Nonpenetrating deep sclerectomy versus trabeculectomy in bilateral primary open-angle glaucoma

Effect of Trabeculodescemetic Window Perforation in Deep Sclerectomy on Intraocular Pressure in Primary Congenital Glaucoma

INTRODUCTION

Primary congenital glaucoma causes vision loss if intraocular pressure is uncontrolled. Nonpenetrating deep sclerectomy is effective in treating primary congenital glaucoma. However, the effects of inadvertent trabeculodescemetic window perforation remain unclear.

METHODS

This retrospective cohort study included patients with primary congenital glaucoma who underwent nonpenetrating deep sclerectomy between 2014 and 2021. The perforation group had intraoperative trabeculodescemetic window perforations; the non-perforation group did not. The primary outcome was intraocular pressure between the groups over 15 months. The secondary outcomes included surgical success and complications.

RESULTS

The study included 74 eyes of 44 patients. The cohort comprised 31 perforated and 43 non-perforated eyes. Both groups showed significant intraocular pressure reduction without significant between-group differences in complete (68 vs. 77%), qualified (19 vs. 9%), or failed (13 vs. 14%) treatments. The median intraocular pressure decreased from 39 to 14 mmHg in the perforation group and 35 to 12 mmHg in the non-perforation group. Of the 74 treated eyes, 68 (92%) showed no complications.

CONCLUSIONS

An inadvertent trabeculodescemetic window perforation during nonpenetrating deep sclerectomy for primary congenital glaucoma did not significantly affect intraocular pressure outcomes compared to non-perforated cases over 15 months. Nonpenetrating deep sclerectomy reduced intraocular pressure regardless of intraoperative perforation in patients with primary congenital glaucoma. Perforation of the trabeculodescemetic window was associated with a low incidence of postoperative complications.

Uncommon Complication Post-deep Sclerectomy: Giant Retinal Tear

Glaucoma is a prevalent neurodegenerative disease. It causes progressive visual loss and is one of the most common causes of blindness worldwide. It can be categorized into open-angle or closed-angle glaucoma. Primary congenital glaucoma (PCG) is a subdivision of open-angle glaucoma. Non-penetrating deep sclerectomy (NPDS) is a surgical method for managing open-angle and primary congenital glaucoma, which was first introduced in 1990. During NPDS, a sclera flap is raised but not completely removed, and the outer part of Schlemm's canal and trabecular meshwork, along with the juxtacanalicular tissue, are excised without completely penetrating the eye. Therefore, it is considered a safe and efficient option for controlling intraocular pressure. This report shows a unique case of uncommon complication post-deep sclerectomy, a giant retinal tear, after undergoing non-penetrating deep sclerectomy for primary congenital glaucoma.

Functional and Morphological Outcomes after Trabeculectomy and Deep Sclerectomy-Results from a Monocentric Registry Study

The aim of this study was to compare the effectiveness of trabeculectomy (TE) and deep sclerectomy (DS) in lowering intraocular pressure (IOP) and thereby preserving visual field and peripapillary retinal nerve fiber layer (RNFL) tissue in primary open-angle glaucoma (POAG) cases. IOP, number of IOP-lowering medications, visual acuity, mean defect of standard automated perimetry, and mean peripapillary RNFL thickness were retrospectively collected and followed up for 3 years after surgery. TE was performed in 104 eyes and DS in 183 eyes. Age, gender, laterality, IOP, number of medications, visual acuity, perimetry mean defect, and peripapillary RNFL thickness were equally distributed at baseline. Mean IOP decreased from 23.8 ± 1.4 mmHg and 23.1 ± 0.4 mmHg to 13.4 ± 0.6 mmHg (p < 0.001) and 15.4 ± 0.7 mmHg (p = 0.001) in the TE and DS groups, respectively. Mean defect remained stable (TE: -11.5 ± 0.9 dB to -12.0 ± 1.1 (p = 0.090); DS: -10.5 ± 0.9 dB to -11.0 ± 1.0 dB (p = 0.302)), while mean peripapillary RNFL thickness showed further deterioration during follow-up (TE group: 64.4 ± 2.1 μm to 59.7 ± 3.5 μm (p < 0.001); DS group: 64.9 ± 1.9 μm to 58.4 ± 2.1 μm (p < 0.001)). Both TE and DS were comparably effective concerning postoperative reduction in IOP and medication. However, glaucoma disease further progressed during follow-up.

Trabeculectomy Vs Non-penetrating Deep Sclerectomy for the Surgical Treatment of Open-Angle Glaucoma: A Long-Term Report of 201 Eyes

Introduction

Glaucoma is the second leading cause of vision loss worldwide. The reduction of intraocular pressure remains the backbone of its therapy. Among surgical techniques for its treatment, deep non-penetrating sclerotomy is the most widely practiced non-penetrating surgery. The purpose of this study was to evaluate the long-term efficacy and safety of deep non-penetrating sclerotomy compared to standard trabeculectomy in patients with open-angle glaucoma.

Patients and methods

Retrospective study including 201 eyes with open-angle glaucoma. Closed-angle and neovascular cases were excluded. Absolute success was considered when intraocular pressure under 18 mmHg, or a reduction of at least 20% in patients with a baseline intraocular pressure below 22 mmHg, was obtained after 24 months, without the use of medication. Qualified success was considered when those targets were met with or without the use of hypotensive medication.

Results

Deep non-penetrating sclerectomy showed a slightly lower long-term hypotensive effect compared to standard trabeculectomy, with significant differences at 12 months, but not at 24 months of follow-up. The absolute and qualified success rates were 51.85% and 65.43% for the trabeculectomy group and 50.83% and 60.83% for the deep non-penetrating sclerectomy, without significant differences. Regarding postoperative complications, mainly due to postoperative hypotonia, or related to the filtration bleb, they were significantly different between groups, with 10.8% and 24.7%, in deep-nonpenetrating sclerectomy and trabeculectomy groups, respectively.

Conclusion

Deep non-penetrating sclerectomy seems to be an effective and safe surgical option for patients with open-angle glaucoma unable to be controlled by non-invasive strategies. Data suggests that the intraocular pressure-lowering effect of this technique may be marginally lower than that of trabeculectomy, but the achieved efficacy outcomes were similar, with a significantly lower risk of complications.

Outcomes of Non-Penetrating Deep Sclerectomy for Primary Congenital Glaucoma Performed by Experienced versus Trainee Surgeons: A Cohort Study

Purpose

To compare the outcomes of non-penetrating deep sclerectomy (NPDS) for primary congenital glaucoma (PCG) performed by experienced vs trainee surgeons.

Patients and Methods

This retrospective cohort study was conducted in 2022 in Saudi Arabia. Consultants (Gr-1) and trainee pediatric ophthalmologists (Gr-2) performed NPDS on pediatric patients with PCG. Success was defined as an intraocular pressure (IOP) less than 21 mmHg at 6 months after surgery. Complications, glaucoma medications, and additional procedures were also observed in the two groups.

Results

Gr-1 and Gr-2 operated on 14 and 39 eyes with PCG, respectively. The absolute success rates were 90.9% (95% confidence interval [CI]: 73.9, 100) in Gr-1 and 96.7% (95% CI: 90.2, 100) in Gr-2 (odds Ratio=1.1; 95% CI: 0.87, 1.3; P=0.54). Survival analysis suggested that the failure rate in the first 6 months after NPDS was not significantly different between the two groups (hazard ratio=1.45; 95% CI: 0.13, 16.0; P=0.767). The complications included hypotony (2 cases), vitreous hemorrhage (1 case), and total flap penetration (1 case). Only one eye in Gr-2 needed glaucoma medication after surgery. There was no significant difference in the success rates of one surgeon before and after training (P=0.43). The age (P=0.59) and sex (P=0.77) of patients, type of surgeon (P=0.94), and preoperative IOP (P=0.59) were not significant predictors of a stable IOP at 6 months after NPDS.

Conclusion

At 6 months after NPDS surgery performed by experienced and trainee pediatric ophthalmologists, the outcomes (stabilization of IOP) were similar between the two groups.

Same-site trabeculectomy with mitomycin and Ologen™ following failed non-penetrating deep sclerectomy

PURPOSE

To assess the effectiveness and safety of same-site trabeculectomy (TRAB) with mitomycin C (MMC) and Ologen™ (Aeon Astron Europe BV. Leiden, The Netherlands) in patients with a failed non-penetrating deep sclerectomy (NPDS).

METHODS

A retrospective study of 24 consecutive eyes (22 patients) undergoing reintervention by same-site TRAB with at least one-year follow-up after failed NPDS. Mean visual acuity (VA), intraocular pressure (IOP) and use of glaucoma medications were compared before and one year after surgery. Early and late postoperative complications were registered. Kaplan-Meier survival analysis was performed according to four levels of success criteria.

RESULTS

Overall the mean IOP reduced significantly (24.9 ± 7.1 vs. 14.4 ± 4.5 mmHg; p < 0.001), and the number of glaucoma medications (2.80 ± 1.01 vs. 0.55 ± 0.94; p < 0.001) significantly decreased, one year after surgery. The mean VA remained stable one year after surgery (p = 0.516). Hypotony, defined as IOP ≤ 5 mmHg, in the early postoperative period was observed in 62.5% of eyes, but only in 2 patients (8.33%) in the long term. The mean survival time ranged from 10 months (CI 95% 5-15) to 29 months (CI 95%: 26-32) according to the most stringent and lenient success criteria respectively.

CONCLUSION

Same-site TRAB augmented with MMC and Ologen™ may provide an effective, safe and lasting alternative following failed NPDS, especially when sparing of the conjunctiva is highly desirable. Postoperative hypotony is the most common postoperative complication.

Sutureless versus conventional deep sclerectomy for management of open angle glaucoma

Introduction

To compare sutureless deep sclerectomy to conventional deep sclerectomy regarding their lowering effect on intraocular pressure (IOP) in cases with open-angle glaucoma.

Methods

This is a prospective interventional randomized comparative study that included 60 eyes of 50 patients with open-angle glaucoma (OAG) who were indicated for surgical intervention. Patients were recruited from the glaucoma subspecialty clinic of the Cairo University teaching hospital and were divided into two groups: group A (underwent sutureless deep sclerectomy) and group B (underwent conventional deep sclerectomy).

Results

Both surgeries showed significant reduction of IOP all through the study period: in group A, mean reduction was 71.37%, 53.35%, 50.3%, and 44.33% at 1st day, 1 month, 3 months, and 6 months respectively, and in group B, mean reduction was 57.62%, 40.63%, 37.41%, and 31.68% at 1st day, 1 month, 3 months, and 6 months, respectively. Comparison between percentage of reduction in both groups showed no statistically significant difference. Also, use of anti-glaucoma medications dropped significantly at 6 months postoperatively in both groups with no significant difference between the 2 groups. Regarding reported complications, 12.9% in group A and 10.3% in group B presented with non-serious complications. One month postoperatively, UBM detected non-functioning blebs in 6.4% of group A and 3.4% in group B. Other cases with non-functioning blebs were detected at 3 and 6 months postoperatively, and all cases were managed.

Conclusion

Sutureless deep sclerectomy seems to be a safe and effective modification, with significant IOP reduction in POAG.

High-Frequency Deep Sclerotomy as Adjunctive Therapy in Open-Angle Glaucoma Patients

INTRODUCTION

Glaucoma is a chronic, progressive disease of the optic nerve that can cause vision loss and blindness. High-frequency deep sclerotomy (HFDS) is a novel ab interno procedure used to lower intraocular pressure (IOP). This study aims at examining hypotensive effects of HFDS in patients with medically uncontrolled primary open-angle glaucoma (POAG).

METHODS

23 patients (23 eyes) participated in this study. They were all affected by POAG and used maximum prescribed medical therapy. It is important to note that the target IOP was not detected in any study participant. The target IOP is the highest IOP value at which no new damages of the optic nerve occur. The procedure was performed with a custom-made, high-frequency dissection probe by applying bipolar current of 500 kHz. Six pockets (1 mm deep, 0.3 mm high, and 6 mm wide) were made ab interno in nasal sclera (through trabecular meshwork and Schlemm's canal). Tobramycin/dexamethasone and pilocarpine eye drops were administered postoperatively for a month.

RESULTS

The mean value of the base IOP had been 25.6 mm Hg before the procedure. Significant complications were not recorded either during the surgery or in a postoperative follow-up period. The average IOP for our patients reduced by 8.6 mm Hg (33.6%) after a year. The mean value of the instilled anti-glaucoma eye drops had been 2.78 (SD = 0.45) before the HFDS and 0.61 (SD = 1.04) at the end of the research. The target IOP was not achieved in five cases (21.7% of our sample).

DISCUSSION/CONCLUSION

This study presents the data on our first surgical experience with HFDS that was conducted on 23 patients who had medically uncontrolled POAG. The results indicate that HFDS is safe and efficient in reducing IOP.

[Why trabeculectomy is better than its reputation]

BACKGROUND

Trabeculectomy (TE) remains one of the most frequently performed glaucoma procedures. This surgery enables sufficient reduction of intraocular pressure (IOP) and freedom from using eye drops; however, complication management and time-consuming postoperative care make many ophthalmic surgeons reluctant to include TE in their treatment regimen.

AIM

This review presents the value of TE compared to other forms of filtering and nonfiltering glaucoma surgery.

CONCLUSION

The use of TE is still the most effective method for lowering IOP and in comparison to other forms of glaucoma surgery in most cases enables freedom from eye drops with a subsequent high quality of life. Postoperative complications occur more frequently, but usually heal spontaneously or can be treated adequately and safely by surgery; however, TE requires intensive postoperative care, which should not be neglected. Repeated surgery due to insufficient IOP reduction is less frequent compared to other forms of glaucoma surgery.

Outcomes of Deep Sclerectomy following Failed XEN Gel Stent Implantation in Open-Angle Glaucoma: A Prospective Study

Background: The purpose of this study is to evaluate the outcome of deep sclerectomy (DS) as a secondary procedure following failed ab-interno XEN gel stent implantation in patients with open-angle glaucoma. Methods: Prospective, single-center, non-randomized, interventional study. Consecutive eyes that underwent mitomycin C (MMC) augmented XEN gel stent surgery, with uncontrolled intraocular pressure (IOP) or signs of disease progression, were included to undergo MMC-augmented DS. Primary efficacy outcome was surgical success, defined as complete when the unmedicated IOP was 12 mmHg or less, or 15 mmHg or less and 20% lower than at the timing of XEN failure and defined as qualified when the IOP fulfilled the same conditions with fewer medications than before deep sclerectomy. Secondary measures were mean reduction in IOP and in the number of medications, and the rates of complications. Results: Seventeen eyes were enrolled with a mean age of 72.1 ± 8.2 years (66.7% women). The mean follow-up was 20.1 ± 4.9 months, with more than 12-month data available from 15 eyes. Following DS, IOP decreased significantly from 22.6 ± 5.3 mmHg to 12.3 ± 5.5 (45.6%; p < 0.001). Antiglaucoma medications dropped from 1.1 ± 0.9 to 0.3 ± 0.7. Complete success was obtained in 40% of eyes using the threshold of 12 mmHg or less and a 20% decrease of IOP, and in 60% using the 15 mmHg or less threshold. Adverse events were observed in 20% of eyes (bleb leakage (13.3%); hypotony (6.7%)). No cases of choroidal detachment or hypotony maculopathy were reported. Conclusions: Failed XEN gel stent implantation does not seem to negatively affect the safety and efficacy of subsequent deep sclerectomy surgery.

Refractive astigmatism in phaco-canaloplasty vs phaco-non-penetrating deep sclerectomy

This study aimed to assess refractive astigmatism, in phaco-canaloplasty (PC) vs phaco-non-penetrating deep sclerectomy (PDS) in a randomized, prospective study within 24 months. Patients were randomized pre-operatively, 37 underwent PC and 38 PDS. The following data was collected: BCVA, IOP, number of antiglaucoma medications, refraction with autokeratorefractometry. The assessment of astigmatism was simple arithmetic and vector analysis (calculations included cylinder with axis in form of centroids) and included double angle plots and cumulative refractive astigmatism graphs. Pre-operative mean BCVA in PC was 0.40 ± 0.43 and was comparable to BCVA in PDS 0.30 ± 0.32logMAR (P = 0.314). In the sixth month follow-up, mean BCVA showed no difference (P = 0.708) and was 0.07 ± 0.13 and 0.05 ± 0.11, respectively. However, 2 years after the intervention mean BCVA was better in PC 0.05 ± 0.12 than in PDS 0.12 ± 0.23 and it was statistically significant (P = 0.039). Mean astigmatism in PC at baseline was 1.13 ± 0.73Dcyl, at 6 months it was 1.09 ± 0.61 and at 2 years 1.17 ± 0.51. In PDS at baseline 1.35 ± 0.91 at 6 months 1.24 ± 0.86 and at 2 years 1.24 ± 0.82. There were no differences between the groups in mean astigmatism throughout the study. Centroids (mean of a cylinder with axis) in PC were pre-operatively 0.79D@172˚ ± 1.10Dcyl, at 6 months 0.75D@166˚ ± 1.01 and at 24-months 0.64D@164˚ ± 1.11 and in PDS pre-operatively 0.28D@10˚ ± 1.63D at 6 months 0.26D@11˚ ± 1.5 and at 24-months 0.47D@20˚ ± 1.43. The direction of mean astigmatism was against the rule in all analyzed time points. The mean baseline IOP in PC was 19.4 ± 5.8 mmHg and 19.7 ± 5.4 mmHg in PDS(P = 0.639). From the 6-month IOP was lower in PC, at 24-months it was 13.8 ± 3.3 mmHg in PC and 15.1 ± 2.9 mmHg in PDS(P = 0.048). In both groups preoperatively patients used median(Me) of three antiglaucoma medications(P = 0.197), at 24-months in PC mean 0.5 ± 0.9 Me = 0.0 and 1.1 ± 1.2 Me = 1.0 in PDS(P = 0.058). Both surgeries in mid-term observation are safe and effective. They do not generate vision-threatening astigmatism and do not even change the preoperative direction of mean astigmatism. Refractive astigmatism is stable throughout the observation.

Reintervention rate in glaucoma filtering surgery: A systematic review and meta-analysis

PURPOSE

Reintervention rate is an important factor impacting on patients, surgeons, and society. To date, only a few studies have focused on this topic. For this reason, a systematic review and meta-analysis was undertaken to assess the reintervention rate after glaucoma filtering surgery.

MATERIALS AND METHODS

Prospective studies reporting the reintervention rate after glaucoma filtering surgery and with at least 12 months of follow-up were systematically searched on PubMed, Medline and Embase databases. The primary outcome was the total reintervention rate following surgery. Secondary outcomes were: the rate of manipulation, in-clinic and in-operating room reintervention; the reintervention rate for intraocular pressure (IOP) control and for complications; demographic, clinical and surgical variables associated with reintervention rate.

RESULTS

Ninety-three studies with a total of 8345 eyes were eligible. The total reintervention rate was 1.84 (95% CI 1.57-2.13), with a lower rate for Baerveldt (0.53, 95% CI 0.29-0.83) and Preserflo (0.60, 95% CI 0.15-1.29), and a higher rate for Xen (4.26, 95% CI 2.59-6.31). The manipulation rate was 0.99 (95% CI 0.77-1.23), the in-clinic reintervention rate was 0.08 (95% CI 0.05-0.12) and the in-operating room reintervention rate was 0.28 (95% CI 0.22-0.35). The reintervention rate for IOP control was 1.26 (95% CI 1.04-1.51) and the reintervention rate for complications was 0.27 (95% CI 0.21-0.35).

CONCLUSIONS

All types of surgery presented a total reintervention rate similar to the overall findings, except studies on Baerveldt and Preserflo Microshunt, with a lower rate, and Xen, with a higher rate. None of the variables evaluated were found to be directly associated with the explored outcomes.

Rotational extraction of incarcerated iris (REII): a slit lamp technique to reduce incarcerated iris after nonpenetrating deep sclerectomy for glaucoma

PURPOSE

Iris incarceration is a complication of glaucoma filtering surgery that often requires surgery. We describe a technique for reduction of incarcerated iris at the slit lamp, dubbed rotational extraction of incarcerated iris (REII). A retrospective analysis of visual function and intraocular pressure (IOP) was done in patients treated with REII after nonpenetrating deep sclerectomy.

METHODS

We retrospectively evaluated a cohort of patients who received REII for iris incarceration after nonpenetrating deep sclerectomy for glaucoma. IOP (applanation) and visual acuity (VA) were measured day-of, and 1, 3, 6, and 12 months post-REII. Adverse events were recorded. Kaplan-Meier survival analysis was done with definitions of IOP control at 15, 18, and 21 mmHg.

RESULTS

Forty-one eyes of 41 patients were treated with REII. Median time to iris incarceration from glaucoma surgery was 50 days (range 1-1906). Mean pre-REII IOP ± SD was 33.7 ± 14.1 mmHg, which reduced to 11.5 ± 6.1 mmHg day-of. LogMAR VA was 0.72 ± 0.8 log units at baseline and was unchanged at 12 months (P = 0.53). Survival analysis demonstrated varying efficacy depending on the definition of success. 79.0 to 92.2% of eyes achieved IOP control immediately after REII, 39.5 to 71.1% at 1 month, 26.3 to 52.6% at 3 months, 21.1 to 44.3% at 6 months, and 10.5 to 38.0% at 12 months. Nearly half (47.4%) of eyes required a tube shunt by 12 months.

CONCLUSION

REII may be a safe, minimally invasive slit lamp procedure that can reduce incarcerated iris and delay more invasive intervention for 3-6 months in most eyes.

Surgical outcomes of phakic, pseudophakic and combined phaco-trabeculectomy in a tertiary care centre in Saudi Arabia

PURPOSE

To compare the outcomes of phakic, pseudophakic and combined phaco-trabeculectomy in eyes of Saudi patients.

METHODS

This was a retrospective cohort study. Eyes of patients with primary open angle glaucoma, primary angle closure glaucoma or secondary exfoliation glaucoma (XFG) that underwent phakic (n = 152), pseudophakic (n = 40) or combined phaco-trabeculectomy (n = 45) at the King Khaled Eye Specialist Hospital, Riyadh from January 2012 to December 2017 were included. The primary outcome measure was the success at 3 years after surgery. Complete success was defined as achieving an intraocular pressure (IOP) of ≥ 6 and ≤ 21 mmHg without topical antiglaucoma medications; qualified success as achieving the same IOP criteria with or without the use of glaucoma medications. Cumulative probabilities of failure were computed using Kaplan-Meier survival analysis. We used Cox regression analysis to identify factors associated with treatment failure. Reduction in mean IOP and AGM over time was estimated using mixed-effects linear models.

RESULTS

The mean decrease in IOP at 3 years from baseline in the phakic, pseudophakic and combined groups was 12.0 (95% CI, 9.9, 14.1) mmHg, 10.1 (95% 6.3, 13.9) mmHg, and 6.4 (95% CI, 1.9, 11.0) mmHg, respectively, and was not significantly different from each other. The values for qualified success were also comparable: 95.2% (95% CI: 86.7-99.0), 95.3% (95% CI: 76.2-99.9), 92.3% (95% CI: 64.0-99.8). Failure was significantly associated with postoperative suturelysis (p = 0.004), XFG (p = 0.018) and AGM (p = 0.038).

CONCLUSIONS

This is the first study to provide relative surgical outcomes of trabeculectomy, phaco-trabeculectomy and pseudophakic trabeculectomy in Saudi Arabia and did not show any significant difference in terms of overall success.

The surgical management of glaucoma: A review

After a long period of little change, glaucoma surgery has experienced a dramatic rise in the number of possible procedures in the last two decades. Glaucoma filtering surgeries with mitomycin C and glaucoma drainage devices remain the standard of surgical care. Other newer surgeries, some of which are minimally or microinvasive glaucoma surgeries, target existing trabecular outflow, enhance suprachoroidal outflow, create subconjunctival blebs, or reduce aqueous production. Some require the implantation of a device such as the iStent, Hydrus, Ex-PRESS, XEN and PRESERFLO, whilst others do not-Trabectome, Kahook dual blade, Ab interno canaloplasty, gonioscopy-assisted transluminal trabeculotomy, OMNI and excimer laser trabeculotomy. Others are a less destructive variation of an established procedure, such as micropulse transscleral cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cycloplasty. Cataract surgery alone can be a significant glaucoma operation. These older and newer glaucoma surgeries, their mechanism of action, efficacy and complications are the subject of this review.

Clinical outcomes of viscocanalostomy and phacoviscocanalostomy in primary open angle glaucoma: Two years follow-up

PURPOSE

To compare the outcomes of phacoviscocanalostomy and viscocanalostomy in patients with primary open angle glaucoma.

METHODS

This non randomized, prospective comparative study included 168 eyes of 168 patients with primary open angle glaucoma (POAG). Phacoviscocanalostomy was performed in 94 eyes with POAG and cataract and viscocanalostomy was performed in 74 eyes with POAG. Preoperative and postoperative intraocular pressures (IOP), number of antiglaucoma medication, intraoperative and postoperative complications were recorded throughout the follow-up period.

RESULTS

The mean follow-up after surgery was 20.13 ± 7.9 months. Mean IOP decreased significantly 1 month after surgery in both groups (p < 0.001) and remained significantly lower from its preoperative value at all follow-up visits. The postoperative mean IOP at the last follow up in phacoviscocanalostomy and viscocanalostomy was 14.98 ± 4.8 mmHg and 16.84 ± 5.0 mmHg, respectively (p = 0.001). Complete success rate in phacoviscocanalostomy and viscocanalostomy groups was 83.1% and 56.8%, respectively (p = 0.008). Qualified success rate was achieved in 89.4% eyes in the phacoviscocanalostomy group and 83.8% of viscocanalostomy group (p = 0.534). The Best corrected visual acuity (BCVA) in phacoviscocanalostomy group improved significantly post-operatively (p = 0.001). Postoperative antiglaucoma medication in both groups were significantly less than the preoperative values (p = 0.001).

CONCLUSIONS

Both Phacoviscocanalostomy and viscocanalostmy are effective procedures in the control of IOP in patients with POAG with and without cataract. Higher complete success rates and BCVA were achieved in phacoviscocanalostomy. Therefore, phacoviscocanalostomy and viscocanalostomy are recommended in eyes with medically uncontrolled primary open-angle glaucoma with and without coexisting cataract.

Comparison of Long-Term Effects After Modified CO2 Laser-Assisted Deep Sclerectomy and Conventional Trabeculectomy in Chinese Primary Open-Angle Glaucoma

Introduction

To compare the long-term effect after modified CO₂ laser-assisted sclerectomy surgery (MCLASS) and conventional trabeculectomy (TRAB) in medically uncontrolled Chinese primary open-angle glaucoma (POAG) patients.

This was a retrospective comparative study.

Methods

A total of 87 patients were reviewed, including 45 in the MCLASS group and 42 in the TRAB group. Intraocular pressure (IOP), best-corrected visual acuity (BCVA), and use of supplemental medical therapy were retrospectively compared at baseline, and until 36 months postoperatively.

Results

Patients in both groups achieved a significant IOP decrease from baseline (P < 0.001); postoperative IOP in the MCLASS group was significantly lower than that in the TRAB group at 24 and 36 months. The reduced use of medication was statistically significant in both groups, and the number of postoperative medications was significantly more in TRAB group at 24 and 36 months. At 24 and 36 months, the complete success rate was 60% and 53.3% for MCLASS versus 66.7% and 59.5% for TRAB, and the qualified success rate was 91.1% and 88.9% for MCLASS versus 83.3% and 80.9% for TRAB, respectively. BCVA deterioration post TRAB was clinically more serious than that post MCLASS at 24 and 36 months, although the difference was not statically significant at any time point postoperatively. Compared with MCLASS, more complications occurred postoperatively in the TRAB group.

Conclusions

MCLASS is an effective surgical option for Chinese POAG patients. Compared to TRAB, eyes undergoing MCLASS experience a comparable success rate, a greater IOP reduction, fewer medications, and a lower risk of complications up to 36 months.

Lasers in Glaucoma: an Overview

Lasers have been in use as a treatment modality of glaucoma for more than last four decades. Each passing year has added newer dimensions to the existing laser technologies enhancing their safety and efficacy profile. This has become possible due to continuous research and innovations with proper understanding of the mechanism of action of different variety of lasers as treatment options. Each category of glaucoma has different underlying pathologies. Adequate knowledge and understanding of indications, limitations and hazards of these laser procedures are must before their application for improvising outcome. Recent years have witnessed a revolution this field. A thorough literature search was conducted in PubMed, Medline, the Cochrane Library Database, EMBASE, and Scopus and Google Scholar until May 2020 using the keywords, and all the articles pertaining to the relevant topics were included in this review. Purpose of this review is to summarize the important laser procedures currently in use for managing glaucoma along with updating the readers with recent advances in laser technologies, their extended applications and also analyzing possible future implications.

Efficacy and Safety of Trabeculectomy Versus Nonpenetrating Surgeries in Open-angle Glaucoma: A Meta-analysis

PURPOSE

The purpose of this study was to conduct a meta-analysis on the efficacy and safety of trabeculectomy (TE) and nonpenetrating glaucoma surgery (NPGS) techniques in patients with primary open-angle glaucoma, pseudoexfoliation glaucoma, pigmentary glaucoma, and normal-tension glaucoma.

METHODS

All studies were identified by searching electronic sources (PubMed, Medline, Scopus, and Embase) until February 5, 2018. Primary outcome was mean intraocular pressure (IOP) reduction at 6, 12, and 24 months. Complications, number of antiglaucomatous medications, and visual outcomes were also evaluated.

RESULTS

Twenty-one studies were included. Ten studies compared TE with deep sclerectomy (DS), 5 with viscocanalostomy (VC), 1 study with both DS and VC, and 5 with canaloplasty (CP). TE was superior to DS, VC, and CP in reducing IOP at 6 and 12 months, and to DS at 24 months. When comparing TE to VC and to CP at 24 months, there was no significant difference in IOP reduction. Hypotony, choroidals, anterior chamber shallowing or flattening, and cataract formation or progression were more associated with TE than with NPGSs. TE was more effective in reducing antiglaucomatous medications than VC and CP.

CONCLUSIONS

TE is more effective in reducing IOP. TE presents a higher risk of complications as compared with NPGS, except for hyphema.

Outcome and Complications of Combined Modified Deep Sclerectomy and Trabeculectomy for Surgical Management of Glaucoma: A Pilot Study

Purpose

To report the outcome and complications of a combined surgical technique of modified deep sclerectomy and trabeculectomy (mDST) for glaucoma.

Patients and Methods

Retrospective study of 44 eyes of 43 patients with open and closed angle glaucoma who underwent mDST. Outcome measures were: Surgical Success with 3 criteria - (i) criterion 1 = intraocular pressure (IOP) ≤21 mmHg or reduced by ≥20% of pre-operative IOP or IOP ≥6 mmHg on 2 consecutive time points after 3 months; (ii) criterion 2 = IOP ≤18 mmHg or reduced by ≥30% of pre-operative IOP or IOP ≥6 mmHg on 2 consecutive time points after 3 months and (iii) criterion 3 = IOP ≤15 mmHg or reduced by ≥40% of pre-operative IOP or IOP ≥6 mmHg on 2 consecutive time points after 3 months; IOP Reduction; Use of Anti-glaucoma Medication; Complications; Visual Acuity and Postoperative Interventions.

Results

Median follow-up was 40 months (range 24–77 months). At the final follow-up visit, the mean postoperative IOP was 11.5 ± 4.7 mmHg (p<0.0001). Mean number of anti-glaucoma medications decreased from 2.45 ± 1.21 to 0.54 ± 0.95 (p<0.0001). Surgical success in terms of IOP reduction was 50%; 43.2%; 36.4% for the 3 criteria respectively (complete success) and 70.5%; 56.8%; 47.7% for the 3 criteria respectively (qualified success). The complications noted were shallow/flat anterior chamber in 2 (4.54%), hyphema & bleb leak in 3 (6.81%), aqueous misdirection in 1 (2.27%), hypotonic maculopathy in 2 (4.45%) and hypotony requiring intervention in 6 (13.63%) eyes.

Conclusion

Combined mDST was found to be an effective surgical procedure in reducing IOP. It was associated with complications commonly encountered in glaucoma filtering surgery. The use of intra-scleral space maintainer may help lower the risk of flat or shallow anterior chamber during the early postoperative period.

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Prospective evaluation of penetrating deep sclerectomy in advanced open-angle glaucoma: Filtration surgery adapted to resource scarcity in developing countries

PURPOSE

Two of the hurdles that are facing ophthalmologists in developing countries are scarcity of resources and patient follow-up. Deep sclerectomy (DS) has proven less costly and more effective than topical therapies and has a more favorable safety profile than trabeculectomy. The main factors preventing its use in developing countries are the need to perform laser goniopuncture in 40-80% of cases to maintain filtration and the risk of postoperative iris incarceration. The purpose of this study is to assess the efficacy and safety profile in advanced open-angle glaucoma of a relatively new surgical technique designed to overcome this limitation: penetrating DS.

SETTING

This was an investigator-initiated, prospective, interventional study, conducted at a single ophthalmology center in Kinshasa, Congo. The study was conducted in full compliance with the Declaration of Helsinki.

METHODS

Fifty-one eyes (34 patients) with uncontrolled advanced primary open-angle glaucoma (visual field mean deviation<-10 dBs) were enrolled between October 2012 and June 2016. Age, gender, comorbidities (hypertension/diabetes), best-corrected visual acuity, topical medications, medicated and unmedicated intraocular pressure (IOP) were recorded. All patients underwent penetrating DS, during which, following standard dissection of the scleral flaps, the anterior chamber was penetrated through the trabeculo-Descemet membrane and an iridectomy was performed. Patients attended postoperative appointments at months 1, 3, 6 and 12. Surgical success was defined as a 20% reduction of IOP from baseline in conjunction with a 12-month unmedicated IOP≤12mmHg.

RESULTS

The mean age was 64.5±14.0 years (44.1% female, 100% African). Mean IOP decreased from 20.2±6.1 (medicated) and 30.7±9.8mmHg (unmedicated) preoperatively to 12.1±4.1 at 12 months. Concomitantly, the number of topical medications decreased from 1.5±0.7 to 0.0. Complete surgical success was achieved in 64.7%. Four eyes (7.8%) were considered surgical failures due to uncontrolled IOP. None of the eyes lost light perception or required additional surgery. A significant association between surgical failure and hypertension was observed (HR=1.49; P=0.008). There were no intraoperative complications. Postoperatively, 4 bleb encapsulations (7.8%) and 1 iris incarceration (2%) were observed.

CONCLUSIONS

The present study demonstrates that penetrating DS achieved similar efficacy and safety results to traditional non-penetrating DS. In addition, it showed a lower potential for intraoperative complications, which might be associated with a more benign surgical learning curve. Finally, the rates of serious postoperative complications (iris incarceration, choroidal effusion and hypotony) were significantly lower than in DS and trabeculectomy, and this technique does not require subsequent Nd: YAG laser goniopuncture to maintain filtration, making frequent follow-up visits less critical. In view of these findings, perforating deep sclerectomy could offer a viable option for glaucoma management in developing countries as well as worldwide.

Reverse meridional cyclodialysis ab interno in management of open angle glaucoma — a preliminary report

The uveoscleral outflow as an alternate route of aqueous drainage is of great interest in glaucoma surgical treatment. A cyclodialysis cleft allows one to create a direct connection between the anterior chamber (AC) and the suprachoroidal space (SCS) which is the key element of uveoscleral outflow. The purpose of the study was to evaluate the safety and effectiveness of reverse meridional cyclodialysis ab interno (RMCai) in decreasing intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG) and refractory glaucoma (RG). Fourteen patients who exhibited POAG and RG (11 men and 3 women, age 77.3 ± 7.8 years) were included in the study. All patients underwent RMCai with the help of custom-designed spatula. The spatula, inserted through a clear corneal incision, was used to detach the ciliary body from the scleral spur to create a 2.0–2.5 mm wide and 6.0–6.5 mm deep cleft. Outcome measures were IOP change, use of hypotensive medication(s), complications, and need for a second surgery. Decrease in IOP by more than 20% and IOP between 6 and 21 mmHg without hypotensive medication constituted complete success. Similar changes in IOP with medication constituted partial success. Need for second surgery constituted failure. The follow-up period was >3 months. Baseline IOP and hypotensive medication use were 22.0 ± 8.5 mmHg (95% confidence interval (CI), 17.6–26.4) and 2.6 ± 0.9 (95% CI, 2.2–3.1). At 3, 6, 12, 18, and 24 months, complete success was achieved in 64.3%, 77.8%, 55.6%, 37.5%, and 40% of patients respectively; partial success — in 14.3%, 22.2%, 44.4%, 50.0%, and 60.0%. Four patients required a second surgery. Failure occurred because of cleft closure by fibrosis. It was concluded that RMCai is safe and effective in decreasing IOP in POAG and RG patients.

The EX-PRESS glaucoma shunt versus nonpenetrating deep sclerectomy with Esnoper implant in combined surgery for open-angle glaucoma: a prospective randomized study

PURPOSE

To report 1-year treatment outcomes of P50 EX-PRESS implant versus nonpenetrating deep sclerectomy (NPDS) with Esnoper V2000 combined with phacoemulsification.

DESIGN

Randomized, prospective and multicentre clinical trial.

METHODS

Settings: Six clinical centres.

POPULATION

Patients 54-89 years of age without previous filtering surgery with cataract and glaucoma who required lower levels of intraocular pressure (IOP).

INTERVENTIONS

Phaco-EX-PRESS P50 or Phaco-NPDS with Esnoper V2000, both groups with mitomycin C (0.2 mg/ml for 2 min).

MAIN OUTCOME MEASURES

IOP, complete success rate (IOP: ≥6 and ≤18 mmHg), visual acuity, use of medical therapy and systematic assessment of complications and postoperative interventions.

RESULTS

A total of 98 eyes were enrolled, including 50 in the EX-PRESS group and 48 in the NPDS group. At 12 months, IOP (mean ± SD) was 13.9 ± 3.3 mmHg in EX-PRESS group and 13.3 ± 3.6 mmHg in NPDS group (p = 0.38). Success rate was 75% and 80% in EX-PRESS and NPDS groups, respectively (p = 0.53). The number of glaucoma medications (mean ± SD) was 0.2 ± 0.55 in EX-PRESS group and 0.17 ± 0.44 in NPDS group (p = 1.00). The total number of complications was 66 in 35 subjects in EX-PRESS group and 39 in 23 subjects in NPDS group (p = 0.02). The incidence of more than one complication was n = 13 (26%) versus n = 9 (18.8%) in EX-PRESS and NPDS groups, respectively (p = 0.38). The total number of required postoperative interventions was 59 and 26 in EX-PRESS and NPDS groups, respectively (p = 0.01). Visual acuity was similar in both groups at month 12 (p = 0.13). Surgical time (mean ± SD) was 52.6 ± 13.6 min in EX-PRESS group and 63.3 ± 19.4 min in NPDS group (p = 0.01).

CONCLUSION

Phaco-EX-PRESS surgery had similar success rate compared to Phaco-NPDS during 1 year of follow-up. Both procedures were associated with similar IOP reduction and use of additional medical therapy at 12 months. EX-PRESS surgery required more postoperative interventions and had more complications, but needed less surgical time compared to NPDS.

Primary glaucoma surgery in Fuchs' heterochromic uveitis: a comparison of trabeculectomy versus deep sclerectomy

Background:

Deep sclerectomy offers the potential advantage of less postoperative inflammation and better survival in Fuchs’ patients. The aim of this study was to compare survival and safety profiles of Fuchs’ heterochromic uveitis patients undergoing trabeculectomy or deep sclerectomy.

Methods:

A retrospective study was conducted of two separate cohorts who had undergone either trabeculectomy or deep sclerectomy. Patient demographics, best-corrected visual acuity, intraocular pressure, antimetabolite used, postoperative complications and subsequent procedures were analysed.

Results:

In total, 13 trabeculectomy patients and 14 deep sclerectomy patients were included. Mean preoperative intraocular pressure was similar at 30.1 mmHg in the trabeculectomy group and 35.9 mmHg in the deep sclerectomy group, with no significant difference between the two (p = 0.22). Kaplan–Meier survival outcomes for success at <22 mmHg and <19 mmHg showed no significant differences between the groups and this was also the case for intraocular pressure at 3 years (analysis of variance; p = 0.47).

Conclusion:

Both procedures appear to have similar efficacy and safety profiles, suggesting that both are effective.

Evaluation of the Early to Mid-term Efficacy and Safety of Deep Sclerectomy without an Intrascleral Spacer for Open-angle Glaucoma in an Australian Population

Purpose

This study aims to evaluate the early to the midterm efficacy of deep sclerectomy (DS) without an intra-scleral spacer for open-angle glaucoma (OAG) patients.

Materials and methods

Retrospective study of 99 eyes (88 patients) with open-angle glaucoma who underwent DS were recruited in a consecutive order following informed consent. Intraocular pressure (IOP) was collected up to 60 months post operation (mean 19.87 ± 15.13 months). Criteria of success were defined as the qualified success (QS) or complete success (CS) with IOP level less than 21, 18 and 15 mm Hg and a reduction of more than 20% IOP from baseline. QS includes additional medication post-DS, while CS requires no other medications or surgery post-DS. Further analysis includes comparing the criteria of success based on several factors. The data were analyzed using statistical package for social sciences (SPSS version 21) statistical software.

Results

The QS at 60 months for IOP less than 21, 18 and 15 mm Hg is 71.3% (45.12 ± 2.46), 63.9% (40.41 ± 2.75) and 48.7% (35.62 ± 2.85), respectively. The CS at 60 months for IOP less than 21, 18 and 15 mm Hg are 69.3% (47.51 ± 2.77), 57.9% (40.41 ± 2.75) and 45.2% (35.62 ± 2.85), respectively. There was no significant difference between QS and DS post-DS based on the level of experience of the surgeons; intraoperation complication; age and gender. There was a significant reduction in IOP post operation (p < 0.001).

Conclusion

DS is observed to be an effective surgical method with a favorable safety profile to manage patients with open-angle glaucoma. It has a better safety profile compared to trabeculectomy (TE) and can be performed by surgeons of different experience safely and successfully.

Clinical significance

To our knowledge, this is the first report of DS in an Australian population with up to 60 months of follow-up. It is an effective procedure for IOP control in patients with OAG and has fewer complications compared to TE. DS is less popular than TE primarily due to a perceived steep learning curve, but most of the literature on DS describe single surgeon results. Our study compared the outcome of five surgeons with a variety of experience and found no significant differences in the rate of success for all levels of IOP.

How to cite this article

Hui MM, Clement CI. Evaluation of the Early to Mid-term Efficacy and Safety of Deep Sclerectomy without an Intrascleral Spacer for Open-angle Glaucoma in an Australian Population. J Curr Glaucoma Pract 2018;12(3):107-112.

Combined phacoemulsification and viscocanalostomy with Ologen implant versus combined phacoemulsification and viscocanalostomy

BACKGROUND

To study the efficacy of the biodegradable collagen implant Ologen® as an adjuvant in phaco-viscocanalostomy in patients with coexisting cataract and primary open angle glaucoma.

METHODS

This prospective, interventional, randomized clinical study was done at Alpha Vision Center, Zagazig, Egypt. Patients with coexisting cataract and glaucoma were randomized to receive either phaco-viscocanalostomy (Phacovisco group) (39 eyes) or phaco-viscocanalostomy with Ologen® implant (OloPhacovisco group) (40 eyes). Follow-up period was 2 years. Nd:YAG laser goniopuncture was done in cases where the intraocular pressure (IOP) was elevated above 21 mmHg after discontinuation of corticosteroid eye drops at any follow-up visit.

RESULTS

No significant operative or postoperative complications (other than failure) were encountered in either group. At 2 years follow-up, the mean IOP level was statistically significantly decreased in the OloPhacovisco group (p = 0.02) and complete success occurred in 23 eyes (59.0%) in the Phacovisco group and in 32 eyes (80.0%) in the OloPhacovisco group. There was a statistically significant higher success rate regarding complete success in patients that received Ologen® implant (p = 0.04).

CONCLUSIONS

Ologen® implant improved the success rate of phaco-viscocanalostomy. Larger studies with longer follow-up periods may be required to confirm these findings.

TRIAL REGISTRATION

This trial was retrospectively registered on 20/12/2018 under the number ( NCT03782051 ).

Changes in choroidal thickness and optic nerve head morphology after filtering surgery: nonpenetrating deep sclerectomy versus trabeculectomy

Background

The purpose of this study was to evaluate the changes in choroidal thickness and lamina cribrosa position after nonpenetrating deep sclerectomy (NPDS) and trabeculectomy.

Methods

Twenty-three eyes with glaucoma that required filtering surgery were included (12 NDPS and 11 trabeculectomies) in this prospective observational study. OCT-enhanced depth imaging (OCT-EDI) was used to measure choroidal thickness, prelaminar tissue thickness and lamina cribrosa position before and 7 days and 1 month after surgery. All results are shown as median (interquartile range values).

Results

Intraocular pressure (IOP) was significantly lower 1 week after surgery than at baseline (7 (6/10) mmHg vs. 21 (18/26) mmHg; p < 0.001) with a mean 64% decrease. IOP remained significantly lower at 1 month with a 55% mean decrease as compared to baseline (10 (8/12) mmHg; p < 0.001). One week after surgery, the subfoveolar choroidal thickness (SFCT) significantly increased (372 (306/523) μm vs. 317 (227/413) μm; p = 0.04) and the prelaminar tissue (PLT) was significantly thicker (269 (162/360) μm vs. 138 (87/268) μm; p = 0.02) as compared to preoperative measurements. These changes were not statistically significant at one month. There were no differences concerning these parameters between the NPDS and trabeculectomy groups. During the first week, the SFCT increase was correlated with IOP reduction (r = − 0.41; p = 0.04).

Conclusions

OCT-EDI allowed the visualization of structural changes at the level of the optic nerve and choroidal vascularization during acute IOP changes. No difference was observed between NPDS and trabeculectomy concerning these structural modifications.

Decompression retinopathy following nonpenetrating deep sclerectomy for primary congenital glaucoma

BACKGROUND

To describe a unique case of decompression retinopathy manifesting as pre-macular subhyaloid hemorrhage that occurs in a nine-day old child after undergoing a non-penetrating deep sclerectomy for primary congenital glaucoma.

CASE PRESENTATION

We report a single case of a 9-day-old boy who was referred to our department of ophthalmology for bilateral buphtalmia and corneal edema. He presented marked elevation of the intraocular pressure in both eyes (22 mmHg and 26 mmHg, in the right eye and left eye respectively) associated with significant optic nerve cupping. Non-penetrating deep sclerectomy was performed for each eye, with effective reduction of the intraocular pressure during the first week postoperatively (11 mmHg and 7 mmHg in the right eye and left eye respectively). The right eye presented an isolated subhyaloid hemorrhage located in the pre-macular area, persisting 3 weeks after the initial surgery and requiring pars-plana vitrectomy to clear the visual axis. This uncommon complication was identified as decompression retinopathy. The intraocular pressure remained controlled in the normal range three years after initial surgery in both eyes, with reversal of optic disc cupping.

CONCLUSIONS

Decompression retinopathy is a potential complication after non-penetrating deep sclerectomy in primary congenital glaucoma, requiring prompt treatment strategy to prevent potential organic amblyopia.

CO2 laser-assisted sclerectomy surgery compared with trabeculectomy in primary open-angle glaucoma and exfoliative glaucoma. A 1-year follow-up

PURPOSE

To report on the efficacy and safety of CO₂ laser-assisted sclerectomy surgery (CLASS) compared with trabeculectomy in primary open-angle glaucoma and exfoliative glaucoma.

METHODS

One hundred and thirty-one patients underwent CLASS (66 patients) or trabeculectomy (65 patients) and were followed up for 12 months. 'Complete success' was defined as intraocular pressure (IOP) between 10 and 18 mmHg and reduced by at least 30% from the baseline without medications, while 'qualified success' was compliant with the above criteria with or without the medications.

RESULTS

Comparing CLASS with trabeculectomy at 1 year, the mean IOP reduction rate was 32.6 ± 10.8% versus 40.6 ± 15.9% (p < 0.001) and the average use of medications was 1.4 ± 1.4 versus 0.7 ± 1.1 (p < 0.05). At 12 months, the complete success rate was 35% for CLASS versus 60% for trabeculectomy (p < 0.01), while the qualified success rate was 74% versus 75%, respectively, with no significant difference in qualified success rate between the groups at any time-point (p > 0.05). Compared with CLASS, patients after trabeculectomy developed a higher rate of early complications (9.1% versus 29.2%, p = 0.004), higher endothelial cell density (ECD) loss (1.4 ± 1.4% versus 6.5 ± 4.8%, p < 0.001), higher astigmatism (0.0 ± 0.1 versus 0.1 ± 0.2, p < 0.001) and significant visual acuity deterioration (0.1 ± 0.1; range 0-2 lines versus 0.4 ± 0.6; range 0-3 lines, p = 0.016).

CONCLUSION

Although CLASS shows a less potent hypotensive effect, it is similar to trabeculectomy in the qualified success rate and offers the reduction in medications up to 12 months. With a more attractive complications profile, CLASS may be an alternative to trabeculectomy, especially at the earlier glaucoma stage and in patients with a low ECD.

Long-term results of deep sclerectomy in normal-tension glaucoma

PURPOSE

To study the long-term outcome of deep sclerectomy with and without mitomycin-C (MMC) in patients with normal-tension glaucoma (NTG).

METHODS

We prospectively analysed consecutive patients randomized to surgery performed either with (MMC group) or without (non-MMC) MMC. Surgery was considered totally successful if, after surgery, the preoperative intra-ocular pressure (IOP) level was reduced by 25% without medication, and a qualified success if medication was required to achieve the same limits.

RESULTS

A total of 37 patients were enrolled, 15 in the MMC and 22 in the non-MMC group. The median (range) follow-up was 7.9 (1.0-9.0) years, with a drop-out of three (8%) patients. The preoperative IOP was 15 (11-21) mmHg in the MMC and 15 (10-19) mmHg in the non-MMC group. At the last 6- to 9-year follow-up, IOP was significantly reduced to 9 (2-13) mmHg (p = 0.002) and 10 (5-13) mmHg (p < 0.001). The overall (groups combined) complete and qualified success rates were 50% and 71%, with no significant difference between groups (p = 0.48 and p = 0.25). Goniopuncture was performed in 87% and 100% of eyes in the MMC and non-MMC groups (p = 0.14). Needling with MMC injection was performed 0 (0-1) times in the MMC group and 0.5 (0-4) times in the non-MMC group (p = 0.056). We encountered no cases of hyphema, shallow anterior chamber, hypotony maculopathy, choroidal effusion, late bleb leakage, blebitis, endophthalmitis or malignant glaucoma.

CONCLUSION

In NTG, long-term significant IOP reduction can be achieved with deep sclerectomy with a low incidence of sight-threatening complications.

Evaluating displacement of lamina cribrosa following glaucoma surgery

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ultrasound Biomicroscopy in Nonperforating Filtering Surgery with Intraoperative 5-fluorouracil and no implant: Long-term Results

Purpose

To evaluate the long-term morphologic changes in the anterior segment structures after nonpenetrating filtering surgery (NPFS) supplemented with 5-fluorouracil (5-FU) and no scleral implant using ultrasound biomicroscopy (UBM).

Methods

Thirteen eyes of 13 consecutive patients who underwent NPFS with intraoperative 5-FU under the conjunctiva and the scleral flap and no implant were evaluated in an observational nonrandomized, consecutive case series study conducted 2 years postoperatively. Patients were assessed for the presence of a subconjunctival filtering bleb, the volume of an intrascleral cavity, and a suprachoroidal hypoechoic area. The intraocular pressure (IOP) was measured preoperatively and postoperatively at the time of UBM.

Results

The IOP decreased significantly (p=0.01) from 24±7.6 mmHg to 13.7±4.1 mmHg. In most patients (69.2%), the postoperative IOP decreased at least 30% from the preoperative value without medications and in 84.6% with medication. UBM showed a subconjunctival empty space in 92.3% of eyes. In 84.6% of patients, an intrascleral cavity was seen, the mean volume of which was 1.68 mm3 (range, 0–4.07). We found a negative correlation between the height, width, and volume of the intrascleral lake and the IOP. In 92.3% of eyes, a hypoechoic area in the suprachoroidal space also was seen.

Conclusions

UBM showed a filtering intrascleral cavity, subconjunctival filtering bleb, and a suprachoroidal space after NPFS supplemented with 5-FU under the conjunctiva and the scleral flap without an implant.

Combined Phacoemulsification and Nonpenetrating Deep Sclerectomy in the Treatment of Chronic Angle-Closure Glaucoma with Cataract

Purpose

To review the result of nonpenetrating deep sclerectomy (NPDS) combined with phacoemulsification in the treatment of chronic angle-closure glaucoma (CACG) with coexisting cataract.

Methods

This is a retrospective review of 29 eyes of 26 patients who had undergone combined non-penetrating deep sclerectomy and phacoemulsification for cataract and chronic angle-closure glaucoma between January 2001 and June 2003. The visual acuity, intraocular pressure (IOP) and complications were analyzed.

Results

The mean follow-up period was 33.8 months (range 23.3 to 54.0 months). Postoperative visual acuity improved in 21 eyes (72%) and remained the same in 6 eyes (21%). The IOP was reduced significantly from 20.3±3.9 mmHg (mean ± SD) preoperatively to 15.9±3.1 mmHg postoperatively at last follow-up visit (p<0.001). The number of antiglaucoma medications was also reduced significantly from 2.9±0.8 (mean ± SD) preoperatively to 1.0±1.2 at last follow-up (p<0.001). Fifteen eyes (52%) achieved complete success with IOP ≤ 21 mmHg without antiglaucoma medications and 25 eyes (86%) achieved qualified success with IOP ≤ 21 mmHg with or without medications at the last follow-up visit. Of the 25 eyes achieving qualified success, 24 (96%) had a reduction in the number of medications. There were 4 failures, defined as uncontrolled IOP requiring further filtering operation or oral drug treatment. Intraoperative complications included one accidental anterior chamber puncture and one iris plug intraoperatively. Postoperative complications included one choroidal effusion, three wound leaks requiring repair, and two punctate epithelial erosions. There was no shallowing of the anterior chamber, hyphema, hypotony, or infection encountered.

Conclusions

Combined NPDS and phacoemulsification could be a safe and effective surgical option for the management of CACG with cataract. (Eur J Ophthalmol 2007; 17: 208–15)

Ultrasound Biomicroscopy and Optical Coherence Tomography Imaging of Filtering Blebs after Deep Sclerectomy with New Collagen Implant

Purpose

To identify the clinical and anatomic characteristics of filtering blebs after glaucoma surgery with a new biodegradable collagen implant, Ologen, using ultrasound biomicroscopy (UBM) and Visante anterior segment optical coherence tomography (OCT).

Methods

The authors conducted a prospective interventional case series in 15 eyes with open-angle glaucoma. The authors performed limbal-based deep sclerectomy with Ologen implantation in the scleral bed. UBM, Visante anterior segment OCT, and a complete ophthalmic examination were performed at each follow-up visit, at 1 day, and 1, 4, and 12 weeks postoperatively.

Results

Intraocular pressure (IOP) was significantly reduced (p<0.001) from a mean preoperative value of 24.2±6.8 mmHg (n=2.82 glaucoma medications) to a mean postoperative value of 8.1±1.2 (n=0), 8.5±1.3 (n=0), 11.7±3.2 (n=0), and 14.2±3.9 mmHg (n=0.33) at 1 day, and 1, 4, and 12 weeks, respectively. Lower IOP correlated with bleb height and low trabeculocorneal membrane thickness (r=0.79, p<0.01, r=0.91, p<0.001) based on UBM examination. Lower IOP correlated with thin bleb wall, large subconjunctival fluid spaces, and low bleb tissue reflectivity (r=0.81, p<0.01, p<0.001, and p<0.001) based on OCT examination. No postoperative complications were reported.

Conclusions

UBM and OCT examinations are useful methods to evaluate outflow mechanisms after glaucoma surgery. Deep sclerectomy with Ologen implantation seems to be an effective and well-tolerated method to reduce IOP.

Nonpenetrating Deep Sclerectomy: A 6-Year Retrospective Study

Purpose

Nonpenetrating trabeculectomy, also called nonpenetrating deep sclerectomy (NPDS), is a filtering surgery where the internal wall of Schlemm's canal is excised, allowing sub-conjunctival filtration without actually entering the anterior chamber. This technique was developed to minimize the complications of trabeculectomy. The authors investigated its safety and efficacy in a retrospective noncomparative study.

METHODS

A total of 258 eyes (179 patients, mean age 61.4±11.56 years) with uncontrolled open angle glaucoma with prior medical therapy were treated. NPDS with a biocompatible collagen device (157 eyes) sutured to deep scleral bed or with the use of a 5-fluorouracil sponge (90 eyes) were analyzed. The main outcome measure was postoperative intraocular pressure (IOP) with an average follow-up of 54.4±17.07 months (range 1–85). Efficacy was determined 1 month, 3 months, and every 6 months after the procedure for 6 years.

Results

Mean preoperative IOP was 24.47±5.92 mmHg. Mean postoperative IOP was 14.44±5.31 mmHg (average lowering of the IOP was 38.94±23.81%) at 1 month, 15.16±4.57 mmHg (35.73±21.35%) at 3 months, 15.87±4.24 mmHg (32.45 ±20.52%) at 6 months, 16.32±4.53 mmHg (29.96±23.69%) at 12 months, 17.12±4.45 mmHg (26.51±23.93%) at 18 months, 16.77±4.44 mmHg (28.18±21.73%) at 24 months, 16.43±4.15 mmHg (28.89±23.69%) at 30 months, 16.34±4.12 mmHg (30.05±21.61%) at 36 months, 16.16±4.01 mmHg (30.06±22.55%) at 42 months, 15.71±3.74 mmHg (32.49±19.08%) at 48 months, 15.61±3.48 mmHg (31.26±21.01%) after 5 years, and 15.81 ±3.79 mmHg (33.73±20.9%) after 6 years. YAG goniopuncture was performed in 47.3% of cases with a mean follow-up of 12±13 months. These goniopunctures were effective in lowering IOP after a long-term follow-up (24 months). Additional 5-fluorouracil injections were used in 7% of cases. Visual field (Octopus or Humphrey mean defect and corrected loss variance or loss variance) was not modified (p<0.01). Number of preoperative glaucoma medications was 2.01±0.58 and number of postoperative glaucoma medications was 0.85±0.92. Complications were peroperative microperforations in 27 eyes (10.5%), shallow anterior chamber in 2 eyes, hyphema in 2 eyes (0.8%), cataract in 5 eyes (2%), and dellen in 1 eye (0.4%). No cases of endophthalmitis or choroidal detachment were found. After surgery, 23 eyes (8.9%) required a new filtering surgical procedure, and diode laser cyclophotocoagulation was necessary in 2 eyes (0.8%). The probability success rate, defined as an IOP lower than 21 mmHg, was 66.46% (Kaplan Meier) at 60 months off all glaucoma medications and 80.32% with medical or new surgical treatment.

CONCLUSIONS

NPDS appears to be an effective and safe filtering procedure for lowering IOP and could be an alternative to trabeculectomy in open angle glaucoma with the advantage of having fewer complications.

Prospective evaluation of CO2 laser-assisted sclerectomy surgery (CLASS) with Mitomycin C

PURPOSE

Our purpose was to evaluate the clinical safety and efficacy of CO₂ laser-assisted sclerectomy surgery (CLASS) with Mitomycin C (MMC) in open angle glaucoma (OAG).

METHODS

This was a prospective, uncontrolled, interventional case series. All subjects underwent CLASS procedure by a single surgeon. After the dissection of a partial thickness scleral flap, topical MMC 0.2 mg/ml was applied to the sclera and the conjunctiva for 3 min. The CO₂ laser with a beam-manipulating system was used to ablate the scleral tissue and expose the Schlemm's canal area. Primary outcomes: intraocular pressure (IOP) change, number of IOP-lowering medicaments change. Adverse events were evaluated as secondary outcomes.

RESULTS

Twenty-one eyes of 21 patients underwent the CLASS procedure. Thirteen were primary OAG (62%), two normal pressure glaucoma (10%), three exfoliative glaucoma (14%) and three others secondary OAG. With a mean (SD) follow-up of 15.3 (5.9) months, the IOP changed from 25.4 (6.7) mmHg at baseline to 10.9 (3.4) mmHg al the last visit. Mean reduction of IOP was -14.5 mmHg (95% CI, -17.7 to -11.2, P < 0.001). The median (IQR) number of IOP-lowering medication decreased from 3 (3-3) at baseline to 1 (0-1) at the last visit (P < 0.001). Visual acuity did not change significantly. Adverse events: five eyes (24%) developed iris adhesion to the filtration area that was successfully managed with office-based procedures. In one case (5%), CLASS was converted to trabeculectomy due to intraoperative perforation of the ablated area. There was one case of hypotony maculopathy successfully treated with placement of additional transconjunctival scleral flap sutures.

CONCLUSIONS

The CLASS procedure with MMC is clinically safe and effective maintaining a large reduction in IOP and in the number of IOP-lowering medications with a mean follow-up of 15 months. Iris adhesion at the filtrating area warrants further evaluation and possibly reflects the surgeon's learning curve.

[Outpatient management without day 1 clinical follow-up of patients undergoing uncomplicated filtering surgery]

INTRODUCTION

Although the general increase in ambulatory surgery allows for a 20% reduction in costs of hospitalization, the necessity of a day 1 postoperative visit remains the main problem for elderly patients or those who reside at considerable distance. For these reasons, in 2014, we decided to only see patients with uncomplicated filtering surgery at D5 and D21 and to replace the D1 visit with a telephone call. The primary goal of our study was to analyze a population of patients undergoing uncomplicated filtering surgery who were not seen at D1 and to describe the frequency of postoperative complications, intraocular pressure results and therapeutic management at D5 and D21.

PATIENTS AND METHODS

This was a retrospective monocentric study in the department of ophthalmology. All patients (naïve of surgical treatment for glaucoma) underwent surgery for primary open-angle glaucoma in an ambulatory surgery unit between May 2014 and July 2016. A nurse made a phone call to the patients at day 1 and they responded to a standardized questionnaire. Depending upon their responses, the patients were seen quickly (<24hr) or on the systematic schedule at day 5 and day 21.

RESULTS

One hundred and forty-four eyes (126 patients) were included in our study. The mean preoperative IOP was 20.4±6.4mmHg. After the phone call, only five patients were examined before the first planned follow-up at day 5. For 3 of them, the examination revealed the presence of a hyphema, and their topical medication was changed. The other two patients had no treatment modifications. At day 5, the mean IOP was 10.6±5.9mmHg. Thirty-two eyes (22.2%) required a change in their medication at day 5. The mean IOP at day 21 was 12.9±4.6mmHg. Our success rate (IOP<21mmHg with no topical medication) at day 21 was 95.6%.

DISCUSSION

The guidelines for filtering glaucoma surgery recommend examining the patient at day 1 (or at least before day 3), day 8, day 15 and day 30 or more frequently according to the case. We replaced the day 1 visit with a telephone call. We did not note a substantial rate of complications due to the elimination of the D1 visit. The criteria of success of filtering glaucoma surgery vary in the literature, but our success rate at D21 seems to be similar that in the literature and may suggest that the day 1 visit is not necessary if the surgery for primary open angle glaucoma is uncomplicated.

Secondary Epiretinal Membrane After Trabeculectomy

PURPOSE

To determine the frequency of epiretinal membranes (ERM) in eyes with primary open-angle glaucoma subjected to trabeculectomy.

METHODS

We conducted a retrospective study on patients subjected to trabeculectomy with at least a 6-month follow-up. Ophthalmologic examination and spectral-domain optical coherence tomography (SD-OCT) were analyzed. Eyes with previous surgical or laser treatments or other pathologies (other than glaucoma and ERM) were excluded.

RESULTS

A total of 50 eyes (40 patients) were included in this study. The mean follow-up time after surgery was 27.8 months. After surgery, 9 eyes (18%) had preretinal macular fibrosis and 19 eyes (38%) had cellophane macular reflex. Of the 16 eyes with a preoperative macular SD-OCT, 3 (18.8%) developed ERM and 4 (25%) progressed from cellophane macular reflex to preretinal macular fibrosis, after surgery. The ERM frequency did not differ significantly between eyes subjected to trabeculectomy with or without the use of antimetabolites (P=0.08), or between eyes subjected to simple or combined surgery (phacotrabeculectomy) (P=0.09).

CONCLUSION

Trabeculectomy may predispose one to the appearance and progression of ERM. Further studies are needed to clarify this intriguing relation.

Glaucoma treatment trends: a review

Glaucoma is one of the most common causes of blindness worldwide, and its prevalence is increasing. The aim of the present review is to describe the current medical and surgical treatment trends in the management of open-angle glaucoma. There has been an increase in the availability of glaucoma medications and the use of laser trabeculoplasty over the past decade, with a subsequent decrease in invasive incisional surgery. In addition, a new class of glaucoma procedures, termed microinvasive glaucoma surgery, has emerged, which aims to fill the gap between conservative medical management and more invasive surgery.

Differences in Corneal Biomechanics in Nonpenetrating Deep Sclerectomy and Deep Sclerectomy Reconverted into Trabeculectomy

PURPOSE

To evaluate the differences in intraocular pressure (IOP) and in corneal biomechanics in eyes with uneventful nonpenetrating deep sclerectomy (NPDS) in 1 eye and with intended deep sclerectomy reconverted into trabeculectomy (RIT) in the fellow eye of the same patient.

PARTICIPANTS

Forty eyes of 20 patients with both types of glaucoma surgery and more than 6 months of follow-up, and 31 eyes of 50 controls.

METHODS

IOP was assessed with Goldmann applanation tonometry (GAT), ocular response analizer (ORA), and dynamic contour tonometer (DCT). Student t test for independent samples and a univariate generalized estimating equations model were used to analyze the results.

MAIN OUTCOME MEASURES

Overall, no significant differences were found between IOP of NPDS and RIT eyes when measured with 3 tonometers.

RESULTS

Although NPDS showed lower values of IOP measured with GAT and ORA, RIT presented lower IOP if DCT is the chosen tonometry. Biomechanically, NPDS eyes had higher corneal hysteresis (CH) and corneal resistance factor (CRF). When compared with control patients, eyes that underwent glaucoma surgery had lower IOP using GAT, DCT and ORA (P<0.001, 0.315, and 0.260, respectively), and lower CRF (P<0.001).

CONCLUSIONS

Eyes with NPDS tended to have higher values of CH and CRF and lower IOP than RIT eyes, as measured with 3 of 4 tonometry methods; these differences did not reach statistical significance.

Deep Sclerectomy in Primary Open-Angle Glaucoma and Exfoliative Glaucoma

Purpose

To study the effect of deep sclerectomy (DS) in primary open-angle glaucoma (POAG) and exfoliative glaucoma (EXG).

Methods

We retrospectively analyzed the intraocular pressure (IOP)-lowering effect of DS in 235 consecutive eyes. Eyes were divided into 2 groups according to glaucoma subtype: POAG (127 eyes) and EXG (108 eyes). Postoperative IOP was the main outcome measurement. We recorded complete and qualified surgical success, need for YAG-laser goniopuncture, and need for postoperative glaucoma medication. We studied factors related to outcome of surgery in a Cox regression model.

Results

In the POAG group, the mean (SD) IOP decreased from 22.6 (5.1) mm Hg preoperatively to 16.8 (7.5) mm Hg, with qualified success achieved in 70% of eyes. Postoperatively, 57% were without medication. In the EXG group, IOP decreased from 25.5 (6.5) mm Hg preoperatively to 16.5 (7.8) mm Hg postoperatively, with qualified success achieved in 66% of eyes. Postoperatively, 50% were without medication. Decrease in IOP was statistically significant in both groups (p<0.001). In the POAG group, 12%, and in the EXG group, 24% needed a reoperation in the follow-up period (p = 0.037). In the Cox regression model, 1 week IOP between 2 and 14 mm Hg without medication lowered the hazard rate of losing complete success by 34% (p = 0.031) and the hazard rate of losing qualified success by 54% (p = 0.004).

Conclusions

The IOP 1 week postoperatively seems to be a prominent indicator of surgical success. Deep sclerectomy is effective in reducing IOP in POAG and EXG subgroups, with reoperations more common in EXG eyes.