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Year : 2002  |  Volume : 50  |  Issue : 4  |  Page : 287-293

Mitomycin-C-augmented trabeculectomy for neovascular glaucoma. A preliminary report.

VST Centre for Glaucoma Care, L V Prasad Eye Institute, L V Prasad Marg, Banjara Hills, Hyderabad 500 034, India

Correspondence Address:
Anil K Mandal
VST Centre for Glaucoma Care, L V Prasad Eye Institute, L V Prasad Marg, Banjara Hills, Hyderabad 500 034
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Source of Support: None, Conflict of Interest: None

PMID: 12532493

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PURPOSE: This study aimed to investigate the safety and efficacy of trabeculectomy with intraoperative mitomycin C (MMC) in the management of eyes with neovascular glaucoma (NVG). METHODS: Fifteen eyes of 14 patients with NVG were included in the study. NVG was secondary to central retinal vein occlusion (3 eyes), hemiretinal vein occlusion (2 eyes), proliferative diabetic retinopathy (8 eyes), branch retinal vein occlusion (1 eye) and idiopathic (1 eye). Preoperative retinal ablation was performed in eyes with evidence of posterior segment ischaemia. Following this, all eyes underwent trabeculectomy with intraoperative MMC (0.4 mg/ml for 3 minutes). Clinical outcome assessment included visual acuity, intraocular pressure (IOP), bleb appearance, identification of complications and antiglaucoma medications required to control IOP. RESULTS: The mean IOP decreased from 38.6 +/- 12.9 mmHg (range, 15-64 mmHg) to 17.4 +/- 9.33 mmHg (range, 4-34 mmHg) (P = 0.001). Preoperative visual acuity ranged from light perception to 6/9 in the affected eye. Thirteen (86.6%) of 15 eyes improved vision or retained preoperative vision, one (6.7%) eye lost light perception and one (6.7%) eye developed tractional retinal detachment two years after trabeculectomy. Ten (66.7%) of 15 eyes were classified as surgical success with a mean follow-up of 28.6 +/- 26.3 months (range, 2-82 months). None of the patients developed choroidal haemorrhage, hypotony maculopathy, late onset bleb leak or endophthalmitis. CONCLUSION: Trabeculectomy with intraoperative MMC is a good treatment modality in the management of eyes with NVG.

Keywords: Neovascular glaucoma, retinal ablation, trabeculectomy, mitomycin-C

How to cite this article:
Mandal AK, Majji AB, Mandal SP, Das T, Jalali S, Gothwal VK, Jain SS, Nutheti R. Mitomycin-C-augmented trabeculectomy for neovascular glaucoma. A preliminary report. Indian J Ophthalmol 2002;50:287-93

How to cite this URL:
Mandal AK, Majji AB, Mandal SP, Das T, Jalali S, Gothwal VK, Jain SS, Nutheti R. Mitomycin-C-augmented trabeculectomy for neovascular glaucoma. A preliminary report. Indian J Ophthalmol [serial online] 2002 [cited 2022 Nov 28];50:287-93. Available from: https://www.ijo.in/text.asp?2002/50/4/287/14764


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Before the introduction of retinal ablation therapy, glaucoma filtering surgery in severely compromised eyes with neovascular glaucoma (NVG) was largely unsuccessful.[1] The congested anterior segment along with persistent neovascularisation of the iris (NVI) was the source of severe intraoperative bleeding. Carbon dioxide laser, because of its ability to cauterise and cut at the same time, had been employed to perform trabeculectomy in a relatively bloodless manner.[2][3][4] With the introduction of panretinal photocoagulation (PRP) to eliminate the stimulus for neovascularisation, filtering surgery for NVG has been more successful. Using standard filtration techniques with preoperative PRP, several investigators have reported improved success in NVG.[5][6][7] Encouraging surgical results with the use of "modified" filtration surgery have been reported in several studies with short follow-up.[8][9][10] However, extended follow-up data indicate that there is a high risk of longterm failure with loss of useful vision.[10]

With the use of 5-fluorouracil (5 - FU), Heuer et al and Rockwood et al had similar success rates in patients with NVG in aphakia and following failed filtering surgery.[11][12][13] In the later study of 28 patients with NVG, a 3-year success rate was 68% and the average dose of subconjunctival 5-FU in successful eyes was 68 38 mg.[13] Tsai et al analysed the Kaplan-Meier survival curve in 34 patients treated with filtering surgery with 5-FU for NVG and reported the success rates at 4 and 5 year intervals as 41% and 28% respectively.[14] Failure of filtration surgery in NVG occurred early in most of the series and was due to the scarring of conjunctiva.[5],[8],[13],[14] Both early and late failures have been observed in series where postoperative 5-FU injections had been given.[13],[14] In addition to early failure, chronic breakdown of the blood-aqueous barrier could predispose to late bleb failure by allowing serum proteins (which stimulate scarring) access to the bleb.[15] It has also been suggested that MMC-augmented trabeculectomy may yield better results than subconjunctival 5-FU application.[15]

To our knowledge, there has been no published report on MMC-augmented trabeculectomy in NVG (Medline search), although its potential to increase the success of this procedure has been suggested.[16] To determine the safety and efficacy of MMC-augmented trabeculectomy in NVG, this pilot study evaluated the results and complications of a series of patients who underwent the same surgery following successful retinal ablation at our institute.

  Materials and Methods Top

Patients presenting to the VST Centre for Glaucoma Care at the L V Prasad Eye Institute from January 1992 to March 2000 with a diagnosis of NVG were prospectively enrolled.

The diagnosis of NVG was established and we included only those eyes that met the following criteria: (1) Presence of NVI (grading system of Wand et al[17]); (2) IOP > 21 mmHg; (3) Various degrees of angle closure with or without neovascularisation of the angle; (4) Visual acuity of at least light perception with accurate projection in the affected eye, tested using the brightest illumination of the indirect ophthalmoscope at 25 cms; and (5) MMC-augmented trabeculectomy.

The clinical data included: demographics; aetiology of NVG; lens status; previous ocular surgical history; previous retinal ablation; preoperative and postoperative IOP, pre-and postoperative best-corrected visual acuities, antiglaucoma medications; exposure time and concentration of MMC; significant complications; re-operations and time of surgical failure (where applicable).

Medical treatment consisted of topical corticosteroid (Betamethasone), cycloplegic, timolol maleate 0.5% and systemic carbonic anhydrase inhibitors when tolerated. Osmotic agents were also used occasionally on a short-term basis. Retinal ablation therapy was instituted as an urgent measure in an effort to decrease fibrovascular activity and surgery was delayed for 2-3 weeks in order to maximise the response to retinal ablation. Surgery had to be performed urgently in one patient because of high IOP (64 mmHg) and persistent corneal oedema in spite of maximally tolerated antiglaucoma medications. All the surgeries were performed by a single surgeon (AKM). Informed consent was obtained from all patients and the use of MMC in association with trabeculectomy was approved by the Ethics Committee for Human Research at the L V Prasad Eye Institute.

  Surgical technique Top

The surgery was performed using a standardised technique similar to that described by Cairns.[18] A limbus-based conjunctival flap was made 8-9 mm posterior to the limbus in the superior quadrant. After haemostasis of the episcleral blood vessels with wet-field cautery, a half-thickness triangular scleral flap (4-mm base at the limbus) was dissected. Special precautions were taken to prevent premature entry into the anterior chamber before application of MMC.

The MMC was always freshly prepared in the hospital pharmacy by mixing 2 mg MMC powder with 5 ml balanced salt solution (BSS). A cellulose sponge, 4x4 mm in size, was soaked in 0.4 mg/ml MMC. This was applied over the dissected scleral bed and the superficial scleral flap; the conjunctivo-Tenon layer were then draped over the sponge. The free edge of the conjunctival flap was held away from the sponge so as to avoid direct contact with MMC. After 3 minutes, the sponge was removed and the entire area was thoroughly irrigated with 20 ml of BSS. A 2 x 1 mm deep trabecular block was removed and peripheral iridectomy performed. Very often, the removal of the trabeculectomy specimen initiated mild bleeding because of its adherence to the iris tissue by the fibrovascular membrane. This bleeding was controlled by meticulous application of wet-field cautery. Occasionally, new blood vessels remained on the iris surface and cautery was applied to the iris surface before it was lifted with forceps for iridectomy. Two or three exposed ciliary processes (a potential source for future neovascularisation) were cauterised with bipolar under-water cautery. Extreme care was taken to avoid lens touch. The scleral flap was closed with three interrupted 10-0 nylon sutures (one at the apex and one on each side of the triangular scleral flap). The conjunctivo-Tenon layer was closed with an 8-0 polyglactin (Vicryl) suture on a tapered needle (Aurolab, Madurai, India). The aim was to always obtain a watertight wound. One drop each of corticosteroid preparation (Betamethasone) and topical 1% atropine were instilled in the conjunctival sac and the eye patched.

  Postoperative medications and follow-up Top

After surgery, all patients were treated with topical 1% atropine thrice daily for 1 month and corticosteroid-antibiotic preparation (0.1% betamethasone and neomycin) six times a day, tapered gradually over a 6-week period. All the patients were examined on the first post-operative day and at the end of 1, 3, and 6 weeks and at every 3 months thereafter. Patients who developed complications were followed up more frequently.

  Success criteria Top

The surgical outcome were defined as follows:

  1. Complete success as IOP below or equal to 21 mmHg without antiglaucoma medication;

  2. Qualified success as IOP below or equal to 21 mmHg with antiglaucoma medication;

  3. Complete failure was labelled for eyes that required further antiglaucoma surgery, developed phthisis bulbi or lost light perception.

  Statistical analysis Top

Results were expressed as mean standard deviation. Comparison of IOP and number of antiglaucoma medications and visual acuity at baseline with the same parameters after surgery were made by using the Wilcoxan signed rank test. A probability value < 0.05 was considered to be statistically significant. Cumulative success probability was determined using the Kaplan-Meier survival analysis.

  Results Top

Fifteen eyes of 14 patients were identified, which met the inclusion criteria. Only one of these patients had bilateral NVG and both eyes were considered in the analysis of surgical outcome. The various aetiologies of NVG included diabetic retinopathy (8 eyes), central retinal vein occlusion (3 eyes), hemiretinal vein occlusion (2 eyes), branch retinal vein occlusion (1 eye) and idiopathic (1 eye). All patients with evidence of posterior segment ischaemia underwent retinal ablation, either pan-retinal photocoagulation (PRP) using the slitlamp/indirect ophthalmoscopic delivery system or anterior retinal cryotherapy (ARC) 2-3 weeks prior to antiglaucoma surgery. MMC in dosage of 0.4 mg/ml for 3 minutes intraoperative was used in all patients. The details of each patient who underwent MMC-augmented trabeculectomy have been summarised in the [Table - 1].

The study consisted of 12 male and 2 female patients aged 44 to 84 years (59.9 10.6 yrs). The mean age of the study group was 59.9 10.6 years (range, 44- 84 years). The mean preoperative IOP was 38.6 12.9 (range, 15 - 64 mmHg). The mean postoperative IOP was 17.4 9.33 (range, 4-34 mmHg). Most patients presented with severe pain, corneal oedema and blurred vision in the affected eye. Preoperative visual acuity ranged from light perception to 6/9 in the affected eye. One patient received bilateral surgery (case 4) in different operative sessions. This patient was phakic in one eye and aphakic in the other. Ten (66.7%) of 15 eyes were classified as surgical success with a mean follow-up of 28.6 26.3 months. Thirteen (86.6%) of 15 eyes had improved vision (≥ 1 Snellen line) or no change in vision, only 1(6.7 %) eye (patient 1) lost light perception and 1(6.7 %) eye (patient 5) developed tractional retinal detachment 2 years after trabeculectomy. Vision in the last mentioned patient unfortunately reduced to light perception.

The mean number of anti-glaucoma medications used before surgery was 2.3 0.5 (range, 2-3). The mean number of anti-glaucoma medications used postoperatively was 0.6 0.7 (range, 0-2). Postoperatively, IOP was controlled in 10 eyes without any antiglaucoma medications while 3 eyes required single topical medication (timolol maleate 0.5% twice daily), 2 eyes required three antiglaucoma medications (betaxolol, acetazolamide, and brimonidine) for control of IOP.

Thirteen of the 15 eyes had evidence of posterior segment ischaemia (as proven by fundus fluoresecein angiography) and underwent PRP, laser indirect photocoagulation (LIP) or anterior retinal cryopexy (ARC) and had documented regression of NVI (as evaluated by slitlamp biomicroscopy and photography) prior to surgery. In addition they had decreased inflammation postoperatively. [Figure - 1] shows the anterior segment of the left eye (patient 4) at presentation. [Figure:2] shows complete regression of the NVI in the same eye 3 weeks after retinal ablation therapy. [Figure:3] shows the same eye one year after surgery, showing bleb appearance in diffuse illumination. The bleb was characterised by a large, elevated avascular, transparent appearance in all eyes except one in which it appeared similar to that in standard glaucoma filtering surgery without any antimetabolite. This was the only eye in the present series that underwent ECCE with PC IOL implantation through superior clear corneal incision 3 years after MMC-augmented trabeculectomy for NVG. Till the last follow-up, this patient had a visual acuity of 6/9 with no NVI and the IOP was under control with timolol maleate. One pseudophakic eye (patient 9) was operated without any prior retinal ablation therapy as there was no evidence of posterior segment ischaemia and had significant intraoperative bleeding after peripheral iridectomy even though the iris was cauterised with bipolar wet-field cautery. This was the only eye that developed total hyphaema on the first postoperative day. However, IOP was within normal limits and hence no attempt was made to drain the hyphaema. On spontaneous absorption with conservative therapy, the eye showed endocapsular haematoma during the third postoperative week and took 6 weeks for complete clearance of hyphaema and endocapsular haematoma. Finally the patient regained a postoperative visual acuity of 6/9 with a good filtration bleb and control of IOP without any antiglaucoma medication.

The postoperative complications are listed in [Table - 2]. One eye (patient 9) developed endocapsular haematoma that was managed conservatively. Another eye

(patient 5) developed tractional retinal detachment 2 years postoperatively. One eye lost light perception (patient 1) because of the progression of the retinal pathology. No patient developed choroidal haemorrhage, hypotony maculopathy, late onset bleb leak or endophthalmitis. The Kaplan-Meier survival curve is shown in [Figure:4]. The complete success probability of patients at 6, 12, 24 and 36 months was 78.6 % 11%, 71.4% 12.1%, 62.5% 13.5% and 52.1% 14.7% respectively.

  Discussion Top

Neovascular glaucoma is a devastating disease. Its management is complex and frequently requires the integrated use of medical, laser and surgical modalities. The key to its management lies in elimination of the angiogenic stimulus before surgery by adequate PRP or ARC. The success of all types of filtration surgery, depends ultimately on prevention of filtration bleb fibrosis[16], infection and wound leaks.

Prior to filtration surgery, all our patients were treated with topical corticosteroids and atropine as well as aqueous suppressants. Wherever necessary, osmotic agents such as intravenous mannitol and oral glycerol were also used on a short-term basis to enhance the activity of the antiglaucoma and anti-inflammatory agents. All patients with evidence of ischaemia in the posterior segment had received either PRP or ARC. All our patients responded to retinal ablation therapy as evidenced by documented regression of NVI within the 3-week period. As the optic nerve was not severely compromised in any of our patients, we waited for 2 to 3 weeks before filtration surgery for regression of NVI even though IOP was significantly elevated on antiglaucoma medication in all cases except one, where emergency surgery was performed. We are in agreement with the previous investigators that appropriate preoperative retinal ablation and medical management significantly increase the chances of success in filtration surgery with NVG.[5][6][7][8],[10],[13],[14]

When useful vision exists, filtering surgery has been an increasingly common means of achieving IOP control in NVG.[5][6][7] A success rate of 67% to 100% has been reported using standard filtration technique with preoperative PRP.[5][6][7] Early failure of filtering surgery is attributed to gradual scarring of the conjunctiva in the early postoperative period.

In order to improve the success rate of surgery in eyes with NVG, several modifications or adjunctive treatment are advocated. They include application of bipolar cautery to iris/ciliary processes exposed by iridectomy,[8][9][10] and subconjunctival 5-FU injection during surgery.[11][12][13][14] This has not improved the long-term success.

Our decision to use MMC in glaucoma filtering surgery for patients with NVG was based on several prospective randomised studies in adults with high-risk glaucoma filtering surgery. These studies have shown that intraoperative MMC may be a superior alternative to postoperative 5-FU.[19-22] Using strict criteria of success (IOP ≤ 21 mmHg) the success rate of the present series was 66.7% with a mean follow-up of 28.6 26.3 months. This was better than the studies using 5-FU.[13],[14]

Intraoperative hyphaema occurred in one patient who was not considered for preoperative retinal ablation therapy in the absence of documented posterior segment pathology. Postoperatively he had total hyphaema and the endocapsular haematoma took 6 weeks to clear completely. His postoperative visual acuity improved to the preoperative level (6/9) and IOP was under control without any antiglaucoma medication.[23] The bleb appearance was satisfactory. The cause of NVI in this patient was presumably multifactorial. Cataract surgery and pseudoexfoliation could have contributed to diffuse iris hypoxia leading to NVI and NVG. Ocular ischaemic syndrome was ruled out in absence of abnormal carotid studies. Shallow anterior chamber occurred in one eye but recovered spontaneously. One eye demonstrated progression of cataract postoperatively. Sight-threatening complica-tions occurred in two eyes - one with tractional retinal detachment 2 years following surgery and another patient whose vision reduced from light perception to no light perception. The patient with tractional retinal detachment was not considered for further surgery due to poor prognosis. None of the patients developed choroidal haemorrhage, late bleb leakage, hypotony maculopathy or endophthalmitis. Our complication rate was lower compared to the previous series with 5-FU.[13],[14]

The optimal dose of MMC in NVG is not yet established. We used 0.4 mg/ml of MMC for 3 minutes in all patients; we feel that this dose is effective and safe. However, in the absence of a comparative control group with different concentrations and exposure times of MMC, our results must be interpreted with caution. The appearance of the bleb was satisfactory in all cases except one where it was not typical of MMC-augmented filtering bleb. It was flat, not of the usual pale hue and fine blood vessels were seen on its surface. This was one of the patients who required timolol maleate for control of IOP.

There was no change in bleb appearance following ECCE with PC IOL and the postcataract surgery visual acuity was 6/9. We attribute the success to the PRP followed by MMC-augmented trabeculectomy. These eyes are less likely to develop sight-threatening complications following cataract surgery.

The artificial drainage devices are a viable option in such a form of refractory glaucoma. Recent studies with various artificial drainage devices have reported improved results in advanced cases of NVG.[24][25][26][27] In contrast, the study of Lavin et al that compared 3 different implant devices found that NVG was associated with 2.1 times higher risk of failure than other types of glaucoma.[28]

In conclusion, we feel that once NVI is regressed with retinal ablation in patients with refractory NVG, the intraoperative use of MMC with trabeculectomy is an excellent option and possibly superior to subconjunctival 5-FU. However, the patients should be examined periodically and they should be educated about the possible late complications.

The results of this pilot study indicate the need for a large randomised trial to evaluate all possible antimetabolites/ drainage devices in NVG. Considering the fact that these cases are not very common, such a study may not be feasible.

  References Top

Weber PA. Neovascular glaucoma: Current management. Surv Ophthalmol 1981,26:149-53.  Back to cited text no. 1
Beckman H, Fuller TA. Carbon dioxide laser scleral dissection and filtering procedure for glaucoma. Am J Ophthalmol 1979;88:73-77.  Back to cited text no. 2
Ticho U, Monselize M, Levene S, Kaye R. Carbon dioxide laser filtering surgery in hemorrhagic glaucoma. Glaucoma 1979;1:114-18.  Back to cited text no. 3
L'Esperance FA Jr, Mittl RN. Carbon dioxide laser trabeculostomy for the treatment of neovascular glaucoma. Trans Am Ophthalmol Soc 982;80:262-87.  Back to cited text no. 4
Allen RC, Bellows AR, Hutchinson BT, Murphy SD. Filtration surgery in the treatment of neovascular glaucoma. Ophthalmology 1982;89:1181-87.  Back to cited text no. 5
Clearkin LG. Recent experience in the management of neovascular glaucoma by panretinal photocoagulation and trabeculectomy. Eye 1987;1:397-400.  Back to cited text no. 6
Fernandez-Vigo J, Castro J, Cordido M, Fernandez-Sabugal J. Treatment of diabetic neovascular glaucoma by panretinal ablation and trabeculectomy. Acta Ophthalmol (Copenh) 1988;66:612-16.  Back to cited text no. 7
Herschler J, Agness D. A modified filtering operation for neovascular glaucoma. Arch Ophthalmol 1979;97:2339-41.  Back to cited text no. 8
Lee PF, Shihab ZM, Fu Y-A. Modified trabeculectomy: A new procedure for neovascular glaucoma. Ophthalmic Surg 1980;11:181-85.  Back to cited text no. 9
Parrish R, Herschler J. Eyes with end-stage neovascular glaucoma: Natural history following successful modified filtering operation. Arch Ophthalmol 1983;101:745-46.  Back to cited text no. 10
Heuer DK, Parrish RK II, Gressel MG, Hodapp E, Palmbelg PF, Anderson DR. 5-Fluorouracil and glaucoma filtering surgery: II.A pilot study. Ophthalmology 1984; 91:384-94.  Back to cited text no. 11
Heuer DK, Parrish RK II, Gressel MG, Hodapp E, Desjaronis DC, Skuta GLl. 5-Fluorouracil and glaucoma filtering surgery: III. Intermediate follow-up of a pilot study. Ophthalmology 1986;93:1537-46.  Back to cited text no. 12
Rockwood EJ, Parrish RK II, Heuer DK, Skuta GL, Hodapp E, Palmberg PP, et al. Glaucoma filtering surgery with 5-fluorouracil. Ophthalmology 1987;94:1071-78.  Back to cited text no. 13
Tsai JC, Feuer WJ, Parrish RK II, Grajewski AL. 5-Fluorouracil filtering surgery and neovascular glaucoma: Long-term follow-up of the original pilot study. Ophthalmology 1995;102:887-93.  Back to cited text no. 14
Ritch R. Discussion. Ophthalmology 1995;102:892-3. Comment on: Ophthalmology 1995;102:887-92.  Back to cited text no. 15
Sivak-Callcott JA, O'Day DM, Gass DM, Tsai JC. Evidence-based recommendations for the diagnosis and treatment of neovascular glaucoma. Ophthalmology 2001;108:1761-78.  Back to cited text no. 16
Wand M, Dueker D, Aiello L, Grant WM. Effects of panretinal photocoagulation on rubeosis iridis, angle neovascularization, and neovascular glaucoma. Am J Ophthalmol 1978;86:332-39.  Back to cited text no. 17
Cairns JE. Trabeculectomy. Preliminary report of a new method. Am J Ophthalmology 1968;66:673-79.  Back to cited text no. 18
Kitazawa Y, Kawase K, Matsushita H, Minobe M. Trabeculectomy with mitomycin. A comparative study with fluorouracil. Arch Ophthalmol 1991;109:1693-98.  Back to cited text no. 19
Palmer SS. Mitomycin as adjunct chemotherapy with trabeculectomy. Ophthalmology 1991;98:317-21.  Back to cited text no. 20
Skuta GL, Beeson CC, Higginbotham EJ, Lichter PR, Musch DO, Belgastrom TJ, et al. Intraoperative mitomycin versus postoperative 5-fluorouracil in high risk glaucoma filtering surgery. Ophthalmology 1992;99:438-44.  Back to cited text no. 21
Katz GJ, Higginbotham EJ, Lichter PR, Skuta GL, Musch DC, Bergastrom TJ, et al. Mitomycin C versus 5-fluorouracil in high-risk glaucoma filtering surgery : extended follow-up. Ophthalmology 1995;102:1263-69.  Back to cited text no. 22
Mandal AK, Gothwal VK. Endocapsular hematoma: report of a case following glaucoma surgery in a pseudophakic eye. Ophthalmic Surg Lasers 1999;30:389-93.  Back to cited text no. 23
Molteno ACB. New implant for drainage in glaucoma: clinical trial. Br J Ophthalmol 1969;53:606-15.  Back to cited text no. 24
Ancker E, Molteno ACB. Molteno drainage implant for neovascular glaucoma. Trans Ophthalmol Soc UK 1982;102:122-24.  Back to cited text no. 25
Schocket SS, Lakhanpal V, Richards RD. Anterior chamber tube shunt to an encircling band in the treatment of neovascular glaucoma. Ophthalmology 1982;89:1188-94.  Back to cited text no. 26
Krupin T, Kaufmann P, Mandell AI, Terry SA, Ritch R, Podos SM, et al. Long-term results of valve implants in filtering surgery for eyes with neovascular glaucoma. Am J Ophthalmol 1983;95:775-82.  Back to cited text no. 27
Lavin MJ, Franks WA, Wormland RP, Hithcings RA. Clinical risk factors for failure in glaucoma tube surgery : A comparison of three tube designs. Arch Ophthalmol 1992;110:480-85.  Back to cited text no. 28


  [Figure - 1]

  [Table - 1], [Table - 2]

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