Surgical site characteristics after CLASS followed by ultrasound biomicroscopy and clinical grading scale: a 2-year follow-up

Effect of Trabeculodescemetic Window Perforation in Deep Sclerectomy on Intraocular Pressure in Primary Congenital Glaucoma

INTRODUCTION

Primary congenital glaucoma causes vision loss if intraocular pressure is uncontrolled. Nonpenetrating deep sclerectomy is effective in treating primary congenital glaucoma. However, the effects of inadvertent trabeculodescemetic window perforation remain unclear.

METHODS

This retrospective cohort study included patients with primary congenital glaucoma who underwent nonpenetrating deep sclerectomy between 2014 and 2021. The perforation group had intraoperative trabeculodescemetic window perforations; the non-perforation group did not. The primary outcome was intraocular pressure between the groups over 15 months. The secondary outcomes included surgical success and complications.

RESULTS

The study included 74 eyes of 44 patients. The cohort comprised 31 perforated and 43 non-perforated eyes. Both groups showed significant intraocular pressure reduction without significant between-group differences in complete (68 vs. 77%), qualified (19 vs. 9%), or failed (13 vs. 14%) treatments. The median intraocular pressure decreased from 39 to 14 mmHg in the perforation group and 35 to 12 mmHg in the non-perforation group. Of the 74 treated eyes, 68 (92%) showed no complications.

CONCLUSIONS

An inadvertent trabeculodescemetic window perforation during nonpenetrating deep sclerectomy for primary congenital glaucoma did not significantly affect intraocular pressure outcomes compared to non-perforated cases over 15 months. Nonpenetrating deep sclerectomy reduced intraocular pressure regardless of intraoperative perforation in patients with primary congenital glaucoma. Perforation of the trabeculodescemetic window was associated with a low incidence of postoperative complications.

Efficacy and safety of deep sclerectomy with uveoscleral implant plus collagen matrix implant overcoming the superficial scleral flap in glaucoma surgery

AIM

To assess the efficacy and safety of non-penetrating deep sclerectomy (NPDS) with uveoscleral implant plus subconjunctival and intrascleral collagen matrix overcoming the superficial scleral flap lips (modified deep sclerectomy technique, DS) and minimal use of mitomycin C in glaucoma surgery.

METHODS

A retrospective review of 47 consecutive glaucoma patients who underwent NPDS with DS between January 2017 and May 2018. Best-corrected visual acuity, intraocular pressure (IOP), post-operative need for glaucoma medications, visual field mean deviation (MD), re-interventions, needling revisions and laser goniopuncture were noted. Absolute success was defined as IOP≤18 mm Hg without topical medication. Relative success was defined as the same criteria but with the addition of any antihypertensive medication. IOP over 18 mm Hg on two consecutive follow-up visits was considered as a failure.

RESULTS

Fifty-two eyes of 47 patients were evaluated. Mean preoperative IOP was 25.37±6.47 mm Hg, and decreased to 15.04±4.73 at 12mo and 12.21±4.1 at 24mo (all P<0.0001). Requirement for topical medications dropped from a mean of 3.06±0.25 per patient to 0.51±0.99 and 1.11±1.23 respectively after 12 and 24mo (all P<0.0001). No medications were required in 45.5% of patients after 24mo. Relative and absolute success rate at 24mo were 85.5%±5% and 48.5%±7.4%, respectively.

CONCLUSION

DS is a safe and effective non-penetrating glaucoma surgery variation. It aims to retain the patency of all pathways created for aqueous humor drainage: the intrascleral bleb, the supraciliary space and the open communication between intrascleral and subconjunctival compartments.

CO2 Laser-Assisted Sclerectomy Surgery Alone or Combined with Phacoemulsification in Primary Open-Angle Glaucoma: Comparison of 1-Year Outcomes

Introduction

To compare 1-year outcomes of CO₂ laser-assisted sclerectomy surgery (CLASS) alone or combined with phacoemulsification (CLASS + Phaco) in eyes with primary open-angle glaucoma (POAG).

Methods

This was a prospective, comparative, case series study. A total of 46 eyes with POAG underwent CLASS or CLASS + Phaco were followed up for 1 year. The primary outcomes included changes in intraocular pressure (IOP), medication and best corrected visual acuity (BCVA). The secondary outcomes were success rate, functional bleb, postoperative laser intervention and complications.

Results

CLASS alone resulted in a greater IOP reduction compared with CLASS + Phaco. BCVA improved remarkably in CLASS + Phaco group, but there was no difference in BCVA before and after CLASS. The number of antiglaucoma medications significantly decreased at 12 months postoperatively in both groups. Functional blebs were more commonly seen in the CLASS than combination group. The overall success rate was higher in the CLASS than CLASS + Phaco group at 1 year after surgery. The incidence of peripheral anterior synechiae (PAS) in CLASS + Phaco group was significantly lower than that of CLASS alone.

Conclusion

CLASS alone achieved a greater IOP reduction, more common functional bleb formation and a higher success rate compared to CLASS combined with Phaco, while combination surgery yielded a better BCVA improvement and a lower PAS incidence than CLASS alone. Both surgical strategies have favorable safety and efficacy among POAG patients. Combined surgery could be a viable option for patients with co-existing POAG and cataract.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00539-2.

CO2 Laser-Assisted Sclerectomy vs. Microcatheter-Assisted Trabeculotomy in the Management of a Bilateral Congenital Ectropion Uveae With Glaucoma: A Case Report and Literature Review

Introduction

Bilateral congenital ectropion uveae (CEU) is rare syndrome, usually accompanied by refractory glaucoma. Proper and timely treatment was very important for the prognosis. The report aims to compare the long-term outcomes and complications between the two eyes after different approaches of surgery in a case of bilateral CEU with advanced glaucoma.

Case Presentation

The patient was a 20-year-old male with bilateral CEU and glaucoma. The intraocular pressure (IOP) was 48 mm Hg in the right eye (OD) and 52 mm Hg in the left eye (OS). The vertical cup-to-disc (C/D) ratio was nearly 1.0 in both eyes. Despite maximum medical therapy, the target IOP could not be achieved. Therefore, CO2 laser-assisted sclerectomy surgery (CLASS) was performed in OS, and the IOP was remarkably decreased. 1 month after the surgery, the IOP rebounded slightly and was controlled with a fixed-combination anti-glaucoma medicine. 3-month postoperatively, a YAG laser goniopuncture (LGP) was performed to enhance the IOP-lowing effect and the anti-glaucoma agent was discontinued. An ab externo microcatheter-assisted trabeculotomy (MAT) was performed in OD, and the IOP was also significantly decreased. During the follow-up period, the IOP was well controlled for both eyes without any medication. Shallow anterior chamber and complicated cataract developed in OS after CLASS, and there was no obvious late complication in OD after MAT.

Conclusions

To our knowledge, this was the first attempt to perform two different surgeries, CLASS and MAT, in both eyes of a single patient presented with bilateral CEU with glaucoma. Our results showed that the IOP was lower after CLASS, but there were potential complications such as shallow anterior chamber and complicated cataract. MAT could achieve a moderate IOP-lowing effect but had a higher safety. CLASS and MAT may be considered effective surgical options for the management of such patients.

Management of Intraocular Pressure Elevation After CO2 Laser-Assisted Sclerectomy Surgery in Patients With Primary Open-Angle Glaucoma

Purpose: To report the safety and efficiency of carbon dioxide (CO₂) laser-assisted sclerectomy surgery (CLASS) in Chinese patients with primary open-angle glaucoma (POAG) and the management of unexpected postoperative intraocular pressure (IOP) elevation.

Methods: This was a prospective case series study. A total of 23 eyes from 23 patients with POAG who underwent CLASS were involved and followed-up for 12 months. The primary outcomes included the changes in best corrected visual acuity (BCVA), IOP, and medications before and after CLASS. The secondary outcomes were success rate and postoperative laser interventions.

Results: The mean age of the patient was 42.6 ± 16.0 years. There was no significant change in BCVA and visual field at baseline and 12 months after CLASS. The number of medications was significantly reduced after CLASS. The IOP was also significantly decreased and remained well controlled during the follow-up period, except for a transient elevation at 1 month postoperatively, due to the occurrence of peripheral anterior synechiae (PAS). Generally, 17 patients (73.9%) were treated with neodymium-doped yttrium aluminum garnet (Nd:YAG) laser synechiolysis to remove iris obstruction in the filtration site and seven patients (30.4%) underwent Nd:YAG laser goniopuncture to deal with scleral reservoir reduction. Only one patient (4.3%) received surgical repositioning due to iris incarceration. The complete success rate and total success rate at 12 months were 69.6 and 95.7%, respectively.

Conclusion: CLASS was a safe and effective approach for Chinese patients with POAG. Peripheral anterior synechiae (PAS), iris incarceration, and scleral reservoir reduction were common causes of unexpected postoperative IOP elevation. Individualized Nd:YAG laser intervention helps to improve the long-term outcomes after CLASS.

Microcatheter-Assisted Trabeculotomy Combined With Deep Sclerectomy and Trabeculectomy in Young to Middle-Aged Adults With Advanced Primary Open-Angle Glaucoma: 1-Year Result

Objective: We aimed to evaluate the safety and clinical efficacy of ab externo microcatheter-assisted trabeculotomy combined with deep sclerectomy and trabeculectomy (MATT-DS-Trab) in the surgical management of advanced primary open-angle glaucoma (POAG).

Methods: According to the inclusion criteria, we retrospectively collected and analyzed 37 POAG cases in advanced stage who received MATT-DS-Trab. The intraocular pressure (IOP), best corrected visual acuity (BCVA), use of anti-glaucoma drugs, shape of the filtering bleb, size of the scleral lake, complications, and the surgical success rate were recorded.

Results: The mean IOP was 37.50 ± 8.11 mmHg before the operation, while it depleted to 10.08 ± 2.01 and 11.43 ± 2.07 mmHg at 1 week and 12 months after the operation, respectively (both P < 0.001 compared to preoperative IOP). From none to two kinds of anti-glaucoma drugs were used 12 months after surgery on the patients, which were significantly reduced compared with that preoperatively (P < 0.001). An L-type filtering bleb was the main form at all time points after the operation. At 12 months following surgery, an F-type filtering bleb accounted for 5.41% and no E-type filtering bleb was recorded. The length and height of the scleral lake shrunk with time, but there was no statistical significance (P > 0.05). Also, there was no correlation between the size of the scleral pool and the IOP (P > 0.05). At 12 months after the operation, the complete success rates were 94.59, 83.78, and 72.97% according to standards A (≤18 mmHg), B (≤15 mmHg), and C (≤12 mmHg), respectively. Intraoperative complications were mainly anterior chamber hemorrhage, and no complications related to the filtration bleb were observed after the operation.

Conclusion: Based on multichannel mechanisms, MATT-DS-Trab is able to effectively reduce IOP in advanced POAG patients, with few serious complications and a high success rate.