Nonpenetrating deep sclerectomy: a 6-year retrospective study.

PURPOSE: Nonpenetrating trabeculectomy, also called nonpenetrating deep sclerectomy (NPDS), is a filtering surgery where the internal wall of Schlemm's canal is excised, allowing subconjunctival filtration without actually entering the anterior chamber. This, technique was developed to minimize the complications of trabeculectomy. The authors investigated its safety and efficacy in a retrospective noncomparative study. METHODS: A total of 258 eyes (179 patients, mean age 61.4 +/- 11.56 years) with uncontrolled open angle glaucoma with prior medical therapy were treated. NPDS with a biocompatible collagen device (157 eyes) sutured to deep scleral bed or with the use of a 5-fluorouracil sponge (90 eyes) were analyzed. The main outcome measure was postoperative intraocular pressure (IOP) with an average follow-up of 54.4 +/- 17.07 months (range 1-85). Efficacy was determined 1 month, 3 months, and every 6 months after the procedure for 6 years. RESULTS: Mean preoperative IOP was 24.47 +/- 5.92 mmHg. Mean postoperative IOP was 14.44 +/- 5.31 mmHg (average lowering of the IOP was 38.94 +/- 23.81%) at 1 month, 15.16 +/- 4.57 mmHg (35.73 +/- 21.35%) at 3 months, 15.87 +/- 4.24 mmHg (32.45 +/- 20.52%) at 6 months, 16.32 +/- 4.53 mmHg (29.96 +/- 23.69%) at 12 months, 17.12 +/- 4.45 mmHg (26.51 +/- 23.93%) at 18 months, 16.77 +/- 4.44 mmHg (28.18 +/- 21.73%) at 24 months, 16.43 +/- 4.15 mmHg (28.89 +/- 23.69%) at 30 months, 16.34 +/- 4.12 mmHg (30.05 +/- 21.61%) at 36 months, 16.16 +/- 4.01 mmHg (30.06 +/- 22.55%) at 42 months, 15.71 +/- 3.74 mmHg (32.49 +/- 19.08%) at 48 months, 15.61 +/- 3.48 mmHg (31.26 +/- 21.01%) after 5 years, and 15.81 +/- 3.79 mmHg (33.73 +/- 20.9%) after 6 years. YAG goniopuncture was performed in 47.3% of cases with a mean follow-up of 12 +/- 13 months. These goniopunctures were effective in lowering IOP after a long-term follow-up (24 months). Additional 5-fluorouracil injections were used in 7% of cases. Visual field (Octopus or Humphrey mean defect and corrected loss variance or loss variance) was not modified (p < 0.01). Number of preoperative glaucoma medications was 2.01 +/- 0.58 and number of postoperative glaucoma medications was 0.85 +/- 0.92. Complications were peroperative microperforations in 27 eyes (10.5%), shallow anterior chamber in 2 eyes, hyphema in 2 eyes (0.8%), cataract in 5 eyes (2%), and dellen in 1 eye (0.4%). No cases of endophthalmitis or choroidal detachment were found. After surgery, 23 eyes (8.9%) required a new filtering surgical procedure, and diode laser cyclophotocoagulation was necessary in 2 eyes (0.8%). The probability success rate, defined as an IOP lower than 21 mmHg, was 66.46% (Kaplan Meier) at 60 months off all glaucoma medications and 80.32% with medical or new surgical treatment. CONCLUSIONS: NPDS appears to be an effective and safe filtering procedure for lowering IOP and could be an alternative to trabeculectomy in open angle glaucoma with the advantage of having fewer complications.

[Scoring system for chronic open glaucoma]. / Evaluation du glaucome chronique à angle ouvert par un score de gradation: analyse préliminaire.

PURPOSE: The aim of this study was to evaluate a scoring system for chronic open-angle glaucoma. We devised an empirical scoring system grading severity of the disease and correlated this with treatment. MATERIAL: and methods: Ninety patients were evaluated on 11 parameters: 1) Family history of glaucoma: blindness (2), yes (1) no (1); 2) Age: infantile (4), juvenile (4); 3) Race: Caucasian (0), Asian (1), Afro-Caribbean (2); 4) Myopia: 0-6 diopters (1), 6-12 diopters (2),>12 diopters (3); 5) Pigment dispersion or pseudoexfoliation (1); 6) Intraocular pressure without treatment:>30 mmHg (4); 25-30 mmHg (3), 20-25 mmHg (2); 7) Corneal central thickness:<500 micro m (3),>500 micro m (0); 8) Optic disc appearance: suspect (1), pathological (4); 9) Visual field defect: early (1), moderate (3), advanced (5); 10) Vascular risk factors: yes (1), no (0); 11) Loss of eyesight in one eye due to glaucoma (4). Scoring values were 2-34. We correlated this score with patient treatment: medical or surgical, number of glaucoma medications. RESULTS: Patients were divided into three groups: group 1 (36 patients), score 0-8; group 2 (24 patients), score 9-13; group 3 (30 patients), score above 13. Distribution between patients treated with medicine (mean number of medications) and patients with filtering surgery was: group 1, medical treatment with 1.63+/-0.73 medications, surgery 4/36; group 2, medical treatment with 2.00+/-0.7 medications, surgery 17/24 and group 3, medical treatment with 2.12+/-0.67 medications, surgery 27/30. In group 1, 88% of the patients did not have filtering surgery, but 90% of the patients in group 3 had filtering surgery. CONCLUSION: This scoring system seems to be an easy and practical tool to evaluate chronic open-angle glaucoma, which could also be used to evaluate target pressure. Other studies are necessary to validate this scoring system.

Non penetrating deep scleroctomy (N.P.D.S.) with or without collagen device (C.D) in primary open-angle glaucoma: middle-term retrospective study

The purpose of this study is to evaluate the middle term tonometric results of a new filtering procedure, the non penetrating deep sclerectomy with or without collagen device, in primary open-angle glaucome. This technic aims to eliminate or minimize the complications of classical trabeculectomy

[Non-penetrating deep sclerectomy combined with a collagen implant in primary open-angle glaucoma. Medium-term retrospective results]. / La sclérectomie profonde non perforante associée à la pose d'un implant de collagène dans le glaucome primitif à angle ouvert. Résultats rétrospectifs à moyen terme.

PURPOSE: To evaluate the middle term tonometric results of a new filtering procedure, the non penetrating deep sclerectomy with collagen device, in primary open-angle glaucoma. This technique aims to eliminate or minimize the complications of classical trabeculectomy. MATERIAL AND METHOD: This procedure has been developed by Koslov et al. Under a limbal-base conjunctival flap and a superficial scleral flap, the ablation of a deep scleral flap takes away the external wall of Schlemm's canal, leaving only the Descemet membrane. A visible filtration across the opened Schlemm's canal and Descemet membrane is obtained. To improve the aqueous filtration, a cylindric collagen device, made from biocompatible porcine scleral tissue, known for its high water content, is fixed in the deep scleral bed with a 10/0 nylon suture. This device provides a support for the elimination route of aqueous humor and acts like a sponge, carrying the liquid by capillary action. It is sterilized by irradiation. Full guarantee against viral contamination is provided. This procedure ends in one suture (40/0 nylon) of superficial scleral flap and conjunctival closing suture. We conducted a retrospective study. Our material included 159 patients (92 males, 65 females), 2/9 eyes. The mean age was 65 years (11-91). The mean follow-up : 8 months (3-20). The types of glaucoma were: POAG: 183 eyes; juvenile POAG: 18 eyes: pigmentary glaucoma: 11 eyes; capsular glaucoma: 7 eyes, 58 eyes (40 patients) presented one or several risk factors of failure for filtering surgery. RESULTS: The mean pre-operative IOP was 24 mmHg +/- 6.60; 15.7 +/- 5.30 at the end of the follow-up (delta average IOP: 9.1 +/- 7.1). The probability success rate (IOP < or = 20 mmHg), according to the Kaplan-Meier Method, was 89% at six months, 75.6% at 16 months. With monotherapy with beta blockers, 79% at 16 months. It was better in the without risk factors group. The mean change in visual acuity was inferior to 0.1 at the end of the follow-up. Except several hyphemas, no complications of the trabeculectomy were observed. The reelevation of IOP was due to an internal obstruction (goniosynechiae or bad filtration), it was treated with Nd-Yag laser with a 2/3 of success rate. External obstruction was treated by 5FU injections into the bleb. CONCLUSION: Non penetrating deep sclerectomy with collagen device can be an excellent alternative to trabeculectomy in open and wide angles. It does not modify visual actuity. It carries less complications than trabeculectomy and the use of antimitotic agents is safer.

Non-penetrating deep sclerectomy (NPDS) with or without collagen device (CD) in primary open-angle glaucoma: middle-term retrospective study.

The purpose of this study is to evaluate the middle-term tonometric results of a new filtering procedure, the nonpenetrating deep sclerectomy with or without collagen device, in primary open-angle glaucoma. This technic aims to eliminate or minimize the complications of classical trabeculectomy. METHOD: This procedure was carried out by Koslov and colleagues. This is performed under a limbal-based conjunctival flap and a superfical scleral flap, the ablation of a deep scleral flap taking away the external wall of Schlemm's canal, only living in place the Descemet membrane. One must obtain a visible filtration across the opened Schlemm's canal and Descemet membrane. To improve the aqueous filtration, a cylindric collagen device, made from porcine scleral tissue, biocompatible, known for its high water content, is fixed in the deep scleral bed with a 10/0 nylon suture. This device provides a support for the elimination route of aqueous humor and acts like a sponge, carrying the liquid by capillary action. It is sterilized by irradiation. Full guarantee against viral contamination is provided. This procedure ends in one suture (10/0 nylon) of superficial scleral flap and conjunctival closing suture. When NPDS is performed without CD a sponge of 5FU is used and the superficial scleral flap is not sutured. RETROSPECTIVE STUDY: Our material included 111 patients, 148 eyes in CD group; 43 patients, 55 eyes in the group without CD. The average follow-up was 13.3 +/- 5.8 months in the CD group, 7.2 +/- 3.5 months in the group without CD. All patients presented a POAG without risk factors of bleb failure. RESULTS: The delta average IOP before the operation and at the end of the follow-up period was 7.2 +/- 6.3 mmHg in the CD group; 8.3 +/- 7.6 mmHg in the group without CD (no significant difference). The probability-success rate with the Kaplan-Meier method (IOP < or = 20 mmHg) was, in the CD group, at 18 months, 68% and 69% in the group without CD, without medical treatment. With monotherapy, the success rate was 85% in the CD group, 74% in the group without CD (p < or = 0.05). PROSPECTIVE STUDY: Afterwards, we have conducted a prospective study comparing two groups of patients with POAG without risk factors of bleb failure, operated with and without collagen device, without 5FU in the second group. Our material included 31 patients, 31 eyes, one eye for each patient, two surgeons; 17 eyes in the CD group, 14 eyes in the group without CD. The average age was 65.8 +/- 8.2 years in the first group; 64.1 +/- 10.3 in the second group. The average follow-up was 11 months in both groups. RESULTS: delta average IOP was 8.3 +/- 5.8 in the CD group; 12.3 +/- 6 in the group without CD (p < 0.05). The probability-success rate without treatment at 12 months: 58% in the first group, 90% in the second group (p < 0.05) and with monotherapy: 80% and 90% (N.S.). In both studies, in both groups, except microperforations, more frequent in the prospective group without CD, no complications of the trabeculectomy were observed. The mean change in visual acuity was inferior to 0.1 at the end of the follow-up. A postoperative rise in IOP can occur. It can be due to an internal obstruction (goniosynechiae or bad filtration). It can be treated with Nd-Yag laser. It can also be due to external obstruction, treated by 5FU injections into the bleb. The success of these procedures were similar in the whole group. CONCLUSION: Non penetrating deep sclerectomy can be considered as an excellent alternative to trabeculectomy in open and wide angles. It does not modify visual acuity. It carries away less complications than trabeculectomy and the use of antimitotic agents is safer. Collagen device does not seem, at middle-term, to improve tonometric results.