Three-year follow-up of the tube versus trabeculectomy study

Comparing the outcome of delayed postoperative versus intraoperative mitomycin C use in trabeculectomy: A randomized control trial

PurposeTo compare the effect of delayed postoperative mitomycin C (MMC) application on surgical outcome and bleb morphology with intra-operative application in trabeculectomy.MethodThis monocentric, unmasked randomized control trial recruited primary glaucoma patients between 18-70 years of age. They were randomized into Group I (intraoperative MMC group) and Group II (postoperative MMC group). All patients underwent standard fornix-based trabeculectomy with differences only in the MMC application step. In Group I, 0.2 mg/ml MMC was applied intraoperatively for two minutes, while in Group II, 0.01 mg (0.25 ml of 0.04 mg/ml) of MMC was injected 7-14 days postoperatively above the bleb. The primary outcome was surgical success, whereas the secondary outcome measures were rate of complications and bleb morphology. Complete and qualified success was defined as intraocular pressure (IOP) between 6-21 mm Hg without and with ≤2 anti-glaucoma medications (AGMs).ResultsFifty-six eyes (31 in Group I and 25 in Group II) were analyzed for the outcome at 18 months follow-up. Surgical success was comparable (70.9% vs 68%) (p = 0.811) between the groups. There were higher incidences of hypotony (41.9% vs 36%) in Group I. Incidences of persistent-hypotony (p = 0.032) and late-hypotony (p = 0.127) were higher in Group I. Two eyes developed hypotony maculopathy in Group I, while none in Group II. The blebs in Group I were more avascular, cystic and developed thinning, while those in Group II were diffuse and shallow.ConclusionsDelayed postoperative MMC application may be as effective as standard trabeculectomy with MMC in lowering IOP with a lower rate of complications.

Outcomes of Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Advanced Glaucoma: A Retrospective Analysis

Background and Objectives: The search for less invasive and more effective methods in the surgical treatment of glaucoma continues. For advanced glaucoma, all surgical options carry a high risk of complications and vision loss. The aim of this study was to evaluate the outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) surgery in advanced glaucoma. Materials and Methods: In this retrospective study, advanced open-angle glaucoma (OAG) patients were followed up on the 1st day, 1st week, and 1st month, then monthly for 6 months and then every 3 months after GATT surgery. Outcomes at 6 and 24 months were analyzed to evaluate early and long-term surgical success. Surgical success was defined as a ≥20% intraocular pressure (IOP) reduction from baseline, final IOP ≤21 mmHg, and no need for additional glaucoma surgery. Pre- and postoperative measurements included IOP, retinal nerve fiber layer (RNFL) thickness by optical coherence tomography (OCT), peripapillary vessel density (VD) via optical coherence tomography angiography, and visual field (VF) tests. Results: Among 44 advanced glaucoma patients (61.4% pseudoexfoliative glaucoma), surgical success was 81.8% at 6 months and 76.5% at 24 months. Mean IOP decreased from 26.9 ± 10.4 mmHg preoperatively to 13.8 ± 8.3 mmHg at 3 months (40.36% reduction, p < 0.001) and 13.9 ± 4.0 mmHg at final follow-up (42.12% reduction, p < 0.001). Disease progression was absent in 66% of patients. BCVA initially declined (0.61 ± 0.36 to 0.41 ± 0.33 logMAR at 3 months, p = 0.011) but returned to baseline (0.59 ± 0.35 logMAR at final follow-up, p = 1.00). Glaucoma medications decreased by 66.2%, and peripapillary VD remained stable (p > 0.05). The most common complication was mild hyphema (34.1%), which resolved without intervention; only one patient (2.3%) experienced vision-threatening complications (wipe-out phenomenon in degenerative myopia). Conclusions: GATT is a safe and effective alternative to trabeculectomy for advanced glaucoma, achieving significant IOP reduction with stable VD and low rates of serious complications. This study provides novel insights by offering long-term (24-month) follow-up data, evaluating peripapillary VD stability, and specifically assessing GATT outcomes in an advanced glaucoma cohort. However, caution is advised in patients with additional ocular pathologies.

Reporting outcomes of minimally invasive glaucoma surgery

PURPOSE OF REVIEW

This review presents guidelines for designing studies and reporting efficacy and safety outcomes in minimally invasive glaucoma surgery (MIGS) research.

RECENT FINDINGS

Adherence to reporting guidelines in MIGS studies is crucial for providers and patients to appraise surgical options. Recent guidelines have outlined appropriate methodology, efficacy outcomes, and safety reporting, so that study results are presented in an interpretable and uniform manner.

SUMMARY

MIGS are changing the glaucoma treatment paradigm by offering safer, less invasive alternatives to traditional filtering surgery. However, inconsistent reporting of outcomes in MIGS trials hampers comparison and clinical decision-making. Recent guidelines have aimed to highlight appropriate methodology and encourage standardization in reporting outcomes to improve the quality of MIGS literature. Key considerations include defining baseline intraocular pressure, reporting standardized demographic data, using consistent endpoints, presenting standardized figures, evaluating medication use, and documenting adverse events. By adhering to these guidelines, MIGS trials can offer clearer insights into surgical outcomes, aiding both surgeons and patients in treatment decisions.

Cost-Effectiveness Analysis of Hydrus Microstent for Patients with Mild to Moderate Primary Open-Angle Glaucoma in Canada

OBJECTIVE

To assess the cost-effectiveness of Hydrus Microstent combined with cataract surgery (CS) vs. CS alone for treating patients with mild to moderate primary open-angle glaucoma (POAG).

DESIGN

Cost-utility analysis using efficacy and safety results of a pivotal randomized clinical trial.

SUBJECTS

Modeled cohort of patients with mild to moderate POAG and visually significant cataract.

METHODS

A semi-Markov model was developed to model effects and costs over a 15-year time horizon from the Canadian public health care payer perspective for patients with mild or moderate POAG receiving Hydrus Microstent during CS vs. CS alone. The model utilizes the Hydrus Microstent for Lowering IOP in Glaucoma Patients Undergoing Cataract Surgery (HORIZON) trial patient cohort. Progression was guided using the annualized rate of progression derived from a post hoc analysis of 5-year visual field loss data from the HORIZON trial. The amount of visual field lost was mapped on a sequential addition of medications used as a proxy for irreversible progression. Costs were derived from various publicly available sources and publications. Utility values were sourced from a published analysis that conducted a mapping exercise based on Health Utilities Index mark 3 using Canadian tariffs. We conducted deterministic and probabilistic sensitivity analyses to examine the uncertainty around alternative model input values. Scenario analyses explored structural uncertainty.

MAIN OUTCOME MEASURES

Total costs per patient, quality-adjusted life years (QALYs), and incremental cost-utility ratio.

RESULTS

Compared with CS alone, Hydrus + CS was a dominant strategy (greater benefits and lower costs). Although life years were equivalent between the 2 treatments (11.41 years), the Hydrus + CS arm was associated with higher benefits (9.351 vs. 9.040 in QALYs). This translated into an additional 0.311 QALYs for Hydrus + CS. Total costs were lower with Hydrus + CS (Can$ 26 770 vs. Can$ 27 145) resulting in a saving of Can$ 375. Results of scenario analyses showed robustness of the model. The cost-effectiveness acceptability curve shows a probability of 85.3% of Hydrus + CS being cost-effective compared with CS alone at a willingness-to-pay threshold of 50 000/QALY.

CONCLUSIONS

Hydrus Microstent combined with CS is a cost-effective long-term treatment for patients with POAG.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Effectiveness and safety of the XEN45 gel stent compared to trabeculectomy in primary open-angle glaucoma: the Gold-Standard Pathway Study

AIM

To compare the gel stent to trabeculectomy in the Gold-Standard Pathway Study (GPS) patients with primary open-angle glaucoma (POAG).

METHODS

In the GPS, patients with elevated intraocular pressure (IOP) poorly controlled with IOP-lowering medication were randomised (2:1, gel stent:trabeculectomy). Aggregate primary endpoint: patients (%) at month 12 achieving ≥20% IOP reduction from baseline without medication increase, clinical hypotony, vision loss to counting fingers or secondary surgical intervention (SSI). Secondary endpoints included changes in mean IOP and medication count from baseline; postoperative interventions; visual recovery; postoperative complications; and the Symptom and Health Problem Checklist (SHPC-18) questionnaire.

RESULTS

Of 130 eyes with POAG treated/analysed (gel stent, n=88; trabeculectomy, n=42); 61.4% and 69.0% met the primary endpoint, respectively (p=0.394). At month 12, the change from baseline in mean IOP was statistically greater post-trabeculectomy (by 2.8 mm Hg; p=0.028) than post-gel stent. Postoperative intervention and postoperative complication rates were 39.8% and 75.0% (gel stent) versus 76.2% and 92.9% (trabeculectomy), respectively. Hypotony (IOP ≤6 mm Hg at two consecutive visits) rates were 14.8% (gel stent) and 28.6% (trabeculectomy). Visual recovery was faster/better (per the mean and time to first return to baseline best corrected visual acuity) and SHPC-18-related improvements were greater post-gel stent than post-trabeculectomy.

CONCLUSION

Similar proportions of eyes with POAG achieved the primary endpoint post-gel stent and post-trabeculectomy. The mean IOP reduction was statistically greater post-trabeculectomy. The gel stent resulted in fewer postoperative interventions, faster/better visual recovery, favourable patient-reported outcomes and fewer specific adverse events, although more SSIs and IOP elevations were observed.

Special Commentary: Reporting Clinical Endpoints in Studies of Minimally Invasive Glaucoma Surgery

Minimally invasive glaucoma surgery (MIGS) refers to a group of procedures generally characterized by an ab interno approach, minimal trauma to ocular tissue, moderate efficacy, an excellent safety profile, and rapid recovery. The number of MIGS procedures continues to increase, and their use has become widespread among glaucoma and cataract specialists. Standardization of the methodology and reporting of clinical endpoints in MIGS investigations enhances interpretation and comparison across different studies. The assessment of surgical interventions not only should consider statistical significance, but also whether the outcome is meaningful to patients. Minimal clinically important difference (MCID) is defined as the smallest change in a treatment outcome that is considered beneficial for an individual patient and prompts a change in their clinical management. Expert consensus is an accepted approach to determine the MCID. The American Academy of Ophthalmology's Glaucoma Preferred Practice Pattern® Committee is an expert panel that develops guidelines identifying characteristics and components of quality eye care. The Committee recommends that the cumulative probability of surgical success at 2 years with Kaplan-Meier survival analysis be used as the primary efficacy endpoint in MIGS studies. The Committee suggests that surgical success for standalone MIGS be defined as intraocular pressure (IOP) of 21 mmHg or less and reduced by 20% or more from baseline without an increase in glaucoma medications, additional laser or incisional glaucoma surgery, loss of light perception vision, or hypotony. The proposed MCID for the cumulative probability of success of standalone MIGS at 2 years is 50%. The panel recommends that surgical success for MIGS combined with cataract extraction with intraocular lens implantation (CE-IOL) be defined as a decrease in glaucoma medical therapy of 1 medication or more from baseline without an increase in IOP or IOP of 21 mmHg or less and reduced by 20% or more from baseline without an increase in glaucoma medications, additional laser or incisional glaucoma surgery, loss of light perception vision, or hypotony. The suggested MCID for the cumulative probability of success for MIGS combined with CE-IOL at 2 years is 65%. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Update on Surgical Techniques Best Practices to Optimize Outcomes Following Gel Stent Implantation

The XEN®45 Glaucoma Treatment System (gel stent; Allergan, an AbbVie company, Irvine, CA, USA) is a minimally invasive bleb-forming surgical device that was originally approved to lower intraocular pressure by diverting the aqueous humor from the anterior chamber to the subconjunctival space (like trabeculectomy) following ab-interno placement. Since approval of the gel stent in multiple countries, the implantation technique has evolved considerably, being performed ab interno or ab externo with open or closed conjunctiva, based on patients' needs and/or surgeons' preferences. Additional technical variations that can facilitate gel stent placement and/or improve outcomes have also emerged. This article aims to increase awareness of these developments to facilitate informed decision-making and improve surgical success and outcomes for patients.

Structural reversal of disc cupping measured in Bruch's membrane opening-based OCT morphometry after PRESERFLO microshunt implantation for open-angle glaucoma

BACKGROUND/ AIMS

To analyze the longitudinal change in Bruch's membrane opening minimal rim width (BMO-MRW) and peripapillary retinal nerve fiber layer (pRNFL) thickness using optical coherence tomography (OCT) after implantation of a PRESERFLO® microshunt for surgical glaucoma management in adult glaucoma patients.

METHODS

Retrospective data analysis of 59 eyes of 59 participants undergoing implantation of a PRESERFLO microshunt between 2019 and 2022 at a tertiary center for glaucoma management. Surgical management included primary temporary occlusion of the glaucoma shunt to prevent early hypotony. Pre- and post-operative OCT examinations of the optic nerve head (ONH) and intraocular pressure (IOP) were assessed. Longitudinal change in morphometric spectral domain OCT parameters of the ONH was correlated to change in IOP.

RESULTS

BMO-MRW increased significantly between baseline (BL) and follow-up (FU) within the first three months after surgery (BL = 171.15 ± 66.80 μm; FU = 180.78 ± 70.394 μm; p = 0.034). For the same postoperative period, the mean preoperative IOP of 24.97 ± 7.22mmHg was lowered after surgery to 13.70 ± 5.09 mmHg. Eighteen months after surgery, there was no significant change in BMO-MRW compared to baseline (BL = 169.83 ± 52.69 μm; FU = 164.98 ± 55.85 μm; p = 0.271), while mean IOP was 13.08 ± 4.48 mmHg. A decrease in IOP correlated significantly with a change in BMO-MRW (r = 0.453, p < 0.05) three months after surgery. Peripapillary RNFL thickness was unchanged in follow-up after three months (p > 0.16) and significantly decreased in later follow-up (p = 0.009).

CONCLUSION

PRESERFLO® microshunt implantation with primary temporary occlusion leads to a significant transient increase in BMO-MRW. This phenomenon is also known as structural reversal of disc cupping (SRDC). The effect seems to be less pronounced and of shorter duration when compared to previous data after trabeculectomy with comparable pre- and postoperative IOP levels.

Ab interno trabeculectomy revision with 5-flourouracil for failed trabeculectomy in advanced glaucoma: 3-year outcomes

OBJECTIVE

To describe the 3-year outcomes of patients who underwent ab interno trabeculectomy revision with a translimbal sclerostomy spatula augmented with 5-flourouracil.

DESIGN

Retrospective cohort study.

PARTICIPANTS

In this single-centre study, inclusion criteria included patients who were 18 years of age or older with advanced glaucoma who had undergone ab interno trabeculectomy revision with 5-flourouracil due to subconjunctival fibrosis and above-target intraocular pressure (IOP). Patients were required to have a minimum follow-up of 3 years.

METHODS

The primary outcome measure was IOP. Secondary outcome measures included number of topical IOP-lowering medications, best-corrected distance visual acuity, visual field mean deviation, and postoperative complications.

RESULTS

Forty-one eyes of 41 patients met the criteria for inclusion. Survival analysis demonstrated success defined by criterion A (IOP <15 mm Hg and >20% reduction) in 44% of eyes without medication (complete success) and 71% of eyes with or without medication (qualified success) at 3-year follow-up. Complete and qualified successes defined by criterion B (IOP <12 mm Hg and >20% reduction) were achieved by 31% and 44% of eyes, respectively. Early complications included transient hypotony in 26 eyes (63%) and transient hyphema in 3 eyes (7.3%). No persistent complications were reported within the 3-year study period.

CONCLUSION

Ab interno trabeculectomy revision can be an effective technique for achieving a low target IOP in patients with advanced glaucoma in up to 3-year follow-up.

Matched case-control comparison of surgical success after XEN45 Gel Stent and PRESERFLO MicroShunt implantation in a Caucasian population

BACKGROUND

The aim of this study was to compare the outcome of implantation of a XEN45 Gel Stent with the outcome of implantation of a Preserflo MicroShunt in a matched-pair analysis in eyes being naïve to filtering surgery.

METHODS

In this comparative, retrospective study, 50 eyes that had undergone XEN45 Gel Stent implantation were compared with 50 eyes after Preserflo implantation. Follow-up was at least 6 months, and surgical success was measured by criteria A (IOP < 21 mmHg, IOP reduction >20%, no repeat surgery); criteria B (IOP < 18 mmHg, IOP reduction >20%, no repeat surgery); and criteria C (IOP ≤15 mmHg, IOP reduction ≥40%, no repeat surgery).

RESULTS

After a follow-up period of 12 months, mean IOP had decreased from preoperative 25.2 ± 4.8 mmHg in the XEN group to 14.5 ± 4.0 (n = 35) and from 25.3 ± 6.8 mmHg to 11.9 ± 2.9 (n = 41) in the Preserflo group, respectively. The IOP at the last follow-up of the two groups differed significantly (p < 0.01). The probability of surgical success did not differ concerning Criteria A and B, but surgical success was significantly higher in the Preserflo group for Criteria C (60%, p < 0.01).

CONCLUSION

Both the Preserflo and XEN45 Gel Stent provide an effective and safe treatment option for advanced glaucoma and have a high potential to reduce intraocular pressure. Absolute IOP levels of <16 mmHg after 12 months were significantly more frequent in the Preserflo group.

Systematic Literature Reviews Comparing the Long-Term Safety Outcomes for the Port Delivery System with Ranibizumab (PDS) Versus Other Ocular Implants

OBJECTIVES

To determine whether the types and rates of post-surgical complications associated with the Port Delivery System with ranibizumab (PDS) are comparable with those reported for other ocular implants that cross the sclera.

METHODS

Systematic literature reviews were conducted to determine the long-term (≥ 18-month) safety of ocular implants that cross the sclera in clinical trials and real-world studies. Complication types and rates were compared with those reported for the PDS in phase III clinical trials (Archway, Pagoda, and Pavilion).

RESULTS

Sixteen clinical trials (24 publications) and 43 real-world studies were identified reporting 30 complications in eyes with 15 implant types and 8 ocular diseases. Implants were associated with an acceptable, well-characterized safety profile, with most complications resolving spontaneously or with treatment. Device-related complications were reported in 0.7% (0.0-5.0%) of study eyes in clinical trials and 1.3% (0.0-14.5%) of eyes in real-world studies. Rates of conjunctival complications were 2.1% (0.0-22.8%) and 2.2% (0.9-4.6%), respectively. The overall types and rates of adverse events of special interest reported for the PDS in phase III trials (cataract, conjunctival bleb, vitreous hemorrhage, conjunctival erosion, conjunctival retraction, endophthalmitis, implant dislocation, retinal detachment, and hyphema) were within the ranges reported for other ocular implants.

CONCLUSIONS

The rates of complications reported in phase III clinical trials for the PDS were within the ranges reported for other ocular implants that cross the sclera. This suggests that the long-term safety of the PDS is consistent with other ocular devices established in ophthalmology clinical practice.

TRIAL REGISTRATION

PROSPERO international prospective register of systematic reviews: CRD5202234129, CRD42022343129.

MIGS in Severe Glaucoma: 12-Month Retrospective Efficacy and Safety of Microinvasive Glaucoma Surgery with Cataract Extraction

Purpose

Despite holding promise, reports of using MIGS in severe glaucoma are scarce, and none has described combining multiple MIGS in this population. To the best of our knowledge, this is the largest study to report outcomes of phacoemulsification and MIGS (Phaco/MIGS) in patients with severe glaucoma.

Methods

This retrospective review comprised 327 clinical visits of 71 patients with severe glaucoma who underwent Phaco/MIGS with iStent, endocyclodestruction, Kahook Dual Blade, Hydrus Microstent, or a combination of these MIGS (cMIGS) performed between 2016 and 2021. Primary outcomes included intraocular pressure (IOP) and medication burden evaluated by Generalized Estimating Equations, as well as Kaplan-Meier Estimates. Further analyses compared the efficacy of cMIGS and single Phaco/MIGS (sMIGS), procedure duration, visual acuity, and complications.

Results

Mean preoperative IOP was 16.7 mmHg ± 5.8 (SD) on 2.3 ± 1.9 medications overall (N = 71), 16.9 ± 6.3 mmHg on 1.7 ± 1.9 medications in the sMIGS group (N = 37), and 16.4 ± 5.3 mmHg on 2.9 ± 1.6 medications in the cMIGS group (N = 34). Throughout 12 months, Phaco/MIGS led to significant reduction patterns in IOP (p < 0.001) and medications (p = 0.03). At 12 months, 47.5%, 87.5%, and 64.7% of the patients achieved IOP ≤ 12 mmHg, 17 mmHg, or predetermined goal IOP, respectively, without additional medication or procedure. Mean 12-month IOP was 13.5 ± 3.1 mmHg on 1.8 ± 1.7 medications. After adjusting for baseline medication burden, the reduction pattern in IOP (p < 0.05) was different between cMIGS and sMIGS, favoring cMIGS, and the groups had similar reduction patterns in medications (p = 0.75).

Conclusion

The use of Phaco/MIGS in patients with cataract and severe glaucoma may significantly reduce IOP and medication burden throughout 12 months and, thus, may serve as a stepping stone in severe glaucoma patients with visually significant cataract before proceeding with more invasive glaucoma surgery. This effect may be potentiated by the combination effect of cMIGS.

A new self-adjustable glaucoma valve

Introduction: Glaucoma, the leading cause of irreversible blindness globally, affects more than 70 million people across the world. When initial treatments prove ineffective, especially for cases with high intraocular pressure (IOP), the preferred approach involves employing glaucoma drainage devices (GDDs). Methods: This study introduces a novel self-adjustable glaucoma drainage device (SAGDD) designed to maintain IOP within the desired biological range (10 mmHg < IOP <18 mmHg) by dynamically modulating its fluidic resistance. Inspired by the starling resistor, we designed a circular valve with a thin, flexible membrane placed over the valve's inlet and outlet. To achieve the ideal design for the SAGDD and optimize its parameters, we utilized fluid-solid interaction (FSI) numerical models and conducted parametric studies, wherein simulations demonstrated the validity of the concept. Subsequently, to confirm and validate the numerical results, we fabricated a SAGDD at a 3:1 scale and subjected it to in vitro testing. Results: Our findings demonstrate that, on a 3:1 scale, a circular SAGDD with a diameter of 8.1 mm and a stainless-steel membrane with a thickness of 10 µm effectively maintained IOP within the target range when the membrane exposed to external pressures of 7.5 or 10 mmHg. Discussion: In summary, our study establishes a strong foundation for further exploration of the potential efficacy of SAGDD as a promising treatment for glaucoma. The cost-effectiveness and simplicity of its design, devoid of costly instrumentation, hold considerable promise in addressing the challenges associated with glaucoma.

A Retrospective Comparison of Phaco-tube vs. Phaco-trabeculectomy in Glaucoma Patients

PURPOSE

To compare surgical outcomes of phacoemulsification combined with Baerveldt implantation (phaco-tube) or trabeculectomy with mitomycin-C (MMC) (phaco-trab) in patients without prior incisional ocular surgery.

DESIGN

Single-center, retrospective, comparative case series.

PARTICIPANTS

A total of 90 patients underwent surgical treatment, including 45 patients in the phaco-tube group and 45 patients in the phaco-trab group.

METHODS

Eligible patients were identified using current procedural terminology (CPT) codes, and their medical records were retrospectively reviewed.

MAIN OUTCOME MEASURES

The primary outcome measure was the rate of surgical failure (IOP ≤5 mmHg or >21 mmHg or reduced <20% from baseline on 2 consecutive study visits after 3 months, reoperations for glaucoma, or experienced loss of light perception vision). Patients who had successful surgical outcomes without use of glaucoma medications were classified as complete successes, while those who used glaucoma medications were classified as qualified successes. Secondary outcome measures were visual acuity (VA), visual field mean deviation (VFMD), intraocular pressure (IOP), glaucoma medication use, and complications.

RESULTS

The cumulative probability of failure was 6.7% in the phaco-tube group and 32.8% in the phaco-trab group after 3 years (P = 0.005; Restricted Mean Survival Time = 5.9 months, 95% CI = 1.4-10.4 months). The IOP was 13.1 ± 3.4 mmHg in the phaco-tube group and 13.3 ± 6.2 mmHg in the phaco-trab group at 3 years (P = 0.90), and the number of glaucoma medications was 2.6 ± 1.5 in the phaco-tube group and 1.7 ± 1.3 in the phaco-trab group (P = 0.015). The logarithm of the minimum angle of resolution VA was 0.39 ± 0.58 in the phaco-tube group and 0.43 ± 0.73 in the phaco-trab group at 3 years (P = 0.82), and VFMD was -18.3 ± 9.0 dB in the phaco-tube group and -14.1 ± 7.0 dB in the phaco-trab group (P = 0.16). Postoperative complications developed in 21 patients (47%) in the phaco-tube group and 15 patients (33%) in the phaco-trab group (P = 0.28).

CONCLUSIONS

Phaco-tubes had a significantly lower rate of surgical failure compared to phaco-trabs after 3 years of follow-up. However, phaco-trabs used significantly fewer glaucoma medications at multiple postoperative timepoints and had a higher proportion of complete success.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Comparing Outcomes of Tube Versus Trabeculectomy Among Patients With Angle-closure Glaucoma

PURPOSE

Compare outcomes of tube shunt surgery (Tube) and trabeculectomy with mitomycin C (Trab-MMC) in patients with angle-closure glaucoma (ACG).

DESIGN

Retrospective nonrandomized comparative study.

PARTICIPANTS

A total of 80 eyes from 80 patients with ACG who underwent either Tube (N = 50) or Trab-MMC (N = 30) between January 2015 and January 2022 at Massachusetts Eye and Ear.

METHODS

Reviewed and analyzed 390 visits from patient charts.

MAIN OUTCOME MEASURES

Kaplan-Meier (KM) success rates, intraocular pressure (IOP), medication burden, best-corrected visual acuity (BCVA), adjusted hazard ratios (HRs), and complications.

RESULTS

Baseline demographics were similar between both groups, except for a higher proportion of patients with pseudophakia and prior incisional ocular surgery in the Tube group. The Trab-MMC procedure had significantly higher KM complete success (CS) rates than the Tube procedure, but similar qualified success (QS) rates. Under QS, the cumulative probability of survival was 87% in the Tube group and 83% in the Trab-MMC group at year 1 (P = 0.77), and 75% in the Tube group and 58% in the Trab-MMC group at year 2 (P = 0.14). Under CS, the cumulative probability of survival was 13% in the Tube group and 59% in the Trab-MMC group at year 1 (P < 0.001), and 11% in the Tube group and 41% in the Trab-MMC group at year 2 (P < 0.001). Both Tube and Trab-MMC procedures resulted in significant patterns of IOP and medication reduction from baseline up to 2 years with mean IOP reduced to 12.6 ± 5.9 mmHg on 2.8 ± 1.4 medications after Tube and 12.1 ± 6.6 mmHg on 2.4 ± 1.7 medications after Trab-MMC. Patients who underwent Trab-MMC required less IOP-lowering medications at every follow-up visit up to year 1, but a similar number at year 2. No significant differences were found in IOP reduction, BCVA, or complication rates between groups.

CONCLUSIONS

We demonstrate that Trab-MMC confers similar IOP reduction and QS rates to Tube placement in patients with ACG. Trab-MMC, however, demonstrated greater medication burden reduction up to 1 year, and more favorable CS rates up to 2 years, while still maintaining similar complication rates to Tube.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Combined versus standalone XEN45 Gel Stent implantation in either phakic or pseudophakic patients: a case-matched study

PURPOSE

To determine differing outcomes among either phakic or pseudophakic patients who received standalone XEN45 Gel Stent (Allergan, an AbbVie Company, CA, USA) implantation and patients who underwent combined surgery with phacoemulsification.

METHODS

This retrospective single-center study involved 180 eyes of 180 participants who underwent XEN45 Gel Stent implantation, of which 60 eyes received combined surgery with phacoemulsification (combined group). Standalone stent implantation was performed on 60 phakic (phakic group) and on 60 pseudophakic eyes (pseudophakic group). The groups were matched in a ratio of 1:1:1 based on multiple criteria. Successful surgery was defined by three scores: IOP at the longest follow-up of < 21 mmHg (Score A) or < 18 mmHg (Score B) and an IOP reduction > 20% or IOP ≤ 15 mmHg and an IOP reduction ≥ 40% (Score C). In all scores, one open conjunctival revision was allowed, and additional repeat surgery was considered a failure.

RESULTS

After an average follow-up time interval of 20.6 ± 12.6 months, there was a mean IOP-reduction by 37% among the entire cohort. Comparative analysis between the three groups did not show significant differences regarding postoperative IOP, postoperative medication score, side effects, revision rate, repeat surgery rate or success rate. A dysfunctional stent was detected in eight eyes (4%) during open conjunctival revision in 76 eyes.

CONCLUSION

The clinical endpoints investigated did not differ significantly among either phakic or pseudophakic patients who received standalone stent implantation and patients who underwent combined surgery. However mean latency between primary stent implantation and first revision surgery after combined surgery was markedly shorter.

Wound modulation in glaucoma surgery: The role of anti-scarring agents

Filtration surgery is one of the most frequently performed surgeries in the management of glaucoma, and trabeculectomy is considered the gold standard surgical technique for the same. Though trabeculectomy has been reported to have an excellent initial success rate, about 30% of them fail in 3 years, and nearly 50% of them fail in 5 years. The most significant risk of failure still seems to be wound scarring, especially episcleral fibrosis, leading to bleb failure. As a result, it is essential to explore the role of anti-scarring agents, including mitomycin C, and 5-fluorouracil in wound modulation and improving the bleb survival rate. Since these agents are widely used in trabeculectomy, it is crucial to understand the various modes of application, advantages, and adverse effects of these agents. On an evidence-based approach, all these points have been highlighted in this review article. In addition, the newer agents available for wound modulation and their scope for practical application are discussed.

Early Outcomes of Combined Phacoemulsification and Ab Interno Tanito Microhook Trabeculotomy in Open-Angle Glaucoma

PURPOSE

To study the early postoperative efficacy and safety of an Ab Interno microhook trabeculotomy (microLOT) combined with cataract surgery in patients with open-angle glaucoma.

METHODS

This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and mild-moderate open-angle glaucoma. One hundred fourteen patients were included for analysis. The patients were randomized to undergo microhook trabeculotomy with phacoemulsification (group 1) or phacoemulsification alone (group 2). All patients were evaluated on postoperative day 1, 15, and 30, as well as 3, 6, and 12 months postoperatively. A P value < 0.05 was considered statistically significant. Baseline and follow-up visits were compared to determine significant differences in the number of antiglaucoma medications (AGMs), intraocular pressure (IOP), and best-corrected visual acuity.

RESULTS

There were 57 patients in each group. The baseline characteristics were similar between the 2 groups, except the number of AGMs, which was greater in group 2. The mean preoperative IOP for group 1 (phaco-microLOT) was 26.5 mmHg ± 5.2 and group 2 (phaco-alone group) was 25.3 mmHg ± 3.1 which decreased to 12.5 mmHg ±3.6 (P < 0.001) and 20.0 mmHg ± 2.7(P < 0.001) at 12 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.48 (interquartile range [IQR], 0.30-0.60) preoperatively to 0.00 (0.00-0.18) postoperatively (P < 0001) in group 1 and improved from 0.30 (IQR, 0.30-0.48) to 0.00 (0.00-0.00) in group 2 (P < 0.001). In group 1, the mean (standard deviation [SD]) AGM used preoperatively was 0.6 (0.9) which was significantly reduced to 0.2 (0.5) at 12 months postoperatively, whereas in group 2, at 12 months, the mean (SD) AGM used was reduced from 1.4 (0.6) to 1.1 (0.9). In group 1, 90.3% of eyes achieved complete success at the end of 1 year. The most common complication was hyphema, noted in 4 patients with 1 eye requiring an anterior chamber washout.

CONCLUSION

Ab interno microhook trabeculotomy (microLOT) combined with phacoemulsification in patients with open-angle glaucoma is an efficacious procedure with relatively minimal complications.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ab-Externo MicroShunt versus Trabeculectomy in Primary Open-Angle Glaucoma: Two-Year Results from a Randomized, Multicenter Study

PURPOSE

To compare the effectiveness and safety of the MicroShunt (Santen Inc) versus trabeculectomy in patients with primary open-angle glaucoma (POAG).

DESIGN

Prospective, randomized, multicenter trial conducted in the United States and Europe.

PARTICIPANTS

Adult patients (aged 40-85 years) with mild to severe POAG inadequately controlled on maximum tolerated medical therapy and intraocular pressure (IOP) ≥ 15 mmHg and ≤ 40 mmHg.

METHODS

Patients were randomized 3:1 to stand-alone MicroShunt implantation (n = 395) or trabeculectomy (n = 132), both augmented with mitomycin C (MMC) 0.2 mg/ml for 2 minutes.

MAIN OUTCOME MEASURES

The primary effectiveness end point was surgical success, defined as ≥ 20% reduction in mean diurnal IOP from baseline with no increase in glaucoma medications. Secondary end points included changes in mean IOP and medication use from baseline and the need for postoperative interventions.

RESULTS

At 2 years, the rate of surgical success was lower in the MicroShunt group than in the trabeculectomy group (50.6% vs. 64.4%, P = 0.005). Mean diurnal IOP was reduced from 21.1 ± 4.9 mmHg at baseline to 13.9 ± 3.9 mmHg at 24 months in the MicroShunt group and from 21.1 ± 5.0 mmHg at baseline to 10.7 ± 3.7 mmHg at 24 months in the trabeculectomy group (P < 0.001 compared with baseline in both groups). Mean medication use decreased from 3.1 to 0.9 in the MicroShunt group and from 2.9 to 0.4 in the trabeculectomy group (P < 0.001 compared with baseline in both groups). Adverse events at 2 years were generally similar in the 2 groups, except that hypotony was more common in eyes undergoing trabeculectomy (51.1% vs. 30.9%, P < 0.001). Repositioning or explantation of the implant occurred in 6.8% of MicroShunt patients. The majority of these patients had device removal at the time of subsequent glaucoma surgery. Vision-threatening complications were uncommon in both groups.

CONCLUSION

At 2 years, both the MicroShunt and trabeculectomy provided significant reductions in IOP and medication use, with trabeculectomy continuing to have greater surgical success.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Hypotony in the early postoperative period after MicroShunt implantation versus trabeculectomy: A registry study

PURPOSE

A comparison of the safety and efficacy of the MicroShunt versus trabeculectomy in the early postoperative period, with a particular focus on hypotony.

METHODS

In this registry study, we evaluated 200 eyes of 200 glaucoma patients who underwent filtration surgery at Oslo University Hospital between 2017 and 2021. Of these patients, 100 had a Preserflo MicroShunt (Santen) implantation and 100 had a trabeculectomy procedure. The patients were examined per standard hospital protocol after filtration surgery. Data were extracted from the 4- and 8-week visits. We defined hypotony as intraocular pressure (IOP) < 6 mmHg.

RESULTS

The mean preoperative IOP was 20.6 ± 7.1 mmHg in the MicroShunt group and 21.6 ± 7.1 mmHg in the trabeculectomy group, and the patients used a mean of 3.0 ± 0.9 and 3.1 ± 0.9 glaucoma medications, respectively. After 8 weeks, IOP was reduced to 10.4 ± 5.4 mmHg and 11.3 ± 4.6 mmHg, respectively (p = 0.23). During the early postoperative period, hypotony was registered in 63% of the MicroShunt patients and in 21% of the patients in the trabeculectomy group (p < 0.001); and 11% and 1%, respectively, of the patients developed choroidal detachments (p < 0.003). One patient in the MicroShunt group required reoperation due to hypotony.

CONCLUSIONS

In this registry study, we found that the Preserflo MicroShunt and trabeculectomy had equally satisfactory IOP-lowering effects during the early postoperative period. In this same period, a high number of patients in the MicroShunt group developed hypotony.

Efficacy and Safety of an Adjustable Glaucoma Drainage Device (eyeWatch System) for Refractory Glaucoma: A 2-Year Prospective Study

PRCIS

In this study, we report a 2-year follow-up after implantation of an adjustable glaucoma drainage device combined with a novel orbital filtering plate. The IOP was efficiently controlled postoperatively with limited complications and an excellent safety profile.

PURPOSE

To report the clinical results at 2 years after implantation of an eyeWatch (eW) system, which comprises an adjustable glaucoma drainage device (eW implant) combined with a novel orbital filtering plate (eyePlate), in refractory glaucoma.

PATIENTS AND METHODS

Monocentric, prospective, noncomparative clinical trial. Patients suffering from refractory glaucoma after several failed surgeries were operated using the eW system. The primary outcome was the success rate, defined as an IOP ≤18 mm Hg and reduction of more than 20% from baseline, IOP ≥6 mm Hg. Secondary outcomes were mean IOP, visual acuity, the number of antiglaucoma medications, and the number and type of complications.

RESULTS

Forty-two eyes from 42 patients were included. The mean follow-up time was 22.0±4.0 months. The mean baseline IOP decreased from 23.2±7.2 mm Hg before surgery to 11.9±4.4 mm Hg at 12 months ( P <0.001) and 11.5±3.0 at 24 months. The mean number of glaucoma medications decreased from 2.9±0.9 before surgery to 0.7±0.9 at 12 months ( P <0.001) and 1.0±0.9 at 24 months. The qualified success rate was 93% at 12 months and 90% at 24 months whereas the complete success rate was 46% and 40% at 12 and 24 months, respectively. Complications occurred in 7 patients.

CONCLUSIONS

Implantation of the eW system effectively lowered IOP and reduced glaucoma medications for a 2-year period in patients who had previously failed glaucoma surgery. Persistent hypotony was not observed and the number of complications was low.

Prediction of multiclass surgical outcomes in glaucoma using multimodal deep learning based on free-text operative notes and structured EHR data

OBJECTIVE

Surgical outcome prediction is challenging but necessary for postoperative management. Current machine learning models utilize pre- and post-op data, excluding intraoperative information in surgical notes. Current models also usually predict binary outcomes even when surgeries have multiple outcomes that require different postoperative management. This study addresses these gaps by incorporating intraoperative information into multimodal models for multiclass glaucoma surgery outcome prediction.

MATERIALS AND METHODS

We developed and evaluated multimodal deep learning models for multiclass glaucoma trabeculectomy surgery outcomes using both structured EHR data and free-text operative notes. We compare those to baseline models that use structured EHR data exclusively, or neural network models that leverage only operative notes.

RESULTS

The multimodal neural network had the highest performance with a macro AUROC of 0.750 and F1 score of 0.583. It outperformed the baseline machine learning model with structured EHR data alone (macro AUROC of 0.712 and F1 score of 0.486). Additionally, the multimodal model achieved the highest recall (0.692) for hypotony surgical failure, while the surgical success group had the highest precision (0.884) and F1 score (0.775).

DISCUSSION

This study shows that operative notes are an important source of predictive information. The multimodal predictive model combining perioperative notes and structured pre- and post-op EHR data outperformed other models. Multiclass surgical outcome prediction can provide valuable insights for clinical decision-making.

CONCLUSIONS

Our results show the potential of deep learning models to enhance clinical decision-making for postoperative management. They can be applied to other specialties to improve surgical outcome predictions.

Microfluidics in the eye: a review of glaucoma implants from an engineering perspective

Glaucoma is a progressive optic neuropathy in the eye, which is a leading cause of irreversible blindness worldwide and currently affects over 70 million individuals. Clinically, intraocular pressure (IOP) reduction is the only proven treatment to halt the progression of glaucoma. Microfluidic devices such as glaucoma drainage devices (GDDs) and minimally invasive glaucoma surgery (MIGS) devices are routinely used by ophthalmologists to manage elevated IOP, by creating an artificial pathway for the over-accumulated aqueous humor (AH) in a glaucomatous eye, when the natural pathways are severely blocked. Herein, a detailed modelling and analysis of both the natural microfluidic pathways of the AH in the eye and artificial microfluidic pathways formed additionally by the various glaucoma implants are conducted to provide an insight into the causes of the IOP abnormality and the improvement schemes of current implant designs. The mechanisms of representative glaucoma implants have been critically reviewed from the perspective of microfluidics, and we have categorized the current implants into four groups according to the targeted drainage sites of the AH, namely Schlemm's canal, suprachoroidal space, subconjunctival space, and ocular surface. In addition, we propose to divide the development and evolution of glaucoma implant designs into three technological waves, which include microtube (1st), microvalve (2nd) and microsystem (3rd). With the emerging trends of minimal invasiveness and artificial intelligence in the development of medical implants, we envision that a comprehensive glaucoma treatment microsystem is on the horizon, which is featured with active and wireless control of IOP, real-time continuous monitoring of IOP and aqueous rate, etc. The current review could potentially cast light on the unmatched needs, challenges, and future directions of the microfluidic structural and functional designs of glaucoma implants, which would enable an enhanced safety profile, reduced complications, increased efficacy of lowering IOP and reduced IOP fluctuations, closed-loop and on-demand control of IOP, etc.

[Real-world outcomes of glaucoma surgical procedures for open-angle glaucoma]

This article provides an overview of real-world outcomes in glaucoma surgical procedures. While randomized clinical trials provide valuable insights, they do not fully reflect real-world clinical practice. Real-world studies enable the evaluation of outcomes in uncontrolled settings and play a crucial role in counselling and decision-making for glaucoma treatment. By examining real-world data the article aims to identify rare adverse events that may go unnoticed in controlled clinical trials. The focus is on assessing the effectiveness and safety of glaucoma surgical procedures beyond the controlled trial setting.

Comparison of Repeat Trabeculectomy Versus Ahmed Valve Implantation After Initial Failed Trabeculectomy Surgery

PRCIS

Repeat trabeculectomy is associated with similar postoperative intraocular pressure (IOP), a lower complication rate, and a lower need for medications when compared with Ahmed valve implantation (AVI) when performed after initially failed trabeculectomy.

OBJECTIVE

The goal of this study was to compare the efficacy of repeat trabeculectomies and AVI after an initial failed trabeculectomy.

METHODS

All studies that investigated the postoperative success of patients who underwent AVI or repeat trabeculectomy with mitomycin- C after a prior failed trabeculectomy with mitomycin- C found in PubMed, Cochrane Library, Scopus, and CINAHL were included. Mean preoperative and postoperative IOP, proportions of complete and qualified successes, and proportions of complications were extracted from each study. Meta-analyses were performed to compare the differences between the two surgical approaches. Methods of measuring complete and qualified success were too heterogeneous among the included studies to allow for meta-analysis.

RESULTS

The literature search yielded 1305 studies, and 14 studies were included in the final analysis. Mean IOP was not significantly different between the two groups preoperatively and then after 1, 2, and 3 years. Mean number of medications between the two groups was similar preoperatively. After 1 and 2 years, the mean amount of glaucoma medications in the AVI group was approximately twice that of the trabeculectomy group; however, this relationship was only significant at 1 year of follow-up ( P = 0.042). In addition, the cumulative proportion of overall and sight-threatening complications was significantly higher in the AVI group.

CONCLUSION

Repeat trabeculectomy with mitomycin- C and AVI may both be considered after failed primary trabeculectomy. However, our analysis suggests that repeat trabeculectomy may be the preferred method as it provides similar efficacy with fewer disadvantages.

Gel Stent Versus Trabeculectomy: The Randomized, Multicenter, Gold-Standard Pathway Study (GPS) of Effectiveness and Safety at 12 Months

PURPOSE

To compare effectiveness and safety of the gel stent to trabeculectomy in open-angle glaucoma (OAG).

DESIGN

Prospective, randomized, multicenter, noninferiority study.

METHODS

Patients with OAG and intraocular pressure (IOP) 15 to 44 mm Hg on topical IOP-lowering medication were randomized 2:1 to gel stent implantation or trabeculectomy. Primary end point (surgical success): percentage of patients at month 12 achieving ≥20% IOP reduction from baseline without medication increase, clinical hypotony, vision loss to counting fingers, or secondary surgical intervention (SSI) in a noninferiority test with 24% margins. Secondary end points (month 12) included mean IOP and medication count, postoperative intervention rate, visual recovery, and patient-reported outcomes (PROs). Safety end points included adverse events (AEs).

RESULTS

At month 12, the gel stent was statistically noninferior to trabeculectomy (between-treatment difference [Δ], -6.1%; 95% CI, -22.9%, 10.8%); 62.1% and 68.2% achieved the primary end point, respectively (P=.487); mean IOP and medication count reductions from baseline were significant (P<.001); and the IOP change-related Δ (2.8 mm Hg) favored trabeculectomy (P=.024). The gel stent resulted in fewer eyes requiring in-office postoperative interventions (P=.024 after excluding laser suture lysis), faster visual recovery (P≤.048), and greater 6-month improvements in visual function problems (ie, PROs; P≤.022). The most common AEs were reduced visual acuity at any time (gel stent, 38.9%; trabeculectomy, 54.5%) and hypotony (IOP <6 mm Hg at any time) (gel stent, 23.2%; trabeculectomy, 50.0%).

CONCLUSIONS

At month 12, the gel stent was statistically noninferior to trabeculectomy, per the percentage of patients achieving ≥20% IOP reduction from baseline without medication increase, clinical hypotony, vision loss to counting fingers, or SSI. Trabeculectomy achieved a statistically lower mean IOP, numerically lower failure rate, and numerically lower need for supplemental medications. The gel stent resulted in fewer postoperative interventions, better visual recovery, and fewer AEs.

Distinguishing Glaucoma, Cataract, and Glaucoma Suspect Based on Visual Symptoms

PRCIS

Cataract, glaucoma, and glaucoma suspect patients report differing visual symptoms. Asking patients about their visual symptoms may provide useful diagnostic information and inform decision-making in patients with comorbid conditions.

PURPOSE

To compare visual symptoms in glaucoma, glaucoma suspect (controls), and cataract patients.

METHODS

Glaucoma, cataract, and glaucoma suspect patients at Wilmer Eye Institute responded to a questionnaire rating the frequency and severity of 28 symptoms. Univariate and multivariable logistic regression determined the symptoms that best differentiate each disease pair.

RESULTS

In all, 257 patients (mean age: 67.4 ± 13.4 y; 57.2% female; 41.2% employed), including 79 glaucoma, 84 cataract, and 94 glaucoma suspect patients, participated. Compared with glaucoma suspects, glaucoma patients were more likely to report poor peripheral vision (OR 11.29, 95% CI: 3.73-34.16), better vision in 1 eye (OR 5.48, 95% CI: 1.33-22.64), and light sensitivity (OR 4.85, 95% CI: 1.78-13.24), explaining 40% of the variance in diagnosis (ie, glaucoma vs. glaucoma suspect). Compared with controls, cataract patients were more likely to report light sensitivity (OR 3.33, 95% CI: 1.56-7.10) and worsening vision (OR 12.20, 95% CI: 5.33-27.89), explaining 26% of the variance in diagnosis (ie, cataract vs. glaucoma suspect). Compared with cataract patients, glaucoma patients were more likely to report poor peripheral vision (OR 7.24, 95% CI: 2.53-20.72) and missing patches (OR 4.91, 95% CI: 1.52-15.84), but less likely to report worsening vision (OR 0.08, 95% CI 0.03-0.22), explaining 33% of the variance in diagnosis (ie, glaucoma vs. cataract).

CONCLUSIONS

Visual symptoms distinguish disease state to a moderate degree in glaucoma, cataract, and glaucoma suspect patients. Asking about visual symptoms may serve as a useful diagnostic adjunct and inform decision-making, for example, in glaucoma patients considering cataract surgery.

Clinical Outcomes and Cost Analysis of PreserFlo versus Trabeculectomy for Glaucoma Management in the United Kingdom

PURPOSE

Clinical evaluation and cost analysis of mitomycin-C-augmented PreserFlo MicroShunt versus trabeculectomy.

DESIGN

Retrospective cohort study across 3 teaching hospitals.

PARTICIPANTS

A total of 134 consecutive eyes of 129 patients (70 undergoing MicroShunt, 64 trabeculectomy).

METHODS

Primary and secondary glaucoma cases with uncontrolled intraocular pressure (IOP) were included. Neovascular glaucoma and surgery combined with cataract extraction were excluded. The cost analysis used results from the clinical study to estimate operative costs (equipment and staff costs) and postoperative costs (follow-up visits, nonglaucoma medications, and postoperative procedures) per eye for PreserFlo and trabeculectomy.

MAIN OUTCOME MEASURES

The primary clinical outcome measure was surgical failure (defined as IOP > 21 mmHg or < 20% reduction from baseline, IOP ≤ 5 mmHg, reoperation, or loss of light perception) or qualified and complete success (with or without medication) at 18 months. Secondary measures were IOP, glaucoma medications, visual acuity, mean deviation, time to cessation of steroid drops, complications, surgical time, follow-up visits, postoperative interventions, and reoperations. The cost analysis evaluated costs of PreserFlo compared with trabeculectomy.

RESULTS

Baseline characteristics were similar, except for more non-White patients in the trabeculectomy group (51% Black and Asian vs. 32% MicroShunt, P = 0.02) and more cases with prior ab externo glaucoma surgery in the MicroShunt group (19% vs. 3% in the trabeculectomy group, P = 0.004). Overall, 59% of eyes had primary open-angle glaucoma. Mean follow-up was 19.9 months for both groups. At 18 months, surgical failure was 25% for MicroShunt compared with 35% for trabeculectomy (P = 0.18). Failure in MicroShunt cases was due to inadequate IOP reduction (84%) or reoperation for glaucoma (16%). Failure in trabeculectomy cases was due to inadequate IOP reduction (58%), persistent hypotony (29%), or reoperation for glaucoma (13%). Combined blebitis and endophthalmitis rate was 1.4% for MicroShunt and 3.1% for trabeculectomy. Cost analysis showed a savings of £245 to £566 per eye in the MicroShunt group, driven mostly by reduced postoperative procedures and follow-up visits. This is in contrast to prior randomized controlled trial data reporting the incremental cost of $2058 of PreserFlo over trabeculectomy.

CONCLUSIONS

Our experience of introducing PreserFlo MicroShunt surgery showed it was safer than trabeculectomy and is a cost-saving and effective option that offers potential to free up highly limited National Health Service resources.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

SPARC-YAP/TAZ inhibition prevents the fibroblasts-myofibroblast transformation

BACKGROUND

Fibrotic scar is a severe side effect of trabeculectomy, resulting in unsatisfactory outcomes for glaucoma surgery. Accumulating evidence showed human Tenon's fibroblasts (HTFs) play an important role in fibrosis formation. We previously reported that the aqueous level of secreted protein acidic and rich in cysteine (SPARC) was higher in the patients with primary angle closure glaucoma, which was associated with the failure of trabeculectomy. In this study, the potential effect and mechanism of SPARC in promoting fibrosis were explored by using HTFs.

METHODS

HTFs were employed in this study and examined under a phase-contrast microscope. Cell viability was determined by CCK-8. The expressions of SPARC-YAP/TAZ signaling and the fibrosis-related markers were examined with reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR), Western blot, and immunofluorescence, subcellular fractionation was conducted to further determined the variation of YAP and phosphorylated YAP. The differential gene expressions were analyzed with RNA sequencing (RNAseq), followed by Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses.

RESULTS

Exogenous SPARC induced HTFs-myofibroblast transformation, as evidenced by the increased expression of α-SMA, collagen I and fibronectin in both protein and mRNA levels. SPARC knockdown decreased the expressions of the above genes in TGF-β2-treated HTFs. KEGG analysis showed that the Hippo signaling pathway was mostly enriched. SPARC treatment increased the expressions of YAP, TAZ, CTGF and CYR61 as well as enhanced YAP translocation from cytoplasm to nucleus, and decreased the phosphorylation of YAP and LAST1/2, which was reversed by SPARC knockdown. Knockdown of YAP1 decreased the fibrosis-related markers, such as α-SMA, collagen I and Fibronectin, in SPARC-treated HTFs.

CONCLUSIONS

SPARC induced HTFs-myofibroblast transformation via activating YAP/TAZ signaling. Targeting SPARC-YAP/TAZ axis in HTFs might provide a novel strategy for inhibiting fibrosis formation after trabeculectomy.

Clinical and surgical outcomes of glaucoma drainage device tube in ciliary sulcus versus anterior chamber in North Indian glaucoma patients

Purpose

To evaluate the outcome of glaucoma drainage device (GDD) insertion of tube through ciliary sulcus (CS) versus anterior chamber (AC) placement in the North Indian population.

Methods

This retrospective comparative case series included 43 patients in CS group and 24 in AC group, who underwent GDD implantation, from March 2014 to February 2020. The main outcome measures were intraocular pressure (IOP), number of anti-glaucoma medications, best corrected visual acuity (BCVA), and complications.

Results

Sixty-seven eyes of 66 patients were included in study with mean follow-up of 25.04 months (range, 12-69 months) in the CS group and 17.4 months (range, 13-28 months) in the AC group. Preoperatively the two groups were similar except for postpenetrating keratoplasty glaucoma (PPKG) and pseudophakic patients, which were higher in the CS group (P < 0.05). Both groups showed statistically insignificant difference in postoperative IOP and BCVA at last follow-up (P = 0.173, P = 0.495, respectively). Postoperative complications were similar, except for corneal decompensation which was significantly higher in the AC group (P = 0.042).

Conclusion

Our findings suggest that there was no statistically significant difference in mean IOP between the CS and AC groups at the last follow-up. CS placement of tube of GDD appears to be effective and safe technique. However, CS placement of tube resulted in lesser corneal decompensation and thus should be preferred in pseudophakic/aphakic patients, especially PPKG.

Gonioscopy-assisted transluminal trabeculotomy for open-angle glaucoma with failed incisional glaucoma surgery: two-year results

BACKGROUND

To evaluate the safety and efficacy of gonioscopy-assisted transluminal trabeculotomy (GATT) in treating patients with open-angle glaucoma (OAG) who had failed prior incisional glaucoma surgery.

METHODS

A consecutive case series of OAG patients aged ≥ 18 who underwent GATT with previous failed glaucoma incision surgery was retrospectively analyzed. Main outcome measures included intraocular pressure (IOP), the number of glaucoma medications, surgical success rate, and occurrence of complications. Success was defined as an IOP of ≤ 21 mmHg and a reduction of IOP by 20% or more from baseline with (qualified success) or without (complete success) glaucoma medications. For eyes with preoperative IOP of < 21 mmHg on 3 or 4 glaucoma medications, postoperative IOP of ≤ 18 mmHg without any glaucoma medications was also defined as complete success.

RESULTS

Forty-four eyes of 35 patients (21 with juvenile-onset open-angle glaucoma and 14 with adult-onset primary open-angle glaucoma) with a median age of 38 years were included in this study. The proportion of eyes with 1 prior incisional glaucoma surgery was 79.5%, and the others had 2 prior surgeries. IOP decreased from 27.4 ± 8.8 mm Hg on 3.6 ± 0.7 medications preoperatively to 15.3 ± 2.7 mm Hg on 0.5 ± 0.9 medications at the 24-month visit (P < 0.001). The mean IOP and the number of glaucoma medications at each follow-up visit were lower than the baseline (all P < 0.001). At 24 months postoperatively, 82.1% of the eyes had IOP ≤ 18 mmHg (versus 15.9% preoperatively, P < 0.001), 56.4% reached IOP ≤ 15 mmHg (versus 4.6% preoperatively, P < 0.001), and 15.4% achieved IOP ≤ 12 mmHg (compared to none preoperatively, P = 0.009). While 95.5% of eyes took 3 or more medications preoperatively, 66.7% did not take glaucoma medication 24 months after GATT. Thirty-four (77.3%) eyes achieved IOP reduction greater than 20% on fewer medications. The complete and qualified success rates were 60.9% and 84.1%, respectively. No vision-threatening complications occurred.

CONCLUSIONS

GATT was safe and effective in treating refractory OAG patients who failed prior incisional glaucoma surgery.

Long-term success after trabeculectomy in open-angle glaucoma: results of a retrospective cohort study

OBJECTIVE

To evaluate the long-term outcomes of trabeculectomy (TE) surgery in a large cohort with a minimum follow-up of 3 years.

DESIGN

Retrospective cohort study.

SETTING

University Eye Hospital, Germany.

PARTICIPANTS

Three hundred and seventy-nine patients with open-angle glaucoma underwent TE with mitomycin C (MMC) between January 2013 and February 2017 with a minimal follow-up of 3 years. Eligible patients were identified via an electronic surgical case register.

INTERVENTIONS

All patients had undergone TE with MMC following a set surgical protocol. To assess the influence of cataract surgery following TE, eyes which underwent cataract surgery at least 6 months after TE were matched 1:3 by sex and age to eyes who did not undergo cataract surgery during the follow-up period.

MAIN OUTCOME MEASURES

Primary outcome was the proportion of surgical success based on intraocular pressure (IOP), surgical complications, the need for revision surgery, loss of light perception and the need for additional pressure-lowering medication.

RESULTS

The mean follow-up time was 6 (±0.8, IQR: 5.4-6.5) years. Seventy-three per cent of eyes achieved qualified surgical success at the last follow-up (IOP≥5 mm Hg and ≤18 mm Hg, without surgical complications or complete loss of vision) but necessitated additional medical therapy, complete surgical success with no additional medical therapy was achieved in 69% of eyes. There was no significant difference in the success probability between eyes that had undergone cataract surgery after TE and those that had not (p=0.45).

CONCLUSIONS

The results demonstrate a high and stable success rate of TE after a mean follow-up time of approximately 6 years, that is, not affected by later cataract surgery.

Safety and efficacy of Aurolab aqueous drainage implant in refractory glaucoma: A prospective study

Purpose

This study was conducted to assess the intraocular pressure (IOP) control and postoperative complications following a non-valved glaucoma drainage device (GDD) surgery in refractory glaucoma.

Methods

This was a prospective interventional study conducted on patients with glaucoma refractory to maximal medications or failed surgical treatment who underwent Aurolab aqueous drainage implant (AADI; Aurolabs, India) surgery. Primary outcome measures were IOP control, postoperative complications, and reduction in the number of antiglaucoma medications (AGM).

Results

Thirty-four eyes were analyzed and the mean follow-up was 16.06 ± 5.63 months. The preoperative median (Q1, Q3) IOP was 31 mmHg (28, 36.5) which decreased to 12 mmHg (12, 14) at 6 months postoperatively. The median (Q1, Q3) number of AGMs decreased from 3 (3, 4) to 0 (0, 1). Significant complications like implant extrusion and tube exposure were noted in two eyes. The total success and failure rates at 6 months were 91.1% and 8.8%, respectively.

Conclusion

AADI is effective in achieving target IOP and significantly reduces the use of AGMs with good safety in the short term. Long-term follow-up studies are needed to assess long-term IOP control and cost-effectiveness.

Topical Anesthesia Offers Sufficient Pain Control for MicroPulse Transscleral Laser Therapy for Glaucoma

Introduction

The aim of this study was to evaluate patient pain during and after MicroPulse Transscleral Laser Therapy (TLT) and vision-related quality of life using two different anesthesia protocols: “Topical Plus” anesthesia without standby anesthesia (study group), and analgosedation with standby anesthesia (control group).

Methods

A retrospective, comparative chart review was conducted to evaluate patient pain between the two groups based on an analog pain scale at baseline and postoperatively (1 hour, 6 hours, 1 day, 1 week, and 1 month). Furthermore, vision-related quality of life at baseline was compared at 1 month postoperatively.

Results

Four eyes underwent MicroPulse TLT under Topical Plus anesthesia and 4 eyes underwent analgosedation. The mean age at the time of the MicroPulse TLT was 78.3 ± 6.4 years. In the study group, the reported pain level increased significantly immediately after the treatment (from 0.5 to 2.8, p=0.003; mild pain); however, no difference was found at any later time point compared to baseline. The vision-related quality of life was similar in both groups and was not negatively impacted by the MicroPulse TLT at 1 month after the treatment. Discussion/Conclusion. The Topical Plus anesthesia protocol provides adequate pain control for the patient to remain comfortable during and post-MicroPulse TLT treatment, with no changes in vision-related quality of life. Although the sample size was small and, thus, the results cannot be generalized, this case series showed that it is possible to perform MicroPulse TLT under topical anesthesia.

One-year Outcomes Following Internal Ligation Suture Removal in 350 mm2 Baerveldt Tube Implant Surgery

Aim

Long-term data of the postoperative management following Baerveldt tube surgery (BVT) is currently limited. This study aims to evaluate the outcome and the safety profile of internal ligation suture removal after BVT surgery for refractory glaucoma.

Materials and methods

A prospective, consecutive, non-comparative case series of patients previously undergoing BVT 350 mm² surgery with 0.4 mg/mL mitomycin C (MMC), 3/0 intraluminal suture (Supramid) insertion, and 10/0 nylon external ligation suture(s). For each patient, data was collected over 12 months after internal ligation suture removal. Follow-up assessments looked at intraocular pressure (IOP), complication rate, and postoperative number of glaucoma medications. Definition of success was adopted as per the World Glaucoma Association recommendations.

Results

Twenty-four patients were included. On average, Supramid was removed at 22 ± 18.2 weeks following BVT surgery. Preoperatively, the mean IOP was 30.9 ± 12.6 mm Hg and the average antiglaucoma medications were 1.95 ± 1.13. At 12 months, the mean IOP was 15.2 ± 5.3 mm Hg and the mean number of glaucoma medications was 1.3 ± 0.2. Qualified success with IOP ≤ 21 mm Hg and IOP ≤ 15 mm Hg was achieved in 62.5% and 33.3%, respectively. Only two patients developed hypotony following Supramid removal; both resolved spontaneously within 1 month.

Conclusion

Our results show a good IOP reduction and safety profile at 1 year from internal ligation suture removal following BVT. A drop in IOP of approximately 50% from the preoperative IOP can be expected.

How to cite this article

Stringa F, Chen R, Agrawal P. One-year Outcomes Following Internal Ligation Suture Removal in 350 mm² Baerveldt Tube Implant Surgery. J Curr Glaucoma Pract 2022;16(1):20-23.

Anterior segment imaging in minimally invasive glaucoma surgery - A systematic review

Minimally invasive glaucoma surgery (MIGS) has grown in popularity over the past decade. This systematic review explores the peri-operative and intraoperative application of anterior segment imaging to maximize the efficacy and safety of MIGS. A review of the PubMed, EMBASE and CINAHL databases was conducted, with inclusion criteria restricted to MIGS that had received United States Food and Drug Administration (FDA) premarket approval, FDA 510(K) premarket notification, or were listed as a class 1 device exempt from FDA approval or notification. 21 manuscripts from 21 unique studies were identified pertaining to MIGS devices including the XEN Gel Stent, Trabectome, iStent Inject, 1st-generation iStent and the Kahook Dual Blade (KDB). Anterior segment imaging modalities included anterior segment optical coherence tomography (AS-OCT), ultrasound biomicroscopy (UBM), aqueous angiography, OCT volumetric scans and in vivo confocal microscopy. Identification and evaluation of aqueous outflow pathways before and after MIGS have potential for improving patient preoperative patient selection and postoperative outcomes. Intraoperative imaging potentially provides the resolution needed for good visualization of angle anatomy and accurate evaluation of surgical endpoints in angle-based MIGS. Anterior segment imaging has been used to identify procedural complications, provide objective information on implant location in relation to surrounding anatomy, assess the post-implantation structural impact of MIGS devices and manage bleb failure and scarring. Technical difficulties in incorporating imaging modalities into the surgical microscope, variable quality of images and optical interference from ocular structures or surgical instruments are remaining barriers, which discourage the widespread clinical use of this technology.

Early Macular Thickness Changes after Trabeculectomy and Combined Phaco-Trabeculectomy

Purpose

To assess postoperative changes in central retinal thickness (RT) following trabeculectomy and combined phaco-trabeculectomy using spectral domain-optical coherence tomography.

Methods

In a prospective interventional comparative study, 64 consecutive glaucoma patients who underwent trabeculectomy (32 eyes) or phaco-trabeculectomy (32 eyes) were included. A macular thickness map using the Early Treatment Diabetic Retinopathy Study circles of 1 mm, 3 mm, and 6 mm was the standard to evaluate the 9-subfield thickness preoperatively and again at 1 and 3 months after surgery. Four subfields in each of the 3 mm and 6 mm rings were considered parafoveal and perifoveal regions, respectively.

Results

Preoperative measurements were similar in the two groups, except patients in the combined group which were older (P = 0.002). The mean RT in the combined phaco-trabeculectomy group at month 1 was significantly higher than baseline measurements at central subfield retinal thickness (CSRT) (P = 0.01), temporal (P = 0.001), and inferior (P = 0.04) parafoveal and temporal (P = 0.01), superior (P = 0.02), and nasal (P < 0.001) perifoveal quadrants; however, RT changes in the trabeculectomy-only group were not statistically significant at months 1 and 3 (P > 0.05). The increase in the temporal perifoveal RT of the combined phaco-trabeculectomy group persisted at month 3 (P = 0.01), while the RT in other sectors returned to preoperative values. The two treatment groups did not differ in terms of changes in the CSRT over time (P = 0.37). In addition, no difference was observed between the treatment groups regarding the parafoveal RTs at each time points (0.06 ≤ P ≤ 0.29).

Conclusions

There was no significant difference in the pattern of changes of CSRT and parafoveal RT between trabeculectomy and combined phaco-trabeculectomy treatment groups up to 3 months after surgery. Some detectable increase in RT in the combined phaco-trabeculectomy will reverse to baseline values 3 months after surgery, except in the temporal perifoveal region.

Characteristic Assessment of Angiographies at Different Depths with AS-OCTA: Implication for Functions of Post-Trabeculectomy Filtering Bleb

This study aimed to analyze the quantitative vascular biomarkers of filtering bleb function at different depths using anterior segment optical coherence tomography angiography (AS-OCTA). This cross-sectional study is registered on Clinicaltrails.gov (NCT 04515017). Forty-six eyes with primary open-angle glaucoma that had undergone trabeculectomy with mitomycin-C for more than six months were included. Vessel density (VD) and vessel diameter index (VDI) in the superficial layer (SL), Tenon’s layer (TL), and deep layer (DL) of the bleb were obtained. The VD and VDI were higher in the failure group (both p = 0.000). Significant correlations were found between the SL, TL, DL’s VDI, and IOP in the success group (p = 0.013, 0.016, 0.031, respectively). The VD of the TL and DL were related to IOP in the failure group (p = 0.012, 0.009). Tenon’s VD (TVD) and Tenon’s VDI (TVDI) correlated with IOP adjusting for TVD, TVDI, and the Indiana Bleb Appearance Grading Scale (IBAGS) (p = 0.009, 0.043) or Kenfeld grading system (KGS) (p = 0.011, 0.016). The area under curve (AUC) of the TVD, TVDI, IBAGS, and KGS to predict surgery failure were 0.960, 0.925, 0.770, and 0.850. AS-OCTA realized the quantitative evaluation of vessels, especially the invisible vascularity beneath the conjunctiva. TVD and TVDI as detected by AS-OCTA better reflected bleb function than conventional grading systems.

Effects of Postoperative Intravitreal Injections on Outcomes of Traditional Glaucoma Surgery in Patients with Preoperative Intravitreal Injections

PURPOSE

To compare outcomes of glaucoma drainage device (GDD) implantation and trabeculectomies with and without postoperative intravitreal injections (IVIs) in glaucoma patients with a history of preoperative IVIs.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 133 eyes of 133 glaucoma patients who underwent GDD implantation or trabeculectomy with at least 1 IVI preoperatively between January 2005 and October 2020 at Massachusetts Eye and Ear.

METHODS

Chart review of glaucoma patients with traditional glaucoma surgery and at least 1 IVI before surgery. All statistical analyses were conducted with R statistical programming software.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP), medication burden, best-corrected visual acuity (BCVA), Kaplan-Meier success rates, adjusted hazard ratios (HRs), and complications.

RESULTS

Baseline demographics were similar between the groups with and without postoperative IVIs. The group with postoperative IVIs had a higher proportion of diabetic retinopathy and retinal vascular occlusions than the group without postoperative IVIs, which had more eyes with age-related macular degeneration. Intraocular pressure, medication burden, and visual acuity were similar between groups at all time points except for IOP at 6 weeks, which was lower in the group with postoperative IVIs. The group with postoperative IVIs had significantly more preoperative IVIs than the group without postoperative IVIs (6.6 vs. 3.3, P = 0.017). For success defined as IOP reduction ≥ 20% with 5 < IOP ≤ 21 mmHg, Kaplan-Meier analyses demonstrated similar success rates between groups with and without IVIs. When stratified by the number of IVIs, success rates for the group with 7 or more IVIs were significantly higher than the success rates for the group with 0-6 IVIs (P = 0.005). Each additional postoperative IVI resulted in a 7.2% decrease in the hazard of failure to achieve our stated success criteria. With regard to late complications, the group with postoperative IVIs had a higher incidence of vitreous hemorrhage (18.5% vs. 3.2%, P = 0.039) than the group without postoperative IVIs.

CONCLUSIONS

A higher number of postoperative IVIs, specifically 7 or more IVIs, may be associated with improved success rates of traditional glaucoma surgery in glaucoma patients who received IVIs before surgery.

Early outcomes of 21-gauge needle-guided ab interno tube sulcus placement of a non-valved implant in pseudophakic eyes

We report the early outcomes and describe an ab interno 21-G needle technique of sulcus placement of the Aurolab aqueous drainage implant (AADI) tube in nine pseudophakic eyes. IOP reduced from a preoperative mean (SD) of 28.33 (9.80) to 11.56 (2.65) mm Hg and the mean (SD) number of preoperative medications reduced from 3.0 (0.7) to 0.4 (0.9) at 3 months. There were no intraoperative complications noted. This technique of sulcus placement of the AADI tube is a precise technique of tube insertion. It may be an alternative to existing ab externo procedures of tube sulcus placement, limiting multiple blind entries.

The surgical management of glaucoma: A review

After a long period of little change, glaucoma surgery has experienced a dramatic rise in the number of possible procedures in the last two decades. Glaucoma filtering surgeries with mitomycin C and glaucoma drainage devices remain the standard of surgical care. Other newer surgeries, some of which are minimally or microinvasive glaucoma surgeries, target existing trabecular outflow, enhance suprachoroidal outflow, create subconjunctival blebs, or reduce aqueous production. Some require the implantation of a device such as the iStent, Hydrus, Ex-PRESS, XEN and PRESERFLO, whilst others do not-Trabectome, Kahook dual blade, Ab interno canaloplasty, gonioscopy-assisted transluminal trabeculotomy, OMNI and excimer laser trabeculotomy. Others are a less destructive variation of an established procedure, such as micropulse transscleral cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cycloplasty. Cataract surgery alone can be a significant glaucoma operation. These older and newer glaucoma surgeries, their mechanism of action, efficacy and complications are the subject of this review.

PreserFlo® MicroShunt: An Overview of This Minimally Invasive Device for Open-Angle Glaucoma

For moderate-to-severe glaucoma, trabeculectomy remains the “gold standard” intraocular pressure (IOP)-lowering treatment; nonetheless, this method requires extensive post-operative maintenance. Microinvasive glaucoma surgery (MIGS) treatments are designed to lessen intra- and post-operative care burden while offering an acceptable IOP decrease for individuals with mild to moderate glaucoma. The PreserFlo® MicroShunt (previously InnFocus MicroShunt) is an 8.5 mm glaucoma drainage device manufactured from poly(styrene-block-isobutylene-block-styrene) (SIBS), an extremely biocompatible and bioinert material. The lumen is narrow enough to prevent hypotony, but big enough to avoid being obstructed by sloughed cells or pigment. The device is implanted ab externo, as a stand-alone procedure or in conjunction with cataract surgery, with intraoperative mitomycin C, and a bleb is produced under the conjunctiva and Tenon’s capsule. The MicroShunt was CE-marked in 2012 and designed for primary open-angle glaucoma, the IOP of which remains uncontrolled after maximally tolerated topical treatment. Several clinical trials evaluating the MicroShunt’s long-term safety and effectiveness have been conducted, highlighting the effectiveness of the device over time, along with a tolerable safety profile. The present review aims to gather evidence of PreserFlo’s effectiveness and safety results almost 10 years after its introduction, and furthermore, to compare it with other MIGS and with the gold-standard trabeculectomy for glaucoma management.

Predictability of success and open conjunctival revision rates in the subsequent eye after XEN45 Gel Stent implantation according to lens status

PURPOSE

To determine the predictability of success and the risk of open conjunctival revision in the subsequent eye after XEN45 Gel Stent implantation according to lens status.

METHODS

This was a retrospective single-centre study involving 132 eyes of 66 participants who had undergone intraocular pressure (IOP)-lowering XEN45 Gel Stent implantation, either as a standalone procedure in phakic and pseudophakic eyes or in combination with phacoemulsification. Successful surgery was defined by three scores: IOP at follow-up < 21 mmHg (score A) or < 18 mmHg (score B) and an IOP reduction > 20% or IOP ≤ 15 mmHg and an IOP reduction ≥ 40% (score C). In all scores, one open conjunctival revision was allowed, and additional repeat surgery was considered a failure. The predictability of success and revision rate depending on the outcome of the first eye were calculated using Bayes' theorem.

RESULTS

IOP-lowering did not differ significantly between the first and second eyes. Success rates of standalone surgery in the second eye after successful surgery in the first eye significantly exceed rates after prior failure. For the combined procedure, the rates did not differ significantly. For score A, we determined a 76.6% chance of success following a prior success and a 57.9% chance, if prior surgery failed. The corresponding probabilities were 75% and 59.1% for score B, while 66.7% and 15.7% for score C, respectively. We calculated a 60% risk for revision surgery in the standalone phakic group. If the first eye was not revised, the risk of revision in the subsequent eye was 20%. The corresponding risks were 72.7% and 5% for the standalone procedure in pseudophakic patients and 38.4% and 41.7% for the combined procedure, respectively.

CONCLUSION

The results of our study offer a tool to predict the outcome of subsequent eye surgeries based on either the outcome in the initial eye and the type of surgery performed, owing to the high predictive potential.

Comparison of Outcomes Following Glaucoma Drainage Tube Surgery Between Primary and Secondary Glaucomas, and Between Phakic and Pseudophakic eyes

PURPOSE

To report outcomes of glaucoma drainage device (GDD) surgery based on primary or secondary glaucoma diagnosis and lens status.

DESIGN

Single-center, retrospective, consecutive cohort study.

METHODS

University of Florida patients aged 18 to 93 years who underwent nonvalved GDD surgery between 1996 and 2015 with a minimum of 1-year follow-up were examined. Of the 186 eyes of 186 patients enrolled, 108 had a primary glaucoma and 78 a secondary glaucoma diagnosis. Excluding 13 aphakic patients, 57 eyes were phakic and 116 pseudophakic. Mean intraocular pressure (IOP), mean number of medications, visual acuity (VA), surgical complications, and failure (IOP ≥18 mm Hg, IOP <6 mm Hg, reoperation for glaucoma, or loss of light perception) were the main outcome measures.

RESULTS

No significant difference was noted in mean IOP and mean medication use (12.8 ± 4.5 and 13.0 ± 6.6 mm Hg on 2.0 ± 1.2 and 1.5 ± 1.1 medication classes, respectively), mean VA (1.08 ± 0.98 and 0.94 ± 0.89, respectively), failure, or numbers of complications and reoperations (P > 0.05) between eyes with primary and secondary glaucomas at up to 5 years postoperatively. Comparison of phakic and pseudophakic eyes showed a statistically significant higher success rate for the pseudophakic patient group at the ≥18 mm Hg upper limit and <6 mm Hg lower limit (P = 0.01), and significantly fewer eyes required reoperation to lower IOP (6.9% vs 23%).

CONCLUSIONS

GDD surgery appears equally effective for secondary glaucomas as for primary glaucomas, and has a better outcome for pseudophakic eyes than phakic eyes.