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Gene May 2020Osteogenesis imperfecta (OI) is a rare disease characterized by increased bone fragility and predisposition to fractures, bone deformities and other major signs such as...
Rare splicing mutation in COL1A1 gene identified by whole exomes sequencing in a patient with osteogenesis imperfecta type I followed by prenatal diagnosis: A case report and review of the literature.
BACKGROUND
Osteogenesis imperfecta (OI) is a rare disease characterized by increased bone fragility and predisposition to fractures, bone deformities and other major signs such as dentinogenesis imperfecta, blue sclera and deafness. Over 90% of OI cases are caused by mutations in the COL1A1 and COL1A2 genes and the inheritance is autosomal dominant.
METHODS
We present a case of a couple requesting genetic counseling, because the man was diagnosed with OI on a clinical and radiological basis and the woman was pregnant. Whole exomes sequencing (WES) was performed in order to identify the mutation (s), followed by prenatal diagnosis.
RESULTS
WES identified a rare splicing mutation c.1155 + 1G > C in the COL1A1 gene recognized to be pathogenic and subsequently confirmed by next generation sequencing. The carrier state of the mutation was excluded for the fetus, so the pregnancy was further pursued and a healthy baby was born at term.
CONCLUSIONS
WES is a new and effective technique for detecting pathogenic variants in monogenic diseases and it is preferable to use such a technique in diseases with genetic heterogeneity especially when time does not allow another time-consuming diagnostic technique such classical Sanger sequencing. WES offers possibility to expand the global spectrum of OI pathogenic variants enabling the diagnosis of the disease.
Topics: Adult; Alternative Splicing; Collagen Type I; Collagen Type I, alpha 1 Chain; Exome; Female; Genotype; High-Throughput Nucleotide Sequencing; Humans; Male; Mutation; Osteogenesis Imperfecta; Pedigree; Pregnancy; Prenatal Diagnosis; Protein Isoforms; Exome Sequencing
PubMed: 32165296
DOI: 10.1016/j.gene.2020.144565 -
Ophthalmic Research 2021Scleral and iris fixation of intraocular lenses (IOL) are useful in the treatment of surgical or traumatic aphakia, luxation, and subluxation of IOL if the patient does...
Scleral and iris fixation of intraocular lenses (IOL) are useful in the treatment of surgical or traumatic aphakia, luxation, and subluxation of IOL if the patient does not present appropriate capsular support. However, there is no consensus in the literature about which of these 2 methods is safer and better. The authors performed a literature review searching the main postoperative outcomes obtained with the use of each surgical method. Scleral and iris fixation of IOL are efficient in correction of the patients' visual acuity, even though each technique presents distinct complications which depend especially on the experience of the surgeon with the performed surgical method. It is important to understand that individuals submitted to scleral or iris fixation present previous preoperative complications in their eyes. Besides, both procedures are very complex, involving intense manipulation of the eye globe. The success rate of these surgical techniques is highly variable and has a close relation to the preoperative conditions of the patient's eye and the improvement of the surgeon's learning curve.
Topics: Humans; Iris; Lens Diseases; Lens Implantation, Intraocular; Lenses, Intraocular; Sclera; Suture Techniques; Visual Acuity
PubMed: 32163944
DOI: 10.1159/000507120 -
Graefe's Archive For Clinical and... Feb 2020To investigate the effectiveness and safety of posterior scleral reinforcement (PSR) combined with vitrectomy for myopic foveoschisis (MF) treatment. (Meta-Analysis)
Meta-Analysis
PURPOSE
To investigate the effectiveness and safety of posterior scleral reinforcement (PSR) combined with vitrectomy for myopic foveoschisis (MF) treatment.
METHODS
We conducted a systematic review and meta-analysis. We evaluated the improvement of best-corrected visual acuity (BCVA) in logMAR unit, the percentage of patients with improved or stabled BCVA, benefit on axial length (AL), the retinal reattachment rate, the macular hole (MH) closure rate, as well as the complication rate.
RESULTS
Fourteen studies (311 eyes) were included. Overall, patients' BCVA improved - 0.46 (95% confidence interval [CI] - 0.52, - 0.40) logMAR unit, with 80% (95%CI 74%, 85%) benefiting from BCVA improvement and 6% (95%CI 3%, 10%) suffering from BCVA loss. Patients' AL was shortened by - 1.74 (95%CI - 2.92, - 0.57) mm, and for patients whose AL was ≥ 30 mm, the average benefit reached - 3.68 (95%CI - 4.59, - 2.77) mm. Ninety-three percent (95%CI 89%, 96%) of the patients achieved retinal reattachment, and 65% (95%CI 47%, 80%) of the MH was closed. Patients' central foveal thickness decreased; the MD was - 187.32 (95%CI - 206.25, - 168.40) mm. The pooled complication rate was 9% (95%CI 8%, 19%), with extrusion, choroidal atrophy, and choroidal neovascularization being the most common complications. Subgroup analysis indicated no statistical difference in BCVA improvement, AL change, retinal reattachment rate, and complication rate between patients with or without MH. Subgroup analysis indicated no statistical difference in the above four outcomes between the primary and the recurrent patients either. There was no statistical difference in the above four outcomes no matter ILM peeling was combined or not.
CONCLUSION
PSR combined with vitrectomy helps improve 80% MF patients' BCVA; the average benefit on BCVA is - 0.46 logMAR unit. The average change in AL is - 1.74 mm; patients with AL ≥ 30 mm benefit much more than the patients with AL < 30 mm. The retinal reattachment rate is up to 93%; the MH closure rate is 65%. About 9% patients will suffer from extrusion, choroidal atrophy, choroidal neovascularization, and other complications. The outcomes were not influenced by presence of MH, disease recurrence, or ILM peeling.
Topics: Fovea Centralis; Humans; Myopia, Degenerative; Retinoschisis; Sclera; Tomography, Optical Coherence; Treatment Outcome; Visual Acuity; Vitrectomy
PubMed: 31823060
DOI: 10.1007/s00417-019-04550-5 -
Ophthalmic Research 2020Myopia, especially high myopia, would cause damage in the choroid, retina and sclera, thereby leading to vision loss. Although refractive error correction can help... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Myopia, especially high myopia, would cause damage in the choroid, retina and sclera, thereby leading to vision loss. Although refractive error correction can help improve visual acuity, the pathology of myopia, a global issue, remains unclear and myopia progression, as well as concomitant fundus progression, remains uncontrolled. Under such circumstances, prevention of myopia is of great significance and thus should be prioritized.
OBJECTIVE
To explore whether outdoor time has positive significance for myopia prevention.
SEARCH METHODS
Databases of Pubmed, Science Direct, the Cochrane Library, the Chinese National Knowledge Infrastructure and the Wanfang Database were searched. The following terms or their combinations were used: myopia, prevention, control, random, randomized, randomization, intervention, outdoor. The full search strategy was shown in the Appendix below. The databases were last searched on -October 24, 2018.
SELECTION CRITERIA
Randomized controlled trials (RCTs) that participants accepted outdoor activity as an intervention measure for myopia prevention were included.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed the risk of bias for included studies. A fixed-effects model was applied, given that the heterogeneity among included studies was small.
MAIN RESULTS
Five RCTs with 3,014 subjects were included. Subjects' age ranged from 6 to 12 years, and the follow-up duration ranged from 9 to 36 months. Spherical equivalent error (SER) of the outdoor group was larger than that of the control group, and the pooled mean difference (MD) was 0.15 (95% CI 0.06-0.23) diopter (D). The change in SER of the outdoor group was smaller than that of the control group, with a pooled MD of 0.17 (95% CI 0.16-0.18) D. New myopia cases in the outdoor group were fewer than that of the control group, and the pooled risk ratio was 0.76 (95% CI 0.67-0.87). The change in axial length of the outdoor group was smaller than that of the control group, and the pooled MD was -0.03 (95% CI -0.03 to -0.03) mm. For all analyzed outcomes, there was no heterogeneity across included studies (I2 = 0%) and there was no publication bias either.
CONCLUSION
Outdoor time helps slow down the change of axial length and reduce the risk of myopia.
Topics: Humans; Myopia; Randomized Controlled Trials as Topic; Seasons; Time Factors; Visual Acuity
PubMed: 31430758
DOI: 10.1159/000501937 -
American Journal of Ophthalmology Aug 2018To compare the clinical outcomes and main complications of transscleral-fixated (TSF), intrascleral-fixated (ISF), and iris-fixated (IF) intraocular lenses (IOLs). (Comparative Study)
Comparative Study Meta-Analysis
PURPOSE
To compare the clinical outcomes and main complications of transscleral-fixated (TSF), intrascleral-fixated (ISF), and iris-fixated (IF) intraocular lenses (IOLs).
DESIGN
Systematic review and network meta-analysis.
METHODS
The authors searched PubMed, EMBASE, and the Cochrane Library for relevant articles up to April 2017 with no language restrictions, and related studies meeting the eligibility criteria were included. A Bayesian framework was applied to compare the visual outcomes and complications of these 3 approaches.
RESULTS
A total of 14 studies with 845 eyes were included in the present report. There was no significant difference between any pair of surgical approaches in best-corrected visual acuity (BCVA) and in final BCVA achieving 20/40 or better (Snellen). ISF presented a lower risk of cystoid macular edema (CME) compared with TSF (risk ratio [RR], 0.45; 95% confidence interval [CI], [0.18, 1.0]). IF showed superiorities in less intraocular hemorrhage (IOH) than ISF (RR, 0.078; 95% CI [0.0095, 0.38]), as well as TSF (RR, 0.26; 95% CI, [0.09, 0.72]). IF had a lower risk of glaucoma escalation; the difference was slightly higher than the conventional level of significance (RR, 0.41; 95% CI, [0.16, 1.04]). Moreover, the surgical time in IF was shorter than TSF (standard mean difference [SMD], -2.98; 95% CI, [-4.32, -1.64]) and ISF (SMD, -2.60; 95% CI, [-3.71, -1.49]). However, IF was associated with a significantly higher risk of endothelial cell density (ECD) impairment (SMD, -0.54; 95% CI, [-1.02, -0.05]) and significantly greater postoperative corneal endothelial cell loss rate (ECLR, %) (SMD, 0.35; 95% CI, [0.08, 0.63]) compared with TSF.
CONCLUSIONS
Postoperative visual outcomes were comparable among TSF, ISF, and IF for eyes with insufficient capsular support. However, the risk of some complications differed among approaches. IF showed its superiorities in lower risk of IOH and glaucoma escalation as well as shorter surgical time, while IF was at a disadvantage in greater endothelial cell impairment. Since some patients might have a clear contraindication to one of the surgical approaches, the decision of surgical approach eventually depends on surgeon experience and the presenting pathology.
Topics: Aphakia, Postcataract; Corneal Endothelial Cell Loss; Eye Hemorrhage; Humans; Iris; Lens Capsule, Crystalline; Lens Implantation, Intraocular; Lenses, Intraocular; Macular Edema; Network Meta-Analysis; Operative Time; Postoperative Complications; Sclera; Visual Acuity
PubMed: 29750951
DOI: 10.1016/j.ajo.2018.04.023 -
BMC Ophthalmology Nov 2017Anti-fibrotic, anti-VEGF (vascular endothelial growth factor) medications, or radiotherapy, as adjuvant for pterygium surgical procedure, has been suggested for reducing... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Anti-fibrotic, anti-VEGF (vascular endothelial growth factor) medications, or radiotherapy, as adjuvant for pterygium surgical procedure, has been suggested for reducing recurrence, but difficulties may be experienced in deciding which treatment to use. The purpose of this study was to compare the efficacies of these different adjuvants for preventing recurrence following pterygium surgery.
METHODS
We conducted a systematic review to identify randomized controlled trials of patients with primary or recurrent pterygium who received anti-fibrotic, anti-VEGF medication, or radiotherapy as adjuvants in combination with surgical procedure. The surgical procedure contained bare sclera technique or petrygium excision combination with tissue grafting. The primary outcome of this study was recurrence. Direct-comparison and Bayesian network meta-analyses were performed to assess direct and indirect evidence of efficacy.
RESULTS
We obtained data from 34 randomized controlled trials, representing a total of 2483 patients. Adjuvants included bevacizumab, 5-FU (5-fluorouracil), MMC (mitomycin C), and β-RT (beta-radiotherapy). Compared with placebo, we found distinguishable improvement in recurrence with bevacizumab (odds ratio [OR] 0.38, 95% confidence interval [CI] 0.18-0.80), MMC (0.12, 95% CI 0.06-0.21), and β-RT (0.17, 95% CI 0.04-0.69), but not with 5-FU (0.41, 95% CI 0.12-1.39). MMC significantly reduced recurrence when compared to bevacizumab (0.31, 95% CI 0.13-0.77) and 5-FU (0.28, 95% CI 0.08-0.99). The probability of having the most recurrences after excision was lowest for MMC, followed by bevacizumab and β-RT. Similar results were found in subgroup analyses, including for primary pterygium, and the patients receiving bare sclera technique or conjunctival autograft.
CONCLUSIONS
Adjuvants such as MMC, bevacizumab, and β-RT could effectively prevent recurrence following pterygium excision. However, their efficacy and acceptability require further clarification in future randomized controlled trials.
Topics: Alkylating Agents; Angiogenesis Inhibitors; Antifibrinolytic Agents; Chemotherapy, Adjuvant; Humans; Ophthalmologic Surgical Procedures; Primary Prevention; Pterygium; Radiotherapy, Adjuvant; Randomized Controlled Trials as Topic; Recurrence; Secondary Prevention; Vascular Endothelial Growth Factor A
PubMed: 29178848
DOI: 10.1186/s12886-017-0601-5 -
Aesthetic Surgery Journal Jul 2017Lower eyelid retraction is a difficult problem to treat, but it is a prevalent condition and a common complication of blepharoplasty. The use of spacer grafts to... (Comparative Study)
Comparative Study Review
BACKGROUND
Lower eyelid retraction is a difficult problem to treat, but it is a prevalent condition and a common complication of blepharoplasty. The use of spacer grafts to increase eyelid height and improve symptoms has been described for a long time, but the optimal choice of spacer graft material is unknown.
OBJECTIVES
The authors reviewed the currently available evidence to determine the best available spacer graft material in terms of efficacy and complications.
METHODS
A systematic review of all available literature published between 1985 and the present was performed using the Pubmed, Ovid MEDLINE, and Cochrane library databases. Inclusion criteria were that the studies contain original content assessing the treatment of lower eyelid retraction in humans using a spacer graft and provide quantitative outcomes data.
RESULTS
One hundred and twelve articles were reviewed following an initial screen using titles, and 19 articles were chosen for inclusion in this systematic review. Analysis of these articles revealed no spacer graft material that is clearly superior to others.
CONCLUSIONS
Due to a lack of high quality evidence, this review did not reveal one spacer graft material that is clearly superior to others. However, a narrative summary of the available evidence reveals unique sets of advantages and disadvantages associated with the various materials currently available. Further research in the form of well-designed studies will be necessary to further clarify advantages of certain spacer graft materials over others.
LEVEL OF EVIDENCE
5.
Topics: Biocompatible Materials; Blepharoptosis; Cartilage; Collagen; Conjunctiva; Dermis; Eyelid Diseases; Eyelids; Humans; Mouth Mucosa; Postoperative Complications; Plastic Surgery Procedures; Sclera; Transplants; Treatment Outcome
PubMed: 28333254
DOI: 10.1093/asj/sjx003 -
The Cochrane Database of Systematic... Dec 2016Pterygium, a growth of the conjunctiva over the cornea, is a progressive disease leading in advanced stages to visual impairment, restriction of ocular motility, chronic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pterygium, a growth of the conjunctiva over the cornea, is a progressive disease leading in advanced stages to visual impairment, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence can be a problem. Currently the best surgical option in terms of recurrence is conjunctival autograft. To date the most common surgical methods of attaching conjunctival autografts to the sclera are through suturing or fibrin glue. Each method presents its own advantages and disadvantages. Sutures require considerable skill from the surgeon and can be associated with a prolonged operation time, postoperative discomfort and suture-related complications, whereas fibrin glue may give a decreased operation time, improve postoperative comfort and avoid suture-related problems.
OBJECTIVES
To assess the effectiveness of fibrin glue compared to sutures in conjunctival autografting for the surgical treatment of pterygium.
SEARCH METHODS
We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2016), Embase (January 1980 to October 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 14 October 2016.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) in any setting where fibrin glue was compared with sutures to treat people with pterygium.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the search results, assessed trial quality, and extracted data using standard methodological procedures expected by Cochrane. Our primary outcome was recurrence of pterygium defined as any re-growth of tissue from the area of excision across the limbus onto the cornea. The secondary outcomes were surgical time and complication rate. We graded the certainty of the evidence using GRADE.
MAIN RESULTS
We included 14 RCTs conducted in Brazil, China, Egypt, India, Malaysia, New Zealand, Philippines, Saudi Arabia, Sweden and Turkey. The trials were published between 2004 and 2016, and were assessed as a mixture of unclear and low risk of bias with three studies at high risk of attrition bias. Only adults were enrolled in these studies.Using fibrin glue for the conjunctival autograft may result in less recurrence of pterygium compared with using sutures (risk ratio (RR) 0.47, 95% CI 0.27 to 0.82, 762 eyes, 12 RCTs; low-certainty evidence). If pterygium recurs after approximately 10 in every 100 surgeries with sutures, then using fibrin glue may result in approximately 5 fewer cases of recurrence in every 100 surgeries (95% CI 2 fewer to 7 fewer cases). Using fibrin glue may lead to more complications compared with sutures (RR 1.92; 95% CI 1.22 to 3.02, 11 RCTs, 673 eyes, low-certainty evidence). The most common complications reported were: graft dehiscence, graft retraction and granuloma. On average using fibrin glue may mean that surgery is quicker compared with suturing (mean difference (MD) -17.01 minutes 95% CI -20.56 to -13.46), 9 RCTs, 614 eyes, low-certainty evidence).
AUTHORS' CONCLUSIONS
The meta-analyses, conducted on people with pterygium in a hospital or outpatient setting, show fibrin glue may result in less recurrence and may take less time than sutures for fixing the conjunctival graft in place during pterygium surgery. There was low-certainty evidence to suggest a higher proportion of complications in the fibrin glue group.
Topics: Autografts; Conjunctiva; Fibrin Tissue Adhesive; Humans; Pterygium; Randomized Controlled Trials as Topic; Recurrence; Secondary Prevention; Sutures; Tissue Adhesives; Transplantation, Autologous
PubMed: 27911983
DOI: 10.1002/14651858.CD011308.pub2 -
The Cochrane Database of Systematic... Feb 2016A pterygium is a fleshy, wing-shaped growth from the conjunctiva, crossing over the limbus onto the cornea. Prevalence ranges widely around the world. Evidence suggests... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
A pterygium is a fleshy, wing-shaped growth from the conjunctiva, crossing over the limbus onto the cornea. Prevalence ranges widely around the world. Evidence suggests that ultraviolet light is a major contributor in the formation of pterygia. Pterygia impair vision, limit eye movements, and can cause eye irritation, foreign body sensation, and dryness. In some susceptible patients, the pterygium can grow over the entire corneal surface, blocking the visual axis.Surgery is the only effective treatment for pterygium, though recurrences are common. With simple excision techniques (that is, excising the pterygium and leaving bare sclera), the risk of recurrence has been reported to be upwards of 80%. Pterygium excision combined with a tissue graft has a lower risk of recurrence. In conjunctival autograft surgery, conjunctival tissue from another part of the person's eye along with limbal tissue is resected in one piece and used to cover the area from which the pterygium was excised. Another type of tissue graft surgery for pterygium is amniotic membrane graft, whereby a piece of donor amniotic membrane is fixed to the remaining limbus and bare sclera area after the pterygium has been excised.
OBJECTIVES
The objective of this review was to assess the safety and effectiveness of conjunctival autograft (with or without adjunctive therapy) compared with amniotic membrane graft (with or without adjunctive therapy) for pterygium. We also planned to determine whether use of MMC yielded better surgical results and to assess the direct and indirect comparative costs of these procedures.
SEARCH METHODS
We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 10, 2015), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2015), EMBASE (January 1980 to November 2015), PubMed (1948 to November 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to November 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (last searched 21 November 2014), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 23 November 2015.
SELECTION CRITERIA
We included in this review randomized controlled trials that had compared conjunctival autograft surgery (with or without adjunctive therapy) with amniotic membrane graft surgery (with or without adjunctive therapy) in people with primary or recurrent pterygium.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened search results and assessed full-text reports from among the potentially eligible trials. Two review authors independently extracted data from the included trials and assessed the trial characteristics and risk of bias. The primary outcome was the risk of recurrence of pterygium at 3 months and 6 months after surgery. We combined results from individual studies in meta-analyses using random-effects models. Risk of recurrence of pterygium was reported using risk ratios to compare conjunctival autograft with amniotic membrane transplant.
MAIN RESULTS
We identified 20 studies that had analyzed a total of 1947 eyes of 1866 participants (individual studies ranged from 8 to 346 participants who were randomized). The studies were conducted in eight different countries: one in Brazil, three in China, three in Cuba, one in Egypt, two in Iran, two in Thailand, seven in Turkey, and one in Venezuela. Overall risk of bias was unclear, as many studies did not provide information on randomization methods or masking to prevent performance and detection bias.The risk ratio for recurrence of pterygium using conjunctival autograft versus amniotic membrane transplant was 0.87 (95% confidence interval (CI) 0.43 to 1.77) and 0.53 (95% CI 0.33 to 0.85) at 3 months and 6 months, respectively. These estimates include participants with primary and recurrent pterygia. We performed a subgroup analysis to compare participants with primary pterygia with participants with recurrent pterygia. For participants with primary pterygia, the risk ratio was 0.92 (95% CI 0.37 to 2.30) and 0.58 (95% CI 0.27 to 1.27) at 3 months and 6 months, respectively. We were only able to estimate the recurrence of pterygia at 6 months for participants with recurrent pterygia, and the risk ratio comparing conjunctival autograft with amniotic membrane transplant was 0.45 (95% CI 0.21 to 0.99). One included study was a doctoral thesis and did not use allocation concealment. When this study was excluded in a sensitivity analysis, the risk ratio for pterygium recurrence at 6 months' follow-up was 0.43 (95% CI 0.30 to 0.62) for participants with primary and recurrent pterygium. One of the secondary outcomes, the proportion of participants with clinical improvement, was analyzed in only one study. This study reported clinical outcome as the risk of non-recurrence, which was seen in 93.8% of participants in the conjunctival limbal autograft group and 93.3% in the amniotic membrane transplant group at 3 months after surgery.We did not analyze data on the need for repeat surgery, vision-related quality of life, and direct and indirect costs of surgery due to an insufficient number of studies reporting these outcomes.Thirteen studies reported adverse events associated with conjunctival autograft surgery and amniotic membrane transplant surgery. Adverse events that occurred in more than one study were granuloma and pyogenic granuloma and increased intraocular pressure. None of the included studies reported that participants had developed induced astigmatism.
AUTHORS' CONCLUSIONS
In association with pterygium excision, conjunctival autograft is associated with a lower risk of recurrence at six months' after surgery than amniotic membrane transplant. Participants with recurrent pterygia in particular have a lower risk of recurrence when they receive conjunctival autograft surgery compared with amniotic membrane transplant. There are few studies comparing the two techniques with respect to visual acuity outcomes, and we identified no studies that reported on vision-related quality of life or direct or indirect costs. Comparison of these two procedures in such outcome measures bears further investigation. There were an insufficient number of studies that used adjunctive mitomycin C to estimate the effects on pterygium recurrence following conjunctival autograft or amniotic membrane transplant.
Topics: Amnion; Autografts; Conjunctiva; Humans; Pterygium; Randomized Controlled Trials as Topic; Recurrence; Time Factors
PubMed: 26867004
DOI: 10.1002/14651858.CD011349.pub2 -
The Cochrane Database of Systematic... Nov 2015Glaucoma is one of the leading largely preventable causes of blindness in the world. It usually is addressed first medically with topical intraocular pressure-lowering... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Glaucoma is one of the leading largely preventable causes of blindness in the world. It usually is addressed first medically with topical intraocular pressure-lowering drops or by laser trabeculoplasty. In cases where such treatment fails, glaucoma-filtering surgery is considered, most commonly trabeculectomy surgery with variations in technique, for example, the type of conjunctival flap (fornix- or limbal-based). In a fornix-based flap, the surgical wound is performed at the corneal limbus; while in a limbal-based flap, the incision is further away. Many studies in the literature compare fornix- and limbal-based trabeculectomy with respect to outcomes and complications.
OBJECTIVES
To assess the comparative effectiveness of fornix- versus limbal-based conjunctival flaps in trabeculectomy for adult glaucoma, with a specific focus on intraocular pressure (IOP) control and complications (adverse effects).
SEARCH METHODS
We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2015), EMBASE (January 1980 to October 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 23 October 2015.We reviewed the bibliographic references of identified randomised controlled trials (RCTs) in order to find trials not identified by the electronic searches. We contacted researchers and practitioners active in the field of glaucoma to identify other published and unpublished trials.
SELECTION CRITERIA
We included RCTs comparing the benefits and complications of fornix- versus limbal-based trabeculectomy for glaucoma, irrespective of glaucoma type, publication status, and language. We excluded studies on children less than 18 years of age, since wound healing is different in this age group and the rate of bleb scarring postoperatively is high.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed trial quality. We contacted study authors for additional information.The primary outcome was the proportion of failed trabeculectomies at 24 months. Failure was defined as the need for repeat surgery or uncontrolled IOP (more than 22 mmHg), despite additional topical/systemic medications. Needling and 5-fluorouracil (5-FU) injections were allowed only during the first six months postoperatively; additional needling or 5-FU injections were considered as failure. Mean post-operative IOP at 12 and 24 months also was recorded.
MAIN RESULTS
The review included six trials with a total of 361 participants. Two studies were conducted in America and one each in Germany, Greece, India, and Saudi Arabia. The participants of four trials had open-angle glaucoma; one study included participants with primary open-angle or primary closed-angle glaucoma, and one study did not specify the type of glaucoma. Three studies used a combined procedure (phacotrabeculectomy). Trabeculectomy with mitomycin C (MMC) was performed in four studies, and trabeculectomy with 5-fluorouracil (5-FU) was performed in only one study.None of the included trials reported trabeculectomy failure at 24 months. Only one trial reported the failure rate of trabeculectomy as a late complication. Failure was higher among participants randomised to the limbal-based surgery: 1/50 eyes failed trabeculectomy in the fornix group compared with 3/50 in the limbal group (risk ratio (RR) 0.33, 95% confidence interval (95% CI) 0.04 to 3.10); therefore we are very uncertain as to the relative effect of the two procedures on failure rate.Four studies including 252 participants provided measures of mean IOP at 12 months. In the fornix-based surgeries, mean IOP ranged from 12.5 to 15.5 mmHg and similar results were noted in limbal-based surgeries with mean IOP ranging from 11.7 to 15.1 mmHg without significant difference. Mean difference was 0.44 mmHg (95% CI -0.45 to 1.33) and 0.86 mmHg, (95% CI -0.52 to 2.24) at 12 and 24 months of follow-up, respectively. Neither of these pooled analyses showed a statistically significant difference in IOP between groups (moderate quality of evidence).One trial reported number of anti-glaucoma medications at 24 months of follow-up with no difference noted between surgical groups. However, three trials reported the mean number of anti-glaucoma medications at 12 months of follow-up without significant difference in the mean number of postoperative IOP-lowering medications between the two surgical techniques. Mean difference was 0.02, (95% CI -0.15 to 0.19) at 12 months of follow-up (high quality of evidence).Because of the small numbers of events and total participants, the risk of many reported adverse events were uncertain and those that were found to be statistically significant may have been due to chance.For risk of bias assessment: although all six trials were randomised selection bias was mostly unclear, with unclear random sequence generation in four of the six studies and unclear allocation concealment in five of the six studies. Attrition bias was encountered in only one trial which also suffered from reporting bias. All other trials had an unclear risk of reporting bias as there was no access to study protocols. All included trials were judged to have high risk of detection bias due to lack of masking of the outcomes. Trabeculectomy is quite a standard procedure and unlikely to induce bias due to surgeon 'performance', hence performance bias was not evaluated.
AUTHORS' CONCLUSIONS
The main result of this review was that there was uncertainty as to the difference between fornix- and limbal-based trabeculectomy surgeries due to the small number of events and confidence intervals that cross the null. This also applied to postoperative complications, but without any impact on long-term failure rate between the two surgical techniques.
Topics: Antihypertensive Agents; Fluorouracil; Glaucoma; Humans; Intraocular Pressure; Limbus Corneae; Mitomycin; Randomized Controlled Trials as Topic; Sclera; Surgical Flaps; Trabeculectomy; Treatment Failure
PubMed: 26599668
DOI: 10.1002/14651858.CD009380.pub2