Incisional Surgery Research Articles

Risk, Prevalence, and Progression of Glaucoma in Eyes With Age-Related Macular Degeneration Treated With Intravitreal Anti–Vascular Endothelial Growth Factor Injections

To examine the risk, prevalence, and progression of glaucoma development in age-related macular degeneration (AMD) eyes receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections compared to controls. Retrospective clinical cohort study. Retrospective review of eyes receiving intravitreal anti-VEGF injections from January 1, 2004, to December 31, 2013, for exudative AMD. Age- and sex-matched control groups of eyes included eyes with nonexudative AMD (NEAMD) and no AMD. Eyes with a diagnosis of glaucoma or glaucoma suspect were reviewed for injection details, type and date of glaucoma diagnosis, glaucoma treatments, standard automated perimetry (SAP), and spectral domain optical coherence tomography (SD-OCT). Qualitative progression was determined by indication of glaucoma progression in provider notes. Quantitative progression was assessed based on change in mean deviation (MD) on SAP, retinal nerve fiber layer thickness on SD-OCT, and intraocular pressure (IOP). There were 707 eyes of 504 patients treated with anti-VEGF injections and 1008 eyes in the NEAMD and no-AMD cohorts. There was no difference in glaucoma or suspect prevalence at initial presentation between eyes treated with injections and NEAMD (6.9% vs 9.7%, P=.22) or no-AMD controls (vs 8.5%, P=.55). There was no difference in cumulative 5-year probability of new glaucoma diagnosis after anti-VEGF injections compared to NEAMD (1.9% vs 1.0%, P=.69) or no-AMD controls (vs 1.6%, P=.88). There was no difference in qualitative progression of glaucoma in the injection cohort vs NEAMD (P=.19) or no-AMD controls (P=.61). The rate of MD change in injection eyes was similar to NEAMD eyes (P=.74) but greater than no-AMD eyes (P=.02). Eyes receiving injections required more topical glaucoma medications compared with NEAMD (P=.03) and more glaucoma laser treatments compared with no-AMD controls (P=.009). Eyes receiving injections did not require more frequent incisional glaucoma surgery compared with NEAMD (21.0% vs 15.0%, P=.95) or no-AMD controls (vs 10.0%, P=.10). Eyes treated with intravitreal anti-VEGF injections for exudative AMD did not have increased risk of developing glaucoma compared with controls. Of those with a glaucoma diagnosis, exudative AMD eyes receiving injections required a greater number of topical glaucoma medications compared with NEAMD eyes and had a greater rate of MD loss than no-AMD controls.

The effectiveness and tolerability of fixed-dose combination netarsudil 0.02%/latanoprost 0.005% at a tertiary glaucoma center.

To assess real-world effectiveness and tolerability of fixed-dose combination netarsudil 0.02%/latanoprost 0.005% (FCNL) in management of glaucoma patients in a tertiary eye care center. This retrospective cohort study included glaucoma patients initiated on FCNL from January 2018 to July 2021 with at least 1-month follow-up. Demographic and clinical data were collected at baseline and at follow-up visits through 12months. Patient-solicited side effects were recorded at each visit. Maximum glaucoma pharmacotherapy was defined as surgery/laser being the next treatment option following an intensive pharmacotherapy regimen, or when pharmacotherapy could not be increased due to allergy/intolerance or all pharmacologic mechanisms already being in use. Seventy-nine eyes of 47 patients were included. Mean age was 67.7 ± 14.7years. Baseline IOP was 18.7 ± 4.9mmHg; mean change in IOP (∆IOP) each study visit compared to baseline ranged from - 1.6 ± 3.5 to - 4.4 ± 4.1mmHg (all p < 0.05). The eyes on maximum glaucoma pharmacotherapy (73.4%) had similar ∆IOP compared to those on non-maximal therapy at each visit (p > 0.2 for all). Forty-three (54.4%) eyes were switched from a prostaglandin analog alone, producing a 1-month IOP reduction of - 4.7 ± 3.9mmHg at 1month which remained significant at each visit for the 12-month study period (all p < 0.05). Across all study visits, conjunctival hyperemia was documented in 26 (32.9%) eyes. Subjective blurry vision was reported in 22 (27.8%) eyes without significant worsening of visual acuity at any visit (all p > 0.05). Six (7.6%) and 7 (8.9%) eyes required further medical or surgical/laser intervention, respectively. Kaplan-Meier analysis revealed no significant difference in the need for subsequent medical or surgical intervention between those on maximum and non-maximal pharmacotherapy (p > 0.4). FCNL was well-tolerated and demonstrated a significant and sustained reduction in IOP, even as last-line therapy before incisional or laser surgery in those on maximum glaucoma pharmacotherapy. FCNL is a viable treatment option for glaucomatous eyes before consideration of surgical intervention.

Treatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 5 Years of Follow-up

To report 5-year treatment outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. Multicenter randomized clinical trial. A total of 242 eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 patients in the tube group and 117 patients in the trabeculectomy group. Patients were enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC) (0.4 mg/ml for 2 minutes). The primary outcome measure was the rate of surgical failure, defined as intraocular pressure (IOP) > 21 mmHg or reduced < 20% from baseline, IOP ≤ 5 mmHg, reoperation for glaucoma, or loss of light perception. Secondary outcome measures included IOP, glaucoma medical therapy, and visual acuity. The cumulative probability of failure after 5 years of follow-up was 42% in the tube group and 35% in the trabeculectomy group (P= 0.21; hazard ratio= 1.31; 95% confidence interval= 0.86-2.01). At 5 years, IOP (mean ± standard deviation) was 13.4 ± 3.5 mmHg in the tube group and 13.0 ± 5.2 mmHg in the trabeculectomy group (P= 0.52), and the number of glaucoma medications (mean ± standard deviation) was 2.2 ± 1.3 in the tube group and 1.3 ± 1.4 in the trabeculectomy group (P < 0.001). Trabeculectomy with MMC and tube shunt surgery produced similar IOPs after 5 years of follow-up in the PTVT Study, but fewer glaucoma medications were required after trabeculectomy. No significant difference in the rate of surgical failure was observed between the 2 surgical procedures at 5 years.

Postoperative Complications in the Primary Tube Versus Trabeculectomy Study During 5 Years of Follow-up

To describe postoperative complications encountered in the Primary Tube Versus Trabeculectomy (PTVT) Study during 5 years of follow-up. Multicenter randomized clinical trial. A total of 242 eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 patients in the tube group and 117 patients in the trabeculectomy group. Patients were enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC, 0.4 mg/ml for 2 minutes). Surgical complications, reoperations for complications, visual acuity, and cataract progression. Early postoperative complications occurred in 24 patients (19%) in the tube group and 40 patients (34%) in the trabeculectomy group (P= 0.013). Late postoperative complications developed in 27 patients (22%) in the tube group and 32 patients (27%) in the trabeculectomy group (P= 0.37). Serious complications producing vision loss and/or requiring a reoperation were observed in 3 patients (2%) in the tube group and 9 patients (8%) in the trabeculectomy group (P= 0.11). Cataract progression was seen in 65 patients (52%) in the tube group and 52 patients (44%) in the trabeculectomy group (P= 0.30). Surgical complications were not associated with a higher rate of treatment failure (P= 0.61), vision loss (P= 1.00), or cataract progression (P= 0.77) CONCLUSIONS: A large number of surgical complications were observed in the PTVT Study, but most were transient and self-limited. The incidence of early postoperative complications was higher following trabeculectomy with MMC than with tube shunt surgery. The rates of late postoperative complications, serious complications, and cataract progression were similar with both surgical procedures after 5 years of follow-up. Surgical complications did not increase the risk of treatment failure, vision loss, or cataract progression.

The choice of suture material and techniques of the laparotomic wound suture

Surgical technique and suture material applied in laparotomic wound suturing are important factors determining the risk of incisional hernias and other wound complications. Optimization of laparotomic wound closure will undoubtedly reduce the frequency of postoperative complications, including incisional hernias and subsequent secondary surgeries in patients. Thus it will improve their quality of life and, in economic terms, significantly reducing the cost of health care resources. Despite the great work carried out in this area by many groups of medical specialists and scientists around the world, today there is no single, generally accepted and proven advantage of the technique for closing a laparotomic wound.

The effect of preoperative skin preparation on clinical outcomes with incisional surgery: a network meta-analysis.

Preoperative skin antiseptics are used prior to surgery to reduce the risk of surgical site infection (SSI). There is debate as to which is the most effective. The aim of this network meta-analysis (NMA) is to compare the effectiveness of different skin preparations at reducing SSIs in patients undergoing incisional surgery. The study protocol was published in PROSPERO (CRD4202181599) a priori with predefined search terms and inclusion/exclusion criteria. The skin preparations for comparison were: chlorhexidine/alcohol (CHA), chlorhexidine/water (CHW), poviodine/alcohol (PVIA), poviodine/water (PVIW). The records identified were screened by two authors independently by title, abstract and in full text. The revised tool for risk-of bias (ROB2) assessment was used. Twenty-nine RCTs involving 15 796 patients were included in the NMA. A significant but small increase in the odds of infection was seen in the PVIW group compared to the CHA group (OR 1.34, 95%CrI 1.09-1.64), but other comparisons were not statistically significantly different. Ranking the treatment arms showed there was a 64% probability that CHA is the most effective and a 62.7% probability that PVIW is the least effective treatment. Chlorhexidine/alcohol (CHA) was found to be the most effective for prevention of superficial and deep SSI while PVIW was the least. There was no differences seen between CHA and PVIA, or CHW and PVIW. The superiority of CHA is likely due to the effect of the alcohol in the base. Hence the choice between CHA and PVIA should be based on health and cost considerations.

The Development of Artificial Intelligence in Hernia Surgery: A Scoping Review.

BackgroundArtificial intelligence simulates human intelligence in machines that have undergone programming to make them think like human beings and imitate their activities. Artificial intelligence has dominated the medical sector to perform various patient diagnosis activities and improve communication between professionals and patients. The main goal of this study is to perform a scoping review to evaluate the development of artificial intelligence in all forms of hernia surgery except the diaphragm and upside-down hernia.MethodsThe study used the Preferred Reporting Items for Systematic and Meta-analyses for Scoping Review (PRISMA-ScR) to guide the structuring of the manuscript and fulfill all the requirements of every subheading. The sources used to gather data are the PubMed, Cochrane, and EMBASE databases, IEEE and Google and Google Scholar search engines. AMSTAR tool is the most appropriate for assessing the methodological quality of the included studies.ResultsThe study exclusively included twenty articles, whereby seven focused on artificial intelligence in inguinal hernia surgery, six focused on abdominal hernia surgery, five on incisional hernia surgery, and two on AI in medical imaging and robotics in hernia surgery.ConclusionThe outcomes of this study reveal a significant literature gap on artificial intelligence in hernia surgery. The results also indicate that studies focus on inguinal hernia surgery more than any other types of hernia surgery since the articles addressing the topic are more. The study implies that more research is necessary for the field to develop and enjoy the benefits associated with AI. Thus, this situation will allow the integration of AI in activities like medical imaging and surgeon training.

Outcomes of femtosecond laser-assisted cataract and refractive lens surgery in patients with prior radial keratotomy.

To investigate outcomes of femtosecond laser (FL)-assisted cataract surgery (FLACS) and refractive lens exchange (RLE) in patients with prior radial keratotomy (RK). Single clinical practice. Retrospective observational case series. All patients with prior RK undergoing FLACS- or FL-assisted RLE surgeries over a 6-year period were reviewed. Inclusion criteria were diurnal stability and stable manifest refraction. Exclusion criteria were any other incisional corneal surgery, macular or glaucomatous pathology, or vision loss due to any other cause. Data collected included demographics, visual acuity, laser settings, and complications. Main outcome measures were intraoperative and postoperative complications and visual outcomes. Safety and efficacy indices were evaluated. 16 eyes of 9 patients were included. Mean age and follow-up time were 59.9 ± 9.9 years (range 44 to 75 years) and 3.3 ± 2.5 months, respectively. The mean number of RK cuts was 11.8 ± 5.3 (range 8 to 20). Mean preoperative uncorrected (UDVA) and corrected distance visual acuity (CDVA) were 0.9 ± 0.4 logMAR (Snellen 20/160) and 0.2 ± 0.3 logMAR (Snellen 20/30), respectively. 2 intraoperative anterior capsule tears were identified. 1 postoperative intraocular lens dislocation occurred. Postoperatively, the mean UDVA and CDVA were 0.2 ± 0.2 logMAR (20/30) and 0.1 ± 0.1 logMAR (20/25), respectively. The safety index was 1.6, and the efficacy index was 1.2. FLACS- or FL-assisted RLE surgery in RK patients has a high risk for anterior capsule tear and should be avoided. Thickened incisional scars are potential sources of incomplete laser penetrance. Toric lens implantation in RK eyes provide unpredictable astigmatic correction and should also be avoided.

Reasons for choice of glaucoma surgery in eyes not treated with anti-glaucoma medications

BackgroundIn the real world, some glaucoma patients can undergo an incisional glaucoma surgery without using medication. The rate of cases with no medication treatment at the time of surgery among those that underwent incisional glaucoma surgeries performed in our department was reported.MethodsThe department database of Shimane University Hospital for eyes that underwent incisional surgeries to manage glaucoma at the hospital between April 2018 and September 2020 were searched. By reviewing the medical charts of 1,417 consecutive eyes listed, 90 (6.4%) eyes of 67 subjects (mean age of 72 ± 16 years; 22 men, 29 eyes; 45 women, 61 eyes) who underwent a surgery without use of antiglaucoma medication were identified. The types of glaucoma, glaucoma procedures, and reasons for choosing the glaucoma surgeries rather than medical therapy were collected for the 90 eyes.ResultsAmong the 90 eyes, primary angle-closure disease (PACD) (60%) was the most frequent type of glaucoma followed by EXG (17%), POAG (16%), and others (8%). Among the reasons for the choice of incisional surgery, relief of angle closure (64%) was the most frequent, the second most frequent was the incidental diagnosis of glaucoma during the ocular examinations both for that eye’s cataract surgery or the contralateral glaucoma surgery (13%). Other reasons included poor medication adherence (10%), dementia (6%), multiple medication allergy (3%), and acute IOP elevation other than PACD (3%). Cataract extraction (CE) alone (33%) was the most frequent glaucoma procedures performed in these eyes, followed by CE combined with goniosynechialysis (27%), CE + iStent (16%), CE + goniotomy by Tanito microhook ab interno trabeculotomy or using the Kahook Dual Blade (11%), Ahmed Glaucoma valve implantation (11%), and trabeculectomy (2%).ConclusionIn the real-world, 6.4% of incisional glaucoma surgeries were performed in the absence of medication use; of them, 32 eyes (2.3%) were with open angle glaucoma. In open angle glaucoma, the reasons can be classified into; 1) patients’ inability to instill the medication, 2) incidental diagnosis of glaucoma during the pre-surgical examinations, and 3) the eyes with acute IOP rise.

The Difficulties of Trabeculectomy in a Primary Angle-Closure Glaucoma Patient

Introduction: Trabeculectomy is an incisional surgery for glaucoma patient. Performing trabeculectomy in primary angle-closure glaucoma (PACG) is quite difficult. Caution is needed for the occurrence of flat anterior chamber (FAC) and malignant glaucoma. We present a case management of trabeculectomy in a PACG patient. Case presentation: A 52-year-old male had blurred vision in his left eye since one year ago. The patient felt left visual field narrowing since eight months ago. Patient had type 2 diabetes mellitus. Visual acuity on the left eye was 5/7.5. Intraocular pressure (IOP) increased (29 mmHg). Gonioscopy showed closed angle and peripheral anterior synechiae. Glaucomatous optic neuropathy was found with C/D ratio value of 0.9 and superior-inferior RNFL thinning on optical coherence tomography (OCT). Anterior segment OCT revealed shallow anterior chamber depth (ACD) 2.54 mm. The right eye visual acuity was 5/5, normal IOP, and shallow ACD (2.66 mm). Patient was underwent left eye trabeculectomy. Postoperatively, left eye anterior chamber and bleb were formed. He had normal IOP without glaucoma medications. Conclusions: Trabeculectomy is a surgical procedure for glaucoma. Close monitoring is required to avoid the risk of postoperative FAC and malignant glaucoma in PACG.

Body Mass Index impact on Extended Total Extraperitoneal Ventral Hernia Repair: a comparative study.

Obesity is a risk factor for developing abdominal wall hernias and is associated with major postoperative complications, such as surgical site infection, delayed wound healing and recurrent hernia. Therefore, treating incisional hernia in this patient subgroup is a challenge. We conducted a comparative, prospective study on patients who underwent primary ventral hernia surgery or incisional hernia surgery through the extended totally extraperitoneal pathway, with body mass indices (BMIs) ≤ 30 (no obesity) and BMI > 30 (with obesity). We collected demographic data, preoperative and intraoperative variables, complication and recurrence rate, hospital stay and follow-up as postoperative data. From May 2018 to December 2020, 74 patients underwent this surgery, 38 patients without obesity and 36 with obesity. The median area of the hernia defect measured by CT was 57 cm2 and 93 cm2 in patients without and with obesity, respectively (p = 0.012). The median follow-up was 16months. One patient without obesity experienced some postoperative complication compared with four patients with obesity (p > 0.05). No patient without obesity had recurrent hernia compared with two patients with obesity (p > 0.05). There were statistically significant differences between patients with and without obesity in the size of the hernia defect. However, there were no significant differences in terms of complications, hospital stay, postoperative pain or relapses. Therefore, the minimally invasive completely extraperitoneal approach for patients with obesity appears to be a safe procedure despite our study limitations. Studies with longer follow-ups and a greater number of patients are needed.

Complete intraluminal migration of IPOM mesh causing sub-acute intestinal obstruction: a rare case report

Incisional hernia is a common complication following an abdominal surgery. They have ideally managed with open/ laparoscopic mesh repair. Mesh related complication are many due to increasing number of surgeries. This is a case of complete transluminal migration of a IPOM mesh and an eroding Onlay mesh presenting as a sub-acute intestinal obstruction after 2 years of incisional hernia surgery. Mesh migration is one of the complications of incisional hernia repair because of inadequate fixation or by ongoing inflammation (foreign body reaction). Complete trans luminal mesh migration is a rare complication with very few reports noted on bowel and urinary bladder. Transluminal migration into small bowel is a rare complication and it should be considered in differentials whenever patient comes with abdominal symptoms with past history of hernia repair.

Changing Trends in Glaucoma Surgery Over the Past 5 Years in China.

To analyze the trends of glaucoma surgery procedures over the past 5 years among hospitals across major provinces in China. This was a retrospective observational study based on medical records. We obtained the annual numbers of commonly performed glaucoma incisional surgeries from 57 hospitals of 30 provincial regions in the Chinese Glaucoma Study Consortium (CGSC) from January 2015 to September 2019. The trend of glaucoma surgery was analyzed by Cochrane-Armitage trend test. Trabeculectomy, cataract extraction combined with goniosynechialysis, cataract extraction combined with trabeculectomy, and surgical peripheral iridotomy (SPI) were the top 4 surgical procedures percentages of which have the most substantial change over the course of 2015 to 2019 (all Ptrend <0.001). Numbers of trabeculectomies decreased significantly from 47.59% in 2015 to 31.21% in 2019; cataract extraction combined with goniosynechialysis increased from 12.12% to 28.48%; cataract extraction combined with trabeculectomy increased from 13.11% to 15.97%; and SPI decreased from 9.03% to 6.34%. The proportion of internal drainage surgery increased from 24.31% in 2015 to 39.29% in 2019 while external drainage surgery decreased from 69.20% to 54.64% (All Ptrend <0.001). The microinvasive glaucoma surgeries including AB-interno Canaloplasty, gonioscopy-assisted transluminal trabeculotomy, and Trabectome, increased from 0.62% to 1.40% (Ptrend<0.001). Across all study hospitals, the trends were similar, except for the Tibet Autonomous Region Eye Center, where SPI and trabeculectomy remained the most common anti-glaucoma surgeries. In the past 5 years, we observed substantial reduction in trabeculectomy, and increase in combination cataract-glaucoma procedures across major hospitals in China. The proportion of internal drainage surgery increased, while external drainage surgery decreased significantly. Detailed understanding of shifting trends in glaucoma surgeries can facilitate better health care resource allocation and training of glaucoma subspecialists in China.

Long-term Outcomes from the HORIZON Randomized Trial for a Schlemm’s Canal Microstent in Combination Cataract and Glaucoma Surgery

To present the 5-year results of the HORIZON trial comparing cataract surgery (CS) combined with an intracanalicular microstent with CS alone. Prospective, multicenter, controlled randomized clinical trial. Patients with cataract and primary open-angle glaucoma treated with 1 or more glaucoma medications, washed-out diurnal intraocular pressure (DIOP) of 22 to 34 mmHg, and no prior incisional glaucoma surgery. Eyes were randomized 2:1 to receive a Hydrus Microstent (HMS; Ivantis, Inc) or no stent after successful CS. Intraocular pressure (IOP), glaucoma medication use, repeat glaucoma surgery, visual acuity, visual field, procedure-related adverse events, and corneal endothelial cell counts. Three hundred sixty-nine eyes were randomized to HMS treatment, and 187 eyes were randomized to CS only. Study groups were well matched for preoperative IOP, medication use, washed-out DIOP, and glaucoma severity. Five-year follow-up was completed in 80% of patients. At 5 years, the HMS group included a higher proportion of eyes with IOP of 18 mmHg or less without medications than the CS group (49.5% vs. 33.8%; P= 0.003), as well as a greater likelihood of IOP reduction of 20% or more without medications than the CS group (54.2% vs. 32.8%; P < 0.001). The number of glaucoma medications was 0.5 ± 0.9 in the HMS group and 0.9 ± 0.9 in the CS group (P < 0.001), and 66% of eyes in the HMS group were medication free compared with 46% in the CS group (P < 0.001). The cumulative risk of incisional glaucoma surgery was lower in the HMS group (2.4% vs. 6.2%; P= 0.027, log-rank test). No clinical or statistically significant differences were found in the rate of endothelial cell loss from 3 to 60 months between the HMS and CS alone groups (P= 0.261). The addition of a Schlemm's canal microstent in conjunction with CS was safe, resulted in lowered IOP and medication use, and reduced the need for postoperative incisional glaucoma filtration surgery compared with CS after 5 years. Long-term presence of the implant did not affect the corneal endothelium adversely.

Clinical outcomes of slow-coagulation continuous-wave transscleral cyclophotocoagulation laser for treatment of glaucoma.

The complications and inadequate efficacy of prior cyclodestructive procedures limited their role in glaucoma management. Recent advances in treatment techniques and parameters for laser cyclophotocoagulation has expanded its role in today's glaucoma practice. In this review, we discuss the treatment outcomes of slow-coagulation continuous-wave transscleral cyclophotocoagulation (CW-TSCPC) as a glaucoma surgical procedure for multiple types of glaucoma in lowering intraocular pressure (IOP). Slow-coagulation TSCPC is a relatively new technique for CW-TSCPC that, unlike the 'pop' power titration technique of laser energy delivery, aims to avoid the production of the 'pop' sound that signals explosive inflammatory energy delivery to the ciliary body and nearby tissue. In slow-coagulation TSCPC, laser energy is applied in a fixed and lower amount over a longer duration, compared with the conventional pop technique. This laser energy approach leads to more stable, reliable, titratable, and selective ciliary body ablation for control of IOP, especially relative to the controversial current use of micropulse TSCPC. Slow-coagulation CW-TSCPC can be used safely, efficiently, reproducibly, and efficaciously in wide range of glaucoma types including those with no history of incisional surgeries, good visual acuity, and medically refractory glaucomas.

Selective laser trabeculoplasty following failed combined phacoemulsification cataract extraction and excimer laser trabeculotomy can control intraocular pressure for a limited time

PurposeTo assess the efficacy of selective laser trabeculoplasty (SLT) following failed phacoemulsification cataract extraction combined with excimer laser trabeculotomy (phaco-ELT).MethodsRetrospectively, the medical records of patients with primary or secondary open-angle glaucoma or ocular hypertension who underwent SLT between January 2001 and February 2015 by one surgeon at a single center after a failed phaco-ELT were evaluated. Exclusion criteria were: angle-closure glaucoma, optic nerve atrophy due to disease other than glaucoma, and additional glaucoma procedures between phaco-ELT and SLT. The main outcome measures were time to failure and Kaplan–Meier survival. Complete success was defined as a reduction of intraocular pressure (IOP) of > 3 mmHg and > 20% compared to baseline, and the number of AGM ≤ baseline.ResultsA total of 23 eyes of 21 subjects were included. Baseline IOP was 19.7 (range, 19.1–22.7) mmHg, and the number of AGM at baseline was 2.5 (range, 1.9–2.9). Median time to failure after SLT was 7.2 (range, 6.6–7.8) months. The number of antiglaucoma medications did not change during that time.ConclusionsIn eyes in which the IOP is no longer controlled following phaco-ELT, SLT could be an option to slow disease progression or prolong time until incisional filtration surgery. However, time to failure after SLT is limited. Thus, close follow-up visits are necessary in order to not delay an incisional surgery.

Incisional hernia repair after kidney transplantation in a tertiary high-volume center: outcomes from a 10-year retrospective cohort study.

Incisional hernia (IH) after Kidney Transplantation (KT) is a challenging complication due to both technical reasons and patients' complexity. Data regarding outcomes of hernia repair in KT recipients are uncertain, since the biggest part of previous papers focused on risk factors for incisional hernia occurrence and not on its outcomes. Aim of the study was to focus on risk factors for incisional hernia recurrence after surgical repair in KT recipients. Data regarding all consecutive patients undergoing kidney transplantations from January 2011 until September 2020 in Montpellier University Hospital were retrospectively collected from a single institutional database. After a median follow-up of 48months (IQR25-75 31-59), data from 1546 consecutive KT were collected. 83 patients underwent 99 incisional hernia surgeries after KT, with 14 patients that had one recurrence (14.4%) and 2 patients that experienced two recurrences (2.4%). Total recurrence rate was 16.8%. At univariate analysis, the only factor associated with an incisional hernia recurrence was having undergone to at least one previous abdominal surgery other than KT (p value 0.002). Overall morbidity was 15% (n = 15), with most of complications classified as mild (59%). No mortality related to incisional hernia repair occurred. IHs after KT represent an important condition. Its surgical management is challenging due to its anatomical complexity and patient's status. This is the largest sample size in the literature of patients treated for IH after KT and it shows that a previous surgery other than the KT is a risk factor for hernia recurrence after surgical repair, without regarding surgical technique or other comorbidity and therapeutical factors.

Surgical trends in glaucoma management: The current Indian scenario.

To assess the current trend in the surgical management of glaucoma in India. An anonymous online survey evaluating the preferred choices in the surgical management of glaucoma was circulated among the members of Glaucoma Society of India (GSI). Survey responses were compared to prior survey among GSI members in 2013 and members of American Glaucoma Society (AGS), 2016. A total of 175 of 879(20%) GSI members participated in the survey of which 75.3% of the survey participants were practicing in the private sector. Trabeculectomy with or without augmentation with Mitomycin C(MMC) was the first-choice glaucoma incisional surgery for 96.6% of the survey participants. Of the participants doing tube surgery, use of valved GDD was the preferred choice (83.4%). Re-trabeculectomy was the preferred approach (60.7%) in case of trabeculectomy failure. For paediatric glaucomas, combined trabeculotomy with trabeculectomy was the preferred surgical approach for both hazy cornea (84.5%) as well as clear cornea (66%). For a POAG patient without prior incisional surgery and presenting with visually significant cataract, phacoemulsification with trabeculectomy was the preferred management approach by 58.7% of the participants. Trabeculectomy continues to be the clear winner for the Indian glaucoma surgeon because of its cost effectiveness, lack of expensive instrumentation, and a more robust surgical training for trabeculectomy during residency programs. A higher proportion of angle closure disease precludes the use of minimally invasive glaucoma surgery and very often tube shunts also. Economics, ease of access and follow-up made a combined cataract and glaucoma surgery a preferred choice among Indian surgeons.

Relationship of degrees of gonioscopy assisted transluminal trabeculotomy and trabecular shelf to success using a marker suture technique.

To evaluate the safety and efficacy of gonioscopy-assisted transluminal trabeculotomy (GATT) using a marker suture which could be a viable low cost alternative to an illuminated micro catheter, by helping the surgeon identify obstruction to suture passage, and estimate the degree of Schlemm's canal cannulated. Thirty four eyes with 360° of open angles with uncontrolled IOP despite maximal medical therapy, non-compliant to medical therapy or failed incisional glaucoma surgery underwent GATT. 5-0 or 6-0 Prolene® suture was used to cannulate Schlemm's canal. An 8-0 Vicryl® suture was tied around the trailing portion of the Prolene® suture and acted as a guide to estimate the length of Schlemm's canal negotiated. The degree of trabecular shelf seen was noted postoperatively. Mean baseline IOP was 24.7 ± 8.8 mm Hg (range 13-54 mmHg). Six patients had appositional angle closure and the rest had open angles. Patients were followed up for a period of 45.0 ± 14.6weeks (range 6 weeks-2 years). The mean IOP 6 weeks after surgery was 13 ± 3.3 mm Hg, and at 1 year was 13.5 ± 2.6 mm Hg. Mean degrees of cannulation achieved was 264.5 ± 84.0˚ (90-360˚). The mean number of medications prior to surgery was 2.1 ± 1.0 and at 6 months review was 0.15 ± 0.3. The absolute success was 92.6% 1 year after surgery. Nine patients lost some of their trabecular shelf in the postoperative period, but this did not seem to affect the short term success rate. Suture GATT is a safe and effective procedure to lower IOP even in patients with partial cannulation. Adding a marker suture is a useful adjunct to help identify the length of Schlemm's canal successfully cannulated and monitor progress of the Prolene® suture.

Association of the Effectiveness of Eye Drop Self-instillation and Glaucoma Progression.

Among patients with glaucoma or ocular hypertension, ineffective self-instillation of eye drops was associated with an increased long-term risk of progression or advancement of treatment to incisional surgery. The purpose of this study was to evaluate the association between the efficacy of self-instillation of eye drops and long-term glaucoma outcomes. In a previous study, video recordings of eye drop self-instillation by patients with glaucoma or ocular hypertension were graded as effective or ineffective depending on whether the patient successfully instilled at least 1 drop on the right ocular surface. Glaucomatous progression was then retrospectively defined as retinal nerve fiber layer thinning as measured by either optical coherence tomography, visual field progression, or need for incisional glaucoma surgery as determined by a glaucoma specialist unaware of patient performance in the eye drop instillation study. Subjects with at least 2 follow-up optical coherence tomography or visual field studies were included in the current study. The original study enrolled 119 patients. Sufficient follow-up data were available for 101 patients. Eighty-eight patients (87.1%) were effective in eye drop instillation at baseline. Mean follow-up was 5.1 years, during which time 73 patients (72.3%) had progression or underwent incisional surgery in either eye. A significantly higher proportion of patients in the ineffective group met the criteria for progression or underwent incisional surgery (effective: 68.2%; ineffective: 100%; N=101; P=0.017, Fisher exact test). Kaplan-Meier survival analyses showed a significantly faster time to reaching an endpoint in the ineffective group (N=101; P=0.012, log-rank test). There was no difference in age, baseline intraocular pressure, or baseline retinal nerve fiber layer thickness between the groups. Ineffective self-installation of eye drops was associated with an increased risk of glaucoma progression or treatment advancement to incisional surgery.