Persistent hypotony after trabeculectomy: incidence and associated factors in the Collaborative Bleb-Related Infection Incidence and Treatment Study

Persistent Serous Choroidal and Retinal Detachment After Ab Interno Trabeculotomy for Glaucoma

We describe a case of serous retinal detachment (SRD) with ciliochoroidal detachment (CCD) that persisted for 2 years and 7 months after minimally invasive glaucoma surgery (MIGS). A 71-year-old woman with primary open angle glaucoma and cataracts had a central corneal thickness of 489 μm/492 μm and an ocular axis length of 24.05 mm/24.30 mm. She underwent phacoemulsification and intraocular lens implantation in the right eye (OD), along with goniosynechialysis and microhook ab interno trabeculotomy. Postoperative intraocular pressure was 4-6 mm Hg in the OD. Five months later, SRD was observed temporally and inferiorly to the macula, with increased choroidal thickness. Best-corrected visual acuity at 5 months was (1.2)/(1.2) (right eye [OD]/left eye [OS]), and intraocular pressure was 6 mm Hg/13 mm Hg. CCD in the OD was accompanied by choroidal vessel dilation and choroidal vascular hyperpermeability. Two years and 7 months postsurgery, intraocular pressure spiked to 50-54 mm Hg but settled at 12 mm Hg 1 week later. CCD resolved, and choroidal folds and SRD disappeared, with decreased choroid thickness. Two years and 10 months postoperatively, there was no SRD recurrence at 10 mm Hg on 2 antiglaucoma eye drops, and best-corrected visual acuity remained stable at (1.0)/(1.0). This case suggests that SRD may result from increased choroidal vessel permeability and retinal pigment epithelium dysfunction secondary to prolonged CCD/low IOP after MIGS. The prolonged disease course may be attributed to the balance between aqueous humor excretion and absorption, influenced by the limited size of the cyclodialysis cleft caused by MIGS.

Factors associated with recurrence of bleb-related infections

PURPOSE

To identify the risk factors for a recurrence of a bleb-related infection (BRI).

STUDY DESIGN

Retrospective cohort study.

METHODS

The medical records of all patients diagnosed with BRI at Gifu University Hospital between January 1989 and December 2020 were reviewed. The time when conjunctival hyperemia could not be detected and when the anterior chamber was quiet were defined as the resolution time of the BRI. The primary endpoint was a recurrence of a BRI. Kaplan-Meier estimation and the Cox proportional hazards model were used to determine the risk of a recurrence from the initial onset data of each eye. Bacteriological studies were performed to determine the pathogen causing the BRI.

RESULTS

There were 108 eyes of 103 patients followed for at least 3 months after the initial BRI. A recurrent bleb infection developed in 21 (19.4%) eyes of 21 patients (13 men, 8 women). Log-rank test at the 10-year follow-up examination revealed that hypotony at the onset of the BRI (P=0.004), the prophylactic use of topical antibiotics at the onset of the BRI (P=0.046), and bleb leakage after the resolution of the BRI (P=0.021) were significantly associated with a BRI recurrence. Cox proportional hazards model showed that ocular hypotony at the onset of the BRI (unadjusted, P=0.007; adjusted for bleb leakage, P=0.015) and bleb leakage after the resolution of the BRI (unadjusted, P=0.027; adjusted for hypotony, P=0.024) were significantly associated with a BRI recurrence. Other factors were not significantly associated with the recurrence of a BRI.

CONCLUSION

We recommend close observations when a bleb leakage is detected after the BRI has resolved.

Micropulse Transscleral Cyclophotocoagulation as Primary Surgical Treatment for Primary Open Angle Glaucoma in Taiwan during the COVID-19 Pandemic

Glaucoma is the leading cause of irreversible blindness worldwide, with primary open angle glaucoma (POAG) accounting for the greatest number of total glaucoma cases. This study aimed to evaluate the efficacy and safety of micropulse transscleral cyclophotocoagulation (MP-TSCPC) as a primary procedure in POAG during the COVID-19 pandemic. We retrospectively analyzed 60 eyes of 52 patients, who were diagnosed with mild-to-end-stage POAG without previous glaucoma surgery and received MP-TSCPC between 1 January 2020 and 31 August 2020. The mean preoperative intraocular pressure (IOP) significantly decreased from 27.8 mm Hg to 19.8, 20.1, 20.3, 20.4, and 20.2 mm Hg at 1, 3, 6, 9, and 12 months, respectively (all p < 0.05). The mean number of IOP-lowering medications used significantly decreased from 3.3 at the baseline to 1.6, 1.8, 1.8, 1.9, and 1.9 at 1, 3, 6, 9, and 12 months, respectively (all p < 0.001). Total withdrawal of antiglaucoma medications was fulfilled in five patients. The main outcome was achieved in 81.7% at postoperative month 12. The most common adverse effect was transient mydriasis (28.3%). No major complications were encountered. MP-TSCPC seems to be an effective and safe treatment to reduce IOP and the medication burden with minimal vision-threatening complications in mild-to-end-stage POAG patients without previous glaucoma surgery.

Bleb Compressive Sutures in the Management of Hypotony Maculopathy after Glaucoma Surgery

PURPOSE

The aim of the study was to assess the efficacy and safety of compressive sutures in patients with hypotony maculopathy after glaucoma surgery.

METHODS

This retrospective case series analyzes the clinical outcomes of conjunctival compressive sutures in 17 patients with hypotony maculopathy developed after glaucoma surgery. Compressive Nylon 10-0 single sutures were used in all patients; in two patients, the procedure was repeated. All patients underwent ophthalmic evaluation and macular OCT scanning before the surgery, one month, six months, and one year after the procedure.

RESULTS

Mean intraocular pressure (IOP) before suturing was 2.3 ± 1.57 mmHg and increased to 14.2 ± 7.03 mmHg (p = 0.00065) one month after the procedure. After six months, mean IOP was 10.2 ± 4.3 mmHg (p = 0.005), and after one year ± 4.7 mmHg (p = 0.0117). To obtain the target pressure, the sutures had to be removed in one patient, and medical therapy was undertaken in three patients. Mean decimal best-corrected visual acuity (BCVA) before the sutures was 0.18 ± 0.13 and increased to 0.53 ± 0.25 (p = 0.0004) after one month, to 0.46 ± 0.31 (p = 0.005) after six months, and to 0.31 ± 0.22 (p = 0.025) after one year. In one case, leakage from the bleb was observed after the procedure and bleb revision was required.

CONCLUSIONS

transconjuctival compressive sutures seem to be an efficient and safe technique for managing hypotony maculopathy after glaucoma surgery.

iStent Trabecular Microbypass Stent Implantation with Phacoemulsification in Patients with Open-Angle Glaucoma: 6-Year Outcomes

Purpose

To investigate the long-term safety and efficacy of an iStent trabecular microbypass stent in combination with cataract surgery in eyes with primary open-angle glaucoma (POAG).

Setting

Private practice; Sioux Falls, South Dakota.

Design

Retrospective, consecutive case series.

Methods

This case series included eyes implanted with a single trabecular microbypass stent in combination with phacoemulsification in patients with mild to severe POAG. Data were collected preoperatively and at day 1, week 1, month 1, and up to 6 years postoperatively. Primary outcome measures included mean intraocular pressure (IOP) and number of glaucoma medications. Safety was noted by assessing the incidence of IOP spikes and need for additional surgery.

Results

The study comprised 411 eyes. Mean IOP was reduced to 14.9±4.2 mmHg compared to 18.8±5.6 mmHg at baseline at 6 years postoperative. The mean number of medications was reduced to 1.2±1.0 from 1.4±1.1 at baseline. In eyes with severe stage of disease, there was a mean IOP reduction >6 mmHg at 6 years postoperative. Eyes with baseline IOP ≥18 mmHg achieved a more robust reduction in IOP. Fifteen eyes underwent a secondary glaucoma procedure. There were no intra- or postoperative complications.

Conclusion

Trabecular microbypass stent implantation in combination with cataract surgery provides a sustained IOP reduction in eyes with mild-to-severe POAG. The degree of IOP reduction was more significant in eyes with higher baseline IOP and severe stage of disease.

Serous retinal detachment accompanied by pachychoroid in hypotony maculopathy after trabeculectomy for diabetic neovascular glaucoma

Purpose

Two diabetic case reports of serous retinal detachment (SRD) accompanied by pachychoroid in hypotony maculopathy after trabeculectomy for neovascular glaucoma (NVG).

Observations

Case 1: A 66-year-old female with stage 3 NVG and decreased vision acuity in the left eye. After trabeculectomy, postoperative laser suture lysis (LSL) resulted in development of hypotony maculopathy, followed by pachychoroid and SRD. Injection of C3F8 gas in the anterior chamber was unsuccessful and transconjunctival scleral re-suturing was performed. Intraocular pressure (IOP) consequently increased and SRD improved. Case 2: A 60-year-old man with stage 2 NVG and decreased vision acuity in the right eye. Trabeculectomy was uneventful, but postoperative LSL also resulted in development of hypotony maculopathy followed by pachychroid and SRD. Intravitreal bevacizumab injection had no effect and transconjunctival flap re-suturing was performed. IOP consequently increased and SRD improved.

Conclusions

SRD accompanied by pachychoroid was observed in hypotony maculopathy in diabetic cases. VEGF-independent exudative change in hypotony maculopathy may be due to hydrostatic pressure elevation in choroidal blood vessels based on Starling's hypothesis with the consequent breakdown of retinal pigment epithelium barrier in diabetic patients.

Effectiveness of trabeculectomy with mitomycin C for glaucomatous eyes with low intraocular pressure on treatment eye drops

PURPOSE

To examine the efficacy and safety of current trabeculectomy with mitomycin C in Japan for glaucomatous eyes with low intraocular pressure (IOP).

METHODS

Two hundred ninety-four eyes of 294 patients with IOP ≤21 mmHg before surgery were studied; all patients were participants in the Collaborative Bleb-related Infection Incidence and Treatment Study (CBIITS), a multicentre, prospective, cohort study conducted at 34 ophthalmological institutions throughout Japan. All eyes had an intraocular pressure ≤ 21 mmHg and had undergone trabeculectomy alone or phacotrabeculectomy. Two success criteria were used: Criterion A comprised 20% reduction of baseline IOP and Criterion B comprised 30% reduction of baseline IOP. The primary outcome was the success rate for each of these criteria.

RESULTS

The qualified success rates were 87.3% for Criterion A and 42.0% for Criterion B at 5 years. Mean IOP was significantly reduced, from 16.7 ± 2.7 to 11.6 ± 4.0 mmHg at 5 years after trabeculectomy (p < 0.0001); the number of anti-glaucoma medications significantly decreased from 2.7 ± 1.1 to 1.0 ± 1.2 (p < 0.0001) at 5 years after the surgery. Three or more trabeculectomies, and needling were related to increased risk of failure. Incidences of postoperative hyphema, infection, shallow anterior chamber and bleb leakage were 2.4%, 2.4%, 2.0% and 3.4%, respectively.

CONCLUSIONS

This study showed that trabeculectomy with mitomycin C is an effective procedure with few surgical complications for reducing IOP in patients, even if preoperative IOP was within the normal range.

Choroidal detachments: what do optometrists need to know?

Choroidal detachments occur when there is an accumulation of fluid or blood in the suprachoroidal space, a potential space situated between the choroid and the sclera. They are an uncommon ocular pathology. The most common cause of choroidal detachment is secondary to trabeculectomy; however, there are other causes such as trauma and inflammation. Clinically, choroidal detachments may vary in presentation from asymptomatic, to very poor vision, severe ocular pain, vomiting and nausea. Ocular findings associated with choroidal detachments include serous retinal detachment, secondary angle closure, and a very shallow anterior chamber. Optometrists, as primary eye care providers, need to be aware of the clinical signs and symptoms associated with choroidal detachments and ensure that appropriate and timely management, with a referral to an ophthalmologist, is instigated for optimal visual outcomes. In this review, the pathophysiology, detection, and associated risk factors for choroidal detachments are discussed, and evidence-based management recommendations in an optometric context are provided. The characteristics and management of uveal effusion syndrome are also reviewed, as this can cause idiopathic exudative choroidal detachments distinct from classical choroidal detachment.

22q11.2 microduplication syndrome and juvenile glaucoma

BACKGROUND

22q11.2 microduplication is a relatively recently recognized syndrome. Findings in affected individuals range from apparent normality to a wide variety of systemic and ocular conditions. We describe the association between 22q11.2 microduplication and juvenile glaucoma in two brothers.

MATERIALS AND METHODS

We reviewed ophthalmological, genetic, and hematological medical records of two patients and their unaffected mother.

RESULTS

A 2.07 Mb interstitial duplication in 22q11.21 and a smaller 182 kb duplication in 22q11.23 were identified in both subjects. Patient 1 showed an initial intraocular pressure (IOP) of 15 mmHg in right eye (RE) and 32 mmHg in left eye (LE) under maximum medical treatment. Deep sclerectomy surgery in LE was converted to trabeculectomy due to a macroperforation of the trabeculo-descemetic membrane. Postoperatively, the patient developed persistent hypotony with retinal folds, while IOP in RE increased to 28 mmHg. Trabeculectomy in RE was also complicated by persistent hypotony. Autologous blood injection was performed, resulting in an increase in both visual acuity and IOP. Patient 2 presented with an IOP of 29 mmHg in RE and 33 mmHg in LE. We planned an elective trabeculectomy and added orally administered acetazolamide. The patient developed bilinear cytopenia that contraindicated the surgical procedure. After hematologic normalization, the patient underwent trabeculectomy in LE, causing persistent hypotony. We performed deep sclerectomy surgery in RE, without any significant intra- or post-operative complications.

CONCLUSIONS

22q11.2 microduplication syndrome can be associated with juvenile glaucoma. Trabeculectomy may be complicated by persistent hypotony. Deep sclerectomy appears to be a better surgical option, although the presence of a thin sclera may result in conversion to trabeculectomy.

The effect of trabeculectomy surgery on the central visual field in patients with glaucoma using microperimetry and optical coherence tomography

PURPOSE

To determine the functional and structural effects of trabeculectomy surgery on patients with advanced glaucoma and central visual field defects in the early post-operative period.

METHODS

Thirty consecutive adult subjects with advanced glaucoma requiring trabeculectomy surgery and an established visual field defect within 10° of fixation underwent microperimetry (MAIA MP-1, CenterVue, Padova, Italy) and optic disc optical coherence tomography (OCT) imaging (Spectralis, Heidelberg Engineering, Germany) pre-operatively, and 1 month and 3 months following trabeculectomy surgery. Main outcome measures were post-trabeculectomy change in mean threshold on microperimetry and nerve fibre layer thickness on OCT. Fellow eyes were used as controls.

RESULTS

The mean change in MP average threshold values from pre-operative to post-operative was 0.6 ± 1.9 dB for treated eyes and 0.1 ± 1.3 dB for control eyes (p = 0.14) at 1 month and 0.2 ± 2.3 and -0.3 ± 1.6 dB at 3 months (p = 0.22). Mean change in global nerve fibre layer thickness was -0.6 and -0.5 µm for operated and control eyes, respectively (p = 0.83), at 1 month and 0.8 and -0.4 µm at 3 months (p = 0.88). The kappa agreement for structure-function correlation between OCT and MP was 0.735 (confidence interval 0.59-0.88) (p < 0.005).

CONCLUSIONS

Central visual function and retinal nerve fibre layer thickness appear to be preserved in glaucoma patients with central visual field defects undergoing trabeculectomy surgery in the early post-operative period. These data may inform glaucoma surgeons considering trabeculectomy surgery in this patient group.

Surgical Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Patients With Open-angle Glaucoma

PURPOSE

To evaluate the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in patients with open-angle glaucoma.

PARTICIPANTS AND METHODS

A retrospective chart review of adult patients who underwent GATT due to inadequately controlled intraocular pressure (IOP) or intolerance to medication. Main outcome measures were success rate, IOP, and number of glaucoma medications. Success was defined as IOP reduction >20% from baseline or IOP between 5 to 21 mm Hg, and no need for further glaucoma surgery. When success criteria were not met for any postoperative visit >3 months after surgery, failure was determined.

RESULTS

In total, 66 patients, average age 62.9±14.9 years (50.8% female) were included in the analysis. Average follow-up was 11.9 months (range, 3 to 30 mo) and overall success rate was 63.0%. Mean IOP was 26.1±9.9 mm Hg preoperatively and 14.6±4.7 mm Hg at 12 months (44% IOP decrease; P<0.001). Mean number of medications decreased from 3.1±1.1 preoperatively to 1.2±0.9 at 12 months (P<0.001). No significant differences between patients with primary open-angle glaucoma and other types of glaucoma were found.The rate of hyphema at 1 week and 1 month postoperatively was 38% and 6%, respectively. Overall GATT success rate among white and black patients was 69% and 42%, respectively, which was statistically significant (P<0.05).

CONCLUSIONS

The future of GATT as a minimally invasive glaucoma surgery in adults seems promising. This position is supported by its low rate of long-term complications and the conjunctiva-sparing nature of the surgery.

Innovations in glaucoma surgery from Dr. Rajendra Prasad Centre for Ophthalmic Sciences

Trabeculectomy surgery is the current standard of care in glaucoma for achieving a low target intraocular pressure if medical therapy is not adequate. Augmentation of trabeculectomy with antimetabolites brought a revolutionary change in the long-term success rates of trabeculectomy, but along with it came a plethora of complications. There still is a big window for therapeutic innovations on this subject. The foremost target for these innovations is to modulate the wound healing response after glaucoma drainage surgery. Achieving the desired balance between long-term success of filtering blebs versus early failure due to scarring of blebs and hypotony due to dysfunctional filtering blebs poses a unique challenge to the ophthalmologists. Alternatives to trabeculectomy such as glaucoma drainage devices and minimally invasive glaucoma surgeries cannot solve the problem of glaucoma blindness in our country, mainly due to their unpredictable results and unfavorable cost-benefit ratio. In this article, we present a summary of our innovations in glaucoma surgery to advance patient care by making it more effective, safer, and economical.

Incidence of short-term complications and associated factors after primary trabeculectomy in Chiang Mai University Hospital

BACKGROUND

To determine the incidence of early postoperative complications and associated factors after primary trabeculectomy in Thai glaucoma patients.

DESIGN

This was a retrospective observational study performed in Chiang Mai University Hospital.

PARTICIPANTS

One hundred and eighteen glaucoma patients participated in the study.

METHODS

All glaucoma patients underwent primary trabeculectomy with mitomycin C (MMC) using fornix-based conjunctival flap technique between December 2011 and May 2013. Surgical complications during the first 3 months of follow-up were recorded, and associated risk factors were analyzed.

MAIN OUTCOME MEASURES

The incidence of posttrabeculectomy complications was the main outcome measure.

RESULTS

One hundred and eighteen eyes of 118 patients were included. Early postoperative complications developed in 55 eyes (56.7%). Complications included hypotony (25 eyes, 27.2%), serous choroidal detachment (CD) (14 eyes, 15.6%), subconjunctival hemorrhage (12 eyes, 13.0%), hyphema (11 eyes, 12.4%), bleb leak (8 eyes, 8.8%), encapsulated bleb (2 eyes, 2.2%), aqueous misdirection (1 eyes, 1.1%), corneal epithelial defect (1 eyes, 1.1%), and overfiltration (1 eyes, 1.1%). There were no reported cases of endophthalmitis or blebitis. Hypotony was associated with serous CD (P = 0.006), and hyphema was associated with neovascular glaucoma (NVG) patients (P = 0.009). NVG was not associated with the increased rate of surgical failure (P = 0.083).

CONCLUSIONS

The incidence of early complications after first-time trabeculectomy with MMC was high (56.7%) in this Thai clinic setting, but most were transient and self-limited conditions. The correlations between hypotony and CD as well as hyphema and NVG were compatible with the previous studies.

Changes in anterior ocular structures and macula following deep sclerectomy with collagen implant

PURPOSE

To determine the effect of intraocular pressure (IOP) lowering with deep sclerectomy (DS) on visual acuity, macular structures, and anterior ocular dimensions during the early postoperative period.

METHODS

We prospectively analyzed 35 eyes of 35 patients scheduled for DS. Our focus with the measurements was on early postoperative changes in anterior ocular and macular structures related to IOP lowering during the first month after DS. In addition to a clinical ophthalmologic examination, our measurements included corneal topography, measurement of ocular dimensions with optical biometry, and examination of macular structure with optical coherence tomography. These measurements were repeated 1, 2, and 4 weeks postoperatively.

RESULTS

Best-corrected visual acuity (BCVA) decreased 1 week postoperatively to 0.22 (0.20) LogMAR (p = 0.006). The BCVA then increased to its preoperative level, 0.17 (0.18) (p = 0.28), after 4 weeks. Axial length decreased from 24.12 (1.81) mm to 24.04 (1.81) (p<0.001) 4 weeks postoperatively. The steeper meridian of corneal curvature and average corneal power increased postoperatively; central corneal thickness was decreased. No significant change appeared in other measurements.

CONCLUSIONS

We found changes in corneal curvature and ocular dimensions after DS. These changes were relatively small and do not completely explain the decrease in visual acuity postoperatively. Macular structures showed no changes.

Impact of intraocular pressure reduction on visual field progression in normal-tension glaucoma followed up over 15 years

PURPOSE

To investigate the impact of surgical or medical reduction of intraocular pressure (IOP) on progressive normal-tension glaucoma followed up over 15 years.

METHODS

Sixty eyes of 60 patients were divided into 3 intervention groups: group 1 (trabeculectomy, n = 17); group 2 (IOP reduction rate ≥15% with prostaglandin analogs, n = 24); and group 3 (IOP reduction rate <15% with prostaglandin analogs, n = 19). The preintervention and postintervention mean deviation (MD) slopes and IOP were compared. Factors associated with the rate of visual field progression were identified by multiple regression analysis.

RESULTS

The mean follow-up was 19.8 years. In group 1, the preintervention and postintervention IOPs were 14.7 ± 1.3 and 9.1 ± 2.0 mmHg, respectively (P < .001, 38% reduction). The MD slope decreased significantly after trabeculectomy (-0.86 ± 0.51 versus -0.19 ± 0.20 dB/y; P < .001). In group 2, the preintervention and postintervention IOPs were 14.7 ± 1.5 and 11.7 ± 1.2 mmHg, respectively (P < 0.001, 20% reduction), with significant differences in the MD slope (-0.52 ± 0.37 versus -0.31 ± 0.30 dB/y; P = .019). In group 3, the preintervention and postintervention IOPs were 14.4 ± 1.8 and 13.2 ± 1.6 mmHg, respectively (P < 0.001, 8% reduction), with no differences in the MD slope (-0.40 ± 0.27 versus -0.50 ± 0.65 dB/y; P > .05). Multiple regression analysis showed that the average IOP, IOP reduction rate, and preintervention MD slope were related to the extent of the postintervention reduction in the MD slope. The difference in the preintervention and postintervention MD slopes significantly correlated with the rate of IOP reduction (r = 0.559, P < .001).

CONCLUSIONS

A pressure-dependent maintenance effect of the visual field was confirmed in progressive normal-tension glaucoma.