A review of the efficacy of mitomycin C in glaucoma filtration surgery

Long-Term Surgical Outcomes and Possible Postoperative Complication with Severe Corneal Endothelial Cell Loss After Trabeculectomy for Cytomegalovirus-Associated Anterior Uveitis with Secondary Glaucoma

PURPOSE

We assess long-term surgical outcomes after an initial trabeculectomy for cytomegalovirus-associated anterior uveitis with secondary glaucoma (CMV-SG).

METHODS

We retrospectively reviewed the medical records of 16 eyes of 15 patients with CMV-SG and 157 eyes of 157 patients with primary open-angle glaucoma. The average follow-up period was approximately 3 years. Surgical success was defined as intraocular pressure (IOP) below 18 mmHg and at least 20% lower than baseline.

RESULTS

Kaplan-Meier survival analysis revealed that bleb survival rates were not significantly different in the CMV-SG and POAG groups (P = 0.75). Bullous keratopathy occurred in 2 of 16 eyes with CMV-SG postoperatively but did not occur in the POAG group. The corneal endothelial cell density decreased by 34.2 ± 22.7% in the CMV-SG group during an average follow-up period of 2.7 ± 2.0 years.

CONCLUSION

Trabeculectomy effectively controlled IOP in CMV-SG, but attention must be paid to corneal endothelial cell loss.

Matched case-control comparison of surgical success after XEN45 Gel Stent and PRESERFLO MicroShunt implantation in a Caucasian population

BACKGROUND

The aim of this study was to compare the outcome of implantation of a XEN45 Gel Stent with the outcome of implantation of a Preserflo MicroShunt in a matched-pair analysis in eyes being naïve to filtering surgery.

METHODS

In this comparative, retrospective study, 50 eyes that had undergone XEN45 Gel Stent implantation were compared with 50 eyes after Preserflo implantation. Follow-up was at least 6 months, and surgical success was measured by criteria A (IOP < 21 mmHg, IOP reduction >20%, no repeat surgery); criteria B (IOP < 18 mmHg, IOP reduction >20%, no repeat surgery); and criteria C (IOP ≤15 mmHg, IOP reduction ≥40%, no repeat surgery).

RESULTS

After a follow-up period of 12 months, mean IOP had decreased from preoperative 25.2 ± 4.8 mmHg in the XEN group to 14.5 ± 4.0 (n = 35) and from 25.3 ± 6.8 mmHg to 11.9 ± 2.9 (n = 41) in the Preserflo group, respectively. The IOP at the last follow-up of the two groups differed significantly (p < 0.01). The probability of surgical success did not differ concerning Criteria A and B, but surgical success was significantly higher in the Preserflo group for Criteria C (60%, p < 0.01).

CONCLUSION

Both the Preserflo and XEN45 Gel Stent provide an effective and safe treatment option for advanced glaucoma and have a high potential to reduce intraocular pressure. Absolute IOP levels of <16 mmHg after 12 months were significantly more frequent in the Preserflo group.

Short-term outcomes of Mitomycin-C augmented phaco-trabeculectomy using subconjunctival injections versus soaked sponges: a randomized controlled trial

OBJECTIVES

To determine whether subconjunctival Mitomycin-C (MMC) injections are as safe and effective as sponge-soaked MMC in phaco-trabeculectomy.

METHODS

This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and an uncontrolled primary open-angle glaucoma. One hundred thirty-nine patients were recruited but 15 were ineligible for analysis. The patients were randomized into a sponge/injection group. All participants received a twin-site phaco-trabeculectomy. They were followed up on days 1, 15, 30, 3 months and 6 months post-operatively. A p-value < 0.05 was considered significant.

INTERVENTIONS

Participants in the sponge group received an augmentation of their phaco-trabeculectomy with sponges soaked in a mixture of 0.04% MMC and 2% preservative-free Lignocaine in a 1:1 ratio, placed in the subconjunctival space for four minutes. Participants in the injection group received the same mixture as a subconjunctival injection, after surgical draping.

RESULTS

There were 62 patients in each group. The groups had no significant differences in their baseline characteristics. The mean IOP at 6 months was significantly lower in the injection group (14.8 ± 3.7 mm Hg) than in the sponge group (17.1 ± 6.4 mm Hg) (p = 0.02). There was no notable difference in the complications or the final post-operative visual outcome but a significantly greater number of patients in the sponge arm required removal of the releasable suture (p = 0.001) and additional anti-glaucoma medications (p = 0.04) at six months post-operatively.

CONCLUSIONS

Subconjunctival MMC achieves a lower IOP with fewer anti-glaucoma medications than sponge-soaked MMC at six months for twin-site phaco-trabeculectomy in primary open-angle glaucoma with no additional risks.

Two-year outcomes of anterior versus posterior scleral application of mitomycin C-soaked sponge in trabeculectomy

PURPOSE

To compare the safety and efficacy of two different application methods of mitomycin C (MMC)-soaked sponge in trabeculectomy.

STUDY DESIGN

Retrospective study.

METHODS

We included 71 eyes of 71 patients that had undergone trabeculectomy. In the anterior scleral application group, 36 eyes were treated using the long side of the MMC-soaked sponge placed parallel to the limbus. The efficacy and safety in these eyes were compared with eyes treated with the posterior scleral application group, consisting of 35 eyes treated with the long side of the MMC-soaked sponge placed perpendicular to the limbus. The follow-up period was 2 years. The safety of the procedure, including bleb morphology and complications, was the primary outcome, while the success rate was the secondary outcome.

RESULTS

The cumulative success rate at 2 years postoperatively was 94.4% in the anterior and and 94.3% in the posterior scleral application group (P = 1.000). However, with the posterior scleral application of the MMC-soaked sponge, blebs were more low-lying (P = 0.048), less in extent (P < 0.001), more normally vascularized (P = 0.027) and more posteriorly directed (P < 0.001). Furthermore, the incidence of thin-walled cystic bleb (P = 0.028) and bleb leakage (P = 0.025) was significantly lower in the posterior scleral application group than in the anterior group.

CONCLUSION

Although there were similar success rates, the posterior scleral application of MMC-soaked sponge with trabeculectomy was safer with a better bleb morphology than the anterior scleral application.

A MEK inhibitor arrests the cell cycle of human conjunctival fibroblasts and improves the outcome of glaucoma filtration surgery

Better agents are needed to improve glaucoma filtration surgery outcomes compared to current ones. The purpose of this study is to determine whether mitogen-activated protein kinase kinase (MEK) inhibitors can effectively arrest the cell cycle of human conjunctival fibroblasts (HCFs) and inhibit the formation of fibrosis and scarring following glaucoma filtration surgery. A cell counting kit‑8 assay revealed that the MEK inhibitor PD0325901 exhibited concentration-dependent growth inhibition of HCFs. Quantitative PCR, immunocytochemistry, and western blotting demonstrated decreased expression of proliferating cell nuclear antigen (PCNA) and cyclin D1 and increased expression of p27 in HCFs treated with PD0325901. Flow cytometry indicated that PD0325901 arrested the cell cycle of HCFs in the G0/1 phase. The cell-migration assay showed that HCF migration rate was significantly suppressed by PD0325901 exposure. Rabbits were divided into PD0325901-treatment and control groups, and glaucoma filtration surgery was performed. Although intraocular pressure did not differ between PD0325901-treatment and control groups, bleb height was greater in the treatment group. Histopathological evaluation revealed that fibrotic changes were significantly attenuated in the PD0325901-treatment group compared to the control group. In conclusion, the MEK inhibitor impedes HCF proliferation via cell-cycle arrest and may be beneficial for glaucoma filtration surgery by reducing bleb scarring.

A case of mitomycin C toxicity after XEN gel stent implantation with the XEN air technique in a glaucoma patient

BACKGROUND

To discuss the first case of mitomycin C (MMC) toxicity after XEN® gel stent implantation in a glaucoma patient, conducted using the XEN "air" technique with an ophthalmic viscosurgical device (OVD).

CASE PRESENTATION

A 44-year-old Asian male presented with increased intraocular pressure (IOP; 52 mmHg) accompanied by keratic precipitates and an edematous cornea. He was diagnosed with uveitic glaucoma in the left eye, and the IOP was controlled with a topical anti-glaucoma agent. However, glaucoma progression was revealed by Humphrey visual field (HVF) and optical coherence tomography (OCT) examinations. The patient underwent uneventful XEN gel stent implantation using the XEN air technique and an MMC (0.02%, 0.1 mL) injection, with subconjunctival air and OVD injection provided prior to XEN implantation in the left eye. The patient exhibited a decreased IOP (11 mmHg), elevated bleb, and extensive subconjunctival hemorrhage on postoperative day 1. On postoperative day 18, diffuse conjunctival injection and a large avascular bleb was noticed around the XEN gel stent. The patient complained of severe eye pain and discomfort, suggestive of MMC toxicity, and the IOP was 12 mmHg. The patient was treated with a topical steroid and antibiotics tapered over a 6-month period. Finally, the toxicity was successfully controlled, with the IOP stabilizing at around 15 mmHg.

CONCLUSIONS

Although significantly greater lowering of the IOP can be expected with the use of subconjunctival OVD injection and MMC during XEN gel stent implantation, a cautious approach and a longer monitoring period are required.

Noncontact Conjunctiva: A Better Mitomycin C Application Site for Trabeculectomy

INTRODUCTION

Bleb scarring is the most important complication of trabeculectomy. Changing the application position of mitomycin C (MMC) during trabeculectomy might affect the surgery outcome. Our aim is to compare the effectiveness and safety of intraocular pressure (IOP) lowering in two different application sites of mitomycin in trabeculectomy.

METHODS

This retrospective trial compared the surgical outcomes of 177 eyes that underwent trabeculectomy with adjunctive mitomycin C. In 70 eyes, an MMC-soaked sponge was applied under the scleral flap without touching Tenon's capsule. In 107 eyes, an MMC-soaked sponge was applied under the scleral flap covered by Tenon's capsule. Outcome measures were the IOP, best-corrected visual acuity (BCVA), success rates, and incidence of complications.

RESULTS

Within both groups, a highly significant IOP reduction was seen during follow-up. The effectiveness in reducing IOP and the change in best-corrected visual acuity (BCVA) were similar between the two groups. Thin-walled blebs and postoperative hypotony were seen more often when MMC-soaked sponges were applied under the scleral flap covered by Tenon's capsule (P = 0.008 and P = 0.012, respectively). There was no significant difference in BCVA or other complications in either group.

CONCLUSION

Since the effectiveness of IOP reduction was similar between both groups and with a low incidence of thin-walled blebs and hypotony, the subscleral application without touching Tenon's capsule seems to be the safer application site of MMC during trabeculectomy.

Analysis of the systemic exposure of Mitomycin C used in glaucoma filtering surgery among women in the reproductive age group

PURPOSE

Systemic absorbtion of topically applied mitomycin C (MMC) during trabeculectomy needs to be evaluated to look for any systemic toxicity, which might be a major concern in certain conditions like pregnancy.

METHODS

After obtaining ethical committee clearance, female patients in the reproductive age group undergoing trabeculectomy with MMC were included. Pregnant/lactating patients, patients with any systemic illness were excluded.During trabeculectomy, 0.02% MMC was applied subconjunctivally for 2 minutes and then washed. Blood samples were withdrawn at 1hr, 2hr, 4hr, 8hr, 12hr, and 24hrs after the surgery and analyzed of MMC levels using Liquid chromatography-tandem mass spectroscopy (LCMS-MS).

RESULTS

The mean age of the participants was 29 ± 12 years. MMC was not detected in any of the plasma samples analyzed as it was less than the detection limit (<1.56ng/mL) of the employed LC-MS/MS assay.

CONCLUSION

It can be deduced that the systemic absorption of MMC is negligible or the plasma concentration is less than 1.56ng/ml (1000 times less than the concentration where systemic toxicity was not observed).

Efficacy of the PRESERFLO MicroShunt and a Meta-Analysis of the Literature

Background: Recent studies on the PRESERFLO MicroShunt suggest that it may be effective in lowering intraocular pressure (IOP); however, the number of studies on this device remains limited. Therefore, we assessed the efficacy of the PRESERFLO MicroShunt in patients with glaucoma and performed a meta-analysis of published results. Methods: Prospective study including all patients that underwent PRESERFLO MicroShunt surgery from 2018 onwards. Sub-analyses were performed for cataract-combined procedures. To compare our results, we performed a systematic review and meta-analysis. IOP, IOP-lowering medication and surgical complications reported in the retrieved studies were assessed. Results: A total of 72 eyes underwent PRESERFLO-implant surgery (59 as standalone procedure and 13 as cataract-combined procedure). No significant differences were found in IOP and IOP-lowering medication between both groups. The mean ± standard deviation IOP and IOP-lowering medications of both groups taken together declined from 21.72 ± 8.35 to 15.92 ± 8.54 mmHg (p < 0.001, 26.7% reduction) and 3.40 to 0.93 (p < 0.001, 72.6% reduction) at 1 year follow-up, respectively. Secondary surgeries were required in 19.4% of eyes, the majority (71.4%) within 6 months. The meta-analysis including 14 studies (totaling 1213 PRESERFLO MicroShunt surgeries) from the systematic review showed a mean preoperative IOP and IOP-lowering medication of 22.28 ± 5.38 and 2.97 ± 1.07, respectively. The three-years postoperative pooled mean was (weighted mean difference, 95% CI) 11.07 (10.27 [8.23−12.32], p < 0.001) mmHg and 0.91 (1.77 [1.26−2.28], p < 0.001) for IOP and IOP-lowering medication, respectively. The most common reported complication was hypotony (2−39%). Conclusion: The PRESERFLO MicroShunt is effective and safe in lowering IOP and the number of IOP-lowering medications.

Endophthalmitis and blebitis following deep sclerectomy and trabeculectomy with routine use of mitomycin C

PURPOSE

The purpose of the study was to investigate the incidence for endophthalmitis and blebitis after deep sclerectomy (DS) and trabeculectomy with routine use of Mitomycin C (MMC) 0.4 mg/ml.

METHODS

Electronic medical records of patients who underwent surgery 1/2008-4/2020 were reviewed. Cumulative incidence for bleb-associated infection (BAI), including both endophthalmitis and blebitis, was calculated with cumulative incidence function (CIF) and Kaplan-Meier analysis. Risk factors for BAI were evaluated with univariate competing risk regression analysis and Log-rank analysis. Competing event in CIF was death.

RESULTS

In this retrospective single-centre cohort study, a total of 2653 patients and 3411 eyes underwent surgery: 3478 glaucoma surgeries, 2419 DS and 1059 trabeculectomies. Two cases of endophthalmitis and three of isolated blebitis developed. Median follow-up from the most recent surgery on the eye until the end of the study was 5.5 years, and until last visit at the ophthalmology department was 1.9 years. For the whole follow-up period in CIF-analysis, cumulative incidence for BAI was 0.16% (95% CI 0.06-0.36) at five years. Incidence was higher with eyes not treated with an antifibrotic during surgery (sub-hazard ratio 11.66, 95% CI 1.94-70.21, p = 0.007). Cumulative incidence between surgery and last visit with Kaplan-Meier analysis was 0.21% (95% CI 0.08-0.52) at five years, similarly, not using an antifibrotic increased incidence (Log-rank p < 0.001).

CONCLUSION

Cumulative incidence for BAI was low despite routine use of high-dose MMC.

Bleb-related Porcine Lymphatic Outflow is Greater from Subconjunctival compared to Subtenon Blebs

Aim

Understanding the mechanism of fluid outflow by comparing the subconjunctival and subtenon spaces can lead to improved ocular therapeutics. The purpose of the current study is to evaluate subconjunctival vs subtenon lymphatic outflow by creating tracer-filled blebs in each location.

Methods

Porcine (n = 20) eyes received subconjunctival or subtenon injection(s) of fixable and fluorescent dextrans. Blebs were angiographically imaged using a Heidelberg Spectralis ([Heidelberg Retina Angiograph] HRA + OCT; Heidelberg Engineering) and bleb-related lymphatic outflow pathways were counted. Optical coherence tomography (OCT) imaging of these pathways was used to assess structural lumens and the presence of valve-like structures. Furthermore, a comparison between tracer injection locations (superior/inferior/temporal/nasal) was made. Histologic analyses for subconjunctival and subtenon outflow pathways were performed, to confirm tracer co-localization with molecular lymphatic markers.

Results

Subconjunctival blebs demonstrated a greater number of lymphatic outflow pathways compared to subtenon blebs in every quadrant [superior: 6.10 ± 1.18 (subconjunctival) vs 0.50 ± 0.27 (subtenon); temporal: 2.30 ± 0.40 vs 0.10 ± 0.10; nasal: 5.30 ± 0.60 vs 0.30 ± 0.21; inferior: 6.00 ±1.29 vs 0.1 ± 0.1; all comparisons p < 0.001]. For subconjunctival blebs, the temporal quadrant showed fewer lymphatic outflow pathways compared to the nasal side (p = 0.005).

Discussion

Subconjunctival blebs accessed greater lymphatic outflow compared to subtenon blebs. Furthermore, regional differences existed, with fewer lymphatic vessels temporal than at the other locations.

Clinical significance

Aqueous humor drainage after glaucoma surgery is incompletely understood. The present manuscript adds to our understanding of how lymphatics might influence filtration bleb function.

How to cite this article

Lee JY, Strohmaier CA, Akiyama G, et al. Bleb-related Porcine Lymphatic Outflow Is Greater from Subconjunctival compared to Subtenon Blebs. J Curr Glaucoma Pract 2022;16(3):144-151.

Early Complications and Results of Preserflo MicroShunt in the Management of Uncontrolled Open-Angle Glaucoma: A Case Series

We analyze the surgical outcomes and early complications with their management of the Preserflo MicroShunt (Santen Pharmaceutical Co., Ltd., Osaka, Japan) at six-month follow-up. The study is conducted between March 2021 and May 2022. Best-corrected visual acuity (BCVA) logMAR, intraocular pressure (IOP), and changes in glaucoma medications are assessed. Thirty eyes of 30 patients (22 women [73.3%] and 8 men [26.7%]) are included. They are augmented with mitomycin C (MMC) 0.5 mg/mL (8 subjects) or MMC 0.2 mg/mL (22 subjects) intraoperatively. BCVA is significantly higher one day after the treatment than before the treatment (MD with 95% CI = 0.05 (<0.01; 0.30); p = 0.045) when analyzing all patients. Such dependency is not observed when analyzing only patients treated with MMC 0.2 or 0.5 mg/mL (p > 0.050 for both analyses). No other statistically significant differences are detected in the level of BCVA before and after treatment. Among the patients, overall IOP is significantly lower at each time point after treatment than before surgery (p < 0.001 for all analyses). Among patients augmented with MMC 0.2 mg/mL, the IOP level is also significantly lower at each time point after treatment than before treatment (p ≤ 0.001 for all analyses). The same differences are observed among patients with MMC = 0.5—the IOP level is significantly lower at each time point after treatment than before treatment (p < 0.050 for all analyses). Five subjects (16.7%) require anti-glaucoma medications three months after the procedure. Early complications (hypotony, choroidal effusion, keratitis, hyphema, and bleb fibrosis) are observed in 46.7% of cases. Our early results show that Preserflo MicroShunt is safe and effective for lowering IOP; however, it is not free from transient complications.

Effect of SMILE-derived decellularized lenticules as an adhesion barrier in a rabbit model of glaucoma filtration surgery

Background

To investigate the effects of small incision lenticule extraction (SMILE)-derived decellularized lenticules on intraocular pressure (IOP) and conjunctival scarring in a rabbit model of glaucoma filtration surgery.

Methods

Trabeculectomy was performed on both eyes of New Zealand rabbits. A decellularized lenticule was placed in the subconjunctival space in one eye of the rabbits (the decellularized lenticule group), and no adjunctive treatment was performed in the fellow eye (the control group). The filtering bleb features and IOP were evaluated 0, 3, 7, 14, 21, and 28 days after surgery, and histopathologic examination was performed 28 days after surgery.

Results

Decellularized lenticules significantly increased bleb survival and decreased IOP postoperatively in the rabbit model with no adverse side effects. The histopathologic results showed a larger subconjunctival space and less subconjunctival fibrosis in the decellularized lenticule group.

Conclusions

Decellularized lenticules can prevent postoperative conjunctiva-sclera adhesion and fibrosis, and they may represent a novel antifibrotic agent for trabeculectomy.

Influence of Mitomycin C on the Therapeutic Success of Stand-Alone Xen45 Gel Stents and Its Combination with Cataract Surgery in Open-Angle Glaucoma Patients

PURPOSE

Minimally invasive glaucoma surgery (MIGS), like Xen45 gel stents, is known as effective therapy in lowering intraocular pressure (IOP); however, fibrotic reactions are a common problem in postoperative management. It was the aim of this study to investigate the therapeutic success of Xen45 gel stents as a stand-alone technique (Xen) and combined with cataract surgery (XenPhaco), and with antimetabolites (mitomycin C, MMC) in open-angle glaucoma patients.

METHODS

Retrospective analysis was performed of 199 eyes of 177 glaucoma patients of the Department of Ophthalmology, University of Erlangen Nürnberg, and from the Erlangen Glaucoma Registry (NCT00494923; ISSN 2191-5008, CS-2011) who underwent implantation of a Xen45 gel stent. Therapeutic success was defined as IOP reduction of ≥ 20% on the same or less anti-glaucomatous medication after 12 months compared to preoperative and without any additional glaucoma-related surgery (except bleb needling). IOP reduction, reduction in local anti-glaucomatous eye drops, and intra- and postoperative complications were monitored.

RESULTS

Stand-alone Xen45 gel stent: therapeutic success was reached in 39% (-MMC) and 55% (+MMC). Failure rate was 61% (-MMC) and 45% (+MMC). XenPhaco: therapeutic success was achieved in 57% (-MMC) and 46% (+MMC). Failure rate was 43% (-MMC) and 54% (+MMC). Data were not different for group and subgroup analyses (p > 0.05).

CONCLUSIONS

The use of MMC seemed to increase the therapeutic success rate after stand-alone Xen45 gel stent implantation and combined with cataract surgery, yet statistical significant was not reached.

XEN® Gel Stent compared to PRESERFLO™ MicroShunt implantation for primary open-angle glaucoma: two-year results

Purpose

To evaluate the long‐term efficacy and safety of two minimally invasive glaucoma surgery implants with a subconjunctival drainage approach: the XEN45 Gel Stent^® (Xen) implant and the PRESERFLO™ MicroShunt (MicroShunt).

Methods

Retrospective comparative case series of primary open‐angle glaucoma (POAG) patients with at least 6 months of follow‐up after a MicroShunt or Xen implantation augmented with mitomycin C.

Results

Forty‐one eyes of 31 patients underwent Xen implantation, and 41 eyes of 33 patients, MicroShunt implantation. Baseline characteristics were similar, except for more combined surgeries with phacoemulsification in the Xen group (37% vs. 2%). Mean baseline IOP ± standard deviation dropped from 19.2 ± 4.4 to 13.8 ± 3.8 mmHg (n = 26) in the Xen group and from 20.1 ± 5.0 to 12.1 ± 3.5 (n = 14) in the MicroShunt group at 24 months of follow‐up (p = 0.19, t‐test). The number of IOP‐lowering medications dropped from 2.5 ± 1.4 to 0.9 ± 1.2 in the Xen group and from 2.3 ± 1.5 to 0.7 ± 1.1 in the MicroShunt group. The probability of qualified success was 73% and 79% at 24 months of follow‐up for the Xen and MicroShunt groups, respectively. Postoperative complications were usually mild and self‐limiting. The number of bleb needling and secondary glaucoma surgery procedures was similar in both groups; however, in the Xen group more additional MicroPulse^® transscleral cyclophotocoagulation procedures were performed.

Conclusion

Xen Gel Stent and PreserFlo MicroShunt implantations achieved comparable results in POAG eyes in terms of IOP‐lowering and surgical success, with a similar high safety profile.

Looking into the future: Gene and cell therapies for glaucoma

Glaucoma is a complex group of optic neuropathies that affects both humans and animals. Intraocular pressure (IOP) elevation is a major risk factor that results in the loss of retinal ganglion cells (RGCs) and their axons. Currently, lowering IOP by medical and surgical methods is the only approved treatment for primary glaucoma, but there is no cure, and vision loss often progresses despite therapy. Recent technologic advances provide us with a better understanding of disease mechanisms and risk factors; this will permit earlier diagnosis of glaucoma and initiation of therapy sooner and more effectively. Gene and cell therapies are well suited to target these mechanisms specifically with the potential to achieve a lasting therapeutic effect. Much progress has been made in laboratory settings to develop these novel therapies for the eye. Gene and cell therapies have already been translated into clinical application for some inherited retinal dystrophies and age-related macular degeneration (AMD). Except for the intravitreal application of ciliary neurotrophic factor (CNTF) by encapsulated cell technology for RGC neuroprotection, there has been no other clinical translation of gene and cell therapies for glaucoma so far. Possible application of gene and cell therapies consists of long-term IOP control via increased aqueous humor drainage, including inhibition of fibrosis following filtration surgery, RGC neuroprotection and neuroregeneration, modification of ocular biomechanics for improved IOP tolerance, and inhibition of inflammation and neovascularization to prevent the development of some forms of secondary glaucoma.

Overfiltering Bleb en Route to Annular Ciliochoroidal Effusion

Annular ciliochoroidal effusion is a rare condition that can complicate trabeculectomy. We report a case of ciliochoroidal effusion mimicking aqueous misdirection after combined glaucoma and cataract surgery. A 75-year-old male with pseudoexfoliation, chronic angle-closure glaucoma, and advanced optic disc damage developed ciliochoroidal effusion after a combined trabeculectomy and phacoemulsification with intraocular lens implantation. The patient presented with overfiltering bleb, hypotony, and a uniformly shallow anterior chamber that mimicked aqueous misdirection in the clinical picture. Reformation of anterior chamber followed by revision of the bleb was performed. Ultrasound biomicroscopy confirmed the diagnosis. Atropine and steroid eye drops improved the condition. Ciliochoroidal effusion should be ruled out in hypotony with shallow anterior chamber post glaucoma surgery.

Comparison of the Efficacy and Safety of Trabeculectomy with Mitomycin C According to Concentration: A Prospective Randomized Clinical Trial

(1) Background: Mitomycin C (MMC) is commonly used during trabeculectomy. However, there is no consensus on which concentration should be used. We aimed to compare the efficacy and safety of 0.2 mg/mL and 0.4 mg/mL of MMC in eyes undergoing trabeculectomy. (2) Methods: Thirty-six eyes (36 glaucoma patients) were randomized to undergo a trabeculectomy with 0.2 mg/mL or 0.4 mg/mL of MMC. The success rate was evaluated according to three criteria: (A) intraocular pressure (IOP) ≤ 18 mmHg and IOP reduction ≥ 20%; (B) IOP ≤ 15 mmHg and IOP reduction ≥ 25%; (C) IOP ≤ 12 mmHg and IOP reduction ≥ 30%. Cox’s proportional hazard model was used to identify the predictive factors for failure. Immunohistochemical procedures for matrix metalloproteinase (MMP) were performed on Tenon’s tissue. Bleb morphology was evaluated. Safety was assessed based on the incidence of complications. (3) Results: Of the 36 eyes, 19 underwent trabeculectomy with 0.2 mg/mL of MMC and 17 with 0.4 mg/mL. The success rates were 75%, 67%, and 47% at 6 months for criteria A, B, and C, respectively. There were no significant differences between the two groups. High MMP-9 staining and low preoperative IOP were associated with failure (hazard ratio (HR), 5.556; p = 0.033, and HR, 0.936; p = 0.033). Complications included hypotony in two eyes (6%), hyphema in one eye (3%), and choroidal detachment in one eye (3%). (4) Conclusions: Trabeculectomy with 0.2 mg/mL and 0.4 mg/mL of MMC showed similar IOP-control effects to those recorded in previous studies, along with a low rate of complications. There was no significant difference in efficacy or safety between the 0.2 mg/mL and 0.4 mg/mL MMC groups.

Injected Versus Sponge-Applied Mitomycin C (MMC) During Modified Trabeculectomy in New Zealand White Rabbit Model

Purpose

Mitomycin C is routinely applied during trabeculectomy surgeries to enhance bleb survival after glaucoma filtration surgery. The current approach involves placing cellulose sponges soaked in mitomycin C at a standard concentration onto bare sclera for a predetermined duration, which varies among surgeons. The purpose of this study was to compare the effects of sponge-applied versus intra-Tenon injection of mitomycin C during modified trabeculectomy.

Methods

Two groups of five New Zealand White rabbits underwent glaucoma filtration surgery with either preoperative intra-Tenon injection of mitomycin C or intraoperative application of mitomycin C using a cellulose sponge. Postoperative intraocular pressure was recorded weekly, and eyes were enucleated and sent for pathological examination and histological analysis.

Results

An intra-Tenon injection of mitomycin C resulted in decreased intraocular pressure measurements and bleb vascularity compared to the controls but increased levels compared to the sponge-applied group. Collagen deposition and cellularity were reduced and the goblet cell population was increased in the intra-Tenon injection group.

Conclusions

This study shows that an intra-Tenon injection can be an effective method for administering mitomycin C compared to the standard-of-care approach of mitomycin C being sponge applied onto bare sclera. Mitomycin C injection led to a greater reduction in intraocular pressure and inhibition of fibroblasts. The associated goblet cell population that can lead to increased mitomycin C toxicity-related morbidity was minimized with the intra-Tenon injection compared to the sponge-applied MMC treatment. Therefore, patients with ocular surface disease may benefit from an intra-Tenon injection.

Translational Relevance

This project provides a direct, qualitative assessment in an animal model of common techniques within glaucoma filtration surgery for drug delivery to improve surgical success.

Stab incision mitomycin C-assisted rapid trabeculectomy: A 'SMART' trabeculectomy alternative

The aim of the present study was to introduce a new modified trabeculectomy technique, stab incision mitomycin C (MMC)-assisted rapid trabeculectomy (SMART), which requires less surgical time and tissue manipulation. A total of 41 eyes with indication for trabeculectomy underwent glaucoma surgery with the SMART technique; superior subconjunctival injection of 0.005 mg MMC mixed with 0.1 ml lidocaine, followed by small, fornix base conjunctival opening. A stab incision was made to enter the anterior chamber 1.5 mm post-limbus using a 2.4 mm cataract knife. Double 0.75 mm punch and peripheral iridectomy were performed. A releasable suture was placed in the scleral opening, and matrix sutures to close conjunctiva. The preoperative mean intraocular pressure (IOP) was 23.8 mmHg, with a mean number of medications of 3.3. The mean follow-up duration was 27.6 months, with a range of 12-46 months. A year post-surgery, the mean IOP was 11 mmHg, with a mean number of medications of 0.7, corresponding to a reduction of 12.8 mmHg in IOP and 2.6 in the number of medications. During follow-up, additional 5-fluorouracil injections were administered when needed. In conclusion, SMART with wound modulation appears to be a safe and quick alternative to classic trabeculectomy. Few minor and no major complications were observed during the first 2.5 years of follow-up, with all eyes maintaining an IOP <15 mmHg.

Intraoperative injection versus sponge-applied mitomycin C during trabeculectomy: One-year study

Purpose

To determine the safety and efficacy of mitomycin C (MMC) injection versus sponge during trabeculectomy.

Methods

It is a prospective analysis of patients who underwent trabeculectomy with MMC and followed up for 1 year, divided into two groups, namely, group 1- injection (n = 21), group 2-> sponge (n = 21). The same concentration of MMC was used for both groups. Inclusion criteria were trabeculectomies with MMC for intraocular pressure (IOP) control in eyes with glaucoma (primary + secondary) with a follow-up of 1 year.

Results

Mean preoperative IOP in group 1 was 29.00 ± 11.92 mmHg and group 2 was 25.87 ± 11.09 mmHg, which reduced to 12.19 ± 4.03 and 15.56 ± 10.72 mmHg at final visit with P value of 0.0002 and 0.001, respectively. Mean preoperative number of antiglaucoma medications was 2.4 ± 0.87 in group 1 and 2.3 ± 0.96 in group 2, which reduced to 0.38 ± 0.5 and 0.91 ± 0.85 with P value of 0.001 and 0.0003, respectively. The complete success rate was 52.4% in the injection group and 26.1% in the sponge group at end of 1 year. Overall, success rate (complete + qualified) was 90.5% and 87% in group 1 and group 2 at final visit. All major complications were encountered in sponge group. 1 (11.1%) patient developed choroidal detachment and one had malignant glaucoma which got resolved by medical management. 33.3% cases had encapsulated bleb which received bleb needling. 44.4% cases underwent Argon laser suture lysis postoperatively.

Conclusion

The MMC injection may be as safe and as effective as conventional sponge application with comparable estimated complete treatment success.

SPARC Levels Modulate the Capacity of Mitomycin to Inhibit the Proliferation of Human Tenon's Capsule Fibroblasts

Purpose

To evaluate the role of SPARC in the antiproliferation effect of MMC on human Tenon's fibroblasts (HTF).

Method

Sixteen PACG patients aged 59 ± 10 years (31-72 years), including 6 males and 10 females, were recruited. Tenon tissue was harvested during filtering surgery. Cell density was evaluated after MMC application with different concentrations and application times, by which the optimized MMC application modality was determined. MMC, si-SPARC, or SPARC protein was used when needed to evaluate the cell densities under different conditions, by which the role of SPARC in MMC-mediated antifibrotic process was identified.

Results

Considering that the cell densities, as well as SPARC expression on mRNA and protein levels, are relatively stable when the MMC concentration is higher than 0.02% and exposure time longer than 90 s, we chose the MMC application pattern with 0.02% and 90 s as an optimized pattern for the downstream work. Compared to control, the si-SPARC and MMC downregulated the SPARC protein by 91% (P < 0.01) and 65% (P < 0.01) and 65% (P < 0.01) and 65% (P < 0.01) and 65% (P < 0.01) and 65% (P < 0.01) and 65% (P < 0.01) and 65% (P < 0.01) and 65% (.

Conclusion

This study demonstrates that in HTF, (1) MMC downregulates the expression of SPARC in protein and mRNA levels; (2) SPARC depletion has synergistic effect on the antifibrotic effect of MMC; and (3) reactive oxygen species are the possible mediator in the antifibrotic effect of MMC and si-SPARC.

Rosiglitazone Treatment Prevents Postoperative Fibrosis in a Rabbit Model of Glaucoma Filtration Surgery

Purpose

To evaluate the potential antifibrotic effect of rosiglitazone (RSG), a peroxisome proliferator-activated receptor γ (PPARγ)-selective agonist, on subconjunctival fibrosis in a rabbit model of glaucoma filtration surgery (GFS) in vivo, and to investigate the underlying mechanisms in human Tenon's fibroblasts (HTFs) in vitro.

Methods

GFS were performed on adult male New Zealand white rabbits with chronic ocular hypertension previously established by injections of 2% methylcellulose into the anterior chamber. Rabbits were treated by RSG, mitomycin C (MMC) or 5-fluorouracil (5-FU) intraoperatively. The morphology of filtering blebs was evaluated by Indiana Bleb Appearance Grading Scale (IBAGS) scoring. Expression of profibrotic genes was determined by quantitative PCR, immunoblot, and/or histochemical analysis. In vitro studies were performed in a transforming growth factor (TGF)-β1-based cell model of fibrosis. Autophagy was evaluated by the formation of autophagosomes and autolysosomes using fluorescent and transmission electron microscopy and by expression of key mediators in the autophagic pathway.

Results

RSG treatment ameliorated a rebound intraocular pressure (IOP) elevation, prolonged the survival of filtering blebs, and attenuated subconjunctival fibrosis in rabbits following trabeculectomy. Pretreatment of HTFs with RSG inhibited TGF-β1-induced expression of profibrotic genes encoding specificity protein 1, connective tissue growth factor, and α smooth muscle actin. RSG augmented TGF-β1-induced autophagy in HTFs via a beclin1/VPS34-dependent mechanism. Augmentation of autophagy is associated with inhibition of TGF-β1-induced profibrotic gene expression by RSG.

Conclusions

RSG treatment prevents subconjunctival fibrosis after GFS by inhibition of profibrotic gene expression through a mechanism involved in promoting autophagy in local fibroblasts. RSG represents a novel antifibrotic drug with the potential to improve the success rate of GFS.

Clinical and ASOCT evaluations of 'bleb-sparing epithelial exchange' in paediatric and adult dysfunctional blebs over 5 years

PURPOSE

To evaluate the long-term outcome of 'bleb-sparing epithelial exchange' surgery for dysfunctional filtering blebs in paediatric and adult eyes.

METHODS

Patients who had undergone bleb revision ≥ 5 years back and were on regular follow-up were included. Age, ocular diagnosis, details of primary filtering surgery including mitomycin-C (MMC) usage, indication and year of bleb revision were recorded. After bleb revision, the mean intraocular pressure (IOP), glaucoma medications and best corrected visual acuity (BCVA) up to 5 years were noted. On last review, clinical details, bleb characteristics and swept source anterior segment tomographic (SSOCT) assessment of bleb were recorded. Comparative analysis of paediatric and adult eyes was performed.

MAIN OUTCOME MEASURES

Change in IOP and BCVA. 'Complete success' was defined as IOP ≥ 6 to ≤ 18mmHg without use of any topical glaucoma medications and 'Qualified success' when ≥ 1 topical glaucoma medication(s) was required.

RESULTS

A total of 51 eyes of 51 consecutive patients were studied, among which 22 were children. The mean duration between filtering surgery and bleb revision was 4.54 ± 1.53 years in paediatric and 6.48 ± 3.5 years in the adult group, p = 0.04. Children underwent trabeculotomy + trabeculectomy with 0.04% MMC, while adults underwent trabeculectomy with 0.02% MMC. The mean pre-revision IOP was 6.38 ± 2.80 and 6.51 ± 2.78 mmHg in the paediatric and adult group respectively, p = 0.86. At 3 months post-revision, it increased to 11.81 ± 3.48 and 12.75 ± 3.52 mmHg respectively (p < 0.001). At final review, mean IOP of paediatric group was 10.90 ± 2.59 and adult group was 11.86 ± 2.66 mmHg, p = 0.20. At 5 years, complete success was 68.18% and 72.41%, and qualified success was 31.87% and 27.59% in the former and latter group respectively, p = 0.49. No failures were seen. Kaplan-Meier probability at 5 years for IOP target ≤ 18, ≤ 15 and ≤ 12 in children was 95.45%, 63.64% and 50% and in adults 93.10%, 65.52% and 41.38% respectively. BCVA improved up to 1 year in paediatric group, with continued improvement in adults up to 3 years. SSOCT measured bleb height was 0.88 ± 0.37 and 1.32 ± 0.49mm in children versus adults (p = 0.006) and wall thickness, 0.35 ± 0.22 and 0.58 ± 0.24mm respectively, p = 0.008.

CONCLUSION

Bleb-sparing epithelial exchange is an equally safe and effective technique with good long-term success in both paediatric and adult dysfunctional blebs.

Ab externo implantation of the MicroShunt, a poly (styrene-block-isobutylene-block-styrene) surgical device for the treatment of primary open-angle glaucoma: a review

Trabeculectomy remains the ‘gold standard’ intraocular pressure (IOP)-lowering procedure for moderate-to-severe glaucoma; however, this approach is associated with the need for substantial post-operative management. Micro-invasive glaucoma surgery (MIGS) procedures aim to reduce the need for intra- and post-operative management and provide a less invasive means of lowering IOP. Generally, MIGS procedures are associated with only modest reductions in IOP and are targeted at patients with mild-to-moderate glaucoma, highlighting an unmet need for a less invasive treatment of advanced and refractory glaucoma. The PRESERFLO® MicroShunt (formerly known as InnFocus MicroShunt) is an 8.5 mm-long (outer diameter 350 μm; internal lumen diameter 70 μm) glaucoma drainage device made from a highly biocompatible, bioinert material called poly (styrene-block-isobutylene-block-styrene), or SIBS. The lumen size is sufficiently small that at normal aqueous flow hypotony is avoided, but large enough to avoid being blocked by sloughed cells or pigment. The MicroShunt achieves the desired pressure range in the eye by draining aqueous humor from the anterior chamber to a bleb formed under the conjunctiva and Tenon’s capsule. The device is implanted ab externo with intraoperative Mitomycin C via a minimally invasive (relative to incisional surgery) surgical procedure, enabling precise control of placement without the need for gonioscopy, suture tension control, or suture lysis. The implantation procedure can be performed in combination with cataract surgery or as a standalone procedure. The MicroShunt received Conformité Européenne (CE) marking in 2012 and is intended for the reduction of IOP in eyes of patients with primary open-angle glaucoma in which IOP remains uncontrolled while on maximum tolerated medical therapy and/or in which glaucoma progression warrants surgery. Three clinical studies assessing the long-term safety and efficacy of the MicroShunt have been completed; a Phase 3 multicenter, randomized clinical study comparing the MicroShunt to primary trabeculectomy is underway. In preliminary studies, the MicroShunt effectively reduced IOP and use of glaucoma medications up to 3 years after implantation, with an acceptable safety profile. This article summarizes current literature on the unique properties of the MicroShunt, the preliminary efficacy and safety findings, and discusses its potential use as an alternative to trabeculectomy for glaucoma surgery.

Evaluating the efficacy of short duration Mitomycin C in safe surgery system trabeculectomy combined with cataract surgery

Purpose: To compare the efficacy of 0.2 mg/ml Mitomycin C (MMC) applied for 1-minute versus 2-minutes in patients undergoing combined surgery for primary glaucoma coexistent with cataract.

Materials and methods: This was a randomized controlled clinical trial of 63 patients operated on for primary glaucoma (POAG or PACG) with visually significant cataract. All patients underwent safe surgery system trabeculectomy with manual small incision cataract surgery (MSIC) and implantation of PC IOL. Patients were randomized into intra-operative MMC 0.2 mg/ml for 1-minute (study group) and MMC 0.2 mg/ml for 2-minutes (control group). Success was measured on the basis of two different intraocular pressure (IOP) goals (IOP ≤21 mmHg, IOP ≤18 mmHg) and mean IOP reduction from baseline at the end of 12 months.

Results: At 12 months, significant decreases in mean IOP were observed in both groups (P<0.001).The mean IOP reduction was 31.33±9.06% in the study group, as compared to 43.32±9.38% in the control group (P<0.001). The overall success for IOP ≤21 mm Hg was 80.5% in the study group and 90.9% in the control group (P<0.05). Kaplan-Meier analysis showed an insignificant difference in overall success rates of the two groups.

Conclusion: The IOP reduction with 2-minute MMC (0.2 mg/ml) is more effective than 1-minute MMC after 12 months. It offers a decrease in anti-glaucoma medications and substantial visual recovery in combined surgery done for primary glaucoma coexistent with cataract.

Four-year results of a minimally invasive transscleral glaucoma gel stent implantation in a prospective multi-centre study

Importance

The transscleral XEN Glaucoma Gel Microstent (XEN‐GGM, Allergan Plc., Parsippany, New Jersey) is implanted by a minimally invasive ab interno technique.

Background

The present study aims to assess the long‐term clinical outcomes in patients after XEN‐GGM implantation.

Design

This prospective, non‐randomized, multi‐centred study was conducted in three countries (Austria, Canada and Germany).

Participants

Sixty‐four consecutive eyes of 64 patients with open angle glaucoma received the XEN‐GGM (63 μm) without Mitomycin C. Thirty‐five (55%) were solo procedures, and 29 (45%) were combined with cataract surgery.

Methods

Visits were planned at baseline, 6 months, 1, 2, 3 and 4 years postoperatively.

Main Outcome Measures

The main outcome measures were mean intraocular pressure (IOP), mean number of IOP lowering medication. Secondary outcome parameters were: visual acuity, visual fields and complete surgical failure (defined as presence of a secondary IOP lowering procedure or loss of light perception) at 4 years, postoperatively.

Results

Mean best‐medicated baseline IOP was 22.5 ± 4.2 mmHg and decreased significantly to 13.4 ± 3.1 mmHg 4 years postoperatively (−40%, n = 34, P < 0.001). Mean number of IOP lowering medication decreased significantly from 2.4 ± 1.3 preoperatively to 1.2 ± 1.3 (−50%, n = 34, P < 0.001) postoperatively. Visual field mean deviation showed no significant change between preoperative and postoperative examinations. Complete surgical failure rate per year was 10%.

Conclusions and Relevance

The XEN‐GGM resulted in lower IOP and a reduction in medications from baseline over 4 years of follow‐up. There was no detectable decrease in visual fields over the study. The surgical failure rate is comparable to other filtration surgeries.

[XEN-45 Gel Stent implant in glaucoma treatment]

The XEN-45 drainage implant is a hypotensive device made of hydrophilic gelatin and stabilized by glutaraldehyde. The implant is designed for modern Microinvasive Glaucoma Surgery (MIGS). Being installed ab interno, the stent drains aqueous fluid from the anterior chamber into the subconjunctival space. According to indications, XEN-45 can be used in treatment of primary open angle glaucoma, pseudoexfoliation or pigment glaucoma with uncompensated intraocular pressure amid maximum tolerated hypotensive therapy, and refractory glaucoma including cases with history of unsuccessful surgery. The implant can also be effectively used in combination with phacoemulsification. The article describes the structure and implantation process of the XEN drainage and reviews existing clinical trials on its effectiveness. The article also presents results on hypotensive efficacy of the implant, as well as characteristics and complications of postoperative management.

Increased aqueous autotaxin and lysophosphatidic acid levels are potential prognostic factors after trabeculectomy in different types of glaucoma

We explored the potential relevance of aqueous lysophosphatidic acid (LPA) and autotaxin (ATX) levels on postoperative outcomes of trabeculectomy, and the effects of ATX on fibrotic response in cultured human conjunctiva fibroblast (HCF) cells. We enrolled 70 glaucomatous eyes which underwent trabeculectomy, and quantified aqueous LPA and ATX. Those eyes were followed up for 12 months, and postoperative filtering blebs were evaluated using anterior segment optical coherence tomography. Also, the ATX-induced fibrotic changes in HCFs and the effects of an ATX inhibitor were assessed. Measured aqueous ATX and LPA levels were significantly different between glaucoma subtypes. In multivariate analyses, aqueous ATX levels were significantly correlated with the presence of needlings at 1, 3, 6 and 12 months after surgery. Exfoliative glaucoma, whose ATX level was significantly high, showed significantly increased numbers of needlings and a lower cumulative success rate without needlings. An in vitro study showed that fibrotic changes were upregulated by ATX treatment in HCFs, which was significantly suppressed by an ATX inhibitor. We presently demonstrate that aqueous ATX may be a prognostic factor affecting the fibrotic response in HCFs and bleb formation, and inhibition of ATX could be a therapeutic target after trabeculectomy.

Efficacy of autologous conjunctival flap on repairing the late-onset filtering bleb leakage

AIM

To evaluate the effectiveness of autologous conjunctival flap surgery for repairing the late-onset filtering bleb leakage after trabeculectomy.

METHODS

This study retrospectively reviewed 106 eyes from 106 patients with late-onset filtering bleb leakage after trabeculectomy who received autologous conjunctival flap surgery at the Zhongshan Ophthalmic Centre from 2005 to 2015. The basic information was recorded, and the interval time between trabeculectomy and autologous conjunctival flap surgery as well as related risk factors, intraocular pressure (IOP), anterior chamber depth (ACD) and best corrected visual acuity (BCVA) were analysed. Moreover, 41 patients who completed the 1-year follow up were analysed to determine the IOP and BCVA changes and long-term success rates.

RESULTS

The 50 male and 56 female subjects (average age 39.13±17.96y) included 47 (44.34%) and 33 (31.13%) cases of primary open angle and primary angle-closure glaucoma. The mean interval between trabeculectomy and repair surgery was 60.60±56.92 (3-264)mo. The mean mitomycin (MMC) concentration during trabeculectomy was 0.27±0.04 (0.12-0.4) mg/mL in the fornix-based conjunctival flap group (68 patients) and 0.28±0.04 (0.20-0.33) mg/mL in the limbal-based conjunctival flap group (11 patients). After bleb leakage, the patients' vision remained stable while the IOP decreased from 10.25±4.76 (3-20.86) to 9.44±4.33 (2-21) mm Hg (P<0.01). In the 41 analysed patients, the IOP was controlled at 15.68±5.11 (7-40) mm Hg in the 1^st year after autologous conjunctival flap surgery and recurrence was not observed, for a long-term success rate of 100%.

CONCLUSION

Autologous conjunctival flap repairing surgery is an effective technique for sealing filtering bleb leakages and controlling IOP postoperatively.

First-in-human phase I study of ISTH0036, an antisense oligonucleotide selectively targeting transforming growth factor beta 2 (TGF-β2), in subjects with open-angle glaucoma undergoing glaucoma filtration surgery

Purpose

To evaluate the safety and tolerability of intravitreal ISTH0036, an antisense oligonucleotide selectively targeting transforming growth factor beta 2 (TGF-β2), in patients with primary open angle glaucoma (POAG) undergoing trabeculectomy (TE; glaucoma filtration surgery).

Methods

In this prospective phase I trial glaucoma patients scheduled for TE with mitomycin C (MMC) received a single intravitreal injection of ISTH0036 at the end of surgery in escalating total doses of 6.75 μg, 22.5 μg, 67.5 μg or 225 μg, resulting in calculated intraocular ISTH0036 concentrations in the vitreous humor of approximately 0.3 μM, 1 μM, 3 μM or 10 μM after injection, respectively. Outcomes assessed included: type and frequency of adverse events (AEs), intraocular pressure (IOP), numbers of interventions post trabeculectomy, bleb survival, visual acuity, visual field, electroretinogram (ERG), slit lamp biomicroscopy and optic disc assessment.

Results

In total, 12 patients were treated in the 4 dose groups. Main ocular AEs observed were corneal erosion, corneal epithelium defect, or too high or too low IOP, among others. No AE was reported to be related to ISTH0036. All other safety-related analyses did not reveal any toxicities of concern, either. The mean medicated preoperative IOP at decision time-point for surgery was 27.3 mmHg +/- 12.6 mmHg (SD). Mean IOP (±SD) for dose levels 1, 2, 3, and 4 were at Day 43 9.8 mmHg ± 1.0 mmHg, 11.3 mmHg ± 6.7 mmHg, 5.5 mmHg ± 3.0 mmHg and 7.5 mmHg ± 2.3 mmHg SD; and at Day 85 9.7 mmHg ± 3.3 mmHg, 14.2 mmHg ± 6.5 mmHg, 5.8 mmHg ± 1.8 mmHg and 7.8 mmHg ± 0.6 mmHg, respectively. In contrast to IOP values for dose levels 1 and 2, IOP values for dose levels 3 and 4 persistently remained below 10 mmHg throughout the observation period.

Conclusion

This first-in-human trial demonstrates that intravitreal injection of ISTH0036 at the end of TE is safe. Regarding IOP control, single-dose ISTH0036 administration of 67.5 μg or 225 μg at the time of TE resulted in IOP values persistently < 10 mmHg over the three month postoperative observation period.

Anastomotic Strictures after Esophageal Atresia Repair: Incidence, Investigations, and Management, Including Treatment of Refractory and Recurrent Strictures

Improved surgical techniques, as well as preoperative and postoperative care, have dramatically changed survival of children with esophageal atresia (EA) over the last decades. Nowadays, we are increasingly seeing EA patients experiencing significant short- and long-term gastrointestinal morbidities. Anastomotic stricture (AS) is the most common complication following operative repair. An esophageal stricture is defined as an intrinsic luminal narrowing in a clinically symptomatic patient, but no symptoms are sensitive or specific enough to diagnose an AS. This review aims to provide a comprehensive view of AS in EA children. Given the lack of evidence-based data, we critically analyzed significant studies on children and adults, including comments on benign strictures with other etiologies. Despite there is no consensus about the goal of the luminal diameter based on the patient's age, esophageal contrast study, and/or endoscopy are recommended to assess the degree of the narrowing. A high variability in incidence of ASs is reported in literature, depending on different definitions of AS and on a great number of pre-, intra-, and postoperative risk factor influencing the anastomosis outcome. The presence of a long gap between the two esophageal ends, with consequent anastomotic tension, is determinant for stricture formation and its response to treatment. The cornerstone of treatment is endoscopic dilation, whose primary aims are to achieve symptom relief, allow age-appropriate capacity for oral feeding, and reduce the risk of pulmonary aspiration. No clear advantage of either balloon or bougie dilator has been demonstrated; therefore, the choice is based on operator experience and comfort with the equipment. Retrospective evidences suggest that selective dilatations (performed only in symptomatic patients) results in significantly less number of dilatation sessions than routine dilations (performed to prevent symptoms) with equal long-term outcomes. The response to dilation treatment is variable, and some patients may experience recurrent and refractory ASs. Adjunctive treatments have been used, including local injection of steroids, topical application of mitomycin C, and esophageal stenting, but long-term studies are needed to prove their efficacy and safety. Stricture resection or esophageal replacement with an interposition graft remains options for AS refractory to conservative treatments.

Contralateral eye comparison study in MICS & MIGS: Trabectome® vs. iStent inject®

PURPOSE

To compare the safety and efficacy profile after combined micro-incision cataract surgery (MICS) and micro-invasive glaucoma surgery (MIGS) with the ab interno trabeculectomy (Trabectome®) in one eye versus two iStent® inject devices in the contralateral eye in patients with open-angle glaucoma (OAG) and cataract.

METHODS

This retrospective, intraindividual eye comparison study included 27 patients (54 eyes) who were treated with combined MICS and ab interno trabeculectomy (group I, Trabectome®) in one eye and two iStent® inject devices (group II, GTS 400) in the fellow eye. Primary outcome measures included intraocular pressure (IOP) and glaucoma medication after 6 weeks, 3, 6, and 12 months follow-up. Secondary outcome measures were number of postoperative interventions, complications, and best-corrected visual acuity (BCVA).

RESULTS

Mean preoperative IOP decreased from 22.3 ± 3.7 mmHg in group I and 21.3 ± 4.1 mmHg in group II to 15.6 ± 3.6 mmHg for Trabectome (p < 0.001) and 14.0 ± 2.3 mmHg for iStent inject (p < 0.001) at 12 months after surgery without a significant difference between the two groups (p > 0.05). No vision-threatening complications such as choroidal effusion, choroidal hemorrhage, or infection occurred. In each group trabeculectomy had to be performed in two eyes due to insufficient IOP lowering effect.

CONCLUSIONS

Ab interno trabeculectomy and iStent® inject were both effective in lowering IOP with a favourable and comparable safety profile in an intraindividual comparative study over a 12-months follow-up in OAG. However, longer follow-up of these patients will be necessary to determine long-term outcomes and to evaluate significant differences.