Comparative Analysis of Filtering Surgery Approaches in Non-Granulomatous Uveitic Glaucoma: Combined or Standalone?

To compare intraocular pressure (IOP) control in eyes with or without clear corneal phacoemulsification following trabeculectomy. The study group included 30 eyes that underwent uneventful clear corneal phacoemulsification and foldable intraocular lens implantation following trabeculectomy without antimetabolites. Thirty eyes that had undergone filtering surgery without cataract extraction were selected as controls. Case and control groups were matched with respect to age, gender, IOP, number of glaucoma medications, glaucoma type (primary open-angle glaucoma/pseudoexfoliative glaucoma), trabeculectomy time and follow-up. Comparisons between the study and control groups (intergroup) and within the same group at different time-points (intragroup) were performed for IOP, glaucoma medications and bleb morphology. Success rates were investigated by Kaplan-Meier survival analysis and the factors influencing final success by logistic regression. Intraocular pressure (p = 0.04) and glaucoma medications (p = 0.001) increased during an average follow-up of 26.1 +/- 9.9 months in both groups. Intragroup differences became statistically significant after the 6-month visit, but intergroup differences remained insignificant. Bleb height decreased significantly following phacoemulsification in the study group (p = 0.017). Success rates decreased with time in both groups, with no intergroup difference (p = 0.46). The final success rate was negatively correlated with IOP and number of glaucoma medications used at the study entry, while there was a positive correlation between the baseline and final success rates. Trabeculectomy success decreased in a time-dependent manner in eyes with and without subsequent phacoemulsification. Uncomplicated clear corneal phacoemulsification was not found to have any additional unfavorable influence on IOP control in eyes with filtering blebs.

Phacotrabeculectomy Meta-analysis

Update on Microinvasive Glaucoma Surgery.

Background Glaucoma is a nonreversible optic neuropathy that may occur primarily or secondary to ocular pathology. Uveitis is a major etiological factor for secondary glaucoma, arising either owing to the inflammation itself or resulting from therapeutic steroid use. Many patients with uveitic glaucoma ultimately require a surgical intervention to maintain optimal intraocular pressures (IOP), often after treatment failure with multiple ocular antihypertensive agents. A leading surgical option for such patients is trabeculectomy augmented by intraoperative administration of mitomycin C (MMC). However, in the context of uveitic glaucoma, the relative merit of trabeculectomy with MMC compared with alternative surgical techniques, such as valve implantation, remains a subject of debate among ophthalmic surgeons. Study design This is a review of the literature to evaluate the efficacy and safety of trabeculectomy with MMC in uveitic glaucoma. Materials and methods A literature review of the use of trabeculectomy with MMC administration as an initial surgical management for uveitic glaucoma in adults was performed. Articles were identified by searches of PubMed and the Cochrane Library, using a strategy that defined the target condition (uveitis OR uveitic glaucoma OR inflammatory glaucoma) AND the intervention (trabeculectomy); limitation to MMC-augmented trabeculectomy was undertaken at the abstract and full-text stage. Data extracted included age of the patients, nature of the uveitis, preoperative status in terms of IOP and number of ocular hypotensive medications used, outcomes at annual time-points including IOP, number of ocular hypotensive medications, and surgical success (defined in terms of IOP) up to 5 years postoperatively. Adverse events were also recorded. Results The search strategy identified 498 papers, of which 32 were duplicates, 431 were excluded at abstract stage, and 28 were excluded at full-text stage; five of the 28 satisfied the inclusion criteria but were found to contain data that were entirely or largely contained within one of the other included papers. A total of seven studies were included, comprising 300 patients, with a weighted mean age of 45.8 years (range=30.0–56.9 years), and a range of uveitis syndromes including idiopathic (30%), Behcet's disease (24.3%), Fuchs’ heterochromic uveitis (13.7%), and Vogt-Koyanagi-Harada syndrome (12.3%). Preoperative IOP and number of medications were reported in all studies. The mean (weighted) preoperative IOP was 34.2 mmHg (range=26.8–39.5 mmHg) and the mean (weighted) number of medications was 3.4 (range=2.3–4.5). Postoperative data were variably reported across the studies; the mean IOP at 1 year was reported in five studies (range=13.8–18.5 mmHg), the mean number of medications at 1 year was reported in four studies (range=0.3–2.6), and surgical success was variably defined preventing direct comparison or aggregation. Conclusion There is limited evidence to evaluate trabeculectomy with MMC as an initial surgical intervention for uveitic glaucoma, with the available evidence being derived entirely from retrospective studies, most of which do not have a parallel comparator group. Variation in reporting limits direct comparison and aggregation of these studies. Comparison between before and after intervention provides some limited evidence of effectiveness and safety. So, there is a need for well-designed prospective randomized controlled trials with long-term follow-up to compare interventions in this vulnerable group of patients.

Comparison of Safety and Efficacy between Silicone and Polypropylene Ahmed Glaucoma Valves in Refractory Glaucoma

The purpose of this study was to evaluate the efficacy of intraocular pressure (IOP) control after combined CyPass Micro-Stent implantation and cataract surgery (combined surgery). All cases of combined surgery performed from February 2017 to July 2018 at Stein and Doheny Eye Institutes were reviewed. The primary outcome was a qualified success with stratified IOP targets based on criteria: final IOP (A) ≤18 mm Hg and reduction of 20%, (B) ≤15 mm Hg and reduction of 25%, (C) ≤12 mm Hg and reduction of 30%. Secondary outcome measures included postoperative IOP and number of medications, complications, additional glaucoma surgery, and postoperative refractive error. Predictive factors for failure were investigated. IOP spike was defined as a postoperative IOP ≥30 or >10 mm Hg increase from preoperative IOP. One hundred forty-one eyes (107 patients) were included. Mean (±SD) preoperative IOP was 15.4±3.4 mm Hg on an average of 2.2±1.1 medications. A statistically significant reduction in IOP and number of medications was seen at 12 months (13.8±4.2 mm Hg, 1.3±1.3 medications, P<0.001). Fifteen eyes (10.6%) had a postoperative IOP spike. Thirteen eyes (9.2%) experienced 17 complications (12.1%). Additional glaucoma surgery was performed in 3 eyes (2 patients). Cumulative success rates at 1 year based on criteria A, B, and C were 42%, 33%, and 28%, respectively. Lower preoperative IOP, greater preoperative medication number, the occurrence of postoperative IOP spike, and non-Caucasian ethnicity were associated with failure. Combined CyPass Micro-Stent implantation and cataract surgery may reduce glaucoma medication burden with a success rate of 28% to 42% at 1 year.

Phacotrabeculectomy with adjunctive mitomycin C is a good option for the management of coexisting cataract and glaucoma. Strict preoperative control of inflammation and close follow-up are essential in the management of eyes with uveitic glaucoma (UG). The purpose of this study was to compare the outcomes of phacotrabeculectomy with adjunctive antimetabolites in the management of patients with UG and patients with primary open-angle glaucoma (POAG). A retrospective case-control study of 112 patients with UG and 120 patients with POAG who underwent phacotrabeculectomy with mitomycin C and had a follow-up of ≥12 months between January 2000 and June 2015 was performed. Patients who had undergone intraocular surgery or cyclodestructive procedures earlier were excluded. The primary outcome was intraocular pressure (IOP) control; secondary outcomes included visual acuity and complication rates. IOP control was similar at the final visit in the UG group (14.52±6.74 mm Hg) and the POAG group (14.39±4.18 mm Hg) (P=0.867). Kaplan-Meier survival analysis showed a cumulative probability of survival (IOP: 6 to 18 with or without medications) in 71% and 77% at the end of 5 years (P=0.094) in the UG and POAG groups, respectively. Visual outcomes were worse in the UG group (0.5±0.68 logMAR units), as compared with the POAG group (0.27±0.47 logMAR units) (P=0.002). Complications such as cystoid macular edema (P=0.025) and posterior capsular opacification (P=0.004) were more common in the UG group. Recurrence of inflammation occurred in 34 eyes (30.04%) in the UG group. Meticulous control of perioperative and postoperative inflammation could have contributed to the favorable long-term outcomes of phacotrabeculectomy in UG, as compared with POAG.

HintergrundDas dynamische Konturtonometer PASCAL (DCT) ist ein digitales, der natürlichen Hornhautgeometrie angepasstes Kontakttonometer. Verglichen wurde das DCT mit dem Goldmann-Applanationstonometer (GAT).MethodikIn einer prospektiven Querschnittstudie wurden 100 Augen vor und nach Pars-plana-Vitrektomie (ppV) vergleichend mit dem GAT und DCT gemessen. Verwendete Endotamponaden waren verschiedene Gase und Silikonöle. Erfasst wurden der präoperative intraokulare Druck (IOD), postoperative Druckveränderungen und die Intertonometerdifferenz.ErgebnissePräoperativ lag der mittlere IOD mit dem GAT gemessen bei 15,8 ± 5,2 mm Hg und dem DCT bei 17,5 ± 5,9 mm Hg. Am ersten postoperativen Tag stieg bei Augen, die mit Gas versorgt wurden, der Druck im Mittel um 2,5 mm Hg (p = 0,035) an. Das DCT erfasste 18 Augen (19,1 %) mit einem postoperativen IOD von ≥ 25 mm Hg. Postoperativ maß das GAT den IOD im Schnitt 2,5 mm Hg niedriger und bei expansiver Gasendotamponade im Mittel um 3,0 mm Hg niedriger als das DCT. Bei IOD-Werten von postoperativ über 20 mm Hg lag das GAT im Mittel 4,7 mm Hg unter dem DCT. Zehn von 18 Augen mit IOD ≥ 25 mm Hg wurden mit dem GAT nicht als hypertensiv (≥ 25 mm Hg) erkannt. Bei 13 % maß das DCT am 1. postoperativen Tag einen um mindestens 6 mm Hg höheren IOD als das GAT. In einem Extremfall wurde der IOD mit dem GAT bei Gasendotamponade um 12 mm Hg unterschätzt.SchlussfolgerungPostoperative Druckanstiege nach ppV sind gefürchtete Komplikationen und können zu irreversiblem Visusverlust führen. Abhängig von der verwendeten Endotamponade misst das GAT den IOD niedriger als das DCT – besonders bei Druckspitzen durch expansive Gase. Die postoperative IOD-Messung nach ppV ist bedeutend und die Messwerte von GAT und DCT können abweichen.

To evaluate the influence of phacoemulsification on intraocular pressure (IOP) control and survival of mitomycin C (MMC)-enhanced trabeculectomy in uveitic glaucoma (UG). Retrospective case-control study included 54 eyes from 40 patients with UG who underwent MMC-enhanced trabeculectomy as an initial procedure to treat glaucoma at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia between 2002 and 2014. Eyes were divided into 2 groups: the first group included eyes that later underwent cataract surgery in the form of phacoemulsification, and the second group included eyes that did not have cataract surgery. The main outcome measures were changes in the IOP, the number of antiglaucoma medications, IOP control, and trabeculectomy survival. There were no differences in the overall trabeculectomy survival of eyes that underwent cataract surgery and those that did not (P=0.681, log-rank) nor the final IOP [15.54 mm Hg (±6.3) in the study group and 13.34 mm Hg (±5.6) in the control group, P=0.247]. However, more antiglaucoma medications were needed to control the IOP after cataract surgery at the last follow-up [1.59 medications (±1.4) in the study group and 0.50 medications (±0.7) in the control group; P=0.009]. UG eyes that underwent phacoemulsification following MMC-enhanced trabeculectomy required more medications to control the IOP than those that did not undergo cataract surgery and therefore less IOP control. Such changes in IOP control did not affect the overall trabeculectomy survival rate.

Purpose To evaluate the long-term outcomes of trabeculectomy with mitomycin C (MMC-TLE) in patients with uveitic glaucoma (UG). Patients and Methods. This was a retrospective, nonrandomized case series study. MMC-TLE was performed on 50 eyes with UG between February 2001 and January 2015 at Hokkaido University Hospital. Age- and sex-matched patients with primary open angle glaucoma (POAG) who underwent MMC-TLE were matched by age and sex and enrolled as controls. Surgical success was defined as an intraocular pressure (IOP) less than 18 or 15 mmHg. The Kaplan–Meier survival curves for surgical failure were analyzed. Results The mean preoperative IOP in UG and POAG was 27.6 ± 10.6 and 18.0 ± 4.5 mmHg, respectively. After the surgery, the mean IOP in UG and POAG was reduced to 11.7 ± 4.2 and 12.2 ± 3.8 mmHg at 12 months, 11.9 ± 7.0 and 12.1 ± 3.1 mmHg at 36 months, and 13.0 ± 5.2 and 10.6 ± 1.2 mmHg at 120 months, respectively. The success rates (IOP <18 mmHg, IOP reduction >20%) in UG and POAG were 91.7% and 88.0% at 12 months, 82.2% and 75.6% at 36 months, and 66.5% and 61.8% at 120 months, respectively. The success rates (IOP <15 mmHg) in UG and POAG were 64.0% and 58.0% at 12 months, 55.1% and 45.5% at 36 months, and 47.9% and 37.8% at 120 months, respectively. There was no significant difference in the success rate between UG and POAG at 120 months after surgery by either definition of surgical success. Conclusions MMC-TLE effectively reduced IOP in both UG and POAG. There was no significant difference in the success rate between UG and POAG. Following sufficient inflammation suppression, surgical outcomes of UG may be comparable with those of POAG.

To evaluate the efficacy of Molteno aqueous shunt as a primary surgical treatment in uveitic glaucoma. Nonrandomized, interventional, retrospective clinical study. The intraocular pressure (IOP), survival rate and complications were analyzed in 30 patients with uveitic glaucoma treated with Molteno implant. The mean follow-up time was 59.3 +/- 18.4 months. Preoperatively, the mean +/- SD IOP was 32.8 +/- 7.5 mmHg (range 20-48), and the mean number of medications was 3.1 +/- 0.6. The mean IOP decreased significantly (p < 0.001) to 17.7 and 15 mmHg at 3 and 6 months postoperatively. The mean number of medications decreased statistically significantly (p < 0.001) from the preoperative number 3.1 to 1.9 three months postoperatively. The number of medications continued to decrease significantly up to 3 years postoperatively. The qualified success rate (Kaplan-Meier estimate) was 97%, 93%, 90% and 85% at 1, 2, 3 and 4 years, respectively. Two patients failed because of hypotony, two patients developed conjunctival erosion and one patient had corneal decompensation. Molteno aqueous shunt as the first glaucoma procedure decreased IOP effectively in uveitic glaucoma. Even after 4 years, the survival estimate was quite high. The IOP decreased continuously during the first year after the surgery, and the medication was slowly tapered even up to 3 years postoperatively. It is suggested that it may be possible to postpone further surgical intervention during the first postoperative year after Molteno implantation even if the IOP is not quite optimal.

Background: This study aimed to evaluate prognostic factors of early filtering blebs using anterior segment swept-source optical coherence tomography (AS SS-OCT) in patients with uveitic and neovascular glaucoma. Methods: This retrospective cohort study included 22 eyes from 22 patients who underwent trabeculectomy (11 eyes each with uveitic or neovascular glaucoma). Intrableb characteristics were assessed using AS SS-OCT at 1 month, postoperatively. Surgical success was defined as intraocular pressure (IOP) ≤ 18 mmHg and ≥30% IOP reduction without medication at 12 months. Logistic regression was used to identify the prognostic factors associated with IOP control. Results: Sixteen eyes (72.7%) achieved surgical success, while six (27.3%) were unsuccessful. Eyes with successful IOP control at 12 months showed thicker and less reflective bleb walls with microcysts compared with unsuccessful cases of IOP control, in the early postoperative phase (all p < 0.033). However, IOP at the time of OCT did not significantly differ between the groups (p = 0.083). Multivariate logistic regression analysis revealed that higher bleb wall reflectivity at 1-month post-trabeculectomy was significantly associated with a higher surgical failure rate at 12 months after trabeculectomy (hazard ratio = 1.072, p = 0.032). Conclusions: Early intrableb assessment using AS SS-OCT may be beneficial for managing filtering blebs after trabeculectomy in uveitic and neovascular glaucoma. Higher bleb wall reflectivity in the early post-trabeculectomy phase may indicate poor features of the filtering bleb, suggesting the need for timely interventions for refractory cases.

BackgroundTo assess the long-term outcomes of patients with glaucoma secondary to iridocorneal endothelial syndrome (GS-ICE) who underwent Ahmed glaucoma valve (AGV) implantation combined with phacoemulsification and intraocular lens (IOL) implantation surgery.MethodsIn this non-comparative retrospective case series study, twelve patients with uncontrolled GS-ICE and cataract underwent Ahmed aqueous shunt combined with phacoemulsification and IOL implantation surgery at Beijing Tongren Eye Center between June 2014 and June 2022. Main medical records included best-corrected visual acuity (BCVA), intraocular pressure (IOP), number of antiglaucoma medications (AGM), corneal status and further surgical interventions. Surgical success was defined as a postoperative IOP ≥ 6mmHg and ≤ 21mmHg without (complete success) or with/without (qualified success) topical AGM and vision of at least light perception during the follow-up period.ResultsTwelve eyes of twelve patients were reviewed. Preoperative IOP was decreased from a mean of 38.5 ± 6.7 mmHg on 3.3 ± 0.9 AGM to a mean of 16.3 ± 4.3 mmHg (P<0.001) on 0.6 ± 1.1 medications (P<0.001) at the last follow-up (47.0 ± 24.7 months). Eight eyes (66.7%) had stable vision or at least one line improvement than that before surgery. Eight eyes (66.7%) achieved qualified success and six eyes (50.0%) achieved complete success after surgery. The surgical procedure had a qualified survival of 91.7% at 1 year, 82.5% at 3 years, 72.2% at 5 years, and 48.1% at 7 years.ConclusionAGV implantation combined with phacoemulsification and IOL implantation seems to be an effective method in IOP control and vision maintain for patients with GS-ICE. The combined surgical procedure may be a reliable option for those GS-ICE patients with coexisting cataract.

All the 560 glaucomatous eyes of 375 Japanese subjects (181 men, 194 women; mean age ± standard deviation, 76.0 ± 13.2 years) who underwent microhook ab interno trabeculotomy (µLOT) alone (159 eyes, 28%) or combined µLOT and cataract surgery (401 eyes, 72%) performed by one surgeon at Matsue Red Cross Hospital between May 2015 and March 2018 to control intraocular pressure (IOP) were retrospectively assessed. Preoperative and postoperative IOPs, numbers of antiglaucoma medications, the logarithm of the minimum angle of resolution visual acuity (logMAR VA), anterior chamber (AC) flare, visual field mean deviation (MD), and corneal endothelial cell density (CECD) were compared up to 36 months. Surgical complications and required interventions were described. The duration of the follow-up was 405 ± 327 (range, 2–1326) days. The mean preoperative IOP (20.2 ± 7.0 mmHg) and number of antiglaucoma medications (2.8 ± 1.1) decreased to 13.9 ± 4.5 mmHg (31% reduction, p < 0.0001) and 2.5 ± 1.0 (11% reduction, p < 0.0001), respectively, at the final visit. After combined surgery, compared with preoperatively, the final VA improved 0.11 logMAR (p < 0.0001), AC flare increased 4.5 photon counts/msec (p = 0.0011), MD improved 0.6 decibel (p < 0.0001), and the CECD decreased 6% (p < 0.0001). Layered hyphema (172 eyes, 31%) and hyphema washout (26 eyes, 5%) were the most common postoperative complication and intervention, respectively. At the final visit, 379 (69%) eyes achieved successful IOP control of ≤18 mmHg and ≥20% IOP reduction, and 349 (64%) eyes achieved successful IOP control of ≤15 mmHg and ≥20% IOP reduction. Older age, steroid-induced glaucoma, developmental glaucoma, and the absence of postoperative complications were associated with lower final IOP; exfoliation glaucoma, other types of glaucoma, and higher preoperative IOP were associated with higher final IOP. µLOT has a significant IOP-lowering potential in patients with glaucoma, and improves visual function when combined with cataract surgery.

To analyse clinical outcomes of trabeculectomy with mitomycin C (MMC) in eyes with uveitic glaucoma (UG) with inactive uveitis and compare them to those in eyes with primary open-angle glaucoma (POAG). Retrospective non-randomized comparative interventional case series. A total of 53 eyes with UG and 80 eyes with POAG that received MMC trabeculectomy as an initial ocular surgery with average follow-up of 5.4 years were reviewed retrospectively. The intraocular pressure (IOP) control and persistence of filtering bleb were analysed using the Kaplan-Meier life-table method based on two definitions of successful IOP control, ie complete success (IOP<or=15 mm Hg without anti-glaucoma medications) and qualified success (IOP<or=15 mm Hg with topical anti-glaucoma medications). The incidences of postoperative complications were also examined. Complete success rate for postoperative IOP control at 5 years after trabeculectomy was 57.1+/-7.5% (mean+/-SE) in UG, being comparable to that in POAG (53.7+/-6.1%), and those of qualified success was 64.7+/-7.0 and 65.9+/-5.5% (P=0.60 and 0.53) respectively. Persistence of filtrating blebs was shorter in UG than in POAG (P=0.031). Postoperative inflammation in UG was associated with worse postoperative IOP control and loss of filtering bleb (P=0.027 and 0.021). Postoperative long-standing ocular hypotony was more frequent in UG (P=0.0063). An MMC trabeculectomy for UG with inactive uveitis as an initial ocular surgery had IOP control comparable to that for POAG, suggesting that pre-existing uveitis itself is not a risk factor for failure of a filtering surgery.