Combined Glaucoma Surgery Research Articles

A Case Report of Secondary Glaucoma in a Patient with HTLV-1: Discussion about the Management of Secondary Glaucoma Due to Recurrent Granulomatous Uveitis

Purpose: to investigate secondary glaucoma resulting from uveitis in a patient infected with Human T-cell Leukemia Virus Type 1 (HTLV-1) pathologically and discuss the management of glaucoma with recurrent uveitis. Clinical course: An octogenarian woman diagnosed as a carrier of HTLV-1 experienced recurrent uveitis and a sudden rise in intraocular pressure (IOP) in both eyes. Due to the uncontrolled IOP and severely damaged visual field in her left eye, a combined procedure of trabeculectomy and DGIS (glaucoma drainage implant surgery, Baerveldt 350) was performed. The presence of HTLV-1 provirus was detected in the aqueous humor. Her trabeculectomy sample was processed for light microscopic observation. Following an irregular follow-up, she presented with a sudden decrease in vision and pain in her fellow eye, four years after the glaucoma surgeries. Her right eye exhibited a significant accumulation of mutton-fat-like keratic precipitates. Results: Clinical manifestations revealed the presence of granulomatous uveitis. The combined glaucoma surgery, along with continuous topical corticosteroid medication post-surgery in her left eye, effectively suppressed the high IOP spikes and the recurrence of uveitis for 4 years. The pathological examination of the outflow pathways showed a range of damages in Schlemm’s canal (SC), including SC endothelial loss, narrowing, and occlusion, as well as loss of trabecular meshwork (TM) cells and fused TM beams. Conclusion: Combined GDIS and trabeculectomy represents a promising approach for managing such refractory cases of secondary glaucoma. Continuous topical corticosteroid medication is strongly recommended to prevent irreversible changes in SC and TM associated with granulomatous uveitis.

Recurrence of Malignant Glaucoma After Vitrectomy Intervention: A Challenging Case Series

Introduction : Malignant glaucoma most commonly occurs after glaucoma filtration surgery. Most cases require surgical intervention such as vitrectomy. However, even after successful treatment, it can reoccur in some cases. We present two cases of recurrent malignant glaucoma.
 Case Illustration : The first case involved a 48-year-old female with primary angle closure glaucoma who developed malignant glaucoma 1-week after undergoing combined glaucoma surgery. The second case involved a 70-year-old man with primary angle closure glaucoma and pseudophakia who developed malignant glaucoma 4-month after trabeculectomy. They received total vitrectomy treatment. We observed anterior chamber deepening in these 2 cases, but intraocular pressure remained increased 2-week after intervention.
 Discussion : We found improvement in anatomy by deepening the anterior chamber, but the intraocular pressure increased in the 2 weeks. Although the problem of releasing aqueous accumulations from the vitreous has been resolved after vitrectomy, but there is no permanent passage between the anterior chamber and the vitreous cavity. So, recurrences can occur. It is possible to manage this condition by restoring aqueous flow from the anterior vitreous to the anterior chamber. YAG laser capsulo- hyaloidotomy or vitrectomy combined with hyaloido-zonula-iridectomy are frequently effective in treating underlying causes.
 Conclusion : Vitrectomy can help to improve the deepening anterior chamber, but intraocular pressure may remain increased after 2-week follow-up. The recurrence of malignant glaucoma may be related to incomplete resolution of the underlying condition.

Clinical efficacy of sclerotonyxis for acute angle-closure glaucoma with persistent high intraocular pressure.

The aim of the study was to investigate the clinical effectiveness and safety of sclerotonyxis in acute angle-closure glaucoma (ACG) with persistent high intraocular pressure (IOP). The clinical data of 50 eyes from 50 patients (mean age: 68.9±7.19 years) with acute ACG and persistently high IOP who were admitted to our department between January 2012 and January 2022 were retrospectively analyzed. Patients who were administered the maximum dose of systemic and topical anti-glaucoma drugs and still had an IOP of >40 mmHg 24 hours after admission underwent sclerotonyxis. After the IOP control, an individualized phase II treatment plan was designed according to the patient's ocular condition. Forty-eight patients showed improvement in their visual acuity 6 months postoperatively compared to their preoperative values. The mean IOPs were 54.84±7.82 mmHg and 21.34±7.81 mmHg 24 hours pre and postoperatively, respectively. The mean anterior chamber depth showed statistically significant differences pre and postoperatively (1.75±0.16 mm and 1.84±0.17 mm, respectively) (p<0.05). After IOP stabilized, four patients underwent YAG laser peripheral iridectomy, 18 underwent simple cataract phacoemulsification combined with intraocular lens (IOL) implantation, 21 underwent cataract phacoemulsification combined with IOL implantation and goniosynechialysis under a gonioscope, and 7 patients underwent combined surgery of glaucoma and cataract. The mean IOPs were 15.94±3.3 mmHg and 15.64±2.99 mmHg 1 week and 6 months after stage II surgery, respectively. Moreover, 42 eyes (84%) attained complete success and 8 eyes (16%) attained conditional success 6 months postoperatively. No serious complications, such as corneal endothelial decompensation, malignant glaucoma, vitreous or eruptive choroidal hemorrhage, and retinal detachment, were observed intraoperatively or postoperatively in both procedures. Sclerotonyxis can rapidly lower IOP, release the pupillary blockage, reconstruct the anterior chamber, and reduce systemic complications caused by long-term high-dose antiglaucoma drugs. Thus, it normalizes the IOP and provides a safe operating space for stage II surgery, effectively reducing complications in patients in a persistent high IOP state.

Short-term surgical outcomes of twin-site combined phaco-emulsification and mitomycin-C augmented trabeculectomy in pseudo-exfoliation glaucoma versus primary open-angle glaucoma.

To compare the short-term outcomes of combined phaco-emulsification with posterior chamber intra-ocular lens and mitomycin augmented trabeculectomy in patients with pseudo-exfoliation glaucoma (PXFG) versus primary open-angle glaucoma (POAG). A total of 144 eyes of 144 patients were enrolled in this prospective interventional comparative study, 72 each of which had PXFG and POAG, respectively. All patients underwent twin-site combined phaco-trabeculectomy at a tertiary eye center in India between December 2017 and December 2018 and were followed up for a period of 12 months. The main outcome measures were intra-ocular pressure (IOP), best corrected visual acuity (BCVA), total surgical time, rate of intra-operative and post-operative complications, and the number of ocular hypotensive medications needed. Success rates were determined via Kaplan-Meier survival analysis. The mean age was 63.9 ± 7.9 years in the POAG group and 66.4 ± 6.8 years in the PXFG group (P - 0.04). The baseline BCVA, IOP, and cup-disc ratio were comparable between two groups. Intra-operative complications and post-operative outcomes were comparable between the two groups. There was a significant drop in anti-glaucoma medications in both groups. Six patients, three (4.2%) in each group, were lost to follow-up after 6 months. Three patients (4.2%) in PXFG needed additional glaucoma intervention for controlling IOP, one patient needed a non-valved glaucoma drainage device, and two patients required diode cyclo-photocoagulation within the follow-up period. Patients with PXFG had a longer surgical time than POAG. Similar success and complication rates were observed following combined twin-site phaco-trabeculectomy in both POAG and PXFG at 1 year. Combined glaucoma surgery resulted in good IOP control, improvement in BCVA, and lower requirement of ocular hypotensives in both the groups.

Combining flanged intrascleral IOL fixation with Glaucoma Surgery: Initial experience.

To report the initial clinical outcomes of combining glaucoma surgery with flanged intrascleral intraocular lens (F-SFIOL) fixation as a single stage procedure. Retrospective, non-comparative case-series of eyes which underwent combined surgery for glaucoma with F-SFIOL and had at least 6-months of follow-up. A fellowship-trained senior glaucoma surgeon managed all the cases. Twelve-eyes of 10 glaucoma patients (8 males, 2 females) underwent F-SFIOL; only 8 of these eyes were combined with a glaucoma procedure. Mean age of patients was 55.1 ± 16.1 years (95%CI [44.4,73.2], median 61 years) and were followed-up for a mean of 21.0 ± 9.5 months, 95% CI [13.1,28.9], median 18 months. F-SFIOL was combined with trabeculectomy ± Mitomycin C in 4 eyes, Ahmed Glaucoma Valve in 3 eyes and needling of a pre-existing bleb in 1. Each eye had controlled intraocular pressure (IOP) at last follow-up (pre-procedure 29.1 ± 13.4 mmHg, 95% CI [17.9, 40.3], median 27 mmHg to 14.5 ± 3.2 mmHg, 95% CI [11.8, 17.1], median 13 mmHg, p = 0.006) and decreased need for number of anti-glaucoma medication (AGM) (pre-procedure 3.7 ± 1.1, 95% CI [2.8,4.6], median 4 to 0.7 ± 0.7, 95% CI [0.1,1.3] median 1, p < 0.001). In all the eyes, best corrected visual acuity (BCVA) was either stable or improved; only 1 eye had astigmatism worse than that pre-existing. In 1 eye IOL was explanted, with an additional procedure to control IOP. No serious long-term complications occurred in any subject. The initial experience of single-stage F-SFIOL along with glaucoma surgery, both being performed by the same anterior-segment surgeon, is promising, thereby avoiding the cost, specialised skill, and potential complications of a posterior approach. Glaucoma surgery combined with and adapted to suture-less, flap-less, glue-less intra-scleral IOL fixation is hitherto unreported.

Pars plana vitrectomy combined with penetrating keratoplasty and transscleral-sutured intraocular lens implantation in complex eyes: a case series

BackgroundThe aim of this study was to evaluate the clinical outcomes of pars plana vitrectomy (PPV) combined with penetrating keratoplasty (PKP) and transscleral-sutured intraocular lens (IOL) implantation (IOL-suture) in complex eyes.MethodsIn this prospective, consecutive interventional case series, patients who underwent PKP combined with PPV and IOL implantation from July 2014 to March 2018 at Yokohama Minami Kyosai Hospital were enrolled. The postoperative best corrected visual acuity (BCVA) (converted to logarithm of the minimal angle of resolution [logMAR] units), intraocular pressure (IOP, mmHg), endothelial cell density (ECD, cells/mm2), graft survival, complications, astigmatism, and spherical equivalent (dioptres [D]) were evaluated.ResultsThis study included 11 eyes of 11 patients (three females and eight males; mean age, 61.8 ± 13.9 years) with an injury (n = 6) or bullous keratopathy (n = 5). The BCVA significantly improved from 1.50 ± 0.66 logMAR preoperatively to 0.78 ± 0.59 logMAR (p < 0.001) postoperatively. The baseline ECD significantly decreased from 2396 ± 238 cells/mm2 preoperatively to 1132 ± 323 cells/mm2 (p < 0.001) postoperatively. Despite two rejection episodes, graft survival rates were 100%. The mean follow-up period was 38.0 ± 20.5 months. Two patients required combined glaucoma surgery, and three patients underwent subsequent glaucoma surgery. Postoperative astigmatism and spherical equivalent were 3.9 ± 3.2 D and 0.29 ± 2.18 D, respectively.ConclusionThe combination of PKP, PPV, and IOL-suture implantation could be a safe and effective approach for eyes requiring anterior segment surgery; however, these eyes are associated with a higher incidence of glaucoma surgery.

К вопросу о выборе антиглаукомного компонента при сочетанной хирургии глаукомы и катаракты (обзор литературы)

«Российская офтальмология онлайн» - электронное информационное издание, создается с 1 марта 2010 года под эгидой Российского общества офтальмологов. Основная задача проекта - научно-информационная поддержка специалистов в области офтальмологии.

Отдаленные результаты трабекулотомии ab interno в хирургии глаукомы и катаракты

Purpose. To study long-term results of combined surgery for glaucoma and cataract by trabeculotomy ab interno. Material and Methods. 62 patients (64 eyes) with combination of glaucoma and cataract. The age of patients is from 53 to 84 years. The initial stage of glaucoma - 10 eyes, developed - 33 eyes, far-advanced - 21 eyes, level of intraocular pressure (IOP) before surgery in all eyes was intolerant for these stages of glaucoma and ranged from 21 to 36 mmHg. Indications for surgical treatment were absence of persistent IOP level compensation in hypotensive mode, the presence of lens opacification, which affects central visual acuity (VA). Best corrected VA is from 0.01 to 0.6. The technique of combined surgery included: 1st stage - phacoemulsification with implantation of flexible IOL; 2nd stage - trabeculotomy ab interno. The observation period is 18 months. Results. During the observation period of up to 18 months, IOP decreased on average to 20.8±3.1 mmHg. The target level of IOP without an additional antihypertensive regimen remained in 22 eyes (34.37%), with antihypertensive regimen - in 42 eyes (65.63%). In most patients VA increased to 0.2–1.0 and only in 2 cases decreased due to development of posterior capsular fibrosis. Conducting trabeculotomy ab interno has significantly reduced number of drugs used. However, 3-12 months after surgery, IOP increase up to 26-30 mmHg was observed in 4 eyes with antihypertensive drug regimen; microinvasive non-penetrating deep sclerectomy was performed to compensate for it. Conclusion. Trabeculotomy ab interno in combination with phacoemulsification with IOL implantation was effective and safe operation. Sufficient hypotensive effect and high visual functions observe at 18 months observation period.

Application of triamcinolone acetonide in combined surgery of glaucoma and cataract

Objective To observe the efficacy of intravitreal triamcinolone acetonide (TA) injection in combined surgery of acute angle-closure glaucoma and cataract. Methods A prospective control study. Fifty-two eyes of 52 patients of acute angle closure glaucoma combined with cataract from Jan. 2017 to Mar. 2018 were randomly divided into two groups, 26 eyes in each group. All patients underwent phacoemulsification combined with trabeculectomy. In TA group, intravitreal injection of TA was proformed during operation. The follow-up time was 1 month. Results The visual acuity of TA group after operation was better than that of the control group (t=-2.614, P=0.018). At 1 and 10 days after operation, the control of anterior chamber inflammation in TA group was better than that of the control group (P=0.005, 0.004). The difference was not significant in intraocular pressure between the two groups at each time points after operation (P>0.05). Conclusion Intravitreal injection of TA can effectively control the inflammatory reaction after the combined operation of glaucoma and cataract, can get better visual acuity. Key words: Glaucoma, cataract; Phacoemulsification; Trabeculectomy; Triamcinolone acetonide, intravitreal injection

Endophthalmitis after Cataract Surgery in Korea: A Nationwide Study Evaluating Incidence and Risk Factors in a Korean Population.

PurposeTo assess the nationwide rate of acute postoperative endophthalmitis (APE) after cataract extraction in Korea and to evaluate potential risk factors thereof.Materials and MethodsNationwide insurance claims data from July 2014 to June 2017 were reviewed. All patients with phacoemulsification or extracapsular/intracapsular cataract extraction were included. Exclusion criteria were combined glaucoma surgery or total vitrectomy or when the patient had a history of intraocular foreign body.ResultsIn total, 1505103 cases (982203 patients) were included. APE developed in 953 cases (938 patients) with an overall incidence of 0.063%. After adjusting for possible confounding factors, male sex [odds ratio (OR) 1.42; 95% confidence interval (CI) 1.25–1.61; p<0.001], primary clinical setting, operations performed in non-major cities, usage of sutures (OR 2.82; 95% CI 2.13–3.74; p<0.001), anterior vitrectomy (OR 8.71; 95% CI 6.71–11.32; p<0.001), aphakic cataract surgery (OR 1.52; 95% CI 1.03–2.22; p=0.033), hypertension (OR 1.40; 95% CI 1.18–1.66; p<0.001), diabetes (OR 1.59; 95% CI 1.31–1.93; p<0.001), and chronic renal failure (OR 1.28; 95% CI 1.01–1.62; p=0.039) were found to be related to APE development.ConclusionThe incidence of APE after cataract extraction was consistent with reports from other studies. Additional research is needed to determine the relationship of newly found risk factors, such as hypertension, primary clinical setting, chronic renal failure, and usage of suturing, with APE development.

Наш опыт применения комбинированной хирургии глаукомы у пациентов с сочетанной патологией катаракты и псевдоэксфолиативной глаукомы

Наш опыт применения комбинированной хирургии глаукомы у пациентов с сочетанной патологией катаракты и псевдоэксфолиативной глаукомы

Changing patterns of surgical treatment for glaucoma in the Eye Hospital of Wenzhou Medical University during the past ten years

Objective: To investigate the patterns of surgical treatment for patients with glaucoma in the Eye Hospital of Wenzhou Medical University from 2005 to 2014. Methods: Retrospective case series about 6 781 glaucoma patients (7 751 eyes) who received surgical treatment from January 1, 2005 to December 31, 2014 in the Eye Hospital of Wenzhou Medical University. Among them, 2 869 were males and 3 912 were females, aged (62±14) years. The data of patients' demographic information, diagnosis and surgical procedures [trabeculectomy, aqueous shunts of ExPRESS and Ahmed for extraocular reservoir, cataract extraction with intraocular lens (IOL) implantation, and combined operations for glaucoma and cataract] were collected and the patterns of surgical treatment were evaluated. SPSS 21.0 statistical software was used, mainly for statistical description of the data. Results: The ratio of trabeculectomies increased between 2005 and 2009, from 48.2% (95/197) to 57.7% (488/846), but decreased to 21.1% (220/1 041) in 2014. The ratio of aqueous shunts of ExPRESS and Ahmed increased to 6.1% (63/1 041) and 7.6% (79/1 041) from 2005 to 2014, respectively. The ratio of cataract extraction with IOL implantation increased to 28.4% (294/1 036) in 2012, but decreased to 21.6% (225/1 041) in 2014. The ratio of combined operations for glaucoma and cataract decreased to 6.6% (47/717) from 2005 to 2010, and increased to 36.6% (381/1 041) in 2014. Over the decade, the ratio of cataract extraction with goniosynechialysis increased from 2.4% (15/623) to 17.7% (184/1 041). The rate of iridotectomy decreased to 0.2% (2/1041) in 2014. Conclusions: Trabeculectomy, cataract surgery and combined surgery for glaucoma with cataract were still the mainstream of glaucoma surgery in the Eye Hospital of Wenzhou Medical University from 2005 to 2014. And the ratio of cataract extraction with IOL implantation, aqueous shunts of ExPRESS and Ahmed, and combined operation for glaucoma and cataract rapidly increased, with cataract extraction with goniosynechialysis increasing most rapidly and becoming the mainstream procedure of treatment for glaucoma and cataract. Inversely, the rate of trabeculectomies and iridotectomies decreased dramatically over this period.(Chin J Ophthalmol, 2018, 54: 184-188).

The effect of self-made flexible iris hooks in the combined surgery for glaucoma with cataract

Objective To evaluate the effect of self-made flexible iris hooks for small pupil in the combined surgery of glaucoma and cataract.Methods The self-made flexible iris hooks was used in 33 cases(35 eyes)with small pupil in the combined surgery of glaucoma with cataract.Only 3 iris hook were used in an operation.Results Circular capsulorhexis and phacoemulsification were done under good surgical field,and trabeculectomy was done by using hook for contracting pupil.The surgery was successful without serious complication in 33 cases(35 eyes).Conclusion Using of self-made flexible iris hooks improves safety of the combined surgery for glaucoma and cataract with small pupil. Key words: Iris hooks; flexible; self-made; Glaucoma; Cataract; Combined surgery

Comparison of ex‐press miniature implant with standard trabeculectomy after combined glaucoma surgery

AbstractPurpose To evaluate postoperative outcomes after combined phacoemulsification and glaucoma surgery with Ex‐PRESS miniature implant compared with combined surgery with standard trabeculectomy.Methods Prospective series of 24 consecutive eyes we compared 12 eyes in patients treated with combined phacoemulsification and glaucoma filtering surgery with the Ex‐PRESS miniature glaucoma implant under a scleral flap with 12 matched control eyes in patients who underwent combined cataract and glaucoma surgery with trabeculectomy.Results The average follow‐up was 10 months (range 3.4 to 14) for the Ex‐PRESS group and 12.3 months (range 4.0 to 16.5) for the trabeculectomy group. The mean IOP was significantly higher in the early postoperative period in the Ex‐PRESS group compared with the trabeculectomy group. Complications rate in the early postoperative period was significantily higher in the trabeculectomy group. No significant differences were objectified in success between both groups after the first week.Conclusion The Ex‐PRESS implant is an effective alternative to standard trabeculectomy in selected cases which makes possible to reduce the classic early postoperative complications associated with trabeculectomy.

Comparison of Deep Sclerectomy with Implant and Combined Glaucoma Surgery

To evaluate the efficacy of combined glaucoma surgery, 42 glaucomatous patients were randomly divided into two groups: deep sclerectomy with implant (DS) alone was performed in 21 patients, and combined deep sclerectomy and phacoemulsification (PDS) was performed in the other 21 patients. Follow-up was carried out at regular intervals for 12 months. A comparative study on intraocular pressure (IOP) was designed. Although further study is needed, PDS appears to have better postoperative long-term results in IOP control than DS alone.