Primary Open-angle Glaucoma Surgery Research Articles

Long-Term Outcome after Canaloplasty and Phacocanaloplasty in Primary Open-Angle Glaucoma.

Canaloplasty and phacocanaloplasty achieve a statistically significant IOP-reduction for up to 11 years and decrease the long-term need for glaucoma medications. Both procedures have a low long-term complication rate. To evaluate the long-term outcome of canaloplasty with and without cataract surgery in primary open-angle glaucoma (POAG) patients. 48 eyes of 34 patients with POAG who successfully received canaloplasty alone (group A, n=28) or with phacoemulsification (group B, n=20) were retrospectively analyzed. Demographic data, intraocular pressure (IOP) and IOP-lowering medication were recorded pre- and post-surgery with a follow-up of up to 14 years. The mean follow-up time in group A was 91.4±45.0 months. Mean IOP dropped from 22.0±3.8mmHg at baseline to 14.0±3.3mmHg, 14.3±3.1mmHg, 14.4±3.8mmHg and 16.5±1.2mmHg at 1, 4, 7, 10 years, respectively. IOP-lowering medication count decreased from 1.5±1.0 at baseline to 0.1±0.4, 0.3±0.6, 0.6±0.9 and 0.9±1.1 at 1, 4, 7, 10 years, respectively. The mean follow-up time in group B was 109.1±25.7 months. Mean IOP dropped from 24.5±6.0mmHg at baseline to 13.8±2.9mmHg, 14.9±3.6mmHg, 15.3±2.9mmHg and 14.8±2.0mmHg at 1, 4, 7, 10 years, respectively. IOP-lowering medication count decreased from 2.2±1.2 before surgery to 0.0, 0.1±0.3, 0.1±0.2 and 0.5±0.9 at 1, 4, 7, 10 years, respectively. Canaloplasty and phacocanaloplasty achieved a comparable decrease in IOP and glaucoma medication count with a low complication rate. Both procedures showed a high long-term success rate.

Comparative evaluation of iStent versus iStent inject W combined with phacoemulsification in open angle glaucoma.

The study aimed to compare the 12-month post-operative outcomes of iStent and iStent inject W (inject W), and the factors associated with their success in open-angle glaucoma. This single-center, retrospective comparative case series evaluated the medical records of patients who underwent iStent (comprising 1 stent) or inject W (comprising 2 stents) implantation with cataract surgery for primary open-angle glaucoma and normal tension glaucoma between January 2019 and March 2022. The 12-month post-operative efficacy outcomes included intraocular pressure (IOP), glaucoma medications, and survival analysis of the probability of success. "Failure" was defined as any of the following conditions compared to baseline: 1) IOP elevation, 2) increased glaucoma medication, or 3) IOP decline not exceeding 20% when glaucoma medication scores were comparable, and 4) need for additional glaucoma surgery. The safety outcomes included intra- and post-operative adverse events and changes in the best-corrected visual acuity and visual field. The study comprised 55 eyes in the iStent and 105 in the inject W groups. At 12 months, treatment success was achieved in 66.0% of iStent and 78.4% of inject W eyes. The mean IOP was lower, and the percent reduction from baseline was equal in iStent-treated eyes (8.0% reduction, 14.8 mmHg to 13.7 mmHg, P<0.01) and inject W-treated eyes (11.9% reduction, 15.0 mmHg to 13.8 mmHg, P<0.01) (between-group comparison, P = 0.23). The mean medication burden decreased significantly from 2.5 to 1.1 for iStent (55.0% reduction, P<0.01) and 2.9 to 1.7 for iStent inject (46.8% reduction, P<0.01), with no significant differences between the two groups (P = 0.17). Both devices exhibited excellent safety. Both devices significantly reduced IOP and glaucoma medication 12 months post-operatively. The outcome measures did not differ significantly between the two groups, and lower baseline IOP was predictive of surgical failure.

Pressure Results of Primary Open-Angle Glaucoma Surgery by Trabeculectomy in Kankan, Guinea

Purpose: To assess the pressureal outcomes of primary open-angle trabeculectomy surgery for primary open-angle glaucoma. Materials and Methods: This was a six-month prospective observational study. Patients operated by the trabeculectomy technique and followed during the study period were included. Not included were those who had combined surgery. Recruitment was comprehensive. Our variables were epidemiological, clinical, paraclinical and therapeutic. Epi info version 7.4.0 was used for data analysis. Conclusion: Glaucoma remains a public health problem in Kankan. Trabeculectomy concluded an overall success in lowering postoperative intraocular pressure with almost no complications. Given these results, it would be better to undertake it in 1st intention.

Comparison of the results of Ex-PRESS® surgery for primary open-angle glaucoma between high and low preoperative intraocular pressure.

To compare surgical outcomes of Ex-PRESS® (EXP) surgery for primary open-angle glaucoma (POAG) between low preoperative intraocular pressure (IOP) and high preoperative IOP. This was a retrospective non-randomized study. Seventy-nine POAG patients who underwent EXP surgery and were followed for > 3years were included. Patients with a preoperative IOP of ≦ 16mmHg and > 16mmHg with tolerant glaucoma medications were defined as the low IOP group and the high IOP group, respectively. We compared the surgical outcomes, postoperative IOP and number of glaucoma medications. Success was defined as a postoperative IOP of ≦15mmHg and a reduction of > 20% from the preoperative IOP to the postoperative IOP. EXP surgeries significantly decreased IOPs from 13.2 ± 2.0 to 9.1 ± 2.9mmHg in the low IOP group (p < 0.001), and from 22.5 ± 4.8 to 12.5 ± 4.0mmHg in the high IOP group (p < 0.001). The mean postoperative IOP was significantly low in the low IOP group at 3years (p = 0.0008). Success rates compared using the Kaplan-Meier survival curve were not significantly different (p = 0.449). EXP surgery was useful for POAG patients with a low preoperative IOP.

12-month outcomes of ab interno excisional goniotomy combined with cataract surgery in primary open-angle glaucoma and normal tension glaucoma

PurposeTo evaluate the efficacy and safety of excisional goniotomy performed with the Kahook Dual Blade (KDB) combined with cataract surgery in patients with pimary open angle glaucoma (POAG) and Normal Tension Glaucoma (NTG) under topical therapy. Further sub-analysis was performed to compare between 90 and 120 degrees goniotomy.MethodsThis was a prospective case series of 69 eyes from 69 adults (age 78 ± 5.9 years; male = 27, female = 42). Indications for surgery included insufficient IOP control with topical medication, glaucomatous damage progression under topical therapy and reduction of medication burden. Complete success was defined as IOP lowering below 21 mmHg without the need for topical medication. For NTG patients, complete success was defined as IOP lowering below 17 mmHg without the need for topical medication.ResultsIOP was significantly lowered from 19.7 ± 4.7 to 15.1 ± 2.7 at 2 months, 15.8 ± 2.3at 6 months and 16.1 ± 3.2 at 12 months (p < 0.05) for POAG and 15.1 ± 2.5 to 14.1 ± 2.4 at 2 months, 14.1 ± 3.1 at 6 months and 13.6 ± 1.8 at 12 months (p > 0.08) for NTG, respectively. Complete success was achieved in 64% of the patients. IOP lowering under 17 mmHg without the need for topical medication was achieved in 60% of the patients at 12 months. In NTG patients (14 eyes) IOP lowering under 17 mmHg without the need for topical medication was achieved in 71%. No significant difference was recorded in terms of IOP lowering at 12 months in-between 90° and 120° of treated trabecular meshwork (p > 0.7). No severe adverse reactions were recorded in this study.ConclusionOne-year results show that KDB combined with cataract surgery is an effective treatment option for glaucoma patients. IOP lowering was successfully achieved in NTG patients with complete success in 70% of the patients. In our study, no significant differences were recorded in-between 90° and 120° of treated trabecular meshwork.

The effect of phacoemulsification of age-related cataract on intraocular pressure and iridocorneal angle parameters in primary open-angle glaucoma

This study investigates the changes in anterior chamber angle configuration and IOP level before and after cataract surgery in primary open-angle glaucoma (POAG) eyes, and assesses its possible relationship with the axial length of the eye. The study included 38 patients with immature senile cataract and compensated unoperated stage I-II POAG. Patients underwent anterior segment optical coherence tomography (AS-OCT) with measurement of the angle opening distance (AOD750) and trabecular-iris space area (TISA750) before and six weeks after the surgery, as well as axial length and corneal-compensated IOP (IOPcc). After the surgery 92.11% of patients showed a decrease in IOPcc an average of 1.84±1.95 mm Hg (by 12.33±10.21% of the baseline); the maximum decrease in the IOPcc level was 8.35 mm Hg (by 40.97% of the baseline). AS-OCT data indicates that cataract phacoemulsification causes an increase in anterior chamber angle width: AOD750 increased from 0.510±0.175 to 0.771±0.156 mm, and TISA750 increased from 0.266±0.090 to 0.494±0.096 mm2. The strongest correlations were found between the axial length, postoperative TISA750 increase (Δ%TISA750) and postoperative IOPcc reduction (Δ% IOPcc). Postoperatively, specific changes could be observed in the trabecular meshwork in 28.95% of cases in the form of elongation and strain of the membrane. Cataract extraction contributes to a significant reduction in IOP due to anterior chamber angle expansion, trabecular meshwork stretching, and improved aqueous outflow.

Safety and Efficacy of Three Variants of Canaloplasty with Phacoemulsification to Treat Open-Angle Glaucoma and Cataract: 12-Month Follow-Up.

A single-center prospective randomized observational study to compare three types of canaloplasty, i.e., ab externo (ABeC), minicanaloplasty (miniABeC) and ab interno, (ABiC) combined with cataract surgery in primary open-angle glaucoma (POAG) patients over 12 months. 48 POAG patients underwent one of three canaloplasty procedures: ABeC (16 eyes), miniABeC (16 eyes) or ABiC (16 eyes) or combined with phacoemulsification. Patients were assessed at baseline, at day 0-1-7 and at month 1-3-6-12. Successful treatment was defined as unmedicated IOP reduction ≥20%. Complete surgical success was defined as an IOP ≤ 15 mmHg without medications, and a qualified surgical success as IOP ≤ 15 mmHg with or without medications. Pre-washout IOP median values (mmHg) were 17 (ABeC), 18 (miniABeC) and 17 (AbiC) and decreased at 12-month follow up postoperatively to 13 (p = 0.005), 13 (p = 0.004) and 14 (p = 0.008), respectively-successful treatment was achieved in approximately 100% of patients for ABeC and in 93.8% for both miniABeC and AbiC groups. Preoperatively, the median number of medications was 2.0 (range 1-3) (ABeC), 2.0 (1-3) (miniABeC) and 2.0 (0-4) (ABiC); 12-month post-operatively, all medications were withdrawn except in two patients (followed miniABeC and AbiC). The three variants of canaloplasty significantly reduced IOP and the number of medications in patients with mild to moderate POAG and gave no significant complications.

Short-term outcomes of trabeculectomy surgery in primary open-angle glaucoma

Introduction: Trabeculectomy controls the intraocular pressure (IOP) and decreases the progress of open-angle glaucoma; the outcome of such procedure has not been ascertained in Libya. Objective: We report the short-term outcome of trabeculectomy in terms of IOP in primary open-angle glaucoma (POAG). Settings and Design: The medical records of the trabeculectomy patients previously diagnosed with POAG were reviewed retrospectively. Patients and Methods: Case characteristics were extracted including preoperative IOP and the IOP outcome 6 months postoperatively using Goldmann applanation tonometry. Data were presented as frequencies and mean ± standard deviation. Wilcoxon signed-ranks test was used to analyze the changes in the measurement of IOP after trabeculectomy. Results: Fifty-seven cases had trabeculectomy with a mean age of 51.6 ± 12.2 years. There was a statistically difference (P &lt; 0.0001) in the IOP measurement pre and 6 months post trabeculectomy. 39 patients (68.4%) achieved an IOP of ≤21 mmHg 6 months after surgery without medications. IOP decreased from 33.2 ± 6.5 mmHg before surgery to 18.8 ± 5.8 mmHg after surgery. All the cases with preoperative IOP of 21–30 mmHg had a posttrabeculectomy IOP ≤ 21 mmHg (P &lt; 0.0001). The rate of complications was low; seven eyes (12.3%) developed early postoperative complications that resolved within 2 weeks. Conclusions: This is the first report on trabeculectomy surgery in Libya. The results are encouraging with a low complication rate. This warrants further evaluationsof long term outcomes.

Factors associated with achieving intraocular pressure lower than 15\xa0mmHg by Trabectome surgery in primary open-angle glaucoma

To assess good prognostic factors of Trabectome surgery in primary open-angle glaucoma (POAG), clinical records of patients with POAG who underwent Trabectome surgery with/without cataract surgery as the first additive therapy to eye drops between January 2015 and March 2018 were retrospectively reviewed. Overall, data of 79 eyes (79 patients; 50 men; mean age, 68.0 years) up to postoperative 24 months were analyzed. Their mean intraocular pressure (IOP) was 20.4 ± 6.0 mmHg at baseline. Forty-two eyes (53.2%) achieved an IOP < 15 mmHg and ≥ 20% reduction from baseline without additional treatments. Phakic eyes had a better survival probability than pseudophakic eyes after adjusting for age, sex, baseline IOP, best-corrected visual acuity, and eye drop score (hazard ratio 3.096; 95% confidence interval [95% CI] 1.367–7.013; P = 0.007). Phakic eyes treated with combined Trabectome and cataract surgeries (mean survival time, 22.250 months; 95% CI 17.606–26.894) had a better survival probability than pseudophakic eyes treated with Trabectome surgery only (mean survival time, 12.111 months; 95% CI 8.716–15.506; P = 0.009) after the adjustment. Among the eyes treated with Trabectome surgery only, phakic eyes required significantly less additional treatments than pseudophakic eyes (P = 0.04). Trabectome surgery may be indicated for phakic eyes with POAG in addition to eye-drop therapy.

Активация увеолимфатического пути оттока водянистой влаги при непроникающей хирургии глаукомы без формирования фильтрационной подушки: клинические случаи

The authors propose a modified technique of non-penetrating filtering glaucoma surgery for primary open-angle glaucoma (POAG) to improve the uveoscleral outflow. The study enrolled 11 patients with POAG. A novel surgical technique included two steps. The first step was modified deep sclerectomy and cyclodyalysis with collagen implant placed into the supraciliary space. The second step (after 7–10 days) was YAG laser trabeculotomy. Surgical site and adjacent areas were examined by optical coherence tomography (OCT). After 6 months, mean IOP significantly reduced by 52% (from 30.0±10.3 mm Hg to 14.6±5.0 mm Hg, р=0.0004) while the number of IOP-lowering medications reduced by 79% (from 2.9±1.0 to 0.6±0.4, р=0.000001). The aqueous humor outflow occurred through conjunctival lymphatic vessels without filtering bleb formation, as illustrated by OCT. Postoperative complications were minor and easy-to-treat. Three case reports are discussed. Keywords: open-angle glaucoma, glaucoma surgery, conjunctival lymphatics, filtering bleb, non-penetrating glaucoma surgery, uveolymphatic outflow pathway. For citation: Kumar V., Abu Zaalan K.A., Frolov M.A. et al. Activation of uveolymphatic outflow pathway after non-penetrating glaucoma surgery without filtering bleb: case reports. Russian Journal of Clinical Ophthalmology. 2021;21(2):108–115. DOI: 10.32364/2311-7729-2021- 21-2-108-115.

Comparative efficacy and cost\u2013utility of combined cataract and minimally invasive glaucoma surgery in primary open-angle glaucoma

PurposeTo assess the comparative efficacy and the long-term cost–utility of alternative minimally invasive glaucoma surgeries (MIGSs) when combined with cataract surgery in patients with primary open-angle glaucoma (POAG).MethodsTreatment effects, as measured by the 1-year reduction in intraocular pressure (IOP), were estimated with an adjusted indirect treatment comparison. Evidence from randomized clinical trials was identified for four different MIGS methods. A disease-transition model was developed by capturing clinically relevant POAG stages and the expected natural disease evolution. Outcomes of the disease-transition model were the comparative utility [quality-adjusted life years (QALYs)], cost and cost–utility of included strategies in a lifetime horizon.ResultsEstimated 1-year IOP reductions were: cataract surgery − 2.05 mmHg (95% CI − 3.38; − 0.72), one trabecular micro-bypass stent − 3.15 mmHg (95% CI − 5.66; − 0.64), two trabecular micro-bypass stents − 4.85 mmHg (95% CI − 7.71; − 1.99) and intracanalicular scaffold − 2.25 mmHg (95% CI − 4.87; 0.37). Discounted outcomes from the disease-transition model appraised the strategy of two trabecular micro-bypass stents with cataract surgery in the moderate POAG stage as the one providing the greatest added value, with 10,955€ per additional QALY. Improved outcomes were seen when assessing MIGS in the moderate POAG stage.ConclusionsWhen indirectly comparing alternative MIGS methods combined with cataract surgery, the option of two trabecular micro-bypass stents showed both a superior efficacy and long-term cost–utility from a German perspective. Moreover, outcomes of the disease-transition model suggest POAG patients to beneficiate the most from an earlier intervention in the moderate stage contrary to waiting until an advanced disease is present.

Three-year outcomes of combined trabecular micro-bypass and phacoemulsification in a predominantly Hispanic population with primary open-angle glaucoma.

Purpose: To present long-term, real-world outcomes after implanting one trabecular micro-bypass stent with cataract surgery for primary open-angle glaucoma (POAG) in a predominantly Hispanic patient population.Patients and methods: This retrospective, consecutive case series evaluated intraocular pressure (IOP), medications, and safety through 36 months after implanting one iStent® during phacoemulsification cataract surgery. Eyes were stratified into 2 subgroups classified by preoperative IOP and surgical goal. The Controlled Group had IOP <18 mmHg on ≥1 medications, and goal to reduce medications. The Uncontrolled Group had IOP ≥18 mmHg and/or maximum tolerated medication load, and goal to reduce IOP. Assessments included IOP, medications, visual fields (VF), retinal nerve fiber layer thickness (RNFL), adverse events, and secondary surgeries.Results: Of 168 total operated eyes, 87 eyes (49 Controlled, 38 Uncontrolled) completed 36 months of follow-up and comprise the Consistent Cohort in this report. At baseline, 79.6% (39/49) of Controlled eyes and 71.1% (27/38) of Uncontrolled eyes were from Hispanic patients. In the Controlled Group desiring medication reduction, mean medications were reduced by 77.3% (2.6 medications preoperatively vs 0.6 at 36 months; p<0.001. All Controlled eyes maintained or reduced medications versus preoperative; no eyes were on ≥3 medications (vs 61.2% preoperatively); and 58.3% were medication-free (vs 0% preoperatively). In the Uncontrolled Group desiring IOP reduction, mean IOP decreased by 31.2% (19.4 mmHg preoperatively vs 13.4 mmHg at 36 months; p<0.001), 91.7% of eyes achieved IOP ≤18 mmHg, 69.4% reached IOP ≤15 mmHg, and 77.8% decreased IOP ≥20% vs baseline. Uncontrolled eyes also experienced a 45.3% medication reduction (2.2 medications preoperatively vs 1.2 at 36 months; p<0.001). Favorable safety included no intraoperative complications, and stable VF and RNFL through 36 months.Conclusion: In this predominantly Hispanic patient cohort, significant IOP and medication reductions were sustained safely through 36 months after iStent implantation during cataract surgery.

COMPARATIVE ANALYSIS OF USING EX-PRESS DRAINAGE DEVICE AND POLYMER MICRO SHUNT REPER-NN» MANUFACTURED IN RUSSIA IN PRIMARY OPEN-ANGLE GLAUCOMA SURGERY

Purpose of the study was to analyze and compare the outcomes of implantation of polymer micro shunt «Reper-NN» manufactured in Russia and «Ex-PRESS» shunt in surgical treatment of open-angle glaucoma. Material and methods. The results of treating 74 patients with open-angle glaucoma were analyzed. All patients were divided into 2 groups: group I consisted of 48 patients underwent micro shunt «Ex-PRESS» implantation, group II with 26 patients underwent Russian polymer micro shunt implantation. The control criteria in the early and remote postoperative period were: Maklakov tonometry, visual acuity, computer perimetry. Results and discussion. The significant reduction in intraocular pressure compared with the preoperative level has been achieved in the early and remote period as a result of implanting both shunts. The implantation simplicity and design features of polymer micro shunt «Reper-NN» provided with the relatively similar to «Ex-PRESS» shunt risks of complications such as postoperative hypotonia and ciliochoroidal detachment. Thus, the first experience of using Russian manufactured polymer shunt showed the sufficient efficacy and safety in primary open-angle glaucoma surgery and allowed recommending its further application in clinical practice.

Prise en charge ambulatoire sans contrôle clinique à j1 de patients opérés d’une chirurgie filtrante non compliquée en peropératoire

Although the general increase in ambulatory surgery allows for a 20% reduction in costs of hospitalization, the necessity of a day 1 postoperative visit remains the main problem for elderly patients or those who reside at considerable distance. For these reasons, in 2014, we decided to only see patients with uncomplicated filtering surgery at D5 and D21 and to replace the D1 visit with a telephone call. The primary goal of our study was to analyze a population of patients undergoing uncomplicated filtering surgery who were not seen at D1 and to describe the frequency of postoperative complications, intraocular pressure results and therapeutic management at D5 and D21. This was a retrospective monocentric study in the department of ophthalmology. All patients (naïve of surgical treatment for glaucoma) underwent surgery for primary open-angle glaucoma in an ambulatory surgery unit between May 2014 and July 2016. A nurse made a phone call to the patients at day 1 and they responded to a standardized questionnaire. Depending upon their responses, the patients were seen quickly (<24hr) or on the systematic schedule at day 5 and day 21. One hundred and forty-four eyes (126 patients) were included in our study. The mean preoperative IOP was 20.4±6.4mmHg. After the phone call, only five patients were examined before the first planned follow-up at day 5. For 3 of them, the examination revealed the presence of a hyphema, and their topical medication was changed. The other two patients had no treatment modifications. At day 5, the mean IOP was 10.6±5.9mmHg. Thirty-two eyes (22.2%) required a change in their medication at day 5. The mean IOP at day 21 was 12.9±4.6mmHg. Our success rate (IOP<21mmHg with no topical medication) at day 21 was 95.6%. The guidelines for filtering glaucoma surgery recommend examining the patient at day 1 (or at least before day 3), day 8, day 15 and day 30 or more frequently according to the case. We replaced the day 1 visit with a telephone call. We did not note a substantial rate of complications due to the elimination of the D1 visit. The criteria of success of filtering glaucoma surgery vary in the literature, but our success rate at D21 seems to be similar that in the literature and may suggest that the day 1 visit is not necessary if the surgery for primary open angle glaucoma is uncomplicated.

Budget Impact of A Supra-Ciliary Micro-Stent In Both Stand-Alone Surgery And In Combination With Cataract Surgery For Primary Open-Angle Glaucoma From A UK Secondary Care Perspective

Budget Impact of A Supra-Ciliary Micro-Stent In Both Stand-Alone Surgery And In Combination With Cataract Surgery For Primary Open-Angle Glaucoma From A UK Secondary Care Perspective

Pseudophakic Macular Edema in Primary Open-Angle Glaucoma: A Prospective Study Using Spectral-Domain Optical Coherence Tomography

To determine the incidence of and risk factors for pseudophakic macular edema (PME) after uncomplicated cataract surgery in primary open-angle glaucoma (POAG) using spectral-domain optical coherence tomography (SDOCT). Cohort study. Macular retinal thickness was evaluated using SDOCT at 1week before surgery and at 1, 3, 6, and 12months postoperatively, in 70 POAG and 68 control eyes. Forty-three healthy subjects without impaired vision or cystoid PME were recruited separately as pilot samples to define significant PME. Significant PME was defined as an increase in the average thickness exceeding the mean+ 3 standard deviations of the increase shown in the pilot samples. Significant PME (increase in the foveal 3-mm zone thickness of >19.5μm) was observed in 31 (44%) eyes with POAG and in 14 (21%) control eyes (P=.003). The extent of PME was maximal at 3months postoperatively and decreased gradually until 12months. Regression tree analysis revealed that the risk of PME was the greatest in the POAG group using prostaglandin analogue (PGA) (odds ratio [OR]= 5.51), followed by POAG not using PGA (OR= 1.70), and control group (OR= 1.0). Risk factors for PME were younger age in all groups (OR= 1.07), systemic hypertension in PGA users (OR= 6.42), higher untreated IOP in PGA nonusers (OR= 1.09) and male sex (OR= 14.06) and diabetes mellitus (OR= 16.71) in the control group. The incidence of PME as observed by SDOCT was higher than previously reported after uncomplicated cataract surgery. Eyes with POAG were at greater risk for PME, which was mainly associated with perioperative PGA use.

A New Expander for Schlemm Canal Surgery in Primary Open-angle Glaucoma-Interim Clinical Results.

To evaluate a new canal expander in circumferential viscocanalostomy (canaloplasty) for whites with primary open-angle glaucoma (POAG). Prospective, single-center, noncomparative study. Twenty-two eyes of 22 consecutive patients with medically uncontrolled POAG underwent primary viscocanalostomy and implantation of the Stegmann Canal Expander into Schlemm canal with a follow-up time of at least 1 year. Schlemm canal was unroofed ab externo, and dilated with viscoelastic material and microcatheter. The Stegmann Canal Expander is a flexible, fenestrated hollow implant of 9 mm in length. One expander was implanted into either side of the surgically created of ostium to keep the Schlemm canal permanently open. The superficial scleral flap was closed watertight. Laser goniopuncture of the trabeculo-Descemet membrane window was performed if postoperative intraocular pressure (IOP) exceeded 16 mm Hg. Complete successes were defined as a confirmed IOP≤21, ≤18, and ≤16 mm Hg without medications, respectively, combined with a 30% IOP reduction. Number of antiglaucomatous medications, best-corrected visual acuity, and intraoperative and postoperative complications were recorded. The mean IOP dropped from 27.1±5.3 mm Hg preoperatively to 13.6±1.6 mm Hg at 6 months, 13.0±1.5 mm Hg at 9 months, and 13.1±2.2 mm Hg at 12 months (P<0.001). The complete success rates for an IOP≤21, ≤18, and ≤16 mm Hg combined with a 30% IOP reduction were 91% [95% confidence interval (CI), 0.80-1.0], 91% (95% CI, 0.80-1.0), and 91.0% (95% CI, 0.80-1.0) at 6 months, and 86% (95% CI, 0.73-1.0), 82% (95% CI, 0.67-1.0), and 82.0% (95% CI, 0.67-1.0) at 12 months. The success rate of an IOP≤16 mm Hg without medications did not depend on age [hazard ratios (HR) 1.02; 95% CI, 0.85-1.12; P=0.74], preoperative IOP (HR 0.97; 95% CI, 0.83-1.23; P=0.89), and mean visual defect (HR 1.05; 95% CI, 0.72-1.27; P=0.76). Laser goniopuncture was performed on 2 eyes (9%) 4.1 months postoperatively; the mean IOP was 19.5 mm Hg before and 13.6 mm Hg after goniopuncture. The number of medications dropped from 2.9±0.6 before surgery to 0.05±0.2 after surgery (P<0.001). The postoperative best-corrected visual acuity at last visit (0.12±0.09; range, 0 to 0.39) was comparable to preoperative values (mean±SD, 0.16±0.10; range, 0 to 0.39) (P=0.35). Minor intraoperative or postoperative complications included microhyphema (8 eyes) and transient elevated IOP (steroid responder; 2 eyes). Implantation of the Stegmann Canal Expander in canaloplasty lowered IOP significantly in POAG without complications related to the device in this 1-year observation period.

Autophagy and Mitochondrial Dysfunction in Tenon Fibroblasts from Exfoliation Glaucoma Patients.

PurposeTo test the hypothesis that autophagy dysfunction is involved in exfoliation syndrome (XFS), a systemic disorder of extracellular elastic matrices that causes a distinct form of human glaucoma.MethodsFibroblasts derived from tenon tissue discards (TFs) from filtration surgery to relieve intraocular pressure in XFS patients were compared against age-matched TFs derived from surgery in primary open-angle glaucoma (POAG) patients or from strabismus surgery. Differential interference contrast light, and electron microscopy were used to examine structural cell features. Immunocytochemistry was used to visualize LOXL1 and Fibulin-5, lysosomes, endosomes, Golgi, and microtubules. Light scatter, Cyto-IDTM and JC1 flow cytometry were used to measure relative cell size, autophagic flux rate and mitochondrial membrane potential (MMPT), respectively. Enhanced autophagy was induced by serum withdrawal.ResultsIn culture, XFS-TFs were 1.38-fold larger (by light scatter ratio, p = 0.05), proliferated 42% slower (p = 0.026), and were morphologically distinct in 2D and 3D culture compared to their POAG counterparts. In extended 3D cultures, XFS-TFs accumulated 8–10 times more Fibulin-5 than the POAG-TFs, and upon serum withdrawal, there were marked deficiencies in relocation of endosomes and lysosomes to the perinuclear area. Correspondingly, the XFS-TFs displayed significant accumulation of the autophagasome marker LC3 II (3.9 fold increase compared to POAG levels, p = 0.0001) and autophagic flux rate as measured by Cyto-ID dye was 53% lower in XFS-TFs than in POAG-TFs (p = 0.01), indicating reduced clearance of autophagasomes. Finally the percent of cells with diminished MMPT was 3–8 times larger in the XFS-TFs than in POAG-TFs (p = 0.02).ConclusionsOur results provide for the first time a link between XFS pathology to autophagy dysfunction, a major contributor to multiple age related diseases systemically throughout the body, in the brain and in the retina. A diminished capacity for degradation of denatured protein and aging cellular organelles may underpin the development of extracellular protein aggregates in XFS.

Lens Position Parameters as Predictors of Intraocular Pressure Reduction After Cataract Surgery in Glaucomatous Versus Nonglaucomatous Eyes.

PurposeTo evaluate the relationship between lens position parameters and intraocular pressure (IOP) reduction after cataract surgery in patients with primary open-angle glaucoma (POAG) and in nonglaucomatous patients.MethodsThe main outcomes of this prospective study were percent and absolute IOP change, which were calculated using the preoperative IOP and the IOP 4 months after cataract surgery in POAG and nonglaucomatous eyes. Lens position (LP), defined as anterior chamber depth (ACD) + one-half lens thickness (LT), was assessed preoperatively using parameters from optical biometry. Preoperative IOP, axial length (AL), ACD, LT, relative lens position (RLP), and the ratio of preoperative IOP to ACD (PD ratio) were also evaluated as potential predictors of IOP change.ResultsFour months postoperatively, the average IOP reduction was 2.80 ± 3.83 mm Hg (15.79%) from the preoperative mean of 14.73 ± 2.89 mm Hg for nonglaucomatous eyes. The average IOP reduction was 2.66 ± 2.07 mm Hg (16.98%) from the preoperative mean of 14.86 ± 2.97 mm Hg for POAG eyes. Preoperative IOP, sex, AL, ACD, PD ratio, and LP predicted IOP change in nonglaucomatous eyes. Preoperative IOP and PD ratio predicted IOP change in POAG eyes.ConclusionsIntraocular pressure reduction after phacoemulsification cataract surgery in nonglaucomatous eyes is significantly greater in more anteriorly positioned lenses. Though it did not reach statistical significance in patients with glaucoma, the association of LP with IOP reduction is in the same direction as in nonglaucomatous patients where smaller LP appears to predict greater IOP reduction. Lens position is a simple, easily calculable, accurate, and widely available parameter, which clinicians can potentially utilize in managing glaucoma.

Anti–Vascular Endothelial Growth Factor Therapy in Glaucoma Filtration Surgery

To examine evidence supporting the use of vascular endothelial growth factor (VEGF) inhibition in controlling wound healing after glaucoma filtration surgery in primary open-angle glaucoma, to identify the optimum method of administration, and to clarify the potential position of anti-VEGF monoclonal antibodies in comparison with 5-fluorouracil and mitomycin C. Perspective based on an overview of evidence from current peer-reviewed literature. Analysis of evidence from animal studies, in vitro studies, human studies, and from the use of anti-VEGF monoclonal antibodies in systemic disease. There is evidence that glaucoma patients have elevated levels of VEGF in the aqueous before filtration surgery, that this increases in animals after filtration surgery, and that both can be suppressed in animals by intraocular injection of bevacizumab. VEGF not only has a role in angiogenesis, but also has a direct action on fibroblast activity that may be modified directly at the time of filtration surgery. There is evidence for a role for VEGF in wound healing after glaucoma filtration surgery. The optimum route of administration and dosing regimen of anti-VEGF antibodies and their positioning in comparison with 5-fluorouracil and mitomycin C are uncertain. There is some evidence that subconjunctival injection may produce sustained intraocular tissue levels. There is also evidence that bevacizumab may act in synergy with 5-fluorouracil. Although there are no direct comparative studies, it seems unlikely that bevacizumab alone will be as effective as mitomycin C, although bleb morphologic features may be better.