Primary Deep Sclerectomy in Open-Angle Glaucoma

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.

Short-term safety and efficacy of Preserflo™ Microshunt in glaucoma patients: a multicentre retrospective cohort study

BACKGROUND/AIMS

To evaluate 1-year success rates and safety profile of Preserflo™ Microshunt in glaucoma patients.

METHODS

Retrospective multicentre cohort study of 100 consecutive eyes (91 patients) from four tertiary-referral glaucoma centres. Four intraocular pressure (IOP) criteria were defined: A: IOP ≤ 21 mmHg+IOP reduction ≥20% from baseline; B: IOP ≤ 18 mmHg+IOP reduction ≥20%; C: IOP ≤ 15 mmHg+IOP reduction ≥25%; D: IOP≤12 mmHg+IOP reduction ≥30%. Success was defined as qualified or complete based on whether reached with or without medication. Primary outcome was success according to the above criteria. Secondary outcomes included: IOP, best-corrected visual acuity (BCVA), medication use, complications, postoperative interventions, and failure-associated factors.

RESULTS

Qualified and complete success rates (95% CI) at 12 months were 74%(66-83%) and 58%(49-69%) for criterion A, 72%(63-82%) and 57%(48-68%) for B, 52%(43-63%) and 47%(38-58%) for C, 29%(21-40%) and 26%(19-36%) for D. Overall median (interquartile range (IQR)) preoperative IOP decreased from 21.5(19-28) mmHg to 13(11-16) mmHg at 12 months. BCVA was not significantly different up to 12 months (p = 0.79). Preoperative median (IQR) number of medications decreased from 3 (2-3) to 0 (0-1) at 12 months. Twelve eyes underwent needling, five surgical revision and one device removal due to corneal oedema. There were no hypotony-related complications. Non-Caucasian ethnicity was the only risk factor consistently associated with increased failure.

CONCLUSIONS

Preserflo™ Microshunt is a viable surgical option in glaucoma patients, with reasonable short-term success rates, decreased medications use, excellent safety profile, smooth postoperative care, and rapid learning curve. Success rates for the most stringent IOP cutoffs were modest, indicating that it may not be the optimal surgery when very low target IOP is required.

Advances in Glaucoma Surgery

Glaucoma is one of the leading causes of irreversible sight loss worldwide, with a prevalence of 64 [...].

Same-site trabeculectomy with mitomycin and Ologen™ following failed non-penetrating deep sclerectomy

PURPOSE

To assess the effectiveness and safety of same-site trabeculectomy (TRAB) with mitomycin C (MMC) and Ologen™ (Aeon Astron Europe BV. Leiden, The Netherlands) in patients with a failed non-penetrating deep sclerectomy (NPDS).

METHODS

A retrospective study of 24 consecutive eyes (22 patients) undergoing reintervention by same-site TRAB with at least one-year follow-up after failed NPDS. Mean visual acuity (VA), intraocular pressure (IOP) and use of glaucoma medications were compared before and one year after surgery. Early and late postoperative complications were registered. Kaplan-Meier survival analysis was performed according to four levels of success criteria.

RESULTS

Overall the mean IOP reduced significantly (24.9 ± 7.1 vs. 14.4 ± 4.5 mmHg; p < 0.001), and the number of glaucoma medications (2.80 ± 1.01 vs. 0.55 ± 0.94; p < 0.001) significantly decreased, one year after surgery. The mean VA remained stable one year after surgery (p = 0.516). Hypotony, defined as IOP ≤ 5 mmHg, in the early postoperative period was observed in 62.5% of eyes, but only in 2 patients (8.33%) in the long term. The mean survival time ranged from 10 months (CI 95% 5-15) to 29 months (CI 95%: 26-32) according to the most stringent and lenient success criteria respectively.

CONCLUSION

Same-site TRAB augmented with MMC and Ologen™ may provide an effective, safe and lasting alternative following failed NPDS, especially when sparing of the conjunctiva is highly desirable. Postoperative hypotony is the most common postoperative complication.

Endophthalmitis and blebitis following deep sclerectomy and trabeculectomy with routine use of mitomycin C

PURPOSE

The purpose of the study was to investigate the incidence for endophthalmitis and blebitis after deep sclerectomy (DS) and trabeculectomy with routine use of Mitomycin C (MMC) 0.4 mg/ml.

METHODS

Electronic medical records of patients who underwent surgery 1/2008-4/2020 were reviewed. Cumulative incidence for bleb-associated infection (BAI), including both endophthalmitis and blebitis, was calculated with cumulative incidence function (CIF) and Kaplan-Meier analysis. Risk factors for BAI were evaluated with univariate competing risk regression analysis and Log-rank analysis. Competing event in CIF was death.

RESULTS

In this retrospective single-centre cohort study, a total of 2653 patients and 3411 eyes underwent surgery: 3478 glaucoma surgeries, 2419 DS and 1059 trabeculectomies. Two cases of endophthalmitis and three of isolated blebitis developed. Median follow-up from the most recent surgery on the eye until the end of the study was 5.5 years, and until last visit at the ophthalmology department was 1.9 years. For the whole follow-up period in CIF-analysis, cumulative incidence for BAI was 0.16% (95% CI 0.06-0.36) at five years. Incidence was higher with eyes not treated with an antifibrotic during surgery (sub-hazard ratio 11.66, 95% CI 1.94-70.21, p = 0.007). Cumulative incidence between surgery and last visit with Kaplan-Meier analysis was 0.21% (95% CI 0.08-0.52) at five years, similarly, not using an antifibrotic increased incidence (Log-rank p < 0.001).

CONCLUSION

Cumulative incidence for BAI was low despite routine use of high-dose MMC.

Systematic Review of MIGS and Non-Penetrating Glaucoma Procedures for Uveitic Glaucoma

Minimally invasive glaucoma surgeries (MIGS) and non-penetrating glaucoma procedures have changed the surgical management of glaucoma in recent years and are being explored in the management of uveitic glaucoma. Deep sclerectomy, Xen45 gel stent, gonioscopy-assisted transluminal trabeculotomy (GATT), trabectome, and canaloplasty are described in the literature as alternative surgeries that may work for uveitic glaucoma. While most of the published studies are retrospective case series, the results suggest success even in refractory cases and with less inflammation than more traditional surgeries.

Long-term outcome of supraciliary gold micro shunt in refractory glaucoma

Purpose

To evaluate the 10‐year follow‐up efficacy and safety of gold micro shunt (GMS) in patients with refractory glaucoma, and the potential risk factors for failure.

Methods

Retrospective data analyses based on medical records from 55 patients who underwent GMS implant for refractory glaucoma between March 2007 and April 2008. The primary outcome measure was the cumulative probability of success defined as intraocular pressure (IOP) below 21 mmHg together with a 33% lowering of the baseline IOP with (qualified) or without (complete) topical medications, no reoperation for glaucoma or loss of light perception.

Results

Mean IOP 10 years after the GMS implantation was 21.6 ± 5.1 mmHg with 2.7 ± 0.7 drugs. Qualified success was achieved in 8/55 patients (14.5%) with a mean of 2.9 ± 0.8 drugs at 5 years and in 2/55 patients (3.6%) with a mean of 2.7 ± 1.0 drugs at 10 years. None of the patients reached complete success at five years from surgery. The cumulative probability of complete success was 14%, 9% and 0% at 1, 2 and 5 years, respectively, and 72%, 67%, 36% and 3.6% at 1, 2, 5 and 10 years, respectively, for qualified success criterion. Baseline IOP for complete success, number of baseline medication for qualified success and age at the time of GMS implantation for both criteria were risk factors significantly associated with failure.

Conclusion

A very low long‐term survival rate of GMS in refractory glaucoma was found. Most patients did not reach the IOP success criteria of the study, even with the re‐introduction of medications, leading to the need for further surgical procedures.

Rotational extraction of incarcerated iris (REII): a slit lamp technique to reduce incarcerated iris after nonpenetrating deep sclerectomy for glaucoma

PURPOSE

Iris incarceration is a complication of glaucoma filtering surgery that often requires surgery. We describe a technique for reduction of incarcerated iris at the slit lamp, dubbed rotational extraction of incarcerated iris (REII). A retrospective analysis of visual function and intraocular pressure (IOP) was done in patients treated with REII after nonpenetrating deep sclerectomy.

METHODS

We retrospectively evaluated a cohort of patients who received REII for iris incarceration after nonpenetrating deep sclerectomy for glaucoma. IOP (applanation) and visual acuity (VA) were measured day-of, and 1, 3, 6, and 12 months post-REII. Adverse events were recorded. Kaplan-Meier survival analysis was done with definitions of IOP control at 15, 18, and 21 mmHg.

RESULTS

Forty-one eyes of 41 patients were treated with REII. Median time to iris incarceration from glaucoma surgery was 50 days (range 1-1906). Mean pre-REII IOP ± SD was 33.7 ± 14.1 mmHg, which reduced to 11.5 ± 6.1 mmHg day-of. LogMAR VA was 0.72 ± 0.8 log units at baseline and was unchanged at 12 months (P = 0.53). Survival analysis demonstrated varying efficacy depending on the definition of success. 79.0 to 92.2% of eyes achieved IOP control immediately after REII, 39.5 to 71.1% at 1 month, 26.3 to 52.6% at 3 months, 21.1 to 44.3% at 6 months, and 10.5 to 38.0% at 12 months. Nearly half (47.4%) of eyes required a tube shunt by 12 months.

CONCLUSION

REII may be a safe, minimally invasive slit lamp procedure that can reduce incarcerated iris and delay more invasive intervention for 3-6 months in most eyes.

Intermediate Outcomes of Deep Sclerectomy in Juvenile Glaucoma

PRCIS

In this retrospective study of patients with predominantly severe juvenile open-angle glaucoma, deep sclerectomy (DS) achieved a success rate [defined as intraocular pressure (IOP) between 5 to 18 mm Hg] of 72% at 3 years.

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of DS in patients with juvenile open-angle glaucoma (JOAG).

METHODS

A retrospective chart review of all JOAG patients that underwent DS with mitomycin C at a tertiary care eye center during the period from May 2014 to May 2019.

RESULTS

A total of 50 eyes in 37 patients were included. The mean age at the time of surgery was 27.1±11.3 years and the majority of patients (86%) had a cup-disc ratio of 0.8 to 0.9. The mean duration of follow-up was 26.1±13.4 months (range 12 to 54 mo). Mean IOP was reduced from 26.1±13.4 mm Hg at baseline to 15.2±6.4 mm Hg at the last follow-up visit (P<0.01). Moreover, the mean number of glaucoma medications decreased from 3.8±0.5 at baseline to 0.8±1.2 at the last follow-up visit (P<0.01). The cumulative probabilities of overall success (defined as IOP between 5 and 18 mm Hg) at 12, 24, and 36 months were 94%, 85%, and 72%, respectively. Hypotony occurred in 4 eyes (8%), and in one of these patients, the final visual acuity was >2 lines worse compared with presentation. No other vision-threatening complications were encountered.

CONCLUSION

DS in JOAG was safe and successfully controlled IOP in most patients for 3 years.

Bilateral Nonpenetrating Deep Sclerectomy: Difference in Outcomes Between First- and Second-Operated Eyes at 24 Months

BACKGROUND/AIM

The aim of this study was to assess the difference in outcome between the first-operated and the second-operated eyes after nonpenetrating deep sclerectomy (DS), and to identify potential success predictors for the second eye.

METHODS

This single-surgeon, retrospective study analyzed the outcomes of all bilateral nonsimultaneous DS with at least 24 months of follow-up. Its main outcome measure was surgical success, defined as unmedicated intraocular pressure (IOP) ≤15 mm Hg associated with a relative reduction ≥20%.

RESULTS

In all, 104 eyes of 52 patients who underwent bilateral (standalone or combined) DS, within a mean of 344.3±526.3 days of each other, were analyzed. Postoperatively, the mean medicated IOP decreased from 20.7±7.9 (first-operated eyes) and 19.3±6.6 mm Hg (second-operated eyes) at baseline (P=0.107) to 13.8±4.8 [(-33.3%; P<0.001) first-operated eyes) and 12.7±3.8 mm Hg [(-34.2%; P<0.001) second-operated eyes] after 2 years (P=0.619). Postoperative IOP and treatment reduction, respectively, showed fair (r=0.53) and good (r=0.71) levels of correlation between fellow eyes. The rates of complete success were comparable between first-operated and second-operated eyes (32.7% and 40.4%, respectively; P=0.364). At 2 years, among patients whose first-operated eyes were considered a success, 82.4% of surgeries in second eyes were successful (P=0.001). The odds ratio of a second-operated eye experiencing complete success were 6.32 (P=0.011) if the first-operated eye experienced complete success.

CONCLUSIONS

The present study demonstrated a strong association between first-operated and second-operated eyes after DS, in terms of surgical outcomes and IOP reduction. In effect, surgical success in the first-operated eye increases the odds of success in the second eye by 6-fold.

Safety, efficacy, and timing of Nd:YAG laser goniopuncture after nonpenetrating deep sclerectomy for glaucoma: A retrospective cohort study

BACKGROUND

Neodymium-doped yttrium aluminum garnet laser goniopuncture is an adjuvant procedure for nonpenetrating deep sclerectomy. We investigated optimal laser goniopuncture timing and the effect of laser iridoplasty on success rates.

METHODS

This single-center retrospective cohort study compared intraocular pressure control in patients with early versus late laser goniopuncture after nonpenetrating deep sclerectomy and evaluated the effects of laser iridoplasty pretreatment. A 3-month cut-off was used to define early versus late laser goniopuncture. The primary outcome was the proportion of patients maintaining intraocular pressure control according to definitions of complete (no medications) and qualified (with medications) success at 15, 18, and 21 mmHg thresholds. Data were analyzed using right-censored Kaplan-Meier estimation and log-rank testing.

RESULTS

A total of 124 eyes of 124 patients were analyzed. Complete success rates after 3 years were 9.2%, 14.6%, and 23.3% for early laser goniopuncture and 21.8%, 26.0%, and 55.4% for late laser goniopuncture for 15, 18, and 21 mmHg, respectively (all p < .01). Qualified success rates after 3 years were 16.6%, 24.8%, and 40.9% for early laser goniopuncture and 21.5%, 56.1%, and 69.6% for late laser goniopuncture for 15, 18, and 21 mmHg, respectively (p  =  .096, .0026, .0061). Late laser goniopuncture was associated with decreased risk of iris incarceration and bleb collapse. Iridoplasty pretreatment was not associated with improved outcomes.

CONCLUSION

Late laser goniopuncture (3-month cut-off) was associated with better intraocular pressure control and less adverse events than early laser goniopuncture.

Hypotony-associated Complications After Deep Sclerectomy: Incidence, Risk Factors, and Long-term Outcomes

PRECIS

Chronic hypotony is not uncommon following deep sclerectomy (DS), but only a minor proportion of patients develop hypotony-associated complications. Numerical hypotony does not affect the visual outcomes. This study identifies factors associated with hypotony.

PURPOSE

To investigate the incidence and risk factors of hypotony and hypotony-associated complications after DS.

METHODS

Retrospective cohort study of 1765 eyes (1385 patients) undergoing DS with or without cataract extraction between 2001 and 2020 in 2 UK centers. Chronic hypotony was defined as intraocular pressure (IOP) ≤5 mm Hg in ≥2 consecutive visits lasting >90 days or as any IOP ≤5 mm Hg associated with hypotony-related complications or requiring surgical intervention. Clinical hypotony was defined as the presence of: serous or hemorrhagic choroidal detachment, hypotony maculopathy, flat anterior chamber requiring reformation, decompression retinopathy. The incidence of hypotony was calculated with Kaplan-Meier statistics, and Cox regression was used to identify risk factors.

RESULTS

The median (interquartile range) age and follow-up were 76 (67 to 82) years and 45.4 (20.9 to 79.8) months, respectively. The incidence (95% confidence interval) of chronic and clinical hypotony at 5 years was 13.4% (11.5%-15.3%) and 5.6% (4.3%-6.9%), respectively. Sixteen eyes (15.7%) with hypotony-associated complications had IOP >5 mm Hg. Male sex (hazard ratio [HR]: 1.89, P=0.018), non-Caucasian ethnicity (HR: 2.49, P=0.046), intraoperative bevacizumab (HR: 3.96, P=0.01), pigmentary glaucoma (HR: 3.59, P=0.048), previous vitreoretinal surgery (HR: 5.70, P=0.009), intraoperative microperforation (HR: 4.17, P<0.001) and macroperforation (HR: 20.76, P<0.001), and avascular bleb (HR: 1.80, P=0.036) were associated with clinical hypotony.

DISCUSSION

Chronic hypotony is not uncommon following DS, but clinical hypotony is infrequent. Hypotony associated-complications can occur in eyes without statistical hypotony.

Pigmentdispersionssyndrom

Das Pigmentdispersionssyndrom ist eine Erkrankung, die durch Abschilferung von Pigment aus dem Irispigmentepithel und dessen Ablagerung im vorderen Augenabschnitt charakterisiert ist. Typisch ist eine Trias aus Ablagerungen am Hornhautendothel, zirkulären Iristransilluminationen und einer Pigmentierung des Trabekelwerks. Das Spektrum reicht vom einfachen Pigmentdispersionssyndrom bis zum Pigmentdispersionsglaukom mit Optikusatrophie.

[Pigment Dispersion Syndrome]

Pigment dispersion syndrome (PDS) is a disorder predominantly affecting young, myopic adults. It is characterised by the liberation of pigment of the iris and deposition of it on various structures of the anterior segment leading to multiple specific findings in slit lamp examination. Typical alterations are a deposition of pigment on the central corneal endothelium, circular iris transillumination defects in the mid periphery, a posterior bowing of the iris and increased pigmentation of the trabecular meshwork. Findings are usually bilateral symmetric. Posterior bowing of the iris causes rubbing of the pigmented iris epithelium against lens structures like zonular fibres with a consecutive liberation of pigment. Trabecular meshwork changes because of pigment deposition reduce aqueous outflow facility with the risk of elevated intraocular pressure and glaucoma. Pigmentary glaucoma (PG) is a secondary open angle glaucoma. Treatment of PG is similar to primary open angle glaucoma, including medical therapy, laser therapy and surgery. Peripheral laser iridotomy was shown to change iris configuration but its efficacy in the prevention of PG has not been confirmed in the literature. The purpose of this paper is to summarize information regarding ocular manifestations of PDS to facilitate an early diagnosis and to present a general view of the treatment of PG.