Tube Shunt Surgery Research Articles

Pupillary Peaking & Presence of Dysphotopsias Following Glaucoma Tube Shunt Surgery

ABSTRACT Purpose To describe the presence of pupillary peaking and dysphotopsias in a sample of eyes following glaucoma drainage device (GDD) surgery. Methods Cross-sectional analysis of 68 glaucoma patients with GDD, 45 patients with glaucoma and no GDD, and 50 control patients was conducted in a single academic center. Patients with an appropriate diagnosis that met the inclusion criteria were asked to enroll in the study. All patients received an 8-item dysphotopsia questionnaire and were age-matched. Photographs of pupils were taken to assess pupillary peaking. One-way analysis of variance (ANOVA) testing was performed for statistical analysis. Results Of the 68 patients with GDD, 25 (36.76%) had pupillary abnormalities with peaking most commonly occurring in the direction of the tube entry superotemporally, and 50 (73.53%) had reported one or more dysphotopsias. In patients reporting one or more dysphotopsias, the rate of lines, crescents, ghost images, and shadows was significantly higher when compared to glaucoma patients without GDD and control patients (p < .01). This corresponded to a lower best-corrected visual acuity in the GDD group compared to the glaucoma and control groups (p < .001). Conclusions Over a third of glaucoma patients receiving GDD had pupillary abnormalities, and nearly 3 out of 4 patients with GDD reported one or more dysphotopsias when compared to glaucoma patients without GDD and an age-matched control group. Glaucoma specialists and patients should be aware of these complications when proceeding with GDD surgery.

Retinal toxicity secondary to inadvertent subretinal mitomycin C injection

Purpose: To report a patient who developed retinal toxicity following inadvertent subretinal mitomycin C injection during glaucoma surgery. Methods: Case report and review of the literature. Results: A 73-year-old man underwent glaucoma tube shunt surgery with sub-Tenon’s mitomycin C injection. Postoperatively he developed retinal edema, hemorrhages, and occlusive vasculopathy localized to the quadrant of the mitomycin C injection. It was determined that the sclera had been inadvertently punctured during mitomycin C injection, resulting in subretinal placement of the medication and resultant retinal toxicity. At postoperative month one, there was diffuse chorioretinal atrophy in the area of the injection. The macula was spared and he retained his preoperative visual acuity. Conclusion: Inadvertent subretinal mitomycin C injection may occur when attempting to inject the drug into the sub-Tenon’s space and can result in localized retinal toxicity.

The efficacy of adjunctive mitomycin C and/or anti-VEGF agents on glaucoma tube shunt drainage device surgeries: a systematic review

PurposeThe effectiveness of mitomycin C (MMC) in trabeculectomy has long been established. The aim of this review is to evaluate the efficacy and safety of adjunctive agents in tube shunt drainage device surgery for glaucoma or ocular hypertension, since controversy still exists regarding their benefit.MethodsWe searched CENTRAL, PubMed, Embase, Web of Science, Scopus, and BASE for RCTs, which have used adjuvant antimetabolites—either MMC or 5-Fluorouracil (5-FU)—and/or anti-vascular endothelial growth factors (anti-VEGF) agents. The main outcome was IOP reduction at 12 months.ResultsTen studies met our inclusion criteria. Nine used the Ahmed Glaucoma Valve (AGV) implant, while the double-plate Molteno implant was used in one study. Four studies used MMC. The remaining six studies used an anti-VEGF drug – either bevacizumab, ranibizumab or conbercept.Only one MMC-study reported a significant difference in the IOP reduction between groups at 12 months, favouring the MMC group (55% and 51%; p < 0.01). A significant difference was also reported by two out of five bevacizumab-studies, both favouring the bevacizumab group (55% and 51%, p < 0.05; 58% and 27%, p < 0.05), with the highest benefit seen in neovascular glaucoma cases, especially when panretinal photocoagulation (PRP) was also used. Neither ranibizumab nor conbercept were found to produce significant differences between groups regarding IOP reduction.ConclusionThere is no high-quality evidence to support the use of MMC in tube shunt surgery. As for anti-VEGF agents, specifically bevacizumab, significant benefit seems to exist in neovascular glaucoma patients, especially if combined with PRP.

Visual Field Outcomes in the Primary Tube Versus Trabeculectomy Study

PurposeTo describe visual field outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. DesignCohort analysis of a prospective multicenter randomized clinical trial. SubjectsA total of 155 eyes from 155 subjects randomly assigned to treatment with tube shunt surgery (n=84) or trabeculectomy with mitomycin C (n=71). MethodsThe PTVT Study was a multicenter randomized clinical trial comparing the safety and efficacy of trabeculectomy and tube shunt surgery in eyes without prior intraocular surgery. Subjects underwent standard automated perimetry (SAP) at baseline and annually for five years. SAP tests were deemed reliable if the false positive rate was ≤15%. Tests were excluded if visual acuity was ≤20/400 or loss of ≥2 Snellen lines from baseline were attributed to a non-glaucomatous etiology. Linear mixed-effects models were used to compare rates of change in SAP mean deviation (MD) between the two treatment groups. Intraocular pressure (IOP) control was assessed by percentage of visits with IOP <18 mmHg and mean IOP. Outcome MeasuresRate of change in SAP MD during follow-up. ResultsA total of 730 SAP tests were evaluated, with an average of 4.7 tests per eye. The average SAP MD at baseline was -12.8±8.3 dB in the tube group and -12.0±8.4 dB in the trabeculectomy group (p=0.57). The mean rate of change in SAP MD was -0.32±0.39 dB/year in the trabeculectomy group and -0.47±0.43 dB/year in the tube group (p=0.23). Eyes with mean IOP 14-17.5 mmHg had significantly faster rates of SAP MD loss compared to eyes with mean IOP <14 mmHg (-0.59±0.13 vs. -0.27±0.08 dB/year, p=0.012) and eyes with only 50-75% of visits with IOP <18 mmHg had faster rates than those with 100% of visits with IOP <18 mmHg (-0.90±0.16 vs. -0.29±0.08 dB/year, p<0.001). Multivariable analysis identified older age and worse IOP control as risk factors for faster progression in both treatment groups. ConclusionsNo statistically significant difference in mean rates of visual field change was observed between trabeculectomy and tube shunt surgery in the PTVT Study. Worse IOP control was significantly associated with faster rates of SAP MD loss during follow-up. Older patients were also at risk for faster progression.

Comparing Outcomes of Tube Versus Trabeculectomy Among Patients with Angle-closure Glaucoma

PurposeCompare outcomes of tube shunt surgery (Tube) and trabeculectomy with Mitomycin C (Trab-MMC) in patients with angle-closure glaucoma (ACG). DesignRetrospective, nonrandomized comparative study. SubjectsA total of 80 eyes from 80 patients with ACG who underwent either Tube (N = 50) or Trab-MMC (N = 30) between January 2015 and January 2022 at Massachusetts Eye and Ear. MethodsReviewed and analyzed 390 visits from patient charts. Main outcome measuresKaplan-Meier (KM) success rates, Intraocular pressure (IOP), medication burden, best-corrected visual acuity (BCVA), adjusted hazard ratios (HRs), and complications. ResultsBaseline demographics were similar between both groups, except for a higher proportion of patients with pseudophakia and prior incisional ocular surgery in the Tube group. The Trab-MMC procedure had significantly higher Kaplan-Meier complete success (CS) rates than the Tube procedure, but similar qualified success (QS) rates. Under QS, the cumulative probability of survival was 87% in the Tube group and 83% in the Trab-MMC group at year 1 (P=0.77), and 75% in the Tube group and 58% in the Trab-MMC group at year 2 (P=0.14). Under CS, the cumulative probability of survival was 13% in the Tube group and 59% in the Trab-MMC group at year 1 (P<0.001), and 11% in the Tube group and 41% in the Trab-MMC group at year 2 (P<0.001). Both Tube and Trab-MMC procedures resulted in significant patterns of IOP and medication reduction from baseline up to 2 years with mean IOP reduced to 12.6 ± 5.9 mmHg on 2.8 ± 1.4 medications after Tube, and 12.1 ± 6.6 mmHg on 2.4 ± 1.7 medications after Trab-MMC. Patients who underwent Trab-MMC required less IOP-lowering medications at every follow-up visit up to year 1, but a similar number at year 2. No significant differences were found in IOP reduction, BCVA, or complication rates between groups.” ConclusionWe demonstrate that Trab-MMC confers similar IOP reduction and QS rates to Tube placement in ACG patients. Trab-MMC, however, demonstrated greater medication burden reduction up to 1 year, and more favorable CS rates up to 2 years, while still maintaining similar complication rates to Tube.

Case study and pilot results: Stepwise approach to teach a resident tube shunt surgery

PurposeTo illustrate the utility of a previously published stepwise rubric for evaluating a resident's progress learning aqueous tube shunt surgery. MethodUsing a stepwise rubric, a single PGY3 ophthalmology resident and attending glaucoma surgeon evaluated the resident's performance after each aqueous tube shunt surgery. The rubric subdivides the surgery into 12 consecutive steps and scores the resident's proficiency in each step with either a 0 (observation), 2 (novice), 3 (beginner), 4 (advanced beginner), or 5 (competent). ResultsThe resident's cumulative score increased significantly throughout the 17 surgeries performed, with the resident's self-evaluated score and attending's score increasing from 12 to 27 and 14 to 27 from the first to last surgery, respectively. Scores were consistent between the resident and attending; for any given surgery, the resident's own score never deviated from the attending's score by more than 1 point. The resident completed at least 50% of the steps in 11 of the 17 cases. While some surgical steps were mastered earlier on (“tube tying” and “suture implantation”), other steps were more challenging to master (“tunnel in sclera and enter the AC” and “close conjunctiva”, as demonstrated by fewer overall attempts or never attaining a score of ‘5’ despite multiple attempts. Conclusions and ImportanceThis study demonstrates the utility of the stepwise rubric in tracking resident surgical scores chronologically via self and attending assessment. The ability to compare their own scores to that of an attending allows the resident to learn how to effectively evaluate their own performance. Most importantly, statistics obtained for each step provides the resident with personalized and real-time feedback for learning specific surgical steps. In conclusion, the stepwise rubric is a useful add-on to a resident's aqueous tube shunt surgery education.

Silent Progressive Glaucoma in Encephalofacial angiomatosis (Sturge-Weber Syndrome): A Vision-Preserving Trabeculectomy

Introduction : Encephalofacial angiomatosis, also known as Sturge-Weber Syndrome (SWS), is a rare, non- hereditary condition affecting multiple organs. Glaucoma occurs in almost 70% SWS children, more commonly when the port-wine stain involves the upper eyelid skin. Secondary glaucoma was present due to elevated venous pressure.&#x0D; Case Illustration : An 8-year-old boy with typical port-wine stain involving eyelid, came with recurrent painful right eye (RE) and headache in the past 3 months. He was diagnosed with SWS at 1 year and was on daily doses of carbamazepine and valproic acid for seizure control. His best visual acuity and intraocular pressure were 0.5/60 RE, 6/38 LE, 38 mmHg RE, 28 mmHg LE, respectively. Examination revealed Cup-disc-ratio (CDR) 0.9-1.0 RE and 0.5-0.6 LE. During the first three months, he showed favourable outcome with timolol and latanoprost (controlled IOP with target of &lt;12 mmHg and markedly similar Cup-Disc Ratio). However, at 4th and 5th month visit, his IOP significantly increased despite of additional regiments, thus underwent trabeculectomy on both eyes for preserving his sight. After procedure, his IOP remained stable &lt;12mmHg with maintained bleb, deep anterior chamber, also attached posterior segment.&#x0D; Discussion : Treatments of secondary glaucoma of SWS typically involved surgery with significantly lower success rate compared to Primary Congenital Glaucoma. Trabeculectomy or tube shunt surgery should be performed with caution due to risks of choroidal effusion and hemorrhages.&#x0D; Conclusion : Secondary glaucoma in children with SWS is common and challenging. Trabeculectomy should be pursued when the benefit outweighs the risks, even with a slim chance, to preserve the vision.

Deep learning-based identification of eyes at risk for glaucoma surgery

To develop and evaluate the performance of a deep learning model (DLM) that predicts eyes at high risk of surgical intervention for uncontrolled glaucoma based on multimodal data from an initial ophthalmology visit. Longitudinal, observational, retrospective study. 4898 unique eyes from 4038 adult glaucoma or glaucoma-suspect patients who underwent surgery for uncontrolled glaucoma (trabeculectomy, tube shunt, xen, or diode surgery) between 2013 and 2021, or did not undergo glaucoma surgery but had 3 or more ophthalmology visits. We constructed a DLM to predict the occurrence of glaucoma surgery within various time horizons from a baseline visit. Model inputs included spatially oriented visual field (VF) and optical coherence tomography (OCT) data as well as clinical and demographic features. Separate DLMs with the same architecture were trained to predict the occurrence of surgery within 3 months, within 3–6 months, within 6 months–1 year, within 1–2 years, within 2–3 years, within 3–4 years, and within 4–5 years from the baseline visit. Included eyes were randomly split into 60%, 20%, and 20% for training, validation, and testing. DLM performance was measured using area under the receiver operating characteristic curve (AUC) and precision-recall curve (PRC). Shapley additive explanations (SHAP) were utilized to assess the importance of different features. Model prediction of surgery for uncontrolled glaucoma within 3 months had the best AUC of 0.92 (95% CI 0.88, 0.96). DLMs achieved clinically useful AUC values (> 0.8) for all models that predicted the occurrence of surgery within 3 years. According to SHAP analysis, all 7 models placed intraocular pressure (IOP) within the five most important features in predicting the occurrence of glaucoma surgery. Mean deviation (MD) and average retinal nerve fiber layer (RNFL) thickness were listed among the top 5 most important features by 6 of the 7 models. DLMs can successfully identify eyes requiring surgery for uncontrolled glaucoma within specific time horizons. Predictive performance decreases as the time horizon for forecasting surgery increases. Implementing prediction models in a clinical setting may help identify patients that should be referred to a glaucoma specialist for surgical evaluation.

Effect of bimatoprost sustained-release intracameral implant on intraocular pressure and medication burden in patients with prior glaucoma surgery

The present retrospective study evaluated intraocular pressure (IOP) and medication burden after bimatoprost sustained-release (bimatoprost SR, Durysta, Allergan) implantation in patients with glaucoma. A secondary objective was to examine an effect of bimatoprost SR in a subset of patients with prior minimally invasive and incisional glaucoma surgery. A retrospective chart review of 122 eyes that received bimatoprost SR by 6 glaucoma specialists at Wills Eye Hospital between March 2020 and September 2021 was performed. One hundred and eighteen eyes from 84 patients had a reduction in IOP (18.5±5.7mmHg vs. 16.0±5.4mmHg, P<0.01) and required fewer glaucoma medications (2.1±1.4 vs. 1.2±1.2, P<0.01) after bimatoprost SR implantation. In 41 eyes from 31 patients who previously underwent glaucoma surgery (including iStent, goniotomy, trabeculectomy, Xen Gel Stent, or tube shunt surgery), medication burden was decreased after bimatoprost SR implantation (1.9±1.3 vs. 1.0±1.0, P<0.001). These data suggest that bimatoprost SR is an efficacious treatment modality for glaucoma, even in post-surgical patients.

Risk Factors for Fibrous Ingrowth in Eyes Requiring Primary Keratoplasty.

The aim of this study was to define risks for corneal transplantation associated with fibrous ingrowth among first-time transplant recipients. We performed a retrospective case-control study of patients with a histopathologic diagnosis of fibrous ingrowth between 2002 and 2019. Patients with fibrous ingrowth from a first corneal specimen were included. Those with incomplete records were excluded. A 1:2 case-control ratio was used. Controls were matched using surgical indication, surgery year, transplantation method, sex, and age. Seventy-eight eyes (76 patients) were included and matched with 160 control eyes. The incidence of fibrous ingrowth found on a first corneal transplant was 0.6% per year. The most common keratoplasty indications were pseudophakic corneal edema (n = 25, 32%) and aphakic corneal edema (n = 15, 19%). Cases were more likely to have a history of ocular trauma (odds ratio [OR], 2.94; 95% CI, 1.30-6.30; P = 0.007), uveitis (OR, 2.73; 95% CI, 1.12-6.63; P = 0.022), retinal detachment or previous retinal surgery (OR, 2.40; 95% CI, 1.34-4.30; P = 0.003), glaucoma tube-shunt surgery (OR, 2.70; 95% CI, 1.29-5.65; P = 0.007), aphakia (OR, 3.02; 95% CI, 1.61-5.67; P = 0.0004), or iris derangement (OR, 10.52; 95% CI, 5.45-20.30; P <0.0001). A multivariate logistic regression model using iris derangement, history of ocular trauma, history of uveitis, and history of cataract surgery demonstrated 81% sensitivity and 66% specificity in predicting presence of fibrous ingrowth. A history of ocular trauma, uveitis, retinal detachment or previous retinal surgery, glaucoma tube-shunt surgery, aphakia, and iris derangement are risks for detecting fibrous ingrowth among first-time keratoplasty recipients. Patients with these conditions should be monitored closely for corneal decompensation.

Effect of Early Aqueous Suppression After Valved Tube Shunt Surgery for Uveitic Glaucoma

To compare outcomes of early aqueous suppression (EAS) and standard therapy (ST) after Ahmed Glaucoma Valve (AGV) implantation for uveitic glaucoma. Retrospective comparative cohort study. All patients with uveitic glaucoma underwent AGV implantation from January 2010 to October 2020 at Northwestern Medicine. Excluding the first postoperative day 1 (POD1), only eyes with IOP 10-15 mmHg at their first visit with IOP ≥ 10 mmHg were included in the main analysis. Early aqueous suppression (EAS) was defined as initiation of ocular hypotensive therapy when IOP was first 10-15 mmHg. Standard therapy was initiation of therapy at any later time. Failure was defined as IOP > 21 mmHg, < 5 mmHg, or < 20% reduction in IOP from baseline after 3 months, for 2 consecutive study visits. Hypotony was defined as IOP ≤ 5 mmHg for ≥ 2 visits. Hypertensive phase was defined as IOP > 21 mmHg for 2 consecutive visits in the first 3 months. Proportion achieving overall success; incidence of hypotony and hypertensive phase. Twenty-eight eyes of 26 patients were in the EAS group and 20 eyes of 19 patients were in the ST group, with a mean follow-up of 17.7 and 28.2 months, respectively. Baseline IOP was similar in the EAS (31.2±10.1 mmHg) and ST (34.6±12.2 mmHg) groups; P=0.18. Final IOP was lower in the EAS group (12.9±4.6 mmHg) than the ST group (16.4±5.7 mmHg; P=0.02) on 2.6±0.9 medications in the EAS group and 1.8±1.5 in the ST group (P=0.07). Overall success was achieved in 87% of EAS eyes and 74% of ST eyes (P=0.43). There were no statistically significant differences in the occurrence of additional glaucoma surgery (4%for EAS, 20% for ST; P=0.11), hypotony (7% for EAS, 0% for ST; P=0.50), or hypertensive phase (4%forEAS, 21% for ST; P=0.09). EAS was associated with a lower final IOP after AGV in uveitic glaucoma eyes; however, more medications were in use at the final visit. No statistically significant differences in overall success or the incidence of adverse events were observed. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Nationwide Analysis of Glaucoma Surgeries in Fiscal Years of 2014 and 2020 in Japan.

Nationwide trends in glaucoma surgical procedures were assessed by using the NDB Open Data 2014 and 2020. In Japan, 33,340 non-laser, 54,569 laser, and 88,019 total glaucoma surgeries were performed in 2014. In 2020, 60,108 non-laser, 60,547 laser, and 120,655 total glaucoma surgeries were performed. The rates from 2014 to 2020 were 180%, 111%, and 137%, respectively. In each procedure, angle surgery (326%), tube shunt surgery (383%), ciliary coagulation (489%), and gonio-laser (225%) were remarkably increased, while iridectomy (75%) and iris laser (77%) decreased during the same period. An increase in laser surgery was seen in young age groups, namely, 55-59 years old and younger, while non-laser surgery was increased in old age groups, namely, 45-49 years old and older. In 2020, 47.6 non-laser, 48.0 laser, and 95.6 total glaucoma surgeries were performed per 100,000 persons. None of the vital statistics, including prefectural population, mean age, and rate of ≥65-year-old people, were significantly associated with the number of glaucoma surgeries. Glaucoma practice patterns changed each time a new device or procedure was introduced. The results of the current study reflected the use of new procedures, such as minimally invasive glaucoma surgery, tube shunt, selective laser trabeculoplasty, and micropulse cyclophotocoagulation.

Outcomes of microPulse transscleral laser therapy in eyes with prior glaucoma aqueous tube shunt.

To evaluate the outcomes of micropulse transscleral laser therapy (MP-TLT) in patients with uncontrolled glaucoma and prior glaucoma aqueous tube shunt. In this single‑center, retrospective, interventional case series, eyes that underwent MP-TLT and had prior glaucoma aqueous tube shunt surgeries were included. The Cyclo Glaucoma Laser System (IRIDEX Corporation, Mountain View, CA, USA) with the MicroPulse P3 probe (version 1) was used. Post‑operative data were collected at day 1, week 1, and months 1, 3, 6, 12, 18, 24, 30 and 36. A total of 84 eyes (84 patients) with mean age of 65.8 ± 15.2years and with advanced glaucoma (baseline mean deviation -16.25 ± 6.80dB and best-corrected visual acuity 0.82 ± 0.83 logMar) were included in the study. Baseline mean IOP was 19.95 ± 5.6mm Hg with a mean number of medications 3.39 ± 1.02. There were statistically significant differences in IOP between baseline and all follow-up visits (p < 0.01 for all). The mean percentage of IOP reduction between baseline and different follow-up visits ranged from 23.4% to 35.5% (p < 0.01). There was a significant reduction of visual acuity (≥ 2-lines) at 1year (30.3%) and 2years (76.78%). There was a statistically significant reduction in the number of glaucoma medications between baseline and all follow-up visits after postoperative week 1 (p < 0.05 for all). No severe complications including persistent hypotony and related complications were observed. At the last follow-up visit, only 24 (28%) eyes out of 84 eyes remained in the study. MP-TLT is an effective treatment for reducing IOP and decreasing the number of medications in patients with advanced glaucoma and prior glaucoma aqueous tube shunt.

10-Year Clinical Outcomes of Tube Shunt Surgery at a Tertiary Care Center

To report 10-year clinical outcomes of tube shunt surgery at a tertiary care center. Retrospective cohort study METHODS: Eyes undergoing a first tube shunt (TS) surgery between 1/2005 and 12/2011 at a tertiary referral eye hospital with at least 10 years follow up. Demographic and clinical data were collected. Failure was defined as reoperation to lower intraocular pressure (IOP), IOP greater than 80% of baseline for 2 consecutive visits, or progression to no light perception (NLP). 85 eyes of 78 patients were included in the Study Group; 89 eyes were selected as a Comparison Group. Mean follow up was 11.9±1.7 years. 51(60%) valved, 25 (29%) non-valved, and 9 (11%) unknown TS were placed. At the final visit, mean IOP was reduced from 29.2 ± 10.4 mmHg on 3.1 ± 1.2 medications to 12.6 ± 5.8 mmHg on 2.2 ± 1.4 (IOP: p=1.0136E-12; medications: p=.00000390). 48 (56%) eyes failed. 29 (34%) eyes underwent additional glaucoma surgery. 8 (10%) eyes progressed to NLP. 34 (40%) eyes also required TS revisions. Best corrected visual acuity (BCVA) logMAR (minimal angle of resolution) worsened from .8 ± .7 (20/125) to 1.4 ± 1.0 (20/500) at the last visit (p=.00000714). Average visual field MD was -13.9 ± 7.5 dB at baseline and -17.0 ± 7.0 dB at last follow up (p=.0605) CONCLUSIONS: 10 years following tube shunt, many eyes maintain IOP control, but 56% met failure criteria, 39% had substantial vision loss and 34% underwent additional surgery Outcomes did not differ with tube shunt model.

Risk factors for Baerveldt glaucoma drainage implantation for uveitic glaucoma

Uveitic glaucoma (UG) is sometimes intractable, including intricate interaction between intraocular pressure (IOP) elevation associated with inflammation and side effects of steroids. Based on the Tube Versus Trabeculectomy study in refractory glaucoma results in 2012, tube shunt surgeries have been performed for UG, but few reports have focused on UG. We retrospectively examined the surgical efficacy, complications, and risk factors in 62 eyes with UG that underwent Baerveldt glaucoma drainage device (BGD) implantation at Kumamoto University. The IOPs significantly dropped, and the mean number of glaucoma medications was reduced by more than two. Kaplan‒Meier survival curves were presented under 2 conditions: an IOP reduction of 20% and 6 ≤ IOP ≤ 18 mmHg (criterion A) or 6 ≤ IOP ≤ 15 mmHg (criterion B). In criterion A, the median survival times (MST) were 124 days (complete) and 997 days (qualified). In criterion B, the MST was 129 days (complete) and 867 days (qualified). The Cox hazard proportional model found that the hazard ratio was 0.170 for a history of cataract surgery (95% CI 0.0303–0.950) and 8.669 for systemic immunosuppressive therapy (95% CI 1.810–41.51). BGD implantation is effective for treating UG, but the presence of systemic treatment and the lens status should be considered.

Outcomes of Selective Laser Trabeculoplasty After Prior Incisional Surgery for Open Angle Glaucoma.

This retrospective case series of patients with open angle glaucoma and prior trabeculectomy or tube shunt surgery found that selective laser trabeculoplasty (SLT) resulted in significant intraocular pressure (IOP) reductions in the intermediate follow-up period in select cases. The purpose of this study was to assess the IOP-lowering effect and tolerability of SLT after prior trabeculectomy or tube shunt surgery. Open angle glaucoma patients at Wills Eye Hospital who previously underwent incisional glaucoma surgery and subsequently received SLT between 2013 and 2018 were included, along with an age-matched control group. Baseline characteristics, procedural data, and post-SLT data were recorded at 1, 3, 6, 12 months, and most recent visit. The primary success of SLT treatment was defined as IOP reduction of 20% or greater without the use of additional glaucoma medications compared to pre-SLT IOP. Secondary success was defined as IOP reduction ≥20% with the use of additional glaucoma medications compared to pre-SLT IOP. There were 45 eyes in the study group and 45 eyes in the control group. In the study group, IOP decreased from a baseline of 19.5±4.7mmHg on 2.2±1.2 medications to 16.7±5.2mmHg ( P =0.002) on 2.2±1.1 glaucoma medications ( P =0.57). In the control group, IOP decreased from 19.5±4.2mmHg on 2.4±1.0 medications to 16.4±5.2mmHg ( P =0.003) on 2.1±1.3 medications ( P =0.36). There was no difference in IOP reduction or change in number of glaucoma medications after SLT at any postoperative visit between the 2 groups ( P ≥0.12 for all). Primary success rates at 12 months were 24.4% for the control group and 26.7% for the prior incisional glaucoma surgery group with no significant difference between the groups ( P =0.92). There were no persistent complications after SLT treatment in either group. SLT may effectively lower IOP in patients with open angle glaucoma who have had previous incisional glaucoma surgery and should be considered in select cases.

The Need for Glaucoma Management in Glaucoma Patients with Concurrent Obstructive Sleep Apnea: A Population-Based Cohort Study.

We try to evaluate glaucoma management numbers in patients with both glaucoma and obstructive sleep apnea (OSA) using the National Health Insurance Research Database (NHIRD) of Taiwan. A retrospective cohort study was conducted and patients with glaucoma were enrolled and divided into the OSA and non-OSA populations. A total of 11,778 participants were selected in both the OSA and non-OSA groups. The primary outcomes were the number of anti-glaucomatous medications each year and the total number of glaucoma laser and glaucoma surgeries. The Cox proportional hazard regression was utilized to produce the adjusted hazard ratios (AHR) with corresponding 95% confidence intervals (CI) between the two groups. After a study period of 18 years, 286 and 352 events of laser and surgeries for glaucoma were found in the OSA and non-OSA groups, respectively. After considering the effect of potential confounders, no significant difference concerning the numbers of laser trabeculoplasty, trabeculectomy and tube shunt surgery, cyclodestructive procedure and eyeball removal were found between the two groups (all 95% CIs included one). In addition, the multiple anti-glaucomatous medication usages were similar between the two groups (all p &gt; 0.05) In the subgroup analyses, glaucoma patients older than 60 years and with OSA received significantly lesser trabeculectomy and tube shunt surgery compared to glaucoma patients older than 60 years without OSA (AHR: 0.774, 95% CI: 0.611-0.981) while other analyses revealed insignificant results (all 95% CIs included one). In conclusion, the presence of OSA does not increase the need for glaucoma management.

One-year costs of incisional glaucoma surgery and laser therapy.

This study aimed to calculate one-year total costs of incisional glaucoma surgery and laser therapy in a real-world clinical setting. We conducted a retrospective cohort study from July 2010 to March 2021 using the Diagnosis Procedure Combination database. We included patients hospitalized for incisional glaucoma surgery (trabeculectomy, trabeculotomy, tube shunt surgery, Ex-PRESS surgery, or iStent implantation) or laser therapy (laser peripheral iridotomy, surgical iridectomy, laser trabeculoplasty, cyclocryotherapy, or cyclophotocoagulation). The outcomes were total costs, including costs of hospitalization, re-admissions, antiglaucoma drugs, ophthalmic examinations, and outpatient visits for incisional glaucoma surgery and laser therapy within one year. We identified 49,202 eligible hospitalizations. The one-year median total cost was 707,497 yen [interquartile range: 546,887-944,664 yen]. The median total cost was the highest in patients undergoing tube shunt surgery, followed by Ex-PRESS surgery, iStent implantation, and trabeculectomy. The number and cost of postoperative outpatient visits and length of hospital stay were higher in patients who underwent trabeculectomy and Ex-PRESS surgery than in those after tube shunt surgery. The total costs of laser therapies were lower than those of incisional glaucoma surgeries. The total cost was the highest in the 0-19 age group (856,398 [649,419-1,258,844] yen). Tube shunt surgery was the costliest in terms of total one-year costs. Trabeculectomy and Ex-PRESS surgery were associated with long hospital stays and incurred high postoperative costs. The costs of laser therapies were relatively low. However, cost-effectiveness of laser therapies compared with incisional surgeries needs to be analyzed in future research.

The Incidence of Urgent Tube Shunt Surgery for Diabetic Neovascular Glaucoma at a Tertiary Academic Medical Center.

Diabetic neovascular glaucoma is a secondary glaucoma that may require immediate correction of elevated intraocular pressure to control pain and protect the optic nerve. While there is a seasonal trend to glucose levels, it is unknown if a seasonal trend exists for diabetic neovascular glaucoma. This study evaluates the incidence of urgent glaucoma tube shunt implantation in diabetic neovascular glaucoma in a tertiary academic referral center in Southern California. Electronic medical records were queried for urgent glaucoma tube shunt surgery from 2014 to 2021. The number of cases were separated by month of occurrence, and average hemoglobin A1c values were calculated per month. Data were analyzed via ANOVA tests and one-tailed t-tests. A total of 127 cases were identified. The months of March and April contained the most cases averaging 3 and 2.75 cases, respectively. April had statistically significant higher case numbers than that of other months (P = .041). ANOVA tests excluding April showed no statistically significant difference between the remaining months (P = .901). Average hemoglobin A1c values were highest in the months of April and March at 9.8 and 9.6%, respectively. Emergency glaucoma tube shunt surgery for diabetic neovascular glaucoma occurs most frequently in April. This observation may provide insight into disease prevention through diabetes management and help improve surgical operations such that staffing and resources are allocated accordingly.

Haptic Erosion Following Sutureless Scleral-fixated Intraocular Lens Placement

To describe the clinical features and visual outcomes of eyes with conjunctival haptic erosion after sutureless intrascleral (SIS) fixated intraocular lens (IOL) placement. Retrospective case series. Patients experiencing haptic erosion after SIS fixation between January 1, 2013, and March 1,2022. A multicenter, multisurgeon, retrospective review. Clinical features, visual outcomes, and treatment options following haptic erosions after SIS fixation. Nineteen eyes with haptic erosion were identified. The mean age at initial SIS fixation was 64 ± 12 years (range, 38-81 years). There were 5 (26%) eyes with a history of conjunctiva involving ocular surgery, including scleral buckle surgery and tube shunt surgery. Trocar-assisted fixation was performed in 15 (79%) eyes, whereas needle fixation was used in 4 (21%) eyes. Eighteen (95%) sets of haptics were flanged with a low temperature cautery. Seventeen (90%) sets of haptics were externalized superiorly and inferiorly, and 2 (10%) sets of haptics were externalized nasally and temporally. Haptics were covered by conjunctiva in 14 (74%) eyes and by scleral flap in 5 (26%) eyes. All patients experienced a single haptic erosion, of which 8 (43%) were located superiorly, 9 (47%) inferiorly, and 2 (10%) temporally. The mean interval between the initial SIS fixation and haptic erosion was 278 ± 437 days. After correction of the erosion, 18 (95%) eyes had a stable IOL at the last follow-up, with no recurrence of haptic erosion. In this series, there were no cases of endophthalmitis. Haptic erosion is a notable complication after SIS fixated IOL surgery but may be repaired with favorable visual outcomes. Careful evaluation of the conjunctiva should be considered before the surgery. Proprietary or commercial disclosure may be found after the references.