Ординатура / Офтальмология / Английские материалы / Mechanisms of the Glaucomas_Shields, Tombran-Tink, Barnstable_2008
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were maintained below 15 mmHg in all three eyes with the novel GDD, but rose to >20 mmHg within 1–4 weeks in the three control eyes undergoing standard trabeculectomies. Pseudomonas aeruginosa was repeatedly applied to the external aspect of the GDD in one eye without producing an endophthalmitis, whereas the same strain injected into a rabbit eye produced a fulminant endophthalmitis (75).
Another external drainage device has been described, which uses a transcorneal route and a Millipore filter to control outflow resistance and prevent infection (76,77). The device was implanted in 10 eyes of 10 patients, who were legally blind with end-stage glaucoma, previously failed trabeculectomies, and a variety of primary and secondary glaucomas. Reported problems in the pilot study included extrusion of the device, foreign body sensation, and failure to control IOP because of occlusion of the external ostium.
Improvements in the concept of external drainage have recently been made (see Fig. 2F) (78). The device consists of a Silastic tube with a beveled end lying in the anterior chamber. The tube passes through the limbus and lies on the episcleral surface for 4–7 mm beneath a pericardial patch graft, Tenon’s capsule, and conjunctiva before exiting through conjunctiva into a tolerable component lying on the external ocular surface in the conjunctival cul de sac beneath the lid. A micro-pore filter spans the lumen of the tube and is linked to the external component of the device, protecting against microbial invasion while providing appropriate resistance to set the IOP at the desired postoperative target. An inserting device was designed to properly place the device (with a pre-placed pericardial patch) into the eye through conjunctival and limbal puncture wounds without requiring sutures. The external component coupled with the micro-pore filter is replaceable and enables postoperative adjustment of IOP as needed. This novel GDD provides a simple and quick insertion process, a barrier against infection, and a predictable and adjustable postoperative IOP without a bleb or dependence on the vagaries of wound healing. Clinical trials will determine its relative utility in the management of glaucoma.
Another new GDD, which consists of mini-modules composed of hollow-fiber membrane, with a cylindrical porous glass and silicone tube, has been designed to reduce IOP by draining aqueous humor to the external ocular surface in the conjunctival fornix (79–81). In vitro testing suggests the potential to control IOP (79–81).
Overall, reports involving GDDs to the external ocular surface are preliminary. Very few clinical data are available. Efficacy, safety, and tolerability have yet to be demonstrated in the clinical setting.
Drainage to other Tissues or Spaces
A tube draining aqueous from the anterior chamber to the lacrimal sac or ethmoid sinuses has been proposed (82–84). Twenty eyes (19 of the 20 with a keratoprosthesis) of 19 patients underwent surgery with a specially designed Ahmed valve that was connected from the eye to the maxillary sinus (n = 10), ethmoid sinuses (n = 6), lacrimal sac (n = 2), or lower lid fornix (n = 2). With follow-up of 1–31 months, IOPs in the low teens were achieved in 14 eyes without glaucoma medications, whereas 2 eyes required removal of the valve housings, 2 required additional medications, and 2 required further procedures. None of the eyes were reported to develop endophthalmitis (82–84).
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Drainage of aqueous humor to the frontal sinus has also been proposed. One such GDD was implanted in 3 dogs with primary glaucoma with some success (85).
CONCLUSIONS
The safety and efficacy of current glaucoma surgery is suboptimal. Whereas cataract surgery is one of the most successful and safest procedures that is performed in the medical field, glaucoma surgery is still one of the most problematic because of its unpredictability. Adjustability is another aspect of glaucoma surgery which has not yet been achieved. Only some, but not all, of the new procedures described above address these important issues of predictability and adjustability. One common aspect of all the new procedures described above is that they eliminate the conjunctival filtering bleb, which is an important advantage because of the numerous associated problems. In addition, none of the new procedures described in this chapter require an episcleral plate attached in the equatorial region of the globe, which results in a surrounding fibrous capsule, as occurs with the currently used GDDs. These new procedures, therefore, avoid the problems of episcleral and/or subconjunctival fibrosis, which can cause failure of both standard glaucoma filtering procedures and currently used GDDs, as well as the majority of the postoperative complications associated with both of these types of procedures.
Important to understand is that very few of the procedures described above have been reported in the peer-reviewed literature. Most of the above results were found in abstracts of presentations at meetings. The safety and efficacy of these and other new devices and procedures have yet to be evaluated in properly designed large, multicenter controlled clinical trials. The procedures described in this chapter are meant to provide the reader with a flavor for what might lie ahead in the surgical management of glaucoma. Our sincere hope is that these innovations eventually will improve the surgical outcome for our patients with glaucoma.
ACKNOWLEDGMENTS
The authors are greatly appreciation of the artwork provided for the figures by Ms. Lucinde J. Camras. Supported input by an unrestricted grant from Research to Prevent Blindness, New York, NY.
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Index
A
Acetazolamide, 504, 507, 620 Activin receptor, 342
Acute optic neuritis, 646 Adenosine receptor (AdoR)-A3, 121
Adenylate cyclase activator forskolin, 602 Advanced glycation end-products (AGEs), 436 Age-related macular degeneration, 297 Aggrecan 1 (chondroitin sulfate
proteoglycan 1), 374 Aggregation-prone protein, 223 Ahmed implant, 716, 720, 725 Alkylated phosphines, 648 All-trans-retinal (RAL), 243
Alpha-2 adrenergic agonist, 88, 142, 169 Alpha-beta crystalline, 319 Alpha-smooth muscle (sm) actin, 314 Alpha tubulin, 350
Alzheimer’s disease, 297, 320 Aminoguanidine, 629 AMPA/kainate receptor, 405-Amyloid, 297
Amyloid P, 119
Androgen receptor (AR), 382 Angioresonance, 143
Angle-closure glaucoma (ACG), 85, 159, 475, 624 Angle recession glaucoma, 94
Aniridia, 92
Anterior chamber hypoxia, 117, 122 Anterior elastic tendons, 317
Anterior segment dysgenesis (ASD), 198 Anterior shunts, 716
Anterior uveitis, 84, 159 Anti-apoptotic signaling, 404, 668 Anti-cholinergic agents, 167 Anticoagulant therapy, 143 Antifibrosis agents, 702, 716 Antioxidants, 122, 319
AP-1 transcription factor, 278 Apoplipoprotein E (ApoE), 194, 289, 293, 298 Apoptosis, 277, 463, 590, 647, 657 Apraclonidine, 616
Aqueous humor outflow, 58, 88, 313 Aqueous shunts, 715
Aqueous suppressants, 142 Arachadonic acid, 623
Argon laser peripheral iridoplasty (ALPI), 177 Argon laser photocoagulation, 93
Argon laser trabeculoplasty (ALT), 130, 161, 685 Arterial-venous fistulas (AVF), 149 Arteriovenous fistulas, 147
Aryl hydrocarbon (AH) receptor, 241 Ascorbic acid, 319
Astrocytes, 364
Asymmetrical intraocular pressure, 56 Atherosclerosis, 320
Atrial natriuretic peptides, 630 Autoimmunity, 586
Automated stereoscopic optic disk analyzes, 25 Autoregulation of blood flow, 495 Autosomal-dominant juvenile-onset open-angle
glaucoma (ADJOAG), 317 Axenfeld-Rieger anomaly or syndrome, 92, 198 Axonal regeneration, 408
Axonal transport, 518, 645
B
Bad, 591, 668
Baerveldt devices, 716, 719, 720, 725 Bak, 591
Baltimore Eye Survey, 10
Barbados Eye Study, 10 Bax, 403, 591, 668 Bc1-XL, 404, 668
Bcl-2, 277, 403, 591, 668 Beaver Dam Eye Study, 10, 35
Beta-adrenergic blockers, 88, 107, 169, 406, 611, 614, 618
Beta adrenergic receotrirs, 192 Betaxolol, 406, 617, 619 Bevacizumab (Avastin), 162 Bid, 403, 668
Bimatoprost, 623, 625 BIRC-4 caspase inhibitor, 406 Bjerrum’s area, 291
Blockage of axonal transport, 399 Blood-aqueous barrier defects, 117 Blood-nerve barrier, 373, 396
753
754 |
Index |
Blue Mountain Eye Study, 10, 35 Blumenthal dissector, 701 Blumenthal lens, 709
Blunt ocular trauma, 94, 179 Bone metabolism, 339
Brain-derived neurotrophic factor (BDNF), 400, 463, 646, 648, 658
Branch retinal artery occlusion, 84 Branch retinal vein occlusion, 84 Brimonidine tartrate, 617, 620 Brinzolamide, 621
Bruch’s membrane, 100, 298 Buphthalmos, 197, 235
C
Ca++-induced death processes, 405 Ca++ influx, 405
Cadherin, 281, 373 Calcification, 146, 339 Calcium channel blockers, 629 Canal’s lumen, 334 Carbachol, 622
Carbonic anhydrase inhibitors, 88, 169, 504, 506, 611, 620
Carcinogen activation, 241
Carotid artery obstructive disease, 84 Carotid-cavernous fistula (CCF), 84, 143, 149 Carteolol, 619
Caspases, 277, 402, 406, 669 Cataract, 50, 130, 163, 169, 180 Cavernous sinus thrombosis, 143 CD44, 345
CD45, 396
Cdc42, 369
Cell adhesion, 373 Cell-cell recognition, 365
Cell-matrix interactions, 221, 345 Cellular senescence, 320
Cell volume, 348
Central retinal artery disease, 84
Central retinal vein occlusion (CRVO), 84, 143, 183
Central visual acuity, 291 C-Fos, 250, 376 Chandler’s syndrome, 162
Chaperonin-containing TCP1, 341 Chemosis, 143
Chloride channels, 348
Chondroitin sulfate proteoglycan (CSPG), 374, 409
Choroidal detachment, 149 Choroidal hemangioma, 146
Chronic compressive optic neuropathy, 646
Ciliary body, 315, 459, 461 Ciliary flush, 291
Ciliary muscle, 314 Ciliary muscle cells, 459
Ciliary neurotrophic factor (CNTF), 365, 400, 408, 463, 646, 648, 663
c-Jun, 376 Clonidine, 616
Cochlin, 320, 444, 446 Cogan-Reese syndrome, 162 Co-immunoprecipitation, 437 Collagen degradation, 448 Collagen type 1 1, 375 Collagen type II, 375 Collagen type IV, 314 Collagen type XI, 374 Collagen type XII, 346
Color-coded Doppler sonography, 151 Complement components, 464 Complicated cataract surgery, 117 Computed tomography, 143
Confocal scanning laser ophthalmoscopy (CSLO), 67, 562
Congenital glaucoma, 58 Conjunctival chemosis, 141, 149 Conjunctival cul de sac, 613 Conjunctival incision, 697 Conjunctival insertion, 699
Connective tissue growth factor (CTGF), 350 Contrast sensitivity, 594
Corectopia, 89
Corneal edema, 89, 235, 552 Corneal endothelium, 117, 579 Corneal reflex, 143 Corneo-scleral envelope, 478 Corneoscleral meshwork, 120, 129 Corneoscleral region, 107 Coronary vascular disease, 296
COX2-mediated arachidonic acid metabolism, 367 Cribriform plexus, 99, 314, 316
Critical flicker fusion (DFF), 539 Crozafon-De Laage punches, 706B-Crystallin, 342, 350
Cup area, 124 Cup volume, 124 Cyanosis, 144
Cyclooxygenase-2 (COX2), 367 Cyclopentolate, 180 Cyclophosphamide, 142 Cycloplegics, 182
Cystoid macular edema, 616 Cytochrome C, 404, 591
Index |
755 |
Cytochrome P450 (CYP26), 243
Cytochrome P450 (CYP4501B1),
235, 240
D
Dark-adapted ERG, 565
Darkroom indentation gonioscopy, 174 DBA/2J mouse, 580
Deep scleral flap, 711 Deep sclerectomy, 710 Demecarium bromide, 622
Descemet’s membrane, 93, 160 Desquamating epithelium, 94 Developmental glaucomas, 197 Dexamethasone (DEX), 347 Diabetic retinopathy, 84
3- dihydrosteroid dehydrogenases (HSD), 379 Diode transscleral cyclophotocoagulation, 88 Dipivefrin, 616, 620
Diplopia, 143 Dithiothreitol (DTT), 648
DNA oxidative damage, 319 Doppler flowmetry, 504
Dorsal root ganglion (DRG), 409 Dorzolamide, 130, 504, 617, 621 Double-plate Molteno, 725 Double vision, 141
Drainage devices, 715, 741 Drainage into Schlemm’s canal, 742
E
E-cadherin, 281 Echothiophate iodide, 622 Egr2 (Krox-20), 379 Elastic-like fibers, 314 Elastic microfibrils, 119 Elastin, 119
Elastin-related microfibrillopathy, 196 Electroretinogram (ERG), 85, 565 Endoplasmic reticulum (ER), 279 Endothelial dysfunction, 122 Endothelin-1 (ET-1), 121, 368, 377, 630 EphB1/ephrinB1 pathway, 373 EphrinB1, 373
EphrinB2, 373 Ephrin receptors, 366
Epidermal growth factor receptor (EGFR), 366 Epinephrine, 616
Episcleral venous system, 139, 335, 337 Epithelial cysts, 93
Epithelial-Descemet’s membrane interface, 163 Epithelial ingrowth, 93, 163
Ethacrynic acid, 629
Excavation, 461
Excitatory neurotransmitter glutamate receptors, 405
Excitotoxicity, 405, 605 Exophthalmos, 144 Exosome-like vesicles, 220 Exposure keratopathy, 143 External ocular surface, 745
Extracellular matrix (ECM), 314, 316, 364, 374, 376, 444, 474, 519
Extracellular signal-regulated kinases 1/2 (ERK 1/2), 377, 590, 662, 666
Extrahepatic tissues, 240 Extraocular muscle dysfunction, 141
Extrinsic (receptor-mediated) apoptotic pathway, 402
Eyelid edema, 149
F
Fas, 587
FasL, 587
Feedback loop for IOP control, 473 Fibrillin-1, 119, 314
Fibroblast growth factor (FGF-2), 84, 365, 400, 463, 665
Fibroblast growth factor receptor (FGFR), 366, 373, 666
Fibronectin, 221, 314, 350 Fibrovascular membrane, 83, 159 Filtering surgery, 131, 740
Finite element (FE) modeling, 481 Flicker perimetry, 539
Flotillin-1, 221 Flow restrictors, 718
Fluorescein angiography, 85 Fluorophotometric outflow facility, 313 5 Fluorouracil (5-FU), 163, 700 Fornix-based flap, 697
Fornix incision, 697 Forskolin, 646 FOXC1, 200
Framingham Eye Study, 10
Frequency doubling technology (FDT), 67, 536 Fuchs’ endothelial dystrophy, 91
Fuchs’ heterochromic iridocyclitis, 95 Fundus stereoscopy, 51
G
G-actin, 314
GFAP. See Glial fibrillary acidic protein (GFAP) Giant vacuoles, 104
Glaucoma drainage devices, 715 Glaucoma drainage surgery, 163 Glaucoma-linked genes, 346