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Trabeculectomy Bleb Assessment Via Three-Dimensional Anterior Segment Optical Coherence Tomography

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Trabeculectomy Bleb Assessment Via Three-Dimensional Anterior Segment Optical Coherence Tomography Central JSM Ophthalmology Research Article *Corresponding author Takahiro Kawaji, Department of Ophthalmology, Faculty of Life Sciences, Kumamoto University, 1-1-1 Trabeculectomy Bleb Honjo, Chuo-ku, Kumamoto 860-8556, Japan, Tel: +81-96-373-5247; Fax: +81-96-373-5249; Email: Assessment via Three- Submitted: 23 February 2014 Accepted: 03 March 2014 dimensional Anterior Segment Published: 07 March 2014 ISSN: 2333-6447 Optical Coherence Tomography Copyright Takahiro Kawaji*, Toshihiro Inoue, Riyo Matsumura, Utako © 2014 Kawaji et al. Kuroda, Kei-Ichi Nakashima and Hidenobu Tanihara OPEN ACCESS Department of Ophthalmology, Kumamoto University, Japan Keywords Abstract • Glaucoma • Trabeculectomy Background: To evaluate the morphological features of filtering blebs after • Bleb trabeculectomy by using three-dimensional anterior segment optical coherence • Three-dimensional anterior segment optical tomography (3D AS-OCT). coherence tomography Methods: This retrospective cross-sectional study evaluated 47 patients who had undergone trabeculectomy with mitomycin C. All blebs were imaged with 3D AS-OCT and analyzed with our custom software. We assessed blebs quantitatively for the following features: bleb height, fluid-filled cavity height, bleb wall thickness, and bleb wall intensity. Results: The mean (± standard deviation [SD]) time period between trabeculectomy and 3D AS-OCT measurement was 9.5 ± 6.2 months; the mean (±SD) intraocular pressure (IOP) measured 14.0 ± 4.3 mm Hg at the time of 3D AS-OCT imaging. IOP and the bleb height (rs = -0.609, P = < .0001), the fluid-filled cavity height (rs = -0.381, P = 0.009), the bleb wall thickness (rs = -0.503, P = 0.0004) and the bleb wall intensity (rs = 0.612, P = < .0001) showed statistically significant correlations. Eyes with limbus-based conjunctival flaps had a higher bleb height (P = 0.02), an increased fluid-filled cavity height (P = 0.002), and a lower bleb wall intensity (P = 0.03) compared with eyes with fornix-based flaps. Bleb wall thickness in these 2 groups did not differ significantly (P = 0.19). Conclusion: Our 3D AS-OCT imaging, which can evaluate morphological features of trabeculectomy blebs quantitatively and noninvasively, showed that the bleb height, the fluid-filled cavity height, the bleb wall thickness, and the bleb wall intensity had significant relationships to the IOP. Limbus-based procedures produced higher blebs, increased fluid- filled cavities, and lower intensity of the bleb wall. INTRODUCTION Trabeculectomy is the surgical treatment most often used Tomography (OCT) [12], time-domain Anterior Segment OCT for patients with medically uncontrolled glaucoma [1]. Because (AS-OCT) [13-16], and three-dimensional (3D) AS-OCT [17,18]. has enabled us to obtain more precise information on internal The recent development of AS-OCT, particularly 3D AS-OCT, procedure have attempted to improve it since its introduction. bleb morphology in a noninvasive and safe manner. We need to Theseof fundamental changes includedifficulties using with releasable trabeculectomy, sutures changes [2] and in laser the identify a complete scleral flap in the C-scan image (tomographic suture lysis [3]; using antifibrosis agents [4-5]; and shifting, by image of the slice plane perpendicular to the depth direction) some surgeons, from utilizing Limbus-Based Conjunctival Flaps to evaluate a precise internal bleb structure. However, it was (LBCF) to Fornix-Based Conjunctival Flaps (FBCF) [6,7]. relatively easy for us to identify the complete scleral flap when the flap was created at the uppermost region, but not in the Many clinical investigators have shown that the existence developedtemporal (or new nasal) custom scleral software flaps, becausefor rotation the C-scanof the dataimage that plane we of filtration blebs is correlated with intraocular pressure (IOP) does not always agree with the scleral plane. Therefore, we values after trabeculectomy [8-18]. To evaluate bleb morphology, some grading methods have included slit-lamp examinations obtained. The software allowed us to approve arbitrary cross- and color photography [8,9], ultrasound biomicroscopy [10], section images from the restructured 3D data, and thereby we confocal microscopy [11], conventional retinal Optical Coherence could identify the complete scleral flap. By using 3D AS-OCT and Cite this article: Kawaji T, Inoue T, Matsumura R, Kuroda U, Nakashima KI, et al. (2014) Trabeculectomy Bleb Assessment via Three-dimensional Anterior Segment Optical Coherence Tomography. JSM Ophthalmol 2(2): 1020. Kawaji et al. (2014) Email: Central P value of less custom software, we have recently found that, in most cases with correlation coefficients were used for analyses. A functional filtration blebs, filtration openings can be identified as thanRESULTS .05 was considered to be statistically significant. pits and/or troughs in fluid-filled cavities in both horizontal and vertical raster and corresponding C-scan images of scleral flap margin in the blebs [19]. Table 1 summarizes the demographics and baseline characteristics of the patients. The mean (±SD) duration between Thus, this 3D technique allows more precise evaluation of trabeculectomy and 3D AS-OCT imaging was 9.5 ± 6.2 months. internal structures of the filtration blebs than currently in use. imaging. The mean (±SD) IOP was 14.0 ± 4.3 mmHg at the time of OCT This study aimed, therefore, to investigate the morphological features of filtering blebs after trabeculectomy and to assess software.the relationship between Intraocular Pressure (IOP) and the Figure 2 shows a representative photograph and 3D AS- quantitative bleb parameters by means of 3D AS-OCT and custom OCT images, and Figure 3 presents the correlation between the METHODS IOP and the quantitativer bleb parameters.P The IOP showed a significant negative correlations with the bleb height (Spearman cavity height (rs P rs = correlationP coefficient [ ] = -0.609, = < .0001), the fluid-filled This study adhered to the tenets of the Declaration of Helsinki intensity of the bleb = -0.381, wall (r = 0.009), Pthe bleb wall thickness ( and was approved by the Institutional Review Board and Ethics -0.503, = 0.0004) and a significants positive correlation with the study.Committee of the Faculty of Life Sciences of Kumamoto University. = 0.612, = < .0001). Informed consent was obtained from all patients included in the We also compared, via 3D AS-OCT, bleb morphologic features after trabeculectomy with the 2 different conjunctival incisions— We retrospectively examined 47 glaucomatous eyes of 47 FBCF and LBCF. The basic characteristics of the FBCF and LBCF patients who underwent trabeculectomy with mitomycin C groups showed no significant differences. Table 2 shows the at Kumamoto University Hospital. All patients were Asians; results of bleb measurements. Compared with the FBCF group, the 26 men and 21 women had an age range from 46 to 90 years (mean ± Standard Deviation [SD], 71.3 ± 11.2 years). The diagnoses included primary open-angle glaucoma in 21 eyes and pseudoexfoliation glaucoma in 26 eyes. All eyes had had trabeculectomy with the intraoperative use of topical 0.04% Goldmanmitomycin applanation C for 4 minutes. tonometry LBCF wasbefore used the in surgery 12 eyes and and at FBCF the was used in 35 eyes. All IOP measurements were obtained via time of 3D AS-OCT imaging. We utilized 3D AS-OCT (Casia; Tomey, Nagoya, Japan) to Figure 1 assess internal bleb structures. Patients were asked to look down, and an examiner used a finger to gently elevate the upper lid to 3D AS-OCT image of a bleb analyzed with current software: tilted image of a triangular scleral flap. B: Precise en face image of the expose the filtration bleb. For each bleb, at least two ways of scans Abbreviations: flap (arrowheads: outer frame) obtained via our custom software. were obtained as horizontal and vertical raster, and each raster 3D AS-OCT: Three-Dimensional Anterior Segment consisted of 512 scans. Each bleb was scanned at least twice, Optical Coherence Tomography and the examined area was chosen to include the entire scleral Table 1: flap and bleb. We analyzed the OCT images that we obtained Patients Demographics and Characteristics and Baseline CharacteristicsTotal FBCFof the patients.LBCF quantitatively with our newly developed software. This software, 12 by whichen we face could rotate and tilt the 3D images, allowed us to easily evaluate, in minute detail, the internal bleb structure of Patients, number 47 35 3D and images of the scleral flap (Figure 1) and drainage Sex, M/F, number 26/21 19/16 7/5 11.2 route, and to quantify the intensity of the bleb structures. 71.3 ± 71.2 ± 71.9 ± 9.1 Age, years 11.7 We measured the total bleb height, fluid-filled cavity height, (56–84) (46–90) (46–90) bleb wall thickness, and intensity of the bleb wall. We defined the total bleb height as the maximum distance between the Duration between trabeculectomy 9.5 ± 6.2 9.6 ± 5.5 8.9 ± 8.1 and 3D AS-OCT, months (4–25.1) (4–20.1) (4–25.1) conjunctival surface and the surface of the scleral flap. We defined 14.0 ± 4.3 14.1 ± 3.7 12.1 ± 4.6 the fluid-filled cavity height as the maximum height of the region IOP at imaging, mm Hg (4–23) (6–23) (4–18) of significantly low-reflective fluid-filled space adjacent to the 21 Diagnosis differentscleral flap. reviewers We measured evaluated the blebcomplete wall thicknessimages of and the intensityinternal 18 8 of the bleb wall above the internal fluid-filled cavity. At least 3 Abbreviations:POAG 17 4 PEX 26 LBCF: Limbus-Based Conjunctival Flap; FBCF: Fornix- bleb structure and assessed the 3D AS-OCT images. Based Conjunctival Flap; 3D AS-OCT: Three-dimensional Anterior U Statistical analyses were performed with JMP, Version 7 (SAS Segment Optical Coherence Tomography; IOP: Intraocular Pressure; POAG: Primary Open Angle Glaucoma; PEX: Pseudoexfoliation Glaucoma. Institute Inc., Cary, NC). The Mann-Whitney test and Spearman Values are means ± SD (range).
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