Vision-related quality of life in patients with glaucoma before and after trabeculectomy

PURPOSE

To determine vision-related quality of life (VR-QoL) and functional and structural parameters associated with VR-QoL in patients with glaucoma before and 12 months after trabeculectomy.

METHODS

Fifty-eight patients undergoing trabeculectomy were included. Participants completed the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) prior to and 12 months after trabeculectomy. Functional (visual acuity and visual fields) and structural (ganglion cell layer volume) parameters were evaluated for their association with VR-QoL using multiple linear regression of VFQ-25 subscale scores. Intraocular pressure and the number of glaucoma medications were also included in the analyses.

RESULTS

The VFQ-25 composite score did not change after trabeculectomy (before: 74.9; 12 months: 74.0; p = 0.512). The subscale mental health had a significantly higher score 12 months after trabeculectomy (before: 65.6; 12 months: 71.4; p = 0.017). The VFQ-25 scores for general health (before: 68.5; 12 months: 62.5; p = 0.009) and role difficulties (before: 78.9; 12 months: 53.7; p < 0.001) were significantly lower 12 months after trabeculectomy. No functional or structural parameters were associated with VFQ-25 composite score.

CONCLUSION

Overall, VR-QoL in glaucoma patients was similar before and after trabeculectomy, reflecting the procedure's stabilizing effect on both objective and subjective visual function. The absence of correlations between VR-QoL and clinical parameters emphasizes the multifaceted nature of VR-QoL and highlights the limitations of depending solely on objective clinical metrics to evaluate patients' subjective experiences. Using both objective measures and VR-QoL, clinicians can better understand the challenges patients face due to glaucoma and trabeculectomy, potentially leading to better solutions.

Visual Field Outcomes in the Primary Tube Versus Trabeculectomy Study

PURPOSE

To describe visual field outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study.

DESIGN

Cohort analysis of a prospective multicenter randomized clinical trial.

SUBJECTS

A total of 155 eyes from 155 subjects randomly assigned to treatment with tube shunt surgery (n=84) or trabeculectomy with mitomycin C (n=71).

METHODS

The PTVT Study was a multicenter randomized clinical trial comparing the safety and efficacy of trabeculectomy and tube shunt surgery in eyes without prior intraocular surgery. Subjects underwent standard automated perimetry (SAP) at baseline and annually for five years. SAP tests were deemed reliable if the false positive rate was ≤15%. Tests were excluded if visual acuity was ≤20/400 or loss of ≥2 Snellen lines from baseline were attributed to a non-glaucomatous etiology. Linear mixed-effects models were used to compare rates of change in SAP mean deviation (MD) between the two treatment groups. Intraocular pressure (IOP) control was assessed by percentage of visits with IOP <18 mmHg and mean IOP.

OUTCOME MEASURES

Rate of change in SAP MD during follow-up.

RESULTS

A total of 730 SAP tests were evaluated, with an average of 4.7 tests per eye. The average SAP MD at baseline was -12.8±8.3 dB in the tube group and -12.0±8.4 dB in the trabeculectomy group (p=0.57). The mean rate of change in SAP MD was -0.32±0.39 dB/year in the trabeculectomy group and -0.47±0.43 dB/year in the tube group (p=0.23). Eyes with mean IOP 14-17.5 mmHg had significantly faster rates of SAP MD loss compared to eyes with mean IOP <14 mmHg (-0.59±0.13 vs. -0.27±0.08 dB/year, p=0.012) and eyes with only 50-75% of visits with IOP <18 mmHg had faster rates than those with 100% of visits with IOP <18 mmHg (-0.90±0.16 vs. -0.29±0.08 dB/year, p<0.001). Multivariable analysis identified older age and worse IOP control as risk factors for faster progression in both treatment groups.

CONCLUSIONS

No statistically significant difference in mean rates of visual field change was observed between trabeculectomy and tube shunt surgery in the PTVT Study. Worse IOP control was significantly associated with faster rates of SAP MD loss during follow-up. Older patients were also at risk for faster progression.

A novel LTBP2 gene variant in a Turkish family with juvenile-onset open-angle glaucoma

BACKGROUND

Juvenile-onset open-angle glaucoma (JOAG) is a rare form of primary open-angle glaucoma (POAG) with an early age of onset before 40 years. Latent transforming growth factor-beta binding protein 2 (LTBP-2) is an extracellular matrix protein with a multi-domain structure and homology to fibrillins. LTBP2 gene variants have been associated with JOAG in a small number of patients. Herein, we report a novel missense variant in the LTBP2 gene in a Turkish family with JOAG.

MATERIALS AND METHODS

Blood samples were obtained from three siblings (a 20-year-old woman with JOAG, 26-year-old man with JOAG, and 15-year-old girl with posterior embryotoxon) for genetic analysis. Their father had moderate-severe POAG and the 24-year-old brother had JOAG. The mother and 32-year-old sister were healthy. Although the parents reported no consanguinity, they come from the same village.

RESULTS

Clinical exome sequencing analysis of the two siblings with JOAG revealed a novel c.607C>T p.(R203C) (rs777450651) homozygous LTBP2 variant, while the variant was heterozygous in their 15-year-old sister. There were no mutations in the MYOC, CYP1B1, or FBN1 genes.

CONCLUSION

We documented a novel missense mutation in the LTBP2 gene leading to a severe form of JOAG with refractory IOP and progressive optic nerve damage, which seems to show autosomal recessive inheritance.

Navigating hypotony challenges with XEN gel implantation

INTRODUCTION

The XEN Gel, a hydrophilic tube meticulously crafted to adhere to the principles of the Hagen - Poiseuille law, is designed to facilitate efficient aqueous shunting without inducing hypotony. Implantable ab interno or ab externo, with or without conjunctival opening, the device shows no significant outcome differences. Despite numerical hypotony signaling failure, patients may fare well below 6 mmHg.

AREAS COVERED

This review provides insights into device variability, challenges related to hypotony, associated risk factors, and hypotony management.

EXPERT OPINION

The progressive evolution of the XEN Gel constitutes a significant advancement in the field of glaucoma management. Comparative studies investigating diverse implantation methodologies, particularly the ab interno and closed conjunctival approaches, highlight the device versatility in addressing individual patient needs. Exploring hypotony from both statistical and clinical perspectives challenges the traditional view of intraocular pressure as a straightforward success or failure indicator. The incidence of hypotony-related issues varies between device models, emphasizes the need for an individualized approach during device selection. Overall, understanding the dynamics of hypotony is crucial for optimizing the outcomes of XEN Gel implantation.

Wound modulation in glaucoma surgery: The role of anti-scarring agents

Filtration surgery is one of the most frequently performed surgeries in the management of glaucoma, and trabeculectomy is considered the gold standard surgical technique for the same. Though trabeculectomy has been reported to have an excellent initial success rate, about 30% of them fail in 3 years, and nearly 50% of them fail in 5 years. The most significant risk of failure still seems to be wound scarring, especially episcleral fibrosis, leading to bleb failure. As a result, it is essential to explore the role of anti-scarring agents, including mitomycin C, and 5-fluorouracil in wound modulation and improving the bleb survival rate. Since these agents are widely used in trabeculectomy, it is crucial to understand the various modes of application, advantages, and adverse effects of these agents. On an evidence-based approach, all these points have been highlighted in this review article. In addition, the newer agents available for wound modulation and their scope for practical application are discussed.

Trabeculectomy with concurrent intravitreal bevacizumab in neovascular glaucoma

PURPOSE

To evaluate the clinical efficacy of concurrent intravitreal bevacizumab (IVB) injection with trabeculectomy with mitomycin-C (MMC) in neovascular glaucoma (NVG).

METHODS

Patients with NVG who underwent trabeculectomy with concurrent IVB (group 1) and those who underwent IVB sequentially, followed by trabeculectomy with MMC (group 2) in 1-2 weeks between January 2021 and August 2022, were included in this retrospective hospital-based study. The need for medications for intraocular pressure (IOP) control at 6 months in the two groups was the primary outcome measured and compared between the groups. The association of the need for medications postoperatively with clinical variables was assessed using stepwise multivariate regression statistics.

RESULTS

We finally included 40 patients ( n = 12 in group 1, n = 28 in group 2) with no significant differences in presenting age between groups. The IOP at 1 day and 1 week were not significantly different between groups though the IOP at 1, 3, and 6 months. IOP was lower in group 1 eyes with the 6-month IOP, being significantly lower in group 1, P = 0.05. Three eyes in group 1 and 11 eyes in group 2 required anti-glaucoma medications in the postoperative period. Multivariate regression identified preoperative IVB >3 (β =0.7, P < 0.001) and recurrent vitreous hemorrhage (β = 0.7, P = 0.004) as prognostic factors ( R2 = 40.6%) determining the need for anti-glaucoma medication (AGM) postoperatively in both groups.

CONCLUSION

Concurrent IVB with trabeculectomy with mitomycin-C is a feasible alternative in patients with NVG with refractory high-presenting IOP. This may serve to address raised IOP as well as retinal ischemia, thereby improving surgical success rates in the most challenging NVG cases.

Changes in Ocular Biometry Following PreserFlo MicroShunt Implantation and Trabeculectomy: A Prospective Observational Study

Background This study aimed to evaluate postoperative changes in ocular biometry following initial PreserFlo MicroShunt implantation and trabeculectomy. Methodology This prospective, observational study analyzed 27 cases of PreserFlo MicroShunt implantation and 29 cases of trabeculectomy performed by a single surgeon. Visual acuity, intraocular pressure, corneal curvature, central corneal thickness, anterior chamber depth, and axial length were assessed at baseline and postoperatively at one day, one week, two weeks, one month, two months, three months, and six months. Patients requiring additional surgery and those with missing data were excluded. Consecutive data were compared with the baseline values using multiple comparisons. Results In both groups, intraocular pressure was significantly decreased from baseline at all postoperative time points (all p < 0.01). Visual acuity decreased in both groups at one day and one week postoperatively. Corneal curvature remained unchanged in both groups throughout the six-month follow-up. Central corneal thickness increased at one day and one week postoperatively in the PreserFlo group, but not in the trabeculectomy group. Anterior chamber depth exhibited a significant decrease at one week postoperatively in both groups. Axial length significantly decreased postoperatively until three months in the PreserFlo group and at all postoperative time points in the trabeculectomy group. Conclusions Ocular biometry following PreserFlo and trabeculectomy had a similar tendency postoperatively.

Hypotony in the early postoperative period after MicroShunt implantation versus trabeculectomy: A registry study

PURPOSE

A comparison of the safety and efficacy of the MicroShunt versus trabeculectomy in the early postoperative period, with a particular focus on hypotony.

METHODS

In this registry study, we evaluated 200 eyes of 200 glaucoma patients who underwent filtration surgery at Oslo University Hospital between 2017 and 2021. Of these patients, 100 had a Preserflo MicroShunt (Santen) implantation and 100 had a trabeculectomy procedure. The patients were examined per standard hospital protocol after filtration surgery. Data were extracted from the 4- and 8-week visits. We defined hypotony as intraocular pressure (IOP) < 6 mmHg.

RESULTS

The mean preoperative IOP was 20.6 ± 7.1 mmHg in the MicroShunt group and 21.6 ± 7.1 mmHg in the trabeculectomy group, and the patients used a mean of 3.0 ± 0.9 and 3.1 ± 0.9 glaucoma medications, respectively. After 8 weeks, IOP was reduced to 10.4 ± 5.4 mmHg and 11.3 ± 4.6 mmHg, respectively (p = 0.23). During the early postoperative period, hypotony was registered in 63% of the MicroShunt patients and in 21% of the patients in the trabeculectomy group (p < 0.001); and 11% and 1%, respectively, of the patients developed choroidal detachments (p < 0.003). One patient in the MicroShunt group required reoperation due to hypotony.

CONCLUSIONS

In this registry study, we found that the Preserflo MicroShunt and trabeculectomy had equally satisfactory IOP-lowering effects during the early postoperative period. In this same period, a high number of patients in the MicroShunt group developed hypotony.

A 3-Year Follow-Up Study

PURPOSE

Uveitis can lead to secondary glaucoma, a condition with challenging management that can carry irreversible visual loss. Filtering surgery has demonstrated a higher failure rate, increased incidence of postoperative complications and reinterventions in uveitic patients. There is no consensus on the optimal surgical approach for uveitic glaucoma (UG) due to limited data comparing various intraocular pressure (IOP)-lowering surgeries. This retrospective cohort aims to assess the clinical outcomes of trabeculectomy (TBT), non-penetrating deep sclerectomy (NPDS), Ex-PRESS shunt and Ahmed glaucoma valve, providing additional insights into the long-term IOP control and safety of filtering surgeries in UG.

METHODS

The filtering surgery was performed on 32 eyes of 27 UG patients. Complete success was defined as IOP ≤ 18 mmHg or a 30% reduction. Qualified success allowed topical hypotensive treatment.

RESULTS

Complete success was 40.63% (13/32) at 12 months and 36.67% (11/30) at 36 months. Qualified success was 84.38% (27/32) at 12 months and 63.33% (19/30) at 36 months. In the survival analysis, both NPDS and Ex-PRESS demonstrated decreased failure rates compared to TBT (NPDS vs TBT: HR = 0.20, p = 0.049; Ex-PRESS vs TBT: HR = 0.28, p = 0.13). One or more reinterventions were required in 34.38% (11/32) of the eyes. NPDS had the lowest incidence of hypotony. Secondary cataract was a common complication in all groups.

CONCLUSION

Various filtering surgeries are safe and effective procedures for lowering IOP and reducing the requirement of topical antihypertensives in UG at 36 months. However, one-third of the patients will require another IOP-lowering procedure.

Comparing the safety and efficacy of Preserflo Microshunt implantation and trabeculectomy for glaucoma: A systematic review and meta-analysis

To compare the safety and efficacy of the Preserflo Microshunt with trabeculectomy in the treatment of patients with glaucoma. A systematic review and meta-analysis was conducted. The primary outcome measures recorded as a measure of efficacy of the interventions were intra-ocular pressure (IOP) at final follow-up and IOP reduction (IOPR). Secondary outcomes recorded to measure efficacy were reduction in the number of glaucoma medications and reinterventions. To assess safety profile, the proportions of patients with post-operative complications were recorded. Seven articles were included in this study. A total of 1353 eyes were included in this review (Preserflo: 812, trabeculectomy: 541). Post-operative IOP (mean difference [MD] = 0.78 [0.66, 0.90], p < 0.001) results are significantly lower for trabeculectomy than Preserflo. The IOPR (MD = -1.20 [-2.30, -0.09], p = 0.034) results significantly favour trabeculectomy over Preserflo Microshunt. The reduction in topical glaucoma medications (MD = -0.32 [-0.58, -0.07], p = 0.014) is significantly higher for trabeculectomy. There is no statistically significant difference in levels of hypotony (risk ratio [RR] = -0.05 [-0.47, 0.37], p = 0.806), choroidal effusion/detachment (RR = -0.12 [-0.42, 0.19], p = 0.444), hyphaema (RR = 0.20 [-0.11, 0.51], p = 0.216) and flat anterior chamber (RR = 0.49 [-1.02, 0.03], p = 0.066). There are significantly more bleb-related complications in the trabeculectomy groups than Preserflo groups (RR = -0.63 [-1.01, -0.24], p = 0.001). There were statistically more reinterventions required in the trabeculectomy groups than Preserflo groups (RR = -0.48 [-0.65, -0.30], p < 0.001). Compared to trabeculectomy, the Preserflo Microshunt is not as effective in lowering intra-ocular pressure, has a similar safety profile and has a lower reintervention rate. Further research is required given the lack of randomised controlled trials within this study and resulting low strength of evidence.

Steroids and/or Non-Steroidal Anti-Inflammatory Drugs as Postoperative Treatment after Trabeculectomy-12-Month Results of a Randomized Controlled Trial

This prospective randomized controlled trial aimed to compare the efficacy and safety of topical preservative-free diclofenac (DICLO) to dexamethasone (DEX) eyedrops, and their combination (DEX+DICLO) after trabeculectomy. Sixty-nine patients with medically uncontrolled glaucoma were randomized to receive topical postoperative treatment with DICLO (n = 23), DEX (n = 23), or a combination of DEX and DICLO (n = 23). The primary outcome was the intraocular pressure (IOP) 12 months postoperatively. Secondary outcomes included surgical success, failure, visual field, and visual acuity from baseline to 12 months postoperatively. IOP reached the lowest point one day after trabeculectomy. At 12 months, IOP was 10.0 mmHg (95% CI, 8.4-11.6 mmHg) for DICLO, 10.9 mmHg (95% CI, 9.4-12.3 mmHg) for DEX, and 11.2 mmHg (95% CI, 9.1-13.3 mmHg) for DEX+DICLO. There were no significant differences in IOP, surgical success, failure, visual field, or visual acuity between the DICLO, DEX, or DEX+DICLO groups. We found that topical diclofenac was not statistically different from topical dexamethasone in controlling IOP 12 months after trabeculectomy. Combining diclofenac and dexamethasone offered no added IOP control compared to dexamethasone alone.

Glaucoma Surgery and Ocular Blood Flow in Colour Doppler Imaging: Is There a Link?

Glaucoma is a common cause of blindness worldwide. This disease is characterised by increased intraocular pressure (IOP) and the concomitant disruption of ocular haemodynamic. Several studies have demonstrated that trabeculectomy is associated with changes in extraocular blood flow. In this study, we reviewed the available evidence on the use of colour Doppler imaging to evaluate and manage patients with open-angle glaucoma. We present the detailed anatomy of ocular blood flow to provide a background for the research findings. We also discuss the physiological foundations of ocular blood flow and detailed flow characteristics of specific extraocular vessels. Finally, we reviewed published studies that analysed the effects of glaucoma surgery on the blood flow parameters of the eye.

Functional and Morphological Outcomes after Trabeculectomy and Deep Sclerectomy-Results from a Monocentric Registry Study

The aim of this study was to compare the effectiveness of trabeculectomy (TE) and deep sclerectomy (DS) in lowering intraocular pressure (IOP) and thereby preserving visual field and peripapillary retinal nerve fiber layer (RNFL) tissue in primary open-angle glaucoma (POAG) cases. IOP, number of IOP-lowering medications, visual acuity, mean defect of standard automated perimetry, and mean peripapillary RNFL thickness were retrospectively collected and followed up for 3 years after surgery. TE was performed in 104 eyes and DS in 183 eyes. Age, gender, laterality, IOP, number of medications, visual acuity, perimetry mean defect, and peripapillary RNFL thickness were equally distributed at baseline. Mean IOP decreased from 23.8 ± 1.4 mmHg and 23.1 ± 0.4 mmHg to 13.4 ± 0.6 mmHg (p < 0.001) and 15.4 ± 0.7 mmHg (p = 0.001) in the TE and DS groups, respectively. Mean defect remained stable (TE: -11.5 ± 0.9 dB to -12.0 ± 1.1 (p = 0.090); DS: -10.5 ± 0.9 dB to -11.0 ± 1.0 dB (p = 0.302)), while mean peripapillary RNFL thickness showed further deterioration during follow-up (TE group: 64.4 ± 2.1 μm to 59.7 ± 3.5 μm (p < 0.001); DS group: 64.9 ± 1.9 μm to 58.4 ± 2.1 μm (p < 0.001)). Both TE and DS were comparably effective concerning postoperative reduction in IOP and medication. However, glaucoma disease further progressed during follow-up.

Efficacy and Safety of Different Types of Intraocular Pressure-Lowering Surgeries in Patients with Primary Angle Closure (PAC) or PAC Glaucoma: Systematic Review and Network Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

To compare the intraocular pressure (IOP)-lowering effect of different types of surgery available in the literature using a network meta-analysis (NMA) based on a systematic review.

METHODS

PubMed and the Cochrane database were searched. Randomized clinical trials involving surgical interventions for high IOP for PAC (primary angle closure) or PACG (primary angle closure glaucoma) were included. Descriptive statistics and outcomes were extracted. Bayesian NMA was performed to compare the IOP-lowering effect and the change in the number of antiglaucoma drugs required between baseline and endpoint, as well as success rates.

RESULTS

This NMA included 21 articles with 1237 eyes with PAC or PACG. Interventions were characterised as phacoemulsification (phaco), trabeculectomy, goniosynechialysis (GSL) with viscoelastic or blunt device, goniosurgery (GS) (trabeculotomy or goniotomy), micro-bypass stent (Istent®), endocyclophotocoagulation (ECPL) or various combinations of these procedures. Phaco+GSL [-1.73 (95%CrI: -3.53 to -0.13)] and phaco+GSL+GS [-3.92 (95%CrI: -6.91 to -1.31)] provided better IOP lowering effects than phaco alone. Phaco+trabeculectomy [-3.11 (95%CrI: -5.82 to -0.44)] was inferior to phaco+GSL+GS. Phaco+trabeculectomy [-0.45 (95%CrI: -0.81 to -0.13)] provided a better outcome in terms of reducing the need for antiglaucoma drug compared to phaco alone. There were no differences between the other surgeries in terms of reduction of antiglaucoma drug number and IOP lowering effect. Success rates were similar for all surgical procedures.

CONCLUSIONS

Phaco+GSL+GS showed the most promising results for lowering IOP. Phaco+trabeculectomy resulted in a significant reduction in the number of antiglaucoma drugs compared to phaco alone.

Safety and Efficacy of the Rho-Kinase Inhibitor (Ripasudil) in Bleb Needling after Trabeculectomy: A Prospective Multicenter Study

Ripasudil, a rho-associated protein kinase inhibitor ophthalmic solution, shows a protective effect in preventing excessive scarring in vitro. This study aims to evaluate the safety and efficacy of ripasudil for glaucoma patients submitted to the needling procedure. In this prospective, multicenter, single-arm study, we included 20 eyes of 20 patients with glaucoma who underwent the needling procedure without antimetabolites. All patients administered ripasudil after needling for three months. The primary endpoint of this study was the safety of ripasudil in patients, and the secondary endpoint was the change in IOP at 12 weeks after the needling procedure. No serious complications were found in the patients. One eye experienced pruritus and conjunctival follicle, while another eye had conjunctival follicle. These complications were transient and resolved quickly after discontinuation of ripasudil. The mean preoperative IOP was 14.6 ± 4.6 mmHg, which decreased to 11.0 ± 4.7 mmHg (p = 0.0062) at 1 week postoperatively. The IOP reduction effect continued to 12 weeks (11.8 ± 3.1 mmHg; p = 0.0448). The administration of the ROCK inhibitor, ripasudil, after the needling procedure is safe and effective in maintaining IOP for 12 weeks.

Changes to glaucoma surgery patterns during the coronavirus disease 2019 pandemic: a shift towards less invasive procedures

PURPOSE

The aim of the study was to compare the quantity, type of glaucoma surgeries, and the disease stage before and during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This was a retrospective, single-centre consecutive case series that included medical records of patients who underwent glaucoma surgery at the University Hospital in Białystok between 4 September, 2018, and 3 March, 2020 (pre-pandemic group) and compared it with patients treated between 4 March, 2020, and 4 September, 2021 (pandemic group). Adult patients with primary or secondary open-angle or closed-angle glaucoma who underwent surgery were included in this study. Finally, 534 operated eyes (362 and 172 eyes operated on before and during the pandemic, respectively) were examined.

RESULTS

The number of glaucoma surgeries dropped by 50% during the pandemic compared to a similar pre-pandemic period, with a significant difference in the kind of procedure between the two groups (p < 0.001). The most common procedures in the pre-pandemic group were Ex-Press implantation (33.7%) and trabeculectomy (31.5%). Within the pandemic group, half of the eyes underwent trabeculectomy (50.0%), followed by Preserflo microshunt (11.6%), iStent (8.7%), and transscleral cyclophotocoagulation (TSCP) (8.7%). A significant difference in the average intraocular pressure was revealed among patients who qualified for surgery.

CONCLUSION

The COVID-19 pandemic is associated with a decrease in the number of extended antiglaucoma procedures and an increase in the number of short procedures performed, such as TSCP and minimally invasive glaucoma surgery.Key MessagesOur study has shown the negative impact of the COVID-19 pandemic in reducing the number of antiglaucoma procedures.The number of glaucoma surgeries dropped by 50% during the pandemic compared to those in a similar pre-pandemic period, and the type of performed procedures has changed.The COVID-19 pandemic is associated with a decrease in the number of combined antiglaucoma procedures, in opposite: the number of minimally invasive glaucoma surgeries increased due to safety reasons.

Efficacy and Safety of Manual Small-Incision Cataract Surgery With Trabeculectomy Versus Phacotrabeculectomy in Patients With Glaucoma and Cataract: A Systematic Review and Meta-Analysis

The coexistence of two globally leading causes of blindness, glaucoma and cataracts, is common. Combining trabeculectomy with cataract surgery is a common practice while determining the preferred surgical management for patients is a complex consideration. Therefore, a systematic review and meta-analysis were conducted to compare the efficacy and safety of two surgical procedures, manual small-incision cataract surgery (MSICS) combined with trabeculectomy and phacotrabeculectomy. A comprehensive search was performed in PubMed, Science Direct, and Cochrane Library published up to March 2023. Articles not indexed in those databases were also searched. Pooled odds ratios (OR) and mean differences (MD) with corresponding 95% confidence interval (CI) were also retrieved to compare the outcomes estimating efficacy and safety. Biases in selected studies were assessed. A total of seven studies consisting of 352 eyes for MSICS with trabeculectomy and 348 eyes for phacotrabeculectomy were included. Postoperative intraocular pressure (IOP) was comparable between the two techniques (MD: -0.45; 95% CI: -1.07 to 0.16; p = 0.15). Postoperative best corrected visual acuity (BCVA) <6/12 (OR: 1.26; 95% CI: 0.62 to 2.53; p = 0.52), complete success (OR: 0.92; 95% CI: 0.51 to 1.67; p = 0.78), and postoperative complications (OR: 1.27; 95% CI: 0.75 to 2.15, p = 0.38) did not differ significantly. This meta-analysis indicated comparable efficacy and safety profile between MSICS with trabeculectomy and phacotrabeculectomy. Further high-quality studies are required to confirm these findings.

Changes in corneal endothelial cell density after trabeculectomy

BACKGROUND

Glaucoma is a leading cause of blindness worldwide for which trabeculectomy is the most effective surgical intervention for advanced disease. However, trabeculectomy has been associated with alterations to corneal endothelium, including a decrease in corneal endothelial cell density (CECD). The purpose of this study was to investigate changes in CECD after trabeculectomy, and identify factors contributing to cell loss, such as pre-operative biometry and lens status.

METHODS

This retrospective study included 72 eyes of 60 patients who underwent trabeculectomy between January 2018 and June 2021 at two private hospitals. Demographic and clinical data were obtained at baseline. Corneal specular microscopy was performed pre-operatively and at 6 months after surgery. CECD was evaluated and compared between groups to quantify changes to corneal endothelium and identify significant factors affecting decreases in cell density.

RESULTS

Mean CECD was 2284.66 ± 375.59 pre-operatively and 2129.52 ± 401.96 after 6 months (p < 0.001). A greater decrease in CECD (p = 0.005) was observed in phakic eyes (235.45 ± 118.32) compared to pseudophakic eyes (137.82 ± 107.30). The amount of cell loss was negatively correlated with pre-operative central corneal thickness (p = 0.009) and anterior chamber (AC) depth (p = 0.033). There were no significant correlations between changes to CECD and patient age, gender, number of pre-operative glaucoma medications and number of post-operative antifibrotic agents.

CONCLUSIONS

Significant decreases in CECD occurred after trabeculectomy. Less corneal endothelial cell loss occurred in pseudophakic eyes. Hence, if patients need trabeculectomy and cataract surgery, it may be better to perform cataract surgery first. Longer term studies should derive more information.

Swept-Source Anterior Segment Optical Coherence Tomography Imaging and Quantification of Bleb Parameters in Glaucoma Filtration Surgery

This paper describes a technique for using swept-source anterior segment optical coherence tomography (AS-OCT) to visualize internal bleb microstructure and objectively quantify dimensions of the scleral flap and trabeculo-Descemet window (TDW) in non-penetrating glaucoma filtration surgery (GFS). This was a cross-sectional study of 107 filtering blebs of 67 patients who had undergone deep sclerectomy surgery at least 12 months prior. The mean post-operative follow-up duration was 6.5 years +/- 4.1 [standard deviation (SD)]. The maximal bleb height was significantly greater in the complete success (CS) blebs compared to the qualified success (QS) and failed (F) blebs (1.48 vs. 1.17 vs. 1.10 mm in CS vs. QS vs. F, one-way ANOVA, p < 0.0001). In a subcohort of deep sclerectomy blebs augmented by intraoperative Mitomycin-C, the trabeculo-Descemet window was significantly longer in the complete success compared to the qualified success group (613.7 vs. 378.1 vs. 450.8 µm in CS vs. QS vs. F, p = 0.004). The scleral flap length, thickness, and width were otherwise similar across the three outcome groups. The quantification of surgical parameters that influence aqueous outflow in non-penetrating GFS can help surgeons better understand the influence of these structures on aqueous outflow and improve surgical outcomes.

Evaluation of New and Preexisting Epiretinal Membranes Following Glaucoma Filtration Surgery

Secondary epiretinal membranes (ERMs) can develop from various causes, including those associated with glaucoma treatments such as trabeculectomy (TLE) and EX-PRESS (EXP) insertion surgery. This study aimed to investigate the occurrence of new ERMs and changes in preexisting ERMs following TLE or EXP insertion. Between April 2018 and March 2019, 102 and 74 eyes that underwent primary and standalone TLE and EXP insertion, respectively, were evaluated. Of these, 48 eyes were included in the TLE group and 32 eyes were included in the EXP group. Optical coherence tomography (OCT) was used to assess preoperative and postoperative ERMs. In the TLE group, postoperative ERMs were observed in one (case 1) (3%) out of 34 eyes without preexisting ERMs and in one (case 2) (7%) out of 14 eyes with preexisting ERMs, showing an increase in ERM stage. In the EXP group, postoperative ERMs were observed in one (case 3) (5%) out of 22 eyes without preexisting ERMs and in one (case 4) (10%) out of 10 eyes with preexisting ERMs, showing a decrease in the ERM stage. Case 1 was a 58-year-old man with primary open-angle glaucoma (POAG) in the left eye who underwent TLE. Although no preoperative ERMs were observed, postoperative ERM was noted at the three-month follow-up. Case 2 was a 49-year-old man with POAG in the right eye who underwent TLE. Although ERM was observed preoperatively, ERM progressed at six months postoperatively. Case 3 was a 59-year-old woman with POAG in the right eye who underwent EXP insertion. No preoperative ERMs were observed, but an ERM was noted at the 15-month follow-up. Case 4 was a 72-year-old woman with steroid-induced glaucoma in the right eye who underwent EXP insertion surgery. A preoperative ERM was present, and the foveal pit was absent; however, the foveal pit was observed at the 12-month follow-up. Despite the low incidence of ERMs, filtration surgery may be associated with ERM development and the progression or regression of preexisting ERMs.

Toxic anterior segment syndrome following trabeculectomy with mitomycin C

Objective

Toxic anterior segment (TASS) is a rare acute sterile anterior segment inflammation that typically develops within 12 to 24 hours after an anterior segment surgery. The purpose of this case report is to alert surgeons to the possibility of this complication following any anterior segment surgery, including trabeculectomy, and to highlight the possible etiologies and measures to prevent it.

Patient and method

A 58-year-old male glaucoma patient was initially managed medically for primary open angle glaucoma with antiglaucoma medications. There was rapidly progressive glaucomatous optic nerve damage in his left eye within the following year, despite the use of antiglaucoma medications, hence the need for trabeculectomy.

Result

The post-operative condition of the patient's eye was stormy with diffuse limbus-to-limbus corneal edema and profound Descemet's membrane folds, among other features of TASS, with associated deteriorating visual acuity.

Conclusion

Although there is no documented report of TASS following trabeculectomy with mitomycin C, surgeons should be alerted to this possibility. Preventive measures include extreme care to avoid errors while preparing and administering diluted solutions, especially medications that are administered into the intracameral space.

Recurrence of gigantic overhanging bleb post excision: a case report

Purpose

To report the case of an extremely large overhanging bleb, extending from superior fornix to limbus, in a 57-year-old poorly controlled diabetic, six years after trabeculectomy for an uncontrolled primary open angle glaucoma (POAG) with recurrence, months after complete excision.

Methods

An overhanging bleb is defined as a filtering cicatrix which has been massaged downward over the cornea by eyelid action. It has been linked to anti-metabolite use during glaucoma filtering surgery. Despite being functional, these blebs result in patient discomfort ranging from foreign body sensation and lacrimation to dysphotopsia. A 57-year-old male presented with complaints of reduced vision, foreign body sensation, watering, and difficulty in eye closure in the left eye (OS) for past 6 months. He had undergone trabeculectomy with mitomycin C 6 years ago for advanced primary open-angle glaucoma with no follow-up beyond the initial one 4 weeks post-surgery.

Results

At presentation, he had a giant multi-loculated, cystic filtering bleb (15 mm x 8 mm x 4-5 mm), which was carefully excised. Amniotic membrane was used as an anti-fibrotic as well to cover the defect. Seven months after surgery, there was recurrence of this overhanging cystic bleb when it was again excised with debulking of the conjunctiva done and cryotherapy applied to its margins.

Conclusion

Although multiloculated cystic overhanging blebs have been documented before, such a large (posterior extent till fornix), thick-walled multiloculated bleb with histopathological evidence of chronic inflammatory process has not been reported prior.

Recent Advancements in Glaucoma Surgery-A Review

Surgery has long been an important treatment for limiting optic nerve damage and minimising visual loss in patients with glaucoma. Numerous improvements, modifications, and innovations in glaucoma surgery over recent decades have improved surgical safety, and have led to earlier and more frequent surgical intervention in glaucoma patients at risk of vision loss. This review summarises the latest advancements in trabeculectomy surgery, glaucoma drainage device (GDD) implantation, and minimally invasive glaucoma surgery (MIGS). A comprehensive search of MEDLINE, EMBASE, and CENTRAL databases, alongside subsequent hand searches-limited to the past 10 years for trabeculectomy and GDDs, and the past 5 years for MIGS-yielded 2283 results, 58 of which were included in the final review (8 trabeculectomy, 27 GDD, and 23 MIGS). Advancements in trabeculectomy are described in terms of adjunctive incisions, Tenon's layer management, and novel suturing techniques. Advancements in GDD implantation pertain to modifications of surgical techniques and devices, novel methods to deal with postoperative complications and surgical failure, and the invention of new GDDs. Finally, the popularity of MIGS has recently promoted modifications to current surgical techniques and the development of novel MIGS devices.

Short-Term Outcomes of Trabeculectomy With or Without Anti-VEGF in Patients With Neovascular Glaucoma: A Systematic Review and Meta-Analysis

Objectives

The aim of this study was to compare the safety and efficacy of trabeculectomy alone or combined with intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents for the treatment of neovascular glaucoma.

Methods

We conducted a systematic review and meta-analysis to compare the effects of trabeculectomy alone or combined with intravitreal injections of anti-VEGF agents for the treatment of neovascular glaucoma. We searched four databases (PubMed, Cochrane Library, Embase, and Web of Science) up to January 2023 and extracted data on three surgical outcomes: postoperative intraocular pressure, success rate and complications. We used a random-effects model to calculate pooled relative risk (RR) or standardized mean difference (SMD) estimates and 95% confidence intervals (CIs). We assessed publication bias using Begg and Egger tests.

Results

We included seven studies with 353 eyes. Compared to trabeculectomy alone, trabeculectomy with anti-VEGF had a lower risk of postoperative complications (RR, 0.60; 95% CI, 0.41-0.89) and higher success rate (RR, 1.19; 95% CI, 1.02-1.40). The intraocular pressure reduction was significantly greater in the trabeculectomy with anti-VEGF augmentation group than the trabeculectomy group from 1 week (SMD, -1.36; 95% CI, -2.76 to 0.04) to 6 months (SMD, -0.79; 95% CI, -1.50 to -0.07) after surgery.

Conclusions

According to current evidence, adding intravitreal injection of anti-VEGF agents to trabeculectomy may improve the short time outcomes of patients with neovascular glaucoma.

Clinical Factors Impacting Outcomes From Failed Trabeculectomy Leading to Glaucoma Drainage Device Implantation and Subsequent Penetrating Keratoplasty

PRCIS

We evaluated the factors that impacted time from glaucoma drainage implant (GDI) surgery to penetrating keratoplasty (PK) in eyes with previously clear corneas (ie, GDI-first sequence), and that specifically underwent a trabeculectomy before GDI surgery for intraocular pressure (IOP) control.

PURPOSE

To describe through an event-triggered data collection method the clinical course and the long-term outcomes of 2 procedures that are commonly performed sequentially in complex clinical situations: GDI surgery and PK. The study investigates the clinical factors associated with the progression to PK and determines the GDI success rate and graft survival.

METHODS

A single, tertiary-care center retrospective interventional cases series including patients with a sequential history of trabeculectomy, GDI surgery, and PK from 1999 to 2009. Outcome measures included IOP, visual acuity, graft failure, GDI failure, and time from GDI to PK.

RESULTS

Of the eyes, 56% had primary open angle glaucoma. The time from the last trabeculectomy to GDI was 66.5 ± 66.7 months. Of the eyes, 84% received a Baerveldt GDI. Time from GDI to PK was 36.4 ± 28.4 months. IOP at the time of PK was between 5 mm Hg and 21 mm Hg in 90% of eyes. At the last follow-up, 48% of grafts were clear. At 5 years post-PK, 33% of corneal grafts remained clear, whereas 81% of tubes remained functional.

CONCLUSIONS

Nearly half of the corneal grafts are clear at the last long-term follow-up. Graft failure occurs at a higher rate than tube failure suggesting that IOP control is only one and possibly not the most important factor in graft survival in eyes with prior glaucoma surgery.

Two Year Outcomes of Trabeculectomy in Cytomegalovirus Anterior Uveitis with Uncontrolled Intraocular Pressure

PURPOSE

To describe the two-year outcome of trabeculectomy in cytomegalovirus(CMV) anterior uveitis(AU).

METHODS

Records of 29 eyes of 29 consecutive CMV AU patients undergoing MMC-augmented trabeculectomy for uncontrolled IOP despite maximal tolerated topical medications were retrospectively reviewed. Treatment success was defined as IOP≤21 mmHg with same or reduced number of IOP-lowering medications compared to baseline, without systemic acetazolamide or further interventions for uncontrolled IOP.

RESULTS

Treatment success was 79.3% (23/29) at 24 months. Both median IOP and number of IOP-lowering medications dropped significantly from baseline (p < .01 and p < .001, all time-points, Wilcoxon sign-rank test, respectively), with 63.2% and 19.0% reduction in AU relapse/year and steroid use(p = .001 and 0.03, respectively), without sight-threatening sequelae. At 24 months, AU frequency was not significantly different between successful cases with and without ≥12-month use of topical ganciclovir (p = .51, Mann-Whitney U test).

CONCLUSION

MMC-augmented trabeculectomy was efficacious for IOP control in nearly 80% of CMV AU cases over two years.

Treatment of filtration bleb dysfunction after glaucoma surgery by needle revision of filtration bleb combined with conbercept

Filtration surgery (Trabeculectomy) is the main treatment for glaucoma. The scarring of the filtration bleb and obstruction of the outflow of aqueous humor through the filtration channel are the main reasons of the surgery failure. The objective of this study was to determine the clinical efficacy of needle revision of filtration blebs combined with subconjunctival injection of conbercept on the functional bleb formation in glaucoma patients with eye pressure out of control after trabeculectomy. A total of 48 eyes with poor filtration bleb function after trabeculectomy for glaucoma were treated with needle revision of filtration bleb combined with subconjunctival injection of conbercept. After the treatment, the patients were followed up for 3 months during which visual acuity, intraocular pressure, slit lamp and ultrasound biomicroscope examinations were performed. Intraoperative and postoperative complications were recorded. The visual acuity and intraocular pressure were significantly improved after the needle revision of filtration blebs. Among the 48 eyes, 39 eyes still had functional blebs at the end of the follow-up period, and filtration blebs failed in 9 eyes 2 to 8 weeks after the removal of the needle. The survival rate of filtration blebs at 3 months after needle revision was (79.06 ± 3.42%), and 81.25% (39/48) of the eyes showed good formation rate of functional bleb at the last follow-up. Three months after needle revision, there was local scar formation in some filtration blebs. Part of the filtration blebs showed mild thickening of the local subconjunctival tissue, and the filtration bleb was slightly raised and diffuse, showing a multi-cavity and thin-walled shape in some blebs. Ultrasound biomicroscopy examination showed relative structural manifestations. Subconjunctival hemorrhage occurred in 43 patients during and after the operation. Low intraocular pressure occurred in 8 patients with the lowest pressure of 5 mm Hg. Choroidal edema was observed in 3 patients. Five patients had intraoperative conjunctival hemorrhage in the anterior chamber, and hyphema occurred. All complications were self-limited and resolved without surgical intervention. Needle revision of filtration bleb combined with anti-VEGF drugs is a safe and effective method for the treatment of filtration bleb dysfunction after surgery of glaucoma.

Influence of Trabeculectomy with Mitomycin C on Longitudinal Changes in the Visual Field in Glaucoma Patients with High Myopia

Purpose

To evaluate the effect of trabeculectomy (Trab MMC) on visual field (VF) progression in eyes with glaucoma and high myopia.

Patients and Methods

Patients diagnosed with primary open-angle glaucoma or exfoliation glaucoma who underwent Trab MMC as the first glaucoma surgery along with ≥3 VF tests preoperatively and postoperatively were enrolled. High myopia was defined as an axial length ≥26.5 mm. Postoperative reductions in intraocular pressure (IOP) were assessed by survival analysis using IOP measurements obtained preoperatively. The longitudinal trends of the outcome measures were evaluated using linear mixed models.

Results

Thirty-five eyes of 32 patients were included in this study, including 22 eyes of 20 patients in non-highly myopic group and 13 eyes of 12 patients in highly myopic group. IOP decreased after Trab MMC, and the survival rate did not differ significantly in relation to axial length. Linear mixed-model analyses suggested that the inhibitory effects of Trab MMC on the rate of mean deviation (MD) changes were significant in the non-highly myopic group (-0.53 ± 0.15 dB/year preoperatively to -0.16 ± 0.13 dB/year postoperatively; P = 0.004), but not in the highly myopic group (-0.66 ± 0.19 dB/year preoperatively to -0.48 ± 0.18 dB/year postoperatively; P = 0.32).

Conclusion

Trab MMC reduced IOP in both highly myopic and non-highly myopic eyes, and IOP reduction was very similar in both groups. The VF deterioration rate decreased in both groups, but the change was weaker and nonsignificant in the highly myopic group.

Effectiveness and Safety of Xen Gel Stent in Glaucoma Surgery: A Systematic Review of the Literature

Although topical medical therapy and selective-laser-trabeculoplasty represent the treatments of choice to reduce intraocular pressure, many patients do not achieve adequate glaucoma control; therefore, they require further options and eventually surgery. Trabeculectomy is still considered the gold standard, but the surgical management of glaucoma has undergone continuous advances in recent years, XEN-gel-stent has been introduced as a safer and less traumatic means of lowering intraocular pressure (IOP) in patients with open-angle glaucoma (OAG). This study aimed to review the effectiveness and safety of clinical data on XEN-stent in OAG patients with a Synthesis-Without-Meta-analysis (SWiM) methodology. A total of 339 studies were identified following a literature search adhering to PRISMA guidelines and, after evaluation, 96 studies are discussed. XEN63 and XEN45 device data were collected both short and long term. In addition, this document has evaluated different aspects related to the XEN implant, including: its role compared to trabeculectomy; the impact of mitomycin-C dose on clinical outcomes; postoperative management of the device; and the identification of potential factors that might predict its clinical outcomes. Finally, current challenges and future perspectives of XEN stent, such as its use in fragile or high myopia patients, were discussed.

Posterior scleral application of a mitomycin C-soaked sponge during trabeculectomy

AIM

To evaluate the safety and efficacy of posterior scleral application (a modified technique) of an antimetabolite mitomycin C-soaked sponge in trabeculectomy for patients with glaucoma.

METHODS

This retrospective study included 101 patients (115 eyes) with glaucoma (aged 12-83y) who underwent trabeculectomy using a modified mitomycin C-soaked sponge placement method. A piece of 3.5×10 mm2 sponge was placed vertically and posteriorly with the long side perpendicular to the limbus. The mitomycin C concentration and exposure time were 0.2-0.5 mg/mL and 1-5min, respectively. Intraocular pressure, best-corrected visual acuity, and hypotensive medications were recorded at baseline and at the final visit. Complications, interventions required, and bleb morphology were recorded postoperatively. The primary outcome was trabeculectomy safety, including complications and bleb morphology; the secondary outcome was the trabeculectomy success rate.

RESULTS

At the final follow-up [median 28mo, range 7-67mo and interquartile range (IQR) 13mo], the qualified (cumulative) success rate was 93.0% and the complete success rate was 60.0%. No bleb-related complications were observed. The mean height, extent, and vascularity grades were 0.6±0.9, 1.1±0.4, and 2.4±0.9, respectively. All Seidel tests were negative. The mean posteriority grade was 0.8±0.4.

CONCLUSION

Trabeculectomy with the long side of a mitomycin C-soaked sponge placed perpendicular to the corneal limbus is safe and effective.

A comparative study on surgical outcomes of trabeculectomy with and without anti-metabolites in juvenile open-angle glaucoma

Purpose

To compare the surgical outcomes of trabeculectomy with and without anti-metabolites in patients with juvenile open-angle glaucoma (JOAG).

Methods

This retrospective comparative case series included 98 eyes of 66 patients with JOAG who underwent either trabeculectomy without anti-metabolites (group A, n = 53 eyes) or with anti-metabolites (group B, n = 45 eyes) with a minimum of 2 years follow-up. The main outcome measures were intra-ocular pressure (IOP), number of glaucoma medications, visual acuity, additional surgical interventions, surgical complications, and risk factors for failure. Surgical failure was defined as IOP >18 mmHg or failure to reduce IOP by <30% from the baseline value or IOP ≤5 mmHg or re-operation for refractory glaucoma or a complication or loss of light perception vision.

Results

The mean post-operative IOP reduced significantly from baseline at all post-operative visits until 6 months and thereafter. The cumulative probability of failure at 2 years was 28.7% in group A [95% confidence interval (CI) = 17.6-44.8%] and 29.1% in group B (95% CI = 17.1-46.7%) (P = 0.78). Surgical complications occurred in 18 eyes (34%) in group A and 19 eyes (42%) in group B. Re-operations for glaucoma or complications were performed in two eyes (3.8%) in group A and two eyes (4.4%) in group B. Cox-hazard regression model revealed male gender (HR = 0.29; P = 0.008), baseline high IOP (HR = 0.95; P = 0.002), and an increased number of pre-operative glaucoma medications (HR = 2.08; P = 0.010) as significant factors associated with failure.

Conclusion

: Our study results on trabeculectomy in JOAG revealed a success of 71% in both groups at 2 years follow-up. There was no significant difference in success or failure rates between the two groups. The risk factors for poor surgical outcome in JOAG were male gender, baseline high IOP, and an increased number of glaucoma medications.

Trabeculectomy Vs Non-penetrating Deep Sclerectomy for the Surgical Treatment of Open-Angle Glaucoma: A Long-Term Report of 201 Eyes

Introduction

Glaucoma is the second leading cause of vision loss worldwide. The reduction of intraocular pressure remains the backbone of its therapy. Among surgical techniques for its treatment, deep non-penetrating sclerotomy is the most widely practiced non-penetrating surgery. The purpose of this study was to evaluate the long-term efficacy and safety of deep non-penetrating sclerotomy compared to standard trabeculectomy in patients with open-angle glaucoma.

Patients and methods

Retrospective study including 201 eyes with open-angle glaucoma. Closed-angle and neovascular cases were excluded. Absolute success was considered when intraocular pressure under 18 mmHg, or a reduction of at least 20% in patients with a baseline intraocular pressure below 22 mmHg, was obtained after 24 months, without the use of medication. Qualified success was considered when those targets were met with or without the use of hypotensive medication.

Results

Deep non-penetrating sclerectomy showed a slightly lower long-term hypotensive effect compared to standard trabeculectomy, with significant differences at 12 months, but not at 24 months of follow-up. The absolute and qualified success rates were 51.85% and 65.43% for the trabeculectomy group and 50.83% and 60.83% for the deep non-penetrating sclerectomy, without significant differences. Regarding postoperative complications, mainly due to postoperative hypotonia, or related to the filtration bleb, they were significantly different between groups, with 10.8% and 24.7%, in deep-nonpenetrating sclerectomy and trabeculectomy groups, respectively.

Conclusion

Deep non-penetrating sclerectomy seems to be an effective and safe surgical option for patients with open-angle glaucoma unable to be controlled by non-invasive strategies. Data suggests that the intraocular pressure-lowering effect of this technique may be marginally lower than that of trabeculectomy, but the achieved efficacy outcomes were similar, with a significantly lower risk of complications.

An overview and update of CO2 laser‑assisted sclerectomy surgery in primary open angle glaucoma (Review)

Glaucoma is the second leading cause of blindness worldwide. The proportion of cases of primary open-angle glaucoma (POAG) in China is gradually increasing. Glaucoma surgery has become more effective, safer, minimally invasive and personalized over the years. CO₂ laser-assisted sclerectomy surgery (CLASS) is a minimally invasive glaucoma treatment. CLASS has recently been used to gradually lower intraocular pressure (IOP) in patients with POAG, pseudocapsular detachment syndrome and secondary glaucoma. In this operation, precise ablation of dry tissue followed by photocoagulation and effective absorption of water and percolating aqueous humor using CO₂ laser are performed, and the IOP is lowered by the laser ablation of the deep sclera and the outer wall of the Schlemm's canal, facilitating the drainage of the aqueous humor. Compared with other filtering surgeries, CLASS has a shorter learning curve, lower technical difficulty and higher safety. The present study reviews the clinical application progress, safety and effectiveness of CLASS.

Suture manipulation post-trabeculectomy: A practical guide

Background

Trabeculectomy is the gold standard filtration surgery for diverting aqueous from anterior chamber to the subconjunctival space. More than the surgery, postoperative follow-ups and management of the blebs play a critical role in the long-term success. This video is aimed at showing the real-world management of blebs postoperatively.

Purpose

This video will serve as a practical guide to the postoperative management of trabeculectomy blebs with specific focus on the suture manipulation.

Synopsis

This video will demonstrate various suturing techniques of trabeculectomy and their manipulation in the postoperative period. Complications related to each will be discussed.

Highlights

We demonstrate how to place and remove, releasable, and fixed sutures. We also address the practical points on why and when to remove the sutures. Suture-related complications and their management have been shown along with practical examples.

Video Link

https://youtu.be/2WFQJAPyOvY.

Clinical value of anterior segment optical coherence tomography‑assisted Wuerzburg bleb classification system for bleb assessment following trabeculectomy

The Wuerzburg bleb classification system (WBCS) is an established tool for evaluating filtering blebs, while anterior segment optical coherence tomography (ASOCT) provides detailed information on inner bleb structure. The present study aimed to investigate the clinical value of ASOCT-assisted WBCS following trabeculectomy (TRAB). The present prospective, observational study included eyes that underwent TRAB. Bleb assessments using the WBCS were based on the image acquired by ASOCT. The WBCS scores were assessed at postoperative week 2 and postoperative month (POM) 1, 2, 3, 6 and 12. The surgical outcomes at 1 year were determined as success or failure. Spearman's analysis explored the correlation of WBCS scores with intraocular pressure (IOP) and surgical outcome. A total of 32 eyes from 32 patients were included in the present study. The WBCS total score significantly correlated with IOP at POM 1, 2, 3, 6 and 12 (P<0.05). For single parameters, microcysts demonstrated a good correlation with IOP at POM 1, 2, 3, 6 and 12 (P<0.05). The WBCS total score correlated well with surgical outcome at POM 2, 3, 6 and 12 (P≤0.005). Microcysts, vascularity and encapsulation significantly correlated with surgical outcomes (P<0.05). The results of the present study suggest that ASOCT-assisted WBCS is a simple and effective measurement system for blebs after TRAB in clinical practice, which correlates well with IOP and surgical outcomes. Blebs with a higher WBCS total score and microcysts score in the early postoperative period, such as at POM 2 and 3, are less likely to have surgical failure in the long term.

Glaucoma in Uveitic Eyes: Long-Term Clinical Course and Management Measures

BACKGROUND

The management of glaucoma in uveitis is challenging. A meticulous combination of anti-glaucoma and anti-inflammatory agents is often needed to control the intraocular pressure (IOP) and preserve the visual status in an otherwise blinding disease.

AIM

To study the clinical course and management of glaucoma in uveitic eyes.

METHODS

A retrospective study analyzing the case records of patients over 12 years, referred for the management of uveitic glaucoma in the last two decades.

RESULTS

The analysis of 582 uveitic glaucoma eyes of 389 patients was done, and the mean IOP at baseline was 25.89 (±13.1) mmHg. Non-granulomatous uveitis (102 eyes) was the most common diagnosis. Granulomatous uveitis was the most common diagnosis among the treatment failure eyes and in eyes requiring more than one surgical intervention for glaucoma.

CONCLUSION

An appropriate and adequate combination of anti-inflammatory and IOP-lowering therapy will lead to better clinical outcomes.

A retrospective study to assess visual field improvement following augmented trabeculectomy

Purpose

To explore the visual field (VF) changes two years following augmented trabeculectomy.

Methods

A retrospective study of patients who underwent augmented trabeculectomy surgery with mitomycin C by a single surgeon at East Lancashire Teaching Hospitals NHS Trust over 3 years. Patients with a minimum of two years postoperative follow-up were included. Baseline characteristics, intraocular pressure (IOP), VF, number of glaucoma medications, and complications were recorded.

Results

In total, 206 eyes were included, 97 (47%) patients were female, and the mean age was 73.8 ± 10.3 (range 43 to 93) years. One hundred thirty-one (63.6%) eyes were pseudophakic before trabeculectomy. The patients were divided into three outcome groups according to VF outcome. Seventy-seven (37.4%) patients had stable VF, 35 (17.0%) patients showed VF improvement, and 94 (45.6%) had VF deterioration. The overall mean preoperative IOP was 22.7 ± 8.0 mmHg and postoperative IOP 10.4 ± 4.2 mmHg, with a reduction of 50.2% (P < 0.001). In total, 84.5% of postoperative patients did not require glaucoma medications. A higher number of patients with postoperative IOP ≥15 mmHg had deteriorating VF (P < 0.001). Based on preoperative MD distribution, VF improvement or stability was more achievable with patients with a preoperative VF defect up to -12 dB (n = 41, 59.4%) and in those with greater than -24 dB (n = 25, 64.1%).

Conclusion

Trabeculectomy continues to be an effective means of lowering IOP in patients with uncontrolled glaucoma and is important in stabilizing or improving visual fields. We recommend early trabeculectomy to prevent further VF deterioration. This may help in maintaining VF for driving status and, thus, quality of life.

Endoscopic cyclophotocoagulation for glaucoma compared to alternative procedures -A Systematic review

INTRODUCTION

Despite many recent developments, preference in the choice of surgical treatment of uncontrolled intraocular pressure (IOP) remains a challenge.

OBJECTIVE

This study compares the clinical efficacy and safety of endoscopic cyclophotocoagulation (ECP) to alternative surgical procedures, for all types of glaucoma.

METHODOLOGY

The methodology adheres to the preferred reporting items for systematic reviews and meta-analyses guidelines for systematic review reporting. Studies reporting ECP and alternative surgeries in treating refractory glaucoma, neovascular glaucoma, aphakic glaucoma, filtering surgical failure-induced glaucoma, congenital or juvenile glaucoma, and secondary glaucoma such as uveitis glaucoma, traumatic glaucoma, secondary glaucoma postcorneal transplantation, etc. were included. The efficacy was evaluated from the number of IOP-lowering drugs, and mean change in pre- and post-IOP were the outcomes assessed in ECP and non-ECP groups in this review. Evaluations of the postoperative complications revealed the safety assessment of the procedure.

RESULTS

In total, 11 relevant studies were selected in this study with a total of 5418 eyes, including 763 eyes in the ECP group and 4655 in the non-ECP group. This review observed that both ECP and non-ECP procedures had been successful in reducing postoperative IOP.

CONCLUSION

It can be deduced from this review, that all types of glaucoma can be treated efficiently with significantly higher success rates with ECP and ECP demonstrates lowest postoperative complications when compared to non ECP procedures. This review provides updated scientific evidence which caters to support clinical decisions for surgical treatment of glaucoma.

Unilateral chronic angle-closure glaucoma in a pediatric patient with neurofibromatosis: a case report

Neurofibromatosis type 1 (NF1) is an autosomal dominant genetic disease that causes multi-system damage. It is rarely associated with angle-closure glaucoma, especially in pediatric patients. We herein report a case of unilateral chronic angle-closure glaucoma in a patient with NF1. A 5-year-old girl with a large subcutaneous soft mass and multiple scattered coffee-milk spots presented with low vision, increased intraocular pressure, and angle closure in her right eye. Lisch nodules were seen in both eyes. In her right eye, ectropion uveae was observed at the top and bottom margins of the pupil. Magnetic resonance imaging of the skull and orbit revealed no abnormalities. Finally, trabeculectomy was performed on the right eye, after which the right eye showed a stable intraocular pressure. NF1 combined with angle-closure glaucoma is rare and easily missed in the clinical setting. Early diagnosis and treatment may achieve good results.

RETINAL TOXICITY FOLLOWING PRESUMED INADVERTENT INTRAOCULAR INJECTION OF MITOMYCIN C DURING TRABECULECTOMY

PURPOSE

To describe a case of postoperative retinal toxicity following the use of mitomycin C during a routine trabeculectomy.

METHODS

Case report of a single patient who underwent complete ophthalmic examination and multimodal imaging, including color fundus photos, optical coherence tomography, fundus autofluorescence, and fluorescein angiography. The study was declared exempt by the Institutional Review Board of Northwestern University. This research followed the tenets of the Declaration of Helsinki.

RESULTS

The patient developed profound vision loss and retinal damage during the postoperative course. Posterior segment findings include loss of vascular perfusion, diffuse loss of the outer, then inner, retinal layers, and subsequent total retinal detachment.

CONCLUSION

Although mitomycin C is commonly used in glaucoma filtering surgeries, reports of postoperative posterior segment toxicity are rare. The etiology of postoperative toxicity in this case is probable inadvertent intraocular injection of mitomycin C.

A 5-year retrospective study of intraocular pressure control after trabeculectomy: a retrospective cohort study

Glaucoma is a group of diseases that damage the optic nerve in the eye, resulting in vision loss and, in severe cases, blindness. The prevalence of glaucoma and glaucoma blindness is highest in West Africans.

Objective

The study presents a 5-year retrospective analysis of intraocular pressure (IOP) and complications after trabeculectomy.

Materials and methods

Trabeculectomy was performed using 5 mg/ml of 5-fluorouracil. A gentle diathermy was performed to secure hemostasis. Using a blade fragment of the scleral thickness, a 4×3 mm rectangular scleral flap was dissected. The central part of the flap was dissected 1 mm into the clear cornea. Before being tailed down, the patient was given topical 0.05% dexamethasone qid, 1% atropine tid, and 0.3% ciprofloxacin qid for 4-6 weeks. Patients with pain were given pain relievers, and all patients with photophobia were given sun protection. A successful surgical outcome was defined as a postoperative IOP of 20 mmHg or less.

Results

There were 161 patients over the 5-year period under review, with men constituting 70.2% of the total. Out of 275 eyes operated on, 82.9% were bilateral cases, while 17.1% were unilateral. Glaucoma was found in both children and adults aged 11-82 years. However, it was observed to predominate between the ages of 51 and 60, with males having the highest incidence. The average preoperative IOP was 24.37 mmHg, while it was 15.24 mmHg postoperatively. The complication with the highest ranking was shallow anterior chamber (24; 8.73%) due to overfiltration, followed by leaking bleb (8; 2.91%). The most common late complications were cataract (32; 11.64%) and fibrotic bleb (8; 2.91%). Bilateral cataracts developed at an average of 25 months after trabeculectomy. It was seen in patients aged 2-3 with a frequency of 9, whereas 5 years after, 77 patients had improved vision, with a postoperative visual acuity of 6/18-6/6.

Conclusion

Postoperatively, the patients had satisfying surgical outcomes as a result of the decrease in preoperative IOP. Although postoperative complications occurred, they had no effect on the surgical outcomes because they were temporary and not optically threatening. In our experience, trabeculectomy is an effective and safe procedure for achieving IOP control.

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.

Advances in Canaloplasty-Modified Techniques Yield Strong Pressure Reduction with Low Risk Profile

For decades, trabeculectomy (TE) was considered the gold standard for surgical treatment of open-angle glaucoma owing to its powerful intraocular pressure (IOP)-lowering potency. However, owing to the invasive nature and high-risk profile of TE, this standard is changing, and minimally invasive procedures are becoming more preferable. In particular, canaloplasty (CP) has been established as a much gentler alternative in everyday life and is under development as a full-fledged replacement. This technique involves probing Schlemm's canal with a microcatheter and inserting a pouch suture that places the trabecular meshwork under permanent tension. It aims to restore the natural outflow pathways of the aqueous humor and is independent of external wound healing. This physiological approach results in a significantly lower complication rate and allows considerably simplified perioperative management. There is now extensive evidence that canaloplasty achieves sufficient pressure reduction as well as a significant reduction in postoperative glaucoma medications. Unlike MIGS procedures, the indication is not only mild to moderate glaucoma; today, even advanced glaucoma benefits from the very low hypotony rate, which largely avoids a wipeout phenomenon. However, approximately half of patients are not completely medication-free after canaloplasty. As a consequence, a number of canaloplasty modifications have been developed with the goal of further enhancing the IOP-lowering effect while avoiding the risk of serious complications. By combining canaloplasty with the newly developed suprachoroidal drainage procedure, the individual improvements in trabecular facility and uveoscleral outflow facility appear to have an additive effect. Thus, for the first time, an IOP-lowering effect comparable to a successful trabeculectomy can be achieved. Other implant modifications also enhance the potential of canaloplasty or offer additional benefits such as the possibility of telemetric IOP self-measurement by the patient. This article reviews the modifications of canaloplasty, which has the potential to become a new gold standard in glaucoma surgery via stepwise refinement.

Factors Affecting the Incidence of Ptosis after Trabeculectomy

Objectives

The aim of this study was to investigate the incidence of postoperative ptosis after primary trabeculectomy and the possible factors contributing to ptosis.

Materials and Methods

A total of 312 patients (339 eyes) who underwent trabeculectomy with mitomycin-C between 2015 and 2020 were retrospectively evaluated. Patients who had regular follow-up for at least 6 months and no history of ptosis or ptosis surgery were included. Age, sex, glaucoma type, preoperative and postoperative intraocular pressure, preoperative and postoperative antiglaucoma medications, number of antiglaucoma drops, duration of antiglaucoma medication use, history of eye itching due to antiglaucoma medication-associated allergy, duration of follow-up, postoperative needling, needling time, and ocular massage were recorded. Ptosis was defined as ≥2 mm reduction in margin-reflex distance 1 from preoperative levels. Ptosis that had not improved for at least 6 months was considered persistent ptosis. Multivariate logistic regression was used to determine potential predictors of ptosis development.

Results

Ptosis after trabeculectomy was observed in 35 of 339 eyes (10.3%). Thirty eyes of 30 patients (8.8%) had transient ptosis and 5 eyes of 4 patients (1.5%) had persistent ptosis. Preoperative duration of antiglaucoma medication use, drug(s) used (prostaglandin analogs, beta-blockers, alpha-2 agonists, carbonic anhydrase inhibitors, or combinations of these), needling time, and ocular massage after trabeculectomy did not differ significantly between groups (p>0.05). Needling and eye itching due to antiglaucoma medication-associated allergy were significantly higher in patients with ptosis (p<0.05).

Conclusion

Ptosis after trabeculectomy is an important problem for glaucoma patients. It has been observed that needling and a history of eye itching due to antiglaucoma drug-associated allergy may increase the risk of ptosis.

One-Year Outcomes of PreserfloTM MicroShunt Implantation versus Trabeculectomy for Pseudoexfoliation Glaucoma

This retrospective, single-center study evaluates the safety and efficacy of Preserflo^TM MicroShunt (MicroShunt) implantations compared to trabeculectomies (TETs) in patients diagnosed with pseudoexfoliation glaucoma (PEXG). A total of 31 eyes from 28 patients received a MicroShunt implantation, and 29 eyes from 26 patients received a TET. Surgical success was defined as an intraocular pressure (IOP) between 5 mmHg and 17 mmHg at the end of the follow-up period, no need for surgical revisions or secondary glaucoma surgery, and no loss of light perception. In the MicroShunt group, the mean IOP dropped from 20.8 ± 5.9 mmHg at baseline to 12.4 ± 2.8 mmHg (p < 0.0001) after one year. In the TET group, the mean IOP dropped from 22.3 ± 6.5 mmHg to 11.1 ± 3.7 mmHg (p < 0.0001) after 12 months. In both of the groups, the mean number of medications was reduced significantly (MicroShunt from 2.7 ± 1.2 to 0.2 ± 0.7; p < 0.0001 vs. TET from 2.9 ± 1.2 to 0.3 ± 0.9; p < 0.0001). Considering the success rates, 83.9% of the MicroShunt eyes achieved complete success, and 90.3% qualified for success at the end of the follow-up period. In the TET group, the rates were 82.8% and 93.1%, respectively. The postoperative complications were comparable between both groups. In conclusion, the MicroShunt implantation demonstrated non-inferiority regarding its efficacy and safety profile compared to TET in PEXG at a follow-up of one year.

Clinical and Histopathological Effects of Intracameral Ranibizumab in Experimental Trabeculectomy

Post-surgical scarring is a known cause of trabeculectomy failure. The aim of this study was to investigate the effectiveness of ranibizumab as an adjuvant anti-scarring agent in experimental trabeculectomy. Forty New Zealand white rabbits were randomised into four eye treatment groups: groups A (control), B (ranibizumab 0.5 mg/mL), C (mitomycin C [MMC] 0.4 mg/mL), and D (ranibizumab 0.5 mg/mL and MMC 0.4 mg/mL). Modified trabeculectomy was performed. Clinical parameters were assessed on post-operative days 1, 2, 3, 7, 14, and 21. Twenty rabbits were euthanised on day 7, and the other twenty were euthanised on day 21. Eye tissue samples were obtained from the rabbits and stained with haematoxylin and eosin (H&E). All treatment groups showed a significant difference in IOP reduction compared with group A (p < 0.05). Groups C and D showed a significant difference in bleb status on days 7 (p = 0.001) and 21 (p = 0.002) relative to group A. H&E staining showed significantly low fibrotic activity (p < 0.001) in group C on both days and inflammatory cell grade in group B on day 7 (p < 0.001). The grade for new vessel formation was significantly low in groups B and D on day 7 (p < 0.001) and in group D on day 21 (p = 0.007). Ranibizumab plays a role in reducing scarring, and a single application of the ranibizumab-MMC combination showed a moderate wound-modulating effect in the early post-operative phase.

Evaluation of the ocular surface in asymptomatic glaucoma patients on topical medications and following trabeculectomy - A cross-sectional study

Purpose

This present prospective, cross-sectional study aims to comprehensively evaluate the ocular surface in asymptomatic patients with diffuse blebs after trabeculectomy versus chronic anti-glaucoma medication use and compare it with the age-matched normal population.

Methods

Objective clinical evaluation was done by tear film break-up time (TBUT) and Schirmer's test (ST) in the three groups-trabeculectomy >6 months with a diffuse bleb (Wurzburg bleb classification score ≧10), chronic anti-glaucoma medication (AGM >6 months) group, and normal population. In all groups, tear film osmolarity was checked with the TearLab_® device (TearLab Corp., CA, USA), and subjective evaluation was performed by administering Ocular Surface Disease Index (OSDI) questionnaire. Patients already on chronic lubricants or any other drug for the treatment of dry eyes (viz. steroids, cyclosporin) or having symptoms suggestive of an abnormal ocular surface, who had undergone refractive or intraocular surgery, and contact lens users were excluded.

Results

In total, 104 subjects/eyes were recruited over 6 weeks. Thirty-six eyes recruited in the trab group were compared with 33 eyes studied in the AGM group, and both these groups were compared to 35 normal eyes. When compared to normals, TBUT and ST were significantly lower (P = 0.003 and 0.014) and osmolarity and OSDI were statistically significantly higher (P = 0.007 and 0.003) in the AGM group, whereas only TBUT was statistically significantly different (P = 0.009) when the trab group was compared to normals. Also, when the trab group was compared to the AGM group, ST was found to be higher (P = 0.003) and osmolarity was lower (P = 0.034).

Conclusion

To conclude, ocular surface is affected even in asymptomatic patients on AGM but near normalcy is possible following trabeculectomy when blebs are diffuse.

Controversies in Pediatric Angle Surgery and Secondary Surgical Treatment

Pediatric glaucoma is a constellation of challenging ophthalmic conditions that, left untreated, can result in irreversible vision loss. The mainstay of treatment for primary congenital glaucoma and select secondary glaucoma subtypes is angle surgery, either trabeculotomy or goniotomy. More recently, MIGS devices have been utilized to enhance the efficacy of these procedures. Despite the high success rates of these primary surgical options, refractory cases are challenging to manage. There is no consensus on the next step of treatment following primary angle surgery. Glaucoma drainage devices and trabeculectomies have been the traditional options, with laser treatment reserved for more severe cases. The benefits and disadvantages of each of these options are discussed.

Device-modified trabeculectomy for glaucoma

BACKGROUND

Glaucoma is an optic neuropathy that leads to visual field defects and vision loss. It is the second leading cause of irreversible blindness in the world. Treatment for glaucoma aims to reduce intraocular pressure (IOP) to slow or prevent further vision loss. IOP can be lowered with medications, laser, or incisional surgery. Trabeculectomy is a surgical approach which lowers IOP by shunting aqueous humor to a subconjunctival bleb. Device-modified trabeculectomy techniques are intended to improve the durability and safety of this bleb-forming surgery. Trabeculectomy-modifying devices include the Ex-PRESS, the XEN Gel Stent, the PreserFlo MicroShunt, as well as antifibrotic materials such as Ologen, amniotic membrane, expanded polytetrafluoroethylene (ePTFE) membrane, Gelfilm and others. However, the comparative effectiveness and safety of these devices are uncertain.

OBJECTIVES

To evaluate the benefits and harms of different devices as adjuncts to trabeculectomy on IOP control in eyes with glaucoma compared to standard trabeculectomy.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search was August 2021.

SELECTION CRITERIA

We included randomized controlled trials in participants with glaucoma comparing device-modified trabeculectomy techniques with standard trabeculectomy. We included studies that used antimetabolites in either or both treatment groups.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. change in IOP and 2. mean postoperative IOP at one year. Our secondary outcomes were 3. mean change in IOP from baseline, 4. mean postoperative IOP at any time point, 5. mean best-corrected visual acuity (BCVA), 6. visual field change, 7. quality of life, 8. proportion of participants who are drop-free at one year, 9. mean number of IOP lowering medications at one year, and 10. proportion of participants with complications.

MAIN RESULTS

Eight studies met our inclusion criteria, of which seven were full-length journal articles and one was a conference abstract. The eight studies included 961 participants with glaucoma, and compared two types of devices implanted during trabeculectomy versus standard trabeculectomy. Seven studies (462 eyes, 434 participants) used the Ex-PRESS, and one study (527 eyes, 527 participants) used the PreserFlo MicroShunt. No studies using the XEN Gel Stent implantation met our criteria. The studies were conducted in North America, Europe, and Africa. Planned follow-up periods ranged from six months to five years. The studies were reported poorly, which limited our ability to judge risk of bias for many domains. None of the studies explicitly masked outcome assessment. We rated seven studies at high risk of detection bias. Low-certainty of evidence from five studies showed that using the Ex-PRESS plus trabeculectomy compared with standard trabeculectomy may be associated with a slightly lower IOP at one year (mean difference (MD) -1.76 mmHg, 95% confidence interval (CI) -2.81 to -0.70; 213 eyes). Moderate-certainty of evidence from one study showed that using the PreserFlo MicroShunt may be associated with a slightly higher IOP than standard trabeculectomy at one year (MD 3.20 mmHg, 95% CI 2.29 to 4.11). Participants who received standard trabeculectomy may have a higher risk of hypotony compared with those who received device-modified trabeculectomy, but the evidence is uncertain (RR 0.73, 95% CI 0.46 to 1.17; I² = 38%; P = 0.14). In the subgroup of participants who received the PreserFlo MicroShunt, there was a lower risk of developing hypotony or shallow anterior chamber compared with those receiving standard trabeculectomy (RR 0.44, 95% CI 0.25 to 0.79; 526 eyes). Device-modified trabeculectomy may lead to less subsequent cataract surgery within one year (RR 0.46, 95% CI 0.27 to 0.80; I² = 0%).

AUTHORS' CONCLUSIONS

Use of an Ex-PRESS plus trabeculectomy may produce greater IOP reduction at one-year follow-up than standard trabeculectomy; however, due to potential biases and imprecision in effect estimates, the certainty of evidence is low. PreserFlo MicroShunt may be inferior to standard trabeculectomy in lowering IOP. However, PreserFlo MicroShunt may prevent postoperative hypotony and bleb leakage. Overall, device-modified trabeculectomy appears associated with a lower risk of cataract surgery within five years compared with standard trabeculectomy. Due to various limitations in the design and conduct of the included studies, the applicability of this evidence synthesis to other populations or settings is uncertain. Further research is needed to determine the effectiveness and safety of other devices in subgroup populations, such as people with different types of glaucoma, of various races and ethnicity, and with different lens types (e.g. phakic, pseudophakic).

Surgical Glaucoma Treatment in Patients with Juvenile Idiopathic Arthritis-Associated Uveitis: Results after Trabeculectomy or Ahmed Glaucoma Valve Implantation

PURPOSE

Patients with juvenile idiopathic arthritis (JIA) associated uveitis (JIAU) are at risk for secondary glaucoma, frequently requiring surgical management. We compared the success rates for trabeculectomy (TE) and Ahmed glaucoma valve (AGV) implantation.

METHODS

We conducted a retrospective analysis of TE (45 eyes), primary AGV (pAGV) (7 eyes), or secondary AGV (sAGV) implantation after TE (11 eyes) in JIAU at the 2-year follow-up.

RESULTS

All groups achieved significant pressure reduction. After 1 year, the overall success rate was higher in the Ahmed groups (p = 0.03). After adjusting the p-value according to Benjamin Hochberg, there is no significant difference between the groups in the Kaplan-Meier, despite a significant logrank test between all groups (p = 0.0194) and a better performance in the Ahmed groups.

CONCLUSION

Slightly better success rates were achieved with pAGV in managing JIAU patients with glaucoma refractory to medical treatment.