Bimanual trabecular aspiration in pseudoexfoliation glaucoma: an alternative in nonfiltering glaucoma surgery

The Effect of Trabecular Aspiration on Intraocular Pressure, Medication and the Need for Further Glaucoma Surgery in Eyes with Pseudoexfoliation Glaucoma

PURPOSE

To investigate whether trabecular aspiration (TA) has an effective medium-term intraocular pressure (IOP)-lowering and medication-saving effect in patients with pseudoexfoliation glaucoma (PEG). In addition, a subgroup analysis of patients with or without a previous trabeculectomy was performed.

METHODS

Records of 290 consecutive eyes with PEG that underwent TA between 2006 and 2012 at the Department of Ophthalmology, Mainz, Germany, were retrospectively analyzed with a follow-up period of 3 years. The main outcomes were IOP and the need for further medical treatment.

RESULTS

Of the 290 eyes with PEG that received TA, 167 eyes from 127 patients met the inclusion criteria. Among these eyes, 128 received TA and cataract surgery (Phaco-TA) without having had a trabeculectomy (group I) before, 29 had Phaco-TA after a previous trabeculectomy (group II) and 10 underwent stand-alone TA after a previous trabeculectomy (group III). In the whole cohort, the median IOP decreased immediately after TA and remained significantly lower compared to the baseline throughout the period of 36 months. Likewise, the median number of antiglaucoma drugs was reduced over the whole period. At the same time, in group I, the median IOP and the number of antiglaucoma drugs were reduced over 36 months. In contrast, in the post-trabeculectomy groups (group II and III), the median IOP and the number of antiglaucoma drugs could not be reduced. While most of the patients that received Phaco-TA with or without a previous trabeculectomy (group I and II) did not require further surgical intervention during the follow-up period, almost all patients receiving stand-alone TA after a previous trabeculectomy (group III) needed surgical therapy, most of them between the second and the third year following TA.

CONCLUSIONS

Phaco-TA has an effective medium-term pressure-lowering and medication-saving effect, especially in patients without a previous trabeculectomy. In trabeculectomized eyes, the effect of TA is limited but still large enough to delay more invasive surgical interventions in some patients.

Comparison of intraocular pressure fluctuation and glaucoma progression rate between phakic and pseudophakic eyes in pseudoexfoliation glaucoma

The management of patients with concurrent pseudoexfoliation glaucoma (PXG) and cataract is challenging given its worse prognosis compared to other glaucoma types and the increased risk associated with cataract surgery. In this retrospective study, we investigated the long-term outcomes of cataract surgery in patients with PXG. We enrolled patients with PXG who had undergone cataract surgery at least 2 years previously and compared them with mean deviation (MD) matched patients with phakic eyes. The results showed that both groups experienced a decrease in MD, with the group of pseudophakic eyes exhibiting a significantly higher rate of decline (-2.15 ± 2.66 dB/year vs. -0.86 ± 0.95 dB/year; P = 0.040). Similarly, there was a trend towards more rapid thinning of the retinal nerve fiber layer in the pseudophakic group (-2.92 ± 2.34 μm/year vs. -1.79 ± 1.71 μm/year; P = 0.074). No significant differences in the intraocular pressure parameters were observed between the two groups. Multivariate analysis revealed that pseudophakic lens status was significantly associated with a faster rate of MD decline in patients with PXG (regression coefficient, -1.391; P = 0.022). These findings underscore the importance of close monitoring of patients with pseudophakic PXG to effectively manage glaucoma progression.

Outcomes of Prolene Gonioscopy-assisted Transluminal Trabeculotomy in Primary Open-angle Glaucoma and Pseudoexfoliative Glaucoma: A Comparative Study

PRCIS

Gonioscopy-assisted transluminal trabeculotomy (GATT) provides greater intraocular pressure (IOP) reduction in pseudoexfoliative glaucoma (PXG) than in primary open-angle glaucoma (POAG) in the first years of surgery; however, the difference between groups equalizes in the long-term.

PURPOSE

To compare outcomes of GATT in eyes with POAG and PXG.

METHODS

Single-center, retrospective, comparative case series. A total of 202 eyes (91 eyes of POAG; 111 eyes of PXG) were included. GATT was performed as a standalone procedure or in combination with cataract extraction (CE). Outcome measures were change in IOP and number of medications at all time points (1, 3, 6, 9, 12, 18, 24, and 36 mo after surgery), success rate (IOP reduction ≥20% from baseline or IOP between 6-21 mmHg, without further glaucoma surgery), and complication rate. Cumulative success probabilities were compared using Kaplan-Meier survival analyses.

RESULTS

The mean IOP decreased by 8.8 mmHg (34.4%) in the POAG group with a mean decrease of 2 glaucoma medications at final visit. In the PXG group, the mean IOP decreased by 12.8 mm Hg (44.6%) on 2.3 fewer medications. Mean IOP reduction was significantly higher in PXG than POAG at all time points up to 2-year visit (P<0.05 for all), after which the difference was not significant. Cumulative success probability during the first year was significantly higher in PXG (97.6%) than in POAG (86.8%) (P=0.01); no significant difference was found at 2-year (P=0.07) and 3-year visits (P=0.24).

CONCLUSION

GATT was safe and effectively reduced the IOP and medication burden in patients with POAG and PXG. In the first year following GATT, a significantly higher success rate was noted in PXG compared to POAG, however, in subsequent years, the success rate was similar at ~ 75%.

[Secondary open-angle glaucoma: pseudoexfoliative glaucoma, pigmentary glaucoma and neovascular glaucoma]

Secondary open-angle glaucomas are a heterogeneous group of diseases in which a variety of pathophysiological mechanisms result in an elevation of intraocular pressure. This article is the first part of a review of the more common forms of secondary open-angle glaucomas. The pathogenesis, characteristic clinical findings and treatment of pseudoexfoliative glaucoma, pigmentary glaucoma and neovascular glaucoma are discussed. An emphasis is placed on the differences in treatment compared to primary open-angle glaucoma and prophylactic treatment approaches are explained where possible.

Comparison of phacoemulsification parameters in eyes with and without exfoliation syndrome

OBJECTIVE

To evaluate and to compare the phacoemulsification machine parameters in eyes with and without XFS, requiring cataract surgery.

METHODS

Patients who underwent phacoemulsification and in-the-bag IOL implantation for cataract were included in this retrospective study. All surgeries were performed by the same experienced surgeon using the stop & chop technique with the same phacoemulsification device (Infiniti Vision System, Alcon Laboratories, Inc., USA). Patients were divided into two groups according to the presence of exfoliation material (XFM). Each group consisted of consecutive patients. Their characteristics and intraoperative phacoemulsification parameters were compared.

RESULTS

Sixty-eight eyes of 68 patients [29 in the exfoliation syndrome (XFS) (-) group, 39 in XFS (+)] were enrolled. There were no statistical differences regarding preoperative patient characteristics. There was a statistically significant difference in total U/S time, phaco time, aspiration time and estimated fluid used between the XFS (+) and XFS (-) groups (P=0.021, P=0.017, P=0.009 and P=0.002, respectively). Considering that the use of a CTR (capsule tension ring) might be an important factor potentially affecting surgical parameters, the data were analyzed accordingly. Aspiration time and estimated fluid used remained statistically significant (P=0.046 and P=0.017, respectively); however, although the U/S total and phaco time were found to be longer in XFS (+) group compared to XFS (-) group, the difference did not show statistical significance (P=0.061 and P=0.059, respectively). There were no differences between groups regarding endothelial cell loss or any other postoperative complications.

CONCLUSIONS

The presence of XFS results in longer total U/S time, phaco and aspiration time and more estimated fluid used in phacoemulsification, but this prolongation does not result in additional complications.

Goniowash: a new surgical approach combined with cataract surgery to lower intraocular pressure in pseudoexfoliation syndrome

Purpose

Pseudoexfoliation syndrome is common in elderly patients and is associated with intraocular pressure elevation. Goniowash is a novel surgical technique to remove pseudoexfoliation material from the irido-corneal angle to decrease intraocular pressure. We assessed the long-term efficacy of Goniowash on relevant parameters in patients with pseudoexfoliation syndrome, after cataract surgery.

Methods

The study enrolled 122 patients with pseudoexfoliation syndrome, who underwent routine cataract surgery combined with Goniowash. Best-corrected visual acuity, intraocular pressure and medication status were recorded in study participants during 5 years of follow-up.

Results

Data from 190 eyes (122 patients of average age 73.8 ± 7.7 years) were assessed. Mean best-corrected visual acuity increased from 0.60 to 1.0 (p < 0.001) one year after surgery and remained stable throughout the follow-up. Average intraocular pressure decreased from 26.4 ± 7.3 mmHg pre-operatively to 15.9 ± 3.0 mmHg post operatively at one year (p < 0.001), 16.1 ± 3.3 mmHg (p < 0.001) at 3 years and 16.8 ± 2.9 (p < 0.001) at 5 years. Mean number of ocular hypotensive medications decreased from 1.5 ± 0.8 pre-operatively to 0.4 ± 0.7 post-operatively (75% reduction) (p < 0.001). No unexpected and severe adverse events related to the surgical procedure were reported.

Conclusions

Goniowash combined with cataract surgery provides stable and long-lasting reduction of intraocular pressure and hypotensive medications. It is a safe procedure and may be an alternative for patients with pseudoexfoliation syndrome and elevated intraocular pressure.

Prospective Studies of Minimally Invasive Glaucoma Surgeries: Systematic Review and Quality Assessment

Glaucoma is a common blinding disease; while there is no cure, effective treatments include medications, laser, and incisional surgery. There is significant interest from patients and doctors to develop safer surgical options throughout the spectrum of disease, to minimize treatment burden in mild glaucoma patients and to minimize risk of complications in patients needing more aggressive treatment. Surgical procedures called Minimally or Micro-Invasive Glaucoma Surgery (MIGS) are growing in popularity. Eighty-seven prospective studies on MIGS were identified and assessed for quality. Most (74%) did not have a control group. Twelve of the highest quality were reviewed. MIGS procedures appeared to have fewer complications, and lowered intraocular pressure, and reduced medication use. Studies were limited by small sample size, narrow spectrum of glaucomatous disease, and/or conflicts of interest. There is a need for high quality, independently funded and performed, comparative studies on the MIGS to help make treatment decisions.

Monitoring and management of the patient with pseudoexfoliation syndrome: current perspectives

Pseudoexfoliation syndrome (PES) is a complex and age-related systemic disorder characterized by the progressive accumulation and granular deposition of pseudoexfoliative material in various intraocular and extraocular tissues. The diagnosis of PES is so important because it is a major risk factor for complications during cataract surgery and the most frequent cause of secondary glaucoma. In addition to ocular complications, PES is related with numerous systemic abnormalities, for which the list is growing steadily. Therefore, management and monitoring of patients with PES are crucial. The aim of this paper was to review current perspectives on monitoring patients with PES and addressing management of ocular and systemic associations of this clinically important and biologically fascinating disease.

What have we learned about exfoliation syndrome since its discovery by John Lindberg 100 years ago?

Exfoliation syndrome (XFS) is a systemic disease with significant ocular manifestations, including glaucoma and cataract. The disease impacts close to 70 million people globally and is now recognised as the most common identifiable cause of open-angle glaucoma. Since the discovery of XFS 100 years ago by Dr John G. Lindberg, there has been considerable advancement in understanding its pathogenesis and resulting clinical implications. The purpose of this paper is to summarise information regarding the epidemiology, pathophysiology, ocular manifestations and systemic associations of XFS with the objective of sharing clinical pearls to assist in early detection and enhanced management of patients.

Intraocular Pressure Changes after Clear Corneal Phacoemulsification in Nonglaucomatous Pseudoexfoliation Syndrome

Purpose

To present a prospective, nonrandomized study of intraocular pressure (IOP) after clear corneal phacoemulsification in eyes with pseudoexfoliation (PEX) syndrome.

Methods

A PEX group of 39 consecutive open angle, nonglaucomatous eyes with cataract in PEX syndrome, and a control group of 40 consecutive open angle, nonglaucomatous eyes with cataract, were operated on by the same surgeon (D.J.C.), using a standard phaco technique along with bimanual anterior epithelial cells aspiration and, in the PEX group, a bimanual anterior capsule PEX material aspiration. The mean diurnal Goldmann tonometer IOP was calculated preoperatively, after 3 and 6 months and 1 year.

Results

The PEX group preoperative mean IOP was 18.3 mmHg, with a maximum of 24 and a minimum of 11 mmHg. Three months postoperatively a mean IOP change of −3.7 mmHg was found (p<0.0001), with a maximum IOP change of −10 mmHg. Six months and 1 year postoperatively the mean IOP change was −3.7 (p<0.0001) and −3.5 mmHg (p<0.0001), respectively. The control group preoperative mean IOP was 13.9 mmHg, with a maximum of 18 and a minimum of 10 mmHg. Three months postoperatively a mean IOP change of −0.9 mmHg was found (p=0.028), with a maximum IOP change of −3 mmHg. Six months and 1 year postoperatively the mean IOP change was −1.4 (p<0.001) and −0.48 mmHg (p=0.11), respectively.

Conclusions

Phacoemulsification with anterior capsule PEX material aspiration significantly reduced the mean diurnal IOP in the PEX group lasting 1 year postoperatively.

Ab interno trabeculectomy: patient selection and perspectives

Ab interno trabeculectomy is one among several recently introduced minimally invasive glaucoma surgeries that avoid a conjunctival incision and full-thickness sclerostomy involved in traditional glaucoma surgery. Ablation of the trabecular meshwork and inner wall of Schlemm's canal is performed in an arcuate fashion via a clear corneal incision, alone or in combination with phacoemulsification cataract surgery. Intraocular pressure reduction following ab interno trabeculectomy is limited by resistance in distal outflow pathways and generally stabilizes in the mid-to-high teens. Relief of medication burden has been demonstrated by some studies. A very low rate of complications, most commonly transient hyphema and intraocular pressure elevations in the immediate postoperative period, have been reported. However, available data are derived from small retrospective and prospective case series. Randomized, controlled trials are needed to better elucidate the potential merits of ab interno trabeculectomy in the combined setting versus phacoemulsification cataract surgery alone and to compare it with other minimally invasive glaucoma surgeries.

Predictors of intraocular pressure change after phacoemulsification in patients with pseudoexfoliation syndrome

AIM

To evaluate anterior chamber biometric factors and intraoperative metrics associated with the intraocular pressure (IOP) reduction after phacoemulsification in non-glaucomatous pseudoexfoliative syndrome (PXS) eyes.

METHOD

Thirty-three patients were enrolled in this prospective interventional study. Images were excluded if they had poor quality, poor perpendicularity or inability to locate sclera spurs. Anterior chamber depth (ACD), anterior chamber area (ACA), iris thickness, iris area, iris curvature, lens vault, angle opening distance (AOD500, AOD750) and trabecular iris space area (TISA500, TISA750) were measured in qualified images using the Zhongshan Angle Assessment Program and compared preoperatively and 3 months postoperatively. Cumulative dissipated energy (CDE), aspiration time and infusion fluid usage during cataract surgery were obtained from the phacoemulsification machine's metrics record. Postoperative IOP change was compared with these anatomical and intraoperative metric parameters.

RESULTS

Mean IOP was 18.1±3.4 mm Hg preoperatively and decreased by 3.3 mm Hg (18%) to 14.8±3.6 mm Hg at 3 months postoperatively (p<0.001). All angle parameters, ACD and ACA increased significantly postoperatively (p<0.001 for all) and iris curvature decreased (p<0.001). In univariate analysis, preoperative IOP (B=-0.668, p=0.002), infusion fluid usage (B=-0.040, p=0.04) and aspiration time (B=-0.045, p=0.003) were negatively associated with IOP decrease after phacoemulsification. Changes in IOP did not demonstrate significant associations with CDE measurements or anterior segment optical coherence tomography measurements, including preoperative angle, iris or anterior segment parameters. In the final multivariate regression model, preoperative IOP (B=-0.668, p=0.002) and infusion fluid usage (B=-0.041, p=0.04) were significantly associated with IOP drop and together can predict 45.1% (p=0.002) of the variability in IOP change.

CONCLUSIONS

Non-glaucomatous patients with PXS experience moderate IOP reduction following phacoemulsification, and this effect is correlated with preoperative IOP, aspiration time and infusion fluid used intraoperatively.

Pseudoexfoliation Syndrome and Pseudoexfoliation Glaucoma: A Review of the Literature with Updates on Surgical Management

Pseudoexfoliation syndrome (PES) is a systemic disorder caused by progressive accumulation of extracellular material over various tissues. PES usually determines increased intraocular pressure, changes in the anatomical aspects of the optic nerve, and visual field alterations leading to the diagnosis of pseudoexfoliation glaucoma (PEG). Use of topical medical treatment usually leads to poor results in terms of long-term follow-up but many surgical techniques, such as Argon Laser or Selective Laser Trabeculoplasty, have been proposed for the management of PEG affected patients. The present paper is a review on the pseudoexfoliation syndrome and pseudoexfoliation glaucoma with an update on surgical management.

Management of exfoliative glaucoma: challenges and solutions

Exfoliative glaucoma is the most common type of secondary open-angle glaucoma worldwide. It is characterized by high intraocular pressure (IOP) and worse 24-hour IOP characteristics. In order to minimize progression, treatment of exfoliative glaucoma has to provide a low long-term mean IOP and good 24-hour IOP control. To achieve these goals, fixed-dose combination eye drops, argon and selective laser trabeculoplasty, and various forms of surgery (trabeculectomy, deep sclerectomy, viscocanalostomy, ab interno trabeculotomy, trabecular aspiration, and cataract surgery) all need to be considered during the long-term management of the disease. Since exfoliative glaucoma is a disease of the elderly, and is frequently associated with systemic vascular disease, interdisciplinary consultations are of great clinical importance. These management aspects and the current medical, laser, and surgical results are covered in this review, with a special focus on the needs of the general ophthalmologist.

Ocular and systemic manifestations of exfoliation syndrome

Exfoliation syndrome is an age-related disease characterized by the production and progressive accumulation of a fibrillar extracellular material in many ocular tissues. It leads to the most common identifiable cause of open-angle glaucoma worldwide, comprising the majority of glaucoma in some countries. The material in the eye appears as white deposits on the anterior lens surface and/or pupillary border. During pupillary movement, the iris scrapes exfoliation material from the lens surface, while the material on the lens causes rupture of iris pigment epithelial cells, with concomitant pigment dispersion into the anterior chamber and its deposition on anterior chamber structures. Exfoliation material can be found in many different organs. It is an ischemic disease and is associated with elevated serum homocysteine. Systemic associations include transient ischemic attacks, hypertension, angina, myocardial infarction, cerebrovascular and cardiovascular disease, aortic aneurysm, Alzheimer disease, and hearing loss. The discovery in 2007 of nonsynonymous single nucleotide polymorphisms in the LOXL1 (lysyl oxidase-like 1) gene are expected to make a major impact not only in understanding exfoliation syndrome, but in leading to new avenues of therapy.

Future prospects: assessment of intraoperative optical coherence tomography in ab interno glaucoma surgery

PURPOSE

Ab interno glaucoma surgery, such as trabecular aspiration or ab interno trabeculotomy, has been introduced as an alternative, non-filtering procedure to lower intraocular pressure in glaucoma patients. The purpose of the present study was to assess the feasibility of intraoperative spectral domain optical coherence tomography (iOCT) for improving ab interno glaucoma surgery.

MATERIALS AND METHODS

Intraoperative optical coherence tomography was performed to visualize the anterior chamber angle, the aspiration canula during trabecular aspiration, and the trabectome device during ab interno trabeculotomy. A commercially available 840-nm iOCT was used in a clinical setting, a 1310-nm spectral-domain OCT in an experimental setting.

RESULTS

In the clinical setting using the 840-nm iOCT, visualization of the aspiration canula and the trabectome device was possible, however, with rather limited visibility of the chamber angle and the trabecular meshwork. In the experimental setting, the 1310-nm OCT enabled excellent visualization of the chamber angle and detailed evaluation of the instrument-trabecular meshwork relation.

CONCLUSIONS

Intraoperative use of optical coherence tomography may be helpful for ab interno glaucoma surgery. Adjustments of the commercially available iOCT, including longer wavelengths and oblique scanning options, are necessary for the clinical use.

Washout of pseudoexfoliation material combined with cataract surgery: a new surgical approach to lower intraocular pressure in pseudoexfoliation syndrome

Glaucoma or ocular hypertension can be caused by the presence of pseudoexfoliation (PEX) material and/or pigmented cells in the trabecular meshwork (TM) and/or in the irido-corneal angle (ICA). Accumulation of this material can be highlighted by slit-lamp (SL), gonioscopy, and ultrasound biomicroscopy (UBM). Such material prevents aqueous humor from flowing out and thus induces intraocular pressure (IOP) elevation. A new technique using a special cannula for washing the TM and ICA, combined with cataract surgery, can lower IOP and reduce the number of hypotensive drugs needed. This study analyzed 11 patients (13 eyes) presenting a pseudoexfoliation glaucoma with cataract. They all had cataract surgery combined with the special washing technique. Visual acuity and IOP were noted before surgery, just after surgery and during follow-up. The number of hypotensive drugs needed was also recorded. Mean follow-up time was 34.4 months (range 21.8–59.2). The first case underwent surgery in 2007 and has a 5-year follow-up time. Local status was controlled by SL, gonioscopy, and UBM. Mean age was 79 years (range 71.6–86.0). Mean visual acuity was 0.37 pre-op (range 0.05–0.6) and 0.89 post-op (range 0.05–1.0). Mean IOP before and after surgery was 32.8 ± 8.7 mmHg (range 20–53) and 15.1 ± 3.5 mmHg (range 10–20), respectively. The amount of hypotensive drugs needed was 87 % lower after surgery. No PEX material recurrence was seen with SL, gonioscopy, and UBM during the mean follow-up of 3 years. No complication was recorded in this study. Cataract surgery combined with the new washout technique of the TM and ICA to remove PEX material or pigmented cells significantly lowers IOP and the amount of drugs needed. Long-term follow-up gives good results with no complication or recurrence. Eye status after surgery remains physiological and further glaucoma surgery can be performed if necessary. More research with a higher number of patients should be initiated to confirm this technique.

Techniques and outcomes of minimally invasive trabecular ablation and bypass surgery

Minimally invasive glaucoma surgeries (MIGS) can improve the conventional, pressure-dependent outflow by bypassing or ablating the trabecular meshwork (TM), or creating alternative drainage routes into the suprachoroidal or subconjunctival space. They have a highly favourable risk profile compared to penetrating surgeries, and lower intraocular pressure with variable efficacy that may depend on the extent of outflow segments accessed. Since they are highly standardised procedures that use clear corneal incisions, they can elegantly be combined with cataract and refractive procedures to improve vision in the same session. There is a growing need for surgeons to become proficient in MIGS to address the increasing prevalence of glaucoma and cataracts in a well-informed, aging population. Techniques of visualisation and instrumentation in an anatomically highly confined space with semitransparent tissues are fundamentally different from other anterior segment surgeries, and present even experienced surgeons with a substantial learning curve. Here, we provide practical tips, and review techniques and outcomes of TM bypass and ablation MIGS.

Combined clear cornea phacoemulsification in the treatment of pseudoexfoliative glaucoma associated with cataract: significance of trabecular aspiration and ab interno trabeculectomy

BACKGROUND

In the present study, the effectiveness of combined cataract surgery and ab interno trabeculectomy (Trabectome) in exfoliation glaucoma (PEX) was compared with combined cataract surgery and trabecular aspiration.

METHODS

In this retrospective comparative cohort outcome study, 27 consecutive patients (mean age 73.41 years ± 10.78) in group 1 suffering from visually significant cataract and PEX glaucoma (mean preoperative IOP 23.41 mmHg ± 5.86) were treated with phacoemulsification combined with Trabectome; and 28 consecutive patients (73.83 years ± 8.94) were treated with phacoemulsification combined with trabecular aspiration (mean preoperative IOP 22.22 mmHg ± 6.33). The intraocular pressure (IOP) and the number of antiglaucoma eyedrops before and after surgery were evaluated.

RESULTS

Examinations were performed prior to surgery, 1 day, 6 weeks, 3 months, 6 months, and 1 year after surgery. In both groups there was a statistically significant decrease in postoperative IOP during the whole follow-up period. Comparing the two groups, there was a statistically significant lower IOP in the Trabectome group 1 day (p = 0.019), 6 months (p = 0.025), and 1 year (p = 0.019) after surgery. Between the two groups, there was no statistically significant difference in the number of antiglaucoma eyedrops at any time.

CONCLUSIONS

Both procedures have the ability to significantly lower the postoperative IOP during the first year. However, clear cornea phacoemulsification combined with Trabectome seems to be more effective in IOP reduction in cases of PEX glaucoma associated with cataract.

Influence of prostaglandin analogue on outcome after combined cataract surgery and trabecular aspiration in pseudoexfoliative glaucoma

PURPOSE

The aim of this study was to analyze the postoperative outcome and risk profile after combined clear cornea phacoemulsification and trabecular aspiration in the treatment of pseudoexfoliative glaucoma (PEX) associated with cataract. 


METHODS

In this retrospective study, 69 eyes of 60 patients with visually significant cataract and PEX were treated with small-incision cataract surgery combined with trabecular aspiration. The intraocular pressure (IOP), number of antiglaucoma eyedrops before and after surgery, as well as complications were measured at all postoperative visits (1 day, 7 days, 6 weeks, 6 months, 12 months). 


RESULTS

There was a statistically significant decrease in postoperative IOP during the follow-up 
period. There was no significant difference in the number of medications being used after 6 weeks follow-up. Six months and 12 months after surgery, the number of antiglaucoma eyedrops decreased significantly. Complications were fibrinotic iritis in 4 eyes (5.9%), cystoid macular edema in 3 eyes (4.4%), and hyphema in 1 eye (1.4%). Fibrinotic iritis and macular edema were present in only 37 of 
69 eyes that were treated with prostaglandin analogues.


CONCLUSIONS

Small-incision cataract surgery combined with trabecular aspiration in cases of PEX associated with cataract is effective in IOP reduction over a 1-year follow-up. Prostaglandin analogues may increase the risk of postoperative macular edema and fibrinotic iritis. Preoperative medication exchange may be considered.

Directed therapy for exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disorder of the extracellular matrix that leads the production of abnormal fibrillar material that leads to elevated intraocular pressure and a relatively severe glaucoma. Exfoliation material is deposited in numerous ocular tissues and extraocular organs. XFS is associated with ocular ischemia, cerebrovascular disease, neurodegenerative disease and cardiovascular disease. Current modalities of treatment include intraocular pressure lowering with topical antihypertensives, laser trabeculoplasty and filtration surgery. The disease paradigm for XFS should be expanded to include directed therapy designed specifically to target the underlying disease process. Potential targets include preventing the formation or promoting the depolymerization of exfoliation material. Novel therapies targeting trabecular meshwork may prove particularly useful in the care of exfoliative glaucoma. The systemic and ocular associations of XFS underscore the need for a comprehensive search for neuroprotective agents in its treatment.

Directed therapy for exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disorder of the extracellular matrix that leads the production of abnormal fibrillar material that leads to elevated intraocular pressure and a relatively severe glaucoma. Exfoliation material is deposited in numerous ocular tissues and extraocular organs. XFS is associated with ocular ischemia, cerebrovascular disease, neurodegenerative disease and cardiovascular disease. Current modalities of treatment include intraocular pressure lowering with topical antihypertensives, laser trabeculoplasty and filtration surgery. The disease paradigm for XFS should be expanded to include directed therapy designed specifically to target the underlying disease process. Potential targets include preventing the formation or promoting the depolymerization of exfoliation material. Novel therapies targeting trabecular meshwork may prove particularly useful in the care of exfoliative glaucoma. The systemic and ocular associations of XFS underscore the need for a comprehensive search for neuroprotective agents in its treatment.

UBM/slit-lamp-photo imaging of pseudoexfoliation deposits in the iridocorneal angle: imaging clues to the genesis of ocular hypertension

This photo essay is aimed at showing slit-lamp photographic views and its ultrasound biomicroscopy (UBM) corollaries of angle deposits in pseudoexfoliation syndrome cases and contributes visual arguments to the hypotheses and explanations of the genesis of ocular hypertension.

The management of exfoliative glaucoma

Exfoliation syndrome (XFS) is an age-related, generalized disorder of the extracellular matrix characterized by the production and progressive accumulation of a fibrillar extracellular material in many ocular tissues and is the most common identifiable cause of open-angle glaucoma worldwide. XFS plays an etiologic role in open-angle glaucoma, angle-closure glaucoma, cataract, and retinal vein occlusion. It is accompanied by an increase in serious complications at the time of cataract extraction, such as zonular dialysis, capsular rupture, and vitreous loss. It is associated systemically with an increasing number of vascular disorders, hearing loss, and Alzheimer's disease. XFS appears to be a disease of elastic tissue microfibrils. The characteristic fibrils, composed of microfibrillar subunits surrounded by an amorphous matrix comprising various glycoconjugates, contain predominantly epitopes of elastic fibers, such as elastin, tropoelastin, amyloid P, vitronectin, and components of elastic microfibrils, such as fibrillin-1, fibulin-2, vitronectin, microfibril-associated glycoprotein (MAGP-1), and latent TGF-beta binding proteins (LTBP-1 and LTBP-2), the proteoglycans syndecan and versican, the extracellular chaperone clusterin, the cross-linking enzyme lysyl oxidase, and other proteins. A recent milestone study showed that two common single nucleotide polymorphisms in the coding region of the lysyl oxidase-like 1 (LOXL1) gene located on chromosome 15 were specifically associated with XFS and XFG. LOXL1 is a member of the lysyl oxidase family of enzymes, which are essential for the formation, stabilization, maintenance, and remodeling of elastic fibers and prevent age-related loss of elasticity of tissues. LOXL1 protein is a major component of exfoliation deposits and appears to play a role in its accumulation and in concomitant elastotic processes in intra- and extraocular tissues of XFS patients. This discovery should open the way to new approaches and directions of therapy for this protein disorder.

Cataract and glaucoma surgery in pseudoexfoliation syndrome: a review

Pseudoexfoliation syndrome is a risk factor in cataract surgery because of the increased weakness of zonular apparatus and reduced pupillary dilatation. The surgical outcome of using phacoemulsification in the central zone, inducing minimal stress on the zonules, inserting a capsular tension ring in selected cases, and stretching the pupil mechanically in eyes with miotic pupils, may turn out to be uneventful in most cases. Postoperative fibrosis with subsequent shrinkage of the capsule is increased in these eyes, and these centripetal forces will further loosen the zonular fibres. Late in-the-bag intraocular lens dislocation is therefore anticipated to become a growing problem in the future. Despite the dysfunctioning of the blood-aqueous barrier in eyes with pseudoexfoliation syndrome, the frequency of postoperative inflammatory reaction is low due to the improvements made in surgical technique and equipment in recent years. Glaucoma frequently occurs in eyes with pseudoexfoliation syndrome. Compared with primary open-angle glaucoma, optic damage is more pronounced in these eyes at the time of diagnosis and response to medical therapy is poorer. Although responses to argon laser therapy and filtering surgery are roughly similar between the two types of glaucoma, there are indications that primary laser trabeculoplasty has a higher success rate in pseudoexfoliation glaucoma than in primary open-angle glaucoma.

Intraocular pressure following phacoemulsification in patients with and without exfoliation syndrome: a 2 year prospective study

AIM

To determine the long term intraocular pressure (IOP) response to phacoemulsification in patients with and without exfoliation syndrome (XFS).

METHODS

Prospective, multicentre, cohort study with the following inclusion criteria: age over 50 years, open iridocorneal angle, and cataract. Two groups were enrolled: those with XFS and those without. The main outcome was mean IOP reduction 2 years after phacoemulsification cataract extraction (PCE). Univariate and multivariate analyses were performed.

RESULTS

183 patients were enrolled, 71 with and 112 without XFS. There were 29 patients with glaucoma in both groups. Mean baseline IOP was higher in XFS compared to control eyes (17.60 (SD 3.23) mm Hg v 16.08 (3.18) mm Hg, p = 0.002). Overall IOP reduction was significantly greater in the XFS group at the 2 year time point (-1.85 mm Hg v -0.62 mm Hg in the controls (p = 0.0037)). Multivariate analysis demonstrated that the IOP lowering effect in the XFS group may be related to irrigation volume at the time of surgery. In the subgroup analyses IOP lowering was significantly greater in the XFS and XFG patients than in controls without glaucoma, and POAG controls, respectively. The percentage of patients with a postoperative IOP spike was similar and relatively high in both XFS and control groups (34% v 25%; p = 0.54).

CONCLUSION

IOP decreases more in patients with XFS following PCE compared to control eyes without XFS. This effect is more pronounced in glaucoma patients and persists for at least 2 years.

Pigment dispersion syndrome and pigmentary glaucoma

BACKGROUND

Pigmentary glaucoma is a common secondary glaucoma that results from pigment being liberated from the posterior iris with subsequent buildup in the trabecular mesh-work. Following this, there is a decrease in aqueous outflow and resultant rise in intraocular pressure.

PURPOSE

While this presentation typically occurs in white myopic males, there is a distinct subtype that occurs in patients of African descent. While there are similarities between the races, there are also significant differences in the clinical presentation of pigmentary glaucoma in white patients and patients of African descent. Iris transillumination defects, corneal endothelial pigment accumulation, and a concave iris-common in whites-are typically absent in patients of African descent.

METHOD

The literature is reviewed in order to summarize pigment dispersion syndrome and pigmentary glaucoma.

Phacoemulsification and intraocular lens implantation in eyes with open-angle glaucoma

PURPOSE

To study the effect of phacoemulsification and intraocular lens implantation (PHACO IOL) on intraocular pressure (IOP) and glaucoma medication in open-angle glaucoma (OAG) eyes.

METHODS

38 open-angle glaucoma (OAG) eyes with cataract underwent phacoemulsification and intraocular lens implantation (PHACO IOL) performed by one surgeon (RJU). None of the patients had prior intraocular surgery. Surgery was performed by scleral incision on 37% and by clear corneal incision on 63%. Patients were re-examined on the first postoperative day, after one week, 4 months, and in 29 cases 1-3.7 (mean 2.8) years after the operation.

RESULTS

The mean preoperative IOP was 18.4+/-3.3 mmHg with a mean of 1.7 glaucoma medications. On the first postoperative day, the mean IOP rose to 28.2 +/- 12.5 mmHg. IOP > or = 30 mmHg occurred in 39.5% of the eyes. After one week, IOP had returned to the preoperative level. After 4 months, IOP had further decreased to 16.1 +/- 3.8 mmHg (p = 0.0027). After a mean follow-up of 1-3.7 (mean 2.8) years, the average postoperative IOP was 15.1 +/- 2.9 mmHg, being significantly (p = 0.001) lower than the preoperative IOP with 86% of the patients having a mean of 1.6 drugs on average. The type of incision (scleral vs. corneal) did not affect the postoperative IOP level. Using the criteria of Bigger and Becker (1971) the long-term IOP control after PHACO-IOL surgery was improved or unchanged in 86% and worse in 14% of the preoperatively well-controlled OAG eyes.

CONCLUSIONS

In OAG eyes PHACO IOL is associated with a significant decrease in IOP with less medication up to 1-3.7 (mean 2.8) years.

Exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disorder of the extracellular matrix characterized by production and progressive accumulation of small, white deposits of a fibrillar extracellular material in many ocular tissues, most commonly seen on the pupillary border and anterior lens capsule. Characteristic signs of pigment liberation and deposition throughout the anterior segment aid in the diagnosis. Exfoliation syndrome predisposes to both open-angle and angle-closure glaucoma, and to capsular rupture, zonular dehiscence, and vitreous loss during cataract extraction. Exfoliation syndrome is associated with ocular and perhaps systemic ischemia. The exact chemical composition of exfoliation material remains unknown. Medical, laser, and surgical therapy are similar to treatment of primary open-angle glaucoma.

Intraocular pressure after phacoemulsification and intraocular lens implantation in nonglaucomatous eyes with and without exfoliation

PURPOSE

To evaluate intraocular pressure (IOP) after phacoemulsification and intraocular lens (IOL) implantation in nonglaucomatous eyes with and without exfoliation.

SETTING

Department of Ophthalmology, Helsinki University Central Hospital, Helsinki, Finland.

METHODS

One hundred ninety-six eyes that had phacoemulsification with IOL implantation were examined. Eyes with a history of intraocular disease or surgery that could affect IOP were excluded. The study comprised the remaining 160 eyes: 23 with exfoliation (EXF group) and 137 without exfoliation (non-EXF group). Follow-up data were available for 136 eyes. The same surgeon performed all surgeries. Patients were examined on the first postoperative day and after 1 week, 4 months, and 1.0 to 2.7 years.

RESULTS

One day postoperatively, IOP rose in the EXF group from a mean preoperative level of 16.3 mm Hg +/- 2.7 (SD) to 21.0 +/- 8.5 mm Hg, a 28.4% increase (P =.0061). In the non-EXF group, mean IOP rose from 16.2 +/- 3.4 mm Hg to 20.5 +/- 5.7 mm Hg, a 29.9% increase (P =.001). In 4 eyes (17.4%) in the EXF group and 8 eyes (5.8%) in the non-EXF group, IOP increased to 30 mm Hg or higher at 1 day. After this, significant IOP decreases occurred in both the EXF and non-EXF group, respectively, as follows: 14.2 +/- 3.0 mm Hg (12.0% decrease from preoperative value; P =.001) and 15.0 +/- 2.9 mm Hg (5.9%; P =.001) 1 week postoperatively; 12.8 +/- 2.7 mm Hg (20.2%; P =.0002) and 13.8 +/- 2.7 mm Hg (13.2%; P =.001) after 4 months; and 12.3 +/- 2.6 mm Hg (23.2%; P =.0001) and 12.7 +/- 2.7 mm Hg (21.2%; P =.001) after 1.0 to 2.7 years. There was no significant difference between the 2 groups.

CONCLUSION

After phacoemulsification with IOL implantation, IOP decreased significantly and remained lower than preoperatively in eyes with and without exfoliation. One day postoperatively, transient pressure peaks were more common in eyes with exfoliation. One eye without exfoliation developed glaucoma.

How does nonpenetrating glaucoma surgery work? Aqueous outflow resistance and glaucoma surgery

Histologic, experimental, and theoretical studies of the aqueous outflow pathways point toward the juxtacanalicular region and inner wall of Schlemm's canal as the likely site of aqueous outflow resistance in the normal eye. At least 50% of the aqueous outflow resistance in the normal eye and the bulk of the pathologically increased resistance in the glaucomatous eye resides in the trabecular meshwork and the inner wall of Schlemm's canal. The uveoscleral, or uveovortex, pathway, which accounts for perhaps 10% of the aqueous drainage in the healthy aged human eye, can become a major accessory route for aqueous drainage after pharmacologic treatment. Surgeries designed to incise or remove the abnormal trabecular meshwork of glaucoma address the pathologic problem of the disease. Surgeries that unroof Schlemm's canal or expand the canal, such as viscocanalostomy, probably cause inadvertent ruptures of the inner wall and juxtacanalicular tissue, thus relieving the abnormal outflow resistance of glaucoma. This review is a summary of current thought on the pathophysiology of aqueous outflow resistance in glaucoma and, in light of this, provides an interpretation of the mechanism of pressure reduction created by these new surgeries.

Exfoliation syndrome

Exfoliation syndrome (XFS) is an age-related disease in which abnormal fibrillar extracellular material is produced and accumulates in many ocular tissues. Its ocular manifestations involve all of the structures of the anterior segment, as well as conjunctiva and orbital structures. Glaucoma occurs more commonly in eyes with XFS than in those without it; in fact, XFS has recently been recognized as the most common identifiable cause of glaucoma. Patients with XFS are also predisposed to develop angle-closure glaucoma, and glaucoma in XFS has a more serious clinical course and worse prognosis than primary open-angle glaucoma. There is increasing evidence for an etiological association of XFS with cataract formation, and possibly with retinal vein occlusion. XFS is now suspected to be a systemic disorder and has been associated preliminarily with transient ischemic attacks, stroke, systemic hypertension, and myocardial infarction. Further ramifications await discovery. Deposits of white material on the anterior lens surface are the most consistent and important diagnostic feature of XFS. The classic pattern consists of three distinct zones that become visible when the pupil is fully dilated. Whereas the classic picture of manifest XFS has been often described, the early stages of beginning exfoliation have not been well defined. Next to the lens, exfoliation material is most prominent at the pupillary border. Pigment loss from the iris sphincter region and its deposition on anterior chamber structures is a hallmark of XFS. Despite extensive research, the exact chemical composition of exfoliation material (XFM) remains unknown. An overproduction and abnormal metabolism of glycosaminoglycans have been suggested as one of the key changes in XFS. The protein components of XFM include both noncollagenous basement membrane components and epitopes of the elastic fiber system such as fibrillium. Regardless of etiology, typical exfoliation fibers have been demonstrated electron microscopically in close association with the pre-equatorial lens epithelium, the nonpigmented ciliary epithelium, the iris pigment epithelium, the corneal endothelium, the trabecular endothelium, and with almost all cell types of the iris stroma, such as fibrocytes, melanocytes, vascular endothelial cells, pericytes, and smooth muscle cells. The presence of XFS should alert the physician to the increased risks of intraocular surgery, most commonly zonular dehiscence, capsular rupture, and vitreous loss during cataract extraction. Heightened awareness of this condition and its associated clinical signs are important in the detection and management of glaucoma, and preoperative determination of those patients at increased risk for surgical complications.

Perspectives in trabecular surgery

The aim of trabecular surgery is to selectively combat the diseased structure central to the pathogenesis of chronic open-angle glaucoma, thereby reducing potential hazards during and after conventional filtering procedures. This overview considers new techniques in ab interno trabecular surgery. Special emphasis is placed on the description of each novel technique, its instrumentation, presumed mechanism of action and clinical results. Trabecular aspiration is evaluated as a method of clearing intertrabecular spaces of extracellular debris in pseudoexfoliation glaucoma with or without simultaneous cataract surgery or goniocurettage, while laser trabecular ablation is discussed for the treatment of absolute glaucomas. Where corneal haze has formed visualisation of the anterior chamber angle structures and trabecular surgery is performed with the aid of a microendoscope. Although the results are very promising it should be understood that some of these procedures are still in the experimental phase and are undergoing careful clinical evaluation, leaving plenty of room for refinements and further developments.

Exfoliation syndrome and exfoliation glaucoma

Exfoliation syndrome abnormal deposition in the anterior segment of the eye of an unknown substance thought to be related to elastic fibres and basement membrane components is associated with accelerated cataract progression. increased frequency of intraoperative and postoperative complications and increased risk for glaucoma and. therefore, is a clinically important finding. A clear association has been shown with age. The syndrome occurs worldwide but its prevalence seems to vary from country to country. The best-known sign of exfoliation syndrome is deposits of greyish-white material on the anterior lens surface. Sometimes exfoliation material can also be seen at the pupillary border, on the anterior iris surface, corneal endothelium, and on the anterior vitreous face. When clinically detected, exfoliation syndrome is somewhat more often unilateral than bilateral. According to recent investigations clinically unilateral exfoliation syndrome is probably never truly unilateral but rather asymmetric, because exfoliation material has been detected ultrastructurally and immunohistochemically around iris blood vessels of the nonexfoliative fellow eyes. Indeed, electron microscopy identifies in various organs of patients with exfoliation syndrome fibrils similar to those seen in intraocular exfoliation deposits. Other clinical signs associated with exfoliation syndrome are pigment dispersion, transillumination defects of the iris and reduced response to mydriatics. In unilateral exfoliation syndrome, intraocular pressure (IOP) of the exfoliative eye is approximately 2 mmHg higher than IOP of the nonexfoliative fellow eye. Whether elevated IOP, vascular changes or exfoliation syndrome itself is the main factor causing optic nerve head damage and conversion of an exfoliative eye to glaucomatous, is not known. Glaucoma in the exfoliation syndrome has been shown to have a more serious clinical course than in primary open-angle glaucoma (POAG). At the time of diagnosis, IOP and its diurnal variation are generally higher and visual field defects tend to be greater in exfoliation glaucoma than in POAG. Because the decrease in lOP variation and lowering of the mean IOP level has been shown to improve visual field prognosis more in exfoliation glaucoma than in POAG, the glaucomatous process is considered to be more pressure-related in exfoliation glaucoma. Furthermore, progression of optic disc damage has been shown to be similar in exfoliation glaucoma and POAG when lOPs are lowered to a comparable level by the treatment. However, vascular disturbances in the posterior segment of the eye might after all be of equal importance in these two types of glaucoma; optic disc haemorrhages and venous occlusions have been reported to be as frequent in exfoliation glaucoma as in POAG. Perhaps in exfoliation glaucoma circullatory disturbances combined with high IOP lead to a particularly relentlessly progressing form of the disease.

Effect of trabecular aspiration on intraocular pressure in pigment dispersion syndrome and pigmentary glaucoma

OBJECTIVE

Recently, we described a new form of nonfiltering glaucoma surgery-trabecular aspiration-designed to increase trabecular outflow in pseudoexfoliation glaucoma. This study was carried out to investigate whether trabecular aspiration is equally safe and effective in the treatment of pigment dispersion syndrome (PDS) and pigmentary glaucoma (PG).

STUDY DESIGN

Prospective, nonrandomized comparative trial with historical control.

PARTICIPANTS

Twenty eyes of 20 patients with medically uncontrolled intraocular pressure (IOP) caused by PDS or PG were treated by trabecular aspiration.

INTERVENTION

Trabecular pigment particles were cleared with a pressure of 100 to 200 mmHg using a specially designed aspiration probe.

MAIN OUTCOME MEASURES

The IOP and number of medications before and after surgery were measured. Intraoperative and postoperative complications were analyzed. Surgical success was defined as IOP < or = 21 mmHg with no more than one topical medication. Results were compared with those previously reported with similar treatment of pseudoexfoliative glaucoma.

RESULTS

Mean pretreatment IOP averaged 27.0 (standard deviation [SD], 3.3) mmHg and was significantly reduced to 23.7 (SD, 3.9) mmHg at last follow-up (20.1 +/- 8.6 months). However, the cumulative life-table success rates were only 42% and 15% at 3 and 12 months, respectively. Considering both groups separately, the success rates in the PDS group were 63% and 18% at 3 and 12 months compared with a success rate of 12% in the PG group as early as 1 month after surgery.

CONCLUSIONS

Eyes with PDS responded better to trabecular aspiration than do those with PG, indicating that PDS and PG are two successive stages of the same disease process. Altogether, trabecular aspiration failed to achieve long-term pressure control in either of the two groups.

Management of coincident glaucoma and cataract

Phacoemulsification for visually significant cataract and trabeculectomy for uncontrolled glaucoma are two of the most commonly performed ophthalmic surgeries. Many articles pertaining to cataract extraction in the glaucoma patient have been published during the 1-year scanning period of this periodical. This discussion reviews the recent literature as it pertains to the management of coincident cataract and glaucoma. Important topics addressed by the recent literature include long-standing controversies such as limbus-based versus fornix-based approaches to trabeculectomy and one-site versus two-site approaches to combined surgery, as well as innovative techniques in cataract and glaucoma surgery. This article also addresses perhaps the most controversial issue with regard to coincident cataract and glaucoma surgery, that is, the indications for the procedure. It should be noted that this article is not a comprehensive review but rather discusses the literature published within the 1-year scanning period.