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The Early Flat Anterior Chamber After Trabeculectomy A Randomized, Prospective Study of 3 Methods of Management Daniela S. Monteiro de Barros, MD,* Julia B.V. Kuntz Navarro, MD,* Anand V. Mantravadi, MD,* Ghada A. Siam, MD,* Moataz E. Gheith, MD,* Ethan H. Tittler, BA,* Karin A. Baez, MD,* Silvana M. Martinez, MD,* and George L. Spaeth, MD*w filtration in glaucomatous eyes.1–3 Edmunds and co- Purpose: To evaluate prospectively 3 different approaches to authors,3 in a study of 1240 cases, found that 23.9% had the management of a flat anterior chamber (FAC) because of shallow AC (without iridocorneal touch) in the first 2 overfiltration in the early postoperative period after trabeculec- postoperative weeks, 2.3% were found to have iridocorneal touch and 0.2% had corneolenticular touch.3 Flat anterior Materials and Methods: Thirty-six eyes diagnosed with a FAC with chamber (FAC) after trabeculectomy is usually, but not total iridocorneal touch, but no lenticular touch (grade II) always, owing to decreased resistance to aqueous outflow because of overfiltration in the first 14 days after trabeculectomy through the sclera with resultant hypotony. It may be were randomized prospectively into 3 groups: group 1—anterior associated with the development of a choroidal effusion chamber reformation with viscoelastic substance; group 2— that may further decrease aqueous fluid formation. Left anterior chamber reformation with balanced salt solution and untreated, a FAC may lead to secondary complications, concurrent drainage of choroidal effusion; and group 3—pharma- including synechiae, cataract progression, and corneal cologic therapy with atropine, phenylephrine, and in select casesoral acetazolamide. Outcome measures were visual acuity, amount endothelial decompensation.4 In addition, posterior seque- of intraocular pressure (IOP) reduction, and achievement of lae of prolonged hypotony may ensue, such as persistent choroidal detachment and hypotony maculopathy.5,6 Theincidence of FAC has decreased since the introduction of Results: Treatment group 2 had a greater number of eyes staged pressure reduction in the early postoperative with acuity decline of two or more lines relative to group 3 period.7,8 However, an early FAC remains an important (P = 0.04). Group 1 had more eyes with acuity decline of two ormore lines relative to group 3, but this was not significant complication with the more commonplace use of adjunc- tive antimetabolites9,10 and more aggressive target pres-sures.11,12 Conclusions: For grade II FACs because of overfiltration in the A FAC is the situation in which there is contact early postoperative period after trabeculectomy, reformation between the posterior surface of the cornea and either the of the anterior chamber with drainage of choroidal effusion iris, lens, or vitreous. This has been classified anatomically may be associated with greater long-term trabeculectomy success,but is associated with greater visual acuity loss relative to medicinal into 3 stages (Fig. 1).13 A grade II FAC denotes contact therapy alone. Reformation with viscoelastic resulted in a trend between the entire iris and the corneal endothelium. This is toward lowest final IOP in comparison to medicinal therapy in contrast to grade I, in which iris/corneal touch is limited to the periphery of the iris, and grade III, in which there isboth total iris apposition and also contact between the lens Key Words: flat anterior chamber, glaucoma, intraocular pressure, In this report, we refer only to those cases, which involve the iris from the far periphery to the pupil margin(grade II FAC)13 as a consequence of insufficient resist-ance to aqueous outflow after filtration surgery for arly flattening of the anterior chamber (AC) in associa- Although there is general agreement that a grade III tion with hypotony is an important complication after FAC poses the greatest risk for subsequent corneal trabeculectomy and other procedures designed to improve decompensation and cataract progression, warranting moreurgent intervention, the management of an earlier stage ofFAC (grade II) is controversial.1,3,4,14 Expectant observa- Received for publication October 8, 2007; accepted February 17, 2008.
tion with medicinal therapy,1,4,14 reformation of the AC From the *William and Anna Goldberg Glaucoma Service, Wills Eye Institute, Jefferson Medical College; and wDepartment of Ophthal- with air or an ophthalmic viscoelastic substance,15–18 and mology, Jefferson Medical College, Philadelphia, PA.
surgical drainage of choroidal effusion with AC reforma- Supported by the Glaucoma Service Foundation to Prevent Blindness- tion,19–22 have all been advocated for management of the Glaucoma Service Foundation, Wills Eye Institute, Jefferson The authors have no financial interest related to the article.
The purpose of this study is to evaluate prospectively 3 Statistical help was provided by Dr Ben Leiby from Jefferson Medical different approaches to management of a grade II FAC: watchful waiting; reformation of the AC with viscoelastic Reprints: George L. Spaeth, MD, Wills Eye Hospital, 840 Walnut Street, substance or reformation of the AC in association with Suite 1110, Philadelphia, PA 19107 (e-mail: [email protected]).
Copyright r 2009 by Lippincott Williams & Wilkins drainage of the choroidal effusion.
J Glaucoma  Volume 18, Number 1, January 2009 J Glaucoma  Volume 18, Number 1, January 2009 All cases in which a grade II FAC developed within 2 weeks of surgery were considered for enrollment. Patientswere enrolled in the study between 1985 and 1990, each casewithin 2 weeks of the time of surgery for that patient. Themedicinal management remained the same, except thatatropine 1% twice daily was added in all cases not alreadyreceiving atropine.
The cause for the FAC in all cases in the present study was insufficient resistance to aqueous flow through thesclera. This was established by the following: measuringthe IOP to assure that IOP was below 8 mm Hg; testing theconjunctiva with fluorescein to assure that there wasno leakage through the conjunctiva; noting the presenceof a markedly elevated filtering bleb; questioning thepatient carefully regarding symptoms of any discomfort;and examining the fundus to rule out the possibility ofsuprachoroidal hemorrhage.
When a patient was identified within 2 weeks after surgery as having a grade II FAC owing to insufficientresistance to outflow, the patient was examined thefollowing day. If the appearance of the AC had notchanged and the IOP remained low or was lower,the patient was considered for enrollment in the study.
The medicinal management remained the same, except thatatropine 1% twice daily was added in all cases not alreadyreceiving atropine.
If after an informed consent the patient wished to participate, he/she was randomly assigned to one of the3 groups of the study. Approval for this study was obtainedfrom the Institutional Review Board of Wills Eye Hospital.
Thirty-six phakic eyes of thirty-two patients met the criteria for the study. Patients were enrolled between 1985and 1990 and randomized into one of 3 treatment groups:group 1: reformation of the AC with sodium hyaluronateviscoelastic material (Healon, Advanced Medical Optics,Santa Ana, CA); group 2: reformation of AC with BSS anddrainage of the choroidal effusion from the suprachoroidalspace; and group 3: medicinal therapy using atropine,phenylephrine, and, in select cases, a carbonic anhydraseinhibitor.
Randomization and initiation of treatment were FIGURE 1. Classification of a flat anterior chamber. From instituted in the first day after the diagnosis of grade II Ophthalmic Surgery: Principles and Practice, 2nd ed. Philadelphia: FAC. Stage of disease for all patients meeting enrollment criteria was evaluated in terms of amount of optic disccupping (A = none or mild cupping, B = cupping tothe rim, and C = far-advanced cupping). Although demo-graphic data, preoperative visual acuity, and prior surgical history were collected, they were not considered in All 1191 trabeculectomies that constituted the source of cases were performed with similar technique, by a singlesurgeon (G.L.S.), between 1985 and 1990. Neither relea- sable sutures nor antimetabolites were employed and a Under topical anesthesia, the AC was partially rectangular scleral flap was made, with 1 scleral suture in reformed with BSS, using a no. 30 gauge blunt cannula each posterior corner and additional sutures in one or both through the intraoperative paracentesis track previously radial grooves as needed; these sutures were interrupted fashioned. Sodium hyaluronate viscoelastic material (Hea- using 10/0 nylon. In all cases, the AC was reformed with lon) was introduced using a no. 30 gauge blunt cannula balanced salt solution (BSS) at the close of the operative connected to the ‘‘Healon’’ applicator, until the entire AC procedure to assure there was adequate filtration through was deemed as deep as or deeper than the fellow eye.
the sclera, no leakage through the conjunctiva, a well-formed AC that remained formed, and an intraocular pressure (IOP) between 10 and 25 mm Hg, measured by The surgical technique employed for drainage of finger tension IOP estimation technique.23 All patients choroidal effusions was similar to previously described received topical antibiotic drops, prednisolone acetate methods.19–22 The AC was reformed with BSS. The 1% four times daily and atropine 1% twice daily post- conjunctiva was incised in the inferotemporal quadrant 4 to 8 mm posterior to the limbus. After hemostasis J Glaucoma  Volume 18, Number 1, January 2009 was achieved with light cautery, a 3-mm radial sclerotomy The Wilcoxon rank sum test was used to determine if with a no. 67 Beaver blade was made. Once the incision was the distribution of loss of visual acuity defined as loss completed, suprachoroidal fluid spontaneously drained.
of Snellen lines relative to pretrabeculectomy vision (non- This was further facilitated by lifting the edges of the scleral parametric data) differed between pairs of treatment groups.
incision; however, no instrument was placed through the Categorical outcomes of reduction in IOP by 30%, achieve- incision within the suprachoroidal space. After drainage of ment of predetermined target IOP set by surgeon, trabecu- fluid, the sclerostomy was closed with no. 7-0 polyglycolate, lectomy failure as defined by IOP greater than 20 mm Hg on followed with double layered closure of Tenon capsule and medications, and the need for repeat surgery were examined.
conjunctiva with no. 8-0 chromic collagen. As noted prior, The Fisher exact test was used to determine statistical patients clinically suspected of having a suprachoroidal significance of categorical data with smaller sample sizes.
hemorrhage were excluded from this study, and thus allpatients randomized had effusions that were presumed serous based on preoperative clinical appearance. No A total of 36 eyes of 32 patients were enrolled in this patient randomized to group 2 was noted intraoperatively study. The mean age was 56.8 ( ± 14.4) for group 1, 67.5 to have a hemorrhagic component to the fluid evacuated.
( ± 13.5) for group 2, and 65.3 ( ± 21.0) for group 3, with a Postoperative care included topical antibiotics, predniso- range of 22 to 85 across all groups. A large majority lone acetate 1%, and atropine 1% four times daily, with the of the patients enrolled were white (97%). Primary open- selective addition of phenylephrine 2.5% in cases of poor angle glaucoma comprised the diagnosis of 61% of patients. Patient demographics and preintervention diag-noses are depicted in Table 1.
Of the 14 eyes of group 1, a grade II FAC developed No surgical intervention was performed in group 3.
between the day of surgery and 11th day postoperatively This group employed medicinal management with an initial (mean ± SD = 4.3 ± 2.6 d); the 10 eyes of group 2 developed course of atropine 1% one drop every 5 minutes grade II FAC between the second and 11th day post- for 4 doses, and phenylephrine 2.5% one drop every 5 operatively (5.0 ± 2.9 d); and the 12 eyes of group 3 developed minutes for 4 doses, followed by atropine and phenyl- grade II FAC between the second and 11th postoperative day ephrine 4 times daily. Acetazolamide 250 mg orally was (4.6 ± 2.5 d). Mean follow-up was 38.4 months for group 1, given in 4 cases to suppress aqueous formation and 30.8 months for group 2, and 38.5 for group 3.
After initial treatment, 8 eyes in groups 1 and 2 were Following institution of treatment, all patients were considered to have failed initial treatment and required a examined daily initially until deemed stable, and subse- second procedure owing to reoccurrence of a grade II FAC.
quently at 1, 2, and 4 weeks, and between 3 and 12-month Five of these eight eyes were from group 1 (viscoelastic reformation). The second intervention was repeat reforma- Failure of treatment was defined as the persistence or tion with viscoelastic alone for 2 eyes. Surgical drainage of reoccurrence of a grade II FAC. In patients who failed the choroidal effusion with BSS reformation was performed treatment, a second intervention identical to the first was as the second intervention rather than repeat reformation performed. However, if a second treatment identical to the with viscoelastic alone for 2 eyes owing to the rapidity and first was considered to present too high a risk in the opinion severity of FAC reoccurrence at the discretion of the of the surgeon based on certain clinical features or if failure surgeon. Last, for 1 eye, repeat reformation with visco- of treatment occurred a second time, then subsequent elastic as the second intervention was followed later by a intervention thought most definitive, decided by the third intervention deemed most definitive, which was surgeon’s discretion, was performed.
surgical drainage of choroidal effusion and reformation.
TABLE 1. Demographics and Preoperative Diagnosis of Patients Having Grade II Flat AnteriorChamber After Trabeculectomy J Glaucoma  Volume 18, Number 1, January 2009 TABLE 2. Comparison of Visual Acuity Preoperative and TABLE 3. Success in Terms of Intraocular Pressure and Postoperative in the 3 Different Groups and Stage of the Disease Medications at Last Visit (1 Year ± 3 Months Postoperatively) *Anterior chamber reformation with viscoelastic twice.
*Anterior chamber reformation with viscoelastic twice.
A indicates minimal cupping of optic nerve; B, moderate cupping; C, advanced cupping; CF, count finger; HM, hand motion; LP, lightperception; VA, visual acuity.
cataract (patients 12, 9, and 21), and glaucoma progression(patient 19).
Table 3 summarizes postoperative IOP and number of medications needed at final follow-up. Success in IOP excluded the 3 group 1 patients whose subsequent inter- lowering was defined as a decrease in IOP to the target vention was surgical drainage, and a second analysis range set preoperatively. This range is based on lowering of at least 30%, modified for the glaucoma stage at the The ‘‘last visit’’ (final follow-up) of the study was around 1 year postoperatively for all cases; the range was Table 4 represents results of the Wilcoxon rank sum test for loss of visual acuity. In the comparison of surgical Table 2 demonstrates the loss in visual acuity in drainage of choroidal effusions (group 2) with medicinal Snellen lines at final follow-up relative to pretreatment treatment using atropine and phenylephrine (group 3), the (pretrabeculectomy) acuity and indicates the relative difference in loss of Snellen lines was statistically significant disease stage of each patient. The mean loss of Snellen (P = 0.04) with greater loss in the former treatment group.
lines was 1.2 ± 2.7 (mean ± SD) in group 1, 3.3 ± 3.2 in Also represented in Table 4 are the Fisher exact test group 2, and 0.5 ± 2.2 in group 3. Severe visual loss (SVL) outcomes for reduction of IOP of 30%, achievement of predetermined target IOP, failure with IOP>20 on 4 Snellen lines was limited to groups 1 (1 case) and 2 medications, and the need for repeat surgery owing to (3 cases). The etiology of SVL in the patient in group 1 was cataract and coexistent macular changes (patient 3). In Table 5 represents a comparison of the 3 groups after group 2, reasons for SVL included vein occlusion (patient 12), J Glaucoma  Volume 18, Number 1, January 2009 TABLE 4. Comparison of 3 Groups Having Only One Method of Management Group 1: Reformation with viscoelastic substance as initial and only treatment.
Group 2: Drainage of suprachoroidal space and reformation of anterior chamber is initial and only treatment.
Group 3: Neither chamber reformation nor drainage of choroidal.
*Visual acuity: P values for Wilcoxon rank sum test. All others categories P values for Fisher exact test.
wMedian (range) decrease in visual acuity.
zIOP decreased > 30% with no medication.
yIOP target was set at the highest level the physician believed would not cause optic nerve damage.
JRepeat surgery needed for recurrent grade II flat anterior chamber.
IOP indicates intraocular pressure.
Figures 2 and 3 represent percentages of patients evaluate prospectively the differences in outcomes of in each treatment group who achieved target IOP and in 3 different strategies employed in the management of a which IOP reduction of greater than 30% was achieved, FAC because of overfiltration after trabeculectomy in the respectively. Figure 4 demonstrates the number of Snellen early postoperative period. Surgical revision of the scleral lines lost among the 3 treatment groups.
flap with additional sutures, or tightening preexistingsutures to increase resistance to aqueous outflow is alsoan option, but was considered inappropriate in these cases, as it was felt such a procedure might predispose to excessive The reported incidence of FAC after trabeculectomy varies widely from 2% to 41%.1–4,14,20,24–26 Reduction in The combination of a low IOP, a high filtering bleb, the incidence of early FAC after trabeculectomy has largely absence of leakage through the conjunctiva, presence been owing to modified techniques with graduated pressure of an apparently open iridectomy, and no evidence of reduction in the early postoperative course, using various suprachoroidal hemorrhage reduced the likelihood that releasable suture or laser suture lysis techniques,7,8 and/or these FAC cases were caused by pupillary block, aqueous the adjunctive use of intraoperative viscoelastics.27 None- misdirection syndrome, or suprachoroidal hemorrhage.
theless, the early FAC after trabeculectomy remains an Group 1 employed injection of viscoelastic substance important complication. One of the factors driving the for reformation of the AC. This technique has been development of ‘‘nonpenetrating’’ surgeries for glaucoma, advocated by some for short-term maintenance of chamber such as deep sclerectomy, has been the desire to eliminate depth after surgery to prevent further complications such as corneal decompensation, cataract progression, or the In phakic patients, a grade III FAC with lenticulo- development of synechiae, choroidal detachment, and corneal apposition is an indication for immediate surgical aqueous misdirection syndrome.4,15–18 Furthermore, it has reformation.4,28 However, in grade II FAC, the exact become a frequently used method of treating FAC.16,18 timing and nature of initial intervention is less clear, In many cases, especially before the availability of ranging from conservative medicinal management to viscoelastic substances, the standard treatment for FAC surgical interventions.2,4,14,28 This report is an attempt to following a filtration procedure was drainage of the TABLE 5. Comparison of 3 Groups With Subsequent Interventions Group 1: Reformation with viscoelastic substance as initial treatment, with 5 cases having repeat reformation—2 with viscoelastic and 3 with choroidal Group 2: Drainage of suprachoroidal space and reformation of anterior chamber as initial and only treatment.
Group 3: Neither chamber reformation nor drainage of choroidal.
*Visual acuity: P values for Wilcoxon rank sum test. All others: relative risk and 95% confidence interval. P values for Fisher exact test.
wMedian (range) decrease in visual acuity.
zIOP decreased > 30% with no medication.
yIOP target was set at the highest level the physician believed would not cause optic nerve damage.
JRepeat surgery needed for flat anterior chamber.
IOP indicates intraocular pressure.
J Glaucoma  Volume 18, Number 1, January 2009 Percentage of Patients
Treatment Groups
FIGURE 2. Patient achieved target intraocular pressure.
choroidal detachment and reformation of the AC with anxiety and complexity of trying to save vision in a patient saline solution. The outcome of drainage of choroidal with glaucoma. When there are multiple options regarding effusion with reformation of the AC as employed in group 2 management of a visual-threatening complication, consid- in this study, was often associated with improved vision and ering which may result in the greatest preservation of visual acuity is relevant. Of the 33 eyes included in final analysis, As it was known that many patients with overfiltration 15 patients (45%) lost two or more lines of visual acuity, after trabeculectomy eventually spontaneously reform their emphasizing the visual significance of the complications of AC, ‘‘watchful waiting’’ has been advised by some as the a FAC. Treatment groups 1 and 2 had a greater number of appropriate treatment. In our study, in which surgeries eyes with acuity decline of two or more lines (54% and were performed without mitomycin-C, group 3 employed 60%, respectively) relative to group 3 (25%). The difference nonsurgical measures associated with decreasing inflamma- was statistically significant between groups 2 and 3 tion, modest deepening of the AC, and prevention of (P = 0.04). Etiologies of visual decline in groups 1 and 2 pupillary block and posterior synechiae with a small pupil included cataract or glaucoma progression, whereas a vein while awaiting episcleral fibrosis at the filtration site to occlusion occurred in 1 patient. This study, then, showed increase the resistance to outflow and cause reformation of that cases treated medicinally are less likely to lose vision the chamber. More studies with mitomycin-C trabeculec- than when a surgical intervention is performed (reforma- tomies should be necessary to prove that watchful waiting tion with viscoelastic or drainage of the choroidal detach- An outcome of immediate importance to patients The ultimate purpose of treatment is preservation of is visual disability after an intervention.29 The ultimate vision, and the way this is accomplished in patients with purpose of performing a filtration procedure, such as glaucoma is by lowering IOP. In fact, many studies of trabeculectomy in a person with glaucoma, is to preserve filtration procedures in glaucoma report rate of success only vision. Complications that are vision threatening add to the in terms of the amount of lowering the IOP.25,26 When Percentage of Patients
Treatment Groups
FIGURE 3. Fall of intraocular pressure >30%.
J Glaucoma  Volume 18, Number 1, January 2009 Number of Lines Lost
Treatment Groups
considering the ‘‘IOP success’’ in our study, we defined treatment options, 2 of them (reformation of the AC with success as achievement of predetermined target IOP, or viscoelastic and medicinal therapy) seemed to be more reduction of IOP greater than 30% relative to preoperative reasonable than a third (choroidal drainage). We doubt pressure without medications. In our cases, there was an that enough funds and energy could be accumulated to observed trend toward greater rates of success in groups 1 perform a randomized, controlled study of the approxi- and 2 (Figs. 2, 3). These differences almost reached statistical mately 900 cases that would be required to find small but significance between groups 1 and 3 for absolute IOP perhaps meaningful differences in outcomes. It would be reduction of greater than 30% (P = 0.09). Though not extremely difficult to assure that surgical technique was well statistically significant, the trend of 91% (group 1), 70% (group 2), and 58% (group 3) suggests that reformation with This study represents the first attempt to analyze 3 viscoelastic is more likely to result in a satisfactory post- modes of management of a FAC in a prospective, operative IOP than treating the patient only with medica- randomized fashion. A strength of this study was standar- tions. It has been suggested that the very development of a dization in the method of trabeculectomy—as a single FAC leads to lower short-term postoperative success rates surgeon performed all cases. Moreover, despite the sample (2 to 8 mo) relative to eyes undergoing trabeculectomy that size, one statistically significant finding emerged among the 3 treatment groups. Specifically, there seems to be little The explanation for the apparent greater trend toward justification for draining choroidal detachment in an eye eventual lower IOP in groups 1 and 2 is not clear.
with grade II FAC. Also a possibly important trend Reformation of the AC with a viscoelastic substance or emerged, notably that when visual acuity preservation is a BSS (with resultant immediate elevation of IOP) may primary concern, medicinal treatment alone may be encourage filtration by disruption of the filtration site. In preferable, but when control of IOP is a high priority, contrast, aqueous flow is decreased in eyes with hypotony/ reformation of the AC with a viscoelastic substance is a choroidal detachment, and this may be decreased further by use of aqueous suppressants; this is the theoretical basisbehind this intervention, which has been advised bysome.30–32 Possible disruption of the filtering area mayalso explain the increased tendency of eyes in groups 1 and 2 to develop recurrent FAC after intervention in compar- 1. Kim YY, Jung HR. The effect of flat anterior chamber on the ison with group 3—perhaps reformation encouraged more success of trabeculectomy. Acta Ophthalmol Scand. 1995;73: A serious limitation of this study is a small sample size 2. Jampel HD, Musch DC, Gillespie BW, et al. Perioperative that prevented a more robust statistical evaluation to detect complications of trabeculectomy in the collaborative initial differences in treatment effect of FAC. Approximately 900 glaucoma treatment study (CIGTS). Am J Ophthalmol. 2005; cases would have been needed to prove that various treatments did not produce different outcomes. (Assump- 3. Edmunds B, Thompson JR, Salmon JF, et al. The National tions used in power calculations, with a sample size of 900: Survey of Trabeculectomy. III. Early and late complications.
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