Search results for: dysesthesia of the bleb

Authors: Blanca Fatela Cantillo, Silvia Iglesias Cerrato, Guadalupe Garrido Ceca

Abstract:

Purpose: Bleb dysfunction is a late complication following glaucoma filtration surgery. We describe our surgical technique for excision and reconstruction of a hypertrophic bleb complication using bovine pericardium patch graft (Tutopatch®) and amniotic membrane. Material and methods: The case report presents a hypertrophic bleb over the cornea with good intraocular pressure control. The hanging bleb without leak caused dysesthesia and high irregular astigmatism. Bleb reconstruction involved the excision of corneal fibrous material and avascular conjunctiva, preserving the original scleral and tennon. Bovine pericardium patch graft (Tutopatch®) was sited over these with fixed sutures, reinforcing the underlying scleral, and the conjunctiva advanced. The superior epithelium corneal defect was covered using an amniotic membrane. Conclusion: Repair of bleb dysfunction with varied techniques has been reported, including conjunctival advancement, use of scleral patch graft, dural patch graft, or pericardium. Additional use of amniotic membrane promotes epithelialization and exhibits anti-fibrotic and anti-inflammatory features. Reconstruction with bovine pericardium patch graft and amniotic membrane resulted in pain relief, visual rehabilitation, and good aesthetic results, with preservation of bleb function.

Keywords: reconstruction, hypertrophic bleb, bovine pericardium, amniotic membrane, dysesthesia of the bleb

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Authors: Sushma Tejwani, Shoruba Dinakaran, Rupa Rokhade, K. Bhujang Shetty

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Introduction and aim: One of the major causes for failure of trabeculectomy is fibrosis and scarring of subconjunctival tissue around the bleb, and hence intra operative usage of anti-fibrotic agents like Mitomycin C (MMC) has become very popular. However, the long term effects of MMC like thin, avascular bleb, hypotony, bleb leaks and late onset endophthalmitis cannot be ignored, and may preclude its usage in routine trabeculectomy. In this particular study we aim to study the outcomes of trabeculectomy with and without MMC in uncomplicated glaucoma patients. Methods: Retrospective study of series of patients that underwent trabeculectomy with or without cataract surgery in glaucoma department of a tertiary eye care centre by a single surgeon for primary open angle glaucoma (POAG), angle closure glaucoma (PACG), Pseudoexfoliation glaucoma (PXF glaucoma). Patients with secondary glaucoma, juvenile and congenital glaucoma were excluded; also patients undergoing second trabeculectomy were excluded. The outcomes were studied in terms of IOP control at 1 month, 6 months, and 1 year and were analyzed separately for surgical outcomes with and without MMC. Success was considered if IOP was < 16 mmHg on applanation tonometry. Further, the necessity of medication, 5 fluorouracil (5FU) postoperative injections, needling post operatively was noted. Results: Eighty nine patient’s medical records were reviewed, of which 58 patients had undergone trabeculectomy without MMC and 31 with MMC. Mean age was 62.4 (95%CI 61- 64), 34 were females and 55 males. MMC group (n=31): Preoperative mean IOP was 21.1mmHg (95% CI: 17.6 -24.6), and 22 patients had IOP > 16. Three out of 33 patients were on single medication and rests were on multiple drugs. At 1 month (n=27) mean IOP was 12.4 mmHg (CI: 10.7-14), and 31/33 had success. At 6 months (n=18) mean IOP was 13mmHg (CI: 10.3-14.6) and 16/18 had good outcome, however at 1 year only 11 patients were available for follow up and 91% (10/11) had success. Overall, 3 patients required medication and one patient required postoperative injection of 5 FU. No MMC group (n=58): Preoperative mean IOP was 21.9 mmHg (CI: 19.8-24.2), and 42 had IOP > 16 mmHg. 12 out of 58 patients were on single medication and rests were on multiple drugs. At 1 month (n=52) mean IOP was14.6mmHg (CI: 13.2-15.9), and 45/ 58 had IOP < 16mmHg. At 6 months (n=31) mean IOP was 13.5 mmHg (CI: 11.9-15.2) and 26/31 had success, however at 1 year only 23 patients came for follow up and of these 87% (20/23) patients had success. Overall, 1 patient required needling, 5 required 5 FU injections and 5 patients required medication. The success rates at each follow up visit were not significantly different in both the groups. Conclusion: Intra-operative MMC usage may not be required in all patients undergoing trabeculectomy, and the ones without MMC also have fairly good outcomes in primary glaucoma.

Keywords: glaucoma filtration surgery, mitomycin C, outcomes of trabeculectomy, wound modulation

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Authors: Fossarello Maurizio, Mattana Giorgio, Tatti Filippo.

Abstract:

The most widely performed surgical procedure in Open-Angle Glaucoma (OAG) is trabeculectomy. Although this filtering procedure is extremely effective, surgical failure and postoperative complications are reported. Due to the its invasive nature and possible complications, trabeculectomy is usually reserved, in practice, for patients who are refractory to medical and laser therapy. Recently, a number of micro-invasive surgical techniques (MIGS: Micro-Invasive Glaucoma Surgery), have been introduced in clinical practice. They meet the criteria of micro-incisional approach, minimal tissue damage, short surgical time, reliable IOP reduction, extremely high safety profile and rapid post-operative recovery. Xen45 Gel Implant (Allergan, Dublin, Ireland) is one of the MIGS alternatives, and consists in a porcine gelatin tube designed to create an aqueous flow from the anterior chamber to the subconjunctival space, bypassing the resistance of the trabecular meshwork. In this study we report the results of this technique as a favorable option in the treatment of OAG for its benefits in term of efficacy and safety, either alone or in combination with cataract surgery. This is a retrospective, single-center study conducted in consecutive OAG patients, who underwent Xen45 Gel Stent implantation alone or in combination with phacoemulsification, from October 2018 to June 2019. The primary endpoint of the study was to evaluate the reduction of both IOP and number of antiglaucoma medications at 12 months. The secondary endpoint was to correlate filtering bleb morphology evaluated by means of anterior segment OCT with efficacy in IOP lowering and eventual further procedures requirement. Data were recorded on Microsoft Excel and study analysis was performed using Microsoft Excel and SPSS (IBM). Mean values with standard deviations were calculated for IOPs and number of antiglaucoma medications at all points. Kolmogorov-Smirnov test showed that IOP followed a normal distribution at all time, therefore the paired Student’s T test was used to compare baseline and postoperative mean IOP. Correlation between postoperative Day 1 IOP and Month 12 IOP was evaluated using Pearson coefficient. Thirty-six eyes of 36 patients were evaluated. As compared to baseline, mean IOP and the mean number of antiglaucoma medications significantly decreased from 27,33 ± 7,67 mmHg to 16,3 ± 2,89 mmHg (38,8% reduction) and from 2,64 ± 1,39 to 0,42 ± 0,8 (84% reduction), respectively, at 12 months after surgery (both p < 0,001). According to bleb morphology, eyes were divided in uniform group (n=8, 22,2%), subconjunctival separation group (n=5, 13,9%), microcystic multiform group (n=9, 25%) and multiple internal layer group (n=14, 38,9%). Comparing to baseline, there was no significative difference in IOP between the 4 groups at month 12 follow-up visit. Adverse events included bleb function decrease (n=14, 38,9%), hypotony (n=8, 22,2%) and choroidal detachment (n=2, 5,6%). All eyes presenting bleb flattening underwent needling and MMC injection. The higher percentage of patients that required secondary needling was in the uniform group (75%), with a significant difference between the groups (p=0,03). Xen45 gel stent, either alone or in combination with phacoemulsification, provided a significant lowering in both IOP and medical antiglaucoma treatment and an elevated safety profile.

Keywords: anterior segment OCT, bleb morphology, micro-invasive glaucoma surgery, open angle glaucoma, Xen45 gel implant

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Authors: Yang Zhao, Feng Zhang, Xuanchu Duan

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Trans-differentiation of human Tenon fibroblasts (HTFs) to myo-fibroblasts and fibrosis of episcleral tissue are the most common reasons for the failure of glaucoma filtration surgery, with limited treatment options like antimetabolites which always have side-effects such as leakage of filter bulb, infection, hypotony, and endophthalmitis. Rosiglitazone, a specific thiazolidinedione is a synthetic high-affinity ligand for PPAR-r, which has been used in the treatment of type2 diabetes, and found to have pleiotropic functions against inflammatory response, cell proliferation and tissue fibrosis and to benefit to a variety of diseases in animal myocardium models, steatohepatitis models, etc. Here, in vitro we cultured primary HTFs and stimulated with TGF- β to induced myofibrogenic, then treated cells with Rosiglitazone to assess for fibrogenic response. In vivo, we used rabbit glaucoma model to establish the formation of post- trabeculectomy scarring. Then we administered subconjunctival injection with Rosiglitazone beside the filtering bleb, later protein, mRNA and immunofluorescence of fibrogenic markers are checked, and filtering bleb condition was measured. In vitro, we found Rosiglitazone could suppressed proliferation and migration of fibroblasts through macroautophagy via TGF- β /Smad signaling pathway. In vivo, on postoperative day 28, the mean number of fibroblasts in Rosiglitazone injection group was significantly the lowest and had the least collagen content and connective tissue growth factor. Rosiglitazone effectively controlled human and rabbit fibroblasts in vivo and in vitro. Its subconjunctiiva application may represent an effective, new avenue for the prevention of scarring after glaucoma surgery.

Keywords: fibrosis, glaucoma, macroautophagy, rosiglitazone

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Authors: Ana Miguel

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Purpose: Glaucoma is the second cause of worldwide blindness and the first cause of irreversible blindness. Trabeculectomy, the standard glaucoma surgery, has a success rate between 36.0% and 98.0% at three years and a high complication rate, leading to the development of different surgeries, micro-invasive glaucoma surgeries (MIGS). MIGS devices are diverse and have various indications, risks, and effectiveness. We intended to review MIGS’ surgical techniques, indications, contra-indications, and IOP effect. Methods: We performed a literature review of MIGS to differentiate the devices and their reported effectiveness compared to traditional surgery (tubes and blebs). We also conducted a video review of the last 1000 glaucoma surgeries of the author (including MIGS, but also trabeculectomy, deep sclerectomy, and tubes of Ahmed and Baerveldt) performed at glaucoma and advanced anterior segment fellowship in Canada and France, to describe preferred surgical techniques for each. Results: We present the videos with surgical techniques and pearls for each surgery. Glaucoma surgeries included: 1- bleb surgery (namely trabeculectomy, with releasable sutures or with slip knots, deep sclerectomy, Ahmed valve, Baerveldt tube), 2- MIGS with bleb, also known as MIBS (including XEN 45, XEN 63, and Preserflo), 3- MIGS increasing supra-choroidal flow (iStar), 4-MIGS increasing trabecular flow (iStent, gonioscopy-assisted transluminal trabeculotomy - GATT, goniotomy, excimer laser trabeculostomy -ELT), and 5-MIGS decreasing aqueous humor production (endocyclophotocoagulation, ECP). There was also needling (ab interno and ab externo) performed at the operating room and irido-zonulo-hyaloïdectomy (IZHV). Each technique had different indications and contra-indications. Conclusion: MIGS are valuable in glaucoma surgery, such as traditional surgery with trabeculectomy and tubes. All glaucoma surgery can be combined with phacoemulsification (there may be a synergistic effect on MIGS + cataract surgery). In addition, some MIGS may be combined for further intraocular pressure lowering effect (for example, iStents with goniotomy and ECP). A good surgical technique and postoperative management are fundamental to increasing success and good practice in all glaucoma surgery.

Keywords: glaucoma, migs, surgery, video, review

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Authors: Ritesh Verma, Manisha Rathi, Chand Singh Dhull, Sumit Sachdeva, Jitender Phogat

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Temporal trabeculectomy with the Ologen implant was done in a 66-year-old lady with uveitic glaucoma. Serial IOP measurement was done to assess the efficacy of ologen implant in uveitic glaucoma. The patient had an IOP of 4mmhg day 1 postoperatively and Ologen implant was in place with a well-formed bleb. On follow up patient had an IOP of 14mmhg and unaided visual acuity of 6/12 on day 10 postoperatively. After 12 weeks of Trabeculectomy with Ologen implant, the IOP of the patient was 14 mmHg, the vision was 6/6 with -1.25 DS and -1.25 DC at 90 degrees. Trabeculectomy performed in patients with uveitic glaucoma has a higher chance of failure due to increased inflammation and fibrosis. Trabeculectomy with ologen implant done in a patient of uveitic glaucoma provides excellent postoperative results and the patient has a well-controlled IOP even after 56 weeks of surgery and a best corrected visual acuity of 6/6. Trabeculectomy with the ologen implant is superior to other surgeries in cases of secondary glaucoma with increased inflammation.

Keywords: glaucoma surgery, ologen implant, temporal trabeculectomy, uveitic glaucoma

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Authors: Abraham Finkelman

Abstract:

Computerized Surgical Guides have been proven to be a predictable way to perform dental implants, with a relatively high accuracy in comparison to a treatment plan. When using the CSG Bone supported, it allows us to make the necessary changes of the hard tissue prior to the implant placement and after the implant placement. The CSG gives us an accurate position for the drilling, and during the implant placement it allows us to alter the vertical position of the implant altering the final position of the abutment and avoiding any risk of any damage to the adjacent anatomical structures. Any Changes required to the bone level can be done prior to the fixation of the CSG using a reduction guide, which incur extra surgical fees and the need of a second surgical guide. Any changes of the bone level after the implant placement are at the risk of damaging the implant neck surface. The technique consists of a universal system that allows us to remove the excess bone around the implant sockets prior to the implant placement which then enables us to place the implant in the vertical position with accuracy as planned with the CSG. The systems consist of a hollow pin of different sizes and diameters. Depending on the implant system that we are using. Length sizes are from 6mm-16mm and a diameter of 2.6mm-4.8mm. Upon the completion of the drilling, the pin is then inserted into the implant socket-using the insertion tool. Once the insertion tool has unscrewed the pin, we can continue with the bone reduction. The bone reduction can be done using conventional methods upon the removal of all the excess bone around the pin. The insertion tool is then screwed into the pin and the pin is then removed. We now, have the new bone level at the crest of the implant socket which is our mark for the vertical position of the implant. In some cases, when we are locating the implant very close to anatomical structures, any form of deviation to the vertical position of the implant during the surgery, can cause damage to such anatomical structures, creating irreversible damages such as paresthesia or dysesthesia of the mandibular nerve. If we are planning for immediate loading and we have done our temporary restauration in base of our computerized plan, deviation in the vertical position of the implant will affect the position of the abutment, affecting the accuracy of the temporary prosthesis, extending the working time till we adapt the prosthesis to the new position.

Keywords: bone reduction, computer aided navigation, dental implant placement, surgical guides

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Authors: Lalit Tejwani, Reetika Sharma, Arun Singhvi, Himanshu Shekhar

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Purpose: To assess the efficacy of collagen matrix implant (Ologen) in phacotrabeculectomy augmented with mitomycin C (MMC). Methods: A biodegradable collagen matrix (Ologen) was placed in the subconjunctival and subscleral space in twenty-two eyes of 22 patients with glaucoma and cataract who underwent combined phacoemulsification and trabeculectomy augmented with MMC. All of them were examined preoperatively and on the first postoperative day. They were followed for twelve months after surgery. Any intervention needed in follow-up period was noted. Any complication was recorded. The primary outcome measure was postoperative intraocular pressure at one year follow-up. Any additional postoperative treatments needed and adverse events were noted. Results: The mean age of patients included in the study was 57.77 ± 9.68 years (range=36 to 70 years). All the patients were followed for at least one year. Three patients had history of failed trabeculectomy. Fifteen patients had chronic angle closure glaucoma with cataract, five had primary open angle glaucoma with cataract, one had uveitic glaucoma with cataract, and one had juvenile open angle glaucoma with cataract. Mean preoperative IOP was 32.63 ± 8.29 mm Hg, eighteen patients were on oral antiglaucoma medicines. The mean postoperative IOP was 10.09 ± 2.65 mm Hg at three months, 10.36 ± 2.19 mm Hg at six months and 11.36 ± 2.72 mm Hg at one year follow up. No adverse effect related to Ologen was seen. Anterior chamber reformation was done in five patients, and three needed needling of bleb. Four patients needed additional antiglaucoma medications in the follow-up period. Conclusions: Combined phacotrabeculectomy with MMC with Ologen implantation appears to be a safe and effective option in glaucoma patients needing trabeculectomy with significant cataract. Comparative studies with longer duration of follow-up in larger number of patients are needed.

Keywords: combined surgery, ologen, phacotrabeculectomy, success

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Authors: Angeli Marie P. Lagman, Nephtali M. Gorgonio

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Catamenial pneumothorax is defined as a recurrent accumulation of air in the pleural cavity, which occurs in the period of 72 hours before or after menses. In a menstruating woman presenting with the difficulty of breathing and chest pain with concomitant radiographic evidence of pneumothorax, a diagnosis of catamenial pneumothorax should be entertained. Two cases of catamenial pneumothorax were reported in our local literature. This report added two more cases. The first case is 45 years old G1P1, while the second case is 46 years old G2P2. These two patients had a history of pelvic endometriosis in the past. All other signs and symptoms were similar to the previously reported cases. All patients presented with difficulty of breathing associated with chest pain. Imaging studies showed right-sided pneumothorax in all patients. Intraoperatively, subpleural bleb, diaphragmatic fenestrations, and endometriotic implants were found. Three patients underwent video-assisted thoracosurgery (VATS), while one patient underwent open thoracotomy with pleurodesis. Histopathology revealed endometriosis in only two patients. All patients received postoperative hormonal therapy, and there were no recurrences noted in all patients. Endometriosis-related catamenial pneumothorax is a rare condition that needs early recognition of the symptoms. Several theories may be involved to explain the pathogenesis of catamenial pneumothorax. Two cases show a strong significant association between a history of pelvic endometriosis and the development of catamenial pneumothorax, while one case can be explained by the hormonal theory. The difficulty of breathing and chest pain in relation to menses may prompt early diagnosis. One case has shown that pneumothorax may occur even after menstruation. A biopsy of the endometrial implants may not always show endometrial glands and stroma, nor will immunostaining, which will not always show estrogen and progesterone receptors. Video-assisted thoracoscopic surgery is the gold standard in the diagnosis and treatment of catamenial pneumothorax. Postoperative hormonal suppression will further reduce the disease recurrence and facilitate the effectiveness of the surgical treatment.

Keywords: catamenial pneumothorax, endometriosis, menstruation, video assisted thoracosurgery

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Authors: Xie Xiaobin, Zhang Yan, Shi Yipeng, Sun Wenying, Chen Shuang, Cai Zhipeng, Zhang Hong, Zhang Lixia, Xie Like

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Objective: The objective of this research is to compare the efficacy of the late in-situ surgical revision augmented with continuous infusion and needle revision on failed trabeculectomy blebs. Methods From December 2018 to December 2021, a prospective randomized controlled trial was performed on 44 glaucoma patients with failed bleb ≥ 6months with medically uncontrolled in Eye Hospital, China Academy of Chinese Medical Sciences. They were randomly divided into two groups. 22 eyes of 22 patients underwent the late in-situ surgical revision with continuous anterior chamber infusion in the study group, and 22 of 22 patients were treated with needle revision in the control group. Main outcome measures include preoperative and postoperative intraocular pressure (IOP), the number of anti-glaucoma medicines, the operation success rate, and the postoperative complications. Results The postoperative IOP values decreased significantly from the baseline in both groups (both P<0.05). IOP was significantly lower in the study group than in the control group at one week, 1, and 3 months postoperatively (all P<0.05). IOP reductions in the study group were substantially more prominent than in the control group at all postoperative time points (all P<0.05). The complete success rate in the study group was significantly higher than in the control group (71.4% vs. 33.3%, P<0.05), while the complete failure rate was significantly lower in the study group (0% vs. 28.5%, P<0.05). According to Cox’s proportional hazards regression analysis, high IOP at baseline was independently associated with increased risks of complete failure (adjusted hazard ratio=1.141, 95% confidence interval=1.021-1.276, P<0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P>0.05). Conclusion: Both in-situ surgical and needle revision have acceptable success rates and safety for the late failed trabeculectomy blebs, while the former is likely to have a higher level of efficacy over the latter. Needle revision may be insufficient for eyes with low target IOP.

Keywords: glaucoma, trabeculectomy blebs, in-situ surgical revision, needle revision

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