Novel surgical procedures in glaucoma: Advances in penetrating glaucoma surgery

Glaucoma Consultation Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts 02048, USA.
Current Opinion in Ophthalmology (Impact Factor: 2.5). 04/2008; 19(2):149-54. DOI: 10.1097/ICU.0b013e3282f4f49e
Source: PubMed


Despite late modifications and enhancements, traditional penetrating glaucoma surgery is not without complications and is reserved for patients in whom pharmacologic treatment and/or laser trabeculoplasty do not suffice to control the intraocular pressure. This article critically reviews recent advances in penetrating glaucoma surgery with particular attention paid to two novel surgical approaches: ab interno trabeculectomy with the Trabectome and implantation of the Ex-PRESS shunt.
Ab interno trabeculectomy (Trabectome) achieves a sustained 30% reduction in intraocular pressure by focally ablating and cauterizing the trabecular meshwork/inner wall of Schlemm's canal. It has a remarkable safety profile with respect to early hypotonous or infectious complications as it does not generate a bleb, but it can be associated with early postoperative intraocular pressure spikes that may necessitate additional glaucoma surgery. The Ex-PRESS shunt is more commonly implanted under a partial thickness scleral flap, and appears to have similar efficacy to standard trabeculectomy offering some advantages with respect to the rate of early complications related to hypotony.
Penetrating glaucoma surgery will continue to evolve. As prospective randomized clinical trials become available, we will determine the exact role of these surgical techniques in the glaucoma surgical armamentarium.

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Available from: Theodoros Filippopoulos, Sep 29, 2015
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    • "In comparison to traditional trabeculectomy, ExPRESS implantation has the advantage of decreased early postoperative complications and faster visual recovery [11, 12]. Some have concluded that ExPRESS implantation is most appropriate in patients in whom the risk of complications, such as hypotony, is high [13, 14]. The case described in this paper is, to the best of our knowledge, unique in the literature and has not been reported previously in relation to ExPRESS implantation. "
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    ABSTRACT: Purpose. To present a unique case of decompression retinopathy after the implantation of ExPRESS drainage device. Method. A 25-year-old female patient underwent implantation of ExPRESS drainage device in the left eye for the management of steroid-induced ocular hypertension. Results. On the postoperative day one, best-corrected visual acuity in the left eye was 20/50. Fundus examination revealed diffuse intraretinal hemorrhages, some white-centered, throughout the retina. There was also marked tortuosity to the retinal vasculature and no evidence of choroidal effusion. Intravenous fluorescein angiography and indocyanine green did not contribute to the aetiopathogenesis. Conclusion. Decompression retinopathy can occur following the implantation of ExPRESS drainage device. It is very important to be aware of this complication in patients with relatively high intraocular pressure who is planned for filtration surgery, including the ExPRESS implant.
    12/2011; 2011:303287. DOI:10.1155/2011/303287
    • "The cumulative incidence of a subsequent glaucoma surgical procedure was 8% for this cohort with the overwhelming majority (85%) of surgeries being performed within 6 months after the Trabectome procedure, and 67% of the treating physicians preferring trabeculectomy as the second procedure. In 30% of the cases, the Trabectome™ procedure was combined with cataract extraction.12 Francis et al. reported the short-term results of combined phacoemulsification and ab interno trabeculectomy with Trabectome™ (n = 304). "
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    ABSTRACT: Anterior chamber drainage angle surgery, namely trabeculotomy and goniotomy, has been commonly utilized in children for many years. Its' reported success has ranged between 68% and 100% in infants and young children with congenital glaucoma. However, the long-term success of these procedures has been limited in adults presumably due to the formation of anterior synechiae (AS) in the postoperative phase. Recently, ab interno trabeculectomy with the Trabectome™ has emerged as a novel surgical approach to effectively and selectively remove and ablate the trabecular meshwork and the inner wall of the Schlemm's canal in an attempt to avoid AS formation or other forms of wound healing with resultant closure of the cleft. This procedure seems to have an appealing safety profile with respect to early hypotony or infection if compared to trabeculectomy or glaucoma drainage device implantation. This might be advantageous in some of the impoverish regions of the Middle East and Africa where patients experience difficulties keeping up with their postoperative visits. It is important to note that no randomized trial comparing the Trabectome to other glaucoma procedures appears to have been published to date. Trabectome surgery is not a panacea, however, and it is associated with early postoperative intraocular pressure spikes that may require additional glaucoma surgery as well as a high incidence of hyphema. Reported results show that postoperative intraocular pressure (IOP) remains, at best, in the mid-teen range making it undesirable in patients with low-target IOP goals. A major advantage of Trabectome surgery is that it does not preclude further glaucoma surgery involving the conjunctiva, such as a trabeculectomy or drainage device implantation. As prospective randomized long-term clinical data become available, we will be better positioned to elucidate the exact role of this technique in the glaucoma surgical armamentarium.
    Middle East African journal of ophthalmology 10/2010; 17(4):287-9. DOI:10.4103/0974-9233.71585
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    ABSTRACT: Histocompatibility antigen typing was carried out in 50 Caucasian patients with primary open-angle glaucoma (POAG) and 50 Caucasian ocular-normotensive subjects. HLA-A 3 was present in 46%, B7 in 52%, B12 in 50%, and either B7 or B12 in 88% of p,tients with POAG. These prevalences in POAG patients were significantly greater than in ocular-normotensive subjects (p less than 0.01, p less than 0.0005, p less than 0.001, and p less than less than 0.0005, respectively). The prevalences of A 3-B 7, A 3-B 12 and either combination were also significantly greater in POAG patients than in the ocular normotensives (p less than 0.005, p less than 0.005, and p less than 0.0005, respectively). HLA-BW 35 was noted to be in deficit in Caucasian POAG patients (8%) as compared to Caucasian ocular normotensives (32%; p less than 0.01).
    International archives of allergy and applied immunology 02/1977; 55(1-6):546-50. DOI:10.1159/000231970
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