Optical coherence tomography study of filtering blebs after primary trabeculectomy with a fornix-based conjunctival flap

Department of Ophthalmology, Kagawa University Faculty of Medicine, Kagawa, Japan.
Acta ophthalmologica (Impact Factor: 2.84). 12/2008; 88(1):60-4. DOI: 10.1111/j.1755-3768.2008.01401.x
Source: PubMed


To investigate the relationship between filtering bleb function and Stratus optical coherence tomography (OCT) images.
We studied 72 eyes of 65 consecutive patients who had a fornix-based conjunctival flap in primary trabeculectomy with mitomycin C (MMC). Filtering blebs with various types of glaucoma were examined using Stratus OCT. Success rates were defined as intraocular pressure (IOP) < or = 15 mmHg and IOP reduction > or = 25% without medication or additional surgery. Success rates among classified groups were compared using Kaplan-Meier survival curves and the log-rank test.
Blebs were classified into three different categories on the basis of the following Stratus OCT patterns: cystoid type (multiple cysts inside the bleb; 17 eyes), diffuse type (low to high reflective areas that were mixed inside the bleb; 31 eyes) and layer type (medium to high reflective layer inside the bleb; 24 eyes). Success rates in the cystoid-, diffuse- and layer-type blebs were 94%, 97% and 75% (P = 0.02), respectively.
In trabeculectomy with MMC and a fornix-based conjunctival flap, there is a significant association between the success rates and the postoperative Stratus OCT findings of filtering blebs.

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    • "Some investigators have recently shown evidence of a correlation between OCT images and histological sections of the bleb (Babighian et al. 2006; Theelen et al. 2007) and have demonstrated high agreement between OCT findings and histological features . We recently reported that success rates in the three different bleb types were poorest in layer-type blebs (Hirooka et al. 2008). Based on our own histological data, we propose that the medium-to-highly reflective layer observed inside the bleb represents the fibroblast. "

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    ABSTRACT: Die internen Strukturen von Sickerkissen in verschiedenen postoperativen Phasen konnten sowohl mit dem Vorderabschnitts-OCT als auch in-vivo konfokalmikroskopisch am Patienten dargestellt und analysiert werden. Hierbei konnte bei beiden Verfahren festgestellt werden, dass bestimmte Parameter prognostische Relevanz für die Funktion des Sickerkissens haben. Eine gute Sickerkissenfunktion korrelierte in der IVKM frühpostoperativ mit einem geringen Rundzellinfiltrat und einem geringem Gefäßdurchmesser und spät-postoperativ mit einer hohen Zahl epithelialer Zysten. Bei der optischen Kohärenztomographie ließ sich frühpostoperativ ein signifikanter Zusammenhang zwischen der Anwesenheit supraskleraler Flüssigkeitsräume sowie dem Nachweis des „striping“- Phänomens und einer guten Sickerkissen-Funktion nachweisen. Eine Kombination dieser Verfahren mit dem klinischen Befund können in Zukunft dazu beitragen, die unterschiedlichen postoperativen Ergebnisse nach Trabekulektomie auf histopathologischer Ebene besser zu verstehen. Dadurch könnte das chirurgische Vorgehen sowie die adjuvante Medikamentengabe optimiert werden, das postoperative Sickerkissen-Management erleichtert werden und somit gegebenenfalls rechtzeitig interveniert werden. Somit könnte die Erfolgsrate nach filtrierenden Glaukomoperationen zukünftig gesteigert werden. The internal structures of filtering blebs in different postoperative phase could be detected and analyzed with the Visante-OCT and in vivo confocal microscopy. Both methods could show that certain parameters have prognostic relevance for the function of the blebs. A good function of the bleb correlated early postoperatively with a small roundcell infiltrate and a small vessel diameter, and late postoperatively with a high number of epithelial cysts in in-vivo microscopy. Optical coherence tomography showed a significant correlation between the presence of suprascleral fluid spaces and evidence of the "striping"-phenomenon and a good bleb function early postoperativly. A combination of these methods to the clinical findings may contribute to better postoperative results. Thus, the surgical procedure and adjuvant medication could be optimized and the postoperative bleb management could become easier. This would increase the success rate of glaucoma filtering operations.
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    ABSTRACT: To correlate the cross-sectional features of filtering blebs on anterior-segment optical coherence tomography (AS-OCT) 2 weeks after trabeculectomy with bleb function at 6 months. Forty-eight eyes followed for 6 months or more after trabeculectomy with mitomycin C were included. Bleb wall reflectivity of developing blebs on AS-OCT 2 weeks postoperatively was correlated with mature bleb function at 6-month postoperative visit. Developing bleb walls at 2 weeks were classified as uniform in 10/48 eyes (20.8%) and multiform in 38/48 eyes (79.2%). Blebs with uniform reflectivity were significantly more likely to have worse function at 6 months (P < 0.001). Multiform bleb walls had hyporeflective areas seeming to represent loosely-arranged connective tissue (multiple-layer structures), subconjunctival separation, and microcysts. Blebs with multiple-layer structures at 2 weeks were associated with better bleb function at 6 months (P = 0.025). Intraocular pressure (IOP) of developing blebs at 2 weeks did not correlate with bleb function at 6 months (P = 0.471). Bleb wall reflectivity on AS-OCT 2 weeks after surgery may predict bleb function at 6 months, whereas IOP of developing blebs may not.
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