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1/8Zdrav Vestn Supl | The outcome of filtration surgery in end-stage glaucoma I-29

IZVIRNI LANEK/ORIGINAL ARTICLE

The outcome of filtration surgery inend-stage glaucoma

Rezultati filtracijske kirurgije pri glavkomu v konnem stadiju

Toma Graner, Duica Pahor

IzvleekIzhodia: Ovrednotiti rezultate filtracijske ki-rurgije pri glavkomu v konnem stadiju.

Metode:V to retrospektivno klinino raziskavoje bilo vkljueno oi bolnikov z razlinimioblikami glavkoma v konnem stadiju. Pri vsehoeh je bil narejena goniotrepanacija s skleral-nim poklopcem brez medoperativne uporabeantimetabolitov. Izmerjen je bil oesni tlak, ovre-dnotena je bila najbolja korigirana vidna ostri-na, tevilo protiglavkomskih zdravil in rezultatitestiranja vidnega polja pred in po kirurkemposegu.

Rezultati:as opazovanja po kirurkem poseguje bil pri vseh oeh mesecev. Povpreni oesnitlak je bil pred kirurkim posegom , mmHg(SD ,) in , mmHg (SD ,) ob koncu opazo-

vanja, po kirurkem posegu niji v celotnem asuopazovanja (p< ,). Povprena najbolja ko-rigirana vidna ostrina pred kirurkim posegom

je bila , (SD ,), mesece po kirurkem po-segu , (SD ,) (p = .) in , (SD ,) obkoncu opazovanja (p = ,). Povpreno teviloprotiglavkomskih zdravil pred kirurkim pose-gom je bilo , (SD ,), ki se je zmanjalo napovpreno , (SD ,) ob koncu opazovanja pokirurkem posegu (p< ,). Pred kirurkim

posegom je bila povprena vrednost povprenedeviacije pri oeh na avtomatski perimetriji-, dB (SD ,) in -, dB (SD ,) po ki-rurkem posegu (p = .). Pred kirurkim po-segom je bil povpreen otok vidnega polja pri oeh na Goldmannovi perimetriji , (SD ,)in , (SD ,) po kirurkem posegu (p = .).

Zakljuek:S filtracijsko kirurgijo pri glavkomuv konnem stadiju se je po mesecih opazova-nja znailno in stabilno znial oesni tlak, vid pa

je bil ohranjen brez nastanka t. i. pojava wipe-

-out.

AbstractBackground:o evaluate the outcome o filtra-tion surgery in end-stage glaucoma.

Methods: Tis retrospective study included eyes o patients with different orms o end-stage glaucoma in which goniotrephining withscleral flap without intraoperative antimetabo-lites was done. Intraocular pressure, best-cor-rected visual acuity, number o antiglaucomamedications and visual field test results beoreand afer surgery were evaluated.

Results: Te ollow-up afer glaucoma surgerywas months in all eyes. Te mean preoperativeintraocular pressure was . mmHg (SD .)and . mmHg (SD .) at the end o ollow-up;postoperatively it was lower at all ollow-up vis-its (p < .). Te mean preoperative best-cor-rected visual acuity was . (SD .), monthspostoperatively . (SD .) (p = .) and .(SD .) at the end o ollow-up (p = .). Temean number o antiglaucoma medications was. (SD .) preoperatively, decreasing postop-eratively to a mean o . (SD .) at the end oollow-up (p < .). Preoperatively, the mean

value o the mean deviation in eyes on au-tomated perimetry was -. dB (SD .), and-. dB (SD .) postoperatively (p=.).

Preoperatively, the mean visual field island in eyes on Goldmann perimetry was . (SD .),and . (SD .) postoperatively (p=.).

Conclusion: Filtration surgery in end-stageglaucoma ollowed or months resulted in asignificant and stable reduction o intraocularpressure and vision was preserved with no oc-currences o wipe-out phenomenon.

Univezitetni klininicenter Maribor, Oddelekza oesne bolezni,Ljubljanska ,

Maribor, Slovenija

Korespondenca/Correspondence:doc. dr. Toma Graner,dr. med.Univerzitetni klininicenter Maribor, Oddelekza oesne bolezniLjubljanska , Maribor, SlovenijaTel.: E-mail: [email protected]

Kljune besede:filtracijska kirurgija,glavkom v konemstadiju, rezultati, oesnipritisk, vidno polje

Key words:filtration surgery,end-stage glaucoma,outcome, intraocularpressure, visual field

Citirajte kot/Cite as:

Zdrav Vestn ;: I-

Prispelo: . dec. ,Sprejeto: . apr.


2/8I-30 Zdrav Vestn Supl | junij 2012 | Letnik 81


End-stage glaucoma was defined on thebasis o VF examination. Te VF was exa-mined by either automated static perimet-ry (Swedish Interactive Treshold Algori-thm [SIA] standard program o theHumphrey Field Analyser) or kinetic peri-metry (Goldmann perimetry), dependingon the patients capability to respond at thefield examination. All patients had advancedglaucomatous VF loss with mean deviation> - dB according to the Hodapp classifica-tion on automated perimetry, or an extensi-ve ring-shaped or hal-ring-shaped absolutedeect in the paracentral VF area with a cen-tral island stage IV according to the Aulhornclassification on Goldmann perimetry.

Indications or filtration surgery inclu-

ded end-stage glaucoma with a cup-disc ra-tio (C/D) o . and severe VF deects withpartially preserved central unction andinsufficient control o intraocular pressure(IOP) including causes such as allergies, lowcompliance and high number o antiglauco-ma medications.

All patients were operated on by an expe-rienced surgeon (.G.), using local anesthe-sia afer peribulbar injection o mixtureso lidocaine hydrochloride (Xylocain-

e) and bupivacaine hydrochloride . (Marcaine). Te surgical technique supe-rior goniotrephining with a scleral flap wi-thout intraoperative antimetabolites wasthe same in all eyes. A ornix-based co-njunctival flap was created, incising the co-njunctiva and enons capsule at the limbusat the oclock position. A mm x mmhal-thickness scleral flap was dissected un-til the clear cornea was reached. Te gonio-trephination was carried out with a rotating

trephine with a diameter o . mm and ol-lowed by peripheral iridectomy. Te scleralflap was closed with two . Vicryl suturestied in a way that allowed guarded filtrationo aqueous humor. At the end o the operati-on the conjunctiva was closed using separate. Vicryl sutures. At the end o the surgicalprocedure, mg o dexamethasone was ap-plied subconjunctivally to all eyes. Te usualpostoperative treatment included: cyclople-gic eye drops ( atropine) once a day or

one week; a combination o dexamethasone,neomycin and polymyxin B (Maxitrol) eye

Introduction

Tere is controversy about the outcomeo filtration surgery in end-stage glaucoma.By a number o investigators it has been re-ported that filtration surgery in end-stage

glaucoma may be associated with the risko immediate unexplained postoperativevisual field (VF) loss, which includes fixati-on with an accompanying change in centralvisual acuity, termed wipe-out phenome-non. Tere are conflicting reports aboutthe requency o wipe-out phenomenonwhich results in a decreased quality o lieor glaucomatous patients. So, some statethe rate o severe loss o central vision aferfiltration surgery as high as . , whereas

others regard this phenomenon as extreme-ly rare.

Te purpose o this clinical study was toevaluate the outcome o filtration surgery inend-stage glaucoma during the immediateand mid-term postoperative period.

Patients and methods

In this retrospective clinical study weincluded all patients rom the glaucoma

unit o the Department o Ophthalmologyo the University Medical Centre Maribor,Maribor, Slovenia, who had different ormso end-stage glaucoma with a cup-disc ratio(C/D) o . and severe VF deects with par-tially preserved central unction, in whomfiltration surgery was perormed betweenJanuary and December .

All preoperative, operative and posto-perative medical data were acquired romaccessible medical documentation. Te pati-

ents were inormed o the risks, benefits andalternatives o surgery, and their inormedconsent was obtained.

Te data recorded preoperatively inclu-ded diagnosis, age, gender, ocular history,duration o glaucoma medical treatment,number o antiglaucoma medications, best--corrected visual acuity (BCVA) (decimalequivalents o Snellens visual acuity), slitlamp examination, Goldmann applanationtonometry, undus evaluation and perimet-ry.




last ollow-up visit afer surgery were usedor comparison.

Students t-test or paired data and thechi-squared test were used or statisticalanalysis o the results. Significant P valueswere considered to be less than ..

Results

wenty eyes o patients were inclu-ded in this retrospective clinical study. Terewere men ( ) and women ( ) andtheir mean age was . years (SD .), witha range o years. Te most requentdiagnosis was pseudoexoliation glaucomaound in eyes ( ), eyes ( ) hadprimary open-angle glaucoma and eyes

( ) had chronic angle-closure glaucoma.

drops five or six times a day or weeks, thenour times a day or weeks, then three ti-mes a day or weeks, then twice a week or weeks, then once a day or weeks, altoge-ther or the duration o weeks. Intraope-rative and postoperative complications andtheir management were noted.

Te data recorded postoperatively in-cluded slit lamp examination, Goldmannapplanation tonometry, BCVA, number oantiglaucoma medications, undus evalu-ation and perimetry. Te IOP was measu-red or one week, at one, , , , and months afer surgery. Te BCVA and thenumber o antiglaucoma medications wereevaluated months afer surgery and at theend o ollow-up. Te VF test results within

months beore and months beore the

Table :Baseline characteristics.

Patient Gender Age (years) Eye Glaucoma Type

1 F 62 OD PEX

2 F 76 OD POAG

3 M 61 OD PEX

4 F 72 OD PEX

5 M 70 OS POAG

6 M 76 OD PEX

7 F 71 OS PEX

8 F 67 OD POAG

9 M 83 OS CAG

10 M 63 OD POAG

11 F 79 OS POAG

12 M 76 OD CAG

13 F 68 OD PEX

14 M 69 OS PEX

15 M 76 OS PEX

16 M 68 OD PEX

17 M 70 OD PEX

18 F 67 OS POAG

19 M 70 OS PEX

20 M 71 OD PEX

PEX Pseudoexfoliation glaucomaPOAG Primary open-angle glaucomaCAG Chronic angle closure glaucoma




months afer filtration surgery was statisti-cally nonsignificant (P= .). At the lastpostoperative ollow-up visit, a cataractwith a decrease o BCVA was noted in eyes ( ). At the last postoperative ollow--up visit the mean BCVA was . (SD .),with a range o ... Te difference bet-ween the mean preoperative BCVA and themean BCVA afer filtration surgery at theend o ollow-up was statistically significant(P= .).

Te mean number o antiglaucoma me-dications months afer filtration surgerywas . (SD .), with a range o . At thelast postoperative ollow-up visit the meannumber o antiglaucoma medications was. (SD .), with a range o . Te di-

erence between the mean number o anti-glaucoma medications beore filtration sur-gery and the mean number o antiglaucomamedications afer filtration surgery at theend o ollow-up was statistically significant(P < .). In eyes ( ) antiglaucomamedications had to be added during the ol-low-up afer filtration surgery because o aninsufficient reduction o IOP (in one eye twoantiglaucoma medications afer monthsand then another one afer months; in

one eye three antiglaucoma medications months afer surgery).

Postoperatively, the mean value o MDwas -. dB (SD .) on automated peri-metry. Te difference between the meanpreoperative MD and the mean MD aferfiltration surgery was statistically nonsigni-ficant (P= .). Postoperatively, the meanVF island was . (SD .) on Goldmannperimetry. Te difference between the meanpreoperative VF island and the mean VF

island afer filtration surgery was statistical-ly nonsignificant (P= .).

IOP, BCVA, number o antiglaucomamedications and visual field test results be-ore and afer filtration surgery in the cohorto patients with end-stage glaucoma arelisted in able .

Discussion

Large clinical trials have clearly shown

that successul lowering o IOP is associatedwith a decrease in VF progression. Pa-

Te baseline characteristics are listed in a-ble .

All eyes were phakic without demon-stration o previous ocular trauma, uveitisor ocular surgery, except or laser trabecu-loplasty or laser iridotomy. Beore filtrationsurgery, a selective laser trabeculoplasty wasdone in one eye ( ) and a peripheral laseriridotomy was done in one eye ( ).

Te mean duration o glaucoma medicaltreatment beore filtration surgery was .years (SD .), with a range o . years.

Te mean number o antiglaucoma me-dications beore filtration surgery was .(SD .), with a range o .

Te mean preoperative BCVA was .(SD .), with a range o ...

Te VF was examined by threshold au-tomated perimetry in eyes ( ) and byGoldmann perimetry in eyes ( ). Pre-operatively, the mean value o the mean de-viation (MD) was -. dB (SD .) on au-tomated perimetry. Preoperatively the meanVF island was . (SD .) on Goldmannperimetry.

Te mean IOP beore filtration surgerywas . mmHg (SD .), with a range o mmHg.

No intraoperative complications such asanterior chamber hyphema or others werenoted.

Postoperatively, transient hypotony withflat anterior chamber and choroidal deta-chment was noted in eyes ( ) and re-solved in all eyes within days.

Te ollow-up period afer filtration sur-gery was months in all eyes.

Te mean IOP one week afer filtrati-on surgery was . mmHg (SD .), at one

month postoperatively . mmHg (SD .),at months . mmHg (SD .), at months. mmHg (SD .), at months . mmHg(SD .), at months . mmHg (SD .),and at the end o months o ollow-up. mmHg (SD .). At all ollow-up visitsafer filtration surgery the mean IOP wasstatistically lower than the mean IOP beoresurgery (P< .).

Te mean BCVA months afer filtrationsurgery was . (SD .), with a range o

... Te difference between the meanpreoperative BCVA and the mean BCVA




mend filtration surgery because o concernsabout the possibility o the occurrence owipe-out phenomenon. In the publishedstudies the rate o the occurrence o wipe--out phenomenon is controversially evalu-ated and discussed.

Although the exact mechanism o thewipe-out phenomenon remains elusive, ithas been suggested that it may be associatedwith the occurrence o sudden, intraopera-tive ocular hypotony during glaucoma sur-gery. Tis may result in optic nerve hemor-

tients with end-stage glaucoma with a cup--disc ratio (C/D) o . and severe VF deec-ts with partially preserved central unctionand insufficient control o IOP are at highrisk o urther disease progression, whichmay affect the central vision. A reduction orstabilization o IOP can be achieved eitherwith medication or by surgery. It has beenshown that the IOP could be reduced moreeffectively with filtration surgery than withmedication. In patients with end-stage gla-ucoma surgeons may be hesitant to recom-

Table :Intraocular pressure, best-corrected visual acuity, number of antiglaucoma medications and visual field test results beforeand after filtration surgery in the cohort of patients with end-stage glaucoma.

Patient

IOP

(mmHg)Entry

IOP

(mmHg)Exit

BCVAEntry

BCVAExit

No.GMEntry

No.GMExit

AP

(MD)Entry

AP

(MD)Exit

GP

( )Entry

GP

()Exit

1 23 10 0.16 0.16 3 0 -28.77 -28.99 / /

2 23 15 0.2 0.2 3 0 / / 30 30

3 30 17 0.01 0.01 3 0 / / 20 20

4 30 8 0.1 0.1 3 0 -26.55 -26.88 / /

5 26 12 0.5 0.4 4 0 -27.50 -27.85 / /

6 22 10 0.8 0.2 3 0 -29.92 -29.27 / /

7 34 8 0.7 0.7 3 0 -25.50 -27.24 / /

8 17 10 0.1 0.05 3 0 / / 30 30

9 24 14 0.1 0.16 4 0 / / 20 20

10 26 14 1.0 0.8 3 3 -25.23 -26.00 / /

11 18 11 1.0 0.1 3 0 / / 10 7

12 28 20 0.4 0.2 3 3 / / 20 20

13 27 14 0.7 0.7 3 0 / / 30 30

14 35 10 0.2 0.2 3 0 / / 10 10

15 27 12 0.3 0.4 3 0 -30.86 -30.02 / /

16 28 16 1.0 0.2 3 0 -26.30 -26.50 / /

17 43 14 0.6 0.2 3 0 -25.84 -26.54 / /

18 17 12 0.4 0.4 3 0 -30.36 -30.03 / /

19 24 10 0.01 0.01 2 0 / / 5 5

20 37 14 0.6 0.5 3 0 -25.57 -25.72 / /

IOP Intraocular pressureBCVA Best-corrected visual acuity (decimal equivalents of Snellens visual acuity)No.GM Number of antiglaucoma medicationsAP Automated perimetryMD Mean deviation (dB)GP Goldmann perimetryDegrees


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selected subpopulations within the sameoutcome study. Despite the limitations, me-aningul inormation can be derived romoutcome studies. Te results o our studyprovided inormation about the outcomeo filtration surgery in end-stage glaucomaduring the immediate and mid-term posto-perative period that resulted in a significantand stable reduction o IOP and vision waspreserved with no occurrences o wipe--out phenomenon.

On the basis o the results o our ownand other studies we can conclude that awipe-out phenomenon afer filtration su-rgery in end-stage glaucoma represents avery rare complication. Tereore, end-stageglaucoma should not be a contraindication

or filtration surgery.

timetabolites during the immediate andmid-term postoperative period. Te VF wasexamined by either automated perimetry orGoldmann perimetry. During the immedia-te postoperative period, months afer filte-ring surgery, we ound a significant reducti-on o IOP, a stable VF and stable BCVA. Tepostoperative transient hypotony with flatanterior chamber and choroidal detachmentin hal o the operated eyes was the con-sequence o overfiltration and may be pre-vented by the use o adjustable or releasablesutures at the time o surgery. During themid-term postoperative period we ound asignificant and stable reduction o IOP anda significant decrease in the number o an-tiglaucoma medications. Te statistically si-

gnificant difference between the mean preo-perative BCVA and the mean postoperativeBCVA at the end o ollow-up, monthsafer filtration surgery can be explained as aconsequence o the occurrence o a cataract,which was observed in eyes ( ). So, inour study afer filtration surgery in end-sta-ge glaucoma during the immediate and mid--term postoperative period no occurrenceo wipe-out phenomenon was observed.

Because o the differences in glaucoma

orms, age, gender, previous ocular history,duration o glaucoma medical treatment,type o antiglaucoma medications, amounto glaucomatous optic neuropathy, type oVF examination, grade o VF deterioration,operative technique, number o includedeyes, ollow-up time, study design, evalua-tion and statistical analysis o the results oincluded patients, a comparison o the men-tioned studies is very difficult and its pos-sibility limited. Te result o our study o a

significant reduction o IOP and no occur-rence o wipe-out phenomenon duringthe immediate postoperative period aferfiltration surgery in end-stage glaucoma areconsistent with the results o studies peror-med by opouzis et al., Awai et al. and Lawet al.

Tere are limitations o interpreting re-sults rom outcome studies. Tere is no con-trol group in such a study. Surgical outcomestudies allow the comparison o individual

or group practitioner results with other pu-blished historical surgical reports or with




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