Outcomes of trabeculectomy in eyes with refractory acute primary angle-closure in Indian eyes

Purpose:

To report the outcomes of trabeculectomy in eyes with refractory acute primary angle-closure attack.

Methods:

Patients with acute primary angle-closure attack and who underwent trabeculectomy for medically uncontrolled intraocular pressure within 2 months of presentation were retrospectively analyzed. Primary outcome was intraocular pressure (IOP). Secondary outcome measures were visual acuity, number of antiglaucoma medication (AGM), complications, and risk factors for failure of trabeculectomy.

Results:

Thirty-five eyes of 31 patients with median (interquartile range) follow-up of 3 (0.5, 9) years were included in the study. Median age at presentation was 55 (47, 60) years. Median duration of symptoms at presentation was 10 (4, 16) days and median time from presentation to surgery was 13 (6, 25) days. Median IOP reduced from 42 (36, 46) to 13 (12, 16) mmHg (P < 0.001) and median number of AGM reduced from 3 (1, 3) to 0 (0, 0) after trabeculectomy at the end of 1 year. The probability of complete and qualified success was 88% (95% confidence interval [CI]: 72%–95%) and was 97% (95% CI: 81%–99%) at 1 year, respectively. Failure was noted in six eyes. Subsequent cataract surgery was needed in 13 eyes (37%) with a median duration from trabeculectomy being 6.75 (1, 11) years. None of the preoperative, intraoperative, or postoperative factors tested were associated with failure (P > 0.10 for all associations on Cox proportional hazard regression analysis).

Conclusion:

In medically unresponsive cases of acute primary angle-closure attack, primary trabeculectomy seems safe and effective in Indian eyes.

Effect of Trabeculectomy on Mean and Centroid Surgically Induced Astigmatism

This study aimed to investigate the arithmetic mean of surgically induced astigmatism (M-SIA) and the centroid of surgically induced astigmatism (C-SIA) after standard trabeculectomy. We comprised 185 eyes of 143 consecutive patients (mean age ± standard deviation, 67.7 ± 11.6 years) who underwent trabeculectomy and completed at least a 3-month routine follow-up. In all cases, the scleral flap was made at the nasal-superior location. Corneal astigmatism was measured with an automated keratometer. We calculated the M-SIA and the C-SIA using vector analysis and applied the astigmatism double angle plot. The magnitude of corneal astigmatism increased significantly, from 1.17 ± 0.92 D preoperatively to 1.77 ± 1.05 D postoperatively (paired t-test, p < 0.001). The M-SIA was 1.12 ± 0.55 D, and the C-SIA was 0.73 D @64° ± 1.02 D in the right eye group, and the M-SIA was 1.08 ± 0.48 D and the C-SIA was 0.60 D @117° ± 1.03 D in the left eye group. The C-SIA showed an astigmatic shift toward the nasal-superior location of the scleral flap creation. Our results revealed that trabeculectomy induced the SIA in the direction of the scleral flap location and that the C-SIA was much lower than the M-SIA in eyes undergoing trabeculectomy.

[On refraction shift after trabeculectomy]

PURPOSE

To determine the factors affecting the shift of refraction after trabeculectomy.

MATERIAL AND METHODS

The study included 42 patients who were examined prior to trabeculectomy and at the following timepoints: 1 week, 1 month and 3 months after surgery. Examination included tonometry with assessment of corneal biomechanical properties, keratorefractometry with vector analysis, and biometry. The obtained data was processed for regression analysis and to find the possible correlations.

RESULTS

All significant correlations between the measured parameters only occur on week 1. Postoperative spherical component of refraction (sphere) correlates negatively both with preoperative axial length (AL) and anterior chamber depth (ACD) (r=-0.699 and r=-0.458, p<0.05) and postoperative AL and ACD (r= -0.767 and r= -0.415, p<0.011). Dependence of sphere on AL is also expressed as a regression model. The magnitude of AL change depends on the magnitude of intraocular pressure (IOP) change (r=0.729, p<0.0001) and correlates negatively with postoperative IOP (r=-0.454, p=0.009) and baseline corneal hysteresis (CH; r= -0.482, p=0.009). Dependence of AL on IOP is also expressed as a regression model. The magnitudes of sphere and cylinder shifts correlate negatively with each other (r=-0.416, p=0.038). Keratometry reveals that the overall cylinder value correlates with the corneal cylinder, and so do the magnitudes of their shifts (r=0.589 and r=0.574, p<0.0001). Dependence of corneal hysteresis on IOP is expressed as a regression model; however, neither tonometric nor biomechanical corneal properties correlate with refraction.

CONCLUSIONS

Sphere correlates negatively with AL and ACD. In turn, AL is related to the reduction in IOP. This dependence is likely the most important one for the refraction shift after trabeculectomy. No correlations were found for the change of astigmatism.

[Calculation of intraocular lens power after trabeculectomy]

PURPOSE

To assess biometric changes in eyes after trabeculectomy (TE) and its impact on refractive outcomes of phacoemulsification (PE) in order to determine the corrections for calculation of intraocular lens (IOL) power.

MATERIAL AND METHODS

The study included two groups of patients: the 1^st group consisted of 116 patients who were assessed by optical biometry (IOL-Master 500) for mean biometric values before and after TE; the 2^nd group included 31 patients with history of TE (study subgroup) and 47 individuals without glaucoma (control subgroup) who underwent PE with subsequent comparison of IOL calculation accuracy.

RESULTS

There was significant axial length (AL) shortening in the 1^st group from 23.28±0.97 to 23.19±0.97 mm (p<0.001) 6 months after TE, which positively correlated (r=0.296, p=0.001) with intraocular pressure (IOP) decrease (from 25.4±5.34 to 17.2±4.42 mm Hg, p<0.001). Mean keratometry and anterior chamber depth values did not significantly change after TE. Mean IOL power calculation error after PE in the 2^nd group was -0.05±0.47 D and 0.003±0.62 D for the control and study subgroups, respectively (p=0.697). However, significant impact of preoperative IOP on IOL power calculation error was discovered in the study subgroup (R²=0.526, p<0.001), but not in the control subgroup (R²=0.061, p=0.052). Based on linear regression, the expected IOL power calculation errors depending on the preoperative IOP were determined for patients with history of TE.

CONCLUSION

AL shortening due to decrease in IOP in patients with history of TE leads to IOL power calculation errors. Expected IOL calculation error related to preoperative IOP level was determined, which could help improve refractive outcomes of PE in patients with history of TE.

'Progressive peripheral anterior synechiae in iridocorneoendothelial syndrome- a crawling disaster'

PURPOSE

Iridocorneal endothelial (ICE) syndrome is well known to cause refractory glaucoma in young adults. Commonly acclaimed mechanism for trabeculectomy failure in these cases include accelerated subconjunctival fibrosis, abnormal endothelial proliferation, and closure of ostium. In the following article, we present a case of Iridocorneal endothelial syndrome that presented with refractory glaucoma after trabeculectomy due to rapidly progressive peripheral anterior synechiae causing angle closure and corneal decompensation that mandated a tailored surgical approach of management. Methods: This is a descriptive case report based on electronic medical records, patient observation, surgical intervention, and follow-ups. Case description: A thirty-eight-year-old-male presented to us with signs suggestive of iridocorneal endothelial syndrome with gonioscopy revealing peripheral anterior synechiae (PAS) over four clock-hours temporally. Uncontrolled intraocular pressure (IOP) despite maximal medical therapy mandated augmented trabeculectomy with anti-fibrotics. The bleb failed within 3 weeks of trabeculectomy, with evidence of progressive crawling PAS causing endothelial decompensation and raised IOP. He underwent Ahmed glaucoma valve (AGV) implant surgery with viscosynechiolysis and sectoral iridectomy under antiviral cover. This helped control IOP and retain corneal clarity, with no recurrence of PAS in the affected area. Conclusion: Progressive peripheral synechiae in ICE syndrome can cause early bleb failure and refractory glaucoma. Careful viscosynechiolysis and sectoral iridectomy alongside a second implant surgery can help salvage visual functions and preserve corneal clarity while preventing further progression of PAS in these eyes.

Impact of Early COVID-19 Pandemic on Common Ophthalmic Procedures Volumes: A US Claims-Based Analysis

PURPOSE

The COVID-19 pandemic has had a profound effect on the delivery of healthcare in the United States and globally. The aim of this study was to evaluate the impact of COVID-19 on common ophthalmic procedure utilization and normalization to pre-pandemic daily rates.

METHODS

Leveraging a national database, Clinformatics™ DataMart (OptumInsight, Eden Prairie, MN), procedure frequencies and daily averages, defined by Current Procedural Terminology codes, of common elective and non-elective procedures within multiple ophthalmology sub-specialties were calculated. Interrupted time-series analysis with a Poisson regression model and smooth spline functions was used to model trends in pre-COVID-19 (January 1, 2018-February 29, 2020) and COVID-19 (March 1, 2020-June 30, 2020) periods.

RESULTS

Of 3,583,231 procedures in the study period, 339,607 occurred during the early COVID-19 time period. Anti-vascular endothelial growth factor injections (44,412 to 39,774, RR 1.01, CI 0.99-1.02; p = .212), retinal detachment repairs (1,290 to 1,086, RR 1.07, CI 0.99-1.15; p = .103), and glaucoma drainage implants/trabeculectomies (706 to 487, RR 0.93, CI 0.83-1.04; p = .200) remained stable. Cataract surgery (61,421 to 33,054, RR 0.77; CI 0.76-0.78; p < .001), laser peripheral iridotomy (1,875 to 890, RR 0.82, CI 0.76-0.88; p < .001), laser trabeculoplasty (2,680 to 1,753, RR 0.79, CI 0.74-0.84; p < .001), and blepharoplasty (1,522 to 797, RR 0.71, CI 0.66-0.77; p < .001) all declined significantly. All procedures except laser iridotomy returned to pre-COVID19 rates by June 2020.

CONCLUSION

Most ophthalmic procedures that significantly declined during the COVID-19 pandemic were elective procedures. Among these, the majority returned to 2019 daily averages by June 2020.

Combining flanged intrascleral IOL fixation with Glaucoma Surgery: Initial experience

PURPOSE

To report the initial clinical outcomes of combining glaucoma surgery with flanged intrascleral intraocular lens (F-SFIOL) fixation as a single stage procedure.

METHODS

Retrospective, non-comparative case-series of eyes which underwent combined surgery for glaucoma with F-SFIOL and had at least 6-months of follow-up. A fellowship-trained senior glaucoma surgeon managed all the cases.

RESULTS

Twelve-eyes of 10 glaucoma patients (8 males, 2 females) underwent F-SFIOL; only 8 of these eyes were combined with a glaucoma procedure. Mean age of patients was 55.1 ± 16.1 years (95%CI [44.4,73.2], median 61 years) and were followed-up for a mean of 21.0 ± 9.5 months, 95% CI [13.1,28.9], median 18 months. F-SFIOL was combined with trabeculectomy ± Mitomycin C in 4 eyes, Ahmed Glaucoma Valve in 3 eyes and needling of a pre-existing bleb in 1. Each eye had controlled intraocular pressure (IOP) at last follow-up (pre-procedure 29.1 ± 13.4 mmHg, 95% CI [17.9, 40.3], median 27 mmHg to 14.5 ± 3.2 mmHg, 95% CI [11.8, 17.1], median 13 mmHg, p = 0.006) and decreased need for number of anti-glaucoma medication (AGM) (pre-procedure 3.7 ± 1.1, 95% CI [2.8,4.6], median 4 to 0.7 ± 0.7, 95% CI [0.1,1.3] median 1, p < 0.001). In all the eyes, best corrected visual acuity (BCVA) was either stable or improved; only 1 eye had astigmatism worse than that pre-existing. In 1 eye IOL was explanted, with an additional procedure to control IOP. No serious long-term complications occurred in any subject.

CONCLUSION

The initial experience of single-stage F-SFIOL along with glaucoma surgery, both being performed by the same anterior-segment surgeon, is promising, thereby avoiding the cost, specialised skill, and potential complications of a posterior approach. Glaucoma surgery combined with and adapted to suture-less, flap-less, glue-less intra-scleral IOL fixation is hitherto unreported.

Use of Amniotic Membrane in MMC-Augmented Trabeculectomy: A Retrospective Comparative Study

Purpose

Amniotic membrane transplantation (AMT) has shown promising results as an antifibrotic agent in trabeculectomy. We aimed to evaluate the additional effect of AMT in MMC-augmented trabeculectomy.

Patients and Methods

This retrospective study analyzed the results of the first 12 postoperative months of glaucomatous eyes submitted to Moorfields Safer Surgery Trabeculectomy with MMC alone (non-AMT group) compared to MMC and AMT (AMT group). Both groups were compared in terms of intraocular pressure (IOP), number of antihypertensive medications and need for surgical reinterventions. Absolute and relative success rates 12 months after surgery were defined as IOP <18 mmHg, without and with the use of antihypertensive medications, respectively.

Results

The analysis included 51 eyes of 45 glaucoma patients (29 eyes in the non-AMT group and 22 in the AMT group). Mean IOP decreased from 24.72±5.11 mmHg and 26.86±10.62 mmHg preoperatively in non-AMT and AMT groups to 12.86±4.22 mmHg and 12.60±4.43 mmHg, respectively, at 12 months (p = 0.84). Postoperative number of medications decreased significantly in both groups. Absolute success was seen in 71% of non-AMT eyes and 55% of AMT eyes (p = 0.46), whereas relative success was obtained in 14% and 30%, respectively (p = 0.55). Reinterventions were needed in 28% of the eyes (11 bleb injection/needling and 4 Ahmed tube implantation) in the non-AMT group and in 27% of the AMT group (10 bleb injection/needling and 1 Ahmed tube implantation) (p = 0.89).

Conclusion

Trabeculectomy combined with MMC and AMT did not show better results than trabeculectomy with MMC alone.

Cytokine profile in tear and aqueous humor of primary open-angle patients as a prognostic factor for trabeculectomy outcome

OBJECTIVE

To evaluate the cytokine profile in tear and aqueous humor in primary open-angle glaucoma before trabeculectomy and correlate preoperative cytokine levels with the surgical outcome.

METHODS

Prospective study. Twenty-nine patients with primary open-angle glaucoma undergoing primary trabeculectomy were included. Levels of 27 cytokines were measured in tear an aqueous humor using the Bio-Plex Pro Human Cytokine 27-Plex Immunoassay kit (Bio-Rad Laboratories, Hercules, CA, USA).

RESULTS

29 patients who underwent trabeculectomy were included and their first-year follow-up visits were recorded. Mean age was 76.0 ± 7.0 years (range 56-84), mean intraocular pressure was 18.2 ± 3.6 mmHg and mean number of topical medications was 2.3 ± 0.9. At the one-year visit, 5 patients were classified as surgical failure. In aqueous humor, preoperative cytokine levels of regulated on activation normal T cell expressed and secreted (RANTES) were significantly higher in those patients with surgical failure at one year. IL-8 in tear and interferon gamma-induced protein (IP-10) in aqueous humor correlated positively with one-year IOP reduction. No statistically significant correlations were found with changes in visual field mean defect or global peripapillary retinal nerve fiber layer thickness (all, p >0.05).

CONCLUSIONS

Preoperative RANTES levels in aqueous humor as well as other cytokines could serve as useful biomarkers for trabeculectomy outcome.

A Patient with Primary Open-Angle Glaucoma with Re-Elevated Nocturnal Sitting Intraocular Pressure after Restarting Medical Therapy due to a Bleb Failure

We describe the case of a primary open-angle glaucoma patient with re-elevated nocturnal sitting intraocular pressure (IOP) after restarting medical therapy due to a failing bleb. IOP was markedly higher than diurnal IOP during multiple-drug therapy in both eyes, but it did not increase in the left eye with a functional bleb without medical therapy after trabeculectomy with adjuvant mitomycin. However, nocturnal sitting IOP was re-elevated after restarting multiple-drug therapy due to a failing bleb, while diurnal IOP was maintained at a low level.

A Modified Technique in Applying Sponge Soaked with Mitomycin C in Trabeculectomy

ABSTRACT

Trabeculectomy with adjunctive use of Mitomycin C (MMC) has been a benchmark for glaucoma filtration surgery for decades. However, there are many variations in the ways that the sponges soaked with MMC are applied during the trabeculectomy surgery. We herein describe our way of placing the MMC-soaked sponges to improve the safety and efficacy of the trabeculectomy. The sponges are placed vertically and posteriorly with the long side of the sponge perpendicular to the limbus, not parallel. This will reduce the size of the conjunctival wound at the limbus to preserve more virgin conjunctiva that can be used for repeated trabeculectomy when needed. This will also facilitate a more posteriorly directed flow of aqueous drainage that, in turn, may increase the success rate of the trabeculectomy. We have obtained encouraging results in our practice, and further large-scale randomized studies seem warranted.

Inflammatory cytokines levels in aqueous humour and surgical outcomes of trabeculectomy in patients with prior acute primary angle closure

PURPOSE

To quantify the levels of three inflammatory cytokines in the aqueous humour of patients with prior acute primary angle closure (APAC) and investigate their correlation with surgical outcomes of trabeculectomy.

METHODS

In this prospective cohort study, aqueous humour samples were collected from 44 prior APAC eyes. Analyte concentrations of monocyte chemoattractant protein-1 (MCP-1), vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6) were measured using multiplexed immunoassay kits. Intraocular pressure was measured using Goldmann application tonometry.

RESULTS

Forty-four prior APAC eyes were followed up for 24 months after trabeculectomy and divided into success and failure groups according to surgical outcomes. Monocyte chemoattractant protein-1 (MCP-1) levels in the aqueous humour were significantly higher in the failure group (p = 0.0118). Univariate and multivariate analyses showed that MCP-1 level was a significant risk factor for trabeculectomy outcomes (univariate analysis: p = 0.016, odds ratio = 14.538; multivariate analysis: p = 0.023, odds ratio = 13.718). When prior APAC eyes were divided according to MCP-1 levels, the overall success rate was significantly higher in eyes with low MCP-1 levels than eyes with high MCP-1 levels (p = 0.0249).

CONCLUSION

In prior APAC patients, the MCP-1 level in the aqueous humour predicts trabeculectomy results. Therefore, modulation of MCP-1 expression may have potential clinical applications after filtration surgery.

Trabeculectomy for neovascular glaucoma in proliferative diabetic retinopathy, central retinal vein occlusion, and ocular ischemic syndrome: Surgical outcomes and prognostic factors for failure

PURPOSE

To evaluate the outcomes of trabeculectomy in the eyes with neovascular glaucoma (NVG), caused by proliferative diabetic retinopathy (PDR), central retinal vein occlusion (CRVO), and ocular ischemic syndrome (OIS).

METHODS

A retrospective review of NVG eyes that underwent trabeculectomy between 1991 and 2019. Complete success was defined as intraocular pressure (IOP) between 6 and 21 mmHg without antiglaucoma medications (AGM). The risk factors were analyzed by Cox's proportional hazard model.

RESULTS

The study included 100 eyes of 100 subjects with a mean age of 58 ± 9.8 years and a median follow-up of 1.27 years (interquartile range: 0.63, 2.27). The cause of NVG was PDR in 59 eyes (59%), CRVO in 25 eyes (25%), and OIS in 16 eyes (16%). Trabeculectomy with mitomycin-C was performed in 88 eyes and trabeculectomy in 12 eyes. The cumulative complete success probability of trabeculectomy in PDR was 50% (95% confidence interval [CI]: 38, 65) at 1 year, 8% (1, 46) at 3-5 years. In OIS, it was 64% (43, 96) from 1 to 5 years. In CRVO, it was 75% (59, 94) at 1 year, 45% (23, 86) from 2 to 5 years. The PDR was associated with a higher risk of surgical failure compared to OIS (P = 0.04) and CRVO (P = 0.004). Other significant risk factors were increasing age (P = 0.02), persistent neovascularization of iris (NVI) (P = 0.03), higher number of anti-vascular endothelial growth factor (VEGF) injections prior to trabeculectomy (P = 0.02), and delay in performing trabeculectomy (P = 0.02).

CONCLUSION

Compared to CRVO and OIS, the eyes with NVG secondary to PDR had poor success with trabeculectomy. Older age, persistent NVI, need for a higher number of anti-VEGF injections, and delayed surgery were associated with a higher risk for trabeculectomy failure.

Effects of glaucoma surgery on visual field progression in open-angle glaucoma considering the floor effect

Purpose

The aim of this retrospective analysis was to investigate whether trabeculectomy (TRAB) and XEN® Gel Stent implantation (XEN) – both filtrating surgery techniques – can slow down the deterioration of visual field (VF) parameters considering the floor effect, which could lead to a misestimation of pre‐ and postoperative VF rate of progression (ROP).

Methods

Included in this study were patients with open‐angle glaucoma, who underwent either TRAB or XEN® gel stent implantation and who had at least three VF tests before and after surgery, over an observation period of 13 years. The annual ROP of the mean defect (MD) and the square root of loss variance (sLV) were calculated with two different censoring thresholds: by censored regression and by ordinary least squares regression (OLSR). In addition, the diagnostic range of sLV was calculated.

Results

48 eyes of 39 glaucoma patients were included in the study. The annual rate of MD progression was significantly reduced by filtering surgery when calculating the yearly ROP using OLSR (p = 0.006) and by censoring values exceeding a precalculated cut‐off of 14.20 dB (p = 0.041) and a cut‐off from the literature of 15.00 dB (p = 0.028). On average, the MD was impacted by a significant floor effect of 14.20 dB (95% CI: 12.83‐15.56), corresponding to 17.7/59 absolute defects or 29.9% of the whole VF. When applying both OLSR and censored regression, the annual rate of sLV progression did not show a significant difference. The sLV showed a diagnostic boundary at a MD of 15.78 dB.

Conclusion

This study shows that filtering surgery can reduce the progression of VF in patients with open‐angle glaucoma, especially those whose disease develops aggressively. This is valid even if the floor effect in advanced cases is compensated by censored regression. On average, the ROP of MD is affected by a significant floor effect at about 29.9% absolute loss of the whole VF.

Comparison of subconjunctival microinvasive glaucoma surgery and trabeculectomy

PURPOSE

To assess surgical success and the post-operative development of intraocular pressure between XEN45^® gelstent, Preserflo^® MicroShunt and trabeculectomy with mitomycin C.

METHODS

Data from 105 eyes from 105 patients of matched cases with refractory open-angle glaucoma, who underwent surgery between January 2019, and August 2020, were evaluated. Patients underwent either stand-alone XEN gelstent insertion with Mitomycin C, stand-alone Preserflo with Mitomycin C or trabeculectomy with Mitomycin C. The primary outcome was the proportion of complete surgical success at 6 months post-operatively (i.e. intraocular pressure between 5mmHg and 18mmHg, no revision surgery, no loss of light perception and no post-operative pharmaceutical antiglaucomatous treatment). The reduction of intraocular pressure after 6 months, the classes of antiglaucomatous medication used post-operatively, best-corrected visual acuity, spherical refractive errors and astigmatism were assessed as secondary outcomes.

RESULTS

We included 35 eyes in each group. After 6-month follow-up, complete success was 73.5% [95%-CI: 57.9%-89.2%] in the trabeculectomy group, 51.4% [95%-CI: 34.0%-68.8%] in the XEN group and 74.2% [95%-CI: 57.9%-90.5%] in the Preserflo group (p = 0.08). Regarding secondary outcomes, the reduction of intraocular pressure was 12.1 ± 7.9 mmHg in the trabeculectomy group and was thereby 5.8 [95%-CI: 2.2-9.6] mmHg greater compared with the XEN group (p < 0.001) and 4.8 [95%-CI: 0.9-8.7] mmHg higher than the Preserflo group (p = 0.01).

CONCLUSIONS

No statistically significant differences were found between trabeculectomy, XEN45^® gelstent implantation and Preserflo^® MicroShunt implantation regarding surgical success after 6 months. Yet reduction in intraocular pressure was significantly higher in the trabeculectomy group. However, all three interventions resulted in sufficiently low post-operative intraocular pressure and may therefore be considered individually for glaucoma treatment.

Swept Source OCT in monitoring uveal effusion after trabeculectomy in a nanophtalmic eye

Uveal effusion syndrome describes serous detachments of the choroid and ciliary body with exudative retinal detachment. It is a complication following glaucoma filtering surgeries such as trabeculectomy especially in nanophthalmic eyes. We report a rare case of a 42-year-old-woman, with nanophtalmos, who developed posterior serous retinal detachment and uveal effusions after trabeculectomy for chronic angle closure glaucoma. The patient was put on oral steroids with good clinical outcome. Anterior Segment OCT allowed monitoring of iridocorneal angle and anterior chamber depth, Swept Source OCT was useful for monitoring retinal reattachment and choroidal thickness.

Microcatheter-Assisted Trabeculotomy Combined With Deep Sclerectomy and Trabeculectomy in Young to Middle-Aged Adults With Advanced Primary Open-Angle Glaucoma: 1-Year Result

Objective: We aimed to evaluate the safety and clinical efficacy of ab externo microcatheter-assisted trabeculotomy combined with deep sclerectomy and trabeculectomy (MATT-DS-Trab) in the surgical management of advanced primary open-angle glaucoma (POAG).

Methods: According to the inclusion criteria, we retrospectively collected and analyzed 37 POAG cases in advanced stage who received MATT-DS-Trab. The intraocular pressure (IOP), best corrected visual acuity (BCVA), use of anti-glaucoma drugs, shape of the filtering bleb, size of the scleral lake, complications, and the surgical success rate were recorded.

Results: The mean IOP was 37.50 ± 8.11 mmHg before the operation, while it depleted to 10.08 ± 2.01 and 11.43 ± 2.07 mmHg at 1 week and 12 months after the operation, respectively (both P < 0.001 compared to preoperative IOP). From none to two kinds of anti-glaucoma drugs were used 12 months after surgery on the patients, which were significantly reduced compared with that preoperatively (P < 0.001). An L-type filtering bleb was the main form at all time points after the operation. At 12 months following surgery, an F-type filtering bleb accounted for 5.41% and no E-type filtering bleb was recorded. The length and height of the scleral lake shrunk with time, but there was no statistical significance (P > 0.05). Also, there was no correlation between the size of the scleral pool and the IOP (P > 0.05). At 12 months after the operation, the complete success rates were 94.59, 83.78, and 72.97% according to standards A (≤18 mmHg), B (≤15 mmHg), and C (≤12 mmHg), respectively. Intraoperative complications were mainly anterior chamber hemorrhage, and no complications related to the filtration bleb were observed after the operation.

Conclusion: Based on multichannel mechanisms, MATT-DS-Trab is able to effectively reduce IOP in advanced POAG patients, with few serious complications and a high success rate.

Spontaneous Trabeculectomy Bleb Reformation and Regain of Function Following Phacoemulsification

Phacoemulsification and cataract surgery in general often lead to trabeculectomy bleb failure. We herein describe an unusual occurrence in a 79-year-old female who had a failed trabeculectomy bleb for one year prior to presentation, and whose failed bleb became reformed, and she regained function on the first day post-phacoemulsification, manifesting as a decrease in intraocular pressure. Topical corticosteroids were used for one month postoperatively and the bleb remained functional over more than six months of follow-up. It is most likely that the intraocular pressure elevation that occurs during phacoemulsification was responsible for the reformation of the bleb, even after having been a failed bleb for a whole year.

Intraocular Pressure Changes Are Predictive of Ocular Hypertension Onset After Fluocinolone Acetonide Implant: Significant Cutoffs and the Role of Previous DEX Implant

Background: Fluocinolone acetonide (FAc) implant represents a long-term strategy for the management of diabetic macular edema (DME). Because of the 3-year duration, the careful monitoring of the intraocular pressure (IOP) is necessary. The main aim of the study was to provide quantitative IOP cutoffs associated with the onset of IOP increases.

Methods: The study was retrospectively conducted with 2-year of follow-up. We separately considered eyes with good IOP control (Group 1), eyes requiring IOP-lowering medications (Group 2) and eyes undergoing IOP-lowering surgery (Group 3). The statistical analysis assessed Delta% IOP changes over the 2-year follow-up. ROC analysis was performed to detect significant cutoffs associated with Group 2 and Group 3. IOP changes occurring after a previously administered dexamethasone (DEX) implant were also evaluated.

Results: We included 48 eyes (48 patients), stratified as follows: Group 1 (25/48; 52%), Group 2 (19/48; 40%) and Group 3 (4/48; 8%). ROC analysis performed on IOP values detected 2-months later DEX implant showed a mean Delta IOP increase>24% significantly associated with IOP-lowering medications after FAc implant, whereas a mean Delta IOP increase>35% was significantly associated with IOP-lowering surgery after FAc implant. With respect to IOP changes occurred after FAc implant, our ROC analysis showed a mean Delta IOP increase>8% significantly associated with IOP-lowering medications, whereas a mean Delta IOP increase>15% was significantly associated with IOP-lowering surgery. DEX-related IOP changes showed 52% sensitivity and 100% specificity of FAc-related IOP increases.

Conclusions: IOP changes provides clinically relevant cutoffs associated with the onset of FAc-related IOP increases.

Long-term Surgical Outcomes of Phacoemulsification with Endoscopic Cyclophotocoagulation vs Phacoemulsification with Trabeculectomy and Mitomycin in Cataract and Glaucoma Patients

Purpose

To evaluate the long-term surgical outcomes of endoscopic cyclophotocoagulation (ECP) after four years follow-up in cataract and glaucoma patients that needed combined phacoemulsification and ECP (phaco-ECP) in comparison to combined phacoemulsification with trabeculectomy (phaco-trabeculectomy) with mitomycin C (MMC).

Patients and Methods

Retrospective case–control study of 34 patients (34 eyes) with glaucoma who underwent phaco-ECP compared with phaco-trabeculectomy in tertiary eye specialist hospital in Saudi Arabia from 2010 to 2012. Participants were enrolled in two groups; ECP and trabeculectomy with MMC when combined with phacoemulsification. Success is defined as complete success when the IOP ≤21 mmHg without medication, qualified success when the IOP ≤21 mmHg with aid of topical medication.

Results

Mean IOP decreased from 25.76 SD ±8.227 to 15.24 SD ±7.049 at last visit in phaco-trabeculectomy group and from 21.47 SD ±4.215 to 12.88 SD ±3.480 in phaco-ECP group. Mean medication use reduced from 2.89 SD ±0.3 preoperatively to 1.50 SD ±1.1 postoperatively (P<0.001) in phaco-trabeculectomy group. It reduced in phaco-ECP group from 2.24 SD ±0.8 preoperatively to 2.00 SD ±0.9 postoperatively, 35.3% of phaco-trabeculectomy group developed vision-threatening complications while 0% in phaco-ECP group (P<0.001), 29.4% in phaco-trabeculectomy group required second surgical intervention compared to 17.6% in phaco-ECP group. In phaco-trabeculectomy group, 29.4% reached complete success, meanwhile in phaco-ECP group, 64.7% reached qualified success (P=0.026).

Conclusion

ECP illustrates significant reduction of IOP and less postoperative complications if associated with phacoemulsification. Furthermore, it is safe and effective as a primary procedure alternative to combined cataract and trabeculectomy surgery for glaucoma patients having cataract and requiring surgical intervention.

Chorioretinal Folds in the Trabeculectomized Eye with Normal Intraocular Pressure after Phacoemulsification

Background and Objectives: This case report discusses possible causes of chorioretinal fold (CRF) formation. Materials and Methods: A case report. Results: A 48-year-old man presented with a history of high myopia and primary open-angle glaucoma in both eyes. He underwent a trabeculectomy followed by phacoemulsification in both eyes. Two months later, he complained of blurred vision in the right eye. The intraocular pressure (IOP) was 17 mmHg in the left eye and 9 mmHg in the right eye. Refraction showed a hyperopic shift in both eyes. Slit-lamp examination showed a deep anterior chamber without cells and a well-functional bleb without leakage. Fundus examination revealed CRFs in the macula of the right eye. No papilledema, choroidal lesions, or other retinal lesions were found. Wrinkling of CRFs at the macula, an increase in central foveal thickness, and a fluid cleft were demonstrated by spectral-domain optical coherence tomography. After using steroid eye drops, the IOP in the right eye and refraction in both eyes recovered to the baseline level. Visual acuity improved in both eyes. Conclusions: CRFs in trabeculectomized eyes with normal IOP after phacoemulsification have not been reported. This case demonstrated that the trabeculectomized eye remains at risk of CRF formation, even if the IOP is normal without hypotony. The importance of a detailed fundus examination in patients with unexplained blurred vision may be necessary after having undergone these procedures. The early recognition of the cause of visual loss may facilitate immediate treatment and may avoid irreversible changes with permanent visual loss.

Long-term outcomes of blebs repaired with scleral patch graft and conjunctival advancement in late-onset leak post-trabeculectomy

Purpose:

To report long-term outcomes in eyes that developed late-onset bleb leak post trabeculectomy, with or without hypotony and/or maculopathy, due to a scleral melt/fistula and who required a scleral patch graft and conjunctival advancement for repair.

Methods:

Retrospective, non-comparative, interventional case series over a decade (2010–2019), presenting with late bleb leak post-filtration-surgery. All cases required a scleral patch graft and conjunctival advancement for management via a standard technique, performed by an experienced glaucoma surgeon.

Results:

A total of 18 eyes were included. Mean age was 51.5 ± 10.2 years (95% CI [46.4–56.7]) and were followed up after repair for 52.4 ± 26.9 months, 95%CI [39.1–65.8]. 66.7% eyes (n = 12) had IOP ≦6 mmHg and also had hypotony maculopathy. None of the eyes presented with blebitis. 44.5% (n = 8) eyes underwent phacoemulsification as significant cataract was present. LogMAR best-corrected visual acuity (BCVA) was 0.8 ± 0.7 (95% CI [0.4–1.1]) prior to intervention and improved to 0.4 ± 0.6 (95% CI[0.1–0.6], P = 0.004). 22.3% (n = 4) eyes had persistent choroidal folds but BCVA was improved. Mean pre-intervention intraocular pressure (IOP) was 6.3 ± 3.8 mmHg (95% CI 4.4–8.2]) which increased to 12.1 ± 2.9 mmHg (95%CI[10.6–13.5], (P < 0.001). 27.8% (n = 5) eyes needed laser suture lysis post repair to control IOP; two needed further surgical intervention. Number of anti-glaucoma medications at last follow-up was 0.4 ± 0.9 (95% CI [−0.1–0.8], P = 0.09). No serious complications were encountered.

Conclusion:

Scleral patch graft and conjunctival advancement is a useful technique for repair of a scleral fistula post-filtering surgery, and this is recommended not only for the restoration of anatomy for prevention of infection and control of IOP, but also for visual rehabilitation.

A Novel Procedure for the Management of Severe Hyphema after Glaucoma Filtering Surgery: Air-Blood Exchange under a Slit-Lamp Biomicroscopy

Background and Objectives: This study introduces a novel office-based procedure involving air–blood exchange under a slit-lamp microscope for treatment of severe hyphema after filtering surgery. Materials and Methods: This retrospective study enrolled 17 patients (17 eyes) with a diagnosis of primary open-angle glaucoma with severe hyphema (≥4-mm height) after filtering surgery. All patients were treated with air–blood exchange under a slit-lamp using room air (12 patients) or 12% perfluoropropane (C3F8; five patients). Results: The procedures were successful in all 17 patients; they exhibited clear visual axes without complications during follow-up. In the room air group, the mean visual acuity (VA) and hyphema height significantly improved from 1.70 ± 1.07 LogMAR and 5.75 ± 1.14 mm before the procedure to 0.67 ± 0.18 LogMAR and 2.83 ± 0.54 mm after the procedure (p = 0.004; p < 0.001). In the C3F8 group, the mean VA showed a trend, though not significant, for improvement from 1.70 ± 1.10 LogMAR to 0.70 ± 0.19 LogMAR (p = 0.08); the mean hyphema height showed a trend for improvement from 5.40 ± 0.96 mm to 3.30 ± 0.45 mm. Compared with the C3F8 group, the room air group showed the same efficacy with a shorter VA recovery time. Conclusions: “Air–blood exchange under a slit-lamp using room air” is a convenient, rapid, inexpensive, and effective treatment option for severe hyphema after filtering surgery, and may reduce the risk of failure of filtering surgery.

Factors Associated with Increased Neuroretinal Rim Thickness Measured Based on Bruch's Membrane Opening-Minimum Rim Width after Trabeculectomy

Purpose: To investigate the factors associated with an increase in the neuroretinal rim (NRR) thickness measured based on Bruch’s membrane opening-minimum rim width (BMO-MRW) after trabeculectomy in patients with primary open-angle glaucoma (POAG). Methods: We analyzed the BMO-MRW using spectral-domain optical coherence tomography (SD-OCT) of patients with POAG who underwent a trabeculectomy for uncontrolled intraocular pressure (IOP) despite maximal IOP reduction treatment. The BMO-MRW was measured before and after trabeculectomy in patients with POAG. Demographic and systemic factors, ocular factors, pre- and post-operative IOP, and visual field parameters were collected, together with SD-OCT measurements. A regression analysis was performed to investigate the factors that affected the change in the BMO-MRW after the trabeculectomy. Results: Forty-four eyes of 44 patients were included in the analysis. The IOP significantly decreased from a preoperative 27.0 mmHg to a postoperative 10.5 mmHg. The mean interval between the trabeculectomy and the date of post-operative SD-OCT measurement was 3.3 months. The global and sectoral BMO-MRW significantly increased after trabeculectomy, whereas the peripapillary retinal nerve fiber layer thickness did not show a difference between before and after the trabeculectomy. Younger age and a greater reduction in the IOP after the trabeculectomy were significantly associated with the increase in the BMO-MRW after trabeculectomy. Conclusions: The NRR thickness measured based on the BMO-MRW increased with decreasing IOP after trabeculectomy, and the increase in the BMO-MRW was associated with the young age of the patients and greater reduction in the IOP after trabeculectomy. Biomechanically, these suggest that the NRR comprises cells and substances that sensitively respond to changes in the IOP and age.

The therapeutic effect of Healaflow in glaucoma surgery

OBJECTIVE

To explore the clinical effectiveness of Healaflow in primary angle-closure glaucoma surgery.

METHODS

From August 2018 to July 2019, 100 primary angle-closure glaucoma patients admitted to our ophthalmology department were divided into a control group (trabeculectomy alone) and an observation group (trabeculectomy + Halver), with 50 patients in each group, and 53 eyes in the control group and 56 eyes in the observation group. All the patients were followed up for half a year. The vision, intraocular pressure, bleb morphology, efficacy, and adverse reactions were evaluated.

RESULTS

There was no significant difference in the visual acuity between the two groups of patients during the follow-up (P > 0.05). The intraocular pressure levels in the two groups of patients during the follow-up were significantly lower than they were before the treatment (P < 0.05), and the difference in the intraocular pressure levels between the 6th month postoperative groups was significant (P < 0.05). During the last follow-up, 45 eyes in the control group developed functional filtration blebs, and 8 eyes had non-functioning filtration blebs. There were 55 functional filtration blebs and 1 non-functional filtration bleb in the observation group (χ² = 4.731, P = 0.030). The total effective rate in the observation group was higher than it was in the control group (92.86% VS 77.36%, χ² = 4.058, P = 0.044). During the follow-up period, the control group had 2 eyes with anterior chambers, 1 eye with low intraocular pressure, and 1 eye with an iris adhesion. The observation group had 1 eye with an anterior chamber, and no significant difference in the complications between the groups was evident (P > 0.05).

CONCLUSION

Healaflow is of great value in maintaining functional filtration blebs and in controlling and stabilizing intraocular pressure. It is safe and reliable in clinical application, and it helps to reduce the unstable intraocular pressure after glaucoma surgery caused by scar adhesions in the filtration channel.