Trabeculectomy bleb-associated infections

Comparison between MIGS with trabeculectomy in the management of open-angle glaucoma with cataract: A systematic review

Age is an important risk factor for both glaucoma and cataract. As global life expectancy continues to rise, the prevalence of concomitant open-angle glaucoma (OAG) and cataracts is increasing. Currently, there is a lack of definitive consensus on the optimal management approach for such individuals. Conventionally, trabeculectomy (Trab) in combination with phacoemulsification is the preferred method. Recent developments in microinvasive glaucoma surgery (MIGS), which offer similar results with fewer complications, provide a new possible approach to this condition. This study aimed to assess the current knowledge of combination surgery in patients with cataract and OAG to provide a comprehensive understanding and help its implementation in clinical settings. A comprehensive systematic search was conducted in May 2021 on five databases (MEDLINE, Embase, SCOPUS, Proquest, EBSCO, and Cochrane Library). The results were filtered for English and human studies but not publication year. All studies published up to May 2021 were reviewed. Newcastle-Ottawa Scale and PEDro scale were used to screen studies for risk of bias where appropriate. Four studies satisfied the inclusion criteria and were subsequently added in this review. Study designs consisted of one RCT and three descriptive studies. Appropriate assessment tools were used; these studies demonstrated moderate to good quality. Postoperative mean IOP, IOP reduction, and qualified success rates were comparable in the Phaco-MIGS (Phaco-endoscopic cyclophotocoagulation (ECP), Phaco-ab interno trabeculectomy (AIT)) and Phaco-Trab group. Severe complication was reported only in the latter. Phaco-MIGS (in particular, trabectome) shows excellent promise as an option for individuals with OAG and concomitant cataract; further research through RCT is required to validate these findings.

Two-year outcomes of anterior versus posterior scleral application of mitomycin C-soaked sponge in trabeculectomy

PURPOSE

To compare the safety and efficacy of two different application methods of mitomycin C (MMC)-soaked sponge in trabeculectomy.

STUDY DESIGN

Retrospective study.

METHODS

We included 71 eyes of 71 patients that had undergone trabeculectomy. In the anterior scleral application group, 36 eyes were treated using the long side of the MMC-soaked sponge placed parallel to the limbus. The efficacy and safety in these eyes were compared with eyes treated with the posterior scleral application group, consisting of 35 eyes treated with the long side of the MMC-soaked sponge placed perpendicular to the limbus. The follow-up period was 2 years. The safety of the procedure, including bleb morphology and complications, was the primary outcome, while the success rate was the secondary outcome.

RESULTS

The cumulative success rate at 2 years postoperatively was 94.4% in the anterior and and 94.3% in the posterior scleral application group (P = 1.000). However, with the posterior scleral application of the MMC-soaked sponge, blebs were more low-lying (P = 0.048), less in extent (P < 0.001), more normally vascularized (P = 0.027) and more posteriorly directed (P < 0.001). Furthermore, the incidence of thin-walled cystic bleb (P = 0.028) and bleb leakage (P = 0.025) was significantly lower in the posterior scleral application group than in the anterior group.

CONCLUSION

Although there were similar success rates, the posterior scleral application of MMC-soaked sponge with trabeculectomy was safer with a better bleb morphology than the anterior scleral application.

Phacogoniotomy versus phacotrabeculectomy for advanced primary angle-closure glaucoma with cataract: A randomized non-inferiority trial

PURPOSE

To investigate the effectiveness and safety of phacogoniotomy versus phacotrabeculectomy (PVP) among patients with advanced primary angle-closure glaucoma (PACG) and cataracts.

DESIGN

Multicenter, randomized controlled, non-inferiority trial.

METHODS

A total of 124 patients (124 eyes) with advanced PACG and cataracts were enrolled, with 65 in the phacogoniotomy group and 59 in the phacotrabeculectomy group. Patients were followed up for 12 months with standardized evaluations. The primary outcome was the reduction in intraocular pressure (IOP) from baseline to 12 months postoperatively, of which a non-inferiority margin of 4 mmHg was evaluated. Secondary outcomes included the cumulative surgical success rate, postoperative complications, and changes in the number of glaucoma medications.

RESULTS

After 12 months, phacogoniotomy demonstrated non-inferiority to phacotrabeculectomy in terms of IOP reduction, with mean IOP reductions of - 26.1 mmHg and - 25.7 mmHg (P = 0.383), respectively, from baseline values of around 40 mmHg. Both groups experienced a significant reduction in the mean number of medications used postoperatively (P < 0.001). The cumulative success rate was comparable between the groups (P = 0.890). However, phacogoniotomy had a lower rate of postoperative complications and interventions (12.3% and 4.6%) compared to phacotrabeculectomy (23.7% and 20.3% respectively). The phacogoniotomy group reported shorter surgery time (22.1 ± 6.5 vs. 38.8 ± 11.1 min; P = 0.030) and higher quality of life (EQ-5D-5 L) improvement at 12 months (7.0 ± 11.5 vs. 3.0 ± 12.9, P = 0.010) than the phacotrabeculectomy group.

CONCLUSIONS

Phacogoniotomy was non-inferior to phacotrabeculectomy in terms of IOP reduction for advanced PACG and cataracts. Additionally, phacogoniotomy provided a shorter surgical time, lower postoperative complication rate, fewer postoperative interventions, and better postoperative quality of life.

Bleb-related infection after primary trabeculectomy: medical chart reviews from 1993 to 2021

BACKGROUND

To investigate the incidence of and risk factors for bleb-related infection (BRI) in patients who underwent mitomycin C-augmented primary trabeculectomy.

METHODS

We reviewed the medical charts of consecutive patients who had received primary trabeculectomy in Taipei Veterans General Hospital. We recorded the demographic and clinical characteristics of patients before, during and after surgery. Furthermore, we recorded the time interval between surgery and infection onset, clinical manifestations and visual outcomes of patients with BRI. The cumulative incidence of BRI was estimated using the Kaplan-Meier method. A Cox proportional hazards model was used to explore factors associated with BRI.

RESULTS

In total, 1663 eyes were postoperatively followed up for 94.57±65.23 months. The cumulative incidence of BRI was 1.86 per 1000 person-years during the 28-year follow-up period: 24 (1.44%) patients developed BRI and 6 (0.36%) patients additionally developed endophthalmitis. A multivariate analysis revealed a significant association of BRI with wound manipulation, high myopia and hyperlipidaemia. Patients younger than 60 years were more likely to receive wound manipulation than their elderly counterparts (<0.001). One year after BRI, the best corrected visual acuity of the eyes with blebitis did not change significantly, whereas that of the eyes with endophthalmitis worsened significantly.

CONCLUSION

Risk factors for BRI after trabeculectomy include wound manipulation, high myopia and hyperlipidaemia. Considering myopia is highly prevalent throughout the world and is a risk factor for glaucoma, the lifelong risk of BRI after trabeculectomy in eyes with high myopia warrants the attention of ophthalmologists.

Tongqiao Mingmu formula alleviates retinal ganglion cell autophagy through PI3K/AKT/mTOR pathway

Glaucoma is a severe blindness-causing optic nerve disease characterized by a loss of retinal ganglion cells (RGCs). Previous studies have shown that the Tongqiao Mingmu (TQMM) formula can reduce retinal and optic nerve damage, but its mechanism of action requires further elucidation. In this study, an RGC injury model was prepared using glutamate and then treated with serum-containing drug from the TQMM formula (hereafter called "TQMM formula serum"). In the glutamate-induced RGC injury model, cell viability decreased with an increase in glutamate concentration, whereas the expression of autophagy-related biomarkers LC3 and Belicin-1 increased. An adenovirus transfection experiment revealed that glutamate markedly promoted autophagic flux in RGCs. Notably, TQMM formula serum inhibited the expression of autophagy-related biomarkers, reduced autophagy flux, and reversed the damage caused by glutamate to RGCs. Furthermore, the PI3K inhibitor LY294002 was used to intervene in the RGC autophagy model and was found to suppress the PI3K/AKT/mTOR pathway and enhance RGC autophagy. However, TQMM formula serum could generate an opposite effect and upregulate the expressions of the PI3K/AKT/mTOR pathway genes and proteins. In conclusion, the TQMM formula can prevent glutamate-induced autophagy in RGCs, possibly by activating the PI3K/AKT/mTOR pathway and reducing the expression of autophagy-related biomarkers LC3 and Belicin-1 to attenuate autophagy and maintain RGC viability.

Glaucoma: now and beyond

The glaucomas are a group of conditions leading to irreversible sight loss and characterised by progressive loss of retinal ganglion cells. Although not always elevated, intraocular pressure is the only modifiable risk factor demonstrated by large clinical trials. It remains the leading cause of irreversible blindness, but timely treatment to lower intraocular pressure is effective at slowing the rate of vision loss from glaucoma. Methods for lowering intraocular pressure include laser treatments, topical medications, and surgery. Although modern surgical innovations aim to be less invasive, many have been introduced with little supporting evidence from randomised controlled trials. Many cases remain undiagnosed until the advanced stages of disease due to the limitations of screening and poor access to opportunistic case finding. Future research aims to generate evidence for intraocular pressure-independent neuroprotective treatments, personalised treatment through genetic risk profiling, and exploration of potential advanced cellular and gene therapies.

Safety and Efficacy of Goniotomy following Failed Surgery for Glaucoma

PRCIS

Goniotomy (GT) is an alternative surgery for patients with prior failed surgery for glaucoma.

PURPOSE

To evaluate the efficacy and safety of GT in patients with prior failed surgery for glaucoma.

MATERIALS AND METHODS

A prospective, observational multicentered study was performed for patients who underwent GT with prior single or multiple surgery for glaucoma. Outcome measures included intraocular pressure (IOP) change, best-corrected visual acuity change, ocular hypotensive medication use, and occurrence of adverse events through 12 months. Complete success was defined as a postoperative IOP within 6-18 mmHg and a 20% reduction from baseline without ocular hypotensive medications. Qualified success was the same as the definition of complete success, except for postoperative use of medication. Logistic regression models were used to investigate the potential factors for surgical success.

RESULTS

A total of 38 eyes of 34 patients were included. Twenty-three eyes had only 1 prior surgery, 13 eyes had 2 prior surgeries, 1 eye had 3 prior surgeries, and 1 eye had 4 prior surgeries. At month 12, there was complete success in 42.1% of the eyes and qualified success in 78.9% of the eyes. Preoperatively, the mean IOP was 29.4±6.9 mmHg and the median number of glaucoma medications used was 3.0 (2.0, 4.0); this decreased to 16.7±3.6 mmHg (43.2% reduction; P <0.001) and 2.0 (0.0, 3.0) ( P <0.001) at month 12, respectively. The most common complications included hyphema (13.2%), IOP spike (7.9%), and corneal edema (5.2%). Older age significantly contributed to surgical success.

CONCLUSIONS

GT seems to be a safe and effective procedure for patients with prior failed surgery for glaucoma.

Ahmed to Baerveldt glaucoma drainage device exchange in pediatric patients

BACKGROUND

There is no consensus and few reports as to the surgical management of encapsulated Ahmed glaucoma drainage devices (GDD) which no longer control intraocular pressure (IOP), especially within the pediatric population. The purpose of this study was to report outcomes of exchanging the Ahmed GDD for a Baerveldt GDD in children with refractory glaucoma.

METHODS

Retrospective review of children (< 18yrs) who underwent removal of Ahmed FP7 and placement of Baerveldt 350 (2016-2021) with ≥ 3-month follow-up. Surgical success was defined as IOP 5-20 mmHg without additional IOP-lowering surgeries or visually devastating complications. Outcomes included change in best-corrected visual acuity (BCVA), intraocular pressure (IOP), and number of glaucoma medications.

RESULTS

Twelve eyes of 10 patients underwent superotemporal Ahmed FP7 to Baerveldt 350 GDD exchange at 8.8 ± 3.6 years. Time to Ahmed failure was 2.7 ± 1.9 years with 1-, 3-, and 5-year survival rates of 83% with a 95% CI[48,95], 33% with a 95% CI[10, 59], and 8% with a 95% CI[0, 30]. At final follow-up (2.5 ± 1.8 years), success rate for Baerveldt 350 GDDs was 75% (9 of 12 eyes) with 1 and 3-yr survival rates of 100% and 71% with 95% CI[25,92], respectively. IOP (24.1 ± 2.9 vs. 14.9 ± 3.1 mmHg) and number of glaucoma medications (3.7 ± 0.7 vs. 2.7 ± 1.1) were significantly decreased (p < 0.004). BCVA remained stable. Two eyes required cycloablation and 1 eye developed a retinal detachment.

CONCLUSIONS

Ahmed removal with Baerveldt placement can improve IOP control with fewer medications in cases of refractory pediatric glaucoma. However, more eyes with greater follow-up are required to determine long-term outcomes.

Endophthalmitis and blebitis following deep sclerectomy and trabeculectomy with routine use of mitomycin C

PURPOSE

The purpose of the study was to investigate the incidence for endophthalmitis and blebitis after deep sclerectomy (DS) and trabeculectomy with routine use of Mitomycin C (MMC) 0.4 mg/ml.

METHODS

Electronic medical records of patients who underwent surgery 1/2008-4/2020 were reviewed. Cumulative incidence for bleb-associated infection (BAI), including both endophthalmitis and blebitis, was calculated with cumulative incidence function (CIF) and Kaplan-Meier analysis. Risk factors for BAI were evaluated with univariate competing risk regression analysis and Log-rank analysis. Competing event in CIF was death.

RESULTS

In this retrospective single-centre cohort study, a total of 2653 patients and 3411 eyes underwent surgery: 3478 glaucoma surgeries, 2419 DS and 1059 trabeculectomies. Two cases of endophthalmitis and three of isolated blebitis developed. Median follow-up from the most recent surgery on the eye until the end of the study was 5.5 years, and until last visit at the ophthalmology department was 1.9 years. For the whole follow-up period in CIF-analysis, cumulative incidence for BAI was 0.16% (95% CI 0.06-0.36) at five years. Incidence was higher with eyes not treated with an antifibrotic during surgery (sub-hazard ratio 11.66, 95% CI 1.94-70.21, p = 0.007). Cumulative incidence between surgery and last visit with Kaplan-Meier analysis was 0.21% (95% CI 0.08-0.52) at five years, similarly, not using an antifibrotic increased incidence (Log-rank p < 0.001).

CONCLUSION

Cumulative incidence for BAI was low despite routine use of high-dose MMC.

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.

Bleb-related Porcine Lymphatic Outflow is Greater from Subconjunctival compared to Subtenon Blebs

Aim

Understanding the mechanism of fluid outflow by comparing the subconjunctival and subtenon spaces can lead to improved ocular therapeutics. The purpose of the current study is to evaluate subconjunctival vs subtenon lymphatic outflow by creating tracer-filled blebs in each location.

Methods

Porcine (n = 20) eyes received subconjunctival or subtenon injection(s) of fixable and fluorescent dextrans. Blebs were angiographically imaged using a Heidelberg Spectralis ([Heidelberg Retina Angiograph] HRA + OCT; Heidelberg Engineering) and bleb-related lymphatic outflow pathways were counted. Optical coherence tomography (OCT) imaging of these pathways was used to assess structural lumens and the presence of valve-like structures. Furthermore, a comparison between tracer injection locations (superior/inferior/temporal/nasal) was made. Histologic analyses for subconjunctival and subtenon outflow pathways were performed, to confirm tracer co-localization with molecular lymphatic markers.

Results

Subconjunctival blebs demonstrated a greater number of lymphatic outflow pathways compared to subtenon blebs in every quadrant [superior: 6.10 ± 1.18 (subconjunctival) vs 0.50 ± 0.27 (subtenon); temporal: 2.30 ± 0.40 vs 0.10 ± 0.10; nasal: 5.30 ± 0.60 vs 0.30 ± 0.21; inferior: 6.00 ±1.29 vs 0.1 ± 0.1; all comparisons p < 0.001]. For subconjunctival blebs, the temporal quadrant showed fewer lymphatic outflow pathways compared to the nasal side (p = 0.005).

Discussion

Subconjunctival blebs accessed greater lymphatic outflow compared to subtenon blebs. Furthermore, regional differences existed, with fewer lymphatic vessels temporal than at the other locations.

Clinical significance

Aqueous humor drainage after glaucoma surgery is incompletely understood. The present manuscript adds to our understanding of how lymphatics might influence filtration bleb function.

How to cite this article

Lee JY, Strohmaier CA, Akiyama G, et al. Bleb-related Porcine Lymphatic Outflow Is Greater from Subconjunctival compared to Subtenon Blebs. J Curr Glaucoma Pract 2022;16(3):144-151.

A Review on Pathogens and Necessary Diagnostic Work for Bleb-Related Infections (BRIs)

At the present time, as newer techniques and minimally invasive procedures gain popularity among anterior segment surgeons for regulating intraocular pressure, trabeculectomy still has a leading role in glaucoma surgery. Trabeculectomy retains a highly successful and safe profile; however, one of the major complications includes bleb-related infections (BRIs). To date, the most common pathogens remain Gram-positive cocci, but the list of pathogens that have been identified in the literature includes more than 100 microorganisms. Because antibiotic use is more widespread than ever before and our ability to identify pathogens has improved, the pathogen spectrum will broaden in the future and more pathogens causing BRIs will be described as atypical presentations. The scope of this review was to identify all pathogens that have been described to cause bleb-related infections to date, as well as focus on the risk factors, clinical presentation, and various available diagnostic tools used for an appropriate diagnostic workup.

Ologen augmentation of Ahmed valves in pediatric glaucomas

BACKGROUND

We previously showed that Ologen increased success and survival rates of Ahmed glaucoma devices in a small number of children. The current study analyzed the same surgical technique in an expanded cohort.

METHODS

Retrospective interventional case series of children who underwent Ologen augmentation of Ahmed glaucoma device (OAGD) from 2018 to 2021 with ≥6 months' postoperative follow-up. Complete success was defined as intraocular pressure (IOP) of 5-20 mm Hg without glaucoma medications or additional IOP-lowering surgeries. Complete or qualified success was defined as above, except that IOP control was maintained with or without glaucoma medications.

RESULTS

A total of 26 eyes of 18 patients underwent OAGD at a median age of 2.0 years. Diagnoses included primary congenital glaucoma (5 eyes) and glaucoma secondary to nonacquired ocular anomalies (9 eyes), nonacquired systemic anomalies (8 eyes), and acquired conditions (4 eyes). Seventeen eyes had ≥1 prior eye surgery (average, 1.6 ± 0.9 surgeries per eye). Preoperative IOP was 29.4 ± 9.9 mm Hg on an average of 2.7 ± 1.0 glaucoma medications. At final follow-up (1.3 ± 1.0 years; median 1.0), IOP (13.4 ± 4.7 mm Hg) and number of glaucoma medications (0.3 ± 0.7, median 0) were significantly decreased (P < 0.0001). Complete success was achieved in 77% of eyes (20/26); Kaplan Meier analysis showed 1- and 3-year survival rates of 82% (95% CI, 59-93) and 60% (95% CI, 25-83), respectively. Complete or qualified success was achieved in 100% of eyes (26/26) at final follow-up. There were no visually devastating complications.

CONCLUSIONS

OAGD showed a high rate of success defined by decreased IOP and medication dependency in our study cohort of pediatric glaucoma patients.

Outcomes of Baerveldt Glaucoma Drainage Devices in Pediatric Eyes

PRCIS

In children, Baerveldt implants showed 84% success at 1 year, but decreased to 32% at 8 years. Age, race, and glaucoma type were not risk factors for failure. Concurrent intraocular surgery was associated with complications.

PURPOSE

Evaluate success and risk factors for failure and complications of Baerveldt glaucoma implants in children.

METHODS

Retrospective case series of children who underwent Baerveldt implant placement (2012-2019 by single surgeon) with ≥1 year follow-up. Ocular examination and surgical details were collected. Failure defined as intraocular pressure (IOP) <5 mm Hg or >21 mm Hg for 2 consecutive visits, need for IOP related surgery, or visually significant complication.

RESULTS

One hundred-six eyes of 76 patients underwent 110 Baerveldt placement at median 6.4 years. Baerveldt placement was combined with additional procedures in 49% with vitrectomy most common (30%). Success of first Baerveldt (per patient) was 64% at final follow-up (median 4.7 y). One-, 5-, and 8-year survival rates were 84%, 60%, and 32%, respectively. There was no difference (P=0.97) in survival between first Baerveldt and all Baerveldt surgeries. Failure of first Baerveldt was not associated with sex, age, ethnicity, prior IOP-lowering surgery, concurrent intraocular surgery, or glaucoma type. Complications occurred in 14% and were associated with concurrent surgery. Twenty-six percent required additional IOP-lowering surgery. At final follow-up, IOP and glaucoma medications were significantly decreased (P<0.0001). Eyes underwent an average of 3.8±2.3 ocular surgeries and 3.0±2.0 glaucoma surgeries.

CONCLUSIONS

Baerveldt implants showed good success initially, but survival rates declined over time. No risk factors for failure of first implanted Baerveldt were identified. Concurrent surgery was associated with complications. Majority of eyes required multiple surgeries to achieve IOP control and preserve vision.

Surgical Advancement of Tenon's Layer During Trabeculectomy Improves Bleb Morphology

Trabeculectomy surgery remains the gold standard incisional glaucoma surgical procedure in many practices, particularly for patients requiring intraocular pressure (IOP) in the low teens or below. However, trabeculectomy surgery is associated with complications including leakage, over filtration, or fibrosis of the surgical bleb. Morphology of the surgical bleb is an important predictor of surgical success defined as long-term IOP reduction with minimal to no complications. There have been many, often subtle, variations in the surgical technique in hopes of improving long-term IOP reduction. However, fewer changes have been implemented specifically to modify bleb morphology. In our surgical practice, we began performing a thorough dissection and advancement of Tenon's layer with incorporation into the conjunctival closure in a 2-layered manner. This technique allowed flow of aqueous to a delineated potential space between sclera and Tenon's layer. Our clinical observations were improved bleb morphology characterized by diffuse, low-lying blebs with nonischemic overlying conjunctiva compared with those performed with a more traditional trabeculectomy technique. Since we incorporated this change into our practice at a defined time, we have a small number of patients in our practice that had a more traditional trabeculectomy technique in the fellow eye. Therefore, in our surgical practice, a small number of patients had trabeculectomy in 1 eye before implementation of this new technique, and then had trabeculectomy in the fellow eye after this technique was adopted, providing opportunity for comparison of bleb morphology with and without Tenon advancement. In series we present two representative, index cases and describe our surgical technique.

Outcomes of combined endoscopic vitrectomy and posteriorly placed glaucoma drainage devices in pediatric patients

Background

This study aims to describe outcomes of posteriorly-placed glaucoma drainage devices (GDD) with concurrent endoscopic vitrectomy in pediatric patients with glaucoma and corneal opacification.

Methods

This retrospective case series identified patients under 18 years of age who underwent posteriorly-placed GDD implantation with concurrent endoscopic vitrectomy between 2012 and 2021. Data collected included ocular diagnoses, prior intraocular surgeries, type and position of GDD, surgical complications, and additional surgeries. Preoperative and final visual acuity, intraocular pressure (IOP), number of glaucoma medications, and exam findings were also recorded. Surgical data included type and position of GDD, Success was defined as IOP between 5-21 mmHg without visually devastating complication or need for additional glaucoma surgery.

Results

Ten patients (14 eyes) with sclerocornea (6), Peters Anomaly (4), corneal decompensation from increased IOP (3), and corneal scar (1) underwent combined endoscopic vitrectomy with posteriorly-placed GDD (Baerveldt (10 eyes), Ahmed (4 eyes)) at 4.6 ± 5.8 years of age. Four eyes of 3 patients remained successful at final follow-up, while 10 eyes of 7 patients required 2.4 ± 1.3 additional surgeries for glaucoma (7) or hypotony (3). Kaplan Meier analysis demonstrated 1- and 2-year survival rates of 36% and 18%, respectively. At final follow-up (3.7 ± 2.4 years), after an average of 4.4 ± 2.4 glaucoma surgeries, 13 of 14 eyes had obtained IOP control on significantly fewer (p<0.0001) IOP-lowering medications. Additional complications included retinal detachment (2), chronic corneal graft failure (2), phthisis (1) and band keratopathy (1).

Conclusions

Management of glaucoma in pediatric eyes with corneal opacification is challenging and often requires multiple surgeries. A combined endoscopic vitrectomy and posteriorly placed GDD is a viable technique to establish aqueous humor outflow. Although the success rate is low, this surgical approach may be useful in ultimately obtaining IOP control and preserving vision in these complex eyes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02373-3.

Ab-interno trabeculotomy with Kahook dual blade in secondary traumatic glaucoma in a child

Purpose

To report a successful ab-interno trabeculotomy with Kahook Dual Blade (KDB) in secondary traumatic angle recession glaucoma in a child and discuss the possible mechanisms of action.

Observations

A 7 years-old boy presented, after a blunt trauma in the left eye, with angular recess surroundings 110° and concomitant intra-ocular pressure (IOP) elevation around 35 mmHg, despite the maximum topical and systemic ocular hypotensive therapy. As there was no glaucomatous neuropathy yet, a KDB ab-interno trabeculotomy was performed. After KDB's surgery, oral and topical hypotensive medications were gradually withdrawn until complete suspension with IOP levels around 11 mmHg, which has remained the same in the last 2 years. Both functional and structural assessment of glaucoma have maintained stable throughout the follow-up until the present moment.

Conclusion and Importance

The KDB has demonstrating a favorable safety profile and a useful surgical technique that should be considered mainly in trabecular glaucomas, as well as those secondary to trauma. Studies are still needed to define which patient and glaucoma profile are the most suitable for the procedure and for how long it is effective.

Long-term results of the safety and effectiveness of a novel microshunt in Japanese patients with primary open-angle glaucoma

PURPOSE

To evaluate the long-term safety and effectiveness of the Preserflo MicroShunt in Japanese primary open-angle glaucoma (POAG) patients.

STUDY DESIGN

Single-site, nonrandomized observational study.

PATIENTS AND METHODS

Eight eyes of 7 POAG patients were included. The surgical complications and interventions were monitored. The preoperative and postoperative intraocular pressures (IOPs), numbers of antiglaucoma medications, logarithm of the minimum angle of resolution visual acuity (VA), mean deviation (MD) slope, and corneal endothelial cell density (CECD) were compared retrospectively.

RESULTS

The mean follow-up period was 68.9 months (range, 48-76 months). The baseline IOP of 17.9 ± 3.5 mmHg and the number of glaucoma medications of 3.5 ± 0.5 were significantly reduced at subsequent follow-up visits. At 1, 2, 3, 4, 5, and 6 years postoperatively, the IOPs were 13.8 ± 2.9, 12.8 ± 2.3, 12.1 ± 3.2, 12.6 ± 2.5, 12.3 ± 1.0, and 13.5 ± 3.1 mmHg, respectively, with the use of 1.6 ± 1.4, 1.6 ± 1.6, 1.5 ± 1.4, 1.5 ± 1.4, 1.9 ± 1.3, and 2.0 ± 1.1 medications. Postoperative transient hyphema occurred in 1 eye. Postoperative needling was required in 5 eyes, 12 times in total. No eyes showed significant VA decline, except for 1 eye with a severe central visual field defect that existed preoperatively. The preoperative MD slope of - 1.6 ± 1.2 dB/year improved significantly, to - 0.3 ± 0.2 dB/year (P = 0.023), postoperatively. The baseline CECD decreased from 2595 ± 292 to 2478.4 ± 255 postoperatively.

CONCLUSION

The microshunt surgical procedure is safe and effective for Japanese POAG patients.

A Modified Technique in Applying Sponge Soaked with Mitomycin C in Trabeculectomy

ABSTRACT

Trabeculectomy with adjunctive use of Mitomycin C (MMC) has been a benchmark for glaucoma filtration surgery for decades. However, there are many variations in the ways that the sponges soaked with MMC are applied during the trabeculectomy surgery. We herein describe our way of placing the MMC-soaked sponges to improve the safety and efficacy of the trabeculectomy. The sponges are placed vertically and posteriorly with the long side of the sponge perpendicular to the limbus, not parallel. This will reduce the size of the conjunctival wound at the limbus to preserve more virgin conjunctiva that can be used for repeated trabeculectomy when needed. This will also facilitate a more posteriorly directed flow of aqueous drainage that, in turn, may increase the success rate of the trabeculectomy. We have obtained encouraging results in our practice, and further large-scale randomized studies seem warranted.

[Postoperative endophthalmitis-a review of literature]

Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.

Neovascularization of angle following trabeculectomy augmented with mitomycin-C

The purpose of this study was to report a case of neovascularization of angle (NVA) following trabeculectomy with mitomycin-c (MMC) in a patient with primary open-angle glaucoma. This case report describes a 68-year-old woman who developed NVA and hyphema 2 weeks following an uneventful trabeculectomy with MMC. Trabeculectomy may be associated with serious and vision-threatening complications such as hypotony, suprachoroidal hemorrhage, endophthalmitis, and bleb-related complications. However, neovascularization of the anterior segment is not a commonly reported complication. Neovascularization of the anterior segment is a rare postoperative complication that usually occurs following strabismus or retinal detachment surgeries. The underlying ischemic trigger for anterior segment neovascularization is usually a posterior segment pathology or carotid artery insufficiency. These causative factors were excluded in our patient by lack of any abnormal finding in fundus fluorescein angiography and carotid Doppler ultrasonography. The patient received three subconjunctival bevacizumab injections (1.25 mg/0.1 ml) with frequent topical steroids and showed marked regression of the neovessels. The bleb was functional, and intraocular pressure remained at low teen afterward. NVA following trabeculectomy without any posterior segment or carotid pathologies responded well to subconjunctival bevacizumab and topical steroids.

Capnocytophaga canimorsus blebitis: case report and review of literature

Background

Capnocytophaga canimorsus is a facultative anaerobic, slow-growing, capnophilic, Gram-negative bacillus, that is commonly found in the microflora of canine and feline oral cavities. Capnocytophaga infections are an emerging zoonotic disease that can cause fatal systemic infections in immunocompromised individuals. Localized ocular Capnocytophaga infections, including keratitis, blepharitis, and endophthalmitis, can lead to severe eye threatening situations. To our knowledge, there is currently no documented case of Capnocytophaga canimorsus blebitis with bleb perforation after trabeculectomy.

Case presentation

Our case report and literature review features a novel case of Capnocytophaga blebitis that occurred after trabeculectomy, associated with close dog contact (i.e. face licking). The patient had underwent trabeculectomy 10 years prior and presented with conjunctival injection, perforated bleb, and hypotony. Overall, patient was medically treated subconjunctival vancomycin, gentamicin and moxifloxacin drops. Trabeculectomy revision was performed with good visual outcome. Bacterial cultures grew Capnocytophaga canimorsus.

Conclusions

We discuss the strategies for diagnosis, treatment, and common risk factors for ocular Capnocytophaga infections. At-risk patients with ocular infections should be asked about close contact with dogs and cats; and treated promptly with the proper antibiotic regimen.

Safety and efficacy of bilateral simultaneous XEN implant surgery: a pilot study

OBJECTIVE

To evaluate the efficacy and safety of the bilateral simultaneous XEN (BISIXEN) surgery in open-angle glaucoma patients.

METHODS

Retrospective analysis of a prospective data base conducted on uncontrolled glaucoma patients who underwent BISIXEN surgery. Primary endpoint measure was the incidence of sight-threatening complications. Secondary endpoints included intraocular pressure (IOP) reduction and in number of required antiglaucoma medications.

RESULTS

Ten patients (20 eyes) were included in the analysis. Median (95% confidence interval) follow-up was 12.0 (7.0-12.0) months, with 14 eyes having a follow-up of 12 months. No sight-threatening complications, such as endophthalmitis, retinal detachment, corneal decompensation, or intraocular hemorrhages were observed in any eye of study sample. Mean IOP decreased significantly from 25.2 (21.5-28.9) mm Hg at baseline to 15.1 (13.4-16.8) mm Hg at the last follow-up visit (p = 0.0001). Mean number of antiglaucoma medications was significantly reduced from 2.9 (2.5 to 3.3) drugs at baseline to 0.40 (0.00-0.70) at the end of the study (p < 0.0001). At the last study visit, 14 (70.0%) eyes had an IOP ≥ 6 and ≤ 18 mm Hg without treatment. Two eyes needed surgical revision and three ones needed a new glaucoma surgery: two underwent Ahmed valves (one eye with aniridia and the other previously operated on) and one underwent non-penetrating deep sclerectomy.

CONCLUSIONS

Bilateral simultaneous XEN implantation may be a feasible strategy in those patients with high anesthetic risk.

Pluripotent epigenetic regulator OBP-801 maintains filtering blebs in glaucoma filtration surgery model

Inhibition of fibrosis is indispensable for maintaining filtering blebs after glaucoma filtration surgery (GFS). The purpose of this study was to investigate the ability of a pluripotent epigenetic regulator OBP-801 (OBP) to ameliorate extracellular matrix formation in a rabbit model of GFS. Rabbits that underwent GFS were treated with OBP. The gene expression profiles and intraocular pressure (IOP) were monitored until 30 postoperative days. The bleb tissues were evaluated for tissue fibrosis at 30 postoperative days. In in vitro models, OBP interfered the functions of diverse genes during the wound-healing process. In in vivo GFS models, the expressions of TGF-β3, MMP-2, TIMP-2 and 3, LOX, COL1A and SERPINH1 were significantly inhibited at 30 postoperative days in the OBP group compared with those in the vehicle control group. OBP treatment involving subconjunctival injection or eye drops showed no adverse effects, and reduced levels of α-SMA and collagen deposition at the surgical wound site. OBP maintained the long-lived bleb without scar formation, and IOP was lower at 30 postoperative days compared with the vehicle control group. These findings suggest that OBP is an effective and useful candidate low-molecular-weight agent for improving wound healing and surgical outcomes in a rabbit model of GFS.

Research Trends and Hotspot Analysis of Conjunctival Bacteria Based on CiteSpace Software

OBJECTIVE

To sort out the literature related to conjunctival bacteria and summarize research hotspots and trends of this field.

MATERIALS AND METHODS

The relevant literature data from 1900 to 2019 was retrieved from the Web of Science Core Collection database. After manual selection, each document record includes title, author, keywords, abstract, year, organization, and citation. We imported the downloaded data into CiteSpace V (version 5.5R2) to draw the knowledge map and conduct cooperative network analysis, discipline and journal analysis, cluster analysis, and burst keyword analysis.

RESULTS

After manual screening, there were 285 relevant papers published in the last 28 years (from 1991 to 2019), and the number is increasing year by year. The publications of conjunctival bacteria were dedicated by 1381 authors of 451 institutions in 56 countries/regions. The United States dominates this field (82 literatures), followed by Germany (23 literatures) and Japan (23 literatures). Overall, most cited papers were published with a focus on molecular biology, genetics, nursing, and toxicology. Most papers fall into the category of ophthalmology, veterinary sciences, and pharmacology and pharmacy. The only organized cluster is the "postantibiotic effect," and the top 5 keywords with the strongest citation bursts include "postoperative endophthalmiti(s)," "infectious keratoconjunctiviti(s)," "conjunctiviti(s)," "resistance," and "diversity".

CONCLUSION

The global field of conjunctival bacteria has expanded in the last 28 years. The United States contributes most. However, there are little cooperation among authors and institutions. Overall, this bibliometric study organized one cluster, "postantibiotic effect", and identified the top 5 hotspots in conjunctival bacteria research: "postoperative endophthalmiti(s)," "infectious keratoconjunctiviti(s)," "conjunctiviti(s)," "resistance," and "diversity". Thus, further research focuses on these topics that may be more helpful to prevent ocular infection and improve prophylaxis strategies to bring a benefit to patients in the near future.

EX-PRESS Glaucoma Filtration Device: Management of Complications

The EX-PRESS glaucoma filtration device appears to be an effective addition to our options to treat refractory glaucoma. The possibility to create a sclerostomy without tissue excision provides a safe and reliable outflow pathway for aqueous that is standard in size, reducing much of the variability associated with a surgical procedure. Prospective randomized studies comparing EX-PRESS implantation with trabeculectomy show encouraging results. However, complications usually encountered in filtration surgery have been reported, and EX-PRESS implantation can also lead to specific device-related complications. This article reviews the most common complications associated with this procedure.

Surgical outcomes of Glaucoma associated with Axenfeld-Rieger syndrome

Background

The surgical management of glaucoma associated with Axenfeld-Rieger Syndrome (ARS) is poorly described in the literature. The goal of this study is to compare the effectiveness of various glaucoma surgeries on intraocular pressure (IOP) management in ARS.

Methods

Retrospective cohort study at a university hospital-based practice of patients diagnosed with ARS between 1973 and 2018. Exclusion criterion was follow-up less than 1 year. The number of eyes with glaucoma (IOP ≥ 21 mmHg with corneal edema, Haabs striae, optic nerve cupping or buphthalmos) requiring surgery was determined. The success and survival rates of goniotomy, trabeculotomy±trabeculectomy (no antifibrotics), cycloablation, trabeculectomy with anti-fibrotics, and glaucoma drainage device placement were assessed. Success was defined as IOP of 5-20 mmHg and no additional IOP-lowering surgery or visually devastating complications. Kaplan-Meier survival curves and the Wilcoxon test were used for statistical analysis.

Results

In 32 patients identified with ARS (median age at presentation 6.9 years, 0–58.7 years; median follow-up 5.4 years, 1.1–43.7 years), 23 (71.9%) patients were diagnosed with glaucoma at median age 6.3 years (0–57.9 years). In glaucomatous eyes (46 eyes), mean IOP at presentation was 21.8 ± 9.3 mmHg (median 20 mmHg, 4-45 mmHg) on 1.0 ± 1.6 glaucoma medications. Thirty-one eyes of 18 patients required glaucoma surgery with 2.2 ± 1.2 IOP-lowering surgeries per eye. Goniotomy (6 eyes) showed 43% success with 4.3 ± 3.9 years of IOP control. Trabeculotomy±trabeculectomy (6 eyes) had 17% success rate with 14.8 ± 12.7 years of IOP control. Trabeculectomy with anti-fibrotics (14 eyes) showed 57% success with 16.5 ± 13.5 years of IOP control. Ahmed© (FP7 or FP8) valve placement (8 eyes) had 25% success rate with 1.7 ± 1.9 years of IOP control. Baerveldt© (250 or 350) device placement (8 eyes) showed 70% success with 1.9 ± 2.3 years of IOP control. Cycloablation (4 eyes) had 33% success rate with 2.7 ± 3.5 years of IOP control. At final follow-up, mean IOP (12.6 ± 3.8 mmHg, median 11.8 mmHg, 7-19 mmHg) in glaucomatous eyes was significantly decreased (p < 0.0001), but there was no difference in number of glaucoma medications (1.6 ± 1.5, p = 0.1).

Conclusions

In our series, greater than 70% of patients with ARS have secondary glaucoma that often requires multiple surgeries. Trabeculectomy with anti-fibrotics and Baerveldt glaucoma drainage devices showed the greatest success in obtaining IOP control.

Phacotrabeculectomy using collagen matrix implant (Ologen® ) versus mitomycin C: a prospective randomized controlled trial

PURPOSE

To compare the efficacy and safety of collagen matrix implant (Ologen^® ; OLO) with mitomycin C (MMC) in phacotrabeculectomy.

METHODS

Prospective, single-centre, nonblinded, randomized controlled trial. A total of 53 eyes of 45 patients were enrolled in the study protocol with 27 eyes randomly assigned to OLO and 26 to MMC. The follow-up was 12 months. The primary outcome measure was mean change from baseline intraocular pressure (IOP) in both groups after 12 months. The secondary outcome measures were cumulative success rates at 12 months with Kaplan-Meier analysis, change in number of medications, change in best corrected visual acuity (BCVA), and bleb morphology assessed using Moorfields Bleb Grading System and anterior segment swept-source optical coherence tomography.

RESULTS

The mean IOP decreased from 26.4 ± 6.1 mmHg to 13.7 ± 3.8 in the OLO group and from 23.4 ± 3.6 mmHg to 13.3 ± 2.8 in the MMC group at 1 year without significant intergroup differences. At 1 year, the overall success rates were 92.6% and 92.3% in the OLO and MMC groups, respectively. There were no significant differences in the overall success rates, BCVA, number of medications, morphology of the filtering blebs and rate of complications at the end of the follow-up.

CONCLUSION

Ologen (OLO) provides similar surgical outcomes in phacotrabeculectomy compared with adjunctive MMC. It may be a new, safe and effective alternative to MMC for combined phacoemulsification and trabeculectomy surgery.

Transduction Pattern of AAVs in the Trabecular Meshwork and Anterior-Segment Structures in a Rat Model of Ocular Hypertension

Adeno-associated viruses (AAVs) are the vector of choice for gene therapy in the eye, and self-complementary AAVs (scAAVs), which do not require second-strand DNA synthesis, can be transduced into cells of the trabecular meshwork (TM). The scAAV transduction patterns in the anterior segment of normotensive eyes have been investigated previously, but those in ocular hypertensive (OHT) eyes have not. We assessed the transduction efficiencies of AAV serotypes 2, 5, and 8 in the anterior-segment structures of the eyes of Sprague-Dawley rats with OHT by circumlimbal suturing, followed 3 days later by intracameral injection of scAAV serotype 2 (scAAV2), scAAV5, or scAAV8 packaged with EGFP. The transduction of scAAV2 and scAAV5 in the TM of OHT rats was markedly enhanced after 1 month, and transduction of scAAV5 was more efficient than that of scAAV2; transduction of scAAV8 into the TM did not occur. The transduction of scAAV2, scAAV5, and scAAV8 was enhanced in the ciliary body, iris, and corneal endothelium of the OHT eyes for 3 months. The expression levels of receptors for scAAV2 and scAAV5 were significantly increased in the OHT compared with control eyes. The results demonstrated that scAAV2 and scAAV5 target the ciliary body and TM in OHT eyes, and that the OHT-related changes in anterior-segment structures enhance scAAV transduction.

Bacteroides Spp. Blebitis, Keratitis, and Endophthalmitis Following Uncomplicated Trabeculectomy

PURPOSE

To describe the first known case of Bacteroides spp. related blebitis, keratitis, and endophthalmitis following uncomplicated trabeculectomy.

METHODS

This was a case report and literature review.

CASE

A 63-year-old immunocompetent white male underwent uncomplicated trabeculectomy of his right eye. Two weeks later, a blebitis with adjacent keratitis was diagnosed, progressing over several days to endophthalmitis despite hourly topical fortified antibiotic therapy. Although gram stain and culture of the bleb surface, a conjunctival suture, the aqueous humor, and the vitreous were negative, topical real-time quantitative polymerase chain reaction testing disclosed the presence of Bacteroides spp. Following treatment with topical and intravitreal clindamycin and intravenous meropenem, all clinical evidence of infection resolved. Best spectacle-corrected visual acuity improved to 20/25 (0.8) subsequent to combined cataract extraction, intraocular lens implantation, and pars plana vitrectomy for persistent vitreous debris.

CONCLUSIONS

Bacteroides may be a rare cause of postoperative blebitis, keratitis, and endophthalmitis. A favorable outcome may be attained, provided that an accurate diagnosis and effective treatment can be provided, which may be facilitated by real-time quantitative polymerase chain reaction in select cases.

Two-year outcomes of ab interno trabeculectomy with the Trabectome for Chinese primary open angle glaucoma: a retrospective multicenter study

AIM

To evaluate the 2-year efficacy and safety of ab interno trabeculectomy with the Trabectome in Chinese primary open angle glaucoma (POAG) patients.

METHODS

This was a multicenter, retrospective, observational study and included POAG patients with or without visually-significant cataracts. The Chinese patients were enrolled from three glaucoma centers and a group of comparable Japanese POAG patients was analyzed from our international Trabectome database. The patients received Trabectome or a combined surgery with phacoemulsification and intraocular lens implantation. The primary outcome was intraocular pressure (IOP) reduction. Secondary outcomes included reduction of glaucoma medications, surgical complications, and success at 2y. Success was defined as: 1) IOP≤21 mm Hg and at least 20% IOP reduction from baseline after 3mo at any two consecutive visits; 2) no additional glaucoma surgery required.

RESULTS

A total of 42 Chinese POAG patients from three glaucoma centers were enrolled. Twelve patients underwent Trabectome surgery combined with phacoemulsification and intraocular lens implantation while the remainder underwent Trabectome surgery alone. Thirteen patients had a history of failed glaucoma surgery and were considered as complicated cases. In China data, the mean preoperative IOP was 21.4±1.23 mm Hg. The Trabectome lowered IOP to 17.9±1.8 mm Hg at 2y (P=0.05). The number of glaucoma medications also decreased significantly from a baseline of 2.0±0.9 to 1.1±0.8 at 2y post-surgery (P=0.04). The overall 2-year success rate was 78%, with patients undergoing combined surgery having a higher success rate compared with those undergoing Trabectome surgery alone (100% vs 76%). In Japan data, the mean preoperative IOP was 20.8±7.7 mm Hg. The Trabectome lowered IOP to 12.20±2.0 mm Hg at 2y. The number of glaucoma medications also decreased significantly from a baseline of 2.1±0.9 to 3.4±0.6 at 2y post-surgery. In all patients, no major complications were seen.

CONCLUSION

Surgery with the Trabectome appears to be an efficient and safe procedure in Chinese POAG patients in the long-term.

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.