A prospective trial of phaco-trabeculotomy combined with deep sclerectomy versus phaco-trabeculectomy

Corneal endothelial cell loss after trabeculectomy and phacoemulsification in one or two steps: a prospective study

Objective

The objective of this study was to analyse the results of the surgical treatment of coexisting cataract and glaucoma and its effects on corneal endothelial cell density (CECD).

Methods

We include two longitudinal prospective studies: one randomised that included 40 eyes with open angle glaucoma that received one- (n = 20) or two-step (n = 20) phacotrabeculectomy and another that included 20 eyes that received phacoemulsification. We assess the impact of surgery on different clinical variables and in particular in CECD using Confoscan 4™ confocal microscopy and semiautomatic counting methods.

Results

Phacoemulsification and phacotrabeculectomy, but not trabeculectomy, increase significantly best-corrected visual acuity and anterior chamber depth and trabeculectomy and one- or two-step phacotrabeculectomy decreased similarly the intraocular pressure. We document percentages of endothelial cell loss of 3.1%, 17.9%, 31.6% and 42.6% after trabeculectomy, phacoemulsification and one- or two-step phacotrabeculectomy, respectively. The coefficient of variation did not increase significantly after surgery but the percentage of hexagonality decreased significantly after phacoemulsification and after two-step phacotrabeculectomy.

Conclusions

Trabeculectomy, phacoemulsification and phacotrabeculectomy are surgical techniques that cause morphological changes and decrease the densities of the corneal endothelial cells. Trabeculectomy produces lesser endothelial cell loss than phacoemulsification, and phacoemulsification lesser cell loss than phacotrabeculectomy. Two-step phacotrabeculectomy (trabeculectomy followed 3 months later by phacoemulsification) causes more cell loss than one-step phacotrabeculectomy, and this could be due to the cumulative effects of two separate surgical traumas or to a negative conditioning lesion effect of the first surgery. For the treatment of coexisting glaucoma and cataract, one-step phacotrabeculectomy is the treatment of choice.

Prospective evaluation of penetrating deep sclerectomy in advanced open-angle glaucoma: Filtration surgery adapted to resource scarcity in developing countries

PURPOSE

Two of the hurdles that are facing ophthalmologists in developing countries are scarcity of resources and patient follow-up. Deep sclerectomy (DS) has proven less costly and more effective than topical therapies and has a more favorable safety profile than trabeculectomy. The main factors preventing its use in developing countries are the need to perform laser goniopuncture in 40-80% of cases to maintain filtration and the risk of postoperative iris incarceration. The purpose of this study is to assess the efficacy and safety profile in advanced open-angle glaucoma of a relatively new surgical technique designed to overcome this limitation: penetrating DS.

SETTING

This was an investigator-initiated, prospective, interventional study, conducted at a single ophthalmology center in Kinshasa, Congo. The study was conducted in full compliance with the Declaration of Helsinki.

METHODS

Fifty-one eyes (34 patients) with uncontrolled advanced primary open-angle glaucoma (visual field mean deviation<-10 dBs) were enrolled between October 2012 and June 2016. Age, gender, comorbidities (hypertension/diabetes), best-corrected visual acuity, topical medications, medicated and unmedicated intraocular pressure (IOP) were recorded. All patients underwent penetrating DS, during which, following standard dissection of the scleral flaps, the anterior chamber was penetrated through the trabeculo-Descemet membrane and an iridectomy was performed. Patients attended postoperative appointments at months 1, 3, 6 and 12. Surgical success was defined as a 20% reduction of IOP from baseline in conjunction with a 12-month unmedicated IOP≤12mmHg.

RESULTS

The mean age was 64.5±14.0 years (44.1% female, 100% African). Mean IOP decreased from 20.2±6.1 (medicated) and 30.7±9.8mmHg (unmedicated) preoperatively to 12.1±4.1 at 12 months. Concomitantly, the number of topical medications decreased from 1.5±0.7 to 0.0. Complete surgical success was achieved in 64.7%. Four eyes (7.8%) were considered surgical failures due to uncontrolled IOP. None of the eyes lost light perception or required additional surgery. A significant association between surgical failure and hypertension was observed (HR=1.49; P=0.008). There were no intraoperative complications. Postoperatively, 4 bleb encapsulations (7.8%) and 1 iris incarceration (2%) were observed.

CONCLUSIONS

The present study demonstrates that penetrating DS achieved similar efficacy and safety results to traditional non-penetrating DS. In addition, it showed a lower potential for intraoperative complications, which might be associated with a more benign surgical learning curve. Finally, the rates of serious postoperative complications (iris incarceration, choroidal effusion and hypotony) were significantly lower than in DS and trabeculectomy, and this technique does not require subsequent Nd: YAG laser goniopuncture to maintain filtration, making frequent follow-up visits less critical. In view of these findings, perforating deep sclerectomy could offer a viable option for glaucoma management in developing countries as well as worldwide.

Penetrating deep sclerectomy in primary open-angle and pseudoexfoliative glaucoma

PURPOSE

To evaluate the outcomes of a new antiglaucoma surgical method, a modification of the standard deep sclerectomy, the penetrating deep sclerectomy.

PARTICIPANTS

Patients with medically uncontrolled primary open-angle glaucoma or pseudoexfoliative glaucoma were prospectively, in a consecutive way, enrolled in this study.

METHODS

The study was conducted in Glaucoma Unit, Department of Ophthalmology, University of Hospital of Alexandroupolis, Greece, in 29 eyes of 29 patients. In a fornix-based surgical procedure, all eyes underwent the proposed penetrating deep sclerectomy (deep sclerectomy plus trabeculectomy) with the use of mitomycin C applied intraoperatively (0.2 mg/mL for 2 min). The follow-up period was 3 years. Ocular examination was conducted before the operation and at 1, 3, 6, 12, 18, 24, and 36 months postoperatively.

RESULTS

The average reduction in intraocular pressure at the end of follow-up was 11.24 (57.88%). The complete success rate (intraocular pressure ⩽21 mm Hg without medication) after 3 years was 58.6%. The qualified success rate (intraocular pressure ⩽21 mm Hg without or with medication) was 75.86%. Postoperatively, the mean number of medication dropped from 3.75 ± 0.89 to 0.89 ± 0.98. Low postoperative complications were recorded.

CONCLUSION

During the 3-year follow-up period, penetrating deep sclerectomy presented very positive outcome. The addition of a controlled perforation of the trabeculo-Descemet's membrane in deep sclerectomy, playing the role of an early goniopuncture, seems to ensure a satisfactory outcome and is not associated with additional complications.

Comparative outcomes of trabeculotomy ab externo versus trabecular ablation ab interno for open angle glaucoma

PURPOSE

To compare clinical outcomes between trabeculotomy ab externo (TLO) and trabecular ablation ab interno using a Trabectome (TAT) for open angle glaucoma (OAG).

STUDY DESIGN

Prospective and retrospective cohort study.

METHODS

We prospectively recruited 68 patients who underwent TAT between May 2013 and July 2015, and retrospectively recruited 59 patients who underwent TLO between April 2010 and May 2013. We included OAG patients who could be followed up for more than 12 months after surgery. Surgical outcomes were compared between groups. Kaplan-Meier analyses and Cox proportional hazards' models were used for four sets of criteria using postoperative intraocular pressures (IOP) ≤ 18 or ≤ 16 mmHg, and/or showing ≥ 20% reduction from baseline.

RESULTS

Mean preoperative IOPs were 22.6 ± 7.4 mmHg in the TAT group and 24.3 ± 6.6 mmHg in the TLO group. Mean postoperative IOPs in the TAT group were 15.8 ± 3.6 mmHg at 12-months, and 15.7 ± 5.5 mmHg at 36-months, and 16.0 ± 3.4 mmHg at 12 months and 15.2 ± 3.8 mmHg at 36 months in the TLO group. Postoperatively, success rates at 36-months were significantly higher in the TLO group in some criteria; IOP reductions at 1- and 2- years were significantly higher in the TLO group; these differences were not significant after adjustment with other potential prognostic factors. The number of glaucoma medications were significantly higher in the TAT group, at 2-years (P < 0.001) but not at 3-years (P = 0.22).

CONCLUSION

Surgical successes following TLO and TAT are not significantly different 3 years postoperatively after adjustment of potential prognostic factors.

Phacoemulsification combined with a new ab interno gel stent to treat open-angle glaucoma: Pilot study

PURPOSE

To study the effect on intraocular pressure (IOP) of implanting a new gelatin stent at the time of cataract surgery in the treatment of open-angle glaucoma (OAG).

SETTING

Multicenter university and private-practice settings.

DESIGN

Nonrandomized prospective clinical trial.

METHODS

The implantation of 2 models of a gelatin stent (Xen140 and Xen63) was performed at the time of cataract surgery without mitomycin-C. Complete success was defined as a postoperative IOP of less than 18 mm Hg and more than a 20% reduction in IOP at 12 months without glaucoma medication. Failure was defined as loss of light perception vision or worse, a need for additional glaucoma surgery, or less than a 20% reduction in the IOP from baseline.

RESULTS

The study included 37 eyes of 37 patients. The mean preoperative IOP was 22.4 mm Hg ± 4.2 (SD) on 2.5 ± 1.4 medication classes. Twelve months postoperatively, the mean IOP was reduced to 15.4 ± 3.0 mm Hg on 0.9 ± 1.0 medication classes (P < .0001). This resulted in a qualified success of 85.3% and a complete success rate off medications of 47.1%. There were no failures.

CONCLUSION

Cataract surgery combined with implantation of the gelatin stent resulted in a significant reduction in IOP in eyes with OAG.

FINANCIAL DISCLOSURE

Dr. Sheybani has received travel reimbursement from Aquesys, Inc. Dr. Ahmed is a paid consultant to Aquesys, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Outcomes of 360° suture trabeculotomy with deep sclerectomy combined with cataract surgery for primary open angle glaucoma and coexisting cataract

BACKGROUND

The purpose of this study was to investigate treatment outcomes in 360° suture trabeculotomy with deep sclerectomy combined with phacoemulsification and aspiration and intraocular lens implantation (360P-LOT + DS).

METHODS

Thirty-two eyes in 32 consecutive patients treated by 360P-LOT + DS for primary open angle glaucoma with coexisting cataracts at Sato Eye Clinic from March 2011 to April 2013 were retrospectively compared with 23 eyes in 23 consecutive patients treated by cataract surgery and 120° trabeculotomy with deep sclerectomy (120P-LOT + DS) at the same clinic from January 2010 to February 2011. The parameters investigated during the 15 months after surgery were the course of intraocular pressure, number of antiglaucoma medications, best-corrected visual acuity, and complications.

RESULTS

Both groups showed a significant decrease in intraocular pressure starting at one month after surgery when compared with values before surgery. At 3, 6, 9, and 15 months after surgery, the intraocular pressure was significantly lower and the survival rate was significantly higher in the 360P-LOT + DS group compared with the 120P-LOT + DS group. The number of antiglaucoma medications, best-corrected visual acuity value, and complications did not differ significantly between the groups.

CONCLUSION

Although the complications are similar to those seen in 120P-LOT + DS, treatment of primary open angle glaucoma and coexisting cataracts using 360P-LOT + DS may yield better outcomes.

[Minimally invasive angle surgery. The Trabectome]

The Trabectome provides a new perspective in angle surgery for open angle glaucoma. Through a 1.7 mm clear cornea tunnel, the juxtacanalicular meshwork is electroablated under gonioscopic control. Thereby, the collector channels in the outer wall of Schlemm's canal are uncovered and resistance to trabecular outflow is removed. From the literature and from our own experience, a pressure reduction by 30-35% can be achieved with a simultaneous reduction of eye drops by 50%. The Trabectome can conveniently be combined with phako-emulsification. Serious complications have not yet been reported. As the conjunctiva remains completely untouched, trabeculectomy, if necessary, could be performed without prognostic restrictions. With a realistic target pressure of approximately 16 mmHg, Trabectome surgery is indicated in patients with moderate optic nerve damage.

Minimally invasive strabismus surgery (MISS) for inferior obliquus recession

Purpose

To present a novel, minimally invasive strabismus surgery (MISS) technique for inferior obliquus recessions.

Methods

Graded MISS inferior obliquus recessions were performed in 20 eyes of 15 patients by applying two small conjunctival cuts, one at the insertion of inferior obliquus and another where the scleral anchoring of the muscle occurred.

Results

The amount of recession was 12.2 ± 2.3 mm (range 6 to 14 mm). The vertical deviation, which was measured in 25° of adduction, decreased from preoperatively 12.8° ± 5.6° to 2.7° ± 2.2° (p < 0.0001) at 6 months. LogMAR visual acuity was preoperatively −0.10 ± 0.17 and at 6 months −0.14 ± 0.22 (p > 0.1). In one eye (2.5%) the two cuts had to be joined because of excessive bleeding. Binocular vision improved in eight patients, remained unchanged in six patients, and decreased from 30 to 60 arcsec in one patient (p > 0.1). Conjunctival and lid swelling were hardly visible on the first postoperative day in primary gaze position in 10/20 (50%) of eyes. Five of the eyes (25%) had mild and five (25%) moderate visibility of surgery. One patient out of 15 (7%) needed repeat surgery because of insufficient reduction of the sursoadduction within the first 6 months. The dose–effect relationship 6 months postoperatively for an accommodative near target at 25° adduction was 0.83° ± 0.43° per mm of recession.

Conclusions

This study demonstrates that small-incision, minimal dissection inferior obliquus graded recessions are feasible and effective to improve ocular alignment in patients with strabismus sursoadductorius.