Previous cyclodestruction is a risk factor for late-onset hypotony and suprachoroidal haemorrhage after glaucoma drainage device surgery

Incidence and risk factors of perioperative suprachoroidal hemorrhage: A systematic review and meta-analysis

Suprachoroidal hemorrhage (SCH) is a potentially visually devastating complication of intraocular surgery, but estimates of perioperative SCH incidence vary. We performed a systematic review and meta-analysis of perioperative SCH incidence among population-based studies published between 1990 and 2023. Thirty-five studies collectively reported 1657 cases of perioperative SCH from a population of 3,028,911 surgeries. The estimated incidence of SCH was 0.12 % (95 % CI, 0.10-0.14 %), or about 1 in every 800 surgeries. The estimated incidence of perioperative massive SCH was 0.06 % (95 % CI, 0.04-0.08 %). In multivariable meta-regression, greater SCH incidence was significantly associated with smaller study population size, comparative study design, multicenter study setting, and intraoperative or delayed SCH timing (vs intraoperative alone), while lower SCH incidence was significantly associated with vitreoretinal or mixed surgery type (vs. cataract) (all P < 0.05). Study year was not a significant predictor of SCH incidence, suggesting that the incidence of SCH has not decreased over the past 3 decades despite improvements in surgical technologies and techniques. Given the rarity of SCH, and the strong effect of study population size on reported SCH incidence rates, future studies of SCH incidence should include a minimum population size of at least 1000 surgeries to obtain an accurate estimate of SCH incidence.

Suprachoroidal Hemorrhage

Suprachoroidal hemorrhage (SCH) refers to the accumulation of blood in the suprachoroidal space, a relatively uncommon but significant complication that can occur spontaneously, during ophthalmic surgery, or as a consequence of ocular trauma. If left undiagnosed and untreated, SCH can lead to severe vision loss or even blindness. Therefore, it is crucial for ophthalmologists to have a thorough understanding of this complication, taking proactive measures to prevent it during surgery and being knowledgeable about effective management strategies for patients with SCH. This review article aimed to provide a comprehensive overview of SCH, covering its risk factors, diagnostic approaches, and the best practices for its management. By enhancing awareness and knowledge in this area, we can improve patient outcomes and minimize the impact of SCH in ophthalmic practice.

[Cyclophotocoagulation - current applications and practical aspects]

Despite the advent of a large variety of minimally invasive glaucoma surgery (MIGS) techniques cyclophotocoagulation (CPC) remains a popular treatment option to lower intraocular pressure (IOP) in glaucoma patients. Guidelines for glaucoma treatment point to the rather unphysiological mode of action and, thus, recommend CPC mainly for refractory glaucoma and/or eyes with limited visual potential. The primary target of CPC is the pigmented secretory ciliary body epithelium resulting in a decreased production of aqueous humor. In addition, an increase of aqueous outflow may contribute to the IOP lowering. CPC is generally considered a low risk intervention. However, macular edema, prolonged intraocular inflammation, vision loss, hypotony, pain or phthisis occur at considerable rates. Over the past decades new promising modes of cyclophotocoagulation have evolved aiming at reducing the risk of adverse effects and improving the efficiency. This article provides an overview of the different currently available cyclophotocoagulation modes: Besides the classic transscleral continuous-wave cyclophotocoagulation it covers endoscopic cyclophotocoagulation, micropulse transscleral laser treatment and transscleral controlled cyclophotocoagulation. Various practical aspects of the treatment in light of the current literature are being discussed.

Novel Surgical Techniques to Control Flow With PreserFlo MicroShunt for Late Hypotony After Baerveldt Drainage Device Implantation

We report a new surgical technique for controlling flow with a PreserFlo MicroShunt, in patients with late postoperative hypotony, following a Baerveldt glaucoma drainage device implantation. We present 2 cases with late postoperative hypotony after Baerveldt-shunt implantations. In both cases, the outflow resistance of the Baerveldt tube was modulated by the insertion of a PreserFlo MicroShunt into the lumen of the Baerveldt tube. In the first case, the Microshunt was inserted through the distal opening of the tube in the anterior chamber. In the second case, an end plate, sided approach was chosen after opening the conjunctiva. In both cases, the hypotony was successfully treated. The intraocular pressure rose immediately after the procedure, and it remained well controlled within the targeted range during the first postoperative months without additional pressure-lowering medication. This novel surgical technique provided predictable flow reductions, according to the Hagen-Poiseuille equation. This approach offers a valuable alternative to permanent tube ligation.

Risk Factors and Treatments of Suprachoroidal Hemorrhage

Suprachoroidal hemorrhage (SCH) is a rare but serious sight-threatening complication of inner eye surgery. Despite continuous advances in treatment, visual prognosis remains poor. The disease has a more typical clinical presentation, the etiology and pathogenesis are not well defined, and intraoperative ocular and systemic factors may induce fulminant SCH. To investigate risk factors and treatments of SCH-associated intraocular surgeries, summarize diagnosis, characteristics, management, and prevention of SCH developed during and after intraocular surgeries. A retrospective study of SCH occurred in six cases of intraocular surgeries including cataract, glaucoma, pars plana vitrectomy (PPV), and silicone oil removal surgery. Assess baseline systemic and ocular characteristics of SCH eyes. Analyze the second surgery timing and technique, and visual outcomes were measured. SCH occurred in six patients including five eyes during surgeries and one eye after the surgery. Three eyes that underwent cataract surgery had hard nucleuses (nuclear sclerotic 4+). One eye was due to hypotony during the vitrectomy procedure. One eye developed SCH when silicone oil was extracted from the eyeball. One eye developed delayed SCH after glaucoma surgery. Incision closure and anterior chamber deepening were performed. B-scan ultrasonography was used to diagnose SCH, and determine the timing and location of sclerotomy for the second surgery. Vitrectomy and sclerotomy were performed in five eyes. The median follow-up time was six months. The final best-corrected visual acuity (BCVA) was 0.3 in one eye, one eye had light perception with retinal adherence, and four eyes had no light perception with retinal detachment. The results showed that risk factors including advanced age, hypertension, taking anticoagulants, antiplatelet drugs, and cardiovascular drugs were systemic risk factors, and hard nucleus (nuclear sclerosis 4 +) cataract, long-term uncontrolled ocular hypertension glaucoma, vitrectomy, silicone oil removal, high myopia, aphakia, previous intraocular surgery, intraocular pressure during surgery, and others were ocular risk factors. The most important risk factor is a sudden drop in intraocular pressure during or after surgery. The outcome of visual acuity depends on retinal status. Because of the poor prognosis, the prevention of SCH is of utmost importance during intraocular surgery.

Preliminary Surgical Outcomes of a Trimmed-Plate Aurolab Aqueous Drainage Implant (AADI) in Eyes at High Risk of Hypotony

Purpose

We describe the technique of trimming the 350 mm² AADI glaucoma shunt plate and report preliminary results that test the hypothesis that the IOP-lowering efficacy of the trimmed AADI glaucoma shunt is comparable to the Baerveldt 250 mm² glaucoma drainage implant with a comparable safety profile to the standard AADI implant.

Methods

Consecutive patients who had received the modified trimmed-plate AADI, standard AADI and Baerveldt 250 mm² were included in the study. This included patients with refractory or primary or secondary glaucoma of all ages and eyes with and without previous glaucoma surgery. The decision for trimming the AADI plate was made according to the surgeon’s perceived risk of hypotony. Pre-operative, intraoperative and post-operative data were collected from the hospital electronic medical record system. Surgical success was defined as IOP ≥5 mmHg and ≤21 mmHg on two consecutive visits after 3 months, whilst maintaining at least LP vision and avoiding re-operation for glaucoma.

Results

The sample consisted of 69 eyes (19 with trimmed-plate AADI implant; 36 eyes with the standard AADI implant and 14 eyes who received a BGI-250). The mean IOP reduction at 1 year was 15 mmHg for the Baerveldt-250, 10 mmHg for the AADI and 13 mmHg for the trimmed-plate AADI. The surgical success rate of the implants over 1 year was 85.7% (95% CI, 53.9–96.2%) for BGI-250, 81.5% (62.6–91.5%) for standard AADI and 78.2% (51.7–91.3%) for the trimmed AADI.

Conclusion

Trimming the plate of the AADI manually may provide a safe and low-cost method of obtaining a successful surgical outcome in eyes at high risk of hypotony.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma

PURPOSE

Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion.

METHODS

A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures.

RESULTS

Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term.

CONCLUSION

Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.

The Effect of Tube Ligature on the Safety and Efficacy of Ahmed Glaucoma Valve Surgery

PRECIS

In this matched case-control study, ligature of the Ahmed glaucoma valve (AGV) was associated with a reduction in the rate of postoperative complications without affecting the surgical success rate or the visual outcome following the procedure.

PURPOSE

The purpose of this study was to compare the safety and efficacy of AGV surgery with and without tube ligation.

MATERIALS AND METHODS

This was a retrospective, matched case-control study. A review was performed of patients who underwent AGV surgery with tube ligation between June 2015 and December 2017 (ligated AGV group). Cases were matched with controls who underwent AGV surgery without tube ligation (nonligated AGV group). Data were compared on postoperative intraocular pressure (IOP), the number of glaucoma medications, surgical success rates, complications, and vision.

RESULTS

There were 49 eyes in the ligated AGV group, and 98 eyes in the nonligated AGV group. Baseline characteristics were similar between groups except for the number of glaucoma medications (3.72±0.55 in the ligated AGV group vs. 3.92±0.92 in the nonligated AGV group; P<0.01). At 18 months, IOP was 16.7±6.3 mm Hg in the ligated AGV group and 17.3±8.0 mm Hg in the nonligated AGV group (P=0.76). In addition, the mean number of glaucoma medications was 2.38±1.10 in the ligated AGV group and 1.68±1.51 in the nonligated AGV group (P=0.56). The overall success rate at 12 months was similar between groups (P=0.84). The overall rate of complications was statistically lower in the ligated AGV group (28.6%) compared with the nonligated AGV group (73.5%) (P<0.01). The mean change in logarithm of the minimum angle of resolution acuity was similar between groups (P=0.50).

CONCLUSION

Tube ligation in AGV surgery may be an effective measure that reduces the rate of postoperative complications without affecting the success rate or visual outcomes of the surgery.

Management of Anticoagulation and Antiplatelet Therapy in Glaucoma Surgery

The use of antithrombotic therapy is rising as the population of older adults grows and novel agents with wider indications emerge. Likewise, surgical treatment of glaucoma may become increasingly common as the prevalence of glaucoma increases and innovative treatment options are developed. These trends highlight the need to understand how best to manage antithrombotic therapy in the context of glaucoma surgery. This review article describes current literature on antithrombotic therapy and perioperative thromboembolic risk evaluation based on individual factors. In addition, guidance is offered on the management of antithrombotic therapy in the setting of each type of glaucoma surgery, with an emphasis on a multidisciplinary approach involving the patients' treating physicians.

Dynamics of structural reversal in Bruch's membrane opening-based morphometrics after glaucoma drainage device surgery

PURPOSE

Structural reversal of disc cupping is a known phenomenon after trabeculectomy. The aim of this retrospective, longitudinal, cross-sectional analysis was to evaluate the postoperative dynamics of Bruch's membrane opening-based morphometrics of the optic nerve head following glaucoma drainage device surgery.

METHODS

Forty-three eyes, treated by glaucoma drainage device surgery, were included in the study. Individual changes in the spectral domain optic coherence tomography (SD-OCT) parameters Bruch's membrane opening minimum rim width (BMO-MRW), Bruch's membrane opening minimum rim area (BMO-MRA) and peripapillary retinal nerve fiber layer (RNFL) thickness as well as mean defect in 30-2 perimetry were analyzed. Changes were correlated to postoperative intraocular pressure levels over time. Available follow-up visits were aggregated and grouped into a short-term follow-up (20 to 180 days after surgery), a midterm follow-up (181 to 360 days after surgery) and a long-term follow-up (more than 360 days after surgery).

RESULTS

In short-term follow-up, BMO-MRW and BMO-MRA increased significantly (p <= 0.034). This increase correlated negatively with the intraocular pressure at the time of the follow-up (Pearson's rho = - 0.49; p = 0.039). From 6 months after surgery on, there was no statistically significant change in BMO-MRW and BMO-MRA (p >= 0.207). RNFL thickness and mean defect of 30-2 perimetry showed no significant changes after GDD implantation (p >= 0.189).

CONCLUSIONS

Lowering of intraocular pressure by glaucoma drainage device surgery leads to an increase of Bruch's membrane opening based parameters in the first 6 months after surgery. These changes have to be taken into account when evaluating patients' longitudinal follow-up after glaucoma drainage device implantation.

Incidence and outcome of suprachoroidal hemorrhage associated with pediatric glaucoma surgery

PURPOSE

To report the incidence and outcomes of suprachoroidal hemorrhage (SCH) associated with pediatric glaucoma surgery.

METHOD

The medical records of pediatric patients (<18 years of age) who had undergone glaucoma surgery and developed SCH from June 2014 to September 2017 were reviewed retrospectively. In all cases, the SCH was suspected clinically and was confirmed by B-scan ultrasound. Baseline characteristics, intraoperative details (including surgery type), and subsequent and final outcomes were extracted from the records.

RESULTS

Of 2,656 glaucoma surgeries during the study period, 17 cases of SCH were documented, for an overall incidence of 0.64%. Of the 17 cases, 16 occurred postoperatively, and 1 was noted intraoperatively. By surgery type, the incidence of SCH was highest for trabeculectomy (4/121), followed by glaucoma drainage device surgery (6/463), deep sclerectomy (6/851), and transcleral cyclophotocoagulation (1/542). Four children had received prior transcleral cyclophotocoagulation, and 5 of the children were aphakic at the time of the glaucoma surgery. At a mean final follow-up of 1.71 ± 1.08 years), visual acuity in the affected eye was 20/50 or better in 3 children, between 20/50 and 20/200 in 5 children, and counting fingers or worse in 9 children.

CONCLUSIONS

In our study cohort, the overall incidence of SCH associated with glaucoma surgery was 0.64%. Further study of risk factors for SCH associated with glaucoma surgery in children is needed.

[Glaucoma Drainage Devices - Evaluation of Surgical Modifications to Avoid Postoperative Complications]

BACKGROUND

In glaucoma therapy, there are many treatment options, such as glaucoma drainage devices (GDI). The aim of this study is to compare postoperative outcomes after using different surgical techniques.

MATERIAL AND METHODS

269 eyes of 250 patients who received a GDI at the ophthalmological center at the university hospital in Cologne between February 2010 and September 2016 were included in this study. The patients' baseline parameters were collected: age, sex, intraocular pressure, visual acuity, glaucoma medication, diagnosis, operated eye (right or left), number of previous eye surgeries (including laser therapy), duration-of-stay at the hospital as well as all glaucoma complications and complication-related reoperations.

RESULTS

The mean individual pressure reduction was 39, 42 and 46% after 6, 12 and 24 months respectively, while the use of medication was reduced by 38, 42 and 50%. The success rates after 1 to 5 years was 75, 60, 57, 50 and 37% with a median survival of 48 months. 86 eyes (32%) experienced early complications and 156 eyes (56%) experienced late complications. 52% of the eyes (n = 139) had to be re-operated. The technique of creating a track to enter the anterior chamber had statistically significant influence on the early postoperative hypotony (p < 0,001). Fibrin glue had no influence on early hypotony. In the univariate analysis of early postoperative hypertension requiring paracentesis, the implant type (p = 0,009), tracking-technique with a paracentesis knife or a 22-gauge needle (p = 0,004), the occlusion method (p = 0,001) and the application of viscoelastics (p = 0,001) were statistically significant parameters. If GDI were implanted as a second implant, significantly more conjunctival erosion was recorded (p = 0.040).

CONCLUSION

The use of a 22-gauge needle entering the anterior chamber reduces the hypotony risk when compared to fibrin glue. That risk is not increased by adding venting slits. When implanting GDI as a second implant, the higher risk of conjunctival erosion should be considered.

Supraciliary Implant Placement and Postoperative Suprachoroidal Hemorrhage After Nonpenetrating Deep Sclerectomy

PURPOSE

The purpose if this study was to evaluate the clinical characteristics and risk factors of 3 eyes (3 patients), with primary open-angle glaucoma (POAG), in whom a postoperative suprachoroidal hemorrhage (SCH) occurred after a previous nonpenetrating deep sclerectomy (NPDS) augmented with a supraciliary nonabsorbable implant placement.

METHODS AND SURGICAL TECHNIQUE

This is a report of 3 eyes of the 3 patients who underwent NPDS in 3 different centers, by 3 experienced surgeons, and were the only ones to develop postoperative SCH in the last 18 years. All were operated with a one-third thickness outer scleral flap measuring 5×5 mm dissected until it reached 1 to 2 mm into the clear cornea. Mitomycin C (MMC, 0.02%) was applied for 1 minute and an inner scleral flap measuring 4×4 mm was dissected leaving only 10% of scleral thickness below. Then, the inner wall of Schlemm canal was removed. A supraciliary implant, T-flux (Carl Zeiss Meditec, Zeiss, Spain) in case 2 and Esnoper (AJL Ophthalmics SA, Miñano, Spain) in cases 1 and 3, was placed through a full-thickness escleral incission 2 mm behind the scleral spur.

RESULTS

Three eyes with uncontrolled primary open-angle glaucoma had a delayed SCH after an uneventful NPDS. Time lapse from filtering surgery to the SCH ranged from 12 hours in case number 1, to 3 weeks in case 3. Several risk factors for DSH were present, but the only common clinical feature for all of them, was the nonabsorbable implant that was placed in the supraciliary space. A Hema implant (Esnoper) was used in 2 eyes (cases 1 and 3), and T-flux, was implanted in the case 2. Case 1 required vitreoretinal surgery and had poor visual outcome, but cases 2 and 3 recovered with conservative treatment.

CONCLUSIONS

Although taking the potential bias arising from the nature of the current cases report into consideration, supraciliary placement of the implant in NPDS could be a risk factor for SCH. Consequently, it seems reasonable to avoid it, especially in the presence of other best recognized factors.

[Revision surgery in episcleral glaucoma drainage devices]

Episcleral glaucoma drainage devices (e.g., Ahmed or Baerveldt drainage device) are often used at a late stage in the care of glaucoma patients. At this stage other surgical techniques, such as trabeculectomy or viscocanaloplasty, have failed. However, the trend towards earlier implant surgery is supported by large randomized trials. Physicians should be aware of typical complications and, if possible, these should already be avoided by careful surgical technique. In this review article, we focus on postoperative hypotension, postoperative pressure increases, implant exposure, and possible corneal decompensation.