A Prospective Controlled Study

PURPOSE

To assess the advantages and adverse effects of intraoperative low-dose Mitomycin C in filtering glaucoma surgery.

METHODS

Sixty eyes of 48 patients undergoing surgery for uncontrolled glaucoma were randomized to two groups: one underwent standard trabeculectomy, the other had trabeculectomy with intraoperative application of 0.1 mg/ml mitomycin C. Follow-up was at least one year.

RESULTS

The success rate (IOP < 18 mmHg) was 96.6% in the mitomycin C group and 73.3% in the control group. Mean IOP at one year of successful cases was 11.1 +/- 3.1 mmHg in the mitomycin C group and 16.4 +/- 6.1 mmHg in controls (p < 0.0001). Two patients in the mitomycin C group (6.6%) and six (20%) in the control group needed antiglaucomatous drugs to keep IOP below 18 mmHg.

CONCLUSIONS

Mitomycin C is a useful adjunct to glaucoma surgery. Adverse effects at the dosage used are mainly due to hypotony and are preventable with two-layer suture. Low-dose mitomycin C may be useful in standard primary trabeculectomy.

PERG and P-VEP after Surgical Trabeculectomy in Primary Open-Angle Glaucoma

Pattern-reversal electroretinograms (PERG) and visual evoked potentials (P-VEP) were measured for 10 eyes from 10 rigorously selected patients with bilateral advanced primary open angle glaucoma (POAG), before and after surgical trabeculectomy. The aim was to establish whether electrofunctional examinations improved after major IOP reduction. Only one eye at random was operated, and the fellow eye was used as control. The aim of this study, using electrofunctional examinations, was to clarify whether ganglion cell damage was reversible after marked reduction of IOP by surgery. The results indicate that glaucomatous damage seems to be irreversible.

Evaluating displacement of lamina cribrosa following glaucoma surgery

PURPOSE

The purpose of the study is to assess the displacement of lamina cribrosa (LC) and prelaminar tissue area (PTA) changes following trabeculectomy and non-penetrating deep sclerectomy (NPDS) using spectral-domain optical coherence tomography (SD-OCT) with enhanced depth imaging technology.

METHODS

A total of 30 patients underwent glaucoma surgery. Sixteen patients underwent trabeculectomy, and 14 patients undertook NPDS. Serial horizontal B-scan images of optic nerve head (ONH) were obtained using SD-OCT preoperatively, and at 2-week, 1-, 3-, and 6-month postoperative visit (6 pv). LC displacement magnitude and PTA changes were determined from selected B-scan images. Correspondingly, OCT retinal nerve fiber layer (RNFL) parameters were measured.

RESULTS

Intraocular pressure (IOP) decreased from 27.4 ± 10.3 mmHg (mean ± standard deviation) to 10.2 ± 4.0 mmHg (P = 0.011) and from 19.9 ± 4.0 mmHg to 11.9 ± 3.6 mmHg (P = 0.012) at 6 pv, for trabeculectomy and NPDS, respectively. There was a significant decrease in the LC depth from a baseline glaucomatous LC displacement of 468.0 ± 142.4 to 397.6 ± 125.2 μm in the trabeculectomy group (P = 0.001) and from 465.2 ± 129.6 to 412.0 ± 122.4 μm in the NPDS group (P = 0.029) at 6 pv. The PTA differed between the procedures at baseline (P = 0.002), but was not statistically significant postoperatively. Multivariate analysis for all patients including age, magnitude of IOP reduction, baseline glaucomatous LC displacement, magnitude of LC displacement, and the type of surgery revealed that only the magnitude of LC displacement was associated with significant RNFL thinning on average (r² = 0.162, P = 0.027) and in the following sectors: temporal superior (r² = 0.197, P = 0.014), temporal (r² = 0.150, P = 0.034), and nasal superior (r² = 0.162, P = 0.027).

CONCLUSIONS

Decrease in the LC depth after NPDS surgery can be observed at 6 pv. Regardless of the performed procedure, magnitude of LC displacement is associated with significant, focal RNFL thinning.

[Glaucoma Drainage Devices: Tube versus Trabeculectomy Study]

While trabeculectomy with mitomycin C has previously been the gold standard in penetrating glaucoma surgery, glaucoma drainage implants used early within glaucoma surgery were examined in the course of the tube versus trabeculectomy (TVT) study. Glaucoma drainage implants are now being used earlier, as materials are tissue-compatible and surgery has been improved. While in the past, the use of such implants was often carried out after multiple preoperations, implants are now being used at an earlier stage. Glaucoma drainage implants are typically still used in the pseudophakic eye, where 1-2 glaucoma preoperations (e.g. trabeculectomy) have already been performed.

Impact of Intraocular Pressure after Filtration Surgery on Visual Field Progression in Primary Open-Angle Glaucoma

PURPOSE

To compare visual field progression after trabeculectomy in eyes showing a postoperative intraocular pressure (IOP) less than or equal to 16 mmHg and eyes with an IOP of 17 to 21 mmHg.

METHODS

A retrospective cohort study design was used. A total of 101 eyes of 101 consecutive patients undergoing trabeculectomy for primary open-angle glaucoma (POAG) with a postoperative IOP less than or equal to 21 mmHg were divided into two groups: Group 1 included eyes showing a postoperative IOP less than or equal to 16 mmHg at all visits and Group 2 included eyes with a postoperative IOP between 17 and 21 mmHg. In turn, each of these groups was divided into two subgroups according to whether treatment was required for IOP control. Glaucomatous visual field control during follow-up was compared between the subject groups.

RESULTS

Kaplan-Meier analysis revealed glaucomatous visual field control in 98.53% of the eyes in Group 1 and 89.06% of those in Group 2 at 5 years, the difference between the groups being significant.

CONCLUSIONS

Glaucomatous disease progression is less frequent when IOP is less than or equal to 16 mmHg in all the follow-up visits after trabeculectomy. The results indicate a definite benefit of low IOP in visual field control.

Intraocular Pressure Response of Capsular Glaucoma and Primary Open-Angle Glaucoma to Selective Nd:Yag Laser Trabeculoplasty: A Prospective, Comparative Clinical Trial

PURPOSE

To compare the intraocular pressure (IOP) response of uncontrolled capsular glaucoma (CG) and primary open-angle glaucoma (POAG) to selective laser trabeculoplasty (SLT) in a prospective clinical trial.

METHODS

Ten eyes often patients suffering from uncontrolled CG (CG Group) and ten eyes of ten patients with uncontrolled POAG (POAG Group) were treated with a frequency-doubled, Q-switched Nd:YAG laser (532 nm). The baseline characteristics were similar in both groups. IOP was measured before and 1 day, 1 week, 1 month and 3, 6, 9, 12, 15 and 18 months after treatment. Success was defined as IOP more than 20% lower than before treatment. Any change of hypotensive medication led to the subjects' exclusion from the study. The two groups were compared using the independent-sample t test for continuous variables and the log-rank test for survival analysis. A value of p<0.05 was considered significant.

RESULTS

The mean follow-up was 12.0 months (SD 5.5) for the CG group and 13.5 months (SD 4.3) for POAG (n.s.). No significant difference was found between the two groups for mean pretreatment IOP (23.6 mmHg +/- 5.70 in the CG group and 22.8 mmHg +/- 2.44 in the POAG group) or for mean IOP and mean IOP reductions during the follow-up. At all follow-up visits, IOP was reduced less in the CG group than in the POAG group (24.8% +/- 11.15 vs. 27.7% +/- 9.91 at 6 months, 22.0% +/- 6.66 vs. 30.6% +/- 6.35 at 12 months, and 31.4% +/- 5.55 vs. 35.1% +/- 1.75 at 18 months), but the difference was significant only at 12 months. Kaplan-Meier survival analysis gave an 18-month success rate of 64% in the CG group and 78% in the POAG group, with no significant differences between the groups.

CONCLUSIONS

SLTis an effective procedure forlowering IOP in CG and POAG eyes, although the effect seems to last less in CG eyes.

Primary acute angle-closure glaucoma complicating ciliochoroidal detachment: report of four cases and review of the literature

PURPOSE

To describe the ultrasound biomicroscopy (UBM) and B-scan ultrasonography findings and therapeutic approach for ciliochoroidal detachment secondary to acute primary angle-closure glaucoma (APACG) in four patients. We also reviewed the literature.

METHODS

Case report and systematic literature review.

RESULTS

The four patients were referred to our department for further management of APACG. The UBM and B-scan ultrasonography examinations were conducted 2 days after the beginning of medical treatment and demonstrated ciliochoroidal detachment in four eyes of the four patients. The patients all received intravenous infusion of corticosteroid therapy (10 mg dexamethasone once daily for 5-7 days). We reviewed the UBM findings, which confirmed that the ciliochoroidal detachment disappeared. The patients then underwent trabeculectomy combined with peripheral iridotomy surgery. The patients all ultimately recovered very well.

CONCLUSION

APACG with ciliochoroidal detachment is rare and has hidden clinical manifestations, and the pathophysiological mechanism is not yet fully understood. Anti-glaucoma surgery may increase the detachment. UBM and B-scan ultrasounds are useful tools for ciliochoroidal detachment diagnosis in APACG patients before operative treatment.

Effect of trabeculectomy on visual field progression in Japanese progressive normal-tension glaucoma with intraocular pressure < 15 mmHg

We examined the effectiveness of trabeculectomy in decreasing the slope of mean deviation (MD) in Japanese patients with progressive normal-tension glaucoma (NTG) at low intraocular pressure (IOP) levels. The charts of patients who had undergone initial trabeculectomy with adjunctive mitomycin C for progressive NTG with medically controlled IOP < 15 mmHg in 2010–2013 were retrospectively reviewed. Seventeen eyes of 13 NTG patients who had undergone at least 5 times of visual field (VF) examinations in both of preoperatively and postoperatively with postoperative follow-up of ≥ 2 years were enrolled. Preoperative and postoperative MD slopes were compared to evaluate the effectiveness of trabeculectomy in slowing progression of VF. Mean IOP (8.1 ± 2.9 mmHg) and number of IOP-lowering medications (0.8 ± 1.5) were significantly lower postoperatively than preoperatively (13.9 ± 0.9 mmHg; P < 0.001 and 3.0± 0.4; P < 0.0001). In total, 91.7% of eyes with single-digit IOP postoperatively showed improvement in MD slope, whereas only 20.0% of eyes with IOP ≥ 10 mmHg postoperatively showed the improvement. Three eyes (17.6%) showed a decrease in visual acuity (VA) of ≥ 0.1 unit; this group had a lower mean postoperative IOP (6.0 ± 1.0 vs. 8.6 ± 3.0 mmHg; P = 0.1717) and a higher mean IOP reduction rate (56.2 vs. 38.5%; P = 0.8296) than eyes with a VA decrease of < 0.1 unit or no change. Thus, in this analysis of Japanese NTG patients with medically controlled IOP < 15 mmHg, achieving an IOP < 10 mmHg with trabeculectomy was beneficial for reducing the VF progression rate in progressive NTG at low IOP levels. However, an IOP < 7 mmHg by surgery would be required careful attention to VA decline.

Aqueous shunts for glaucoma

BACKGROUND

Aqueous shunts are employed to control intraocular pressure (IOP) for people with primary or secondary glaucomas who fail or are not candidates for standard surgery.

OBJECTIVES

To assess the effectiveness and safety of aqueous shunts for reducing IOP in glaucoma compared with standard surgery, another type of aqueous shunt, or modification to the aqueous shunt procedure.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 8), MEDLINE Ovid (1946 to August 2016), Embase.com (1947 to August 2016), PubMed (1948 to August 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to August 2016), ClinicalTrials.gov (www.clinicaltrials.gov); searched 15 August 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 15 August 2016. We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 15 August 2016. We also searched the reference lists of identified trial reports and the Science Citation Index to find additional trials.

SELECTION CRITERIA

We included randomized controlled trials that compared various types of aqueous shunts with standard surgery or to each other in eyes with glaucoma.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results for eligibility, assessed the risk of bias, and extracted data from included trials. We contacted trial investigators when data were unclear or not reported. We graded the certainty of the evidence using the GRADE approach. We followed standard methods as recommended by Cochrane.

MAIN RESULTS

We included 27 trials with a total of 2099 participants with mixed diagnoses and comparisons of interventions. Seventeen studies reported adequate methods of randomization, and seven reported adequate allocation concealment. Data collection and follow-up times varied.Four trials compared an aqueous shunt (Ahmed or Baerveldt) with trabeculectomy, of which three reported one-year outcomes. At one-year, the difference in IOP between aqueous shunt groups and trabeculectomy groups was uncertain (mean difference (MD) 2.55 mmHg, 95% confidence interval (CI) -0.78 to 5.87; 380 participants; very low-certainty evidence). The difference in logMAR visual acuity was also uncertain (MD 0.12 units, 95% CI -0.07 to 0.31; 380 participants; very low-certainty evidence). In two trials, the difference in visual field score was uncertain (MD -0.25, 95% CI -1.91 to 1.40; 196 participants; very low-certainty evidence). The mean number of antiglaucoma medications was higher in the aqueous shunt group than the trabeculectomy group in one trial (MD 0.80, 95% CI 0.48 to 1.12; 184 participants; low-certainty evidence). The effect on needing additional glaucoma surgery was uncertain between groups in two trials (risk ratio (RR) 0.24, 95% CI 0.04 to 1.36; 329 participants; very low-certainty evidence). In one trial, fewer total adverse events were reported in the aqueous shunt group than the trabeculectomy group (RR 0.59, 95% CI 0.43 to 0.81; 212 participants; very low-certainty evidence). No trial reported quality-of-life outcomes at one-year follow-up.Two trials that compared the Ahmed implant with the Baerveldt implant for glaucoma found higher mean IOP in the Ahmed group at one-year follow-up (MD 2.60 mmHg, 95% CI 1.58 to 3.62; 464 participants; moderate-certainty evidence). The difference in logMAR visual acuity was uncertain between groups (MD -0.07 units, 95% CI -0.27 to 0.13; 501 participants; low-certainty evidence). The MD in number of antiglaucoma medications was within one between groups (MD 0.35, 95% CI 0.11 to 0.59; 464 participants; moderate-certainty evidence). More participants in the Ahmed group required additional glaucoma surgery than the Baerveldt group (RR 2.77, 95% CI 1.02 to 7.54; 514 participants; moderate-certainty evidence). The two trials reported specific adverse events but not overall number of adverse events. Neither trial reported visual field or quality-of-life outcomes at one-year follow-up.One trial compared the Ahmed implant with the Molteno implant for glaucoma over two-year follow-up. Mean IOP was higher in the Ahmed group than the Molteno group (MD 1.64 mmHg, 95% CI 0.85 to 2.43; 57 participants; low-certainty evidence). The differences in logMAR visual acuity (MD 0.08 units, 95% CI -0.24 to 0.40; 57 participants; very low-certainty evidence) and mean deviation in visual field (MD -0.18 dB, 95% CI -3.13 to 2.77; 57 participants; very low-certainty evidence) were uncertain between groups. The mean number of antiglaucoma medications was also uncertain between groups (MD -0.38, 95% CI -1.03 to 0.27; 57 participants; low-certainty evidence). The trial did not report the proportion needing additional glaucoma surgery, total adverse events, or quality-of-life outcomes.Two trials compared the double-plate Molteno implant with the Schocket shunt for glaucoma; one trial reported outcomes only at six-month follow-up, and the other did not specify the follow-up time. At six-months, mean IOP was lower in the Molteno group than the Schocket group (MD -2.50 mmHg, 95% CI -4.60 to -0.40; 115 participants; low-certainty evidence). Neither trial reported the proportion needing additional glaucoma surgery, total adverse events, or visual acuity, visual field, or quality-of-life outcomes.The remaining 18 trials evaluated modifications to aqueous shunts, including 14 trials of Ahmed implants (early aqueous suppression versus standard medication regimen, 2 trials; anti-vascular endothelial growth factor agent versus none, 4 trials; corticosteroids versus none, 2 trials; shunt augmentation versus none, 3 trials; partial tube ligation versus none, 1 trial; pars plana implantation versus conventional implantation, 1 trial; and model M4 versus model S2,1 trial); 1 trial of 500 mm² Baerveldt versus 350 mm² Baerveldt; and 3 trials of Molteno implants (single-plate with oral corticosteroids versus single-plate without oral corticosteroids, 1 trial; double-plate versus single-plate, 1 trial; and pressure-ridge versus double-plate with tube ligation, 1 trial).

AUTHORS' CONCLUSIONS

Information was insufficient to conclude whether there are differences between aqueous shunts and trabeculectomy for glaucoma treatment. While the Baerveldt implant may lower IOP more than the Ahmed implant, the evidence was of moderate-certainty and it is unclear whether the difference in IOP reduction is clinically significant. Overall, methodology and data quality among existing randomized controlled trials of aqueous shunts was heterogeneous across studies, and there are no well-justified or widely accepted generalizations about the superiority of one surgical procedure or device over another.

Clinical study of water drinking test and 24-hour intraocular pressure monitoring in patients with primary open angle glaucoma

This paper aims to observe the relevance of 24-hour intraocular pressure (IOP) monitoring and water drinking test (WDT) in patient with primary open angle glaucoma (POAG). 55 patients (90 eyes) with POAG was selected and randomly divided into operation group and drug group. Operation group, with 30 cases (48 eyes), were treat with trabeculectomy. And the other 25 cases (42 eyes) were treated with antiglaucoma medication. 24-hour intraocular pressure and WDT were measured before treatment and 6 months after treatment. The correlation between the peak value of 24-hour intraocular pressure (IOP) and intraocular pressure (IOP) fluctuation and the drinking water test were analyzed. Pearson correlation analysis showed a strong positive correlation between the peak value of diurnal IOP and the peak value of WDT IOP (r=0.758); and the Pearson correlation analysis also showed a strong positive correlation between the peak value of diurnal IOP and the peak value of WDT IOP after 6 months of POAG surgery or drug therapy (r=0.759,0.712). The peak value of IOP and IOP fluctuation in operation group were lower than those in the drug group at 6 months after operation, the difference was statistically significant. The peak value of WDT IOP can reflect the curve peak value of 24-hour IOP, which can be used to evaluate the current treatment. There were significant differences in IOP and IOP fluctuation between the drug group and the operation group at 6 months after treatment. Operation groups could achieve lower IOP and IOP fluctuation.

The Effect of Change in Intraocular Pressure on Choroidal Structure in Glaucomatous Eyes

Purpose

Choroidal thickness increases linearly with intraocular pressure (IOP) lowering. We studied the relationship between the change in size of the choroidal vasculature and IOP lowering after glaucoma procedures.

Methods

Thirty eyes of twenty-nine patients were examined pre- and postoperatively for up to 6 months with standard clinical assessment, enhanced depth imaging spectral-domain optical coherence tomography (OCT), and axial length measurement. Each enhanced depth imaging spectral-domain OCT image was analyzed using three separate methods to determine the choroidal thickness, choroidal vessel thickness, choroidal interstitial thickness, large choroidal vessel layer thickness, medium choroidal vessel layer thickness, and light-dark ratio. Bivariate linear regression analysis was completed with largest change in IOP as the independent variable. The dependent variables included choroidal thickness, choroidal vessel thickness, and choroidal interstitial thickness, at the largest change in IOP. Multivariable regression analysis using a generalized estimating equation to account for multiple measurements per eye was also completed.

Results

Mean choroidal vessel thickness increases 1.5 μm for every 1 mm Hg decrease in IOP (P < 0.0001; 95% confidence interval [CI], 0.8, 2.1) and choroidal interstitial thickness increases 1.3 μm for every 1 mm Hg change in IOP (P < 0.0001; 95% CI, 0.8, 1.8). There was no significant association between change in IOP and change in large choroidal vessel layer temporally (P = 0.13), nasally (P = 0.20), or subfoveally (P = 0.18). There was also no association between IOP and the light-dark ratio (P = 0.16).

Conclusions

The increase in choroidal thickness at lower IOP is associated with approximately equal increases in its intravascular and extravascular compartments.

Management of neovascular glaucoma with intravitreal ranibizumab, panretinal photocoagulation, and subsequent 5-fluorouracil augmented trabeculectomy: A case report

RATIONALE

Neovascular glaucoma (NVG) is one of the most refractory types of glaucoma caused by high ischemic retinal disorders, resulting in severe visual loss. Intravitreal injections of ranibizumab have been reported to have anatomical and functional success in treating NVG.

PATIENT CONCERNS-DIAGNOSES-INTERVENTIONS

We report a case with neovascular glaucoma due to central retinal vein occlusion who received combination therapy with intravitreal ranibizumab (IVR) injection, panretinal photocoagulation (PRP) and subsequent 5-fluorouracil (5-FU) augmented trabeculectomy.

OUTCOMES

One week after IVR injection, the intraocular pressure (IOP) had partially decreased to 33 mmHg, and there was a complete regression of neovascularization of the iris (NVI) and the angle (NVA). PRP was feasible after IVR due to improvement of corneal edema which made an adequate view of the posterior pole of fundus. The surgery of trabeculectomy with 5-FU was performed 2 weeks after IVR to control the IOP. The intraoperative and postoperative courses were uneventful without any adverse complication. Post trabeculectomy, his vision remained stable and the IOP was in the range of 4-15 mmHg without topical antiglaucoma medications. A functioning bleb was maintained and there was no recurrence of NVI and NVA during the complete follow-up period of 6 months.

LESSONS

Combined treatment of IVR, PRP, and subsequent 5-FU augmented trabeculectomy is demonstrated to be a possible new paradigm for the management of advanced NVG with angle closure and intractable elevation of IOP.

Safety of Using Matrix Metalloproteinase Inhibitor in Experimental Glaucoma Filtration Surgery

We evaluated the safety of matrix metalloproteinase (MMP) inhibitor in experimental glaucoma filtration surgery in an animal model. Fifteen New Zealand white rabbits underwent an experimental trabeculectomy and were randomly allocated into 3 groups according to the adjuvant agent: no treatment group (n = 5), 0.02% mitomycin C (MMC) soaking group (n = 5), and MMP inhibitor (ilomastat) subconjunctival injection group (n = 5). Slit lamp examination with Seidel testing, pachymetry, and specular microscopy was performed preoperatively and postoperatively. The conjunctiva and ciliary body toxicity were evaluated with scores according to the pathologic grading systems. Electron microscopy was used to examine the structural changes in cornea, conjunctiva, and ciliary body. In the ilomastat-treated group, there was no statistically significant change in central corneal thickness preoperatively and at 28 days postoperatively (P = 0.655). There were also no significant changes in specular microscopy findings over the duration of the study in the ilomastat-treated group. The conjunctival toxicity score was 1 in the control group, 1.5 in the ilomastat-treated group, and 2 in the MMC-treated group. When assessing ciliary body toxicity scores, the ilomastat-treated group score was 0.5 and the MMC-treated group score was 1.5. Transmission electron microscopy did not show structural changes in the cornea and ciliary body whereas the structural changes were noticed in MMC group. A single subconjunctival injection of MMP inhibitor during the experimental trabeculectomy showed a less toxic affect in the rabbit cornea, conjunctiva, and ciliary body compared to MMC.

Efficacy and safety of preoperative IOP reduction using a preservative-free fixed combination of dorzolamide/timolol eye drops versus oral acetazolamide and dexamethasone eye drops and assessment of the clinical outcome of trabeculectomy in glaucoma

Introduction

To demonstrate that preoperative treatment for 28 days with topical dorzolamide/timolol is non-inferior (Δ = 4 mm Hg) to oral acetazolamide and topical dexamethasone (standard therapy) in terms of intraocular pressure (IOP) reduction 3 and 6 months after trabeculectomy in glaucoma patients.

Materials and methods

Sixty-two eyes undergoing trabeculectomy with mitomycin C were included in this monocentric prospective randomized controlled study. IOP change between baseline and 3 months post-op was defined as the primary efficacy variable. Secondary efficacy variables included the number of 5-fluorouracil (5-FU) injections, needlings, suture lyses, preoperative IOP change, hypertension rate and change of conjunctival redness 3 and 6 months post-op. Safety was assessed based on the documentation of adverse events.

Results

Preoperative treatment with topical dorzolamide/timolol was non-inferior to oral acetazolamide and topical dexamethasone in terms of IOP reduction 3 months after trabeculectomy (adjusted means -8.12 mmHg versus -8.30 mmHg; Difference: 0.18; 95% CI -1.91 to 2.26, p = 0.8662). Similar results were found 6 months after trabeculectomy (-9.13 mmHg versus -9.06 mmHg; p = 0.9401). Comparable results were also shown for both groups concerning the classification of the filtering bleb, corneal staining, and numbers of treatments with 5-FU, needlings and suture lyses. More patients reported AEs in the acetazolamide/dexamethasone group than in the dorzolamide/timolol group.

Discussion

Preoperative, preservative-free, fixed-dose dorzolamide/timolol seems to be equally effective as preoperative acetazolamide and dexamethasone and has a favourable safety profile.

[Selective Laser Trabeculoplasty - Implication for Medicament Glaucoma Treatment Interruption in Pregnant and Breastfeeding Women]

During the period of the last six years (2010-2016), the authors performed Selective Laser Trabeculoplasty (SLT) in 32 women (64 eyes); pregnant women patients with primary open angle glaucoma were referred to the Department of Ophthalmology, First Medical Faculty, Charles University, and Central Military Hospital in Prague, Czech Republic, European Union, to perform this procedure with the goal to interrupt their antiglaucomatic treatment by means of eye drops during the pregnancy and the breastfeeding period. In other 7 cases (14 eyes), they performed the SLT with the goal to terminate the local medicament treatment before planned pregnancy. The procedure was performed on the outpatient basis, during one session, always in both eyes, after one-shot local anesthesia, following their own protocol in the range of 270° of the iridocorneal angle circumferentially, with the parameters 1.0 mJ, 80 shots, 400 μm, using the Tango laser device. All the current local antiglaucomatic treatment was after the performing of the procedure stopped. During the period of pregnancy and breastfeeding, no subjective ophthalmologic problems were neither present, nor objective worsening of visual functions was noticed. According to their own experience, the authors offer the possibility to get over the period of pregnancy and breastfeeding in women patients with primary open angle glaucoma by means of performing the selective laser trabeculoplasty, so without the risk of medicament antiglaucomatic treatment adverse effects.Key words: glaucoma, selective laser trabeculoplasty (SLT), treatment, pregnancy, breastfeeding.

Ophthalmologists' practice patterns and challenges in achieving optimal management for glaucoma in Nigeria: results from a nationwide survey

PURPOSE OF THE STUDY

Glaucoma, a chronic non-communicable disease, and leading cause of irreversible blindness worldwide is a public health problem in Nigeria, with a prevalence of 5.02% in people aged ≥40 years. The purpose of this nationwide survey was to assess Nigerian ophthalmologists' practice patterns and their constraints in managing glaucoma.

STUDY DESIGN

Ophthalmologists were sent a semistructured questionnaire on how they manage glaucoma, their training in glaucoma care, where they practice, their access to equipment for diagnosis and treatment, whether they use protocols and the challenges they face in managing patients with glaucoma.

RESULTS

153/250 ophthalmologists in 80 centres completed questionnaires. Although 79% felt their training was excellent or good, 46% needed more training in glaucoma diagnosis and surgery. All had ophthalmoscopes, 93% had access to applanation tonometers, 81% to visual field analysers and 29% to laser machines (in 19 centres). 3 ophthalmologists had only ophthalmoscopes and schiøtz tonometers. For 85%, a glaucomatous optic disc was the most important feature that would prompt glaucoma work-up. Only 56% routinely performed gonioscopy and 61% used slit-lamp stereoscopic biomicroscopy for disc assessment. Trabeculectomy (with/without antimetabolites) was the only glaucoma surgery performed with one mention of canaloplasty. Poor compliance with medical treatment (78%) and low acceptance of surgery (71%) were their greatest challenges.

CONCLUSIONS

This study indicates that a systems-oriented approach is required to enhance ophthalmologist's capability for glaucoma care. Strategies to improve glaucoma management include strengthening poorly equipped centres including provision of lasers and training, and improving patients' awareness and education on glaucoma.

Glaucoma after chemical burns and radiation

Glaucoma after chemical burns represents a posttraumatic glaucoma, usually open-angle glaucoma. It is a frequent complication of chemical burns, especially with alkali and it can appear in the acute stage or as a late complication. Because of the complications and scars, the treatment is very difficult. Topical treatment is based on AC inhibitors, β-blockers, α2-agonists. Trabeculectomy, shunts, cyclophotocoagulation, and cryotherapy are the solutions in the late stages. Glaucoma after irradiation is a closing-angle secondary glaucoma. The risk factors such as the radiation dose and the volume of the radiated structure are important in the appearance and evolution of this type of glaucoma. Topical treatment is usually ineffective, the preferable options being laser and surgical treatments. Although it is not a frequently seen pathology, it is important to know how to diagnose and treat this type of glaucoma. There are various options available for treatment, but choosing one is difficult because of the possible complications.

[Trabeculotomy with Schlemm's Canal Endothelium Removal and Deep Sclerectomy]

Purpose: To evaluate the effects of trabeculotomy (TLO) combined with Schlemm's canal endothelium removal (SER) and deep sclerectomy (DS). Method: This retrospective study involved 131 adults eyes, diagnosed with glaucoma that were enrolled with at least 1 year follow-up after TLO. Fifty three eyes received TLO+SER+DS and 78 eyes underwent TLO+DS without SER. SER was performed as peeling of Schlemm's canal endothelium opening under the scleral flap. Surgical success was defined by the need for additional glaucoma surgery, or intraocular pressure (IOP) ≤20 mmHg (criterion A) and ≤16 mmHg (criterion B). Results: The occurrence rate of transient ocular hypertension (≥30 mmHg) was significantly less (p<0.001) in SER (3.8%) compared with Non-SER (21.8%). SER decreased IOP at 3 years without significant efficacy in terms of lowered IOP compared with Non-SER. At 3 years, Kaplan-Meier survival analysis revealed that the success rate of SER was higher than Non-SER for criterion A (p=0.008), but comparable for criterion B (p=0.06). Conclusions: SER was effective for reducing the rate of transient ocular hypertension in TLO and controlling IOP≤20 mmHg in adult eyes.

Structural and Functional Progression in the Early Manifest Glaucoma Trial

PURPOSE

To elucidate the temporal relationship between detection of glaucomatous optic disc progression, as assessed by fundus photography, and visual field progression.

DESIGN

Prospective, randomized, longitudinal trial.

PARTICIPANTS

Three hundred six study eyes with manifest glaucoma with field loss and 192 fellow eyes without any field defect at the start of the trial, from a total of 249 subjects included in the Early Manifest Glaucoma Trial (EMGT), were assessed.

METHODS

Evaluation of visual field progression and optic disc progression during an 8-year follow-up period. Three graders independently assessed optic disc progression in optic disc photographs. Visual field progression was assessed using glaucoma change probability maps and the EMGT progression criterion.

MAIN OUTCOME MEASURES

Time to detection of visual field progression and optic disc progression.

RESULTS

Among study eyes with manifest glaucoma, progression was detected in the visual field first in 163 eyes (52%) and in the optic disc first in 39 eyes (12%); in 1 eye (0%), it was found simultaneously with both methods. Among fellow eyes with normal fields, progression was detected in the visual field first in 28 eyes (15%) and in the optic disc first in 34 eyes (18%); in 1 eye (1%), it occurred simultaneously.

CONCLUSIONS

In eyes with manifest glaucoma, progression in the visual field was detected first more than 4 times as often as progression in the optic disc. Among fellow eyes without visual field loss at baseline, progression was detected first as frequently in the optic disc as in the visual field.

Refusal of Trabeculectomy for the Fellow Eye in Collaborative Initial Glaucoma Treatment Study (CIGTS) Participants

PURPOSE

To understand the reasons for refusal of fellow eye surgical treatment for glaucoma after first eye trabeculectomy.

DESIGN

Post hoc analysis of data collected in a multicenter, randomized clinical trial.

METHODS

Data from participants in the Collaborative Initial Glaucoma Treatment Study (CIGTS) who were randomized to and underwent initial trabeculectomy on their study eye, and whose fellow eye was eligible for surgical treatment, were analyzed. Participant demographic data and characteristics, surgical data from the study eye, and quality-of-life survey results were compared between groups that received or refused trabeculectomy in their fellow eye. The main outcome measure was patient refusal of fellow eye surgery for glaucoma.

RESULTS

Of 159 participants who were randomized to and underwent trabeculectomy on their study eye and had a fellow eye that was eligible for surgery, 30 (19%) refused fellow eye surgery. Eligible patients who refused fellow eye trabeculectomy did not differ significantly in visual function or local eye symptoms from those that underwent fellow eye trabeculectomy (all P > .05). In a multivariable analysis of data, increased fellow eye preoperative intraocular pressure (IOP) was associated with decreased odds (OR = 0.89, P = .0188), study eye hypotony at 3 months postoperatively was associated with increased odds (OR = 7.24, P = .0125), and argon suture lysis procedure was associated with decreased odds (OR = 0.38, P = .0385) of surgery refusal.

CONCLUSIONS

Refusal of fellow eye surgery was not uncommonly encountered in the CIGTS. Those who refused fellow eye surgery had lower fellow eye IOP and were more likely to have had hypotony after study eye trabeculectomy.

The Influence of Phacoemulsification on Surgical Outcomes of Trabeculectomy with Mitomycin-C for Uveitic Glaucoma

PURPOSE

To evaluate the influence of phacoemulsification after trabeculectomy on the postoperative intraocular pressure (IOP) in eyes with uveitic glaucoma (UG).

SETTING

Kumamoto University Hospital, Kumamoto, Japan.

DESIGN

A retrospective cohort study.

METHODS

The medical records of patients with UG who had trabeculectomy with mitomycin-C (MMC) were reviewed. Complete and qualified surgical failures were defined by an IOP of ≥21 mmHg (condition A), ≥18 mmHg (condition B), or ≥15 mmHg (condition C) without and with glaucoma eye drops, respectively. Kaplan-Meier survival analysis, generalized by the Wilcoxon test, and the Cox proportional hazards model analysis were conducted. Post-trabeculectomy phacoemulsification was treated as a time-dependent variable. In 24 (30%) of the included 80 eyes, phacoemulsification was included, and they were divided into two groups: groups I (8 eyes with phacoemulsification within 1 year after trabeculectomy) and group II (16 eyes after 1 year following trabeculectomy).

RESULTS

Multivariable Cox proportional hazards model analysis showed post-trabeculectomy phacoemulsification was a significant factor in both complete success and qualified success based upon condition C (P = 0.0432 and P = 0.0488, respectively), but not for the other conditions. Kaplan-Meier survival analyses indicated significant differences in success probabilities between groups I and group II for complete success and qualified success based upon condition C (P = 0.020 and P = 0.013, respectively). There was also a significant difference for qualified success based upon condition B (P = 0.034), while there was no significant difference for the other conditions.

CONCLUSION

Post-trabeculectomy phacoemulsification, especially within 1 year, can cause poor prognosis of IOP control of UG eyes after trabeculectomy with MMC.

Mitomycin C versus 5-Fluorouracil for wound healing in glaucoma surgery

BACKGROUND

Raised intraocular pressure is a risk factor for glaucoma. One treatment option is glaucoma drainage surgery (trabeculectomy). Antimetabolites are used during surgery to reduce postoperative scarring during wound healing. Two agents in common use are mitomycin C (MMC) and 5-Fluorouracil (5-FU).

OBJECTIVES

To assess the effects of MMC compared to 5-FU as an antimetabolite adjunct in trabeculectomy surgery.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015 Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2015), EMBASE (January 1980 to October 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to October 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 October 2015.

SELECTION CRITERIA

We included randomised controlled trials where wound healing had been modified with MMC compared to 5-FU.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and collected data. The primary outcome was failure of a functioning trabeculectomy one year after surgery. Secondary outcomes included mean intraocular pressure at one year. We considered three subgroups: high risk of trabeculectomy failure (people with previous glaucoma surgery, extracapsular cataract surgery, African origin and people with secondary glaucoma or congenital glaucoma); medium risk of trabeculectomy failure (people undergoing trabeculectomy with extracapsular cataract surgery) and low risk of trabeculectomy failure (people who have received no previous surgical eye intervention).

MAIN RESULTS

We identified 11 trials that enrolled 687 eyes of 679 participants. The studies were conducted in the United States, Europe, Asia and Africa. Five studies enrolled participants at low risk of trabeculectomy failure, five studies enrolled participants at high risk of failure, and one study enrolled people with both high and low risk of failure. None of the included trials enrolled participants with combined trabeculectomy/cataract surgery.We considered one study to be at low risk of bias in all domains, six studies to be at high risk of bias in one or more domains, and the remaining four studies to be at an unclear risk of bias in all domains.The risk of failure of trabeculectomy at one year after surgery was less in those participants who received MMC compared to those who received 5-FU, however the confidence intervals were wide and are compatible with no effect (risk ratio (RR) 0.54, 95% confidence interval (CI) 0.30 to 1.00; studies = 11; I(2) = 40%). There was no evidence for any difference between groups at high and low risk of failure (test for subgroup differences P = 0.69).On average, people treated with MMC had lower intraocular pressure at one year (mean difference (MD) -3.05 mmHg, 95% CI -4.60 to -1.50), but the studies were inconsistent (I(2) = 52%). The size of the effect was greater in the high-risk group (MD -4.18 mmHg, 95% CI -6.73 to -1.64) compared to the low-risk group (MD -1.72 mmHg, 95% CI -3.28 to -0.16), but again the test for interaction was not statistically significant (P = 0.11).Similar proportions of eyes treated with MMC lost 2 or more lines of visual acuity one year after surgery compared to 5-FU, but the confidence intervals were wide (RR 1.05, 95% CI 0.54 to 2.06).Adverse events occurred relatively rarely, and estimates of effect were generally imprecise. There was some evidence for less epitheliopathy in the MMC group (RR 0.23, 95% CI 0.11 to 0.47) and less hyphaema in the MMC group (RR 0.62, 95% CI 0.42 to 0.91).None of the studies reported quality of life.Overall, we graded the quality of the evidence as low largely because of risk of bias in the included studies and imprecision in the estimate of effect.

AUTHORS' CONCLUSIONS

We found low-quality evidence that MMC may be more effective in achieving long-term lower intraocular pressure than 5-FU. Further comparative research on MMC and 5-FU is needed to enhance reliability and validity of the results shown in this review. Furthermore, the development of new agents that control postoperative scar tissue formation without side effects would be valuable and is justified by the results of this review.

Characteristics of Children With Primary Congenital Glaucoma Receiving Trabeculotomy and Goniotomy

PURPOSE

To describe the groups of patients who received trabeculotomy or goniotomy for the treatment of primary congenital glaucoma (PCG) regarding age at treatment, intraocular pressure (IOP) outcome, and medication burden.

METHODS

A retrospective chart review of patients with PCG seen at Rutgers New Jersey Medical School, Newark, New Jersey, from 1998 to 2012 was conducted. Inclusion criteria were patients who received trabeculotomy or goniotomy with at least 9 months of follow-up. Presenting examination, surgical intervention, IOP, and number of medications at 1 and 2 years postoperatively were recorded. Absolute and qualified success, defined as IOP greater than 5 and less than 21 mm Hg without and with medications, respectively, was determined.

RESULTS

Fifty eyes of 29 patients were diagnosed as having PCG. Of those, 25 eyes received trabeculotomy or goniotomy, with 19 fulfilling inclusion criteria. Average age at the time of trabeculotomy was 8 months versus 21 months for patients undergoing goniotomy. Mean IOP was significantly reduced (P < .001) for both trabeculotomy and goniotomy by 29.5% at 1 year and 33.3% at 2 years. There was no significant difference in IOP control between trabeculotomy and goniotomy groups. Patients in the goniotomy group were treated with significantly more medications before and after surgery compared to patients receiving trabeculotomy (P < .01), resulting in a greater rate of absolute success in trabeculotomy at 1 and 2 years.

CONCLUSIONS

Patients with PCG who underwent trabeculotomy had higher IOP and were treated at an earlier age than those who had goniotomy. Both effectively lowered IOP up to 2 years with greater medication burden in patients receiving goniotomy.

TIMP1, TIMP2, and TIMP4 are increased in aqueous humor from primary open angle glaucoma patients

PURPOSE

Elevated intraocular pressure (IOP) is the only known modifiable risk factor for primary open angle glaucoma (POAG), and it can be caused by reduced aqueous humor outflow from the anterior chamber. Outflow is predominantly regulated by the trabecular meshwork, consisting of specialized cells within a complex extracellular matrix (ECM). An imbalance between ECM-degrading matrix metalloproteinases (MMPs) and the tissue inhibitors of MMPs (TIMPs) within the trabecular meshwork is thought to contribute to POAG. This study aimed to quantify levels of TIMPs and MMPs in aqueous humor samples from glaucomatous and non-glaucomatous eyes, analyze MMP/TIMP ratios, and correlate results with age, IOP, and Humphrey's visual field pattern standard deviation (PSD).

METHODS

Aqueous humor samples were collected from 26 non-glaucomatous control subjects before cataract surgery and 23 POAG patients undergoing trabeculectomy or cataract surgery. Analyte concentrations were measured using multiplexed immunoassays. Statistical significance was assessed with Mann-Whitney U tests, and Spearman's method was used to assess correlations with age, IOP, and PSD.

RESULTS

Concentrations of TIMP1 (p = 0.0008), TIMP2 (p = 0.002), TIMP4 (p = 0.002), and MMP2 (p = 0.020) were significantly increased in aqueous humor samples from POAG versus cataract samples. For the majority of MMP/TIMP molar ratios calculated for the cataract group, TIMPs outweighed MMPs. In POAG, molar ratios of MMP2/TIMP1 (p = 0.007) and MMP9/TIMP1 (p = 0.005) showed a significant decrease, corresponding to an elevated excess of TIMPs over MMPs in POAG compared to cataract samples. Conversely, MMP2/TIMP3 (p = 0.045) and MMP3/TIMP3 (p = 0.032) molar ratios increased. Several MMP/TIMP molar ratios correlated with IOP (r = 0.476-0.609, p = 0.007-0.034) and PSD (r = -0.482 to -0.655, p = 0.005-0.046) in POAG samples and with age in cataract control samples.

CONCLUSIONS

An imbalance among MMPs and TIMPs was found in glaucomatous aqueous humor samples, with a shift toward raised TIMP levels. This may result in the inhibition of MMP activity, leading to an altered ECM composition in the TM and thereby contributing to increased outflow resistance.

Suppression of Type I Collagen Expression by miR-29b Via PI3K, Akt, and Sp1 Pathway, Part II: An In Vivo Investigation

PURPOSE

We investigated the efficacy of miR-29b in inhibiting scar formation in rabbits who undergo glaucoma filtering surgery (GFS).

METHODS

Trabeculectomy was performed on 60 rabbits diagnosed with glaucoma. The rabbits were divided into 5 groups: a blank group, single surgery group, positive control group that was treated with intraoperative mitomycin C (MMC), negative control group that was treated twice with empty vector postoperatively, and experimental group that was treated twice with Lentivirus-mediated miR-29b after being subjected to trabeculectomy. The operated eyes were tracked and followed up from postoperative days 1 to 28 (D1-D28). After the surgery, real-time PCR and Western blot analysis were performed on D28.

RESULTS

At 1 week after undergoing GFS, the IOP was significantly lower in the eyes having filtering blebs. No statistically significant difference was found in the four treatment groups. After 21 days, the filtering bleb function score of the experimental group was the highest; however, their IOP was the lowest. On postoperative D28, the mean number of fibroblasts in the experimental group was significantly the lowest. The experimental group had the least collagen content according to Sircol assay. In the experimental group, the level of Col1A1 expression also was reduced in the sclera and conjunctival areas.

CONCLUSIONS

A subconjunctival injection of lentivirus-mediated miR-29b lowers postoperative IOP and sustains the function of filtering bleb. It inhibits the proliferation of fibroblasts and reduces collagen deposition by repressing the PI3K/Akt/Sp1 pathway in rabbits subjected to GFS.

Interface Fluid Syndrome Induced by Uncontrolled Intraocular Pressure Without Triggering Factors After LASIK in a Glaucoma Patient: A Case Report

This study sought to describe a glaucoma patient with interface fluid syndrome (IFS) induced by uncontrolled intraocular pressure (IOP) without triggering factors after laser in situ keratomileusis (LASIK). Case report and review of the literature. A 23-year-old man with open-angle glaucoma underwent bilateral LASIK for myopia in 2009. Two years later, the patient reported sudden vision loss. The IOP in the right eye was not measurable using Goldmann applanation tonometry (GAT), but was determined to be 33.7 mm Hg using a noncontact tonometer. IFS was diagnosed based on the presence of space-occupying interface fluid on anterior segment optical coherence tomography images. After a trabeculectomy was performed, the IOP decreased to 10 mm Hg, and GAT measurement became possible. However, the corneal fold remained visible in the flap interface. Six months later, the IOP in the left eye increased, and a trabeculectomy was performed during the early stages of this increase in IOP. Following this procedure, the IOP decreased, and visual acuity remained stable. In glaucoma cases that involve a prior increase in IOP, IOP can continue to increase during the disease course even if temporary control of IOP has been achieved. If LASIK is performed in such cases, the treatment of glaucoma becomes insufficient because of underestimation of the typical IOP. In fact, the measurement of IOP can become difficult because of high-IOP levels. Therefore, LASIK should not be performed on patients with glaucoma who are at high risk of elevated IOP.

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

PURPOSE

This study aimed to categorize patients with childhood glaucoma into groups, study the clinical characteristics of the eyes affected, and determine the outcomes after surgery.

DESIGN

This was a retrospective, consecutive, nonrandomized study.

METHODS

Patients with childhood glaucoma who underwent planned primary trabeculectomy or combined trabeculotomy-trabeculectomy (CTT) between January 2003 and December 2008 were enrolled. Main outcome measures were intraocular pressure (IOP), visual acuity, corneal clarity, and any surgical and anesthetic complications.

RESULTS

One hundred thirty-one eyes of 81 patients were included. They were 61.7% male. Mean patient age was 6.1 ± 4.1 years, and the mean age at surgery was 35.8 ± 40.9 months. Postoperatively, the improvement in visual acuity was highly statistically significant at all follow-ups (P < 0.001). The IOP values showed a significant reduction from 29.2 ± 9.7 mm Hg preoperatively to 13.7 ± 5.3 mm Hg (P < 0.001) at 6-month follow-up and 12.1 ± 2.2 mm Hg at last follow-up. Cumulative corneal clarity improved significantly postoperatively (P < 0.001). A comparison of trabeculectomy alone and CTT showed that both procedures were quite effective. At 1 year, overall complete success was seen in 73.3%, qualified success in 16.8%, and failure in 10.7%.

CONCLUSIONS

This study suggests that CTT is safe and effective in both primary and secondary childhood glaucomas. Trabeculectomy alone is also highly effective in certain cases, and proper case selection is essential to attain optimum results. Surgical intervention leads to improvement in vision and corneal clarity and also achieves long-term IOP control.

Long-Term Outcomes and Prognostic Factors of Trabeculectomy following Intraocular Bevacizumab Injection for Neovascular Glaucoma

PURPOSE

To evaluate long-term outcomes and identify prognostic factors of trabeculectomy following intraocular bevacizumab injection for neovascular glaucoma.

METHODS

Sixty-one eyes of 54 patients with neovascular glaucoma treated by trabeculectomy following intraocular bevacizumab injection were consecutively enrolled. Surgical success criteria were sufficient intraocular pressure (IOP) reduction (IOP ≤ 21 mmHg, ≥ 20% IOP reduction, no additional medications or glaucoma surgeries) without devastating complications (loss of light perception, phthisis bulbi, and endophthalmitis) or significant hypotony (IOP ≤ 5 mmHg continued ≥ 6 months and until the last follow-up visit or hypotony requiring intervention). Kaplan-Meier survival curves and Cox regression analysis were used to examine success rates and risk factors for surgical outcomes.

RESULTS

The follow-up period after trabeculectomy was 45.0 ± 22.2 months (mean ± standard deviation). Surgical success rate was 86.9 ± 4.3% (± standard error), 74.0 ± 6.1%, and 51.3 ± 8.6% at 1, 3, and 5 years. Multivariate Cox regression analysis identified two risk factors; lower preoperative IOP (≤ 30 mmHg) for surgical failure and hypotony [hazard ratio (HR), 2.92, 6.64; 95% confidence interval (CI), 1.22 to 7.03, 1.47 to 30.0; P = 0.018, 0.014, respectively], and vitrectomy after trabeculectomy for surgical failure with or without hypotony criteria (HR, 2.32, 4.06; 95% CI, 1.02 to 5.28, 1.30 to 12.7; P = 0.045, 0.016, respectively).

CONCLUSIONS

The long-term outcomes of trabeculectomy following intraocular bevacizumab injection for neovascular glaucoma were favorable. Lower baseline IOP was associated with development of significant hypotony, while additional vitrectomy was related to insufficient IOP reduction.

Surgical Management of Glaucoma After Congenital Cataract Surgery

PURPOSE

Cataract surgery in children is a difficult entity with possible complications, glaucoma being particularly common. The purpose of this study was to explore the results of surgical intervention for glaucoma after congenital cataract surgery in Alexandria University, Egypt.

METHODS

The study was a retrospective chart review of 32 children with glaucoma after congenital cataract surgery between 2005 and 2012. Preoperative, operative, and postoperative data were collected. Complications were noted. Success was studied at the end of follow-up.

RESULTS

The study included 41 (36 aphakic, 5 pseudophakic) eyes of 32 children undergoing 57 glaucoma surgical procedures. The mean ± standard deviation age at the time of surgery was 17.2 ± 21.6 months (range: 3.0 to 103.5 months) and the mean follow-up period was 39.1 ± 25.2 months (range: 1 to 75 months). The most common (78%) primary glaucoma surgical procedure was combined trabeculotomy-trabeculectomy with mitomycin C. The mean preoperative intraocular pressure, corneal diameter and thickness, cup-disc ratio, and axial length of the study eyes was 22.3 ± 6.1 mm Hg (range: 10 to 34 mm Hg), 11.4 ± 0.9 mm (range: 10 to 13 mm) and 617.6 ± 66.8 µm (range: 538 to 758 µm), 0.5 ± 0.3 mm (range: 0 to 1 mm), and 22.85 ± 2.75 mm (range: 18.55 to 29.17 mm), respectively, and postoperatively at last follow-up was 11.0 ± 7.3 mm Hg (range: 1 to 36 mm Hg), 11.5 ± 0.9 mm (range: 10 to 13 mm) and 576.8 ± 83.3 µm (range: 461 to 736 µm), 0.4 ± 0.3 mm (range: 0 to 1 mm), and 24.62 ± 2.81 mm (range: 19.70 to 32.81 mm), respectively. Success was reported in 34 (82.9%) eyes. Complications included endophthalmitis, hypotony disc edema, and retinal detachment.

CONCLUSIONS

Glaucoma after congenital cataract surgery is a difficult entity, often requiring more than one surgical procedure to control it. Long-term follow-up is mandatory to detect any failure of treatment at any time point and manage accordingly.

Intraocular Pressure Changes Post Selective Laser Trabeculoplasty in the Contralateral Untreated Eyes of Nigerian Patients With Primary Open Angle Glaucoma

BACKGROUND

Glaucoma is the commonest cause of irreversible blindness in Nigeria and raised intraocular pressure (IOP) is the only modifiable risk factor. Selective laser trabeculoplasty (SLT), one of the treatment modalities, has been reported to have a cross-over effect on the fellow untreated eyes.

OBJECTIVES

To determine the lOP lowering effect of SLT on the contralateral untreated eyes in patients with primary open angle glaucoma.

METHODS

This was a retrospective chart review of patients who underwent SLT at Guinness Eye Centre, Lagos from June 2011-June 2012. Information on bio-data, diagnosis and modality of treatment were retrieved. Excluded were patients who had glaucoma surgery or needed additional medications. Each patient had SLT in one eye either as primary or adjunctive treatment. IOPs were measured post-operatively in both treated and untreated eyes at various time points using the Goldmann applanation tonometer. Data was analysed using paired and unpaired two-tailed t-test for comparison of means with level of significance set at p<0.05.

RESULTS

Forty eyes of twenty subjects were included. 60% (12) were males and 40% (8) were females. The mean age was 48.9 +/- 17.0 years (range, 23-74 years). Reduction in IOP from baseline was found in both the treated and the fellow untreated eyes at the various time points. Mean IOP reduction was maximal at 3 months; 8 mmHg or 26% (p=0.024) in the treated eyes and 7 mmHg or 25.9% (p=0.097) in the untreated eyes. Mean IOP reduction from baseline-were 1.3 +/- 5.9mmHg or 6.3% (P=.624) in the treated eyes and 2.9 +/- 7.5 mmHg or 9.7% (P=.418) in the untreated eyes at 6 months.

CONCLUSION

This study shows that there is a sustained IOP reduction in the fellow untreated eyes following SLT in patients with POAG. In view of the retrospective nature of the study, small sample size, non-randomization and lack of control definite conclusions cannot be drawn from the findings.

Primary congenital glaucoma outcomes: lessons from 23 years of follow-up

PURPOSE

To determine in primary congenital glaucoma whether age of presentation influences surgical success, the degrees of angle surgery needed to achieve glaucoma control, and whether there are critical ages where glaucoma progresses, requiring further surgical management.

DESIGN

Retrospective cohort study.

METHODS

The medical records of patients with primary congenital glaucoma over a 23-year period were reviewed: 192 procedures were performed on 117 eyes (70 patients). The number and age of angle procedures and final visual acuity was analyzed. Surgical success was defined as stable intraocular pressure and optic disc appearance.

RESULTS

Procedures involving 83 of the 110 eyes (75.5%) undergoing angle surgery were successful, with 2-, 4-, 6-, and 10-year success rates of 92%, 86%, 84%, and 75%, respectively. Subgroup analysis (<3 months; 3-6 months; >6 months) comparing age of diagnosis to visual outcome (<20/200, 20/200-20/40, >20/40) was significant (P = .04). The age at first operation (P = .94), the number of angle operations (P = .43), and their effect on angle surgery success was not significant. Seven of 192 operations were performed after the age of 8 years (3.6%). After the initial angle surgeries within the first year of life, the third procedure occurred at a median age of 2.4 years (interquartile ratio [IQR] 0.6-3.8 years) and the fourth procedure occurred at a median age of 5.3 years (IQR 2.5-6.1 years).

CONCLUSIONS

Children diagnosed at <3 months of age had a visual outcome of <20/200 despite successful glaucoma control. Age of presentation did not affect surgical success. A total of 78.9% of cases undergoing primary trabeculotomy were controlled with 1 operation: 4 clock hours of angle (120 degrees). Analysis of glaucoma progression suggests critical ages where further glaucoma surgery is required at around 2 and 5 years of age.

ICE SYNDROME--CASE REPORT

Iridocorneal endothelial (ICE) syndrome encompasses a group of rare ocular pathologies with unilateral involvement, frequently affecting young women. The disease complex includes essential iris atrophy, Chandler's syndrome, and Cogan-Reese syndrome. In the following article, we present a case of Iridocorneal endothelial syndrome in which a late diagnosis was made and who underwent surgery for advanced glaucoma.

Ex-PRESS miniature glaucoma shunt in treatment of refractory glaucoma

Refractory glaucoma in a complicated type of glaucoma of different ethyologies with one same characteristic--intraocular pressure of great resistance to therapy. There are different methods of treatment in such glaucomas, primary surgical options. Ex-PRESS miniature glaucoma shunt implantation was our treatment of choice. In our group of patients we achieved stabile intraocular pressure values in 4 month period of time with no serious or unexpected complications.