- Email: [email protected]
Surgical Management of Post-traumatic Angle Recession Glaucoma
Surgical Management of Post' traumatic Angle Recession Glaucoma Andre Mermoud, MD, John F. Salmon, FRCS, Adrian Barron, MB ChB, Clive Straker, FRCS, Anthony D. N. Murray, FRCS
Purpose: The purpose of this study is to compare the results of three different drainage procedures performed for uncontrolled post-traumatic angle recession glaucoma. Methods: A retrospective analysis was undertaken of 87 drainage procedures performed on 65 patients over an 8-year period. The results of trabeculectomy (47 procedures), Molteno single-plate implantation (20 procedures), and trabeculectomy combined with antimetabolite (20 procedures) were compared. Of those treated with antimetabolite, 11 received postoperative subconjunctival injections of 5-fluorouracil and 9 received an intraoperative application of 0.02% mitomycin C to the trabeculectomy site. Results: In the group undergoing trabeculectomy with antimetabolite therapy, the intraocular pressure (lOP) drop was Significantly greater, the percentage of successful cases at 3 and 6 months postoperatively was significantly higher, and the number of postoperative glaucoma medications was significantly lower than the other two groups. No statistically significant differences were found between the groups undergoing trabeculectomy without antimetabolite therapy and Molteno implantation. Of concern were three cases of late bleb infection in the group that received postoperative antimetabolite therapy. Conclusion: In medically uncontrolled post-traumatic angle recession glaucoma, trabeculectomy with antimetabolite therapy is the most effective surgical procedure. However, late bleb infection is a significant risk. Ophthalmology 1993;100:634-642
Anterior chamber angle recession is the commonest complication of blunt trauma to the eye. 1 The risk of late onset glaucoma after a contusion injury and the correlation between the degree of angle recession and the development of glaucoma have been well described. 1-8 However, little has been published on the treatment of post-traumatic angle recession glaucoma. Medical treatOriginally received: October 9, 1992. Manuscript accepted: November 19, 1992. From the Ophthalmology Department, Groote Schuur Hospital & University of Cape Town. Supported in part by a grant from Foundation Florian Verrey, Lausanne, Switzerland, the Department of National Education, Pretoria, South Africa, and Foundation Rey-Willer, Ecublens, Switzerland. Reprint requests to John F. Salmon, FRCS, Ophthalmology Department, Medical School, University of Cape Town, Observatory 7925, South Africa.
634
ment is often unsuccessful, and the results of argon laser trabeculoplasty are unsatisfactory2,8,9 (unpublished data; Scharf et aI, presented as a poster at the ARVO Annual Meeting, Sarasota 1992). The few cases of post-traumatic angle recession glaucoma that can be found in series describing the results of surgery for refractory glaucoma do not allow a comparison of different drainage procedures. IO- 14 To assess the surgical management of post-traumatic angle recession glaucoma, we retrospectively reviewed the results of all patients with this diagnosis who had undergone drainage surgery during an 8-year period. We report herein our experience of 87 procedures performed on 65 patients treated either with trabeculectomy, Molteno tube implantation, or trabeculectomy and antimetabolite therapy. While this report lacks the advantages of a prospective study, it nevertheless provides guidelines as to how this condition can be managed.
Mermoud et al
Post-traumatic Angle Recession Glaucoma
Materials and Methods From June 1984 to March 1992, 139 patients with traumatic glaucoma undelWent drainage surgery at Groote Schuur Hospital, Cape Town, South Africa. Of 139 patients, 48 were excluded due to partial or total dislocation of the lens and 10 due to angle closure secondary to peripheral anterior synechiae. An additional 16 patients with traumatic angle recession glaucoma and a follow-up of less than 3 months also were excluded. The remaining 65 patients with post-traumatic angle recession glaucoma undelWent 87 drainage procedures on either one or both eyes. The type of trauma causing the angle recession is listed in Table 1 and the condition of the contralateral eye is presented in Table 2. The mean number of degrees of angle recession was 311 ° ± 32° (range, 90°-360°); 7% (6/87) had recession of less than 180°, 19% (17/87) had recession from 180° to 270°, and 74% (64/87) had recession from 270° to 360°. Glaucoma was first diagnosed at a mean period of 7.6 ± 9.5 years (± standard deviation) after ocular trauma. All patients initially were treated with glaucoma medication, and then undelWent drainage surgery if poor compliance was demonstrated or if the intraocular pressure (lOP) was uncontrolled, despite maximum-tolerated glaucoma medication (mean period of medical therapy, 8 ± 9.5 months [± standard deviation]; range, 15 days to 3 years). Analysis was performed on three groups of patients. Each group was similar in terms of age, sex, race, and preoperative lOP (Table 3). Trabeculectomy was performed on 47 eyes from 1984 to 1988. Molteno tube implantation was performed in 20 eyes, 9 of which had undergone previous trabeculectomy (1987-1989). Trabeculectomy with adjunct antimetabolite therapy was performed in 20 eyes, 7 of which had undergone previous trabeculectomy (11 eyes received postoperative subconjunctival injections of 5-fluorouracil and 9 received an intraoperative application of mitomycin C) (1989-1992). Thus, a total of 16 eyes had a secondary procedure after failed trabeculectomy. Four parameters were compared to determine the efficacy of each drainage procedure: the mean lOP at different time intervals postoperatively, the mean change of
Table 1. Cause of Injury in Post-traumatic Angle Recession Glaucoma Type of Injury
No. (%)
Assault Industrial accident Sport and recreation Road traffic accident Denial of trauma* Unknown
57 (65) 6 (7)
5 (6) 3 (4) 7 (8) 9 (10)
• With other signs of trauma (lid scars, pupillary sphincter tears).
Table 2. Diagnoses in the Contralateral Eye (65 Patients) Diagnosis Normal eye Traumatic glaucoma Medical treatment Surgical treatment Absolute glaucoma Traumatic dislocation of the lens Traumatic corneal scar Traumatic vitreous hemorrage Enucleation for injury Amblyopia
No. (%) 23 (35)
36 (55) 8 (12) 22 (34) 6 (9) 2 (3) 1 (2) 1 (2) 1 (2) 1 (2)
lOP, the percentage of patients with lOP 21 mmHg or lower, and the mean number of postoperative medications required to control the lOP. The results of the nine patients who undelWent Molteno implantation after failure of trabeculectomy were compared with the results from the seven patients who undelWent trabeculectomy combined with antimetabolite therapy after failure of trabeculectomy. Surgical Procedure Trabeculectomy. A technique similar to that described by Cairns 15 was used. Depending on the surgeons' preference, a limbus- or fornix-based conjunctival flap was used. A 4 X 4-mm limbus-based scleral flap was dissected into clear cornea. A 1 X 2-mm deep scleral block was removed and a peripheral iridectomy was performed. The scleral flap was closed with two to four interrupted 10-0 nylon sutures. In eyes with a fornix-based conjunctival flap, the conjunctiva was closed with interrupted to-O nylon sutures, whereas in eyes with a limbus-based conjunctival flap, the conjunctiva was closed with a running to-O nylon suture. Subconjunctival injections of gentamicin (20 mg) and betamethasone acetate (1.5 mg) were administered in the inferior fornix. Postoperatively, topical homatropine 1% was instilled twice daily for the first week after surgery. Topical chloramphenicol was used for 4 weeks after surgery and topical prednisolone 1% four times daily for 3 months. Molteno Tube Implantation. The surgical techniques and the postoperative topical medication have been described in detail elsewhere. 12 In brief, after reflecting a fornix-based conjunctival flap, a single-plate Molteno long tube implant was inserted. The tube was occluded using a 6-0 Vicryl suture. A limbus-based scleral flap measuring 3 X 6 mm was fashioned to cover the tube. The anterior chamber was entered with a 22-gauge needle, the tube was inserted down this tract and projected 3 mm into the anterior chamber. The scleral flap was sutured over the tube, and the conjunctiva was closed. Donor sclera was not used to cover the tube. Postoperative medication was similar to that used after trabeculectomy.
635
Ophthalmology
Volume 100, Number 5, May 1993
Table 3. Post-traumatic Angle Recession Glaucoma: Demographic Features (65 Patients, 87 Procedures)* Trabeculectomy
Age (yrs) Mean ± SD Range Race Mixed Black White Sex M F Preoperative lOP (mmHg) Mean ± SD Range
Total
Trabeculectomy
Molteno
+ Antimetabolites
46.7 ± 15.7 12-82
45.3 ± 16.1 12-82
41.1 ± 14.6 15-65
49.6 ± 17.3 17-71
43 (66%) 21 (32%) 1 (2%)
29 (63%) 16 (35%) 1 (2%)
14 (70%) 6(30%)
12 (67%) 6 (33%)
51 (78%) 14 (22%)
36 (78%) 10 (22%)
16 (80%) 4(20%)
16 (89%) 2 (11%)
39.7 ± 9.2 21-64
39.9 ± 9.4 21-60
41.6 ± 6.7 30-52
36.6 ± 10.4 21-64
SO = standard deviation; lOP = intraocular pressure . • Because the disease was often bilateral and 22 patients had bilateral drainage procedures, the total number of procedures was 87 in 65 patients. In the trabeculectomy group, 47 procedures were performed in 46 patients; in the Molteno group, 20 procedures were performed in 20 patients; and in the trabeculectomy + antimetabolite group, 20 procedures were performed in 18 patients.
Trabeculectomy with Postoperative Adjunct 5-fluorouracil Subconjunctival Injection. The surgical procedure used was similar to that described in the Trabeculectomy section above, although there were a few subtle modifications. The conjunctival flap was always limbalbased, and particular attention was directed at avoiding the creation of a buttonhole in the conjunctiva. Tenon's capsule and the conjunctival layer were sutured separately using a continuous 10-0 nylon suture on a round-bodied needle for each layer. Postoperatively for 3 to 6 days, subconjunctival injections of 5-fluorouracil (5 mg) were given in the inferior fornix. The 5-fluorouracil was not administered if there was evidence of corneal toxicity (as demonstrated by an epithelial defect), a flat anterior chamber, or a conjunctival wound leak. The total amount of 5fluorouracil administered ranged between 15 and 30 mg (mean, 22.4 ± 5.6 mg). Trabeculectomy with Intraoperative Application of Mitomycin C. The surgical procedure used was similar to that used with postoperative subconjunctival injection of 5-fluorouracil in the Trabeculectomy with Postoperative Adjunct 5-fluorouracil Subconjunctival Injection section above. After hemostasis of the episclera, a surgical sponge (Merocel, cat. no 400200, Merocel Corp, Mystic, CT) which had been previously soaked in a 0.2-mg/ml solution of mitomycin C (Kyowa, Syntex Pharm AG, Allschwil, Switzerland) was applied between the sclera and the conjunctiva for 5 minutes. The mitomycin C solution was prepared just before surgery by mixing the contents of a 2-mg vial of mitomycin C with 10 ml of balanced salt solution. After 5 minutes, the sponge was removed and the entire area was irrigated with balanced salt solution.
Success Criteria The following definitions of surgical outcome were adopted: a complete success was defined as an lOP below
636
or equal to 21 mmHg without medication, a qualified success as an lOP below or equal to 21 mmHg with antiglaucoma medication, a qualified failure as a pressure higher than 21 mmHg with or without medication, and a complete failure as an eye that required further glaucoma drainage surgery, developed phthisis bulbi, or lost light perception.
Statistical Analysis Comparisons between the results of the three surgical techniques was performed using the Student's t test. Kaplan-Meier survival curves were drawn, and inter-curve analysis was performed using the log-rank test. Success rate comparisons between groups was performed using the chi-square test. A finding was considered significant at a P value of < 0.05.
Results The follow-up of the trabeculectomy plus antimetabolite group is shorter at 8.8 ± 7.3 months (range, 3-28 months) than the total mean follow-up of 23.1 ± 19.7 months (range, 3-72 months) (P = 0.003). The surgical and visual results are summarized in Table 4. All three surgical techniques were effective in lowering a mean preoperative lOP of 39.7 ± 9.2 mmHg (range, 21-64 mmHg) to a 2-year postoperative mean lOP of 19.4 ± 8.9 mmHg (range, 444 mmHg) (P < 0.001). The mean lOP at each period of follow-up for each group is shown in Figure 1. The mean postoperative lOP of the trabeculectomy plus antimetabolite group is significantly lower than the mean lOP of the two other groups at 15 days and at 1, 3, and 6 months. At the 6-month follow-up, the mean lOP of the group undergoing Molteno tube implantation is statistically
Mermoud et al . Post-traumatic Angle Recession Glaucoma Table
4. Surgical and Visual Outcome in Post-traumatic Angle Recession Glaucoma Trabeculectomy
Follow-up (mos) Mean Range No. of medications preoperatively No. of medications postoperatively Visual outcome Same or better Worse Surgical successt 1 roo 3 roos 6roos 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 6 yrs
+ Antimetabolite
Total (n = 87)
Trabeculectomy (n = 47)
Molteno (n = 20)
Adjunct Therapy· (n = 20)
23.1 ± 19.7 3-72 2.05 ± 1.1 0.99 ± 0.89
27.5 ± 22 3-72 2.04 ± 1.2 1.11 ± 1.24
19.6 ± 15.1 3-58 2 ± 1.2 1.05 ± 1
8.8 ± 7.3 3-28 2.1 ± 0.7 0.22 ± 0.5
63 (74%) 24 (26%)
34 (72%) 13 (28%)
14 (70%) 6 (30%)
15 (75%) 5 (25%)
0.94 0.86 0.81 0.74 0.62 0.53 0.42 0.29 0.10
± 0.02 ± 0.02 ± 0.03 ± 0.04 ± 0.05 ± 0.05 ± 0.06 ± 0.08 ± 0.08
0.97 0.89 0.76 0.56 0.49 0.41 0.27 0.27
± 0.02 ± 0.03 ± 0.05 ± 0.07 ± 0.08 ± 0.10 ± 0.13 ± 0.13
0.98 0.96 0.92 0.74 0.45
± ± ± ± ±
0.02 0.03 0.05 0.12 0.24
• 5-Fluorouracil or mitomycin C.
t
Cumulative probabiliry of survival using Kaplan-Meier life-table analysis with standard error.
higher than the mean lOP of the trabeculectomy group
(P = 0.02) and the trabeculectomy plus antimetabolite group (P = 0.001). When the mean reduction of lOP is
analyzed, the trabeculectomy plus antimetabolite group demonstrated a significantly greater reduction ofIOP than the Molteno tube and the trabeculectomy groups (P = 0.02) (Table 5).
Kaplan-Meier life-table analysis representing longitudinal success rates are shown in Figure 2 and Table 4, and the percentage of successful cases at each follow-up visit is given in Figure 3. More patients who underwent a trabeculectomy with antimetabolite were completely successful at 1, 3, and 6 months after surgery than those who underwent trabeculectomy or Molteno tube implan-
Figure 1. Mean intraocular lOP (mmHg) pressure (lOP) after trabecu40 lectomy, Molteno tube implantation and trabeculectomy with antimetabolite for post-traumatic angle-recession glaucoma, at different 30 follow-up periods from 15 days to 6 years. There is no statistically significant differ••••••••••• • •••• ~. "fI'" •••• ....,..,..: ••c:. ••;...._.-... ence between the trabeculec20 tomy and Molteno group, but the trabeculectomy plus antimetabolite group demonstrates a significantly lower 10 •••••••••• Trabeculectomy lOP at 15 days and at I, 3, • Molteno and 6 months (P = 0.001, c - Trabeculectomy + A.M. 0.024, <0.001, and <0.001, respectively). No statistically o +-----~----~----~------r-----~----,-----~----_.----~~--~ significant differences were o 15 D 3M IY 2Y 5Y 3Y 1M 6M 4Y 6Y shown thereafter because of shorter follow-up on eyes undergoing trabeculectomy plus antimetabolite. D = day; M = month; Y = year.
.....
......... .........
.......•
······w .... ·.... ·...... ·.. ·..
637
Volume 100, Number 5, May 1993
Ophthalmology
Table 5. Mean Reduction ofIntraocular Pressure (in Percent) 42.3 35.9 41.1 59
Total T rabeculectomy Molteno Trabeculectomy + antimetabolites' • Significantly better than other groups (P
=
± ± ± ±
higher success rate in the group undergoing secondary Molteno tube implantation is, however, not statistically significant. Postoperatively, the vision was the same or improved in 74% (63/87) and was worse in 26% (24/87). Details for each group are presented in Table 4 and Figure 4. Loss of light perception was caused by uncontrolled lOP in three eyes and was secondary to endophthalmitis in one eye. Other early and late complications of surgery are listed in Table 6. There were three late postoperative infections in the trabeculectomy plus antimetabolite group (15%, 3/ 20) compared with 0% (0/47) in the trabeculectomy group, (P = 0.024) and 0% (0/20) in the Molteno group (not significant). One patient presented with a Staphylococcus aureus endophthalmitis 12 months after a trabeculectomy plus 5-fluorouracil and two other patients presented with infected filtering blebs 9 and 13 months after a trabeculectomy plus 5-fluorouracil. Of the 87 procedures, there were 36 failures (22 after trabeculectomy, 8 after Molteno implantation and 6 after trabeculectomy with antimetabolite therapy). These included 11 eyes classified as a "qualified" failure with an lOP between 22 and 30 mmHg and stable visual fields, in whom no further surgery was considered, and 25 classified as complete failures. Of these, 4 lost light perception and 21 underwent a second drainage procedure. The mean time from surgery to failure was 5 ± 6.6 months (range, 5 days to 18 months), and the mean time from the first operation to the second was 16.3 ± 19.2 months (range, 15 days to 72 months).
33% 36.8% 21% 24.8%
0.02).
tation (P = 0.022, 0.0 II, and 0.018, respectively). However, using the log-rank test on the cumulative probability survival curve, because of the small number of patients and the short follow-up period of those undergoing trabeculectomy with antimetabolite therapy, no statistically significant difference was found. The mean number of glaucoma medications used preoperatively was the same in each group, namely 2.05 ± 1.1 medication per patient. (Table 4). Postoperatively, in all groups the need for additional glaucoma medication was significantly reduced (P = 0.001). Comparison between groups showed a significantly reduced need for glaucoma medication in the trabeculectomy plus antimetabolite group (0.22 ± 0.55 medication per patient, versus 1.05 ± I medication per patient in the Molteno group [P = 0.005], and versus 1.11 ± 1.24 medication per patient in the trabeculectomy group [P = 0.004]). Of 16 patients who had previously undergone an unsuccessful trabeculectomy and were treated with a secondary drainage procedure, 9 underwent Molteno tube implantation and 7 had trabeculectomy with antimetabolite. When used as a secondary procedure, Molteno tube implantation was successful in 78% (7/9) and trabeculectomy plus antimetabolite was successful in 57% (4/7). The
Discussion The association of blunt ocular trauma with subsequent development of glaucoma was first described clinically in
Cumulative Success Probability
1.0
0.8
I-F~I----o
,··········1'-----:-, ............ ,. ......... .
• •••••••••• ~
0.6
0.4
Molteno Trabeclliectomy Trabeclliectomy + A.M.
,. ..........,
•.......... ,
t===~l____.............., .............
0.2
...... 0.0 +-----~----~----~----_r----~----_,----~~----r_----~--~ 1M 3M IY 2Y 3Y 4Y 6Y o 6M 5Y
638
Figure 2. Cumulative success probability after trabeculectomy, Molteno tube implantation, and trabeculectomy with antimetabolite in traumatic angle-recession glaucoma using a Kaplan-Meier life-table analysis. No statistically significant difference was shown when the surgical outcome for each operation was compared using the logrank test. Cumulative probability survival intervals and standard errors are shown in Table 4. M = month; Y = year.
Mermoud et al . Post-traumatic Angle Recession Glaucoma Successrate ( % ) Figure 3. Success rate (in percent) after trabeculectomy, Molteno tube implantation, and trabeculectomy plus antimetabolite for traumatic angle-recession glaucoma from 1 month to 5 years postoperatively. There is a statistically significant difference between the Molteno tube and the trabeculectomy plus antimetabolite groups at 3 and 6 months (P = 0.02 and 0.015, respectively) and between trabeculectomy and trabeculectomy plus antimetabolite groups at 1 and 3 months (P = 0.02 and 0.01, respectively). M = month; Y = year.
100
F.::::---oo----o-.__
80
........
on.
....................
........
60
.........................
.........
..
40 •
Molteno
••••••••••
20
..............•
~
Trabeculectomy Trabeculectomy + A.M.
O+-------~-----,------~------.-------~------r_----~------_, 5Y lY 4Y o 1M 3M 6M 2Y 3Y
1945 by D'Ombrain. 16 The pathologic features were described by Wolff and Zimmerman8 in 1962 who showed
testing. It has therefore been suggested that eyes with an underlying tendency to develop open-angle glaucoma are more likely to develop a late increase in lOP after blunt trauma. 3,17 While recession of the irido-corneal angle is common after blunt trauma (60%-94%), the late development of glaucoma is rare (2%_10%).1-5,7,18 The lOP rise that occurs immediately after a nonpenetrating eye injury can be severe but usually lasts only days or weeks, and in most
histologic retrodisplacement of the iris root. Pathologic changes have been demonstrated in the trabecular meshwork, and angle recession is not responsible for the obstruction to aqueous outflow. 17 It has been reported that the normal fellow eyes of patients with unilateral angle recession glaucoma are more likely to have an elevated lOP with a positive response to corticosteroid-provocative 6/6
•
6/9 6/12
Figure 4. Scattergram of visual acuity before (x) and after (y) trabeculectomy, Molteno tube implantation, and trabeculectomy plus antimetabolite in 87 procedures for traumatic anglerecession glaucoma. NLP = no light perception; LP = light perception; HM = hand motions; CF = counting fingers.
.,cOIl ...::I '"...
.,
.:::<.s
•
6/18
6
6/24
•
6/36
6
~ til
•
0
•
6
0
6
0
•
•
0
•
HM
6
••
LP NLP NLP
0
0
6•
6/60
CF
•
• •
•
6
::I
;;'"
•
•
••
0 0
0
C
'5
•
6
•
6
6
Molteno tube
0
Trabeculectomy + antimetabolite
• Trnbeculectomy
LP
HM
CF
6/60
6/36
6/24
6/18
6/12
6/9
6/6
Visual acuity before surgery
639
Ophthalmology
Volume 100, Number 5, May 1993
Table 6. Complications of Surgery in Post-traumatic Angle Recession Glaucoma Trabeculectomy
Early (sl mol Positive Seidel Hyphema Shallow anterior chamber Choroidal detachment Inflammation Late (>1 mol Loss of light perception Encapsulation Endophthalmitis Infected bleb Cataract Corneal edema Corneal decompensation Tube block Tube exposure
Trabeculectomy No. (%)
Molteno No. (%)
+ Antimetabolites
8 (17) 7 (15) 5 (11) 5 (11) 1 (2)
2 (10) 2 (10) 4 (20)
3 (15)
4 (20)
3 (15)
2 (4) 10 (21)
1 (5) 4 (20)
1 (5) 2 (10) 1 (5) 2 (10)
1 (2)
1 (5) 2 (10) 1 (5) 1 (5) 3 (15)
cases can be controlled with glaucoma medication alone. 19 Traumatic glaucoma with chronic elevation ofIOP, optic nerve cupping, and visual field damage usually occurs years or even decades after blunt trauma. In our series, the mean time between injury and the diagnosis of glaucoma was 7.6 ± 9.5 years, which is shorter than has been previously reported. Herschler, 17 in a series of 18 patients, reported a mean time of 16.5 years between injury and discovery of glaucoma. Late glaucoma is more frequent ifthe recession involves 180 0 or more of the angle. 2.5•6 In our series, the mean degree of angle recession was 311 0 ± 32 0 , and 60% (52/ 87) had 360 0 recession of the angle. The cause of injury inducing angle recession and subsequently traumatic glaucoma has been previously reported to have occurred either as a result of sport or other recreational accidents (33% [9/27] in the series of Alper6 and 55.6% [114/205] by Canavan and Archer l). In our series, the main cause was assault (65%, 57/87), which also may explain why 63% (41/65) of patients had bilateral evidence of trauma. Cases of traumatic glaucoma are reported in series of refractory glaucoma, but because of small numbers no conclusions regarding the surgical management can be made. Success after trabeculectomy was achieved in 33% (1/3) and 67% (4/6) in the series of Mills 10 and Ridgway, II respectively. In our series, the success of trabeculectomy when judged by Kaplan-Meier life-table analysis was 62% ± 5% after 2 years of follow-up, 42% ± 6% after 4 years, and 10 ± 8% after 6 years. This poor long-term success rate may be related to the young age of patients (mean age, 46.7 ± 15.7 years) and their race (black or mixed race) but also may be a feature of post-contusional injury, with an increased tendency to fibroblast proliferation.8.2o.21 The question of whether post-traumatic angle recession is a risk factor for failure of filtering surgery independently of youth and race will be comprehensively addressed in a separate comparative study of matched patients with
640
No. (%)
3 (15) 1 (5)
primary open-angle glaucoma. However, in a comparative study of Molteno single-plate implantation performed mainly in young black patients with refractory glaucoma, it was found that the overall success rate of traumatic glaucoma (46%, 6/13) was worse than in patients with aphakic and pseudophakic glaucoma (56%, 9/16) or in patients with previous failed filtering surgery (71%,10/14).12 With the addition of artificial drainage devices to our surgical options in glaucoma surgery, we had hoped that our success rate for patients with traumatic glaucoma would improve. However, the success rates after 5 years of follow-up with Molteno single-plate insertion (27% ± 13% of patients) were similar to those found after trabeculectomy (29% ± 8% of patients). Freedman l3 reported two patients with traumatic glaucoma treated with Molteno single-plate implants, with a follow-up period of 12 months. One had a final lOP of22 mmHg and the second was a failure with loss of light perception. Our results were significantly improved by using adjunct antimetabolite therapy in association with trabeculectomy, despite the relatively low doses of 5-fluorouracil and mitomycin C that were used to decrease the antimetabolite-related complications. 22.23 In our series, the mean lOP drop after drainage surgery was significantly greater in the trabeculectomy plus antimetabolite group (59% ± 24%) than that found in the Molteno tube implantation group (4l.l % ± 21 %; P = 0.02) or trabeculectomy group (35.9% ± 36.8%; P = 0.015). Similarly, the success rate in the trabeculectomy plus antimetabolite group was significantly better than in the other groups at 1, 3, and 6 months postoperatively. Statistical significance was not shown at the 1- and 2-year follow-up visits, because the number of patients treated with 5-fluorouracil or mitomycin C was small. The need for glaucoma medication after surgery was significantly lower in the trabeculectomy plus antimetabolite group than in the trabecu-
Mermoud et al . Post-traumatic Angle Recession Glaucoma lectomy or in the Molteno groups. Besides the two patients with traumatic glaucoma who were treated with trabeculectomy and adjunct mitomycin C application (success rate, 100%; decrease oflOP, 64.4% ± 3%; follow-up, 9.5 ± 5 months) and the one patient successfully treated with trabeculectomy and adjunctive 5-fluorouracil, we are not aware of other reports of traumatic glaucoma treated with trabeculectomy and antimetabolites. 14,23 If the first surgical procedure fails to control lOP in patients with post-traumatic angle recession glaucoma and further drainage surgery is contemplated, the question arises as to whether the best result can then be achieved with a second trabeculectomy with antimetabolite or by inserting a drainage device. Comparing our success rates oftrabeculectomy plus antimetabolite with Molteno tube implantation when both techniques are used as secondary procedures, better results were achieved when a singleplate Molteno implant was inserted (78%, 7/9 overall success) than were achieved with secondary trabeculectomy plus antimetabolite (57%, 4/7 overall success), although statistical significance was not shown. Secondary Molteno implantation was more successful (78%, 7/9) than primary Molteno implantation (45%, 5/11), but the numbers are small, and statistical significance was not shown. No demographic or pathologic differences could be found between the patients undergoing primary or secondary Molteno implantation. In two patients in whom secondary Molteno implantation was considered a failure, one had an lOP of25 mmHg and no evidence of progressive visual field loss and the other had a successful second Molteno implantation. Early complications (::; 1 month) such as conjunctival wound leak, shallow anterior chamber, anterior chamber inflammation, or hyphema were transient and did not affect the surgical outcome; in addition, no significant differences between the three surgical techniques were found. Late complications (> 1 month) were more common in the Molteno group. Three patients (15%) presented with a conjunctival erosion over the tube and required secondary surgical repair with a donor scleral graft. This complication can be reduced by meticulous attention to detail and by inserting a donor scleral patch over the tube at the time of surgery. Encapsulation of the drainage bleb was less common in the trabeculectomy plus antimetabolite group (10%, 2/20) than in the trabeculectomy (21 %, 10/47) and the Molteno groups (20%, 4/20). Late bleb infection which occurred in three patients who received 5-fluorouracil injections postoperatively is a major concern. In one patient (5%, 1/20), S. aureus endophthalmitis occurred 1 year after successful surgery, and despite vitrectomy as well as topical, systemic, and intravitreal antibiotic therapy, vision was lost. Two patients (10%, 2/20) presented with a bleb infection 9 and 13 months after surgery. The infection was successfully treated with antibiotics in both patients, but resulted in scarring of the filtration bleb in one patient. All three patients had water-tight thin cystic filtering blebs, came from a poor socioeconomic background, and presented late to the hospital. This complication has been reported in several studies of trabeculectomy with postoperative
subconjunctival injection of 5-fluorouracil. Rockwood et al 24 reported three patients (2%,3/155) with endophthalmitis, and Heuer et al 25 reported two (2%, 2/104) with Hemophilus influenzae endophthalmitis. Wolner et al 26 (with a mean follow-up of 23.7 ± 16.3 months) reported an incidence of 5.7% (13/229) of bleb-related endophthalmitis after 5-fluorouracil trabeculectomy. There are no reports of bleb-related bacterial endophthalmitis after the use of an intraoperative application of mitomycin C,14,27 except for one case of possible endophthalmitis reported by Skuta et al,28 but the follow-up in these series is short. In our experience, the surgical management of posttraumatic angle recession glaucoma is difficult because the patients are young, the disease is often advanced, and follow-up and compliance are poor. Our results of surgical treatment of post-traumatic angle recession glaucoma using three different surgical approaches suggest that if medical treatment alone does not control the lOP, a trabeculectomy with antimetabolite therapy should be performed. A single intraoperative application of mitomycin C is easier, more cost-effective, and may be the current method of choice. If further drainage surgery is required after a failed trabeculectomy, either a trabeculectomy with antimetabolite or the insertion of a Molteno single-plate implant can be considered. In those in whom antimetabolite is used, the risk of a subsequent bleb infection is significant, whereas in those undergoing Molteno implantation additional topical medication may be required to control the lOP. To prevent the devastating complication of glaucoma after blunt trauma, every effort should be made to reduce the level of violence in the community and to improve socioeconomic standards. 29
References 1. Canavan YM, Archer DB. Anterior segment consequences of blunt ocular injury. Br J Ophthalmol 1982;66:549-55. 2. Blanton FM. Anterior chamber angle recession and secondary glaucoma. A study of the aftereffects of traumatic hyphemas. Arch Ophthalmol 1964;72:39-43. 3. Spaeth GL. Traumatic hyphema, angle recession, dexamethasone hypertension, and glaucoma. Arch Ophthalmol 1967;78:714-21. 4. Mooney D. Angle recession and secondary glaucoma. Br J OphthalmoI1973;57:608-12. 5. Tonjum AM. Intraocular pressure and facility of outflow late after ocular contusion. Acta Ophthalmol 1968;46:886908. 6. Alper MG. Contusion angle deformity and glaucoma. Gonioscopic observations and clinical course. Arch Ophthalmol 1963;69:455-67. 7. Kaufman JH, Tolpin DW. Glaucoma after traumatic angle recession. A ten-year prospective study. Am J Ophthalmol 1974;78:648-54. 8. WolffSM, Zimmerman LE. Chronic secondary glaucoma: associated with retrodisplacement of iris root and deepening of the anterior chamber angle secondary to contusion. Am J Ophthalmol 1962;54:547-63. 9. Thomas JV, Simmons RJ, Belcher CD III. Argon laser trabeculoplasty in the presurgical glaucoma patient. Ophthalmology 1982;89:187-91.
641
Ophthalmology
Volume 100, Number 5, May 1993
10. Mills KB. Trabeculectomy: aretrospective long-term followup of 444 cases. Br J Ophthalmol 1981 ;65:790-5. 11 . Ridgway AEA. Trabeculectomy. A follow-up study. Br J Ophthalmol 1974;58:680-6. 12. Mermoud A, Salmon JF, Straker C, Murray ADN. Use of the single-plate Molteno implant in refractory glaucoma. Ophthalmologica 1992;205: 113-20. 13. Freedman J. The use of the single stage Molteno long tube seton in treating resistant cases of glaucoma. Ophthalmic Surg 1985;16:480-3 . 14. Palmer SS. Mitomycin as adjunct chemotherapy with trabeculectomy. Ophthalmology 1991 ;98:317-2 1. 15. Cairns JE. Trabeculectomy. Preliminary report of a new method. Am J Ophthalmol 1968;66:673-9. 16. D'Ombrain A. Traumatic monocular chronic glaucoma. Trans Ophthalmol Soc Aust 1945;5: 116-21. 17. Herschler J. Trabecular damage due to blunt anterior segment injury and its relationship to traumatic glaucoma. Trans Am Acad Ophthalmol Otolaryngol 1977 83: OP23948. 18. Thiel H-J, Aden G, Pi.i1horn G. Kammerwinkelveranderungen und Augeninnendruck nach Bulbuskontusionen. Klin Monatsbl Augenheilkd 1980;177:165-73. 19. Hoskins HD Jr, Kass MA. Becker-Shaffer's Diagnosis and Therapy of the Glaucomas. 6th ed. St Louis: C V Mosby, 1989;325-7. 20. Skuta GL, Parrish RK II. Wound healing in glaucoma filtering surgery. Surv Ophthalmol 1987;32:149-70.
642
21. Iwamoto T, Witmer R, Landolt E. Light and electron microscopy in absolute glaucoma with pigment dispersion phenomena and contusion angle deformity. Am J Ophthalmol 1971 ;72:420-34. 22. Weinreb RN. Adjusting the dose of 5-fluorouracil after filtration surgery to minimize side effects. Ophthalmology 1987;94:564-70. 23. Whiteside-Michel J, Liebmann JM, Ritch R. Initial 5-fluorouracil trabeculectomy in young patients. Ophthalmology 1992;99:7-13. 24. Rockwood EJ, Parrish RK II, Heuer DK, et al. Glaucoma filtering surgery with 5-fluorouracil. Ophthalmology 1987;94: 1071-8. 25. Heuer DK, Parrish RK II, Gressel MG, et al. 5-Auorouracil and glaucoma filtering surgery. III. Intermediate follow-up ofa pilot study. Ophthalmology 1986;93:1537-46. 26. Wolner B, Liebmann JM, Sassani JW, et al. Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5fluorouracil. Ophthalmology 1991 ;98: 1053-60. 27. Kitazawa Y, Kawase K, Matsushita H, Minobe M. Trabeculectomy with mitomycin. A comparative study with fluorouracil. Arch Ophthalmol 1991 ; 109: 1693-8. 28. Skuta GL, Beeson CC, Higginbotham EJ, et al. Intraoperative mitomycin versus postoperative 5-fluorouracil in highrisk glaucoma filtering surgery. Ophthalmology 1992;99: 438-44. 29. Yinger PF. Eye injury resulting from violence: research and prevention [editorial]. Arch Ophthalmol 1992; 110:765-6.
Purpose: The purpose of this study is to compare the results of three different drainage procedures performed for uncontrolled post-traumatic angle recession glaucoma. Methods: A retrospective analysis was undertaken of 87 drainage procedures performed on 65 patients over an 8-year period. The results of trabeculectomy (47 procedures), Molteno single-plate implantation (20 procedures), and trabeculectomy combined with antimetabolite (20 procedures) were compared. Of those treated with antimetabolite, 11 received postoperative subconjunctival injections of 5-fluorouracil and 9 received an intraoperative application of 0.02% mitomycin C to the trabeculectomy site. Results: In the group undergoing trabeculectomy with antimetabolite therapy, the intraocular pressure (lOP) drop was Significantly greater, the percentage of successful cases at 3 and 6 months postoperatively was significantly higher, and the number of postoperative glaucoma medications was significantly lower than the other two groups. No statistically significant differences were found between the groups undergoing trabeculectomy without antimetabolite therapy and Molteno implantation. Of concern were three cases of late bleb infection in the group that received postoperative antimetabolite therapy. Conclusion: In medically uncontrolled post-traumatic angle recession glaucoma, trabeculectomy with antimetabolite therapy is the most effective surgical procedure. However, late bleb infection is a significant risk. Ophthalmology 1993;100:634-642
Anterior chamber angle recession is the commonest complication of blunt trauma to the eye. 1 The risk of late onset glaucoma after a contusion injury and the correlation between the degree of angle recession and the development of glaucoma have been well described. 1-8 However, little has been published on the treatment of post-traumatic angle recession glaucoma. Medical treatOriginally received: October 9, 1992. Manuscript accepted: November 19, 1992. From the Ophthalmology Department, Groote Schuur Hospital & University of Cape Town. Supported in part by a grant from Foundation Florian Verrey, Lausanne, Switzerland, the Department of National Education, Pretoria, South Africa, and Foundation Rey-Willer, Ecublens, Switzerland. Reprint requests to John F. Salmon, FRCS, Ophthalmology Department, Medical School, University of Cape Town, Observatory 7925, South Africa.
634
ment is often unsuccessful, and the results of argon laser trabeculoplasty are unsatisfactory2,8,9 (unpublished data; Scharf et aI, presented as a poster at the ARVO Annual Meeting, Sarasota 1992). The few cases of post-traumatic angle recession glaucoma that can be found in series describing the results of surgery for refractory glaucoma do not allow a comparison of different drainage procedures. IO- 14 To assess the surgical management of post-traumatic angle recession glaucoma, we retrospectively reviewed the results of all patients with this diagnosis who had undergone drainage surgery during an 8-year period. We report herein our experience of 87 procedures performed on 65 patients treated either with trabeculectomy, Molteno tube implantation, or trabeculectomy and antimetabolite therapy. While this report lacks the advantages of a prospective study, it nevertheless provides guidelines as to how this condition can be managed.
Mermoud et al
Post-traumatic Angle Recession Glaucoma
Materials and Methods From June 1984 to March 1992, 139 patients with traumatic glaucoma undelWent drainage surgery at Groote Schuur Hospital, Cape Town, South Africa. Of 139 patients, 48 were excluded due to partial or total dislocation of the lens and 10 due to angle closure secondary to peripheral anterior synechiae. An additional 16 patients with traumatic angle recession glaucoma and a follow-up of less than 3 months also were excluded. The remaining 65 patients with post-traumatic angle recession glaucoma undelWent 87 drainage procedures on either one or both eyes. The type of trauma causing the angle recession is listed in Table 1 and the condition of the contralateral eye is presented in Table 2. The mean number of degrees of angle recession was 311 ° ± 32° (range, 90°-360°); 7% (6/87) had recession of less than 180°, 19% (17/87) had recession from 180° to 270°, and 74% (64/87) had recession from 270° to 360°. Glaucoma was first diagnosed at a mean period of 7.6 ± 9.5 years (± standard deviation) after ocular trauma. All patients initially were treated with glaucoma medication, and then undelWent drainage surgery if poor compliance was demonstrated or if the intraocular pressure (lOP) was uncontrolled, despite maximum-tolerated glaucoma medication (mean period of medical therapy, 8 ± 9.5 months [± standard deviation]; range, 15 days to 3 years). Analysis was performed on three groups of patients. Each group was similar in terms of age, sex, race, and preoperative lOP (Table 3). Trabeculectomy was performed on 47 eyes from 1984 to 1988. Molteno tube implantation was performed in 20 eyes, 9 of which had undergone previous trabeculectomy (1987-1989). Trabeculectomy with adjunct antimetabolite therapy was performed in 20 eyes, 7 of which had undergone previous trabeculectomy (11 eyes received postoperative subconjunctival injections of 5-fluorouracil and 9 received an intraoperative application of mitomycin C) (1989-1992). Thus, a total of 16 eyes had a secondary procedure after failed trabeculectomy. Four parameters were compared to determine the efficacy of each drainage procedure: the mean lOP at different time intervals postoperatively, the mean change of
Table 1. Cause of Injury in Post-traumatic Angle Recession Glaucoma Type of Injury
No. (%)
Assault Industrial accident Sport and recreation Road traffic accident Denial of trauma* Unknown
57 (65) 6 (7)
5 (6) 3 (4) 7 (8) 9 (10)
• With other signs of trauma (lid scars, pupillary sphincter tears).
Table 2. Diagnoses in the Contralateral Eye (65 Patients) Diagnosis Normal eye Traumatic glaucoma Medical treatment Surgical treatment Absolute glaucoma Traumatic dislocation of the lens Traumatic corneal scar Traumatic vitreous hemorrage Enucleation for injury Amblyopia
No. (%) 23 (35)
36 (55) 8 (12) 22 (34) 6 (9) 2 (3) 1 (2) 1 (2) 1 (2) 1 (2)
lOP, the percentage of patients with lOP 21 mmHg or lower, and the mean number of postoperative medications required to control the lOP. The results of the nine patients who undelWent Molteno implantation after failure of trabeculectomy were compared with the results from the seven patients who undelWent trabeculectomy combined with antimetabolite therapy after failure of trabeculectomy. Surgical Procedure Trabeculectomy. A technique similar to that described by Cairns 15 was used. Depending on the surgeons' preference, a limbus- or fornix-based conjunctival flap was used. A 4 X 4-mm limbus-based scleral flap was dissected into clear cornea. A 1 X 2-mm deep scleral block was removed and a peripheral iridectomy was performed. The scleral flap was closed with two to four interrupted 10-0 nylon sutures. In eyes with a fornix-based conjunctival flap, the conjunctiva was closed with interrupted to-O nylon sutures, whereas in eyes with a limbus-based conjunctival flap, the conjunctiva was closed with a running to-O nylon suture. Subconjunctival injections of gentamicin (20 mg) and betamethasone acetate (1.5 mg) were administered in the inferior fornix. Postoperatively, topical homatropine 1% was instilled twice daily for the first week after surgery. Topical chloramphenicol was used for 4 weeks after surgery and topical prednisolone 1% four times daily for 3 months. Molteno Tube Implantation. The surgical techniques and the postoperative topical medication have been described in detail elsewhere. 12 In brief, after reflecting a fornix-based conjunctival flap, a single-plate Molteno long tube implant was inserted. The tube was occluded using a 6-0 Vicryl suture. A limbus-based scleral flap measuring 3 X 6 mm was fashioned to cover the tube. The anterior chamber was entered with a 22-gauge needle, the tube was inserted down this tract and projected 3 mm into the anterior chamber. The scleral flap was sutured over the tube, and the conjunctiva was closed. Donor sclera was not used to cover the tube. Postoperative medication was similar to that used after trabeculectomy.
635
Ophthalmology
Volume 100, Number 5, May 1993
Table 3. Post-traumatic Angle Recession Glaucoma: Demographic Features (65 Patients, 87 Procedures)* Trabeculectomy
Age (yrs) Mean ± SD Range Race Mixed Black White Sex M F Preoperative lOP (mmHg) Mean ± SD Range
Total
Trabeculectomy
Molteno
+ Antimetabolites
46.7 ± 15.7 12-82
45.3 ± 16.1 12-82
41.1 ± 14.6 15-65
49.6 ± 17.3 17-71
43 (66%) 21 (32%) 1 (2%)
29 (63%) 16 (35%) 1 (2%)
14 (70%) 6(30%)
12 (67%) 6 (33%)
51 (78%) 14 (22%)
36 (78%) 10 (22%)
16 (80%) 4(20%)
16 (89%) 2 (11%)
39.7 ± 9.2 21-64
39.9 ± 9.4 21-60
41.6 ± 6.7 30-52
36.6 ± 10.4 21-64
SO = standard deviation; lOP = intraocular pressure . • Because the disease was often bilateral and 22 patients had bilateral drainage procedures, the total number of procedures was 87 in 65 patients. In the trabeculectomy group, 47 procedures were performed in 46 patients; in the Molteno group, 20 procedures were performed in 20 patients; and in the trabeculectomy + antimetabolite group, 20 procedures were performed in 18 patients.
Trabeculectomy with Postoperative Adjunct 5-fluorouracil Subconjunctival Injection. The surgical procedure used was similar to that described in the Trabeculectomy section above, although there were a few subtle modifications. The conjunctival flap was always limbalbased, and particular attention was directed at avoiding the creation of a buttonhole in the conjunctiva. Tenon's capsule and the conjunctival layer were sutured separately using a continuous 10-0 nylon suture on a round-bodied needle for each layer. Postoperatively for 3 to 6 days, subconjunctival injections of 5-fluorouracil (5 mg) were given in the inferior fornix. The 5-fluorouracil was not administered if there was evidence of corneal toxicity (as demonstrated by an epithelial defect), a flat anterior chamber, or a conjunctival wound leak. The total amount of 5fluorouracil administered ranged between 15 and 30 mg (mean, 22.4 ± 5.6 mg). Trabeculectomy with Intraoperative Application of Mitomycin C. The surgical procedure used was similar to that used with postoperative subconjunctival injection of 5-fluorouracil in the Trabeculectomy with Postoperative Adjunct 5-fluorouracil Subconjunctival Injection section above. After hemostasis of the episclera, a surgical sponge (Merocel, cat. no 400200, Merocel Corp, Mystic, CT) which had been previously soaked in a 0.2-mg/ml solution of mitomycin C (Kyowa, Syntex Pharm AG, Allschwil, Switzerland) was applied between the sclera and the conjunctiva for 5 minutes. The mitomycin C solution was prepared just before surgery by mixing the contents of a 2-mg vial of mitomycin C with 10 ml of balanced salt solution. After 5 minutes, the sponge was removed and the entire area was irrigated with balanced salt solution.
Success Criteria The following definitions of surgical outcome were adopted: a complete success was defined as an lOP below
636
or equal to 21 mmHg without medication, a qualified success as an lOP below or equal to 21 mmHg with antiglaucoma medication, a qualified failure as a pressure higher than 21 mmHg with or without medication, and a complete failure as an eye that required further glaucoma drainage surgery, developed phthisis bulbi, or lost light perception.
Statistical Analysis Comparisons between the results of the three surgical techniques was performed using the Student's t test. Kaplan-Meier survival curves were drawn, and inter-curve analysis was performed using the log-rank test. Success rate comparisons between groups was performed using the chi-square test. A finding was considered significant at a P value of < 0.05.
Results The follow-up of the trabeculectomy plus antimetabolite group is shorter at 8.8 ± 7.3 months (range, 3-28 months) than the total mean follow-up of 23.1 ± 19.7 months (range, 3-72 months) (P = 0.003). The surgical and visual results are summarized in Table 4. All three surgical techniques were effective in lowering a mean preoperative lOP of 39.7 ± 9.2 mmHg (range, 21-64 mmHg) to a 2-year postoperative mean lOP of 19.4 ± 8.9 mmHg (range, 444 mmHg) (P < 0.001). The mean lOP at each period of follow-up for each group is shown in Figure 1. The mean postoperative lOP of the trabeculectomy plus antimetabolite group is significantly lower than the mean lOP of the two other groups at 15 days and at 1, 3, and 6 months. At the 6-month follow-up, the mean lOP of the group undergoing Molteno tube implantation is statistically
Mermoud et al . Post-traumatic Angle Recession Glaucoma Table
4. Surgical and Visual Outcome in Post-traumatic Angle Recession Glaucoma Trabeculectomy
Follow-up (mos) Mean Range No. of medications preoperatively No. of medications postoperatively Visual outcome Same or better Worse Surgical successt 1 roo 3 roos 6roos 1 yr 2 yrs 3 yrs 4 yrs 5 yrs 6 yrs
+ Antimetabolite
Total (n = 87)
Trabeculectomy (n = 47)
Molteno (n = 20)
Adjunct Therapy· (n = 20)
23.1 ± 19.7 3-72 2.05 ± 1.1 0.99 ± 0.89
27.5 ± 22 3-72 2.04 ± 1.2 1.11 ± 1.24
19.6 ± 15.1 3-58 2 ± 1.2 1.05 ± 1
8.8 ± 7.3 3-28 2.1 ± 0.7 0.22 ± 0.5
63 (74%) 24 (26%)
34 (72%) 13 (28%)
14 (70%) 6 (30%)
15 (75%) 5 (25%)
0.94 0.86 0.81 0.74 0.62 0.53 0.42 0.29 0.10
± 0.02 ± 0.02 ± 0.03 ± 0.04 ± 0.05 ± 0.05 ± 0.06 ± 0.08 ± 0.08
0.97 0.89 0.76 0.56 0.49 0.41 0.27 0.27
± 0.02 ± 0.03 ± 0.05 ± 0.07 ± 0.08 ± 0.10 ± 0.13 ± 0.13
0.98 0.96 0.92 0.74 0.45
± ± ± ± ±
0.02 0.03 0.05 0.12 0.24
• 5-Fluorouracil or mitomycin C.
t
Cumulative probabiliry of survival using Kaplan-Meier life-table analysis with standard error.
higher than the mean lOP of the trabeculectomy group
(P = 0.02) and the trabeculectomy plus antimetabolite group (P = 0.001). When the mean reduction of lOP is
analyzed, the trabeculectomy plus antimetabolite group demonstrated a significantly greater reduction ofIOP than the Molteno tube and the trabeculectomy groups (P = 0.02) (Table 5).
Kaplan-Meier life-table analysis representing longitudinal success rates are shown in Figure 2 and Table 4, and the percentage of successful cases at each follow-up visit is given in Figure 3. More patients who underwent a trabeculectomy with antimetabolite were completely successful at 1, 3, and 6 months after surgery than those who underwent trabeculectomy or Molteno tube implan-
Figure 1. Mean intraocular lOP (mmHg) pressure (lOP) after trabecu40 lectomy, Molteno tube implantation and trabeculectomy with antimetabolite for post-traumatic angle-recession glaucoma, at different 30 follow-up periods from 15 days to 6 years. There is no statistically significant differ••••••••••• • •••• ~. "fI'" •••• ....,..,..: ••c:. ••;...._.-... ence between the trabeculec20 tomy and Molteno group, but the trabeculectomy plus antimetabolite group demonstrates a significantly lower 10 •••••••••• Trabeculectomy lOP at 15 days and at I, 3, • Molteno and 6 months (P = 0.001, c - Trabeculectomy + A.M. 0.024, <0.001, and <0.001, respectively). No statistically o +-----~----~----~------r-----~----,-----~----_.----~~--~ significant differences were o 15 D 3M IY 2Y 5Y 3Y 1M 6M 4Y 6Y shown thereafter because of shorter follow-up on eyes undergoing trabeculectomy plus antimetabolite. D = day; M = month; Y = year.
.....
......... .........
.......•
······w .... ·.... ·...... ·.. ·..
637
Volume 100, Number 5, May 1993
Ophthalmology
Table 5. Mean Reduction ofIntraocular Pressure (in Percent) 42.3 35.9 41.1 59
Total T rabeculectomy Molteno Trabeculectomy + antimetabolites' • Significantly better than other groups (P
=
± ± ± ±
higher success rate in the group undergoing secondary Molteno tube implantation is, however, not statistically significant. Postoperatively, the vision was the same or improved in 74% (63/87) and was worse in 26% (24/87). Details for each group are presented in Table 4 and Figure 4. Loss of light perception was caused by uncontrolled lOP in three eyes and was secondary to endophthalmitis in one eye. Other early and late complications of surgery are listed in Table 6. There were three late postoperative infections in the trabeculectomy plus antimetabolite group (15%, 3/ 20) compared with 0% (0/47) in the trabeculectomy group, (P = 0.024) and 0% (0/20) in the Molteno group (not significant). One patient presented with a Staphylococcus aureus endophthalmitis 12 months after a trabeculectomy plus 5-fluorouracil and two other patients presented with infected filtering blebs 9 and 13 months after a trabeculectomy plus 5-fluorouracil. Of the 87 procedures, there were 36 failures (22 after trabeculectomy, 8 after Molteno implantation and 6 after trabeculectomy with antimetabolite therapy). These included 11 eyes classified as a "qualified" failure with an lOP between 22 and 30 mmHg and stable visual fields, in whom no further surgery was considered, and 25 classified as complete failures. Of these, 4 lost light perception and 21 underwent a second drainage procedure. The mean time from surgery to failure was 5 ± 6.6 months (range, 5 days to 18 months), and the mean time from the first operation to the second was 16.3 ± 19.2 months (range, 15 days to 72 months).
33% 36.8% 21% 24.8%
0.02).
tation (P = 0.022, 0.0 II, and 0.018, respectively). However, using the log-rank test on the cumulative probability survival curve, because of the small number of patients and the short follow-up period of those undergoing trabeculectomy with antimetabolite therapy, no statistically significant difference was found. The mean number of glaucoma medications used preoperatively was the same in each group, namely 2.05 ± 1.1 medication per patient. (Table 4). Postoperatively, in all groups the need for additional glaucoma medication was significantly reduced (P = 0.001). Comparison between groups showed a significantly reduced need for glaucoma medication in the trabeculectomy plus antimetabolite group (0.22 ± 0.55 medication per patient, versus 1.05 ± I medication per patient in the Molteno group [P = 0.005], and versus 1.11 ± 1.24 medication per patient in the trabeculectomy group [P = 0.004]). Of 16 patients who had previously undergone an unsuccessful trabeculectomy and were treated with a secondary drainage procedure, 9 underwent Molteno tube implantation and 7 had trabeculectomy with antimetabolite. When used as a secondary procedure, Molteno tube implantation was successful in 78% (7/9) and trabeculectomy plus antimetabolite was successful in 57% (4/7). The
Discussion The association of blunt ocular trauma with subsequent development of glaucoma was first described clinically in
Cumulative Success Probability
1.0
0.8
I-F~I----o
,··········1'-----:-, ............ ,. ......... .
• •••••••••• ~
0.6
0.4
Molteno Trabeclliectomy Trabeclliectomy + A.M.
,. ..........,
•.......... ,
t===~l____.............., .............
0.2
...... 0.0 +-----~----~----~----_r----~----_,----~~----r_----~--~ 1M 3M IY 2Y 3Y 4Y 6Y o 6M 5Y
638
Figure 2. Cumulative success probability after trabeculectomy, Molteno tube implantation, and trabeculectomy with antimetabolite in traumatic angle-recession glaucoma using a Kaplan-Meier life-table analysis. No statistically significant difference was shown when the surgical outcome for each operation was compared using the logrank test. Cumulative probability survival intervals and standard errors are shown in Table 4. M = month; Y = year.
Mermoud et al . Post-traumatic Angle Recession Glaucoma Successrate ( % ) Figure 3. Success rate (in percent) after trabeculectomy, Molteno tube implantation, and trabeculectomy plus antimetabolite for traumatic angle-recession glaucoma from 1 month to 5 years postoperatively. There is a statistically significant difference between the Molteno tube and the trabeculectomy plus antimetabolite groups at 3 and 6 months (P = 0.02 and 0.015, respectively) and between trabeculectomy and trabeculectomy plus antimetabolite groups at 1 and 3 months (P = 0.02 and 0.01, respectively). M = month; Y = year.
100
F.::::---oo----o-.__
80
........
on.
....................
........
60
.........................
.........
..
40 •
Molteno
••••••••••
20
..............•
~
Trabeculectomy Trabeculectomy + A.M.
O+-------~-----,------~------.-------~------r_----~------_, 5Y lY 4Y o 1M 3M 6M 2Y 3Y
1945 by D'Ombrain. 16 The pathologic features were described by Wolff and Zimmerman8 in 1962 who showed
testing. It has therefore been suggested that eyes with an underlying tendency to develop open-angle glaucoma are more likely to develop a late increase in lOP after blunt trauma. 3,17 While recession of the irido-corneal angle is common after blunt trauma (60%-94%), the late development of glaucoma is rare (2%_10%).1-5,7,18 The lOP rise that occurs immediately after a nonpenetrating eye injury can be severe but usually lasts only days or weeks, and in most
histologic retrodisplacement of the iris root. Pathologic changes have been demonstrated in the trabecular meshwork, and angle recession is not responsible for the obstruction to aqueous outflow. 17 It has been reported that the normal fellow eyes of patients with unilateral angle recession glaucoma are more likely to have an elevated lOP with a positive response to corticosteroid-provocative 6/6
•
6/9 6/12
Figure 4. Scattergram of visual acuity before (x) and after (y) trabeculectomy, Molteno tube implantation, and trabeculectomy plus antimetabolite in 87 procedures for traumatic anglerecession glaucoma. NLP = no light perception; LP = light perception; HM = hand motions; CF = counting fingers.
.,cOIl ...::I '"...
.,
.:::<.s
•
6/18
6
6/24
•
6/36
6
~ til
•
0
•
6
0
6
0
•
•
0
•
HM
6
••
LP NLP NLP
0
0
6•
6/60
CF
•
• •
•
6
::I
;;'"
•
•
••
0 0
0
C
'5
•
6
•
6
6
Molteno tube
0
Trabeculectomy + antimetabolite
• Trnbeculectomy
LP
HM
CF
6/60
6/36
6/24
6/18
6/12
6/9
6/6
Visual acuity before surgery
639
Ophthalmology
Volume 100, Number 5, May 1993
Table 6. Complications of Surgery in Post-traumatic Angle Recession Glaucoma Trabeculectomy
Early (sl mol Positive Seidel Hyphema Shallow anterior chamber Choroidal detachment Inflammation Late (>1 mol Loss of light perception Encapsulation Endophthalmitis Infected bleb Cataract Corneal edema Corneal decompensation Tube block Tube exposure
Trabeculectomy No. (%)
Molteno No. (%)
+ Antimetabolites
8 (17) 7 (15) 5 (11) 5 (11) 1 (2)
2 (10) 2 (10) 4 (20)
3 (15)
4 (20)
3 (15)
2 (4) 10 (21)
1 (5) 4 (20)
1 (5) 2 (10) 1 (5) 2 (10)
1 (2)
1 (5) 2 (10) 1 (5) 1 (5) 3 (15)
cases can be controlled with glaucoma medication alone. 19 Traumatic glaucoma with chronic elevation ofIOP, optic nerve cupping, and visual field damage usually occurs years or even decades after blunt trauma. In our series, the mean time between injury and the diagnosis of glaucoma was 7.6 ± 9.5 years, which is shorter than has been previously reported. Herschler, 17 in a series of 18 patients, reported a mean time of 16.5 years between injury and discovery of glaucoma. Late glaucoma is more frequent ifthe recession involves 180 0 or more of the angle. 2.5•6 In our series, the mean degree of angle recession was 311 0 ± 32 0 , and 60% (52/ 87) had 360 0 recession of the angle. The cause of injury inducing angle recession and subsequently traumatic glaucoma has been previously reported to have occurred either as a result of sport or other recreational accidents (33% [9/27] in the series of Alper6 and 55.6% [114/205] by Canavan and Archer l). In our series, the main cause was assault (65%, 57/87), which also may explain why 63% (41/65) of patients had bilateral evidence of trauma. Cases of traumatic glaucoma are reported in series of refractory glaucoma, but because of small numbers no conclusions regarding the surgical management can be made. Success after trabeculectomy was achieved in 33% (1/3) and 67% (4/6) in the series of Mills 10 and Ridgway, II respectively. In our series, the success of trabeculectomy when judged by Kaplan-Meier life-table analysis was 62% ± 5% after 2 years of follow-up, 42% ± 6% after 4 years, and 10 ± 8% after 6 years. This poor long-term success rate may be related to the young age of patients (mean age, 46.7 ± 15.7 years) and their race (black or mixed race) but also may be a feature of post-contusional injury, with an increased tendency to fibroblast proliferation.8.2o.21 The question of whether post-traumatic angle recession is a risk factor for failure of filtering surgery independently of youth and race will be comprehensively addressed in a separate comparative study of matched patients with
640
No. (%)
3 (15) 1 (5)
primary open-angle glaucoma. However, in a comparative study of Molteno single-plate implantation performed mainly in young black patients with refractory glaucoma, it was found that the overall success rate of traumatic glaucoma (46%, 6/13) was worse than in patients with aphakic and pseudophakic glaucoma (56%, 9/16) or in patients with previous failed filtering surgery (71%,10/14).12 With the addition of artificial drainage devices to our surgical options in glaucoma surgery, we had hoped that our success rate for patients with traumatic glaucoma would improve. However, the success rates after 5 years of follow-up with Molteno single-plate insertion (27% ± 13% of patients) were similar to those found after trabeculectomy (29% ± 8% of patients). Freedman l3 reported two patients with traumatic glaucoma treated with Molteno single-plate implants, with a follow-up period of 12 months. One had a final lOP of22 mmHg and the second was a failure with loss of light perception. Our results were significantly improved by using adjunct antimetabolite therapy in association with trabeculectomy, despite the relatively low doses of 5-fluorouracil and mitomycin C that were used to decrease the antimetabolite-related complications. 22.23 In our series, the mean lOP drop after drainage surgery was significantly greater in the trabeculectomy plus antimetabolite group (59% ± 24%) than that found in the Molteno tube implantation group (4l.l % ± 21 %; P = 0.02) or trabeculectomy group (35.9% ± 36.8%; P = 0.015). Similarly, the success rate in the trabeculectomy plus antimetabolite group was significantly better than in the other groups at 1, 3, and 6 months postoperatively. Statistical significance was not shown at the 1- and 2-year follow-up visits, because the number of patients treated with 5-fluorouracil or mitomycin C was small. The need for glaucoma medication after surgery was significantly lower in the trabeculectomy plus antimetabolite group than in the trabecu-
Mermoud et al . Post-traumatic Angle Recession Glaucoma lectomy or in the Molteno groups. Besides the two patients with traumatic glaucoma who were treated with trabeculectomy and adjunct mitomycin C application (success rate, 100%; decrease oflOP, 64.4% ± 3%; follow-up, 9.5 ± 5 months) and the one patient successfully treated with trabeculectomy and adjunctive 5-fluorouracil, we are not aware of other reports of traumatic glaucoma treated with trabeculectomy and antimetabolites. 14,23 If the first surgical procedure fails to control lOP in patients with post-traumatic angle recession glaucoma and further drainage surgery is contemplated, the question arises as to whether the best result can then be achieved with a second trabeculectomy with antimetabolite or by inserting a drainage device. Comparing our success rates oftrabeculectomy plus antimetabolite with Molteno tube implantation when both techniques are used as secondary procedures, better results were achieved when a singleplate Molteno implant was inserted (78%, 7/9 overall success) than were achieved with secondary trabeculectomy plus antimetabolite (57%, 4/7 overall success), although statistical significance was not shown. Secondary Molteno implantation was more successful (78%, 7/9) than primary Molteno implantation (45%, 5/11), but the numbers are small, and statistical significance was not shown. No demographic or pathologic differences could be found between the patients undergoing primary or secondary Molteno implantation. In two patients in whom secondary Molteno implantation was considered a failure, one had an lOP of25 mmHg and no evidence of progressive visual field loss and the other had a successful second Molteno implantation. Early complications (::; 1 month) such as conjunctival wound leak, shallow anterior chamber, anterior chamber inflammation, or hyphema were transient and did not affect the surgical outcome; in addition, no significant differences between the three surgical techniques were found. Late complications (> 1 month) were more common in the Molteno group. Three patients (15%) presented with a conjunctival erosion over the tube and required secondary surgical repair with a donor scleral graft. This complication can be reduced by meticulous attention to detail and by inserting a donor scleral patch over the tube at the time of surgery. Encapsulation of the drainage bleb was less common in the trabeculectomy plus antimetabolite group (10%, 2/20) than in the trabeculectomy (21 %, 10/47) and the Molteno groups (20%, 4/20). Late bleb infection which occurred in three patients who received 5-fluorouracil injections postoperatively is a major concern. In one patient (5%, 1/20), S. aureus endophthalmitis occurred 1 year after successful surgery, and despite vitrectomy as well as topical, systemic, and intravitreal antibiotic therapy, vision was lost. Two patients (10%, 2/20) presented with a bleb infection 9 and 13 months after surgery. The infection was successfully treated with antibiotics in both patients, but resulted in scarring of the filtration bleb in one patient. All three patients had water-tight thin cystic filtering blebs, came from a poor socioeconomic background, and presented late to the hospital. This complication has been reported in several studies of trabeculectomy with postoperative
subconjunctival injection of 5-fluorouracil. Rockwood et al 24 reported three patients (2%,3/155) with endophthalmitis, and Heuer et al 25 reported two (2%, 2/104) with Hemophilus influenzae endophthalmitis. Wolner et al 26 (with a mean follow-up of 23.7 ± 16.3 months) reported an incidence of 5.7% (13/229) of bleb-related endophthalmitis after 5-fluorouracil trabeculectomy. There are no reports of bleb-related bacterial endophthalmitis after the use of an intraoperative application of mitomycin C,14,27 except for one case of possible endophthalmitis reported by Skuta et al,28 but the follow-up in these series is short. In our experience, the surgical management of posttraumatic angle recession glaucoma is difficult because the patients are young, the disease is often advanced, and follow-up and compliance are poor. Our results of surgical treatment of post-traumatic angle recession glaucoma using three different surgical approaches suggest that if medical treatment alone does not control the lOP, a trabeculectomy with antimetabolite therapy should be performed. A single intraoperative application of mitomycin C is easier, more cost-effective, and may be the current method of choice. If further drainage surgery is required after a failed trabeculectomy, either a trabeculectomy with antimetabolite or the insertion of a Molteno single-plate implant can be considered. In those in whom antimetabolite is used, the risk of a subsequent bleb infection is significant, whereas in those undergoing Molteno implantation additional topical medication may be required to control the lOP. To prevent the devastating complication of glaucoma after blunt trauma, every effort should be made to reduce the level of violence in the community and to improve socioeconomic standards. 29
References 1. Canavan YM, Archer DB. Anterior segment consequences of blunt ocular injury. Br J Ophthalmol 1982;66:549-55. 2. Blanton FM. Anterior chamber angle recession and secondary glaucoma. A study of the aftereffects of traumatic hyphemas. Arch Ophthalmol 1964;72:39-43. 3. Spaeth GL. Traumatic hyphema, angle recession, dexamethasone hypertension, and glaucoma. Arch Ophthalmol 1967;78:714-21. 4. Mooney D. Angle recession and secondary glaucoma. Br J OphthalmoI1973;57:608-12. 5. Tonjum AM. Intraocular pressure and facility of outflow late after ocular contusion. Acta Ophthalmol 1968;46:886908. 6. Alper MG. Contusion angle deformity and glaucoma. Gonioscopic observations and clinical course. Arch Ophthalmol 1963;69:455-67. 7. Kaufman JH, Tolpin DW. Glaucoma after traumatic angle recession. A ten-year prospective study. Am J Ophthalmol 1974;78:648-54. 8. WolffSM, Zimmerman LE. Chronic secondary glaucoma: associated with retrodisplacement of iris root and deepening of the anterior chamber angle secondary to contusion. Am J Ophthalmol 1962;54:547-63. 9. Thomas JV, Simmons RJ, Belcher CD III. Argon laser trabeculoplasty in the presurgical glaucoma patient. Ophthalmology 1982;89:187-91.
641
Ophthalmology
Volume 100, Number 5, May 1993
10. Mills KB. Trabeculectomy: aretrospective long-term followup of 444 cases. Br J Ophthalmol 1981 ;65:790-5. 11 . Ridgway AEA. Trabeculectomy. A follow-up study. Br J Ophthalmol 1974;58:680-6. 12. Mermoud A, Salmon JF, Straker C, Murray ADN. Use of the single-plate Molteno implant in refractory glaucoma. Ophthalmologica 1992;205: 113-20. 13. Freedman J. The use of the single stage Molteno long tube seton in treating resistant cases of glaucoma. Ophthalmic Surg 1985;16:480-3 . 14. Palmer SS. Mitomycin as adjunct chemotherapy with trabeculectomy. Ophthalmology 1991 ;98:317-2 1. 15. Cairns JE. Trabeculectomy. Preliminary report of a new method. Am J Ophthalmol 1968;66:673-9. 16. D'Ombrain A. Traumatic monocular chronic glaucoma. Trans Ophthalmol Soc Aust 1945;5: 116-21. 17. Herschler J. Trabecular damage due to blunt anterior segment injury and its relationship to traumatic glaucoma. Trans Am Acad Ophthalmol Otolaryngol 1977 83: OP23948. 18. Thiel H-J, Aden G, Pi.i1horn G. Kammerwinkelveranderungen und Augeninnendruck nach Bulbuskontusionen. Klin Monatsbl Augenheilkd 1980;177:165-73. 19. Hoskins HD Jr, Kass MA. Becker-Shaffer's Diagnosis and Therapy of the Glaucomas. 6th ed. St Louis: C V Mosby, 1989;325-7. 20. Skuta GL, Parrish RK II. Wound healing in glaucoma filtering surgery. Surv Ophthalmol 1987;32:149-70.
642
21. Iwamoto T, Witmer R, Landolt E. Light and electron microscopy in absolute glaucoma with pigment dispersion phenomena and contusion angle deformity. Am J Ophthalmol 1971 ;72:420-34. 22. Weinreb RN. Adjusting the dose of 5-fluorouracil after filtration surgery to minimize side effects. Ophthalmology 1987;94:564-70. 23. Whiteside-Michel J, Liebmann JM, Ritch R. Initial 5-fluorouracil trabeculectomy in young patients. Ophthalmology 1992;99:7-13. 24. Rockwood EJ, Parrish RK II, Heuer DK, et al. Glaucoma filtering surgery with 5-fluorouracil. Ophthalmology 1987;94: 1071-8. 25. Heuer DK, Parrish RK II, Gressel MG, et al. 5-Auorouracil and glaucoma filtering surgery. III. Intermediate follow-up ofa pilot study. Ophthalmology 1986;93:1537-46. 26. Wolner B, Liebmann JM, Sassani JW, et al. Late bleb-related endophthalmitis after trabeculectomy with adjunctive 5fluorouracil. Ophthalmology 1991 ;98: 1053-60. 27. Kitazawa Y, Kawase K, Matsushita H, Minobe M. Trabeculectomy with mitomycin. A comparative study with fluorouracil. Arch Ophthalmol 1991 ; 109: 1693-8. 28. Skuta GL, Beeson CC, Higginbotham EJ, et al. Intraoperative mitomycin versus postoperative 5-fluorouracil in highrisk glaucoma filtering surgery. Ophthalmology 1992;99: 438-44. 29. Yinger PF. Eye injury resulting from violence: research and prevention [editorial]. Arch Ophthalmol 1992; 110:765-6.