathways, therefore it may become a specific new target in the anti-scarring therapy. [ABSTRACT FROM AUTHOR]

Purpose: To explore the relationship between the bleb vasculature and surgical outcome after trabeculectomy (TRAB) using optical coherence tomography angiography (OCT-A).Methods: A prospective study was conducted, which included 26 eyes of 26 primary glaucoma patients in the final analysis. Thereinto, six patients underwent TRAB combined 5-FU and 12 patients received subconjunctival 5-FU injection postoperation. The bleb vessel was evaluated using OCT-A 1 week, 2 weeks, 1 month, 3 months, and 6 months after TRAB. Intraocular pressure (IOP), filtering bleb height, and bleb wall thickness were recorded at the same time. Pearson’s correlation analysis and linear regression analysis were performed to determine the correlation of the vessel area data with other parameters.Results: Compared with vessel area 1 week after surgery, there was significant increase of the vessel area (△vessel area) 2 weeks (11.13 ± 11.91%, p < 0.05) and 1 month (16.91 ± 14.85%, p < 0.0001) after surgery in all patients. The △vessel area was significantly greater in acute angle closure (AAC) and primary angle closure glaucoma (PACG) 1-month post-TRAB as compared with that 1 week (p < 0.05). The results indicated that the △vessel area 1-month post-TRAB was positive correlated with IOP 6-month post-TRAB (β = 3.88, p = 0.042).Conclusions: Filtering bleb vascularization evaluation using OCT-A could potentially predict IOP 6-month post-TRAB. Surgery effect predicted by filtering bleb vascularization detection is conducive to the select specific postoperative intervention to improve the success rate of TRAB. [ABSTRACT FROM AUTHOR]

Aim: The aim of the study is to assess the outcomes of transconjunctival mitomycin C (MMC)-augmented revision in eyes with failed trabeculectomy. Materials and Methods: This is a retrospective, noncomparative case series. One hundred and twenty-one eyes of 113 consecutive glaucoma patients with previously failed trabeculectomy who underwent transconjunctival revision with at least 12 months of follow-up were initially included in the study. The success was determined on the basis of intraocular pressure (IOP) alone. The main outcome measures were IOP, best-corrected distance visual acuity, complications, bleb appearance, lens status, visual field progression, and time between primary trabeculectomy and MMC revision. The main purpose of the study was to determine the efficacy of a single MMC-augmented needle revision. Results: Mean follow-up was 2.3 years. Twelve months after revision, IOP had declined from 26.1 ± 8.4 mmHg to 14.1 ± 4.8 mmHg (P < 0.05) and remained 16.0 ± 5.6 mmHg at 24 months, 15.7 ± 5.8 mmHg at 48 months, and 15.2 ± 4.0 mmHg at 60 months. Complete success was achieved in 53% of cases, 84% achieved qualified success, and 16% were classified as failures 12 months after revision. Early complications developed in 45 of the initial 121 eyes (37.2%). Conclusions: Transconjunctival MMC-augmented revision appears to be a safe and useful tool in reducing IOP and re-establishing filtration after trabeculectomy failure. This simple procedure has a high rate of success and helps avoid other surgical interventions which are more destructive for the conjunctiva.

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.

The article presents a review of literature on a micro-invasive surgical treatment of glaucoma based on the principle of recovery of natural pathways of aqueous humor outflow through the Schlemm’s canal. The surgical experience of this operation revealed a number of advantages versus the trabeculectomy, including, a more physiologic approach, a less quantity of intraand postoperative complications, a rapid rehabilitation of the patients.

Clinical case of high thin-wall cystic limited filtering bleb needling revision in the early post-op period after trabeculectomy with sinusotomy accompanied by toxic keratopathy is presented. Optical coherence tomography (OCT) demonstrated that filtering bleb height was 2700 μm and bleb wall thickness was 70 μm. Bleb needling revision with its lateralwall dissection and subconjunctival injection of dexamethasone, fluorouracil, and ranibizumab near to the bleb site was performed. In 1.5 hours after the procedure, bleb height decreased to 550 μm (by 5 times) while bleb wall thickness increased up to 100 μm. Topical antibacterial, steroid, and non-steroid anti-inflammatory therapy was recommended. The next day IOP level reduced from 11 mm Hg to 4.5 mm Hg. It was accompanied by choroidal effusion that was managed conservatively with cycloplegic agents (drops and injections) for 3 days. On day 6, central corneal edema affecting all layers, Descemet’s membrane folds, and ocular hypertension were revealed. Metabolic therapy resolved corneal edema within 3 days. Re-needling bleb revision decreased IOP level to 6.2 mm Hg. This resulted in transient Descemet’s membrane folds. This paper describes filtering bleb needling revision with its lateral wall dissection and anti-inflammatory, cytostatic, and anti-VEGF agents use to prolong glaucoma filtering surgery effect in excessive scarring. The procedure was accompanied by toxic corneal endothelium decompensation with corneal edema and Descemet’s membrane folds treated with active metabolic therapy.

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. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether anterior-segment optical coherence tomography (AS-OCT) can be used to predict post-trabeculectomy bleb outcomes. Materials and methods: We divided 58 eyes of 47 trabeculectomy patients into success or failure groups based on their status at 12 months after surgery. We then compared various AS-OCT measurement parameters between the two groups at 1 and 2 weeks and 1, 3, 6, and 12 months. We also analyzed the early post-trabeculectomy bleb parameters with multiple logistic regression, stepwise multiple regression, and the receiver operating characteristic (ROC) curve, to evaluate the power of these parameters to predict long-term outcomes. Results: Intraocular pressure 3 or more months after trabeculectomy was significantly lower in the success group than the failure group (all: P < 0.0016). Cleft volume was significantly higher 6 or more months after trabeculectomy in the success group than the failure group (P = 0.0027 and <0.0016). Reflectivity of the bleb wall was significantly higher in the failure group than the success group at 2 weeks and all later time points (all: P < 0.0016). Reflectivity of the bleb wall at 2 weeks after trabeculectomy was a risk factor for failure, with an odds ratio (OR) for failure of 2.48 (95% confidence interval, 1.31-4.68, increasing per 10 AU). The area under the ROC curve for reflectivity of the bleb wall at 2 weeks after trabeculectomy was 0.775 when the cutoff value was set at 122.8, with sensitivity, specificity, and OR of 78.3%, 80.0%, and 14.4, respectively. A stepwise multiple regression analysis showed that reflectivity of the bleb wall at 2 weeks was an independent factor indicating postoperative bleb survival period (β = −0.39, P = 0.007). Conclusions: Reflectivity of the bleb wall, measured by AS-OCT, may be an early post-trabeculectomy predictor of bleb outcome. [ABSTRACT FROM AUTHOR]

The Wuerzburg bleb classification system (WBCS) is an established tool for evaluating filtering blebs, while anterior segment optical coherence tomography (ASOCT) provides detailed information on inner bleb structure. The present study aimed to investigate the clinical value of ASOCT-assisted WBCS following trabeculectomy (TRAB). The present prospective, observational study included eyes that underwent TRAB. Bleb assessments using the WBCS were based on the image acquired by ASOCT. The WBCS scores were assessed at postoperative week 2 and postoperative month (POM) 1, 2, 3, 6 and 12. The surgical outcomes at 1 year were determined as success or failure. Spearman's analysis explored the correlation of WBCS scores with intraocular pressure (IOP) and surgical outcome. A total of 32 eyes from 32 patients were included in the present study. The WBCS total score significantly correlated with IOP at POM 1, 2, 3, 6 and 12 (P<0.05). For single parameters, microcysts demonstrated a good correlation with IOP at POM 1, 2, 3, 6 and 12 (P<0.05). The WBCS total score correlated well with surgical outcome at POM 2, 3, 6 and 12 (P≤0.005). Microcysts, vascularity and encapsulation significantly correlated with surgical outcomes (P<0.05). The results of the present study suggest that ASOCT-assisted WBCS is a simple and effective measurement system for blebs after TRAB in clinical practice, which correlates well with IOP and surgical outcomes. Blebs with a higher WBCS total score and microcysts score in the early postoperative period, such as at POM 2 and 3, are less likely to have surgical failure in the long term. [ABSTRACT FROM AUTHOR]

AIM:To investigate the efficacy and safety of needle revision combined with subconjunctival injection of 5-Fluorouracil(5-FU)for the treatment of early non-functioning blebs after Ex-PRESS glaucoma drainage device implantation.METHODS:The medical records of 18 cases(23 eyes)with non-functional blebs within postoperative 3mo treated with needle revision combined with subconjunctival injection of 5-FU after Ex-PRESS glaucoma drainage device implantation in our hospital were retrospectively analyzed. All cases were followed up for at least 6mo.The IOP, the changes of filtering blebs morphology before and after treatments and complications were analyzed. RESULTS:The IOP before and immediately, 1, 3, 6mo after treatments were 24.13±2.94, 15.13±4.93, 14.98±5.12, 15.18±3.77 and 15.54±5.07mmHg(1mmHg=0.133kPa)respectively. The IOP at every time point after treatments was significantly decreased compared with that before treatments(all PCONCLUSION:It is safe, convenient and effective to treat early non-functional blebs after Ex-PRESS glaucoma drainage device implantation by needle revision combined with subconjunctival injection of 5-FU around the filtering bleb.

Purpose: To identify the cross-sectional characteristics of filtering blebs associated with intraocular pressure (IOP) control at 1 year after trabeculectomy with a square scleral flap and a fornix-based conjunctival flap. Methods: A retrospective consecutive case series study was conducted. Eighty-four eyes of 79 patients who had undergone primary trabeculectomy were included. Surgical success was defined as IOP ≤15 mmHg and a >20% reduction in IOP without glaucoma medication and without additional glaucoma surgery at 1 year after trabeculectomy. The subjects were classified into two groups according to whether surgery was successful or unsuccessful. Filtering blebs were examined using swept-source three-dimensional anterior segment optical coherence tomography and evaluated for the following quantitative parameters: maximum bleb height, maximum bleb wall thickness, and ratio of hypo-reflective space of the bleb wall. Results: Sixty-six eyes were determined to be successful and 18 eyes unsuccessful. Univariate analysis showed significant differences between the two groups regarding bleb height ( P < 0.001), bleb wall thickness ( P = 0.011), and ratio of hypo-reflective space of the bleb wall ( P = 0.002). Multivariate logistic regression analysis confirmed that the bleb height was significantly associated with success in trabeculectomy [odds ratio 13.996 (95% confidence interval 1.184-165.420); P = 0.036]. Conclusion: A tall bleb with a thick hypo-reflective wall may be a feature of the well-functioning bleb. [ABSTRACT FROM AUTHOR]

Purpose: To report the occurrence of endophthalmitis after trabeculectomy for glaucoma that was treated by vitrectomy without bleb closure and recurred 3 times after an initial clinically inapparent period of about 2 years. Methods: Interventional case report and short review of the pertinent literature. Results: A 73-year-old Caucasian female underwent trabeculectomy (without mitomycin) for glaucoma. Four years after the trabeculectomy, an endophthalmitis with Staphylococcus epidermidis as the causative organism occurred and was treated with a pars plana vitrectomy (20-gauge) and a combined antibiotic and anti-inflammatory drug regimen. The bleb was not covered during the emergency procedure because the filtering bleb was heavily infected and filled with pus. As the filtering bleb healed nicely and the filtering function was restored, the filtering bleb was left as it was, and best-corrected visual acuity initially recovered to 0.8. After 22 months, the endophthalmitis recurred, this time with Enterococcus faecalis as the causative organism. Its treatment required a total of four further vitrectomies (23-gauge), each accompanied by the same antibiotic and anti-inflammatory drug regimen that had been applied previously. However, the visual acuity could not be preserved, and the eye is blind with defective light projection. Conclusions: The literature suggests an aggressive surgical approach to endophthalmitis, and the present case report confirms this. Since the visual prognosis of eyes after endophthalmitis is poor, the course of treatment for endophthalmitis after trabeculectomy should emphasize recurrence prophylaxis rather than address glaucoma symptoms and therefore include safe bleb leak coverage.

La trabeculectomía es generalmente un procedimiento exitoso para reducir la presión intraocular en pacientes con glaucoma. Sin embargo, el fallo de la ampolla de filtración puede ocurrir y provocar un incremento de la presión intraocular. Esto conllevaría a una intervención médica o quirúrgica adicional. Se realiza una revisión bibliográfica sobre la cistitomía transconjuntival, asociada al uso de antimetabolitos (mitomicina C o 5-fluorouracilo) o no. Se demuestra que es mínimamente invasiva, con escasas complicaciones y que constituye un método eficaz, fácil y barato para restablecer el drenaje acuoso y disminuir la presión intraocular.Trabeculectomy is usually a successful procedure to reduce intraocular pressure in glaucoma patients. However, the failure of the filtering bleb can occur, leading to increased intraocular pressure and to a further medical or surgical intervention. A literature review on transconjunctival cystotomy, with or without the use of mitomycin C or 5-fluorouracil, was made. It was demonstrated that this method is minimally invasive with few complications, effective, easy-to-apply and inexpensive to restore aqueous drainage and lowering intraocular pressure.

Aim: The aim of the study is to assess the outcomes of transconjunctival mitomycin C (MMC)-augmented revision in eyes with failed trabeculectomy.Materials and Methods: This is a retrospective, noncomparative case series. One hundred and twenty-one eyes of 113 consecutive glaucoma patients with previously failed trabeculectomy who underwent transconjunctival revision with at least 12 months of follow-up were initially included in the study. The success was determined on the basis of intraocular pressure (IOP) alone. The main outcome measures were IOP, best-corrected distance visual acuity, complications, bleb appearance, lens status, visual field progression, and time between primary trabeculectomy and MMC revision. The main purpose of the study was to determine the efficacy of a single MMC-augmented needle revision.Results: Mean follow-up was 2.3 years. Twelve months after revision, IOP had declined from 26.1 ± 8.4 mmHg to 14.1 ± 4.8 mmHg (P < 0.05) and remained 16.0 ± 5.6 mmHg at 24 months, 15.7 ± 5.8 mmHg at 48 months, and 15.2 ± 4.0 mmHg at 60 months. Complete success was achieved in 53% of cases, 84% achieved qualified success, and 16% were classified as failures 12 months after revision. Early complications developed in 45 of the initial 121 eyes (37.2%).Conclusions: Transconjunctival MMC-augmented revision appears to be a safe and useful tool in reducing IOP and re-establishing filtration after trabeculectomy failure. This simple procedure has a high rate of success and helps avoid other surgical interventions which are more destructive for the conjunctiva. [ABSTRACT FROM AUTHOR]

Background The aim of the study is to determine the relationship between post-trabeculectomy bleb structure evaluated using anterior segment optical coherence tomography (AS-OCT) and postoperative intraocular pressure (IOP). Design Rretrospective is showed for the design of this study. Participants There are twenty-seven eyes of 27 trabeculectomy patients. Methods We drew contour lines for the bleb and cleft on 8-radius-scanned AS-OCT images, and determined correlations of AS-OCT measurements to postoperative IOP at 6 months. Main Outcome Measures The parameter used in this study is an anterior segment optical coherence tomography measurements of bleb structure, including cleft volume, wall volume, and the brightness of the bleb wall. Results We found significant correlations between postoperative IOP at 6 months and cleft volume at 3 and 6 months (r = −0.56, P = 0.007 and r = −0.82, P <0.001), bleb wall volume at 6 months ( r = −0.48, P = 0.042), bleb vertical brightness at 3 and 6 months ( r = 0.73, P < 0.001 and r = 0.49, P = 0.040), and bleb horizontal brightness at 1 week, 2 weeks, 3 months and 6 months ( r = 0.49, P = 0.016, r = 0.65, P < 0.001, r = 0.52, P = 0.013 and r = 0.71, P = 0.001). A stepwise multiple regression analysis of bleb structural measurements made ≤2 weeks postoperatively showed that the strongest independent factor indicating postoperative IOP at 6 months was bleb horizontal brightness at 2 weeks ( β = 0.50, P = 0.006). Conclusions Early postoperative AS-OCT measurements of blebs, especially horizontal brightness of the bleb wall, were associated with postoperative IOP at 6 months. AS-OCT measurements of blebs may be useful predictors of trabeculectomy outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

AIM: To evaluate the therapeutic efficacy of a repeated bleb needling technique combined with subconjunctival injection of 5-FU in eyes with previous glaucoma surgery that had malfunctional filtering blebs. METHODS: A retrospective review of 34 consecutive patients(34 eyes)of repeated bleb needling combined with subconjunctival injection of 5-FU in eyes, which had malfunctional filtering blebs after previous glaucoma surgery in our hospital from March 2009 to February 2013 was performed. The intraocular pressures(IOP), shapes of filtering blebs and complications after surgery were analyzed. RESULTS: There was significant reduction of mean IOP from 35.51mmHg to 14.43mmHg(PCONCLUSION: Repeated needling with adjunctive 5-FU proved a highly effective, safe alternative to treat malfunctional filtering blebs after previous glaucoma surgery.