Ex-PRESS Shunt Research Articles

Surgical Outcomes in Uveitic Glaucoma: Long-Term Evaluation of Trabeculectomy, Non-Penetrating Deep Sclerectomy, Ex-PRESS Shunt and Ahmed Glaucoma Valve. A 3-Year Follow-Up Study

ABSTRACT Purpose Uveitis can lead to secondary glaucoma, a condition with challenging management that can carry irreversible visual loss. Filtering surgery has demonstrated a higher failure rate, increased incidence of postoperative complications and reinterventions in uveitic patients. There is no consensus on the optimal surgical approach for uveitic glaucoma (UG) due to limited data comparing various intraocular pressure (IOP)-lowering surgeries. This retrospective cohort aims to assess the clinical outcomes of trabeculectomy (TBT), non-penetrating deep sclerectomy (NPDS), Ex-PRESS shunt and Ahmed glaucoma valve, providing additional insights into the long-term IOP control and safety of filtering surgeries in UG. Methods The filtering surgery was performed on 32 eyes of 27 UG patients. Complete success was defined as IOP ≤ 18 mmHg or a 30% reduction. Qualified success allowed topical hypotensive treatment. Results Complete success was 40.63% (13/32) at 12 months and 36.67% (11/30) at 36 months. Qualified success was 84.38% (27/32) at 12 months and 63.33% (19/30) at 36 months. In the survival analysis, both NPDS and Ex-PRESS demonstrated decreased failure rates compared to TBT (NPDS vs TBT: HR = 0.20, p = 0.049; Ex-PRESS vs TBT: HR = 0.28, p = 0.13). One or more reinterventions were required in 34.38% (11/32) of the eyes. NPDS had the lowest incidence of hypotony. Secondary cataract was a common complication in all groups. Conclusion Various filtering surgeries are safe and effective procedures for lowering IOP and reducing the requirement of topical antihypertensives in UG at 36 months. However, one-third of the patients will require another IOP-lowering procedure.

Epiretinal membrane development after Ex-Press glaucoma filtration device implant: 2-year results of a case control study

BackgroundThe most common retinal complications after glaucoma surgery are choroidal detachment, hypotony maculopathy, malignant glaucoma, vitreous hemorrhage, endophthalmitis and retinal detachment. However, if glaucoma surgery is a risk factor for the ERM development needs to be clarified. This study aims to assess the incidence of epiretinal membrane (ERM) in 2 years of follow-up in patients with primary open-angle glaucoma (POAG) treated with Ex-Press shunt implant.MethodsA prospective, consecutive, single-center, case–control study. We enrolled patients affected by POAG and scheduled for Ex-Press device implant with or without concomitant cataract surgery. The control group was the contralateral eyes which continues anti-glaucomatous eyedrops. Complete ophthalmologic evaluation and spectral-domain optical coherence tomography were performed before surgery, at 6 months and 24 months of follow-up.ResultsEighty-two eyes of 41 consecutive patients, 18 males and 23 females with a mean age of 70, 29 ± 8,45, were analyzed at 24 months. 39.1% of eyes developed ERM: 29.3% were cellophane macular reflex (CMR) and 9.8% were pre-macular fibrosis (PMF). In the control group, 19.5% of eyes developed ERM: 17.1% were CMR and 2.4% were PMF. No statistically significant difference was reported (p = 0.121) between treated and control group. ERM development did not affect significantly the central foveal thickness (260.13 ± 35.01 μm at baseline, 265.03 ± 34.90 μm at 6 months and 275.18 ± 33.31 μm at 24 months) and macular volume (7.75 ± 0.43 mm3 at baseline, 7.77 ± 0.48 mm3 at 6 months and 7.77 ± 0.46 mm3 at 24 months), remained comparable to reported average measures in healthy individuals during the follow-up. Concomitant cataract surgery did not increase the ERM incidence.ConclusionEx-Press implant may increase the ERM incidence regardless concomitant cataract surgery, accelerating or inducing a posterior vitreous detachment, such as other ocular surgical procedure. Nevertheless, the vast majority of ERM are CMR, not affecting the macular profile.

Дренажная хирургия с клапаном Ахмеда при увеальной глаукоме

Aim. To evaluate the efficiency of Ahmed valve use for patients with refractory uveal glaucoma (UG). Methods. The effectiveness of the use of the drainage device – Ahmed valve presented on the example of three clinical cases of chronic uveitis with UG. Previosly all the patients had antiglaucomatous surgery, including non-penetrating deep sclerctomy, sinustrabeculectomy, stent surgery with ExPress shunt and subsequent filtering bleb needling Fast scarring was noticed in every case in the area of operation. Prescription of maximal medicamentous therapy was required from 2 to 6 months after the surgery and it was effective for a short period of time. Results. Implantation of Ahmed valve was performed in a period of stable medical remission of uveitis. Postsurgical period was unremarkable, within follow-up for 6–15 months intraocular pressure was normalized without medicamentous therapy, valve position and filtration were stable. Сonclusion. Stent surgery with the use of Ahmed valve for patients with UG gives more stable and prolonged hypotensive effect. Key words: intraocular pressure; uveal glaucoma; antiglaucomatous surgery; Ahmed valve.

Medium-term efficacy and safety analysis of Ex-PRESS shunt implantation for the treatment of secondary glaucoma in Sturge-Weber syndrome

Objective: To evaluate the medium-term efficacy and safety of Ex-PRESS shunt implantation in the treatment of secondary glaucoma associated with Sturge-Weber Syndrome (SWS). Methods: This was a retrospective case series study. Medical records of patients diagnosed with secondary glaucoma due to SWS who underwent Ex-PRESS shunt implantation at Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, between January 2013 and February 2020 were collected. Only the right eye were included in the analysis when both eyes were affected. Follow-up visits were scheduled at postoperative week 1, 3 months, 6 months, 1 year, 2 years, and 3 years. Clinical data including intraocular pressure (IOP), vertical cup-to-disc (C/D) ratio, corneal horizontal diameter, visual field, anterior chamber condition, anti-glaucoma medication usage, and additional surgeries were evaluated and analyzed before and after the procedure. Surgical success rates and procedure-related complications at each follow-up time point were assessed. Statistical analyses were performed using t-test, Mann-Whitney U test, and χ2 test. Results: A total of 21 patients (21 eyes) were included in the study, comprising 10 females and 11 males. Among them, 15 eyes were on the right side, and 6 eyes were on the left side. The patients' ages ranged from 3 to 51 years, with a median age of 8.1 (6.3, 11.9) years. The follow-up period ranged from 3 to 53 months, with a median of 11 (6, 24) months. Preoperatively, the IOP in the 21 operated eyes was (32.9±9.1) mmHg (1 mmHg=0.133 kPa), significantly higher than the IOP in the 19 healthy eyes, which was (17.1±4.3) mmHg (t=5.80, P<0.001). The C/D ratio in the operated eyes was (0.75±0.13), also significantly higher than that in the healthy eyes, which was (0.32±0.10) (t=11.22, P<0.001). At the 1-year, 2-year, and 3-year follow-up, 8 eyes out of 16 operated eyes, 6 eyes out of 9 operated eyes, and 7 eyes out of 10 operated eyes achieved overall surgical success (complete success+conditional success), respectively. The number of eyes with complete success at the three follow-up time points was 3, 2, and 4, respectively. The IOP in the operated eyes was significantly reduced at all follow-up time points compared to preoperative values (all P<0.05), while there was no statistically significant difference in C/D ratio before and after surgery (all P>0.05). Two operated eyes experienced retinal detachment or choroidal leakage postoperatively, both of which recovered after conservative treatment. One eye developed postoperative degree Ⅰ shallow anterior chamber, and it resolved spontaneously on the third day after surgery. No serious surgical complications, such as bleb-related complications, malignant glaucoma, expulsive choroidal hemorrhage, or endophthalmitis, were observed postoperatively. Conclusions: Ex-PRESS shunt implantation for the treatment of secondary glaucoma in SWS demonstrated a relatively high level of safety. The medium-term IOP in the operated eyes significantly decreased compared to preoperative values. However, the majority of operated eyes did not achieve complete surgical success.

Ex-PRESS shunt combined with ab-interno peripheral iridectomy: A new surgical procedure for iridocorneal endothelial syndrome

PurposeIridocorneal endothelial (ICE) syndrome may cause refractory glaucoma due to progressive synechial closure or membrane formation at the anterior chamber angle. Filtration surgeries are often required but are associated with a higher rate of surgical failure or complications than other types of glaucoma. Herein, we report a new and effective surgical procedure for glaucoma secondary to ICE syndrome: Ex-PRESS shunt combined with ab-interno peripheral iridectomy using a small-gauge vitreous cutter. MethodsThree patients with ICE syndrome who underwent surgery were included. Intraoperatively, an ab-interno peripheral iridectomy was performed using a small-gauge vitreous cutter through a corneal incision in the superior-nasal or superior-temporal quadrants to create space for the insertion of Ex-PRESS shunt free from the iris tissue. The shunt was inserted under the scleral flap. The first patient underwent combined cataract surgery, whereas patients 2 (pseudophakia) and 3 (phakia) underwent Ex-PRESS alone. ResultsNo intraoperative complications were observed. The intraocular pressure remained stable until the final postoperative visits at approximately 7, 4, and 1 year in Cases 1, 2, and 3, respectively. Case 2, with mild preoperative corneal edema due to graft failure in Descemet's stripping automated endothelial keratoplasty (DSAEK), underwent reDSAEK 6 months postoperatively. Conclusions and importanceEx-PRESS shunt combined with ab-interno peripheral iridectomy using a small-gauge vitreous cutter may be a safe and effective surgical procedure in patients with ICE syndrome, regardless of the lens status.

Aqueous Flare Changes in Ex-PRESS Glaucoma Shunt Eyes After 4.7 Tesla High-Field Magnetic Resonance Imaging

Ex-PRESS glaucoma shunt stainless steel devices have been used worldwide for glaucoma treatment. The purpose of this study was to evaluate the safety of high-field magnetic resonance imaging (MRI) for Ex-PRESS-inserted eyes. Using rabbits, we performed Ex-PRESS shunt surgery in one eye in each rabbit and divided the rabbits into MRI and non-MRI groups. In the MRI group, 1 week after Ex-PRESS shunt surgery under low specific absorption rate (SAR) conditions and 1 week later under high SAR conditions, high-field 4.7-Tesla MRI was performed. Aqueous flare counts were measured before and after the Ex-PRESS shunt surgery and each MRI examination. The rabbits in the non-MRI group received only general anesthesia, and aqueous flare counts were measured as for those of the MRI group. Aqueous flare counts were expressed in photon counts per millisecond. No dislocation of the Ex-PRESS shunt device was observed after MRI. The flare count ratio (MRI/non-MRI) in Ex-PRESS-inserted eyes 2 hours after high SAR MRI increased significantly compared with that before MRI (0.8 ± 0.3 vs 2.7 ± 0.8; pre-high SAR MRI vs 2 hours after high SAR MRI, respectively; P = 0.01). The day after MRI, the flare count improved spontaneously to the same level as that before MRI. Our results indicate that high-field MRI can be performed relatively safely after Ex-PRESS shunt surgery. This study demonstrates the safety of high-field MRI for Ex-PRESS-inserted eyes using a rabbit model.

Trabeculectomy vs. Express P-200 Shunt Surgery in Post Cataract Patients

There was no difference found in the efficacy of trabeculectomy when compared with Ex-PRESS shunt in pseudophakic eyes. Ex-PRESS shunt was generally found to be a safer procedure, though this difference didn’t reach statistical significance

Impact of Fellowship Training on Practice Patterns of Glaucoma Surgeons Treating Medicare fee-for-service Beneficiaries

ABSTRACT Purpose Analyze practice patterns of glaucoma surgeons with and without fellowship training. Materials and Methods Physician-specific 2017 Medicare data were obtained from the Centers for Medicare & Medicaid Services website. Current Procedural Terminology codes identified procedures including iStent, tube shunts, trabeculectomy, complicated trabeculectomy, endoscopic cyclophotocoagulation, internal Xen Implant, external Xen or Express shunt, Gonioscopy-Assisted Transluminal Trabeculotomy, and Kahook Dual Blade Goniotomy. Physicians with fellowship training were identified via the American Glaucoma Society website. Results A total of 1547 glaucoma surgeons were identified, of which 319 had completed fellowship training. Overall, fellowship-trained glaucoma surgeons performed more services (50.4 ± 47.0 vs 40.5 ± 35.3, P < .001) with a larger variety of procedures (1.8 ± 1.0 vs 1.3 ± 0.6, P < .001) than those without fellowship training. Surgeons without fellowship training were more likely to perform iStent and endoscopic cyclophotocoagulation and less likely to perform the remaining procedures than their fellowship-trained counterparts. Medicare payments did not differ between groups and the number of Medicare beneficiaries only differed for internal Xen implant (P = .03). Patient comorbidity burden was similar between groups with about one-third of patients being diagnosed with ischemic heart disease. Conclusions Surgeons without fellowship training can treat a similar volume of glaucoma patients as those with fellowship training. However, based on surgical procedures employed, their practices are skewed towards mild and moderate glaucoma and they are more limited in their breadth of procedures. In addition, ischemic heart disease was prevalent in the glaucoma patient population.

Long-Term Changes in Corneal Endothelial Cell Density after Ex-PRESS Implantation: A Contralateral Eye Study.

Our purpose is to evaluate long-term changes in corneal endothelial cells after Ex-PRESS shunt implantation for the treatment of glaucoma in Chinese patients by comparison with the contralateral eye. In this retrospective observational study, glaucoma patients with a single eye undergoing Ex-PRESS shunt implantation surgery were consecutively enrolled. For each patient, the clinical assessment, including corneal endothelial cell density (CECD) before surgery and at 6, 12 months, and at last follow-up (2.43 ± 0.63 years) after surgery was reviewed. The operated eyes were in the study group and the unoperated contralateral eyes were used as the control group to compare the CECD change. A total of 48 subjects (age, 51.02 ± 17.96 years) were included. The follow-up period was 2.08~3.17 years, with an average of 2.43 ± 0.63 years. At the last follow-up after the surgery, the CECD decrease in the operated eyes (5.0%) was similar to that in the contralateral eyes (3.2%) (p = 0.130). There were no significant differences in CECD reduction between the two groups at baseline and each postoperative follow-up (6 months, 12 months and at the last follow-up) (all p > 0.05). The average IOP reduction after the surgery was 50.8%, and the number of IOP-lowering medications was significantly reduced (p < 0.05). In addition, visual acuity showed no significant differences during follow-up (p > 0.05). In this study, we found that the CECD reduction of Ex-PRESS shunt-implanted Chinese eyes was similar to that of contralateral eyes without surgery.

Результаты хирургии глаукомы: клапан ahmed и ex-press шунт у пациентов с вторичной глаукомой

Purpose. To increase the efficiency of surgical treatment of patients with secondary glaucoma using microfistulizing and micro-shunting operations: Ahmed valve implantation and Ex-press shunt. Material and methods. 53 patients (53 eyes) with secondary glaucoma underwent surgical treatment in the form of implantation of Ex-press shunt and Ahmed valve (models FP7, FP8) in the Orenburg branch of The S. Fyodorov Eye Microsurgery Federal State Institution. We analyzed the results of surgical treatment of these groups of patients 1, 3, 6 and 12 months after surgery. Results. The Ahmed valve system creates a longer stable hypotensive effect in secondary glaucoma in 26 cases (85.7 %) during follow-up up to 1 year after surgery than Ex-press shunt implantation, suspending the progression of glaucoma neuroopticopathy. The degree of proliferative and scarring changes in the angle of the anterior chamber directly depends on the values of IOP: the lower the IOP level, the less the degree of changes in the angle of the anterior chamber of the eye. Conclusion. Implantation of the Ahmed valve and Ex-press shunt is a low-traumatic operation and is an effective way to compensate for secondary glaucoma due to other eye diseases in these patients, at the same time, both the hypotensive and optical effects persist even one year after the operation. Keywords: unstabilized glaucoma, Ahmed valve, Ex-press valve, true pressure.

Ocular Hypotony after Glaucoma Surgery

Background: Postoperative hypotony is associated with choroidal effusion, suprachoroidal haemorrhage, aqueous misdirection syndrome (malignant glaucoma), choroidal folds and hypotony maculopathy, anterior chamber (AC) shallowness or loss and subsequent failure of the original filtration of procedure. This work aimed to study the causes, risk factors, adverse effects, and management plans of ocular hypotony after different glaucoma surgeries.&#x0D; Methods: This retrospective study was carried out on 205 eyes underwent glaucoma surgery with follow up for more than 3 months. Patients were divided into two groups: 30 cases were diagnosed with post-operative hypotony, 175 eyes were without hypotony. Patients were subjected to glaucoma diagnosis, type of glaucoma operation and recorded IOP for 3 months at least.&#x0D; Results: CPC, Visco-Trab, Phaco Visco-Trab Visco and express valve were significantly different between the two groups (P=0.049, P=0.012, P=0.043 and P&lt;0.001 respectively) and other types of operation were insignificantly different between the two groups. IOP was significantly decreased at first diagnosis of hypotony and at last follow up compared to before operation (P value &lt;0.001). IOP at last follow up was significantly increased compared to first diagnosis of hypotony (P value &lt;0.001). Criteria of hypotony eyes were insignificantly different between patients needed surgical intervention and no surgical intervention.&#x0D; Conclusions: Postoperative hypotony was most common in pseudo-exfoliative glaucoma cases compared to other glaucoma types. While the most type of glaucoma surgery that was associated with postoperative hypotony was viscocanalostomy combined with express shunt. The adverse effects reported in our study were choroidal effusion and hypotony maculopathy.

The Role of Automated Peripheral Iridectomy Combined with Phacoemulsification and Mini Ex-PRESS Shunt Implantation in Patients with Chronic Angle Closure Glaucoma.

PurposeTo evaluate the role of automated peripheral iridectomy as an adjunctive tool combined with phacoemulsification and ExPRESS shunt implantation in management of cases with chronic angle closure glaucoma.SettingMagrabi eye hospital.MethodsThis prospective study included 22 eyes of 22 patients with chronic angle closure glaucoma and cataract who underwent Ex-PRESS shunt implantation, cataract extraction and surgical peripheral iridectomy at the site of shunt implantation in the period between January 2018 and April 2020.ResultsAfter surgery, the mean IOP was 11.3±1.2 mm Hg, 14.5±1.6 mm Hg, 14.8±2.1 mm Hg, 15.3±1.9 mm Hg and 17.4±1.8 mm Hg at 7 days, 1 month, 3 months, 6 months and 12 months, respectively. All postoperative IOP was significantly lower compared with preoperative IOP (P = 0.001). There was a significant decrease in the number of medications required after surgery. The baseline mean number of medications was 3.4±0.02 (range from 1 to 4), while postoperatively the mean number of medications decreased to 0.7±0.01 at 12 months (P < 0.01). The qualified success rate was 6/22 eyes, and the complete success rate was 16/22 (72.7%) at 12 months, respectively.ConclusionThe combined phacoemulsification and Ex-PRESS shunt implantation with automated peripheral iridectomy is an effective and safe procedure to treat chronic angle closure glaucoma.

Glaucoma Treatment Outcomes in Open Angle Glaucoma Patients of African Descent.

Open angle glaucoma (OAG), characterized by structural changes to the optic nerve head and retinal nerve fiber layer, is a progressive multifactorial optic neuropathy and a leading cause of irreversible blindness globally. Currently, intraocular pressure is the only modifiable risk factor; however, others have been identified, including genetics and race. Importantly, OAG is much more prevalent in persons of African descent (AD) compared with those of European descent (ED). OAG patients of AD are also known to have a more severe course of the disease, a finding potentially explained by structural and/or vascular differences within eye tissues. In addition, disparities in treatment outcomes have been identified in OAG patients of AD. Specifically, prostaglandin analogues have been suggested to be more effective in patients of AD than in those ED, while beta-adrenergic receptors have been suggested to be less effective, although the evidence is inconsistent. AD has also been identified as a risk factor for trabeculectomy failure while laser trabeculoplasty has been conversely found to be very effective in lowering intraocular pressure in patients of AD. Alternative surgical options, including Ex-Press shunt implantation, viscocanalostomy, and canaloplasty are promising in equivalence but require further research to evaluate disparity in outcome properly. In addition to treatment outcomes, social disparities affecting clinical care also exist for AD persons in the form of reduced adherence, access, and choice. Overall, data suggest the need for properly designed prospective trials with AD populations as a primary focus to identify the potential mechanisms driving disparities in treatment and address overall potential bias in glaucoma management.

Retinal Pigment Epithelium Tear after Glaucoma Surgery

Retinal pigment tear (RPE) is a very rare complication of glaucoma filtering surgeries. The right eye of a 65-year-old woman underwent an Ex-Press shunt implantation to treat uncontrolled primary open-angle glaucoma. On day 3, the intraocular pressure (IOP) was 5 mmHg with an over-filtering bleb. Wide-field fundus color and autofluorescence images showed peripheral choroidal detachment, RPE detachment (arrow), RPE tear, and macula-off exudative retinal detachment (Fig A-B). Additional sutures were placed on the scleral flap to achieve an increase in IOP.

Reoperation Rates and Disease Costs for Primary Open-Angle Glaucoma Patients in the United States Treated with Incisional Glaucoma Surgery

To evaluate the claims-based 5-year economic and reintervention burden for patients with primary open-angle glaucoma (POAG) after incisional glaucoma surgery in the United States. Retrospective Medicare claims analysis. One thousand nine hundred forty-five Medicare fee-for-service patients with POAG treated with trabeculectomy, tube shunt, or EX-PRESS shunt procedures from 2010 through2011. Patients with POAG treated with incisional glaucoma surgery (trabeculectomy, tube shunt, or EX-PRESS shunt) from 2010 through 2011 were identified in the Medicare 5% Standard Analytical Files. Ten years of claims data for each patient (2005-2016) were evaluated for prior incisional surgeries and downstream procedures in the treated eye within 5 years of index. Patients' characteristics, downstream procedures, and POAG-related costs were evaluated. Proportions of patients with downstream procedures in the index eye indicating failure of the index surgery, glaucoma reoperations, nonfailure complications, interventions, or cataract surgery were assessed over 5 years of follow-up. Cumulative rates of index surgery failure and glaucoma reoperations over 5 years after incisional glaucoma surgery. Of 1945 patients, 223 underwent EX-PRESS shunt, 551 underwent tube shunt, and 1171 underwent trabeculectomy at index. Rates of failure, glaucoma reoperations, or nonfailure complications rose over 5 years after index for all patient subgroups. At 1 year, 15.1% of EX-PRESS shunt patients, 11.6% of tube shunt patients, and 8.8% of trabeculectomy patients had experienced failure based on postindex procedures. By 5 years follow-up, these rates were 31.5% of EX-PRESS shunt patients, 27.1% of tube shunt patients, and 23.5% of trabeculectomy patients. Five-year rates of glaucoma reoperations were 18.3%, 14.0%, and 15.1%, respectively. Among tube shunt and trabeculectomy patients with prior incisional surgery, the 5-year failure rates were 32.5% and 32.6%, and reoperations rates were 12.0% and 26.1%, respectively. More than one-fourth of patients with POAG treated with incisional surgery underwent additional procedures to address index surgery failure within 5 years. Of these, more than half underwent additional incisional glaucoma surgery. These outcomes from clinical practice settings demonstrate that patients with POAG who require incisional surgery continue to need additional safe and effective surgical treatment options to manage their glaucoma.

Displacement of Ex-PRESS Shunt Head Outside the Conjunctiva in a Uveitis Patient: A Case Report

Ex-PRESS mini shunt is recently involved in trabeculectomy surgery with a good outcome. We present a 14-year-old male with a history of juvenile idiopathic arthritis, non-granulomatous anterior uveitis, and secondary glaucoma operated with trabeculectomy Ex-PRESS shunt in his right eye. The patient developed extrusion of the implant head outside the conjunctiva after 4 years of surgery. The patient admitted to the hospital with removal of Ex-PRESS shunt under general anesthesia with the suturing of the scleral defect and closure of the conjunctiva.

Trabeculectomy with Ologen implant versus trabeculectomy with P 50 Ex-PRESS shunt in primary open-angle glaucoma

BackgroundThis is the first randomized controlled trial of trabeculectomy with Ex-Press Shunt versus Ologen implant in primary open-angle glaucoma (POAG) in Indian eyes. MethodsA prospective randomized controlled trial of patients of POAG treated with two different methods of augmented trabeculectomy. Group A with Ex-PRESS shunt (P50 model) and Group B with Ologen implant. Surgical success was defined as intraocular pressure of 21 mm Hg or lower at 6 months postoperative. ResultsN = 40 eyes of 33 patients. Baseline IOP in Group A was 23.70 ± 4.6 mm Hg (Range 22–36 mm Hg), and Group B was 26.00 ± 4.0 mm Hg (Range 23–36 mm Hg). Surgical success was achieved in 85% of patients in both Groups. Change in IOP from baseline was statistically significant in both groups at 1, 4, 8, 12 weeks, and 6 months postoperative. No statistically significant difference in the change in IOP between the two groups. Postoperative complications were lesser in Group A compared to Group B, in both early (35% vs 50%) and late stage (20% vs 30%). The drop in visual acuity became statistically insignificant at 4 weeks in Group A and 8 weeks in Group B. ConclusionsThere is no difference between the surgical success rates of trabeculectomy with Ex-PRESS Shunt versus Ologen. However, the Ex-PRESS shunt fares better with lower complication rates and faster visual recovery than the Ologen group.

An Ex-Press implant versus trabeculectomy in a fibrotic bleb with late failure after previous trabeculectomy

To compare the outcome of an Ex-Press implant and subscleral trabeculectomy (SST) in the management of glaucoma after previous trabeculectomy on a fibrotic bleb. This randomized prospective study included 28 eyes from 28 patients (age range: 42-55y) with primary open angle glaucoma (POAG) presented with elevated intraocular pressure (IOP) with fibrotic bleb despite previous SST for more than 4mo. The eyes enrolled in the study were divided into two groups: group I (subjected to Ex-Press implant surgery) and group II [subjected to SST with mitomycin C (MMC)]. The follow-up continued one year after surgery to evaluate IOP, visual acuity (VA), visual field (VF), and postoperative complications. A significant decrease in IOP was found in both groups with a higher reduction in Ex-Press implant surgery with the mean IOP of 14.50 mm Hg (P=0.001), while the SST group recorded the mean IOP of 16.50 mm Hg (P=0.001) after one year. However, the difference between the two groups in terms of the decrease in IOP was insignificant. Fewer postoperative complications were recorded in the Ex-Press implant surgery and more cases requiring further anti-glaucomatous medications were seen in the SST group. Both groups showed stability in terms of VA and VF. Ex-Press implant surgery and SST with MMC are two surgical alternatives for controlling IOP in late failure that occurs more than 4mo after previous SST with a fibrotic bleb. However, Ex-Press shunt is a safer surgery with fewer complications.

Comparative outcome analysis of bleb needling of fibrotic blebs in the clinic versus the operating room: a retrospective case series

BackgroundTo compare 6 month outcomes of bleb needling performed in the clinic vs. the operating room (OR) in adult glaucoma patients with failed bleb.MethodsA retrospective case series of 47 eyes from 41 glaucoma patients who received needling with mitomycin C (MMC) of scarred bleb from prior bleb-forming procedures in clinic (32 eyes) vs. the OR (15 eyes), including trabeculectomy (14 eyes), ExPress shunt (16 eyes), and ab-interno XEN gel stent (17 eyes). The primary outcome was needling success, defined as IOP ≤ 18 mmHg on 0 glaucoma medications without requiring an additional IOP lowering procedure within 6 months after needling.ResultsAt 6 months, bleb needling success rate was similar when performed in the clinic vs. in the OR (28% vs. 20%, P = 0.54). Success rate was not statistically different in patients with prior trabeculectomy, ExPress shunt, and XEN gel stent (29% vs. 38% vs. 12%, P = 0.26). When comparing clinic vs. the OR needling procedures at 6 months, there was no difference in mean IOP (14.2 vs. 14.9 mmHg, P = 0.73), mean glaucoma medications (1.4 vs. 1.7, P = 0.69), additional IOP-lowering procedure rate (16% vs. 27%, P = 0.37), or complication rate (0% vs. 7%, P = 0.32).ConclusionBleb needling with MMC in clinic may be a safe and effective way to revise failed bleb after trabeculectomy, ExPress shunt, and XEN gel stent procedures when compared to needling in the OR.

A Comparison of Clinical Outcomes After XEN Gel Stent and EX-PRESS Glaucoma Drainage Device Implantation.

Although the XEN stent offers a lower risk of hypotony and choroidal effusions with fewer clinic visits postoperatively, its surgical success rate was inferior to the EX-PRESS shunt. To compare the clinical efficacy and safety outcomes of the XEN stent and EX-PRESS glaucoma drainage device in glaucomatous eyes. One hundred eyes from 88 patients underwent ab interno XEN stent or EX-PRESS shunt implantation (52 XEN and 48 EX-PRESS) for uncontrolled glaucoma at the University of Colorado Eye Center. The primary outcome was surgical success defined as intraocular pressure (IOP) ≥6 and ≤18 mm Hg, without reoperation for uncontrolled glaucoma, loss of light perception, or use of glaucoma medications (complete success). Secondary outcomes were the same requirements allowing for medications (qualified success), mean IOP, medication use, adverse events, and number of postoperative clinic visits in the first 3 months. Baseline characteristics including glaucoma type and severity were similar between groups, with the exception of XEN patients having fewer men (17% vs. 46%), older patients (median age, 78 vs. 68), and a higher percentage of white patients (89% vs. 69%). Adjusted hazard ratio of failure of XEN relative to EX-PRESS was 3.94 (95% confidence interval, 1.73-9.00, P=0.001) for complete success and 1.61 (95% confidence interval, 0.40-6.38, P=0.501) for qualified success. There were significantly fewer postoperative clinic visits during the first 3 months in the XEN group (5.3 vs. 9.1 visits, P<0.001). The incidence of serous choroidal effusions and hypotony was significantly less after XEN compared with EX-PRESS (1 vs. 9, P=0.02 and 15 vs. 25, P=0.023, respectively). Three XEN stents (5.8%) required removal. In this population, although the XEN stent offers a better safety profile and fewer postoperative clinic visits, complete surgical success was inferior to the EX-PRESS shunt.