Long-term Intraocular Pressure Control Research Articles

Bleb Management Following Trabeculectomy and Glaucoma Drainage Device Implantation

While treatment options available to patients with glaucoma are expanding, trabeculectomy and glaucoma drainage device implantation (GDI) remain a mainstay in glaucoma surgical care. This article reviews key aspects of bleb management following trabeculectomy and GDI surgery. Basics of postoperative management of trabeculectomy and GDIs are reviewed, as well as how to manage complications such as early and late bleb leaks, fibrosis, bleb dysesthesia and the hypertensive phase. In general, careful surgical technique, close postoperative monitoring and appropriate intervention can help patients achieve safe outcomes and long-term control of intraocular pressure.

Evaluation of primary Ahmed Glaucoma valve implantation in post-traumatic angle recession glaucoma in Indian eyes.

To highlight the efficacy of primary Ahmed glaucoma valve implantation in angle recession glaucoma following blunt ocular trauma in Indian eyes. A retrospective analytical study. This study included 52 patients of angle recession glaucoma, who presented between Mar 2006 to Feb 2016, out of which 38 patients had undergone primary AGV implantation, while the rest were managed with topical anti-glaucoma medications. Preoperative data included age, sex, type and mode of injury, duration of injury, assessment of best-corrected visual acuity (BCVA) and intraocular pressure (IOP). The extent of angle recession was observed by gonioscopy. The intraocular pressure, visual acuity, and the number of anti-glaucoma medications were measured postoperatively. The success of this technique was analyzed by using a Kaplan-Meier cumulative survival curve. Following AGV implantation, the mean IOP was significantly reduced to 8.7 ± 2.2 at 1st day, 10.1 ± 2.2 at 7th day, 14.2 ± 3.4 at 3rd month, 15.6 ± 3.7 at 1year, and 15.6 ± 3.6 at 3rd-year follow-up showing statistically significant values (p < 0.001) at each visit. The IOP was successfully controlled at the last follow-up without topical treatment. Mean BCVA at 3years -post-AGV was 0.144 (0.151) (LogMAR) which was statistically significant (p < 0.001) as compared to the mean BCVA of 0.898 (± 0.205) LogMAR units at presentation. The success rate by Kaplan-Meier survival curve analysis was 90% at the mean follow-up duration of 29.47 ± 3.39months. Overall surgical complications were noted in the form of prolonged hypotony, hyphema in 7 patients (13.5%). In medically uncontrolled post-traumatic angle recession glaucoma, primary AGV Implantation is a safe and effective surgical procedure with lesser complication rates providing long-term IOP control in a younger population.

Long-Term Effect of Early Phacoemulsification in Primary Angle Closure Glaucoma Patients with Cataract: A 10-Year Follow-Up Study.

PurposeTo assess the 10-year effects of early phacoemulsification with intraocular lens (IOL) implantation in primary angle closure glaucoma (PACG) patients with cataract.Patients and MethodsThis prospective cohort study included 102 eyes of 102 patients with PACG. All patients had coexisting cataracts compromising vision. Patients underwent phacoemulsification and foldable IOL implantation. The main outcome measures were anterior chamber depth (ACD), angle width, value of intraocular pressure (IOP), and number of medications needed postoperatively and during follow-up.ResultsHalf (53%) of the patients were female, with ages ranging from 55 to 73 with a mean of 59.82±5.19 years. Mean IOP decreased significantly from 22.15±2.08 mmHg at baseline to 14.08±2.13 mmHg postoperatively (p˂ 0.05). The ACD increased from 2.2±0.21 preoperatively to 3.73±0.25 postoperatively (p˂0.001). Nasal angle width increased postoperatively to 40.05±2.09 compared to the preoperative value of 16.02±2.08 (p˂0.001). Temporal angle width increased from 13.05±2.07 to 41.9600±1.94 (p˂0.001). Anti-glaucoma treatment significantly decreased postoperatively (p˂0.001). A significant positive correlation was detected between ACD and angle width, while a negative correlation was detected between IOP and both ACD and angle width (p˂0.001). There was also a significant negative correlation between postoperative angle width and IOP (p˂0.001). Preoperative lens thickness was positively correlated with preoperative IOP and number of medications, while it was negatively correlated with preoperative AC depth and angle width. Preoperative lens thickness positively correlated with postoperative IOP and medications. Complete and qualified success was achieved in 69.65% and 30.4% of cases, respectively, while 2.9% failed to be controlled. Visual acuity significantly improved from 0.17±0.1 to 0.9±0.08 (p˂0.001). All parameters showed high stability throughout the follow-up period.ConclusionPhacoemulsification with IOL implantation is a safe and effective early modality for long-term control of IOP in PACG patients with coexisting cataract. The effects can persist for at least 10 years.

Improving long-term intraocular pressure and visual outcomes in eyes with aniridic glaucoma.

To study the long-term intraocular pressure (IOP) and visual outcomes in treated aniridic glaucoma. A retrospective chart review of patients with aniridia and glaucoma, with ≥ 2-year follow-up, was performed. Eyes in early glaucomatous stages were medically managed, while moderate-severe stage eyes underwent a trabeculectomy with mitomycin-c (MMC). Success was termed 'complete' when average final IOP was ≤ 18mmHg without usage of glaucoma medications, and 'qualified' when with/without topical glaucoma therapy. A significant change in vision was defined as > 2-line change on Snellen vision chart or > 0.2 change in logMAR units in in either direction (better or worse). Thirty-five eyes of 20 patients were included. The mean duration of follow-up was 7.29 ± 5.75years. Associated ocular anomalies were present in 19 eyes (54.29%). Twelve eyes (34.28%) were maintained on medical management, while 23 eyes (65.71%) had undergone a trabeculectomy with MMC. The mean baseline IOP was 31.46 ± 6.34mmHg, and mean IOP on last follow-up was 13.25 ± 5.82mmHg, p < 0.001. Seventy-five percent of the medically managed eyes achieved an IOP ≤ 18mmHg. 52.17% and 95.65% of the surgically treated eyes achieved 'complete' and 'qualified' success respectively. The median best corrected visual acuity (BCVA) at baseline was 1.48(0.6-2) logMAR units and on final follow-up was 1.3 (0.48-5) logMAR units, p = 0.21. Fifty percent of the eyes remained stable, 35.71% showed an improvement and 14.29% a deterioration of > 0.2 logMAR units. Patients with a longer follow-up (> 10years) and those who had undergone a trabeculectomy with MMC were more likely to show good IOP control (p = 0.003; p = 0.004 respectively). Aniridic glaucoma can be managed efficiently by medications in early glaucomatous neuropathy, and with trabeculectomy augmented with mitomycin-C and releasable sutures for more advanced glaucomas, offering favourable long-term IOP control, visual stability and safety.

Primary congenital glaucoma surgery: outcomes and visual function

PurposeTo assess the long-term visual outcomes of children with PCG, irrespective of the type of surgical procedure, and to create visual acuity curves to help in predicting the development of visual function in these patients. The secondary aim is to identify associated factors for visual decline or loss, highlighting differences between neonatal and infantile subgroups.MethodsThe medical records of pediatric glaucoma patients from 1996 to 2017 at the University Hospital of Verona (Verona, Italy) were retrospectively reviewed. Visual acuities, surgeries, PCG subtype and etiology of vision impairment were recorded. Statistical analyses were performed to detect factors associated with vision decline.ResultsSixty-seven eyes (40 patients) were included in the study. Developmental predictive curves of visual acuity showed that children with infantile PCG had a better visual outcome than children with neonatal PCG at each step of follow-up. A good-to-moderate VA (< 1 LogMAR) was achieved in 56 eyes (83.6%), while 11 eyes (16.4%) had poor VA (≥ 1 LogMAR). The age at onset, sex, number of surgeries, intraocular pressure (IOP) control (with or without antiglaucoma drugs), axial length (AL) and corneal opacities were statistically associated with vision impairment (p < 0.01). The main cause of visual impairment was amblyopia.ConclusionsVisual outcomes of PCG significantly correlate with the age at diagnosis. Although a good long-term IOP control can often be achieved in PCG, often the visual acuity remains below the lower limits of the normal range. Poor vision in childhood is related to global developmental problems, and referral to third-level services should not be delayed to prevent vision impairment. In this regard, visual acuity curves can be a useful tool for the consultant ophthalmologist to define the visual development of children affected by PCG.

Long-term results (>1 year) in 19 dogs treated with MicroPulse transscleral diode cyclophotocoagulation for refractory glaucoma.

To report the long-term (>1year) outcome of MicroPulse transscleral diode cyclophotocoagulation (MP-TSCP) in dogs. Client owned dogs that underwent MP-TSCP at a veterinary referral center. Retrospective study of 19 dogs treated with MP-TSCP. Dogs were evaluated at a median follow-up time of 30.5months postoperatively. Reported outcomes were intraocular pressure (IOP), retention or loss of vision, number of medications, and additional procedures performed. Variables associated with time to treatment failure were evaluated. Data from 19 dogs (24 eyes) was available. Median laser settings employed were 140s and 2200mW at 31.3% duty cycle. Long-term postoperative IOP was lower than preoperative IOP values (14mmHg (IQR=22mmHg, range: 4-52mmHg) versus 30mmHg (IQR=31mmHg, range: 8-62mmHg), respectively). Laser settings >2000mW were associated with a significantly longer time to reported failure. MP-TSCP was the sole therapy performed in 16/24 eyes resulting in long-term IOP control in 13/24 eyes and retention of vision in 6 of the 14 sighted eyes. Repeat MP-TSCP was performed in 10/24 eyes. Eight of 24 eyes required additional procedures with long-term IOP control in 4/8 eyes. MicroPulse transscleral diode cyclophotocoagulation can be an effective treatment for refractory glaucoma in select cases. Higher laser settings increased time to reported failure, whereas age, glaucoma type, and preoperative IOP did not affect survival. MP-TSCP as sole therapy or coupled with additional glaucoma procedures controlled the IOP in 70% of cases.

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

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

Long-Term Follow-Up After Successful Trabeculectomy: A Case Report of Reversal of Cupping and Recovery of Visual Field Progression

Glaucoma is one of the leading causes of blindness worldwide, and reduction of intraocular pressure (IOP) is the only available evidence-based treatment that reduces visual field deterioration in glaucoma. We present a representative case of structural recovery and recovery of visual field progression after successful trabeculectomy (TLE) with long-term follow-up. A 35-year-old woman with glaucoma visited our hospital in 2008. The IOP in her right eye was 11 mmHg at the first visit, and subsequently increased to values in the high teens to 20 mmHg despite treatment with anti-glaucoma eye drops. During this period, the progression of this eye’s visual field deterioration was fast (mean deviation [MD] slope = −0.63 dB/year) and the optic disc cupping was advanced. In the seven-year period after successful TLE in 2014, the IOP declined to between 8 and 12 mmHg without any anti-glaucoma medication. During the first two years after TLE, the MD values were poorer than those before TLE. However, by 2020, MD values improved gradually to a state better than that before the surgery (MD slope during this period was +0.75 dB/year). The appearance of the optic disc was monitored using fundus photography, which showed optic disc morphological changes during topical glaucoma medication before and after TLE. In particular, a remarkable reversal of optic disc cupping enlargement started at two weeks after TLE, and the optic disc shape in 2021 was similar to that in 2008.Minimally invasive glaucoma surgeries are often preferred; however, our findings suggest that successful TLE followed by long-term rigorous IOP control can result in structural recoveries. Additionally, despite the deterioration in visual field in the early years after TLE, in the long term, it may settle down to the same level before the surgery with recovery of visual field progression, which may be a part of functional recovery.

Effectiveness of Selective Laser Trabeculoplasty Applied to 360° vs. 180° of the Angle.

Purpose To compare the effectiveness and safety of 360° and 180° of Selective Laser Trabeculoplasty (SLT) for the treatment of elevated intraocular pressure (IOP). Methods Retrospective cohort study. The main outcome measure was the Kaplan–Meier analysis comparing the cumulative probabilities of survival between the 360° and 180° SLT groups in terms of IOP reduction. Success was defined as ≥20% IOP reduction from baseline with an IOP between 5–18 mmHg and ≤1 glaucoma medication added postoperatively. Additional outcome measures included changes in average IOP, number of glaucoma medications, and the incidence of postoperative IOP spikes. Measurements were obtained at 6 weeks, 1 year, and 2 years postoperatively. Results Two hundred and fifty-eight eyes of 258 patients were included in the 360° group, and 196 eyes of 196 patients were included in the 180° group. The mean IOP reductions at 2 years were 2.21 ± 2.02 mmHg and 2.43 ± 1.81 mmHg (p=0.33) in the 180° and 360° groups, respectively. There were no significant differences in the incidence of postoperative IOP spikes between the two groups. There was a significant difference in the survival curves of the two groups (p=0.035). The Cox proportional-hazard model indicated that 360° of SLT application was a significant predictor of long-term success (p=0.030). Conclusions 360° of SLT application seems to provide for greater long-term IOP control than 180° of application without putting patients at an elevated risk for postoperative IOP spikes.

Looking into the future: Gene and cell therapies for glaucoma.

Glaucoma is a complex group of optic neuropathies that affects both humans and animals. Intraocular pressure (IOP) elevation is a major risk factor that results in the loss of retinal ganglion cells (RGCs) and their axons. Currently, lowering IOP by medical and surgical methods is the only approved treatment for primary glaucoma, but there is no cure, and vision loss often progresses despite therapy. Recent technologic advances provide us with a better understanding of disease mechanisms and risk factors; this will permit earlier diagnosis of glaucoma and initiation of therapy sooner and more effectively. Gene and cell therapies are well suited to target these mechanisms specifically with the potential to achieve a lasting therapeutic effect. Much progress has been made in laboratory settings to develop these novel therapies for the eye. Gene and cell therapies have already been translated into clinical application for some inherited retinal dystrophies and age-related macular degeneration (AMD). Except for the intravitreal application of ciliary neurotrophic factor (CNTF) by encapsulated cell technology for RGC neuroprotection, there has been no other clinical translation of gene and cell therapies for glaucoma so far. Possible application of gene and cell therapies consists of long-term IOP control via increased aqueous humor drainage, including inhibition of fibrosis following filtration surgery, RGC neuroprotection and neuroregeneration, modification of ocular biomechanics for improved IOP tolerance, and inhibition of inflammation and neovascularization to prevent the development of some forms of secondary glaucoma.

A Prospective Randomized Trial of Ahmed Glaucoma Drainage Device Implantation with or without Ologen Collagen Matrix

The purpose of this study is to evaluate the effectiveness of Ologen collagen matrix (OCM; Aeon Astron Corporation) in the prevention of the postoperative hypertensive phase and on long-term intraocular pressure (IOP) control after Ahmed glaucoma valve (AGV; New World Medical) implantation. This is a prospective, randomized, controlled study of 26 patients treated at a tertiary care center, with 13 eyes assigned to each treatment arm. Consecutive patients with refractory glaucoma requiring AGV implantation were enrolled. Refractory glaucoma was defined as IOP >21 mmHg on maximum tolerated glaucoma medications or progressive visual field and optic nerve head changes despite maximal tolerated medical therapy. In Ologen eyes, a round 12 × 1-mm OCM segment was placed flush over the AGV-FP7 plate immediately before conjunctival closure. Control eyes received conventional AGV surgery without OCM implantation. The primary outcomes were postoperative IOP and requirement of pressure-lowering medications. On the basis of these measures, the rates of complete and qualified success over the course of follow-up were calculated. Complete success was defined as IOP ≤21 mmHg without antihypertensive medications. Qualified success was defined as IOP ≤21 mmHg with or without medications. Frequency of hypertensive phase was also determined. Patients receiving Ologen-augmented AGV surgery exhibited significantly lower IOPs compared with control subjects at the 1-, 2-, and 3-month time points (P < 0.04). Maximum mean IOP postoperatively was 25.2 ± 7.4 for control eyes and 16.8 ± 8.9 for Ologen eyes, peaking at month 2 for both groups and stabilizing by month 6. No differences in average number of pressure-lowering medications were detected between groups. There were no statistically significant differences in complete or qualified success rates at 6 and 12 months. The frequency of hypertensive phase was 61.5% in control eyes and 38.5% in OCM-implanted eyes. Ologen collagen matrix-augmented AGV surgery may provide better IOP control in the intermediate postoperative period and blunt the hypertensive phase compared with AGV implantation alone.

Ten-Year Outcome of Glaucoma Drainage Device Surgery After Penetrating Keratoplasty.

In eyes with intractable glaucoma, drainage devices provide long-term control of intraocular pressure also after penetrating keratoplasty (PK). There is a high incidence of corneal graft failure. To compare very long-term results of eyes with glaucoma drainage device (GDD) after PK. We retrospectively reviewed medical records of all patients who underwent GDD placement after PK at our institution between 2001 and 2017. Forty eyes of 40 patients were studied. Glaucoma outcome was assessed by postoperative intraocular pressure (IOP), number of medications, and need for further glaucoma surgery. Corneal outcome was assessed by graft rejection, failure, and visual acuity. Surgical procedures before and during the study period, and their complications were evaluated. The mean follow-up was 125.0±52.3 (median, 116.5) months. Twenty of 40 eyes had a follow-up of at least 10 years. The mean preoperative IOP was 34.0±8.3 (median, 32.0) mm Hg with 3.2±1.3 (median, 3.5) glaucoma medications. At last postoperative follow-up, the mean IOP decreased to 12.7±4.9 (median, 14.0) mm Hg with 1.0±1.2 (median, 0.0) glaucoma medications. GDD implantation successfully controlled glaucoma in 88%, 88%, 85%, 80%, 78%, 75%, and 70% of eyes, at 1, 2, 3, 4, 5, 7, and 10 years, respectively. At last follow-up 68% showed glaucoma success. The corneal grafts remained clear in 74%, 63%, 45%, 45%, 37%, 32%, and 26% of eyes at 1, 2, 3, 4, 5, 7, and 10 years, respectively. Only 7 corneal grafts (17.5%) remained clear at last follow-up. A GDD can successfully control intractable glaucoma even after a very long period of time also after PK. However, the survival of the corneal grafts is low.

Efficacy and safety of oral valganciclovir in cytomegalovirus anterior uveitis with uncontrolled intraocular pressure

Background/aimsWhile cytomegalovirus (CMV) anterior uveitis (AU) patients often require glaucoma surgery, the effectiveness of systemic anti-viral in long-term intraocular pressure (IOP) control is not well established. Our study aims to...

Long-term Outcomes of Glaucoma Drainage Implants in Uveitic Eyes With Fluocinolone Acetonide Implants.

In eyes with uveitis and a history of fluocinolone acetonide (FA) implantation, glaucoma drainage implants (GDIs) provides excellent long-term control of intraocular pressure (IOP). The purpose of this study was to evaluate the long-term control of IOP achieved by GDIs in uveitic eyes with glaucoma and a FA implant. Retrospective case series of 56 eyes from 37 patients with a history of noninfectious posterior uveitis who underwent both FA implantation and GDI surgery at the Cleveland Clinic Cole Eye Institute between April 2001 and April 2017. Patients were excluded if they did not undergo FA implantation before, or concurrently with, a GDI. Data was collected up to 10 years after GDI surgery. Outcome measures included IOP, number of IOP-lowering medications, and surgical success rate at each timepoint. Success was defined as IOP between 6 and 21 mm Hg at the most recent follow-up visit, without need for GDI removal or additional IOP-lowering surgeries, or loss of light perception. The mean follow-up time was 71.0 months (median 72.0 mo). IOP was reduced by a mean of 52.9% (range: 43.1% to 62.3%) and the number of IOP-lowering medications decreased by a mean of 69.0% (range: 56.3% to 93.8%) between 1 and 10 years postoperatively. The percentage of eyes with IOP <21 mm Hg was 32.1% at baseline and ranged between 76.8% and 100% at follow-up. The percentage of eyes with IOP <18 mm Hg was 21.4% at baseline and ranged between 67.9% and 100% at follow-up. The surgical success rate was 71.4% at 10 years. In eyes with uveitis that undergo FA implantation, concurrent or subsequent GDI surgery offers excellent long-term control of IOP. Postoperative IOP and number of IOP-lowering medications dropped considerably and remained stable.

The Effects of Trabeculectomy on Pseudoexfoliation Glaucoma and Primary Open-Angle Glaucoma.

Purpose To compare long-term effects of trabeculectomy on pseudoexfoliation glaucoma (PXG) and primary open-angle glaucoma (POAG). Methods This retrospective case-control study included 53 eyes of PXG and 76 eyes of POAG. Intraocular pressure (IOP), number of antiglaucoma medications used, surgical success rate, and occurrence of complications were observed and statistically analyzed in both groups at 3 and 6 months and at 1, 3, and 5 years after trabeculectomy. Surgical success was defined according to the following 3 criteria: (1) IOP ≤ 21 mmHg; (2) IOP ≤ 18 mmHg; (3) IOP ≤ 15 mmHg. Complete success is defined as patients met these criteria without medical treatment, and qualified success is defined as patients met these criteria with medical treatment (≤3 medications). Cumulative probabilities of success were compared using the Kaplan–Meier survival analysis. Results For the 3 criteria, there were no statistically significant differences in complete and qualified success rates between the two groups at 3 and 6 months after trabeculectomy (P > 0.05). For criterion A, complete success rates in PXG at 3 and 5 years after surgery were lower than those in POAG; for criterion B, complete and qualified success rates in PXG at 3 and 5 years after surgery were lower than those in POAG; for criterion C, complete and qualified success rates in PXG at 1, 3, and 5 years after surgery were lower than those in POAG, the differences were statistically significant (P < 0.05). Conclusions The short-term success rates of both types of glaucoma were similar; however, the long-term success rate of PXG was significantly lower, and it was difficult to achieve long-term control of IOP at a low target level.

Netarsudil and latanoprost ophthalmic solution for the reduction of intraocular pressure in open-angle glaucoma or ocular hypertension

ABSTRACTIntroduction: Netarsudil and latanoprost ophthalmic solution (0.02%/0.005%) is indicated for intraocular pressure (IOP) lowering in open-angle glaucoma (OAG) or ocular hypertension (OHTN). The once-daily agent combines the mechanism of action for each of the individual components and provides a new avenue for long-term intraocular pressure control. This review aims to cover the agent’s current efficacy and safety data and opine as to its role in glaucoma management.Areas covered: This article will cover Phase II-III clinical efficacy and safety data as well as basic science literature pertaining to the agent’s mechanism of action and pharmacodynamics. In selecting articles for inclusion in this review, a literature search using the PubMed database was carried out. Cross-referencing was carried out where applicable. We did not use any date or language restrictions in electronic searches.Expert opinion: Netarsudil and latanoprost ophthalmic solution plays a pivotal role in management of individuals with OAG and OHTN. The agent may be used as first-line therapy to provide substantial IOP-lowering or when additional lowering is indicated and prostaglandins have provided insufficient IOP lowering. The once-daily dosing regimen decreases the risk of inadequate treatment due to nonadherence.

Argon Laser Peripheral Iridoplasty and Argon Laser Pupilloplasty: Alternative Management for Medically Unresponsive Acute Primary Angle Closure.

Objective To introduce the combined laser technique, argon laser peripheral iridoplasty (ALPI) and argon laser pupilloplasty (ALPP), in the management of medically unresponsive acute primary angle closure (APAC). Design Retrospective study. Methods We retrospectively reviewed the records of 23 patients (27 eyes) with APAC, who were applied ALPI and ALPP when traditional treatment failed. The visual acuity and intraocular pressure (IOP) were monitored before surgery and at 1, 2, 12, 24, and 48 h after surgery. Additionally, the angle-opening status was monitored before surgery and 48 h after the treatment by using an ultrasonic biological microscope (UBM), and the presurgical and postsurgical cornea edema statuses were observed by using a slit lamp. We also documented the complications of laser treatment. Results For the ALPI + ALPP laser-effective group, the presurgical IOP was 52.1 ± 9.3 mmHg and the postsurgical IOP was 37.6 ± 10.9 mmHg (1 h), 28.4 ± 12.4 mmHg (2 h), 19.9 ± 9.0 mmHg (6 h), 16.8 ± 7.3 mmHg (12 h), 15.9 ± 5.9 mmHg (24 h), and 14.9 ± 5.0 mmHg (48 h), with statistically significant differences (p < 0.05) in each time point. It was observed in all the patients that the corneal edema alleviated, the angles opened, and visual acuity recovered with varying degrees at 48 h after applying combined laser treatment. For the ALPI + ALPP laser-ineffective group, further interventions were taken. Definite treatment was given in both groups to maintain the long-term IOP control. Conclusions Although the combination of ALPI and ALPP is a temporizing therapeutic strategy for APAC, it is effective in relieving pupillary block which is unresponsive to miotic agents, opening the closed angle to a certain extent, restoring the transparency of cornea, and reducing IOP to a safe level for further definitive treatment.

The Implications of an Ab Interno Versus Ab Externo Surgical Approach on Outflow Resistance of a Subconjunctival Drainage Device for Intraocular Pressure Control.

PurposeMinimally invasive glaucoma surgery (MIGS) devices that drain into the subconjunctival space can be inserted via an ab externo or ab interno approach. Limited experimental data exists as to the impact of either technique on intraocular pressure (IOP) control. We performed microfluidic studies by using ex vivo rabbit eyes to assess the effect of each approach on outflow resistance of a subconjunctival drainage device for IOP control.MethodsA microfluidic experiment system was designed, consisting of a controlled reservoir of water connected to a pressure pump/flow sensor. The flow rate of water was fixed at 2 μl/min to simulate aqueous humor production. The pressure readings for each approach were recorded at a frequency of 1 Hz. A baseline reading was made before tube insertion into the eye (PEEK tube length set to aim for an initial outflow resistance of 5 to 10 mm Hg/μL/min) followed by measurements for a cumulative 2-ml volume entering the subconjunctival space. Results were adjusted for water viscosity at 37°C and reported as outflow resistance (mm Hg/μL/min ± standard error of mean).ResultsOutflow resistance via the ab interno approach was 90.4% higher than with the ab externo approach being measured at 0.80 ± 0.11 mm Hg/μL/min and 0.42 ± 0.05 mm Hg/μL/min, respectively. Bleb formation was observed to be less predictable with the ab interno approach.ConclusionsThe ab interno approach demonstrated greater outflow resistance and less predictable bleb formation than the ab externo approach. These results have implications for long-term IOP control and success depending on the approach to device insertion and could be an important consideration for future MIGS devices.Translational RelevanceThe effect of the ab interno versus ab externo approach of a MIGS device inserted into the subconjunctival space was assessed. The ab interno approach demonstrated greater outflow resistance and less predictable bleb formation that may have implications for the development of future MIGS devices.

Long-term Functional Outcomes of Trabeculectomy Revision Surgery

To describe the long-term results of revision surgery for complications from trabeculectomy in a case series from an academic glaucoma service. Retrospective case series. A total of 310 eyes (310 individuals) who underwent revision of trabeculectomy at the Wilmer Eye Institute between 2007-2015. Retrospective study of patients who underwent revision of trabeculectomy at the Wilmer Eye Institute between 2007-2015. Success of revision, defined as maintenance of long-term intraocular pressure (IOP) control at or below target, no further glaucoma-related reoperations, no major complications during revision surgery, and no dysfunctional hypotony; need for additional surgery after revision; change in visual acuity (VA) between original trabeculectomy; revision surgery; and last follow-up visit. The mean time between original surgery and revision was 3.1±4.0 years, and the mean follow-up from revision to last examination was 4.4±2.9 years. The overall successes at 1, 2, 5, and 8 years after revision were 76%, 68%, 57%, and 50%, respectively (Kaplan-Meier). The success was similar among revision indications (P= 0.43). The 5-year Kaplan-Meier survival was 60% for eyes undergoing revision for hypotony, 57% for bleb leak, 63% for dysesthesia, and 44% for uncontrolled IOP. Revisions in which the original surgery was performed by surgeons other than present Wilmer faculty were 5 times more likely to fail than cases in which the original surgery was performed by the Wilmer surgeon performing the most trabeculectomy and revision surgeries (P= 0.04). Further surgery after revision was required in 30% of cases during follow-up. Approximately half were additional IOP-lowering procedures, and half were further revisions. Duration of symptoms before revision was not consistently associated with the loss of VA between original surgery and last follow-up. Eyes that lost the most VA before revision surgery for hypotony tended to be the same eyes that regained the most vision after revision; eyes that underwent revision for hypotony with shorter duration of symptoms showed a greater improvement of VA between revision surgery and last follow-up (P= 0.01). Revision of trabeculectomy provided successful resolution of complications associated with trabeculectomy surgery in many cases.

One-month IOP in mitomycin C-augmented trabeculectomy can predict long-term IOP control in chronic primary angle-closure glaucoma.

To investigate the predictors of long-term intraocular pressure (IOP) in chronic primary angle-closure glaucoma (CPACG) treated with primary trabeculectomy. This study systematically reviewed cases of CPACG treated with primary trabeculectomy. The scleral flaps in all cases were sutured with two stitches in situ and two releasable sutures to ensure watertight under normal IOP conditions during surgery. Mitomycin C was used in all eyes. All patients were followed for 2years. Digital massage of the bulbus and removal of the releasable suture were performed according to the IOP and shape of the filtering bleb. Demographic data and clinical outcomes were recorded. Factors predicting long-term IOP were identified. A total of 72 patients (88 eyes) with a mean age of 58.51 ± 10.60years were included in this study. The complete success rate was 89.77% after 2years. The IOP began to stabilize after 7days and reached its lowest point at the 1-month follow-up. The preoperative and early postoperative high or low IOP does not affect long-term effects (P > 0.05). There was a positive correlation between postoperative IOP at the 1-month and 2-year follow-ups (r = 0.64, P < 0.001). In CPACG patients undergoing primary trabeculectomy, scleral flaps sutured watertightly with two stitches in situ and two releasable sutures under normal IOP conditions can ensure controllable, effective and safe treatment of CPACG. The preoperative and early postoperative high or low IOP does not affect long-term effects. One-month postoperative IOP can be used as a predictor of long-term IOP control.