Ab Externo Research Articles

Ab Externo Transconjunctival XEN® 45 Gel Stent Implantation: Efficacy and Safety of a New Surgical Technique

Ab Externo Transconjunctival XEN® 45 Gel Stent Implantation: Efficacy and Safety of a New Surgical Technique

Long-term efficacy and safety of ab externo canaloplasty in the Polish Caucasian population with open-angle glaucoma: A 3-year retrospective study.

This study aimed to assess the effectiveness and safety of ab externo canaloplasty over a 3-year follow-up period in Polish Caucasian patients with glaucoma. This retrospective study of a cases series was conducted at the Department of Ophthalmology Medical University of Bialystok, Poland. Primary outcome measures were intraocular pressure and medication burden. Secondary outcome measures were best corrected visual acuity, retinal nerve fiber layer thickness, visual field test results, endothelial cell density, intraoperative and postoperative complications, and additional glaucoma surgery. The study group consisted of 160 eyes diagnosed with early to-moderate primary open-angle glaucoma and treated with ab externo canaloplasty from 2014 to 2020. The criteria for qualified and complete success were intraocular pressure < 18 mmHg or ≥ 20% reduction in intraocular pressure from baseline with or without antiglaucoma medications, respectively. After surgery, the mean intraocular pressure decreased from 19.23 ± 4.33 to 14.52 ± 3.79 mmHg, which constituted a 36.7 ± 7.8% reduction compared to the baseline value. The number of medications decreased by two at the end of the study period (from 2.69 ± 1.05 to 0.32 ± 0.75). Complete and qualified success were achieved in 58.7% and 68.7% of the patients, respectively, at the end of follow-up. An incomplete cannulation of Schlemm's canal was the most common intraoperative complication, occurring in 32 eyes (20%). The most frequent postoperative complications were hyphema, Descemet's membrane detachment, and a transient increase in intraocular pressure. Additional surgical procedure was required in seven cases (4.4%). In 16 patients (10%), medical treatment was re-administered. Overall, our findings suggest that ab externo canaloplasty is a good option for Polish Caucasian patients with primary open-angle glaucoma. It reduces intraocular pressure and has a low postoperative complication rate. Additional glaucoma surgery or re-administration of medications is required if the target intraocular pressure is unsatisfactory.

Outcomes of Trabeculectomy and Predictors of Success in Patients of African Ancestry with Primary Open Angle Glaucoma.

To investigate outcomes of trabeculectomy ab externo in African ancestry primary open-angle glaucoma (POAG) patients, and to analyze the impact of demographic and phenotypic factors on surgical success and complication rates. A retrospective case-control study enrolled 63 eyes of 55 POAG cases who underwent trabeculectomy ab externo. Data on demographics, family glaucoma history, surgical specifics, and pre/postoperative measures (intraocular pressure, visual acuity, visual field, medication usage, complications within one year) were collected. Analysis included linear/logistic regression models adjusting for inter-eye correlation. Trabeculectomy yielded success without additional medication in 46%, qualified success with medication in 22%, and surgical failure necessitating further intervention in 32% within one year. Subjects experienced reduction in intraocular pressure (IOP) (46%), daily glaucoma medication (73%), and eye drop usage (67%) 1-year post-trabeculectomy (all P<0.001). However, there was a postoperative decline of 56% in visual acuity (VA) (P<0.001) and a significant worsening of visual field parameters, including a 14% decrease in mean deviation (P=0.02) and a 19% decrease in visual field index (P=0.004). Top of FormBottom of Form59% of patient eyes experienced complications within one year of surgery. Univariate analysis of predictive factors for surgical outcomes revealed that younger age at surgery (P=0.01) and family history of glaucoma (P=0.046) were predictive of lower rates of surgical success. Multivariable analysis revealed worse preoperative VA (OR 0.79 per 0.1 LogMAR increases, P=0.02) was associated with lower likelihood of surgical success. This study underscores the low rates of trabeculectomy success and high rates of complications in an African ancestry population with POAG. While the procedure exhibited positive effects on IOP control and medication reduction, our analysis found that multiple factors, particularly age, family history, and worse preoperative VA play crucial roles in influencing surgical success. Trabeculectomy in African ancestry individuals with primary open-angle glaucoma shows a 46% success rate and frequent complications, indicating that younger age and family history are significant predictors of surgical failure in this high-risk population.

Large animal model species in pluripotent stem cell therapy research and development for retinal diseases: a systematic review.

Retinal cell therapy modalities, in the category of advanced therapy medicinal products (ATMPs), are being developed to target several retinal diseases. Testing in large animal models (LAMs) is a crucial step in translating retinal ATMPs into clinical practice. However, challenges including budgetary and infrastructure constraints can hinder LAM research design and execution. Here, to facilitate the comparison of the various LAMs in pluripotent retinal cell therapy research, we aimed to systematically evaluate the species distribution, reported scientific utility, and methodology of a range of LAMs. A systematic search using the words retina, stem cell, transplantation, large animal, pig, rabbit, dog, and nonhuman primate was conducted in the PubMed, Embase, Science Direct and GoogleScholar databases in February 2023. We included 22 studies involving pluripotent stem cells (induced pluripotent stem cells or human embryonic stem cells) in LAMs, including non-human primates (NHP), pigs, dogs, and rabbits. Nearly half of the studies utilized wild-type animal models. In other studies, retinal degeneration features were simulated via laser, chemical, or genetic insult. Transplants were delivered subretinally, either as cell suspensions or pre-formed monolayers (with or without biodegradable scaffolding). The transplanted cells dose per eye varied widely (40,000 - 4,000,000 per dose). Cells were delivered via vitrectomy surgery in 15 studies and by an "ab externo" approach in one study. Structural outcomes were assessed using confocal scanning laser ophthalmoscopy imaging. Functional outcomes included multifocal electroretinogram and, in one case, a measure of visual acuity. Generally, cell suspension transplants exhibited low intraretinal incorporation, while monolayer transplants incorporated more efficiently. Immune responses posed challenges for allogeneic transplants, suggesting that autologous iPSC-derived transplants may be required to decrease the likelihood of rejection. The use of appropriate LAMs helps to advance the development of retinal ATMPs. The anatomical similarity of LAM and human eyes allows the implementation of clinically-relevant surgical techniques. While the FDA Modernization Act 2.0 has provided a framework to consider alternative methods including tissue-on-a-chip and human cell culture models for pharmacologic studies, LAM testing remains useful for cell and tissue replacement studies to inform the development of clinical trial protocols.

Efficacy and safety of penetrating canaloplasty versus ab externo canaloplasty for primary open-angle glaucoma: A randomized controlled trial.

To report the 2-year efficacy and safety of penetrating canaloplasty versus ab externo canaloplasty for the treatment of primary open-angle glaucoma (POAG). A single surgical site in China. This was a prospective, randomized controlled trial. POAG patients were randomly assigned to the penetrating canaloplasty or ab externo canaloplasty group. This study enrolled POAG patients who underwent penetrating canaloplasty or ab externo canaloplasty randomly. Surgical success, intraocular pressure (IOP), number of glaucoma medications, and surgical complications were evaluated until 24 months post-operatively. Surgical success was defined as 6 mmHg ≤ IOP ≤21 mmHg with an IOP reduction ≥20%, which included qualified success (with or without medications) and complete success (without medications). A total of 52 eyes (45 patients) were randomly assigned to one of two groups: the penetrating canaloplasty group (PCP, n = 26) or the ab externo canaloplasty group (CP, n = 26). The probabilities of qualified success and complete success were 92.3% and 76.9%, respectively, in the PCP group and 64.1% and 52.1%, respectively, in the CP group at 24 months (p = 0.013, p = 0.042, log-rank test). The mean IOP decreased from 30.8 ± 10.7 and 28.6 ± 11.8 mmHg to 14.1 ± 3.3 mmHg in the PCP group and 22.1 ± 13.6 mmHg in the CP group at year two (p = 0.007). The PCP group also received fewer medications (0.2 ± 0.5) than did the CP group (0.7 ± 1.2) at year two (p = 0.038). Post-operative complications were similar, and the most common complications were transient IOP elevation and hyphema in the PCP group (42.3%, 46.2%) and the CP group (38.5%, 23.1%) (p > 0.05). Compared to ab externo canaloplasty, penetrating canaloplasty had a greater surgical success rate and better IOP reduction with a comparable rate of complications.

Plasma rich in growth factors (PRGF) technology as adjuvant to Ab Externo trabeculectomy.

Plasma rich in growth factors (PRGF) technology creates blood-derived products with growth factors that promote wound healing and regeneration. The goal of this study was to assess the potential role of PRGF products as wound modulators in trabeculectomy. Our premise is that due to PRGF's regenerative and antifibrotic properties, its use in trabeculectomy may produce a more physiological bleb, without altering IOP reduction. A retrospective, longitudinal study was conducted in a Hospital in Portugal. Patients with eyes with open angle glaucoma were included. Trabeculectomy was performed on all patients using PRGF membrane (mPRGF) under the conjunctiva, as adjuvant. Data regarding patients' demographics and number of medications used, was collected. Intraocular pressure (IOP) before surgery, 8days, 1month, 3month, 6month, 9month and 1year after surgery was recorded. Bleb morphology was classified according to Moorfields Bleb Grading System 6months after surgery. Nine eyes of 9 patients were enrolled. Mean age was 71 ± 5.1years old. Six were male. Mean IOP decreased from 24.0 ± 8.8mmHg pre-surgery to 12.9 ± 2.6mmHg at one year follow-up. The number of hypotensive drugs (mean ± SD) was 4.3 ± 0.9 preoperatively and 0.8 ± 1.1 at 1-year. Complete success was defined as IOP equal to or less than 21mm Hg without ocular hypotensive medications and qualified success as IOP equal to or less than 21mm Hg with medications. Complete success was 66.7% and qualified success was 100% at 1year follow-up. In our study, trabeculectomy with mPRGF demonstrated both safety and efficacy. Low values of bleb height (1.6 ± 0.8) were recorded. mPRGF could improve wound healing and produce a more well-tolerated, favourable bleb, avoiding antimetabolite complications.

Double implantation of Xen 45 gel stent in primary open-angle glaucoma: a pilot study.

To describe the outcomes of double implantation of Xen 45 Gel Stent (Xen) using an ab externo approach with closed conjunctiva. Retrospective single-centre case series of primary open-angle glaucoma patients with at least six months of follow-up after implantation of a second Xen in the same eye via ab externo technique without conjunctival opening. Eight pseudophakic eyes of 8 patients were included. Intraocular pressure (IOP) dropped from 30 ± 2.6mmHg pre-operatively to 22.4 ± 2.3mmHg one month after the first Xen implant (mean difference: -7.6mmHg [95% confidence interval: -9.4, -5.9mmHg], p = 0.0092). A second Xen was then implanted to achieve the target IOP. The procedure showed no significant intraoperative or postoperative complications. The IOP dropped to 16.1 ± 2.7mmHg six months following this second implant (mean difference: -6.3mmHg [95% confidence interval: -7.2, -5.3mmHg], p = 0.0183); however, 3 patients needed medical therapy to further reduce the IOP towards the target value. Sequential implantation of two Xen 45 Gel Stents using an ab externo approach with closed conjunctiva appears a promising procedure that showed a favorable safety and efficacy profile in this small case series. This pilot data might pave the way for further studies to evaluate the safety and efficacy of the procedure.

Mitomycin C 0.2 mg/ml versus Mitomycin C 0.4 mg/ml during the Implantation of an Ab Externo Polystyrene-isobutylene-styrene Microshunt: A Mega-analysis

PurposeTo compare the effectiveness and adverse event profile of standalone SIBS microshunt implantation with adjunct MMC 0.2 mg/ml and MMC 0.4 mg/ml. DesignMega-analysis using individual patient data from international prospective and retrospective clinical studies. Study PopulationPatients with glaucoma who underwent implantation of a SIBS microshunt with MMC as a standalone procedure. MethodsA comparison of eyes that received MMC 0.2 mg/ml or 0.4 mg/ml Main Outcomes MeasuresPrimary outcome was complete success defined as the proportion of eyes at one year with all of the following: (1) no two consecutive IOPs > 17 mmHg; (2) no clinical hypotony (3) ≥20% IOP reduction from baseline and (4) no use of glaucoma medications. Secondary outcomes included IOP thresholds of 12 mmHg,14 mm Hg and 21mmHg, median IOP, number of medications, risk factors for failure, interventions, adverse events, and reoperations. ResultsAt 1 year, the complete success rate was significantly higher (71.3% vs 50.46%, p<0.001) and the median IOP significantly lower (13.0 vs. 14.2 mmHg, p<0.05) in the MMC 0.4 mg/ml group. MMC 0.2 mg/ml was found to be a significant risk factor for failure (HR 1.75 95%CI 1.14 to 2.67). Needling and surgical revision occurred at a lower rate in the MMC 0.4 mg/ml group (7% vs. 18.8%, p= 0.002 and 4.3% vs.13.7% p= 0.0087, respectively). Adverse events occurred at a similar frequency in both groups (26.6% MMC 0.2 mg/ml vs. 29.6% MMC 0.4 mg/ml, p=0.46), most of which were early and transient. ConclusionSIBS microshunt implantation with MMC 0.4 mg/ml resulted in a higher success rate with greater IOP reduction compared to MMC 0.2 mg/ml. Higher MMC concentration was not associated with increased serious adverse events.

Xen-DS: a novel technique of ab externo Xen implantation augmented with a modified deep sclerectomy for surgical treatment of glaucoma.

The Xen gel stent is a surgical glaucoma device which creates a subconjunctival filtering bleb, which has demonstrated good intraocular pressure (IOP) lowering and safety. Nonetheless, bleb-related problems have been reported. We present a case series of ab externo Xen procedures augmented with a deep intra-scleral lake, aiming to improve both IOP-lowering and post-operative management. A retrospective review of 20 patients who underwent combined Xen gel stent implantation with modified deep sclerectomy at our institution from June to November 2022, with a 6-month follow-up period. We reviewed demographics, past ocular history, visual acuity (VA), IOP, visual fields, glaucoma medication use, complications, and perioperative information. 20 eyes of 20 patients, with a mean age of 67.45 ± 14.38 underwent surgery. Pre-operative initial IOP was 24.5 ± 7.96 mmHg, improving to 11.50 ± 2.96 mmHg at 6 months; a change of -12.89 ± 8.34 mmHg and a mean decrease of 51.13 ± 20.15% (p < 0.0001) Patients were on 3.1 ± 0.72 glaucoma medications pre-operatively, improving to 0.72 ± 1.27 at 6 months (p < 0.0001). Visual field mean deviation was -13.99 ± 9.98 dB pre-operatively and -10.27 ± 9.06 dB at 6 months, with VA of 0.287 ± 0.69 pre-operatively and 0.31 ± 0.76 LogMAR post-operatively. No patients required bleb needling. 2 patients underwent subsequent bleb revision surgery. 2 patients developed choroidal effusions, which were managed conservatively with good visual outcomes. In this preliminary study, we have found the modification of Xen gel stent implant surgery with a modified deep sclerectomy to offer good IOP lowering, with low rates of bleb needling and a good safety profile.

Склерокорнеальная фиксация заднекамерных интраокулярных линз в осложненных случаях хирургии катаракты с использованием политетрафторэтиленовых нитей

Original article Sclerocorneal fixation of posterior chamber intraocular lenses in complicated cases of cataract surgery using polytetrafluoroethylene sutures T.G. Sazhin, M.O. Sokolova Clinical Hospital «RZD-Medicine», Saint Petersburg, Russian Federation S.M. Kirov Militar y Medical Academy Ministr y of Defense of the Russian Federation, St. Petersburg, Russian Federation Relevance. Dislocation of the intraocular lens (IOL) is a serious complication in cataract surgery. Therefore, the search for an effective method of IOL fixation for non-standard surgical situations is still important. Purpose. To analyze clinical results of flanged corneoscleral IOL fixation the technique using polytetrafluoroethylene sutures. Material and methods. The results of surgical treatment of 34 patients (34 eyes) who underwent IOL suturing with suture material made of polytetrafluoroethylene 6-0 (Ecoflon) through the sclera and fixation of flanges in the lumen of corneal paracentesis (Sclerocorneal IOL Fixation Technique) without incisions of the conjunctiva and sclera were analyzed. Results. The average index of maximally corrected visual acuity before surgery was 0.27±0.11. A day after surgery, this parameter increased to 0.41±0.1. One week after surgery, the average index of maximally corrected visual acuity was 0.65±0.1, while the improvement in visual acuity was statistically significantly different from the parameter before surgery and a day after surgery (p&lt;0.05). Conclusion. Application of polytetrafluoroethylene suture material in the ab externo technique, passing through the sclera and fixing the flanges in the lumen of the corneal paracentesis is safe and effective method. As a result, patients had positive visual acuity dynamics with a low frequency of complications. Key words: dislocation of IOL, aphakia, sclerocorneal fixation, polytetrafluoroethylene suture, flanged technique

In vivo evaluation of a nanotechnology-based microshunt for filtering glaucoma surgery

To carry out the preclinical and histological evaluation of a novel nanotechnology-based microshunt for drainage glaucoma surgery. Twelve New Zealand White rabbits were implanted with a novel microshunt and followed up for 6 weeks. The new material composite consists of the silicone polydimethylsiloxane (PDMS) and tetrapodal Zinc Oxide (ZnO-T) nano-/microparticles. The microshunts were inserted ab externo to connect the subconjunctival space with the anterior chamber. Animals were euthanized after 2 and 6 weeks for histological evaluation. Ocular health and implant position were assessed at postoperative days 1, 3, 7 and twice a week thereafter by slit lamp biomicroscopy. Intraocular pressure (IOP) was measured using rebound tonometry. A good tolerability was observed in both short- and medium-term follow-up. Intraocular pressure was reduced following surgery but increased to preoperative levels after 2 weeks. No clinical or histological signs of inflammatory or toxic reactions were seen; the fibrotic encapsulation was barely noticeable after two weeks and very mild after six weeks. The new material composite PDMS/ZnO-T is well tolerated and the associated foreign body fibrotic reaction quite mild. The new microshunt reduces the IOP for 2 weeks. Further research will elucidate a tube-like shape to improve and prolong outflow performance and longer follow-up to exclude medium-term adverse effects.

Ab Externo Scleral-Fixated Intraocular Lens As A Management in Aphakic Eye

Introduction : Varied technique of secondary intraocular lens (IOL) implantation are exist. Scleral-fixated IOL implantation become popular both with or without sutures. The one of sutures technique is ab externo&#x0D; Case Illustration : A 68 year old man came with blurry vision on left eye (LE) since one month ago. He had history of primary angle closure suspect and posterior subcapsular cataract on LE and managed with Intracapsular Cataract Extraction in January 2021. Ophthalmology examination of LE revealed uncorrected visual acuity (UCVA) 1/60, irregular updrawn pupil with diameter 7.4mm x 5.3 mm, and aphakic lens. The best corrected visual acuity (BCVA) with S+12.00 C-0.75 x 80 was 0.4f. The patient underwent secondary IOL by using 3 pieces IOL with ab externo scleral- fixated on his left eye (Figure 1). Power IOL determined was +24.00 diopter with target of refraction was emmetropia. One day postoperatively, the UCVA was 0.08 pinhole 0.125 with good centration of scleral fixation IOL. First month postoperatively, BCVA with S-1.75 C-1.00 x 50 was 0.4 on snellen chart.&#x0D; Discussion : Aphakia with inadequate capsular support can be seen in several conditions. Technique of introducing two suture loops for scleral fixation of an IOL by ab externo procedure, which proved safe and effective. Scleral fixation of IOL in the posterior chamber, although technically demanding, allows good visual outcomes.&#x0D; Conclusion : Ab externo scleral-fixated IOL implantation is an effective rescue procedure for eyes with deficient capsular support.

A Review of Canaloplasty in the Treatment and Management of Glaucoma.

To review the published literature evaluating the safety and efficacy outcomes of canaloplasty performed in the treatment of glaucoma. Canaloplasty is a nonpenetrating glaucoma procedure involving combined 360° circumnavigation and viscodilation of Schlemm's canal. The procedure may be performed under an ab externo (with tensioning suture) or ab-interno (conjunctiva-sparing) approach. Given the wide variety of glaucoma procedure types and approaches, further investigation into the role of canaloplasty in ophthalmological practice is warranted. The objectives of this narrative review are to synthesize the existing literature in order to investigate indications, safety and efficacy outcomes, and the optimal place of canaloplasty in glaucoma treatment and management. A total of 60 articles were included in this review. Both ab externo and ab-interno canaloplasty (ABiC) were found to be significantly effective at reducing intraocular pressure (IOP) and glaucoma medication burdens in patients with mild-to-moderate open-angle glaucoma (OAG). These findings remained consistent regardless of phacoemulsification status. ABiC was found to exhibit a safety profile favorable compared to trabeculectomy and comparable to minimally invasive trabecular bypass implants. Canaloplasty is a nonpenetrating surgical intervention that is highly effective in treating patients with mild-to-moderate OAG across a large variety of clinical scenarios. These findings support the clinical use of canaloplasty in ophthalmological practice, clarify its patient profile, and compare procedural outcomes to other minimally invasive glaucoma surgery (MIGS) devices on the market. Wagner IV, Towne C, Saade MC, et al. A Review of Canaloplasty in the Treatment and Management of Glaucoma. J Curr Glaucoma Pract 2024;18(2):79-85.

Ten-year results of scleral-fixated intraocular lens implantation: outcomes of ab externo scleral fixation with 10-0 polypropylene suture.

To describe long-term visual and anatomical outcomes of sutured scleral-fixated intraocular lens (SF IOL) implantation. Tertiary eyecare hospital in India. Retrospective interventional noncomparative study. Postoperative change in corrected distance visual acuity (CDVA) and occurrence of complications were assessed from the patient medical records. Long-term SF IOL survival rates and factors affecting the occurrence of postoperative IOL-related complications were assessed. Patients with postoperative follow-up less than 10 years or incomplete medical records were excluded. 64 eyes of 53 patients were included. Follow-up duration was 11.4 ± 1.2 years. Mean preoperative CDVA was 0.71 ± 0.43 logMAR (Snellen equivalent: 6/30), and mean CDVA at the final visit was 0.52 ± 0.49 logMAR (Snellen equivalent: 6/18) (P < .01). 48% cases had CDVA of 6/12 or better at the last follow-up. 58% cases had coexistent ocular pathology affecting the final visual outcome. IOL and suture-related complications were the commonest and included IOL decentration (17% cases), IOL drop (14%), and suture exposure (6%). The probability of IOL survival (postoperative period without IOL-related complications) was 90.6% at 8 years and 81.2% at 10 years (Kaplan-Meier analysis). Occurrence of postoperative IOL-related complications was unaffected by patient sex, age, indication for surgery (trauma or other), previous intraocular surgery, or technique of scleral fixation (2-point or 4-point) (multivariate regression analysis). Although sutured SF IOL implantation is viable with favorable long-term visual outcomes, there is a risk of postoperative IOL-related complications. Occurrence of postoperative IOL-related complications is unaffected by patient and ocular factors.

Ab Externo Choroidal Fluid Drainage, Pars Plana Vitrectomy, and Endotamponade for the Management of Persistent Hypotony following Glaucoma Surgery.

Persistent severe serous choroidal detachment is a rare complication after glaucoma surgery. Surgical treatment with choroidal fluid drainage through a scleral incision is an option in these cases. Combining this procedure with pars plana vitrectomy and gas endotamponade has potential advantages. In the following, the perioperative course of this surgical option in a small cohort will be presented. This is a retrospective cohort study of the postoperative course of ab externo drainage of persistent serous choroidal detachment (≥4 weeks) in combination with pars plana vitrectomy and gas endotamponade in six eyes of six patients after exhausting all conservative treatment options. Inclusion criterion was persistent hypotony with severe serous choroidal detachment after intraocular pressure (IOP) lowering surgery due to medically uncontrolled glaucoma. Eyes were evaluated according to resolution of choroidal detachment, change in IOP and visual acuity (VA), postdrainage complications, and need for further surgeries. Before surgery, all patients presented with flat anterior chamber, decreased vision, and persistent choroidal detachment. The surgery itself was uneventful, but due to the complexity of the cases, tailoring the procedure to each patient's needs was required. Complete resolution of choroidal effusion was achieved by one month in 5 eyes and in 1 eye by month 3. There was an increase in average IOP from 5 (±2.1) mmHg before surgery to 11.3 (±3.7) mmHg and in VA from 1.7 (±0.8) to 1.2 (±0.6) logMAR. Five out of six patients required additional surgery, mainly to further increase the IOP even though choroidal detachment had already resolved. Ab externo choroidal fluid drainage combined with pars plana vitrectomy and gas endotamponade seems to be an effective and safe treatment option in persistent ocular hypotony. Although repeated surgeries might be necessary, large-scale prospective studies must be undertaken to provide corroborative evidence.

Comparing Outcomes of Trabeculectomy with Mitomycin C to 45-μm Gelatin Stent Placed Ab Externo with Open Conjunctiva

PurposeTo compare trabeculectomy with mitomycin C (trab-MMC) and XEN®45 Gel Stent placed ab externo with open conjunctiva (XGS AEO) with or without cataract surgery in patients with glaucoma. DesignNonrandomized, retrospective comparative study. SubjectsA total of 204 eyes from 204 glaucoma patients who received XGS placed AEO or underwent trab-MMC with or without cataract surgery between July 2018 and August 2021 at Massachusetts Eye and Ear. MethodsVisits from 204 patients’ charts were reviewed following either trab-MMC or XGS AEO from 2018-2021 from a level 3 triage center. Main Outcome MeasuresIntraocular pressure (IOP), medication burden, Kaplan-Meier success rates, 5-fluorouracil impact, and complications. Results157 patients underwent trab-MMC and 47 underwent XGS AEO. Groups had similar baseline intraocular pressure (IOP) and medications (meds). IOP and meds decreased similarly at 1.5 years (11.2 mmHg vs 7.4 mmHg, p=0.62; 2.9 vs 2.8 meds, p=0.92, respectively for trab-MMC and XGS AEO). Success was defined as IOP reduction ≥ 20% with 5 mmHg ≤ IOP ≤ 18 mmHg for 2 consecutive visits. Complete success (CS) did not allow meds; qualified success (QS) allowed for ≤ baseline meds. When IOP fluctuations in the first 60 days were not counted as failures, CS was 43% for trab-MMC, about 8.5% higher than for XGS AEO (p<0.01). QS was similar between the groups (65-67%). Procedure time was shorter for XGS AEO than trab-MMC (44 vs 63 min, p<0.01). ConclusionsXGS AEO may provide similar benefits to trab-MMC, especially for patients who tolerate some meds, with shorter procedure times.

Trabeculotomy (ab externo) as primary intervention for open-angle glaucoma : 5-year results

The published results of trabeculotomy ab externo (TOT), as an outflow channel surgery in adults with open-angle glaucoma, are underrepresented in comparison with other pressure-lowering glaucoma procedures. To determine the long-term pressure lowering effect and complications of TOT as astand-alone procedure or in combination with phacoemulsification with intraocular lens implantation (PIT) as aprimary pressure-lowering procedure in adult patients with forms of chronic open-angle glaucoma. This was aretrospective analysis of 121 eyes of 106 patients wherby 90eyes underwent TOT and 31eyes underwent PIT. The follow-up period was 5years. Follow-up was performed in the same center under standardized conditions. Preoperative as well as postoperative best-corrected distance visual acuity, intraocular pressure, pressure-lowering medication, and complications were recorded. For success criterion1, the intraocular pressure was not allowed to exceed 17 mm Hg at any control. For success criterion2, the intraocular pressure was allowed to be above 17 mm Hg at 1 control throughout the follow-up period. Preoperative intraocular pressure in the TOT group was 25.92 mm Hg (SD 6.58) and 26.32 mm Hg (SD 6.06) in the PIT group. The annual cumulative success rates with pressure-lowering medications for success criterion1 were 92.8%, 82.5%, 70.5%, 52.7% and 26.1%. For success criterion2 these were 97.9%; 94.9%, 93.2%, 91.3%, and 89%. We found no relevant difference in pressure reduction between TOT and PIT. Without pressure-lowering medications, success rates were significantly lower for both success criteria. No serious complications occurred. The most common postoperative complication was spontaneously resorbable hyphema. Performing TOT or PIT as aprimary glaucoma procedure for chronic open-angle glaucoma in adults is reasonable, has a significant pressure-lowering effect and very low complication rate.

Closed-loop Scleral Fixation with 4-eyelet Intraocular Lens Implantation for Aphakia: Clinical Outcomes

Purpose: We present a modified, closed-loop scleral fixation technique. We inserted a 4-eyelet intraocular lens (IOL) into the anterior chamber prior to fixation. We investigated the clinical results.Methods: We retrospectively reviewed 39 eyes (39 patients) that underwent modified four-point scleral fixation of an inserted lens in our center from May 2019 to June 2022. The surgical procedure features conjunctival peritomy, 4-eyelet IOL insertion, eyeball penetration using a 9-0 polypropylene needle, eyelet placement using an ab externo technique to form a continuous loop, centering of the optic, and tying of a knot. We compared preoperative and 6-month postoperative changes in best-corrected visual acuity (BCVA), intraocular pressure, and refraction errors, and described postoperative complications.Results: The mean patient age was 62 years. The indications for surgery included complicated cataracts (20.5%), aphakia (20.5%), staged surgery for complicated cataract (12.8%), non-traumatic IOL dislocation (30.8%), traumatic IOL dislocation (12.8%), and crystalline lens dislocation (5.1%). The postoperative BCVA (0.40 logarithm of the minimum angle of resolution [logMAR]) was significantly better than the preoperative BCVA (0.69 logMAR) (&lt;i&gt;p&lt;/i&gt; = 0.018). The postoperative spherical equivalent and the target diopter measurement were in high agreement (&lt;i&gt;p&lt;/i&gt; = 0.002, intraclass correlation coefficient = 0.616). All of ocular hypertension (7.7%), hypotony (5.1%), bullous keratopathy (5.1%), and macular edema (5.1%) were noted, but 78% of the conditions improved with short-term medication. There was no re-dislocation of a fixated IOL.Conclusions: Our surgical technique simply and rapidly treats aphakia. Optic repositioning was easy, the IOL stability high, and the risk of complications during IOL fixation low.

Recanalization of Xen45 gel stent implant occlusion using 10 − 0 nylon suture in refractory glaucoma: a case report

BackgroundXen Gel Stent implant is a new minimally invasive surgical treatment for glaucoma that has been proven effectiveness and safety profile. However, it may also lead to some complications. Xen Gel Stent occlusion is a relatively rare complication reported less frequently and has limited treatment experience. In our case report, we proposed a novel surgical treatment using a 10 − 0 nylon suture to successfully recanalize the occluded Xen45 Gel Stent.Case presentationA 16-year-old female patient had bilateral juvenile glaucoma for the past 5 years. Her right eye had undergone three glaucoma surgeries but failed. At a presentation to our hospital, the right eye’s intraocular pressure (IOP) was 30 mmHg despite applying four different active principles. Xen45 Gel Stent implant was chosen for treatment, but six days after implantation, the IOP rose to 40 mmHg as a result of an anterior chamber tip occlusion of the Xen45 Gel Stent. Nd: YAG laser shockwave therapy was attempted but failed. The patient eventually had to return to the operating room for a revision procedure. The Xen45 Gel Stent was recanalized from the ab externo by making an L-shaped conjunctival incision at the fornix base and threading a 10 − 0 nylon suture through it. The IOP was successfully controlled in the 11-month follow-up without medication.ConclusionIf postoperative occlusion arises after Xen45 Gel Stent implantation, surgery using 10 − 0 nylon suture to recanalize Xen45 Gel Stent should be considered as a relatively safe, effective that does not require removal of Xen45 Gel Stent.

Comparing Outcomes of 45 Xen Implantation Ab Interno With Closed Conjunctiva to Ab Externo With Open Conjunctiva Approaches.

Ab externo with open conjunctiva placement may lead to improved gelatin stent (XEN Gel Stent; Allergan) success rate compared with ab interno with closed conjunctiva because it conferred more favorable intraocular pressure (IOP) and medication burden reduction based on our complete and qualified success criteria. To compare outcomes of a gelatin stent (XEN 45 Gel Stent; Allergan) placed either ab interno with closed conjunctiva (AIC) or ab externo with open conjunctiva (AEO) with or without cataract surgery in patients with glaucoma. Retrospective, nonrandomized comparative study of 85 eyes from 85 glaucoma patients who received XEN 45 Gel Stent placed either AIC (N=32) or AEO (N=53) with or without cataract surgery between July 2018 and January 2022 at Massachusetts Eye and Ear. Patients were included if they were 18 years of age or above and had at least 30 days of follow-up without any disqualifying event. Baseline demographics were similar between both groups, except for the glaucoma type. Both AIC and AEO procedures resulted in significant patterns of IOP and medication reduction from baseline up to 1 year. At postoperative year (POY)1, mean IOP was reduced to 11.34±4mmHg on 1.29±1.34 medications after AEO and 13.70±3.32mmHg on 2±1.81 medications after AIC. The average IOP reduction was significantly greater in the AEO group at all postoperative time points beyond postoperative week 2. There were significant differences in the survival curves of AEO and AIC groups under both the complete success criteria and the qualified success criteria. Under the complete success criteria, the cumulative probability of survival at POY1 was 28.5% in the AEO group and 3.8% in the AIC group. Under the qualified success criteria, the cumulative probability of survival at POY1 was 60.3% in the AEO group and 21.9% in the AIC group. In our study, we demonstrate that both placements reduce IOP and medication from baseline, with AEO placement having more favorable success rates compared with AIC placement.