Comparison of phacotrabeculectomy versus phacocanaloplasty in the treatment of patients with concomitant cataract and glaucoma

Clinical Profile of Patients on Highly Active Antiretroviral Therapy (HAART) Seen in a Tertiary Eye Clinic

Background

Highly active antiretroviral therapy (HAART) is the medication regimen for the management of human immunodeficiency virus. Over time, it has been dubbed to have revolutionised the clinical course and outcomes of HIV/AIDS.

Objective

The objective of this study is to determine the clinical factors associated with the ocular manifestation of HIV/AIDS among patients on HAART.

Materials and Methods

This was a descriptive cross-sectional study conducted at the ophthalmology department of the University of Nigeria Teaching Hospital (UNTH) in 2017 among adult patients (≥18 years) attending the hospital's antiretroviral therapy (ART) clinic and selected using systematic random sampling technique. Statistical Package for Social Sciences (SPSS) version 21 was used for data analysis, with variables being summarised using frequencies and proportions. Inferential statistics (t test, Chi-square test, and Fisher's exact test) was used to test associations between variables. A level of significance was set at a P value of less than 0.05 corresponding to a 95% confidence interval.

Results

A majority of patients were in WHO stages 1 and 2 of HIV and the mean CD4+ cell count of the whole population was 575.0 ± 512.56 cells/µL, while that of those with ocular manifestations was 315.2 ± 290.76 and 633.7 ± 533.54 cells/µL for those who do not have ocular manifestation. There was a significant association between CD4+ cell count and ocular manifestations such as conjunctival microvasculopathy, anterior uveitis, and cytomegalovirus retinitis.

Conclusion

Our results suggest that HAART has some positive effect on the clinical profile of people with HIV/AIDS with CD4+ count being a major determinant of ocular manifestations.

A Review of Canaloplasty in the Treatment and Management of Glaucoma

Aim

To review the published literature evaluating the safety and efficacy outcomes of canaloplasty performed in the treatment of glaucoma.

Background

Canaloplasty is a nonpenetrating glaucoma procedure involving combined 360° circumnavigation and viscodilation of Schlemm's canal. The procedure may be performed under an ab externo (with tensioning suture) or ab-interno (conjunctiva-sparing) approach. Given the wide variety of glaucoma procedure types and approaches, further investigation into the role of canaloplasty in ophthalmological practice is warranted. The objectives of this narrative review are to synthesize the existing literature in order to investigate indications, safety and efficacy outcomes, and the optimal place of canaloplasty in glaucoma treatment and management.

Review of results

A total of 60 articles were included in this review. Both ab externo and ab-interno canaloplasty (ABiC) were found to be significantly effective at reducing intraocular pressure (IOP) and glaucoma medication burdens in patients with mild-to-moderate open-angle glaucoma (OAG). These findings remained consistent regardless of phacoemulsification status. ABiC was found to exhibit a safety profile favorable compared to trabeculectomy and comparable to minimally invasive trabecular bypass implants.

Conclusion

Canaloplasty is a nonpenetrating surgical intervention that is highly effective in treating patients with mild-to-moderate OAG across a large variety of clinical scenarios.

Clinical significance

These findings support the clinical use of canaloplasty in ophthalmological practice, clarify its patient profile, and compare procedural outcomes to other minimally invasive glaucoma surgery (MIGS) devices on the market.

How to cite this article

Wagner IV, Towne C, Saade MC, et al. A Review of Canaloplasty in the Treatment and Management of Glaucoma. J Curr Glaucoma Pract 2024;18(2):79-85.

Spontaneous resolution of parafoveal macular hole post YAG hyaloidotomy in a case of Valsalva retinopathy

PURPOSE

To report a rare case of spontaneous resolution of parafoveal macular hole post YAG hyaloidotomy in case of Valsalva retinopathy.

METHODS

Case Report.

RESULTS

A 29-year-old female presenting with sudden diminution of vision in her left eye (LE) for two months following a bout of vomiting was diagnosed with pre-macular haemorrhage. Patient was planned for YAG hyaloidotomy on the same day followed by propped up positioning. On follow up haemorrhage was seen to be cleared around macula with corresponding improvement of visual acuity. Patient was found to have developed a parafoveal hole post procedure which spontaneously healed without any intervention. Visual acuity was subsequently improved with resolution of macular hole as seen on fundus imaging and Optical coherence tomography (OCT).

CONCLUSION

Pre-macular haemorrhage is quite common phenomenon in Valsalva retinopathy cases and YAG hyaloidotomy is an established surgical modality for management of the same in literature with good clinical outcomes. However, formation of macular hole is not very common but described in literature post procedure. It is a rare phenomenon to have spontaneous resolution of macular hole. Hence, observation can be an option for managing such cases.

Deep sclerectomy-trabeculectomy with mitomycin C in treating glaucoma: postoperative long-term results

AIM

To determine the long-term postoperative outcomes of deep sclerectomy-trabeculectomy (DST) with mitomycin C (MMC) in the treatment of glaucoma.

METHODS

Patients who underwent DST with MMC between 2010 and 2017 were included in this retrospective observational study. Complete success was defined as postoperative intraocular pressure (IOP) ≤21 mm Hg or 30% reduction of IOP from baseline without any topical IOP-lowering agent, and qualified success defined as IOP≤21 mm Hg or 30% reduction of IOP from baseline with/without single topical agent. We evaluated the surgical success rates and complication rates of this procedure, as well as described the IOP profiles, best corrected visual acuity (BCVA) profiles and mean deviations (MD) of Humphrey visual field (HVF) 24-2 performance at each follow-up time point. Mixed linear regression models were constructed to determine estimated predictive values of demographic data, use of topical IOP-lowering agents, baseline and postoperative IOP and optical profiles (e.g., BCVA and MD).

RESULTS

Totally 98 eyes (mean postoperative follow-up 67.5mo) showed mean IOP reduction at every follow-up interval. Both median BCVA and MD of visual fields were maintained throughout the follow-up intervals when comparing to baseline. The number of IOP-lowering medications decreased from 2.8±0.8 to 0.3±0.7 (P=0.068). Totally 84 (85.7%) eyes achieved complete success at final follow-up. Transient hyphaema and transient choroidal effusion developed in 15 eyes (15.3%) and 11 eyes (11.2%) respectively. Other complications included shallow anterior chamber in 5 eyes (5.1%), bleb leak in 4 eyes (4.1%), bleb revision in 7 eyes (7.1%), bleb needling in 9 eyes (9.2%) and repeat trabeculectomy in 1 eye (1.0%). There was no endophthalmitis, blebitis or macular oedema. There was no significant correlation between postoperative IOP control and postoperative BCVA.

CONCLUSION

DST with MMC demonstrates effective and sustained long-term outcomes in the treatment of glaucoma with no major complication.

Persistent Subretinal Fluid Following Successful Rhegmatogenous Retinal Detachment Surgery

PURPOSE

To provide an updated, critical summary of the literature on the topic of persistent subretinal fluid (PSF) following successful rhegmatogenous retinal detachment surgery.

METHODS

Narrative literature review.

RESULTS

PSF remains an insufficiently studied topic. Incidence rates vary significantly between reports, but pars plana vitrectomy seems associated with lower rates than buckle surgery. Multiple etiologies and risk factors have been proposed, none being conclusive. PSF gradually resolves in most cases which may be a lengthy process, often with no effect on potential final visual acuity. There is concern that some cases with PSF may sustain photoreceptor damage, retinal displacement, or retinal fold formation. There is no current evidence to support any treatment modality over observation in uncomplicated cases of PSF.

CONCLUSION

Future large, well-controlled, prospective trials could help elucidate incidence rate, etiological factors, and sequelae of PSF, as well as the value of different interventions in its prevention and management.

Speed management across road environments of varying complexities and self-regulation behaviors in drivers with cataract

Evidence suggests that drivers with cataract self-regulate their driving, but there is a lack of objective information. This study compared speed behavior in older drivers with and without cataract and how the parameter is influenced by road traffic complexity and driver characteristics. The study included 15 drivers with cataract and a control group of 20 drivers. Visual status was assessed using visual acuity, contrast sensitivity, and intraocular straylight. Speed management was studied using a driving simulator. Driving difficulty and self-regulation patterns were evaluated by means of the Driver Habits Questionnaire (DHQ). The cataract group showed a significant decrease in visual function in all the parameters evaluated (p < 0.05). These drivers tended to drive at lower speeds than the control group. Road characteristics, gender, and intraocular straylight in the better eye were identified as significant predictors of speed management. Drivers with cataract experience greater driving difficulty, particularly when driving at night (p < 0.05). Drivers with cataract reduce their driving speed more than older drivers without visual impairment. The straylight parameter may be a good indicator of each driver's subjective perception of their own visual ability to drive. This work helps shed light on the mechanisms through which age-related visual impairment influences driving behavior.

Outcomes of 360° suture trabeculotomy after unsuccessful canaloplasty

BACKGROUND

Canaloplasty is a well-established non-penetrating glaucoma surgery. Unsuccessful outcomes can be enhanced by micro-invasive 360° suture trabeculotomy (360°trabeculotomy), analyzed in this study.

METHODS

This retrospective study included twenty eyes of 19 patients, mean age 59.7±17.2 years, with primary open-angle glaucoma (POWG n = 14), pseudoexfoliation glaucoma (PEX n = 3), juvenile glaucoma (n = 2) and aphakic glaucoma (n = 1), who underwent micro-invasive 360° trabeculotomy after unsuccessful (intraocular pressure (IOP) >21 mmHg under maximum glaucoma eye drop therapy (Meds)) canaloplasty. IOPs, Meds, complications and failure rates (IOP >21 mmHg at two consecutive follow-ups) were evaluated. Complete success (no Meds) and qualified success (with Meds) rates for IOP levels ≤21 mmHg and ≤ 18 mmHg at the last follow-up were evaluated.

RESULTS

IOPs and Meds were significantly reduced from before to 1 week (10.3±3.1 days) after 360° trabeculotomy (IOP, 28.3±6.0 mmHg to 15.8±4.5 mmHg; p < 0.001; Meds, 3.1 ± 1.2 to 1.0 ± 1.2; p < 0.001). IOPs (p = 0.37) and Meds (p = 0.33) did not decrease further from 1 week until the last follow-up (18.3 ± 8.2 months (IOP, 14.4±3.8 mmHg; Meds, 1.5±1.3)). Complete and qualified success was 25% (5/20) and 70% (14/20) for IOP ≤21 mmHg, as well as 25% (5/20) and 60% (12/20) for IOP ≤18 mmHg. Four eyes had postoperative hyphema, which resolved after a mean period of 4.0 ± 2.2 days. Five failures occurred after a mean of 40.6 ± 51.9 days after 360° trabeculotomy. All failures underwent trabeculectomy. Eyes that needed early (≤3 months post canaloplasty) 360° trabeculotomy showed higher IOPs before (p < 0.001) and lower (p = 0.03) IOPs 2 months post 360° trabeculotomy than eyes with late (>3 months) 360° trabeculotomy surgery.

CONCLUSIONS

360° trabeculotomy is a safe, micro-invasive, simple and successful method to enhance failed canaloplasty.

Identification of Potential Biomarkers in Peripheral Blood Supernatants of South African Patients with Syphilitic and Herpetic Uveitis

Purpose: To identify potential diagnostic biomarkers for herpetic and syphilitic uveitis.Methods: Blood samples were collected from 92 uveitis patients. Concentrations of 47 biomarkers were evaluated in unstimulated Quantiferon supernatants using the Luminex platform.Results: Results showed 11 patients (12%) had herpetic uveitis, 11 (12%) syphilis, 40 (43.5%) other infectious causes, 16 (17.4%) established noninfectious causes and 14 (15.2%) were idiopathic. Biomarker analysis revealed three proteins (Apo-A1, Apo-CIII, CRP) that differed between syphilis and other causes. A three-marker biosignature (CCL4/MIP-1β, Apo-CIII and CRP) separated syphilis from other groups with AUC = 0.83 (95% CI: 0.68-0.98). Apo-CIII and CRP differed between herpetic cases and other groups (p < .05). A three-analyte biosignature (Apo-A1, SAP and CRP) separated the herpetic group from other groups with AUC = 0.79 (95% CI: 0.65-0.93).Conclusion: We have identified candidate biomarkers with potential to differentiate between herpetic, syphilitic and other causes of uveitis. These results warrant further investigation in larger future studies.

Comparison of surgical outcomes between canaloplasty and trabeculectomy with mitomycin C at 2-year follow-up: A longitudinal cohort study

Purpose:

To compare operative outcomes of patients after canaloplasty and trabeculectomy with mitomycin C (MMC) through 2-year follow-up.

Methods:

We included 31 eyes of 31 patients with primary open-angle glaucoma (POAG) who underwent canaloplasty and 37 eyes of 37 patients with POAG who underwent trabeculectomy with MMC with 24 months of postoperative follow-up. All surgeries were performed by a single surgeon between January 2005 and May 2011. Failure was defined as intraocular pressure (IOP >18 or <4 mmHg at 2 years), second operative procedure, or loss of light perception. Change in IOP, visual acuity (VA), glaucoma medications, and complication rates at 24 months were analyzed.

Results:

Caucasians made up to half of the patients included in this study (58% vs. 43%) while the rest where either African Americans (32% vs. 43%) or Hispanic (10% vs. 14%) patients between the canaloplasty and trabeculectomy group. Both groups showed significant reduction in IOP from baseline at 24 months. Trabeculectomy patients had a greater mean reduction of IOP compared to canaloplasty patients (12.2 ± 12 vs. 4.7 ± 7.5, P = 0.003) and also achieved lower IOP at 24 months (12.2 ± 4.1 vs. 14.9 ± 6.0, P = 0.03). Postoperative glaucoma medication use was less in the trabeculectomy group (n = 0, interquartile range [IQR] 0–2) compared to those in whom canaloplasty was performed (n = 2, IQR 0–3, P = 0.02). VA showed no statistical change in either group over 2 years. Overall failure rates at 2 years were comparable between the two groups: 32% for trabeculectomy and 26% for canaloplasty (P = 0.6). Subgroup analysis revealed a lower failure rate in Caucasions (15%) when compared to Blacks (42%) and Hispanics/others (50%, P = 0.03).

Conclusion:

Canaloplasty and trabeculectomy both achieved significant reduction in IOP with comparable success rates. Trabeculectomy can achieve a greater reduction in IOP while requiring fewer medications however is associated with more intensive postoperative care and frequent interventions. Pigmented populations have worse outcomes compared to Caucasians.

A retrospective analysis of the use of loteprednol etabonate ophthalmic suspension 0.5% following canaloplasty

Background

While loteprednol etabonate (LE) suspension 0.5% is approved for the treatment of postoperative ocular inflammation, there have been no reported studies of its use in glaucoma patients undergoing canaloplasty.

Methods

This was a retrospective medical chart review conducted at a single US center. Data were collected on patients with glaucoma who underwent canaloplasty with or without cataract surgery, and were prescribed LE suspension 0.5% postoperatively. Outcomes evaluated included postsurgical inflammation (anterior chamber [AC] cells and flare), intraocular pressure (IOP), number of IOP-lowering medications, and postsurgical complications.

Results

Data were collected on 204 patients (262 eyes) with a mean (SD) age of 71.6 (11.3) years. The most frequent LE dosing regimens at day 1, week 1, and month 1 postsurgery were QID (92.3%; 241/261), TID (52.6%; 133/253), and QD (65.5%; 78/119), respectively. Inflammation (AC flare and cells), mostly mild, was noted in 33.2% (86/259) of eyes on postoperative day 1 and 8.6% (21/244) of eyes at month 1. Mean IOP and mean number of IOP-lowering medications were significantly reduced from baseline (P<0.001) at all time points postoperatively. Complete (no IOP-lowering medication) or qualified (use of ≤2 IOP-lowering medications) surgical success was achieved in 78.8% and 90.6% of eyes, respectively, at month 6 and 63.4% and 92.7% of eyes at month 36. The most frequently observed postoperative complication was hyphema in 48.7% (126/259) eyes at day 1, which decreased to 0.4% (1/244) of eyes by month 1. IOP ≥30 mmHg was noted in 13 (5.3%) eyes at postoperative week 1 and rarely thereafter, and no patient discontinued therapy because of an IOP increase.

Conclusion

These real-world data suggest that canaloplasty with or without cataract surgery managed postoperatively with LE suspension 0.5% is effective and safe in the glaucoma patient.

Safety and efficacy of canaloplasty versus trabeculectomy in treatment of glaucoma

We assess the efficacy and safety of canaloplasty and trabeculectomy for treatment of glaucoma. We searched the China National Knowledge Infrastructure, PubMed, Web of Science, and WanFang databases for potentially eligible studies. Pooled risk ratio (RR) with 95% confidence interval (CI) was calculated using random- or fixed-effect models if appropriate. Eight studies were included for meta-analysis. There was no difference in intraocular pressure at 6 months (WMD = 0.97, 95%CI: -0.48-2.41). Intraocular pressure in canaloplasty group 12 months after operation was higher than in trabeculectomy group (WMD = 1.90, 95%CI: 0.12-3.69), P < 0.05). The canaloplasty group showed higher success rate than trabeculectomy group (RR = 0.86, 95%CI: 0.77-0.97). The canaloplasty group was more likely to have hyphema (RR = 2.96, 95%CI: 1.51-5.83), P < 0.05) than trabeculectomy group (RR = 0.24, 95, CI(0.06-0.89), P < 0.05]. The incidence of and hypotony and postoperative choroid abnormalities in canaloplasty group was significantly lower than that in trabeculectomy group (RR = 0.30, 95%CI: 0.11-0.83; RR = 0.24, 95%CI: 0.09-0.66), P < 0.05). Both trabeculectomy and canaloplasty can significantly reduce the intraocular pressure in glaucoma patients at 12 months after operation, trabeculectomy leads a more marked IOP decrease than canaloplasty at the cost of a higher complication rate and more demanding for postoperative care.

A System Review and Meta-Analysis of Canaloplasty Outcomes in Glaucoma Treatment in Comparison with Trabeculectomy

Purpose. This system review studied the efficiency and safety of canaloplasty (CP) and compared the outcomes between CP and trabeculectomy (TE). Methods. Literatures were searched in PubMed and EMBASE. The meta-analysis was conducted on the postoperative outcomes in CP and then on the differences of outcomes between CP and TE. Results. In the meta-analysis, IOP decreased by 9.94 (95% CI 8.42 to 11.45) mmHg with an average AGM reduction of 2.11 (95% CI 1.80 to 2.42) one year after CP. The IOP reduction was significantly higher after TE than after CP, with an average difference of 3.61 (95% CI 1.69 to 5.53) mmHg at 12 months postoperationally. For complications, the incidence of hyphema was significantly higher in CP and the Descemet membrane detachment was just reported in CP, with an incidence of 3%. However, the incidence was significantly lower in CP of hypotony and of choroidal effusion/detachment. Meanwhile, suprachoroidal hemorrhage and bleb needling were only reported in TE. Conclusions. CP was less effective in IOP reduction than TE, but CP was able to achieve similar postoperative success rates and reduce the number of AGMs likewise. CP was also associated with lower incidence of complications. More high-quality researches are needed in the future to verify our findings in this system review.

Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma

PURPOSE

To provide efficacy and safety of surgery with Trabectome combined with phacoemulsification in primary open-angle glaucoma.

METHODS

In this interventional case series, 30 consecutive eyes that have had combined phacoemulsification with Trabectome were included. The main outcome measures were change in intraocular pressure (IOP), glaucoma medication use, and the rate of complications.

RESULTS

Mean IOP was 18.25 ± 3.28 mmHg preoperatively which decreased to 13.50 ± 2.53 mmHg at 1 year. (P < 0.05). There was a corresponding drop in glaucoma medications from 2.52 ± 0.60 at baseline to 1.40 ± 0.53 at 12 months (P < 0.01). The preoperative BCVA (Log Mar) was improved from 0.68 ± 0.26 pre-operatively to 0.26 ± 0.19, 0.18 ± 0.13, 0.17 ± 0.13, 0.11 ± 0.12, at 5 days and 2, 6, and 12 months, respectively (P < 0.01). The only frequent complication was transient blood reflux resolving spontaneously within a few days. No vision-threatening complication occurred.

CONCLUSION

Combined phacoemulsification and Trabectome significantly lowered IOP and medication use, with early visual rehabilitation in the majority of patients.

Comparison of canaloplasty and trabeculectomy for open angle glaucoma: a Meta-analysis

AIM

To evaluate the advantage of canaloplasty compared to trabeculectomy for patients with open angle glaucoma.

METHODS

Potentially relevant studies were systematically searched using various databases from inception until December 2015. The outcome analyses performed automatically using Revman 5.3 included intraocular pressure reduction (IOPR), postoperative success rate, anti-glaucoma medications reduction and the incidence of adverse events.

RESULTS

We included four qualified studies incorporating a total of 215 eyes for quantitative synthesis. The weighted mean difference (WMD) of IOPR between canaloplasty and trabeculectomy from baseline to 12mo was -2.33 (95%CI: -4.00, -0.66). There was not significant improvement in the complete or qualified success rate (OR: 0.58, 95%CI: 0.26, 1.31; OR: 0.50, 95%CI: 0.10, 2.44, respectively). Similarly, no statistically significance was observed in anti-glaucoma mediations reduction (WMD: -0.54, 95%CI: -1.18, 0.09). Sensitivity analysis of the primary outcome estimate confirmed the stability of the Meta-analysis result.

CONCLUSION

Trabeculectomy seems to be more effective in lowering IOP up to 12mo when comparing with canaloplasty. Canaloplasty does not seem to be inferior to trabeculectomy considering the postoperative success rate or the number of postoperative anti-glaucoma medications. Meanwhile, it has an advantage of less bleb related complications.

[Revision procedures after canaloplasty]

Canaloplasty is a recently introduced non-penetrating surgical technique for glaucoma, which seeks to improve the natural outflow of aqueous humor through Schlemm's canal and the collector channels. Just as in all forms of glaucoma surgery there are a certain number of failures of the procedure and further surgery is often needed to reduce the intraocular pressure in these cases. This article describes some of the revision procedures after canaloplasty.

Canaloplasty: Current Value in the Management of Glaucoma

Canaloplasty is a nonpenetrating blebless surgical technique for open-angle glaucoma, in which a flexible microcatheter is inserted within Schlemm's canal for the entire 360 degrees. When the microcatheter exits the opposite end, a 10-0 prolene suture is tied and it is then withdrawn, by pulling microcatheter back through the canal in the opposite direction. Ligation of prolene suture provides tension on the canal and facilitates aqueous outflow. The main advantage of canaloplasty is that this technique avoids the major complications of fistulating surgery related to blebs and hypotony. Currently, canaloplasty is performed in glaucoma patients with early to moderate disease and combination with cataract surgery is a suitable option in patients with clinically significant lens opacities.

Comparison of 1-Site and 2-Site Phacotrabeculectomy in the Small Adult Eyes With Concomitant Cataract and Glaucoma

The aim of this study was to compare the outcomes after phacotrabeculectomy at 1 or 2 sites in the small adult eyes with concomitant cataract and glaucoma.Patients who had 1-site (n = 26) or 2-site (n = 14) phacotrabeculectomy over a 4-year period at an eye surgery center were included. Eighteen eyes of 18 patients with glaucoma using any 1 prostaglandin analogue (latanoprost, travoprost, or bimatoprost) were compared with 8 normal control patients. The records of patients were reviewed, and intraocular pressure, best-corrected visual acuity, axial length, anterior chamber depth, corneal endothelial cell (CEC) density, Diopter were measured. The outcome was compared with postoperative and preoperative measurements for 3-month follow-ups.The follow-up time was 3 months. There was no difference between the operations in improving best-corrected visual acuity, lowering intraocular pressure, shortening axial length, and deepening anterior chamber depth. However, 2-site surgery was associated with significantly more CEC loss and refractive error. Postoperative complications were not different between the 2 groups.The CEC loss and the refractive error in 2-site group were higher than that of 1-site group. One-site surgery seems to cause less CEC damage and refractive error than the 2-site operation during the follow-up time of 3 months.

Comparison of Surgical Outcomes Between Phacocanaloplasty and Phacotrabeculectomy at 12 Months' Follow-up: A Longitudinal Cohort Study

PURPOSE

To compare operative outcomes of patients after phacocanaloplasty and phacotrabeculectomy through 12 months' follow-up.

DESIGN

Retrospective, nonrandomized, comparative case series.

MATERIALS AND METHODS

We included 36 eyes of 36 patients with open-angle glaucoma who underwent combined phacoemulsification and canaloplasty (phacocanaloplasty) and 41 eyes of 41 patients with open-angle glaucoma who underwent combined phacoemulsification and trabeculectomy with mitomycin C (phacotrabeculectomy) with 12 months' of postoperative follow-up. All surgeries were performed by a single surgeon (R.S.A.) between January 2007 and May 2011.

MAIN OUTCOME MEASURES

Failure was based on intraocular pressure (IOP; >18 or <4 mm Hg at 1 y), second operative procedure (any eye requiring reoperation), or decrease in visual acuity by 0.20 logMAR. Change in IOP, visual acuity (VA), glaucoma medications, and complication rates at 12 months were analyzed.

RESULTS

There were no differences in demographics other than the sex between the groups. There were also no significant differences in previous surgery or in preoperative VA, IOP, or use of glaucoma medications between the groups, though the phacotrabeculectomy group had a higher preoperative IOP at baseline and a larger SD. Both groups showed significant reduction in IOP from baseline at every time point (P<0.001). No significant difference in mean IOP at 12 months was found, with a mean of 14.1±4.4 mm Hg in the phacocanaloplasty group and 11.8±5.4 mm Hg in the phacotrabeculectomy group (P=0.07). The phacotrabeculectomy group showed a significantly greater median absolute (8 vs. 5 mm Hg) and percent (40% vs. 28%) reduction in IOP at 12 months (P=0.02). Postoperative glaucoma medication use was similar between the 2 groups.Overall failure rates at 1 year were comparable between the 2 groups: 22% for phacocanaloplasty versus 20% for phacotrabeculectomy (P=0.79). Phacotrabeculectomy eyes experienced more visual failures (5% vs. 0%, P=0.50), whereas phacocanaloplasty experienced more IOP failures (17% vs. 12%, P=0.75). No difference in operative failure rate was found between the phacocanaloplasty and phacotrabeculectomy groups (6% vs. 5%, P=1.00) and this held after controlling for covariates. Final VA was not statistically different between the 2 groups.

CONCLUSIONS

Phacocanaloplasty and phacotrabeculectomy both achieved significant reduction in IOP and improvement in VA at 12 months with comparable success rates. Phacotrabeculectomy achieved a statistically greater median percentage decrease in IOP, but the 2 procedures resulted in comparable mean IOP at 12 months.

Trabeculectomy versus canaloplasty (TVC study) in the treatment of patients with open-angle glaucoma: a prospective randomized clinical trial

Purpose

To compare the outcomes of canaloplasty and trabeculectomy in open‐angle glaucoma.

Methods

This prospective, randomized clinical trial included 62 patients who randomly received trabeculectomy (n = 32) or canaloplasty (n = 30) and were followed up prospectively for 2 years. Primary endpoint was complete (without medication) and qualified success (with or without medication) defined as an intraocular pressure (IOP) of ≤18 mmHg (definition 1) or IOP ≤21 mmHg and ≥20% IOP reduction (definition 2), IOP ≥5 mmHg, no vision loss and no further glaucoma surgery. Secondary endpoints were the absolute IOP reduction, visual acuity, medication, complications and second surgeries.

Results

Surgical treatment significantly reduced IOP in both groups (p < 0.001). Complete success was achieved in 74.2% and 39.1% (definition 1, p = 0.01), and 67.7% and 39.1% (definition 2, p = 0.04) after 2 years in the trabeculectomy and canaloplasty group, respectively. Mean absolute IOP reduction was 10.8 ± 6.9 mmHg in the trabeculectomy and 9.3 ± 5.7 mmHg in the canaloplasty group after 2 years (p = 0.47). Mean IOP was 11.5 ± 3.4 mmHg in the trabeculectomy and 14.4 ± 4.2 mmHg in the canaloplasty group after 2 years. Following trabeculectomy, complications were more frequent including hypotony (37.5%), choroidal detachment (12.5%) and elevated IOP (25.0%).

Conclusions

Trabeculectomy is associated with a stronger IOP reduction and less need for medication at the cost of a higher rate of complications. If target pressure is attainable by moderate IOP reduction, canaloplasty may be considered for its relative ease of postoperative care and lack of complications.

Use of Various Glaucoma Surgeries and Procedures in Medicare Beneficiaries from 1994 to 2012

PURPOSE

Determine how procedural treatments for glaucoma have changed between 1994-2012.

DESIGN

Retrospective, observational analysis.

PARTICIPANTS

Medicare Part B beneficiaries.

METHODS

We analyzed Medicare fee-for-service paid claims data between 1994-2012 to determine the number of surgical/laser procedures performed for glaucoma in the Medicare population each year.

MAIN OUTCOME MEASURES

Number of glaucoma-related procedures performed.

RESULTS

Trabeculectomies in eyes without previous scarring decreased 52% from 54 224 in 1994 to 25 758 in 2003, and a further 52% to 12 279 in 2012. Trabeculectomies in eyes with scarring ranged from 9054 to 13 604 between 1994-2003, but then decreased 48% from 11 018 to 5728 between 2003-2012. Mini-shunts done via an external approach (including ExPRESS [Alcon Inc, Fort Worth, TX]) increased 116% from 2718 in 2009 to 5870 in 2012. The number of aqueous shunts to the extraocular reservoir increased 231% from 2356 in 1994 to 7788 in 2003, and a further 54% to 12 021 in 2012. Total cyclophotocoagulation procedures increased 253% from 2582 in 1994 to 9106 in 2003, and a further 54% to 13 996 in 2012. Transscleral cyclophotocoagulations decreased 45% from 5978 to 3268 between 2005-2012; over the same period, the number of endoscopic cyclophotocoagulations (ECPs) increased 99% from 5383 to 10 728. From 2001 to 2005, the number of trabeculoplasties more than doubled from 75 647 in 2001 to 176 476 in 2005, but since 2005 the number of trabeculoplasties decreased 19% to 142 682 in 2012. The number of laser iridotomies was fairly consistent between 1994-2012, increasing 9% over this period and ranging from 63 773 to 85 426. Canaloplasties increased 1407% from 161 in 2007 to 2426 in 2012. Between 1994-2012, despite a 9% increase in beneficiaries, the total number of glaucoma procedures and the number of glaucoma procedures other than laser procedures decreased 16% and 31%, respectively.

CONCLUSIONS

Despite the increase in beneficiaries, the number of glaucoma procedures performed decreased. Glaucoma procedures demonstrating a significant increase in use include canaloplasty, mini-shunts (external approach), aqueous shunt to extraocular reservoir, and ECP. Trabeculectomy use continued its long-term downward trend. The continued movement away from trabeculectomy and toward alternative intraocular pressure-lowering procedures highlights the need for well-designed clinical trials comparing these procedures.

Update on Schlemm's canal based procedures

Surgical options for glaucoma have expanded in recent years. This article provides an evidence-based update on the novel or emerging surgical techniques for the treatment of open-angle glaucoma that are based on the Schlemm's canal (SC). Canaloplasty is an ab externo approach and was developed as an alternative to traditional filtering surgeries. The Hydrus microstent (Ivantis Inc., Irvine, CA) is a so-called SC scaffold that directly bypasses the trabecular meshwork to drain aqueous humor into the SC, which it keeps dilated over approximately one quadrant. Canaloplasty has also been shown to lower intraocular pressure (IOP) by up to 40% and combined with cataract surgery. IOP was lowered 44% at 24 months while maintaining a favorable safety profile. The Hydrus device has been proposed as an adjunct to cataract extraction surgery. To date, no published evidence from clinical trials is available on its in vivo safety and efficacy. Schlemm's canal based glaucoma procedures show promise as alternative treatments to traditional glaucoma surgery. Surgeons must be comfortable with angle anatomy. A prerequisite for functionality of these techniques is the integrity of the distal outflow system. At present, however, it is not possible to conclude whether these novel procedures will be viable alternatives to standard filtering surgery over the long-term.

Canaloplasty versus non-penetrating deep sclerectomy - a prospective, randomised study of the safety and efficacy of combined cataract and glaucoma surgery; 12-month follow-up

PURPOSE

To compare outcomes of phaco-canaloplasty (PC) and phaco-non-penetrating deep sclerectomy (PDS) with a viscoelastic compound.

METHODS

This study included 29 eyes after PC and 30 after PDS. Indications were uncontrolled primary open-angle glaucoma (POAG) and a cataract. Corrected distance visual acuity (CDVA), intraocular pressure (IOP), and number of medications were evaluated. Follow-up examinations were performed on days 1 and 7, and after 1, 3, 6, and 12 months. Complete and qualified success was an IOP ≤ 18 mmHg.

RESULTS

At the 12-month follow-up, mean IOP decreased in the PC group from 19.0 ±6.9 mmHg to 12.6 ±2.7 mmHg, and in the PDS group, from 19.1 ±5.8 mmHg to 14.3 ±3.5 mmHg (P < 0.05). Both groups preoperatively and at 12 months showed no significant differences in IOP (P > 0.05). There was no statistically significant difference between the number of medications used (P > 0.05). Complete and qualified success rates for both groups were 79.0 % and 76.9 % (P = 0.701). The most frequent postoperative PC complication was hyphema (58.0 %); for PDS, bleb fibrosis was most frequent (26.7 %). No PC patients required postoperative management. PDS patients required postoperative interventions 58.7 % of the time, including a 5-fluorouracil (5-FU) injection (58.7 %), suture lysis (48.3 %), and needling (27.6 %).

CONCLUSIONS

Both PC and PDS lead to an effective decrease in IOP on a short-term follow-up basis and demonstrate similar efficacy and safety profiles. PDS patients required additional procedures including 5-FU injections, suture lysis, or needling. PC patients required no additional procedures.

Outcomes of 360° suture trabeculotomy with deep sclerectomy combined with cataract surgery for primary open angle glaucoma and coexisting cataract

BACKGROUND

The purpose of this study was to investigate treatment outcomes in 360° suture trabeculotomy with deep sclerectomy combined with phacoemulsification and aspiration and intraocular lens implantation (360P-LOT + DS).

METHODS

Thirty-two eyes in 32 consecutive patients treated by 360P-LOT + DS for primary open angle glaucoma with coexisting cataracts at Sato Eye Clinic from March 2011 to April 2013 were retrospectively compared with 23 eyes in 23 consecutive patients treated by cataract surgery and 120° trabeculotomy with deep sclerectomy (120P-LOT + DS) at the same clinic from January 2010 to February 2011. The parameters investigated during the 15 months after surgery were the course of intraocular pressure, number of antiglaucoma medications, best-corrected visual acuity, and complications.

RESULTS

Both groups showed a significant decrease in intraocular pressure starting at one month after surgery when compared with values before surgery. At 3, 6, 9, and 15 months after surgery, the intraocular pressure was significantly lower and the survival rate was significantly higher in the 360P-LOT + DS group compared with the 120P-LOT + DS group. The number of antiglaucoma medications, best-corrected visual acuity value, and complications did not differ significantly between the groups.

CONCLUSION

Although the complications are similar to those seen in 120P-LOT + DS, treatment of primary open angle glaucoma and coexisting cataracts using 360P-LOT + DS may yield better outcomes.

New options for combined cataract and glaucoma surgery

PURPOSE OF REVIEW

To review the current literature regarding the effectiveness and risks of new surgeries that can be combined with phacoemulsification in the management of cataract and glaucoma.

RECENT FINDINGS

Surgical options for concurrently managing cataract and glaucoma have expanded in recent years. Endoscopic cyclophotocoagulation, trabecular micro-bypass stent, ab interno trabeculectomy, and canaloplasty may be performed in conjunction with cataract extraction to provide additional intraocular pressure (IOP) reduction. Studies evaluating these new glaucoma procedures combined with phacoemulsification generally include retrospective case series without a comparison group. Because cataract surgery alone is associated with IOP reduction, the relative contribution of the glaucoma procedure in lowering IOP cannot be determined in these studies. Randomized clinical trials are needed to better evaluate the efficacy and safety of newer glaucoma procedures in combination with cataract surgery.

SUMMARY

The newer glaucoma procedures appear less effective than trabeculectomy, but they are associated with a lower risk of surgical complications.

One Year of Glaucoma Research in Review: 2012 to 2013

PURPOSE

The objective of this study was to provide the practicing clinical ophthalmologist with an update of pertinent glaucoma literature published from 2012 to 2013.

DESIGN

Literature review.

METHODS

The authors conducted a 1-year (July 1, 2012, to September 30, 2013) English-language glaucoma literature search on PubMed using the following terms: glaucoma, automated perimetry, optic nerve imaging, optical coherence tomography, glaucoma structure and function, intraocular pressure, central corneal thickness, glaucoma medical therapy, neuroprotection, glaucoma laser treatment, secondary glaucoma, glaucoma surgery, and miscellaneous topics in glaucoma.

RESULTS

Of 2659 articles on glaucoma published during our time frame, this review selected original and review articles that reflect novel aspects and updates in the field of glaucoma, while excluding letters to the editor, unpublished works, and abstracts. Preference was given to human research.

CONCLUSIONS

This review focuses on literature that is applicable to ophthalmologists in practice and also highlights studies that may enhance the diagnosis and management of glaucoma.

Update on Minimally Invasive Glaucoma Surgery (MIGS) and New Implants

Traditional glaucoma surgery has been challenged by the advent of innovative techniques and new implants in the past few years. There is an increasing demand for safer glaucoma surgery offering patients a timely surgical solution in reducing intraocular pressure (IOP) and improving their quality of life. The new procedures and devices aim to lower IOP with a higher safety profile than fistulating surgery (trabeculectomy/drainage tubes) and are collectively termed “minimally invasive glaucoma surgery (MIGS).” The main advantage of MIGS is that they are nonpenetrating and/or bleb-independent procedures, thus avoiding the major complications of fistulating surgery related to blebs and hypotony. In this review, the clinical results of the latest techniques and devices are presented by their approach, ab interno (trabeculotomy, excimer laser trabeculotomy, trabecular microbypass, suprachoroidal shunt, and intracanalicular scaffold) and ab externo (canaloplasty, Stegmann Canal Expander, suprachoroidal Gold microshunt). The drawback of MIGS is that some of these procedures produce a limited IOP reduction compared to trabeculectomy. Currently, MIGS is performed in glaucoma patients with early to moderate disease and preferably in combination with cataract surgery.

Surgical Decisions in Primary Open Angle Glaucoma with Low or Normal Tension

Glaucoma, given its insidious nature, is often coined 'the sneak thief of sight'. Following this trail of thought, primary open angle glaucoma with low or normal tension (POAGLNT) could be coined 'the king of thieves'. The lack of a compelling red fag of high intraocular pressure (IOP), together with the diurnal fuctuation of the deceptively low baseline IOP, POAGLNT poses a therapeutic challenge in terms of judging when to intervene, and how. In this review article, we will outline the considerations before undergoing surgery: risk stratification, defining goal in terms of target pressure and IOP modulation. We will also review the strengths, weaknesses and pearls of available options. How to cite this article: Shum JW, Leung DY. Surgical Decisions in Primary Open Angle Glaucoma with Low or Normal Tension. J Current Glau Prac 2013;7(3):121-127.