CO2 Laser-Assisted Deep Sclerectomy Surgery Compared with Trabeculectomy in Primary Open-Angle Glaucoma: Two-Year Results

CO2 laser-assisted sclerectomy surgery for secondary open-angle glaucoma after vitrectomy

Purpose

To explore the efficiency and safety of carbon dioxide (CO2) laser-assisted sclerectomy surgery (CLASS) in Chinese patients with glaucoma secondary to vitrectomy.

Methods

This retrospective study consisted of 16 eyes from 16 patients with glaucoma secondary to vitrectomy who underwent CLASS and were followed up for 12 months. Main outcome measures included preoperative and postoperative intraocular pressure, best corrected visual acuity (BCVA), number of anti-glaucoma medications, and postoperative surgical success rate and complications.

Results

The postoperative IOP and number of anti-glaucoma medications used at all follow-up time point were significantly lower than those preoperatively. The difference in BCVA was not significant before and after surgery. The main complicatios were peripheral anterior synechiae (PAS) and scleral reservoir reduction, which were controlled after neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, 2 (12.50%) patients underwent re-operation. The complete and total success rates at 12 months were 68.75% and 87.50%, respectively.

Conclusion

CLASS is a safe and effective procedure for Chinese patients with glaucoma secondary to vitrectomy. PAS and scleral reservoir reduction is a major contributor to postoperative IOP elevation, and trabecular minimally invasive perforation with the Nd:YAG laser is effective in lowering IOP and increasing scleral cistern volume.

Clinical application of the CO2 laser in Ab externo Schlemm's canal surgery

Purpose

This study aimed to investigate the clinical application of laser as a knife in Ab externo Schlemm's canal (SC) surgery and compare the efficacy and safety of the CO₂ laser with the conventional procedure using a surgical knife.

Methods

Patients who underwent either canaloplasty or trabeculotomy with CO₂ laser system which was used to locate and ablate the outer wall of SC at the time interval between May 2020 and May 2021 were identified, their medical files were reviewed, and their results were compared with conventional surgery group who underwent canaloplasty or trabeculotomy with conventional surgical knife at the same time period. The following datas were conducted and compared: age, sex, intraocular pressure (IOP), number of drugs, best-corrected visual acuity (BCVA), mean deviation and pattern standard deviation of visual field examination, SC opening related complications.

Results

A total of 49 patients (49 eyes) were included in this study, including 23 in the Laser surgery group and 26 in the conventional surgery group. Time for SC opening was 49.33 ± 25.23 s and 116.50 ± 31.79 s for laser surgery group and conventional surgery group, respectively. This difference between the two groups was statistically significant (P < 0.01). Hemorrhage occurred in five eyes during ablation for the laser surgery group and in 24 eyes for the conventional surgery group. In addition, anterior chamber penetration occurred in two cases for the laser surgery group and in six cases for the conventional surgery group. The success rate of identifying and opening outer wall of SC was 91.30% (21 eyes) for the laser surgery group and 76.92% (20 eyes) for the conventional surgery group. The difference between preoperative and postoperative intraocular pressure for each group was statistically significant (P < 0.01), and there were no statistically significant differences across the two groups in terms of postoperative IOP (P = 0.238) and BCVA (P = 0.389).

Conclusion

Compared with the conventional procedure using a surgical knife, CO₂ laser-assisted ablation of the outer wall of SC was less time-consuming and less technically challenging. CO₂ laser-assisted ablation also resulted in fewer complications. Furthermore, it had a shorter learning curve and a higher success rate of identifying and opening SC.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

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

Introduction

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

Case Presentation

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

Conclusions

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

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

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

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

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

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