Needle Revision Research Articles

Needle Revision and Digital Ocular Massage for Treatment of Ocular Hypertension Phase after Ahmed Valve Implantation

Purpose: To evaluate the effects and safety of needle revision with 5-fluorouracil (5-FU) subconjunctival injection and digital ocular massage for the treatment of ocular hypertension phase following Ahmed valve implantation (AVI).Methods: We retrospectively analyzed the medical records of patients who underwent needle revision with 5-FU subconjunctival injection and digital ocular massage for treatment of ocular hypertension phase. Changes in visual acuity, intraocular pressure (IOP), and the number of anti-glaucoma medications before and after the procedure were compared. The cumulative success rate of the procedure was analyzed using Kaplan–Meier survival analysis. Success was categorized as complete when the IOP was 6-21 mmHg without medication and qualified when it was 6-21 mmHg with medication.Results: In total, 53 eyes of 53 patients were included in this study. The average time interval between AVI and the first procedure was 25 days, and 2.1 ± 0.8 procedures were performed per patient. The mean IOP before and at 48 weeks after the procedure was 24.4 ± 2.9 and 16.9 ± 3.5 mmHg, respectively. At each follow-up visit, the IOP was significantly lower than that before the procedure. At 48 weeks after the procedure, the complete and qualified success rates were 22.6%, and 81.1%, respectively.Conclusions: Needle revision with 5-FU subconjunctival injection and digital ocular massage are effective and safe for the treatment of ocular hypertension phase following AVI.

Usefulness of Intraocular Pressure With the Ocular Response Analyzer to Predict Postoperative Hypotony Complications in Glaucoma.

To investigate the usefulness of intraocular pressure (IOP) using the ocular response analyzer to predict the occurrence of hypotony complications following trabeculectomy or bleb needling revision with mitomycin C. This study included 66 eyes of 66 patients who underwent trabeculectomy (58 eyes of 58 patients) or bleb needling (8 eyes of 8 patients) with mitomycin C. A significant predictor of hypotony complications was identified from (1) operation (trabeculectomy or bleb needling), (2) age, (3) sex, (4) disease type (primary open-angle glaucoma, primary angle closure glaucoma, or exfoliation glaucoma), (5) lens status (phakia or pseudophakia), (6) preoperative Goldmann applanation tonometry IOP, (7) preoperative central corneal thickness, (8) preoperative axial length, (9) preoperative anterior chamber depth, (10) preoperative corneal hysteresis, (11) preoperative corneal resistance factor, (12) preoperative corneal compensated IOP (IOPcc), and (13) minimum IOP (IOP value when hypotony complications occurred, otherwise the minimum IOP during 3 months from trabeculectomy or bleb needling) using multivariate logistic regression. The probability of the occurrence of hypotony complications tended to increase by applying higher cutoff values to preoperative Goldmann applanation tonometry IOP and IOPcc, but not lower cutoff values to the minimum IOP. Multivariate logistic regression suggested that higher preoperative IOPcc and pseudophakia were significant predictors of the occurrence of hypotony complications (P = 0.0062 and 0.0069, respectively). Higher preoperative IOPcc and pseudophakia were significant predictors of the occurrence of hypotony complications. It is useful to measure IOP using the ocular response analyzer before trabeculectomy.

A modified trabeculectomy technique with direct filtration into the Tenon's capsule

ObjectiveTo report the surgical outcomes of a modified trabeculectomy technique involving implanting the Tenon's layer under the scleral flap. DesignProspective, interventional case series. Participants51 eyes with medically uncontrolled glaucoma were enrolled for this study. A new trabeculectomy technique, the Tenon's filtration technique for trabeculectomy (TFT-LEC) was used in 26 eyes, while a conventional procedure, normal trabeculectomy (N-LEC), was used for 25 eyes. MethodsIntraocular pressure (IOP) control, the number of glaucoma medications, the need for additional interventions, and postoperative complications were assessed. ResultsTwelve months postoperatively, the mean IOP was 13.5 ± 0.5 mmHg in the TFT-LEC group and 15.4 ± 0.5 mmHg in the N-LEC group (p = 0.13). The TFT-LEC group required an average of 1.3 ± 1.0 additional glaucoma medications (21 cases required only ripasudil) postoperatively, with no cases of bleb needling revision or reoperation. The N-LEC group required an average of 1.7 ± 1.5 glaucoma medications (p = 0.43) compared to TFT-LEC group, eight cases (32%) required bleb needling revision (p = 0.002), and one case (4%) of reoperation (p = 0.49). The complications in the TFT-LEC group included shallow anterior chamber in six (23 %) cases (p = 1.00) compared to N-LEC group, choroidal detachment in two (8%) cases (p = 0.42), and anterior chamber hemorrhage in seven (27%) cases (p = 0.29). None of these complications affected visual function. ConclusionsThis new technique involving implanting the Tenon's layer under the scleral flap may improve the postoperative outcomes of trabeculectomy.

Usefulness of Eye Deformation in the Corvis ST Measurement to Predict Postoperative Hypotony Complications in Glaucoma

PurposeThis study aimed to investigate the usefulness of measuring biomechanical parameters using the Corvis ST to predict the occurrence of hypotony maculopathy and choroidal detachment (CD) following trabeculectomy or bleb needling revision with mitomycin C (MMC). DesingClinical cohort study MethodsThis study included 100 eyes of 100 patients who underwent trabeculectomy (88 eyes of 88 patients) or bleb needling (12 eyes of 12 patients) with MMC. A significant predictor of hypotony complications was identified from 1) operation (trabeculectomy or bleb needling), 2) age, 3) sex, 4) disease type (primary open angle glaucoma [POAG], exfoliation glaucoma [EG] or other), 5) lens status (phakia or pseudophakia), 6) preoperative Goldmann applanation tonometry (GAT) intraocular pressure (IOP), 7) preoperative central corneal thickness (CCT), 8) preoperative axial length (AL), 9) preoperative anterior chamber (AC) depth, 10) “Min IOP” (IOP value when hypotony complications occurred, otherwise the minimum IOP during 3 months from trabeculectomy or bleb needling), 11) preoperative corneal curvature, and 12- 24) 12 Corvis ST parameters using multivariate logistic regression. ResultsThere were 13 and 21 eyes developed hypotony maculopathy and CD, respectively. Male gender, greater preoperative GAT IOP and greater HC deflection Amplitude were significant predictors of the occurrence of hypotony maculopathy (p <0.05). On the other hand, shorter axial length, thinner CCT, greater preoperative GAT IOP and pseudophakia were significant predictors of the occurrence of CD (p <0.05). ConclusionsA careful attention should be paid to the occurrence of hypotony maculopathy with male gender and greater HC deflection Amplitude despite higher preoperative GAT IOP. Different risk factors were identified; shorter axial length, thinner CCT, greater preoperative GAT IOP and pseudophakia.

Bleb vessel density as a predictive factor for surgical revisions after Preserflo Microshunt implantation.

Bleb failure is a common complication after glaucoma filtration surgery. Different bleb classification schemes incorporating filtration bleb vascularization have been proposed, but the reported correlation with intraocular pressure (IOP) has been variable, possibly because of subjective vascularization grading. The purpose of the present study was to evaluate bleb vascularization after Preserflo Microshunt (PM) implantation using anterior segment OCT-angiography (AS-OCTA) as a biomarker for bleb failure. Twenty-three eyes of twenty-three patients underwent PM implantation. Up to 12 months after surgery PM scleral passage-centred AS-OCTA measurements (PLEX Elite 9000) for bleb-vessel density (BVD) determination were performed and IOP as well as necessity for surgical revisions (needling and open revision) were documented. After multi-step image analysis (region of interest definition, artefact removal, binarization, BVD calculation), the predictive value of early postoperative BVD for surgical revisions was assessed using logistic regression modelling. Baseline IOP (23.57 ± 7.75 mmHg) decreased significantly to 8.30 ± 2.12, 9.17 ± 2.33 and 11.70 ± 4.40 mmHg after 1, 2 and 4 week(s), and 13.48 ± 5.83, 11.87 ± 4.49, 12.30 ± 6.65, 11.87 ± 3.11 and 13.05 ± 4.12 mmHg after 2, 3, 6, 9 and 12 month(s), respectively (p < 0.001). Nine patients (39%) needed surgical revisions after a median time of 2 months. Bleb vessel densities at 2 and 4 weeks were significantly associated with future surgical revisions upon logistic regression analysis (2 W/4 W likelihood-ratio test p-value: 0.0244/0.0098; 2 W/4 W area under the receiver operating characteristics curve: 0.796/0.909). Filtration bleb vessel density can be determined using AS-OCTA in the early postoperative period and is predictive for bleb failure after PM implantation.

Factors Associated with the Efficacy of XEN Gel Implant.

Microinvasive glaucoma surgery (MIGS) is a growing trend, and XEN gel implant is one of the most effective types of MIGS. This study aimed to examine factors associated with the surgical success of XEN gel implants. This retrospective cohort study enrolled patients with glaucoma receiving XEN implantation alone or combined with phacoemulsification (PHACOXEN) with a follow-up period of more than 6months at Hualien Tzu Chi Hospital, Taiwan. If intraocular pressure (IOP) elevated above 20mmHg during the follow-up, needling or open revision was performed. The primary outcome measures included IOP and the number of glaucoma medications. Male patients had lower postoperative IOP; male patients and higher preoperative IOP were associated with higher IOP change rates, and older patients had a higher chance of achieving IOP < 18mmHg and being medication-free at months 12, 24, and 36. The Kaplan-Meier curve showed that the probability of free-of-rescue intervention over the follow-up period was not different between the XEN alone and the PHACOXEN group (P = 0.859). Both needling and open revision were effective rescue interventions, but open revision had a higher chance of achieving IOP ≤ 18mmHg and being medication-free (P = 0.031) and required less medication afterward (P = 0.044). Older age (P = 0.013) and male patients (P = 0.022) had a lower IOP after rescue interventions. Compared with open revision, needling was associated with higher IOP (P = 0.048) and more required medications (P = 0.048). XEN alone and PHACOXEN had comparable surgical outcomes, whereas open revision had a better IOP lowering effect than needling as a rescue intervention. Male and older patients had better surgical results in primary XEN implantations and rescue interventions.

Treatment of filtration bleb dysfunction after glaucoma surgery by needle revision of filtration bleb combined with conbercept.

Filtration surgery (Trabeculectomy) is the main treatment for glaucoma. The scarring of the filtration bleb and obstruction of the outflow of aqueous humor through the filtration channel are the main reasons of the surgery failure. The objective of this study was to determine the clinical efficacy of needle revision of filtration blebs combined with subconjunctival injection of conbercept on the functional bleb formation in glaucoma patients with eye pressure out of control after trabeculectomy. A total of 48 eyes with poor filtration bleb function after trabeculectomy for glaucoma were treated with needle revision of filtration bleb combined with subconjunctival injection of conbercept. After the treatment, the patients were followed up for 3 months during which visual acuity, intraocular pressure, slit lamp and ultrasound biomicroscope examinations were performed. Intraoperative and postoperative complications were recorded. The visual acuity and intraocular pressure were significantly improved after the needle revision of filtration blebs. Among the 48 eyes, 39 eyes still had functional blebs at the end of the follow-up period, and filtration blebs failed in 9 eyes 2 to 8 weeks after the removal of the needle. The survival rate of filtration blebs at 3 months after needle revision was (79.06 ± 3.42%), and 81.25% (39/48) of the eyes showed good formation rate of functional bleb at the last follow-up. Three months after needle revision, there was local scar formation in some filtration blebs. Part of the filtration blebs showed mild thickening of the local subconjunctival tissue, and the filtration bleb was slightly raised and diffuse, showing a multi-cavity and thin-walled shape in some blebs. Ultrasound biomicroscopy examination showed relative structural manifestations. Subconjunctival hemorrhage occurred in 43 patients during and after the operation. Low intraocular pressure occurred in 8 patients with the lowest pressure of 5 mm Hg. Choroidal edema was observed in 3 patients. Five patients had intraoperative conjunctival hemorrhage in the anterior chamber, and hyphema occurred. All complications were self-limited and resolved without surgical intervention. Needle revision of filtration bleb combined with anti-VEGF drugs is a safe and effective method for the treatment of filtration bleb dysfunction after surgery of glaucoma.

Results of open bleb revision as management of primary bleb failure following XEN 45 gel stent and Preserflo™ Microshunt

PurposeThe success of filtering surgery as in XEN-Gel-Stent (XEN) and Preserflo-Microshunt (PF) depends mainly on a functioning bleb. Primary bleb failure (PBF) is not uncommon and can be treated with needling or open bleb revision (OBR). The aim of the study is to compare surgical outcomes of OBR after XEN and PF.MethodsEyes which received OBR as management of PBF following implantation of XEN or PF were retrospectively included. Intraocular pressure (IOP), number of IOP lowering medications (NoM), and success rates (SR) were compared between groups. Complete and qualified success were defined as IOP ≤18mmHg and a reduction of >20%, without and with medications, respectively.Results29 eyes after XEN and 23 eyes after PF were included. Six months following OBR, IOP reduced from 24.2±4.7 to 13.5±4.6 after XEN and from 27.3±8.7 to 15.9±5.8mmHg after PF (both p<0.001). NoM did not change (0.7±1.3 to 0.4±0.8 after XEN and 1.2±1.3 to 1.0±1.5 after PF, p>0.05 for both). Complete SR were higher after XEN than after PF (58.6% vs. 30.4%, p=0.04). Complications were mild and managed mainly conservatively. Additional glaucoma surgery was needed in 17% and 30% of eyes after XEN and PF, respectively (p=0.26).ConclusionAlthough OBR was effective as management of PBF following XEN and PF, SR were higher after XEN than after PF along with comparable safety profile. The change of the surgical approach from ab interno during XEN-Implantation to ab externo during OBR seems to enhance SR compared to PF, where both interventions are done ab externo.

Iris abnormalities may influence the efficacy and filtration strategies of Posner-Schlossman syndrome: a retrospective study involving trabeculectomy, ExPRESS and Ahmed valve implants.

To evaluate and compare the one-year efficacy and influencing factors of different filtration surgeries on Posner-Schlossman syndrome (PSS) patients. A retrospective study enrolling 91 PSS patients who underwent filtering surgeries and were followed for at least one year. Unilateral PSS was diagnosed as recurrent attacks of mild, unilateral, non-granulomatous anterior uveitis, elevated intraocular pressure (IOP), keratic precipitates (KPs) on the corneal endothelium, open angle, no posterior synechia, and no inflammatory lesions in the posterior segment; the IOP and anterior segment returned to normal between attacks. Medical histories and thorough ocular examination results were collected. Trabeculectomy and ExPRESS were chosen as the first line and AGV was considered for those under high risk of fibrosis. Follow-up data, mainly IOP, best-corrected visual acuity (BCVA), and anterior segment manifestations at the 1st week, 6th month, and 12th month were generated and analyzed. Iris abnormalities were determined by depigmentation or atrophic changes on the anterior segment photograph. Complete surgical success was defined as 5 mmHg < IOP ≤ 21 mmHg without IOP-lowering drug or needle revision; qualified surgical success was defined as 5 mmHg < IOP ≤ 21 mmHg with IOP-lowering drugs or needle revisions. Survival analysis was performed to obtain the success rates. At the 12th month, the complete surgical success rate of trabeculectomy (N = 54), ExPRESS (N = 23), and AGV group (N = 14) was 58.97% (95%CI 46.91-77.09%), 84.21% (95%CI 68.33-100.87%), and 100%; the qualified success rate was 71.79% (95%CI 62.46-88.34%), 89.47% (95%CI 77.07-103.33%), and 100%, respectively. Patients undergoing trabeculectomy experienced the largest decline of BCVA (from 0.58±0.46 to 1.01±0.51, P < .05); the trabeculectomy group endured the highest IOP (20.84±9.92 mmHg) compared to ExPRESS (14.51±2.86 mmHg, P < .05) and AGV group (13.17±3.32 mmHg, P < .05). At the 12th month, in the ExPRESS group, patients with iris abnormalities had higher IOP than the normal ones (15.65±2.05 mmHg, 12.93±3.17 mmHg, P < .05). ExPRESS helped patients with iris abnormalities maintain lower IOP than trabeculectomy (15.65±2.05 mmHg, 22.52±10.67 mmHg, P < .05). Three patients developed hypotony at the 3rd month (1 in ExPRESS and 2 in trabeculectomy group). AGV and ExPRESS performed better than trabeculectomy in PSS patients in terms of IOP and success rate. Iris abnormalities might influence the postoperative IOP and this may be valuable in guiding filtration strategies. Chinese Clinical Trial Registry (No. ChiCTR1800017532, date: 2018/08/02).

Treatment outcomes of Mitomycin‐C (MMC) augmented bleb needling in failing trabeculectomy blebs in NHS Tayside

AbstractPurposeTrabeculectomy is the gold standard surgical option in managing glaucoma when intraocular pressure (IOP) is uncontrolled with topical anti‐hypertensive. Bleb failure is not uncommon in trabeculectomy. Bleb needling is a relatively straightforward procedure that can be conducted to re‐establish flow from the trabeculectomy.1,2 We aim to investigate treatment outcomes of MMC augmented needling of failing trabeculectomy blebs in NHS Tayside.MethodsRetrospective cohort study was performed by reviewing clinical notes of all MMC‐augmented bleb needling procedure after trabeculectomy performed in NHS Tayside from May 2012 to June 2016, patients were identified from surgical records. Data were analysed using IBM® SPSS software and R software (R Foundation for Statistical Computing, Vienna, Austria).Results111 patients were identified, 34 excluded as they were lost to follo‐ ups or did not have clinical notes.86 eyes (77 patients) were included in this study. Median number of months between index filtration surgery and the first needling was 23 months. Mean IOP was reduced by 32.6% by the end of Year 1 (23.94 vs 16.14) and 40.4% by the end of Year 3 (23.94 vs 14.28).This was statistically significant at the 0.05 level.28 eyes (32.6%) required further surgical procedures to control IOP (repeat trabeculectomy, glaucoma drainage device, cyclodiode). 9 eyes (10.5%) had complications related to needling with 3 hyphema, 2 post‐operative needling spike,and 1 each had bleb leak, aqueous misdirection, choroidal effusion and hypotony respectively.ConclusionsBleb needling is a safe procedure that can be carried out re‐establish flow in failing trabeculectomy to achieve satisfactory control.Bibliography1. Lin S, Byles D, Smith M. Long‐term outcome of mitomycin C‐augmented needle revision of trabeculectomy blebs for late trabeculectomy failure. Eye. 2018;32(12):1893‐1899.2. Panarelli J, Vinod K, Huang G, Sidoti P. Transconjunctival Revision With Mitomycin‐C Following Failed Trabeculectomy. Journal of Glaucoma. 2016;25(7):618‐622.

Post-trabeculectomy early bleb localization mimicking a 'ring of steel'.

A 54-year-old-man underwent trabeculectomy with mitomycin-C (0.02%). At 4-week follow-up, there was an elevated, well-circumscribed bleb with raised intra-ocular pressure (IOP) of 32-mmHg, with a classic “ring of steel” appearance, typically seen in a tenon's cyst. A sub-tenon needle revision re-established aqueous flow. Two weeks later, the IOP was 8-mmHg without any anti-glaucoma medications. A diffuse well formed bleb was noted. Careful ocular examination helps to identify early post-operative localized bleb that may appear like a “ring of steel” but can be managed by needling, unlike a tenon's cyst, which would require more extensive intervention.

Open Conjunctival Approach for Sub-Tenon's Xen Gel Stent Placement and Bleb Morphology by Anterior Segment Optical Coherence Tomography.

Sub-Tenon's implantation of the Xen Gel stent resulted in significant intraocular pressure (IOP) lowering along with a low rate of postoperative bleb needling, and a favorable bleb morphology on anterior segment optical coherence tomography (AS-OCT). The aim was to assess clinical outcomes and bleb morphology following sub-Tenon's implantation of the Xen Gel Stent. The medical records of patients who underwent sub-Tenon's Xen Gel Stent implantation with intraoperative mitomycin-C through an open conjunctival approach were reviewed. Postoperative IOP and number of glaucoma medications at 1, 3, 6, 9, and 12 months were assessed. Bleb morphology was analyzed at various timepoints using AS-OCT (Topcon DRI OCT version 1.1.1). Twenty-six eyes were included in the study. Mean age was 69.4±8.0 years. Mean preoperative IOP was 28.1±7.8 mm Hg on an average of 3.5±0.9 glaucoma medications. Mean IOP at postoperative month 12 (n=23 eyes) was 12.9±4.0 mm Hg (P<0.01) on an average of 0.3±0.6 (P<0.01) glaucoma medications. Three eyes (12%) required postoperative needle revision. Bleb morphology in the early postoperative period (≤3 mo) was characterized by multiple small subconjunctival microcysts on AS-OCT. At the intermediate (6 to 12 mo) and long-term (>12 mo) timepoints, reduction in microcysts with multiple internal parallel layers of aqueous flow and a uniform pattern were more frequently noted. All functional blebs were characterized by the presence of a posterior episcleral fluid lake. Failed blebs showed absence of aqueous humor around the distal end of the microshunt. Following an open conjunctival approach, sub-Tenon's placement of the Xen Gel Stent with significant IOP lowering was achieved. In eyes with good shunt function, bleb morphology by AS-OCT showed a posterior episcleral fluid lake similar to findings following trabeculectomy.

XEN45 Gelstent Implantation in the Treatment of Glaucoma Secondary to Fuchs Uveitis Syndrome

ABSTRACT Purpose Evaluation of treatment efficacy of XEN45 gelstent for glaucoma secondary to Fuchs uveitis syndrome (FUS). Methods This retrospective case series evaluated patients with glaucoma secondary to FUS, who underwent XEN45 implantation. Complete success was defined as IOP lowering of ≥ 20% and cutoff IOP at ≤ 18 mmHg. Success was qualified if additional glaucoma medication was necessary. Additional glaucoma surgery except for needling and open bleb revision was regarded as failure. Results Twelve eyes of 12 patients were included. Qualified and complete success rates were 50% after one year (n = 10). Qualified success was achieved in 66.6% of patients with 33.3% of patients achieving complete success after two years (n = 6). Conclusions XEN45 implantation had some success in the treatment of glaucoma secondary to FUS, but needling was frequently necessary to improve outcome.

Needling and open filtering bleb revision after XEN-45 implantation\u2014a retrospective outcome comparison

PurposeTo compare efficacy and safety of needling and open bleb revision after XEN-45 surgery.MethodsThis retrospective study represents real-life data of patients who underwent XEN-45 surgery between November 2014 and June 2018 in the Vienna General Hospital. The following groups were formed for data evaluation: (PSEA) primary surgery secondary intervention allowed (n = 268); (PS) primary surgery until secondary intervention (n = 268); (N) first needling until additional secondary intervention (n = 55); (BR) first bleb revision until additional secondary intervention (n = 105). Main outcome measures were pre- and postoperative intraocular pressure (IOP), number of glaucoma medication (GM), Kaplan–Meier success rates, and secondary intervention rates. Success was defined as postoperative IOP < 21 mmHg and < 18 mmHg together with ≥ 20% IOP reduction with medication allowed.ResultsIOP (and GM) was lowered from 23.5 ± 8.0 (GM 3.1 ± 1.0) to 14.9 ± 8.2 mmHg (1.2 ± 1.4) in group PSEA and 18.1 ± 8.2 mmHg (1.5 ± 1.4) in group PS, in group N from 23.2 ± 10.1 (1.5 ± 1.0) to 19.3 ± 8.5 mmHg (2.2 ± 1.3) and in group BR from 22.0 ± 8.0 mmHg (2.5 ± 1.1) to 15.5 ± 6.4 mmHg (1.3 ± 1.5) after a median follow-up of 16.0, 8.4, 4.8, and 7.3 months, respectively. Success rates at 1 year were significantly higher in group BR (50.7%) compared to PS (37.7%, p = 0.019) and N (24.3%; p = 0.015). An additional intervention was required less frequently in group BR (17.1%) compared to group PS (49.6%, p < 0.001) and group N (54.5%, p < 0.001).ConclusionOur data appear to indicate favorable outcomes for open XEN bleb revision in terms of Kaplan–Meier success rates and secondary intervention rate compared to the needling procedure.

XEN45 real-life evaluation: Survival analysis with bleb needling and major revision outcomes.

To evaluate real-life outcomes of XEN45 stent surgery including bleb needling (BN) and surgical bleb revision (SBR). Retrospective analysis of all XEN45 gel stents implanted in a tertiary glaucoma center with a minimum follow-up of 6 months. The main outcomes were intraocular pressure (IOP), the number of glaucoma medications, postoperative maneuvers like BN, and subsequent SBR. Success was defined as IOP ⩽ 18 and 20% reduction (criterion A), ⩽15 and 25% reduction (criterion B), and ⩽12 mmHg and 30% reduction (criterion C) reached with (qualified) or without (complete) medications at the last visit. Complete failure was defined as additional glaucoma surgery, loss of light perception, or sight-threatening complications. Multivariable Cox regression and Kaplan-Meier survival estimates tests were performed. Fifty-eight eyes with either stand-alone or combined Phaco-XEN surgery were included. Complete success by the different definitions was 50.0% (95% confidence interval, 5.8%-84.5%) (A), 50.0% (5.8%-84.5%) (B), and 25% (0.9%-66.5%) (C) whereas qualified success was 38.3% (1.6%-80.1%), 31.7% (2.0%-71.4%), and 0%, respectively, at the 24-months visit. 30% of cases underwent BN with 5-Fluorouracil, and SBR was performed in 17.5% of eyes. Low IOP levels at 1-month and early BN were significantly associated with success. The highest chance of failure was achieved in the combined Phaco-XEN group undergoing SBR. In our real-life setting, the first month IOP was associated with greater success rates. Although BN obtained improved IOP values, SBR was associated with a greater bleb survival in the stand-alone XEN group. Both BN and SBR had poor outcomes in the combined Phaco-XEN group.

Efficacy and safety of 5-fluorouracil in infrared monitor guided bleb revision

PurposeInfrared monitor-guided bleb revision (IRGBR), an alternative needling system, visualizes anterior-segment tissues around the bleb not visible during needle revision after trabeculectomy. This study determined the safety and efficiency of 5-fluorouracil (5-FU) as an adjunctive anti-metabolite in IRGBR.MethodsWe retrospectively analyzed 43 consecutive eyes (40 patients; 14 eyes, primary open-angle; 29 eyes, secondary glaucoma) treated with IRGBR for failing filtering blebs. The patients were divided into two groups. The first one had IRGBR without adjunctive 5-FU subconjunctival injection, and the second one had IRGBR with 5-FU. We performed Kaplan-Meier survival analysis using log-rank tests after 2 years of follow-up and Cox proportional hazards regression model to analyze the dependence of the survival time on predictor variables. Two failure criteria were defined as the need for additional surgery for intraocular pressure (IOP) reduction and the IOP at two consecutive follow-up visits based on definition 1, IOP ≧22 mmHg and definition 2, IOP ≧17 mmHg.ResultsThirty eyes (29 cases) underwent IRGBR with subconjunctival 5-FU injection (group A in the second term) and 13 eyes (11 cases) without 5-FU (group B in the first term). The success rates 24 months after IRGBR were 73.3 and 23.1%, respectively, in groups A and B based on the definition 1 failure and 56.7 and 7.7% based on the definition 2 failure. Complications included transient bleb leaks (group A, 3 eyes; group B, none) and choroidal detachment (group A, 1 eye; group B, none). No use of 5-FU and IOPs ≧10 mmHg 1 week after IRGBR were significant risk factors.ConclusionsAdjunctive 5-FU in IRGBR achieved a better success rate for failing trabeculectomy blebs.

Prospective Evaluation of the First Mitomycin C Augmented Needle Revision in Patients With Failed Nonpenetrating Deep Sclerectomy.

At 6 months the procedure achieved a 33.89% drop in intraocular pressure (IOP), had an overall success rate of 57.15%, and did not change the best-corrected visual acuity. Achieving <8 mm Hg of IOP the day after the procedure may be a prognostic success indicator. The purpose of this study was to evaluate the first mitomycin C (MMC)-augmented needle revision in patients with failed nonpenetrating deep sclerectomy (NPDS) and factors associated with its success. This prospective, nonrandomized comparative trial included 21 consecutive patients (21 eyes) who underwent their first MMC needling revision of failed NPDS blebs. The success was defined as absolute if the IOP decreased >20% from the preoperative value without antiglaucoma treatment and as qualified if that level was achieved with antiglaucoma medications. Preoperative and postoperative factors were evaluated for an association with postoperative success using Kaplan-Meier analysis. A significant reduction in mean IOP from preoperative levels was evident at the end of the follow-up. The overall surgical success rate was 57.15%. On the basis of Kaplan-Meier survival analysis, we found that patients whose IOP on the following day of the procedure was <8 mm Hg had a higher success rate than those whose 1-day postoperative IOP was higher. These patients had a percentage of success of 100%, 84.6%, and 76.9% at 1-, 3-, and 6-month postoperative follow-up, respectively. The IOP level on the first postoperative day could be considered a prognostic indicator of success in needling revision performed in failed NPDS.

Needling after XEN gel implant: What's the efficacy? A 1-year analysis.

To analyse the long-term efficacy and safety of bleb needling in glaucoma patients previously submitted to XEN implantation. Retrospective, observational study. Charts from patients who underwent XEN gel implant surgery between October 2015 and December 2017 were reviewed. Needling protocol involves use of Mitomycin C 0.2 mg/mL in an operating room. Primary outcome was defined as intraocular pressure (IOP) lowering efficacy at 12 months post-operative. Complete success was defined as a decrease in IOP > 20% and overall value <18 mmHg. Secondary outcomes included safety parameters (both intra and post-operative). Exploratory analysis of predictive factors for success were performed. Statistical analysis was performed using SPSS version 24. About 94 charts were reviewed, with 18 patients (19%) having undergone needle revision. This salvage procedure was performed after 3.3 ± 3.4 months, achieving a mean IOP reduction of 8.3 ± 8.4 mmHg at 12 months after the procedure (pre-needling: 24.0 ± 5.2 mmHg vs 12th month: 13.5 ± 5.9 mmHg, p < 0.0001). Accordingly, success was achieved in 72% (complete success in 61% of cases). Among predictive factors, there was a higher tendency for success in patients on two types of medications or fewer pre-operatively, cases of standalone XEN surgery and patients with a higher IOP difference pre-needling - day 1. No vision-threatening complications were recorded. XEN salvage procedure with mitomycin C is a valid option in early bleb failure. This single intervention had a long-lasting effect on bleb survival, with almost two-thirds achieving long term significant drop-free IOP reduction.

Needling revision with marking maneuver to locate the scleral flap

To report a variation of the classical needle revision maneuver with an external marking of the scleral flap, augmented with mitomycin C (MMC) in failed non penetrating deep sclerectomy (NPDS). This observational prospective pilot study included five consecutive patients who underwent an MMC needling revision of failed NPDS with the external marking of the scleral flap. All participants underwent a complete ophthalmologic examination and data were collected preoperatively as well as 1 day, 1 week and 1 month after the surgery. The surgical site was also evaluated during the procedure. A significant reduction of IOP and antiglaucomatous medication from preoperative levels was detected at the end of the follow-up period. Regarding the surgical site, we succeed in locating the scleral flap and observing the bleb formation in all cases. No significant subconjunctival bleeding was detected. This variation of the classical needling technique seems to improve intrasurgical visualization and reduces complications, which might lead to an improvement in surgical success.

Combined and stand-alone XEN 45 gel stent implantation: 3-year outcomes and success predictors.

To evaluate the 3-year treatment outcomes of XEN 45 gel stent in open-angle glaucoma patients. In this prospective, single-centre interventional study, consecutive eyes with uncontrolled intraocular pressure (IOP) or signs of disease progression despite medical treatment underwent XEN implantation either alone or combined with phacoemulsification (Phaco+XEN). Surgical success was defined as 'complete' when 36-month unmedicated IOP was ≤15mmHg with a relative IOP reduction≥20% from medicated baseline, while the definition of qualified success allowed no more medications than at baseline. Other definitions of success with different IOP thresholds were also analysed. Secondary outcomes included mean IOP reduction, changes in ocular hypotensive medications and rates of reoperations. Out of 149 eyes initially included, 92 eyes (61.7%) of 68 patients had complete 3-year data (XEN: n=26; Phaco+XEN: n=66) after 38.2% were lost to follow-up. Mean age was 76.3±9.1years, and 66.2% were female. Mean medicated IOP decreased from 20.8±7.4mmHg (21.0±7.4 [XEN] vs. 20.0±6.9mmHg [Phaco+XEN]) at baseline to 13.1±3.4mmHg (12.9±2.9 [XEN] vs. 12.9±3.4 [Phaco+XEN]) at 3years (-37.0%; p<0.001). Medications decreased from 1.9±1.3 (2.4±1.5 [XEN] vs. 1.9±1.2 [Phaco+XEN]) to 0.4±0.9 (0.3±0.8 [XEN] vs. 0.5±0.9 [Phaco+XEN]) (-78.9%; p<0.001). Complete success and qualified success were achieved in 29.0% and 31.0% of eyes, respectively. Needling revision was performed in 51 eyes (55.4%), and 26.1% underwent reoperations. Risk factors for surgical failure included male gender (odds ratio [OR]:3.6; p=0.03), diagnosis of POAG (OR: 4.5; p<0.01) and undergoing needling revision (OR: 4.6; p<0.01). While the type of procedure had no effect on the outcomes of PEXG, POAG eyes undergoing combined surgery had significantly higher rates of failure (OR: 7.29; p=0.023). Most patients stable at 12-month remained so through to 3years. At 3years, XEN gel stent implantation achieved clinically significant IOP and medication reduction despite relatively high rates of needling and reoperations. Identifying patients at risk preoperatively may help optimize surgical outcomes.