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A Pilot Study on Slit Lamp-Adapted Optical Coherence Tomography Imaging of Trabeculectomy Filtering Blebs

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A Pilot Study on Slit Lamp-Adapted Optical Coherence Tomography Imaging of Trabeculectomy Filtering Blebs Graefe’s Arch Clin Exp Ophthalmol (2007) 245:877–882 DOI 10.1007/s00417-006-0476-2 SHORT COMMUNICATION A pilot study on slit lamp-adapted optical coherence tomography imaging of trabeculectomy filtering blebs Thomas Theelen & Pieter Wesseling & Jan E. E. Keunen & B. Jeroen Klevering Received: 14 June 2006 /Revised: 8 October 2006 /Accepted: 9 October 2006 / Published online: 22 November 2006 # Springer-Verlag 2006 Abstract Results The study included 20 eyes of 20 patients. After Background Our study aims to identify anatomical charac- completion of our study, 15 eyes of 15 patients (mean teristics of glaucoma filtering blebs by means of slit lamp- age±SD 67±16 years) were eligible for data analysis and 5 adapted optical coherence tomography (SL-OCT) and to eyes missed at least one follow-up visit. Filtering surgery identify new parameters for the functional prognosis of the was considered successful (intraocular pressure ≤ 21 mmHg filter in the early post-operative period. without antiglaucomatous medication) in 11 of 15 eyes. SL- Methods Patients with primary open-angle glaucoma, aged OCT frequently demonstrated multiple hypo-reflective 18 years and older, scheduled for primary trabeculectomy at layers within Tenon’s capsule (“striping” phenomenon) in the Department of Ophthalmology, Radboud University the first post-operative week. Presumably, these layers Nijmegen Medical Centre, were considered for our study. corresponded with drainage channels in the histological All patients underwent standardized trabeculectomy with specimen. These channels were present in functional filters intra-operative application of mitomycin C. The filtering but not in the failures. In addition, the visualisation of the blebs were evaluated clinically and with SL-OCT on day 1 sclera below the filtering zone was better defined in failures and 1, 2, 4 and 12 weeks following surgery. The resulting compared with successful filtering blebs (“shading” phe- data were analysed and weighed against surgical success. nomenon). We observed no differences in the volume and To better understand the SL-OCT data a small comparative clinical aspect of the blebs in the successful group histologic study was performed. compared with the unsuccessful group. Conclusions Successful filtering blebs show characteristic optical properties on SL-OCT. These phenomena suggest a diffusely enhanced fluid content and the presence of intra- Meeting presentation Presented in part as a poster at the 1st World Glaucoma Congress, Vienna, Austria, July 2005. bleb drainage channels in functional filtering blebs. Financial disclosure Medical Workshop, Groningen, Netherlands, . made the slit lamp-adapted optical coherence tomography device Keywords Trabeculectomy Optical coherence available to one of the authors (T. Theelen) with support from the tomography. Prospective study manufacturer, Heidelberg Engineering, Lübeck, Germany. There are no other competing interests. T. Theelen (*) : J. E. E. Keunen : B. J. Klevering Department of Ophthalmology, Introduction Radboud University Nijmegen Medical Centre, Philips van Leydenlaan 15, 6525 Nijmegen, The Netherlands The surgical success of a trabeculectomy strongly depends e-mail: [email protected] on the extent of the healing processes at the filtering site. Therefore, careful clinical examination of the filtering bleb P. Wesseling is necessary in the early post-operative period and attempts Department of Pathology, Radboud University Nijmegen Medical Centre, have been made to standardize clinical signs and to develop Nijmegen, The Netherlands risk scores [2, 6]. However, only the surface and superficial 878 Graefe’s Arch Clin Exp Ophthalmol (2007) 245:877–882 layers of the bleb may effectively be examined by slit lamp biomicroscopy. Slit lamp-adapted optical coherence tomography (SL- OCT) is a novel, high-resolution imaging technique that has recently been introduced for assessment of the anterior segment [3]. The non-contact approach of SL-OCT makes it possible to monitor the anterior segment structures non- invasively, which particularly suits the early post-operative evaluation following intraocular surgery. In this study we employed the anterior segment SL-OCT in the early post-operative evaluation of filtering blebs. With this technique we attempted to identify new criteria to recognize failing filters at a very early stage. Materials and methods We performed a prospective, observational study on patients aged 18 years and older consecutively scheduled for primary trabeculectomy for primary open-angle glauco- ma (POAG) at the Department of Ophthalmology, Radboud University Nijmegen Medical Centre. This study was performed in accordance with the tenets of the Declaration of Helsinki and Ethics Committee approval was obtained. Fig. 1 Standardized bleb photographs to interpret the clinical aspects of the bleb in a masked fashion. An overview of the morphological The inclusion criterion was medically uncontrolled situation is acquired with diffuse illumination and ×16 magnification POAG necessitating filtering surgery. We excluded patients (a). A high magnification image (×40) allows the assessment of with glaucomas other than POAG, previous glaucoma microcyst formation (arrowheads) within the epithelial layer of the surgery or any other type of ocular surgery that might have bleb (b). Direction of the vertical and horizontal SL-OCT scans (c) affected the conjunctival integrity, chronic or recurrent affections as well as scarring of the conjunctiva, poor patient cooperation and inability to complete all follow-up visits. study instead of direct clinical evaluation, functional tests All patients underwent a standardized trabeculectomy on bleb appearance were not applicable. procedure [9] performed by one surgeon (TT). However, no In our present study a 1,310 nm laser diode with a adjustable or releasable sutures were used. During surgery, coherence length of 20 μm was used. The same examiner a 2×2 mm sponge soaked with 0.2 mg/ml of mitomycin C (TT) performed two SL-OCT scans of 12.5 mm lateral (MMC) was applied to the determined filtration site for 2 width on each study eye. The first scan was directed min. After MMC application the area was irrigated with vertical and the second horizontal to the corneoscleral 60 ml of physiologic saline [Balanced Salt Solution (BSS), limbus. The scanning depth in air was 6.5 mm and the Alcon Laboratories, Fort Worth, TX, USA]. resolution in ocular tissue was approximately 10 μm All patients underwent a standard ophthalmologic exam- longitudinally and 16 μm laterally. All scans were directed ination including best-corrected visual acuity, slit lamp through the most prominent parts of the filtering blebs. examination, Goldmann applanation tonometry and binoc- Time delay and intensity of the reflected infrared light were ular fundus examination on day 1 and 1, 2, 4 and 12 weeks computed into logarithmic grey-scale images to allow post-operatively. We defined surgical success as intraocular tomographic bleb analysis. To estimate the bleb volume, pressure (IOP)≤21 mmHg without additional antiglauco- the tomograms enclosed the peripheral cornea and the matous medication and no need for bleb needling or bleb clinically non-filtering conjunctiva. On both tomograms revision independent of IOP values. We documented the made, the peak distance between the most superior bleb trabeculectomy filtering blebs by slit lamp photography reflex (presumed epithelium) and increased reflex within (Imagenet, Topcon Corporation, Tokyo, Japan) and slit the depth of the filtering zone (presumed sclera) was lamp-adapted optical coherence tomography (SL-OCT, determined and taken for further analysis. The lateral Heidelberg Engineering, Lübeck, Germany). borders of the filtering zone, e.g. the beginning of oedema, Bleb photography included an overview as well as a were determined by comparison with scans of the conjunc- detail shot (Fig. 1). As we used photographs in our present tiva away from the bleb. Assuming that the filtering zone Graefe’s Arch Clin Exp Ophthalmol (2007) 245:877–882 879 Table 1 Semi-quantitative conversion scales for clinical features and SL-OCT characteristics of filtering blebs after trabeculectomiesa Evaluation by Qualities measured Estimation of bleb qualities 01 2 3 Clinical photograph Hyperaemia None Mild Moderate Strong Corkscrew vessels None Mild Moderate Strong Epithelial microcysts No Yes –– Demarcation (Tenon’s cyst) No Yes –– SL-OCT Mean reflectivity bleb wall – Low Moderate Strong Mean reflectivity deep bleb tissue – Low Moderate Strong Superficial cyst-like hypo-reflective spaces None Single small Multiple small Single large Deep cyst-like hypo-reflective spaces None Single small Multiple small Single large Hypo-reflective layer formation within bleb None Single Multiple (“striping”) – Visibility of sclera beneath the filtering zone – Poor Moderate Good a Conversion of data was repeated for all visits of all patients, e.g. for day 1 and weeks 1, 2, 4 and 12 after surgery. This resulted in 750 data points from 15 eyes available for analysis may be approximated by a bisected ellipsoid, we calculated Windows (SPSS Inc., Chicago, IL, USA). Differences the volume of a bleb as between successful and unsuccessful cases and sex-depen- dent divergences were put through Fisher’s exact test. 4= p Á x Á y Á z ð1Þ 3 Pearson correlation coefficients were evaluated to analyse with x=maximal width, y=maximal length and z=maximal relations between OCT bleb measurements and IOP. We height of the filtering
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