Macular changes detected by Fourier-domain optical coherence tomography in patients with hypotony without clinical maculopathy

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.

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.

Phacotrabeculectomy versus Phaco with Implantation of the Ex-PRESS Device: Surgical and Refractive Outcomes-A Randomized Controlled Trial

The aim of this study was to compare surgical and refractive outcomes between phacotrabeculectomy (P-Trab) and phaco with Ex-PRESS (P-Ex-PRESS) for glaucoma at a 6-month follow-up. This prospective randomized controlled trial included 81 eyes; 43 eyes (53%) and 38 eyes (47%) were assigned to the P-Ex-PRESS and P-Trab groups, respectively. Refraction, intraocular pressure (IOP), and best-corrected visual acuity were measured. Refractive change was analyzed using the cylinder’s magnitude, and polar analysis assessed the change in the trend of astigmatism [with-the-rule, against-the-rule (ATR), oblique (OBL)], evaluating mean astigmatism in centroid form. All patients showed a statistically significant postoperative decrease in IOP (P < 0.05). There were no differences between the groups in terms of postoperative IOP and visual outcomes or in astigmatism preoperatively or postoperatively (P = 0.61, P = 0.74). In both groups, the mean preoperative and postoperative astigmatism were ATR and OBL, respectively. Preoperative and postoperative centroids in the P-Ex-PRESS group were 0.44 ± 1.32 D at 177° and 0.35 ± 1 D at 8°, respectively, (P = 0.5) and in the P-Trab group were 0.16 ± 1.5 D at 141° and 0.39 ± 1.38 D at 29°, respectively (P = 0.38). Both P-Ex-PRESS and P-Trab showed comparable antihypertensive efficacy in treating open-angle glaucoma over 6 months. Preoperative and postoperative astigmatism did not differ between groups. The groups showed comparable results for final visual acuity.

Frequency of hypotonic maculopathy observed by spectral domain optical coherence tomography in post glaucoma filtration surgery eyes

Purpose

To report the frequency of post glaucoma filtration surgery hypotonic maculopathy determined by spectral domain optical coherence tomography (SD-OCT).

Methods

A cross-sectional retrospective observational study. Post glaucoma filtration surgery patients whose intraocular pressures (IOP) achieved 30% reduction from baseline or was controlled to IOP <14 mm Hg and had SD-OCT images and fundus photographs were enrolled. Hypotonic maculopathy was diagnosed independently on SD-OCT images and on fundus photographs.

Results

112 eyes of 88 patients were included in this study. 17 eyes of 14 patients were diagnosed with hypotonic maculopathy on SD-OCT images (17/112, 15.2%). Among these eyes, only 3 eyes were also diagnosed with hypotony maculopathy on fundus photography. Hypotonic maculopathy on SD-OCT was found only in eyes with IOP ≤10 mm Hg. (17.4% in eyes with IOPs between 7 and 10 mm Hg, and 22.7% in eyes with IOP ≤ 6 mm Hg). Associations with age, sex, central corneal thickness, refractive error, IOP reduction rate and interval between surgery and OCT acquisition were not significant (P > 0.05).

Conclusion

In most cases, hypotonic maculopathy detected by SD-OCT were not recognizable on fundus photographs. Hypotonic maculopathy was detected not only in eyes with conventional ocular hypotony (IOP < 6 mm Hg) but also in eyes with IOP between 7 and 10 mm Hg.

Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors

Aim

To investigate surgical outcomes and success predictors of transconjunctival scleral flap resuturing for the management of hypotony due to overfiltration following trabeculectomy with mitomycin C.

Materials and methods

Noncomparative, retrospective, interventional case series in which all glaucoma patients from two glaucoma services undergoing transconjunctival scleral flap resuturing between May 2012 and July 2016 were enrolled. Included eyes had to have hypotony [intraocular pressure (IOP) < 6 mm Hg] and/or hypotony maculopathy caused by excessive filtration following trabeculectomy. Key exclusion criteria were wound/bleb leaking and postoperative ocular trauma or infection. Preoperative and postoperative IOP, best-corrected visual acuity (BCVA), fundus imaging, surgical complications, and any subsequent related events or procedures were recorded. Rates of postsurgical hypotony and/or maculopathy resolution and possible success predictors were investigated.

Results

A total of 22 patients (22 eyes) with a mean age of 56.4 ± 15.2 years were included. Median follow-up was 245 days [interquartilerange (IR); 120-817 days] and mean IOP was increased from 2.9 ± 1.5 mm Hg (1-6 mm Hg) to 8.5 ± 3.1 mm Hg (2-16 mm Hg) at the last follow-up visit (p < 0.01). Approximately 75% of the cases (16 out of 22) had an IOP between 7 and 18 mm Hg at the end of the follow-up period. Median BCVA (log MAR) at last follow-up visit [0.1 (IR; 0.0- 0.3)] was significantly better than preoperative BCVA [0.4 (IR; 0.11.0); p < 0.01]. Hypotony resolved in 81% of the cases, while maculopathy resolution was found in 85% of the cases. Time interval between trabeculectomy and flap resuturing was the only factor significantly associated with patient’s IOP at last follow-up visit (R² = 0.23; p = 0.036). Success rates (IOP > 6 mm Hg at last follow-up visit) were halved in those left untreated for more than 6 months. No serious adverse event was recorded.

Conclusion

Our findings support the use of transconjunctival scleral flap resuturing as an effective and safe alternative for hypotony management due to overflitration following trabeculectomy. As time interval seems to influence the odds of hypotony resolution, early intervention is recommended.

How to cite this article

Scoralick ALB, Almeida I, Ushida M, Dias DT, Dorairaj S, Prata TS, Kanadani FN, Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017;11(2):58-62.

Bleb revision for resolution of hypotony maculopathy following primary trabeculectomy

PURPOSE

To describe a surgical method of bleb revision for hypotony maculopathy, to evaluate its long-term efficacy, and to define the relationship between the duration of hypotony maculopathy and visual acuity (VA) outcomes.

DESIGN

Noncomparative retrospective case series.

METHODS

Medical records of 33 patients with hypotony maculopathy who underwent primary bleb revision between June 1999 and September 2012 by a single surgeon at an academic medical center were reviewed. Hypotony maculopathy was characterized by the presence of a decrease in VA, retinal striae, and macular edema in the setting of decreased intraocular pressure (IOP) after glaucoma filtering surgery. The main outcome measure was final logMAR VA after bleb revision at 6 and 12 months.

RESULTS

Thirty-three eyes of 33 patients were followed for 4.68 ± 3.56 years (range 0.55-12.69 years). Mean duration of hypotony maculopathy was 4.98 ± 8.93 months. LogMAR VA improved from 0.78 ± 0.40 at baseline to 0.34 ± 0.34 (P < .001) 6 months after bleb revision and to 0.45 ± 0.55 (P < .001) 12 months after bleb revision. Spearman rank coefficient (rs) correlating duration of hypotony and BCVA at both 6 and 12 months was significant (P = .015 and rs = 0.426, P = .028 and rs = 0.416, respectively). Mean IOP increased from 3.51 ± 2.27 mm Hg to 12.06 ± 4.06 mm Hg (P < .001) at 12 months. Fifty-two percent were on no antiglaucoma medications at last follow-up. Five eyes (15%) required a second bleb revision to correct persistent hypotony maculopathy.

CONCLUSION

Surgical repair for hypotony maculopathy provided a significant improvement in VA at 6 and 12 months. Surgical bleb revision is associated with good long-term control of IOP and improved VA in eyes with hypotony maculopathy after previous glaucoma filtering surgery.