Racial differences in the results of glaucoma filtration surgery: are racial differences in the conjunctival cell profile important?

[Glaucoma surgeries: Long-term results - A review]

The surgical treatment of glaucoma has been and is still based on filtering surgeries, commonly used for about half a century. The safety and efficacy of these techniques have been well described, as it has also been done for cyclophotocoagulation and valves or tubes, indicated in France mostly for refractory glaucoma. Minimally invasive glaucoma surgeries have emerged in recent decades, increasing the number of therapeutic options, and allowing treatment decisions to be as patient-centered as possible. Most of these techniques have now been studied for more than five years. Since glaucoma is a chronic, progressive optic neuropathy, the sustainability of each surgery's results is essential. The amount of available data concerning long-term efficacy and safety of glaucoma surgeries is increasing, so we have decided to describe it through this review of the literature.

One-Year Outcomes of Ab Externo XEN45 Gel Stent Implantation with an Open Conjunctiva Approach in Patients with Open-Angle Glaucoma

PURPOSE

This study aimed to evaluate the 1-year surgical outcomes of XEN45 gel stent implantation with an open conjunctiva approach in patients with open-angle glaucoma (OAG).

METHODS

This retrospective cohort study included 19 eyes of 19 patients who underwent XEN45 gel stent implantation with an open conjunctival approach. Surgical success was defined by intraocular pressure (IOP) ≤18 mmHg and one of the following: IOP reduction ≥30% or reduction of two glaucoma medications with final IOP if baseline IOP ≤18 mmHg. The cumulative probability of success rate was analyzed using Kaplan-Meier survival analysis. Cox proportional hazard regression analysis was used to assess prognostic factors for surgical failure.

RESULTS

IOP reduced from 32.37 ± 12.08 mmHg preoperatively to 15.14 ± 2.25 mmHg at 1 year (p = 0.001). The number of glaucoma medication reduced from 3.89 ± 0.32 preoperatively to 0.86 ± 1.35 at 1 year (p = 0.001). The success rates were 78.9% at 6 months and 73.7% at 1 year. Eyes with bleb horizontal extent ≥2 clock hours at 1 month postoperatively had a significantly higher success rate (log-rank test, p < 0.001). Greater bleb horizontal extent at 2 weeks and 1 month postoperatively was associated with a lower surgical failure rate (2 weeks: hazard ratio, 0.119; p = 0.024; 1 month: hazard ratio, 0.046; p = 0.007). Bleb needling and additional glaucoma surgeries were necessary in 10 (52.6%) and five eyes (26.3%), respectively.

CONCLUSIONS

XEN45 gel stent implantation with the open conjunctiva approach is effective in reducing IOP and glaucoma medication for over 1 year in patients with OAG.

Complications and post-operative interventions in XEN45 gel stent implantation in the treatment of open angle glaucoma-a systematic review and meta-analysis

BACKGROUND

The XEN45 Gel Stent is a subconjunctival filtering device that has demonstrated promising efficacy. This meta-analysis quantitatively evaluates reported complications and interventions after XEN45 implantation in the treatment of open angle glaucoma (OAG).

METHODS

Pilot, cohort, observational studies, and randomised controlled trials that included at least ten patients undergoing ab interno or externo XEN45 surgery, with or without phacoemulsification were deemed eligible for inclusion. A meta-analysis of proportions with random-effect models was performed using the meta routine in R version 3.2.1. Outcomes included the rate of complications and post-operative interventions.

RESULTS

One hundred and fifty-two studies were identified on initial literature search and 33 were included in final analysis. Numerical hypotony was the most common post-operative complication, involving 20% of patients (95% CI: 10-31%). Post-operative gross hyphema occurred in 14% (95% CI: 7-22%) and transient intra-ocular pressure (IOP) spikes (>30 mmHg) in 13% (95% CI: 4-27%). Stent exposure occurred in 1% (95% CI: 0-2%). Stent migration occurred in 1% (95% CI: 0-3%). XEN45 revision and/or a second XEN45 implantation was performed in 5% of patients (95% CI: 3-7%). Stent relocation was performed in 3% (95% CI: 1-7%). A second glaucoma procedure was performed in 11% (95% CI: 8-15%). 26% underwent one (95% CI: 17-36%), 13% underwent two (95% CI: 5-24%) while 4% underwent three (95% CI: 2-6%) bleb needling procedures. 35% of patients (95% CI: 29-40%) required at least one needling. The average rate of needling per patient was 0.38 (95% CI: 0.20-0.59). However, there is a lack of high-quality data, with 8 of the 33 studies assessed to have a moderate to high risk of bias.

CONCLUSIONS

While literature suggests that XEN45 Gel Stent implantation is safe in the treatment of OAG, the overall current level of evidence is low and further studies are needed. More than a third of patients require at least one post-operative bleb needling procedure.

Filtering Bleb Size in the Early Postoperative Period Affects the Long-term Surgical Outcome after Trabeculectomy

PURPOSE

To investigate whether postoperative filtering bleb size affects the surgical outcome after trabeculectomy.

METHODS

In this study, we retrospectively reviewed 145 medically uncontrolled glaucoma patients with intraocular pressure (IOP) values >21 mmHg before surgery and data from ≥2 years of follow-up. Postoperative IOP, filtering bleb size including extent and height, and other clinical factors were measured after trabeculectomy. We divided bleb extent into quadrants and bleb height by 0.5 intervals of corneal thickness. The main outcome measure was surgical success. We confirmed complete success when the IOP was ≤21 mmHg and decreased by >20% from baseline without medication or additional procedures. Qualified success used the same criteria but allowed for medication or additional procedures. Cases with reoperation or two consecutive IOP measurements <6 mmHg were considered failures.

RESULTS

A total of 145 eyes of 145 patients was included. The average observation period was 30.8 ± 10.9 months. During multivariate Cox regression analysis, a larger extent of filtering bleb revealed significantly low hazard ratios in both complete and surgical success (0.509 and 0.494, respectively); however, there was no significant relationship between bleb height and surgical outcome.

CONCLUSIONS

The extent of the filtering bleb was associated with surgical outcomes of trabeculectomy in glaucoma patients.

Racial Disparities Affecting Black Patients in Glaucoma Diagnosis and Management

Black patients are more affected by glaucoma and suffer from more advanced disease. Diagnostic challenges among black patients with glaucoma include lower rates of diagnostic testing and thinner average central corneal thickness, the latter of which affects intraocular pressure measurement. Treatment challenges include poor follow-up, medication adherence, and trust in providers. Black patients undergoing trabeculectomy have higher rates of failure compared to white patients. Race is not a definitive factor affecting success for tube shunts, laser trabeculoplasty, cyclophotocoagulation, and micro-invasive glaucoma surgeries, but the body of evidence is limited by low inclusion of black patients in these studies. Future steps should include increased attention toward improving trust between patients and providers, improving access to care, and increased representation of black patients in glaucoma research to better understand factors affecting racial disparities in glaucoma management and outcomes in this population disproportionately affected by the disease.

Risk Factors for Glaucoma Drainage Device Revision or Removal Using the IRIS Registry

PURPOSE

To elucidate risk factors for revision or removal of glaucoma drainage devices (GDD) in glaucoma patients in the United States.

DESIGN

Retrospective cohort study.

METHODS

IRIS Registry (Intelligent Research in Sight) patients who underwent GDD insertion between January 1, 2013 and December 31, 2018 were included. Various demographic and clinical factors were collected. Kaplan-Meier survival plots, Cox proportional-hazard models utilizing Firth's Penalized Likelihood, and multivariate linear regression models were used. The main outcome measures were hazard ratios (HR) and beta coefficient (β) estimates.

RESULTS

A total of 44,330 distinct patients underwent at least 1 GDD implantation, and 3354 of these underwent subsequent GDD revision or removal surgery. With failure defined as GDD revision/removal, factors significantly associated with decreased failure included unknown race (HR = 0.83; P = .004) and unknown ethnicity (HR = 0.68; P < .001). Factors associated with increased risk of GDD revision/removal surgery included presence of chronic angle-closure glaucoma (HR = 1.32; P < .001) and dry eye disease (HR = 1.30; P = .007). Additionally, factors associated with a decreased average time (in days) to GDD revision/removal included male sex (β = -25.96; P = .044), unknown race (β = -55.28; P = .013), and right-eye laterality (β = -38.67; P = .026). Factors associated with an increased average time to GDD revision/removal included having a history of a past eye procedure (β = 104.83; P < .001) and being an active smoker (β = 38.15; P = .024).

CONCLUSIONS

The size and scope of the IRIS Registry allows for detection of subtle associations between risk factors and GDD revision or removal surgery. The aforementioned demographic and clinical factors may all have an impact on GDD longevity and can inform the treatment options available for glaucoma patients.

Glaucoma Treatment Outcomes in Open Angle Glaucoma Patients of African Descent

Open angle glaucoma (OAG), characterized by structural changes to the optic nerve head and retinal nerve fiber layer, is a progressive multifactorial optic neuropathy and a leading cause of irreversible blindness globally. Currently, intraocular pressure is the only modifiable risk factor; however, others have been identified, including genetics and race. Importantly, OAG is much more prevalent in persons of African descent (AD) compared with those of European descent (ED). OAG patients of AD are also known to have a more severe course of the disease, a finding potentially explained by structural and/or vascular differences within eye tissues. In addition, disparities in treatment outcomes have been identified in OAG patients of AD. Specifically, prostaglandin analogues have been suggested to be more effective in patients of AD than in those ED, while beta-adrenergic receptors have been suggested to be less effective, although the evidence is inconsistent. AD has also been identified as a risk factor for trabeculectomy failure while laser trabeculoplasty has been conversely found to be very effective in lowering intraocular pressure in patients of AD. Alternative surgical options, including Ex-Press shunt implantation, viscocanalostomy, and canaloplasty are promising in equivalence but require further research to evaluate disparity in outcome properly. In addition to treatment outcomes, social disparities affecting clinical care also exist for AD persons in the form of reduced adherence, access, and choice. Overall, data suggest the need for properly designed prospective trials with AD populations as a primary focus to identify the potential mechanisms driving disparities in treatment and address overall potential bias in glaucoma management.

Preparing the ocular surface for glaucoma filtration surgery: an unmet clinical need

The mutual relationship among medical therapy, ocular surface (OS) and filtration surgery (FS) represents one of the most crucial issues in glaucoma management. As the long-term use of intraocular pressure-lowering medications significantly affect the OS health, patients with an uncontrolled disease frequently undergo glaucoma surgery in less-than-ideal conditions. As we known, OS changes strongly affect the post-operative bleb filtration capability. Therefore, improving the OS conditions before proceeding with FS is needed. Currently, given the rapid diffusion of new surgical procedures, this need is even more perceived. Nevertheless, despite surgeons retain the OS preparation of primary importance, and recognize the OS disease (OSD) as the only modifiable risk factor for filtration failure, there is no agreement on which strategies should be preferred to prepare patients. This is largely due to the lack of validated guidelines, which forces clinicians to adopt personal approaches based on evidence derived from low-quality studies. In this review, we provided an overview of risk factors involved in the FS failure, with particular attention to those depending on OS changes, and how OSD negatively affects the aqueous humor resorption after surgery. Moreover, we reported the most exploited measures to mitigate the OSD before surgery, the possible reasons underlying the absence of shared approaches, and the upcoming area of intervention to preserve the OS health during glaucoma management. Finally, based on the current evidence, we proposed a pre-operative outline reporting the main risk factors that should be considered before surgery, and the therapeutical options available to improve the OS.

Outcomes and risk factors for failure after trabeculectomy in Taiwanese patients: medical chart reviews from 2006 to 2017

AIMS

To determine long-term outcomes and risk factors for failure after mitomycin C (MMC)-augmented initial trabeculectomy (IT) in Taiwanese patients.

METHODS

We reviewed medical records of patients with glaucoma undergoing IT during December 2006-December 2016. We defined complete success as an intraocular pressure (IOP) of >5 or ≤21 mm Hg or IOP reduction of ≥20% from baseline without supplemental medications and qualified success as the aforementioned IOP levels with or without supplemental medications. Kaplan-Meier survival and Cox proportional analyses evaluated success rates and risk factors for failure, respectively.

RESULTS

We enrolled 190 patients (237 eyes; mean age: 54.0±15.3 years; mean postoperative follow-up period: 68.4±35.1 months). Mean IOP and glaucoma medications decreased from 22.2±10.8 to 14.4±5.2 mm Hg (p<0.001) and 3.0±0.7 to 1.8±1.2 (p=0.015), respectively, at the last visit. Cumulative qualified success rates were 93.9%, 93.0%, 86.5% and 67.1% at the 1, 2, 5 and 10 years follow-up, respectively; however, only 7.7% of the eyes reached complete success at the last visit. Eyes with poor preoperative visual acuity were associated with low qualified success rates (HR=1.689, p=0.027); patients aged >70 years had higher complete success rates than did those aged ≤70 years. Five cases (2.11%) exhibited bleb-associated complications.

CONCLUSION

Despite satisfactory long-term success rates, most eyes needed medication for IOP control, supporting the notion of predisposed scarring vitality in patients of Chinese ethnicity following MMC-augmented trabeculectomy.

Predictors of Intraocular Pressure Lowering after Phacoemulsification and iStent Implantation

PURPOSE

To explore the demographic and clinical variables associated with intraocular pressure (IOP) lowering after cataract extraction (CE) alone or CE in combination with the iStent (Glaukos Corporation) placement (CE+IS).

DESIGN

Retrospective data extraction and survival analysis of consecutive patients identified over a 2-year period.

PARTICIPANTS

Patients with mild to moderate glaucoma who underwent CE (48 eyes of 32 patients) or CE+IS (61 eyes of 37 patients) were analyzed.

METHODS

Inability to reduce the number of medications or the IOP by at least 20% compared with baseline on 2 consecutive visits was considered surgical failure. Using Cox proportional hazards models, survival analysis was performed, and demographic and clinical variables were evaluated as risk factors.

MAIN OUTCOME MEASURES

Time to failure after surgical procedure.

RESULTS

CE+IS had lower odds of failure than CE alone (hazard ratio [HR], 2.01; P = 0.047). In White patients, CE+IS showed greater odds of success compared with CE alone (HR, 2.86; P = 0.007). For non-White patients, no difference was found in the outcomes for the 2 procedures (HR, 0.59; P = 0.48). In the multivariate analysis, non-White race (HR, 8.75; P = 0.0002) and longer axial length (HR, 1.61; P = 0.03) were associated with greater hazard of failure after CE+IS. In the CE group, greater odds of failure were associated with steeper corneal curvature (HR, 1.74; P = 0.008), shallower anterior chamber (HR, 0.22; P = 0.008), and longer axial length (HR, 1.58; P = 0.01).

CONCLUSIONS

Addition of the iStent to CE improved the duration of IOP lowering in White patients, but not in non-White patients. Associations between IOP lowering after CE and biometric parameters may allow for leveraging these clinical parameters for better case selection for these procedures.

Access to Schlemm's canal for canaloplasty: an intra-individual comparison of two dissection techniques

PURPOSE

To compare a modified incision technique with classic scleral flap dissection for canaloplasty with canal expander regarding efficacy and safety.

METHODS

In a prospective randomized pilot study of 32 eyes of 16 patients with primary open-angle glaucoma, access to Schlemm's canal was created by deep lamellar dissection (scleral flap excision, group 1) or by vertical cut-down incision (group 2). Following canal opening and viscodilation with microcannula and sodium hyaluronate, two Stegmann Canal Expanders were implanted, and the scleral flap or vertical incision, respectively, was closed watertight.

RESULTS

Mean preoperative intraocular pressure (IOP) was 34.9 mmHg ± 6.7 [standard deviation (SD)] in group 1 and 33.8 mmHg ± 7.7 (SD) in group 2 (p = 0.66); mean postoperative IOP without medications was 14.3 mmHg ± 2.9 (SD) in group 1 and 14.8 mmHg ± 5.2 (SD) in group 2 at 1 month (p = 0.76), and 14.4 mmHg ± 1.9 (SD) in group 1 and 16.8 mmHg ± 3.1 (SD) in group 2 at 12 months (p = 0.01). Overall, there was a significant preoperative-postoperative IOP difference between groups (19.4 mmHg ± 10.1, group 1; 16.6 mmHg ± 8.9, group 2; p = 0.02). Surgery type had a significant effect when adjusted for preoperative IOP, cup-disc ratio, eye side, follow-up number and surgery type (p < 0.01, anova). No filtering bleb was observed in either group. Intra- and postoperative complications were rare and included peripheral Descemet's membrane detachment (3), microhyphema (2) and cannulation into the anterior chamber (1).

CONCLUSIONS

In this intra-individual comparative study of ab externo canaloplasty with the canal expander, IOP reduction was substantial in both groups and slightly greater in the group with deep scleral flap excision. Additional IOP reduction by transscleral drainage through the Descemet's membrane window and intrascleral lake is suggested.

Augmented Subscleral Trabeculectomy With Beta Radiation and Mitomycin C in Egyptian Glaucoma Patients

PURPOSE

Subscleral trabeculectomy is the most common surgical treatment for glaucoma. However, wound healing and scar formation may result in bleb fibrosis, leading to bleb failure. The healing response of the wound is reported to be the single most important risk factor in determining the final intraocular pressure (IOP) after glaucoma filtration surgery. Thus, we aimed to evaluate the effect of preoperative beta irradiation and intraoperative mitomycin C (MMC) treatment as combined adjuncts to subscleral trabeculectomy in the management of glaucoma in Egyptian patients.

PATIENTS AND METHODS

This prospective, interventional, comparative masked clinical study was performed between October 2016 and January 2018. This study included 50 subjects, 25 of whom underwent trabeculectomy augmented by MMC intraoperatively and beta radiation preoperatively at the bleb area (patient group #1). The remaining 25 subjects underwent trabeculectomy with MMC alone (control group #2). Beta radiation was administered 5 to 7 days before the surgery as a single dose (1000 cGy) using a strontium-90 probe. MMC (0.2 mg/mL) was administered for 2 minutes.

RESULTS

There was a statistically significant difference in postoperative IOP between the groups from the second week. Intraoperative hyphema occurred in 6 cases in the control group #2, whereas no intraoperative hyphema was observed in patient group #1; this difference was statistically significant.

CONCLUSIONS

Subscleral trabeculectomy augmented by beta radiation and MMC gives greater control over IOP. Therefore, we recommend using beta radiation before trabeculectomy in patients who may have a high risk of developing conjunctival fibrosis.

Animal models of scarring control

Filtration surgery has, for the past 50 years been key in the treatment of glaucoma yet a significant issue in the long-term success of such surgery is fibrosis limiting aqueous drainage. Numerous methods have been used to reduce such scarring after filtration surgery and animal models have been important in the development of such techniques. First animal models have been central in understanding molecular and cellular changes occurring in fibrosis and thus which pathways might be valuable therapeutic. Secondly animal models have been critical in determining which of these therapies is likely to be most worthwhile. Having said that animals differ substantially from humans in the anatomy of their aqueous drainage pathways and in the mechanisms of fibrotic change. Rodents and lagomorphs vary more markedly from humans than do primates at an anatomic, biochemical and physiological level, and thus the latter might seem more appropriate as models for antifibrotic techniques. However the welfare implications, and thus ethical issues, in using primates are more concerning than with rodents or rabbits and efforts to refine, reduce and replace living animals in such model systems are crucially important. One problem is that the animal models normally involve healthy eyes, not ones with glaucoma. In veterinary ophthalmology we see large numbers of dogs with glaucoma, many of which have filtration implants placed. Potentially these could be a valuable animal model where benefits of antifibrotic treatment could benefit the animals involved and the research seeking to optimise such treatments.

Long-term follow-up of phacotrabeculectomy surgery in Tanzania

INTRODUCTION

The glaucomas often co-exist with cataract. We previously reported a large trial of anti-scarring treatment in combined phacotrabeculectomy surgery. Long-term outcomes in an African population are extremely rarely reported. We present here the outcomes in IOP, acuity, bleb morphology and patient perceptions at 3-5-years post surgery.

METHODS

Tanzanian patients with glaucoma and visually significant cataract underwent combined phacotrabeculectomy surgery. In November 2015 an attempt was made to contact all participants in the study inviting them for a repeat examination. All who attended were given a detailed examination. A semi-structured interview in Swahili was administrated to determine patient experience and satisfaction with the surgery.

RESULTS

Sixty-eight (23%) attended for repeat review in 2015. The mean time from original surgery was 4.5-years (range 2.3-6.6-years). Overall 53 (78%) had IOP < 21 mm Hg and 29 (43%) an IOP < 16 mm Hg at final follow-up. A flat bleb at 26 and 100 days was associated with failure by IOP criteria at 4.5-years post-operatively. A vascular bleb at those time points was not any more associated with late failure than a non-vascular bleb. A majority of patients were pleased with the surgery. The cost of surgery is high but it is a price patients were willing to pay. Nearly all patients (95%) would recommend the service to family and friends.

DISCUSSION

Owing to the small proportion reviewed, our conclusions are severely limited. Phacotrabeculectomy worked well in a majority of the reviewed population long-term and is accepted by a majority of these patients as worthwhile.

Baerveldt or Ahmed glaucoma valve implantation with pars plana tube insertion in Japanese eyes with neovascular glaucoma: 1-year outcomes

Purpose

To describe the 1-year surgical outcomes of both Baerveldt glaucoma implant (BGI) and the Ahmed glaucoma valve (AGV) implant with pars plana tube insertion in Japanese eyes with neovascular glaucoma (NVG).

Patients and methods

This was a retrospective study of 21 eyes of 18 patients who had undergone BGI (10 eyes) or AGV (11 eyes) implantation. The 1-year surgical outcomes in the two groups were compared. Surgical success was defined as an intraocular pressure (IOP) of 6–21 mmHg (criterion A) or 6–18 mmHg (criterion B) with >20% reduction regardless of the use of antiglaucoma medications.

Results

The mean preoperative IOP was 33.9±6.6 mmHg in the BGI group and 30.9±5.3 mmHg in the AGV group (P=0.31). The IOP at 1-year was lower in the BGI group at 10.3±5.9 mmHg than in the AGV group at 14.8±3.3 mmHg (P=0.044). The mean number of glaucoma medications at 1 year was 1.0±1.3 in the BGI group and 1.4±1.4 in the AGV group (P=0.57). The incidence of postoperative complications during the 1-year follow-up was not statistically different between the two groups; however, one eye in the BGI group lost light perception after additional surgery for Hoffman elbow exposure. The 1-year success rates of the BGI group was 60.0% and that in the AGV group was 90.9% based on criterion A (P=0.095), and 50.0% and 81.8% based on criterion B (P=0.074).

Conclusions

Significant reductions of the IOP and number of glaucoma medications were achieved at 1 year after both types of implants in Japanese eyes with NVG.

ReGAE 12: preventing glaucoma blindness in the Caribbean through implementation of the Moorfields Safer Surgery System and skills transfer from the UK to Trinidad and Tobago

Objective

The objective of the study was to present evidence of successful skills transfer of the Moorfields Safer Surgery System (MSSS) from the UK to Trinidad and Tobago and the safety and efficacy of this technique.

Methods

Hospital-based retrospective, consecutive, non-comparative case series study of 33 eyes (24 African-Caribbean patients; 16 male patients) with primary open-angle glaucoma undergoing trabeculectomy + mitomycin C (MSSS) by a single surgeon with UK Glaucoma Fellowship training. The clinical outcome measures included intraocular pressure (IOP), bleb morphology, postsurgical interventions, postoperative complications, and best-corrected visual acuity (BCVA) at the final follow-up.

Results

All patients were self-identified as African-Caribbean. The median age was 56 years (range 34-79 years). The mean preoperative IOP on maximum tolerated medical treatment was 22.4 mmHg (SD=5.9 mmHg). With or without medication, IOP was ≤21 mmHg in 92.6% at 1 year and 87.5% at 5 years. At 1 year, IOP was ≤18 mmHg in 78%, ≤15 mmHg in 73% and ≤14 mmHg in 52%. Removal of scleral flap releasable suture(s) was performed in 84%, 5-fluorouracil injection(s) in 88% and bleb needling revision in 38%. The most common complication was early transient bleb leak (52%). No patient developed endophthalmitis, hypotony maculopathy, suprachoroidal hemorrhage, or malignant glaucoma. At the final follow-up, 91% had excellent or satisfactory bleb morphology, and 73% had equal or better BCVA.

Conclusion

Skills transfer between different geographical and economic regions contributes to the prevention of avoidable blindness through disease control - one of the core strategies of the World Health Organization's Vision 2020 initiative. In the Caribbean (Trinidad and Tobago), the MSSS was utilized by a surgeon with Glaucoma Fellowship training and achieved outcomes similar to best-published data. This success can be reproduced in other geographic locations.

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.

Ab interno trabeculectomy with Trabectome: outcomes in African American versus Caucasian patients

OBJECTIVE

To compare the intraocular pressure-lowering efficacy and complication rate of ab interno trabeculectomy with the Trabectome between African American (AA) and Caucasian patients with open-angle glaucoma.

METHODS

A total of 164 patients (82 AA and 82 Caucasian) who underwent ab interno trabeculectomy over an 8-year period were included in this prospective, case-control study. The Neomedix database was used to look for AA or Caucasian patients with open-angle glaucoma who underwent Trabectome with or without phacoemulsification.

RESULTS

The average IOP of AA patients was reduced from 21.2 ± 6.8 mm Hg to 16.1 ± 4.1 mm Hg at 12 M (p < 0.01), and the mean number of glaucoma medications was reduced from 2.4 ± 1.3 to 2.0 ± 1.4 (p = 0.13). Among Caucasians, the mean IOP was reduced from 21.2 ± 6.8 mm Hg to 15.7 ± 4.2 mm Hg at 12 M (p < 0.01), and the number of medications dropped from 2.4 ± 1.2 to 1.7 ± 1.3 (p < 0.01). No statistically significant difference was found between these 2 race groups in IOP, number of medications, and complications. For complications with Trabectome alone, 13% of AA and 9% of Caucasian patients needed secondary surgery. There was only 1 case of hypotony which was in the AA group. For complications with Trabectome combined with phacoemulsification, 4% of AA as well as 4% of Caucasian patients required secondary surgery. There was only 1 case of hypotony which was in the Caucasian group.

CONCLUSION

Ab interno trabeculectomy with Trabectome is associated with a reduction in IOP in both race groups with a similar complication and survival profiles.

Surgical Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Patients With Open-angle Glaucoma

PURPOSE

To evaluate the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in patients with open-angle glaucoma.

PARTICIPANTS AND METHODS

A retrospective chart review of adult patients who underwent GATT due to inadequately controlled intraocular pressure (IOP) or intolerance to medication. Main outcome measures were success rate, IOP, and number of glaucoma medications. Success was defined as IOP reduction >20% from baseline or IOP between 5 to 21 mm Hg, and no need for further glaucoma surgery. When success criteria were not met for any postoperative visit >3 months after surgery, failure was determined.

RESULTS

In total, 66 patients, average age 62.9±14.9 years (50.8% female) were included in the analysis. Average follow-up was 11.9 months (range, 3 to 30 mo) and overall success rate was 63.0%. Mean IOP was 26.1±9.9 mm Hg preoperatively and 14.6±4.7 mm Hg at 12 months (44% IOP decrease; P<0.001). Mean number of medications decreased from 3.1±1.1 preoperatively to 1.2±0.9 at 12 months (P<0.001). No significant differences between patients with primary open-angle glaucoma and other types of glaucoma were found.The rate of hyphema at 1 week and 1 month postoperatively was 38% and 6%, respectively. Overall GATT success rate among white and black patients was 69% and 42%, respectively, which was statistically significant (P<0.05).

CONCLUSIONS

The future of GATT as a minimally invasive glaucoma surgery in adults seems promising. This position is supported by its low rate of long-term complications and the conjunctiva-sparing nature of the surgery.

Genotype-Phenotype Associations of IL6 and PRG4 With Conjunctival Fibrosis After Glaucoma Surgery

Importance

Postsurgical fibrosis is a critical determinant of the long-term success of glaucoma surgery, but no reliable biomarkers are currently available to stratify the risk of scarring.

Objective

To compare the clinical phenotype of patients with conjunctival fibrosis after glaucoma surgery with candidate gene expression tissue biomarkers of fibrosis.

Design, Setting, and Participants

In this cross-sectional study, 42 patients were recruited at the time of glaucoma surgery at the Moorfields Eye Hospital from September 1, 2014, to September 1, 2016. The participants were divided into those with fibrosis and those without fibrosis.

Main Outcomes and Measures

Genotype-phenotype correlations of the IL6 or PRG4 gene and detailed clinical phenotype. The IL6 and PRG4 protein expression in conjunctival tissues was also assessed using in situ immunohistochemical analysis. Central bleb area, maximal bleb area, and bleb height were graded on a scale of 1 to 5 (1 indicating 0%; 2, 25%; 3, 50%; 4, 75%; and 5, 100%). Bleb vascularity was graded on a scale of 1 to 5 (1 indicating avascularity; 2, normal; 3, mild; 4, moderate; and 5, severe hyperemia).

Results

A total of 42 patients were recruited during the study period; 28 participants (67%) had previously undergone glaucoma surgery (fibrotic group) (mean [SD] age, 43.8 [3.6 years]; 16 [57%] female; 22 [79%] white), and 14 participants (33%) had not previously undergone glaucoma surgery (nonfibrotic group) (mean [SD] age, 47.7 [6.9] years; 4 [29%] female; 9 [64%] white). The fibrotic group had marked bleb scarring and vascularization and worse logMAR visual acuity. The mean (SD) grades were 1.4 (0.1) for central bleb area, 1.4 (0.1) for bleb height, and 3.4 (0.2) for bleb vascularity. The IL6 gene was upregulated in fibrotic cell lines (mean, 0.040) compared with nonfibrotic cell lines (mean, 0.011) (difference, 0.029; 95% CI, 0.015-0.043; P = .003). The PRG4 gene was also downregulated in fibrotic cell lines (0.002) compared with nonfibrotic cell lines (mean, 0.109; difference, 0.107; 95% CI, 0.104-0.110; P = .03). The study found a strong correlation between the IL6 gene and the number of glaucoma operations (r = 0.94, P < .001) and logMAR visual acuity (r = 0.64, P = .03). A moderate correlation was found between the PRG4 gene and the number of glaucoma operations (r = -0.72, P = .005) and logMAR visual acuity (r = -0.62, P = .03).

Conclusions and Relevance

IL6 and PRG4 represent potential novel tissue biomarkers of disease severity and prognosis in conjunctival fibrosis after glaucoma surgery. Future longitudinal studies with multiple postoperative measures are needed to validate the effect of these potential biomarkers of fibrosis.

Glaucoma Surgery Outcome in Rwanda

PURPOSE

To assess long-term intraocular pressure (IOP) outcome after adult trabeculectomy surgery in Central Africa.

PATIENTS AND METHODS

All adult glaucoma patients who underwent trabeculectomy surgery in the Kabgayi Eye Unit, Rwanda between August 2003 and March 2008 were invited for a follow-up visit. Surgical and clinical data were collected from medical records. At the study visit, best-corrected visual acuity was measured and Goldmann applanation tonometry and biomicroscopy were done. Good IOP outcome was defined as both an IOP<21 mm Hg and achieving ≥30% reduction from the preoperative IOP. Considering first operated eyes, univariate and multivariate logistic regression was used to investigate risk factors for failure.

RESULTS

Of 163 individuals operated 3 had died, 118 (74%) participated. Preoperatively, the mean IOP was 31 mm Hg (SD=11; range, 12 to 60). At the time of the follow-up study visit the mean postoperative IOP was 13 mm Hg (SD=5; range, 4 to 35). Good IOP outcome was achieved in 132 eyes (84%). Univariate analysis suggested a protective effect against failure of use of antimetabolites [odds ratio (OR)=0.39; 95% confidence interval (CI), 0.14-1.11; P=0.07] and a decrease in success with length of follow-up (OR=3.57; 95% CI, 1.09-12.50; P=0.03). The latter remained borderline significant with multivariate analysis. Seven eyes went from previously better vision (at least hand movements) down to perception of light or no perception of light after trabeculectomy. Particularly a flat anterior chamber in the first postoperative week (OR=0.07; 95% CI, 0.01-0.49; P<0.001) and late hypotony (OR=0.04; 95% CI, 0.002-0.99; P=0.004) were significant risk factors for severe visual loss.

CONCLUSIONS

Trabeculectomy with antimetabolites is one of the best available options for glaucoma management in Africa. However, the IOP control reduced at a follow-up duration beyond 2 years, highlighting the importance of regular long-term follow-up.

Outcomes of Ex-PRESS and Trabeculectomy in a Glaucoma Population of African Origin: One Year Results

Aim

To compare the efficacy and safety of Ex-PRESS glaucoma filtration surgery to trabeculectomy in African origin patients.

Materials and methods

A retrospective chart review was performed on 56 African American patients undergoing Ex-PRESS glaucoma shunt (E) or trabeculectomy (T) between 2004 and 2012. Data collected included intraocular pressure (IOP) and glaucoma medication use at baseline and postoperative week 1, Month (M) 1, M3, M6, M12. Postoperative interventions including laser suture lysis (LSL) and 5FU injections were analyzed. Complete and qualified success rate, and eyes failing and requiring more surgery were determined. Means, SD, chi-square, and Student’s t-test were performed.

Results

A total of 56 subjects (E 28, T 28) were included in the analysis. There was a statistically significant reduction (p < 0.05) in IOP and number of glaucoma medications at all time points compared to baseline for both groups. Extent of IOP reduction between groups was not statistically significant at any time point, except postoperative week 1. Mean number of glaucoma medications between groups was not significant, except at 3 months (lower in EXP group). The cumulative number of postoperative interventions within 3 months (LSL and 5-FU) was significantly greater for the TRAB than EXP (3.89 ± 2.4 vs 2.36 ± 2.2, p = 0.007). Success rates were comparable between both groups (Table 2).

Conclusion

Our study is unique in patients of African origin showing statistical significance in the requirement of less postoperative 5-FU injections during the first 3 months following surgery in the Ex-PRESS group vs the trabeculectomy group. The Ex-PRESS shunt was as effective as trabeculectomy in reducing IOP and use of glaucoma medications up to 1 year.

Clinical significance

The possible benefit of this article is to help guiding ophthalmologists to select the type of glaucoma filtration surgery to undergo in an African American patient with glaucoma.

How to cite this article

Bustros YD, Fechtner R, Khouri AS. Outcomes of Ex-PRESS and Trabeculectomy in a Glaucoma Population of African Origin: One Year Results. J Curr Glaucoma Pract 2017;11(2):42-47.

Genome-wide RNA-Sequencing analysis identifies a distinct fibrosis gene signature in the conjunctiva after glaucoma surgery

Fibrosis-related events play a part in most blinding diseases worldwide. However, little is known about the mechanisms driving this complex multifactorial disease. Here we have carried out the first genome-wide RNA-Sequencing study in human conjunctival fibrosis. We isolated 10 primary fibrotic and 7 non-fibrotic conjunctival fibroblast cell lines from patients with and without previous glaucoma surgery, respectively. The patients were matched for ethnicity and age. We identified 246 genes that were differentially expressed by over two-fold and p < 0.05, of which 46 genes were upregulated and 200 genes were downregulated in the fibrotic cell lines compared to the non-fibrotic cell lines. We also carried out detailed gene ontology, KEGG, disease association, pathway commons, WikiPathways and protein network analyses, and identified distinct pathways linked to smooth muscle contraction, inflammatory cytokines, immune mediators, extracellular matrix proteins and oncogene expression. We further validated 11 genes that were highly upregulated or downregulated using real-time quantitative PCR and found a strong correlation between the RNA-Seq and qPCR results. Our study demonstrates that there is a distinct fibrosis gene signature in the conjunctiva after glaucoma surgery and provides new insights into the mechanistic pathways driving the complex fibrotic process in the eye and other tissues.

Efficacy, Safety, and Risk Factors for Failure of Standalone Ab Interno Gelatin Microstent Implantation versus Standalone Trabeculectomy

PURPOSE

To compare the efficacy, safety, and risk factors for failure of standalone ab interno gelatin microstent implantation with mitomycin C (MMC) versus trabeculectomy with MMC.

DESIGN

International, multicenter, retrospective interventional cohort study.

PARTICIPANTS

Three hundred fifty-four eyes of 293 patients (185 microstent and 169 trabeculectomy) with no prior incisional surgery.

METHODS

Consecutive eyes with uncontrolled glaucoma underwent microstent or trabeculectomy surgery from January 1, 2011 through July 31, 2015 at 4 academic ophthalmology centers: Toronto, Canada; Frankfurt, Germany; Salzburg, Austria; and Leuven, Belgium.

MAIN OUTCOME MEASURES

Primary outcome measure was hazard ratio (HR) of failure, with failure defined as 2 consecutive intraocular pressure (IOP) readings of <6 mmHg with vision loss or >17 mmHg without glaucoma medications (complete success) at least 1 month after surgery despite in-clinic interventions (including needling). Secondary outcome measures included IOP thresholds of 6 to 14 mmHg and 6 to 21 mmHg and same thresholds allowing for medications (qualified success), interventions, complications, and reoperations.

RESULTS

Baseline characteristics were similar, except more men (56% vs. 43%), younger patients (average, by 3 years), better preoperative visual acuity (22% vs. 32% with 0.4 logarithm of the minimum angle of resolution vision or worse), and more trabeculoplasty (52% vs. 30%) among microstent eyes. The adjusted HR of failure of the microstent relative to trabeculectomy was 1.2 (95% confidence interval [CI], 0.7-2.0) for complete success and 1.3 (95% CI, 0.6-2.8) for qualified success, and similar for other outcomes. Time to 25% failure was 11.2 months (95% CI, 6.9-16.1 months) and 10.6 months (95% CI, 6.8-16.2 months) for complete success and 30.3 months (95% CI, 19.0-∞ months) and 33.3 months (95% CI, 25.7-46.2 months) for qualified success. Overall, white ethnicity was associated with decreased risk of failure (adjusted HR, 0.49; 95% CI, 0.25-0.96), and diabetes was associated with increased risk of failure (adjusted HR, 4.21; 95% CI, 2.10-8.45). There were 117 and 165 distinct interventions: 43% and 31% underwent needling, respectively, and 50% of trabeculectomy eyes underwent laser suture lysis. There were 22 and 30 distinct complications, although most were transient. Ten percent and 5% underwent reoperation (P = 0.11).

CONCLUSIONS

There was no detectable difference in risk of failure and safety profiles between standalone ab interno microstent with MMC and trabeculectomy with MMC.

LONG TERM OUTCOMES OF AUGMENTED TRABECULECTOMY WITH 5-FLUOROURACIL IN NIGERIA

BACKGROUND

Glaucoma in sub-Saharan Africa has been described as a surgical disease because of the high cost of medical treatment, poor compliance and unavailability of medications.

AIM

This study reports the long-term outcomes and complication rates following trabeculectomy with 5-fluorouracil in a case series of Nigerians.

DESIGN OF STUDY

This was a retrospective, observational, non-comparative case series.

SETTING

University College Hospital, Ibadan, Nigeria.

METHODOLOGY

Each patient had complete ophthalmic evaluation. The post-operative intraocular pressure (IOP), visual acuity outcomes and post operative complications were assessed. The World Glaucoma Association consensus on surgical outcome was used to evaluate surgical outcome.

RESULTS

Of the 292 patients who presented with glaucoma during this period, a total of 47 eyes of 31 patients (10.6%) had trabeculectomy with 5-FU. The mean presenting intraocular pressure (IOP) was 31.8±12.2mmHg. At three years post-operatively, 48.5% achieved complete success without medications while 90.9% achieved success with or without medications at an IOP cut off of ≤21mmHg. At the same time point of 3 years and an IOP cut off of ≤15mmHg, 63.6% achieved success with or without medications. At a mean post-operative period of 43± 19.6 months, (range 12-86 months), mean IOP had reduced from a preoperative mean of 31.8±12.2mmHg to 15.4±4.7mmHg (P<0.001).

CONCLUSION

Trabeculectomy with 5-Fluorouracil is effective in the long term in reducing IOP with minimal complications in this population of Nigerians.

The Ahmed Glaucoma Valve in Refractory Glaucoma: Experiences in Southwest Ethiopia

Background

The management of refractory glaucoma is a challenging task for any glaucoma surgeon. This study is aimed to evaluate the efficacy of Ahmed Glaucoma Valve implantation in refractory glaucomas in South-West Ethiopia.

Methods

A retrospective review was conducted on the charts of consecutive patients treated with Ahmed glaucoma valve implantation at Jimma University Specialized Hospital between August 2012 and August 2014. Success was defined as Intraocular Pressure (IOP) less than 22 mm Hg and greater than 5mm Hg at 6 months, with at least 30% reduction from baseline, without medical therapy (complete success) or either with or without medication (qualified successes).

Results

A total of 12 eyes of 11 patients were included. The mean age of patients was 40.7 (SD= 19.0) years; 63.6% of them were males. The main types of glaucoma were pseudoexfoliative (3 eyes), uveitic (2 eyes), chronic angle closure (2 eyes) and Juvenile Open Angle (JOAG) (2 eyes). The mean IOP was reduced from preoperative level (32.75±7.14 mmHg) to (15.75 ±4.35 mmHg) at six postoperative months, (P<0.001); 66.7% eyes had complete successes while 83.3% had qualified success. Intra-operative complications were encountered in 2(16.7%) eyes, while 5/12 (41.7%) eyes had post-operative complications-hypotony (one with choroidal effusion) and progression of cataract in 2 eyes each. Hypertensive phase was diagnosed in 2(16.7%) eyes.

Conclusion

The Ahmed glaucoma valve implant appears to be effective and relatively safe for treating complicated glaucomas with success rate comparable with those reported from other studies. KEYWORDS: Ahmed glaucoma valve, refractory glaucoma, complications, Ethiopia

Is Beta Radiation Better than 5 Flurouracil as an Adjunct for Trabeculectomy Surgery When Combined with Cataract Surgery? A Randomised Controlled Trial

INTRODUCTION

In an African setting surgery is generally accepted as the treatment of first choice for glaucoma. A problem with trabeculectomy surgery for the glaucomas is the frequent co-existence and exacerbation of cataract. We report a randomized controlled trial to compare the use of beta radiation with 5FU in combined cataract and glaucoma surgery.

PARTICIPANTS AND METHODS

Consenting adults aged >40 years with glaucoma, an IOP>21mmHG and cataract were enrolled and randomised to receive either 1000cG β radiation application or sub-conjunctival 5fluorouracil (5FU) at the time of combined trabeculectomy and phaco-emulsification with lens implant surgery.

RESULTS

385 individuals were eligible for inclusion of whom 301 consented to inclusion in the study (one eye per patient). 150 were randomised to the 5FU arm and 151 received β radiation. In the 12 months following surgery there were 40 failures (IOP>21mmHg) in the 5FU arm and 34 failures in the beta arm. The hazard ratio for the beta radiation arm compared to the 5FU arm, adjusted for IOP at baseline, was 0.83 (95% c.i. 0.54 to 1.28; P = 0.40). The improvement from mean presenting visual acuities of 0.91 and 0.86 logMAR to 0.62 and 0.54 in the 5FU and beta arms respectively was comparable between groups (P = 0.4 adjusting for baseline VA). Incidence of complications did not differ between the two groups.

DISCUSSION

This study highlights several important issues in the quest for a therapeutic strategy for the glaucomas in an African context. Firstly, there is no evidence of an important difference between the use of 5FU and beta radiation as an anti-metabolite in phacotrabeculectomy. Secondly phacotrabeculectomy is a successful operation that improves visual acuity as well as controlling IOP in a majority of patients. Although the success of trabeculectomy in lowering IOP is reduced when combined with phacoemulsification compared with trabeculectomy alone, this finding has to be set against the possible need for subsequent cataract surgery following trabeculectomy alone, which represents a second trip and expense for the patient and results in 10-61% failure of the trabeculectomy at one year post-cataract surgery.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN36436933.

Topical fluorouracil after surgery for ocular surface squamous neoplasia in Kenya: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Ocular surface squamous neoplasia (OSSN) is an aggressive eye tumour particularly affecting people with HIV in Africa. Primary treatment is surgical excision; however, tumour recurrence is common. We assessed the effect of fluorouracil 1% eye drops after surgery on recurrence.

METHODS

We did this multicentre, randomised, placebo-controlled trial in four centres in Kenya. We enrolled patients with histologically proven OSSN aged at least 18 years. After standard surgical excision, participants were randomly allocated to receive either topical fluorouracil 1% or placebo four times a day for 4 weeks. Randomisation was stratified by surgeon, and participants and trial personnel were masked to assignment. Patients were followed up at 1 month, 3 months, 6 months, and 12 months. The primary outcome was clinical recurrence (supported by histological assessment where available) by 1 year, and analysed by intention to treat. The sample size was recalculated because events were more common than anticipated, and trial enrolment was stopped early. The trial was registered with Pan-African Clinical Trials Registry (PACTR201207000396219).

FINDINGS

Between August, 2012, and July, 2014, we assigned 49 participants to fluorouracil and 49 to placebo. Four participants were lost to follow-up. Recurrences occurred in five (11%) of 47 patients in the fluorouracil group and 17 (36%) of 47 in the placebo group (odds ratio 0·21, 95% CI 0·07-0·63; p=0·01). Adjusting for passive smoking and antiretroviral therapy had little effect (odds ratio 0·23; 95% CI 0·07-0·75; p=0·02). Adverse effects occurred more commonly in the fluorouracil group, although they were transient and mild. Ocular discomfort occurred in 43 of 49 patients in the fluorouracil group versus 36 of 49 in the placebo group, epiphora occurred in 24 versus five, and eyelid skin inflammation occurred in seven versus none.

INTERPRETATION

Topical fluorouracil after surgery substantially reduced recurrence of OSSN, was well-tolerated, and its use recommended.

FUNDING

British Council for Prevention of Blindness and the Wellcome Trust.

Development of a novel CsA-PLGA drug delivery system based on a glaucoma drainage device for the prevention of postoperative fibrosis

The formation of a scar after glaucoma surgery often leads to unsuccessful control of intraocular pressure, and should be prevented by using a variety of methods. We designed and developed a novel drug delivery system (DDS) comprising cyclosporine A (CsA) and poly(lactic-co-glycolic acid) (PLGA) based on a glaucoma drainage device (GDD) that can continuously release CsA to prevent postoperative fibrosis following glaucoma surgery. The CsA@PLGA@GDD DDS was observed by field emission scanning electron microscopy and revealed an asymmetric pore structure. Thermogravimetric analysis was performed to measure the weight loss and evaluate the thermal stability of the CsA@PLGA@GDD DDS. The in vitro drug release profile of the DDS was studied using high performance liquid chromatography, which confirmed that the DDS released CsA at a stable rate and maintained adequate CsA concentrations for a relatively long time. The biocompatibility of the DDS and the inhibitory effects on the postoperative fibrosis were investigated in vitro using rabbit Tenon's fibroblasts. The in vivo safety and efficacy of the DDS were examined by implanting the DDS into Tenon's capsules in New Zealand rabbits. Bleb morphology, intraocular pressure, anterior chamber reactions, and anterior chamber angiography were studied at a series of set times. The DDS kept the filtration pathway unblocked for a longer time compared with the control GDD. The results indicate that the CsA@PLGA@GDD DDS represents a safe and effective strategy for preventing scar formation after glaucoma surgery.

Biodegradable collagen matrix implant versus mitomycin-C in trabeculectomy: five-year follow-up

Background

Clinical studies comparing trabeculectomy augmented with Ologen implant (OLO) versus trabeculectomy plus mitomycin-C (MMC) show contradictory results. To obtain long-term data, we report an extended 5-year follow-up trial evaluating the safety and efficacy of OLO as adjuvant compared to low-dosage MMC in trabeculectomy.

Methods

Forty glaucoma patients (40 eyes) assigned to trabeculectomy with MMC or Ologen. Primary outcome: target IOP at ≤21, ≤17 and ≤15 mmHg; complete and qualified success endpoint rates. Secondary outcomes: visual acuity (VA), mean deviation (MD), bleb evaluation, according to Moorfields Bleb Grading System (MBGS); spectral domain OCT (SD-OCT) bleb examination; number of glaucoma medications; frequency of postoperative complications.

Results

The mean preoperative IOP was 26.7(±5.2) in MMC and 27.3(±6.0) in OLO eyes. Mean 60-month percentage reduction in IOP was significant in both groups [40.9 (±14.2) and 42.1(±13.3) P = 0.01], with an endpoint value of 15.2 (±3.2) and 15.8 (±2.3) mmHg in MMC and OLO, respectively. Complete success rates at ≤ 21 mmHg target IOP were 65 % and 70 %, at ≤17 mm Hg 60 % and 55 %, and at the ≤15 mm Hg target IOP 35 % and 45 % in MMC and OLO, respectively.

The Kaplan–Meier curves did not differ both for complete and qualified success at any target IOP, with no significant endpoint intergroup difference at ≤ 15 mm Hg (log-rank P = 0.595).The intergroup MBGS scores differed due to reduced central and peripheral vascularity in MMC group (P = 0.027; P = 0.041).

SD-OCT analysis denied differences in bleb height between MMC vs OLO (140.5 ± 20.3 μ vs 129.2 ± 19.3 μ respectively; P =0.079).

Mean antiglaucoma medications were significantly reduced (P < 0.0005) from 2.5 (±0.3) to 1.2 (±0.4) in MMC and from 2.6 (±0.2) to 1.4 (±0.3) in OLO group, with no intergroup differences (P = 0.08).

Six (30 %) cystic thin avascular blebs without oozing were recorded in the MMC group and 2 (10 %) in the OLO group, without intergroup difference (P = 0.235).

Conclusions

Our extended follow-up results confirm that Ologen implant yields efficacy and long-term success rates quite similar to MMC, with at least equivalent safety.

Electronic supplementary material

The online version of this article (doi:10.1186/s12886-016-0198-0) contains supplementary material, which is available to authorized users.

Current and Future Techniques in Wound Healing Modulation after Glaucoma Filtering Surgeries

Filtering surgeries are frequently used for controlling intraocular pressure in glaucoma patients. The long-term success of operation is intimately influenced by the process of wound healing at the site of surgery. Indeed, if has not been anticipated and managed accordingly, filtering surgery in high-risk patients could end up in bleb failure. Several strategies have been developed so far to overcome excessive scarring after filtering surgery. The principal step involves meticulous tissue handling and modification of surgical technique, which can minimize the severity of wound healing response at the first place. However, this is usually insufficient, especially in those with high-risk criteria. Thus, several adjuvants have been tried to stifle the exuberant scarring after filtration surgery. Conventionally, corticosteroids and anti-fibrotic agents (including 5-fluorouracil and Mitomycin-C) have been used for over three decades with semi-acceptable outcomes. Blebs and bleb associated complications are catastrophic side effects of anti-fibrotic agents, which occasionally are encountered in a subset of patients. Therefore, research continues to find a safer, yet effective adjuvant for filtering surgery. Recent efforts have primarily focused on selective inhibition of growth factors that promote scarring during wound healing process. Currently, only anti-VEGF agents have gained widespread acceptance to be translated into routine clinical practice. Robust evidence for other agents is still lacking and future confirmative studies are warranted. In this review, we explain the importance of wound healing process during filtering surgery, and describe the conventional as well as potential future adjuvants for filtration surgeries.

Difference in Outcomes between First-Operated vs. Fellow-Operated Eyes in Patients Undergoing Bilateral Trabeculectomies

MAIN OBJECTIVE

To compare the course and outcome of first- and fellow-operated eyes in patients who underwent bilateral trabeculectomies and to investigate the factors associated with the difference.

METHODS

Preoperative characteristics, including the interval between surgeries, were compared between the first- and fellow-operated eyes in 42 patients who underwent bilateral trabeculectomies. Postoperative intraocular pressure and bleb vascularity, using postoperative anterior segment photos, were compared at various time points between the first- and fellow-operated eyes. Surgical success was evaluated at 1 year after surgery and at the final follow-up. Factors affecting the difference between the first and fellow eyes were analyzed.

RESULTS

There was no significant difference in success or failure rates at 1 year postoperatively and at the final follow-up between the first- and fellow-operated eyes. Early postoperative IOP and the degree of bleb vascularity were higher in the fellow-operated eyes (P = 0.001 and 0.003, respectively at week 1 postoperative). The difference in IOP between the first- and fellow-operated eyes was greater in patients whose interval between surgeries was shorter than 3 weeks (P = 0.026).

CONCLUSIONS

In patients undergoing bilateral trabeculectomies, early postoperative IOP was higher in the fellow-operated eyes than the first-operated eyes; the difference was greater when the interval between surgeries was shorter. The first-operated eye may influence the early postoperative inflammatory response in the fellow-operated eye. Our findings have clinical implications for planning treatment of patients who may need bilateral surgery.

Conjunctival TGF-B Level in Primary Augmented Trabeculectomy

Purpose :

To compare the levels of conjunctival transforming growth factor beta (TGF-β) between glaucoma and control patients and to determine conjunctival TGF-β levels before and 3 months after augmented primary trabeculectomy.

Methods :

Patients with primary open angle glaucoma (POAG) or primary angle closure glaucoma (PACG) admitted for mitomycin (MMC) augmented primary trabeculectomy due to failure in achieving target pressure after maximum medical therapy were selected. Age-matched non-glaucoma patients were controls. Impression cytology of the conjunctiva was obtained twice from glaucoma patients (1 week before augmented primary trabeculectomy and 3 months after surgery) and once from controls. Conjunctival cells were tagged with an anti-TGF-β antibody and analyzed by flow cytometry.

Results :

Eighteen patients (11 POAG and 7 PACG patients) and 18 age-matched control patients were included. Conjunctival TGF-β levels were significantly different between glaucoma (35.21% ± 14.12%) and control patients (14.96% ± 6.34%) (p = 0.001). There was a significant reduction in conjunctival TGF-β levels after augmented trabeculectomy (23.0% ± 13.8%) (p < 0.001). A significantly greater reduction in conjunctival TGF-β levels (61.6% ± 17.9%) was associated with complete success of trabeculectomy at 3 months (83.3%) after surgical intervention (p = 0.029).

Conclusion :

The reduction of TGF-β on the conjunctival post primary augmented trabeculectomy may suggest TGF-β as potential predicting marker of short term trabeculectomy success. However, the result may be affected by site of impression, topical pressure lowering drugs and small sample size.

Long-term results of up to 12 years of over 700 cases of viscocanalostomy for open-angle glaucoma

PURPOSE

To study the safety and long-term efficacy of classic viscocanalostomy in patients with open-angle glaucoma (OAG) in different populations.

METHODS

A total of 726 eyes of 726 patients from Europe or South Africa with primary OAG (POAG) and pseudoexfoliative glaucoma (PXFG) were included in this retrospective multicentre study. Complete (qualified) success was defined as an intraocular pressure (IOP) equal to or lower than 21, 18 and 16 mmHg without (with or without) medications, respectively. A failed procedure was defined if IOP was above 21 mmHg, not controllable by laser goniopuncture or medications.

RESULTS

The mean IOP before surgery was 42.6 ± 14.2 mmHg for all patients, 29.6 ± 6.6 mmHg for European patients and 48.1 ± 12.9 mmHg for African patients. The follow-up time was 86.2 ± 43.1 months. Mean IOP was 15.4 ± 3.6 mmHg at 5 years, 15.5 ± 4.4 mmHg at 10 years and 16.8 ± 4.2 mmHg at 15 years. The qualified success rate for an IOP of 21, 18 or 16 mmHg or less after 5 years was 92% [95% confidence interval (CI) 0.88-0.96], 70% (95% CI 0.63-0.77) and 43% (95% CI 0.36-0.51) in European patients, and 90% (95% CI 0.87-0.93), 77% (95% CI 0.74-0.81) and 67% (95% CI 0.63-0.72) in African patients, respectively. There was no difference between the success rate for POAG and PXFG for an IOP of 21, 18 or 16 mmHg or less at 5 years (p = 0.64, p = 0.20, p = 0.22, respectively). Laser goniopuncture was performed postoperatively on a total of 127 eyes (17.7%), lowering the pressure from 23.1 ± 1.9 mmHg to 15.0 ± 2.2 mmHg. There were no significant complications, in particular, no blebitis or endophthalmitis.

CONCLUSION

Viscocanalostomy produced a sustained long-term reduction of IOP with a low-risk profile in European and African patients with OAG over 12 years.

Time Heals All Wounds: Obstacles in Glaucoma Surgery from an Asian Perspective

Glaucoma is the leading cause of irreversible blindness worldwide and is a particular burden on the Asian population. Glaucoma surgeries such as trabeculectomy and glaucoma drainage implants are routinely performed to lower intraocular pressure (IOP) to prevent disease progression. However, scarring of the filtering bleb limits their long-term success and Asian eyes are more at risk. Although this is so, many existing studies have been done on Caucasian patients, but few have focused solely on Asian patients. Intraoperative anti-metabolites such as Mitomycin-C (MMC) and 5-Fluorouracil (5-FU) are the current mainstay of adjunctive treatments to reduce scarring, and in this review, we evaluate the evolution, benefits and side effects of these agents. Recently, newer methods of wound modulation including anti-vascular endothelial growth factor (VEGF) agents and collagen implants are also being investigated as part of a multi-pronged approach to tackle this problem. Some opportunities exist to limit scarring post-operatively, but it is an ongoing battle.

Subconjunctival bevacizumab to augment trabeculectomy with mitomycin C in the management of failed glaucoma surgery

Purpose

To provide a feasible solution to the problem of failed glaucoma surgery. The aim was to evaluate the efficacy and safety of the additional effects of a combined surgical approach. This approach augments the application of trabeculectomy with mitomycin C (MMC) by adding subconjunctival bevacizumab injection. The results were compared with those of trabeculectomy with only adjunctive MMC.

Methods

A randomized controlled prospective clinical trial included 28 eyes diagnosed with failed scarred bleb of a previous trabeculectomy. The eyes were divided into two equal groups: combined group A, “trabeculectomy with adjunctive MMC and subconjunctival bevacizumab,” and control group B, “trabeculectomy with adjunctive MMC only.” The main outcome results included the cumulative probability of surgical success, intraocular pressure (IOP) values, and number of IOP-lowering medications needed to achieve the target IOP.

Results

Group A achieved a cumulative probability of complete success of 0.769 and of qualified success of 0.231 at the end of the 24 month study period; group B achieved cumulative probabilities of 0.538 and 0.308, respectively. Group A achieved a lower mean IOP value than group B, with fewer antiglaucoma drugs at all postoperative visits, but this lower value did not reach a statistically significant level (P>0.05). There was no statistically significant difference between both groups regarding best corrected visual acuity, visual field parameters, operative and/or postoperative complications, and additional interventions. No significant adverse effects were caused by this combined approach.

Conclusion

Bevacizumab was not found to add much to the favorable long-term outcome of conventional trabeculectomy with MMC as a solution to the problem of scarred failed bleb.

Impact of trastuzumab on wound healing in experimental glaucoma surgery

BACKGROUND

To investigate the effects of subconjunctivally administered trastuzumab on wound healing in experimental glaucoma filtration surgery.

DESIGN

Comparative, experimental study.

SAMPLES

Twenty eight eyes.

METHODS

Twenty-eight male New Zealand white rabbits were randomly assigned to four groups, each including seven rabbits: The rabbits in the control group were not operated on and did not receive any treatment. The rabbits in the sham group underwent trabeculectomy and had one drop of saline instilled four times a day for 14 days. The rabbits in the mitomycin-C group underwent trabeculectomy, and a sponge soaked in 0.4 mg/mL mitomycin-C was applied intraoperatively to the scleral surgical site for 3 min. The rabbits in the trastuzumab group underwent trabeculectomy and were injected subconjunctivally once with 1.2 mg/0.1 mL of the drug. On day 14 of the experiment, the operated and control eyes were enucleated and immunohistochemically analyzed.

MAIN OUTCOME MEASURES

Mean values of fibroblast, mononuclear cell and immunostaining intensities of the transforming growth factor-β, fibroblast growth factor-β, and platelet derived growth factor.

RESULTS

The mean cell numbers and immunostaining intensities in the sham group were higher than those of the control group (P < 0.01). The mean cell numbers and immunostaining intensities in the mitomycin-C group and trastuzumab group were statistically significantly lower than those of the sham group (P < 0.01) while mean cell numbers and immunostaining intensities in the mitomycin-C group and trastuzumab group were similar (P > 0.05).

CONCLUSION

Subconjunctival trastuzumab injection effectively suppressed subconjunctival scarring after experimental glaucoma filtration surgery.

Safety and efficacy of Ahmed glaucoma valve implantation in refractory glaucomas in Northern Indian eyes

PURPOSE

To evaluate the safety and efficacy of Ahmed glaucoma valve (AGV) implantation in refractory glaucoma in Northern Indian eyes.

BACKGROUND

The success rate of trabeculectomy remains low in cases of refractory glaucoma even with the use of antifibrotics. Glaucoma drainage devices have proven to be more efficacious in reducing intraocular pressure (IOP) in these glaucomas.

METHODS

Retrospective records of 55 consecutive patients who underwent AGV implantation at Dr. Shroff's Charity Eye Hospital, New Delhi, India from January 2003 to December 2012 were reviewed. Pre-operative data included age, gender, eye laterality, specific diagnosis, number of anti-glaucoma medications, number of prior incisional surgeries, visual acuity and IOP on medical treatment. Postoperative data included visual acuity and IOP on day one, 1 week, 1 month, 3 months, 6 months, 1 year and yearly thereafter, number of anti-glaucoma medications, any complication or additional surgical intervention required. Success was defined as IOP >5 and <22 mmHg with or without treatment.

RESULTS

Mean IOP decreased from 39.71 ± 8.99 pre-operatively to 17.52 ± 5.72 mmHg at last follow-up (p < 0.001) and number of medications reduced from 3.27 ± 0.84 to 1.25 ± 0.88 (p < 0.001). Visual acuity remained within one Snellen line or improved at last follow-up in 47 cases (85.4%). The cumulative probability of success was 85.45% at 1 year and 79.63% at 3 years. The incidence of post-operative complications was 25.45%.

CONCLUSION

AGV implantation has proven to be safe and is effective in controlling IOP in refractory glaucoma in Northern Indian eyes.

5-Fluorouracil for glaucoma surgery

BACKGROUND

Trabeculectomy is performed as a treatment for many types of glaucoma in an attempt to lower the intraocular pressure. The surgery involves creating a channel through the sclera, through which intraocular fluid can leave the eye. If scar tissue blocks the exit of the surgically created channel, intraocular pressure rises and the operation fails. Antimetabolites such as 5-Fluorouracil (5-FU) are used to inhibit wound healing to prevent the conjunctiva scarring down on to the sclera. This is an update of a Cochrane review first published in 2000, and previously updated in 2009.

OBJECTIVES

To assess the effects of both intraoperative application and postoperative injections of 5-FU in eyes of people undergoing surgery for glaucoma at one year.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2013), EMBASE (January 1980 to July 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 July 2013. We also searched the reference lists of relevant articles and the Science Citation Index and contacted investigators and experts for details of additional relevant trials.

SELECTION CRITERIA

We included randomised trials of intraoperative application and postoperative 5-FU injections compared with placebo or no treatment in trabeculectomy for glaucoma.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We used standard methodological procedures expected by The Cochrane Collaboration. We contacted trial investigators for missing information. Data were summarised using risk ratio (RR), Peto odds ratio and mean difference, as appropriate.The participants were divided into three separate subgroup populations (high risk of failure, combined surgery and primary trabeculectomy) and the interventions were divided into three subgroups of 5-FU injections (intraoperative, regular dose postoperative and low dose postoperative). The low dose was defined as a total dose less than 19 mg.

MAIN RESULTS

Twelve trials, which randomised 1319 participants, were included in the review. As far as can be determined from the trial reports, the methodological quality of the trials was not high, including a high risk of detection bias in many. Of note, only one study reported low-dose postoperative 5-FU and this paper was at high risk of reporting bias.Not all studies reported population characteristics, of those that did mean age ranged from 61 to 75 years. 83% of participants were white and 40% were male. All studies were a minimum of one year long.A significant reduction in surgical failure in the first year after trabeculectomy was detected in eyes at high risk of failure and those undergoing surgery for the first time receiving regular-dose 5-FU postoperative injections (RR 0.44, 95% confidence interval (CI) 0.29 to 0.68 and 0.21, 0.06 to 0.68, respectively). No surgical failures were detected in studies assessing combined surgery. No difference was detected in the low-dose postoperative 5-FU injection group in patients undergoing primary trabeculectomy (RR 0.93, 95% CI 0.70 to 1.24). Peroperative 5-FU in patients undergoing primary trabeculectomy significantly reduced risk of failure (RR 0.67, 95% CI 0.51 to 0.88). This translates to a number needed to treat for an additional beneficial outcome of 4.1 for the high risk of failure patients, and 5.0 for primary trabeculectomy patients receiving postoperative 5-FU.Intraocular pressure was also reduced in the primary trabeculectomy group receiving intraoperative 5-FU (mean difference (MD) -1.04, 95% CI -1.65 to -0.43) and regular-dose postoperative 5-FU (MD -4.67, 95% CI -6.60 to -2.73). No significant change occurred in the primary trabeculectomy group receiving low-dose postoperative 5-FU (MD -0.50, 95% CI -2.96 to 1.96). Intraocular pressure was particularly reduced in the high risk of failure population receiving regular-dose postoperative 5-FU (MD -16.30, 95% CI -18.63 to -13.97). No difference was detected in the combined surgery population receiving regular-dose postoperative 5-FU (MD -1.02, 95% CI -2.40 to 0.37).Whilst no evidence was found of an increased risk of serious sight-threatening complications, other complications are more common after 5-FU injections. None of the trials reported on the participants' perspective of care.The quality of evidence varied between subgroups and outcomes, most notably the evidence for combined surgery and low-dose postoperative 5-FU was found to be very low using GRADE. The combined surgery postoperative 5-FU subgroup because no surgical failures have been reported and the sample size is small (n = 118), and the low-dose postoperative 5-FU group because of the small sample size (n = 76) and high risk of bias of the only contributing study.

AUTHORS' CONCLUSIONS

Postoperative injections of 5-FU are now rarely used as part of routine packages of postoperative care but are increasingly used on an ad hoc basis. This presumably reflects an aspect of the treatment that is unacceptable to both patients and doctors. None of the trials reported on the participants' perspective of care, which constitutes a serious omission for an invasive treatment such as this.The small but statistically significant reduction in surgical failures and intraocular pressure at one year in the primary trabeculectomy group and high-risk group must be weighed against the increased risk of complications and patient preference.

Glaucoma drainage implant surgery--an evidence-based update with relevance to sub-Saharan Africa

Glaucoma represents a leading cause of preventable vision loss in Sub-Saharan Africa. Recent studies evaluating outcomes of glaucoma drainage implant (GDI) surgery suggest an important role for this approach in the African patient population. The Tube Versus Trabeculectomy study demonstrated a higher success rate with non-valved GDI surgery compared to trabeculectomy with mitomycin C after five years. The Ahmed Baerveldt Comparison study showed no difference in surgical failure rates between the Ahmed Glaucoma Valve and the Baerveldt Glaucoma Implant (BGI) but better intraocular pressure outcomes with the BGI at one year. The Ahmed Versus Baerveldt study demonstrated a lower failure rate for the BGI, but also a requirement for more post-operative interventions. Further study of GDI surgery in the Sub-Saharan Africa is necessary to determine its optimal place in the treatment paradigm for glaucoma patients in the region.

Long-term outcomes and risk factors for failure with the EX-press glaucoma drainage device

PURPOSE

To report on the long-term outcomes and risk factors for failure with the EX-PRESS shunt implanted under a scleral flap.

SETTINGS

Eye Department, University of Ancona, Ancona, Italy and the Oxford Eye Center, University of Witwatersrand, Johannesburg, South Africa.

METHODS

The medical records of glaucoma patients who underwent consecutive EX-PRESS implantations under a scleral flap between 2000 and 2009 were reviewed. The operations were performed by two experienced surgeons using an identical surgical technique. The potential risk factors for failure that were analysed included age, sex, race, glaucoma type, previous antiglaucoma medications, previous glaucoma surgeries, diabetes, and smoking. Complete success was defined as postoperative intraocular pressure (IOP) 5 mm Hg>IOP<18 mm Hg without antiglaucoma medications. Qualified success was defined as 5 mm Hg>IOP<18 mm Hg with or without antiglaucoma medications.

RESULTS

Two hundred and forty-eight eyes of 211 consecutive patients were included. The mean IOP was reduced from 27.63 ± 8.26 mm Hg preoperatively (n=248) to 13.95 ± 2.70 mm Hg at 5 years (n=95). The mean follow-up was 3.46 ± 1.76 years. Complete and qualified success rates decreased gradually from 83% and 85% at 1 year to 57% and 63% at 5 years follow-up, respectively. The risk factors for failure were diabetes, non-Caucasian race, and previous glaucoma surgery. Complete success rates of diabetic patients and non-Caucasian patients decreased from 63% and 75% at 1 year to 42% and 40% at 5 years follow-up, respectively.

CONCLUSIONS

EX-PRESS success rates decrease over time but compare favourably with trabeculectomy literature data. The main identifiable risk factors for failure are diabetes, non-Caucasian race, and previous glaucoma surgery.

Epidemiological properties of primary open angle glaucoma in Nigeria

Background. Primary open angle glaucoma (POAG) is progressive chronic optic neuropathy in adults in which intraocular pressure (IOP) and other currently unknown factors contribute to damage. POAG is the second commonest cause of avoidable blindness in Nigeria. Pattern of Presentation. POAG is characterized by late presentation. Absence of pain which is a driving force for seeking medical help, inadequacy of trained eye care personnel, paucity of facilities, misdistribution of resources, lack of awareness, poor education, and poverty may all contribute to this. Medical and surgical treatment options available are challenging and tasking. Screening for Glaucoma. Screening is the presumptive identification of unrecognized disease (POAG) by applying test(s) which can be applied rapidly. Such test(s) should be of high reliability, validity, yield, acceptable, and cost effective. The test should ideally be sensitive, specific, and efficient. It is difficult to select a suitable test that meets these criteria. Intraocular pressure (IOP) appears to be the easiest option. But, high IOP is not diagnostic nor does normal value exclude the disease. Health education is a possible strategy in early case detection and management. Treatment of POAG. Glaucoma treatment can either be medical or surgical (this includes laser). Considering unavailability, potency, cost, and long-term effects of medication, surgery (trabeculectomy) could be a better option. Laser trabeculoplasty is available in a few centers. Viscocanalostomy is not routinely performed. Patient education is vital to success as management is for life. Conclusion. POAG remains a cause of avoidable blindness in Nigeria. There is need for long-term strategy to identify patients early and institute prompt management. Improvement in training of eye care personnel and provision of up to date equipment is essential in achieving this goal.

Advanced glaucoma: management pearls

A significant proportion of glaucoma patients present late, particularly in the developing world, and unfortunately, in an advanced stage of the disease. They are at imminent danger of losing remaining vision, and may also be afflicted with various socioeconomic and health challenges. The encounter with such a patient is typically characterized by anxiety/fear and sometimes hopelessness from the patient's perspective. The physician may also feel that they are in a difficult position managing the patient's disease. When dealing with such cases, we suggest a holistic, individualized approach taking into account the 'biopsychosociospiritual' (BPSS) profile of each patient. The BPSS model takes into account relevant ocular as well as systemic biology (factors such as the mechanism of glaucoma, level of intraocular pressure [IOP], rate of progression, life expectancy, general health), psychological considerations (e.g., fear, depression), socio-economic factors and spiritual/cultural values and beliefs before being able to decide with the patient and their care partner(s) what treatment goals should be and how they can best be approached. Treatment for advanced glaucoma can be highly effective, and patients and their care partners should be informed that aggressive IOP lowering to the low teens or even single digits offers the best chance of protecting remaining vision. This can be achieved safely and effectively in most cases with trabeculectomy (including an antimetabolite), and in some cases with medical and/or laser therapy. Vision rehabilitation and psychosocial support should also be considered in order to optimize remaining vision, replace fear with hope as appropriate, and thus improve the overall quality of life.