Long-term Intraocular Pressure Control Research Articles

Intermediate-term and long-term outcome of piggyback drainage: connecting glaucoma drainage device to a device in-situ for improved intraocular pressure control.

This study provides results of a treatment option for patients with failed primary glaucoma drainage device. The study aimed to describe and evaluate the long-term intraocular pressure control and complications of a new technique joining a second glaucoma drainage device directly to an existing glaucoma drainage device termed 'piggyback drainage'. This is a retrospective, interventional cohort study. Eighteen eyes of 17 patients who underwent piggyback drainage between 2004 and 2013 inclusive have been studied. All patients had prior glaucoma drainage device with uncontrolled intraocular pressure. The piggyback technique involved suturing a Baerveldt (250 or 350 mm) or Molteno3 glaucoma drainage device to an unused scleral quadrant and connecting the silicone tube to the primary plate bleb. Failure of intraocular pressure control defined as an intraocular pressure greater than 21 mmHg on maximal therapy on two separate occasions or further intervention to control intraocular pressure. The intraocular pressure was controlled in seven eyes (39%) at last follow-up with a mean follow-up time of 74.2 months. The mean preoperative intraocular pressure was 27.1 mmHg (95% confidence interval 23.8-30.3) compared with 18.4 mmHg (95% confidence interval 13.9-22.8) at last follow-up. The mean time to failure was 57.1 months (95% confidence interval 32.2-82), and the mean time to further surgery was 72.3 months (95% confidence interval 49.9-94.7). Lower preoperative intraocular pressure was associated with longer duration of intraocular pressure control (P = 0.048). If the intraocular pressure was controlled over 2 years, it continued to be controlled over the long term. Two eyes (11%) experienced corneal decompensation. Piggyback drainage represents a viable surgical alternative for the treatment of patients with severe glaucoma with failing primary glaucoma drainage device, particularly in those at high risk of corneal decompensation.

Intermediate and Long-term Outcomes of Mitomycin C-enhanced Trabeculectomy as a First Glaucoma Procedure in Uveitic Glaucoma.

To evaluate the intermediate and long-term outcomes of mitomycin C-enhanced trabeculectomy as a first glaucoma procedure in uveitic glaucoma. Retrospective cohort study included 70 eyes of 50 patients with uveitic glaucoma who underwent mitomycin C-enhanced trabeculectomy as a first glaucoma procedure at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia between 1996 and 2014. The main outcome measures were: the intraocular pressure (IOP), the number of antiglaucoma medications, the presence of visually threatening complications, and the need for further surgeries to control the IOP. Surgical outcome of each eye was classified as an absolute success, qualified success, or failure, based on the main outcome measures. The mean follow-up period was 77.0 months (±40.9). The IOP and number of antiglaucoma medications decreased significantly from a mean of 39.5 mm Hg (±8.9) and 3.7 (±0.8) to 14.4 mm Hg (±6.9) and 1 (±1.3) at the last follow-up, respectively (P<0.001 for both). The cumulative probabilities of success were 60% and 35.7% at 36 and 60 months postoperatively, respectively. The most common complications were cataract development and progression (45.3%), hypotony (IOP ≤5 mm Hg) (30%) and IOP spike≥30 mm Hg (10%). Eighteen eyes (25.7%) needed a second procedure to control the IOP. Although mitomycin C-enhanced trabeculectomy offers reasonable intermediate and long-term IOP control and safety in uveitic glaucoma, a significant number of patients needed further procedures to control the pressure. Thus, continuous monitoring of the pressure and inflammation are crucial.

Effect of Long-term Topical Application of 0.005% Latanoprost on Intraocular Pressure Uncontrolled by Multiple or Single Drug Therapy in Dogs with Secondary Glaucoma

Purpose: To evaluate the effect of long-term topical application of 0.005% latanoprost on intraocular pressure (IOP) uncontrolled by multiple or single drug therapy in dogs with secondary glaucoma. Animals Studied: Twenty-seven dogs with secondary glaucoma. Procedure: Baseline IOP was measured before the start of 0.005% latanoprost therapy. The iridocorneal angle (ICA) was measured and graded as open, slightly narrow, narrow or closed. The effect of 0.005% latanoprost on IOP was followed for a minimum of two months. Dogs were classified as responders if IOP decreased with treatment or as non-responders if there was no change in IOP. Results: IOP did not decrease in three dogs (11%). It decreased initially but subsequently increased over time in 21 dogs (78%). IOP remained <25 mmHg for more than 60 months in 3 dogs (11%). No correlation between ICA grade and IOP reduction from baseline was observed. Conclusions: Topical application of 0.005% latanoprost resulted in long-term control of IOP in 11% of the dogs. The remaining dogs showed either no response or just a temporary decrease in IOP with topical 0.005% latanoprost treatment.

Prognosis of different glaucomas seen at a tertiary center: A 10-year overview.

Aim:This study aims to determine treatment patterns, long-term intraocular pressure (IOP) and perimetric control in different glaucomas seen at a tertiary eye center.Settings and Design:Hospital-based, cross-sectional chart review of patients routinely following up at an outpatient glaucoma service.Methods:Patients with a follow-up of at least 10 years were evaluated. Their mean IOP, visual field (VF) status, and medications/surgery required at final assessment were noted.Statistical Analysis:Descriptive statistics (mean, standard deviation, and range) were used for all parameters.Results:A total of 230 patients met our inclusion and exclusion criteria, 79 having ocular hypertension with open angles or primary angle closure (PAC), 35 primary open angle glaucoma (POAG), 50 PAC glaucoma (PACG), 20 primary congenital glaucoma (PCG), 46 secondary glaucoma patients. Ocular hypertensives with open angles showed progression to POAG in 3.7%, those with PAC in 5.2%, at a mean IOP of 17.3 ± 3.37 mmHg and 17.13 ± 4.41 mmHg, respectively. A progression on Humphrey Field Analyzer was seen in 11% of POAG and PACG eyes at a mean IOP of 13.50 ± 5.07 and 13.09 ± 3.95 mmHg, respectively. Fifteen percent of primary congenital glaucomas (PCGs) showed a glaucomatous VF defect after 10 years. In secondary glaucoma eyes, the mean IOP at last follow-up visit was 12.38 ± 3.74 mmHg, with progression noted in 7.69% of eyes.Conclusion:This study provides evidence that routine delivery of care can provide well controlled IOP in glaucomas, both primary and secondary, and the VF stabilized in about 90% of patients over a period of 10 years, with the currently available glaucoma medications and trabeculectomy.

Prospective observation of filtration blebs in high-risk eyes with limbal-based conjunctival flap

ObjectiveTo evaluate time-dependent changes in filtering bleb parameters using 3-dimensional anterior segment optical coherence tomography (3-D AS-OCT) in high-risk eyes after a limbal-based trabeculectomy procedure. DesignProspective, observational study. ParticipantsTwenty-three patients who underwent uncombined limbal-based trabeculectomy surgery and who also had a history of prior intraocular surgery. MethodsOf 23 eyes, 15 eyes were followed for 1 year without additional glaucoma surgeries, and their bleb parameters were measured 0.5, 3, 6, and 12 months after the trabeculectomy using 3-dimensional anterior segment optical coherence tomography. The correlations of these parameters to other clinical data were investigated. ResultsStatistical analysis showed significant changes in the bleb wall thickness (0.7 ± 0.4 mm vs 0.4 ± 0.2 mm; p = 0.007) and fluid cavity height (0.3 ± 0.2 mm vs 0.7 ± 0.4 mm; p = 0.005) between 0.5 and 3 months only. The width of the filtration openings at 0.5 months after trabeculectomy (2.1 ± 1.0 mm) was significantly associated with the intraocular pressure at 12 months (15.1 ± 5.7 mm Hg; R2 = 0.37, t = −2.65, and p = 0.021). ConclusionsThe width of the filtration opening in the early stage may be a prognostic factor for long-term intraocular pressure control.

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

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

Preoperative Preparation and Anesthesia for Trabeculectomy.

ABSTRACTPreoperative preparation should improve the likelihood of successful trabeculectomy surgery. The team can reconsider the appropriateness of the proposed surgery, and steps can be taken to maximize the chance of a good outcome. For example, adjustments to anti-hypertensive or anti-coagulant medications may be made, and topical ocular medications adjusted.Choice of anesthesia technique is of particular relevance to the trabeculectomy patient. Some anesthesia techniques are more likely to have serious complications, and glaucoma patients may be at higher risk of some sight-threatening complications, because the optic nerve is already damaged and vulnerable. Posterior placement of local anesthesia (retrobulbar, peribulbar, posterior sub-Tenon’s techniques) could potentially damage the optic nerve, and thereby cause “wipe-out” of vision. Anesthesia technique may influence the likelihood of vitreous bulge and surgical difficulty. Regarding long-term control of intraocular pressure, there is no good evidence to indicate that any particular anesthesia technique is better than another. There is little high-quality evidence on this topic. The author’s preferred technique for trabeculectomy is subconjunctival-intracameral anesthesia without sedation.How to cite this article: Eke T. Preoperative Preparation and Anesthesia for Trabeculectomy. J Curr Glaucoma Pract 2016; 10(1):21-35.

A role for antimetabolites in glaucoma tube surgery: current evidence and future directions.

Glaucoma is the leading cause of irreversible blindness worldwide. The main treatment modality for glaucoma is the reduction and control of the intraocular pressure (IOP). Glaucoma filtration surgery, including trabeculectomy and/or implantation of a glaucoma drainage device (GDD), is warranted if IOP remains medically uncontrolled. However, postoperative scarring remains a critical determinant of long-term bleb survival and IOP control after drainage surgery. Antimetabolites, such as mitomycin C and 5-fluorouracil, have been used for many years to increase survival time of filtration surgeries by preventing bleb fibrosis and scarring. The aim of this study is to provide an overview of: the current usage of these antimetabolites in GDD, the recent advancements of these antimetabolites in combination with other technologies, and the role of future antimetabolites. Mitomycin C and 5-fluorouracil have been used in GDD and trabeculectomy to prevent the exaggerated cellular reaction that leads to fibrosis. The adjunctive administration of these drugs intraoperatively and postoperatively has resulted in a lower rate of the hypertensive phase, and possibly a better long-term success rate in Ahmed valve surgeries. However, the application of these antimetabolites and their multiple-dosing applications are associated with nonspecific cytotoxicity and potentially severe complications such as bleb leak and conjunctival erosion over the tube. Recent studies are thus focusing on different medications, targeting new molecular pathways, and designing new delivery vehicles to minimize current antimetabolites side-effects and increase their efficacy. Promising results of these studies have led to development of new collaborative medications and advanced drug delivery systems for better modulation of GDD surgeries' predictable outcomes. The development of small molecule therapeutics, combination therapies, and innovative drug vehicles to prevent postsurgical fibrosis and achieve better surgical outcome in glaucoma filtration surgeries is promising.

Amniotic membrane-assisted trabeculectomy for refractory glaucoma with corneal disorders.

PurposeTo report the cases of six consecutive patients who underwent amniotic membrane (AM)-assisted trabeculectomy (TLE) to treat refractory glaucoma with severe corneal disorders.MethodsThis study involved six patients (three males and three females, mean age: 69.5±15.8 years) with refractory glaucoma and severe corneal disorders. The surgical procedure for each patient involved trabecular tissue being excised, and human AM then being placed epithelial side up on the corneal surface, sutured at the limbal sclera, and flipped over onto the sclera to cover the TLE area. The remaining edge of the AM was then inserted into the subconjunctival space and sutured. Medical records of all cases were reviewed with regard to intraocular pressure (IOP), visual acuity, and condition of the filtering bleb and ocular surface.ResultsThe mean observation period was 69.5±15.8 months, and mean IOP at presurgery and at 1, 3, and 7 years postoperative was 40.3±6.9, 23.0±12.1, 25.6±12.8, and 28.5±19.1 mmHg, respectively. Glaucoma medications decreased from 3.0±1.1 drugs (presurgery) to 0.8±1.0 drugs (7 years postoperative). However, in some cases, ocular surface conditions or visual acuity worsened during the follow-up period.ConclusionUsing AM as an internal patch for TLE, moderately good IOP control was obtained initially for the refractory glaucoma with severe corneal disorders; however, ocular surface conditions required special care, and the long-term IOP control was limited in some cases.

The role of lens extraction in the current management of primary angle-closure glaucoma.

Lens extraction for primary angle-closure glaucoma (PACG) is a subject of increased interest recently, with advocates promoting its benefits of anatomical opening of the angle, intraocular pressure (IOP) reduction and improved vision. The present review seeks to evaluate recent available evidence to provide clarity on this potential intervention within the armamentarium of approaches for PACG. The emergence of recent case-control studies, cohort studies and randomized controlled trials has provided a stronger evidence base to equip ophthalmic surgeons with the necessary information to utilize lens extraction in the management of PACG, and to consider whether this should be combined with trabeculectomy or goniosynechialysis. Imaging modalities such as anterior segment optical coherence tomography have yielded new insights into the mechanical features of the lens in angle closure, with the lens thickness and lens vault now quantifiable. A trend is emerging regarding the improvement in IOP control, reduced complication rates and reduced need for IOP-lowering medications in patients who undergo lens extraction for PACG. These issues are discussed, along with aspects of preoperative assessment and surgical techniques. Good outcomes in terms of long-term IOP control have been found following lens extraction for PACG. Lens extraction should be considered in patients with PACG, especially with hyperopia, or a thick and anteriorly vaulted lens.

Filtering blebs using 3-dimensional anterior-segment optical coherence tomography: a prospective investigation.

Posttrabeculectomy changes in bleb parameters measured using 3-dimensional (3-D) anterior-segment optical coherence tomography (OCT) remain uncharacterized and might be related to postsurgical intraocular-pressure (IOP) control. To evaluate time-dependent posttrabeculectomy changes in filtering bleb parameters using 3-D anterior-segment OCT. This prospective observational study was conducted at Kumamoto University Hospital, Kumamoto, Japan. Patients with open-angle glaucoma who underwent uncombined fornix-based trabeculectomy at Kumamoto University Hospital between January 1, 2012, and October 31, 2012, were included. Twenty-nine eyes were enrolled, 23 of which were followed up for 1 year without additional glaucoma surgical procedures; 3 required additional glaucoma surgery. Imaging filtering blebs using 3-D anterior-segment OCT. The primary end points were changes in bleb parameters including the position and width of the filtration openings on the scleral flap, the total bleb height, fluid-filled cavity height, bleb wall thickness, and bleb wall intensity, which were measured using 3-D anterior-segment OCT. The secondary end points were postsurgical IOP measured 0.5, 3, 6, and 12 months after trabeculectomy, and the effects of aqueous cytokine levels on the bleb parameters. We observed increased total bleb height (0.82 to 1.25 mm; difference: 95% CI, 0.10 to 0.75; P = .01), bleb wall thickness (0.46 to 0.61 mm; difference: 95% CI, 0.02 to 0.28; P = .03), and distance from the top of the scleral flap to the filtration opening (1.69 to 2.16 mm; difference: 95% CI, 0.28 to 0.70; P < .001), as well as decreased width of the filtration opening (2.08 to 1.12 mm; difference: 95% CI, -1.75 to -0.49; P = .002) between 0.5 and 12 months posttrabeculectomy. The filtration openings tended to close from the fornix side of the scleral flap during the wound healing process. Moreover, the width of the filtration opening at 0.5 months posttrabeculectomy correlated with the IOP at 12 months (P = .02). The aqueous humor level of monocyte chemoattractant protein-1 was correlated with the width of the filtration opening at 3 and 6 months posttrabeculectomy. The width of the filtration opening at 0.5 months posttrabeculectomy correlated with the IOP at 12 months. The width of the filtration opening at the early stage may be a prognostic factor for long-term IOP control. Large-scale studies with longer follow-up periods are required.

Efficacy and safety of the use of freeze-dried (lyophilized) amniotic membrane transplantation with combined trabeculotomy-trabeculectomy for congenital glaucoma

Purpose The aim of the study was to evaluate the outcome of the surgical technique that utilizes freeze-dried (lyophilized) amniotic membrane transplantation (AMT) with combined trabeculotomy-trabeculectomy in cases of primary congenital glaucoma with respect to its efficacy and complications. Patients and methods This was a prospective controlled study that included 25 eyes of 19 patients with primary congenital glaucoma. The patients were categorized into two groups: group I included 14 eyes that were treated with combined trabeculotomy-trabeculectomy with AMT and group II included 11 eyes that were treated with combined trabeculotomy-trabeculectomy without adjunctive (control group). Results Nineteen patients were included in the study: 13 were male and six were female. The mean age was 6.2 ± 3.5 months and 5.7 ± 2.9 months in groups I and II, respectively; there were no statistically significant differences between groups I and II regarding the patient demographics and preoperative characteristics. The surgical outcome of the two groups showed that absolute success was achieved in 71.4% and qualified success in 14.3% in group I, and in group II absolute success was achieved in 45.5% and qualified success in 27.2%. This difference was highly significant in terms of absolute success and significant in terms of total success between the two groups. The mean intraocular pressure (IOP) in this study was markedly decreased from preoperative values in both groups during postoperative follow-up visits, with statistically significantly lower IOP in group I than in group II at all postoperative visits. The complications encountered were hyphema in 28.6% of patients in group I and in 27.3% of patients in group II. Shallow anterior chamber associated with hypotony occurred in 21.4 and 18.2% of patients in groups I and II, respectively. One case in each group developed serous choroidal detachment. Flat nonfunctioning bleb with high IOP occurred in 14.3% of patients in group I and in 27.3% in group II. The complication rates were statistically insignificant between the two groups. Conclusion AMT-enhanced combined trabeculotomy-trabeculectomy appears to be an effective procedure for the treatment of primary congenital glaucoma with better long-term control of IOP and without added complications.

Ab interno trabeculectomy in the adult patient.

Glaucoma is a potentially blinding disease that affects millions of people worldwide. The mainstay of treatment is lowering of intraocular pressure (IOP) through the use of medications, laser and/or incisional surgery. The trabecular meshwork (TM) is thought to be the site of significant resistance to aqueous outflow in open angle glaucoma. Theoretically, an incision through TM or TM removal should decrease this resistance and lead to a significant reduction in IOP. This approach, commonly referred to as goniotomy or trabeculotomy, has been validated in the pediatric population and has been associated with long-term IOP control. In adults, however, removal of TM tissue has been historically associated with more limited and short-lived success. More recent evidence, reveals that even adult patients may benefit significantly from removal of diseased TM tissue and can lead to a significant reduction in IOP that is long-lasting and safe. In this review, we discuss current evidence and techniques for ab interno trabeculectomy using various devices in the adult patient.

Surgical and Visual Outcomes of Childhood Glaucoma at a Tertiary Eye Care Center in South India.

This study aimed to categorize patients with childhood glaucoma into groups, study the clinical characteristics of the eyes affected, and determine the outcomes after surgery. This was a retrospective, consecutive, nonrandomized study. Patients with childhood glaucoma who underwent planned primary trabeculectomy or combined trabeculotomy-trabeculectomy (CTT) between January 2003 and December 2008 were enrolled. Main outcome measures were intraocular pressure (IOP), visual acuity, corneal clarity, and any surgical and anesthetic complications. One hundred thirty-one eyes of 81 patients were included. They were 61.7% male. Mean patient age was 6.1 ± 4.1 years, and the mean age at surgery was 35.8 ± 40.9 months. Postoperatively, the improvement in visual acuity was highly statistically significant at all follow-ups (P < 0.001). The IOP values showed a significant reduction from 29.2 ± 9.7 mm Hg preoperatively to 13.7 ± 5.3 mm Hg (P < 0.001) at 6-month follow-up and 12.1 ± 2.2 mm Hg at last follow-up. Cumulative corneal clarity improved significantly postoperatively (P < 0.001). A comparison of trabeculectomy alone and CTT showed that both procedures were quite effective. At 1 year, overall complete success was seen in 73.3%, qualified success in 16.8%, and failure in 10.7%. This study suggests that CTT is safe and effective in both primary and secondary childhood glaucomas. Trabeculectomy alone is also highly effective in certain cases, and proper case selection is essential to attain optimum results. Surgical intervention leads to improvement in vision and corneal clarity and also achieves long-term IOP control.

Minimizing the invasiveness of traditional trabeculectomy surgery

Microinvasive invasive glaucoma surgery has become increasingly popular as a surgical alternative for glaucoma. Although the time-honored trabeculectomy remains the unrivaled contender for lowering intraocular pressure (IOP) into the single digits, newer devices are available that attempt to reach similar IOP levels with fewer complications and quicker visual recovery. The Express mini-shunt and the Innfocus microshunt are 2 devices that bring us closer to the goal of repeatable, lower risk surgery; improved patient satisfaction; stabilization of the visual field; and long-term IOP control. The mini-shunt has been approved by the U.S. Food and Drug Administration, while the microshunt is still under review. Dr. Condon is a consultant to and speaker for Alcon Laboratories. Dr. Moster has served on the advisory board of, been a consultant to, received honoraria for lectures from, and performed contracted research for Alcon, Inc.

Using the Early Postoperative Intraocular Pressure to Predict Pressure Control After a Trabeculectomy

The goal of this study was to identify the early postoperative intraocular pressure (IOP) that predicts low pressure control after a trabeculectomy with mitomycin C. This study retrospectively analyzed the medical records of the initial trabeculectomy with mitomycin C in patients with primary open-angle glaucoma. We established 2 target postoperative IOPs, ≤11 and ≤15 mm Hg. The preoperative and early postoperative factors contributing to the success and failure of postoperative IOP control were studied by multiple regression analyses. These factors included the sex and age of patients, record of cataract surgery, number of preoperative medications, preoperative IOP, IOP recorded 2 weeks after surgery, laser suture lysis after surgery, and the presence of a shallow anterior chamber and choroidal detachment during the first month after surgery. The optimal IOP levels 2 weeks after surgery for long-term IOP control were examined using the Kaplan-Meier survival analyses. Sixty-six patients (66 eyes) with open-angle glaucoma participated in the study. The age and IOP 2 weeks after surgery were selected as the confounding factors affecting the probability of successfully satisfying both target IOPs;≤11 and≤15 mmHg postoperatively. An IOP under 8 mm Hg at 2 weeks after surgery was found to be associated with maintaining the postoperative IOP at either ≤11 and ≤15 mm Hg for an extended period. An IOP of 8 mm Hg was associated with successful outcomes in patients undergoing trabeculectomy. Also, younger age was found to be a risk factor for surgical failure.

Bleb Revision for Resolution of Hypotony Maculopathy Following Primary Trabeculectomy

To describe a surgical method of bleb revision for hypotony maculopathy, to evaluate its long-term efficacy, and to define the relationship between the duration of hypotony maculopathy and visual acuity (VA) outcomes. Noncomparative retrospective case series. Medical records of 33 patients with hypotony maculopathy who underwent primary bleb revision between June 1999 and September 2012 by a single surgeon at an academic medical center were reviewed. Hypotony maculopathy was characterized by the presence of a decrease in VA, retinal striae, and macular edema in the setting of decreased intraocular pressure (IOP) after glaucoma filtering surgery. The main outcome measure was final logMAR VA after bleb revision at 6 and 12 months. Thirty-three eyes of 33 patients were followed for 4.68 ± 3.56 years (range 0.55-12.69 years). Mean duration of hypotony maculopathy was 4.98 ± 8.93 months. LogMAR VA improved from 0.78 ± 0.40 at baseline to 0.34 ± 0.34 (P < .001) 6 months after bleb revision and to 0.45 ± 0.55 (P < .001) 12 months after bleb revision. Spearman rank coefficient (rs) correlating duration of hypotony and BCVA at both 6 and 12 months was significant (P = .015 and rs = 0.426, P = .028 and rs = 0.416, respectively). Mean IOP increased from 3.51 ± 2.27 mm Hg to 12.06 ± 4.06 mm Hg (P < .001) at 12 months. Fifty-two percent were on no antiglaucoma medications at last follow-up. Five eyes (15%) required a second bleb revision to correct persistent hypotony maculopathy. Surgical repair for hypotony maculopathy provided a significant improvement in VA at 6 and 12 months. Surgical bleb revision is associated with good long-term control of IOP and improved VA in eyes with hypotony maculopathy after previous glaucoma filtering surgery.

Comparison of long term intraocular pressure control following small flap vs conventional trabeculectomy

Background: Trabeculectomy using a small scleral flap appears to provide medium to long-term IOP control comparable to large flap techniques and may offer potential advantages: reduced surgical tissue trauma, a larger area of undisturbed sclera and conjunctiva should repeat surgery be required, and reduced astigmatism induction. Aims & Objective: To evaluate the long term intraocular pressure (IOP) control of small flap trabeculectomy (microtrabeculectomy) vs conventional trabeculectomy. Materials and Methods: A prospective case control study of small flap trabeculectomy (group I) as against conventional trabeculectomy (group II) was performed on 50 eyes from 50 patients in each group with a minimum follow up of 2 years. Results: All patients had a minimum follow up of 2 years, The mean (SD) intraocular pressures at presentation and preoperatively were 34.3 (5.6) and 23.7 (3.7) mm Hg in group I and 35.2(4.5) and 24.2(2.9) mm Hg in group II. The mean (SD) IOP at 6 months, 1 & 2 years was 12.5 (4.0), 12.9 (4.1), 13.5 (4.5) respectively in group I and 12.0 (4.4), 12.7 mmHg (3.6), 13.0 (3.9) respectively in group II. There was no significant difference in IOP levels at any of the analysis points by one way ANOVA. Conclusion: Small flap trabeculectomy (microtrabeculectomy) is effective at reducing IOP in uncomplicated glaucoma patients with IOP control similar to filtering surgery utilising larger scleral flaps. Well-constructed scleral flaps of both sizes were able to achieve and maintain IOP levels well within the desired range and the small flaps had advantages of avoiding complications associated with larger flaps.

Modified trabeculectomy with an extended subscleral tunnel: could it be a secure way toward successful glaucoma surgery?

Purpose The aim of this study was to describe a modified surgical technique of an extended subscleral tunnel (ESST) with adjunctive application of mitomycin-C (MMC) and to evaluate its safety and efficacy in long-term intraocular pressure (IOP) control in glaucoma patients. Patients and methods This was a randomized-controlled prospective clinical trial that included 54 eyes of 46 patients diagnosed with primary open-angle glaucoma. They were divided into two equal groups: the 'trabeculectomy with adjunctive MMC' treatment, group A, and the 'modified trabeculectomy with adjunctive MMC and ESST' treatment, group B. Ultrasonic biomicroscopy measurement of the aqueous drainage route was performed at 12 and 24 months postoperatively. The main outcome results included the cumulative probability of surgical success, IOP values, and the number of antiglaucoma drugs needed. Results Group B achieved a cumulative probability of complete success of 0.68 and qualified success of 0.96 at the end of the 24-month study period; however, group A achieved a cumulative probability of complete success of 0.44 and qualified success of 0.84. Group B succeeded in achieving lower mean IOP values than group A, with fewer antiglaucoma drugs at all postoperative visits, but this was not statistically significant ( P > 0.05). The aqueous drainage route was always larger in group B and there was a statistically significant decrease in its size only in group A ( P = 0.036). Group B achieved statistically significant fewer early and late postoperative complications and also required fewer additional interventions compared with group A ( P = 0.029). No significant adverse effects were caused by this modified combined technique. Conclusion Modified trabeculectomy with ESST combined with adjunctive MMC could be an efficient, safe, familiar, and applicable treatment technique for a successful trabeculectomy. It may provide a favorable long-term outcome, representing a simple novel way of performing successful glaucoma surgery.

Long-term outcomes following the surgical repair of traumatic cyclodialysis clefts

To evaluate the long-term visual prognosis and intraocular pressure (IOP) control following direct and indirect cycloplexy for the surgical treatment of traumatic cyclodialysis clefts. Retrospective consecutive case series of 17 eyes of 17 patients. All eyes showing signs of ocular hypotony were treated with either cleft cyclocryotherapy and/or direct surgical cycloplexy. Cycloplexy was performed by directly suturing the ciliary body to the scleral spur under a double-lamellar limbal-based scleral flap. The main outcome measures were IOP, best-corrected visual acuity (BCVA), and the occurrence of postoperative complications. The cyclodialysis clefts were post-traumatic in all the 17 eyes and extended for 2.1 ± 1.6 clock-hours (range, 0.5-6 clock-hours). The mean follow-up time was 43.7 ± 24.6 months (range, 12-110 months). Preoperatively, the mean IOP was 6.9 ± 4.0 mm Hg (range, 2-14 mm Hg). Postoperatively, painful reversible IOP spikes of up to 70 mm Hg developed in 13 eyes. The final mean postoperative IOP was 12.2 ± 4.1 mm Hg with no cases of secondary glaucoma. Preoperatively, BCVA was 6/12 or better in 4 eyes (24%), which rose to 12 eyes (71%) at final follow-up. Of the 12 patients who underwent direct cycloplexy, 75% achieved a final BCVA of 6/12 or better. There were no serious complications related to direct cycloplexy, including suprachoroidal haemorrhage or endophthalmitis. Successful cyclodialysis cleft repair can lead to a good long-term visual prognosis and stable IOP control, even in cases with a protracted history of ocular hypotony.