Additional Antiglaucoma Medication Research Articles

Intermediate-Term Outcomes of Ahmed Glaucoma Valve Implantation for Uveitic Glaucoma: A Tertiary Centre Experience

ABSTRACT Purpose To present the outcomes of Ahmed glaucoma valve (AGV) implantation in uveitic glaucoma (UG) in a tertiary eye center in Riyadh, Saudi Arabia. Methods A retrospective review of all UG patients who underwent AGV implantation at a single, tertiary care eye center from January 2008 to December 2018. The main outcome measures were change in mean intraocular pressure (IOP), number of antiglaucoma medications, overall success rate in different follow-up periods, complete and qualified success from last follow up, and complications. The success of the treatment was defined as patients achieving intraocular pressure (IOP) levels between 6- and 21-mm Hg with or without additional antiglaucoma medications and/or a minimum of 20% reduction from baseline IOP. Results The study included 74 patients (86 eyes), with a mean follow-up of 4.9 ± 2.9 years. The mean IOP was 32.2 ± 8.5 mmHg at baseline and 16.3 ± 6.6 mmHg at the last follow-up (p < 0.001). The mean number of antiglaucoma medications decreased from 3.5 ± 0.7 preoperatively to 1.3 ± 1.4 at the last follow-up (p < 0.001). Overall survival rates at 1, 3, 5, and 10 years were 96.5%, 92.7%, 91%, and 56.9%, respectively. Complete and qualified success rates were 37.9% and 48.3% at the end of follow up, respectively. The rate of postoperative complications was 56%, of which 18 eyes (20%) required surgical revision. Bivariate Cox proportional hazards regression analysis did not reveal any factors significantly associated with failure. Conclusions AGV is safe and effective in providing intermediate-term IOP control in UG patients. Complications reported in our cohort were mostly transient and conservatively treated.

Outcomes of Ahmed glaucoma valve surgery performed by glaucoma fellows - A large retrospective study from Eastern India.

Teaching and training of glaucoma fellows on the technique of Ahmed glaucoma valve (AGV) implantation surgery is very important. The purpose of this study was to describe the clinical outcomes and complications of AGV surgery performed by glaucoma fellows of a tertiary eye center from eastern India. This was a retrospective study based on electronic medical records. Thirty-five eyes operated with AGV by five glaucoma fellows from January 2016 to November 2020 were included. Best-corrected visual acuity, intraocular pressure (IOP), and number of antiglaucoma medications (AGMs) were the study outcome measures. The mean (±standard deviation) age of the patients was 40.5 (±19.7) years. The follow-up period was 24.37 (±13.01) months. Both complete success (IOP <21 mmHg without additional AGM) and qualified success (IOP <21 mmHg with an additional AGM) were achieved in eight eyes each (22.8%). Failure of the surgery was noted in 19 eyes (54.3%) as there was a need for repeat surgery for IOP control in 12 eyes and a persistent IOP spike (IOP >21 mmHg with AGM beyond 3 months) in seven eyes. Despite a high rate of failure of the primary surgery, with the consultants' intervention, there was statistically significant improvement in vision and IOP in all patients ( P < 0.01) at the last follow-up. AGV implantation is a challenging surgical skill to be acquired by the glaucoma fellows.

Reticular Epithelial Edema in a Postkeratoplasty Eye Due to Ripasudil.

A 34-year-old female underwent phacoemulsification with Descemet stripping endothelial keratoplasty (Supplementary Digital Content, Fig. 1A, B, http://links.lww.com/APJO/ A132) under a failed previous therapeutic penetrating keratoplasty. The visual acuity was restored to 20/50. At 2 years postoperative period, she developed raised intraocular pressure of 30 mm Hg despite being on 2 antiglaucoma medications, and hence ripasudil was initiated as an additional antiglaucoma medication. The endothelial cell density was 920 cells/mm.1Figure 1: Slitlamp image (A) and anterior segment optical coherence tomography (B) illustrating reticular edema in superficial cornea after 4 months of ripasudil use.Her intraocular pressure at 1 month of starting ripasudil was 12 mm Hg. Subsequently, 3 months later, she presented with counting finger vision, honeycomb edema in the superficial cornea (Fig. 1). Ripasudil was discontinued and 1 month later, although the epithelial net-like pattern disappeared, the graft was diffusely edematous and failed to recover the clarity until a follow-up of 3 months (Supplementary Digital Content, Fig. 1C, D, http://links.lww.com/APJO/A132) when repeat endothe-lial keratoplasty was planned. Rho kinase inhibitors have gained popularity in the management of glaucoma and corneal endothelial diseases.2 Ripasudil and netarsudil are Rho kinase inhibitors approved for clinical use. Reticular bullous epithelial edema has been reported with the use of 0.02% netarsudil, which improves in some eyes after the medication is discontinued.1 In our patient, similar pattern of edema was noted with 0.4% ripasudil after 4 months of treatment, which failed to resolve on discontinuing ripasudil. The reticular epithelial edema during ripasudil treatment should be distinguished from graft rejection. The medication should be stopped promptly if cornea edema is noted. The likelihood of nonclearance of edema should be explained to the patients.

Phacoemulsification versus Phacoemulsification/Trabeculectomy for the Treatment of Primary Open-Angle Glaucoma Coexistent with Cataract: A Comparative Study.

Background: The purpose of this study was to evaluate the clinical outcomes in patients with primary open-angle glaucoma (POAG) and coexistent cataract treated with phacoemulsification cataract surgery, either alone or in combination with trabeculectomy. Methods: Participants in this retrospective study were 52 patients diagnosed with previously controlled POAG and coexistent cataract, who underwent either uneventful phacoemulsification cataract surgery (Group I, n = 27) or combined uneventful phacoemulsification cataract surgery and trabeculectomy (Group II, n = 25), with at least a 24-month postoperative follow-up. We recorded the changes in intraocular pressure (IOP) and in the need of anti-glaucoma medications before and after surgical procedures. Results: There was a statistically significant decrease in IOP at postoperative day 7 in both groups (p < 0.001), which remained until the end of the 24-month follow-up. At month 24, the two groups did not differ significantly in terms of IOP (14.3 ± 1.4 vs. 13.1 ± 1.2 for Group I and Group II, respectively; p = 0.447). In addition, there was a statistically significant decrease in the number of anti-glaucoma medications needed at postoperative day 7 in both groups (p < 0.001 for both groups compared to baseline). At month 24, patients in both groups needed about one additional anti-glaucoma medication to control their IOP. Of note, during the first month after surgery, 20% of patients in Group II needed 0.1 mL 5-FU injections to the bleb, although antimetabolites were not used in the primary surgery. Conclusions: Both surgical interventions, namely phacoemulsification cataract surgery alone and phacoemulsification/trabeculectomy, were found to be effective in the management of POAG with coexistent cataract, presenting a significant decrease in IOP and in the need of anti-glaucoma medications postoperatively at a long-term follow-up period of 24 months.

Primary trabeculectomy with mitomycin C in the treatment of medically uncontrolled inflammatory glaucoma and primary open-angle glaucoma

Purpose The aim of this study was to compare the outcomes of primary trabeculectomy (PT) with mitomycin C (MMC) in uveitic glaucoma (UG) and primary open-angle glaucoma (POAG). Design This is a retrospective, case–control study. Patients and methods We compared the outcomes of PT with 0.02% MMC for 2 min in 60 adult patients with POAG and 60 adult patients with UG, who underwent surgeries between January 2010 and January 2014 at two major hospitals in Birmingham, UK, and were followed up for 5 years. Trabeculectomy in both groups was performed by fornix-based conjunctival dissection. Results The patients’ age was 53.6±5.4 years in POAG patients compared with 48.3±9.45 years in UG patients, with a statistically significant difference (P=0.046). The rates of qualified success, complete success, and failure at the first, third, and fifth year postoperatively did not differ significantly between the two groups (P=0.73, 0.71, and 0.37, respectively). The maximum postoperative intraocular pressure (IOP) reduction was observed in the first year, followed by a slow rise in IOP, and the number of antiglaucoma medications until the fifth year postoperatively. The 5-year postoperative IOP differed significantly between the two groups (18.33±2.98 vs. 19.88±3.41 mmHg in the POAG vs. UG, respectively, P=0.009). Conclusion The success rate of PT with MMC in UG was not inferior to that in POAG. One-year posttrabeculectomy with MMC, the qualified success rate mildly increased at the expense of the complete success rate while the failure rate remained largely constant, indicating a constant need for additional antiglaucoma medications.

Role of bevacizumab intraocular injection in the management of neovascular glaucoma.

To assess the long-term effects of intraocular bevacizumab (Avastin) injections as an adjunctive drug to manage patients with neovascular glaucoma (NVG). A retrospective study was conducted consisting of 34 eyes with secondary NVG caused by proliferative diabetic retinopathy (n=25), ischemic central retinal vein occlusion (n=8), and retinal ischemia resulting from persistent detachment (n=1) were managed by intraocular injections of bevacizumab (1.25 mg/0.05 mL), in addition to other treatments. The main outcome measure was the change in the degree of iris neovascularization. Secondary outcomes included intraocular pressure and the number of additional interventions or antiglaucoma medications administered after injection. All patients were followed-up for at least 12mo. At the last follow-up, complete regression of rubeosis irides was detectable in 13 (38.2%) eyes and incomplete regression in 21 eyes (61.8%). The mean intraocular pressure was 45.32±7.185 mm Hg at baseline and significantly decreased to 26.15±5.679 mm Hg at the last follow-up visit (P=0.000005). Patients received an average of 4.97 injections. As additional treatments, 12 eyes (35%) received laser photocoagulation and 6 eyes (18%) underwent retinocryopexy. No further treatment was needed in 16 eyes (47.1%). Intravitreal bevacizumab injection can have a favorable effect in controlling intraocular pressure and pain control in patients with NVG because it decreases the angiogenesis and helps to augment the results of conventional procedures. The primary cause of retinal ischemia should be always targeted.

Long-term Results of Ahmed Valve Implantation With Mitomycin-C in Pediatric Glaucoma.

Mitomycin was used with Ahmed valve implantation in 81 eyes of 63 children. After 5 years, probability of intraocular pressure (IOP) control without glaucoma medication was 35±6%; 57% achieved IOP control with topical medications after 10 years. The purpose of this study was to determine the long-term outcomes of Ahmed glaucoma valve (AGV) implantation with intraoperative application of mitomycin-C (MMC) for the treatment of childhood glaucoma. Retrospective review of children undergoing AGV implantation with subtenon application of MMC between 2000 and 2019. We defined surgical success as a final IOP of 5 to 21 mm Hg with no glaucoma medication, no subsequent glaucoma surgery, and no severe complication. Qualified success was defined if the above criteria were met with topical antiglaucoma medication. Eighty-one eyes of 63 patients were included. The probability of complete success was 72±5% (63% to 83%) at 1 year, 58±6% (48% to 70%) at 2 years, and 35±6% (25% to 48%) at 5 years. The probability of qualified success was 92±3% (87% to 98%) at 1 year, 79±5% (70% to 89%) at 5 years, 57±7% (44% to 73%) at 10 years, and 39±9% (24% to 62%) at 14 years. The IOP was reduced by an average of 10.7±9 mm Hg from preoperative visit to the last follow-up, and the number of medications decreased from 3.0±1.4 to 1.5±1.4 after implantation. A significant proportion of patients achieved long-term IOP control without glaucoma medication. The majority achieved IOP control with additional topical antiglaucoma medications. When compared with existing AGV implantation in childhood literature, the use of MMC appears to lengthen the drop-free (complete success) duration, as well as the long-term IOP control with topical medications.

Phaco-UCP; combined phacoemulsification and ultrasound ciliary plasty versus phacoemulsification alone for management of coexisting cataract and open angle glaucoma: a randomized clinical trial

BackgroundVarious surgical techniques have been described, to be combined with cataract surgery in glaucoma patients, aiming for an additional reduction of intraocular pressure (IOP), hence minimizing the burden of anti-glaucoma medication (AGM). Ultrasound ciliary plasty (UCP) is a recent microinvasive glaucoma surgery (MIGS) recommended for primary and refractory glaucoma. This study was conducted to evaluate the safety and efficacy of a new technique; combined phacoemulsification and ultrasound ciliary plasty (Phaco-UCP) as a primary surgical treatment for coexisting cataract and open angle glaucoma.MethodsA randomized clinical trial, including 61 eyes of 61 patients with visually significant cataract and open angle glaucoma, randomized to either Phaco-UCP (study group; 31 eyes) or phacoemulsification alone (Phaco-alone) (control group; 30 eyes). Primary outcomes included reduction in IOP and/or the number of AGM. Secondary outcomes included visual acuity improvement and complications. Qualified Success was defined as an IOP reduction ≥ 20% from baseline value, with an IOP 6–21 mmHg, with no additional AGM or glaucoma surgery. Failure was defined as either < 20% IOP reduction, despite AGM use, the need of glaucoma surgeries or serious complications.ResultsAt 18 months postoperatively, Phaco-UCP group had a median IOP reduction of 7 mmHg (Q1, Q3 = 3, 10) compared to 2 mmHg (Q1, Q3 = 2, 3) in Phaco-alone group (P < 0.001). Phaco-UCP group had significantly higher success rate at all time points reaching 67.7% at the last follow-up versus 16.7% only in Phaco-alone group (P< 0.001). The median number of AGM significantly decreased from [3 (Q1, Q3 = 2, 4), 3 (Q1, Q3 = 2,3)] respectively, (P =0.3)] at baseline to [1 (Q1,Q3 = 1, 2), 2 (Q1,Q3 = 2, 2)] respectively, (P < 0.001)] at 18 months postoperatively. No serious intraoperative or postoperative complications were encountered in either group.ConclusionPhaco-UCP is a simple, safe and effective procedure for management of coexisting cataract and open angle glaucoma.Trial registrationClinicalTrials.gov identifier, NCT04430647; retrospectively registered. June 12, 2020.

Ab interno tube ligation for refractory hypotony following non-valved glaucoma drainage device implantation

PurposeTo report the 2-year outcomes of a novel surgical technique allowing reduction of the intraluminal diameter of the tube without total tube occlusion in order to allow enough increase in outflow resistance to permit resolution of hypotony whilst also achieving adequate IOP control.MethodsThis was a single-surgeon retrospective case note review of all non-valved GDD cases over an 8-year period (2008–2015) that underwent ab interno ligation of the drainage tube in order to manage post-operative hypotony (Baerveldt or Molteno). Twelve eyes of 12 patients (4.4%) developing refractory hypotony that did not respond to multiple intracameral ophthalmic viscoelastic device (OVD) injections were included in this retrospective case series and were treated with our ab interno tube ligation technique. The post-ligation management algorithm consisted of re-instating topical anti-glaucoma agents, laser suture lysis (LSL), or further ab interno ligation.ResultsMean IOP increased from 2.8 mmHg at baseline to 7.8 mmHg, 7.1 mmHg, 9.0 mmHg, 13.6 mmHg, 10.9 mmHg, 13.9 mmHg and 13.6 mmHg at day 1, week 1, month 1, month 3, month 6, year 1 and year 2 respectively, with or without additional topical anti-glaucoma medications. Although hypotony resolution following our technique was achieved in all eyes at 2 years, 8.3% of cases required reinstatement of topical medications to maintain IOP control within the target range.ConclusionsWe propose ab interno partial tube tying as an effective surgical option to achieve an immediate, predictable and sustained IOP elevation either as a primary procedure or when traditional methods have failed to resolve hypotony in eyes with non-valved GDDs.

Intermediate-term outcome of Aurolab aqueous drainage implant.

Purpose:To report the intermediate-term safety and efficacy of Aurolab aqueous drainage implant (AADI) in patients with glaucoma.Methods:Retrospective review of patients who underwent AADI between January 2013 and December 2016. Patients aged >16 years and with a minimum follow-up of 6 months were included. Success was defined as complete when the intraocular pressure was ≥6 and ≤21 mmHg without antiglaucoma medication and as qualified if those requiring additional antiglaucoma medications were included.Results:The study included 55 patients (55 eyes) with a mean age ± standard deviation (SD) of 47.3 ± 18.1 years with a mean follow-up of 16.7 ± 11.4 months. Mean intraocular pressure reduced from 30.8 ± 11.1 mmHg to 13.1 ± 4.7, 14.1 ± 4.8, 15.7 ± 2.5 (P < 0.001) mmHg at 6 months, 1 year, and 2 years, respectively. The mean number of antiglaucoma medications reduced from 3.4 ± 1 to 0.8 ± 1.2, 0.7 ± 1.1, 0.8 ± 1 (P < 0.001) at 6 months, 1 year, and 2 years, respectively. The cumulative probability of complete and qualified success was 62% and 100% at 6 months, 54% and 92% at 1 year, and 43% and 88% at 2 years, respectively. Four patients failed during the follow-up period. Postoperative complication occurred in 28 eyes (51%), of which 17 eyes (31%) required intervention.Conclusion:AADI is a safe and effective treatment for the control of intraocular pressure in patients with glaucoma.

Evaluation of episcleral venous fluid wave during gonioscopy assisted transluminal trabeculotomy in patients with advanced glaucoma.

To evaluate episcleral venous fluid wave (EVFW) during GATT surgery in patients with advanced stage open angle glaucoma and to investigate its relationship with the severity of glaucoma. In all, 34 eyes of 28 open angle glaucoma patients who underwent GATT surgery were included into study. The extent of EVFW was evaluated using surgical records of patients and it was defined as number of clock hours. Correlations between the extent of EVFW and GAAT surgical outcomes as determined by intraocular pressures (IOP) and postoperative antiglaucoma medication needs were investigated. The impact of preoperative maximum IOP on EVFW was also evaluated. There was a significant correlation between IOPs and the extent of the EVFW at 1st, 3rd, 6th and 12th months follow-up visits. 10 of (%29.4) 34 eyes required antiglaucoma medications after the surgery. Mean extents of EVFW in patients who needed and did not need medications during follow-ups were 2.6 ± 1.0 (1-4) and 5.9 ± 1.5 (3-8) clock hours and the difference was statistically significant. Cutoff value of <4.5 clock hours for the EVFW (sensitivity 79.2%, specifity 100%) was found to be associated with the need for additional antiglaucoma medication. The extent of EVFW might be a valuable prognostic indicator for the surgical success of GATT since trabeculotomy is circumferential in this surgical technique making all collector channels accessible.

Outcome of trabeculectomy with Ologen versus Mitomycin C: A comparative prospective study in Bangladesh

To compare the efficacy and safety of trabeculectomy with Ologen versus Mitomycin C in primary glaucoma. This is a prospective study of patients aged 18 years and above, diagnosed with primary glaucoma randomised to having trabeculectomy with Ologen or Mitomycin C. The primary outcome measure was success of trabeculectomy defined as intraocular pressure >5 mmHg but ≤21 mmHg. Complete success was defined as intraocular pressure achieved without anti-glaucoma medication and qualified success was defined as intraocular pressure achieved with additional anti-glaucoma medication. At the end of 12 months follow-up, the postoperative mean intraocular pressure in the Ologen group was 12.8 ± 1.6 mmHg and 13.4 ± 2.2 mmHg in the Mitomycin C group. The Ologen group achieved complete success in 86.5% and qualified success in 13.5% of the patients, while the Mitomycin C group achieved complete and qualified success in 85.5% and 14.5%, respectively. There was no statistically significant difference in the success rate of both the groups ( p = 0.57). Furthermore, no significant intraocular pressure difference was noted between the two groups at the end of 12 months follow-up ( p = 0.14). Trabeculectomy augmented with Ologen appeared to be as successful and safe as trabeculectomy augmented with Mitomycin C, with no reported adverse reaction to Ologen.

Long-term outcomes of uveitic glaucoma treated with Ahmed valve implant in a series of Chinese patients.

To report long-term outcomes of secondary glaucoma due to uveitis treated with Ahmed glaucoma valve (AGV) implantation in a series of Chinese patients. The retrospective study included 67 eyes from 56 patients with uveitic glaucoma who underwent AGV implantation. Success of the treatment was defined as patients achieving intraocular pressure (IOP) levels between 6 and 21 mm Hg with or without additional anti-glaucoma medications and/or a minimum of 20% reduction from baseline IOP. The main outcome measurements included IOP, the number of glaucoma medications at 1, 3, 6, 12, 24, 36, 48 and 60mo after surgery, surgical complications, final best-corrected vision acuity (BCVA), visual field (VF) and retinal nerve fiber layer (RNFL). The mean follow-up was 53.3±8.5 (range 48 to 60)mo. The cumulative probability of success rate was 98.5%, 95.5%, 89.6%, 83.6%, 76.1%, 70.1%, 65.7% and 61.2% at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively. IOP was reduced from a baseline of 30.8±6.8 to 9.9±4.1, 10.1±4.2, 10.9±3.7, 12.9±4.6, 13.8±3.9, 13.2±4.6, 12.3±3.5 and 13.1±3.7 mm Hg at 1, 3, 6, 12, 24, 36, 48 and 60mo, respectively (P<0.01). The number of postoperative glaucoma medications was significantly decreased compared with baseline at all time points during the study period (P<0.05). There was no significant difference between preoperative and postoperative BCVA. Remarkable surgical complications were not found after surgery. The VF and RNFL of the patients were stable after the surgery. AGV implantation is safe and effect in terms of reducing IOP, decreasing the number of glaucoma medications, and preserving vision for patients with uveitic glaucoma.

Self-engineered Acry C plants in nonpenetrating glaucoma surgery.

BACKGROUND:Analysis of safety and efficacy of self-engineered polymethylmethacrylate (Acry C) implants in nonpenetrating glaucoma surgery (NPGS) for control and maintenance of intraocular pressure (IOP) in primary open angle glaucoma (POAG) patients.MATERIALS AND METHODS:This was a hospital-based randomized study. Fifty eyes of 50 POAG patients were divided into 3 groups based on preoperative IOP range. NPGS was done with polymethylmethacrylate implants made from haptics of intraocular lenses. All patients were followed up after 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months. Preoperative IOP range was from 25.62 ± 1.72 to 41.66 ± 1.15 mmHg. Postoperative success was defined as IOP <21 mmHg at 1 month in the absence of additional antiglaucoma medication or other treatment.RESULTS:A significant reduction in IOP was observed postsurgery in all three groups, changing from a preoperative mean of 25.62 ± 1.72 mmHg, 34.38 ± 2.27 mmHg, and 41.66 ± 1.15 mmHg to a postoperative mean of 13.27 ± 2.13 mmHg, 16.50 ± 2.74 mmHg, and 17.66 ± 1.52 mmHg, respectively (P < 0.001) at 12 months. No significant difference was seen with change in position of the implant, i.e., convexity facing limbus or fornix. No intraoperative complications were observed. The main postoperative complication was failure of filtration in 1 case (3.44%) from Group 1, 5 cases (27.78%) from Group 2, and all 3 cases (100%) from Group 3 at 1 month postoperatively. Thus, 9 eyes (41%) required postoperative antiglaucoma medications following which the IOP was controlled.CONCLUSION:NPGS with Acry-C implants is a safe and cost-effective (<1 US dollar) procedure for control of IOP in POAG patients especially those with moderately elevated IOPs.

Intermediate Term Outcomes of Early Posttrabeculectomy Bleb Leaks Managed by Large Diameter Soft Bandage Contact Lens

To study the outcomes of large diameter soft bandage contact lens (BCL) in managing early trabeculectomy bleb leak. Of 972 eyes that underwent fornix-based trabeculectomy between 2011 and 2015, 19 eyes with bleb leak with at least 1 year follow-up were eligible. Bleb leak was conservatively managed using large diameter BCL (≥15.5 mm in diameter). Success was defined as complete, if bleb leak resolved and the intraocular pressure (IOP) was ≥5 and ≤18 mm Hg with no additional antiglaucoma medication and failure if surgical intervention was needed. Mean age (±SD) of subjects was 43.5±11.9 years. Mitomycin C was used in 15/19 eyes. Median time (interquartile range) from trabeculectomy to bleb leak was 9 days (interquartile range: 8 to 19 d). Bleb leak was treated with 15.5 mm BCL in 16 eyes and 17 mm lens in 3 eyes. Bleb leak resolved with BCL in 17 [89.5%; 95% confidence interval (95% CI), 68.6-97] and 2 eyes (10.5%; 95% CI, 2-31) required bleb resuturing. Mean duration of BCL wear for bleb leak resolution was 23.7±8.9 days. Mean IOP increased from 5.8±2.7 to 12.5±3.1 mm Hg after resolution of bleb leak (P<0.05). At 16 months, complete success probability of trabeculectomy was 89.4% (95% CI, 75.6%-100%). Large diameter BCL was effective in the management of early bleb leak with good intermediate term success for IOP control. We suggest a trial of soft contact lens of appropriate diameter to manage early bleb leaks, before planning any invasive intervention.

Outcomes of Primary Trabeculectomy With Mitomycin-C in Glaucoma Secondary to Iridocorneal Endothelial Syndrome.

To report the outcomes of primary trabeculectomy with mitomycin-C (MMC) in eyes with glaucoma secondary to iridocorneal endothelial (ICE) syndrome. We included 16 eyes of 15 subjects with ICE syndrome who underwent primary trabeculectomy with MMC between 1991 and 2013. Surgical success was defined as complete when the intraocular pressure (IOP) was ≥5 and ≤21 mm Hg with no additional antiglaucoma medication (AGM) or surgery and as qualified if IOP was controlled with AGM. The median age (interquartile range) of subjects at the time of trabeculectomy was 41 years (37, 44 y) and the median follow-up period was 23 months (7, 79 mo). Postoperatively, the median IOP significantly reduced from 36 (26, 43) to 14 mm Hg (12, 17 mm Hg) (P<0.001) and median number of AGMs reduced from 3 (2, 4) to 0 (0, 0) (P<0.001). The percentage of complete success was 75% at 6 months, 64% at 12 months, 57% at 36 months, and 33% at 60 months. The percentage of qualified success was 94% at 6 months, 82% at 12 months, 71% at 36 months, and 60% at 60 months. Five eyes failed during the follow-up period. The mean (±SD) number of glaucoma surgeries per eye was 1.3±0.5. Eight eyes developed corneal edema at a median follow-up of 78.5 months and 4 eyes underwent keratoplasty. Primary trabeculectomy with MMC offers moderate surgical success in patients with ICE syndrome. Maintaining long-term IOP control and corneal clarity in these eyes is a big challenge.

The Long-term Outcome of Primary "Bleb-sparing, Epithelial Exchange" in Dysfunctional Filtering Blebs.

To evaluate the long-term outcome of epithelial peeling and conjunctival replacement as a primary procedure in dysfunctional filtering blebs, without excising the bleb. A prospective, observational case series involving 34 consecutive eyes, having prior operated trabeculectomy with a dysfunctional filtering bleb, that met the inclusion criteria and were reviewed for at least 12 months. The bleb epithelium was peeled off and replaced with the adjacent conjunctiva, without bleb excision. Patients were reviewed at 1 week, 1 and 3 months postoperatively, and thereafter every 6 months for best corrected visual acuity (BCVA), applanation tonometry, bleb morphology and leaks, the lens status, glaucoma medications, and any complications. ASOCT was performed preoperatively and at the last review. Complete success (primary outcome) was defined as an intraocular pressure (IOP) >6 and <18 mm Hg without any additional antiglaucoma medications at the last follow-up. The average age of the patients was 36.6±20.7 years. The average time of follow-up was 23.9±6.1 months (range, 13 to 40 mo). The mean preoperative IOP was 5.8±4.2 mm Hg. Postoperatively, the IOP at 24 months was 12.6±3.9 mm Hg (P<0.0001). The bleb characteristics were graded according to the Indiana Bleb Appearance Grading Scale (IBAGS), which showed significant results in terms of the height (H), the vascularity (V), and Seidel (S) (P<0.0001). The preoperative and the postoperative BCVAs in logMAR were 0.51±0.26 and 0.37±0.21 (P=0.0001), respectively. Complete success was noted in 31/34 eyes (91.18%) and qualified success was noted in 3 eyes (8.82%). One patient developed a mild ptosis after bleb revision. Epithelial peeling of the bleb with replacement by advancement, without bleb excision, maintains bleb function and resolves bleb dysfunction in the long term.

A Comparative Evaluation of Phacotrabeculectomy with Manual Phacofracture Trabeculectomy

Purpose: To compare the results of manual phacofracture trabeculectomy (manual small incision cataract surgery trabeculectomy) versus phacotrabeculectomy with respect to visual gain and intraocular pressure (IOP) control. Materials and Methods: Thirty consecutive patients who underwent combined surgery performed by the same surgeon were prospectively evaluated for a minimum period of 12 months. Fifteen patients underwent single site phacotrabeculectomy, and the remaining 15 patients underwent single site phacofracture trabeculectomy at Guru Nanak Eye Hospital, New Delhi. Results: Both surgeries resulted in a highly significant decrease in IOP, the final percentage reduction being 46% in phacotrabeculectomy group and 44% in phacofracture trabeculectomy group. The complete success rate (IOP < 21 mmHg) without additional antiglaucoma medications was 100% for both the groups till l2 months of follow-up. Improvement in visual acuity was similar in both the groups with 53% patients in phacotrabeculectomy and 60% in phacofracture trabeculectomy group attaining a final visual acuity of 20/40 or better. The mean surgically induced astigmatism was 1.33 D and 1.3 D in phacotrabeculectomy and phacofracture trabeculectomy group respectively, at the end of 12 months follow-up. Manual phacofracture trabeculectomy resulted in more early postoperative inflammation within the first 7 days. Conclusions: There was no statistically significant difference in the final visual acuity, IOP control and surgically induced astigmatism between phacofracture trabeculectomy and phacotrabeculectomy groups.

Ranibizumab as adjuvant in the treatment of rubeosis iridis and neovascular glaucoma—results from a prospective interventional case series

To evaluate the capability of adjuvant intraocular ranibizumab (Lucentis) injections in the treatment of rubeosis and intraocular pressure in patients with rubeosis and neovascular glaucoma. Ten eyes with rubeosis (R) and ten eyes with neovascular glaucoma (NVG) received Lucentis injections (ranibizumab 0.5 mg/0.05 ml) in this prospective, monocenter, 12-months, interventional case series. The primary efficacy outcome measure was the change of degree of iris rubeosis as documented by iris fluorescein angiography measured after 12 months. Secondary outcomes were intraocular pressure (IOP), best-corrected visual acuity (BCVA, logMAR), numbers of additional interventions or antiglaucoma medications administered after injection, the gonioscopic status of the anterior chamber angle, and central retinal thickness. In the R group, 3.6 injections and in the NVG group 2.3 injections of Lucentis were administered. Additional treatments were photocoagulation (n = 19), cyclodestructive procedures (n = 9), cryopexy (n = 3), and vitrectomy (n = 1). The mean stage of rubeosis was 3.4 ± 0.7 in the R group and 3.6 ± 0.8 in the NVG group at baseline. At month 12, the rubeosis was almost resolved in the R group (0.1 ± 0.3, p < 0.001), and decreased significantly in the NVG group (0.7 ± 1.1, p < 0.001). In the NVG subgroup, mean IOP was 41.4 ± 13.4 mmHg at baseline, which decreased rapidly (18.2 ± 12.3, day-14, p = 0.005) and stabilized during the follow-up (15.6 ± 2.0 mmHg, p < 0.05). BCVA improved significantly in both groups (p < 0.05, at month 12). Injection of 0.5 mg ranibizumab appears to be beneficial as an adjuvant treatment in neovascular glaucoma and rubeosis due to its anti-angiogenic properties and its ability to prevent establishment or progression of anterior chamber angle obstruction. Conventional therapeutic procedures addressing the retinal ischemia are still required in a stage-wise treatment approach.

Large Diameter Descemet Membrane Endothelial Keratoplasty in Buphthalmic Eyes

To report the outcomes of Descemet membrane endothelial keratoplasty (DMEK) using a large diameter graft in the management of endothelial decompensation in buphthalmic eyes. Four eyes of 4 adults (1 man, 3 women) with bullous keratopathy and buphthalmos secondary to congenital glaucoma were treated with DMEK using posterior lamellar grafts with diameters ranging from 10 to 12 mm. The mean age was 31 (±9) years (range, 20-38 years). Mean follow-up time was 13.5 (±7.5) months (range, 6-24 months). Main outcome measures were best-corrected visual acuity (BCVA), intraocular pressure (IOP), pachymetry, endothelial cell density, and complications after surgery. In all eyes, there was improved corneal clarity with decrease in pachymetry. The final postoperative BCVA improved in most eyes. There was no significant change in IOP, with 3 eyes needing additional antiglaucoma medication. Endothelial cell loss ranged from 37% to 42%. Postoperative complications were early partial graft detachment in 2 eyes, one resolving spontaneously without intervention and the other requiring a rebubbling, and cataract formation requiring phacoemulsification in 1 eye. DMEK using a large or even full diameter Descemet membrane graft may be an effective treatment for bullous keratopathy in buphthalmic eyes. Partial graft detachment after surgery may be the main complication. Postoperative IOP control is mandatory, and BCVA may vary with ocular comorbidity unrelated to the transplanted cornea.