Ahmed glaucoma drainage implant surgery in the management of refractory uveitic glaucoma: Long-term follow up

Intermediate-Term Outcomes of Ahmed Glaucoma Valve Implantation for Uveitic Glaucoma: A Tertiary Centre Experience

PURPOSE

To present the outcomes of Ahmed glaucoma valve (AGV) implantation in uveitic glaucoma (UG) in a tertiary eye center in Riyadh, Saudi Arabia.

METHODS

A retrospective review of all UG patients who underwent AGV implantation at a single, tertiary care eye center from January 2008 to December 2018. The main outcome measures were change in mean intraocular pressure (IOP), number of antiglaucoma medications, overall success rate in different follow-up periods, complete and qualified success from last follow up, and complications. The success of the treatment was defined as patients achieving intraocular pressure (IOP) levels between 6- and 21-mm Hg with or without additional antiglaucoma medications and/or a minimum of 20% reduction from baseline IOP.

RESULTS

The study included 74 patients (86 eyes), with a mean follow-up of 4.9 ± 2.9 years. The mean IOP was 32.2 ± 8.5 mmHg at baseline and 16.3 ± 6.6 mmHg at the last follow-up (p < 0.001). The mean number of antiglaucoma medications decreased from 3.5 ± 0.7 preoperatively to 1.3 ± 1.4 at the last follow-up (p < 0.001). Overall survival rates at 1, 3, 5, and 10 years were 96.5%, 92.7%, 91%, and 56.9%, respectively. Complete and qualified success rates were 37.9% and 48.3% at the end of follow up, respectively. The rate of postoperative complications was 56%, of which 18 eyes (20%) required surgical revision. Bivariate Cox proportional hazards regression analysis did not reveal any factors significantly associated with failure.

CONCLUSIONS

AGV is safe and effective in providing intermediate-term IOP control in UG patients. Complications reported in our cohort were mostly transient and conservatively treated.

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.

Effect of Early Aqueous Suppression After Valved Tube Shunt Surgery for Uveitic Glaucoma

PURPOSE

To compare outcomes of early aqueous suppression (EAS) and standard therapy (ST) after Ahmed Glaucoma Valve (AGV) implantation for uveitic glaucoma.

DESIGN

Retrospective comparative cohort study.

PARTICIPANTS

All patients with uveitic glaucoma underwent AGV implantation from January 2010 to October 2020 at Northwestern Medicine.

METHODS

Excluding the first postoperative day 1 (POD1), only eyes with IOP 10-15 mmHg at their first visit with IOP ≥ 10 mmHg were included in the main analysis. Early aqueous suppression (EAS) was defined as initiation of ocular hypotensive therapy when IOP was first 10-15 mmHg. Standard therapy was initiation of therapy at any later time. Failure was defined as IOP > 21 mmHg, < 5 mmHg, or < 20% reduction in IOP from baseline after 3 months, for 2 consecutive study visits. Hypotony was defined as IOP ≤ 5 mmHg for ≥ 2 visits. Hypertensive phase was defined as IOP > 21 mmHg for 2 consecutive visits in the first 3 months.

MAIN OUTCOME MEASURES

Proportion achieving overall success; incidence of hypotony and hypertensive phase.

RESULTS

Twenty-eight eyes of 26 patients were in the EAS group and 20 eyes of 19 patients were in the ST group, with a mean follow-up of 17.7 and 28.2 months, respectively. Baseline IOP was similar in the EAS (31.2 ± 10.1 mmHg) and ST (34.6 ± 12.2 mmHg) groups; P = 0.18. Final IOP was lower in the EAS group (12.9 ± 4.6 mmHg) than the ST group (16.4 ± 5.7 mmHg; P = 0.02) on 2.6 ± 0.9 medications in the EAS group and 1.8 ± 1.5 in the ST group (P = 0.07). Overall success was achieved in 87% of EAS eyes and 74% of ST eyes (P = 0.43). There were no statistically significant differences in the occurrence of additional glaucoma surgery (4% for EAS, 20% for ST; P = 0.11), hypotony (7% for EAS, 0% for ST; P = 0.50), or hypertensive phase (4% for EAS, 21% for ST; P = 0.09).

CONCLUSIONS

EAS was associated with a lower final IOP after AGV in uveitic glaucoma eyes; however, more medications were in use at the final visit. No statistically significant differences in overall success or the incidence of adverse events were observed.

FINANCIAL DISCLOSURE(S)

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

Long-term prognosis for glaucoma in patients with Posner-Schlossman syndrome

BACKGROUND

The aim of this study is to investigate the long-term prognosis for glaucoma in patients with Posner-Schlossman syndrome (PSS).

METHODS

In this retrospective case series study, a total of 98 patients with PSS from January 2014 to February 2019 were included in this study. Initial presentations and follow-up data were obtained from medical records. Vision-related quality of life (VR-QoL) was assessed using the 25-item National Eye Institute Visual Functioning Questionnaire.

RESULTS

Of the 98 patients included in the study, 66 (67%) presented with glaucoma, and among them, 21 (32%) required glaucoma surgery. The mean follow-up time was 50.1 months (range 1-263 months). Iris involvement was noted in 46 (46.9%) eyes; 26 (26.5%) had sectoral iris changes and 20 (20.4%) showed diffuse iris changes. Eyes with iris involvement had a significantly higher number of acute attacks of uveitis than those without (p = 0.010). The 5-year glaucoma surgery-free interval was 77.8% according to Kaplan-Meier analysis. Significant predictors of glaucoma surgery included iris involvement (hazard ratio [HR] = 5.215; confidence interval [CI] = 1.387-19.610), highest number of anti-glaucoma agents (HR = 5.069; CI = 1.848-13.905), baseline average retinal nerve fiber layer thickness (RNFLT) thickness (HR = 0.949; CI = 0.917-0.982), and disease duration (HR = 0.977; CI = 0.957-0.996). Overall complete surgical success and qualified success at 2 years was 35.3% and 75.5%, respectively. Patients with iris involvement, glaucoma surgery, and thinner average RNFLT had significantly poorer VR-QoL (all, p < 0.05).

CONCLUSIONS

Patients with PSS and glaucoma required glaucoma surgery in a high rate. Iris involvement increased the probability of surgical treatment and lowered the VR-QoL of PSS patients.

Endophthalmitis caused by Mycobacterium houstonense: case report

BACKGROUND

Mycobacterium houstonense is rapidly growing mycobacteria (RGM) that belongs to M. fortuitum group. So far, there have been few associated reports of human diseases induced by M. houstonense worldwide.

CASE PRESENTATION

We present a delayed-onset postoperative endophthalmitis caused by M. houstonense after glaucoma drainage implant (GDI) surgery. The ocular infection lasted for 2 months without appropriate treatment that developed into endophthalmitis and the patient underwent an emergency enucleation.

CONCLUSION

Implant erosion and a delay in diagnosis of ocular infection could lead to irreversible damage as observed in our case. Ophthalmologists should be alert for ocular RGM infection, and prompt laboratory diagnosis with initiation of effective multidrug therapy might prevent loss of vision.

The role of neuroinflammation in the pathogenesis of glaucoma neurodegeneration

The chapter is a review enclosed in the volume "Glaucoma: A pancitopatia of the retina and beyond." No cure exists for glaucoma. Knowledge on the molecular and cellular alterations underlying glaucoma neurodegeneration (GL-ND) includes innovative and path-breaking research on neuroinflammation and neuroprotection. A series of events involving immune response (IR), oxidative stress and gene expression are occurring during the glaucoma course. Uveitic glaucoma (UG) is a prevalent acute/chronic complication, in the setting of chronic anterior chamber inflammation. Managing the disease requires a team approach to guarantee better results for eyes and vision. Advances in biomedicine/biotechnology are driving a tremendous revolution in ophthalmology and ophthalmic research. New diagnostic and imaging modalities, constantly refined, enable outstanding criteria for delimiting glaucomatous neurodegeneration. Moreover, biotherapies that may modulate or inhibit the IR must be considered among the first-line for glaucoma neuroprotection. This review offers the readers useful and practical information on the latest updates in this regard.