Hypotony Maculopathy: Clinical Presentation and Therapeutic Methods

The use of intraluminal PRESERFLO stenting in avoiding early postoperative hypotony

PURPOSE

Postoperative hypotony following PRESERFLO MicroShunt (PMS) implantation is a frequent cause of complications such as choroidal detachment and hypotony maculopathy. This study aims at evaluating the impact of intraluminal stenting of the PMS during the early postoperative period.

METHODS

We retrospectively analyzed the data of 97 patients who underwent PMS implantation with intraoperative placement of a Nylon 10-0 suture as intraluminal stent (PStent) and compared the outcomes to those of an existing database of the traditional MicroShunt implantation technique (PTrad, n = 120). The primary outcome measure was the intraocular pressure (IOP) at one week postoperatively. As a secondary outcome measure, adverse hypotony, defined as an IOP ≤ 5 mmHg with significant choroidal effusion and/or anterior chamber shallowing or the presence of macular folds was also assessed. Additionally, the time to stent removal and the IOP one week after stent removal were reported.

RESULTS

Preoperative median IOP was 25.0 (20.5-30.3) mmHg in PStent and 25.0 (19.3-32.0) mmHg in PTrad (p = 0.62). One week after surgery, the median IOP dropped to 10.0 (8.0-13.0) mmHg in PStent and 7.0 (5.0-9.0) in PTrad (p < 0.01). At one month, the IOP was 12.0 (10.0-14.0) mmHg in PStent and 10.0 (8.0-11.0) mmHg in PTrad (p < 0.01). After 3 months, both groups showed similar median IOP levels of 11.0 (8.0-13.5) mmHg and 10.0 (9.75-13.0) mmHg in PStent and PTrad, respectively (p = 0.66). The presence of adverse hypotony was significantly lower in PStent compared to PTrad (6.2% vs 15.8%, p < 0.05). In PStent the stent was removed after 30.0 (21.0-42.5) days. One week after stent removal the mean IOP drop was 6.1 ± 0.5 mmHg (p < 0.01).

CONCLUSION

In the early follow-up period, intraluminal stenting of the PMS appears to be safe and effective in controlling the IOP while reducing early postoperative hypotony. Surgical success is not compromised by stent placement. Based on our data, it is recommended to remove the suture two to six weeks after surgery for most patients with uncomplicated postoperative clinical findings.

Permanent ocular remodeling in the setting of chronic hypotony after trabeculectomy: A case report

Purpose

Trabeculectomy surgery is a commonly performed procedure for treatment of glaucoma. While the goal is to lower intraocular pressure, over-filtration may cause hypotony with ocular structural changes and vision loss.

Observations

A 53-year-old woman with primary open-angle glaucoma was referred to our service for further evaluation. The patient previously underwent trabeculectomy 9 years prior and was found to have a cataract and hypotony maculopathy in the right eye. Treatment options included cataract surgery alone, bleb revision alone, or combined cataract extraction and bleb revision. Biometry revealed corneal astigmatism in the right eye, and significant disparity in axial length between the two eyes. Since the axial length and corneal astigmatic changes were presumed to be at least partially reversible, measurements from the non-operative left eye influenced the lens selection for the hypotonous right eye. The patient underwent combined phacoemulsification and bleb revision. While IOP increased and hypotony was partly reversed, there was hyperopic and astigmatic refractive surprise after surgery.The patient subsequently underwent intraocular lens exchange using biometric values of the previously hypotonous eye and met the target post-operative refractive goal.

Conclusions and importance

This case demonstrates changes to the axial length and ocular structure following longstanding hypotony maculopathy may be permanent, even after restoration of normotensive intraocular pressure.

Prolonged hypotony maculopathy following uneventful strabismus surgery

Hypotony is a rare postoperative complication of strabismus surgery. Resolution has been reported to occur within 1 month of surgery. Here, we describe the case of a 14-year-old boy with prolonged hypotony maculopathy following uneventful bilateral medial rectus recession. The hypotony resolved without long-term sequela after 7 months of treatment with topical steroids and atropine. Ultrasound biomicroscopy revealed a ciliary body effusion, which we hypothesize was the cause of decreased aqueous humor production and hypotony.

PRESERFLO MicroShunt in Severe Myopia: A Case Report and Review of the Literature

The PRESERFLO™ MicroShunt (MP; Santen Inc., Osaka, Japan) is a minimally invasive bleb surgery (MIBS) manufactured to treat primary open-angle glaucoma (POAG), with lower postoperative adverse effects than with conventional filtering surgeries. We describe here the case study of a 58-year-old woman who presented with bilateral severe myopia with bilateral advanced POAG and unreached target pressure under quadritherapy, who was successfully managed by PM surgery. A review of the literature completes our observation. At presentation, the patient had a spherical equivalent of - 7.50 RE and - 7.75 LE with an IOP of 22 mmHg right and left eye (RLE) under quadritherapy, and with severe bilateral visual field loss, including scotomas within the central 5°. The patient presented with systemic hypertension treated with an antihypertensive drug. Two selective laser trabeculoplasties (SLT), performed 3 months apart, were first tried on the LE, without any change in IOP at 2 months. After considering the high risk of postoperative complications, a PM operation was proposed, with a targeted IOP in the mid-fifteens RLE. The patient's eyes underwent PM surgery with mitomycin C (MMC) MMC0.2 mg/mL for 3 minutes without any complications. The LE required 2 consecutive needlings with 1 mL MMC0.2 mg/mL. At 24 months after surgery, the two eyes gave successful results without the need for any additional medical therapy, and with well-functioning conjunctival blebs. The PM was an effective alternative to the gold standard trabeculectomy in our severely myopic patient. A comparative study between conventional filtering operations and this MIBS in highly myopic patients would confirm our observation.

Reversal of severe myopia by 24 years of hypotony with subsequent stable refraction after 2 years of normal intraocular pressure

Purpose

To report sustained axial length shortening and hyperopic shift (refraction changed from -8 to -2 diopters) induced by 24 years of profound IOP (intraocular pressure) reduction with subsequent refractive stability 2 years after IOP rose to 11-17 mm Hg.

Observations

A 25-year-old woman with elevated episcleral venous pressure glaucoma underwent non-penetrating trabeculectomy and subsequent laser goniopuncture in her left eye. She had chronically low IOP (1-12 mm Hg) for the next 24 years. Hypotony maculopathy was present in postoperative years 13-14 and 18-24 but resolved at age 49 when emesis-induced iris prolapse obstructed the filtering passage and transiently raised IOP to 40. Medical management and iridectomy with flap suturing stabilized IOP between 11 and 17 mm Hg.Refraction before OS trabeculectomy was OD -7.50/OS -9.00. In postoperative year 24 spherical equivalent phakic refraction was OD -9.00/OS -1.50. Biometry 1 year after resolution of hypotony showed axial lengths OD 24.8, OS 22.6 mm. Cataract surgery was performed in postoperative years 24/26 (OD/OS) with Tecnis DCBOO intraocular lenses of powers 14.0/21.5 diopters; postoperative refractions, 2 years after OS IOP rose to 11-17 mm Hg, were OD +0.25-0.50 x 015/OS -0.75-1.25 x 160 with 20/25 corrected acuity in each eye.Cardiovascular symptoms 24 years after the onset of her glaucoma led to a diagnosis of severe pulmonary hypertension.

Conclusions and importance

This case demonstrates that 2 decades of chronic IOP reduction can reverse myopia (by > 2 mm reduction in axial length) with subsequent refractive stability 2 years after IOP normalization. In addition, the case shows that ocular signs of pulmonary hypertension may precede cardiovascular signs by 2 decades.

The Success Rate of Glaucoma Drainage Device Revision

PRCIS

We report the survival of surgical revision to glaucoma drainage devices for several indications in a large cohort of patients, with an overall success rate of 45% at 36 months.

PURPOSE

To evaluate the outcomes of surgical revision for complications of glaucoma drainage devices.

METHODS

Three hundred thirty-five eyes of 318 patients who underwent tube revision or removal at University of California Los Angeles (UCLA) Jules Stein Eye Institute between 1997 and 2019 were included. The pre-defined primary outcome measure was surgical success of the initial revision, defined as resolution of the condition with no additional revisions required, no functionally significant change in vision, and no instances of intraocular pressure > 21 mmHg at 2 consecutive visits postoperatively. Kaplan-Meier survival analysis was applied to evaluate survival at 36 months based on these criteria. The Wilcoxon paired test was used to compare mean preoperative and postoperative intraocular pressure, medication usage, and visual acuity.

RESULTS

Overall, survival of revised tubes at 36 months was 45%. The 4 most common indications for revision were exposure of the implant (42% of all revisions), occlusion (14%), corneal failure or threat of failure (12%), and hypotony (11%). Survival at 36 months for each of these indications was 44%, 45%, 52%, and 37%, respectively.

CONCLUSIONS

These results suggest that eyes with glaucomatous damage with long-term glaucoma drainage device complications can still have a reasonably successful outcome when a revision is performed. However, with substantial rates of vision loss and a frequent need for additional revisions to manage complications, managing patient expectations for success and making them aware of the likelihood of additional surgeries or failure is important.

Quantification of Hypotony Maculopathy Using Spectral-Domain Optical Coherence Tomography

PRCIS

We provide a free-to-use, open-source algorithm to quantify macular hypotony based on optical coherence tomography (OCT) images. This numerical approach calculates a metric that measures the deviations of Bruch's membrane from a smooth ideal retinal layer.

PURPOSE

Hypotony maculopathy is a recurrent complication of glaucoma surgical interventions in which extremely low intraocular pressure triggers changes in the shape of retinal layers. Abnormal folds can often be observed in the retina using standard fundoscopy, but OCT is particularly important to appreciate the severity of symptoms at different depths. Despite the need for metrics that could be used for the informed clinical decision to evaluate the progression and resolution of macular hypotony, algorithms that quantify the retinal folds are not available in the literature or included in clinical imaging equipment. The purpose of this work is to introduce a simple algorithm that can be used to assess hypotony maculopathy from OCT B-Scans and volumes and a free, open-source implementation.

METHODS

The pipeline we present is based on a straightforward segmentation of Bruch's membrane complex. The principal idea of quantification is to compute a smoothed version of this complex and analyze the deviations from an ideal interface. Such deviations are then measured and added to create a metric that characterizes each OCT B-Scan. A full OCT volume reconstruction is thus characterized by the average metric obtained from all planes.

RESULTS

We tested the metric we proposed against the assessment of 3 experts and obtained a very good correspondence, with Pearson correlation coefficients higher than 0.8. Furthermore, agreement with automatic analysis seemed better than between experts. We describe the pipeline in detail and illustrate the results with a group of patients, comparing baseline images, severe hypotony maculopathy, and a variety of outcomes.

CONCLUSION

The tool we introduce and openly provide fills a clinical gap to quantitatively grade hypotony maculopathy. It offers a metric of relatively simple interpretation that can be used to help clinicians in cases where the regression of symptoms is not obvious to the naked eye. Our pilot study demonstrates reliable results, and an open-source implementation facilitates easy improvements to our algorithm.

Anaesthetic considerations for the surgical management of ocular hypotony in adults

Ocular hypotony can occur from many causes, including eye trauma, ophthalmic surgery and ophthalmic regional anaesthesia-related complications. Some of these patients require surgical intervention(s) necessitating repeat anaesthesia. While surgical management of these patients is well described in the literature, the anaesthetic management is seldom discussed. The hypotonous eye may also have altered globe anatomy, meaning that the usual ocular proprioceptive feedbacks during regional ophthalmic block may be altered or lost, leading to higher risk of inadvertent globe injury. In an 'open globe' there is a risk of sight-threatening expulsive choroidal haemorrhage as a consequence of ophthalmic block or general anaesthesia. This narrative review describes the physiology of aqueous humour, the risk factors associated with ophthalmic regional anaesthesia-related ocular hypotony, the surgical management, and a special emphasis on anaesthetic management. Traumatic hypotony usually requires urgent surgical repair, whereas iatrogenic hypotony may be less urgent, with many cases scheduled as elective procedures. There is no universal best anaesthetic technique. Topical anaesthesia and regional ophthalmic block, with some technique modifications, are suitable in many mild-to-moderate cases, whilst general anaesthesia may be required for complex and longer procedures, and severely distorted globes.

Systematic Preserflo MicroShunt Intraluminal Stenting for Hypotony Prevention in Highly Myopic Patients: A Comparative Study

Transient hypotony is the most common early complication after Preserflo MicroShunt (PMS) implantation. High myopia is a risk factor for the development of postoperative hypotony-related complications; therefore, it is advisable that PMS implantation in patients should be performed while employing hypotony preventive measures. The aim of this study is to compare the frequency of postoperative hypotony and hypotony-related complications in high-risk myopic patients after PMS implantation with and without intraluminal 10.0 nylon suture stenting. This is a retrospective, case-control, comparative study of 42 eyes with primary open-angle glaucoma (POAG) and severe myopia that underwent PMS implantation. A total of 21 eyes underwent a non-stented PMS implantation (nsPMS), while in the remaining eyes (21 eyes), PMS was implanted with an intraluminal suture (isPMS group). Hypotony occurred in six (28.57%) eyes in the nsPMS group and none in the isPMS group. Choroidal detachment occurred in three eyes in the nsPMS group; two of them were associated with the shallow anterior chamber and one was associated with macular folds. At 6 months after surgery, the mean IOP was 12.1 ± 3.16 mmHg and 13.43 ± 5.22 mmHg (p = 0.41) in the nsPMS and isPMS group, respectively. PMS intraluminal stenting is an effective measure to prevent early postoperative hypotony in POAG highly myopic patients.

Case Report: Reversal and subsequent return of optic disc cupping in a myocilin (MYOC) gene-associated severe Juvenile Open-Angle Glaucoma (JOAG) patient

To our knowledge, this case report describes the first instance of reversal of glaucomatous optic nerve cupping in a young adult with a rare form of juvenile open-angle glaucoma (JOAG) associated with a novel variant of the myocilin gene (MYOC). This 25-year-old woman with severe-stage MYOC-associated JOAG presented with blurry vision and intermittent pain in her left eye. She had a strong family history of glaucoma in multiple first-degree relatives with an identified novel variant of MYOC. Examination revealed intraocular pressures (IOPs) of 10 mmHg OD and 46 mmHg OS, with cup-to-disc ratios of 0.90 and 0.80. The patient experienced substantial reversal of optic disc cupping OS following dramatic IOP reduction with trabeculectomy, and subsequently experienced a return of cupping after an IOP spike 15 months postoperatively. The reversal of cupping did not correspond to any changes in the patient's visual field. After an initial decrease in retinal nerve fiber layer (RNFL) thickness, RNFL remained stable for over 2 years after trabeculectomy as seen on Optical Coherence Tomography (OCT). This case suggests reversal of cupping can occur well into adulthood in a MYOC-associated JOAG patient, and it demonstrates the potential bidirectionality of this phenomenon. Moreover, it suggests that these structural changes may not correspond to any functional changes in visual fields or RNFL thickness.

Cyclodialysis Clefts following Microinvasive Glaucoma Surgery with Consecutive Intraocular Pressure Spikes

The purpose of this study is to report a case of cyclodialysis clefts associated with microinvasive glaucoma surgery (MIGS) having two distinct consecutive IOP spikes during cleft closure. A 65-year-old female with a history of primary open angle glaucoma was evaluated for right eye blurry vision since cataract surgery 11 months prior. She reported a MIGS procedure that resulted in a cyclodialysis cleft, with resultant hypotony without resolution. On gonioscopy, two clock hours of widened angle were noted nasally, with small clefts (0.5 clock hour) inferonasally and superonasally. Conservative therapy with cycloplegia was unsuccessful. Argon laser photocoagulation was performed for cleft closure. Initially, while there was visible improvement in the cleft size, it did not close completely, and IOP remained low. Additional laser was performed, one week following, she presented with an acute IOP increase to 55 mmHg. On gonioscopy, it was noted that despite the IOP spike indicating inferonasal closure, the superonasal cleft remained small but open. She was started on IOP-lowering therapy. Her IOP normalized shortly thereafter. Two weeks later, she experienced another acute IOP spike to 54 mmHg. On gonioscopy, the residual cleft had closed. Again, her IOP normalized shortly after and has remained normal since. While IOP spikes after cyclodialysis cleft closure have been reported many times, two consecutive IOP spikes of similar magnitude during sequential closure of two concurrent cyclodialysis clefts have not been reported in the literature. This case raises interesting questions about the physiology underlying an acute increase in IOP following cleft closure.

Hypotony Maculopathy Related to Anti-VEGF Intravitreal Injection

Purpose

To describe a case of hypotony maculopathy following anti-VEGF intravitreal injection (IVI) in a patient with pseudoxanthoma elasticum (PE).

Methods

Clinical case report.

Results

A 52-year-old male complained of right eye (OD) vision loss 2 days after an uncomplicated anti-VEGF IVI for the treatment of choroidal neovascularization secondary to angioid streaks. Relevant medical history included PE, pathologic myopia, and a previous pars plana vitrectomy (PPV) due to a retinal detachment. OD best-corrected visual acuity (BCVA) dropped from 6/12 to 6/18 after the IVI. Intraocular pressure (IOP) was 3 mmHg and chorioretinal folds were evident in the posterior pole. Topical dexamethasone and atropine were prescribed, and full recovery was noticed after 3 days. Four months later, the patient developed a new episode of vision loss after another IVI. His BCVA was counting fingers, IOP was 2mmHg, and more noticeable chorioretinal folds were found. This time, an open scleral wound at the injection site was evident and a scleral suture was necessary. Once again, the patient recovered well.

Conclusion

Hypotony maculopathy following intravitreal injection is a rare condition. However, the described patient presented several conditions which could be related with poor scleral wound closure: intrinsic scleral fragility due to myopia and pseudoxanthoma elasticum; repeated IVI procedures; and absence of vitreous in the posterior segment due to prior vitrectomy. Despite the good outcome, hypotony maculopathy may be a sight-threatening condition, and special attention is necessary for specific patients with risk factors.

Maculopathies in Glaucoma

In the presence of glaucoma, various changes in the macula can occur during the course of the disease itself or its treatment. Maculopathies that can be observed in glaucoma include cystoid macular edema, hypotony maculopathy, and microcystic macular edema. The following article discusses the pathophysiology, causes, course, clinical presentation, and treatment of these maculopathies.

XEN-related hypotonous maculopathy from iatrogenic cyclodialysis cleft treated with argon laser gonio-cyclopexy

We present a previously undescribed case of a persistent hypotony maculopathy secondary to an iatrogenic cyclodialysis cleft created during XEN-45 gel stent insertion. We present this case as a further analysis of the Karimi et al case of cyclopexy by the corresponding surgeon. Following right XEN-45 implantation, our patient developed immediate and persistent postoperative hypotony for 4 weeks. Gonioscopy revealed a small cyclodialysis cleft at the 1-2 o'clock position. The cyclodialysis cleft was sealed with direct gonioscopic argon laser cyclopexy. Two months after laser treatment and total of 6 months post XEN-45 insertion, right eye visual acuity returned to 6/4 with intraocular pressure 11 mm Hg without any glaucoma medication. Here, we present details of the non-invasive safe and successful management of hypotony maculopathy secondary to the cleft using Argon laser gonio cyclopexy, with no requirement of return to theatre.

Is canaloplasty with mitomycin c a safe procedure in myopic glaucoma?

PURPOSE

Myopic glaucoma patients display a considerable risk of complications following antiglaucomatous filtering surgery, e.g., trabeculectomy. Canaloplasty with mitomycin C may reduce this risk by avoiding massive overfiltration.

METHODS

We performed retrospective analysis of 31 eyes with myopia that underwent canaloplasty modified with mitomycin C in a consecutive single-surgeon case series. Annual data and success rates were analysed. Twenty-three myopic eyes that had received conventional trabeculectomy with mitomycin C were recorded as a comparison.

RESULTS

The 31 eyes with a follow-up of 40 ± 26 months after canaloplasty had a mean spherical equivalent of - 8.4 ± 4.5 dioptres. Intraocular pressure decreased from 32.3 ± 9.6 mmHg (range: 17 to 58) to 16.8 ± 8.1 mmHg (range: 5 to 44) 1 year after surgery (- 46%; p < 0.001) with a medication score reduction from 5 to 1.2 (p < 0.001). Qualified success rates (Criterion B: no revision surgery, IOP < 21 mmHg, IOP reduction > 20%) were 83% after 1 year and 61% at the 2nd and 3rd years. In 5 eyes (16%), early ocular hypotony (≤ 5 mmHg) was observed. Two eyes (7%) showed transient choroidal detachment and swelling. The 23 eyes that had received trabeculectomy had success rates (Criterion B) of 91% at the 1st and 86% at the 2nd and 3rd years. Hypotony occurred in 10 eyes (44%), and 4 eyes (17%) showed choroidal detachment or macular folds.

CONCLUSIONS

Postoperative complications related to overfiltration were less frequent after canaloplasty with mitomycin C. Midterm data proved good efficacy. Pressure reduction, success rates and rates of medication free patients were significantly higher in trabeculectomy compared to modified canaloplasty with mitomycin C.

Outcome of Bleb Revision With Autologous Conjunctival Graft Alone or Combined With Donor Scleral Graft for Late-onset Bleb Leakage With Hypotony After Standard Trabeculectomy With Mitomycin C

PRCIS

Treatment of leakage with ocular hypotony after trabeculectomy with mitomycin C (MMC) can be safely achieved through conjunctival patch alone or combined with donor scleral graft in cases of melted underlying sclera.

PURPOSE

To report outcomes of 2 surgical approaches for treating ocular hypotony in eyes with blebs with late-onset leakage after standard trabeculectomy with MMC.

METHODS

Thirty consecutive cases with bleb leakage and hypotony underwent bleb revision surgery between 2009 and 2014 by the same surgeon (J.W.) at the Department of Ophthalmology of the Mainz University Medical Center, Germany. In 18 patients, an autologous conjunctival patch graft was applied. In 12 patients, the underlying sclera was found melted and an additional scleral donor graft was sutured in place. The authors analyzed intraocular pressure, visual acuity, and optical coherence tomography of the macula preoperatively at 1 day, 1 week, 4 weeks, and 6 months after surgery.

RESULTS

The mean IOP was 6.2±3.5 mm Hg preoperatively and 21.7±16.4 mm Hg at 1 day, 13.7±6.7 at 1 week, 13.1±5.1 mm Hg at 4 weeks, and 12.1±4.7 mm Hg at 6 months after surgery. Visual acuity (logMar) increased from 0.57±0.49 preoperatively to 0.49±0.40 at 6 months. Optical coherence tomography showed flattening of macular folds that were present before treatment. No serious adverse event was reported.

CONCLUSIONS

This revision technique with conjunctival patch and/or additional donor scleral graft is an effective and safe method for treating late bleb leakage and hypotony maculopathy after trabeculectomy with MMC.

Optic disc edema and chorioretinal folds develop during strict 6° head-down tilt bed rest with or without artificial gravity

Spaceflight associated neuro-ocular syndrome (SANS) is hypothesized to develop as a consequence of the chronic headward fluid shift that occurs in sustained weightlessness. We exposed healthy subjects (n = 24) to strict 6° head-down tilt bed rest (HDTBR), an analog of weightlessness that generates a sustained headward fluid shift, and we monitored for ocular changes similar to findings that develop in SANS. Two-thirds of the subjects received a daily 30-min exposure to artificial gravity (AG, 1 g at center of mass, ~0.3 g at eye level) during HDTBR by either continuous (cAG, n = 8) or intermittent (iAG, n = 8) short-arm centrifugation to investigate whether this intervention would attenuate headward fluid shift-induced ocular changes. Optical coherence tomography images were acquired to quantify changes in peripapillary total retinal thickness (TRT), retinal nerve fiber layer thickness, and choroidal thickness, and to detect chorioretinal folds. Intraocular pressure (IOP), optical biometry, and standard automated perimetry data were collected. TRT increased by 35.9 µm (95% CI, 19.9-51.9 µm, p < 0.0001), 36.5 µm (95% CI, 4.7-68.2 µm, p = 0.01), and 27.6 µm (95% CI, 8.8-46.3 µm, p = 0.0005) at HDTBR day 58 in the control, cAG, and iAG groups, respectively. Chorioretinal folds developed in six subjects across the groups, despite small increases in IOP. Visual function outcomes did not change. These findings validate strict HDTBR without elevated ambient CO2 as a model for investigating SANS and suggest that a fluid shift reversal of longer duration and/or greater magnitude at the eye may be required to prevent or mitigate SANS.

Bleb Compressive Sutures in the Management of Hypotony Maculopathy after Glaucoma Surgery

PURPOSE

The aim of the study was to assess the efficacy and safety of compressive sutures in patients with hypotony maculopathy after glaucoma surgery.

METHODS

This retrospective case series analyzes the clinical outcomes of conjunctival compressive sutures in 17 patients with hypotony maculopathy developed after glaucoma surgery. Compressive Nylon 10-0 single sutures were used in all patients; in two patients, the procedure was repeated. All patients underwent ophthalmic evaluation and macular OCT scanning before the surgery, one month, six months, and one year after the procedure.

RESULTS

Mean intraocular pressure (IOP) before suturing was 2.3 ± 1.57 mmHg and increased to 14.2 ± 7.03 mmHg (p = 0.00065) one month after the procedure. After six months, mean IOP was 10.2 ± 4.3 mmHg (p = 0.005), and after one year ± 4.7 mmHg (p = 0.0117). To obtain the target pressure, the sutures had to be removed in one patient, and medical therapy was undertaken in three patients. Mean decimal best-corrected visual acuity (BCVA) before the sutures was 0.18 ± 0.13 and increased to 0.53 ± 0.25 (p = 0.0004) after one month, to 0.46 ± 0.31 (p = 0.005) after six months, and to 0.31 ± 0.22 (p = 0.025) after one year. In one case, leakage from the bleb was observed after the procedure and bleb revision was required.

CONCLUSIONS

transconjuctival compressive sutures seem to be an efficient and safe technique for managing hypotony maculopathy after glaucoma surgery.

Common and rare complications following filtering surgery for children with congenital glaucoma; a5 years study

PURPOSE

To determine the incidence of postoperative complications following combined trabeculotomy trabeculectomy with mitomycin C (CTTM) for congenital glaucoma (CG), in addition to documentation of some unusual complications and possible ways to manage these complications safely with minimal morbidity.

METHODS

A retrospective observational study was performed on 190 eyes with CG had a CTTM procedure.Included eyes were operated upon between February 2015 and February 2020 in Sohag University Hospitals. Medical records were reviewed and postoperative complications were reported. Incidence of postoperative complications and their management were the main outcome measures.

RESULTS

Early complications developed the form of shallow anterior chamber (AC) (16.3%), hyphema (10.5%), serous choroidal detachment (2%), hemorrhagic choroidal detachment (2%). Unusual and rare complications occurred in the form of iatrogenic Cushing syndrome, unilateral toxic keratopathy developed, vitreous hemorrhage (VH), intercalary staphyloma and decompression retinopathyLate complications included: high postoperative intraocular pressure (IOP) (16.5%), thin cystic blebs (13.1%), hypotony disc edema (2%), cataract (3.2%), one eye developed blebitis and one eye developed endophthalmitis.

CONCLUSION

Surgical management of CG is full of complications in early and late postoperative periods such as shallow AC, hyphema and thin cystic blebs. Some unusual and rare complications developed such as iatrogenic Cushing syndrome, unilateral toxic keratopathy, vitreous hemorrhage, intercalary staphyloma and decompression retinopathy. If identified early; all these complications could be managed properly leading to a successful and favorable outcome.

Conjunctival flap advancement with or without scleral graft for hypotony maculopathy after trabeculectomy

AIM

To investigate the outcomes of adaptive conjunctival flap advancement surgical techniques with or without scleral graft for patients undergoing revision surgery after trabeculectomy.

METHODS

This retrospective study included 28 eyes of 28 subjects from December 2015 to April 2018. A group of 15 eyes underwent conjunctival advancement only while the other 13 eyes did conjunctival advancement with partial thickness scleral graft. In both study groups, we considered the intraocular pressure (IOP) as our primary outcome and visual acuity (VA) as our secondary outcome. Both were assessed pre- and post-operatively till the last follow-up possible point. Additionally, we classified the patients according to complete and qualified success criteria.

RESULTS

The mean age of the conjunctival advancement group was 36.87±19.25y, while it was 44.08±18.04 in the other group. In both study groups, the mean IOP significantly increased after revision surgery at 1, 2, 3mo and the last follow-up visit when compared to prior the surgery (P<0.001). Moreover, VA was significantly improved (P=0.03) in the final follow-up for both surgical techniques. When we compared the change from baseline in both groups, there was no significant difference between IOP improvement in 1mo (P=0.263), while the difference was significant in 2mo (P=0.03), 3mo (P=0.02) and in the final follow-up visit postoperatively. However, this difference was not significant regarding VA (P=0.5).

CONCLUSION

The both adaptive techniques of conjunctival advancement and conjunctival advancement with scleral graft are effective for treating patients with late-onset hypotony. Yet, more prospective studies are needed to assert upon these results.

Concurrent Phacoemulsification and Encircling for Hypotony Maculopathy after Blunt Trauma

A 37-year-old Japanese man had his right eye hit by a fist. His right eye developed hypotony maculopathy and secondary cataract, and his visual acuity decreased to 20/200 with an intraocular pressure of 4 mmHg. He underwent phacoemulsification and aspiration, implantation of the intraocular lens, and encircling with a silicone tire. His visual acuity improved to 20/20 and stable for more than one year postoperatively. The intraocular pressure in his right eye increased to 12 mmHg, and maculopathy was resolved entirely. It was suggested that an encircling buckle obstructed the uveoscleral outflow through the cyclodialysis and increased intraocular pressure. Concurrent cataract surgery and encircling was sufficient to improve the vision.

Dexamethasone Intravitreal Implant Injection in Eyes with Comorbid Hypotony

PURPOSE

To evaluate outcomes in patients with hypotony treated with intravitreal dexamethasone implant (Ozurdex).

DESIGN

Retrospective cohort study.

PARTICIPANTS

Thirteen patients (15 eyes) that received a total of 99 dexamethasone implant injections on occasions at which the intraocular pressure was low, meeting the definition of statistical hypotony.

METHODS

The medical records of 13 patients (15 consecutive eyes) receiving 1 or more intravitreal dexamethasone implants between December 2014 and April 2017 were reviewed retrospectively. Hypotony was defined as intraocular pressure less than 6.5 mmHg. The indications for intravitreal dexamethasone implant injection were intermediate or posterior uveitis (86.7%), diabetic macular edema (13.3%), and/or cystoid macular edema (6.7%).

MAIN OUTCOME MEASURES

The primary outcome measures were safety outcomes and best visual acuity within 6 months of the final intravitreal dexamethasone implant injection in a hypotonous eye.

RESULTS

In 15 eyes (13 patients), 99 injections were administered to eyes under circumstances of hypotony. Uveitic cystoid macular edema or diabetic macular edema was reduced after treatment in all cases. No complications were noted during the injection procedure. Three complications were noted in 2 patients after injection. Pseudophakodonesis and mild vitreous hemorrhage immediately after injection were noted in 1 patient, and a case of delayed-onset vitreous hemorrhage with pigment release was noted in another. All 3 complications resolved without intervention. The primary end point of this study-mean visual acuity-was stable over the follow-up period. In patients with hypotony whose intraocular pressure normalized during the follow-up period, this was attributable to management of glaucoma surgery-related complications rather than an effect of the intravitreal dexamethasone implant.

CONCLUSIONS

Intravitreal dexamethasone implant injection is a reasonable treatment option for patients with comorbid hypotony in whom clinical findings warrant treatment with a sustained-delivery intravitreal steroid implant. Further studies, including imaging of zonules before and after intravitreal dexamethasone implant injection in a hypotonous eye, could help define risks to intraocular lens stability with this procedure.

Severe Hypotony Maculopathy in Anterior Uveitis Associated with Hodgkin Lymphoma

Purpose: To describe the clinical course and management of anterior uveitis complicated by ocular hypotony associated with Hodgkin lymphoma.Design: Case report.Methods: Chart and multimodal imaging review, including ultrasound biomicroscopy, widefield fundus pictures, fundus autofluorescence, fluorescein angiography, and indocyanine green angiography.Results: A 44-year-old female with progressive visual deterioration and history of low-grade fever developed bilateral granulomatous anterior uveitis complicated by severe hypotony maculopathy, not improving with systemic and topical steroids. After starting ibopamine 2% eye drops, ocular hypotony progressively resolved with visual recovery. Histologic examination of a biopsied enlarged lymph node of the neck revealed the presence of Hodgkin lymphoma, for which the patient underwent systemic chemotherapy.Conclusion: Severe hypotony maculopathy complicating anterior uveitis can be associated with Hodgkin lymphoma. Topical ipobamine 2% was safe and effective in the treatment of ocular hypotony in this case.

Pembrolizumab Induced Ocular Hypotony With Near Complete Vision Loss, Interstitial Pulmonary Fibrosis and Arthritis

Clinical outcomes for patients with advanced melanoma have improved significantly with the introduction of immune checkpoint inhibitors. These agents have distinct adverse effects with the potential for heightened host immune responses manifesting as an autoimmune reaction in any organ. We report a unique case who developed pembrolizumab induced arthritis, ocular hypotony with vision loss and pulmonary interstitial fibrosis. A 57-year old gentleman with advanced melanoma was treated with pembrolizumab and attained complete response with no evidence of disease on functional imaging. Treatment was well-tolerated with the only side effect being arthritis controlled with low dose steroids. Following a work related blunt trauma to the right eye, the patient developed bilateral visual impairment secondary to ocular hypotony. The ocular hypotony failed to respond to high-dose glucocorticoid and multiple surgeries. Intraoperatively, ciliary body atrophy was found. Pembrolizumab was ceased after the eye trauma and he remained in complete remission from melanoma. After a further 10 months, the patient developed symptomatic pulmonary fibrosis. There was moderate symptomatic improvement with nintedanib, an antifibrotic agent. This case describes two rare and unique adverse effects. Ocular adverse effects are extremely uncommon and this is the first case to report immune checkpoint inhibitor related ocular hypotony without uveitis to the best of our knowledge. Similarly, the incidence of severe pneumonitis is reported to be low, however limited data is available regarding pulmonary interstitial fibrosis. The occurrence of multiple adverse effects in this case including one occurring several months after cessation of treatment highlights the need for vigilance by clinicians who manage patients treated with immune checkpoint inhibitors. Further research is necessary with regards to rare adverse effects of immune checkpoint inhibitors and the relation of these to treatment administration.

Cauterized suture for complete tube occlusion of Ahmed glaucoma valve in hypotony maculopathy

PURPOSE

To present our experience treating hypotony maculopathy with a simple, minimally invasive, and removable ab interno tube Ahmed glaucoma valve occlusion.

METHODS

Under topical anesthesia a 5-0 polypropylene suture (Prolene; Ethicon) was inserted into the Ahmed glaucoma valve tube. The length of the tube was measured, and an external suture cauterization was performed to allow an easier and safer fixation in the tube. The suture was introduced into the tube itself with the viscoelastic 27-gauge cannula.

RESULTS

This technique was performed in three cases of hypotony maculopathy with a complex history of medical treatments: a 4-year-old boy with Donnai-Barrow syndrome and previous pars plana vitrectomy that developed hypotony maculopathy the day after Ahmed glaucoma valve insertion and two male patients (69 and 49 years old) that underwent hypotony maculopathy after cyclophotocoagulation as a last option to reduce intraocular pressure. One of the men had three filtering surgeries, two 5-fluorouracil needlings and Ahmed glaucoma valve insertion. The other male patient had keratoplasty and posterior Ahmed glaucoma valve insertion. In the three cases, both hypotony and maculopathy were reversed within a week and a month, respectively, after Ahmed glaucoma valve occlusion with no complications. When hypotony maculopathy develops it seems suitable to occlude completely the Ahmed glaucoma valve tube to swiftly reverse clinical and anatomic changes.

CONCLUSION

Intraluminal Ahmed glaucoma valve occlusion with cauterized suture is a simple, quick, reversible, and effective technique that may offer a minimally invasive way to resolve hypotony maculopathy in complex cases and avoid severe loss of vision.

The sign of the cross

Acute, painful, transient, right-sided, monocular visual loss lasting 4 hours developed in a 46-year-old man. This was followed by headache and left-sided transient hemiparesis. The association of ipsilateral transient vision loss with transient contralateral hemiparesis implicates involvement of the ipsilateral internal carotid artery (i.e., a crossed symptom).

Ocular hypotony: A comprehensive review

Ocular hypotony is an infrequent, yet potentially vision-threatening, entity. The list of differential causes is extensive, involving any condition that may compromise aqueous humor dynamics or the integrity of the globe and sometimes following medical treatments or procedures. Depending on the cause and the clinical impact, treatment options aim to correct the underlying pathology and to reestablish anatomical integrity, as well as visual function. We review the pathophysiology, clinical presentation, different causes, and associated therapeutic options of ocular hypotony.

Targeted Drug Delivery in the Suprachoroidal Space by Swollen Hydrogel Pushing

Purpose

The purpose is to target model drug particles to the posterior region of the suprachoroidal space (SCS) of the eye controlled via pushing by hydrogel swelling.

Methods

A particle formulation containing 1% hyaluronic acid (HA) with fluorescent polymer particles and a hydrogel formulation containing 4% HA were introduced in a single syringe as two layers without mixing, and injected sequentially into the SCS of the rabbit eye ex vivo and in vivo using a microneedle. Distribution of particles in the eye was determined by microscopy.

Results

During injection, the particle formulation was pushed toward the middle of the SCS by the viscous hydrogel formulation, but less than 12% of particles reached the posterior SCS. After injection, the particle formulation was pushed further toward the macula and optic nerve in the posterior SCS by hydrogel swelling and spreading. Heating the eye to 37°C, or injecting in vivo decreased viscosity and mechanical strength of the hydrogel, thereby allowing it to swell and flow further in the SCS. A high salt concentration (9% NaCl) in the hydrogel formulation further increased hydrogel swelling due to osmotic flow into the hydrogel. In this way, up to 76% of particles were delivered to the posterior SCS from an injection made near the limbus.

Conclusions

This study shows that model drug particles can be targeted to the posterior SCS by HA hydrogel swelling and pushing without particle functionalization or administering external driving forces.

The treatment of ocular hypotony after trabeculectomy with a scleral lens: A case series

PURPOSE

Ocular hypotony after trabeculectomy may be treated medically, surgically and with a tamponade. Three cases are reported in which a scleral lens was applied to treat ocular hypotony after mitomycin C (MMC) augmented trabeculectomy.

METHODS

In this retrospective case series the records of three eyes of three patients who developed ocular hypotony after they had undergone trabeculectomy augmented with MMC were evaluated. The patients were between 11 and 69 years of age and the intraocular pressure (IOP) after surgery ranged between 3 and 6 mmHg. All three patients showed a negative Seidel test; one had suspected hypotonic maculopathy and one had a collapsed anterior chamber. After unsuccessful treatment with large bandage lenses all three patients were subsequently fitted with a scleral lens. The scleral lens was fitted to fully cover and compress the bleb. Scleral lenses were worn continuously with a check-up after one night of wear and subsequent check-ups when needed. One patient continued to wear the scleral lens for a further 6.5 months on a daily wear basis.

RESULTS

In all three eyes the IOP was higher after wearing the scleral lens. Two patients stopped wearing the scleral lens after the IOP was stable. One patient developed a cataract; the cataract surgery was combined with a bleb revision and scleral lens wear was therefore discontinued.

DISCUSSION

The scleral lens might be a useful tool in the treatment of ocular hypotony after trabeculectomy augmented MMC surgery. The effect of the scleral lens on the ocular pressure is unpredictable. Caution is advised in vulnerable corneas due to risk factors such as hypoxia and infection. Further research is warranted to establish the safety of the procedure, the patient selection and the overall success in a larger patient group.

Standalone Ab Interno Gelatin Stent versus Trabeculectomy: Postoperative Interventions, Visual Outcomes, and Visits

PURPOSE

To evaluate postoperative interventions, visual outcomes, and number of postoperative office visits after standalone ab interno gelatin microstent implantation with mitomycin C (MMC) vs. trabeculectomy with MMC.

DESIGN

International, multicenter, retrospective cohort study.

PARTICIPANTS

A total of 354 eyes of 293 patients, including 185 microstent eyes and 169 trabeculectomy eyes.

METHODS

Consecutive eyes with uncontrolled glaucoma underwent microstent or trabeculectomy surgery from January 1, 2011, through July 31, 2015, at 4 academic ophthalmology centers: Toronto, Canada; Frankfurt, Germany; Salzburg, Austria; and Leuven, Belgium.

MAIN OUTCOME MEASURES

Assessed outcomes included (1) in-clinic interventions, (2) transconjunctival needle revision (TCNR), (3) postoperative visits at 1 and 3 months, (4) >2 lines vision loss at last follow-up, (5) complete visual recovery, and (6) >0.5 or >1 diopter (D) of surgically induced astigmatism.

RESULTS

Ninety-five (51.4%) of the microstent eyes and 105 (62.1%) of the trabeculectomy eyes underwent an intervention by last follow-up (log-rank P = 0.0004). The most common intervention was TCNR, followed by laser suture lysis. Seventy-eight (42.2%) microstent eyes and 55 (32.5%) trabeculectomy eyes received TCNR (adjusted hazard ratio [HR], 1.73 [95% confidence interval (CI), 1.10-2.71]): 128 total TCNRs in the microstent group and 95 in the trabeculectomy group. Predictors for TCNR included prior laser peripheral iridotomy and diabetes. Microstent eyes had on average 1.00 (standard deviation 2.32) fewer visits compared with trabeculectomy eyes in the first month (P < 0.001), adjusted for baseline characteristics. The percentage of eyes that had lost >2 lines of vision at last follow-up or reoperation was 12.4% (95% CI, 8.0%-18.7%) and was 21.9% (95% CI, 15.3%-30.1%) adjusted (P = 0.0383). A higher proportion of microstent eyes regained their baseline preoperative visual acuity compared with trabeculectomy eyes (log-rank P = 0.0250; adjusted HR, 1.46 [95% CI, 1.10-2.00]). Altogether, 25.3% (95% CI, 15.3%-38.9%) of microstent eyes and 40.7% (95% CI, 27.7%-55.3%) of trabeculectomy eyes had > 0.5 D surgically induced astigmatism on an adjusted basis; 8.0% (95% CI, 3.2%-18.6%) vs. 17.3% (95% CI, 8.9%-9.8%) had >1 D.

CONCLUSIONS

Microstent eyes had more TCNRs (though fewer in-clinic interventions), fewer postoperative visits, and less vision loss, and experienced less surgically induced astigmatism, than trabeculectomy eyes. Overall, the postoperative course was less intensive for the microstent, except for more TCNRs.

Transconjunctival suturing of the scleral flap in late hypotony maculopathy after non-penetrating deep sclerectomy

CLINICAL CASE

A 63-year-old man presents with late hypotony maculopathy after non-penetrating deep sclerectomy. Hypotonia and visual acuity are improved after transconjunctival suturing of the scleral flap.

DISCUSSION

Hypotony maculopathy may occur as a late complication after glaucoma surgery. Transconjunctival suturing of the scleral flap can be useful when conservative measures have failed.

Excessive scleral shrinkage, rather than choroidal thickening, is a major contributor to the development of hypotony maculopathy after trabeculectomy

Purpose

We previously reported that eyes with hypotony maculopathy (HM) after trabeculectomy (TLE) exhibited more reduction of axial length (AL) than those without HM, suggesting that inward collapse of the scleral wall may contribute to the development of HM after TLE. However, we did not evaluate change in choroidal thickness (CT), which could influence AL measures. We compared the magnitude and rate of AL and CT changes in eyes with and without HM by simultaneously measuring these parameters before and after TLE.

Methods

We enrolled 77 eyes of 77consecutive patients with glaucoma, who underwent TLE between March 2014 and March 2016. Intraocular pressure (IOP), central corneal thickness, keratometry, AL, and CT were measured pre- and postoperatively, up to 6 months. These biometrics were compared in eyes with and without HM.

Results

The 14 patients who developed HM were significantly younger than those who did not. The eyes with HM exhibited significantly reduced AL (2.8%) compared to those without HM (0.7%). There was no significant difference in CT change between the two groups. The rate of AL reduction was significantly correlated with age, postoperative IOP, and preoperative AL. Post-adjustment logistic regression analysis revealed that eyes with AL reduction rate ≥ 2% had 11.67 higher risk for developing HM (95% confidence interval, 1.28–106.6; P = 0.03).

Conclusions

AL reduction rates ≥ 2% were significantly associated with HM. Excessive reduction in AL, which was seen in eyes with HM, was not an artificial measure resulting from choroidal thickening but rather reflected reductions in the anterior-posterior diameter of the eyeball. Inward collapse of the scleral wall leads to redundancy of the chorioretinal tissue, contributing to the development of HM after TLE.

Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors

Aim

To investigate surgical outcomes and success predictors of transconjunctival scleral flap resuturing for the management of hypotony due to overfiltration following trabeculectomy with mitomycin C.

Materials and methods

Noncomparative, retrospective, interventional case series in which all glaucoma patients from two glaucoma services undergoing transconjunctival scleral flap resuturing between May 2012 and July 2016 were enrolled. Included eyes had to have hypotony [intraocular pressure (IOP) < 6 mm Hg] and/or hypotony maculopathy caused by excessive filtration following trabeculectomy. Key exclusion criteria were wound/bleb leaking and postoperative ocular trauma or infection. Preoperative and postoperative IOP, best-corrected visual acuity (BCVA), fundus imaging, surgical complications, and any subsequent related events or procedures were recorded. Rates of postsurgical hypotony and/or maculopathy resolution and possible success predictors were investigated.

Results

A total of 22 patients (22 eyes) with a mean age of 56.4 ± 15.2 years were included. Median follow-up was 245 days [interquartilerange (IR); 120-817 days] and mean IOP was increased from 2.9 ± 1.5 mm Hg (1-6 mm Hg) to 8.5 ± 3.1 mm Hg (2-16 mm Hg) at the last follow-up visit (p < 0.01). Approximately 75% of the cases (16 out of 22) had an IOP between 7 and 18 mm Hg at the end of the follow-up period. Median BCVA (log MAR) at last follow-up visit [0.1 (IR; 0.0- 0.3)] was significantly better than preoperative BCVA [0.4 (IR; 0.11.0); p < 0.01]. Hypotony resolved in 81% of the cases, while maculopathy resolution was found in 85% of the cases. Time interval between trabeculectomy and flap resuturing was the only factor significantly associated with patient’s IOP at last follow-up visit (R² = 0.23; p = 0.036). Success rates (IOP > 6 mm Hg at last follow-up visit) were halved in those left untreated for more than 6 months. No serious adverse event was recorded.

Conclusion

Our findings support the use of transconjunctival scleral flap resuturing as an effective and safe alternative for hypotony management due to overflitration following trabeculectomy. As time interval seems to influence the odds of hypotony resolution, early intervention is recommended.

How to cite this article

Scoralick ALB, Almeida I, Ushida M, Dias DT, Dorairaj S, Prata TS, Kanadani FN, Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017;11(2):58-62.

Efficacy, Safety, and Risk Factors for Failure of Standalone Ab Interno Gelatin Microstent Implantation versus Standalone Trabeculectomy

PURPOSE

To compare the efficacy, safety, and risk factors for failure of standalone ab interno gelatin microstent implantation with mitomycin C (MMC) versus trabeculectomy with MMC.

DESIGN

International, multicenter, retrospective interventional cohort study.

PARTICIPANTS

Three hundred fifty-four eyes of 293 patients (185 microstent and 169 trabeculectomy) with no prior incisional surgery.

METHODS

Consecutive eyes with uncontrolled glaucoma underwent microstent or trabeculectomy surgery from January 1, 2011 through July 31, 2015 at 4 academic ophthalmology centers: Toronto, Canada; Frankfurt, Germany; Salzburg, Austria; and Leuven, Belgium.

MAIN OUTCOME MEASURES

Primary outcome measure was hazard ratio (HR) of failure, with failure defined as 2 consecutive intraocular pressure (IOP) readings of <6 mmHg with vision loss or >17 mmHg without glaucoma medications (complete success) at least 1 month after surgery despite in-clinic interventions (including needling). Secondary outcome measures included IOP thresholds of 6 to 14 mmHg and 6 to 21 mmHg and same thresholds allowing for medications (qualified success), interventions, complications, and reoperations.

RESULTS

Baseline characteristics were similar, except more men (56% vs. 43%), younger patients (average, by 3 years), better preoperative visual acuity (22% vs. 32% with 0.4 logarithm of the minimum angle of resolution vision or worse), and more trabeculoplasty (52% vs. 30%) among microstent eyes. The adjusted HR of failure of the microstent relative to trabeculectomy was 1.2 (95% confidence interval [CI], 0.7-2.0) for complete success and 1.3 (95% CI, 0.6-2.8) for qualified success, and similar for other outcomes. Time to 25% failure was 11.2 months (95% CI, 6.9-16.1 months) and 10.6 months (95% CI, 6.8-16.2 months) for complete success and 30.3 months (95% CI, 19.0-∞ months) and 33.3 months (95% CI, 25.7-46.2 months) for qualified success. Overall, white ethnicity was associated with decreased risk of failure (adjusted HR, 0.49; 95% CI, 0.25-0.96), and diabetes was associated with increased risk of failure (adjusted HR, 4.21; 95% CI, 2.10-8.45). There were 117 and 165 distinct interventions: 43% and 31% underwent needling, respectively, and 50% of trabeculectomy eyes underwent laser suture lysis. There were 22 and 30 distinct complications, although most were transient. Ten percent and 5% underwent reoperation (P = 0.11).

CONCLUSIONS

There was no detectable difference in risk of failure and safety profiles between standalone ab interno microstent with MMC and trabeculectomy with MMC.

Same-site Trabeculectomy Revision for Failed Trabeculectomy: Outcomes and Risk Factors for Failure

PURPOSE

To evaluate long-term tonometric outcomes of same-site trabeculectomy revision with mitomycin C (MMC) after failure of an initial trabeculectomy, and to identify risk factors for failure in patients with open-angle glaucoma.

DESIGN

Retrospective cohort study.

METHODS

One-hundred and seventeen patients (130 eyes) with primary open-angle, pseudoexfoliation, or pigmentary glaucoma, who failed a first trabeculectomy and who were ≥40 years of age at the time of same-site trabeculectomy revision, were included. Three levels of success criteria were defined: (A) intraocular pressure (IOP) ≤18 mm Hg and IOP reduction of 20%; (B) IOP ≤15 mm Hg and IOP reduction of 25%; and (C) IOP ≤12 mm Hg and IOP reduction of 30%. The primary outcome was the qualified Kaplan-Meier success rate (with or without medications) for each criterion. Cox multivariate regression analysis was used to identify risk factors for failure.

RESULTS

The success rates (± standard error) at the first, third, and fifth years of follow-up for criterion A were 69.7% (± 4.1%), 58.2% (± 4.6%), and 51.1% (± 5.0%); for criterion B these were 60.9% (± 4.4%), 47.8% (± 4.7%), and 44.0 (± 4.8%); and for criterion C, 44.6% (± 4.5%), 29.7% (± 4.4%), and 25.8% (± 4.3%). Mean follow-up was 5.2 (± 3.6) years. A time interval between the first and the same-site trabeculectomy revision of <3 years, worse baseline visual acuity, and dyslipidemia were significant risk factors for failure.

CONCLUSIONS

Given the long-term tonometric success rates along with significant medication reduction, same-site trabeculectomy revision with MMC should be considered as a viable option to achieve reasonable IOP targets after a first failed trabeculectomy in open-angle glaucoma patients.