Trabeculectomy with Releasable Sutures a Prospective, Randomized Pilot Study

CLINICAL SCIENCES Trabeculectomy With Releasable Sutures A Prospective, Randomized Pilot Study

Usha Kaul Raina, MD, FRCS, FRCOphth; Deven Tuli, MS

Objective: To compare the short-term and long-term ef- 10.1%, respectively, in the group without releasable su- ficacy of using releasable sutures vs conventional inter- tures. Hypotony (intraocular pressure Յ6 mm Hg) was rupted sutures for scleral flap suturing in trabeculectomy. noted in 8 (53%) of cases without releasable sutures and 3 (20%) of cases with releasable sutures. Shallow anterior Design: A prospective randomized study. chamber (central anterior chamber depth, Յ1 mm) was noted in 5 (33%) of cases without releasable sutures and 1 Setting: A university-affiliated referral eye hospital. (7%) of cases with releasable sutures. The mean ± SD final bleb score was 5.4 ± 0.3 in the group with releasable su- Patients: Thirty consecutive patients requiring trab- tures compared with 4.2 ± 0.6 in the group without releas- eculectomy for uncontrolled primary glaucoma. able sutures (PϽ.001). The mean ± SD final intraocular pressure at the end of 12 months was 16.9 ± 1.2 mm Hg in the Intervention: Fifteen patients underwent trabeculec- group without releasable sutures and 15.0 ± 0.9 mm Hg in tomy with permanent interrupted sutures; the same num- the group with releasable sutures (PϽ.001). Final intraocu- ber underwent trabeculectomy with releasable sutures. larpressurewascontrolled(intraocularpressureՅ21mmHg) in all patients in the group with releasable sutures, giving a Main Outcome Measures: Incidence of short-term success rate of 100%, and in 12 patients in the group with- shallowing of anterior chamber or hypotony and related out releasable sutures, giving a success rate of 80%. complications, and long-term intraocular pressure con- trol and bleb score. Conclusions: Use of releasable sutures is an effective way at no extra cost or instrumentation to maximize the long- Results: The mean percentage reduction in intraocular term bleb score and lower intraocular pressure, and to mini- pressure on day 1 in the group with releasable sutures was mize the short-term complications of trabeculectomy. 55.2%, while only a 0.8% reduction in anterior chamber depth was noted. This compared with figures of 59.3% and Arch Ophthalmol. 1998;116:1288-1293

URING THE YEARS since its simulate a full-thickness filtration proce- development, trabeculec- dure. In this way, some of the advantages tomy has become the fil- of both the guarded type of filtration sur- tration procedure of choice gery and better pressure-lowering results of for glaucoma, mainly be- full-thickness procedures can be com- Dcause the overlying scleral flap prevents bined into 1 glaucoma filtration operation. overfiltration through the sclerostomy in the The use of releasable sutures in filtration sur- early postoperative period, thereby decreas- gery originated with Schaffer et al,3 but the ing the incidence of hypotony and shallow success of their technique in preventing hy- anterior chamber and their related compli- potony and flat chambers was limited by the cations. However, the resulting “guarded” gross nature of the filtering wound. Inter- aqueous outflow thus prevents the pro- est in releasable sutures was reinitiated af- found and long-lasting reduction of intra- ter Cohen and Osher4 reported their tech- ocular pressure (IOP) typically attained with nique of exteriorizing the releasable sutures a full-thickness filtration procedure.1,2 Use over the cornea in trabeculectomy. Since of releasable sutures allows the surgeon to then, various authors5-9 have suggested close the scleral flap relatively tightly intra- modifications in the technique. Most of operatively, thereby decreasing the inci- these reports are retrospective and do not dence of early postoperative complica- present a detailed analysis of results and tions. When the wound and the anterior complications associated with use of releas- From the Guru Nanak Eye chamber are believed to be stabilized, the able sutures. This prospective, random- Centre, Maulana Azad Medical sutures can be removed serially, to in- ized study was performed to note the short- College, New Delhi, India. crease filtration in small increments and thus and long-term efficacy of releasable sutures

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 PATIENTS AND METHODS nylon sutures, 1 each on the sides and the third at the apex of the triangular scleral flap. The tightness of the sutures was adjusted to maintain anterior chamber depth and to restrict PATIENT SELECTION aqueous runoff around the flap edges to minimal flow. The conjunctival flap was closed with a running, intermittently Patients with the diagnosis of primary open-angle or pri- locked, horizontal mattress 10-0 nylon suture. mary angle-closure glaucoma, uncontrolled, with maxi- mal medical and/or laser therapy and needing filtering sur- TRABECULECTOMY WITH RELEASABLE SUTURES gery, were included in this study. Patients with secondary glaucoma, eg, after uveitis, after trauma, neovascular, or The releasable suture technique was identical except for juvenile glaucoma; those with previous ocular surgery; and closure of the scleral flap. The releasable sutures were placed those needing combined cataract and glaucoma surgery were by the technique of Cohen and Osher.4 The needle of a 10-0 excluded from the study. Patients having any cortical or nylon suture was passed first into the intact sclera poste- subcapsular lens opacities were not considered. Addition- rior to the scleral flap and then brought out anteriorly ally, those found to have nuclear sclerosis greater than grade through the scleral flap. This suture was then passed through 1, as defined by the Lens Opacities Classification Sys- the base of the scleral flap, beneath the conjunctival flap tem,10 were not included. Thirty eyes of 30 patients were insertion, through partial-thickness cornea 1 to 2 mm from randomly divided into 2 groups. One group of 15 eyes un- the limbus, and then out on to the epithelial surface of the derwent trabeculectomy with conventional interrupted 10-0 cornea. A small superficial pass through adjacent cornea nylon sutures.The second group of 15 eyes underwent tra- was then made (Kolker et al’s modification6). Four throws beculectomy with releasable sutures performed by the tech- of the distal end of the suture were passed around the ty- nique of Cohen and Osher4 modified by Kolker et al.6 ing forceps before the suture lying on the surface of the Approval of the institutional review board was ob- scleral flap was grasped to make a hemibow slipknot. Three tained to undertake the present study. All patients gave in- such releasable sutures were inserted, 1 at the apex and 2 formed consent. on the sides of the scleral flap. The tightness of the sutures was adjusted to approximate the edges of the scleral flap PREOPERATIVE ASSESSMENT OF PATIENTS and restrict aqueous flow. The corneal end of the suture was then cut flush to avoid leaving a protruding suture end. A detailed history was taken regarding the duration and treat- No antimetabolites were used in either group in this study ment of glaucoma. Ocular examination included anterior seg- perioperatively or postoperatively. At the end of the sur- ment evaluation with a slitlamp (Haag Streit 900; Haag Streit, gery, in both groups, subconjunctival injection of 2 mg of dexa- Koeniz, Switzerland). The posterior segment was examined methasone and 20 mg of gentamicin sulfate were given 180° by direct ophthalmoscopy, indirect ophthalmoscopy, and slit- away from the bleb site. The operated-on eye was bandaged lamp biomicroscopy in association with a fundus contact lens. until the day after surgery. Topical antibiotic-corticosteroid Intraocular pressure was measured with Goldmann appla- drops were given for 6 to 8 weeks postoperatively. Topical nation tonometry. Central anterior chamber depth (ACD) was cycloplegic (1% cyclopentolate hydrochloride and 1% atro- measured with an optical pachymeter (Haag Streit) (attach- pine sulfate) drops were given for 2 to 4 weeks. Additional ments I and II). Gonioscopy was done with the Goldmann antibiotic ointment at night was given in all patients. single-mirror indirect gonioscope, to grade the angle and to All patients were followed up as outpatients. Fre- note the presence and extent of peripheral anterior syn- quent visits were requested in the first 2 weeks at the pa- echiae, if any. Topical antiglaucoma medication was contin- tients’ convenience in both groups to observe the short- ued in the fellow eye if required. Systemic antiglaucoma medi- term course of the surgery and to release sutures as required cation was discontinued in these patients. in the group with releasable sutures. However, 100% follow-up was ensured on days 1, 7, and 14 and at the comple- OPERATIVE PROCEDURE tion of 1, 3, 6, and 12 months. Postoperative evaluation included recording of best-corrected visual acuity, slitlamp All patients in this study were admitted to the hospital 1 examination, measurement of IOP, ACD, and bleb score. day before the planned surgery. Local anesthesia was Recordings were obtained at the same time of day, be- achieved with an O’Brien facial block and peribulbar/ tween 10 AM and noon in all patients. retrobulbar block. Surgical interventions in all patients were In the releasable-suture group, sutures were released performed by the same surgeon (U.K.R.). with the patient under topical anesthesia and seated at the slitlamp, by pulling the exteriorized corneal loop with a su- CONVENTIONAL TRABECULECTOMY TECHNIQUE ture-holding forceps. Sutures were released in the postoperative period when either the IOP rose above 21 mm Hg A limbus-based conjunctival flap was raised approximately or the bleb score did not improve with digital massage. A 8 to 10 mm from the limbus. The dissection was carried to single suture was released at a time. However, all residual the limbal zone. Superficial bleeding vessels over the site of sutures were released by the 14th postoperative day to avoid the intended scleral flap were cauterized lightly. A triangu- suture breakage beyond this time on attempted release. lar scleral flap measuring 4 ϫ 4 mm and of one-half scleral Among the 3 sutures, the apical suture was released last. thickness was dissected up to the limbal zone. A 3 ϫ 1–mm In the releasable-suture group, IOP, ACD, and bleb score internal sclerostomy opening in the anterior chamber was were recorded both before and after suture release. made just anterior to the scleral spur. A peripheral iridec- The results were statistically evaluated by means of the tomy was made slightly wider than the opening of the scle- ␹2 test for qualitative data and Student t test for quantita- rostomy. The scleral flap was closed with 3 interrupted 10-0 tive data.

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No Releasable Releasable 14 Sutures Sutures P 12 Age, mean ± SD, y 54.7 ± 8.9 53.2 ± 11.0 .70 Sex, male-female, % 33.3:66.7 60.0:40.0 .31 10 Type of glaucoma, open 40:60 20:80 .46 8

angle–angle closure, % mm Hg IOP, 6 Preoperative IOP, 27.1 ± 6.3 32.3 ± 10.0 .80 No Releasable Sutures mean ± SD, mm Hg 4 Releasable Sutures Central anterior chamber 1.6 ± 0.6 1.5 ± 0.5 .57 mean ± SD, mm 2 Visual acuity, No. 0 Ͼ20/200 12 10 .61 1 d 7 d 14 d 1 mo 2 mo 3 mo 6 mo 12 mo Յ20/200 3 5 Time Preoperative medications, 2.1 ± 0.2 2.2 ± 0.3 .40 Figure 1. Variation in postoperative intraocular pressure (IOP). mean ± SD, No. Previous laser therapy, No. 6 6 NA Patients with previous 00NA ocular surgery, No. out releasable sutures and 6.9 ± 0.8 days in the group with *IOP indicates intraocular pressure; NA, not applicable. releasable sutures. One patient who developed hypotony was found to have choroidal detachment. This patient was in the group without releasable sutures and recovered with in comparison with conventional interrupted sutures for conservative management. No patient in this study was closure of the scleral flap in trabeculectomy. found to have hypotony maculopathy. The mean percentage change from preoperative IOP to final IOP at 12 months RESULTS in the 2 groups was 37% and 54%, respectively. The demographic and preoperative data in the 2 groups are POSTOPERATIVE ACD summarized in Table 1. The mean preoperative central ACD in this study was lower than that observed by The mean percentage reduction in ACD on day 1 from Johnstone et al.8 A higher number of patients with angle- the preoperative level was 10.1% in the group without closure glaucoma in the present study may have contrib- releasable sutures, while it was just 0.8% in group with uted to this. The difference in the number of patients with releasable sutures. The ACD in the early postoperative angle-closure glaucoma in the 2 groups was, however, sta- period is noted in Table 2. The incidence of shallow an- tistically nonsignificant (P = .46). terior chamber (defined as central ACD Յ1 mm) was 33% Topical antiglaucoma medication was required in (5 patients) in the group without releasable sutures, while fellow eyes of 6 patients in the group without releasable it was 7% (1 patient) in the group with releasable su- sutures and in 5 patients in the group with releasable tures. The mean ± SD duration of shallow anterior cham- sutures. ber was 9.8 ± 3.8 days in the group without releasable sutures and 7 days in the only case in which shallow anterior POSTOPERATIVE IOP chamber was seen in the group with releasable sutures. No case of flat anterior chamber was noted in this study. The variation of the postoperative IOP is depicted in No patient required surgical reformation of the anterior Figure 1. The IOP in the group with releasable sutures chamber. was higher than that in the group without releasable sutures for the initial few days until the sutures were re- BLEB CHARACTERISTICS leased. There was a significant difference in IOP in the groups without and with releasable sutures (PϽ.05) on day Blebs were graded according to the classification of Mig- 7, coincidental with suture release, with a further de- dals and Hitchings11 (Table 3). The mean bleb score on crease in IOP recorded on day 14 in the group with releas- day 1 was lower in the group with releasable sutures than able sutures. The IOP in the group with releasable sutures in the group without releasable sutures. This is consis- on day 7 and after 1 month was the same (12.3 mm Hg). tent with the tighter closure of the flap with these su- This is different from the IOP pattern in the group with- tures intraoperatively. Subsequently, the bleb score in the out releasable sutures, which showed a progressive in- group with releasable sutures is better than that in the crease in IOP beyond day 7. It is noteworthy that the mean group without releasable sutures (Table 3). At the end IOP in the group without releasable sutures at 6 months of the follow-up period, grade 6 blebs were observed in and 12 months in the postoperative period was signifi- 8 cases (53%) in the group with releasable sutures and cantly higher than that in the group with releasable su- in 2 cases (13%) in the group without releasable sutures (PϽ.05 and PϽ.001, respectively). The percentage tures. On the other hand, blebs with grade 2 or less were incidence of hypotony (defined as IOP Յ6 mm Hg) in the observed in 3 cases (20%) in the group without releas- 2 groups was 53% and 20%, respectively. The mean ± SD able sutures, while no case in the group with releasable duration of hypotony was 11.6 ± 8.1 days in the group with- sutures showed such blebs.

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Table 2. Postoperative Central Anterior Chamber Depth* Table 3. Postoperative Bleb Score*

Anterior Chamber Depth, Mean ± SD, mm Bleb Score, Mean ± SD

Time No Releasable Sutures Releasable Sutures tP Time No Releasable Sutures Releasable Sutures tP 1 d 1.22 ± 0.30 1.54 ± 0.56 2.03 .06 1 d 3.00 ± 0.93 2.73 ± 0.88 0.76 .46 7 d 1.47 ± 0.50 1.65 ± 0.56 0.50 .62 7 d 3.33 ± 0.82 3.40 ± 0.74 0.19 .85 14 d 1.63 ± 0.28 1.76 ± 0.56 0.28 .78 14 d 3.60 ± 0.63 4.27 ± 1.10 2.05 .06 1 mo 1.74 ± 0.31 1.80 ± 0.35 0.84 .41 1 mo 4.07 ± 0.59 4.67 ± 0.82 2.02 .06 2 mo 4.47 ± 0.64 5.27 ± 0.70 2.96 .01 *The mean values beyond 1 month were similar in both groups. 3 mo 4.67 ± 0.62 5.33 ± 0.62 2.79 .01 6 mo 4.50 ± 0.48 5.36 ± 0.51 4.11 .001 12 mo 4.23 ± 0.60 5.35 ± 0.34 6.0 Ͻ.001 ANALYSIS OF THE RELEASABLE-SUTURE GROUP *Blebs were scored according to Migdal and Hitchings11: 1, flat bleb; An analysis of the releasable-suture group (Table 4, 2, elevated engorged conjunctiva; 3, pale elevated area within engorged Figure 2) showed that maximum change in the variables conjunctiva; 4, residual conjunctival engorgement around the suture line; 5, pale and diffusely elevated conjunctiva; and 6, pale cystic conjunctival occurred when sutures were released between days 1 and elevation. 5, while minimal or no change occurred when sutures were released between days 11 and 15. A moderate change was noticed when sutures were released between days 6 and Twelve patients (80%) in the group without releasable su- 10 in the postoperative period.The percentage change tures had IOP controlled with surgical intervention alone, in IOP was 34.8% ± 4.9% on days 1 to 5 compared with while 3 patients required additional medication (single drug 11.5% ± 16.5% on days 11 to 15. Similar changes were ob- only), giving a qualified success rate of 100%. All patients served in ACD and bleb score. No case of dangerously high in the group with releasable sutures had a mean final IOP IOP was noticed in any patient in the group with releasable at 12 months of 21 mm Hg or less without additional an- sutures at any time in the follow-up period. tiglaucoma medication, giving a success rate of 100%. Of a total of 45 releasable sutures, 2 sutures (4%) broke With 15 patients in each group, the power of the study while release was being attempted on the 14th postopera- was 50% with the use of ␣ and ␤ error calculations. tive day. These, however, retracted well into the corneal stroma, producing no complications. COMMENT COMPLICATIONS Previous studies with releasable sutures, being retrospective, have left important questions unanswered: What is the Three cases (20%) in the group without releasable su- correct timing for their release? Does use of releasable sutures showed hyphema in the early postoperative period, tures affect long-term IOP and/or bleb function? Can the ini- which resolved with conservative management. Choroi- tial tight closure of removable sutures produce significantly dal detachment was noticed in 1 case (7%), while another high levels of IOP in the immediate postoperative period? case (7%) showed development of posterior and periph- This study attempted to answer these questions and eral anterior synechiae. Cataract development was seen in to determine whether the use of releasable sutures, apart 3 patients (20%) in this group and in only 1 patient with from minimizing the incidence of hypotony, shallow an- use of releasable sutures. No case of choroidal detach- terior chamber, and related complications, improves the ment, hyphema, synechiae formation, or corneal compli- success rate after trabeculectomy. To our knowledge, this cations of any kind were noted in the group with releas- is the first randomized prospective study with the use of able sutures. No case of hypotony maculopathy was noted releasable sutures. in any patient in either group. All surgical interventions in this study were carried out by the same surgeon (U.K.R.), keeping the type of con- SUCCESS RATES junctival flap, size of the scleral flap, and the inner sclerostomy the same. The number of sutures and the type of Success was defined as a final IOP of 21 mm Hg or less with- suture material used to close the scleral flap were also kept out antiglaucoma medication, and qualified success, as an constant in all patients. Robin12 observed that if the above IOP of 21 mm Hg or less with antiglaucoma medication. factors are not standardized, the procedure may give vari-

Table 4. Change in Variables According to Day of Suture Release*

IOP ACD Day of Suture Release B-A, mm Hg % Change B-A, mm % Change Bleb Score, B-A 1-5 6.00 ± 1.41 34.8 ± 4.9 0.42 ± 0.16 23.1 ± 7.8 −2.00 ± 0 6-10 4.67 ± 2.23 33.8 ± 15.1 0.37 ± 0.21 23.6 ± 13.2 −1.67 ± 0.82 11-15 2.33 ± 3.27 11.5 ± 16.5 0.25 ± 0.28 13.7 ± 14.9 −0.88 ± 0.85

*Data are given as mean±SD. IOP indicates intraocular pressure; B-A, change from before to 1 hour after suture release; and ACD, anterior chamber depth.

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 35 ideal number of sutures to be used, a study could be un- dertaken to see the effect of varying the number of releas- 30 able sutures. 13 14 25 Savage et al and Melamed et al noted in their studies on argon laser suture lysis that the apical suture may 20 act as a “key suture,” such that if this suture were to be lysed 15 early in the postoperative period, a sudden aqueous run-

10 off might result. Additionally, the complete effect of a single IOP Change, % suture removal may not be apparent for 24 hours after re-

Change in Variable Studied Change in Variable 5 ACD Change, % moval. In the present study, a single suture was released Bleb Score, B-A 0 in the early postoperative period in the group with releasable sutures. Care was also taken to release the apical su- –5 1-5 6-10 11-15 ture last. Both of these precautions taken in the present study Day of Suture Release may have contributed to the fact that no case of hypotony or shallow anterior chamber resulted from suture release. Figure 2. Changes in intraocular pressure (IOP), anterior chamber depth (ACD), and bleb score from before to after suture release (B-A). It would be expected that with use of antimetabolites, suture removal would have to be delayed in keeping with the able and unreliable results. Variables in the follow-up pe- slowed wound healing. riod in all patients were measured by the same investiga- Previous authors6,7 have speculated about the possi- tor independent of the surgeon (D.T.). bility of dangerous elevation in IOP with the tight closure Clinical observations in the present study and those of scleral flap with releasable sutures. No such case was of other workers support the fact that releasable sutures noted in the present study at any time in the postoperative provide satisfactory drainage while generally preventing a period. The assurance that the sutures can be released in substantial reduction in ACD in the early postoperative pe- the postoperative period allows the surgeon to secure the riod. In the present study, only a 0.8% decrease in the mean scleral flap tighter than usual, thus minimizing hypotony. ACD was noted, while the mean decrease in IOP on day 1 On the other hand, if high IOP is found in the postopera- was 55.2%. Johnstone et al8 reported a mean decrease of tive period, 1 or more sutures may be released to allow im- 4.6% in ACD and a mean decrease of 65.3% in IOP with proved filtration, which is not possible with permanent su- the use of releasable sutures. tures. Thus, by this dual benefit, releasable sutures may have The overall incidence of hypotony and shallow ante- a special place in eyes with advanced glaucomatous dam- rior chamber was reduced significantly with use of releas- age to prevent snuff-off of vision. able sutures (20% and 7%, respectively) while the inci- Argon laser suture lysis is another technique to ti- dence was higher without use of these sutures (53% and trate the bleb function in the early postoperative period. 33%, respectively). These figures compare with those of In India, the availability and cost of argon laser are major Kolker et al,6 who reported shallow anterior chamber in limiting factors. Additionally, sutures can be obscured by 32.8% of cases and flat anterior chamber in 8.6% of cases hemorrhage, overlying edema, or a thick Tenon capsule pre- with the use of permanent sutures and 14.4% and 1.4% of cluding suture release when it is most needed. The danger cases, respectively, with the use of releasable sutures. No of bleb perforation remains with higher energy levels of case in the present study developed flat anterior chamber laser used. Releasable sutures require a negligible learning or required anterior chamber reformation. curve and minimal and inexpensive equipment. Sutures can It is possible that topical antiglaucoma medication used easily be removed without discomfort with the patient un- in the fellow eye in the postoperative period may affect the der topical anesthesia and seated at the slitlamp. Use of re- IOP in the operated-on eye, but it would not affect the ACD. leasable sutures therefore may be an important develop- The number of patients in each group for whom medica- ment toward outpatient trabeculectomy in this era of day tion was used in the fellow eye was similar (6 and 5 of those care eye surgery. without and with releasable sutures, respectively). We conclude that the use of releasable sutures mini- Complications experienced with use of releasable su- mizestheincidenceofshallowanteriorchamberandhypotony tures were minimal in this study. No cases of hypotony intheearlypostoperativeperiod,thustakingcareoftheshort- maculopathy, choroidal detachment, hyphema, or periph- term complications. Once the wound and anterior cham- eral anterior synechiae were noted in the group with re- ber are believed to be stabilized, the sutures are released to leasable sutures. Only 1 patient (7%) developed cataract enhance the outflow of aqueous humor. The resultant situ- during the follow-up period. This compared with a figure ation, resembling full-thickness surgery, would ensure good of 20% (3 patients) in the group without releasable su- bleb function and provide lower long-term IOP. This is an tures. Significant cataract formation in the postoperative important factor that was not brought forward by previous period may result in enough diminution of vision to re- authors but is clearly shown by our study. Although the quire cataract extraction. One patient in this study devel- samplesizeofthispilotstudyissmall,itbringsforththeshort- oped visually significant cataract and was advised to un- term and long-term advantages of trabeculectomy with re- dergo cataract extraction, but the patient refused at that time. leasable sutures. We found this technique so effective that We have used 3 scleral flap sutures in all patients and we have switched entirely to releasable sutures in our glau- found this number to be satisfactory with a 4 ϫ 4-mm scleral coma practice. We are currently evaluating the effect of us- flap. To avoid any bias, we kept the number of sutures con- ing releasable sutures in trabeculectomy with adjunctive stant in both groups. To answer the question regarding the antimetabolites through a controlled prospective study.

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 Accepted for publication June 25, 1998. 6. Kolker AE, Kass MA, Rait JL. Trabeculectomy with releasable sutures. Arch Oph- Reprints: Usha Kaul Raina, MD, FRCS, FRCOphth, 427, thalmol. 1994;112:62-66. 7. Kolker AE, Kass MA, Rait JL. Trabeculectomy with releasable sutures. Trans Am Hawa Singh Block, Asiad Village Complex, New Delhi Ophthalmol Soc. 1993;91:131-141. 110 049, India (e-mail: [email protected]). 8. Johnstone MA, Wellington DP, Ziel CJ. A releasable scleral flap tamponade suture for guarded filtration surgery. Arch Ophthalmol. 1993;111:398-403. 9. Hsu CT, Yarng SS. A modified removable suture in trabeculectomy. Ophthalmic REFERENCES Surg. 1993;24:579-585. 10. Chylack LT Jr, Leske MC, McCarthy D, Khu P, Kashiwagi T, Sperduto R. Lens Opaci- 1. Lamping KA, Bellows AR, Hutchinson BT, Afran SI. Long term evaluation of ini- ties Classification System II (LOCS II). Arch Ophthalmol. 1989;107:991-997. tial filtration surgery. Ophthalmology. 1986;93:91-101. 11. Migdal C, Hitchings R. The developing bleb: effect of topical antiprostagland- 2. Watkins PH, Brubaker RF. Comparison of partial thickness and full thickness filtra- ins on the outcome of glaucoma fistulising surgery. Br J Ophthalmol. 1983; tion procedures in open angle glaucoma. Am J Ophthalmol. 1978;86:756-761. 67:655-660. 3. Schaffer RN, Hetherington J, Hoskins HD. Guarded thermal sclerostomy. Am J 12. Robin A. In discussion of: Kolker AE, Kass MA, Rait JL. Trabeculectomy with Ophthalmol. 1971;72:769-772. releasable sutures. Trans Am Ophthalmol Soc. 1993;91:141-145. 4. Cohen JS, Osher RH. Releasable scleral flap suture. Ophthalmol Clin North Am. 13. Savage JA, Condon GP, Lyttle RA, Simmons RJ. Suture lysis after trabeculec- 1988;1:187-197. tomy. Ophthalmology. 1988;95:1631-1638. 5. Shin DH. Removable suture closure of the lamellar scleral flap in trabeculec- 14. Melamed S, Ashkenagi I, Glorinski J, Blumenthal M. Tight scleral flap trabeculectomy. Ann Ophthalmol. 1987;19:51-53. tomy with post operative laser suture lysis. Am J Ophthalmol. 1990;109:303-309.

IN OTHER AMA JOURNALS

ARCHIVES OF DERMATOLOGY Therapeutic Efficacy of Interferon Alfa-2b in Infants With Life-Threatening Giant Hemangiomas Lourdes Tamayo, MD; Dulce M. Ortiz, MD; Luz Orozco-Covarrubias, MD; Carola Dura´n-McKinster, MD; Maria Antonieta Mora, MD; Estrella Avila, MD; Fernanda Teixeira, MD; Ramo´n Ruiz-Maldonado, MD Background: Because of their size and the possibility of complications, giant hemangiomas represent a therapeutic chal- lenge. Various forms of treatment have been used, with variable results, including surgery, embolization, lasers, pentoxifyl- line, and corticosteroids. Interferon alfa has been used successfully to treat life-threatening hemangiomas, possibly by means of its antiangiogengenic activity. Observations: We treated 7 infants with organ-interfering and/or life-threatening giant hemangiomas with subcutaneous injections of 3 million U/m2 per day of interferon alfa-2b during the first month and subsequently every 48 to 72 hours, de- pending on the evolution in each case. The treatment lasted from 3 to 12 months. In 2 patients, interferon alfa-2b was admin- istered while prednisone therapy was being tapered. In all 7 patients, there was considerable reduction of the volume of the hemangiomas and remission of their complications. All patients presented with fever, neutropenia, and an increase in serum aminotransferase levels. The patients who received interferon alfa-2b and prednisone seemed to improve at a faster rate. Conclusions: Interferon alfa-2b is a good option for the treatment of patients with steroid-resistant, organ-interfering and/or life-threatening giant hemangiomas. In our experience, the adverse effects were transient and minor and did not require the interruption of the treatment. (1997;133:1567-1571)

Reprints: Lourdes Tamayo, MD, Department of Dermatology, Instituto Nacional de Pediatria, Insurgentes Sur 3700 C, Col. Cuicuilco, Mexico City, DF, 04530 Mexico.

Figure 5. Patient 6. The hemangioma closes the left eye and hinders Figure 6. Patient 6. Vision is possible after 4 months of treatment with vision. interferon alfa-2b.

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