Midterm outcome of single scleral suture technique in trabeculectomy and phacotrabeculectomy: a simplified approach

Purpose

To report outcome of trabeculectomy performed by single scleral suture in Indian eyes.

Methods

Non-randomized, non-masked, retrospective cohort analysis. Medical records of all consecutive patients who underwent trabeculectomy between 1 January 2011 and 31 December 2016 at CL Gupta Eye Institute, Moradabad (India), were reviewed and analyzed. Trabeculectomy was performed using single scleral suture for flap closure. The suture knot was buried inside sclera. The laser lysis of scleral suture was not done. Success was defined as complete success if an intraocular pressure (IOP) was >5 and ⩽21 mmHg without any glaucoma medications or re-surgery. Qualified success was defined as IOP ⩽21 mmHg with or without antiglaucoma medications.

Results

Data of 98 patients was analyzed. A total of 61 (62.2%) of them underwent trabeculectomy, and 37 (37.7%) underwent phacotrabeculectomy. The probability of complete success in patient underwent phacotrabeculectomy was 86% at 3 years, and in-patient underwent only trabeculectomy was 95% at 3 years. The probability of qualified success in patient undergone phacotrabeculectomy was 91% at 3 years, and in patient undergone only trabeculectomy was 97% at 3 years.

Conclusion

The mean postoperative IOP was significantly less then mean preoperative IOP, at all follow-up visits. This simplified technique also resulted in high midterm success probabilities with low complication rates.

Important Metabolites in Maintaining Folate Cycle, Homocysteine, and Polyamine Metabolism Associated with Ranibizumab Treatment in Cultured Human Tenon's Fibroblasts

The anti-fibrotic properties of ranibizumab have been well documented. As an antagonist to vascular endothelial growth factor (VEGF), ranibizumab works by binding and neutralizing all active VEGF-A, thus limiting progressive cell growth and proliferation. Ranibizumab application in ocular diseases has shown remarkable desired effects; however, to date, its antifibrotic mechanism is not well understood. In this study, we identified metabolic changes in ranibizumab-treated human Tenon's fibroblasts (HTFs). Cultured HTFs were treated for 48 h with 0.5 mg/mL of ranibizumab and 0.5 mg/mL control IgG antibody which serves as a negative control. Samples from each group were injected into Agilent 6520 Q-TOF liquid chromatography/mass spectrometer (LC/MS) system to establish the metabolite expression in both ranibizumab treated cells and control group. Data obtained was analyzed using Agilent Mass Hunter Qualitative Analysis software to identify the most regulated metabolite following ranibizumab treatment. At p-value < 0.01 with the cut off value of two-fold change, 31 identified metabolites were found to be significantly upregulated in ranibizumab-treated group, with six of the mostly upregulated having insignificant role in fibroblast cell cycle and wound healing regulations. Meanwhile, 121 identified metabolites that were downregulated, and seven of the mostly downregulated are significantly involved in cell cycle and proliferation. Our findings suggest that ranibizumab abrogates the tissue scarring and wound healing process by regulating the expression of metabolites associated with fibrotic activity. In particular, we found that vitamin Bs are important in maintaining normal folate cycle, nucleotide synthesis, and homocysteine and spermidine metabolism. This study provides an insight into ranibizumab's mechanism of action in HTFs from the perspective of metabolomics.

Ologen implant versus mitomycin-C for trabeculectomy: A meta-analysis

AIM

To evaluate the efficacy and safety of trabeculectomy (Trab) with mitomycin-C (MMC) versus Trab with implant.

METHODS

Studies published in different languages were retrieved by systematically searching Embase, PubMed, Cochrane library, China Biology Medicine disc, and Google Scholar from 1966 to April 2018, as well as manually examining the references of the original articles. The outcome measures of efficacy covered intraocular pressure, glaucoma medications reductions, and success rate. Safety evaluation was measured by relative ratio of complications.

RESULTS

A total of 11 studies involving 443 participants were covered in this meta-analysis. The weighted mean difference (WMD) in the percentage of intraocular pressure (IOP) reduction (IOPR%) comparing Ologen group with MMC group was -3.69 (95% CI: -6.70 to -0.68) at 1 month, -2.69 (-5.17 to -0.21) at 3 months, -3.67 (-6.09 to -1.25)at 6 months, -3.24 (-6.08 to -0.41) at 12 months, 1.24 (-9.43 to 11.90) at 24 months, and 1.10 (-10.11 to 12.31) at 60 months, which showed that there was statistically significant difference at 1,3, 6, and12 months after the surgery. A significantly higher incidence of postsurgery hypotony (0.64 (95% Cl: 0.42 to 0.98)) and suture lysis (0.30 (95% CI: 0.10-0.93)) was observed in MMC group. However, there was no significant difference in the reduction in glaucoma medications, success rate, and incidence of other complications.Trab with 0.2 mg/mL MMC presented higher rates of complete success compared with Trab with 0.4 mg/mL MMC (P = .01).

CONCLUSION

Trab with MMC was associated with a higher IOP-lowering efficacy and a higher incidence of postsurgery hypotony and suture lysis in contrast to that of Trab with Ologen.

Use of trypan blue to assess lymphatic function following trabeculectomy

IMPORTANCE

To illustrate the importance of lymphatic drainage in assessing trabeculectomy bleb function using intracameral trypan blue.

BACKGROUND

To study the lymphatic drainage of trabeculectomy blebs using trypan blue, correlate with bleb function and classify them accordingly.

DESIGN

Prospective cross-sectional study in a tertiary care centre.

PARTICIPANTS

Thirteen glaucoma patients post-trabeculectomy were studied.

METHODS

Trypan blue was injected into the anterior chamber.

MAIN OUTCOME MEASURES

The duration taken for dye to stain a drainage bleb or lymphatics is recorded. The extent of the lymphatic structures were measured in clock hours. Intraocular pressure (IOP) prior to surgery was recorded.

RESULTS

Eight post-trabeculectomy subjects with dye stained lymphatic vessels had lower IOP (12.6 mmHg, P = .013) compared to the five with no lymphatic vessel staining (mean IOP 23.6 mmHg). Lymphatic extent was inversely related to IOP (P = .021).

CONCLUSIONS AND RELEVANCE

Eyes with lymphatic connections to drainage blebs had lower IOP and reduced requirement for topical medications. The extent of lymphatic connection to drainage blebs is related to lower IOP.

Evaluating the efficacy of short duration Mitomycin C in safe surgery system trabeculectomy combined with cataract surgery

Purpose: To compare the efficacy of 0.2 mg/ml Mitomycin C (MMC) applied for 1-minute versus 2-minutes in patients undergoing combined surgery for primary glaucoma coexistent with cataract.

Materials and methods: This was a randomized controlled clinical trial of 63 patients operated on for primary glaucoma (POAG or PACG) with visually significant cataract. All patients underwent safe surgery system trabeculectomy with manual small incision cataract surgery (MSIC) and implantation of PC IOL. Patients were randomized into intra-operative MMC 0.2 mg/ml for 1-minute (study group) and MMC 0.2 mg/ml for 2-minutes (control group). Success was measured on the basis of two different intraocular pressure (IOP) goals (IOP ≤21 mmHg, IOP ≤18 mmHg) and mean IOP reduction from baseline at the end of 12 months.

Results: At 12 months, significant decreases in mean IOP were observed in both groups (P<0.001).The mean IOP reduction was 31.33±9.06% in the study group, as compared to 43.32±9.38% in the control group (P<0.001). The overall success for IOP ≤21 mm Hg was 80.5% in the study group and 90.9% in the control group (P<0.05). Kaplan-Meier analysis showed an insignificant difference in overall success rates of the two groups.

Conclusion: The IOP reduction with 2-minute MMC (0.2 mg/ml) is more effective than 1-minute MMC after 12 months. It offers a decrease in anti-glaucoma medications and substantial visual recovery in combined surgery done for primary glaucoma coexistent with cataract.

Use of trypan blue as an aqueous tracer dye to investigate hypotony where cyclodialysis cleft is suspected

IMPORTANCE

A new method to help diagnose suspected cyclodialysis clefts.

BACKGROUND

To study the use of trypan blue stained aqueous flow patterns in diagnosing causes of hypotony where cyclodialysis clefts were suspected.

DESIGN

A case series in a tertiary care centre.

PARTICIPANTS

Ten subjects presenting with persistent hypotony and retinal changes.

METHODS

Trypan blue was injected into the anterior chamber.

MAIN OUTCOME MEASURES

The pattern of dye flow in the anterior chamber was categorized. Intraocular pressure prior to surgery was recorded.

RESULTS

All seven subjects with cyclodialysis clefts had a preferential flow to the cleft region. Two hypotonous subjects post trabeculectomy had rapid (5 seconds) and extensive lymphatic staining (6 o'clock hours extent) without visible bleb formation.

CONCLUSIONS AND RELEVANCE

Preferential flow of dye to the limbus is a reliable sign of cyclodialysis cleft and helps localize cleft extent. A new cause of hypotony, "lymphatic overdrain," is identified.

Efficacy and safety of the ab interno gelatin stent in severe pseudoexfoliation glaucoma compared to non-pseudoexfoliation glaucoma at 6 months

PURPOSE

To compare the efficacy and safety of the XEN45 Gel Stent surgery between patients with and without severe pseudoexfoliation glaucoma.

METHODS

In this retrospective, single-center, comparative chart review, records of 24 eyes of 23 patients with pseudoexfoliation glaucoma and 24 eyes of 23 patients with non-pseudoexfoliation glaucoma with severe glaucoma, defined as uncontrolled intraocular pressure on maximally tolerated medical therapy, were reviewed. All patients were treated with XEN45 Gel Stent surgery, in either a standalone procedure (84.8%) or combined with phacoemulsification (15.2%). Mean intraocular pressure, mean number of intraocular pressure-lowering medications, change in best-corrected visual acuity and needling or rescue surgery rates were assessed. Success was defined as at least 20% decrease in baseline intraocular pressure among treatment-free patients.

RESULTS

Patient characteristics were similar between the groups. At 6 months, intraocular pressure in the pseudoexfoliation glaucoma group decreased by 32% (24.3 ± 9 mmHg-14.8 ± 7 mmHg, p < 0.001), with comparable decrease in intraocular pressure in the non-pseudoexfoliation glaucoma group (22.6 ± 7 mmHg-16.7 ± 6 mmHg, p = 0.011). Similar rates of patients required topical anti-glaucoma therapy (29% vs 22%, p = 0.559), needling (54% vs 37%, p = 0.247), and rescue trabeculectomy (13% in both, p = 1.00) at the last follow-up. However, intraocular pressure decreased more in the pseudoexfoliation glaucoma group among treatment-free patients (-10.1 ± 8.0 mmHg vs -4.1 ± 8.1 mmHg, p = 0.043), and final intraocular pressure was lower in the pseudoexfoliation glaucoma group (12.2 ± 3.5 mmHg vs 15.8 ± 5.7 mmHg, p = 0.044).

CONCLUSIONS

The XEN45 Gel Stent implant demonstrated similar efficacy and safety among severe pseudoexfoliation glaucoma and non-pseudoexfoliation glaucoma patients. Greater magnitude of decreased intraocular pressure occurred among treatment-free pseudoexfoliation glaucoma patients.

Evaluation of Functional Filtering Bleb Using Optical Coherence Tomography Angiography

Purpose

This study investigated whether filtering blebs can be evaluated using optical coherence tomography angiography (OCT-A) and compared vascularity parameters with conventional bleb grading systems.

Methods

A total of 92 patients with glaucoma, who underwent mitomycin C–augmented trabeculectomy, were enrolled in this study, and 92 eyes were assessed in total. The participants underwent OCT-A in external mode and anterior segment photography for bleb evaluation. For evaluation of bleb vascularity, a blinded observer carefully drew the bleb area on the original OCT-A image using a semiautomated program that calculated the color and brightness densities of the selected area. A blinded observer also classified the grades of the bleb vessels using the Indiana Bleb Appearance Grading Scale (IBAGS) and Moorfields Bleb Grading System (MBGS). The vascularity parameters using OCT-A were compared with the IBAGS and MBGS results. In addition, the correlation between intraocular pressure (IOP) and the bleb vascularity parameters was assessed.

Results

Vessel density measured by OCT-A demonstrated excellent inter- and intraobserver reproducibility. The color and brightness densities were positively correlated with the IBAGS and MBGS vascularity scores. There was no difference in accuracy when predicting IOP risk using vascularity scores from the IBAGS and MBGS or when estimating IOP risk using the color and brightness densities on the net reclassification index.

Conclusions

Bleb evaluation using OCT-A can evaluate vessel vascularity and showed correlation to the IBAGS and MBGS vascularity grading.

Translational Relevance

Bleb vascularity measurements using OCT-A could potentially provide objective and quantitative vessel parameters for bleb evaluation following trabeculectomy.

Comparative analysis of cytokine profiles of glaucomatous tears and aqueous humour reveals potential biomarkers for trabeculectomy complications

Glaucoma is a multifactorial neurodegenerative disease that causes impaired vision and, in advanced cases, blindness. The increasing prevalence of glaucoma due to an ageing population has necessitated the identification of suitable biomarkers for the early detection of the disease. Aqueous humour (AH) has been proposed as a source of biomarkers, but it can only be collected using a minor, yet invasive surgical intervention. Tears, however, are constantly available and can be collected any time via noninvasive methods. In order to examine the utility of tear as a surrogate for aqueous humour in biomarker development, we compared the levels of 27 cytokines and chemokines in paired samples of tear and aqueous humour using a Luminex multiplex immunobead-based technique. Significantly higher levels of cytokines in tear compared to aqueous humour were detected suggesting that tear and aqueous humour are not identical in terms of inflammation response. Furthermore, the levels of IFN-γ, GM-CSF and IL-5 in tear were significantly lower in patients who developed complications after one year, but no statistically significant changes in cytokine levels were observed in aqueous humour. These three molecules may have potential as predictive biomarkers for the appearance of late flap-related complications of trabeculectomy.

Influence of glaucoma surgery on visual function: a clinical cohort study and meta-analysis

Purpose

To determine the cost (loss of visual function associated with the procedure) and benefit (long‐term preservation of the visual field) of glaucoma surgery.

Methods

We included 100 patients who underwent glaucoma surgery (Baerveldt glaucoma implant [BGI], n = 61; trabeculectomy [TE], n = 39). Preoperatively, the median (interquartile range [IQR]) standard automated perimetry mean deviation (MD) was −12 (−16 to −6) dB. We analysed the change in visual acuity (BCVA) and MD due to the procedure and, in a subset with at least 5 years of perimetric follow‐up both pre‐ and postoperatively (n = 20), the change in rate of progression (ROP; time rate of change in MD). For the surgery‐induced change in ROP, we also performed a meta‐analysis including the current and previously published studies. From the surgery‐induced decrease in MD and change in ROP, we calculated the average postoperative duration needed for the benefit to surpass the cost.

Results

Mean (standard deviation) MD decline was 1.3 (2.7) and 1.0 (2.3) dB for BGI (p < 0.001) and TE (p = 0.009), respectively; no significant surgery‐induced changes in BCVA were found (p = 0.08 and p = 0.12, respectively). In our study, surgery was associated with a non‐significant deceleration of ROP (from −0.37 [0.52] to −0.15 [0.48] dB/year; p = 0.23). The meta‐analysis, based on eight studies, showed an overall surgery‐induced change in ROP of 0.44 (95% confidence interval 0.25 to 0.64; p < 0.0001) dB/year.

Conclusion

Glaucoma surgery significantly reduces the progression velocity in glaucoma. On average, the benefit of glaucoma surgery surpasses the cost after approximately 1.5 years.

Calcification of hydrophilic acrylic intraocular lenses following secondary surgical procedures in the anterior and posterior segments

AIMS

To report 15 cases of intraocular lens (IOL) calcification following intraocular surgery and to identify common risk factors.

METHODS

A retrospective case review of patients with IOL calcification reported from the Royal Victorian Eye and Ear Hospital, Melbourne, Australia, and six surgeons in private practice in the Australian states of Victoria, New South Wales and Queensland.

RESULTS

15 cases of IOL calcification were identified. Eight cases were in hydrophilic acrylic IOLs and seven in hydrophilic acrylic IOLs with hydrophobic surface properties. Five cases occurred following intraocular injection of gas during endothelial keratoplasties. Two cases occurred following pars plana vitrectomy where gas was used. The remaining eight cases did not involve the injection of any intraocular gas; six cases were following trabeculectomy surgery, and two cases were after insertion of a 'piggyback' sulcus IOL. In each case, the calcification had a characteristic pattern, being centrally placed in the pupillary zone, mainly affecting the anterior lens surface.

CONCLUSION

The aetiology of IOL calcification is not fully understood, although there are known risk factors such as using hydrophilic acrylic materials and the use of intraocular gas. Surgical consideration of a patient's ocular comorbidities before IOL implantation is an important tool to mitigate some of this risk.

Bleb-associated endophthalmitis: Proportion, presentation, management and outcomes in Victoria, Australia

IMPORTANCE

Bleb-associated endophthalmitis is a potentially vision-threatening complication of trabeculectomy. With improvements in surgical technique and changing patterns of intraoperative antimetabolite use, a re-evaluation of the incidence of bleb-associated endophthalmitis is warranted.

BACKGROUND

To investigate changes in the incidence, presentation, management and outcomes of bleb-associated endophthalmitis between 1997 and 2015 in Victoria, Australia.

DESIGN

A retrospective cohort analysis.

PARTICIPANTS

Consecutive cases of bleb-associated endophthalmitis managed at the Royal Victorian Eye and Ear Hospital (RVEEH) between 1997 and 2015.

METHODS

Medical record review of consecutive cases of bleb-associated endophthalmitis and statistical analysis were performed.

MAIN OUTCOME MEASURES

Visual acuity, including loss of light perception, intraocular pressure, and need for further surgery.

RESULTS

Sixty-seven eyes with bleb-associated endophthalmitis (BAE) were identified. Of these, 41 had trabeculectomy performed in Victoria during the study period, over which time 11 129 trabeculectomies were performed. The proportion of BAE was stable over time (0.4%). The mean age at presentation was 73.7 ± 12.1 years old and the majority of patients were Caucasian (79.1%). The mean duration between glaucoma filtration surgery and the development of bleb-associated endophthalmitis was 3 years (Interquartile Range = 0.4-6.0 years). The cultures were positive in 71.6% of cases. Approximately 1 in 8 patients required enucleation. The final visual acuity was poor with a Snellen Visual Acuity (VA) of 6/60 or worse in two-thirds of patients.

CONCLUSIONS AND RELEVANCE

Bleb-associated endophthalmitis is an uncommon complication following glaucoma filtration surgery. The proportion has remained stable over time. Visual outcomes remain poor.

The effectiveness of trabeculectomy with mitomycin C and releasable suture in posner-schlossman syndrome with secondary glaucoma: A case series

The aim of this study is to describe the effectiveness of trabeculectomy with mitomycin C and releasable suture in Posner-Schlossman syndrome (PSS) with secondary glaucoma. Early treatment is the key to successful management of PSS with secondary glaucoma. However, unremitting exposure of high intraocular pressure (IOP) because of the high recurrence rate of PSS may cause further optic nerve damage and visual field defect. It is assumed that trabeculectomy may become the surgical treatment of choice in order to prevent further damage to the optic nerve despite recurring attack of PSS. Trabeculectomy with mitomycin C and releasable suture was performed in 5 patients (3 females and 2 males) with recurring attacks of PSS and secondary glaucoma after acute attack had subsided. Before surgery, these patients had already suffered more than 3 acute attacks which were alleviated with antiglaucoma and anti-inflammatory medications; however, optic nerve damage and visual field defect had already developed. After trabeculectomy, 4 patients experienced no recurrent attacks during the follow-up period. One patient only suffered another episode of acute attack; however, an abrupt increase in IOP of more than 22 mmHg did not occur. In all cases, blebs were well formed, and no further optic nerve damage or visual field defects were observed up until final follow-up. In PSS with secondary glaucoma, medication may alleviate the IOP increase and inflammation; however, there is still a chance of damage occurring to the optic nerve each time an attack recurs. Trabeculectomy may be considered a safe and effective surgical treatment modality in PSS with secondary glaucoma in order to prevent further optic nerve damage due to the extreme IOP spike in each recurrent attack.

The cost-effectiveness of medication, laser trabeculoplasty, and trabeculectomy for treatment of open-angle glaucoma in South Korea

OBJECTIVES

Open-angle glaucoma (OAG) imposes high disease burden in South Korea. Although various effective interventions are available to manage the progression of OAG, there is limited data on the cost-effectiveness of these treatment strategies in South Korea.

METHODS

Using a Markov cohort model, we evaluated the cost-effectiveness of 3 major treatment strategies (medication, laser trabeculoplasty, and trabeculectomy) for South Korean patients with OAG. We projected a 25-year time horizon to study a hypothetical cohort of 10,000 patients of age 40 with mild OAG. The outcome measures were quality-adjusted life-years (QALYs) gained, cost from the societal perspective, and the incremental cost-effectiveness ratio (ICER) of medication, laser trabeculoplasty, and trabeculectomy. Interventions were evaluated at a willingness-to-pay (WTP) threshold of 30,000,000 KRW ($29,152) per QALY gained. Deterministic and probabilistic sensitivity analyses were conducted to address the model uncertainty.

RESULTS

The mean costs for medication, laser trabeculoplasty, and trabeculectomy were 29,661,740 KRW, 17,34,1342 KRW, and 22,275,438 KRW, respectively. The mean QALYs gained were 15.7, 15.3, and 14.8 for medication, laser trabeculoplasty, and trabeculectomy, respectively. Surgery was strongly dominated because it generated fewer expected QALYs but incurred greater expected cost than laser. The ICER was 30,885,179 KRW per QALY for medication versus laser trabeculoplasty. Laser was cost-effective, however, at a lower WTP threshold of 21,000,000 KRW per QALY gained or below. The results were most sensitive to the progression rates from mild to moderate glaucoma under laser treatment.

CONCLUSION

Under the WTP threshold of 30,000,000 KRW per QALY, medication was cost-effective compared with laser trabeculoplasty and trabeculectomy for treating mild OAG in South Korean population. Laser, however, can be a cost-effective alternative in more resource-limited settings.

The effect on wound healing of pazopanib and bevacizumab compared with corticosteroid in experimental glaucoma filtration surgery

AIM

To compare the effects of bevacizumab and pazopanib with corticosteroids on wound healing after trabeculectomy.

METHODS

In the study, 35 New Zealand white rabbits were randomly divided into five groups. Apart from the first group, limbus-based trabeculectomy was performed for the eyes of rabbits. No postoperative treatment was administered for group I. Topically administered saline, prednisolone acetate (1%), bevacizumab 5 mg/mL, pazopanib 5 mg/mL for group II, III, IV and V respectively were applied for groups 6h daily for 28d. On day 28 of the experiment, eyes were enucleated and histologically and immunohistochemically analyzed.

RESULTS

The fibroblast counts of groups IV and V were determined to be lower than those of groups II and III (P<0.05). In the mononuclear cell (MNC) count evaluation, no statistically significant difference was determined between the treatment groups (P>0.05). The immunohistochemical staining intensity of fibroblast growth factor β (FGF-β) and vascular endothelial growth factor (VEGF) was determined to be lower in groups IV and V than in groups II and III (P<0.05). No statistically significant difference was determined between groups IV and V in respect of fibroblast count, MNC count, FGF-β and VEGF staining intensity (P>0.05). The platelet derived growth factor β (PDGF-β) intensity was lower in group V than in groups II, III and IV (P<0.05). While the PDGF-β staining intensity was significantly lower in group IV than in group II, the difference compared with group III was not statistically significant (P>0.05).

CONCLUSION

Bevacizumab and pazopanib might be good alternatives of corticosteroid treatment on delaying wound healing in glaucoma surgery.

Glaucoma in children with facial port wine stain

PURPOSE

To report on the clinical presentation and surgical treatment (procedure and outcome(s)) of glaucoma in children with facial port wine stain.

MATERIALS AND METHODS

This is a retrospective chart review of children with facial port wine stain referred to Alexandria University paediatric ophthalmology practice from 2005 to 2016. The charts of 22 children (44 eyes) with facial port wine stain were reviewed. The data extracted included demographics, results of ophthalmic examination findings and treatment(s). The main outcome measures were the number of eyes stratified as glaucoma, glaucoma suspects and no glaucoma at the initial and final presentations.

RESULTS

The average age of presentation was 18.2 (±33.9) months. After a follow-up of over 16.1 (±24.8) months, there were 34%, 30% and 36% of the study eyes diagnosed as glaucoma, glaucoma suspects and no glaucoma, respectively with mean ± standard deviation of intraocular pressure of 20.6 ± 5.1, 13.6 ± 5.4 and 7.5 ± 1.7 mmHg. The majority (91%) of eyes presenting with glaucoma had clear corneas. In total, 11 eyes were operated upon for glaucoma. The recorded success rate was 91%. Two eyes developed a postoperative exudative choroidal detachment, of which one resolved spontaneously and the other was successfully managed by intravitreal gas injection.

CONCLUSION

Glaucoma is a significant ocular hazard in children with facial port wine stain that may not be evident on the initial presentation. The presentation is usually with a clear cornea and surgical intervention is associated with a high success rate and a low rate of complications.

Aqueous shunt versus trabeculectomy for treatment of glaucoma

INTRODUCTION

Aqueous shunt has emerged as an alternative technique to trabeculectomy, which is considered the standard treatment for glaucoma surgery. Currently, it is mainly indicated after failure of trabeculectomy or in some types of glaucoma with high risk of failure. However, there is still controversy regarding its effectiveness compared to trabeculectomy.

METHODS

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified five systematic reviews including nine studies overall, of which four were randomized trials. We concluded that aqueous shunt might increase the qualified success compared to trabeculectomy, but it is not clear whether it has any effect on the rest of the critical outcomes for decision-making because the certainty of the evidence is very low.

XEN® implant and trabeculectomy medium-term quality of life assessment and comparison of results

AIM

To evaluate and compare the quality of life of patients submitted to XEN^® implant or trabeculectomy and the relationship with potentially involved variables.

METHODS

A cross-sectional study of patients with advanced open-angle glaucoma who underwent implantation of XEN^® (group 1) and trabeculectomy (group 2) between October 2015 and February 2017. The studied variables were: age, gender, follow-up time, need of topical anti-hypertensive therapy, visual acuity and intraocular pressure (IOP). The quantification of the quality of life was attained through the Glaucoma Symptom Scale (GSS) questionnaire.

RESULTS

Totally 34 eyes (34 patients) were included, 17 in each group. The mean GSS scores for group 1 were 42.6±6.8 (median, 47; p25, 36.5; p75, 48.5) and for group 2 it was 41.6±7.0 (median, 43; p25, 36.5; p75, 47.0; P=0.34). There was a strong negative correlation between the need for topical anti-hypertensive drugs and the GSS result in both groups (r=-0.88, P<0.01, r=-0.59, P=0.01, respectively) and a moderate negative correlation with IOP in group 1 (r=-0.50, P=0.03).

CONCLUSION

The analysis demonstrates the non-inferiority of medium-term quality of life of one group in relation to the other (XEN^® implant and trabeculectomy). The number of topical anti-hypertensive drugs and IOP negatively influenced the quality of life.

[Optical coherence tomography for examination of glaucoma surgery site]

The article reviews the results of using optical coherence tomography (OCT) - a non-invasive non-contact examination method for obtaining a tomographic slice image of the site of glaucoma surgery. The method helped reveal the functional relationships between the newly created outflow pathways and various parameters of the filtering bleb such as its linear dimensions, wall structure, presence of microcysts, position of drainage, etc. Due to its high resolution and noninvasiveness, OCT can be reliably used to examine the structure of aqueous outflow pathways in different postoperative periods with accuracy close to morphometric. The amount of data that had been obtained with the method has allowed the creation of new classifications and clarification of OCT-relevant prognostic signs for glaucoma surgery site.

[Influence of cataract phacoemulsification on eye hydrodynamics in patients with prior trabeculectomy]

At present, phacoemulsification and trabeculectomy are the most widespread surgery methods in cataract and glaucoma treatment, generally recognized as the gold standard. Among elderly patients, comorbid glaucoma and cataract are extremely prevalent, so the order of the two surgeries and the time interval between them are pivotal choices when planning treatment strategy. The reason for it is that almost any eye surgery is considered a risk factor for long-term trabeculectomy effectiveness. In attempts to solve this problem, numerous studies have been conducted on the impact of cataract surgery on filtration bleb scarring. The problem of determining the time interval between surgeries, as well as other treatment nuances, remains relevant despite the long history of research and publications. Some results are cited as general recommendations on treatment tactics (increasing the time interval between operations, using antimetabolite and anti-inflammatory therapy, minimizing intraoperative traumatism). However, currently there are no specific recommendations for one of the most important factors - the time interval between cataract extraction and trabeculectomy.

Trabeculectomy with subconjunctival collagen implant in Indian eyes: Long-term results

Purpose

To report long-term safety and efficacy of trabeculectomy with collagen implant in Indian population.

Methods

All cases of trabeculectomy with Ologen^® Collagen Matrix implant performed over a 7-year period from May 2008 through April 2015 at a tertiary referral institute were reviewed. A total of 30 eyes of 28 patients were included in the study with two patients undergoing bilateral trabeculectomy. Outcomes measured included intraocular pressure (IOP) control, number of antiglaucoma medications used, bleb morphology, and complications/reoperations.

Results

Trabeculectomy resulted in reduction in IOP from 36.46 to 11.65 mm Hg in the immediate postoperative period (day 1), a 68% decrease to 15.18 mm Hg at 84 months (58% decrease). The mean IOP reduction decreased over time from 63% in the first year to 55% after 5 years of follow-up. Fourteen eyes attained a follow-up of 5 years and eight eyes a follow-up of ≥7 years. No sight-threatening complication such as hypotony, bleb leak, and bleb-related endophthalmitis was observed in our series, and only intervention required was 5-fluorouracil needling in one case.

Conclusion

Ologen-augmented trabeculectomy is effective in controlling IOP over a long-term follow up from minimal 3 to maximal 7 years. No untoward events jeopardizing bleb safety were noted at any time. This modality is a viable alternative for patients with contraindications to use of antimetabolites.

ReGAE 12: preventing glaucoma blindness in the Caribbean through implementation of the Moorfields Safer Surgery System and skills transfer from the UK to Trinidad and Tobago

Objective

The objective of the study was to present evidence of successful skills transfer of the Moorfields Safer Surgery System (MSSS) from the UK to Trinidad and Tobago and the safety and efficacy of this technique.

Methods

Hospital-based retrospective, consecutive, non-comparative case series study of 33 eyes (24 African-Caribbean patients; 16 male patients) with primary open-angle glaucoma undergoing trabeculectomy + mitomycin C (MSSS) by a single surgeon with UK Glaucoma Fellowship training. The clinical outcome measures included intraocular pressure (IOP), bleb morphology, postsurgical interventions, postoperative complications, and best-corrected visual acuity (BCVA) at the final follow-up.

Results

All patients were self-identified as African-Caribbean. The median age was 56 years (range 34-79 years). The mean preoperative IOP on maximum tolerated medical treatment was 22.4 mmHg (SD=5.9 mmHg). With or without medication, IOP was ≤21 mmHg in 92.6% at 1 year and 87.5% at 5 years. At 1 year, IOP was ≤18 mmHg in 78%, ≤15 mmHg in 73% and ≤14 mmHg in 52%. Removal of scleral flap releasable suture(s) was performed in 84%, 5-fluorouracil injection(s) in 88% and bleb needling revision in 38%. The most common complication was early transient bleb leak (52%). No patient developed endophthalmitis, hypotony maculopathy, suprachoroidal hemorrhage, or malignant glaucoma. At the final follow-up, 91% had excellent or satisfactory bleb morphology, and 73% had equal or better BCVA.

Conclusion

Skills transfer between different geographical and economic regions contributes to the prevention of avoidable blindness through disease control - one of the core strategies of the World Health Organization's Vision 2020 initiative. In the Caribbean (Trinidad and Tobago), the MSSS was utilized by a surgeon with Glaucoma Fellowship training and achieved outcomes similar to best-published data. This success can be reproduced in other geographic locations.

Motility Changes and Diplopia After Baerveldt Glaucoma Drainage Device Implantation or After Trabeculectomy

Purpose

The purpose of this study was to quantify any diplopia and motility changes after the implantation of a Baerveldt glaucoma implant (BGI) or after trabeculectomy (TE).

Methods

We analyzed 51 patients with a BGI and 52 patients with a TE from a prospective cohort study. To quantify any diplopia, we asked patients about the presence of diplopia at 1 year after surgery. To quantify any ocular motility changes, we measured ductions in eight gaze directions, the patients' ocular alignment and their fusion range before and 1 year after surgery.

Results

In the BGI group, 14 patients (28%) experienced diplopia compared with one patient (2%) in the TE group (P < 0.001). Duction changes were more commonly observed in the BGI group (35%) than in the TE group (19%). In the BGI group, ductions were mostly restricted in elevation (13%; P < 0.001), in abduction (13%), in elevation in 25° adduction (13%; P = 0.044), and in elevation in 25° abduction (25%; P < 0.001). In 32% of the patients, their near horizontal ocular alignment shifted, notably in exodirection (P = 0.04). The fusion range decreased significantly in the horizontal direction (−12.6° ± 10.3°, mean ± standard deviation; P = 0.01).

Conclusions

BGI surgery was significantly associated with postoperative diplopia and impaired eye motility (reduced ductions), mostly present in abduction, elevation, elevation in 25° adduction, and elevation in 25° abduction. Even without impaired ductions, diplopia could come about.

Translational Relevance

By studying diplopia across glaucoma patients prospectively with diplopia questionnaires and extensive orthoptic measurements, we gain better insight into its occurrence.

Primary Baerveldt versus trabeculectomy study after one-year follow-up

PURPOSE

To compare a Baerveldt implant and trabeculectomy with respect to intraocular pressure (IOP) and failure rate at 1 year of follow-up. Secondary outcomes are pharmacological therapy and complications at 1 year of follow-up.

METHODS

This was a randomized, comparative study. A total of 119 glaucoma patients without previous ocular surgery were included at the Rotterdam Eye Hospital, the Netherlands. One eye of each subject was randomized to either a Baerveldt glaucoma drainage device (BGI) or trabeculectomy (TE). Follow-up visits were conducted at 1 day, 2 weeks, 6 weeks, 3 months, 6 months and 1 year after surgery.

RESULTS

After one year, the final IOP was equivalent for both treatment groups: 14 ± 4 mmHg (mean ± SD) for the Baerveldt group versus 13 ± 4 mmHg for the trabeculectomy group. Statistically, we found no significant difference in failure rate between the two groups. However, the Baerveldt group needed significantly more medication to decrease IOP. Overall, self-limiting complication rate was similar in both groups. Diplopia, a serious complication, was significantly more present in the BGI group.

CONCLUSION

One year after surgery, TE shows better results than the BGI. The final IOP, IOP reduction and failure rate are similar, but the need for additional IOP lowering medication in the BGI group is higher as well as the complication rate. The increased risk of developing diplopia after placement of a BGI must be taken into consideration.

Risk factors for flat anterior chamber after glaucoma filtration surgery

AIM

To investigate the incidence rate and risk factors for grade III flat anterior chamber (FAC) after glaucoma filtration surgery based on 5-year data.

METHODS

Patients who underwent glaucoma filtration surgery in Daping hospital from January 2009 to December 2013 were enrolled in this retrospective study. The incidence of grade III FAC following glaucoma filtration surgery was determined. Regression analysis was performed to investigate the influence of glaucoma type, surgical approach, age, and preoperative intraocular pressure (IOP) on the risk of postoperative FAC.

RESULTS

A total of 2179 eyes receiving anti-glaucoma surgery were included. Ninety-one eyes suffered from postoperative FAC, with an overall incidence rate of 4.18%. Of 471 eyes with primary open angle glaucoma (POAG), grade III FAC occurred in only 3 eyes (0.64%). Primary angle-closure glaucoma (PACG) was diagnosed in 1076 eyes, 39 (3.62%) of which developed grade III FAC, including 12 eyes (12/300, 4%) with acute PACG (aPACG) and 27 eyes (27/776, 3.48%) with chronic PACG (cPACG). Six of 259 eyes (2.32%) with secondary glaucoma, 28 of 186 eyes (15.05%) with neovasular glaucoma, 1 of 66 eyes (1.52%) with congenital glaucoma, and 14 of 115 eyes (12.17%) with remnant glaucoma suffered from grade III FAC. Of 6 eyes with mixed glaucoma, none developed grade III FAC after surgery. When stratified by surgical approach, 24 of 766 eyes (3.13%) undergoing trabeculectomy, 21 of 924 eyes (2.27%) treated by trabeculectomy plus mitomycin C (MMC), 18 of 109 eyes (16.51%) undergoing Ahmed glaucoma valve implantation, 23 of 201 eyes (11.44%) managed by Ahmed implantation plus MMC, and 5 of 133 eyes (3.76%) treated by Ahmed implantation plus lens extraction or vitrectomy developed grade III FAC. Logistic regression analysis revealed that factors including neovasular glaucoma, remnant glaucoma, glaucoma valve implantation, glaucoma valve implantation+MMC, glaucoma valve implantation+vitrectomy, age>60y, and IOP at admission >50 mm Hg were significantly associated with an increased risk for grade III FAC.

CONCLUSION

The overall incidence of grade III FAC after glaucoma filtration surgery is 4.18%. Patients with neovasular glaucoma and remnant glaucoma are at a higher risk of developing FAC. Ahmed glaucoma valve implantation is associated with a higher risk for grade III FAC compared with trabeculectomy. No significant correlation was observed between the use of MMC in glaucoma filtration surgery and the risk of postoperative FAC. Higher IOP at admission (>50 mm Hg) and old age (>60y) are risk factors for grade III FAC.

A 10-year review of underlying diseases for endothelial keratoplasty (DSAEK/DMEK) in a tertiary referral hospital in Japan

Purpose

To report a 10-year review of endothelial keratoplasty (EK) procedures, Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet's membrane endothelial keratoplasty (DMEK), and underlying diseases at a tertiary referral hospital in Japan.

Study design

A single-center, retrospective case series.

Methods

We retrospectively reviewed all medical records of bullous keratopathy (BK) surgically treated by EK (DSAEK/DMEK) at Kanazawa University Hospital from January 2007 to December 2016. Changes or modifications to the annual number of EK procedures and underlying diseases were analyzed.

Results

During this period, 320 EK procedures (DSAEK: 288 cases, DMEK: 32 cases) were performed on 250 patients. Total annual EKs gradually increased from 19 to 45 cases between 2007 and 2016. The annual number of DSAEKs was stable, although the proportion of DSAEKs to other procedures decreased significantly as re-DSAEKs and DMEKs increased. BK after argon laser iridotomy (ALI) was the leading cause in 2007, followed by Fuchs' endothelial dystrophy (FED) and failed penetrating keratoplasty. In 2016, BK after trabeculectomy (TLE) was most prevalent, followed by failed DSAEK, failed penetrating keratoplasty, and pseudophakic BK. The decreased ALI and FED, and increased BK after TLE and failed DSAEK were statistically significant.

Conclusion

The distribution of EK procedures (DSAEK/DMEK) and underlying diseases changed over 10 years at a tertiary referral hospital in Japan. The proportion of re-DSAEK and DMEK increased among all EK procedures. Most significantly, among the underlying diseases, decreased ALI and FED and increased TLE and failed DSAEK were observed. Extended multicenter analysis may further elucidate the changes in EK procedures and the causes of BK in Japan.

A 1-year follow-up

PURPOSE

To report on the efficacy and safety of CO₂ laser-assisted sclerectomy surgery (CLASS) compared with trabeculectomy in primary open-angle glaucoma and exfoliative glaucoma.

METHODS

One hundred and thirty-one patients underwent CLASS (66 patients) or trabeculectomy (65 patients) and were followed up for 12 months. 'Complete success' was defined as intraocular pressure (IOP) between 10 and 18 mmHg and reduced by at least 30% from the baseline without medications, while 'qualified success' was compliant with the above criteria with or without the medications.

RESULTS

Comparing CLASS with trabeculectomy at 1 year, the mean IOP reduction rate was 32.6 ± 10.8% versus 40.6 ± 15.9% (p < 0.001) and the average use of medications was 1.4 ± 1.4 versus 0.7 ± 1.1 (p < 0.05). At 12 months, the complete success rate was 35% for CLASS versus 60% for trabeculectomy (p < 0.01), while the qualified success rate was 74% versus 75%, respectively, with no significant difference in qualified success rate between the groups at any time-point (p > 0.05). Compared with CLASS, patients after trabeculectomy developed a higher rate of early complications (9.1% versus 29.2%, p = 0.004), higher endothelial cell density (ECD) loss (1.4 ± 1.4% versus 6.5 ± 4.8%, p < 0.001), higher astigmatism (0.0 ± 0.1 versus 0.1 ± 0.2, p < 0.001) and significant visual acuity deterioration (0.1 ± 0.1; range 0-2 lines versus 0.4 ± 0.6; range 0-3 lines, p = 0.016).

CONCLUSION

Although CLASS shows a less potent hypotensive effect, it is similar to trabeculectomy in the qualified success rate and offers the reduction in medications up to 12 months. With a more attractive complications profile, CLASS may be an alternative to trabeculectomy, especially at the earlier glaucoma stage and in patients with a low ECD.

Objective documentation of anterior chamber depth following trabeculectomy and its correlation with intraocular pressure and bleb functionality

The purpose of this study was to objectively evaluate the anterior chamber depth (ACD) after trabeculectomy and to correlate its variations with the intraocular pressure (IOP) and bleb functionality.Fifty eyes (46 patients) were included in this prospective study. ACD was documented with the use of a non-contact optical device (IOL Master-Carl Zeiss Meditec) and IOP was measured with the Goldmann applanation tonometer.Ophthalmological examination, IOP, and ACD measurements were performed before surgery, the day after and weekly thereafter.Linear regression Analysis between the 2 variables was performed and correlation coefficients were estimated. A 2-tailed t test was used and a P value < .05 was considered as statistically significant.Correlation coefficients between ACD and IOP, during the follow-up period, resulted in a moderate to strong positive relationship (r = 0.2-0.7), which since the 1st week resulted statistically significant at 5%.Twenty seven eyes (54%) needed at least 1 needling procedure. Considering each group separately, until the 3rd post-op week, the correlation coefficients in the needling group resulted higher than those in the non-needling group. Furthermore, in the needling group, the relationship between ACD and IOP, for the 1st, 2nd, 3, and 4th week was statistically significant at 5%.The objective documentation of the ACD in the early post-trabeculectomy period presents a moderate to strong positive correlation with the IOP.Furthermore, the brisk deepening of the ACD during the first 2 to 4 post-operative weeks is strongly correlated with the increase of the IOP and early signs of bleb encapsulation.

Choroidal detachments: what do optometrists need to know?

Choroidal detachments occur when there is an accumulation of fluid or blood in the suprachoroidal space, a potential space situated between the choroid and the sclera. They are an uncommon ocular pathology. The most common cause of choroidal detachment is secondary to trabeculectomy; however, there are other causes such as trauma and inflammation. Clinically, choroidal detachments may vary in presentation from asymptomatic, to very poor vision, severe ocular pain, vomiting and nausea. Ocular findings associated with choroidal detachments include serous retinal detachment, secondary angle closure, and a very shallow anterior chamber. Optometrists, as primary eye care providers, need to be aware of the clinical signs and symptoms associated with choroidal detachments and ensure that appropriate and timely management, with a referral to an ophthalmologist, is instigated for optimal visual outcomes. In this review, the pathophysiology, detection, and associated risk factors for choroidal detachments are discussed, and evidence-based management recommendations in an optometric context are provided. The characteristics and management of uveal effusion syndrome are also reviewed, as this can cause idiopathic exudative choroidal detachments distinct from classical choroidal detachment.

Three-dimensional Laser Scanning Confocal Analysis of Conjunctival Microcysts in Glaucomatous Patients Before and After Trabeculectomy

BACKGROUND/AIM

In glaucoma, conjunctival epithelial microcysts (CEM) have been extensively investigated by means of laser scanning confocal microscopy. In the present case series, we examined eight glaucomatous patients undergoing trabeculectomy to obtain a 3-dimensional (3-D) characterization of CEM.

MATERIALS AND METHODS

Image acquisition was performed in z-scan automatic volume mode by Heidelberg Retina Tomograph III/Rostock Cornea Module and a series of 40 images of 300×300 μm (384×384 pixels) to a maximum depth of 40 μm were acquired throughout the upper bulbar conjunctiva before (at the site planned for surgery) and eight weeks after trabeculectomy. The 3-D volume tissue reconstruction with maximal size of 300×300×40 μm was obtained.

RESULTS

In the enface view, CEM appeared as empty, optically clear, round or oval shaped sub-epithelial structures. The 3-D spatial reconstruction showed microcysts as oval-shaped and optically clear elements, which were close, but clearly separated from the epithelium. CEM were embedded in the extra-cellular spaces and located about 10 μm below the epithelial surface. After trabeculectomy, CEM increased density and area especially along the horizontal axis.

CONCLUSION

The 3-D in vivo confocal reconstruction of CEM permits for better clarification of their microscopic anatomy and patho-physiological significance, confirming their involvement in AH flow through the bleb-wall after filtration surgery for glaucoma.

Conjunctival bleb compression sutures: An effective method of addressing hypotony after trabeculectomy or trabeculectomy-related procedures

PURPOSE:

Over-filtration is a well-known complication of trabeculectomy and related procedures, especially with adjunctive antimetabolites. Secondary hypotony can result in reduced visual acuity and compromise long-term surgical success. Persistent hypotony requires intervention and we describe an effective adaptation of placing conjunctival compression sutures directly over the scleral flap.

METHODS:

A retrospective consecutive case series of all patients who underwent conjunctival compression suturing from 2012 to 2014 at Manchester Royal Eye Hospital, UK. Under sub-tenon's anaesthesia, two 9/0 nylon figure-of-eight transconjunctival sutures were placed horizontally across the bleb: the first over the anterior flap/ostium and the second over the posterior flap edge to reduce flow through the trabeculectomy flap.

RESULTS:

A total of 10 patients underwent conjunctival compression suturing, and all patients had successful reversal of hypotony and symptom resolution within 1 week with corresponding clinical improvement. Intraocular pressure control was maintained without topical pressure-lowering agents in seven patients (median = 10 mmHg, range = 7-12 mmHg) with a median follow-up of 35.9 months (range = 11-61 months). Two patients required topical therapy to maintain intraocular pressure ≤ 14 mmHg and one patient's hypotony returned after 10 months but remained untreated due to pre-existing poor vision. No patients required a return to theatre.

CONCLUSION:

This series demonstrates that conjunctival compression sutures can successfully provide long-term control of trabeculectomy-bleb-related hypotony. This technique offers an effective alternative for glaucoma surgeons in addressing post-trabeculectomy hypotony.

Pars plana insertion of glaucoma shunt in eyes with refractory neovascular glaucoma: Case report

RATIONALE

Neovascular glaucoma (NVG) is one of the most aggressive types of glaucoma in clinical practice. The outcomes are unsatisfactory despite the successful trabeculectomy with glaucoma shunt insertion.

PATIENT CONCERNS

EX-PRESS Glaucoma Filtration Device (Alcon Laboratories, Fort Worth, TX), which is used in open-angle glaucoma surgery, could minimize the potential injury caused by traditional trabeculectomy. However, no study reported about the posterior segment insertion of this device. This article reports an alternative surgical technique and outcomes of pars plana insertion of glaucoma shunt in a patient with refractory NVG.

DIAGNOSES

This research was a retrospective study of a patient with refractory NVG and in whom trabeculectomy with EX-PRESS implantation was performed. However, bleb failure developed three times in four years.

INTERVENTIONS

In this patient, the previous EX-PRESS shunt was retrieved and reinserted into the posterior segment through the pars plana 3.5 mm behind the limbus.

OUTCOMES

The post-operation intraocular pressure was stable for more than eight months after surgery without any surgical intervention or antiglaucoma medication use. No discomfort nor major complication was observed after this operation.

LESSONS

Pars plana insertion of glaucoma shunt may provide an alternative to treat refractory NVG in patients who had received pars plana vitrectomy.

Assessing the role of ranibizumab in improving the outcome of glaucoma filtering surgery and neovascular glaucoma

INTRODUCTION

Ranibizumab was the first anti-vascular endothelial growth factor (VEGF) agent approved for the treatment of neovascular age-related macular degeneration. The use of ranibizumab and other anti-VEGF medications in recent years has revolutionized the treatment of several sight-threatening retinal disorders. Emerging evidence has demonstrated that anti-VEGF treatment can offer advantages in the management of other ocular conditions where VEGFs play a key role: ocular scarring following glaucoma filtering surgery and neovascular glaucoma (NVG). Areas covered: We critically review available evidence on the use of ranibizumab as a wound healing modulator in glaucoma filtering surgery and as an adjunct in the management of NVG. Expert opinion: Based on the available evidence and the authors' clinical experience, ranibizumab is a valuable adjunct in the management of NVG. In glaucoma filtering surgery, however, the role of ranibizumab is less clear and does not provide a significant advantage over mitomycin C. Drawbacks for its use in glaucoma include cost, its off-label use, uncertainty and limited evidence on the various routes of administration, the optimal dosing schemes and its toxicity profile. Future advances in ranibizumab delivery systems allowing less frequent dosing may change this treatment paradigm.

Contemporary approach to the diagnosis and management of primary angle-closure disease

The primary angle-closure disease spectrum varies from a narrow angle to advanced glaucoma. A variety of imaging technologies may assist the clinician in determining the pathophysiology and diagnosis of primary angle closure, but gonioscopy remains a mainstay of clinical evaluation. Laser iridotomy effectively eliminates the pupillary block component of angle closure; however, studies show that, in many patients, the iridocorneal angle remains narrow from underlying anatomic issues, and increasing lens size often leads to further narrowing over time. Recent studies have further characterized the role of the lens in angle-closure disease, and cataract or clear lens extraction is increasingly used earlier in its management. As a first surgical step in angle-closure glaucoma, lens extraction alone often effectively controls the pressure with less risk of complications than concurrent or stand-alone glaucoma surgery, but may not be sufficient in more advanced or severe disease. We provide a comprehensive review on the primary angle-closure disease nomenclature, imaging, and current laser and surgical management.

Outcome of trabeculectomy with Ologen versus Mitomycin C: A comparative prospective study in Bangladesh

AIMS:

To compare the efficacy and safety of trabeculectomy with Ologen versus Mitomycin C in primary glaucoma.

MATERIALS AND METHODS:

This is a prospective study of patients aged 18 years and above, diagnosed with primary glaucoma randomised to having trabeculectomy with Ologen or Mitomycin C. The primary outcome measure was success of trabeculectomy defined as intraocular pressure >5 mmHg but ≤21 mmHg. Complete success was defined as intraocular pressure achieved without anti-glaucoma medication and qualified success was defined as intraocular pressure achieved with additional anti-glaucoma medication.

RESULTS:

At the end of 12 months follow-up, the postoperative mean intraocular pressure in the Ologen group was 12.8 ± 1.6 mmHg and 13.4 ± 2.2 mmHg in the Mitomycin C group. The Ologen group achieved complete success in 86.5% and qualified success in 13.5% of the patients, while the Mitomycin C group achieved complete and qualified success in 85.5% and 14.5%, respectively. There was no statistically significant difference in the success rate of both the groups ( p = 0.57). Furthermore, no significant intraocular pressure difference was noted between the two groups at the end of 12 months follow-up ( p = 0.14).

CONCLUSION:

Trabeculectomy augmented with Ologen appeared to be as successful and safe as trabeculectomy augmented with Mitomycin C, with no reported adverse reaction to Ologen.

Efficacy of autologous conjunctival flap on repairing the late-onset filtering bleb leakage

AIM

To evaluate the effectiveness of autologous conjunctival flap surgery for repairing the late-onset filtering bleb leakage after trabeculectomy.

METHODS

This study retrospectively reviewed 106 eyes from 106 patients with late-onset filtering bleb leakage after trabeculectomy who received autologous conjunctival flap surgery at the Zhongshan Ophthalmic Centre from 2005 to 2015. The basic information was recorded, and the interval time between trabeculectomy and autologous conjunctival flap surgery as well as related risk factors, intraocular pressure (IOP), anterior chamber depth (ACD) and best corrected visual acuity (BCVA) were analysed. Moreover, 41 patients who completed the 1-year follow up were analysed to determine the IOP and BCVA changes and long-term success rates.

RESULTS

The 50 male and 56 female subjects (average age 39.13±17.96y) included 47 (44.34%) and 33 (31.13%) cases of primary open angle and primary angle-closure glaucoma. The mean interval between trabeculectomy and repair surgery was 60.60±56.92 (3-264)mo. The mean mitomycin (MMC) concentration during trabeculectomy was 0.27±0.04 (0.12-0.4) mg/mL in the fornix-based conjunctival flap group (68 patients) and 0.28±0.04 (0.20-0.33) mg/mL in the limbal-based conjunctival flap group (11 patients). After bleb leakage, the patients' vision remained stable while the IOP decreased from 10.25±4.76 (3-20.86) to 9.44±4.33 (2-21) mm Hg (P<0.01). In the 41 analysed patients, the IOP was controlled at 15.68±5.11 (7-40) mm Hg in the 1^st year after autologous conjunctival flap surgery and recurrence was not observed, for a long-term success rate of 100%.

CONCLUSION

Autologous conjunctival flap repairing surgery is an effective technique for sealing filtering bleb leakages and controlling IOP postoperatively.

Conventional trabeculectomy versus trabeculectomy with the Ex-PRESS® mini-glaucoma shunt: differences in postoperative interventions

PURPOSE

To compare the postoperative interventions and outcomes between conventional trabeculectomy and trabeculectomy with the Ex-PRESS® mini-glaucoma shunt device (Ex-Press).

METHODS

This was a retrospective, comparative, single-facility study. We analyzed the cases of 108 glaucoma patients who underwent trabeculectomy and were followed for >1 year. Thirty-nine eyes underwent a conventional trabeculectomy (conventional group) and 69 eyes underwent a trabeculectomy with an Ex-Press (Ex-Press group). As evaluation items, we examined postoperative intraocular pressure (IOP), the surgical success rate, postoperative complications, the number of days to laser suture lysis, and needling.

RESULTS

Trabeculectomy significantly decreased the patients' IOP values from 27.8±7.9 to 11.1±3.9 mmHg in the conventional group (p<0.001) and from 27.7±9.2 to 11.5±3.7 mmHg in the Ex-Press group (p<0.001) after 1 year. The success rate was not significantly different between the groups. The timing of the first laser suture lysis was significantly sooner in the Ex-Press group, and the Ex-Press group showed significantly less choroidal detachment due to low IOP.

CONCLUSION

Earlier laser suture lysis in patients whose trabeculectomy treatment includes an Ex-Press is required to obtain the outcomes comparable to those of conventional trabeculectomy.

Anterior-Segment Optical Coherence Tomography for Predicting Postoperative Outcomes After Trabeculectomy

PURPOSE

To determine whether anterior-segment optical coherence tomography (AS-OCT) can be used to predict post-trabeculectomy bleb outcomes.

MATERIALS AND METHODS

We divided 58 eyes of 47 trabeculectomy patients into success or failure groups based on their status at 12 months after surgery. We then compared various AS-OCT measurement parameters between the two groups at 1 and 2 weeks and 1, 3, 6, and 12 months. We also analyzed the early post-trabeculectomy bleb parameters with multiple logistic regression, stepwise multiple regression, and the receiver operating characteristic (ROC) curve, to evaluate the power of these parameters to predict long-term outcomes.

RESULTS

Intraocular pressure 3 or more months after trabeculectomy was significantly lower in the success group than the failure group (all: P < 0.0016). Cleft volume was significantly higher 6 or more months after trabeculectomy in the success group than the failure group (P = 0.0027 and <0.0016). Reflectivity of the bleb wall was significantly higher in the failure group than the success group at 2 weeks and all later time points (all: P < 0.0016). Reflectivity of the bleb wall at 2 weeks after trabeculectomy was a risk factor for failure, with an odds ratio (OR) for failure of 2.48 (95% confidence interval, 1.31-4.68, increasing per 10 AU). The area under the ROC curve for reflectivity of the bleb wall at 2 weeks after trabeculectomy was 0.775 when the cutoff value was set at 122.8, with sensitivity, specificity, and OR of 78.3%, 80.0%, and 14.4, respectively. A stepwise multiple regression analysis showed that reflectivity of the bleb wall at 2 weeks was an independent factor indicating postoperative bleb survival period (β = -0.39, P = 0.007).

CONCLUSIONS

Reflectivity of the bleb wall, measured by AS-OCT, may be an early post-trabeculectomy predictor of bleb outcome.

Efficacy of predetermined therapeutic measures against bleb-related infection in the Collaborative Bleb-related Infection Incidence and Treatment Study

PURPOSE

To report the efficacy of the predetermined treatment protocol of the Collaborative Bleb-related Infection Incidence and Treatment Study (CBIITS) for bleb-related infection (BRI) patients.

METHODS

A prospective, observational cohort study was conducted at 34 clinical centres in Japan. Nineteen eyes from 19 patients that developed BRI were treated using the CBIITS protocol at 34 clinical centres. The visual acuity (VA) and intraocular pressure (IOP) were monitored for 6 and 12 months after treatment with the predetermined protocol.

RESULTS

The logMAR was 0.623 ± 0.748 (mean ± standard deviation) before the infection developed. It was 1.054 ± 1.156 and 0.950 ± 1.168 at 6 months and 12 months post-infection, respectively. However, in subgroup analyses, there was no significant decrease in post-infection logMAR in stages I and II. In contrast, decimal VA was decreased ≥2 lines in all four cases in stage III. The IOP did not change after infection. It was 10.2 ± 5.0 mmHg (range, 3-22 mmHg) before the infection developed, and 12.9 ± 5.2 mmHg (5-24 mmHg) and 10.7 ± 4.7 mmHg (3-18 mmHg) at 6 months and 12 months after infection, respectively.

CONCLUSION

Because of the small number of BRI patients, the superiority of the treatment was not definitively determined. However, VA was almost maintained in stages I and II, and the IOP did not change after infection. Although further study is necessary, the treatment protocol shown in the study might be a valuable treatment regime.

Cataract and Glaucoma Surgery: Endoscopic Cyclophotocoagulation versus Trabeculectomy

PURPOSE:

To compare the efficacy and safety of endoscopic cyclophotocoagulation (ECP) versus trabeculectomy with mitomycin C (trab) in combination with cataract surgery.

MATERIALS AND METHODS:

We evaluated the 6-month results of patients undergoing phacoemulsification (phaco) with either ECP or trab. The primary outcome was mean intraocular pressure (IOP) at 6 months; secondary outcomes were change in glaucoma medications, visual acuity, intraocular inflammation, and postoperative complications. Complete success was a target IOP of <21 mmHg and >6 mmHg without glaucoma medications. Qualified success was target IOP achieved through glaucoma medications.

RESULTS:

We evaluated 53 eyes of 53 patients; 24 (45.3%) eyes were treated with ECP-phaco and 29 (54.7%) with trab-phaco. At 6 months, there was no significant difference in mean IOP of the two groups (ECP-phaco 14.2 ± 3.6 mmHg; trab-phaco 13.0 ± 2.5 mmHg; P = 0.240). Six (25.0%) ECP-phaco eyes and 20 (69.0%) trab-phaco eyes achieved complete success (P = 0.002). Qualified success was achieved in 18 (75.0%) ECP-phaco eyes and 9 (31.0%) trab-phaco eyes (P = 0.002). The mean reduction of medication from baseline was significant (ECP-phaco 1.2 ± 1.1; trab-phaco 2.1 ± 1.5; P = 0.020). ECP-phaco resulted in more IOP spikes on the 1^st postoperative day (P = 0.040) and more anterior cellular reaction at 1 week and 1 month compared to trab-phaco (P < 0.05). The rate of postoperative complications was not significantly different between groups.

CONCLUSION:

At 6 months, ECP-phaco demonstrated similar improvements in IOP and visual acuity compared to trab-phaco. However, ECP-phaco patients had higher incidences of immediate postoperative IOP spikes and anterior chamber inflammation as well as requiring additional medications postoperatively.

Trabeculectomy with Ologen implant versus mitomycin C in congenital glaucoma secondary to Sturge Weber Syndrome

AIM

To compare the efficacy and safety of collagen matrix implant [Ologen (OLO) implant] versus mitomycin C (MMC) with subscleral trabeculectomy (SST) for the surgical treatment of congenital glaucoma (CG) in Sturge-Weber Syndrome (SWS).

METHODS

A prospective comparative randomized study of 20 eyes of 16 patients with CG associated with SWS was divided into two groups. The first group (MMC Group) included 10 eyes that were subjected to SST with MMC. The second group (OLO Group) included 10 eyes that were subjected to trabeculectomy with a collagen matrix implant (OLO implant). Postoperative evaluation included intraocular pressure (IOP) level, bleb evaluation, complications, and the need for further medication or surgical intervention.

RESULTS

The mean preoperative IOP was 29±3.16 mm Hg in MMC and 29.8±3.08 mm Hg in OLO eyes. Mean 12-month percentage reduction in IOP was significant in both groups (57.9% and 56.3%). At the end of the 12 postoperative follow-up month, in the MMC Group, 80% of eyes achieved the complete success, 20% of eyes had qualified success with no failed surgery in comparison to OLO Group which 70% of eyes achieved the complete success, 20% of eyes had qualified success with 10% failed surgery. In terms of complications, the MMC Group had a higher rate of complications than the OLO Group in the form of thin polycystic bleb in 6 eyes (60%), blebitis in only one eye (10%) treated with topical antibiotics, shallow anterior chamber in two eyes (20%).

CONCLUSION

This study proves that the use of a collagen matrix implant yields equally effective results as MMC when combined with trabeculectomy for the treatment of CG in SWS. Furthermore, OLO implantation is safe and has low incidences of complications.

Factors predicting the success of trabeculectomy bleb enhancement with needling

BACKGROUND

Bleb needling is widely used to restore flow and lower intraocular pressure (IOP) in a failing trabeculectomy. We aimed to measure the safety and efficacy of needling in a large cohort and identify factors that were associated with success and failure.

METHODS

This retrospective audit included all patients who underwent needling at Addenbrooke's Hospital, Cambridge over a 10-year period. Data were available on 91 patients (98% of patients identified), including 191 needlings on 96 eyes. Success was defined as IOP below 21 mm Hg or 16 mm Hg or 13 mm Hg consistently, without reoperation or glaucoma medication. Risk factors for failure were assessed by Cox proportional hazard regression and Kaplan-Meier curves.

RESULTS

Success defined as IOP <16 mm Hg was 66.6% at 12 months and 53% at 3 years and success defined as IOP <21 mm Hg was 77.1% at 12 months and 73.1% at 3 years. Failure after needling was most common in the first 6 months. Factors that predicted failure were flat or fibrotic blebs (non-functional) and no longer injected, while success was predicted by achieving a low IOP immediately after needling. No significant complications were identified.

CONCLUSION

Needling was most successful soon after trabeculectomy, but resuscitation of a long-failed trabeculectomy had lower likelihood of success. The safety and efficacy compare favourably with alternative treatment approaches.

Prevalence of glaucoma in the Israeli Arab population

We describe the prevalence and treatment of glaucoma in a Muslim Arab population in Israel. Based on the medical records of 15 122 persons, the overall prevalence of glaucoma was 3.9%. Prevalence rates of primary open angle glaucoma (POAG) and primary angle-closure glaucoma (PACG) were 3.0% and 0.42%, respectively. Prevalence rates of women were 135% that of men considering all types of glaucoma, 143% for POAG, and 96% for PACG. Prostaglandin analogs and beta blockers, alone or combined with carbonic anhydrase inhibitors, were the preferred medications. Of 68 patients who underwent trabeculectomy, 27 (39.7%) required medications, postoperatively, for treatment of glaucoma; following Ex-Press shunt surgery, 3/11 (27.3%) required medications. During the last three years, 16 (1.3%) individuals with POAG were recorded as legally blind as a result of glaucoma.

Efficacy of selective laser trabeculoplasty following incisional glaucoma surgery

AIM

To evaluate the efficacy of selective laser trabeculoplasty (SLT) in glaucomatous eyes with previous incisional glaucoma surgery.

METHODS

A retrospective cohort of eyes that underwent SLT at a single institution from 2013-2015 were followed for 1y. Reduction in intraocular pressure (IOP) following SLT was evaluated in eyes with prior trabeculectomy with ExPress mini shunt (Alcon, Ft Worth, TX, USA), Ahmed valve (New World Medical, Cucamonga, CA, USA), or combined phacoemulsification-trabeculectomy. A control group was included with eyes without prior surgery that underwent SLT. Success was defined as >20% drop in IOP from pre-SLT baseline.

RESULTS

One-hundred and six eyes were included with 53 in both the prior glaucoma surgery (PGS) and no prior glaucoma surgery (NPGS) groups. Mean pre-SLT IOP was 19.2±4.3 and 20.6±6.0 mm Hg for PGS and NPGS groups, respectively (P=0.17). Both groups produced statistically significant IOP reductions at 1 and 6mo (P<0.04). At 6mo, mean IOP reduction reached 7.3% and 10.8% for the PGS and NPGS groups, respectively (P=0.42). Overall, 27.9% and 31.7% of eyes in PGS and NPGS groups met success criteria at 1y (P=0.70). In the PGS group, eyes with baseline IOP ≥21 mm Hg had IOP reductions of 18.1% (P<0.001), 16.7% (P<0.01), and 8.4% (P=0.31) compared to eyes with baseline IOP <21 mm Hg who had IOP reductions of 2.3% (P=0.39), 3.4% (P=0.19), and 1.1% (P=0.72) at 1, 6mo, and 1y, respectively.

CONCLUSION

SLT is efficacious in eyes with prior incisional glaucoma surgery and results in similar IOP reductions compared to eyes without PGS. A larger IOP reduction is observed following SLT in eyes with higher pre-SLT IOP.

An unusual case of posttrabeculectomy conjunctival granuloma

We report an unusual case of granulomatous inflammation that presented adjacent to bleb 3 weeks postoperatively after combined phacoemulsification and trabeculectomy surgery with mitomycin-C due to retained microfragments of methyl cellulose sponge. The commonly used antimetabolite delivery devices are made of cellulose. Methyl cellulose sponges are friable, and they are likely to leave behind microfragments in subconjunctival space. In our case, bleb integrity was maintained, unlike the earlier reported cases which presented with bleb leak. Hence, one should have high index of suspicion in unusual cases of postoperative inflammation not resolving conservatively. Although rare, retained sponge particles can be a cause of early bleb-related inflammation which can lead to bleb failure.

Merits of trabeculectomy in advanced and end-stage glaucoma

OBJECTIVES

The aim of the study was to evaluate intraocular pressure (IOP) control, potential benefits, and associated complications in advanced cases of glaucoma (visual acuity of <6/60) after trabeculectomy. Although many studies of trabeculectomy in glaucoma patients have been done, very few in such advanced cases.

METHODS

The study was done on 60 cases of advanced primary open-angle glaucoma (POAG). Trabeculectomy was done and IOP control was assessed. Pre-operative workup included a detailed history, slit lamp biomicroscopy, Goldmann applanation tonometry, gonioscopy using Goldmann 2 mirror lens, and detailed fundus examination with the 78D lens. All the patients were to undergo optical coherence tomography and Humphrey automated perimetry.

RESULTS

Out of 60 patients with POAG, 48 were males and 12 were females with a ratio of 4:1. Of all the 60 cases, 36 had a visual acuity of 20/200, 16 had a visual acuity of hand movements, and eight patients had a visual acuity of perception of light. The mean pre-operative IOP was measured as 37.01 mmHg with standard deviation (SD)± 8.82. The mean post-operative IOP was found 17.92 mmHg with SD ± 3.17. There was a mean drop of 19 mmHg of IOP postoperatively. P value was highly significant (P < 0.000).

CONCLUSION

Trabeculectomy is a successful method of controlling IOP in patients with advanced glaucoma. Trabeculectomy is the method of reducing IOP in medically uncontrolled patients. A pain-free eye was associated with better quality of life in patients. A successful trabeculectomy helps to preserve the residual vision in such patients.

A novel suturing technique for filtering glaucoma surgery: the accordion suture

AIM

To present a novel scleral flap suturing technique for filtering glaucoma surgery in order to control high postoperative intraocular pressure (IOP).

METHODS

Description of 'the accordion suture' technique for mitomycin C augmented trabeculectomy. In cases of postoperative high IOP, pulling the loop of the suture helps to lift up the scleral flap by an even pressure on both edges. By means of this technique, the scleral flap opens up in an "accordion" manner, thus preventing flap obstruction and providing adequate aqueous flow.

RESULTS

Our study group consisted of 8 eyes of 8 patients with neovascular glaucoma. Mean age of the subjects was 67.42±8.21y and female/male ratio was 4/4. Mean preoperative IOP was 37±7.48 mm Hg. Mitomycin C augmented trabeculectomy was carried out on the subjects without any complications. The scleral flap closure is performed with three separate sutures; initially, our accordion suture through the center of the flap, and two releasable sutures on both corners. All the patients received removal of two side releasable sutures concomitant with pulling the accordion suture, without any complications. The average traction time was 3.5±0wk postoperatively. The mean postoperative IOP was 11.37±2.72 mm Hg. No suture related complications were observed.

CONCLUSION

This technique can be the suture of choice for filtering glaucoma surgery in experienced hands by its easy learning curve for precisely indicated patients.

Comparison of surgical outcome of trabeculectomy and phacotrabeculectomy in Chinese glaucoma patients

Our study retrospectively reviewed the surgical outcomes up to 3mo of 38 consecutive Chinese glaucoma patients who underwent trabeculectomy (n=18) or phacotrabeculectomy (n=20). Baseline age, visual acuity, and intraocular pressure were comparable. Intraocular pressure from post-operative 1d to 3mo were similar between 2 groups. Complete success was achieved in 65% of phacotrabeculectomy, and 66.7% of trabeculectomy cases; while failure occurred in 16.7% of phacotrabeculectomy, and 10% of trabeculectomy cases at 3mo. Phacotrabeculectomy group consistently showed better improvement in visual acuity. Diffuse blebs occurred in 65% of phacotrabeculectomy and 83% of trabeculectomy eyes; and flat blebs in 35% of phacotrabeculectomy, but none after trabeculectomy. There was more hypotony (5% vs 0) after phacotrabeculectomy. To conclude, phacotrabeculectomy and trabeculectomy demonstrated comparable intraocular pressure control up to 3mo post-operatively. However, phacotrabeculectomy patients had better visual acuity improvement. Nonetheless, more diffuse bleb and less hypotony were present following trabeculectomy.