Amniotic Membrane-Assisted Trabeculectomy for Refractory Glaucoma with Corneal Disorders

Research Articlee

Austin J Clin Ophthalmol. 2014;1(5): 1026.

Amniotic Membrane-Assisted Trabeculectomy for Refractory Glaucoma with Corneal Disorders

Kazuhiko Mori*, Yoko Ikeda, Shigeta Naruse, Morio Ueno and Shigeru Kinoshita

Department of Ophthalmology, Kyoto Prefectural University of Medicine, Japan

*Corresponding author: Kazuhiko Mori, Department of Ophthalmology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Hirokoji-agaru, Kawaramachidori, Kamigyo-ku, Kyoto 602-0841

Received: May 20, 2014; Accepted: June 30, 2014; Published: July 01, 2014


Purpose: To report 6 consecutive cases which underwent amniotic membrane (AM)-assisted trabeculectomy (TLE) to treat refractory glaucoma with severe corneal disorders.

Materials and Methods: This study involved 6 patients (3 males/3 females, mean age: 69.5±15.8 years) with refractory glaucoma and severe corneal disorders. The surgical procedure for each patient involved trabecular tissue being excised, and human AM then being placed epithelial-side-up on the corneal surface, sutured at the limbal sclera, and flipped over onto the sclera to cover the TLE area. The remaining edge of the AM was then inserted into the sub conjunctival space and sutured. Medical records of all cases were reviewed in regard to intraocular pressure (IOP), visual acuity (VA), and condition of the filtering bleb and ocular surface.

Results: The mean observation period was 69.5±15.8 months, and mean IOP at pre surgery and at 1, 3, and 7 years postoperative was 40.3±6.9, 23.0±12.1, 25.6±12.8, and 28.5±19.1 mmHg, respectively. Glaucoma medications decreased from 3.0±1.1 drugs (pre-surgery) to 0.8±1.0 (7 years postoperative). However, in some cases, ocular surface conditions or VA worsened during the follow-up period.

Conclusion: Using AM as an internal patch for TLE, moderately good, long-term IOP control was maintained, however, ocular surface conditions required special care.

Keywords: Amniotic membrane; Refractory glaucoma; Trabeculectomy


Glaucoma with corneal disorders including ocular surface diseases is one of the most refractory types of glaucoma. Filtering surgery often fails due to severe inflammation, recurrent conjunctival scarring, proliferation of subconjunctival fibrous tissue, and the high risk of infection in patients taking immune-suppressive drugs. Other surgical procedures such as tube-shunt surgery are not always effective for severe ocular surface disorders, because they may result in many problems such as cicatricial reaction of the conjunctivae, exposure of the tube or plate, and corneal endothelial damage.

Recently, the use of human amniotic membrane (AM) in ocular surface reconstruction has reportedly yielded good outcomes [1-7]. In 1910, Davis [8] first described the use of AM in skin transplantation procedures. In the field of ophthalmology, AM was reportedly employed in the 1940’s to repair conjunctival defects after chemical burns, [9,10] however, the results were not promising. Successful AM transplantation for ocular surface reconstruction was reported 50 years later [1,4], and AM is now the focus of attention as a biomaterial for the treatment of severe ocular surface diseases such as ocular pemphygoid, Stevens-Johnson syndrome, and chemical burns. Koizumi et al. [6] and Nakamura et al. [7] reported very good prognoses when using AM as a transporter of cultured corneal epithelium to treat patients with severe ocular surface diseases. In ocular surface reconstruction, AM offers several benefits, as it can be easily obtained and preserved for several months, is not rejected immunologically, suppresses fibroblast proliferation, and accelerates cell migration and growth. Therefore, we theorized that AM might be suitable for glaucoma filtering surgery.

To date, there have been few reports on the use of AM in glaucoma surgery [11-14]. Fujishima et al.[11] reported the effectiveness of AM for reducing intraocular pressure (IOP) in high-risk patients when it was placed under the scleral flap, yet Budenz et al. [12] found that AM transplantation was not an effective alternative to conjunctival advancement in patients undergoing the repair of leaking glaucoma filtering blebs; however, it should be noted that their total replacement of the leaking bleb with AM exposed it to constant pressure without supportive structures above or beneath the filtering bleb. In the presence of such structures, AM might be able to resist that pressure and function as part of the bleb wall. Based on these considerations we theorized that an AM patch could be introduced below the filtering bleb. The purpose of this present study was to report 6 patients with refractory glaucoma with corneal severe disorders who were treated with AM-assisted trabeculectomy (TLE).

Patients and Methods

This study involved 6 consecutive patients (3 males and 3 females, mean age: 69.5±15.8 years) with refractory glaucoma and corneal disorders who were treated with AM-assisted trabeculectomy (TLE) between March 2000 and April 2002. Written informed consent was obtained from all patients for the use of AM, and the procedure was approved by the Human Studies Committee of Kyoto Prefectural University of Medicine. IOP measurements of each patient were obtained by use of a Goldman applanation tonometer, and the surgical procedure for each patient was as follows. First, under local anesthesia an adequate amount of sclera was exposed by careful detachment of the scarred conjunctiva and conventional TLE was then performed. A limbal-based conjunctival flap was then produced and inoculated with a 0.4 mg/ml treatment of mitomycin C (MMC) for 3 minutes (Figure 1A). Next, deep-frozen human AM obtained at the time of Caesarean section was thawed, trimmed to the proper size, placed epithelial-side-up on the corneal surface, and sutured at the limbal sclera beside the scleral flap using 10-0 nylon sutures (Figure 1B). The other edge of the AM was then flipped over (epithelial-side-down) to cover the scleral flap (Figure 1C). Finally, continuous conjunctival suturing with 10-0 polypropylene was performed (Figure 1D). A cross-sectional view of the filtering bleb with the AM patch is shown in (Figure 1E).

Citation: Morishige N. In Vivo Sectioning of a Diseased Cornea by Anterior Segment–Optical Coherence Tomography. Austin J Clin Ophthalmol. 2014;1(5): 1026. ISSN : 2381-9162