Comparison of minimally invasive glaucoma surgery with trabecular micro-bypass stent and microhook ab interno trabeculotomy performed in conjunction with cataract surgery.

The aim of this study is to compare the surgical efficacy and safety between microhook ab-interno trabeculotomy (µLOT) and iStent trabecular micro-bypass stent implantation when both were combined with cataract surgery in both eyes of patients. Sixty-four glaucomatous eyes (32 participants; mean age, 75.9 ± 7.6 years; 15 men, 17 women) were included retrospectively. Intraocular pressure (IOP), number of antiglaucoma medications, best-corrected visual acuity (BCVA), anterior chamber flare (ACF) and corneal endothelial cell density (CECD) were evaluated preoperatively, as well as 2, 3, 6, and 12 months postoperatively. Surgical complications and interventions were compared between the procedures. The preoperative IOP and medications with µLOT (18.8 ± 5.7 mmHg and 3.0 ± 1.2, respectively) were higher than with the iStent (15.5 ± 3.4 mmHg and 2.7 ± 1.2, respectively) (p = 0.0001 and p = 0.0437, respectively). At 12 months, the µLOT values (12.6 ± 2.3 mmHg and 2.3 ± 0.9, respectively) were identical to iStent (12.8 ± 2.5 mmHg and 2.3 ± 0.9, respectively) (p = 0.0934 and p = 0.3251, respectively). At 12 months, the IOP decreased more with µLOT (6.2 mmHg, 29.5%) than iStent (2.7 mmHg, 15.6%) (p = 0.0003). The decrease in medications was greater with µLOT (0.7) than iStent (0.4) (p = 0.0437). Survival rate of IOP control ≤15 mmHg and IOP reduction ≥20% was significantly higher after µLOT (40.6% at 12 months) than iStent (18.8%) (p = 0.0277). The frequency of layered hyphema was significantly greater with µLOT (8 eyes, 25%) than iStent (0 eyes, 0%) (p = 0.0048). The increase in the ACF at 2 weeks postoperatively was significantly greater with µLOT than iStent (p = 0.0156), while changes in the BCVA and CECD were identical between groups. The fellow-eye comparison showed that the IOP reduction was greater with µLOT than iStent when combined with cataract surgery.

To explore the efficacy, safety and tolerability of 1 mg intracameral triamcinolone acetonide (TA) in controlling ocular inflammation in patients undergoing cataract surgery. Sixty eyes of 60 patients undergoing cataract extraction with phacoemulsification at the Department of Ophthalmology, Baskent University School of Medicine were randomized into two groups. After surgery, eyes in group A were injected with 1 mg/0.1 ml TA into the anterior chamber, but eyes in group B were not. Postoperatively; in group B, topical prednisolone acetate 1% eyedrops were administered six times per day for 7 days, then four times per day for 15 days, to control postoperative inflammation. In group A, topical corticosteroids were not used. To evaluate the efficacy of intracameral TA, anterior chamber cells, anterior chamber flare and conjunctival hyperaemia were measured on postoperative days 1, 7 and 30 by slit-lamp biomicroscopy. The safety of intracameral TA was evaluated by visual acuity measurements, intraocular pressure values and fundus examination. Tolerance variables were assessed by the degree of burning, stinging and blurred vision. Both treatments were equally effective in controlling postoperative inflammation following phacoemulsification. No statistically significant differences between groups were observed for the efficacy, safety and tolerance variables, and no serious adverse events were observed. Intracameral TA of 1 mg can effectively be used to control postoperative inflammation after uncomplicated cataract surgery with phacoemulsification. This makes it possible to decrease the dosage and duration of topical prednisolone acetate.

To assess the safety and effectiveness of the SOLX gold shunt (GS) in reducing intraocular pressure (IOP) in Japanese patients with open angle glaucoma (OAG). 24 eyes of 24 subjects [mean age of 68.9±12.7years; 13 (54%) women; 16 (67%) POAG, 7 (29%) pseudoexfoliation glaucoma, and 1 (4%) steroid response glaucoma] were implanted with the GS either with or without cataract surgery. Best-corrected visual acuity (BCVA), IOP, corneal endothelial cell density (CECD), anterior chamber (AC) flare, surgical complications, and required interventions were monitored at baseline, and 1day, 1week, 1, 3 and 6months, and 1year postoperatively. Baseline IOP of 21.3±4.1mmHg and glaucoma medications of 3.5±1.0 were significantly reduced at every follow-up visit. At 1year postoperatively, IOP was 16.4±5.8mmHg (23% reduction from baseline, p<0.0001) with use of 2.1±1.1 medications (40% reduction from baseline, p=0.0002). Intraoperative hyphema occurred in 5 (21%) eyes. Transient bleb formation occurred in 20 (83%) eyes, and AC cell was reported in 17 (71%) eyes. Inflammation-related complications such as posterior and anterior synechiae, or iritis/keratic precipitates tended to occur during late postoperative periods. At 1year, BCVA was unchanged or improved in 23 (96%) eyes. AC flare was elevated at 1week postoperatively and later. CECD declined at 3months and 1year postoperatively. The GS is effective in reducing IOP in Japanese patients with OAG. Chronic inflammation in AC might be associated with late onset complications.

Introduction: Corneal affection in glaucoma patients is very high due to various risk factors that may lead to unforeseen and unplanned deleterious effects on the cornea leading to vision loss. Accurate intraocular pressure determination requires corneal thickness measurement and uncontrolled intraocular pressures, use of long term medication, intra ocular surgeries including cataract and glaucoma shunt surgeries may cause significant endothelial loss. Therefore, adequate planning and management and follow-up in these patients is required weighing all the long term consequences and emphasis the need for implementing adequate precautions. Aim: To evaluate and compare the Central Corneal Thickness (CCT) and corneal Endothelial Cell Density (ECD) in patients with glaucoma and without glaucoma by specular microscopy. Materials and Methods: A case-control study conducted in a Shekar Eye Hospital, Bengaluru, Karnataka, India, was conducted from August 2016 till April 2018 on a total 182 eyes from 182 patients were evaluated comprising of 91 cases and 91 controls. All participants underwent a detailed ophthalmological examination including slit lamp biomicroscopy, Intraocular Pressure (IOP) measurement, and CCT and ECD measurement by Tomey EM 3000 noncontact specular microscopy. The Statistical analysis was completes using Statistical Package For the Social Sciences (SPSS) 18.0 and R environment version 3.2.2 software’s. Results: The CCT of the glaucoma patients and the controls showed no significant difference (p-value=0.172). The CCT was comparatively thicker in Ocular Hypertension (OHTN) patients and thinner in Normal Tension Glaucoma (NTG) however statistical significance was not established. The mean ECD of controls was 2509.05±298.48 (cells/mm3) and that of cases was 2465.68±392.91 (cells/mm3) (p-value=0.404). The difference in the ECD amongst the glaucoma subgroups was not statistically significant (p-value=0.588). However, a lower ECD were seen in Pseudoexfoliation Glaucoma (PXG) and Primary Angle Closure Glaucoma (PACG) subgroups. Conclusion: No significant difference was found in CCT and endothelial cell in cornea of patients with and without glaucoma. Normal Tension Glaucoma (NTG) patients have comparatively thinner corneas and OHTN patients had thicker corneas. There was no significant correlation established between ECD of Normal corneal vs. Glaucoma and its subgroups.

Background:Development of endophthalmitis during cataract surgery is one of the most severe complications and it may also result in blindness and globe loss.Aims:To evaluate the effect of an ophthalmic cefuroxime solution (Aprokam®) that is prophylactically used in phacoemulsification surgery performed due to cataract that eventually occurs in patients with or without penetrating keratoplasty.Study Design:Case-control study.Methods:In this retrospective study, patients who had undergone penetrating keratoplasty and for whom phacoemulsification surgery was performed due to cataract and an intracameral ophthalmic cefuroxime solution (Aprokam®) was administered for prophylaxis were evaluated in comparison with patients with cataract without keratoplasty. The following parameters were evaluated: postoperative anterior chamber reaction, intraocular pressure, best corrected visual acuity, corneal endothelial cell density, and central corneal thickness alterations.Results:A total of 42 patients (18 males, 24 females) with keratoplasty and 42 patients (17 males, 25 females) without keratoplasty were included in this study. An increase in visual acuity was observed in all the patients after cataract surgery (p<0.001). The mean corneal endothelial cell densitys were determined to be 2437.20±148.5 cells/mm2 preoperatively in the study group and 2807.1±152.4 cells/mm2 preoperatively in the control group. The mean corneal endothelial cell densitys were determined to be 2103.85±196.5 cells/mm2 after the first postoperative month (p<0.001) in the study group and 2755.92±182.7 cells/mm2 in the control group (p=0.17). The mean central corneal thickness in the study group were 565.78±11.5 μm preoperatively and 584.65±12.7 μm after the first postoperative month (p<0.001). No difference was observed in the control group in terms of preoperative and postoperative central corneal thickness and endothelial cell density. There was no significant difference between the groups in terms of the intraocular pressure, anterior chamber reaction.Conclusion:There was no significant effect of the prophylactic intracameral use of ophthalmic cefuroxime solution (Aprokam®) on the endothelial cells which was used in patients with keratoplasty for whom cataract surgery was performed.

This study compared the post-cataract surgery anti-inflammatory effects of topical treatment with 0.1% bromfenac, 0.1% betamethasone or both on postoperative anterior chamber inflammation and corneal swelling. Seventy-two patients with no eye disease other than cataract were enrolled in a prospective, randomized study to undergo phacoemulsification combined with intraocular lens implantation. After cataract surgery, patients were randomized to treatment with bromfenac, betamethasone or both agents. Twenty-five eyes were assigned to bromfenac, 23 to betamethasone and 24 to the combined treatment group. Inflammatory reactions in the anterior chamber were measured with laser flare photometry preoperatively and at 1 and 3 days, 1 and 2 weeks, and 1 and 2 months postoperatively. Intraocular pressure (IOP) and corneal thickness were measured at the same time-points. Best corrected visual acuity (BCVA) was measured preoperatively and at 2 days, 1 and 2 weeks, and 1 and 2 months postoperatively. Specular microscope endothelial photography of the central region of the cornea was performed preoperatively and at 3 months after surgery. There were no significant differences among the bromfenac, betamethasone and combined treatment groups in BCVA, IOP, aqueous flare or corneal thickness. Cystoid macular oedema was present in one eye treated with betamethasone. There were no significant differences in anti-inflammatory effects among the three treatments. These findings suggest that bromfenac is as effective as betamethasone in minimizing inflammatory reactions after cataract surgery.

AimWe conducted this study to evaluate and compare corneal endothelial cell loss between phacoemulsification with continuous anterior chamber infusion using anterior chamber maintainer (ACM) and phacoemulsification using ophthalmic viscosurgical device (OVD).Materials and MethodsThis was a prospective, randomized controlled trial. Fifty eyes of 47 patients of senile cataract undergoing phacoemulsification were included. Patients were randomly allocated into two groups of 25 eyes each. Cataract surgery was performed by phacoemulsification with anterior chamber (AC) continuous infusion with balanced salt solution (BSS) plus and ACM without OVD in Group A, and in Group B, phacoemulsification was performed using OVD with BSS plus. Corneal endothelial cell count and pachymetry were performed preoperatively and postoperatively on day 1, day 7, and day 30.ResultsThe mean increase in pachymetry was 4.86%, 2.94%, and 1.94%, (Group A) and 5.95%, 3.94%, and 0.51%, (Group B) on first, seventh, and 30th postoperative day respectively. The difference between the percentage increase in pachymetry between the two groups was not significant at day 1 (P = 0.441), day 7 (P = 0.298), and day 30 (P = 0.174) postoperatively. The density of endothelial cells decreased postoperatively (day 30) by 7.38% (Group A) and 7.47% (Group B) without any significant statistical difference (P = 0.983) between two groups.ConclusionUse of ACM for continuous AC infusion and omission of OVD during phacoemulsification did not cause significant difference in corneal swelling or endothelial cell loss in the immediate postoperative period up to one month.

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.

We sought to evaluate central corneal thickness (CCT), corneal endothelial cell density (ECD) and intraocular pressure (IOP) in patients with type 2 diabetes mellitus (DM) and to associate potential differences with diabetes duration and treatment modality in a prospective, randomized study. We measured ECD, CCT and IOP of 125 patients with type 2 DM (mean age 57.1±11.5 years) and compared them with 90 age-matched controls. Measured parameters were analyzed for association with diabetes duration and glucose control modalities (insulin injection or oral medication) while controlling for age. In the diabetic group, the mean ECD (2511±252 cells/mm²), mean CCT (539.7±33.6 μm) and mean IOP (18.3±2.5 mmHg) varied significantly from those the control group [ECD: 2713±132 cells/mm² (P<0.0001), CCT: 525.0±45.3 μm (P=0.003) and IOP: 16.7±1.8 mmHg (P<0.0001)]. ECD was significantly reduced by about 32 cell/mm² for diabetics with duration of >10 years when compared with those with duration of <10 years (P<0.05). CCT was thicker and IOP was higher for diabetics with duration of >10 years than those with duration of <10 years (P>0.05). None of the measured parameters was significantly associated with diabetes duration and treatment modality (P>0.05). In conclusion, subjects with type 2 DM exhibit significant changes in ECD, IOP and CCT, which, however, are not correlated with disease duration or if the patients receive on insulin injection or oral medications.

Update on Microinvasive Glaucoma Surgery.

Corneal thickness and endothelial cell density measured by non-contact specular microscopy and pachymetry in Rhesus macaques ( Macaca mulatta) with laser-induced ocular hypertension

Objective: To evaluate short term changes in anterior chamber depth (ACD), central corneal thickness (CCT), intraocular pressure (IOP), and corneal endothelial cell density (ECD) after intravitreal anti-vascular endothelial growth factor (VEGF) injections.Materials and methods: A total of 100 eyes from 100 patients, who were naive for intravitreal injection treatment, were included in this retrospective study. Patients who received only a single type of intravitreal anti-VEGF injections (bevacizumab, ranibizumab, or aflibercept) for two consecutive months were examined. ACD, CCT, IOP, and ECD measurements were taken at pre-injection and one month after the first and second injections and were compared.Results: The mean corneal ECD for all eyes and phakic eyes was significantly lower one month after the first (p = 0.041 and p = 0.047, respectively) and second injections (p = 0.013 and p = 0.034, respectively) compared to the values at pre-injection levels. Similarly, the mean ACD of all eyes and phakic eyes was significantly lower one month after the first (p < 0.001 and p < 0.001, respectively) and second injections (p < 0.001 and p < 0.001, respectively) compared to the values at pre-injection levels. However, there was no significant difference in pseudophakic eyes one month after the first and second injections (ECD, p = 0.28 and p = 0.23; ACD, p = 0.75 and p = 0.71, respectively). There was no significant change in IOP and CCT values at pre-injection and one month after the first and second injections for all eyes and for both the phakic and pseudophakic eyes.Discussion: After the anti-VEGF injections, IOP and CCT values were not significantly changed and were similar in all eyes and phakic eyes; however, in these groups, there was a small but statistically significant decrease in ACD and ECD. On the contrary, there was no significant difference in pseudophakic eyes. Clinicians performing intravitreal injections must be aware of these associations for a better understanding of ACD and ECD changes in phakic eyes.

To report the early postoperative results and safety profile of ab interno microhook trabeculotomy (μLOT) combined with cataract surgery. This retrospective observational case series included 68 consecutive glaucomatous eyes of 23 Japanese men and 25 Japanese women [mean (SD) age, 76.0±8.5years] who underwent μLOT for intraocular pressure (IOP) and visually relevant cataracts. The LOT site/extent, perioperative complications, and complication treatments were collected from the medical and surgical records. The preoperative and postoperative IOP, numbers of antiglaucoma medications, logarithm of the minimum angle of resolution visual acuity (VA), anterior chamber (AC) flare, and corneal endothelial cell density (CECD) were compared. After small incisional cataract surgery, the trabecular meshwork was incised in the nasal (6 eyes, 3.6±0.5 clock hours), temporal (6 eyes, 3.8±0.8 clock hours), or both nasal and temporal (56 eyes, 6.5±0.6 clock hours) angles. The mean preoperative IOP (16.4±2.9mmHg) and number of antiglaucoma medications (2.4±1.2) decreased significantly (P<0.0001 and P=0.0039, respectively) to 11.8±4.5 and 2.1±1.0mmHg at 9.5months postoperatively. Compared with the preoperative conditions, the final VA improved (P=0.0002), the AC flare increased by 6.3 pc/ms (P=0.0157), and the CECD decreased by 6% (P=0.0005). Hyphema with niveau formation (28 eyes, 41%) and hyphema washout (6 eyes, 9%) were the most common postoperative complication and intervention, respectively. At the final visit, 54 eyes (79%) had achieved successful IOP control of 15mmHg or less and IOP reduction of 15% or greater. Combined μLOT and cataract surgery improves IOP and VA during the early postoperative period in patients with glaucoma and cataract.

This study set out to evaluate the influences of uneventful phacoemulsification on the anterior segment parameters obtained with the Pentacam rotating Scheimpflug camera and intraocular pressure (IOP). A total of 42 eyes of 34 patients (26 men, eight women) were evaluated preoperatively, and at 1, 3 and 6 months postoperatively with the Pentacam. Intraocular pressure was measured with the Goldmann applanation tonometer. The non-parametric paired t-test was used to compare preoperative and 1-, 3- and 6-month postoperative measurements of anterior chamber depth (ACD), anterior chamber volume (ACV), anterior chamber angle (ACA) width, central corneal thickness (CCT), the central 3-, 5- and 7-mm corneal volume (CV), pupil size, and IOP. Pearson's correlation test was used to evaluate the relationships between IOP and ACD, ACV and ACA width. The differences between ACD, ACV, ACA and IOP values taken preoperatively and those taken postoperatively at 1, 3 and 6 months were statistically significant (p<0.05). The differences between CCT, central 3-, 5- and 7-mm CV, and pupil size measurements taken preoperatively and those taken postoperatively at 1, 3 and 6 months were not statistically significant (p>0.05). The decrease in IOP was not correlated with the changes in ACD, ACV and ACA (p>0.05). Uneventful phacoemulsification significantly reduced IOP, increased ACD and ACV, and widened the ACA. However, alterations in CV, CCT and pupil size values were not statistically significant. Alterations in ACD, ACV, ACA and IOP remain stable after the first month of surgery.

To report the first early postoperative results and safety profile after microhook ab interno trabeculotomy (μLOT). This initial retrospective observational case series included 24 consecutive glaucomatous eyes of 17 Japanese patients (7 men, 10 women; mean age±standard deviation, 66.7±17.9years) who underwent μLOT. The trabeculotomy extent, surgical time, perioperative complications, interventions for complications and additional glaucoma surgeries during the follow-up for more than 3months were collected by reviewing the medical and surgical records. The intraocular pressure (IOP), numbers of antiglaucoma medications, logarithm of the minimum angle of resolution visual acuity (VA), anterior chamber (AC) flare and corneal endothelial cell density (CECD) were compared preoperatively and postoperatively. The trabecular meshwork was incised for a mean of 3.6±0.5 clock hours temporally, 3.7±0.5 clock hours nasally and total 7.3±0.6 clock hours during the 6.2±1.6-min surgery. The mean preoperative IOP of 25.9±14.3mmHg and number of antiglaucoma medication of 3.3±1.0 decreased significantly (p=0.0002 and p=0.005, respectively) to 14.7±3.6mmHg and 2.8±0.8 at the final visit at 188.6±68.8days postoperatively. Compared with preoperatively, the final VA, AC flare and CECD did not change significantly. Hyphema with niveau formation (nine eyes, 38%) and washout of hyphema (two eyes, 8%) were the most common postoperative complication and intervention, respectively. At the final visit, 19 eyes (79%) achieved successful IOP control of 18mmHg or less and a 15% reduction or greater. Microhook trabeculotomy normalizes the IOP during the early postoperative period in patients with glaucoma.