Treatment outcomes in the Tube Versus Trabeculectomy (TVT) study after five years of follow-up

Visual Field Outcomes in the Primary Tube Versus Trabeculectomy Study

PURPOSE

To describe visual field outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study.

DESIGN

Cohort analysis.

PARTICIPANTS

A total of 155 eyes (155 subjects) randomly assigned to treatment with tube shunt surgery (n = 84) or trabeculectomy with mitomycin C (n = 71).

METHODS

The PTVT Study was a multicenter randomized clinical trial comparing the safety and efficacy of trabeculectomy and tube shunt surgery in eyes without previous intraocular surgery. Subjects underwent standard automated perimetry (SAP) at baseline and annually for 5 years. Standard automated perimetry tests were deemed reliable if the false-positive rate was ≤ 15%. Tests were excluded if visual acuity was ≤ 20/400 or loss of ≥ 2 Snellen lines from baseline because of a nonglaucomatous etiology. Linear mixed-effects models were used to compare rates of change in SAP mean deviation (MD) between the 2 groups. Intraocular pressure (IOP) control was assessed by percentage of visits with IOP < 18 mmHg and mean IOP.

MAIN OUTCOME MEASURES

Rate of change in SAP MD during follow-up.

RESULTS

A total of 730 SAP tests were evaluated (average of 4.7 tests per eye). The average SAP MD at baseline was -12.8 ± 8.3 decibels (dB) in the tube group and -12.0 ± 8.4 dB in the trabeculectomy group (P = 0.57). The mean rate of change in SAP MD was -0.32 ± 0.39 dB/year in the trabeculectomy group and -0.47 ± 0.43 dB/year in the tube group (P = 0.23). Eyes with mean IOP 14 to 17.5 mmHg had significantly faster rates of SAP MD loss compared with eyes with mean IOP < 14 mmHg (-0.59 ± 0.13 vs. -0.27 ± 0.08 dB/year; P = 0.012), and eyes with only 50% to 75% of visits with IOP < 18 mmHg had faster rates than those with 100% of visits with IOP < 18 mmHg (-0.90 ± 0.16 vs. -0.29 ± 0.08 dB/year; P < 0.001). Multivariable analysis identified older age and worse IOP control as risk factors for faster progression in both treatment groups.

CONCLUSIONS

No statistically significant difference in mean rates of visual field change was observed between trabeculectomy and tube shunt surgery in the PTVT Study. Worse IOP control was significantly associated with faster rates of SAP MD loss during follow-up. Older patients were also at risk for faster progression.

FINANCIAL DISCLOSURE(S)

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

[Glaucoma drainage devices in patients following injector-assisted implantation of an artificial iris into the ciliary sulcus : Video article]

OBJECTIVE OF SURGERY

The aim of this surgical technique is the implantation of a glaucoma drainage device (GDD) in eyes with aphakic glaucoma following injector-assisted implantation of an artificial iris into the ciliary sulcus.

INDICATIONS

This atraumatic tube insertion technique can be performed during GDD implantation after implantation of an artificial iris into the ciliary sulcus.

SURGICAL TECHNIQUE

Following injector-assisted implantation of an artificial iris into the ciliary sulcus of eyes, the iris can shift into the chamber angle. The GDD should be positioned in the quadrant in which the iridectomy is located. Otherwise, GDD implantation is not possible due to the resistance of the artificial iris. Alternatively, the artificial iris can be easily and non-traumatically rotated in the ciliary sulcus by flushing the anterior chamber with balanced salt solution (BSS) to move the iridectomy into the desired area and position the GDD tube in the anterior chamber. A surgical video, which is available online, shows the surgical technique in detail.

FOLLOW-UP

After GDD, dexamethasone eye drops should be applied 8 times daily for 1 week tapering down by 1 drop per week thereafter. Antibiotic eye drops, e.g., ofloxacin eye drops, are prescribed 4 times daily for 1 week and might be discontinued thereafter.

EVIDENCE

To date, this is the first description of a rotation of an artificial iris located in the ciliary sulcus by irrigation of the anterior chamber during GDD implantation.

Cost-Utility Analysis of Prophylactic Laser Peripheral Iridotomy for Primary Angle Closure Suspects

PURPOSE

To assess the cost-utility of prophylactic laser peripheral iridotomy (LPI) for primary angle closure (PAC) suspects (PACS).

DESIGN

Economic evaluation.

METHODS

Our Markov model randomized PACS eyes to LPI or observation for 40 one-year cycles (100,000 iterations per strategy). Each cycle, an eye remained in its current health state, advanced linearly through PAC, mild, moderate, severe, and end-stage PAC glaucoma (PACG), or died. Transition rates were derived from the literature including the Zhongshan Angle Closure Prevention (ZAP) trial and the Singapore Asymptomatic Narrow Angles Laser Iridotomy Study (ANA-LIS). Eyes with acute-angle closure advanced to either PAC or directly to various PACG severities. A tracker monitored accumulated perimetric decibel reduction to progress PACG through increasing severities, with an annual probability of either stable or severity-dependent perimetry loss. We set a willingness to pay of an incremental cost-effectiveness ratio (ICER) <$50,000/quality-adjusted life-years.

RESULTS

At age 50 years, LPI was cost-saving using ZAP data and cost-effective using ANA-LIS data. The ZAP iterations became cost-effective from the societal perspective when the model started at age 55 years and third-party perspective at age 70 years. LPI was no longer cost-effective from the societal perspective using ANA-LIS data at age 80 years or from the societal perspective using ZAP data or third-party perspective with ANA-LIS data at age 85. Probabilistic sensitivity analyses favored LPI until starting age 85.

CONCLUSIONS

Prophylactic LPI for PACS is cost-effective across a spectrum of ages and should be considered from a public health perspective.

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.

Outcomes of bent ab interno needle goniectomy with phacoemulsification in moderate to severe primary open angle glaucoma

PURPOSE

To assess the safety and efficacy of bent ab interno needle goniectomy (BANG) in moderate to severe primary open angle glaucoma (POAG) eyes undergoing phacoemulsification (phaco).

DESIGN

Single-arm, prospective, interventional study.

METHODS

POAG patients with medically uncontrolled intraocular pressure (IOP), >15 mmHg for moderate and >12 mmHg for severe POAG, with visually significant cataract were recruited. All patients underwent BANG using a 26-gauge needle to excise 30° of the trabecular meshwork, along with phaco. Primary outcome was IOP. Secondary outcomes were success rate, percentage reduction in IOP/antiglaucoma medications (AGMs), and intraoperative complications. Success at 12 months was defined as: criterion A: IOP <15 mmHg for moderate glaucoma or <12 mmHg for severe glaucoma with or without AGMs OR criterion B: reduction in number of AGMs by >1.

RESULTS

Thirty-two eyes of 32 patients underwent BANG + phaco. Mean age of the participants was 62.7 ± 8.4 years and there were 25 males and seven females. At 12 months, a significant decrease was noted in both IOP (from 17.6 ± 3.6 to 12 ± 1.6 mmHg, 31.8%; P < 0.001) and AGMs (from 3.7 ± 0.9 to 2.8 ± 0.8, 24.3%; P < 0.001). Twenty percent or more reduction in IOP was achieved in 62.5% (20/32) of eyes. Overall success (meeting either of the criteria A or B) at 12 months was achieved in 87.5% eyes. Mild postoperative hyphema was noted in 10 (31.2%) eyes, and two eyes (6.2%) required additional filtration surgery at 7 months.

CONCLUSION

A 30-degree BANG with phaco in patients of POAG appears to be a safe, effective and affordable MIGS for developing countries.

Ab-Externo XEN Gel stent implantation effectively treated refractory glaucoma with prior failed shunt tube

PURPOSE

To assess the efficacy of a gelatin stent (XEN 45 Gel Stent; Allergan) implant in advanced glaucoma eyes that have failed prior aqueous shunt implantation.

METHODS

We retrospectively reviewed 6 patients with refractory glaucoma, defined as persistently high IOP (> 21 mmHg) despite taking at least 3 IOP-lowering medications subsequent to undergoing a glaucoma drainage device (GDD) with or without a second GDD or cilioablative procedure. Eyes with previous failed GDD underwent subconjunctival 0.3 cc (0.4 mg/ml) mitomycin C, tenonectomy, and placement of an ab- externo XEN stent. The outcome measures included change in IOP and the number of glaucoma medications. Success was defined as patients achieving an IOP ≤ 18 mmHg with a percentage reduction of 25% or 15 mmHg and 40% mean IOP reduction from baseline while taking the same number or fewer medications.

RESULTS

All six eyes with age of 77.6 ± 7.82 years who underwent XEN implantation following previous GDD surgery had primary open-angle glaucoma. The IOP decreased significantly from 32.33 ± 5.99 to 12.67 ± 3.27 mmHg (p < 0.001) with a follow-up of 13.9 ± 2 (11.7-16.7) months. Visual acuity and visual field remained stable after XEN placement. Compared to the baseline number of medications of 4.2 ± 0.8, all medication was discontinued except in one eye on two drops at the end of the follow-up. The overall surgical success rate was 100%. No complications, needling, or additional procedures were required.

CONCLUSION

This study described successful implantation of the XEN stent following failed GDD. XEN Gel stent implantation associated with mitomycin C and tenonectomy can be considered a viable surgical option for patients with a history of previously failed tube shunt requiring further IOP lowering.

[Glaucoma surgeries: Long-term results - A review]

The surgical treatment of glaucoma has been and is still based on filtering surgeries, commonly used for about half a century. The safety and efficacy of these techniques have been well described, as it has also been done for cyclophotocoagulation and valves or tubes, indicated in France mostly for refractory glaucoma. Minimally invasive glaucoma surgeries have emerged in recent decades, increasing the number of therapeutic options, and allowing treatment decisions to be as patient-centered as possible. Most of these techniques have now been studied for more than five years. Since glaucoma is a chronic, progressive optic neuropathy, the sustainability of each surgery's results is essential. The amount of available data concerning long-term efficacy and safety of glaucoma surgeries is increasing, so we have decided to describe it through this review of the literature.

Evaluating the Safety and Efficacy of a Novel Glaucoma Drainage Device in High-Risk Adult Glaucoma Patients: A One-Year Pilot Study

Background: We report on the 12-month safety and efficacy outcomes of a new non-valved glaucoma drainage device, the eyePlate-300 (Rheon Medical, Lausanne, Switzerland), in managing refractory glaucoma. Methods: A retrospective review was conducted on consecutive patients over 18 who underwent glaucoma drainage device (GDD) surgery with the eyePlate-300 after a single glaucoma consultation between February 2020 and April 2021, with at least 12 months of documented post-op follow-up. Results: A total of 16 eyes from 15 patients were included. Complete success was observed in 47% of patients and overall success in 83%. The mean IOP decreased from 31.5 mm Hg to 10.7 mm Hg (67% reduction from baseline), and the number of IOP-lowering drops was reduced from 3.1 to 0.7 at one year. The mean BCVA remained stable. No additional IOP-lowering surgeries were required, and no severe sight-threatening complications were noted. Conclusions: The initial one-year results suggest that the eyePlate could be a safe and effective device for reducing IOP in an ethnically diverse refractory glaucoma population. Further follow-up is necessary to determine the long-term safety and efficacy.

Surgical Outcomes of a Human Umbilical Cord Allograft Over the Ahmed Glaucoma Valve Plate for Refractory Glaucoma

OBJECTIVES

To report the surgical outcomes of sterile dehydrated human umbilical cord allograft over the Ahmed glaucoma valve (AGV) plate for refractory glaucoma.

METHODS

Thirty-four eyes of 34 patients with refractory glaucoma who underwent AGV with umbilical cord allograft (AmnioPlast THICK™; Life Cell International Private Limited, Mumbai, India) placed over the AGV plate between September 2021 and 2022 at a tertiary eye care centre were included (group1) and compared with 30 eyes of 30 patients undergoing AGV without amnioblasts (group 2). The intraocular pressure (IOP) at day one, one month, six months, and final IOP; the necessity for medications; or additional surgeries for IOP control were extracted from the hospital database. Success was defined as achieving an IOP below 22 mm Hg with or without glaucoma medications. IOP spikes after surgery were identified as a rise in pressure beyond 22 mm Hg at any point beyond six weeks post-surgery following an initial reduction of pressure exceeding 30% from the baseline pre-surgical IOP.

RESULTS

A notable reduction in intraocular pressure (37 ± 7.9 mm Hg preoperative versus 14 ± 3.7 mm Hg at the final follow-up and 28 ± 3.6 mm Hg versus 18 ± 6.7 mm Hg in group 1 and 2, respectively) was observed in all eyes, with successful outcomes observed in 23 out of 34 eyes (67%). Ten eyes experienced a pressure spike, occurring at a median time of 12 months (range: 6-18 months), predominantly beyond six months post-surgery in group 1, while group 2 had similar pressure spikes in 21 of 30 eyes at a median time of two months (range: 1-5 months). No eyes necessitated supplementary glaucoma procedures, concluding with a final IOP of 14 ± 3.7 mm Hg at 1.9 ± 0.8 years. Vision loss occurred in only one of the 11 eyes that failed owing to non-glaucoma-related causes in group 1.

CONCLUSIONS

The human umbilical cord allograft plate over the AGV plate may help in postponing the onset of intraocular pressure spikes beyond traditionally defined timelines. This helps in reducing and delaying the hypertensive phase occurring due to fibrosis.

A Prospective Comparison of 180 Versus 360-Degree Gonioscopy-Assisted Transluminal Trabeculotomy Outcomes in Pseudoexfoliation Glaucoma

PRCIS

Analysis of surgical success and intraocular pressure (IOP), best-corrected visual acuity (BCVA), and antiglaucomatous medication (AGM) changes between segmental 180-degree and 360-degree gonioscopy-assisted transluminal trabeculectomy (GATT) in patients with pseudoexfoliation glaucoma (PEXG) showed no significant difference.

OBJECTIVE

To compare surgical outcomes of segmental 180-degree and 360-degree GATT in patients with PEXG.

MATERIALS AND METHODS

Prospective, comparative study of 65 PEXG eyes, who underwent segmental 180-degree GATT (GATT 180-degree group, 31 eyes) and 360-degree GATT (GATT 360-degree group, 34 eyes) in a tertiary academic center over a 12-month of follow-up. Primary outcome was qualified and complete surgical success rates for criterion A (IOP <18 mm Hg and >30% reduction) and criterion B (IOP <15 mm Hg and >30% reduction). Secondary outcome measures included IOP reduction, BCVA change, AGM use, and postoperative complications.

RESULTS

The probabilities of qualified and complete success rates both for criteria A and B did not significantly differ between the groups ( P > 0.05). IOP and BCVA levels were similar at each time point ( P > 0.05). IOP reduction was 59.3 ± 9.5% in the GATT 180-degree group and 55.8 ± 18.1% in the GATT 360-degree group ( P = 0.33). No significant difference in the mean number of AGM was present at the 12-month visit (1.2 ± 1.1 in GATT 180-degree group vs 1.5 ± 1.2 in GATT 360-degree group, P = 0.25). Significantly higher incidences of postoperative hyphema and IOP spikes were observed in the GATT 360-degree group ( P = 0.01 and P = 0.008, respectively).

CONCLUSION

Both segmental 180-degree and 360-degree GATT similarly reduced IOP and AGM with comparable surgical success rates in patients with PEXG at the end of 12 months. Postoperative hyphema and IOP spike rates were significantly higher after 360-degree GATT. Segmental 180-degree GATT may be sufficient to adequately modulate IOP with a lower incidence of postoperative complications in PEXG.

Treatment Outcomes Comparing the Paul and Baerveldt Glaucoma Implants After One Year of Follow-Up

PRCIS

In reducing intraocular pressure (IOP), Paul (PGI) and Baerveldt (BGI) glaucoma implants are safe and effective in patients with glaucoma.

OBJECTIVE

To compare efficacy and safety profiles of the PGI and BGI in the treatment of medically uncontrolled glaucoma at 1 year of follow-up.

METHODS

Retrospective analysis of patients implanted with a PGI or BGI with a minimum of 12 months follow-up. The primary outcome was surgical success defined as IOP ≥6 and ≤18 mm Hg and at least 20% IOP reduction from baseline. Secondary outcomes included IOP measurements, number of medications, and complications.

RESULTS

Twenty-three patients implanted with PGI and 27 with BGI were included. At last visit (12 mo), mean IOP had decreased from 23.7 ± 6.9 to 0.1 ± 2.9 mm Hg in the PGI group versus 26 ± 7.3 to 10.4 ± 4.9 mm Hg with the BGI ( P < 0.001 for both comparisons). Overall qualified success rates were similar between groups (PGI 91% vs BGI 89%, P = 0.784). IOP was significantly lower in the PGI at week 1 and month 1 of follow-up versus the BGI (13.6 ± 6.1 vs 20.1 ± 7.4; 14.6±3.8 vs 21.2 ± 5.8 mm Hg; P < 0.002 for both) with a lower number of medications (1.57 ± 1.47 vs 2.52 ± 1.16 at mo 1, P = 0.015). Most complications were minor and similar in both groups.

CONCLUSION

Both PGI and BGI are safe and effective in reducing IOP in patients with glaucoma, with similar success rates.

The "Pocket" Technique: A Novel Surgical Technique for Repair of Glaucoma Drainage Device Tube Exposure

PRCIS

Presented is a novel surgical technique, termed the "pocket" technique, of scleral patch graft placement into a subconjuntival pocket to cover exposed glaucoma tube shunts, which is particularly useful in cases of scarred and thinned conjunctiva and Tenons.

ABSTRACT

Exposure of glaucoma tube shunts is an uncommon postoperative complication which poses a significant risk to the patient and may be difficult to repair. In this case series, the authors present 2 cases using a novel surgical technique, the "pocket" technique, to place a scleral patch graft to address tube exposure. Patient 1 remained free of tube exposure at most recent follow-up visit after 21 months, and patient 2 remained free of tube exposure at most recent follow-up visit after 4 months. This technique offers an elegant surgical option that has multiple benefits; it allows for stability of the scleral patch graft even in cases of scarred down, thinned conjunctiva with minimal Tenons, allows for repair along the entire length of the tube shunt including perilimbal exposures, and allows for secondary healing when there is not enough conjunctiva to cover both the opening and the patch. These advantages make the "pocket" technique a quick to perform, minimally invasive surgical approach that is useful for addressing both difficult and straightforward tube exposure cases.

Intraluminal Suture Placement for Management of Hypotony After Glaucoma Drainage Device Surgery

PRCIS

Intraluminal 3-0 Supramid stent placement can be an effective long-term solution for hypotony after glaucoma drainage device surgery. This procedure may obviate the need for conjunctival dissection. In some cases, additional procedures are required.

PURPOSE

To describe the utility of implantation of a multifilament polyamide suture (Supramid) in the tube lumen to reverse hypotony after glaucoma drainage device (GDD) surgery.

PATIENTS

Patients who underwent tube revision with intraluminal placement of a 3-0 Supramid stent, with or without external ligature, to manage hypotony following GDD surgery between January 2010 and October 2020.

METHODS

Resolution of hypotony was defined as IOP >5 mm Hg and the absence of hypotony-related structural abnormalities. Overall success was the absence of failure criteria (IOP ≤5 mm Hg, >21 mm Hg, or <20% reduction below baseline IOP after 3 months for 2 consecutive study visits; additional glaucoma surgery; or loss of light perception), with or without adjunctive ocular hypotensive therapy.

RESULTS

Nine eyes of 9 patients underwent placement of a 3-0 Supramid stent with a resolution of hypotony in all eyes with a mean follow-up duration of 33.3 ±24.0 months. Overall success was achieved in 7 of 9 eyes. Four eyes required intervention after stent placement: 1 eye required selective laser trabeculoplasty followed by replacement of the original stent with a shorter 3-0 Supramid suture and external ligature; 1 eye underwent revision for tube exposure; and 2 eyes underwent laser suture lysis to release an external suture ligature.

CONCLUSIONS

In cases of hypotony after GDD, particularly when it is desirable to reduce the extent of additional conjunctival dissection, intraluminal placement of a 3-0 Supramid stent via an intracameral approach can be an effective long-term solution. Postoperative adjustments were required in many cases.

Corneal endothelial density loss in patients after gonioscopy‑assisted transluminal trabeculotomy

PURPOSE

To compare short-term changes in corneal endothelial cells after gonioscopy-assisted transluminal trabeculotomy(GATT).

METHODS

This retrospective comparative study included 138 patients(138 eyes), and 98 of these patients underwent GATT procedure and 40 underwent SLT procedure as a control group. Changes in the corneal endothelium in patients who underwent GATT and SLT were analyzed retrospectively. Endothelial changes in the central cornea were examined using specular microscopy before and 6 months after the GATT and SLT procedure. Intraocular pressure(IOP), number of glaucoma medications, and side effects were evaluated at visits before and after two methods.

RESULTS

One hundred and thirty-eight eyes of 138 patients with a mean age of 62.9±12.7 years in the SLT group and 62.5±11.8 years in the GATT group were included in this study. Pre-procedure mean ± SD IOP was 27.7±3.6 mmHg and 27.4±5.3 mmHg (p=0.173) 2.8±0.5 and 2.9±0.8 (p=0.204) glaucoma drugs are in the SLT and GATT group, respectively. The mean corneal endothelial cell density (CECD) in the SLT group was 2433.1±581.4 cells/mm2 before the procedure and 2435.1±585 cells/mm2 6 months after the procedure, a change of 0.1±0.6% which was not statistically significant (p>0.967).The mean CECD at baseline in the GATT group was 2443.4±508.2 cells/mm2 and decreased to 2290.2±527.7 cells/mm2 6 months after this procedure, representing a cell loss of 6,2±9,1% (p<0.001).

CONCLUSION

GATT caused more CECD damage than SLT at the sixth month after the procedure. Considering the loss of CECD in candidates for GATT, sufficient number of endothelial cells in the central cornea is recommended.

Aqueous shunt exposure repair: outcomes and risk factors for recurrence

OBJECTIVE

To investigate the outcomes of aqueous shunt exposure repair and to identify risk factors for recurrent exposure after surgical repair.

METHODS

This is a retrospective interventional case series of consecutive patients who underwent repair of an exposed aqueous shunt. Demographic and clinical data were extracted from the patients' records and survival analysis was employed to determine the probability of survival of the repair without further exposure. Cox proportional regression analysis was utilised to identify potential risk factors for failure of the repair surgery.

RESULTS

Seventy-six eyes of 76 patients were included in the study. The probability of survival without further exposure was 76.2% (CI 66.9-86.8%), 72.7% (CI 62.8-84.1%) and 54.7% (40.5-73.7%) at 1,2 and 4 years, respectively. No eye in which the tube was repositioned in the anterior chamber or in the sulcus (n = 9; 11.8%) developed a recurrence of the exposure. A shorter interval from the time of tube insertion to the repair surgery (HR 2.87 [CI 1.11-7.39]; p = 0.03; reference longer interval), a history of previous surgical revision (HR 3.06 [1.15-8.12]; p = 0.02; reference no prior revision) and the use of a human pericardial donor patch at the time of revision (HR 3.43 [1.16-10.13]; p = 0.03; reference other than pericardium) was associated with an increased risk of exposure recurrence.

CONCLUSION

Aqueous shunt exposure revision is associated with reasonable mid and long term success. A shorter interval from tube insertion to exposure revision, previous revisions and the use of a human pericardium patch were associated with increased risk of failure.

Long-term effectiveness and safety of XEN45 in open-angle glaucoma patients

BACKGROUND

To investigate the long-term effectiveness and safety of XEN45 implant, either alone or in combination with phacoemulsification, in eyes with open-angle glaucoma (OAG).

METHODS

Retrospective and single center study conducted on consecutive OAG patients who underwent a XEN45 implant between February-2017 and December-2021. The primary endpoint was the mean intraocular pressure (IOP) lowering from preoperative values. Surgical success was defined as an IOP-lowering from preoperative values ≥ 20% and an IOP absolute value between 6 and 13 mm Hg, without (Complete-success) or with (Qualified-success) antiglaucoma medications.

RESULTS

A total of 158 eyes (34 (21.5%) eyes XEN-solo and 124 (78.5%) XEN + Phaco) were included. The median follow-up time was 28.5 months. In the overall study population, the mean preoperative IOP was significantly lowered from 19.4 ± 6.5 mm Hg to 12.4 ± 5.0 mm Hg. The mean preoperative (95% confidence interval) IOP was significantly lowered from 21.3 (19.3-23.2) mm Hg and 18.8 (17.7-20.0) mm Hg to 12.0 (10.4-13.6) mm Hg and 12.5 (11.6-13.5) mm Hg in the XEN-Solo and XEN + Phaco groups, respectively (p < 0.0001 each, respectively). The mean number of ocular-hypotensive medications was significantly reduced in the overall study sample (from 3.4 ± 0.9 to 0.9 ± 1.3, p < 0.0001), XEN-Solo (from 3.5 ± 1.1 to 0.6 ± 1.0, p < 0.0001, and XEN + Phaco (from 3.4 ± 1.1 to 0.9 ± 1.3, p < 0.0001) groups. Eighty-four (53.2%) eyes were categorized as success, with 49 (58.3%) classified as complete success. Eighty-one (51.3%) eyes underwent needling and 15 (9.5%) eyes required an additional surgical procedure. One (0.6%) eye had endophthalmitis.

CONCLUSION

XEN implant, either alone or in combination with phacoemulsification significantly lowered IOP and reduced the need of ocular-hypotensive medication, while maintaining a good safety profile.

Hypotony Failure Criteria in Glaucoma Surgical Studies and Their Influence on Surgery Success

PURPOSE

Review hypotony failure criteria used in glaucoma surgical outcome studies and evaluate their impact on success rates.

DESIGN

Systematic literature review and application of hypotony failure criteria to 2 retrospective cohorts.

PARTICIPANTS

A total of 934 eyes and 1765 eyes undergoing trabeculectomy and deep sclerectomy (DS) with a median follow-up of 41.4 and 45.4 months, respectively.

METHODS

Literature-based hypotony failure criteria were applied to patient cohorts. Intraocular pressure (IOP)-related success was defined as follows: (A) IOP ≤ 21 mmHg with ≥ 20% IOP reduction; (B) IOP ≤ 18 mmHg with ≥ 20% reduction; (C) IOP ≤ 15 mmHg with ≥ 25% reduction; and (D) IOP ≤ 12 mmHg with ≥ 30% reduction. Failure was defined as IOP exceeding these criteria in 2 consecutive visits > 3 months after surgery, loss of light perception, additional IOP-lowering surgery, or hypotony. Cox regression estimated failure risk for different hypotony criteria, using no hypotony as a reference. Analyses were conducted for each criterion and hypotony type (i.e., numerical [IOP threshold], clinical [clinical manifestations], and mixed [combination of numerical or clinical criteria]).

MAIN OUTCOME MEASURES

Hazard ratio (HR) for failure risk.

RESULTS

Of 2503 studies found, 278 were eligible, with 99 studies (35.6%) lacking hypotony failure criteria. Numerical hypotony was predominant (157 studies [56.5%]). Few studies used clinical hypotony (3 isolated [1.1%]; 19 combined with low IOP [6.8%]). Forty-nine different criteria were found, with IOP < 6 mmHg, IOP < 6 mmHg on ≥ 2 consecutive visits after 3 months, and IOP < 5 mmHg being the most common (41 [14.7%], 38 [13.7%], and 13 [4.7%] studies, respectively). In both cohorts, numerical hypotony posed the highest risk of failure (HR, 1.51-1.21 for criteria A to D; P < 0.001), followed by mixed hypotony (HR, 1.41-1.20 for criteria A to D; P < 0.001), and clinical hypotony (HR, 1.12-1.04; P < 0.001). Failure risk varied greatly with various hypotony definitions, with the HR ranging from 1.02 to 10.79 for trabeculectomy and 1.00 to 8.36 for DS.

CONCLUSIONS

Hypotony failure criteria are highly heterogenous in the glaucoma literature, with few studies focusing on clinical manifestations. Numerical hypotony yields higher failure rates than clinical hypotony and can underestimate glaucoma surgery success rates. Standardizing failure criteria with an emphasis on clinically relevant hypotony manifestations is needed.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

New approach to AGV implantation with scleral tunnel method by prolene suture: Şimşek Technique

PURPOSE

To present the short-term outcomes of our novel technique, the suture-assisted method, in long scleral tunnel Ahmed Glaucoma Valve (AGV) implantation.

METHODS

This retrospective study included glaucoma patients who underwent AGV implantation using the suture-assisted long scleral tunnel method and were fellowed for at least 6 months between January 2022 and November 2022. Preoperative and postoperative assessments included best-corrected visual acuity (BCVA), intraocular pressure (IOP), anterior and posterior segment examinations, anti-glaucomatous medications, and intraoperative and postoperative complications were also evaluated.

RESULTS

Eight eyes of seven patients were included in the study. The mean age was 52.25 ± 29.38 years (r:8-76 years), and there were 5 female and 2 male patients. The mean follow-up duration period was 8.62 ± 2.50 months (r:6-12 months). The mean IOP was 27.12 ± 3.48 mmHg preoperatively and 11.62 ± 3.48 mmHg on postoperative on 1st day, 11.62 ± 3.20 mmHg at 1st week, 18.75 ± 8.94 mmHg at 1st month, 16.62 ± 2.72 mmHg at 3rd month, 16.12 ± 3.75 mmHg at 6th month. Postoperative hyphema was observed in one eye, and tenon cyst excision was performed in two eyes. No tube exposure was observed in any eye during the follow-up period. No hypotony-related complications were observed during follow-up.

CONCLUSION

We believe that suture-asissted application of the long scleral tunnel method not only prevents tube exposure but also facilitates the passage of the AGV silicone tube through the scleral tunnel, reducing the surgical time contributing to a decreased the risk of infection.

[Glaucoma Filtration Surgery - Bleb-forming Procedures]

Glaucoma filtration surgery has been a standard surgical therapy for decades. An increasing knowledge about wound healing processes in the eye, the introduction of antimetabolite treatment and continuous improvements of the surgical technique helped making trabeculectomy - the prototype filtration surgery - a very effective therapeutic tool. However, best results will only be regularly achieved with a high level of experience and time dedicated to postoperative follow-up. Furthermore, the potential for severe early and late complications still remains high. Thus, novel stent-based filtration surgery approaches, such as the Preserflo and the XEN shunt have been introduced. This review presents these three bleb-forming filtration procedures, covering the basic principles of surgical technique, data on effectivity as well as complications.

Outcomes of Ahmed glaucoma valve surgery performed by glaucoma fellows - A large retrospective study from Eastern India

PURPOSE

Teaching and training of glaucoma fellows on the technique of Ahmed glaucoma valve (AGV) implantation surgery is very important. The purpose of this study was to describe the clinical outcomes and complications of AGV surgery performed by glaucoma fellows of a tertiary eye center from eastern India.

METHODS

This was a retrospective study based on electronic medical records. Thirty-five eyes operated with AGV by five glaucoma fellows from January 2016 to November 2020 were included. Best-corrected visual acuity, intraocular pressure (IOP), and number of antiglaucoma medications (AGMs) were the study outcome measures.

RESULTS

The mean (±standard deviation) age of the patients was 40.5 (±19.7) years. The follow-up period was 24.37 (±13.01) months. Both complete success (IOP <21 mmHg without additional AGM) and qualified success (IOP <21 mmHg with an additional AGM) were achieved in eight eyes each (22.8%). Failure of the surgery was noted in 19 eyes (54.3%) as there was a need for repeat surgery for IOP control in 12 eyes and a persistent IOP spike (IOP >21 mmHg with AGM beyond 3 months) in seven eyes. Despite a high rate of failure of the primary surgery, with the consultants' intervention, there was statistically significant improvement in vision and IOP in all patients ( P < 0.01) at the last follow-up.

CONCLUSION

AGV implantation is a challenging surgical skill to be acquired by the glaucoma fellows.

The Minimally Important Difference (MID) in Visual Acuity That Represents Changes in Patients' Quality of Life

To assess the minimal change in visual acuity perceived by patients as important in different eye-related interventions. PubMed was utilized to search articles on each of the four major interventions: cataract surgery, keratoplasty, different glaucoma treatments, and refractive eye surgery, each combined with quality of life (QoL) and visual acuity keywords. The search was narrowed to articles between 2000 and 2023. Seventy-four major articles were thus reviewed. Of these, 27 studies reviewed the results of cataract surgery, 20 studies discussed the effect of keratoplasty interventions on the vision-related QoL (VRQoL), most showing that VRQoL improved significantly after keratoplasty, 11 studies investigated the effect of different glaucoma interventions on patients' visual acuity and the QoL, 16 studies reviewed refractive surgery, where they showed an improved QoL in most of the cases, although some of the studies showed a slight superiority of one intervention over the other in the short term. The minimally important difference (MID) perceived in visual acuity depends mainly on the type of surgical intervention (keratoplasty, glaucoma, or refractive surgery), and the impact on QoL on improved visual acuity differs depending on the intervention.

Mitomycin C 0.2 mg/ml vs. Mitomycin C 0.4mg/ml during the implantation of an ab externo SIBS microshunt: A mega-analysis

PURPOSE

To compare the effectiveness and adverse event profile of standalone SIBS microshunt implantation with adjunct MMC 0.2 mg/ml and MMC 0.4 mg/ml.

DESIGN

Mega-analysis using individual patient data from international prospective and retrospective clinical studies.

STUDY POPULATION

Patients with glaucoma who underwent implantation of a SIBS microshunt with MMC as a standalone procedure.

METHODS

A comparison of eyes that received MMC 0.2 mg/ml or 0.4 mg/ml MAIN OUTCOMES MEASURES: Primary outcome was complete success defined as the proportion of eyes at one year with all of the following: (1) no two consecutive IOPs > 17 mmHg; (2) no clinical hypotony (3) ≥20% IOP reduction from baseline and (4) no use of glaucoma medications. Secondary outcomes included IOP thresholds of 12 mmHg,14 mm Hg and 21mmHg, median IOP, number of medications, risk factors for failure, interventions, adverse events, and reoperations.

RESULTS

At 1 year, the complete success rate was significantly higher (71.3% vs 50.46%, p<0.001) and the median IOP significantly lower (13.0 vs. 14.2 mmHg, p<0.05) in the MMC 0.4 mg/ml group. MMC 0.2 mg/ml was found to be a significant risk factor for failure (HR 1.75 95%CI 1.14 to 2.67). Needling and surgical revision occurred at a lower rate in the MMC 0.4 mg/ml group (7% vs. 18.8%, p= 0.002 and 4.3% vs.13.7% p= 0.0087, respectively). Adverse events occurred at a similar frequency in both groups (26.6% MMC 0.2 mg/ml vs. 29.6% MMC 0.4 mg/ml, p=0.46), most of which were early and transient.

CONCLUSION

SIBS microshunt implantation with MMC 0.4 mg/ml resulted in a higher success rate with greater IOP reduction compared to MMC 0.2 mg/ml. Higher MMC concentration was not associated with increased serious adverse events.

The effect of cumulative energy in repeated subliminal transscleral cyclophotocoagulation: a retrospective study

BACKGROUND

The long-term safety and efficacy of repeated applications of subliminal transscleral cyclophotocoagulation (SL-TSCPC) with a focus on cumulative energy was evaluated in glaucoma patients.

METHODS

In this retrospective, multicentric study the data of a total of 82 eyes with various causes of glaucoma that were treated with a single or multiple applications of SL-TSCPC were collected. Treatments were performed under general or local anesthesia with an 810 nm diode laser. Power was 2000 mW; duty cycle, 31.3%; total treatment duration, 80-320 s; equaling a total energy of 50-200 J per treatment session. Fifty-five eyes (55 patients) presented for all follow-ups, and these eyes were selected for further statistical analysis. The mean age was 60.0 ± 17.1 years, and 22 (40%) of the patients were female. Intraocular pressure (IOP) and dependence on further glaucoma medication were evaluated at 12 months following the initial treatment.

RESULTS

Eyes underwent 1 or 2 consecutive SL-TSCPC treatments. Median (min-max) baseline IOP of 34 (13-69) decreased to 21.5 (7-61), 22 (8-68), 20 (9-68), and 19.5 (3-60) mmHg at the 1, 3, 6, and 12-month postoperative timepoints respectively. The mean (± SD) IOP decrease at 12 months was 26 ± 27%, 39 ± 32%, and 49 ± 33% in the low (below 120 J, n = 18), medium (120-200 J, n = 24), and high (above 200 J, n = 13) cumulative energy groups respectively. At the 12-month timepoint, oral carbonic anhydrase use was discontinued in ¾ of the cases.

CONCLUSIONS

It was found that the repeated application of SL-TSCPC safely and efficiently decreases IOP in a Caucasian population with heterogenous causes of glaucoma, eyes with silicone oil responded to a greater extent. Inclusion of cumulative energy scales may contribute to better addressing repeated procedures in a standardized fashion.

Donor Corneal Endothelial Cell Maturity and Its Impact on Graft Survival in Glaucoma Patients Undergoing Corneal Transplantation

PURPOSE

To examine corneal graft survival via corneal endothelial cell density (ECD) and corneal endothelial cell loss (ECL) at 5 years post-transplantation in the eyes of patients with and without a history of undergoing glaucoma surgery according to the maturity of the donor corneal endothelial cells.

DESIGN

Prospective cohort study.

METHODS

This prospective cohort study included 17 patients with glaucoma and 51 patients without glaucoma who underwent Descemet's stripping automated endothelial keratoplasty or penetrating keratoplasty at the Baptist Eye Institute, Kyoto, Japan, between October 2014 and October 2016. Human corneal endothelial cells were cultured from residual peripheral donor cornea tissue, and the maturity of the cells was evaluated by cell surface markers (ie, CD166+, CD44-/dull, CD24-, and CD105-) using fluorescence-activated cell sorting. Kaplan-Meier analysis or the chi-square test was used to assess the rate of successful corneal graft survival post-transplantation.

RESULTS

At 36 months postoperatively, the mean ECD and ECL in the glaucoma-bleb eyes were 1197 ± 352 cells/mm2 and 55.5% ± 13.9% in the high-maturity group and 853 ± 430 cells/mm2 and 67.7% ± 18.1% in the low-maturity group, respectively. Kaplan-Meier analysis revealed that at 5 years postoperatively, the overall rate of survival was 45%, that is, 100% in the high-maturity group and 25% in the low-maturity group (P < .05).

CONCLUSIONS

The findings in this prospective cohort study revealed that the use of donor corneal grafts containing mature-differentiated corneal endothelial cells could maintain the survival of the transplanted graft for a long-term period, even in patients with a history of undergoing glaucoma surgery.

Comparison of Ahmed glaucoma drainage implant outcomes in the anterior chamber versus pars plana

OBJECTIVE

To compare long-term outcomes of eyes undergoing Ahmed glaucoma drainage implants in the anterior chamber versus the pars plana.Retrospective cohort study.

PARTICIPANTS

Operated patients were divided into anterior-chamber or pars plana groups.

METHODS

Follow-up data included intraocular pressure (IOP), need for antiglaucoma medications (AGMs), and postoperative complications. Treatment success was evaluated based on the following criteria: IOP ≤21 mm Hg and no AGM use, IOP ≤21 mm Hg with or without AGM use, IOP ≤18 mm Hg and no AGM use, IOP ≤18 mm Hg with or without AGM use, IOP ≤15 mm Hg and no AGM use, and IOP ≤15 mm Hg with or without AGM use.

RESULTS

A total of 170 eyes were selected and split into an anterior-chamber group (n = 57) and a pars plana group (n = 113). No differences between groups were found on the decrease in IOP (p = 0.612) or number of AGMs (p = 0.695) in the postoperative period. No differences regarding corneal decompensation (p = 0.554) or retinal detachment (p = 0.168) were observed between groups. The 1-year success rates for all the criteria were, respectively, 89%, 96%, 88%, 92%, 88% and 90%; the 3-year success rates for all the criteria were, respectively, 33%, 61%, 32%, 55%, 28%, and 45%; and the 5-year success rates for all the criteria were, respectively, 7%, 48%, 7%, 36%, 4% and 17%.

CONCLUSIONS

No differences between the groups were observed for long-term outcomes of IOP, AGM use, or postoperative complications. Success rates were comparable between groups, decreased along the follow-up time, and were higher when associated with AGM use.

Effect of Lens Status on the Outcomes of Glaucoma Drainage Device Implantation

PURPOSE

To assess the effect of lens status and cataract surgery on glaucoma drainage device (GDD) efficacy.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Two hundred and forty-three eyes of 216 patients that underwent GDD implantation with ≥1 follow-up visit within 3 years postoperatively. Exclusion criteria included GDD combined with other ophthalmic procedures. 90%-94% of GDDs were Ahmed implants; 83%-90% had adjunctive mitomycin-C.

METHODS

Outcomes were compared between phakic eyes (group A), eyes phakic at time of implantation but subsequently underwent cataract surgery within 3 years (group B), and pseudophakic eyes (group C). Outcomes were measured at 1, 3, 6, 12, 24, and 36 months after tube shunt implantation. Multivariable regression models were performed, adjusting for baseline characteristics.

MAIN OUTCOME MEASURES

Intraocular pressure (IOP) after GDD implantation. Secondary outcomes included change in visual acuity (VA), number of glaucoma eye drops, and rate of failure, defined as additional glaucoma surgery, vision decrease to no light perception, or IOP persistently ≤ 5 mmHg or > 21 mmHg or not reduced from baseline by 20%.

RESULTS

There were 65 eyes in group A, 52 in group B, and 126 in group C. Within group B, cataract surgery was performed at a mean of 1.3 ± 0.7 years after GDD implantation. There were no statistically significant differences in mean IOP or medications between the 3 groups at all time points up to 3 years postoperatively. Significant improvement in VA was noted in groups A and B compared to group C at 6 months, 1 year, and 2 years after implantation; however, by postoperative year 3, change in VA was similar across groups. There were no significant differences in the failure rate amongst groups (P = 0.68). IOP and medications up to 12 months after cataract surgery were similar compared to preoperative baseline. Group B had significantly more short-term (P = 0.02) and long-term (P < 0.001) postoperative complications than groups A or C, driven primarily by hypotony.

CONCLUSIONS

There were no differences in IOP, glaucoma medications, or rate of failure 3 years after GDD implantation based on lens status or after undergoing subsequent cataract surgery. These results may inform the management of patients with co-existing glaucoma and cataract.

FINANCIAL DISCLOSURE(S)

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

Evaluation of Verteporfin as a Novel Antifibrotic Agent in a Rabbit Model of Glaucoma Filtration Surgery: A Pilot Study

Purpose

Verteporfin is a benzoporphyrin derivative which is Food and Drug Administration-approved for treatment of choroidal neovascularization in conjunction with photodynamic therapy. It has been shown to prevent fibrosis and scar formation in several organs and represents a promising novel antifibrotic agent for glaucoma surgery. The goal of this study is to determine the effect of verteporfin on wound healing after glaucoma filtration surgery.

Design

Preclinical study using a rabbit model of glaucoma filtration surgery.

Subjects

Eight New Zealand white rabbits underwent glaucoma filtration surgery in both eyes.

Methods

Eyes were randomized into 4 study groups to receive a postoperative subconjunctival injection of 1 mg/mL verteporfin (n = 4), 0.4 mg/mL mitomycin C (MMC; n = 4), 0.4 mg/mL MMC + 1 mg/mL verteporfin (n = 4), or balanced salt solution (BSS) control (n = 4). Bleb survival, vascularity, and morphology were graded using a standard scale over a 30-day period, and intraocular pressure (IOP) was monitored. At 30 days postoperative or surgical failure, histology was performed to evaluate for inflammation, local toxicity, and scarring.

Main Outcome Measures

The primary outcome measure was bleb survival. Secondary outcome measures were IOP, bleb morphology, and bleb histology.

Results

Compared to BSS control blebs, verteporfin-treated blebs demonstrated a trend toward increased surgical survival (mean 9.8 vs. 7.3 days, log rank P = 0.08). Mitomycin C-treated blebs survived significantly longer than verteporfin-treated blebs (log rank P = 0.009), with all but 1 MMC-treated bleb still surviving at postoperative day 30. There were no significant differences in survival between blebs treated with combination verteporfin + MMC and MMC alone. Mitomycin C-treated blebs were less vascular than verteporfin-treated blebs (mean vascularity score 0.3 ± 0.5 for MMC vs. 1.0 ± 0.0 for verteporfin, P < 0.01). Bleb histology did not reveal any significant toxicity in verteporfin-treated eyes. There were no significant differences in inflammation or scarring across groups.

Conclusions

Although verteporfin remained inferior to MMC with regard to surgical survival, there was a trend toward increased survival compared with BSS control and it had an excellent safety profile. Further studies with variations in verteporfin dosage and/or application frequency are needed to assess whether this may be a useful adjunct to glaucoma surgery.

Financial Disclosures

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

Ahmed ClearPath vs. Baerveldt Glaucoma Implant: A Retrospective Noninferiority Comparative Study

PURPOSE

To compare the efficacy and safety of 2 nonvalved glaucoma drainage devices (GDDs): Ahmed ClearPath (ACP) vs. Baerveldt glaucoma implant (BGI).

DESIGN

Single-center, retrospective, comparative study.

PARTICIPANTS

Consecutive patients who underwent ACP or BGI surgery for glaucoma (250 mm2 or 350 mm2 models), had ≥ 6 months of follow-up, and no prior GDD implantation.

METHODS

Chart review of ACP or BGI surgery in patients with glaucoma at Wills Eye Hospital (2020-2023).

MAIN OUTCOME MEASURES

The primary outcome measure was surgical failure at the end of follow-up, defined as intraocular pressure (IOP) > 21 or < 6 mmHg at 2 consecutive visits, progression to no light perception (NLP) vision, glaucoma reoperation, or implant removal. Secondary outcome measures included the rate of postoperative complications and changes in best corrected visual acuity (BCVA), IOP, and glaucoma medications.

RESULTS

A total of 128 eyes of 113 patients (63 ACP, 65 BGI) with similar baseline characteristics and a mean follow-up duration of 19.6 ± 10.8 (median 20.5) months were included. Surgical failure occurred in 12 eyes (9.4%) with no significant difference between ACP and BGI eyes (9.5% vs. 9.2%, respectively; P = 0.810). Reasons for failure included IOP > 21 mmHg (3/12, 25.0%), glaucoma reoperation (5/12, 41.7%), and tube removal (4/12, 33.3%). No eyes progressed to NLP vision. Kaplan-Meier survival analysis showed similar cumulative rate of surgical failure in both groups (P = 0.871). Both groups achieved significant IOP and medication reduction compared to their baseline. Final IOP, BCVA, and complication rates were similar in both groups, but medication number was significantly lower in the ACP group (P = 0.012). Both the 250 mm2 and 350 mm2 models had similar outcomes, but diplopia was significantly associated with the 350 mm2 model of either implant (P = 0.012). Univariate logistic regression analysis did not identify either tube type or plate size as predictors of surgical failure.

CONCLUSIONS

This study compares the recently approved ACP vs. BGI. Both implants had similar surgical failures and complication rates. Final IOP was similar in both groups, but ACP achieved lower medication number. Diplopia was significantly associated with the use of 350 mm2 model of either implant. Neither tube type nor plate size were significant predictors of surgical failure.

FINANCIAL DISCLOSURE(S)

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

Comparison of Tenon duplication with dura mater covering technique for Ahmed glaucoma valve implantation

PURPOSE

To compare the efficacy and complications of Tenon duplication with dura mater covering technique for Ahmed glaucoma valve (AGV) implantation.

METHODS

This retrospective study included 44 refractory glaucoma patients (44 eyes) who underwent AGV implantation from 2017 to 2020 in the Ophthalmology Clinic of Eskişehir Osmangazi University Hospital and attended regular postoperative follow-ups. The patients were divided based on whether they underwent Tenon duplication technique (group 1: n = 20) or dura mater covering technique (group 2: n = 24) during surgery. The patients' age, gender, systemic diseases, glaucoma type, pre-op intraocular pressure (IOP), and ocular surgeries were recorded. The groups were compared for IOP level control, early and late complications, postoperative antiglaucomatous medication requirements, glaucoma surgery requirements, presence of postoperative hypertensive phase (HP), and surgical success which was defined as an IOP ≥5 and ≤21 mmHg, with or without antiglaucoma medication.

RESULTS

By the end of the mean follow-up (22.6 ± 10.6 months), the success rates were 95% (group 1) and 96% (group 2). The groups showed no differences in postoperative complications, postoperative antiglaucomatous drugs' onset time, additional glaucoma surgery, need for needling, presence of HP at 6 months postoperatively, and relationship between the glaucoma type and success rates ( P values: 0.86, 0.9, 0.48, 0.12, 0.36, and 0.8, respectively). The IO P values at the last follow-up were 15.2 ± 4.1 in group 1 and 14.7 ± 4.8 in group 2. The IOP reduction rates showed no significant differences.

CONCLUSION

Since success and complications are similar in both Tenon duplication and dura mater covering technique, unique grafting materials may not be needed in AGV implantation surgery, except in special cases.

Glaucoma Tube Outcomes with and without Anti-VEGF in Patients with Age-related Macular Degeneration

PURPOSE

To compare glaucoma tube outcomes of wet age-related macular degeneration (AMD) eyes receiving anti-VEGF injections versus dry AMD eyes and no anti-VEGF.

DESIGN

Retrospective clinical cohort study.

PARTICIPANTS

Patients with wet AMD and a history of anti-VEGF within a year prior or after stand-alone glaucoma tube surgery and eyes with dry AMD and no history of anti-VEGF with at least 6 months of follow-up. Eyes with neovascular glaucoma or anti-VEGF for reason other than wet AMD were excluded.

METHODS

A Kaplan-Meier analysis compared survival for wet versus dry AMD eyes. Failure was defined as intraocular pressure (IOP) > 21 mmHg or < 20% IOP reduction from baseline or IOP ≤ 5 mmHg for 2 consecutive postoperative visits starting at month 3, additional glaucoma surgery, or no light perception. Complete success was defined as no failure or medications at final follow-up. Hypertensive phase was defined for valved tubes as IOP > 21 mmHg within 3 months of surgery after a reduction to < 22 mmHg during the first postoperative week. Intraocular pressure, percent reduction in IOP, number of glaucoma medications, and early (< 1 year) and late (> 1 year) complications were compared through 5 years.

MAIN OUTCOME MEASURES

Survival analysis, IOP, number of medications.

RESULTS

Baseline IOP, number of medications, or tube type were not significantly different between wet (n = 24) and dry AMD eyes (n = 54). No wet AMD eyes failed versus 10 (18%) dry AMD eyes (P = 0.03). Five-year survival was estimated as 100% for wet AMD and 72% for dry AMD (P = 0.04). Wet AMD eyes had lower IOP (10.6 vs. 12.7 mmHg, P = 0.05), greater IOP reduction (60% vs. 49%, P = 0.04), fewer medications (1.2 vs. 2.1, P = 0.02), and more complete success (50% vs. 15%, P = 0.001) at final follow-up (32 vs. 36 months, P = 0.42). Fewer wet than dry AMD eyes experienced hypertensive phase (0/10 [0%] vs. 4/10 [40%], P = 0.04). There were no significant differences in early or late complications.

CONCLUSIONS

Exposure to anti-VEGF may influence postoperative wound healing and capsule formation which may improve glaucoma tube surgical outcomes. Prospective data is needed to consider perioperative administration of anti-VEGF for glaucoma tube surgery.

FINANCIAL DISCLOSURE(S)

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

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.

Wound Modulations in Glaucoma Surgery: A Systematic Review

Excessive fibrosis and resultant poor control of intraocular pressure (IOP) reduce the efficacy of glaucoma surgeries. Historically, corticosteroids and anti-fibrotic agents, such as mitomycin C (MMC) and 5-fluorouracil (5-FU), have been used to mitigate post-surgical fibrosis, but these have unpredictable outcomes. Therefore, there is a need to develop novel treatments which provide increased effectiveness and specificity. This review aims to provide insight into the pathophysiology behind wound healing in glaucoma surgery, as well as the current and promising future wound healing agents that are less toxic and may provide better IOP control.

The need for more pragmatic trials in glaucoma research

AIM

There have been a number of clinical trials in glaucoma research published in the past two decades. Most of these trials were designed to evaluate very specific issues in selected populations placing them in the explanatory end of the pragmatic-explanatory continuum. The purpose of this study was to assess the level of pragmatism of published randomized controlled trials in glaucoma.

METHODS

A PubMed search using 'glaucoma' from 1995 to 2022 and randomized controlled trial (RCT) article type was done. Each study was assessed by three independent examiners using the Pragmatic-Explanatory Continuum Indicator Summary version 2 (PRECIS-2) toolkit. Scores were calculated for each study to determine the level of pragmatism. A summed score ≥36 was indicative of a very pragmatic study.

RESULTS

Thirty-two different articles were included in the analysis. These papers represented 13 different landmark trials. The median PRECIS-2 score was 32 (range, 25 for the Early Manifest Glaucoma Trial (EMGT) to 34 to the Collaborative Normal Tension Glaucoma Study (CNTGS) and the Ocular Hypertension Treatment Study). The Treatment of Advanced Glaucoma Study (TAGS), was considered very pragmatic and scored 33 points.

CONCLUSION

Despite the number of RCTs in glaucoma, there is still a need for more pragmatic studies.

Efficacy of anti-vascular endothelial growth factor and mitomycin C on wound healing after trabeculectomy in glaucoma patients: A meta-analysis

Trabeculectomy is the main surgical treatment for glaucoma, but scar formation during wound healing may lead to surgical failure. In this study, we evaluated the efficacy of anti-vascular endothelial growth factor (anti-VEGF) and mitomycin C (MMC) on wound healing after glaucoma surgery. We have been looking for Pubmed, Embase and other databases. The last time we looked at an electronic database was August 2023. A case control study was conducted to compare the use of anti-VEGF and mitomycin C for the treatment of glaucoma. We used the Cochrane standard methodology for collecting and analysing the data. Based on the criteria of inclusion, we have determined 369 related papers and selected seven eligible trials for data analysis. Three hundred and twenty-six cases were treated with trabeculectomy, of which 166 were injected with anti-VEGF and 160 were given MMC for trabeculectomy. In six trials, anti-VEGF and MMC were not found to have any statistical significance on postoperative wound leakage after surgery (OR, 1.55; 95% CI, 0.71, 3.35 p = 0.27). The three trials showed that anti-VEGF and MMC did not differ in terms of reducing postoperative wound hypotony after surgery (OR, 0.78; 95% CI, 0.20, 3.11 p = 0.73). Five trials demonstrated that anti-VEGF and MMC were not associated with a lower incidence of shallow anterior chamber (OR, 1.17; 95% CI, 0.5, 2.76 p = 0.71). There is no significant difference in the effect of anti-VEGF and MMC on wound healing after glaucoma surgery. A multicentre randomized controlled trial with a larger sample size is needed to confirm this study.

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.

Superonasal vs Inferonasal Subconjunctival Gel Stent Placement in Patients with Glaucoma

Aim and background

To compare the safety and efficacy of subconjunctival gel stent implantation in the superonasal (SN) vs inferonasal (IN) quadrants in the treatment of glaucoma.

Materials and methods

Patients with a history of IN (n = 29) or SN, (n = 96) gel stent placement with ≥3 months of follow-up were included. Intraocular pressure (IOP) and the number of glaucoma medications were collected preoperatively and postoperatively at months 1, 3, 6, and 12. Safety measures included the number of bleb needlings, complication rate, and additional surgeries.

Results

Mean baseline IOP was 32.4 ± 11.7 mm Hg in the IN group and 21.6 ± 9.2 mm Hg in the SN group (p < 0.01). IOP was similar between groups at 3 months (IN = 15.8, SN = 15.6, p = 0.45), 6 months (IN = 17.4, SN = 15, p = 0.13), and 12 months (IN = 17.9, SN = 14.7, p = 0.15) follow-up. The number of glaucoma medications was also similar at 3 months (p = 0.31), 6 months (p = 0.24), and 12 months (p = 0.39) follow-up. Bleb needling rates were similar with 51.7% (15/29) in the IN group vs 42.7% (41/96) in the SN group (p = 0.39) and subjects requiring further surgery were 17.2% (5/29) in the IN group vs 24.0% (23/96) in the SN group (p = 0.45).

Conclusion

Both IN and SN subconjunctival gel stent placements provide favorable safety and efficacy when treating open-angle glaucoma, with a meaningful decrease in medication use and IOP.

Clinical significance

Implantation of the subconjunctival gel stent in the IN quadrant is an effective and safe alternative to superior implantation in refractory glaucoma.

How to cite this article

Vander Zee BL, Wilson C, Berdahl JP, et al. Superonasal vs Inferonasal Subconjunctival Gel Stent Placement in Patients with Glaucoma. J Curr Glaucoma Pract 2024;18(2):63-67.

A comparative study of cystoid macula edema following glaucoma drainage device surgery versus trabeculectomy

PURPOSE

To assess and compare the risk for development of cystoid macula edema (CME) after glaucoma drainage device (GDD) implantation versus conventional trabeculectomy with mitomycin (trab) for glaucoma.

METHODS

Retrospective review of consecutive patients receiving trab or GDD implantation between 2016 and 2018. Inclusion criteria were availability of pre- and postoperative spectral domain optical coherence tomography (SD-OCT) of the macula. SD-OCT images were evaluated for presence of CME qualitatively, central subfield thickness (CST) and macular volume (MV).

RESULTS

73 eyes could be included, 42 received trab and 31 GDD surgery. Eyes receiving trab on average had 0.8 ± 0.8 previous intraocular operations, while eyes with GDD implantation had 3.1 ± 1.9 (p < 0.001). Occurrence of postoperative CME was significantly more frequent after GDD implantation (6 out of 31 (19.4%)) than after trab (2 out of 42 eyes = 4.8%), (p = 0.049). Mean preoperative CST as well as MV was comparable in both groups (CST before trab: 282.7 ± 23.0 µm, CST before GDD 284.2 ± 27.3 µm, p = 0.287; MV before trab: 7.8 ± 1.1 mm3, MV before GDD: 8.0 ± 0.8mm3, p = 0.305). Mean postoperative CST and MV were significantly higher after GDD (CST 338.5 ± 129.3 µm, MV 8.8 ± 2.6 mm3) than after trabeculectomy (CST 290.6 ± 60.2 µm, p = 0.038; MV 7.8 ± 1.2mm3, p = 0.039).

CONCLUSIONS

In real-life conditions, GDD surgery seems to be associated with a higher risk to develop CME when compared to conventional trabeculectomy. This information may be helpful for glaucoma surgeons to advise the patients on postoperative risks of surgery.

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.

Understanding racial disparities of glaucoma

PURPOSE OF REVIEW

Increased prevalence, earlier onset, and more rapid progression to vision loss from glaucoma has demonstrated racial disparity in numerous studies over decades. Precise etiologies of these important differences among patients of African and Hispanic ancestral background have not been elucidated. This review focuses on currently available epidemiologic/population, genetic, socioeconomic and physiologic studies of racial disparities in this blinding disease.

RECENT FINDINGS

In depth reviews of several landmark studies of glaucoma prevalence in various racial groups have highlighted potential challenges of lack of recruitment of diverse populations in genetic studies and clinical trials, challenges of racial stratification of subjects, and the impact of socioeconomic variables.

SUMMARY

Through a more comprehensive analysis of racial disparities of glaucoma, both clinicians and researchers may provide more effective population screening and management with a holistic approach for individualized patient care to provide improved outcomes. Future studies of interventions in sociodemographic factors and genetic/physiologic variables that influence the prevalence, access, and consequential vision loss from glaucoma will be crucial to minimize/eliminate racial disparities and improve outcomes for all.

Same-quadrant Baerveldt Glaucoma Implant-250 to Baerveldt Glaucoma Implant-350 exchange

Purpose

In eyes with a prior failed aqueous shunt (or "tube") requiring additional intraocular pressure (IOP) control, options include angle surgery, cyclodestruction, second tube, tube revision, or tube exchange. We present a case of a same-quadrant tube exchange of a Baerveldt-250 (BGI-250) to BGI-350.

Observations

The patient is a 71-year-old African American female with severe-stage primary open angle glaucoma of both eyes, and this case focuses on the right eye. This eye had prior cataract surgery with iStent, prior BGI-250 in the anterior chamber (AC), and prior iStent removal with gonioscopy assisted transluminal trabeculotomy (GATT). The visual acuity (VA) was 20/150, and the IOP was 26 mmHg on 3 IOP-lowering medications. The prior superotemporal BGI-250 had its "wings" on top of the superior and lateral rectus muscles and its tube tip in the AC. The implant was removed in its entirety including the superficial and deep layers of its capsule. The new BGI-350 was stented with a 3-0 polypropylene ripcord, ligated with a 7-0 polyglactin suture, and implanted with its wings under the rectus muscles and the tube tip in the sulcus. For early IOP-lowering prior to ligature dissolution, 2 needle stab fenestrations and an additional 7-0 polyglactin wick was used. The capsule from the prior BGI-250 was used as a patch graft for the new BGI-350. The ligature dissolved at postoperative week (POW) 6. By POW8, the IOP was 18 mmHg on 3 IOP-lowering medications and frequent topical steroid, the AC was quiet, and the ripcord was removed. A slow steroid taper finished at postoperative month (POM) 6. By POM 12, the VA was still at baseline 20/150, and the IOP was 14 mmHg on 3 IOP-lowering medications.

Conclusions & importance

Patients with a prior failed tube requiring additional IOP-lowering can undergo a same-quadrant tube exchange. BGI-350s may offer more IOP-lowering than BGI-250s, but the IOP-lowering achieved in this patient's case could be attributable to differences in postoperative management in addition to endplate size; longer follow-up is needed. A tube exchange offers the opportunity to reposition the tube tip from the AC to the sulcus and to use the prior tube's capsule as a patch graft for the new tube.

Assessing the Efficacy of the PAUL Glaucoma Implant in Pseudoexfoliative Glaucoma

Objectives

The aim of the study was to evaluate the outcomes and complications associated with PAUL glaucoma implant (PGI) surgery in pseudoexfoliation glaucoma (PXG) patients, comparing them with a primary open-angle glaucoma (POAG) control group.

Methods

A retrospective analysis included 39 PXG and 29 POAG eyes undergoing PGI surgery between January 2020 and December 2022. Surgical success was defined as intraocular pressure (IOP) between ≤21 and ≥6 mmHg at 12 months and no loss of light perception. Demographic data, ocular examinations, and complications were recorded.

Results

PXG patients (68.5±9.9 years) differed significantly in age from POAG patients (54.1±10.6 years) (p<0.05). Surgical success rates at 12 months were 97.4% (PXG) and 86.2% (POAG). No significant inter-group differences in gender, laterality, lens status, vertical cup/disc ratio, or pre-operative best-corrected visual acuity were observed. Mean IOP comparisons showed significant differences within both groups (p<0.001). Ripcord suture removal occurred at mean 30.3±7.43 days (PXG) and 30.6±9.89 days (POAG). Median pre-operative AGM use was 4 (PXG) and 3 (POAG). No significant differences were noted postoperatively.

Conclusion

To the best of our knowledge, this is the first study to evaluate the results of PGI in PXG and POAG, demonstrating a remarkable success rate and limited complications. Encouragingly, PXG patients with a history of unsuccessful filtration surgery demonstrated positive outcomes. The findings affirm PGI as a promising surgical intervention for PXG and POAG, exhibiting high success rates and manageable complications.

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.

Update on Diagnosis and Treatment of Uveitic Glaucoma

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

Aqueous Shunts with Extraocular Reservoir for Open-Angle Adult Glaucoma: A Report by the American Academy of Ophthalmology

PURPOSE

To evaluate the recently published literature on the efficacy and safety of the use of aqueous shunts with extraocular reservoir for the management of adult open-angle glaucomas (OAGs).

METHODS

A search of peer-reviewed literature was last conducted in April 2023 of the PubMed database and included only articles published since the last aqueous shunt Ophthalmic Technology Assessment, which assessed articles published before 2008. The abstracts of these 419 articles were examined, and 58 studies were selected for full-text analysis. After inclusion and exclusion criteria were applied, 28 articles were selected and assigned ratings by the panel methodologist according to the level of evidence. Twenty-five articles were rated level I and 3 articles were rated level II. There were no level III articles.

RESULTS

Implantation of aqueous shunts with extraocular reservoir can lower intraocular pressure (IOP) by between one-third and one-half of baseline IOP, depending on whether it is undertaken as the primary or secondary glaucoma surgery. Success rates for aqueous shunts were found to be better than for trabeculectomies in eyes with prior incisional surgery. Conversely, in eyes without prior incisional surgery, implantation of aqueous shunts was found to have an overall lower success rate as the primary glaucoma procedure compared with trabeculectomy. Although both valved and nonvalved aqueous shunts with extraocular reservoir were effective, the nonvalved device generally achieved slightly lower long-term IOPs with fewer glaucoma medications and less need for additional glaucoma surgery. Both devices slow the rates of visual field progression with efficacy comparable with that of trabeculectomy. Early aqueous humor suppression after aqueous shunt implantation is recommended for the management of the postoperative hypertensive phase and long-term IOP control. No strong evidence supports the routine use of mitomycin C with aqueous shunt implantation for OAG.

CONCLUSIONS

Implantation of aqueous shunts with extraocular reservoir, including valved or nonvalved devices, has been shown to be an effective strategy to lower IOP. Strong level I evidence supports the use of aqueous shunts with extraocular reservoir by clinicians for the management of adult OAG.

FINANCIAL DISCLOSURE(S)

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

Short-term report of early glaucoma surgery with a clear lens extraction and an intraocular lens, OMNI canaloplasty, and a HYDRUS microstent: a case series in younger patients

Purpose

The purpose of this case series is to report the surgical outcomes from the combination of a clear lensectomy, OMNI® canaloplasty, and a HYDRUS® microstent with an adjacent goniotomy.

Methods

This is a retrospective non-comparative single-center case series of four black patients of African descent with glaucoma who were treated with a clear lensectomy, OMNI canaloplasty, and a HYDRUS microstent with an adjacent goniotomy. The surgeries were performed by an experienced cataract and glaucoma surgeon, Daniel Laroche, MD. The parameters investigated in this study were postoperative intraocular pressure (IOP) and the mean number of preoperative and postoperative medications needed.

Results

The mean age of the four patients was 44.5 years. All patients had a mean postoperative reduction in IOP of 17 mmHg to 12.7 mmHg. The mean number of preoperative medications was 2.2, while the mean number of postoperative medications was 0.3. Potential complications such as hyphema, IOP spikes, or corneal edema were not seen in this series. All patients achieved a lower IOP and stable vision with less refractive error. Patients also experienced improved visual fields, clearer vision, and more open angles.

Conclusion

Clear lensectomy and combined microinvasive glaucoma surgery (MIGS) in patients with primary open-angle glaucoma (POAG) and narrow-angle glaucoma (NAG) results in the safe lowering of IOP. The limitations of this study include the small series size and the retrospective potential for bias. Further research with a larger series and a prospective trial with follow-up should be performed.

Techniques and Preferences for Nonvalved Aqueous Shunts: A Survey of American Glaucoma Society Members

PURPOSE

To assess practice patterns and opinions of glaucoma specialists regarding indications, surgical technique, and postoperative management for nonvalved aqueous shunts.

DESIGN

Anonymous online survey study.

PARTICIPANTS

American Glaucoma Society (AGS) members.

METHODS

An anonymous online survey was distributed to glaucoma specialists via the AGS forum from June to August 2022.

MAIN OUTCOME MEASURES

Survey questions and responses were assessed in 4 sections: (1) general demographics and practice patterns; (2) nonvalved tubes vs. trabeculectomy; (3) nonvalved tubes vs. valved tubes; and (4) nonvalved tube techniques.

RESULTS

There were 132 respondents; nonvalved tubes were reported to be performed more often than trabeculectomy by 61% of respondents within 5 years of completing training and 23% of respondents with more than 15 years since completing training. The most frequently preferred types of nonvalved tubes were Baerveldt-350 (41%), Baerveldt-250 (27%), and ClearPath-250 (18%). In patients with lower target intraocular pressure (IOP), 92% of respondents preferred trabeculectomy over nonvalved tube; 33% cited a cutoff of < 12 mmHg, and 31% cited a cutoff of < 15 mmHg. In patients with higher preoperative IOP, 50% of respondents preferred valved over nonvalved tubes; 29% cited a cutoff of > 40 mmHg, and 38% cited a cutoff of > 30 mmHg. The most frequently used ligature was 7-0 Vicryl (69%). The most frequently used strategies for early IOP lowering were fenestrations without wicks (70%) and with wicks (22%), with one 10-0 Nylon being the most used wick technique (22%). Overall, 37% of respondents use a ripcord; among ripcord users, 55% use it for hypotony prevention (3-0 Prolene most common for this purpose at 35%), and 40% use it for optional early IOP lowering (4-0 Nylon most common for this purpose at 21%). If IOP is too high at postoperative week 4, 38% of respondents do not open the tube early.

CONCLUSIONS

We demonstrate significant heterogeneity regarding specific indications, surgical technique, and postoperative management for nonvalved tubes. Future work is needed to identify and develop standardized guidelines alongside best practices.

FINANCIAL DISCLOSURE(S)

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

Difficult decisions, filtration surgery, and the heartbreak of the numerator

A 70-year-old man had progressive and severe glaucoma in each eye. He was intolerant to dorzolamide, brimonidine, and netarsudil. Each eye had prior selective laser trabeculoplasty (SLT) as well as phacoemulsification plus minimally invasive glaucoma surgery (MIGS) 6 years before current presentation (iStent [Glaukos Corp.] in the right eye and Cypass [Alcon Laboratories, Inc.] in the left eye). Postoperative acuities were 20/20 and 20/25 in the right and left eyes, respectively. When his left eye progressed with loss of central acuity despite peak intraocular pressures (IOPs) in the middle to upper teens, neuro-ophthalmology consultation was obtained (Figure 1JOURNAL/jcrs/04.03/02158034-202401000-00017/figure1/v/2023-12-22T124801Z/r/image-tiff). That workup included magnetic resonance imaging scan and hematologic screening, but all results were negative, and the neuro-ophthalmic consultant concluded that the vision loss was likely on the basis of glaucoma. Accordingly, a trabeculectomy was performed in the left eye achieving consistent IOPs in the range of 7 to 10 mm Hg without medications, rending the left eye stable since the filtration surgery nearly 2 years previously. The right eye continued to progress both subjectively and objectively, and on recent examination, the IOP measured 20 mm Hg and 09 mm Hg in the right and left eyes, respectively (Figure 2JOURNAL/jcrs/04.03/02158034-202401000-00017/figure2/v/2023-12-22T124801Z/r/image-tiff). Medications included timolol and latanoprostene bunod in the right eye only. Central corneal thickness was 526 μm and 527 μm in the right and left eyes, respectively. The visual acuity now measured 20/25 in the right eye and 20/250 in the left eye. The vertical cup-to-disc ratio was 0.9 in the right eye and 1.0 in the left eye. Gonioscopy revealed a wide open angle in each eye with a patent sclerostomy superiorly in the left eye. The conjunctiva and sclera were healthy and without scarring in the right eye. The bleb in the left eye was diffuse, lightly vascularized, and seidel negative. Axial length (AL) was 26.88 μm in the right eye and 26.77 μm in the left eye. The patient was in good health and was not anticoagulated. An extensive discussion ensued about the best course of action for the right eye. How would you proceed in managing definite progression in this individual's right eye, knowing that he had lost fixation in his left eye at similar pressures?

Full Thickness Prophylactic Scleral Windows Decrease the Rate of Choroidal Effusion and Drainage Surgery after Ahmed Glaucoma Valve Implantation

Purpose

To evaluate the effect of creating a full-thickness prophylactic scleral window (PSW) during Ahmed glaucoma valve (AGV) surgery on the rate of postoperative choroidal effusion and choroidal drainage surgery.

Methods

In this retrospective matched case-control study, after insertion of AGV tube a PSW was created in one group. The control-matched group had AGV without a PSW. Primary outcome measures were the rate of choroidal effusion formation and choroidal drainage surgery.

Results

In total, 544 patients (604 eyes) had undergone AGV implantation from 2013 to 2017. The PSW group consisted of 111 eyes of 111 patients and the control group had 111 eyes of 98 matched patients. There were no differences for systemic diseases, number of anti-glaucoma drugs, aspirin use, smoking, laterality of the operated eye, axial length, and central corneal thickness between the groups. Out of 12 eyes with choroidal effusion, only one belonged to the PSW group (P=0.02). Six eyes in the control group needed choroidal drainage surgery, but none of the eyes in the PSW group required this procedure (P=0.02). No intra- and postoperative issues were observed at the site of the scleral window in the PSW group.

Conclusion

PSW creation during AGV surgery is a safe method to decrease the rate of choroidal effusion and choroidal drainage surgery.

Phacogoniotomy versus phacotrabeculectomy for advanced primary angle-closure glaucoma with cataract: A randomized non-inferiority trial

PURPOSE

To investigate the effectiveness and safety of phacogoniotomy versus phacotrabeculectomy (PVP) among patients with advanced primary angle-closure glaucoma (PACG) and cataracts.

DESIGN

Multicenter, randomized controlled, non-inferiority trial.

METHODS

A total of 124 patients (124 eyes) with advanced PACG and cataracts were enrolled, with 65 in the phacogoniotomy group and 59 in the phacotrabeculectomy group. Patients were followed up for 12 months with standardized evaluations. The primary outcome was the reduction in intraocular pressure (IOP) from baseline to 12 months postoperatively, of which a non-inferiority margin of 4 mmHg was evaluated. Secondary outcomes included the cumulative surgical success rate, postoperative complications, and changes in the number of glaucoma medications.

RESULTS

After 12 months, phacogoniotomy demonstrated non-inferiority to phacotrabeculectomy in terms of IOP reduction, with mean IOP reductions of - 26.1 mmHg and - 25.7 mmHg (P = 0.383), respectively, from baseline values of around 40 mmHg. Both groups experienced a significant reduction in the mean number of medications used postoperatively (P < 0.001). The cumulative success rate was comparable between the groups (P = 0.890). However, phacogoniotomy had a lower rate of postoperative complications and interventions (12.3% and 4.6%) compared to phacotrabeculectomy (23.7% and 20.3% respectively). The phacogoniotomy group reported shorter surgery time (22.1 ± 6.5 vs. 38.8 ± 11.1 min; P = 0.030) and higher quality of life (EQ-5D-5 L) improvement at 12 months (7.0 ± 11.5 vs. 3.0 ± 12.9, P = 0.010) than the phacotrabeculectomy group.

CONCLUSIONS

Phacogoniotomy was non-inferior to phacotrabeculectomy in terms of IOP reduction for advanced PACG and cataracts. Additionally, phacogoniotomy provided a shorter surgical time, lower postoperative complication rate, fewer postoperative interventions, and better postoperative quality of life.