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Rabiolo A, Triolo G, Khaliliyeh D, Jin SW, Morales E, Ghirardi A, Anand N, Montesano G, Virgili G, Caprioli J, De Cillà S. Hypotony Failure Criteria in Glaucoma Surgical Studies and Their Influence on Surgery Success. Ophthalmology 2024; 131:803-814. [PMID: 38199527 DOI: 10.1016/j.ophtha.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 01/12/2024] Open
Abstract
PURPOSE Review hypotony failure criteria used in glaucoma surgical outcome studies and evaluate their impact on success rates. DESIGN Systematic literature review and application of hypotony failure criteria to 2 retrospective cohorts. PARTICIPANTS A total of 934 eyes and 1765 eyes undergoing trabeculectomy and deep sclerectomy (DS) with a median follow-up of 41.4 and 45.4 months, respectively. METHODS Literature-based hypotony failure criteria were applied to patient cohorts. Intraocular pressure (IOP)-related success was defined as follows: (A) IOP ≤ 21 mmHg with ≥ 20% IOP reduction; (B) IOP ≤ 18 mmHg with ≥ 20% reduction; (C) IOP ≤ 15 mmHg with ≥ 25% reduction; and (D) IOP ≤ 12 mmHg with ≥ 30% reduction. Failure was defined as IOP exceeding these criteria in 2 consecutive visits > 3 months after surgery, loss of light perception, additional IOP-lowering surgery, or hypotony. Cox regression estimated failure risk for different hypotony criteria, using no hypotony as a reference. Analyses were conducted for each criterion and hypotony type (i.e., numerical [IOP threshold], clinical [clinical manifestations], and mixed [combination of numerical or clinical criteria]). MAIN OUTCOME MEASURES Hazard ratio (HR) for failure risk. RESULTS Of 2503 studies found, 278 were eligible, with 99 studies (35.6%) lacking hypotony failure criteria. Numerical hypotony was predominant (157 studies [56.5%]). Few studies used clinical hypotony (3 isolated [1.1%]; 19 combined with low IOP [6.8%]). Forty-nine different criteria were found, with IOP < 6 mmHg, IOP < 6 mmHg on ≥ 2 consecutive visits after 3 months, and IOP < 5 mmHg being the most common (41 [14.7%], 38 [13.7%], and 13 [4.7%] studies, respectively). In both cohorts, numerical hypotony posed the highest risk of failure (HR, 1.51-1.21 for criteria A to D; P < 0.001), followed by mixed hypotony (HR, 1.41-1.20 for criteria A to D; P < 0.001), and clinical hypotony (HR, 1.12-1.04; P < 0.001). Failure risk varied greatly with various hypotony definitions, with the HR ranging from 1.02 to 10.79 for trabeculectomy and 1.00 to 8.36 for DS. CONCLUSIONS Hypotony failure criteria are highly heterogenous in the glaucoma literature, with few studies focusing on clinical manifestations. Numerical hypotony yields higher failure rates than clinical hypotony and can underestimate glaucoma surgery success rates. Standardizing failure criteria with an emphasis on clinically relevant hypotony manifestations is needed. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Alessandro Rabiolo
- Department of Ophthalmology, University Hospital Maggiore della Carita', Novara, Italy; Department of Health Sciences, Università del Piemonte Orientale "A. Avogadro", Novara, Italy.
| | - Giacinto Triolo
- Department of Surgical Sciences, University Eye Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Daniela Khaliliyeh
- Glaucoma Division, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California
| | - Sang Wook Jin
- Glaucoma Division, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California
| | - Esteban Morales
- Glaucoma Division, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California
| | - Alessandro Ghirardi
- Department of Health Sciences, Università del Piemonte Orientale "A. Avogadro", Novara, Italy
| | - Nitin Anand
- Department of Ophthalmology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom; Department of Ophthalmology, Calderdale and Huddersfield NHS Trust, Huddersfield, United Kingdom
| | - Giovanni Montesano
- National Institute for Health and Care Research, Biomedical Research Centre, Moorfields Eye Hospital, National Health Service Foundation Trust and University College London, Institute of Ophthalmology, London, United Kingdom
| | - Gianni Virgili
- Department NEUROFARBA, University of Florence, Florence, Italy; IRCCS-Fondazione Bietti, Rome, Italy
| | - Joseph Caprioli
- Glaucoma Division, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles, California
| | - Stefano De Cillà
- Department of Ophthalmology, University Hospital Maggiore della Carita', Novara, Italy; Department of Health Sciences, Università del Piemonte Orientale "A. Avogadro", Novara, Italy
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Sarohia GS, Elsayed MEAA, Solarte CE, Hornby SJ, Brookes J, Chang TCP, Malik R. Outcome measures in childhood glaucoma: a systematic review of randomized controlled trials. Graefes Arch Clin Exp Ophthalmol 2023; 261:2625-2639. [PMID: 37119307 DOI: 10.1007/s00417-023-06061-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 03/19/2023] [Accepted: 04/05/2023] [Indexed: 05/01/2023] Open
Abstract
PURPOSE To synthesize the outcome measures used by randomized controlled trials (RCTs) for childhood glaucoma. METHODS MEDLINE, EMBASE, and Scopus were searched from inception to February 17, 2023. Randomized controlled trials and observational studies related to childhood glaucoma were included. Primary and secondary outcomes were extracted and the data was used to generate a literature review. RESULTS This review identified 42 unique reports pertaining to childhood glaucomas. Most of the studies originated from Egypt, India, and the USA. Intraocular pressure (IOP) outcomes were the most frequent outcomes studied, followed by clinical outcomes and safety outcomes. Clinical outcomes were the most common secondary outcomes studied, followed by IOP outcomes and safety outcomes. CONCLUSIONS This systematic review found heterogenous outcomes with IOP outcomes as the most studied primary outcome. As the remaining outcomes were not consistently utilized, this review highlights the need for a consensus on studies of pediatric glaucoma.
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Affiliation(s)
- Gurkaran S Sarohia
- Department of Ophthalmology and Visual Sciences, University of Alberta, 400, 10924, 107 Avenue, Edmonton, AB, T5H 0X5, Canada
| | | | - Carlos Eduardo Solarte
- Department of Ophthalmology and Visual Sciences, University of Alberta, 400, 10924, 107 Avenue, Edmonton, AB, T5H 0X5, Canada.
| | - Stella J Hornby
- Oxford Eye Hospital, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK
| | - John Brookes
- Glaucoma Department, Moorfields Eye Hospital, London, UK
| | | | - Rizwan Malik
- Department of Surgery, Sheikh Khalifa Medical City, Abu Dhabi, UAE
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Animal Model Contributions to Primary Congenital Glaucoma. J Ophthalmol 2022; 2022:6955461. [PMID: 35663518 PMCID: PMC9162845 DOI: 10.1155/2022/6955461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022] Open
Abstract
Primary congenital glaucoma (PCG) is an ocular disease characterized by congenital anterior segmental maldevelopment with progressive optic nerve degeneration. Certain genes, such as cytochrome P450 family 1 subfamily B member 1 and latent TGF-β-binding protein 2, are involved in the pathogenesis of PCG, but the exact pathogenic mechanism has not yet been fully elucidated. There is an urgent need to determine the etiology and pathophysiology of PCG and develop new therapeutic methods to stop disease progression. Animal models can simulate PCG and are essential to study the pathogenesis and treatment of PCG. Various animal species have been used in the study of PCG, including rabbits, rats, mice, cats, zebrafish, and quails. These models are formed spontaneously or by combining with genetic engineering technology. The focus of the present study is to review the characteristics and potential applications of animal models in PCG and provide new approaches to understand the mechanism and develop new treatment strategies for patients with PCG.
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Abstract
BACKGROUND Primary congenital glaucoma (PCG) is an optic neuropathy with high intraocular pressure (IOP) that manifests within the first few years of a child's life and is not associated with other systemic or ocular abnormalities. PCG results in considerable morbidity even in high-income countries. OBJECTIVES To compare the effectiveness and safety of different surgical techniques for PCG. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2020, Issue 4); Ovid MEDLINE; Embase.com; PubMed; metaRegister of Controlled Trials (mRCT) (last searched 23 June 2014); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 27 April 2020. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs comparing different surgical interventions in children under five years of age with PCG. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. MAIN RESULTS We included 16 trials (13 RCTs and three quasi-RCTs) with 587 eyes in 446 children. Eleven (69%) trials were conducted in Egypt and the Middle East, three in India, and two in the USA. All included trials involved children younger than five years of age, with follow-up ranging from six to 80 months. The interventions compared varied across trials. Three trials (on 68 children) compared combined trabeculotomy and trabeculectomy (CTT) with trabeculotomy. Meta-analysis of these trials suggests there may be little to no evidence of a difference between groups in mean IOP (mean difference (MD) 0.27 mmHg, 95% confidence interval (CI) -0.74 to 1.29; 88 eyes; 2 studies) and surgical success (risk ratio (RR) 1.01, 95% CI 0.90 to 1.14; 102 eyes; 3 studies) at one year postoperatively. We assessed the certainty of evidence as very low for these outcomes, downgrading for risk of bias (-1) and imprecision (-2). Hyphema was the most common adverse outcome in both groups (no meta-analysis due to considerable heterogeneity; I2 = 83%). Two trials (on 39 children) compared viscotrabeculotomy to conventional trabeculotomy. Meta-analysis of 42 eyes suggests there is no evidence of between groups difference in mean IOP (MD -1.64, 95% CI -5.94 to 2.66) and surgical success (RR 1.11, 95% CI 0.70 to 1.78) at six months postoperatively. We assessed the certainty of evidence as very low, downgrading for risk of bias and imprecision due to small sample size. Hyphema was the most common adverse outcome (38% in viscotrabeculotomy and 28% in conventional trabeculotomy), with no evidence of difference difference (RR 1.33, 95% CI 0.63 to 2.83). Two trials (on 95 children) compared microcatheter-assisted 360-degree circumferential trabeculotomy to conventional trabeculotomy. Meta-analysis of two trials suggests that mean IOP may be lower in the microcatheter group at six months (MD -2.44, 95% CI -3.69 to -1.19; 100 eyes) and at 12 months (MD -1.77, 95% CI -2.92 to -0.63; 99 eyes); and surgical success was more likely to be achieved in the microcatheter group compared to the conventional trabeculotomy group (RR 1.59, 95% CI 1.14 to 2.21; 60 eyes; 1 trial at 6 months; RR 1.54, 95% CI 1.20 to 1.97; 99 eyes; 2 trials at 12 months). We assessed the certainty of evidence for these outcomes as moderate due to small sample size. Hyphema was the most common adverse outcome (40% in the microcatheter group and 17% in the conventional trabeculotomy group), with greater likelihood of occurring in the microcatheter group (RR 2.25, 95% CI 1.25 to 4.04); the evidence was of moderate certainty due to small sample size (-1). Of the nine remaining trials, no two trials compared the same two surgical interventions: one trial compared CTT versus CTT with sclerectomy; three trials compared various suturing techniques and adjuvant use including mitomycin C, collagen implant in CTT; one trial compared CTT versus Ahmed valve implant in previously failed surgeries; one trial compared CTT with trabeculectomy; one trial compared trabeculotomy to goniotomy; and two trials compared different types of goniotomy. No trials reported quality of life or economic data. Many of the included trials had limitations in study design, implementation, and reporting, therefore the reliability and applicability of the evidence remains unclear. AUTHORS' CONCLUSIONS The evidence suggests that there may be little to no evidence of difference between CTT and routine conventional trabeculotomy, or between viscotrabeculotomy and routine conventional trabeculotomy. A 360-degree circumferential trabeculotomy may show greater surgical success than conventional trabeculotomy. Considering the rarity of the disease, future research would benefit from a multicenter, possibly international trial, involving parents of children with PCG and with a follow-up of at least one year.
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Affiliation(s)
- Meghal Gagrani
- Department of Ophthalmology and Visual Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Itika Garg
- Department of Opthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepta Ghate
- Department of Ophthalmology and Visual Sciences, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Bell K, de Padua Soares Bezerra B, Mofokeng M, Montesano G, Nongpiur ME, Marti MV, Lawlor M. Learning from the past: Mitomycin C use in trabeculectomy and its application in bleb-forming minimally invasive glaucoma surgery. Surv Ophthalmol 2020; 66:109-123. [PMID: 32450159 DOI: 10.1016/j.survophthal.2020.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/26/2022]
Abstract
Trabeculectomy has been performed since the mid-1960s and remains the gold standard for glaucoma surgery. Newer surgical options have evolved, collectively referred to as minimally invasive glaucoma surgeries. Despite producing large intraocular pressure decreases, full-thickness procedures into the subconjunctival space may be limited by fibrosis. Mitomycin C (MMC) and 5-fluorouracil have been in use with trabeculectomy with good evidence of significantly increased success at the cost, however, of an increased risk of complications. Off-label MMC application can be found in almost all clinical trials, including in combination with minimally invasive glaucoma surgeries. We explore current evidence for MMC use in trabeculectomy and how this may differ for minimally invasive glaucoma surgery devices and analyze the range of agents and doses that are used. Although we found that most studies could not show any correlation between MMC dosage and the surgical outcome, the success rates with the Xen® microshunt seemed to be higher when using 20 mcg of MMC than when using 10 mcg. Certain important methodological considerations make this hard to confirm definitively, and other factors such as placement of the device may play a more substantial role. For the PreserFlo® microshunt, preliminary data suggest higher success rates with higher MMC dosage at the cost of higher device-related adverse events and reoperations. Although the ideal dose still needs to be established, it seems very likely that MMC provides significant improvement in outcomes in bleb-forming minimally invasive glaucoma procedures.
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Affiliation(s)
- Katharina Bell
- Experimental and Translational Ophthalmology, Department of Ophthalmology, Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rhineland-Palatinate, Germany.
| | | | | | - Giovanni Montesano
- University of Milan - ASST Santi Paolo e Carlo, Milan, Italy; City, University of London - Optometry and Visual Sciences, London, United Kingdom; NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London, United Kingdom
| | | | | | - Mitchell Lawlor
- Save Sight Institute, Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Sydney Eye Hospital, Macquarie St, Sydney, Australia
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康 欣, 申 颖, 赵 海, 王 召, 关 文, 葛 瑞, 王 瑞, 邰 雪. [Anti-scarring effect of rapamycin in rabbits following glaucoma filtering surgery]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2018; 38:1389-1394. [PMID: 30514691 PMCID: PMC6744124 DOI: 10.12122/j.issn.1673-4254.2018.11.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To study the anti- scarring effect of rapamycin in rabbits receiving glaucoma filtering surgery. METHODS Ninety-six Chinchilla rabbits were randomized equally into 3 rapamycin treatment groups and one control group. All the rabbits underwent trabeculectomy, after which the rabbits in the 3 rapamycin groups were treated with eye drops containing 1%, 3%, or 5% rapamycin in the operated eyes, and those in the control groups were given castor oil 4 times a day. The intraocular pressure (IOP) and inflammatory reaction in the treated eyes were observed, and the PCNA-positive cells in the filtering bleb were detected using immunohistochemistry. RTFs isolated from the Tenon's capsule of the rabbits were cultured in vitro, and the expressions of caspase-3, caspase-8, and caspase-9 in the fibroblasts were detected after treatment with different concentrations of rapamycin. RESULTS The IOP was significantly lower in rapamycin-treated group than in the control group after the surgery (P < 0.05). The counts of the PCNA-positive cells were significantly lower in rapamycin-treated rabbits than in the control group (P < 0.05). Rapamycin treatment dose-dependently increased the expressions of caspase-3 and caspase- 9 at both the mRNA (P < 0.001) and protein (P < 0.001) levels without causing significant changes in the expressions of caspase-8. CONCLUSIONS Rapamycin can inhibit excessive proliferation of the fibroblasts in the filtering bleb to reduce scar formation after glaucoma filtration surgery in rabbits. Rapamycin also increases the expressions of caspase-3 and caspase-9 to induce apoptosis of the RTFs.
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Affiliation(s)
- 欣 康
- />内蒙古医科大学附属医院近视眼激光治疗中心,内蒙古 呼和浩特 010050Center of Myopia, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - 颖 申
- />内蒙古医科大学附属医院近视眼激光治疗中心,内蒙古 呼和浩特 010050Center of Myopia, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - 海霞 赵
- />内蒙古医科大学附属医院近视眼激光治疗中心,内蒙古 呼和浩特 010050Center of Myopia, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - 召格 王
- />内蒙古医科大学附属医院近视眼激光治疗中心,内蒙古 呼和浩特 010050Center of Myopia, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - 文英 关
- />内蒙古医科大学附属医院近视眼激光治疗中心,内蒙古 呼和浩特 010050Center of Myopia, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - 瑞春 葛
- />内蒙古医科大学附属医院近视眼激光治疗中心,内蒙古 呼和浩特 010050Center of Myopia, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - 瑞芳 王
- />内蒙古医科大学附属医院近视眼激光治疗中心,内蒙古 呼和浩特 010050Center of Myopia, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
| | - 雪 邰
- />内蒙古医科大学附属医院近视眼激光治疗中心,内蒙古 呼和浩特 010050Center of Myopia, Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010050, China
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