Change in visual acuity and associated risk factors after trabeculectomy with adjunctive mitomycin C

Usefulness of Intraocular Pressure With the Ocular Response Analyzer to Predict Postoperative Hypotony Complications in Glaucoma

Purpose

To investigate the usefulness of intraocular pressure (IOP) using the ocular response analyzer to predict the occurrence of hypotony complications following trabeculectomy or bleb needling revision with mitomycin C.

Methods

This study included 66 eyes of 66 patients who underwent trabeculectomy (58 eyes of 58 patients) or bleb needling (8 eyes of 8 patients) with mitomycin C. A significant predictor of hypotony complications was identified from (1) operation (trabeculectomy or bleb needling), (2) age, (3) sex, (4) disease type (primary open-angle glaucoma, primary angle closure glaucoma, or exfoliation glaucoma), (5) lens status (phakia or pseudophakia), (6) preoperative Goldmann applanation tonometry IOP, (7) preoperative central corneal thickness, (8) preoperative axial length, (9) preoperative anterior chamber depth, (10) preoperative corneal hysteresis, (11) preoperative corneal resistance factor, (12) preoperative corneal compensated IOP (IOPcc), and (13) minimum IOP (IOP value when hypotony complications occurred, otherwise the minimum IOP during 3 months from trabeculectomy or bleb needling) using multivariate logistic regression.

Results

The probability of the occurrence of hypotony complications tended to increase by applying higher cutoff values to preoperative Goldmann applanation tonometry IOP and IOPcc, but not lower cutoff values to the minimum IOP. Multivariate logistic regression suggested that higher preoperative IOPcc and pseudophakia were significant predictors of the occurrence of hypotony complications (P = 0.0062 and 0.0069, respectively).

Conclusions

Higher preoperative IOPcc and pseudophakia were significant predictors of the occurrence of hypotony complications.

Translational Relevance

It is useful to measure IOP using the ocular response analyzer before trabeculectomy.

Mid-term surgical success after transscleral ab interno glaucoma gel stent implantation

PURPOSE

To investigate the surgical success and efficacy of XEN45 implantation (XEN45 μm, AbbVie Inc., USA) with and without combined cataract surgery up to the first 5 years.

METHODS

In a prospective observational monocentric trial, 192 eyes of 157 patients with open-angle glaucoma received either XEN45 implants only (solo surgery group) or combined surgery/cataract surgeries (combined surgery group). Surgical success (qualified and full success; IOP-limit: ≤12, 15, 18, 21 mmHg), time to secondary IOP-lowering procedure, IOP and number of IOP-lowering medications were analysed for 1, 2, 3, 4 and 5 years.

RESULTS

Compared to baseline, IOP (24.1 ± 8.1 to 12.6 ± 2.8 mmHg, -48%, p < 0.001) and the number of IOP-lowering medications (3.0 ± 1.0 to 1.5 ± 1.2, -50%, p < 0.001) decreased significantly at 5 years. Although no differences between IOP and the number of IOP-lowering medication courses between the groups were detected at 5 years (p > 0.11), the combined procedure (63%, 37%) showed better success rates compared to the solo procedure (36%, 13%) in the definition IOP ≤18 and ≤12 mmHg (p = 0.035, 0.028). Solo XEN45 procedures had a higher rate of secondary IOP-lowering procedures compared to combined XEN45 cataract procedures (hazard ratio: 2.02, 95%CI: 1.03-3.97, p = 0.04). Twenty per cent of the eyes, including both procedures, required a secondary IOP-lowering procedure within 5 years.

CONCLUSIONS

The XEN45 implant is effective in lowering IOP and the number of IOP-lowering medications in patients with open-angle glaucoma in the mid-term. Comparing XEN45 implant results with the results of trabeculectomy available in current literature, we speculate that there might be a higher surgical success rate without medications in favour of trabeculectomy.

Historical and Contemporary Debates in Schlemm's Canal-Based MIGS

Glaucoma is one of the primary causes of blindness worldwide. Canal opening surgery, a type of minimally invasive glaucoma surgery (MIGS) applied in cases of mild to moderate glaucoma, has gained increasing popularity in recent years due to its efficacy in reducing the intraocular pressure, its safety profile, the simplicity of its technique, and the reduced likelihood of compromised vision. Nevertheless, the existing body of histopathological studies remains insufficient for a comprehensive understanding of post-surgical wound healing. Consequently, debates persist among researchers regarding the mechanism through which Schlemm's canal opening surgery reduces the intraocular pressure, as well as the surgical techniques that may impact the outcomes and the factors influencing surgical success. As the history of MIGS is relatively short and lacks sufficient systemic reviews or meta-analyses evaluating the influence of individual factors, this review was conducted to illuminate the disparities in researchers' opinions at the current stage of research.

Usefulness of Eye Deformation in the Corvis ST Measurement to Predict Postoperative Hypotony Complications in Glaucoma

PURPOSE

This study aimed to investigate the usefulness of measuring biomechanical parameters using the Corvis ST to predict the occurrence of hypotony maculopathy and choroidal detachment (CD) following trabeculectomy or bleb needling revision with mitomycin C.

DESIGN

Clinical cohort study.

METHODS

This study included 100 eyes of 100 patients who underwent trabeculectomy (88 eyes of 88 patients) or bleb needling (12 eyes of 12 patients) with mitomycin C. A significant predictor of hypotony complications was identified from (1) operation (trabeculectomy or bleb needling), (2) age, (3) sex, (4) disease type (primary open-angle glaucoma, exfoliation glaucoma or other), (5) lens status (phakia or pseudophakia), (6) preoperative Goldmann applanation tonometry (GAT) intraocular pressure (IOP), (7) preoperative central corneal thickness (CCT), (8) preoperative axial length (AL), (9) preoperative anterior chamber depth, (10) "Min IOP" (IOP value when hypotony complications occurred, otherwise the minimum IOP during 3 months from trabeculectomy or bleb needling), (11) preoperative corneal curvature, and (12-24) 12 Corvis ST parameters using multivariate logistic regression.

RESULTS

There were 13 and 21 eyes developed hypotony maculopathy and CD, respectively. Male gender, greater preoperative GAT IOP, and greater highest concavity deflection Amplitude were significant predictors of the occurrence of hypotony maculopathy (P < .05). On the other hand, shorter AL, thinner CCT, greater preoperative GAT IOP and pseudophakia were significant predictors of the occurrence of CD (P < .05).

CONCLUSIONS

A careful attention should be paid to the occurrence of hypotony maculopathy with male gender and greater highest concavity deflection Amplitude despite higher preoperative GAT IOP. Different risk factors were identified; shorter AL, thinner CCT, greater preoperative GAT IOP, and pseudophakia.

Comparison of Short-term Visual Acuity Changes After Trabeculotomy ab Interno Using Trabectome and Trabeculectomy ab Externo

PURPOSE

To compare short-term visual acuity (VA) changes after trabeculotomy ab interno (TAI) using trabectome and trabeculectomy ab externo (TAE) performed on pseudophakic eyes.

DESIGN

A single-center retrospective study.

PARTICIPANTS

Patients with pseudophakic eyes who had primary open-angle glaucoma or exfoliation glaucoma and underwent TAI or TAE alone.

METHODS

Changes in intraocular pressure (IOP), medication score, Snellen VA, and the number of eyes with vision loss (loss of ≥ 2 Snellen lines) were evaluated at baseline, week 1, and months 1, 3, and 6. The risk factors for vision loss at 6 months postoperatively were analyzed in both groups.

MAIN OUTCOME MEASURES

Visual acuity changes.

RESULTS

A total of 112 eyes of 112 patients were examined: 46 in the TAI group and 66 in the TAE group. Intraocular pressure was significantly lower in both groups at each visit than at baseline. The TAI group had a significantly higher mean postoperative IOP than the TAE group. Medication scores in the TAI group were significantly different after 3 months compared with baseline; however, decreased significantly at all study visits in the TAE group. The mean VA in the TAI group did not decrease significantly at each visit. In the TAE group, it decreased significantly up to 3 months but was not significantly different at 6 months. At all study visits, the number of eyes with vision loss was significantly lower in the TAI group than in the TAE group. Only 2 eyes in the TAI group (4.3%) had vision loss at 6 months, which was caused by macular edema. In the TAE group, 13 eyes (19.7%) experienced vision loss at 6 months. In all cases, the presence of preoperative split fixation [odds ratio = 7.30, P < 0.05] and the occurrence of hypotony-related complications [odds ratio = 6.76, P < 0.05] within 6 months were risk factors for vision loss.

CONCLUSIONS

TAI lowered IOP less than TAE; however, there was less vision loss with TAI. For eyes with a target IOP in the mid-teens, TAI can be recommended as initial surgery.

FINANCIAL DISCLOSURE(S)

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

Trends in the National Ophthalmological Healthcare Focusing on Cataract, Retina, and Glaucoma Over 15 Years in Japan

To assess the trends in ophthalmic healthcare, especially those of cataract, vitreo-retinal diseases, and glaucoma, the national data from the Japanese Ministry of Health, Labour and Welfare, which recorded medical practices for 126.1 million citizens, were studied for 15 years. The volume and expenses of cataract surgeries increased during this period; however, non-surgical expenses decreased. As a result, the total national cataract healthcare expenses decreased over the 15-year period. The volume of vitrectomies increased from 2007 to 2013. After introduction of anti-vascular endothelial growth factor (VEGF) injections, the number of injections increased 8.4 times from 2010 to 2021, while the volume of vitrectomy and retinal photocoagulation declined after 2019 and 2017, respectively. Minimally invasive glaucoma and long-tube shunt surgeries began to increase in 2015 and 2014, respectively. This trend contrasts with the decrease in trabeculectomies after 2019. The coronavirus disease-19 pandemic caused a 30.9% decrease in ophthalmological surgery expenses in 2020. The decreases in volume and expense were greater for cataract surgeries than for other surgeries. The pandemic had a stronger impact on ophthalmological healthcare than that on general medical healthcare. Advancements in technology and methodology have led to cost savings in national cataract healthcare, vitrectomy, and retinal photocoagulation while caused increase in the volume and expenditure of glaucoma surgeries and anti-VEGF injections over a span of 15 years in Japan.

Predictive potential of optical coherence tomography parameters for the prognosis of decreased visual acuity after trabeculectomy in open-angle glaucoma patients with good vision

BACKGROUND

Trabeculectomy (trab) is the most effective surgical procedure for lowering IOP and preventing glaucoma progression. However, decline in best-corrected visual acuity (BCVA) is one of the most serious postoperative complications of trab. Here, we investigated methods to predict decreased BCVA after trab in glaucoma patients with good preoperative BCVA.

METHODS

This study included 35 eyes of 35 open-angle glaucoma (OAG) patients (male / female: 21 / 14, age: 64.0 ± 9.7 years old, preoperative intraocular pressure: 15.9 ± 5.4 mmHg, mean deviation: -18.1 ± 5.6 dB) with preoperative BCVA of 0.7 or better who underwent trab and were observed for more than 12 months. As a preoperative analysis, we measured temporal quadrant circumpapillary retinal nerve fiber layer thickness (cpRNFLT) and ganglion cell complex thickness in a central strip between the disc and fovea (csGCCT), an area that corresponds to the location of the papillomacular bundle (PMB) in swept-source optical coherence tomography (OCT). We defined BCVA decline as a loss of more than 3 lines of BCVA after 12 months. Measurement parameters were compared between the BCVA-decline group and the non-BCVA-decline group.

RESULTS

BCVA decline was detected in 11 cases (31.4%) 12 months after trab. There was a statistically significant difference in axial length (P = 0.049). A single logistic analysis showed that the BCVA-decline group had significantly lower cpRNFLT than the non-BCVA-decline group (27.7 ± 8.0 μm vs. 45.1 ± 5.3 μm, P < 0.001, cut-off value: 33.4 μm), as well as lower csGCCT (72.4 ± 7.7 μm vs. 87.5 ± 5.1 μm, P = 0.002, cut-off value: 82.3 μm). Multivariable logistic analysis showed that the BCVA-decline group had significantly lower temporal quadrant cpRNFLT (P < 0.001) and lower middle csGCCT (P < 0.001) compared to the non-BCVA-decline group.

CONCLUSIONS

Lower temporal quadrant cpRNFLT and middle csGCCT, OCT scan areas that correspond to the location of the PMB, might be biomarkers that predict BCVA decline after trab in OAG patients with good vision.

Early postoperative visual acuity changes after trabeculectomy and factors affecting visual acuity

PURPOSE

To investigate the early visual acuity (VA) changes that occur after trabeculectomy and their reversal with recovery.

METHOD

Two hundred ninety-two eyes of 292 patients after initial trabeculectomy as a standalone procedure fulfilling the following conditions were included: 1) patients with a postoperative follow-up of at least 3 months; 2) patients with preoperative corrected VA less than 0.5 logMAR equivalent; 3) patients with reliable results of visual field; and 4) patients who had open angle glaucoma. VA and intraocular pressure (IOP) changes during the first 3 months after surgery and factors affecting VA postoperatively at 3 months were investigated.

RESULTS

The mean IOPs (mmHg) after trabeculectomy were significantly lower than preoperatively during the entire period (P < 0.0001). The mean corrected VA for all patients was 0.06 ± 0.17, 0.24 ± 0.38, 0.19 ± 0.26, and 0.14 ± 0.27 preoperatively and at 1 week, 1 month, and 3 months postoperatively, respectively, showing a significant decrease from the preoperative period at all time points (P < 0.0001). VA loss of two or more levels was observed in 13 eyes (4.45%) at 3 months postoperatively. Foveal threshold (FT), shallow anterior chamber (SAC), and choroidal detachment (CD) affected the change in VA before and at 3 months after surgery (P < 0.0001, P = 0.0002, P = 0.0004, respectively). The factors that had significant effects on VA change were FT, SAC, and CD in POAG, FT and hypotonic maculopathy in NTG, and FT in XFG (p < 0.05).

CONCLUSION

The frequency of serious vision loss was 4.45% for two or more levels of vision loss, and early postoperative VA changes after trabeculectomy may not be reversed even 3 months later. VA loss is influenced by preoperative FT, postoperative SAC and CD, but the impact of postoperative complications vary with disease type.

Five-year follow-up of corneal endothelial cell density after transscleral ab interno glaucoma gel stent implantation

Purpose

This study investigates the course of the endothelial cell density over a period of 5 years after XEN45 implantation (XEN45µm, Allergan Plc., USA) with or without combined cataract surgery.

Methods

This is a prospective, cross-sectional, monocentric, non-randomized clinical trial with the intention to treat a population of the University Eye Clinic Glaucoma Service Salzburg. One hundred and fifty-five eyes with preoperative central corneal endothelial cell counts were subjected to XEN45 implantation with (combined surgery group) or without (solo surgery group) combined cataract surgery. Endothelial cell density was measured at 3 corneal positions. XEN45 location parameters were determined with anterior segment OCT and gonioscopy.

Results

In the combined surgery group, a significant reduction of central endothelial cell count was found at years 2 and 4 when compared to baseline (p = 0.001 and p = 0.02, n = 86), whereas at years 1, 3, and 5, no change was detected (all p > 0.09). The median reduction of endothelial cell count was − 79 (95% CI: − 183 to − 9) and − 93 (95% CI: − 220 to 23) cells at years 2 and 4, respectively. In the solo surgery group (n = 69), no significant change in endothelial cell counts was detected at any time during the 5-year evaluation period (all p > 0.07). Explorative data analyses revealed that XEN45 location parameters did not significantly influence the course of endothelial cell count over time.

Conclusions

Endothelial cell loss after XEN45 implantation seems to be low. The present data suggest no impact on the position of the implant with regard to central endothelial cell counts in this study.

Refractive Changes after Glaucoma Surgery-A Comparison between Trabeculectomy and XEN Microstent Implantation

Best-corrected visual acuity often decreases temporarily or permanently after trabeculectomy (TE). The purpose of this study was to compare visual acuity and refractive changes after TE or XEN microstent implantation (XEN) in primary open-angle glaucoma (POAG) or pseudoexfoliation glaucoma (PEX) cases naïve to prior glaucoma surgery over a 24-month follow-up period. We analyzed 149 consecutive glaucoma patients who received either TE or XEN because of medically uncontrollable POAG or PEX. Intraocular pressure (IOP), IOP-lowering medication use, subjective and objective refraction and best-corrected visual acuity were evaluated. In addition, surgically induced astigmatism (SIA) was calculated and compared using the vector analysis method described by Jaffe and Clayman. A total of 93 eyes (85 POAG; 8 PEX) were treated with TE and 56 eyes (50 POAG; 6 PEX) with XEN. After 24 months, the mean IOP and number of IOP-lowering medications used decreased significantly after TE (p < 0.01) and XEN (p < 0.01). In the TE group, mean best-corrected visual acuity (BCVA) changed from 0.16 ± 0.26 to 0.23 ± 0.28 logMAR (p < 0.01) after 24 months, while mean BCVA did not change significantly in the XEN group (preoperative: 0.40 ± 0.50 logMAR, postoperative: 0.36 ± 0.49 logMAR; p = 0.28). SIA was almost the same in both groups at the end of the 24-month follow-up period (0.75 ± 0.60 diopters after TE and 0.81 ± 0.56 diopters after XEN; p = 0.57). In addition, there was no significant correlation between SIA and the observed BCVA changes or SIA and IOP reduction 12 or 24 months after TE or XEN. Our results demonstrate that TE and XEN are effective methods for reducing IOP and IOP-lowering medication use. The SIA was nearly similar in both groups. The SIA does not seem responsible for the decreased visual acuity after TE.

Proportion of Glaucoma Types and Surgeries Among Young, Pre-Old, Old, and Oldest-Old Age Groups or Different Sex Groups

Background

We report the real-world distribution of glaucoma types and glaucoma surgeries in each age or sex group in our department.

Methods

The department database of Matsue Red Cross Hospital, a tertiary care hospital, for eyes surgically treated to manage glaucoma between April 2014 and March 2018 was searched. Patient age, sex, disease type, and surgical procedure were collected from the database. The age was stratified by ≤64 years (young), 65–74 years (pre-old), 75–89 years (old), and ≥90 years (oldest-old or super-old).

Results

In the database, 2036 consecutive surgeries (70.3 ± 14.4 years; 1015 males) were identified. Among all subjects, primary open-angle glaucoma (POAG) (42.7%) was the most frequent identifiable glaucoma type followed by primary angle-closure disease (PACD) (18.8%) and exfoliation glaucoma (17.9%). The glaucoma types differed significantly among the age groups (P < 0.0001); POAG was the most frequent type of glaucoma in young and pre-old groups, while PACD and exfoliation glaucoma were the most frequent glaucoma types in the oldest-old group. Among all subjects, trabeculotomy or other goniotomy/gonio-bypass surgery (41.7%) was the most frequent glaucoma surgery followed by long-tube shunt (22.1%) and trabeculectomy (16.2%). The glaucoma surgeries performed differed significantly among the age groups (P < 0.0001). The frequency of trabeculectomy was the highest in the young group (27.8%), trabeculotomy was the highest in the pre-old (42.6%) and old (46.6%) groups, and long tube shunt (41.3%) and cataract extraction + goniosynechialysis (32.6%) were the highest in the oldest-old group. The glaucoma type (P < 0.0001) and surgeries performed (P < 0.0001) differed significantly between sex groups; the rates of PACD and cataract extraction + goniosynechialysis were remarkably higher in female than male group.

Conclusion

The types of glaucoma and required glaucoma surgeries differ among the different age groups and sexes. Primary angle-closure disease and exfoliation glaucoma are the major glaucoma types in the old and oldest-old age groups.

Comparison of Different Procedures in a Combination of Ab Interno Microhook Trabeculotomy and Cataract Surgery

The purpose of this study was to compare the clinical outcomes of ab interno microhook trabeculotomy (µLOT) before and after cataract surgery for the combination of µLOT and cataract surgery. This retrospective case series included 40 eyes that underwent µLOT combined with cataract surgery at Kochi University Hospital. Groups 1 (20 eyes) and 2 (20 eyes) included eyes that underwent µLOT before and after cataract surgery, respectively. The patient characteristics and clinical outcomes were also analyzed. The mean preoperative intraocular pressure (IOP) in Groups 1 and 2 (26.1 ± 12.2 mmHg and 20.6 ± 8.8 mmHg) was reduced significantly to 14.1 ± 3.3 mmHg and 12.9 ± 3.2 mmHg, respectively, at 5–7 months postoperatively. The median preoperative number of antiglaucoma medications in Groups 1 and 2 (4.0 and 3.5) also decreased significantly, to 2.5 and 1.0, respectively, at 5–7 months postoperatively. Postoperative hyphema with niveau formation in Groups 1 and 2 was observed in one eye (5.0%) and six eyes (30.0%), respectively. For the combination of µLOT and cataract surgery, performing µLOT before cataract surgery may be less likely to result in postoperative hyphema with niveau formation.

Long-term results of the safety and effectiveness of a novel microshunt in Japanese patients with primary open-angle glaucoma

PURPOSE

To evaluate the long-term safety and effectiveness of the Preserflo MicroShunt in Japanese primary open-angle glaucoma (POAG) patients.

STUDY DESIGN

Single-site, nonrandomized observational study.

PATIENTS AND METHODS

Eight eyes of 7 POAG patients were included. The surgical complications and interventions were monitored. The preoperative and postoperative intraocular pressures (IOPs), numbers of antiglaucoma medications, logarithm of the minimum angle of resolution visual acuity (VA), mean deviation (MD) slope, and corneal endothelial cell density (CECD) were compared retrospectively.

RESULTS

The mean follow-up period was 68.9 months (range, 48-76 months). The baseline IOP of 17.9 ± 3.5 mmHg and the number of glaucoma medications of 3.5 ± 0.5 were significantly reduced at subsequent follow-up visits. At 1, 2, 3, 4, 5, and 6 years postoperatively, the IOPs were 13.8 ± 2.9, 12.8 ± 2.3, 12.1 ± 3.2, 12.6 ± 2.5, 12.3 ± 1.0, and 13.5 ± 3.1 mmHg, respectively, with the use of 1.6 ± 1.4, 1.6 ± 1.6, 1.5 ± 1.4, 1.5 ± 1.4, 1.9 ± 1.3, and 2.0 ± 1.1 medications. Postoperative transient hyphema occurred in 1 eye. Postoperative needling was required in 5 eyes, 12 times in total. No eyes showed significant VA decline, except for 1 eye with a severe central visual field defect that existed preoperatively. The preoperative MD slope of - 1.6 ± 1.2 dB/year improved significantly, to - 0.3 ± 0.2 dB/year (P = 0.023), postoperatively. The baseline CECD decreased from 2595 ± 292 to 2478.4 ± 255 postoperatively.

CONCLUSION

The microshunt surgical procedure is safe and effective for Japanese POAG patients.

Factors Threatening Central Visual Function of Advanced Glaucoma Patients: A Prospective Longitudinal Observational Study

PURPOSE

To identify risk factors for further deterioration of central visual function in advanced glaucoma eyes.

DESIGN

Prospective observational 5-year study.

PARTICIPANTS

Advanced glaucoma patients with well controlled intraocular pressure (IOP), the mean deviation (MD) of Humphrey Field Analyzer 24-2 program (HFA 24-2) ≤ -20 decibels and best-corrected visual acuity (BCVA) ≥ 20/40.

METHODS

The HFA10-2 test and BCVA examination were performed every 6 months and the HFA 24-2 test every 12 months for 5 years. The Cox proportional hazards model was used to identify risk factors for deterioration of HFA10-2 and 24-2 results and BCVA.

MAIN OUTCOME MEASURES

Deterioration of HFA 10-2 results was defined by the presence of the same ≥ 3 points with negative total deviation slope ≤ -1 decibel/year at P < 0.01 in ≥ 3 consecutive tests, that of HFA 24-2 results as an increase ≥ 2 in the Advanced Glaucoma Intervention Study (AGIS) score in ≥ 2 consecutive tests and that of BCVA as an increase of ≥ 0.2 in the log MAR in ≥ 2 consecutive tests.

RESULTS

A total of 175 advanced glaucoma eyes of 175 patients (mean age, 64.1 years; mean baseline IOP, 13.2 mmHg; mean logMAR, 0.02; Mean HFA 24-2 and 10-2 MD, -25.9 and -22.9 decibels, respectively) were included. The mean IOP during follow-up was 13.0 mmHg. The probabilities of deterioration in HFA 10-2 and 24-2 results and BCVA were 0.269 ± 0.043 (standard error), 0.173 ± 0.031 and 0.194 ± 0.033, respectively, at 5 years. Lower BCVA at baseline (P=0.012) was significantly associated with further deterioration of HFA 10-2 results. Better HFA24-2 MD (P<0.001) and use of systemic antihypertensive agents (P=0.009) were significantly associated with further deterioration of HFA 24-2 results, and a greater β-peripapillary atrophy area/disc area ratio (P<0.001), use of systemic antihypertensive agents (P=0.025) and lower BCVA (P=0.042) were significantly associated with further deterioration of BCVA, respectively.

CONCLUSIONS

In advanced glaucoma eyes with well controlled IOP, BCVA, β-peripapillary atrophy area/disc area ratio and use of systemic antihypertensive agents were significant prognostic factors for further deterioration of central visual function.

MÜLLER CELL CONE-ASSOCIATED FOVEAL DETACHMENT AS A RISK FACTOR FOR VISUAL ACUITY LOSS AFTER GLAUCOMA FILTERING SURGERY

PURPOSE

To examine hypotony-associated foveal lesions (FovLs) using optical coherence tomography, and to assess the risk factors of visual deterioration after glaucoma filtering surgery.

METHODS

Parameters that may be associated with postsurgical deterioration of visual acuity were retrospectively studied in 44 eyes of 44 patients who experienced postsurgical intraocular hypotension ≤6 mmHg between 2015 and 2019.

RESULTS

Six eyes (14%) had FovLs, such as detachment of photoreceptors (5 eyes, 11%) and acquired vitelliform lesions (1 eye, 2%) at 3 months after trabeculectomy. Logistic regression analysis revealed that hypotony maculopathy (P = 0.0141 at 3 months) and FovLs (P = 0.0486 and 0.0296 at 3 and 12 months, respectively) were significant risk factors for Visual acuity loss after trabeculectomy. The FovLs were located just behind the Müller cell cone. Visual acuity at 3 and 12 months after surgery in patients with FovLs was significantly lower than in those without FovLs (P = 0.0013 and P = 0.006, respectively). Epiretinal membrane was more common in eyes with FovLs (5 of 6 eyes, 83%) than in eyes without FovLs (7 of 38 eyes, 18%; P = 0.0037).

CONCLUSION

Müller cell cone-associated FovLs lead to long-lasting visual acuity loss after filtering surgery.

Long-term perimetric stabilization with a management algorithm of set target intraocular pressure in different severities of primary angle-closure glaucoma

Purpose

To evaluate long-term perimetric stabilization at set Target (IOPs) in primary angle-closure glaucoma with visual field defects.

Methods

Two hundred forty-eight eyes, of 124 primary angle-closure glaucoma (PACG) patients on medical treatment, and 124 eyes, of 95 patients after trabeculectomy performed at least 5 years prior were evaluated. One hundred eighty-five eyes had a follow-up of ≥10 years. Target IOPs for mild, moderate, and severe glaucomatous optic neuropathy were set at ≤18, ≤15, and ≤12 mmHg, respectively. Progression was evaluated by event-based changes on guided progression analysis. Primary outcome measure was therapy required to achieve individualized Target IOP. Secondary outcome measure was assessment of perimetric change over time.

Results

Mean baseline IOP was 23.34 ± 6.16 mmHg in medically treated and 36.08 ± 9.73 mmHg in surgically treated eyes (P = 0.0001). All eyes with a baseline IOP of <25 mmHg were on medications alone, 65.33%, of those with a baseline IOP of 25-30 mmHg were on medications, while 34.67% required trabeculectomy. In total, 91.4% of eyes with a baseline IOP of >30 mmHg underwent a trabeculectomy for achieving Target IOP. Perimetric stabilization was achieved in 98.17% of PACG eyes. "Target" IOP was achieved for mild, moderate, and severe glaucomatous optic neuropathy, medically in 90.2, 73.9, and 29.7%, and surgery was required in 9.8, 26.1, and 70.3%, respectively. Overall analysis found that percentage reduction in IOP was significantly more after trabeculectomy than medical treatment, 64.16 ± 14.91 and 43.61 ± 13.73%, P = 0.0001. Decrease in IOP was significantly greater 5-9 years after trabeculectomy, in comparison to ≥10 years, P = 0.001.

Conclusion

Medications controlled IOP to "Target" in PACG eyes with mild and moderate glaucoma for over ≥10 years, when the baseline IOP off treatment was <30 mmHg. Trabeculectomy was necessary in PACG eyes having severe glaucomatous optic neuropathy, or with a baseline IOP of >30 mmHg to achieve Target IOP. These appropriate initial therapeutic interventions and Target IOPs are therefore suggested as a clinically validated algorithm of care for different severities of PACG.

Effects of Preoperative Intraocular Pressure Level on Surgical Results of Microhook Ab Interno Trabeculotomy

To assess the roles of preoperative intraocular pressure (IOP) level on the IOP reducing efficacy of microhook ab interno trabeculotomy (µLOT), 126 consecutive open-angle glaucomatous eyes (90 primary open angle glaucoma, 36 exfoliation glaucoma) of 126 Japanese subjects (60 men, 66 women; mean age ± standard deviation, 70.5 ± 11.4 years) who underwent µLOT alone (25 eyes, 20%) or combined µLOT and cataract surgery (101 eyes, 80%) were retrospectively included, and subdivided into four groups based on the quartile of preoperative IOP: Q1, ≤15 mmHg; Q2, 15–18 mmHg, Q3, 18–21 mmHg, and Q4, >21 mmHg. Preoperative and 12 months postoperative IOPs and numbers of antiglaucoma medications were compared among IOP groups. Factors associated with postoperative IOP were assessed using multivariate analysis, and the success of IOP control was assessed with various definitions. Postoperatively, IOP was significantly higher in Q3 (p < 0.0146) and Q4 (p = 0.0320) groups than Q1 group, while the number of medications was not significantly different among four IOP groups (p = 0.1966). Older age was associated with lower postoperative IOP, and higher preoperative IOP was associated with higher postoperative IOP, while sex, glaucoma type, surgical procedure, lens status, extent of trabeculotomy incision, and preoperative number of medications were not associated with postoperative IOP. The success rates for IOP ≤ 18 and ≤15 mmHg were higher in lower preoperative IOP groups (i.e., Q1 and Q2) than higher preoperative IOP groups (Q3 and Q4), while the success rate for ≥20% IOP reduction was higher in higher preoperative IOP groups than in lower preoperative IOP groups; the success rate for ≥0% IOP reduction was equivalent among groups. By reviewing the previous studies in ab interno trabeculotomy/goniotomy procedures, positive correlation between preoperative and postoperative IOPs was preserved throughout the studies and surgical procedures. After the µLOT, larger %IOP reduction was achieved in higher preoperative IOP groups than in lower preoperative IOP groups, while postoperative IOP was still lower than in lower preoperative IOP groups.

Ocular Hypotension and Epiretinal Membrane as Risk Factors for Visual Deterioration Following Glaucoma Filtering Surgery

PRECIS

Postsurgical hypotension at 1 week and the presence of an epiretinal membrane (ERM) were significant risk factors for the deterioration of postsurgical visual acuity (VA) at 3 and 12 months, respectively.

PURPOSE

The purpose of this study was to assess the effects of an ERM and postsurgical hypotension <6 mm Hg at 1 week on postsurgical VA loss.

PATIENTS AND METHODS

A total of 69 patients (69 eyes) who underwent trabeculectomy with adjunctive mitomycin C between 2017 and 2019 (mean follow-up period: 22.8 mo) were enrolled, and 14 parameters that could be associated with the deterioration of VA at 3 and 12 months were studied.

RESULTS

There was a significant association between VA loss at 3 months and postsurgical intraocular pressure at 1 week (P=0.006 by multiple regression) and hypotony maculopathy (P=0.024 by Fisher exact test). However, this association was lost at 12 months. Instead of postsurgical hypotension, the presence of an ERM was significantly associated with VA loss at 12 months (P=0.035 by Fisher exact test, and P=0.023 by logistic regression).

CONCLUSIONS

Postsurgical hypotension at 1 week was significantly associated with mid-term, but not long-term, postsurgical VA loss. The presence of an ERM, which was not a risk factor for mid-term acuity loss, was a significant risk factor for VA loss at 12 months.

Midterm Results of Microhook ab Interno Trabeculotomy in Initial 560 Eyes with Glaucoma

All the 560 glaucomatous eyes of 375 Japanese subjects (181 men, 194 women; mean age ± standard deviation, 76.0 ± 13.2 years) who underwent microhook ab interno trabeculotomy (µLOT) alone (159 eyes, 28%) or combined µLOT and cataract surgery (401 eyes, 72%) performed by one surgeon at Matsue Red Cross Hospital between May 2015 and March 2018 to control intraocular pressure (IOP) were retrospectively assessed. Preoperative and postoperative IOPs, numbers of antiglaucoma medications, the logarithm of the minimum angle of resolution visual acuity (logMAR VA), anterior chamber (AC) flare, visual field mean deviation (MD), and corneal endothelial cell density (CECD) were compared up to 36 months. Surgical complications and required interventions were described. The duration of the follow-up was 405 ± 327 (range, 2–1326) days. The mean preoperative IOP (20.2 ± 7.0 mmHg) and number of antiglaucoma medications (2.8 ± 1.1) decreased to 13.9 ± 4.5 mmHg (31% reduction, p < 0.0001) and 2.5 ± 1.0 (11% reduction, p < 0.0001), respectively, at the final visit. After combined surgery, compared with preoperatively, the final VA improved 0.11 logMAR (p < 0.0001), AC flare increased 4.5 photon counts/msec (p = 0.0011), MD improved 0.6 decibel (p < 0.0001), and the CECD decreased 6% (p < 0.0001). Layered hyphema (172 eyes, 31%) and hyphema washout (26 eyes, 5%) were the most common postoperative complication and intervention, respectively. At the final visit, 379 (69%) eyes achieved successful IOP control of ≤18 mmHg and ≥20% IOP reduction, and 349 (64%) eyes achieved successful IOP control of ≤15 mmHg and ≥20% IOP reduction. Older age, steroid-induced glaucoma, developmental glaucoma, and the absence of postoperative complications were associated with lower final IOP; exfoliation glaucoma, other types of glaucoma, and higher preoperative IOP were associated with higher final IOP. µLOT has a significant IOP-lowering potential in patients with glaucoma, and improves visual function when combined with cataract surgery.

Optical Coherence Tomography Assessment of Risk Factors for Visual Acuity Decline After Trabeculectomy in Patients With Advanced Open-Angle Glaucoma

PRéCIS:: Thinning of the macular retinal nerve fiber layer (mRNFL) and ganglion cell complex in the papillomacular bundle area contributed significantly to visual acuity (VA) decline in advanced glaucoma patients after trabeculectomy.

PURPOSE

To identify structural parameters that could predict VA decline after trabeculectomy in patients with advanced open-angle glaucoma.

PATIENTS AND METHODS

Retrospective review of 74 eyes of 74 patients with advanced glaucoma (defined as mean deviation -12 dB or worse) and best-corrected VA (BCVA) of ≥40/200. All patients underwent trabeculectomy between 2013 and 2016. Measurements included intraocular pressure, BCVA, visual field parameters, and optical coherence tomography-derived parameters [(in both the overall macula and within the papillomacular bundle (PMB)], including mRNFL thickness (mRNFLT), ganglion cell layer/inner plexiform layer thickness, and ganglion cell complex thickness. Measurements were obtained before and after surgery, and follow-up was at least 6 months. We grouped the patients according to whether they underwent VA decline of >3 lines of BCVA after 6 months. We then compared the VA-decline group and the stable-VA group and performed a receiver operating characteristic analysis to determine optimal cut-off values for predicting VA decline.

RESULTS

The VA-decline group comprised 7 eyes (9.5%) and had lower preoperative mean deviation (P=0.021) and thinner mRNFL, ganglion cell layer/inner plexiform layer, and ganglion cell complex in the PMB (P=0.003, 0.135, and 0.023, respectively) than the stable-VA group. The cut-off values for predicting VA decline were 9.5 μm for mRNFLT in the PMB.

CONCLUSIONS

This study found that thin mRNFLT in the PMB were risk factors for VA decline after trabeculectomy.

Natural Plant Extract Berbamine Is a Potent Inhibitor of Cell Growth and Survival of Human Tenon's Fibroblasts

INTRODUCTION

Post-trabeculectomy scarring due to excessive proliferation of human Tenon's fibroblasts (HTFs) often led to operation failure. Developing a new anti-fibrosis drug with high efficacy to inhibit HTF cell growth will greatly improve the effectiveness of trabeculectomy.

OBJECTIVE

This study aims to investigate the effect of berbamine (BBM) treatment on the cell growth and survival of HTFs.

METHODS

Cultured human fetal Tenon's fibroblasts (HFTFs) were treated with or without different concentrations of BBM. Cell morphology was observed with a phase contrast microscope. A CCK-8 method and Ki67 immunofluorescence were used to determine cell viability and cell proliferation. A scratch test was used to study cell migration. Flow cytometry and TUNEL staining were performed to detect cell apoptosis. The expression of BAX/BCL-2, ERK, and AKT/mTOR pathway components was determined by Western blotting.

RESULTS

BBM treatment disrupted HFTF normal morphology and inhibited its cell growth in a dose-dependent manner. Ki67 immunofluorescence and scratch assay showed BBM suppressed HFTF cell proliferation and migration. Importantly, BBM dose-dependently increased the BAX/BCL-2 ratio and induced apoptosis in HFTF cells. Western blotting showed BBM significantly inhibited the ERK and AKT/mTOR pathway, and PTEN inhibition ameliorated the inhibitory effect of BBM on cell viability and survival in HFTFs.

CONCLUSIONS

BBM potently inhibits the cell growth and survival of HTFs through AKT/mTOR and has the potential to serve as an anti-fibrosis drug after trabeculectomy.

Effectiveness of trabeculectomy with mitomycin C for glaucomatous eyes with low intraocular pressure on treatment eye drops

PURPOSE

To examine the efficacy and safety of current trabeculectomy with mitomycin C in Japan for glaucomatous eyes with low intraocular pressure (IOP).

METHODS

Two hundred ninety-four eyes of 294 patients with IOP ≤21 mmHg before surgery were studied; all patients were participants in the Collaborative Bleb-related Infection Incidence and Treatment Study (CBIITS), a multicentre, prospective, cohort study conducted at 34 ophthalmological institutions throughout Japan. All eyes had an intraocular pressure ≤ 21 mmHg and had undergone trabeculectomy alone or phacotrabeculectomy. Two success criteria were used: Criterion A comprised 20% reduction of baseline IOP and Criterion B comprised 30% reduction of baseline IOP. The primary outcome was the success rate for each of these criteria.

RESULTS

The qualified success rates were 87.3% for Criterion A and 42.0% for Criterion B at 5 years. Mean IOP was significantly reduced, from 16.7 ± 2.7 to 11.6 ± 4.0 mmHg at 5 years after trabeculectomy (p < 0.0001); the number of anti-glaucoma medications significantly decreased from 2.7 ± 1.1 to 1.0 ± 1.2 (p < 0.0001) at 5 years after the surgery. Three or more trabeculectomies, and needling were related to increased risk of failure. Incidences of postoperative hyphema, infection, shallow anterior chamber and bleb leakage were 2.4%, 2.4%, 2.0% and 3.4%, respectively.

CONCLUSIONS

This study showed that trabeculectomy with mitomycin C is an effective procedure with few surgical complications for reducing IOP in patients, even if preoperative IOP was within the normal range.

Does TRABECULECTOMY meet the 10-10-10 challenge in PACG, POAG, JOAG and Secondary glaucomas?

PURPOSE

Evaluation of the intraocular pressure (IOP) lowering efficacy of trabeculectomies over > 10 years and their ability to stabilize glaucomatous optic neuropathy.

METHODS

In total, 181 eyes (136 patients), which underwent trabeculectomy (10 min surgery) at least 10 years prior and were on regular follow-up, were evaluated. Qualified/complete success was taken as criteria A: IOP ≤ 12 mmHg, B: IOP ≤ 15 mmHg and C: IOP ≤ 18 mmHg, with all > 5 mmHg, with/without medications. Target IOP in advanced glaucoma is about 10 mmHg, therefore trabeculectomy 10-10-10 challenge!

RESULTS

The mean age of patients was 46.32 ± 11.50 years. Absolute success was 50.27%, 54.14% and 59.66% according to criteria A, B and C at last follow-up, while qualified success was 70.11%, 81.77% and 96.13%. An IOP of ≤ 12 mmHg was noted in 34, 64.15%, PACG eyes, 14, 73.68%, POAG, 15, 65.22%, JOAG and 64, 74.42%, secondary glaucoma eyes. The reduction in IOP overall was 64.83 ± 16.80% at last review and was 59.47 ± 16.07% in PACG, 62.40 ± 17.72% in POAG, 71.89 ± 8.50% in JOAG and 67.74 ± 18.10% in secondary glaucoma eyes. "Target" IOP was achieved in 97.29% of early glaucoma, 85.71% moderate glaucoma and 70% severe glaucoma eyes. 97.24% of patients were perimetrically stable. 2.21% of eyes post-trabeculectomy had a shallow anterior chamber needing surgical intervention. Visual acuity was maintained or better in 93.92% of patients, with a cataract surgery performed in 6.63% eyes. A repeat trabeculectomy was performed in 3.31% of eyes.

CONCLUSION

Trabeculectomy 10-10-10 is achievable in the long term, with few complications or repeat surgical interventions in the majority of POAG, PACG, JOAG and secondary glaucomas. Therefore, trabeculectomy should not be relegated to a last resort, but should be undertaken as soon as possible, if medical therapy is inadequate, unaffordable or compliance is an issue.

Change in visual acuity 12 and 24 months after transscleral ab interno glaucoma gel stent implantation with adjunctive Mitomycin C

PURPOSE

To analyze changes in best-corrected visual acuity (BCVA) after implantation of the transscleral ab interno glaucoma gel stent (XEN Gel Stent; Allergan, Dublin) in patients with open-angle glaucoma.

METHODS

In a single-center, prospective, non-randomized study of 137 eyes with open-angle glaucoma which underwent implantation with XEN, 69 eyes underwent XEN implantation alone (group 1) and 68 eyes underwent XEN implantation and cataract surgery (group 2). BCVA (Bailey-Lovie chart, logMAR scale) was evaluated at baseline, postoperative day 1, weeks 1 and 2, and months 1, 3, 6, 12, and 24. Risk factors for decline in BCVA were analyzed in multivariate models.

RESULTS

Baseline BCVA in group 1 was 0.21 ± 031; the group's mean BCVA did not change at any postoperative visit, although a ≥ 2-line loss of BCVA was detected in 15% (95% CI 7-29%) and 4% (95% CI 0-20%) after months 12 and 24, respectively. Baseline BCVA in group 2 was 0.33 ± 031; vision increased significantly at months 3 (0.22 ± 0.29, p = 0.015), 6 (0.20 ± 0.26, p = 0.006), 12 (0.18 ± 0.29, p = 0.001), and 24 (0.18 ± 0.29, p = 0.005). A ≥ 2-line loss of BCVA was reported in 4% (95% CI 1-15%) and 7% (95% CI 1-24%) after months 12 and 24, respectively.

CONCLUSIONS

There was no deterioration of BCVA in group 1; those in group 2 had an overall significant increase in BCVA. BCVA decrease was lower than is typically reported in the literature post-trabeculectomy.

Comparing the efficacy of trabeculectomy and diode laser cyclophotocoagulation in primary open-angle glaucoma

PURPOSE

The aim was to compare the postsurgical outcomes of trabeculectomy (TET) and transscleral cyclophotocoagulation (CPC) in a similar cohort of eyes diagnosed with primary open-angle glaucoma (POAG).

MATERIALS AND METHODS

For this monocentric non-randomized retrospective comparative trial, the records of eyes which underwent TET or CPC between 2013 and 2016 at our institution for the treatment of POAG were reviewed. Parameters analyzed before surgery as well as 1 and 2-3 years afterwards were visual acuity (VA), intraocular pressure (IOP), mean defect (MD) of the visual field, number of glaucoma medications and the objective refraction using which the surgically induced astigmatism (SIA) was calculated.

RESULTS

In total, 51 eyes of 51 patients underwent TET and 45 eyes of 45 patients underwent CPC. Mean VA dropped in both groups on the last follow-up after surgery (TET-group: 0.17 ± 0.17 to 0.23 ± 0.28 logMAR, p = 0.01/CPC-group: 0.22 ± 0.22 to 0.26 ± 0.27 logMAR, p = 0.01). In the TET- and CPC-groups IOP decreased significantly (TET: 24.9 ± 6.4 to 14.9 ± 3.1 mmHg, p = 0.001/CPC: 23.0 ± 6.5 to 16.0 ± 4.1 mmHg, p = 0.001) although more pronounced and less depending on IOP-lowering medication in eyes after TET. MD remained stable after TET (7.4 ± 4.8 and 8.1 ± 4.9 dB, p = 0.1) but further deteriorated in eyes after CPC (9.0 ± 4.9 and 10.7 ± 4.6 dB, p < 0.001). SIA was comparable in both groups on the last follow-up (TET: 0.83 ± 0.69 D; CPC: 0.91 ± 0.65 D, p = 0.6).

CONCLUSION

The IOP reduction achieved without medication was more pronounced in the TET-group compared with the CPC-group. Visual field remained stable in the TET-group, while further deteriorating in the CPC-group during follow-up. Eyes undergoing CPC had a higher demand for additional medication to reach comparable success rates as TET. Due to this performing TET is favorable over CPC in POAG eyes.

Four-year results of a minimally invasive transscleral glaucoma gel stent implantation in a prospective multi-centre study

Importance

The transscleral XEN Glaucoma Gel Microstent (XEN‐GGM, Allergan Plc., Parsippany, New Jersey) is implanted by a minimally invasive ab interno technique.

Background

The present study aims to assess the long‐term clinical outcomes in patients after XEN‐GGM implantation.

Design

This prospective, non‐randomized, multi‐centred study was conducted in three countries (Austria, Canada and Germany).

Participants

Sixty‐four consecutive eyes of 64 patients with open angle glaucoma received the XEN‐GGM (63 μm) without Mitomycin C. Thirty‐five (55%) were solo procedures, and 29 (45%) were combined with cataract surgery.

Methods

Visits were planned at baseline, 6 months, 1, 2, 3 and 4 years postoperatively.

Main Outcome Measures

The main outcome measures were mean intraocular pressure (IOP), mean number of IOP lowering medication. Secondary outcome parameters were: visual acuity, visual fields and complete surgical failure (defined as presence of a secondary IOP lowering procedure or loss of light perception) at 4 years, postoperatively.

Results

Mean best‐medicated baseline IOP was 22.5 ± 4.2 mmHg and decreased significantly to 13.4 ± 3.1 mmHg 4 years postoperatively (−40%, n = 34, P < 0.001). Mean number of IOP lowering medication decreased significantly from 2.4 ± 1.3 preoperatively to 1.2 ± 1.3 (−50%, n = 34, P < 0.001) postoperatively. Visual field mean deviation showed no significant change between preoperative and postoperative examinations. Complete surgical failure rate per year was 10%.

Conclusions and Relevance

The XEN‐GGM resulted in lower IOP and a reduction in medications from baseline over 4 years of follow‐up. There was no detectable decrease in visual fields over the study. The surgical failure rate is comparable to other filtration surgeries.

Primary Baerveldt versus trabeculectomy study after one-year follow-up

PURPOSE

To compare a Baerveldt implant and trabeculectomy with respect to intraocular pressure (IOP) and failure rate at 1 year of follow-up. Secondary outcomes are pharmacological therapy and complications at 1 year of follow-up.

METHODS

This was a randomized, comparative study. A total of 119 glaucoma patients without previous ocular surgery were included at the Rotterdam Eye Hospital, the Netherlands. One eye of each subject was randomized to either a Baerveldt glaucoma drainage device (BGI) or trabeculectomy (TE). Follow-up visits were conducted at 1 day, 2 weeks, 6 weeks, 3 months, 6 months and 1 year after surgery.

RESULTS

After one year, the final IOP was equivalent for both treatment groups: 14 ± 4 mmHg (mean ± SD) for the Baerveldt group versus 13 ± 4 mmHg for the trabeculectomy group. Statistically, we found no significant difference in failure rate between the two groups. However, the Baerveldt group needed significantly more medication to decrease IOP. Overall, self-limiting complication rate was similar in both groups. Diplopia, a serious complication, was significantly more present in the BGI group.

CONCLUSION

One year after surgery, TE shows better results than the BGI. The final IOP, IOP reduction and failure rate are similar, but the need for additional IOP lowering medication in the BGI group is higher as well as the complication rate. The increased risk of developing diplopia after placement of a BGI must be taken into consideration.

Contemporary approach to the diagnosis and management of primary angle-closure disease

The primary angle-closure disease spectrum varies from a narrow angle to advanced glaucoma. A variety of imaging technologies may assist the clinician in determining the pathophysiology and diagnosis of primary angle closure, but gonioscopy remains a mainstay of clinical evaluation. Laser iridotomy effectively eliminates the pupillary block component of angle closure; however, studies show that, in many patients, the iridocorneal angle remains narrow from underlying anatomic issues, and increasing lens size often leads to further narrowing over time. Recent studies have further characterized the role of the lens in angle-closure disease, and cataract or clear lens extraction is increasingly used earlier in its management. As a first surgical step in angle-closure glaucoma, lens extraction alone often effectively controls the pressure with less risk of complications than concurrent or stand-alone glaucoma surgery, but may not be sufficient in more advanced or severe disease. We provide a comprehensive review on the primary angle-closure disease nomenclature, imaging, and current laser and surgical management.

Long-term results of deep sclerectomy in normal-tension glaucoma

PURPOSE

To study the long-term outcome of deep sclerectomy with and without mitomycin-C (MMC) in patients with normal-tension glaucoma (NTG).

METHODS

We prospectively analysed consecutive patients randomized to surgery performed either with (MMC group) or without (non-MMC) MMC. Surgery was considered totally successful if, after surgery, the preoperative intra-ocular pressure (IOP) level was reduced by 25% without medication, and a qualified success if medication was required to achieve the same limits.

RESULTS

A total of 37 patients were enrolled, 15 in the MMC and 22 in the non-MMC group. The median (range) follow-up was 7.9 (1.0-9.0) years, with a drop-out of three (8%) patients. The preoperative IOP was 15 (11-21) mmHg in the MMC and 15 (10-19) mmHg in the non-MMC group. At the last 6- to 9-year follow-up, IOP was significantly reduced to 9 (2-13) mmHg (p = 0.002) and 10 (5-13) mmHg (p < 0.001). The overall (groups combined) complete and qualified success rates were 50% and 71%, with no significant difference between groups (p = 0.48 and p = 0.25). Goniopuncture was performed in 87% and 100% of eyes in the MMC and non-MMC groups (p = 0.14). Needling with MMC injection was performed 0 (0-1) times in the MMC group and 0.5 (0-4) times in the non-MMC group (p = 0.056). We encountered no cases of hyphema, shallow anterior chamber, hypotony maculopathy, choroidal effusion, late bleb leakage, blebitis, endophthalmitis or malignant glaucoma.

CONCLUSION

In NTG, long-term significant IOP reduction can be achieved with deep sclerectomy with a low incidence of sight-threatening complications.

Microhook ab interno trabeculotomy, a novel minimally invasive glaucoma surgery

Trabeculotomy (LOT) is performed to reduce the intraocular pressure in patients with glaucoma, both in children and adults. It relieves the resistance to aqueous flow by cleaving the trabecular meshwork and the inner walls of Schlemm’s canal. Microhook ab interno LOT (µLOT), a novel minimally invasive glaucoma surgery, incises trabecular meshwork using small hooks that are inserted through corneal side ports. An initial case series reported that both µLOT alone and combination of µLOT and cataract surgery normalize the intraocular pressure during the early postoperative period in Japanese patients with glaucoma. Microhook can incise the inner wall of Schlemm’s canal without damaging its outer wall easier than the regular straight knife that is used during goniotomy. Advantages of µLOT include: a wider extent of LOT (two-thirds of the circumference), a simpler surgical technique, being less invasiveness to the ocular surface, a shorter surgical time than traditional ab externo LOT, and no requirement for expensive devices. In this paper, the surgical technique of µLOT and tips of the technique are introduced.

Effectiveness and safety of combined cataract surgery and microhook ab interno trabeculotomy in Japanese eyes with glaucoma: report of an initial case series

PURPOSE

To report the early postoperative results and safety profile of ab interno microhook trabeculotomy (μLOT) combined with cataract surgery.

PATIENTS AND METHODS

This retrospective observational case series included 68 consecutive glaucomatous eyes of 23 Japanese men and 25 Japanese women [mean (SD) age, 76.0 ± 8.5 years] who underwent μLOT for intraocular pressure (IOP) and visually relevant cataracts. The LOT site/extent, perioperative complications, and complication treatments were collected from the medical and surgical records. The preoperative and postoperative IOP, numbers of antiglaucoma medications, logarithm of the minimum angle of resolution visual acuity (VA), anterior chamber (AC) flare, and corneal endothelial cell density (CECD) were compared.

RESULTS

After small incisional cataract surgery, the trabecular meshwork was incised in the nasal (6 eyes, 3.6 ± 0.5 clock hours), temporal (6 eyes, 3.8 ± 0.8 clock hours), or both nasal and temporal (56 eyes, 6.5 ± 0.6 clock hours) angles. The mean preoperative IOP (16.4 ± 2.9 mmHg) and number of antiglaucoma medications (2.4 ± 1.2) decreased significantly (P < 0.0001 and P = 0.0039, respectively) to 11.8 ± 4.5 and 2.1 ± 1.0 mmHg at 9.5 months postoperatively. Compared with the preoperative conditions, the final VA improved (P = 0.0002), the AC flare increased by 6.3 pc/ms (P = 0.0157), and the CECD decreased by 6% (P = 0.0005). Hyphema with niveau formation (28 eyes, 41%) and hyphema washout (6 eyes, 9%) were the most common postoperative complication and intervention, respectively. At the final visit, 54 eyes (79%) had achieved successful IOP control of 15 mmHg or less and IOP reduction of 15% or greater.

CONCLUSION

Combined μLOT and cataract surgery improves IOP and VA during the early postoperative period in patients with glaucoma and cataract.

Short-term results of microhook ab interno trabeculotomy, a novel minimally invasive glaucoma surgery in Japanese eyes: initial case series

PURPOSE

To report the first early postoperative results and safety profile after microhook ab interno trabeculotomy (μLOT).

METHODS

This initial retrospective observational case series included 24 consecutive glaucomatous eyes of 17 Japanese patients (7 men, 10 women; mean age ± standard deviation, 66.7 ± 17.9 years) who underwent μLOT. The trabeculotomy extent, surgical time, perioperative complications, interventions for complications and additional glaucoma surgeries during the follow-up for more than 3 months were collected by reviewing the medical and surgical records. The intraocular pressure (IOP), numbers of antiglaucoma medications, logarithm of the minimum angle of resolution visual acuity (VA), anterior chamber (AC) flare and corneal endothelial cell density (CECD) were compared preoperatively and postoperatively.

RESULTS

The trabecular meshwork was incised for a mean of 3.6 ± 0.5 clock hours temporally, 3.7 ± 0.5 clock hours nasally and total 7.3 ± 0.6 clock hours during the 6.2 ± 1.6-min surgery. The mean preoperative IOP of 25.9 ± 14.3 mmHg and number of antiglaucoma medication of 3.3 ± 1.0 decreased significantly (p = 0.0002 and p = 0.005, respectively) to 14.7 ± 3.6 mmHg and 2.8 ± 0.8 at the final visit at 188.6 ± 68.8 days postoperatively. Compared with preoperatively, the final VA, AC flare and CECD did not change significantly. Hyphema with niveau formation (nine eyes, 38%) and washout of hyphema (two eyes, 8%) were the most common postoperative complication and intervention, respectively. At the final visit, 19 eyes (79%) achieved successful IOP control of 18 mmHg or less and a 15% reduction or greater.

CONCLUSION

Microhook trabeculotomy normalizes the IOP during the early postoperative period in patients with glaucoma.