Anthony Cb Molteno

OTAGO GLAUCOMA SURGERY OUTCOME STUDY: LONG-TERM RESULTS OF TRABECULECTOMY: 1976 TO 1995

OBJECTIVE To provide data on the long-term results of trabeculectomy performed in the province of Otago, New Zealand. DESIGN Retrospective noncomparative case series. PARTICIPANTS A total of 289 eyes of 193 patients (excluding 4 eyes lost to follow-up soon after operation); all trabeculectomies performed for the first time on cases of primary glaucoma from 1976 through 1995. INTERVENTION Standard Cairns trabeculectomy. MAIN OUTCOME MEASURES Intraocular pressure, visual acuity, visual field damage. RESULTS Trabeculectomy was effective in controlling intraocular pressure at a level of 21 mmHg or less, with probabilities of 0.93 (95% confidence interval [CI], 0.90-0.97), 0.87 (95% CI, 0.82-0.93), and 0.85 (95% CI, 0.77-0.92) at 5, 10, and 15 years, respectively, after surgery. The mean visual acuity improved from 20/60 to 20/40 immediately after trabeculectomy but then declined steadily over the postoperative years. The decline in visual acuity led to blindness in 47 eyes. The Kaplan-Meier estimated probability of retaining useful vision (visual acuity > 20/400 and visual field > 5 degrees radius) in the overall group was 0.87 (95% CI, 0.79-0.91), 0.72 (95% CI, 0.60-0.79), and 0.6 (95% CI, 0.43-0.69) at 5, 10, and 15 years, respectively, after surgery. Those eyes that had good preoperative visual acuity (visual acuity > or = 20/30) had a significantly better chance of retaining useful vision (P = 0.02). CONCLUSIONS The intraocular pressure was well controlled by trabeculectomy, but a steady long-term decline in visual acuity and visual field occurred, decreasing the probability of an eye retaining useful vision up to the time of death to approximately 0.6.

Otago Glaucoma Surgery Outcome Study ☆: factors controlling capsule fibrosis around Molteno implants with histopathological correlation

OBJECTIVE To describe the histopathology of Molteno implant capsules in cases of primary and secondary glaucoma and to correlate them with surgical technique and clinical outcomes in quiet eyes. DESIGN Human tissue study with clinicopathological correlation. MATERIALS Seventy-five autopsy eyes or surgical pathology specimens obtained between 4 days and 23 years after insertion of Molteno implants were studied. Basic histologic features common to all bleb capsules were described, and the thickness was measured in 28 specimens from quiet eyes. MAIN OUTCOME MEASURES Histologic features of capsules, including wall thickness, distribution of inflammatory cells, and presence or absence of fibrodegeneration, were assessed by light microscopy. RESULTS Without aqueous flow (first stage of 2-stage insertion), the episcleral plates of Molteno implants were encapsulated by a very thin (20-60 micro m) avascular collagenous layer. The second stage of 2-stage insertion, with delayed drainage of aqueous and early temporary postoperative intraocular pressure (IOP) increase to 25 to 35 mmHg, produced thin (190-250 micro m) permeable capsules with fewer fibrovascular than fibrodegenerative components. Insertion of nonligatured implants with immediate aqueous flow produced thicker capsules (300-600 micro m) composed of an outer fibrovascular layer and an inner fibrodegenerative layer of approximately equal thickness. Three-stage insertion of modified Molteno implants with temporary externalization of aqueous flow onto the conjunctival surface and postoperative IOP not exceeding 12 mmHg produced the thickest (375-700 micro m) heavily fibrosed and impermeable capsules composed entirely of dense fibrovascular tissue without a fibrodegenerative layer. CONCLUSIONS Capsules around functioning Molteno implants evolved through a series of histologic stages. Without aqueous flow, the episcleral plate of the implant stimulated encapsulation by a thin avascular collagenous layer. With aqueous flow, an immediate inflammatory reaction developed in the episcleral connective tissues that included collagenous and vascular components. After a variable delay, a fibrodegenerative process developed in the deeper layers of the capsule. The fibrodegenerative process may depend on sufficient increases of IOP for aqueous to displace interstitial tissue fluid from the deeper layers of the capsule. The final thickness and permeability of the capsule probably depend on the relative intensity and timing of these opposing processes, which were influenced by surgical technique and postoperative management.

Long term follow up of bone derived hydroxyapatite orbital implants

Aims: To document the long term experience of bone derived hydroxyapatite orbital implants and compare results using scleral wrapped implants with those not using sclera. Methods: This retrospective case series reviewed the long term follow up of 118 patients with 120 eyes which had undergone enucleation and bone derived hydroxyapatite orbital implant insertion at Dunedin Hospital from 1977 until 2000. Patient details were obtained from theatre records, case note review, patient interview and examination, interview of patient relatives, and family general practitioner records. Results: Of the 120 eyes 84 had bone derived hydroxyapatite orbital implants with sclera and 36 without sclera. Follow up was 0.5–25 years (mean 8.9 years). 25 (19.3%) suffered minor complications of limited exposure of the implant which resolved spontaneously, with implant drilling or wound resuture. Nine (7.5%) suffered major complications requiring explantation. Major complications were more likely in cases with major tissue disruption, ischaemia, or inflammation. There were significantly fewer complications in the group where a bone derived hydroxyapatite orbital implant was implanted without a scleral covering (p<0.05). Conclusions: The placement of a bone derived hydroxyapatite orbital implant in the socket was associated with a low rate of long term complications and good cosmesis in most cases. The omission of a scleral covering over the hydroxyapatite sphere had some advantages and may prove to be the procedure of choice.

Anti-inflammatory fibrosis suppression in threatened trabeculectomy bleb failure produces good long term control of intraocular pressure without risk of sight threatening complications

Aims: To determine the long term outcome of systemic anti-inflammatory fibrosis suppression in cases of threatened trabeculectomy bleb failure in open angle glaucoma. Methods: This prospective non-comparative case series followed 77 eyes of 63 patients which showed signs of threatened early bleb failure and were treated with oral anti-inflammatory fibrosis suppression of prednisone, a non-steroidal anti-inflammatory agent, and colchicine taken for a mean period of 6 weeks, in addition to standard postoperative topical treatment, for a mean follow up of 6 years. Results: Trabeculectomy with anti-inflammatory fibrosis suppression controlled the IOP at ≤21 mm Hg with a probability of 0.91 (95% CI: 0.81 to 1.0) at 8 years and 0.89 (95% CI: 0.56 to 1.1) at 12 years. There were no reported cases of endophthalmitis, hypotonous maculopathy, late bleb leak, or serious systemic side effects. Conclusion: Anti-inflammatory fibrosis suppression provided good control of bleb fibrosis without risk of sight threatening complications in a patient group at high risk of bleb failure.

Otago glaucoma surgery outcome study: long-term follow-up of cases of primary glaucoma with additional risk factors drained by Molteno implants.

OBJECTIVE This study was undertaken to provide data on the long-term results of cases of primary open-angle glaucoma with additional risk factors drained by Molteno implants in the province of Otago, New Zealand. DESIGN Prospective, noncomparative case series PARTICIPANTS One hundred thirty eyes of 103 patients drained by Molteno implants as the first surgery between 1984 and 1999. INTERVENTION Insertion of Molteno implant (Ethicon Inc., Johnson & Johnson, Somerville, NJ) using the Vicryl-tie technique. MAIN OUTCOME MEASURES Intraocular pressure (IOP), visual acuity, visual field. RESULTS Insertion of a Molteno implant controlled the IOP at 21 mmHg or less with a probability of 1.0 (95% confidence interval [CI], 0.90, 1.0) at up to 7 or more years after surgery. The mean preoperative visual acuity of 20/160 improved to 20/50 after operation and then declined to 20/55 at 5 years and 20/80 after 10 years. The probability of retaining useful vision (visual acuity, >20/400; visual field, >5 degrees radius) was 0.86 (95% CI, 0.77, 0.94) and 0.78 (95% CI, 0.67, 0.89) at 5 and 7 or more years, respectively, after surgery. CONCLUSIONS The insertion of Molteno implants using the Vicryl-tie technique in this series of 130 cases of primary open-angle glaucoma with additional risk factors controlled the IOP in all cases.

Long-term follow-up of Molteno drains used in the treatment of glaucoma presenting in childhood

Purpose and methods This study reviews the long-term follow-up (mean 11.2 years, range 9 months to 16 years 9 months) of Molteno drains used in the treatment of glaucoma presenting in childhood, in 34 eyes of 25 patients.Results Intraocular pressure control was achieved in 85% of eyes, and vision (where measurable) was maintained in 57% of eyes. Seventy-one per cent of eyes required further surgical intervention. Thirty-two per cent of these cases were for drain-related problems, which may be avoidable with the use of current surgical techniques. The remaining interventions were for associated ocular defects, and for problems caused by multiple surgical procedures and periods of high intraocular pressure during early childhood.Conclusions Today the implants are used at an earlier stage in the disease process to try to obtain early and definitive IOP control and so help to optimise the long-term visual prognosis.

Systemic anti-inflammatory fibrosis suppression in threatened trabeculectomy failure.

Purpose: To provide a rationale for the use of systemic anti‐inflammatory fibrosis suppression in the postoperative management of threatened early trabeculectomy bleb failure.

Otago Glaucoma Surgery Outcome Study: long‐term results of 841 trabeculectomies

Background:  To describe the long‐term outcomes of trabeculectomies performed at Dunedin Hospital and followed in the Otago Glaucoma Surgery Outcome Study.

Otago Glaucoma Surgery Outcome Study: long term results of cataract extraction combined with Molteno implant insertion or trabeculectomy in primary glaucoma

Background/Aims: To describe the long term results of cases of cataract extraction combined with either Molteno implant insertion or trabeculectomy for primary open angle glaucoma. Methods: This prospective case series followed cases which had cataract extraction and Molteno implant insertion (45 eyes) or trabeculectomy (94 eyes) followed up for a mean of 5.3 years and 3.9 years respectively. Results: Cataract extraction and Molteno implant insertion or trabeculectomy controlled the intraocular pressure at 21 mmHg or less with a probability of 1.00 (95% CI 0.93 to 1.00) at 10 years or more after operation and 0.94 (95% CI 0.89 to 0.99) and 0.73 (95% CI 0.46 to 0.99) at five and 10 years after operation respectively. Conclusions: Cataract extraction combined with insertion of Molteno implants or trabeculectomy controlled the intraocular pressure in 100% (45/45) and 94% (88/94) of cases respectively.

Otago Glaucoma Surgery Outcome Study: the pattern of expression of MMPs and TIMPs in bleb capsules surrounding Molteno implants.

PURPOSE To determine whether MMPs and TIMPs are present in the bleb wall of Molteno implants. METHODS An observational case series consisting of ocular specimens from 10 human eyes obtained postmortem from patients who had undergone placement of Molteno implants for glaucoma. Immunohistochemistry was performed on the specimens to determine the distribution of MMP1, -2, and -3 and TIMP1, -2, and -3 in each bleb. The immunohistochemical staining was correlated with the histologic features observed in hematoxylin and eosin (H&E)-stained sections of the bleb wall. RESULTS The specimens demonstrated extensive cytoplasmic staining for MMP1, -2, and -3 in fibroblasts within the bleb wall and in degenerating collagen near inner bleb wall fibroblasts undergoing apoptosis. In addition, there was staining for the presence of TIMP2 but not -1 or -3. CONCLUSIONS MMPs are present in the bleb walls of Molteno implants. TIMP2 is expressed in most bleb capsules. The observations from this study support the hypothesis that bleb capsules undergo a cycle of collagen breakdown and renewal throughout the life of the bleb as members of the MMP family were localized in the bleb wall.