Comparison of Safety and Efficacy Between Ab Interno and Ab Externo Approaches to XEN Gel Stent Placement

Purpose

To compare the safety and efficacy of two different techniques for implantation of the XEN Gel Stent, a minimally invasive surgical device for the treatment of refractory glaucoma.

Methods

A retrospective chart review of eyes that received ab interno or ab externo XEN Gel Stent placement from February 2017 to October 2019 was conducted. A single surgeon (NMR) performed all operations. Eyes that received the XEN implant concomitant with a glaucoma drainage device insertion or that were lost to 6-month follow-up were excluded. Intraocular pressure (IOP) change, change in glaucoma medications, frequency of slit lamp revision procedures, and frequency of secondary glaucoma surgeries were the primary outcomes compared between groups.

Results

Fifty eyes that underwent ab interno placement and 30 eyes that underwent ab externo placement were studied. The ab interno cohort demonstrated a mean IOP reduction of 8.4 ± 1.7 mmHg (28.6% decrease) by 12 months, compared to a mean reduction of 12.8 ± 3.0 mmHg (40.1% decrease) in the ab externo group (p = 0.208). Mean reduction in medication use was 1.81 ± 0.29 medications in the ab interno group and 1.86 ± 0.37 in the ab externo group (p = 0.913). By 12 months, 58% of ab interno eyes had required 5-fluorouracil injection compared to 36.7% of ab externos (p = 0.105). Bleb needling was applied to 42% and 26.7% of the eyes, respectively (p = 0.231). A second glaucoma surgery was necessary for 20% of the ab interno cohort and 10% of the ab externo cohort (p = 0.351).

Conclusion

There were no differences in outcomes between ab interno and ab externo placement of the XEN Gel Stent. Both approaches are safe and effective for lowering IOP.

Combined Phacoemulsification and 360-Degree Endocyclophotocoagulation with and without a Kahook Dual Blade in Patients with Primary Open-Angle Glaucoma

Purpose

The present study aimed to compare the outcomes of combined phacoemulsification and 360-degree endocyclophotocoagulation with and without goniotomy using a Kahook Dual Blade in patients with glaucoma.

Patients and Methods

We enrolled 37 patients, 21 of whom underwent combined phacoemulsification with 360-degree endocyclophotocoagulation and goniotomy using a Kahook Dual Blade (tri-modal therapy (T-MT) group). The remaining 16 patients underwent phacoemulsification with endocyclophotocoagulation (bi-modal therapy (B-MT) group). Visual acuity, intraocular pressure, and number of glaucoma medications were recorded before the study and postoperatively on the first day, at week 1, and at 1, 3, 6, 9, and 12 months. Surgical success was defined as an IOP ≤12 mmHg and ≥6 mmHg or an at least 20% reduction in IOP from baseline with (qualified success) or without medications (complete success).

Results

Forty-nine eyes were included. Baseline mean IOP was 16.96±3.66 mmHg and 15.64±4.88 mmHg in the T-MT and B-MT groups (p=0.122), respectively. At the 12-month follow-up, mean IOP values were 11.44±2.15 mmHg and 12.45±1.90 mmHg (p=0.031) in the T-MT and B-MT groups, respectively. Complete success rates were 37% in the T-MT group and 31% in the B-MT group, while qualified success rates were 74% and 50%, respectively. Glaucoma medications decreased from 2.0±1.4 to 0.8±1.0 (p<0.001) in the T-MT group and from 1.5±1.3 to 1.0±1.5 in the B-MT group (p=0.032). Similar improvements in visual acuity were observed in both groups. Complications were mild and resolved without intervention.

Conclusion

The tri-modal treatment is safe and may be more effective in reducing IOP and glaucoma medication requirements than bi-modal treatment.

MRI after successful eyeWatchTM implantation

The eyeWatch^TM is a new glaucoma drainage device that includes an adjustable mechanism that can vary the resistance to aqueous humor outflow during the postoperative period to reduce the burden of postoperative intraocular pressure (IOP) management. The mechanism contains a magnetic rotor that can be adjusted using an external magnetic control unit. Adjustments of the position of the rotor are performed mostly in the initial postoperative follow-up period in order to reach the target IOP. However, for some patients, it might be necessary to perform MRI for the sake of medical investigations. As the MRI is creating a strong magnetic field, this magnetic field is likely to interact with the adjustable rotor of the eyeWatch^TM, resulting in modification of the IOP. We report the case of an 82-old female patient successfully operated with the implantation of an eyeWatch^TM. The patient underwent a cerebral MRI for persistent headache. Shortly after the MRI procedure, the patient was checked at the eye clinic to assess the position of the rotor and to measure the IOP. The eyeWatch^TM was readjusted to the former position set before undergoing the MRI. No complications were reported in the follow-up after MRI. This case demonstrates that MRI examinations can be safely performed after glaucoma surgery using an eyeWatch^TM without compromising on the quality of the imaging or the stability of the IOP. This is a complication-free procedure that only requires checking the new position of the rotor and re-adjusting the implant, if necessary, to achieve the target IOP.

Clinical Results of Ab Interno Canaloplasty in Patients with Open-Angle Glaucoma

Purpose

To report treatment outcomes of ab interno canaloplasty using the Visco360 and Omni system devices as a standalone procedure or combined with cataract surgery in patients with open-angle glaucoma (OAG).

Design

Retrospective, single-center, consecutive case series.

Study Patients

Eighty-nine eyes of 64 patients aged 43 to 91 with open-angle glaucoma treated with ab interno canaloplasty between January 2018 and September 2019. Eyes with previous incisional glaucoma surgery and eyes with less than 90 degrees of viscodilation were excluded.

Intervention

Patients underwent ab interno canaloplasty as a stand-alone procedure or in conjunction with cataract surgery. Ab interno canaloplasty was performed with either the Visco360 or Omni System devices (Sight Sciences, Menlo Park, CA). Treatment consisted of viscodilation without trabeculotomy.

Main Outcome Measures

Primary outcome measures were mean IOP and mean number of glaucoma medications. Additional analysis included the impact of degrees of treatment on treatment outcomes.

Results

Preoperative mean IOP was 24.5 ± 8.3; the number of preoperative glaucoma medications was 2.5 ± 1.3. At 18 months postoperative, the mean IOP was reduced 36% to 15.8 ± 2.5 (P<0.001) and glaucoma medications were reduced 32% to 1.7 ± 1.5 (P<0.05). Higher preoperative IOP was significantly correlated with increased IOP lowering. Reduction of mean IOP and medications were not significantly different between standalone ab interno canaloplasty vs cataract surgery/ab interno canaloplasty. Reduction of mean IOP and medications were not significantly different between patients with 180 degrees of treatment vs 360 degrees of treatment.

Conclusion

Ab interno canaloplasty reduces IOP and glaucoma medication use in patients with OAG whether as a standalone surgery or in combination with cataract surgery.

Predictive Value of Bleb Vascularity after Mitomycin C Augmented Trabeculectomy

Background: To evaluate the relationship between bleb vascularity and surgical outcome one year after mitomycin C (MMC) augmented trabeculectomy. Methods: This was a prospective study of 51 eyes of 44 patients after MMC-augmented primary trabeculectomy with follow-up of 12 months. The total vessel area of a bleb was measured with ImageJ software on color photographs of the bleb on day 1 and 14, then months 1, 3, 6 and 12 after trabeculectomy. Blebs were classified clinically as successful (intraocular pressure (IOP) ≤ 18 mmHg and a >30% reduction in IOP without antiglaucoma medications or additional surgical interventions) or failed. Linear regression analysis was performed to determine the correlation of bleb vascularity with IOP and outcome. Results: At 1 year, 40 eyes (78.4%) were classified as successful and 11 eyes (21.6%) as failed. The mean bleb vascularity at 1, 3 and 12 months after surgery was significantly higher in failed blebs (16.31% vs. 13.01%, p = 0.005, 14.93% vs. 10.15%, p = 0.001, 8.99% vs. 6.37%, p = 0.011, respectively). There were no significant differences in mean bleb vascularity at 1 and 14 days postoperatively in successful and failed blebs. The results revealed a significant association between vessel area at 1 and 3 months after trabeculectomy with IOP at 6 months postoperatively (p = 0.005 and p = 0.009, respectively). Conclusions: In this prospective study, we demonstrated a strong relationship between bleb vascularity and the surgical outcomes of trabeculectomy. Vascularity of the filtering bleb during early postoperative period was not correlated with IOP or success of trabeculectomy at one year. Increased bleb vascularity 1, 3 and 12 months after trabeculectomy appears to predict surgical failure at 1 year after trabeculectomy.

[Thermography of ocular surface tissues in the assessment of aseptic postoperative inflammation]

PURPOSE

To determine the thermographic parameters of ocular surface tissues in various types of anti-glaucoma operations.

MATERIAL AND METHODS

The study included 70 patients with glaucoma (140 eyes) and 28 patients (56 eyes) with cataract and planned phacoemulsification. All patients underwent dynamic infrared thermography of the eye surface to evaluate the aseptic inflammatory response before and after surgery.

RESULTS

The increase in the temperature of the ocular surface tissues was longer after penetrating glaucoma surgery than after the non-penetrating type, which indicates a more prolonged inflammatory aseptic reaction in response to surgical intervention.

CONCLUSION

The obtained results allow the development of a rational tactic of preoperative drug preparation and more effective postoperative management.

[Methods of assessing the condition of filtering bleb after glaucoma surgery]

Currently, there is a need to assess the condition of structures at the surgery site after glaucoma intervention due to the necessity to decide further treatment tactics after performed operations, as well as the possibility of developing more advanced methods of surgical treatment of glaucoma. Despite the fact that there are several methods of examining the filtration bleb (FB), some of them have both clear advantages and significant disadvantages. This article reviews the possibilities of using optical coherence tomography (OCT), ultrasound biomicroscopy (UBM), thermography, confocal microscopy, and the Hyperemia-3 program for assessing the structural and functional state of the FB.

Outcomes of Combined Prolene Gonioscopy Assisted Transluminal Trabeculotomy with Phacoemulsification in Open-Angle Glaucoma

Purpose

To describe the clinical outcomes of combined prolene gonioscopy assisted transluminal trabeculotomy (GATT) with phacoemulsification in patients with open-angle glaucoma.

Methods

Retrospective study of patients with cataract and open-angle glaucoma treated with GATT and phacoemulsification with intraocular lens (IOL) implantation. Patients with neovascular glaucoma, corneal decompensation, unstable IOL, and with bleeding disorders were excluded. The cumulative probability of failure was the primary outcome. Secondary outcomes were the complete success rate, the mean change on intraocular pressure (IOP), best-corrected visual acuity (BCVA) and number of glaucoma medications at the last follow-up. The frequency of complications was also recorded.

Results

Thirty two eyes (25 patients) were included. Nineteen (59.3%) were females, with a mean age of 73.4±12.4 (23-87 years) and a mean baseline BCVA of 1.1±0.75 (0.3-3) LogMAR units. The cumulative probability of failure was 3.2% at 1 month and 6.3% at 6 and 12 months. Sixty-eight and 65.5% of eyes achieved complete success at 3 and 6 months, respectively. The reduction of IOP and number of glaucoma medications at 6 months were statistically significant (p<0.0001 and p=0.0002, respectively). There was a statistically significant improvement of BCVA (from 1.1±0.7 to 0.4±0.7) at 6 months (p<0.0001). IOP spikes (18.7%) and transient hyphema (9.3%) were the most common complications.

Conclusion

Combined GATT with cataract surgery reduced the IOP and was associated with low failure rates and few ocular complications. This procedure offers the advantage to avoid the need for a bleb, scleral, or conjunctival incision, allowing the possibility for future glaucoma procedures.

Microinvasive glaucoma surgery: A review of 3476 eyes

Microinvasive glaucoma surgery (MIGS) is a potentially safer and more efficacious method studied in patients with mild-to-moderate open-angle glaucoma requiring less invasive treatment goals; however, the literature on MIGS must be thoroughly evaluated. We conducted a review of MIGS by searching MEDLINE, EMBASE, and Cochrane CENTRAL. Primary efficacy indicators were reductions in intraocular pressure and topical medication use postoperatively. While all comparative randomized controlled trials assessing MIGS in English peer-reviewed journals were included, only observational studies with a target follow-up of at least one year and a high priority score were analyzed, resulting in a total of 3476 eyes across 20 trials. The mean age was 69.5 ± 2.9 years, 53.7% were female, and 77.4% were Caucasian. One study had last follow-up at less than one year, fifteen studies had follow-up extending 1-2 years, and four had longer than two years of follow-up. A pattern of more significant intraocular pressure and medication reduction was observed in patients who underwent MIGS (n = 2170) relative to control (n = 1306) interventions. iStent had the most literature supporting its efficacy, followed by Hydrus. The most common adverse events after MIGS implantation included stent obstruction, inflammation, and subsequent surgical intervention. Surgical complication rates and efficacy are favorable after MIGS. This review helps to consolidate the high-quality evidence that exists for various MIGS procedures and to identify gaps where further research is needed.

Clinical Features of Japanese Patients with Ocular Inflammation and Their Surgical Procedures Over the Course of 20 Years

Purpose

To review clinical characteristics of ocular inflammation patients in Osaka, Japan, over 20 years and investigate the efficacy of required surgeries.

Methods

We conducted a retrospective study involving 2730 eyes of 1815 patients with ocular inflammation examined at the Osaka Medical College Hospital from April 1999 to March 2019.

Results

Patients comprised 843 males and 972 females, with a mean age of 56.3 ± 18.5 years. Anterior uveitis, such as scleritis, acute anterior uveitis, and herpes iritis, was the most common anatomical classification (51.2%), followed by panuveitis (37.2%), posterior uveitis (9.4%), and intermediate uveitis (2.2%). Sarcoidosis occurred in 153 patients (8.4%), Vogt-Koyanagi-Harada disease (VKH) in 83 (4.6%), and Behçet’s disease in 68 (3.7%). Sarcoidosis peaked in two age groups: 30s and 50–70s. Of the 1815 patients, 389 eyes of 271 patients (14.9%) had cataract surgery, 162 eyes of 133 (7.3%) had vitrectomy, and 124 eyes of 103 (5.7%) had glaucoma surgery. Among cataract surgery patients, 49 (18.1%) had sarcoidosis, 14 (5.2%) had VKH, and seven (2.6%) had Behçet’s disease, and visual acuity (VA) was improved in 321 eyes (82.5%). Among vitrectomy patients, 15 (11.3%) had acute retinal necrosis, 14 (10.5%) had sarcoidosis, 12 (9.0%) had fungal endophthalmitis, and 11 (8.3%) had malignant lymphoma (ML); 83 eyes (51.2%) needed vitrectomy due to vitreous opacity, and VA improved in 88 eyes (54.3%). Among glaucoma surgery patients, 13 (12.6%) had sarcoidosis, and nine (8.7%) had Posner-Schlossman syndrome.

Conclusion

Anterior uveitis was the commonest form of uveitis and sarcoidosis was the commonest underlying disease. The age distribution of sarcoidosis was older than in previous reports. 10% of patients with sarcoidosis needed glaucoma surgery, and vitrectomy was required in 50% for vitreous opacity caused by ML or sarcoidosis.

Trabectome, trabecular aspiration and phacoemulsification in a triple procedure for treating exfoliation glaucoma: A long-term follow-up

PURPOSE

This study investigates the long-term intraocular pressure (IOP) lowering potential, risk profile and success rate of a triple procedure comprising phacoemulsification, trabecular aspiration and trabectome (Microsurgical Technology, Redmond, WA, USA) for treating exfoliation glaucoma.

METHODS

A total of 117 eyes of 117 patients with exfoliation glaucoma underwent a combination of phacoemulsification, trabectome and trabecular aspiration. They were followed up for up to 7 years. The success rates were designated according to criteria based on the Tube versus Trabeculectomy Study and the World Glaucoma Association guidelines: A (no resurgery); B/C (IOP < 21/18 mmHg, no resurgery, IOP reduction > 20%); D (IOP ⩽ 15 mmHg, no resurgery, IOP reduction ⩾ 40%).

RESULTS

The mean follow-up period was 46 months. IOP showed a 38% reduction from 24.5 ± 6.1 to 15.2 ± 3.6 mmHg (p < 0.0001). The Medication Score decreased by 23% from 2.2 ± 0.9 to 1.7 ±1.0 (p < 0.0001). The success rates were 87, 76, 74 and 38% according to criteria A, B, C and D. In eyes with an initial IOP of >30 mmHg, a 57% reduction from 34.2 ± 4.4 to 14.8 ± 3.2 mmHg (p < 0.0001) was observed, and the success rates were 91, 91, 82 and 59% for criteria A, B, C and D, respectively.

DISCUSSION

We conclude that the triple procedure may effectively lower IOP in patients with exfoliation glaucoma over a mean follow-up period of 46 months without significant side effects. Therefore, the triple procedure may serve as first-line surgery for patients with exfoliation and cataract, even with a high initial IOP.

Suppression of the TGF-β pathway by a macrolide antibiotic decreases fibrotic responses by ocular fibroblasts in vitro

To elucidate and to inhibit post-surgical fibrotic processes after trabeculectomy in glaucoma therapy, we measured gene expression in a fibrotic cell culture model, based on transforming growth factor TGF-β induction in primary human tenon fibroblasts (hTFs), and used Connectivity Map (CMap) data for drug repositioning. We found that specific molecular mechanisms behind fibrosis are the upregulation of actins, the downregulation of CD34, and the upregulation of inflammatory cytokines such as IL6, IL11 and BMP6. The macrolide antibiotic Josamycin (JM) reverses these molecular mechanisms according to data from the CMap, and we thus tested JM as an inhibitor of fibrosis. JM was first tested for its toxic effects on hTFs, where it showed no influence on cell viability, but inhibited hTF proliferation in a concentration-dependent manner. We then demonstrated that JM suppresses the synthesis of extracellular matrix (ECM) components. In hTFs stimulated with TGF-β1, JM specifically inhibited α-smooth muslce actin expression, suggesting that it inhibits the transformation of fibroblasts into fibrotic myofibroblasts. In addition, a decrease of components of the ECM such as fibronectin, which is involved in in vivo scarring, was observed. We conclude that JM may be a promising candidate for the treatment of fibrosis after glaucoma filtration surgery or drainage device implantation in vivo.

Surgery for glaucoma in modern corneal graft procedures

Glaucoma is a common cause of vision loss after corneal transplantion and is considered a major risk factor for graft failure. Glaucoma may be present before corneal transplant surgery, or increased intraocular pressure may develop after keratoplasty in up to one-third of patients. Pre-existing glaucoma should be controlled before keratoplasty, either medically or surgically. For postkeratoplasty increase in intraocular pressure; identifying the risk factors allows appropiate follow-up and management. Patients undergoing anterior lamellar keratoplasty may take advantage of reduced rates of postkeratoplasty glaucoma. Glaucoma also complicates eyes with endothelial keratoplasties, mostly related to management of intraocular pressure spikes derived from anterior chamber air bubbles. Nevertheless, the severity is less, and the intraocular pressure is more easily controlled when compared with penetrating keratoplasty. Adequate management of glaucoma that develops before or after keratoplasty may save eyes from irreversible damage to the optic nerve and increase graft survival.

EX-PRESS Glaucoma Filtration Device: Management of Complications

The EX-PRESS glaucoma filtration device appears to be an effective addition to our options to treat refractory glaucoma. The possibility to create a sclerostomy without tissue excision provides a safe and reliable outflow pathway for aqueous that is standard in size, reducing much of the variability associated with a surgical procedure. Prospective randomized studies comparing EX-PRESS implantation with trabeculectomy show encouraging results. However, complications usually encountered in filtration surgery have been reported, and EX-PRESS implantation can also lead to specific device-related complications. This article reviews the most common complications associated with this procedure.

[Medicated prevention of scarring after glaucoma surgery]

Modulation of wound healing is one of the main challenges in glaucoma surgery. Modern antiproliferative agents used to reduce postoperative scarring are either insufficiently effective or inadequate in terms of safety. In the search for novel agents devoid of such drawbacks, specialists directed their attention to selective inhibitors of proinflammatory cytokines and growth factors. The article reviews pathophysiologic basis of wound healing, characteristics of inflammatory mediators affecting fibroblast proliferation and scarring, and provides description of the currently used and new, potentially promising antiproliferative agents.

Stab incision mitomycin C-assisted rapid trabeculectomy: A 'SMART' trabeculectomy alternative

The aim of the present study was to introduce a new modified trabeculectomy technique, stab incision mitomycin C (MMC)-assisted rapid trabeculectomy (SMART), which requires less surgical time and tissue manipulation. A total of 41 eyes with indication for trabeculectomy underwent glaucoma surgery with the SMART technique; superior subconjunctival injection of 0.005 mg MMC mixed with 0.1 ml lidocaine, followed by small, fornix base conjunctival opening. A stab incision was made to enter the anterior chamber 1.5 mm post-limbus using a 2.4 mm cataract knife. Double 0.75 mm punch and peripheral iridectomy were performed. A releasable suture was placed in the scleral opening, and matrix sutures to close conjunctiva. The preoperative mean intraocular pressure (IOP) was 23.8 mmHg, with a mean number of medications of 3.3. The mean follow-up duration was 27.6 months, with a range of 12-46 months. A year post-surgery, the mean IOP was 11 mmHg, with a mean number of medications of 0.7, corresponding to a reduction of 12.8 mmHg in IOP and 2.6 in the number of medications. During follow-up, additional 5-fluorouracil injections were administered when needed. In conclusion, SMART with wound modulation appears to be a safe and quick alternative to classic trabeculectomy. Few minor and no major complications were observed during the first 2.5 years of follow-up, with all eyes maintaining an IOP <15 mmHg.

Bleb grading by photographs versus bleb grading by slit-lamp examination

PURPOSE

Using a bleb-grading system clinically facilitates long-term follow-up of patients with previous glaucoma surgery. Clinical evaluation of these patients can be challenging for untrained ophthalmologists. Morphological bleb configuration might influence planning of follow-up visits in glaucoma patients due to different and individual prognosis after trabeculectomy. In this study, we compared the MaBAGS (Mainz Bleb Appearance Grading System), a classification system for filtering blebs with other classification systems (MBGS/Moorfields Bleb Grading System, IBAGS/Indiana Bleb Appearance Grading Scale) in reference to usability and reliability and compare it to grading by bleb photographs.

METHODS

Forty-two eyes of 31 patients after trabeculectomy were included. Three observers, two senior and one junior observer, graded all blebs using MaBAGS, MBGS and IBAGS during slit-lamp examination. Bleb photographs were reviewed at least 4 weeks after clinical examination. Statistical analysis was performed to determine agreement between the observers using intraclass correlation coefficients.

RESULTS

With MaBAGS, excellent and good levels of agreement were found for vascularity indices, Seidel test and transparency. Parameters for area and height yielded moderate agreement, while indices for conjunctival mobility and microcysts failed to show satisfying levels of agreement. Using MBGS resulted in excellent and good interobserver consistency for parameters regarding subconjunctival blood, Seidel test, and central and peripheral vascularity. Height and nonbleb vascularity reached moderate levels of agreement. Agreement for area parameters was low. With IBAGS, good levels of agreement were found for height and vascularity, and moderate for extent. In all grading systems, consistency was considerably better between the two experienced observers compared to the inexperienced grader.

CONCLUSIONS

MaBAGS shows good reproducibility. Using such a grading system improves precision of the description of a highly variable clinical finding. The reliability of grading by slit-lamp examination exceeds that of grading on photographs.

Comparison of Two Tube-Modification Techniques in Baerveldt Glaucoma Implantation in Refractory Glaucoma

Importance

To compare treatment outcomes among a stent group, ligature group and combined group in eyes with refractory glaucoma.

Background

Various techniques have been used intra-operatively to restrict the aqueous flow in Baerveldt glaucoma implantation.

Design

Retrospective chart review.

Participants

All glaucoma patients aged over 18-years old who had Baerveldt implantation in Ramathibodi Hospital, Bangkok, Thailand, between October 2011 and February 2018 were included for analysis.

Methods

Retrospective interventional research was conducted. All glaucoma patients who underwent drainage device implantations were retrospectively reviewed from medical records and divided into three groups: stent group, ligature group, and combined group. The primary outcome was post-operative intraocular pressure (IOP) changes and BCVA (logMAR) change. The secondary outcome is treatment failure. Repeated measurements with mixed models and multi-level parametric survival model stratified by propensity score and eye side were used to compare the primary and secondary outcomes between stent group and ligature group.

Main Outcome Measures

Treatment failure between two groups.

Results

A total of 163 patients with a mean age of 57.11 ± 19.04 years, implanted with Baerveldt tube, were eligible. There were no significant differences between stent and ligature groups in terms of post-operative IOP changes [mean difference with 95% confidence interval = 0.53 (−0.49, +1.55) vs −0.02 (−0.84, +0.81); P = 0.411] and post-operative BCVA (logMAR) change (0.02 (−0.13, +0.18) vs –0.05 (−0.18, +0.07); P = 0.465). The hazard ratio and 95% confidence interval of treatment failure in ligature group were 2.57 (0.72–9.19) compared with the stent group.

Conclusion

This study suggests a trend toward a better result in the stent group compared with the ligature group. Further research with a larger sample size and randomized control trial is warranted.

XEN® Gel Stent: A Comprehensive Review on Its Use as a Treatment Option for Refractory Glaucoma

The XEN Gel Microstent is a subconjunctival microinvasive glaucoma surgical device developed with the aim of improving the predictability and safety profile of bleb-forming glaucoma surgical procedures. The stent is a hydrophilic tube composed of a porcine gel cross-linked with glutaraldehyde with good stability and biocompatibility with minimal tissue reaction. This device has demonstrated promising outcomes with fewer risks compared to traditional surgeries. The aim of the review is to present early studies on different designs of the XEN Gel Stent, to summarize different surgical techniques of implantation and to analyze more comprehensively the results, complications and rates of needling of the commercially available device (Xen 45). The review will address separately special cases (PXG, UVG, ICE, congenital glaucoma) and describe small series and case reports.

Performances of glaucoma operations with Kahook Dual Blade or iStent combined with phacoemulsification in Japanese open angle glaucoma patients

AIM

To compare surgical outcomes of phacoemulsification combined with glaucoma surgical techniques performed with either Kahook Dual Blade (KDB) or iStent for Japanese patients with either primary open angle glaucoma or exfoliation glaucoma.

METHODS

We retrospectively evaluated the surgical outcomes of 129 eyes of 84 Japanese patients with glaucoma who underwent KDB or 44 eyes of 34 patients who underwent phacoemulsification with iStent procedures combined with cataract surgery. The primary outcome was surgical success or failure [with surgical failure being indicated by <20% reduction from preoperative intraocular pressure (IOP) or IOP>18 mm Hg as criterion A; IOP>14 mm Hg as criterion B on two consecutive study visits; or reoperation requirement]. In addition, we assessed the number of postoperative glaucoma medications and the resulting complications.

RESULTS

The probability of success was significantly higher in the KDB group than in the iStent group for criterion A (60.2% vs 46.4%, P=0.019). In the KDB group, the mean preoperative IOP of 19.8±7.3 mm Hg decreased significantly to 13.0±3.1 mm Hg (P<0.01), and the mean number of glaucoma medications at 2.5±1.4 decreased significantly to 1.6±1.6 (P<0.01) 12mo postoperatively. In the iStent group, the mean preoperative IOP of 17.8±2.9 mm Hg significantly decreased to 14.3±2.3 mm Hg (P<0.01), and the mean number of glaucoma medications at 2.2±1.1 decreased significantly to 0.9±1.4 (P<0.01) 12mo postoperatively. The overall IOP reduction percentage was higher in the KDB group (26.2%) than in the iStent group (19.0%) 12mo postoperatively (P=0.03). Hyphema occurred significantly more frequently in the KDB group (16.3%) than in the iStent group (2.3%, P=0.017).

CONCLUSION

KDB and iStent procedures combined with cataract surgery both result in significant IOP and glaucoma medication reductions after the 12-month follow-up. The patients in the KDB group have a higher success rate for the target IOP of less than 18 mm Hg and a higher complication rate than those in the iStent group.

What Is the Impact of Intraoperative Microscope-Integrated OCT in Ophthalmic Surgery? Relevant Applications and Outcomes. A Systematic Review

Background: Optical coherence tomography (OCT) has recently been introduced in the operating theatre. The aim of this review is to present the actual role of microscope-integrated optical coherence tomography (MI-OCT) in ophthalmology. Method: A total of 314 studies were identified, following a literature search adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. After full-text evaluation, 81 studies discussing MI-OCT applications in ophthalmology were included. Results: At present, three microscope-integrated optical coherence tomography systems are commercially available. MI-OCT can help anterior and posterior segment surgeons in the decision-making process, providing direct visualization of anatomic planes before and after surgical manoeuvres, assisting in complex cases, and detecting or confirming intraoperative complications. Applications range from corneal transplant to macular surgery, including cataract surgery, glaucoma surgery, paediatric examination, proliferative diabetic retinopathy surgery, and retinal detachment surgery. Conclusion: The use of MI-OCT in ophthalmic surgery is becoming increasingly prevalent and has been applied in almost all procedures. However, there are still limitations to be overcome and the technology involved remains difficult to access and use.

Circumferential Viscodilation Ab Interno Combined with Phacoemulsification for Treatment of Open-Angle Glaucoma: 12-Month Outcomes

Purpose

To evaluate reduction in intraocular pressure (IOP) and medications for open-angle glaucoma (OAG) patients 12 months post-ab-interno circumferential viscodilation (VISCO360, Sight Sciences, Menlo Park, CA) in conjunction with cataract surgery.

Setting

Surgical center (New York, United States).

Design

Retrospective study of all OAG patients treated with 360-degree ab-interno viscodilation with cataract surgery by a single surgeon (NR) having 12 months of follow-up. Eyes were stratified by baseline IOP. Group 1: ≥18 mmHg (n=111). Group 2: <18 mmHg (n=69).

Methods

IOP was measured using Goldmann applanation tonometry. Medications, the number of medication-free eyes in each group at 12 months, and adverse events (AE) are reported. Analysis includes descriptive statistics and t-tests evaluating change from baseline.

Results

Groups 1 and 2 had mean baseline IOP of 22 and 14.3 mmHg. Medication use was 0.9 and 1.1 for Groups 1 and 2. At 12 months IOP for Group 1 was reduced 22% to 17.2 mmHg (p<0.0001) on 1.0 medications (p=0.7). IOP for Group 2 was similar to baseline (15.4 mmHg) but with a reduction in medications to 0.6 (p<0.05). The proportion medication free at 12 months was 32% and 47% for Groups 1 and 2 versus 34% and 26% at baseline, respectively. There were few AE (hyphema 1.7%, IOP elevation >10 mmHg >30 days post-op 1.1%, mild inflammation <1%) and no secondary surgical interventions excepting a single paracentesis, one-day postoperative.

Discussion

Treatment goals for the two groups differed. Pressure reduction (Group 1) or medication reduction (Group 2). Viscodilation achieved significant IOP reduction in Group 1 and medication reduction in Group 2 with many patients (both groups) medication free at 12 months. AE were infrequent and transient.

Conclusion

Circumferential ab-interno viscodilation can be combined with cataract surgery and provide an IOP lowering and medication reduction benefit sustained for at least 12 months, for many patients with OAG.

[Papillomacular retinoschisis associated with glaucoma]

Peripapillary and macular retinoschisis is one of the rare manifestations of advanced glaucoma of different types. The article presents a case report and a mini-review. Peripapillary and macular retinoschisis with visual deterioration was diagnosed in a patient with advanced decompensated open-angle glaucoma and pseudoexfoliation syndrome. Surgical treatment of glaucoma led to intraocular pressure normalization, gradual regress of retinoschisis and improvement of visual functions. The retinal structure fully restored 1.5 years after the operation. The observation period was 3 years, retinoschisis did not recur. The article discusses the pathogenesis and potential algorithm for the treatment of the disease. Risk factors for the development of retinoschisis include high intraocular pressure, significant visual field defects and a wide range of diurnal intraocular pressure fluctuations. The source of the intra-retinal fluid is the vitreous body. Management of the patient consists of medical, laser and surgical normalization of intraocular pressure and regular monitoring. In case of persisting retinoschisis, patient undergoes vitreoretinal surgery or barrier laser coagulation. Retinal structure recovers gradually after the intervention and takes on average 1 year.

The characteristics of Posner-Schlossman syndrome: A comparison in the surgical outcome between cytomegalovirus-positive and cytomegalovirus-negative patients

This retrospective observational study aims to report the clinical characteristics and surgical results in eyes with Posner-Schlossman syndrome (PSS), and compare these outcomes between cytomegalovirus (CMV)-positive and -negative eyes.We reviewed the medical records of 21 consecutive immunocompetent patients clinically diagnosed with PSS between the years 2010 and 2018. Aqueous humor was collected from all the affected eyes to detect if CMV was present, and polymerase chain reaction (PCR) was performed using the herpesvirus family primers.The average period between the initial PSS attack and aqueous humor sampling at our institute was 9.3 years. Out of the 21 patients, 62% were CMV-positive. Regardless of CMV status, the mean intraocular pressure (IOP), mean deviation (MD), and central corneal endothelium cell (CEC) density, at the initial examination at our institute were already significantly worse in the affected eyes than in the unaffected eyes (all P values < .05). The average visual acuity (VA) was only significantly worse in the CMV-positive group (P = .02). Out of all the patients, those that were CMV-positive had undergone more glaucoma surgeries (P = .056). Fourteen patients underwent either a trabeculectomy (TRAB) or a trabeculotomy (LOT), and their IOP significantly reduced following surgery (P < .001). In 85.7% of those that had surgery, their IOP was successfully lowered to less than 20 mm Hg.Long-lasting PSS causes a decrease in VA, MD, and the CEC density. A prompt diagnosis is required, and an appropriate treatment plan should be formulated. In those patients with PSS that develop uncontrolled glaucoma, both TRAB and LOT may be effective in controlling IOP.

Effect of Trabeculectomy on OCT Measurements of the Optic Nerve Head Neuroretinal Rim Tissue

Purpose

Ophthalmologists commonly perform glaucoma surgery to treat progressive glaucoma. Few studies have examined the stability of OCT neuroretinal rim parameters after glaucoma surgery for ongoing detection of glaucoma progression.

Design

Longitudinal cohort study.

Participants

20 eyes (16 subjects) with primary open angle glaucoma who had undergone a trabeculectomy.

Methods

We calculated the change in OCT parameters (minimum rim area (MRA), minimum rim width (MRW), Bruch's membrane opening (BMO) area, mean cup depth (MCD), anterior lamina cribrosa surface depth (ALCSD), prelaminar tissue thickness (PLTT), retinal nerve fiber layer thickness (RFNLT) during an interval from the visit before the surgery to the visit after the surgery, a span of approximately 6-months. We also calculated changes in the same eyes over two separate 6-month intervals that did not contain trabeculectomy to serve as control. We compared these intervals using a generalized linear model (with compound symmetry correlation structure), accounting for the correlation between time intervals for the same eye.

Main outcomes measures

MRW, MRA, angle above the reference plane for MRW and MRA, BMO area, MCD, mean ALCSD, PLTT, RNFLT and visual field parameters (mean deviation (MD), pattern standard deviation (PSD), and visual field index (VFI)).

Results

The intervals containing trabeculectomy showed a significant decrease in intraocular pressure (-9.2 mmHg, p<.001) when compared to control intervals. Likewise, the following neuroretinal rim parameters showed significant changes with trabeculectomy: increased MRW (+6.04μm, p=.001), increased MRA (+0.014mm², p=.024), increased angle above reference plane of MRW (+2.64°, p<.001), decreased MCD (-11.6μm, p=.007), and decreased mean ALCSD (-18.91μm, p=.006). This is consistent with an increase in rim tissue thickness and a more anterior position of the ILM and ALCS relative to the BMO plane. Conversely, RNFLT change was not significantly different between trabeculectomy and control intervals (p=.37).

Conclusion

Trabeculectomy resulted in anatomical changes to the ONH rim associated with reduced glaucomatous cupping. The RNFL thickness may be a more stable measure of disease progression that clinicians can use to monitor across time intervals containing glaucoma surgery.