Short- to intermediate-term surgical outcome of Keiki Mehta valve implantation in refractory glaucoma

BACKGROUND

Keiki Mehta body pressure (BP) valve is a glaucoma drainage device that works on the simple mechanism of body pressure.

PURPOSE

To evaluate the short- to intermediate-term efficacy and safety of Keiki Mehta valve implantation in treating refractory glaucoma.

METHODS

This was a prospective, interventional, institution-based study. Adult patients (age >18 years) having refractory glaucoma who underwent Keiki Mehta valve implantation from May 2019 to December 2019 in a tertiary hospital in eastern India were followed up to 18 months.

RESULTS

Twenty patients (20 eyes) with refractory glaucoma who underwent Keiki Mehta valve implantation were followed up on postoperative day 1 and at 1, 3, 6, 12, and 18 months postoperatively. Visual acuity, intraocular pressure (IOP), antiglaucoma medications, and success rate were measured at every visit. There was significant reduction in mean IOP from the preoperative values at every postoperative follow-up ( P < 0.05). Kaplan-Meier survival analysis demonstrated a probability of 50% complete success and 20% qualified success at 18 months. Hypotony was the most common postoperative complication.

CONCLUSION

Keiki Mehta valve implantation is an effective and safe treatment for refractory glaucoma.

The outcomes of diode laser transscleral cyclophotocoagulation in refractory primary angle-closure glaucoma in a South Indian population

BACKGROUND

The surgical intervention of refractory primary angle-closure glaucomas (PACGs) is a big challenge to any ophthalmologist since the efficacy of lens extraction in eyes with a long duration of angle closure is limited. Also, trabeculectomy in such eyes is not without vision-threatening complications.

PURPOSE

To evaluate the efficacy and safety of diode laser transscleral cyclophotocoagulation (CPC) in eyes with refractory PACG.

METHODS

A retrospective study analyzing all patients who underwent CPC for refractory PACG in the year 2019 was conducted. Out of the 68 patients recruited, 56 PACG patients fulfilled the study criteria.

RESULTS

The mean age of the participants was 58.5 years. The mean (standard deviation [SD]) intraocular pressure (IOP) at baseline was 38.91 (14.86) mmHg, and it ranged from 21 to 74 mmHg. Participants' mean (SD) follow-up duration was 11.87 (7.83) months. Almost 90.9% of eyes showed IOP reduction from baseline during the follow-up period. There was also a reduction in the mean antiglaucoma medications (AGM) to 2.67 (1.29) in the final follow-up visit compared to the baseline of 3.30 (0.81). Chronic hypotony was noted in four eyes, out of which phthisis bulbi occurred in one eye. Six eyes underwent additional incisional surgical procedures.

CONCLUSION

The outcomes from our study support the role of transscleral diode laser CPC in the interim optimization of IOP in PACG eyes refractory to other modalities. This is emerging as a primary treatment option to optimize IOP to safer limits before any planned incisional procedure. Though complications like chronic hypotony occur as anticipated, vision-threatening complications are rare.

Glaucoma drainage device implantation and cyclophotocoagulation in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty

AIM

To compare the surgical outcomes of glaucoma drainage device implantation (GDI) and trans-scleral neodymium:YAG cyclophotocoagulation (CPC) in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty (DSAEK).

METHODS

This retrospective study on observational case series enrolled 29 patients who underwent DSAEK and posterior anti-glaucoma surgery (15 with GDI and 14 with CPC). The main outcome measures were intraocular pressure (IOP), glaucoma surgery success rate (defined as IOP of 6-21 mm Hg without additional anti-glaucoma operation), number of glaucoma medications, endothelial graft status, and best-corrected visual acuity (BCVA).

RESULTS

The mean follow-up time was 34.1 and 21.0mo for DSAEK or glaucoma surgeries, both for the GDI and CPC groups. Both groups showed significant IOP reduction after glaucoma surgery. The GDI group presented a significantly higher success rate in IOP control than the CPC group (60% vs 21.4%, P=0.03). Both procedures significantly decreased the number of glaucoma medications (P=0.03). Forty percent and 57% of cases in the GDI and the CPC group, respectively, experienced endothelial graft failure during follow-up (P=0.36). Significantly worse BCVA after surgery was observed in the CPC group but not in the GDI group.

CONCLUSION

Both GDI and CPC significantly decrease IOP in eyes with glaucoma after DSAEK. GDI is preferable to CPC in refractory glaucoma cases after DSAEK, as it manifests a significantly higher success rate for IOP control, similar endothelial graft failure rate, and relatively preserves BCVA than CPC.

Inferior implant of XEN63 Gel stent in a refractory open-angle glaucoma due to silicone oil tamponade: A case report

BACKGROUND

To discuss the efficacy of an inferior implant of XEN 63 gel stent in a patient with refractory glaucoma after trabeculectomy failure and vitreoretinal surgery with silicone oil tamponade.

CASE DESCRIPTION

We report the case of a 73-year-old man with a history of refractory open glaucoma with trabeculectomy failure. He experienced recurrent retinal detachments with silicone oil tamponade, with uncontrolled intra-ocular pressure (IOP) after silicone oil removal. Due to the presence of oil emulsion in the anterior chamber, the chosen location for XEN 63 implantation was the infero-temporal quadrant. Mild hyphema and vitreous hemorrhage were seen post-operatively, but were self-limiting. At week 1, the intraocular pressure was 8 mmHg with a well-formed bleb seen in anterior segment optical coherence tomography (AS-OCT). At 6 month follow up, the patient maintained a IOP of 12 mmHg without topical hypotensive drugs. Slit lamp examination revealed a widespread, developed bleb with no signs of inflammation.

CONCLUSION

In this case of refractory glaucoma in a vitrectomized eye with previous oil tamponade, the inferior placement of the XEN 63 gel stent delivered an adequate intraocular pressure even at 6-months follow up, with a diffuse functional infero-nasal bleb seen with AS-OCT.

Intermediate-term outcome of Aurolab aqueous drainage implant in refractory glaucoma

PURPOSE

The purpose of the study was to evaluate the intermediate-term outcomes of Aurolab aqueous drainage implant (AADI) in terms of intraocular pressure (IOP) lowering from baseline levels, the number antiglaucoma medications (AGMs) in the postoperative phase, and the rate of complications.

METHODS

It was a retrospective interventional case series. All patients who underwent AADI surgeries with sulcus fixation from March 2018 to September 2018 at a tertiary eye care hospital in North India with a minimum follow-up of 1 year were recruited for the study. A standard AADI technique was employed. The primary outcome measures were the postoperative IOP, the requirement of AGMs, and early and late postoperative complications.

RESULTS

A total of 20 patients were recruited in the study. The mean follow-up period was 25.25 ± 3.76 months. The mean IOP reduced from 33.20 ± 7.95 mmHg to 19.45 ± 9.19 mmHg at day 1, 13.62 ± 3.92 mmHg at 6 months, 12.78 ± 3.36 mmHg at 1 year, and 13.0 ± 2.53 mmHg at 2 years postoperatively (P < 0.001). The mean number of AGMs also reduced from 3.7 ± 0.97 to 0.35 ± 0.81 at 6 months, 0.42 ± 0.83 at 1 year, and 0.26 ± 0.73 at 2 years postoperatively (P < 0.001). Early postoperative complications, such as hypotony and hyphema, were seen in 5 (25%) patients, although none of them was sight-threatening. Late postoperative complications, such as hypertensive phase and persistent fibrinous membrane, were also seen in five eyes.

CONCLUSION

The study assessed the clinical outcomes, safety profile, and long-term AGM requirement with AADI and found it to be a good viable surgical option in refractory glaucoma.

Aurolab aqueous drainage implant implantation made easy: A video-based step-by-step guide

Background

Glaucoma is one of the major causes of irreversible blindness in the world, with trabeculectomy still being the primary surgical modality for the management of glaucoma. Glaucoma drainage devices (GDDs) have been conventionally used for the treatment of refractory glaucoma and are found to be beneficial in eyes with prior unsuccessful filtration surgeries and primary choice of surgery in certain glaucoma. Aurolab aqueous drainage implant (AADI) is a nonvalved device useful in refractory glaucoma to achieve low intraocular pressure (IOP). The device has been commercially available in India since 2013 and is like the Baerveldt glaucoma implant in design and function. AADI being the most economical and effective GDD in controlling IOP is becoming a popular choice among ophthalmologist in developing countries. AADI surgery has steep learning curve due to large end-plate surface area which needs a rigorous conjunctival dissection, muscle hooking, meticulous plate fixations, and careful tube ligations and insertion. There are different techniques of performing AADI surgery, but the authors have tried to simplify the complex surgery for easy and catchable learning of the procedure by novice surgeon with their experience and have elaborated a step-wise most effective way of performing surgery.

Purpose

This video-based skill transfer depicts steps of AADI surgery with compilation of various modifications and authors' tips and tricks to novice surgeons.

Synopsis

This video depicts detailed steps of AADI surgery with micro-points and authors experience. Video also shows various tailor-made modifications of surgical techniques for different case scenarios.

Highlights

Steps of AADI surgery, modifications, and surgical pearls.

Video Link

https://youtu.be/vmVqBb2FvP4.

Long-Term Outcomes of Ahmed Glaucoma Valve Surgery in a Scottish Cohort of Patients With Refractory Glaucoma

Purpose The purpose of this study was to evaluate the long-term efficacy and safety profile of the Ahmed glaucoma valve (AGV) implantation in cases of refractory glaucoma. Methods We conducted a retrospective audit of patients that underwent AGV implantation between 2006 and 2017 by two glaucoma surgeons in a tertiary glaucoma centre (Glasgow, UK). Primary outcome measures included the post-operative intraocular pressure (IOP), number of glaucoma medications, best-corrected visual acuity, complications, re-operation rates, and failure (defined as IOP > 21 mmHg or not reduced by 20% from baseline, IOP ≤ 5 mmHg, reoperation for glaucoma, removal of implant, or loss of light perception) at pre-defined time points (years 1 to 8). Results A total of 111 eyes of 94 patients were identified with a mean follow-up of 48.5 months (SD: 31.5); 60.3% of eyes had undergone at least one previous glaucoma surgery. Mean presenting IOP was 31.7 mmHg (SD: 11.4), and it reduced to 13.9 mmHg (SD: 4.2) in year 5 and 16.3 mmHg in year 8 (p<0.05). The number of glaucoma medications reduced from 3.8 (SD: 1.4) to 2.4 (SD: 1.4) and 2.6 (SD: 1.4) in the above time points (p<0.05 except year 8). The five-year success rate was 65.2%, and the five-year reoperation rate was 37% excluding cataract surgery. The most common early complications were hyphaema (12.6%) and transient hypotony (8.1%), whereas the most common late complication was an encapsulated bleb (15.1%). Conclusions AGV implantation is an effective procedure for controlling IOP in the long term in cases of refractory glaucoma.

Short-term outcomes of micropulse transscleral cyclophotocoagulation as a primary versus additional therapy in eyes with uncontrolled glaucoma

Purpose

To study the safety and efficacy outcomes of Micropulse Transscleral Cyclophotocoagulation (MP-TSCPC) as a primary versus additional therapy in eyes with uncontrolled glaucoma.

Methods

This was a prospective, interventional, comparative study. All patients with advanced and refractory glaucoma treated with MP-TSCPC from April 2020 to December 2020 were recruited in this study.

Results

A total of 77 eyes of 77 patients were analyzed. Group A (n = 33), included patients with advanced glaucoma at high risk for invasive surgery, who underwent MP-TSCPC as the primary intervention, and group B (n = 44) included patients who had undergone previous surgical intervention and MP-TSCPC was used additionally to control the intraocular pressure (IOP). Mean IOP and mean number of antiglaucoma medications were 34.06 (13.9) mmHg and 3.64 (0.7), respectively, in group A and 35.61 (11.5) mmHg and 3.73 (0.9), respectively, in Group B. Postoperatively, the mean IOP and percentage of IOP reduction were significantly lower at 1, 3, and 6 months, that is, 20.78 (32%), 22.07 (30%), and 19.09 (37%), respectively, in group A and 23.68 (35%), 19.50 (44%), and 19.61 (42%), respectively, in group B, but there was no difference between the groups at all visits. Postoperative need for ocular hypotensive drugs did not differ in group A (P = 0.231); however, it was significantly lower in group B (P = 0.027). Group A had 87%, 77%, and 74% success rates at 1, 3, and 6 months, respectively, whereas group B had 91%, 86%, and 77% success rates at 1, 3, and 6 months, respectively. Postoperative complications and intervention did not reveal any statistical difference between the two groups.

Conclusion

MP-TSCPC may be considered as a temporizing measure both as a primary or as an additional intervention to control the IOP in eyes with refractory and advanced glaucoma that have a high risk of vision-threatening complications with invasive surgery.

Safety and efficacy of Aurolab aqueous drainage implant in refractory glaucoma: A prospective study

Purpose

This study was conducted to assess the intraocular pressure (IOP) control and postoperative complications following a non-valved glaucoma drainage device (GDD) surgery in refractory glaucoma.

Methods

This was a prospective interventional study conducted on patients with glaucoma refractory to maximal medications or failed surgical treatment who underwent Aurolab aqueous drainage implant (AADI; Aurolabs, India) surgery. Primary outcome measures were IOP control, postoperative complications, and reduction in the number of antiglaucoma medications (AGM).

Results

Thirty-four eyes were analyzed and the mean follow-up was 16.06 ± 5.63 months. The preoperative median (Q1, Q3) IOP was 31 mmHg (28, 36.5) which decreased to 12 mmHg (12, 14) at 6 months postoperatively. The median (Q1, Q3) number of AGMs decreased from 3 (3, 4) to 0 (0, 1). Significant complications like implant extrusion and tube exposure were noted in two eyes. The total success and failure rates at 6 months were 91.1% and 8.8%, respectively.

Conclusion

AADI is effective in achieving target IOP and significantly reduces the use of AGMs with good safety in the short term. Long-term follow-up studies are needed to assess long-term IOP control and cost-effectiveness.

Safety and Efficacy of the Preserflo® Microshunt in Refractory Glaucoma: A One-Year Study

Purpose: To evaluate the safety and efficacy of Preserflo^® microshunt implantation in eyes with refractory glaucoma. Methods: In this retrospective study, a cohort of patients who underwent Preserflo^® microshunt implantation between April 2019 and August 2020 for refractory glaucoma were evaluated. At the time of surgery, all eyes had uncontrolled intraocular pressure (IOP) despite maximally tolerated medical therapy and at least one previous failed glaucoma filtering surgery. The primary outcome was a complete success, defined as postoperative IOP ≤ 21 mm Hg with an IOP reduction ≥ 20% and no repeat filtering surgery. The secondary outcome was qualified success, defined as a complete success with the use of antiglaucoma medications. The rates of needling, bleb repair, and postoperative complications were also recorded. Results: Forty-seven eyes with a mean preoperative IOP of 30.1 ± 7.1 mm Hg and a mean of 3.4 ± 1 glaucoma medications were included. The mean number of previous surgeries prior to microshunt implantation was 2.3 ± 1.3. After 1 year, the mean IOP was significantly reduced to 18.8 ± 4.6 mm Hg, with the mean number of medications significantly reduced to 1.4 ± 1.2. Complete success was achieved in 35% of eyes, and a qualified success in 60% of eyes. A decrease in IOP of at least 30% was found in 55% of eyes. Needling or bleb repair was performed in 49% of eyes. Complications were minimal and transient, except for one eye which presented with tube extrusion, and another eye with a transected tube. A repeat glaucoma surgery had to be performed in 17% of eyes. Conclusions: The Preserflo^® Microshunt provided moderate success but a significant reduction in IOP, with a good safety profile after one year of follow-up in eyes at high risk for failure of filtering surgery.

A Case of Refractory Childhood Glaucoma Secondary to Weill-Marchesani Syndrome: Management with Combined CO2 Laser-Assisted Sclerectomy Surgery and Trabeculectomy

A 2-year-old girl was diagnosed as Weill-Marchesani syndrome with typical systemic features of short stature, short and stubby hands and feet, language disorders and mental retardation. He developed bilateral angle closure glaucoma, ectopia lentis and suffered visual loss from the ocular features of Weill-Marchesani syndrome. The child was successfully treated by combined CO2 laser-assisted sclerectomy surgery and trabeculectomy.

XEN® 63 gel stent to treat a refractory uveitic glaucoma: A case report

PURPOSE

To describe the effectiveness of the XEN^® 63 gel stent in a refractory uveitic glaucoma after failure of an Ahmed Glaucoma Valve.

CASE DESCRIPTION

We report the case of a 54-year-old man with a history of uveitic glaucoma on his left eye due to Fuchs heterochromic iridocyclitis and neovascular glaucoma after a central retinal vein occlusion. Pre-operative intraocular pressure was 30 mmHg despite a QD (once-daily) dosed bimatoprost 0.3 mg and timolol 5 mg topical medication. At week 1, the eye exam showed an intraocular pressure of 6 mmHg with a well-formed bleb, a very mild hyphema and a localized choroidal detachment. At month 1, intraocular pressure was 14 mmHg with a formed bleb. Both hyphema and choroidal detachments had resolved. After a year, intraocular pressure was 16 mmHg without any medication and the bleb was still well-formed.

CONCLUSION

The XEN^® 63 gel stent provides a good intraocular pressure reduction and can be an efficient alternative for tube and filtration surgery in refractory glaucoma. Its long-term effectiveness needs to be evaluated.

Pars Plana Ahmed Valve Implantation for Vitrectomized Eyes With Refractory Glaucoma

This study aimed to analyze the surgical outcomes of pars plana Ahmed valve implantation in vitrectomized eyes with refractory glaucoma. We performed a retrospective case review of consecutive patients with refractory glaucoma after undergoing pars plana vitrectomy who underwent pars plana Ahmed valve implantation between July 2019 and December 2020 at the glaucoma unit of the Affiliated Changshu Hospital of Xuzhou Medical University (Changshu, China). All the patients were followed up for ≥12 months postoperatively. We recorded pre- to postoperative changes in best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of anti-glaucoma medication, corneal endothelial count, and surgical complications, if any. There was a significant improvement in the median BCVA from 2.30 (0.87, 2.30) logMAR preoperatively to 1.70 (0.70, 2.30) logMAR at discharge and 1.0 (0.52, 1.85) at final examination (p = 0.011, p = 0.001). Compared with the preoperative IOP level, there was a significant decrease in the postoperative IOP at each postoperative time point (p < 0.001). There was a significant reduction in the median number of anti-glaucoma drugs (including postoperative ocular massage), from 3.00 (2.00, 3.00) preoperatively to 0.00 (0.00, 1.00) at the last follow-up postoperative examination (p < 0.001). A 29-year-old woman with proliferative diabetic retinopathy who underwent surgical treatment at 5 months postoperatively for fibrous wrapping formed around the plate of the Ahmed valve showed an IOP of 14 mmHg at the last follow-up. Our findings indicated that pars plana Ahmed valve implantation can be safely performed for managing vitrectomized eyes with refractory glaucoma.

Long-term outcome of supraciliary gold micro shunt in refractory glaucoma

Purpose

To evaluate the 10‐year follow‐up efficacy and safety of gold micro shunt (GMS) in patients with refractory glaucoma, and the potential risk factors for failure.

Methods

Retrospective data analyses based on medical records from 55 patients who underwent GMS implant for refractory glaucoma between March 2007 and April 2008. The primary outcome measure was the cumulative probability of success defined as intraocular pressure (IOP) below 21 mmHg together with a 33% lowering of the baseline IOP with (qualified) or without (complete) topical medications, no reoperation for glaucoma or loss of light perception.

Results

Mean IOP 10 years after the GMS implantation was 21.6 ± 5.1 mmHg with 2.7 ± 0.7 drugs. Qualified success was achieved in 8/55 patients (14.5%) with a mean of 2.9 ± 0.8 drugs at 5 years and in 2/55 patients (3.6%) with a mean of 2.7 ± 1.0 drugs at 10 years. None of the patients reached complete success at five years from surgery. The cumulative probability of complete success was 14%, 9% and 0% at 1, 2 and 5 years, respectively, and 72%, 67%, 36% and 3.6% at 1, 2, 5 and 10 years, respectively, for qualified success criterion. Baseline IOP for complete success, number of baseline medication for qualified success and age at the time of GMS implantation for both criteria were risk factors significantly associated with failure.

Conclusion

A very low long‐term survival rate of GMS in refractory glaucoma was found. Most patients did not reach the IOP success criteria of the study, even with the re‐introduction of medications, leading to the need for further surgical procedures.

Outcomes of trabeculectomy in eyes with refractory acute primary angle-closure in Indian eyes

Purpose:

To report the outcomes of trabeculectomy in eyes with refractory acute primary angle-closure attack.

Methods:

Patients with acute primary angle-closure attack and who underwent trabeculectomy for medically uncontrolled intraocular pressure within 2 months of presentation were retrospectively analyzed. Primary outcome was intraocular pressure (IOP). Secondary outcome measures were visual acuity, number of antiglaucoma medication (AGM), complications, and risk factors for failure of trabeculectomy.

Results:

Thirty-five eyes of 31 patients with median (interquartile range) follow-up of 3 (0.5, 9) years were included in the study. Median age at presentation was 55 (47, 60) years. Median duration of symptoms at presentation was 10 (4, 16) days and median time from presentation to surgery was 13 (6, 25) days. Median IOP reduced from 42 (36, 46) to 13 (12, 16) mmHg (P < 0.001) and median number of AGM reduced from 3 (1, 3) to 0 (0, 0) after trabeculectomy at the end of 1 year. The probability of complete and qualified success was 88% (95% confidence interval [CI]: 72%–95%) and was 97% (95% CI: 81%–99%) at 1 year, respectively. Failure was noted in six eyes. Subsequent cataract surgery was needed in 13 eyes (37%) with a median duration from trabeculectomy being 6.75 (1, 11) years. None of the preoperative, intraoperative, or postoperative factors tested were associated with failure (P > 0.10 for all associations on Cox proportional hazard regression analysis).

Conclusion:

In medically unresponsive cases of acute primary angle-closure attack, primary trabeculectomy seems safe and effective in Indian eyes.

[Technique for laser activation of scleral hydropermeability in the treatment of patients with refractory forms of glaucoma]

Laser cyclodestructive interventions are considered the method of choice in the treatment of refractory glaucoma. However, the traumatic nature of cyclocoagulation makes it necessary to search for more gentle methods of laser treatment. One of the possible directions is the development of laser transscleral technologies that mainly affect the uveoscleral outflow. This article presents a new technique for laser activation of scleral hydropermeability (LASH) using pulse-periodic erbium glass (Er-glass) fiber-optics laser with wave length of 1.56 μm. The article describes the parameters of laser emission and the technique of LASH, and presents the mechanism of reducing intraocular pressure associated with increased transcleral drainage of intraocular fluid by forming new pores in the sclera. The effectiveness and safety of LASH is supported by a detailed example from clinical practice. This technology has proven itself as a possible alternative to the conventional contact transcleral cyclocoagulation.

XEN Glaucoma Implant for the Management of Glaucoma in Naïve Patients versus Patients with Previous Glaucoma Surgery

This retrospective study analyzed the surgical and refractive outcomes of a XEN Gel Implant (Allergan, Abbvie Company, Irvine, CA, USA) in naïve patients versus those with previous glaucoma surgery. We evaluated the efficacy of XEN implantation in 86 glaucoma patients during a long-term follow-up period. Patients were divided into two groups: naïve patients (Group 1) and patients with previous glaucoma surgery (Group 2). Eyes that received a XEN Gel Stent placement from December 2014 to October 2019 were included. Intraocular pressure (IOP) change, corrected distance visual acuity (CDVA), change in glaucoma medications, frequency of slit lamp revision procedures, and frequency of secondary glaucoma surgeries were the primary outcomes. In Group 1, the mean IOP before surgery was decreased significantly from 25.00 ± 7.52 mmHg to 16.83 ± 5.12 mmHg by the end of the study. In Group 2, the mean IOP decreased significantly from 25.35 ± 7.81 mmHg to 17.54 ± 5.34 mmHg. The mean IOP decrease from baseline was 29% in Group 1 and 27% in Group 2 (p = 0.567). There were no significant differences between the groups in the IOP baseline level, the final level, or the change between preoperative and final levels. The qualified success rate for Group 2 was 68.7% versus 76.5% for Group 1 for the initial procedure and 15.4% vs. 20.2%, respectively, for complete success rate (p > 0.05). However, at the end of the follow-up, more patients achieved an IOP < 18 mmHg in Group 1 than in Group 2. Despite the need for more anti-glaucoma medications, repeat XEN Gel implantation appears to show promising results in patients with previously failed anti-glaucoma procedures, owing to its minimal invasiveness.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma

PURPOSE

Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion.

METHODS

A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures.

RESULTS

Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term.

CONCLUSION

Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.

A graft-free scleral sleeve technique of Ahmed Glaucoma Valve implantation in refractory glaucoma- Rising to the challenge of COVID-19 pandemic

We describe a case of 63-year-old woman, with primary open-angle glaucoma (POAG) who presented to us in the COVID era with uncontrolled intraocular pressure (IOP) on maximum medical therapy (MMT) in the right eye (OD), previously operated twice for trabeculectomy in (OD), and once in left eye (OS). A modified graft-free surgical technique of inserting the Ahmed Glaucoma valve (AGV) tube through a scleral sleeve was employed. Visual acuity and IOP remained stable during 6-month follow-up period.

Risk Factors for Failure in Double-Plate Tube Surgery for Refractory Glaucoma: 25 Years Surgical Experience

Purpose

To investigate risk factors associated with success and failure in double-plate tube surgery.

Methods

This retrospective case-series observational study included 243 consecutive eyes that underwent anterior-segment double-plate tube surgery from 1990 to 2015. Evaluation of the efficacy of the device was based on the final intraocular pressure (IOP) and the need for anti-glaucoma medication. We also assessed success and failure according to risk factors for trabeculectomy and an early hypertensive phase (HP).

Results

Preoperative IOP was 37.3±13.1 mmHg (mean±SD) with 3.0±0.7 medications. After a median follow-up of 44.3 months, the mean IOP was 14.6±6.3 mmHg with 0.4±1.0 medications. The final IOPs ranged from 6 to 21 mmHg in 87.24% of eyes; however, 25.47% required medication. No risk factors studied were associated with surgical failure. Preoperative IOP, glaucoma type, previous surgery, previous anti-glaucoma drugs, implant type, and HP were associated with partial success (p<0.05). HP and preoperative use of brimonidine reduced the probability of complete success by 66.9% and 68.2%, respectively (p<0.05). HP was more likely when chronic preoperative prostaglandin analogues were administered (odds ratio [OR] 4.286; 95% confidence intervals [CI] 1.593–11.529; P=0.0039) and when the tube was located in the posterior chamber (OR 3.561; 95% CI 1.286–9.861; P=0.0145).

Conclusion

Tube surgery is effective and seems to be independent of the major risk factors for glaucoma surgery. However, previous surgery and some chronic preoperative drugs are related to the need for glaucoma medication to achieve the target pressure.

TRANSSCLERAL DIODE CYCLOPHOTOCOAGULATION IN TREATMENT OF GLAUCOMA

Cyclodestructive procedures are an alternative of surgical treatment of medically refractory glaucoma.

AIM

To assess efficiency and safety of diode cyclophotocoagulation (CPC).

METHODS

Retrospective study included 81 eyes with advanced glaucoma operated with CPC for elevated intraocular pressure (IOP) from January 2017 to January 2019. CPC was performed in retrobulbar anesthesia with contact diode laser FOX (A.R.C. Laser, Germany) of wavelength 810 nm, transsclerally to the ciliary body. Energy settings: intensity 2 W, exposition time 2 s, 18 applications in arc of 360°. Decrease of intraocular pressure was investigated during month 1, 6 and 12 after CPC. Safety was evaluated according to the best corrected visual acuity (BCVA) on Snellen optotypes and number of postoperative complications.

RESULTS

Study on 31 eyes of 24 patients, 21 (68 %) women and 10 (32 %) men, with follow-up during more than 12 months. Mean follow-up time was 19.5 ± 6.1 (from 12 to 29) months. Average age was 75.9 ± 9.2 (56 - 93) years. Indication for CPC was primary open angle glaucoma in 15 eyes (49 %), primary angle closure glaucoma in 6 eyes (19 %) and secondary glaucomas in 10 eyes (32 %). All patients were on therapy of 4 antiglaucomatic drops and 10 of them (32 %) on acetazolamide pills. IOP before CPC was 25.4 ± 11.0 (13-56) mm Hg. After 1 year IOP decreased to 16.9 ± 6.1 (8-40) mm Hg. Best corrected visual acuity (BCVA) before CPC was 0.39 ± 0.34 (0-1), 1 year after CPC 0.36 ± 0.33 (0-1). 1 year after CPC, 11 eyes (35 %) lost 0.23 ± 0.14 rows. 6 from these (19 %) due to other acquired ocular pathologies. Hypotony occurred in 6 % and uveitis in 10 % eyes.

CONCLUSION

CPC is a safe and effective method of lowering IOP.

Efficacy and safety of single Ultrasound Cyclo-Plasty to treat refractory glaucoma: Results at 1 year

PURPOSE

To evaluate clinical efficacy and safety of single Ultrasound Cyclo-Plasty (UCP) in the treatment of advanced refractory glaucoma.

METHODS

From January 2018 to August 2018, 25 patients (25 eyes) with refractory glaucoma and intraocular pressure (IOP) not controlled by drugs or conventional filtering surgery were included in the study. All subjects (neovascular glaucoma [n = 12], secondary glaucoma [n = 6], angle closure glaucoma [n = 6], and primary open angle glaucoma [n = 1]) underwent 8-sector Ultrasound Cyclo-Plasty. Patients were followed-up at Day 1, Week 1, and at 1, 3, 6, and 12 months, during which the IOP, the number of IOP lowering drugs and the occurrence of ocular complications were recorded. Clinical outcomes were IOP reduction, success rate, and ocular complications. According to the glaucoma type, patients were divided into a neovascular group (NVG) and a non-NVG group for sub-analysis.

RESULTS

All patients underwent a single UCP procedure and mean IOP reduced significantly from 39.7 ± 6.1 mmHg before UCP to 27.1 ± 11.0 mmHg at 1 year (p < 0.01) corresponding to a mean IOP reduction of 29.6%. The mean number of IOP-lowering drugs used was 2.4 ± 1.2 at baseline and 2.3 ± 1.0 at 12 months. Success rate after a single UCP procedure was achieved in 41.7% patients at 1 year, with a higher success rate in non-NVG than in the NVG group. No major postoperative complications were reported. The main complication was conjunctival congestion, anterior chamber inflammation, scleral ring congestion, and scleral inprint. Of these, scleral ring congestion and scleral imprint are relatively rare complications, which can still be observed 12 months after UCP treatment.

CONCLUSION

UCP for refractory glaucoma is effective in reducing IOP and has a good safety profile. Success rate is lower after a single UCP in NVG than for other types of glaucoma.

Pars plana placement of Ahmed glaucoma valve tube through sclerotomy port in refractory glaucoma: A novel surgical technique

We describe a case of 34-year-old male with post penetrating keratoplasty glaucoma, post trabeculectomy with aphakia in the only seeing eye, in which a modified surgical technique of inserting Ahmed glaucoma valve (AGV) tube in vitreous cavity was done to reduce the risks associated with pars plana incision during pars plana vitrectomy (PPV). A hybrid 20-25 gauge PPV was done concurrently, implant fixed to sclera, and tube inserted through the 25 gauge sclerotomy port in supero-temporal quadrant. Visual acuity and intraocular pressure remained stable during 1-year follow-up.

Intraocular Pressure Rise Linked to Silicone Oil in Retinal Surgery: A Review

Silicone oil represents the main choice for intraocular tamponade in cases of complicated retinal detachment surgery. The intraocular pressure of an eye filled with silicone oil could increase, driven by a variety of different forces, according to several mechanisms. Two main conditions have been highlighted, depending on the onset: early hypertension or late glaucoma. The different types of silicone oils and their physico-chemical properties are varied and may play a role in the determination of intraocular pressure rise. The current body of literature allows for the illustration and categorization of the incidence and risk factors, as well as the pathogenesis and the management of the early postoperative hypertension subtended by an open- and closed-angle, along with the late onset silicone oil-induced glaucoma. Understanding the leading actors on the stage of ocular pressure elevation concurrently with silicone oil application for retinal surgery could help in guiding the timely and appropriate course of treatment.

Safety and Efficacy of Second Ahmed Valve Implant in Refractory Glaucoma

BACKGROUND

Refractory glaucoma still represents a challenge for ophthalmologists to manage intraocular pressure. The present study aimed to evaluate long term efficacy and safety of a second Ahmed valve implantation after the failure of a first implant in patients with refractory glaucoma and elevated intraocular pressure (IOP).

METHODS

Retrospective, multicenter non-comparative case series. Twenty-eight patients were retrospectively recruited between January 2011 and December 2017. Demographic data, glaucoma type, visual acuity, intraocular pressure, medical therapy, and complications were registered. Three criteria of success were established: Type 1 surgical success: IOP ≤ 15 mmHg and a reduction of IOP ≥ 40% from baseline; Type 2 surgical success: IOP ≤ 18 mmHg and a reduction of IOP ≥ 30% from baseline; and Type 3 surgical success: IOP ≤ 21 mmHg and a reduction of IOP ≥ 20% from baseline. Surgical failure has been established as IOP less than 5 mmHg or over 21 mmHg and less than a 20% reduction of IOP from baseline despite medications in two consecutive visits, light perception loss referable to glaucoma, and the necessity for further glaucoma surgery. Failure was observed in six (21%) patients. (3) Results: Mean IOP and mean glaucoma medication number significantly reduced from baseline after the second implantation, and the surgical success rate at 72 months ranged from 10% to 78% based on the different criteria of success. Failure was observed in six (21%) patients.

CONCLUSIONS

This study confirmed the safety and efficacy of a second Ahmed valve implantation in patients with refractory glaucoma and elevated IOP at baseline.

Clinical outcome of a nonvalved Aurolab aqueous drainage implant in posterior segment versus anterior chamber

Purpose

To evaluate the outcome of a nonvalved Aurolab aqueous drainage implant (AADI) in the management of refractory glaucoma.

Methods

Retrospective case series of patients with refractory glaucoma underwent AADI implantation in posterior segment (PS group) or anterior chamber (AC group) with minimum follow-up of 1 year. Primary outcome criterion was success, defined as intraocular pressure (IOP) <18 or >6 mm Hg or IOP reduced to <20% from baseline, for two consecutive visits after 3 months. Failure was defined as inability to meet IOP criteria, any additional glaucoma surgery, loss of light perception, and implant explantation. Secondary outcome criteria compared groups based on mean IOP, mean glaucoma medication use, best-corrected visual acuity, and complications at each postoperative visit.

Results

In the AC and PS group of 64 patients, 32 tubes each were placed. Preoperative mean IOP was 37.41 ± 8.6 and 43.38 ± 10.3 mm Hg in AC and PS, respectively. Postoperatively IOP reduced to 14.22 ± 4.9 and 15.21 ± 8.1 mm Hg in AC and PS groups, respectively (P < 0.001). Preoperative mean antiglaucoma medication changed from 2.56 ± 0.9 and 3.44 ± 0.5 to 1.03 ± 0.9 and 1.67 ± 0.5 in AC and PS, respectively, postoperatively (P < 0.001). No significant change in VA was noted in either group. At 12 months, success rate was 84% in AC group and 72% in PS group, with PS group having 2.63 times higher hazard (risk) of failure than AC group.

Conclusion

AADI implantation in PS or AC is a safe and effective method for IOP control in refractory glaucoma with its low cost being of significance in developing countries.

Micropulse transscleral cyclophotocoagulation using a standard protocol in patients with refractory glaucoma naive of cyclodestruction

PURPOSE

To assess the efficacy and safety of a standardized micropulse transscleral diode laser cyclophotocoagulation procedure in refractory glaucoma.

METHODS

Retrospective, interventional study in a series of 37 consecutive patients with refractory glaucoma, cyclodestructive procedure-naive, who underwent micropulse transscleral diode laser cyclophotocoagulation from December 2016 to October 2017. A successful laser treatment was defined as (1) intraocular pressure between 6 and 18 mm Hg; (2) 20% of baseline intraocular pressure reduction; (3) no additional glaucoma medications; (4) no decrease in vision due to complications or change in intraocular pressure; and (5) no need for additional glaucoma surgery except micropulse transscleral diode laser cyclophotocoagulation retreatment.

RESULTS

Mean age was 60.2 years. Mean follow-up was 9.7 ± 3.9 months. The mean preoperative intraocular pressure (28.7 mm Hg) significantly decreased to 21.0 mm Hg at 1 month, 18.5 mm Hg at 3 months, 18.4 mm Hg at 6 months, and 18.5 mm Hg at 12 months (p < 0.01 at all time points). The mean number of preoperative glaucoma medications (4.7) decreased to 4.0 at 1 month (p = 0.14), 4.5 at 3 months (p < 0.05), 3.9 at 6 months (p < 0.05), and 3.6 at 12 months (p < 0.05). At 1 year, the success rate was 35% with a mean intraocular pressure lowering of 36%. One patient had hypotony and a loss of best-corrected visual acuity. Mild transient postoperative inflammation was observed in 8% of the cases.

CONCLUSION

Using a standardized procedure, micropulse transscleral diode laser cyclophotocoagulation allows a mild intraocular pressure decrease with a low rate of complications and thus achieves a relatively good profit risk benefit, mostly for moderately hypertensive refractory glaucoma.

A prospective randomized controlled study of Aurolab aqueous drainage implant versus Ahmed glaucoma valve in refractory glaucoma: A pilot study

PURPOSE

To study the efficacy of the Aurolab aqueous drainage implant (AADI) compared to Ahmed glaucoma valve (AGV) in patients with refractory glaucoma.

METHODS

This was a prospective, randomized controlled trial. Thirty-eight adult patients (>18 years) scheduled for a glaucoma drainage device (GDD) were randomized into two groups to receive either AGV or AADI. Primary outcome measures: intraocular pressure (IOP) control and requirement of antiglaucoma medications; secondary outcome measures: final best correct visual acuity (log MAR), visual field (Visual field index [VFI], mean deviation [MD] and pattern standard deviation [PSD]), postoperative complications and additional interventions. Complete success was defined as IOP ≥5-≤18 mmHg without antiglaucoma medications/laser/additional glaucoma surgery or any vision threatening complications.

RESULTS

There were 19 age and sex-matched patients in each group. Both groups had comparable IOP before surgery (P = 0.61). The AGV group had significantly lower IOP compared to AADI group (7.05 ± 4.22 mmHg vs 17.90 ± 10.32 mmHg, P = <0.001) at 1 week. The mean postoperative IOP at 6 months was not significantly different in the two groups (13.3 ± 4.2 and 11.4 ± 6.8 mmHg respectively; P = 0.48). At 6 months, complete success rate according to antiglaucoma medication criteria was 78.94% in AADI and 47.36% in AGV groups. AGV group required 1.83 times more number of topical medications than AADI group. There was no significant difference in early (P = 0.75) and late (P = 0.71) postoperative complications in the AADI and AGV group. The complete success rate was higher in AADI group (68.42%) than AGV group (26.31%) (P = 0.034).

CONCLUSION

In this study, AADI appears to have comparable efficacy versus AGV implant with higher complete success rate at 6 months follow-up.

Combined cataract extraction with a new nonvalved glaucoma drainage device in adult eyes with cataract and refractory glaucoma

Purpose:

The purpose of the study is to report the outcomes of simultaneous cataract extraction (CE) and a new nonvalved glaucoma drainage device (GDD), Aurolab Aqueous Drainage Implant (AADI), in eyes with cataract and refractory glaucoma.

Methods:

This was a non-comparative, interventional, retrospective study. Consecutive patients who underwent AADI together with phacoemulsification from June-2015 to January-2017 by a single fellowship trained glaucoma surgeon with documented 3-months of follow-up were included. The main outcomes were intraocular pressure (IOP), antiglaucoma medication (AGM), visual acuity, and complications.

Results:

We included 19 eyes of 17 patients with average follow-up of 14.4 ± 8.4 months. IOP and AGM reduced from 36.9 ± 11.1 mmHg and 4 ± 0.8 preoperatively to 12 ± 4.5 mmHg and 0.8 ± 1.2, respectively (P < 0.001). Complications were seen in seven eyes (36.8%). Total success was seen in 17 eyes (89.5%). None of the patients lost vision.

Conclusion:

Combining cataract extraction with the new non-valved Aurolab Aqueous Drainage Implant, appears to be an effective and safe technique in eyes with refractory glaucoma and cataract. Larger studies and further follow-up is recommended for such patients.

Observation of curative effects of Ex-PRESS and AGV implantation in the treatment of refractory glaucoma

The curative effects of Ex-PRESS implantation and Ahmed glaucoma valve (AGV) implantation in the treatment of refractory glaucoma were compared. A total of 68 patients (76 eyes) with refractory glaucoma treated were randomly divided into Ex-PRESS group and AGV group. Results showed that the intraocular pressure IOP in both Ex-PRESS group and AGV group after operation was significantly decreased compared with that before operation (P<0.001). At 3, 6 and 9 months after operation, IOP in Ex-PRESS group was significantly lower than that in AGV group (P<0.05). At the end of follow-up, BCVA of patients in both groups after operation was slightly decreased compared with that before operation (P>0.05). There was no statistically significant difference in BCVA between the two groups of patients (P>0.05). Moreover, the corneal endothelial cell counts of patients in both groups after operation were obviously decreased compared with those before operation (P<0.05). The number of anti-glaucoma drugs applied was decreased from 3.53±0.86 to 0.55±0.60 in Ex-PRESS, and from 3.24±0.88 to 0.89±0.73 in AGV group. At the end of follow-up, the number of anti-glaucoma drugs applied in Ex-PRESS group was smaller than that in AGV group (P<0.05). There was no statistically significant difference in success rate of operation between the two groups at the end of follow-up (log-rank test; P>0.05). Finally, the incidence rates of postoperative complications and surgical intervention rates had no statistically significant differences between the two groups. Ex-PRESS implantation is a safe and effective treatment for refractory glaucoma, characterized by simple operation, small trauma and less pain, which has an equivalent curative effect to AGV implantation; but its control effect on IOP after operation is superior to that of AGV, and the number of anti-glaucoma drugs applied after operation is small.

Long-term results of Ahmed glaucoma valve implantation in Egyptian population

AIM

To evaluate the long-term results and complications of Ahmed glaucoma valve (AGV) implantation in a cohort of Egyptian patients.

METHODS

A retrospective study of 124 eyes of 99 patients with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 5y was performed. All patients underwent complete ophthalmic examination and intraocular pressure (IOP) measurement before surgery and at 1d, weekly for the 1^st month, 3, 6mo, and 1y after surgery and yearly afterward for 5y. IOP was measured by Goldmann applanation tonometry and/or Tono-Pen. Complications and the number of anti-glaucoma medications needed were recorded. Success was defined as IOP less than 21 mm Hg with or without anti-glaucoma medication and without additional glaucoma surgery.

RESULTS

Mean age was 23.1±19.9y. All eyes had at least one prior glaucoma surgery. IOP was reduced from a mean of 37.2±6.8 to 19.2±5.2 mm Hg after 5y follow-up with a reduced number of medications from 2.64±0.59 to 1.81±0.4. Complete and qualified success rates were 31.5% and 46.0% respectively at the end of follow-up. The most common complications were encapsulated cyst formation in 51 eyes (41.1%), complicated cataract in 9 eyes (7.25%), recessed tube in 8 eyes (6.45%), tube exposure in 6 eyes (4.8%) and corneal touch in 6 eyes (4.8%). Other complications included extruded AGV, endophthalmitis and persistent hypotony. Each of them was recorded in only 2 eyes (1.6%).

CONCLUSION

Although refractory glaucoma is a difficult problem to manage, AGV is effective and relatively safe procedure in treating refractory glaucoma in Egyptian patients with long-term follow-up. Encapsulated cyst formation was the most common complication, which limits successful IOP control after AGV implantation. However, effective complications management can improve the rate of success.

The efficacy of Alahmady ring implantation in the management of neovascular glaucoma

Purpose

To evaluate the efficacy and safety of Alahmady ring implantation in the management of neovascular glaucoma.

Methods

A total of 15 eyes of 15 patients with intractable neovascular glaucoma with intraocular pressure (IOP) ≥28 mmHg not responding to medical treatment were retrospectively analyzed. All patients had poor visual acuity and underwent Alahmady ring implantation. The ring was designed from fenestrated silicon tube used in lacrimal surgeries and was implanted subsclerally after passing it through the anterior chamber. Patients were followed up for at least 24 months. Success in this study was defined based on IOP ≥8 mmHg and <21 mmHg, with not more than 1 glaucoma drug, and improvement of patient symptoms and signs with maximum use of beta blocker as antiglaucoma drug.

Results

A total of 15 eyes of 15 patients (9 males [60%] and 6 females [40%]) were analyzed in this study. The mean IOP before surgery was 38.6 mmHg (standard deviation [SD]: 6.98) and it was 14.05 mmHg (SD =7.57) after surgery. The follow-up range was 24–36 months. Success of silicon drainage device was defined as an IOP <21 mmHg on the last follow-up visit. Medications included only beta-blockers and topical steroids for those who were without severe complications or for those who were not in a condition to undergo a further glaucoma surgery.

Conclusion

Alahmady ring implantation proves to be a good surgical option for neovascular glaucoma; however, a longer follow-up period is recommended.

Gold shunt for refractory advanced low-tension glaucoma with spared central acuity

The aim of this study is to report a case of gold shunt surgery for uncontrolled, low-tension glaucoma with good central vision, after having a previously failed trabeculectomy and tube shunt surgeries. The patient was receiving maximum medical glaucoma therapy of four different types with intraocular pressure of 17 mm Hg prior to gold shunt surgery. Five years later, intraocular pressure is well controlled in the low teens without the need for ocular medications, and glaucoma is stable following gold shunt surgery.

Amniotic membrane-assisted trabeculectomy for refractory glaucoma with corneal disorders

Purpose

To report the cases of six consecutive patients who underwent amniotic membrane (AM)-assisted trabeculectomy (TLE) to treat refractory glaucoma with severe corneal disorders.

Methods

This study involved six patients (three males and three females, mean age: 69.5±15.8 years) with refractory glaucoma and severe corneal disorders. The surgical procedure for each patient involved trabecular tissue being excised, and human AM then being placed epithelial side up on the corneal surface, sutured at the limbal sclera, and flipped over onto the sclera to cover the TLE area. The remaining edge of the AM was then inserted into the subconjunctival space and sutured. Medical records of all cases were reviewed with regard to intraocular pressure (IOP), visual acuity, and condition of the filtering bleb and ocular surface.

Results

The mean observation period was 69.5±15.8 months, and mean IOP at presurgery and at 1, 3, and 7 years postoperative was 40.3±6.9, 23.0±12.1, 25.6±12.8, and 28.5±19.1 mmHg, respectively. Glaucoma medications decreased from 3.0±1.1 drugs (presurgery) to 0.8±1.0 drugs (7 years postoperative). However, in some cases, ocular surface conditions or visual acuity worsened during the follow-up period.

Conclusion

Using AM as an internal patch for TLE, moderately good IOP control was obtained initially for the refractory glaucoma with severe corneal disorders; however, ocular surface conditions required special care, and the long-term IOP control was limited in some cases.

Combined pars plana vitrectomy and Baerveldt glaucoma implant placement for refractory glaucoma

AIM

To evaluate outcomes of combined pars plana vitrectomy and Baerveldt glaucoma implant (PPV-BGI) placement for refractory glaucoma.

METHODS

The medical records of 92 eyes (89 patients) that underwent PPV-BGI were retrospectively reviewed, including 43 eyes with neovascular glaucoma (NVG) and 49 eyes with other types of glaucoma (non-NVG).

RESULTS

Outcome measures were visual acuity (VA), intraocular pressure (IOP), glaucoma medical therapy, complications, and success [VA>hand motions (HM), IOP≥6 mm Hg and ≤21 mm Hg, no subsequent glaucoma surgery]. Cumulative success rates for the non-NVG group and NVG group were 79% and 40% at 1y, respectively (P=0.038). No difference in the rates of surgical success were found between pars plana and anterior chamber tube placement. Preoperative IOP (mean±SD) was 30.3±11.7 mm Hg in the Non-NVG group and 40.0±10.6 mm Hg in the NVG group, and IOP was reduced to 15±9.5 mm Hg in the non-NVG group and 15±10.5 mm Hg in the NVG at 1y. Number of glaucoma medications (mean±SD) decreased from 2.7±1.3 in the non-NVG group and 2.8±1.3 in the NVG group preoperatively to 0.76±1.18 in the non-NVG group and 0.51±1.00 in the NVG group at 1y. Improvement in VA of ≥2 Snellen lines was observed in 25 (27%) eyes, although only 33% of non-NVG eyes and 2.3% of NVG eyes maintained VA better than 20/200 at 1y. Nonclearing vitreous hemorrhage was the most common postoperative complication occurring in 16 (17%) eyes, and postoperative suprachoroidal hemorrhages developed in 5 (5.4%) eyes.

CONCLUSION

PPV-BGI is a viable surgical option for eyes with refractory glaucoma, but visual outcomes are frequently poor because of ocular comorbidities, especially in eyes with NVG. The location of tube placement does not influence surgical outcome and should be left to the discretion of the surgeon.

Outcomes of Ahmed valve surgery for refractory glaucoma in Dhahran, Saudi Arabia

AIM

To evaluate the outcomes of Ahmed glaucoma valve (AGV) implantation surgery for refractory glaucoma.

METHODS

This one-armed historical cohort study was conducted in 2011. Refractory glaucoma was defined as eyes with an intraocular pressure (IOP) greater than 21 mm Hg with maximally tolerated glaucoma medications, failed surgeries, or both. For all eyes with refractory glaucoma that underwent AGV implantation, data were collected on IOP, the best corrected visual acuity (BCVA) and glaucoma medications preoperatively and 4, 6, 12, 24 and 56wk postoperatively. Logarithm values of IOP were calculated and compared.

RESULTS

The study group was comprised of 30 patients (30 eyes, 16 males and 14 females) with refractory glaucoma. Mean preoperative IOP was 39.3±13.8 mm Hg. Postoperative mean IOP was 15.7±7.1 mm Hg, 19.6±12.8 mm Hg and 13.9±14.2 mm Hg at 12, 24 and 56wk respectively. BCVA was ≥ 6/60 in 11 eyes preoperatively, and five eyes had BCVA≥6/60 at 56wk postoperatively. Preoperatively, more than four medications were used to treat glaucoma in 21 eyes. At 12wk postoperatively, no medications were required to control IOP in 20 eyes. At 56wk postoperatively, at least one medication was required to control IOP in 10 eyes. Over the entire follow up period, four eyes were treated with yttrium aluminium garnet (YAG) laser and 14 eyes required a second surgery. The AGV was removed in four eyes.

CONCLUSION

AGV implantation reduced IOP and the number of medications required to control refractory glaucoma. However, there was a higher risk of decreased vision. Long-term follow up and prompt intervention are recommended.

Efficacy of Additional Glaucoma Drainage Device Insertion in Refractory Glaucoma: Case Series with a Systematic Literature Review and Meta-Analysis

PURPOSE

To report the efficacy of additional glaucoma drainage device (GDD) insertion in eyes with refractory glaucoma and which have a failed primary GDD.

METHODS

We conducted a non-comparative, retrospective study on eight eyes of eight patients who had a failed primary GDD and received an additional GDD in the same eye. Intraocular pressure (IOP), visual acuity (VA), the number of anti-glaucomatous medications, and complications were analyzed during the most recent office visit. Success was defined as an IOP between 6 and 21 mmHg and a 20% decrease in IOP after additional GDD insertion, with or without anti-glaucomatous medication.

RESULTS

The mean decrease in IOP at the final follow-up was 19.3 mmHg (56.1%). The mean number of anti-glaucomatous medications used at the final follow-up (2.38) was significantly less than the preoperative mean (3.50). Seven patients achieved the criteria for success, whereas one patient had an unsuccessful outcome because of corneal graft failure after additional GDD insertion.

CONCLUSIONS

We showed that after the failure of a primary GDD, an additional GDD offered favorable IOP control and stable VA. In agreement with a review of previous literature, GDD insertion is the best option for treating refractory glaucoma, even in patients with a failed primary GDD.

Short term outcome of Ahmed glaucoma valve implantation in management of refractory glaucoma in a tertiary hospital in Oman

Background:

We present outcomes of Ahmed Glaucoma Valve (AGV) implantation in treating refractory glaucoma in a tertiary hospital in Oman. Refractory glaucoma was defined as previously failed conventional glaucoma surgery and an uncontrolled intraocular pressure (IOP) of more than 21 mm Hg despite treatment with three topical and/or oral therapy.

Materials and Methods:

This historical cohort study was conducted in 2010. Details of medical and surgical treatment were recorded. Ophthalmologists examined eyes and performed glaucoma surgeries using AGV. The best corrected distant vision, IOP, and glaucoma medications were prospectively reviewed on 1^st day, 1^st, 6^th, 12^th week postoperatively, and at the last follow up.

Result:

Glaucoma specialists examined and treated 40 eyes with refractory glaucoma of 39 patients (20 males + 19 females). Neo-vascular glaucoma was present in 23 eyes. Vision before surgery was <3/60 in 21 eyes. At 12 weeks, one eye had vision better than 6/12, seven eyes had vision 6/18 to 6/60, and eight eyes had vision 6/60 to 3/60. Mean IOP was reduced from 42.9 (SD 16) to 14.2 (SD 8) and 19.1 (SD 7.8) mmHg at one and 12 weeks after surgery, respectively. At 12 weeks, five (12.5%) eyes had IOP controlled without medication. In 33 (77.5%) eyes, pressure was controlled by using one or two eye drops. The mean number of preoperative anti-glaucoma medications (2.38; SD 1.1) was reduced compared to the mean number of postoperative medications (1.92; SD 0.9) at 12 weeks.

Conclusion:

We succeeded in reducing visual disabilities and the number of anti-glaucoma medications used to treat refractory glaucoma by AGV surgery.

Pars plana Baerveldt tube insertion with pars plana vitrectomy for refractory glaucoma

Background:

Glaucoma drainage implants (GDIs) are used for managing recalcitrant glaucoma and are usually placed in the anterior chamber. This approach may lead to complications such as corneal decompensation, and so a pars plana approach is used in at risk eyes.

Aims:

To compare functional outcomes and complications of 250 mm² and 350 mm² pars plana Baerveldt tube insertion with pars plana vitrectomy (PPV) (both 20- and 23-gauge) for managing refractory glaucoma.

Settings and Design:

A retrospective chart review of 38 patients (39 eyes) undergoing combined PPV-Baerveldt procedure for glaucoma recalcitrant to maximal medical treatment or previous filtering procedures with >6 weeks of follow-up.

Materials and Methods:

Main outcome measures were visual acuity, intraocular pressure (IOP), number of glaucoma medications, and postoperative complications.

Statistical Analysis Used:

A paired ‘t’ test was used to evaluate changes in IOP and glaucoma medications, Fisher's exact test was used to compare complication rates, and Kaplan-Meier survival curves were constructed for comparison of overall outcomes.

Results:

Mean patient age was 62.2 years. Mean follow-up period was 33.7 months, with 36 (92%) eyes followed for ≥6 months. Mean±SD preoperative IOP and number of glaucoma medications were significantly reduced by the combined procedure (P<0.05). Thirty-five (90%) eyes maintained final IOP between 6 and 21 mmHg. Vision improved by ≥2 lines in 10 (26%) eyes, remained stable in 15 (38%) eyes, and decreased in 14 (36%) eyes. Two (5.1%) eyes developed no light perception vision, with one (2.6%) eye becoming phthisical. Twenty-four (62%) eyes developed complications managed with conservative measures. Five (13%) eyes required ≥1 surgeries within a year of the combined procedure.

Conclusions:

Pars plana Baerveldt tube implantation with PPV can preserve vision, reduce IOP, and decrease the number of glaucoma medications necessary to achieve target IOP in patients with recalcitrant glaucoma.

Long-term success of ahmed glaucoma valve in refractory glaucoma

AIM

To evaluate the long-term results and complications of ahmed glaucoma valve (AGV) implantation in refractory glaucoma.

METHODS

A retrospective review of 13 patients (13 eyes) with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 18 months was performed. All patients underwent a complete ophthalmologic examination and intraocular pressure (IOP) measurement before surgery and at 1 month, 3 months, 6 months, 1 year after surgery and yearly afterwards. Complications and the number of antiglaucoma medications needed were recorded.

RESULTS

Mean age was 27.3±16.0 years. All eyes (100%) had at least one prior incisional surgery. Mean follow-up was 61.3±30.8 months. IOP was reduced from a mean of 35.0 ±7.0mmHg to 18.2±7.9mmHg at 12 months and to 17.0±4.1mmHg at 96 months (P<0.05) with a lower number of medications from baseline, 76.9% patients required additional procedures to achieve the success criteria set by previously published series. The most common complications were encapculated cyst formation in eight eyes (61.5 %) and tube exposure in four eyes (30.8%).

CONCLUSION

Encapsulated cyst formation was the most common complication which hindered succesful IOP control after AGV implant insertion for refractory glaucoma. Despite cyst excision with anti-fibrotic agents, successful IOP reduction was not achieved in 76.9% of the patients without antiglaucoma medication.

Managing refractory glaucoma with a fixed combination of bimatoprost (0.03%) and timolol (0.5%)

Glaucoma is a chronic progressive optic neuropathy characterized by progressive loss of retinal ganglion cells, which manifests clinically with loss of optic disc neuroretinal rim tissue, defects in the retinal nerve fiber layer, and deficits on functional visual field testing. The goal of glaucoma treatment is to reduce the intraocular pressure to a level that prevents or minimizes the progressive loss of vision. The current standard of management for the newly diagnosed primary open angle glaucoma (PAOG) patient is to start topical medication. Available topical medications include: beta-adrenergic antagonists, alpha-adrenergic agonists, carbonic anhydraze inhibitors, prostaglandin analogues and miotics. In some patients, IOP is not adequately controlled by monotherapy. In those refractory patients, where more efficacy is required, shifting to another medication or adding a second medication is indicated. The complimentary action between two drugs serves as the basis for combination medications. One avenue of delivering a second medication is through a fixed combination medication that has the advantage of providing two medicines within one drop. Bimatoprost/timolol represents a new fixed combination which is clinically and statistically more effective than either of its active constituents for patients with refractory glaucoma. As regard the safety of the combination, there were no signs or symptoms of intolerance and the incidence of conjunctival hyperemia was clinically and statistically significantly less than each of the two components separately. Bimatoprost/timolol fixed combination offers cost and time savings, which may enhance compliance; also reducing the amount of preservative applied to the eye, will improve tolerability and may also favorably improve eventual surgical outcomes in patients who might require filtering procedures.

Efficacy and safety of the pars plana clip in the Ahmed valve device inserted via the pars plana in patients with refractory glaucoma

Purpose:

To evaluate the efficacy and safety of the pars plana clip (PPC) in the Ahmed valve tube inserted via the pars plana in patients with secondary refractory glaucomas.

Methods:

Prospective and interventional case series that included 10 patients with secondary refractory glaucoma. The pars plana vitrectomy and the implant of the modified tube were performed during the same surgery. Control of intraocular pressure (IOP) and the development of intra- and postoperative complications were evaluated during the follow-up.

Results:

Follow-up time was twelve months in all the patients. Control of IOP was achieved in 90% of patients, and 70% needed no antiglaucoma treatment. The complications that occurred were transient hypotony in three cases, choroidal detachment in two cases, and one case of intraocular hemorrhage. No case of tube extrusion or tube kink was observed.

Conclusions:

Our data suggests that implantation of the Ahmed tube modified with the PPC via the pars plana is safe and effective in patients with secondary refractory glaucomas.

Graft-free Ahmed tube insertion: a modified method at 5 mm from limbus

Objective

To determine the medium-term outcome of Ahmed implants inserted through a needle tract at 5 mm from limbus that eliminates the need for a donor scleral graft.

Methods

A retrospective case series of 19 patients undergoing Ahmed implant surgery for refractory glaucoma with a mean follow-up of 12 months. Primary outcome measures included control of intraocular pressure after surgery. Secondary outcome measure included the frequency of intraoperative and postoperative complications.

Results

Intraocular pressure was maintained between 6 and 21 mmHg throughout the study. There was no postoperative hypotony. There were no complications related to this modified technique.

Conclusion

Needle tract at 5 mm from limbus maintains implant’s ability to control intraocular pressure and eliminates the need for a donor scleral graft or heterologous material.

Clinical experience of e-PTFE membrane implant surgery for refractory glaucoma

AIMS

To evaluate the clinical efficacy of membrane tube implant made of expanded polytetrafluoroethylene (e-PTFE, Gore-Tex) membrane and silicone tube in treating refractory glaucoma.

METHODS

A retrospective chart review was performed on 43 eyes of 40 patients who underwent glaucoma tube shunt implant surgery using double layered e-PTFE membrane and silicone tube to treat refractory glaucoma. The surgeries were performed from May 1991 to September 1995, and the subjects were patients with terminal glaucoma without useful vision on the study eye.

RESULTS

The mean follow up period was 32.9 months. The Kaplan-Meier survival for intraocular pressure (IOP) control (IOP between 6 and 21mm Hg without significant complication) was 80.9% at 1 year, 73.9% at 2 years, and 62.2% at 3 years after surgery. After excluding three eyes of three patients who were dropped within 3 months after surgery and did not have any serious complication or problem in IOP control, the average preoperative IOP was 42.5 (SD 14.6) mm Hg and IOP on the last visit was 17.3 (10.2) mm Hg (p = 0.000, n = 40). The number of antiglaucoma medications before surgery (2.2 (0.6)) was reduced to 0.5 (0.8) on the last visit (p = 0.000). The IOP was controlled within the range of 6-21 mm Hg in 26 eyes (65.0%). In the remaining 14 eyes (35%), we could not control the IOP or additional surgery was needed to control the IOP or to treat severe complications. Two cases of endophthalmitis and three of phthisis were found as serious complications. The other complications were similar to those of other commercially available glaucoma implants.

CONCLUSION

A comparable clinical result was obtained with this new implant as with the other commercially available implants. This implant with a thin and non-rigid reservoir has a potential to reduce some complications associated with the large volume and rigid consistency of the other implants, although it is not yet proved. This membrane tube implant may be considered as another substitute in the surgery of refractory glaucoma.