Verena Prokosch-Willing

A New Method for Revision of Encapsulated Blebs after Trabeculectomy: Combination of Standard Bleb Needling with Transconjunctival Scleral Flap Sutures Prevents Early Postoperative Hypotony

Purpose A simple needling procedure is the standard method for restoring the function of an encapsulated bleb after trabeculectomy. However, postoperative hypotony represents a possible hazard. This study describes a new surgical approach for treating encapsulated blebs with reduced risk of early postoperative hypotony: bleb needling combined with transconjunctival sutures tightening the scleral flap directly. Methods The study included two groups of 23 patients with failing bleb following trabeculectomy: “Group 1” underwent simple needling revision of the filtering bleb and served as a control group, while “Group 2” received needling revision with additional transconjunctival scleral flap sutures, if intraoperatively the intraocular pressure was estimated to be very low. Intraocular pressure (IOP), postoperative management and complications were analyzed over a follow-up period of 4 weeks postoperatively. Results were compared using t-test or Mann-Whitney U-tests. Results Adverse effects occurred with a higher frequency after sole needling of the bleb (5 cases of choroidal effusion and 1 case of choroidal hemorrhage) than after the combined method with additional scleral sutures (1 case of choroidal effusion). The IOP on the first postoperative day was significantly lower in group 1, with 9.43 ± 9.01 mm Hg vs. 16.43 ± 8.35 mm Hg in group 2 (P = 0.01). Ten patients with ocular hypotony (IOD of 5 mmHg or lower) were found in group 1 and only two in group 2. One week and one month after surgery the intraocular pressure was similar in both groups (P>0.05). Conclusions This new needling technique with additional transconjunctival scleral flap sutures appears to reduce postoperative hypotony, and may thus protect from further complications, such as subchoroidal hemorrhage.

Postnatal visual deprivation in rats regulates several retinal genes and proteins, including differentiation-associated fibroblast growth factor-2.

Little is known about the retinal cellular basis of amblyopia, which is a developmental disease characterized by impaired visual acuity. This study examined the retinal transcripts associated with experimentally induced unilateral amblyopia in rats. Surgical tarsorrhaphy of the eyelids on one side was performed in pups prior to eye opening at postnatal day 14, thereby preventing any visual experience. This condition was maintained for over 2 months, after which electroretinograms (ERGs) were recorded, the retinal ganglion cell (RGC) arrangement and number were determined using neuroanatomical tracing, the retinal transcripts were studied using microarray analysis, regulated mRNAs were confirmed with quantitative reverse-transcriptase PCR, and proteins were stained using Western blotting and immunohistochemistry. An attenuated ERG was found in eyes that were deprived of visual experience. Retrograde neuroanatomical staining disclosed a larger number of RGCs within the retina on the visually deprived side compared to the non-deprived, control side, and a multilayered distribution of RGCs. At the retinomic level, several transcripts associated with retinal differentiation, such as fibroblast growth factor 2 (FGF-2), were either up- or downregulated. Most of the transcripts could be verified at the mRNA level. To unravel the role of a differentiation-associated protein, we tested FGF-2 in dissociated postnatal retinal cell cultures and found that FGF-2 is a potent factor triggering ganglion cell differentiation. The data suggest that visual experience shapes the postnatal retinal differentiation, whereas visual deprivation induces changes at the functional, cellular and molecular levels within the retina.

Hydrogen Sulfide Protects Retinal Ganglion Cells Against Glaucomatous Injury In Vitro and In Vivo

Purpose Hydrogen sulfide (H2S) is recognized as a novel third signaling molecule and gaseous neurotransmitter. Recently, cell protective properties within the central nervous and cardiovascular system have been proposed. Our purpose was to analyze the expression and neuroprotective effects of H2S in experimental models of glaucoma. Methods Elevated IOP was induced in Sprague-Dawley rats by means of episcleral vein cauterization. After 7 weeks, animals were killed and the retina was analyzed with label-free mass spectrometry. In vitro, retinal explants were exposed to elevated hydrostatic pressure or oxidative stress (H2O2), with and without addition of a slow-releasing H2S donor Morpholin-4-ium-methoxyphenyl-morpholino-phosphinodithioate (GYY4137). In vivo, GYY4137 was injected intravitreally in animals with acute ischemic injury or optic nerve crush. Brn3a+ retinal ganglion cells (RGCs) were counted in retinal flat mounts and compared. Optical coherence tomography (OCT) was performed to examine the vessels. Comparisons were made by t-test and ANOVA (P < 0.05). Results IOP elevation caused significant RGC loss (P < 0.001); 3-mercaptosulfurtransferase, an H2S producing enzyme, showed a 3-fold upregulation within the retina after IOP elevation. GYY4137 protected RGCs against elevated pressure and oxidative stress in vitro depending on the concentration used (P < 0.005). In vivo, intravitreal administration of GYY4137 preserved RGCs from acute ischemic injury and optic nerve crush (P < 0.0001). Retinal vessel diameters enlarged after intravitreal GYY4137 injection (P < 0.0001). Conclusions H2S is specifically regulated in experimental glaucoma. By scavenging reactive oxygen species and dilating retinal vessels, H2S may protect RGCs from pressure and oxidative stress-induced RGC loss in vitro and in vivo. Therefore, H2S might be a novel neuroprotectant in glaucoma.

Revision of encapsulated blebs after trabeculectomy: Long-term comparison of standard bleb needling and modified needling procedure combined with transconjunctival scleral flap sutures.

Purpose To compare two surgical approaches for treating encapsulated blebs after trabeculectomy with mitomycin C, in terms of the development of intraocular pressure and progression of glaucoma in a long-term follow up: 1. bleb needling alone vs. 2. a combined approach of needling with additional transconjunctival scleral flap sutures, to prevent early ocular hypotony. Methods Forty-six patients with failing blebs after trabeculectomy with mitomycin C were enrolled in this study. Patients received either needling revision alone (group 1; n = 23) or a combined needling with additional transconjuctival flap sutures, if intraoperatively the intraocular pressure was estimated to be low (group 2; n = 23). Intraocular pressure (IOP), visual acuity, visual fields, and optic nerve head configuration by means of Heidelberg Retina Tomograph (HRT®) were analysed over time. Results from both groups were compared using Mann-Whitney U-test for single timepoints. Results IOP did not differ significantly between the two groups during follow-up at three months (P = 0.13), six months (P = 0.12), one year (P = 0.92) and two years (P = 0.57) after surgery. Furthermore, there was no significant difference in the course of glaucoma concerning the optic nerve anatomy between the two groups (Rim Area Change in the Moorfields Regression Analysis of HRT®) till two years after surgery (P = 0.289). No functional impairment in visual acuity and visual fields was found in the groups of the study. Conclusions Single needling procedure is a standard successful method for restoring the function of encapsulated blebs. Postoperative hypotony represents a possible hazard, which can be minimized by additional transconjunctival flap sutures. Long-term results suggest that this modification is equally effective in lowering the IOP and preventing the progression of glaucoma as the standard needling procedure. To our knowledge this is the first study to investigate the long-term effect of tranconjunctival sutures for the prevention of hypotony.

Obstruktive Schlafapnoe bei Glaukompatienten

Hintergrund: Das obstruktive Schlafapnoe-Syndrom (OSAS) besitzt in der Bevolkerung eine stark zunehmende Pravalenz. Auserdem erfreut sich dieses Krankheitsbild einer zunehmenden Aufmerksamkeit in der Allgemeinbevolkerung und wird daher immer haufiger diagnostiziert. Obwohl[zum vollstandigen Text gelangen Sie uber die oben angegebene URL]

Suprachoroidal Bleeding after XEN Gel Implantation

Purpose: To report for the first time a clinical case of suprachoroidal bleeding after XEN45 gel implantation. Observations: A 84-year old female patient with pseudoexfoliation glaucoma with intraocular pressure (IOP) (20 mm Hg) above target despite maximal IOP-lowering therapy was scheduled for XEN45 gel implantation. The XEN45 gel implantation went without complications and was properly placed in the anterior chamber and beneath the conjunctiva. On the first postoperative day, the patient presented with an IOP of 4 mm Hg, a functioning bleb and a deep anterior chamber. On the second day she developed suprachoroidal bleeding. A wait and see strategy was followed and the patient monitored steadily. The bleeding resolved spontaneously after 6 weeks. Conclusions and Importance: Minimally invasive glaucoma surgery is developed to provide a safer and less-invasive option to reduce IOP in glaucoma patients compared with trabeculectomy. Although the concept of the XEN45 gel stent seems to be a favorable to reach IOP-lowering results similar to those of trabeculectomy, complications may be similar, too. We have to keep this in mind when informing patients about surgical options.

Spontaneous Resolution of Delayed Suprachoroidal Hemorrhage in the Single Eye Following Needling in Congenital Glaucoma

INTRODUCTION Suprachoroidal hemorrhage (SCH) is a rare, but potentially vision-threatening event with poor long-term visual prognosis. At present, there is disagreement whether surgical intervention or conservative treatment is superior in the management. We report on a case of spontaneous resolution of severe SCH after needling procedure in the only eye of a young patient with congenital glaucoma. CASE PRESENTATION A 43-year-old woman with congenital glaucoma was scheduled for bleb needling in her only eye. Preoperative best-corrected visual acuity was 20/40 and intraocular pressure 20 mm Hg. On the third postoperative day, she developed a massive delayed SCH with appositional (kissing) choroidal bullae and visual acuity was hand motion. Scleral drainage was performed after 10 days, but did not show a significant decrease of the choroidal swelling and further conservative treatment was discussed. After 2 months, choroidal swelling had completely resolved, best-corrected visual acuity was 20/50, and intraocular pressure was 11 mm Hg. DISCUSSION Full functional recovery and decrease of choroidal swelling may be attained with a conservative treatment of massive delayed SCH after needling procedure in congenital glaucoma.