Transient intraocular pressure elevation after trabeculotomy and its occurrence with phacoemulsification and intraocular lens implantation

Trabeculotomy Using the Kahook Dual Blade for Exfoliation Glaucoma and Primary Open Angle Glaucoma: Comparison of Outcomes According to Incision Range

PRCIS

Large amount of trabeculotomy with Kahook Dual Blade (KDB) confers better intraocular pressure (IOP) lowering.

PURPOSE

We compared the postoperative outcomes of trabeculotomy using the KDB in patients with exfoliation glaucoma (EXG) and primary open angle glaucoma between the 120-degree incision and the 210- to 240-degree incision groups.

PATIENTS AND METHODS

We retrospectively analyzed the postoperative outcomes of trabeculotomy performed using the KDB in 101 eyes with EXG and primary open angle glaucoma, who received 120- and 210- to 240-degree incisions at Kumamoto University Hospital between April 25, 2018, and August 11, 2021. Kaplan-Meyer survival curves were used to assess the outcomes. Surgical failure was defined as IOP ≥21 mm Hg (criterion A) and ≥19 mm Hg (criterion B), or an IOP ≤4 mm Hg in either criterion and the need for additional glaucoma surgery.

RESULTS

In total, 64 and 37 eyes were included in the 120 and 210- to 240-degree groups, respectively. The 210- to 240-degree group had a higher 1-year success rate compared with the 120-degree group, both when considering all eyes and when considering only those with EXG (P<0.05).

CONCLUSIONS

In trabeculotomy with KDB, a 210- to 240-degree incision was more effective than a 120-degree incision in lowering IOP in EXG cases.

Circumferential (360°) trabeculotomy for steroid-induced glaucoma in adults

PURPOSE

To evaluate the safety and efficacy of 360° circumferential trabeculotomy (TO) for steroid induced glaucoma (SIG) of short duration.

METHODS

Retrospective analysis of surgical results of 46 eyes of 35 patients undergoing microcatheter-assisted TO. All eyes had high intraocular pressure for at most about 3 years due to steroid use. Follow-up was between 2.63 and 47.9 months (mean 23.9, median 25.6).

RESULTS

Intraocular pressure (IOP) before surgery was 30.8 ± 8.3 mm Hg, with 3.8 ± 1.0 pressure-lowering medications. After 1 to 2 years, mean IOP was 11.2 ± 2.6 mm Hg (n = 28); mean number of IOP-lowering medications was 0.9 ± 1.3. At their last follow-up, 45 eyes had an IOP < 21 mm Hg, and 39 eyes had an IOP < 18 mm Hg with or without medication. After 2 years, the estimated probability of having an IOP below 18 mm Hg (with or without medication) was 85 ± 6%, and the estimated probability of not using medication was 56 ± 7%. Steroid response was no longer present in all eyes receiving steroids after surgery. Minor complications consisted of hyphema, transient hypotony, or hypertony. One eye proceeded to receiving a glaucoma drainage implant.

CONCLUSION

TO is particularly effective in SIG with relative short duration. This concurs with the pathophysiology of the outflow system. This procedure seems particularly suited for eyes for which target pressures in the mid-teens are acceptable, particularly when chronic use of steroids is necessary .

Long-term Outcomes of Modified 360-degree Suture Trabeculotomy for Uveitic Glaucoma Compared with Primary Open Angle Glaucoma

PRCIS

A Kaplan-Meier survival curve analysis showed no significant differences in success rates between UG and POAG 120 months after modified 360-degree suture trabeculotomy, which was effective for both groups in the long term.

PURPOSE

To examine the outcomes of modified 360-degree suture trabeculotomy in patients with uveitic glaucoma (UG) as compared to those with primary open angle glaucoma (POAG).

METHODS

This was a retrospective, non-randomized, and comparative case series study. Modified 360-degree trabeculotomy using a 5-0 nylon suture (S-LOT) was performed on 51 eyes of 51 patients (54.4±13.4 y) with UG between October 2005 and January 2012 at Hokkaido University Hospital. Age-matched patients with POAG who underwent S-LOT during the same period were enrolled as controls. Written informed consent was obtained from all patients enrolled in the present study. Surgical success was defined as an intraocular pressure (IOP) <18 mmHg with similar or lower doses of antiglaucoma medications. Kaplan-Meier survival curves of surgical failure were analyzed and compared between UG and POAG.

RESULTS

The mean follow-up periods (±SD) for UG and POAG were 104.8±44.0 and 98.1±36.3 months (P=0.23), respectively. Mean pre-operative IOP in UG and POAG were 34.9±11.0 and 25.3±9.4 mmHg (P<0.001), respectively. After surgery, mean IOP in UG and POAG decreased to 12.0±4.1 and 13.8±3.2 mmHg, respectively, at 60 months, and 12.1±5.6 and 12.4±1.8 mmHg (P=0.86), respectively, at 120 months. The Kaplan-Meier survival curve analysis showed no significant differences in success rates between UG and POAG at the end of the follow-up (Log-rank test, P=0.13). Success rates in UG and POAG were 70.0 and 62.5% at 60 months, and 67.5 and 41.2% at 120 months, respectively.

CONCLUSION

These results suggest that S-LOT is effective for UG and POAG alike.

Comparison of efficacy and early surgery-related complications between one-quadrant and two-quadrant microhook ab interno trabeculotomy: a propensity score matched study

PURPOSE

We compared the 1-year outcomes and early surgery-related complications between 1-quadrant and 2-quadrant microhook ab interno trabeculotomy (TLO).

METHODS

Medical chart extraction was performed on 47 consecutive patients with 1-quadrant incision and 37 consecutive patients with 2-quadrant incision of trabecular meshwork. Logistic regression analysis was conducted to calculate the propensity score to create a 1:1 match for a comparative analysis of 1-year postoperative success. Success was defined as postoperative intraocular pressure (IOP) between 5-21 mmHg, >20% IOP reduction from baseline, and no additional glaucoma surgery. Outcome-related covariates were age, glaucoma type, mean deviation of visual field tests, preoperative IOP, the number of preoperative glaucoma eye drops and the presence of combined cataract surgery. Thirty eyes from each group were compared.

RESULTS

The median preoperative IOP was not different between the 1-quadrant and 2-quadrant groups (28.5 mmHg, quartile range 23-33.5 versus 27 mmHg, 23.3-30.0, p = 0.47). There was no difference in median postoperative IOP at 1 year (15 mmHg versus 16 mmHg, p = 0.80). The success rate was 73% in the 1-quadrant group versus 70% in the 2-quadrant group (p = 1.00). The 2-quadrant group had a significantly higher proportion of patients with transiently elevated IOP (47%) than the 1-quadrant (17%; Fisher's exact test, p = 0.02). There was no difference of hyphema formation (Fisher's exact test, p = 0.18).

CONCLUSION

The 1-year success rate was not significantly different between 1- and 2-quadrant incisions of microhook TLO. However, the 2-quadrant TLO showed significantly higher proportion of post-surgical transient IOP elevation.

Characteristics of glaucoma patients with intraocular pressure elevation early after trabectome surgery

PURPOSE

To analyze the rate and time of occurrence of intraocular pressure (IOP) elevation early after trabectome surgery (TOM) and the characteristics of glaucoma patients recovering from IOP elevation.

METHOD

Four hundred sixty eyes of 460 glaucoma (191 primary and 269 secondary open-angle glaucoma) patients who underwent TOM were evaluated. IOP elevation early after TOM was diagnosed when IOP increased by more than 5 mmHg over baseline within 1 week to 3 months. If the IOP decreased with the administration of anti-glaucoma eye drops alone, patients were classified as recovered. If the IOP did not decrease despite additional anti-glaucoma eye drop use, patients were classified as non-recovered. The rate and time of occurrence of IOP elevation early after TOM were investigated. Demographic and ocular variables related to recovery and non-recovery were identified by multivariate logistic regression analysis.

RESULTS

Of the 460 patients, IOP elevation early after TOM occurred in 102 (22.2%). IOP elevation occurred most frequently at postoperative week 1. Of the 102 patients with IOP elevation, 55 (53.9%) recovered and 47 (46.1%) did not. A large hyphema size the day after surgery was associated with increased likelihood of recovery from IOP elevation (odds ratio [OR], 6.6). A history of past selective laser trabeculoplasty (SLT; OR, 0.10) and high baseline IOP (OR, 0.86) were associated with reduced likelihood of recovery from IOP elevation.

CONCLUSION

IOP elevation early after TOM occurred most frequently at postoperative week 1. Patients with a large hyphema size, no history of SLT, and a lower baseline IOP recovered from IOP elevation early after TOM. A large hyphema the day after surgery suggested an increased likelihood of recovery from IOP elevation.

Midterm Results of Microhook ab Interno Trabeculotomy in Initial 560 Eyes with Glaucoma

All the 560 glaucomatous eyes of 375 Japanese subjects (181 men, 194 women; mean age ± standard deviation, 76.0 ± 13.2 years) who underwent microhook ab interno trabeculotomy (µLOT) alone (159 eyes, 28%) or combined µLOT and cataract surgery (401 eyes, 72%) performed by one surgeon at Matsue Red Cross Hospital between May 2015 and March 2018 to control intraocular pressure (IOP) were retrospectively assessed. Preoperative and postoperative IOPs, numbers of antiglaucoma medications, the logarithm of the minimum angle of resolution visual acuity (logMAR VA), anterior chamber (AC) flare, visual field mean deviation (MD), and corneal endothelial cell density (CECD) were compared up to 36 months. Surgical complications and required interventions were described. The duration of the follow-up was 405 ± 327 (range, 2–1326) days. The mean preoperative IOP (20.2 ± 7.0 mmHg) and number of antiglaucoma medications (2.8 ± 1.1) decreased to 13.9 ± 4.5 mmHg (31% reduction, p < 0.0001) and 2.5 ± 1.0 (11% reduction, p < 0.0001), respectively, at the final visit. After combined surgery, compared with preoperatively, the final VA improved 0.11 logMAR (p < 0.0001), AC flare increased 4.5 photon counts/msec (p = 0.0011), MD improved 0.6 decibel (p < 0.0001), and the CECD decreased 6% (p < 0.0001). Layered hyphema (172 eyes, 31%) and hyphema washout (26 eyes, 5%) were the most common postoperative complication and intervention, respectively. At the final visit, 379 (69%) eyes achieved successful IOP control of ≤18 mmHg and ≥20% IOP reduction, and 349 (64%) eyes achieved successful IOP control of ≤15 mmHg and ≥20% IOP reduction. Older age, steroid-induced glaucoma, developmental glaucoma, and the absence of postoperative complications were associated with lower final IOP; exfoliation glaucoma, other types of glaucoma, and higher preoperative IOP were associated with higher final IOP. µLOT has a significant IOP-lowering potential in patients with glaucoma, and improves visual function when combined with cataract surgery.

Ab interno trabeculotomy combined with cataract extraction in eyes with primary open-angle glaucoma

OBJECTIVE

To investigate the efficacy and safety of ab interno trabeculotomy using the VISCO360® Viscosurgical System (Sight Sciences, Inc., Menlo Park, CA, USA) combined with cataract extraction in the treatment of primary open-angle glaucoma (POAG).

METHODS

Patients with POAG who underwent ab interno trabeculotomy combined with cataract extraction were retrospectively analyzed. Best-corrected visual acuity (BCVA), intraocular pressure (IOP), the number of antiglaucomatous medications, and complications were recorded preoperatively and 1 week, 1 month, 3 months, 6 months, 1 year, and 2 years postoperatively.

RESULTS

Thirty-four patients (40 eyes) with POAG were included in this study, including 20 men (22 eyes) and 14 women (18 eyes). Compared with the preoperative IOP, the postoperative IOP was significantly lower at each time point. The greatest reduction in IOP was 60.7% at 1 month after surgery. The BCVA was also significantly improved at each postoperative time point. The number of antiglaucomatous medications used by the patients was significantly lower postoperatively than preoperatively.

CONCLUSION

Ab interno trabeculotomy combined with cataract extraction is effective and safe for treatment of POAG.

Clinical safety and efficacy of a hydrophilic acrylic intraocular lens in a real-world population: a 1-year follow-up retro-prospective study

Background

This multicentre, retro-prospective real-world study evaluated the visual, refractive and safety outcomes of a monofocal lens 1 year after implantation in cataract patients with or without pre-existing ocular pathologies.

Methods

Records from 4 centres in Germany and Sweden were reviewed to select eyes with aged-related cataracts, having undergone crystalline lens extraction by phacoemulsification and implantation of a CT ASPHINA 409 IOL. Preoperative, 1-month and 3-month postoperative data was collected retrospectively. In addition, included patients attended a prospective visit 12 months or later after surgery. The examination included: monocular uncorrected (UDVA) and corrected distance visual acuity (CDVA), subjective refraction, slit-lamp examination, optical biometry, intraocular pressure (IOP), endothelial cell count and postoperative complications.

Results

282 eyes, including 94 with pre-existing ocular pathologies, were analysed. Twelve months after the surgery, 95% of eyes achieved monocular CDVA equal or better than 0.3 logMAR, mean postoperative CDVA was 0.06 ± 0.17 logMAR, and mean UDVA 0.31 ± 0.29 logMAR. Visual acuity outcomes were better in eyes with no pre-existing ocular pathologies, but both groups showed a statistically significant improvement after surgery compared with preoperative values (p ≤ 0.002). The mean sphere and spherical equivalent values also improved significantly postoperatively (p = 0.003). Overall, 62.1% of eyes had spherical equivalent within ±0.5 D and 80.9% within ±1.0 D. The IOL was stable in the capsular bag as demonstrated by tilt and decentration measurements. IOP, corneal status, and endothelial cell count values were in the normal range. Nd:YAG treatment was performed on 9.9% of the eyes.

Conclusion

The implantation of the monofocal CT ASPHINA 409 IOL was beneficial to restore vision in eyes with or without concomitant ocular pathology such as macular degeneration, glaucoma, Sicca syndrome, epiretinal membrane, cornea guttata, or amblyopia. Good to excellent long-term visual and refractive outcomes, and a low rate of complications in both healthy and pathological eyes were found 12 months after the surgery.

Trial registration

Trial registered on under the identification NCT03145103 (date of registration 9 May 2017).

Surgical outcomes of combined gonioscopy-assisted transluminal trabeculotomy and cataract surgery

Purpose:

To evaluate the success, safety, and complication rates of gonioscopy-assisted transluminal trabeculotomy (GATT) combined with cataract surgery.

Methods:

A retrospective study was conducted for 32 patients who underwent GATT combined with phacoemulsification and intraocular lens implantation. Patients with primary open-angle glaucoma were enrolled. The primary outcome measures were visual acuity, intraocular pressure (IOP), the number of antiglaucoma medications used, and complications.

Results:

The average preoperative visual acuity of the patients was logMAR 1.57 ± 1.2, and the average postoperative visual acuity was logMAR 0.39 ± 0.38. A significant increase in visual acuity was observed post-surgery (P < 0.05). The average preoperative IOP was 34.2 ± 10.6 mmHg. In the 3^rd postoperative month, the average IOP was 10.5 ± 2.2 mmHg, and in the 6^th postoperative month, the average IOP was 11.2 ± 2.4 mmHg. In all postoperative follow-ups, IOP was significantly lower than that during the preoperative period (P < 0.05). A decrease of 2.7 ± 0.6 on average was detected in the number of glaucoma medications used in the postoperative period compared to the preoperative period, and the average decrease in the number of active ingredients post-surgery was 3.5 ± 0.8. The most frequent complication was hyphaema (31.2%). In only one patient (3.1%), the surgery was considered to have failed due to the development of deep hypotony.

Conclusion:

Performing GATT in the same session as cataract surgery does not reduce the efficacy of GATT, yet this procedure reduces the incidence of the most frequent complication of GATT, i.e. hyphaema. Therefore, in convenient cases, combined surgery can safely be performed.

The long-term outcome of trabeculotomy: comparison with filtering surgery in Japan

Background

To investigate the long-term outcome of trabeculotomy and to compare it with that of trabeculectomy.

Methods

We retrospectively reviewed the medical records of patients who had undergone standalone trabeculotomy. Inclusion criteria included a follow-up period of at least 6 years, availability of reliable static visual field results, etc. Age- and preoperative intraocular pressure -matched trabeculectomy cases served as controls. A Kaplan-Meier analysis was employed as a measure of surgical success. Additional clinical factors were also analyzed.

Results

Twenty-five eyes of 25 trabeculotomy patients and 20 eyes of 20 trabeculectomy patients with a mean postoperative follow-up period of 8.0 years were selected. The Kaplan-Meier analysis estimated that the success probability defined as intraocular pressure < 16 mmHg was 44.0 ± 9.9% and 75.0 ± 9.7% at 6 years for trabeculotomy and trabeculectomy, respectively. The final mean deviation significantly progressed in trabeculotomy cases in Central 30–2 programs of the Humphrey Field Analyzer (P = 0.025). Patient characteristics and postoperative clinical data were analyzed by Mann-Whitney’s U test and Wilcoxon signed-rank test.

Conclusions

While trabeculotomy was inferior to trabeculectomy in terms of intraocular pressure control and visual field stability in our series, surgical indications should always be determined on an individual basis, pending further research.

Outcomes of 360° suture trabeculotomy with deep sclerectomy combined with cataract surgery for primary open angle glaucoma and coexisting cataract

BACKGROUND

The purpose of this study was to investigate treatment outcomes in 360° suture trabeculotomy with deep sclerectomy combined with phacoemulsification and aspiration and intraocular lens implantation (360P-LOT + DS).

METHODS

Thirty-two eyes in 32 consecutive patients treated by 360P-LOT + DS for primary open angle glaucoma with coexisting cataracts at Sato Eye Clinic from March 2011 to April 2013 were retrospectively compared with 23 eyes in 23 consecutive patients treated by cataract surgery and 120° trabeculotomy with deep sclerectomy (120P-LOT + DS) at the same clinic from January 2010 to February 2011. The parameters investigated during the 15 months after surgery were the course of intraocular pressure, number of antiglaucoma medications, best-corrected visual acuity, and complications.

RESULTS

Both groups showed a significant decrease in intraocular pressure starting at one month after surgery when compared with values before surgery. At 3, 6, 9, and 15 months after surgery, the intraocular pressure was significantly lower and the survival rate was significantly higher in the 360P-LOT + DS group compared with the 120P-LOT + DS group. The number of antiglaucoma medications, best-corrected visual acuity value, and complications did not differ significantly between the groups.

CONCLUSION

Although the complications are similar to those seen in 120P-LOT + DS, treatment of primary open angle glaucoma and coexisting cataracts using 360P-LOT + DS may yield better outcomes.

Incidence of Intraocular Pressure Spike and Other Adverse Events after Vitreoretinal Surgery

PURPOSE

To determine the incidence of significant postoperative intraocular pressure (IOP) elevation and other adverse medical events during the first postoperative day in patients undergoing inpatient vitreoretinal surgery.

DESIGN

Noncomparative interventional case series.

PARTICIPANTS

Two hundred two consecutive patients were admitted prospectively as inpatients after vitreoretinal surgery (vitrectomy and/or scleral buckling).

METHODS

Intraocular pressure was measured preoperatively, 5 to 12 hours postoperatively, and on postoperative day 1. Additionally, pain, nausea, and serious systemic adverse events were monitored.

RESULTS

Seventeen patients (8.4%) had a 5- to 12-hour IOP measurement above 29 mmHg. Thirty patients (14.8%) had a postoperative day 1 IOP measurement above 29 mmHg. Three patients (1.5%) required a parenteral narcotic to achieve adequate analgesia. Nine patients (4.5%) utilized a parenteral antiemetic for nausea control. Six patients (3.0%) had a hyperglycemic event. No serious systemic adverse events occurred in the early postoperative period.

CONCLUSIONS

The incidence of a significant IOP spike or systemic adverse events in the early postoperative period in patients undergoing vitreoretinal surgery is low.

Surgical strategies in patients with cataract and glaucoma

PURPOSE OF REVIEW

This review analyzes the most relevant studies on current surgical strategies to treat glaucoma patients with cataracts.

RECENT FINDINGS

No clear evidence has confirmed better results with trabeculectomy alone compared with phacotrabeculectomy. Recent studies have reported successful outcomes combining deep sclerectomy and two-site phacoemulsification. The phacoemulsification cataract extraction will not vary the intraocular pressure of patients with previous deep sclerectomy. Mitomycin C proved to be effective in maintaining lower pressure levels with the combined surgery technique; however, 5-fluorouracil did not show any improvement. Minimally invasive cataract surgery reduces surgical trauma, making it possible to obtain better results with combined surgery and previous glaucoma surgery.

SUMMARY

The surgical strategy decision must be customized to every patient. Only filtering surgeries are recommended in glaucoma patients with incipient cataract. Combined surgical procedures are recommended for progressive or advanced glaucoma. Two-site phacotrabeculectomy with mitomycin C achieves better stabilized results; however, combined phacoemulsification with deep sclerectomy or viscocanalostomy achieves similar results with a lower rate of complications. These promising findings need more study to be confirmed.

Surgical strategies in patients with combined cataract and glaucoma

PURPOSE OF REVIEW

In the elderly population, the combined presence of cataract and glaucoma is a frequent condition. In this situation, several surgical options are possible: cataract surgery only and later maybe trabeculectomy, trabeculectomy only and later maybe cataract surgery, or combined cataract and glaucoma surgery. This review compares the different surgical options on the basis of their achievable postoperative intraocular pressure (IOP) level and success and complication rates.

RECENT FINDINGS

The impression of better IOP regulation with trabeculectomy than with phacotrabeculectomy has been recently confirmed by an evidence-based review. Contrary to this finding, the success of deep sclerectomy or trabeculotomy does not seem to be compromised by simultaneous phacoemulsification. In eyes with previous glaucoma-filtering surgery, cataract surgery with clear corneal incision has no effect on mean IOP but increases the 3-year failure probability. For phacotrabeculectomy, moderate evidence of a beneficial effect of MMC on IOP regulation and only weak evidence for separating the incisions has been recently reported by another evidence-based review.

SUMMARY

The choice of the preferred surgical method depends on the target pressure, the amount of glaucomatous damage, and the grade of visual disturbance caused by the cataract. Phacotrabeculectomy combined with mitomycin C achieves the best IOP lowering of all types of combined cataract and glaucoma surgery currently possible but is associated with potentially sight-threatening complications. In the absence of a low target pressure, phacotrabeculotomy or the combination of phacoemulsification with viscocanalostomy or deep sclerectomy may be the therapy of choice.