臺灣博碩士論文加值系統

目的：在接受絲裂黴素（Mitomycin-C）輔助小樑切除術的病人中，比較使用角膜緣結膜瓣與穹窿結膜瓣之長期術後效果及安全性。
方法：在連續性回溯共273個接受絲裂黴素（Mitomycin-C）輔助小樑切除術的眼睛中，前126 個眼睛接受使用角膜緣結膜瓣術式，後續147個眼睛接受使用穹窿結膜瓣術式。完全成功（Complete success）的定義為術後不使用藥物下眼壓可降低超過術前眼壓20%，或是術前需使用2種以上青光眼藥物維持眼壓小於15毫米汞柱者可在不使用任何藥物下維持術後眼壓小於15毫米汞柱。存活分析追蹤時間為3年或是到下一次青光眼手術前。
結果：使用Kaplan-Meier存活分析及多變數Cox回歸分析模式，在考慮兩組病人組成、術前眼壓和使用降眼壓藥物數量、術中因子的變數下，未發現兩組病人在使用角膜緣結膜瓣或是穹窿結膜瓣之長期術後成功率的不同。使用角膜緣結膜瓣的組別有較多的早期低眼壓性黃斑部病變 （4.8% vs. 0%, P = 0.007）和晚期結膜濾泡相關的感染（濾泡炎：4.8% vs. 0%, P = 0.007；濾泡相關眼內炎： 3.2% vs. 0%, P = 0.03）。
結論：使用穹窿結膜瓣術式的小樑切除術可提供相同於角膜緣結膜瓣術式的長期術後眼壓控制效果，但有較低的併發症發生率，尤其是術後低眼壓及晚期濾泡相關的感染。

Objectives： To compare the long-term effectiveness and safety of limbus-based and fornix-based conjunctival flaps in patients undergoing trabeculectomy with mitomycin-C (MMC) augmentation.
Methods：A retrospective review of 273 consecutive eyes which underwent MMC augmented trabeculectomy. The first 126 eyes received surgery with a limbus-based flap, whereas subsequent 147 eyes had fornix-based trabeculectomy. Complete success was defined as either postoperative intraocular pressure (IOP) reduction >20% without ocular hypotensive medication or medication-free IOP <15 mmHg in eyes whose preoperative IOP was controlled below 15 mmHg with ≥2 anti-glaucoma medications. The follow-up time was 3 years or until subsequent glaucoma surgery.
Results：Using Kaplan-Meier survival analysis and multivariate Cox regression model, no significant difference was detected between the groups with regard to patient demographics, preoperative IOP and number of ocular hypotensive medication. The limbus-based group had higher early complication of hypotonic maculopathy (4.8% vs. 0%, P = 0.007) and more late bleb-related infection (blebitis: 4.8% vs. 0%, P = 0.007; bleb associated endophthalmitis: 3.2% vs. 0%, P = 0.03).
Conclusions：Fornix-based trabeculectomy provides long-term IOP control comparable to limbus-based trabeculectomy, with less incidence of complication such as hypotony and late bleb-related infection.

Acknowledgments----------------------------------------- i
Chinese Abstract---------------------------------------- ii
English Abstract---------------------------------------- iv
Table of Contents--------------------------------------- vi
List of Figures---------------------------------------- viii
List of Tables ---------------------------------------- ix
Chapter 1 Introduction--------------------------------- 1
1.1 Background----------------------------------------- 1
1.2 Purpose-------------------------------------------- 3
Chapter 2 Literature Review---------------------------- 4
2.1 Effect of Conjunctival Closure Method on Intraocular Pressure----------------------------------------------- 4
2.2 Effect of Conjunctival Closure Method on Bleb Morphology and Complications----------------------------6
2.3 Gap ------------------------------------------------8
Chapter 3 Materials and Methods-------------------------9
3.1 Participants----------------------------------------9
3.2 Surgical Techniques --------------------------------10
3.3 Outcome Measurements--------------------------------12
3.4 Statistical Methods --------------------------------15
Chapter 4 Results---------------------------------------16
4.1 Demographic, Preoperative and Operative Data--------16
4.2 Success---------------------------------------------19
4.3 Complications---------------------------------------25
4.4 Subsequent Intervention and Eye Surgery-------------27
4.5 Bleb Morphology-------------------------------------29
Chapter 5 Discussion------------------------------------32
Chapter 6 Conclusion------------------------------------38
References----------------------------------------------39

List of Figures
Figure 1. Examples of Levels of Bleb Extent, Height and Vascularity from The Moorfields Bleb Grading System-----14
Figure 2. Kaplan–Meier Survival Curves for (A) Complete Success and (B) Qualified Success.----------------------20

List of Table
Table 1. Demographics, Preoperative and Operative Ocular Characteristics ----------------------------------------17
Table 2. Multivariate Cox Proportional Hazard Ratios for Risk Factors for Failure -------------------------------23
Table 3. Comparison of Early and Late Postoperative Complications between Limbus-based and Fornix-based Groups ---------------------------------------------------------26
Table 4. Comparison of Subsequent Intervention and Additional Surgery between Limbus-based and Fornixed-based Groups -------------------------------------------------28
Table 5. Bleb Morphology by Type of Conjunctival Flap---30

1. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. The British journal of ophthalmology. 2006;90:262-267
2. Wormald R, Wilkins MR, Bunce C. Post-operative 5-fluorouracil for glaucoma surgery. Cochrane database of systematic reviews (Online). 2001:CD001132
3. Wilkins M, Indar A, Wormald R. Intra-operative mitomycin c for glaucoma surgery. Cochrane database of systematic reviews (Online). 2005:CD002897
4. Alwitry A, Patel V, King AW. Fornix vs limbal-based trabeculectomy with mitomycin c. Eye (London, England). 2005;19:631-636
5. Kohl DA, Walton DS. Limbus-based versus fornix-based conjunctival flaps in trabeculectomy: 2005 update. International ophthalmology clinics. 2005;45:107-113
6. Fukuchi T, Ueda J, Yaoeda K, Suda K, Seki M, Abe H. Comparison of fornix- and limbus-based conjunctival flaps in mitomycin c trabeculectomy with laser suture lysis in japanese glaucoma patients. Japanese journal of ophthalmology. 2006;50:338-344
7. Murchison JF, Jr., Shields MB. Limbal-based vs fornix-based conjunctival flaps in combined extracapsular cataract surgery and glaucoma filtering procedure. American journal of ophthalmology. 1990;109:709-715
8. Jones E, Clarke J, Khaw PT. Recent advances in trabeculectomy technique. Current opinion in ophthalmology. 2005;16:107-113
9. Shuster JN, Krupin T, Kolker AE, Becker B. Limbus- v fornix-based conjunctival flap in trabeculectomy. A long-term randomized study. Archives of ophthalmology. 1984;102:361-362
10. Traverso CE, Tomey KF, Antonios S. Limbal- vs fornix-based conjunctival trabeculectomy flaps. American journal of ophthalmology. 1987;104:28-32
11. Reichert R, Stewart W, Shields MB. Limbus-based versus fornix-based conjunctival flaps in trabeculectomy. Ophthalmic surgery. 1987;18:672-676
12. Brincker P, Kessing SV. Limbus-based versus fornix-based conjunctival flap in glaucoma filtering surgery. Acta Ophthalmol (Copenh). 1992;70:641-644
13. el Sayyad F, el-Rashood A, Helal M, Hisham M, el-Maghraby A. Fornix-based versus limbal-based conjunctival flaps in initial trabeculectomy with postoperative 5-fluorouracil: Four-year follow-up findings. Journal of glaucoma. 1999;8:124-128
14. Lemon LC, Shin DH, Kim C, Bendel RE, Hughes BA, Juzych MS. Limbus-based vs fornix-based conjunctival flap in combined glaucoma and cataract surgery with adjunctive mitomycin c. American journal of ophthalmology. 1998;125:340-345
15. Berestka JS, Brown SV. Limbus- versus fornix-based conjunctival flaps in combined phacoemulsification and mitomycin c trabeculectomy surgery. Ophthalmology. 1997;104:187-196
16. Shingleton BJ, Chaudhry IM, O'Donoghue MW, Baylus SL, King RJ, Chaudhry MB. Phacotrabeculectomy: Limbus-based versus fornix-based conjunctival flaps in fellow eyes. Ophthalmology. 1999;106:1152-1155
17. Kozobolis VP, Siganos CS, Christodoulakis EV, Lazarov NP, Koutentaki MG, Pallikaris IG. Two-site phacotrabeculectomy with intraoperative mitomycin-c: Fornix- versus limbus-based conjunctival opening in fellow eyes. Journal of cataract and refractive surgery. 2002;28:1758-1762
18. Wells AP, Cordeiro MF, Bunce C, Khaw PT. Cystic bleb formation and related complications in limbus- versus fornix-based conjunctival flaps in pediatric and young adult trabeculectomy with mitomycin c. Ophthalmology. 2003;110:2192-2197
19. Solus JF, Jampel HD, Tracey PA, Gilbert DL, Loyd TL, Jefferys JL, et al. Comparison of limbus-based and fornix-based trabeculectomy: Success, bleb-related complications, and bleb morphology. Ophthalmology. 2012;119:703-711
20. Occleston NL, Daniels JT, Tarnuzzer RW, Sethi KK, Alexander RA, Bhattacharya SS, et al. Single exposures to antiproliferatives: Long-term effects on ocular fibroblast wound-healing behavior. Investigative ophthalmology &; visual science. 1997;38:1998-2007
21. Morita K, Gao Y, Saito Y, Higashide T, Kobayashi A, Ohkubo S, et al. In vivo confocal microscopy and ultrasound biomicroscopy study of filtering blebs after trabeculectomy: Limbus-based versus fornix-based conjunctival flaps. Journal of glaucoma. 2012;21:383-391
22. Rai P, Kotecha A, Kaltsos K, Ruddle JB, Murdoch IE, Bunce C, et al. Changing trends in the incidence of bleb-related infection in trabeculectomy. The British journal of ophthalmology. 2012;96:971-975
23. Jampel HD, Solus JF, Tracey PA, Gilbert DL, Loyd TL, Jefferys JL, et al. Outcomes and bleb-related complications of trabeculectomy. Ophthalmology. 2012;119:712-722