A Prospective, Comparative Study between Endoscopic Cyclophotocoagulation and the Ahmed Drainage Implant in Refractory Glaucoma

Cyclophotocoagulation versus Ahmed Glaucoma Implant in Neovascular Glaucoma with Poor Vision at Presentation

Purpose

To evaluate the outcomes of surgical intervention in eyes with neovascular glaucoma (NVG) and poor vision, comparing the Ahmed glaucoma implant with cyclophotocoagulation (CPC).

Patients and Methods

This study is a double-armed cohort retrospective review of medical records of patients with NVG who had a visual acuity of 20/200 or less and underwent one of the two procedures as a primary intervention: Ahmed glaucoma valve (AGV) or cyclophotocoagulation (CPC). The study was conducted at King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia, from January 2014 to June 2019, with a total study period of 1 year. The main outcome measures included the surgical success rate, changes in intraocular pressure (IOP), the number of antiglaucoma medications, corrected distance visual acuity, and the reoperation rate for glaucoma.

Results

The preoperative IOP was 40.4 ± 10.6 mmHg (Median 40) in the CPC group and 39.4 ± 10.2 mmHg (Median 40) in the AGV group (P = 0.6). At 1 year, the IOP ranged from 12.5 to 28 mmHg (Median 18) in the CPC group and 14 to 21.5 mmHg (Median 17) in the AGV group (P = 0.016). Survival analysis showed a 51% success rate in the CPC group and an 89% success rate at 1 year in the AGV group (p>0.0001).

Conclusion

CPC and AGV procedures yielded good outcomes with similar IOP levels 12 months after the surgery. However, AGV demonstrated a higher overall success rate and a lower medication requirement than CPC.

Success of Endoscopic Laser Cyclophotocoagulation vs Repeat Transscleral Treatment after Prior Transscleral Cycloablation

Aim

To compare the efficacy of endoscopic cyclophotocoagulation (ECP) vs repeat transscleral cyclophotocoagulation (TCP) in eyes with persistent glaucoma despite prior treatment with TCP.

Materials and methods

This was a retrospective chart review of glaucoma patients at the American University of Beirut Medical Center over 10 years who underwent ECP or repeat TCP. We reported qualified and complete success; success was defined as postoperative intraocular pressure (IOP) ≤21 mm Hg, with (qualified) or without medications (complete) and without procedure-related complications.

Results

This study included 23 eyes of 21 patients with various forms of uncontrolled glaucoma who had failed TCP. A total of 13 eyes of 12 patients underwent ECP with a mean age of 39.9 ± 23.2 years, and 10 eyes of nine patients underwent repeat TCP with a mean age of 27.2 ± 22.6 years. A significant decrease in IOP was observed from 38.5 ± 7.9 mm Hg preoperatively to 25.2 ± 8.8 mm Hg postrepeat TCP (p = 0.006) and from 33.0 ± 9.5 to 12.8 ± 3.9 mm Hg post-ECP (p < 0.001), noted at a mean follow-up time of 39.2 ± 44.4 and 41.5 ± 37.4 months, respectively. The mean number of antiglaucoma medications decreased in the two groups (from 3.8 ± 1.0 preoperatively to 1.8 ± 0.9 postoperatively for ECP and from 3.5 ± 1.3 to 3.1 ± 0.9 postoperatively for TCP); however, the drop was only statistically significant post-ECP. Qualified success was significantly higher after ECP vs repeat TCP (91.7 vs 40%, respectively). Complete success was achieved only in 1/12 (8.3%) eyes in the ECP group.

Conclusion

Endoscopic cyclophotocoagulation (ECP) performed in glaucomatous eyes previously treated with transscleral cycloablation provided more IOP control as compared to repeat TCP by directly treating viable tissue in previously skipped ciliary processes and in between processes.

Clinical significance

In glaucomatous eyes previously treated with transscleral cycloablation, ECP attained better IOP control than repeat transscleral cycloablation.

How to cite this article

Al-Haddad C, Barikian A, Moussawi ZE, et al. Success of Endoscopic Laser Cyclophotocoagulation vs Repeat Transscleral Treatment after Prior Transscleral Cycloablation. J Curr Glaucoma Pract 2023;17(4):191-196.

Outcomes of vitrectomy, complete pan-retinal photocoagulation, and endoscopic cyclophotocoagulation surgery after anti-VEGF treatment in neovascular glaucoma

Purpose

To establish a comprehensive treatment strategy and evaluate the efficacy of combination of anti-vascular endothelial growth factor (VEGF) injection, pars plana vitrectomy (PPV), endoscopic pan-retinal photocoagulation (PRP), and endoscopic cyclophotocoagulation (ECP) surgery for neovascular glaucoma (NVG) patients.

Methods

This retrospective study included 30 patients (30 eyes) who were suffering from NVG and treated with PPV & PRP & ECP (ECP group, 16 eyes), or Ahmed glaucoma valve implantation (Ahmed group, 14 eyes). The intraocular pressure (IOP), number of postoperative anti-glaucoma medications, best-corrected visual acuity (BCVA), successful rate of surgery, and postoperative complications were recorded and statistically analyzed at the time points of preoperative, 1-day, 1-month, 3-months, 6-months, and 12-months after operation.

Results

An obvious reduction in IOP and number of postoperative anti-glaucoma medications were observed in both the ECP group and Ahmed group after operation (P ​< ​0.05), and the ECP group showed a significantly lower IOP compared to the Ahmed group at the 6-months (P ​= ​0.014) and 12-months (P ​= ​0.047) postoperative time points, while there was no significant difference of medication number between the two groups except for 1-day after surgery. The BCVA showed no marked difference between the two groups preoperatively and postoperatively (P ​> ​0.05), while it was significantly improved in ECP group at 3-months (P ​= ​0.001), 6-months (P ​= ​0.004), and 12-months (P ​= ​0.010) time points comparing with preoperative BCVA. The surgical success rates in ECP group were also slightly higher than Ahmed group. And the complications after operation showed no marked differences.

Conclusions

The comprehensive treatment of PPV, endoscopic PRP, and ECP surgery for NVG patients after anti-VEGF injection can control IOP effectively and be friendly to patients' BCVA without obvious serious complications throughout a 12-months follow-up period.

Effectiveness of Microinvasive Glaucoma Surgery in the United States: Intelligent Research in Sight Registry Analysis 2013-2019

PURPOSE

To evaluate the effectiveness of microinvasive glaucoma surgery (MIGS) with and without concurrent phacoemulsification.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

Patients in the Intelligent Research in Sight (IRIS®) Registry who underwent Xen gel stent (ab interno) implantation, endoscopic cyclophotocoagulation (ECP), or goniotomy or canaloplasty from 2013 through 2019.

METHODS

Kaplan-Meier survival analysis was used to assess reoperation rates. We defined reoperation as any subsequent glaucoma surgery occurring 1 month to 3 years after the initial procedure. Multivariable Cox proportional hazard models were used to determine factors predictive of reoperation.

MAIN OUTCOME MEASURES

Reoperation rate, mean intraocular pressure (IOP) and visual acuity (VA), postoperative complications, predictors of reoperation, and reoperation procedure type.

RESULTS

A total of 79 363 eyes from 57 561 patients were included, with 15 118 eyes (19%) receiving stand-alone MIGS and 64 245 eyes (81%) receiving MIGS concurrent with phacoemulsification. Overall, patients who underwent MIGS concurrently with phacoemulsification showed lower reoperation rates compared with stand-alone MIGS, most pronounced in ECP and goniotomy or canaloplasty. At postoperative year 2, the cumulative reoperation rate for stand-alone procedures was 15% for ECP, 24% for Xen implantation, and 24% for goniotomy or canaloplasty compared with 3% for ECP, 19% for Xen implantation, and 6% for goniotomy or canaloplasty concurrent with phacoemulsification (P < 0.001 for each stand-alone MIGS vs. MIGS with phacoemulsification). Black race, older age, moderate and severe glaucoma, higher baseline IOP, and glaucoma subtype were associated with higher reoperation risk. Although IOP decreased in all groups, stand-alone MIGS showed a more substantial decrease in mean IOP. Complication rates from MIGS were low overall: 1% for ECP, 1% for Xen implantation, and 2% for goniotomy or canaloplasty.

CONCLUSIONS

In current United States clinical practice, MIGS has substantially lower reoperation rates when performed with phacoemulsification, especially for ECP and goniotomy or canaloplasty. Approximately one-sixth of patients undergoing stand-alone ECP and one-quarter of patients undergoing stand-alone Xen implantation or goniotomy or canaloplasty require reoperation by 2 years. Black race, diagnosis coding of moderate to severe glaucoma, and higher baseline IOP were associated with higher risk of reoperation after MIGS procedures.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Six year outcomes of combined phacoemulsification surgery and endoscopic cyclophotocoagulation in refractory glaucoma

PURPOSE

This study is to describe the 6-year results of combined phacoemulsification surgery and endoscopic cyclophotocoagulation (Phaco-ECP) surgery in patients with uncontrolled glaucoma and no previous glaucoma surgery.

METHODS

This is a retrospective case series of 84 eyes. The primary outcome measure was intraocular pressure (IOP) reduction 6 years postoperatively. Secondary outcome measures were the cumulative probability of failure of the surgical procedure at 6 years. Failure was defined as IOP higher than 21 mm Hg or lower than 6 mm Hg or IOP not reduced by 20% from baseline at the 1, 2, 3, 4, 5, or 6-year time points or further laser or other surgery to reduce IOP at any timepoint.

RESULTS

There was a statistically significant decrease in mean IOP from 18.9 mmHg pre-operatively to 13.7, 12.8, 13.0, 12.7, 12.5, and 12.3 mmHg at the 1, 2, 3, 4, 5, and 6 years post-operatively respectively (p < 0.001). Fifty-seven (68%) reached criteria for failure by 6 years. In 36% of cases, this was due to inadequate IOP control, whereas 32% required further laser or surgery. When we excluded patients who only had selective laser trabeculoplasty rather than further surgery, the failure rate reduced to 51%. Eleven percent had a post-operative complication, 2.4% requiring further surgical intervention.

CONCLUSIONS

At 6 years postoperatively, combined phaco-ECP achieved a significant reduction in IOP in patients with uncontrolled glaucoma and no previous drainage surgery. Significant complications were uncommon, but 68% was classified as surgical failures by the six year point.

Neovascular Glaucoma: An Update

Neovascular glaucoma (NVG) is a severe type of secondary glaucoma with devastating complications and generally poor visual prognosis. NVG is defined by the development of pathological neovessels over the iris and the iridocorneal angle that can block the outflow of aqueous humor, causing elevation of intraocular pressure (IOP). The pathogenesis of NVG is, in most cases, associated with ischemia of the posterior segment, which is most frequently associated with proliferative diabetic retinopathy or central retinal vein occlusion. The advanced stages of NVG are by iris and angle neovascularization, angle, and extremely high IOP, accompanied by ocular pain and poor vision. The therapeutic approach of NVG is based on the reduction of retinal ischemia by panretinal photocoagulation. Intravitreal anti-VEGF administration can contribute to the regression of neovascularization, and topical and systemic medications may be necessary for IOP control. However, if medical treatment with these agents is not enough, surgical procedures may be required to lower IOP and prevent glaucomatous optic neuropathy. Early and prompt diagnosis, with identification of the underlying etiology, can improve IOP control and final visual outcome. The aim of this study is to review current knowledge of the pathogenesis and management of NVG.

A multicenter prospective comparative study evaluating cataract surgery and endoscopic cyclophotocoagulation either with or without iStent inject implantation in Brazilian patients with glaucoma

Purpose

Compare 12-month (12 M) safety and efficacy of endoscopic cyclophotocoagulation (ECP) + cataract surgery (Group 1) versus ECP + cataract surgery + iStent inject trabecular micro-bypass implantation (Group 2) in Brazilian patients with open-angle glaucoma (OAG).

Methods

This prospective, multicenter, comparative case series included patients with OAG and cataract who were randomized to receive treatment in Group 1 or Group 2. Outcomes included mean and percent reduction versus preoperative in intraocular pressure (IOP) and number of glaucoma medications; visual acuity; occurrence of adverse events; and rate of secondary surgeries.

Results

Preoperatively, Groups 1 and 2 had similar mean IOP (mean ± standard deviation 22.1 ± 3.6 and 22.0 ± 2.5 mmHg, respectively) and mean number of medications (3.3 ± 0.6 and 3.4 ± 0.6 medications, respectively). At all follow-up timepoints through 12 M, both groups achieved significant IOP and medication reductions versus preoperative (IOP p < 0.001 and number of medications p < 0.001 for both groups). At 12 M, IOP reductions were 24.2% (Group 1) and 43.6% (Group 2) (p < 0.001); mean medication reductions were 50.2% and 71.5%, respectively. Mean postoperative IOP and number of medications were higher in Group 1 than Group 2 (IOP p < 0.01 all visits, medication p < 0.01 at 6 M and 12 M). Adverse events were generally mild and infrequent in both groups.

Conclusion

Both treatment groups (ECP + phacoemulsification, with/without iStent inject implantation) achieved significant and safe reductions in IOP and medications versus preoperative in Brazilian OAG patients. Percent reductions were significantly greater, and mean IOP and medications were significantly lower, in the group receiving iStent inject.

Clinical trial registration (CTR)

CAAE project identification #20053019.5.0000.5078. Protocol #3.587.147. Clinical Trial Database of the Federal University of Goiás, Brazil. Registration Date: September 19, 2019.

Outcomes of Ahmed glaucoma valve and transscleral cyclophotocoagulation in neovascular glaucoma

Purpose

To determine the outcomes of Ahmed glaucoma valve (AGV) and transscleral diode cyclophotocoagulation (CPC) in neovascular glaucoma (NVG).

Methods

This was a single-center retrospective comparative case series involving chart review of consecutive patients who underwent AGV or CPC for treatment of NVG and had ≥6 months of follow-up. Surgical failure at 6 months, defined as an IOP of >21 or <6 mm Hg with hypotony maculopathy after 1 month, progression to no light perception (NLP) vision, glaucoma reoperation, or removal of AGV were the main outcome measures.

Results

In total, 121 eyes of 121 patients were included (70 AGV and 51 CPC). Baseline demographics, visual acuity (VA), and intraocular pressure (IOP) were comparable between groups. At 6 months, failure was significantly higher in the CPC group than in the AGV group (43.1% vs. 17.1%, P = 0.020). Both groups had similar IOP and medication number at 6 months, but VA was significantly lower in the CPC group compared to the AGV group (2.4 ± 0.8 vs. 1.9 ± 1.0, P = 0.017). More CPC eyes required reoperation for glaucoma than AGV eyes (11.8% vs. 1.4%, P = 0.041). Multivariate regression analysis identified higher preoperative IOP (P = 0.001) and CPC surgery (P = 0.004) as independent predictors of surgical failure at 6 months. Age, sex, race, NVG etiology, bilaterality of the underlying retinal pathology, perioperative retina treatment, and prior or combined vitrectomy were not significant.

Conclusion

AGV and CPC had comparable IOP and medication reduction in NVG eyes at 6 months. CPC was more frequently associated with failure, reoperation for glaucoma, and worse visual outcomes. High preoperative IOP and CPC surgery independently predicted surgical failure.

The influence of etiology on surgical outcomes in neovascular glaucoma

Background

The authors sought to evaluate visual outcomes in patients with varying etiologies of neovascular glaucoma (NVG), who were treated with glaucoma drainage devices (GDD).

Methods

This was a retrospective case series of patients at a large academic teaching institution who had surgical intervention for neovascular glaucoma between September 2011 and May 2019. Eyes were included if there was documented neovascularization of the iris/angle with an intraocular pressure (IOP) > 21 mmHg at presentation. Eyes must also have been treated with surgical intervention that included a GDD. Primary outcome measure was visual acuity at the 1-year post-operative visit. Secondary outcome measure was qualified success after surgery defined by: pressure criteria (5 mmHg < IOP ≤ 21 mmHg), no re-operation for elevated IOP, and no loss of LP vision.

Results

One hundred twenty eyes met inclusion criteria. 61.7% had an etiology of proliferative diabetic retinopathy (PDR), 23.3% had retinal vein occlusions (RVO), and the remaining 15.0% suffered from other etiologies. Of patients treated with GDD, eyes with PDR had better vision compared to eyes with RVO at final evaluation (p = 0.041). There was a statistically significant difference (p = 0.027) in the mean number of glaucoma medications with Ahmed eyes (n = 70) requiring 1.9 medications and Baerveldt eyes (n = 46) requiring 1.3 medications at final evaluation.

Conclusions

In our study, many patients with NVG achieved meaningful vision, as defined by World Health Organization (WHO) guidelines, and IOP control after GDD. Outcomes differed between patients with PDR and RVO in favor of the PDR group. Different GDD devices had similar performance profiles for VA and IOP outcomes. Direct prospective comparison of Baerveldt, Ahmed, and cyclophotocoagulation represents the next phase of discovery.

Bullous choroidal detachment requiring drainage following endoscopic cyclophotocoagulation

Endoscopic cyclophotocoagulation is a relatively safe cyclodestructive procedure with a lower complication rate compared to trans-scleral cyclophotocoagulation. Serous choroidal detachment is a complication that has been reported following endoscopic cyclophotocoagulation; however, it is usually mild and transient. A case of bullous choroidal detachment with a flat anterior chamber requiring drainage after endoscopic cyclophotocoagulation is presented, along with a discussion on the risk factors precipitating such complication.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma

PURPOSE

Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion.

METHODS

A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures.

RESULTS

Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term.

CONCLUSION

Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.

Usage Patterns of Minimally Invasive Glaucoma Surgery (MIGS) Differ by Glaucoma Type: IRIS Registry Analysis 2013-2018

Purpose: To examine patterns of standard (trabeculectomy or glaucoma drainage devices, GDDs) vs novel (minimally invasive glaucoma surgery, MIGS) surgical techniques in the US.Methods: We used the American Academy of Ophthalmology (AAO) IRIS® Registry (Intelligent Research in Sight) queried between 2013 and 2018 (inclusive) to calculate the cumulative proportion of stand-alone, concurrent (same day) or sequential (subsequent day) glaucoma surgical techniques performed in each glaucoma diagnosis type. Secondary analyses of adjusted proportions of concurrent and sequential surgeries stratified by glaucoma diagnosis were also performed.Results: Of 203,146 eyes receiving glaucoma surgeries, open angle glaucoma (OAG) was most likely to undergo all types of intervention. The iStent was the most commonly performed MIGS, primarily for those with normal tension glaucoma (NTG) or OAG (p < .001). Conversely, GDD was the most commonly performed procedure in secondary glaucoma or other (specified) glaucoma (p < .001). ECP and iStent were the most common concurrent procedures performed; most often for OAG and NTG (p < .001). After an initial standard surgery, most eyes underwent recurrent standard interventions (90.3%). ECP was the most common MIGS performed after an initial standard surgery; particularly in primary angle-closure (PACG) and secondary glaucoma eyes (p < .001).Conclusion: Glaucoma type may influence the choice of glaucoma procedures and the decision to perform concurrent as well sequential surgical procedures. Given the poorly understood long term safety and effectiveness of MIGS, and with substantially increasing use of MIGS procedures in recent years, future studies comparing their safety and effectiveness vs standard interventions, for a variety of glaucoma types, is needed.

Intraocular endoscopy: A review

Optimal visualization is one of the most challenging aspects of performing vitreoretinal surgery. In situations where conventional microscopic techniques provide poor posterior visualization, the adjunctive skill set of endoscopic visualization may be needed. This allows for by-passing the opaque anterior segment media and getting access to the posterior segment pathology. Endoscopic vitrectomy is a useful and unique adjunct to microincision vitreoretinal surgery. The optical set-up of endoscopy allows for clinical approaches that are impossible with regular microscope viewing systems. These include the ability to observe across optically significant anterior segment opacities and directly visualize the posterior segment of the eye. It also allows for visualizing the difficult-to-access retroirideal, retrolental, and anterior retinal structures. Surgical access to anatomic spaces like the pars plana, pars plicata, ciliary sulcus, ciliary body, and peripheral lens is tedious. This is made simpler by endoscopy. In this review, we summarize and review the usage of the intraocular endoscope as a diagnostic and therapeutic armamentarium across a wide spectrum of ocular pathologies.

Outcomes of neovascular glaucoma in eyes presenting with moderate to good visual potential

PURPOSE

To compare the disease characteristics and treatment outcomes of patients with neovascular glaucoma (NVG) presenting with visual acuity (VA) 6/60 or better in two different health systems.

METHODS

Retrospective chart review of consecutive patients with NVG who presented between January 2016 to January 2018 in 5 tertiary-centres in India and one eye-specialist centre in London (UK) was performed. The baseline characteristics, treatment provisions, and visual outcomes in the India and UK cohorts were compared.

RESULTS

At presentation, 18% (83 of 451) and 22% (59 of 270) of patients with NVG had VA 6/60 or better in India and the UK cohorts, respectively. The aetiologies of NVG were similar with proliferative diabetic retinopathy being the most common cause (60.9%, India; 64.4%, UK; p = 0.38). Previous panretinal photocoagulation was more prevalent in the UK cohort compared to the India cohort (94.9% versus 66.3%, respectively; p < 0.001). The mean number of intravitreal anti-VEGF injections per eye was higher in the Indian cohort (1.65 ± 0.97 versus 1.14 ± 1.02 injections; p < 0.001). The number of eyes with closed angles (36.9% India versus 30.5% UK; p = 0.45) and the number of eyes needing glaucoma interventions (52.1% India; 62.7% UK; p = 0.82) were similar in two cohorts. Among glaucoma surgeries, trabeculectomies were more commonly performed in the Indian cohort (23 vs 4; p < 0.001),while glaucoma drainage device surgeries were more prevalent in the UK cohort (18 vs 4 p < 0.001). After a median follow-up of 21 months (IQR 8.4-34.8 India; 24-36 months UK), favourable visual outcomes (vision stable or improved) were similar in both health systems (52.5% in the Indian cohort vs 43.4% in the UK cohort; p = 0.28). On multivariate regression analysis, the need for trans-scleral cyclophotocoagulation was associated with worse visual outcomes in both cohorts.

CONCLUSIONS

The causes and clinical profile of neovascular glaucoma with presenting visual acuity 6/60 or better in India and the UK were similar. Only up to 50% of eyes achieved favourable visual outcomes with current management protocols in both health systems.

Transscleral cyclophotocoagulation with MicroPulse® laser versus Ahmed valve implantation in patients with advanced primary open-angle glaucoma

PURPOSE

To compare the efficacy of transscleral cyclophotocoagulation with MicroPulse^® laser (Iridex, Silicon Valley, California, USA) with 3000 mW to Ahmed valve implantation in eyes with advanced stage of primary open-angle glaucoma.

METHODS

In a prospective observational clinical study, 30 patients (30 eyes) with advanced open-angle glaucoma were randomized for either micropulse transscleral cyclophotocoagulation with 3000 mW or Ahmed valve implantation. Fifteen eyes were treated with transscleral cyclophotocoagulation with MicroPulse^® laser with 3000 mW (group A) and 15 eyes with Ahmed valve implantation (group B). As inclusion criteria are included the diagnosis of advanced primary open-angle glaucoma, an intraocular pressure above 21 mmHg, cup-to-disk ratio 0.9-1.0, failure to meet the target IOP with either maximal tolerated local medical therapy (2-4 antiglaucoma agents) or systemic therapy (acetazolamide). The follow-up time of the study was 12 months. An absolute success was defined the achievement of IOP between 6 and 15 mmHg and at least 30% reduction of the IOP from baseline under reduced or the same number of antiglaucoma agents after the surgical procedure without following glaucoma surgeries and as qualified success the achievement of IOP between 6 and 18 mmHg and at least 20% reduction of the IOP from baseline regardless of the number of postoperative antiglaucoma agents. The efficacy was evaluated by estimating the absolute success rate and the qualified success rate using the Kaplan-Meier survival analysis.

RESULTS

A reduction of the intraocular pressure > 30% was achieved in 33.3% of group A and in 73.3% of group B during the follow-up period of 12 months. A statistically significant decrease in the number of eye drops was observed in both groups (p < 0.01). 53.3% of the eyes of group A underwent additional anti-glaucoma procedures to achieve target intraocular pressure. The number of the local medications that were administered 12 months after the ocular surgery was 2 (± 1.3) in group A and 0.57 (± 0.9) in group B, compared to 3.2 (± 0.78) in group A and 3.33 (± 0.7) in group B administered prior to the surgery (p: 0.016). 8 eyes (53.33%) in group A were referred for additional treatment due to an acute postoperative rise in IOP (5 eyes: mTS-CPC, 1 eye: canaloplasty, 2 eyes: AGV implantation). No further anti-glaucoma procedures were necessary in group B.

CONCLUSION

The Ahmed valve implantation achieves a more efficient decrease of the intraocular pressure as well as of the number of antiglaucoma agents than the transscleral cyclophotocoagulation with MicroPulse^® diode laser 3000 mW. Additionally, the Ahmed valve implantation showed better results in terms of absolute and qualified success rates in the treatment of advanced primary open-angle glaucoma.

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.

Intraocular Pressure Rise Linked to Silicone Oil in Retinal Surgery: A Review

Silicone oil represents the main choice for intraocular tamponade in cases of complicated retinal detachment surgery. The intraocular pressure of an eye filled with silicone oil could increase, driven by a variety of different forces, according to several mechanisms. Two main conditions have been highlighted, depending on the onset: early hypertension or late glaucoma. The different types of silicone oils and their physico-chemical properties are varied and may play a role in the determination of intraocular pressure rise. The current body of literature allows for the illustration and categorization of the incidence and risk factors, as well as the pathogenesis and the management of the early postoperative hypertension subtended by an open- and closed-angle, along with the late onset silicone oil-induced glaucoma. Understanding the leading actors on the stage of ocular pressure elevation concurrently with silicone oil application for retinal surgery could help in guiding the timely and appropriate course of treatment.

Surgical Outcomes of a Second Ahmed Glaucoma Valve Implant for the Treatment of Refractory Glaucoma

PRéCIS:: In this article, the authors concluded that an additional Ahmed glaucoma valve (AGV) implantation after the failure of an initial AGV, even with the addition of glaucoma medications, maybe a good surgical treatment option for refractory glaucoma.

PURPOSE

To evaluate the surgical outcomes of a second AGV implant in Hispanic patients with refractory glaucoma.

MATERIALS AND METHODS

The medical records of patients who underwent a second AGV implant were reviewed retrospectively. Clinical outcome measures including intraocular pressure (IOP), visual acuity, and glaucoma medication use were collected from the preoperative visit and all follow-up visits up to 18 months after surgery. Failure was defined as one of the following: loss of light perception, sustained IOP >21 or <6 mm Hg, an IOP reduction of <20% from baseline, need for additional glaucoma surgery, including needling revision with subconjunctival adjuvant therapy, or valve extrusion.

RESULTS

A total of 48 patients were included. In all cases, an S-2 model was implanted in the superonasal quadrant. Mean preoperative IOP was 24.3±7.9 mm Hg and was significantly reduced to 13.9±4.8 at 6 months (P<0.05), 15.4±7.2 at 12 months (P<0.05), and 12.9±2.0 at 18 months (P<0.05). Mean glaucoma medications were reduced from 2.8±1.1 preoperatively to 1.9±1.2 at 6 months (P<0.05), 2.4±1.2 at 12 months, and 2.2±1.1 at 18 months; however, the difference was no longer statistically significant after 6 months, and the success rate was 60% at the mean for survival time of 15 months (13.7 to 16.5).

CONCLUSION

The findings of this study demonstrate that a second AGV can achieve a significant reduction in IOP for up to 18 months postoperatively.

Trends in Glaucoma Surgeries Performed by Glaucoma Subspecialists versus Nonsubspecialists on Medicare Beneficiaries from 2008 through 2016

PURPOSE

To characterize the use of laser and incisional glaucoma surgeries among Medicare beneficiaries from 2008 through 2016 and to compare the use of these surgeries by glaucoma subspecialists versus nonsubspecialists.

DESIGN

Retrospective, observational analysis.

PARTICIPANTS

Medicare beneficiaries (n = 1 468 035) undergoing ≥1 laser or incisional glaucoma surgery procedure during 2008 through 2016.

METHODS

Claims data from a 20% sample of enrollees in fee-for-service Medicare throughout the United States were analyzed to identify all laser and incisional glaucoma surgeries performed from 2008 through 2016. We assessed use of traditional incisional glaucoma surgery techniques (trabeculectomy and glaucoma drainage implant [GDI] procedure) and microinvasive glaucoma surgery (MIGS). Enrollee and procedure counts were multiplied by 5 to estimate use throughout all of Medicare. Linear regression was used to compare trends in use of glaucoma surgeries between ophthalmologists who could be characterized as glaucoma subspecialists versus nonsubspecialists.

MAIN OUTCOME MEASURES

Numbers of laser and incisional glaucoma surgeries performed overall and stratified by glaucoma subspecialist status.

RESULTS

The number of Medicare beneficiaries undergoing any glaucoma therapeutic procedure increased by 10.6%, from 218 375 in 2008 to 241 565 in 2016. The total number of traditional incisional glaucoma surgeries decreased by 11.7%, from 37 225 to 32 885 (P = 0.02). The total number of MIGS procedures increased by 426% from 13 705 in 2012 (the first year MIGS codes were available) to 58 345 in 2016 (P = 0.001). Throughout the study period, glaucoma subspecialists performed most of the trabeculectomies (76.7% in 2008, 83.1% in 2016) and GDI procedures (77.7% in 2008, 80.6% in 2016). Many MIGS procedures were performed by nonsubspecialists. The proportions of endocyclophotocoagulations, iStent (Glaukos; San Clemente, CA) insertions, goniotomies, and canaloplasties performed by glaucoma subspecialists in 2016 were 22.0%, 25.2%, 56.9%, and 62.8%, respectively.

CONCLUSIONS

From 2008 through 2016, a large shift in practice from traditional incisional glaucoma surgeries to MIGS procedures was observed. Although glaucoma subspecialists continue to perform most traditional incisional glaucoma surgeries, many MIGS procedures are performed by nonsubspecialists. These results highlight the importance of training residents in performing MIGS procedures and managing these patients perioperatively. Future studies should explore the impact of this shift in care on outcomes and costs.

Differential Efficacy of Combined Phacoemulsification and Endocyclophotocoagulation in Open-angle Glaucoma Versus Angle-closure Glaucoma

PRéCIS:: This retrospective study found that combined phacoemulsification and endocyclophotocoagulation reduced intraocular pressure (IOP) to a greater degree in angle-closure glaucoma versus open-angle glaucoma and was effective for all stages of glaucoma.

PURPOSE

Endocyclophotocoagulation (ECP) laser treatment of the ciliary processes is believed to decrease IOP by reducing aqueous production. Anecdotal experience in angle-closure glaucoma suggests that it may also lower IOP by opening the drainage angle to promote aqueous outflow. This study sought to evaluate combined phacoemulsification and ECP (phaco/ECP) in eyes with different types and stages of glaucoma.

PATIENTS AND METHODS

A Retrospective chart review of eyes that underwent phaco/ECP between October 2010 and December 2016 at one institution was conducted.

RESULTS

In 63 eyes of 63 patients with an average of 3.0±1.7 years of follow-up, the 22 eyes with chronic angle-closure glaucoma (CACG) had greater IOP reduction and medication reduction than the 41 eyes with primary open-angle glaucoma at both 1 year (6.4 vs. 2.1 mm Hg, P=0.01; 0.9 vs. 0.2 medications, P=0.04) and final follow-up (6.2 vs. 2.4 mm Hg, P=0.02; 0.9 vs. 0.3 medications, P=0.05). There was no difference in IOP reduction or medication reduction for eyes with mild, moderate, or advanced glaucoma at both 1 year (3.5, 3.9, 0.5 mm Hg, respectively, P=0.18; 0.3, 0.6, 0.4 medications, P=0.58) and final follow-up (3.3, 4.8, 0.7 mm Hg, P=0.11; 0.1, 0.8, 0.4 medications, P=0.14).

CONCLUSIONS

Eyes with CACG were more responsive to phaco/ECP in terms of IOP and medication reduction compared with eyes with primary open-angle glaucoma. This finding could be partially or entirely due to concurrent cataract extraction and greater CACG preoperative IOP. Phaco/ECP was effective in all stages of glaucoma.

Combined Endoscope assisted Procedures (CEaP) as a complete treatment for neovascular glaucoma

Purpose

To investigate the effect and complications of Combined Endoscope assisted Procedures (CEaP): endoscopic cyclophotocoagulation and pars plana ablation (ECP-plus), along with endoscopic panretinal photocoagulation (PRP).

Patients and methods

The study design is a retrospective and noncomparative interventional case series from a tertiary referral center in Taiwan. Patients experiencing vessel growth at the iris and anterior chamber angle, along with an IOP > 21 mmHg were included.

Results

Twenty-five eyes from 23 patients were included over a 24-month period. After the procedures, all of them had a lower IOP value than their preoperative value. The mean IOP was 38.2± 7.1 mm Hg preoperatively, and 10.2± 4.7 mmHg (1 day), 13.8± 4.6 mmHg (1 week), 15.0± 5.3 mmHg (2 weeks), 17.4± 4.7 mmHg (1 month), 16.6± 4.1 mmHg (3 months), 16.0± 5.0 mmHg (6 months), and 15.7± 5.5 mmHg (12 months) postoperatively. At the 6th and 12th months, the IOP stabilized rate was 84% and 75%, respectively. Complications in the initial postoperative period (< 3 months) included uveitis (24%), and hyphema (16%), which were both resolved in the early postoperative period. Complications beyond 6 months included hypotony and phthisis bulbi in two patients (8%) in our study. There was no subject who suffered from retinal detachment, endophthalmitis or any other severe complications.

Conclusions

The results of this study show that CEaP offers positive results in IOP lowering and NV regression. Additionally, CEaP is a complete treatment for NVG in controlling IOP and NV growth. The IOP lowering effects can be sustained upon completion of the treatment.

Transscleral versus endoscopic cyclophotocoagulation outcomes for refractory glaucoma

OBJECTIVES

Evaluate the efficacy of transscleral cyclophotocoagulation versus endoscopic cyclophotocoagulation to reduce intraocular pressure.

METHODS

A retrospective, non-randomized cohort study with 1 year of follow-up included 62 eyes of 62 refractory glaucoma patients who underwent transscleral cyclophotocoagulation or endoscopic cyclophotocoagulation.

RESULTS

Thirty-two patients were enrolled in transscleral cyclophotocoagulation group and 30 patients in endoscopic cyclophotocoagulation group, and the follow-up period was 1 year. The mean preoperative intraocular pressure was 35.6 ± 12.9 mm Hg in the transscleral cyclophotocoagulation group and 31.8 ± 8.8 mm Hg in the endoscopic cyclophotocoagulation group without significant difference (p = 0.18). When we compare both groups, there was no difference at 1 month (p = 0.46) and 3 months (p = 0.21) after surgery. However, there was a statistically significant difference at month 6 (p = 0.0055) and 1 year (p = 0.0019), finding lower intraocular pressure in the transscleral cyclophotocoagulation group. Cumulative success for intraocular pressure <21 mm Hg was 93.8% in transscleral cyclophotocoagulation group and 83.3% in endoscopic cyclophotocoagulation group after 1 year (p = 0.2). For intraocular pressure <18 mm Hg, the success rate was 78.1% in transscleral cyclophotocoagulation group and 63.3% in endoscopic cyclophotocoagulation group (p = 0.06), and for intraocular pressure <16 mm Hg, the success rate was 62.5% in transscleral cyclophotocoagulation group and 43.3% in endoscopic cyclophotocoagulation group (p = 0.02). Hypotony (p = 0.01) and vision loss of two lines (p = 0.01) were statistically significant lower in endoscopic cyclophotocoagulation group.

CONCLUSION

This study demonstrates that both transscleral cyclophotocoagulation and endoscopic cyclophotocoagulation are effective at decreasing intraocular pressure. However, transscleral cyclophotocoagulation is related to more complications than endoscopic cyclophotocoagulation, whereas endoscopic cyclophotocoagulation shows lower intraocular pressure decrease than transscleral cyclophotocoagulation.

Prospective Studies of Minimally Invasive Glaucoma Surgeries: Systematic Review and Quality Assessment

Glaucoma is a common blinding disease; while there is no cure, effective treatments include medications, laser, and incisional surgery. There is significant interest from patients and doctors to develop safer surgical options throughout the spectrum of disease, to minimize treatment burden in mild glaucoma patients and to minimize risk of complications in patients needing more aggressive treatment. Surgical procedures called Minimally or Micro-Invasive Glaucoma Surgery (MIGS) are growing in popularity. Eighty-seven prospective studies on MIGS were identified and assessed for quality. Most (74%) did not have a control group. Twelve of the highest quality were reviewed. MIGS procedures appeared to have fewer complications, and lowered intraocular pressure, and reduced medication use. Studies were limited by small sample size, narrow spectrum of glaucomatous disease, and/or conflicts of interest. There is a need for high quality, independently funded and performed, comparative studies on the MIGS to help make treatment decisions.

Efficacy and Safety of the Ab-interno Xen Gel Stent After Failed Trabeculectomy

AIMS

To assess the efficacy and safety of the Xen gel stent in reducing intraocular pressure (IOP) in eyes with prior failed trabeculectomy and to determine the frequency of complications and further intervention.

METHODS

Retrospective case note review of all patients with prior trabeculectomy undergoing Xen surgery across 5 centers from August 2015 to May 2017.

RESULTS

In total, 17 surgeries were reviewed. IOP reduced from 21.5 (±2.4) mm Hg preoperatively to 13.6 (±3.4) mm Hg at month 12 (P<0.05). Medication usage reduced from 2.8 (±0.6) preoperatively to 1.0 (±1.3) at month 12 (P<0.05). Adverse events included: numerical hypotony (IOP<6 mm Hg) in 4 cases (23.5%) that all resolved spontaneously, IOP spike of ≥30 mm Hg in 2 (11.8%) cases and transient occlusion of the implant by iris in 1 (5.9%) case. Secondary filtration surgery (Baerveldt tube implantation) was required in 2 (11.8%) cases. Postoperative bleb intervention was required in 9 cases (52.9%), usually in the first month after surgery.

CONCLUSIONS

Xen reduces IOP and number of medications in eyes with failed trabeculectomy. Detailed preoperative conjunctival assessment and targeted stent placement is required. Prospective data and follow-up beyond 12 months are required but Xen seems a viable, effective, and safe option after failed trabeculectomy.

Cyclodestructive procedures for refractory glaucoma

BACKGROUND

Cyclodestructive procedures are often used in patients with refractory glaucoma who have failed to achieve lower intraocular pressure (IOP) from filtration procedures and maximal medical therapy. Destruction of the ciliary body helps to lower IOP by reducing aqueous humor formation. Of the many types of cyclodestructive procedures, laser cyclophotocoagulation (CPC) has become the most common surgical method for reducing aqueous inflow. Options for CPC are wide-ranging: they can be performed using a neodymium:yttrium-aluminum-garnet (Nd:YAG) or diode laser and laser energy can be delivered by either the contact or non-contact method. Another cyclodestructive procedure is endoscopic cyclophotocoagulation (ECP), which the ophthalmologist can use selectively to target the ciliary epithelium and ablate ciliary body tissue. There is debate regarding which cyclodestructive method is best and how they compare to other glaucoma surgeries.

OBJECTIVES

To assess the relative effectiveness and safety of cyclodestructive procedures compared with other procedures in people with refractory glaucoma of any type and to assess the relative effectiveness and safety of individual cyclodestructive procedures compared with each other.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 9); Ovid MEDLINE; Embase.com; PubMed; LILACS BIREME; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 21 September 2018.

SELECTION CRITERIA

We included randomized controlled trials or quasi-randomized trials in which participants underwent a secondary procedure for refractory glaucoma. We included trials with any laser type, route of administration, and laser settings. The primary comparison was any cyclodestructive procedure versus another glaucoma treatment, and the secondary comparisons were individual cyclodestructive procedures versus another cyclodestructive procedure.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the titles and abstracts from the database searches, and after retrieving the full-text reports of those that were potentially relevant, classified the full-text articles as included or excluded. Two review authors independently extracted data from the included studies and assessed the risk of bias. Discrepancies were resolved by discussion or by consultation with a third review author when necessary.

MAIN RESULTS

We included five trials reporting data for 330 eyes (326 participants). One study to had a low risk of bias for most domains and the other studies had an overall unclear risk of bias. This review includes four different comparisons: 1) ECP versus Ahmed implant, 2) micropulse CPC versus continuous-wave CPC; 3) CPC with a diode versus Nd:YAG laser; and 4) CPC with an Nd:YAG laser emitting 8J versus 4J.No study reported data for our primary outcome, change from baseline in pain severity as reported by the participant or change in number of pain medications.For our primary comparison, we included one trial that compared ECP with the Ahmed implant. At 12-month follow-up, the mean difference (MD) in IOPs between groups was -1.14 mmHg (95% confidence interval (CI) -4.21 to 1.93; 58 participants; low-certainty evidence (LCE)). At 24 months postintervention, we found very LCE suggesting that visual acuity may be better among participants in the ECP group than in the Ahmed implant group (MD -0.24 logMAR, 95% CI -0.52 to 0.04; 54 participants), and the difference in the mean number of glaucoma medications used by participants in each group was unclear (MD -0.50, 95% CI -1.17 to 0.17; 54 participants; very LCE). Reported adverse events in the ECP group (34 participants) were one case each of hypotony, phthisis bulbi, retinal detachment, and choroidal detachment; in the Ahmed implant group (34 participants) there was one case of endophthalmitis, two cases of retinal detachment, and six cases of choroidal detachment.Three types of comparisons from four included studies provided data for our secondary comparisons. In the study that compared micropulse with continuous-wave CPC, median IOP was reported to be similar between the two groups at all time points. At 18 months postintervention, the median number of IOP-lowering medications was reduced from two to one in both groups. One participant in the micropulse and two in the continuous group exhibited worsened visual acuity. One case of prolonged inflammation was seen in the micropulse group (23 participants). Seven cases of prolonged inflammation, five cases of hypotony, and one case of phthisis bulbi were seen in the continuous group (23 participants).Two studies compared CPC using a semiconductor diode versus an Nd:YAG laser. At 12 months postintervention, the MD in IOP was 1.02 mmHg (95% CI -1.49 to 3.53) in one study (LCE). The second study did not report mean IOP beyond three months of follow-up. Neither study reported the mean change in best-corrected visual acuity or number of glaucoma medications. Both studies reported hypotony as an adverse event in three participants in each study.One study compared different energy settings of the same Nd:YAG laser. At 12-month follow-up, visual acuity was unchanged or improved in 21 of 33 participants in the 8J group and 20 of 27 participants in the 4J group (risk ratio 0.86, 95% CI 0.61 to 1.21; very LCE). More participants in the 8J group reduced the number of medications taken compared with the 4J group (RR 1.49, 95% CI 0.76 to 2.91; 50 participants; very low-certainty evidence). The presence of fibrin or hyphema were seen in five participants who received 8J and none who received 4J. There was a severe anterior chamber reaction in 11 of 26 (42%) participants who received 8J of energy and 2 of 21 (10%) participants who received 4J of energy.

AUTHORS' CONCLUSIONS

Evidence from five studies included in this review was inconclusive as to whether cyclodestructive procedures for refractory glaucoma result in better outcomes and fewer complications than other glaucoma treatments, and whether one type of cyclodestructive procedure is better than another. The most commonly reported adverse events across all five studies were hypotony and phthisis bulbi. Large, well-designed randomized controlled trials are needed. Patient-reported outcomes such as pain and quality of life should be considered as primary outcomes or important secondary outcomes of future trials.

Endoscopic cyclophotocoagulation (ECP) for open angle glaucoma and primary angle closure

BACKGROUND

Glaucoma is a leading cause of irreversible blindness. A number of minimally invasive surgical techniques have been introduced as a treatment to prevent glaucoma progressing. Among them, endoscopic cyclophotocoagulation (ECP) is a cyclodestructive procedure developed by Martin Uram in 1992.

OBJECTIVES

To evaluate the efficacy and safety of ECP in people with open angle glaucoma (OAG) and primary angle closure whose condition is inadequately controlled with drops.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov and the WHO ICTRP. The date of the search was 12 July 2018.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) of ECP compared to other surgical treatments (other minimally invasive glaucoma device techniques, trabeculectomy), laser treatment or medical treatment. We also planned to include trials where these devices were combined with phacoemulsification compared to phacoemulsification alone.

DATA COLLECTION AND ANALYSIS

Two review authors planned to independently extract data from reports of included studies using a data collection form and analyse data based on methods expected by Cochrane. Our primary outcome was proportion of participants who were drop-free (not using eye drops). Secondary outcomes included mean change in IOP; proportion of participants who achieved an IOP of 21 mmHg or less, 17 mmHg or less or 14 mmHg or less; and proportion of participants experiencing intra- and postoperative complications, We planned to measure all outcomes in the short-term (six to 18 months), medium-term (18 to 36 months), and long-term (36 months onwards).

MAIN RESULTS

We found one ongoing study that met our inclusion criteria (ChiCTR-TRC-14004233). The study compares combined phacoemulsification with ECP to phacoemulsification alone in people with primary angle closure glaucoma. The primary outcome is intraocular pressure (IOP) and number of IOP-lowering drugs. A total of 50 people have been enrolled. The study started in February 2014 and the trialists have completed recruitment and are in the process of collecting data.

AUTHORS' CONCLUSIONS

There is currently no high-quality evidence for the effects of ECP for OAG and primary angle closure. Properly designed RCTs are needed to assess the medium and long-term efficacy and safety of this technique.

Endoscopic Cyclophotocoagulation and Other Cyclodestructive Methods: Histopathologic Comparison of In Vivo Treatment in Humans and Monkeys

PURPOSE

To compare the histologic effects of endoscopic cyclophotocoagulation (ECP) with other ciliary body ablative procedures. A secondary aim was to correlate these findings with historical clinical success and complication rates.

DESIGN

Prospective, qualitative comparison of histopathologic tissue analysis.

PARTICIPANTS

Two eyes of two patients who had undergone ECP for open-angle glaucoma were studied. Two eyes from a healthy monkey were treated with ECP and studied. For comparison, 1 eye each of patients who had undergone contact and noncontact neodymium:yttrium-aluminum-garnet transscleral cyclophotocoagulation (TCP) for open-angle glaucoma were analyzed.

METHODS

The human globes were enucleated and submitted for analysis by gross examination and light and electron microscopy. Monkey eyes were studied by gross examination and light microscopy 1 week, 2 weeks, and 1 month after ECP.

MAIN OUTCOME MEASURES

Gross and histopathologic specimens of all eyes were analyzed with respect to location and type of tissue effects and degree of collateral damage.

RESULTS

The gross analysis of all ECP specimens showed a uniform anterior-to-posterior whitening of each treated ciliary process. This correlated with microscopic evidence of loss of pigmentation from the pigmented ciliary epithelial cells seen with mostly preserved architecture and vasculature of the ciliary processes. By comparison, the TCP specimens showed erratic treatment of the ciliary processes with overlap into the pars plicata of the ciliary body. Microscopic analysis revealed significant disruption of the cells throughout the ciliary processes and loss of vessels within the stroma.

CONCLUSIONS

Treatment with ECP results in less overall tissue destruction and a targeted effect on the pigmented ciliary epithelium of the ciliary processes when compared with TCP.

Cyclodestructive Procedures in Glaucoma: A Review of Current and Emerging Options

The first surgical modalities to reduce aqueous humor production by damaging the ciliary body date back to the early twentieth century. Until recently, however, cyclodestructive procedures (e.g., cyclocryotherapy and transscleral diode laser photocoagulation) have been reserved as last option procedures in refractory glaucoma patients with poor visual potential. Emerging technologic innovation has led to the development of promising, safer and less destructive techniques, such as micropulse diode cyclophotocoagulation, endoscopic cyclophotocoagulation and ultrasound cyclodestruction. Consequently, an emerging paradigm shift is under way with the selection of these surgical options in eyes with less severe glaucoma and good visual potential. Although existing evidence has not, as yet, adequately defined the role and value of these procedures, their emergence is a welcome expansion of available options for patients with moderate-to-severe glaucoma. This article reviews the pertinent evidence on both established and evolving cyclodestructive techniques and describes their growing role in the management of glaucoma.

Lasers in glaucoma

While lasers have been used for many years for the treatment of glaucoma, proper indications and use of the procedures need to be considered before their application. This review summarizes the important laser procedures in Glaucoma.

A review of combined phacoemulsification and endoscopic cyclophotocoagulation: efficacy and safety

As cataract occurs frequently in patients with glaucoma, combining phacoemulsification and endoscopic cyclophotocoagulation has been gaining attention recently due to its minimally invasive nature. A variety of studies had evaluated the efficacy and safety of this procedure and had shown extremely promising results. This review article has shown here that combined phacoemulsification and endoscopic cyclophotocoagulation procedure could effectively reduce intraocular pressure in medically uncontrolled glaucoma patients while avoiding serious complications associated with traditional cyclophotocoagulation procedure and adverse effects related to filtering surgery such as trabeculectomy.

Phacoemulsification plus endoscopic cyclophotocoagulation versus phacoemulsification alone in primary open-angle glaucoma

PURPOSE

To examine the efficacy and safety of combined phacoemulsification and endoscopic cyclophotocoagulation (phaco-ECP) compared to phacoemulsification alone in patients with primary open-angle glaucoma (POAG).

METHODS

We performed a retrospective notes review of 99 consecutive clinical records of patients with POAG from 2 London eye departments. A total of 69 patients who underwent phaco-ECP and 30 sex- and age-matched control patients who underwent cataract surgery alone were included. Data on intraocular pressure (IOP), visual acuity (VA), number of ocular hypotensive medications, and postoperative complications were collected over 12 months. The primary outcome measure was defined as an IOP within normal limits (<21 mm Hg) and at least a 20% reduction in IOP from baseline.

RESULTS

Mean IOP was significantly decreased in both groups after 1 year (p<0.001 from baseline). The success rate was significantly higher in the phaco-ECP group (69.6%) than in the phaco group (40%) after 1 year (p = 0.004). Reduction in mean IOP and number of medications was also greater in the phaco-ECP group after 1 year (IOP reduction: 4.5 ± 5.13 mm Hg vs 1.83 ± 3.61 mm Hg; p = 0.007; number of medications reduction: 0.73 ± 0.71 vs 0.23 ± 0.56; p = 0.001). Both groups achieved a similar improvement in VA. There was a higher incidence of minor and self-limiting complications in the phaco-ECP group (p<0.047).

CONCLUSIONS

Phaco-ECP resulted in a greater reduction in IOP and number of medications than phacoemulsification alone in POAG.

[Ahmed valve in glaucoma surgery]

This is a review on Ahmed valve application in glaucoma surgery. It contains, in particular, data on the Ahmed valve efficiency, results of experimental and histological studies of filtering bleb encapsulation, examines the use of antimetabolites and anti-VEGF agents, and discusses implantation techniques. The current appraisal of antimetabolites delivery systems integrated into the Ahmed valve is presented. Various complications encountered in practice and preventive measures are also covered.

Comparison of Outcomes between Endoscopic and Transcleral Cyclophotocoagulation

Importance: Traditionally cyclophotocoagulation has been reserved as a treatment of last resort for eyes with advanced stage glaucoma, but increasingly it is offered to eyes with less severe disease. Endoscopic approaches in particular are utilized in increasing numbers of patients despite only a small number of publications on its results. Objective: The purpose of this study was to compare the efficacy and safety of endoscopic and transcleral cyclophotocoagulation (ECP and TCP) procedures in eyes with refractory glaucomas. Design, Setting, and Participants: A chart review was performed on consecutive patients who underwent ECP and TCP at a tertiary ophthalmology care center between January 2000 and December 2010. Cases with fewer than 3 months of follow-up or that had concurrent pressure reducing procedures were excluded. The main outcome measures examined were intraocular pressure (IOP), number of glaucoma medications, best corrected visual acuity (BCVA), additional glaucoma procedure required, and complications. Main Outcomes and Measures: Forty-two eyes (42 patients) that underwent ECP and forty-four eyes (44 patients) that underwent TCP were identified. The TCP group had a statistically higher mean age (71.2 ± 16.7 vs. 58.1 ± 22.9 years, respectively), larger proportion of neovascular glaucoma (40.9% vs. 16.7%), worse initial BCVA (logMAR 2.86 vs. 1.81), and higher preoperative IOP (45.3 vs. 26.6 mmHg) than the ECP group. At 12 months follow-up, the mean IOP difference between groups was not statistically significant, although the change in IOP from baseline to 12 months was greater for the TCP group (p = 0.006). The rates of progression to no light perception (NLP) and phthisis bulbi were significantly higher amongst TCP eyes than ECP eyes (27.2% vs. 4.8%, p = 0.017, and 20.5% vs. 0%, p = 0.003, respectively). Of these eyes that progressed, a majority had neovascular glaucoma (NVG). Corneal decompensation was the most frequent complication following ECP (11.9%). Conclusions and Relevance: In patients with preoperative BCVA of 20/400 or better, overall complication rates (cystoid macular edema, exudative retinal detachment, inflammation, cornea decompensation) were higher after ECP than with TCP. In refractory glaucomas in a real world setting (not a trial), TCP was more frequently used in ischemic eyes. TCP was associated with a higher rate of progression to phthisis bulbi and loss of light perception than ECP. However, ECP was associated with a clinically significant rate of corneal decompensation. These outcomes likely were related to the severity of underlying ocular diseases found in these eyes.

Long-term clinical outcomes of Ahmed valve implantation in patients with refractory glaucoma

PURPOSE

To evaluate the long-term efficacy of intraocular pressure (IOP) reduction and complications of Ahmed Glaucoma Valve (AGV) implantation in patients with refractory glaucoma.

DESIGN

Retrospective study.

SUBJECTS

The study involved 302 refractory glaucoma patients who underwent AGV implantation and had a minimum follow-up of 6 months between March 1995 and December 2013.

METHODS

An operation was defined as successful when (1) the postoperative IOP remained between 5 and 21 mmHg and was reduced 30% compared to the baseline IOP with or without medication, (2) there was no loss of light perception or vision-threatening severe complications, and (3) no additional filtering or aqueous drainage surgery was required. Clinical records were reviewed.

MAIN OUTCOME MEASURES

IOP, anti-glaucoma medications, and complications.

RESULTS

The mean follow-up period was 62.25 months (range, 6 to 190 months). The cumulative probability of success was 89% at 6 months, 81% at 1 year, 66% at 3 years, 44% at 10 years, and 26% at 15 years. IOP was reduced from a mean of 32.2 ± 10.5 mmHg to 18.6 ± 9.1 mmHg at 1 month, 15.2 ± 7.0 mmHg at 6 months, and 14.2 ± 3.5 mmHg at 15 years. Surgical failures were significantly increased when preoperative IOP was high, and when severe complications occurred after AGV implantation (P < 0.05).

CONCLUSION

AGV implantation was successful for IOP control in patients with refractive glaucoma in the long term. However, the success rate of surgery decreased over time. Preoperative high IOP and severe complications related to the operation were significant risk factors for failure.

Microinvasive Glaucoma Surgery: An Evidence-Based Assessment

Introduction

The advent of Microinvasive Glaucoma Surgery (MIGS) offers a novel approach in the treatment of glaucoma with the number of procedures developing at an exciting pace.

Areas Covered

MIGS procedures aim to lower intraocular pressure (IOP) via four mechanisms: (1) increasing trabecular outflow, (2) increasing outflow via suprachoroidal shunts, (3) reducing aqueous production, and (4) subconjunctival filtration. A comprehensive search for published studies for each Microinvasive Glaucoma Surgery (MIGS) device or procedure was undertaken using the electronic database PubMed. Search terms included 'minimally invasive glaucoma surgery', 'microincisional glaucoma surgery', and 'microinvasive glaucoma surgery'. A manual search for each device or procedure was also performed. After review, randomized control trials and prospective studies were preferentially included.

Expert Opinion

These procedures offer several benefits: an improved safety profile allowing for intervention in earlier stages of glaucoma, combination with cataract surgery, and decreased dependence on patient compliance with topical agents. Established MIGS procedures have proven efficacy and more recent devices and procedures show promising results. Despite this, further study is needed to assess the long term IOP-lowering effectiveness of these procedures. Particularly, rigorous study with more randomized control trials and head-to-head comparisons would allow for better informed clinical and surgical decision-making. MIGS offers new solutions for glaucoma treatment.

High-Intensity Focused Ultrasound Circular Cyclocoagulation in Glaucoma: A Step Forward for Cyclodestruction?

The ciliary body ablation is still considered as a last resort treatment to reduce the intraocular pressure (IOP) in uncontrolled glaucoma. Several ablation techniques have been proposed over the years, all presenting a high rate of complications, nonselectivity for the target organ, and unpredictable dose-effect relationship. These drawbacks limited the application of cyclodestructive procedures almost exclusively to refractory glaucoma. High-intensity focused ultrasound (HIFU), proposed in the early 1980s and later abandoned because of the complexity and side effects of the procedure, was recently reconsidered in a new approach to destroy the ciliary body. Ultrasound circular cyclocoagulation (UC³), by using miniaturized transducers embedded in a dedicated circular-shaped device, permits to selectively treat the ciliary body in a one-step, computer-assisted, and non-operator-dependent procedure. UC³ shows a high level of safety along with a predictable and sustained IOP reduction in patients with refractory glaucoma. Because of this, the indication of UC³ was recently extended also to naïve-to-surgery patients, thus reconsidering the role and timing of ciliary body ablation in the surgical management of glaucoma. This article provides a review of the most used cycloablative techniques with particular attention to UC³, summarizing the current knowledge about this procedure and future possible developments.

A Review of the Ahmed Glaucoma Valve Implant and Comparison with Other Surgical Operations

The Ahmed glaucoma valve (AGV) is a popular glaucoma drainage implant used for the control of intraocular pressure in patients with glaucoma. While in the past AGV implantation was reserved for glaucoma patients poorly controlled after one or more filtration procedures, mounting evidence has recently encouraged its use as a primary surgery in selected cases. AGV has been demonstrated to be safe and effective in reducing intraocular pressure in patients with primary or secondary refractory glaucoma. Compared to other glaucoma surgeries, AGV implantation has shown favorable efficacy and safety. The aim of this article is to review the results of studies directly comparing AGV with other surgical procedures in patients with glaucoma.

Endoscopic Cyclophotocoagulation for the Treatment of Glaucoma in Boston Keratoprosthesis Type II Patient

We describe the surgical technique of endoscopic cyclophotocoagulation in a Boston keratoprosthesis type II patient. This patient with ocular cicatricial pemphigoid had pars plana endoscopic cyclophotocoagula through wounds created in the eyelids.

Refractive outcome of combined phacoemulsification and endoscopic cyclophotocoagulation

PURPOSE

To compare the refractive outcome of eyes that underwent phacoemulsification combined with endoscopic cyclophotocoagulation (phaco-ECP) with the eyes that underwent phacoemulsification alone.

METHODS

A retrospective case series review of 103 consecutive eyes that underwent phaco-ECP and 62 eyes that underwent phacoemulsification between January 2006 and August 2012 was conducted. Post-operative refractive outcomes were obtained by subjective refraction or autorefraction. Demographic data, best corrected visual acuity, intraocular pressure, number of glaucoma agents and mean deviation of the Humphrey visual field test (MD) were also analysed.

RESULTS

The total number of eyes included in the study was 62 eyes for the phaco-ECP group and 62 eyes for the control group who underwent phacoemulsification alone. More than 90% of eyes (n = 56) in phaco-ECP group achieved post-operative refraction within ±1 dioptre (D) of the target refraction. In the control group, 100% of eyes achieved post-operative refraction within ±1D of the target refraction. When comparing the difference between the target and the actual refractive outcome between the phaco-ECP and the control group, there was no statistically significant difference.

CONCLUSIONS

Refractive outcome after phaco-ECP is comparable to phacoemulsification alone. This study suggests that the intraocular lens power can be selected for cataract surgery alone and that ECP does not change the effective lens position significantly; therefore, no modification of biometry formulae is required. Phaco-ECP should be considered as an effective, safe and predictable surgical treatment option for glaucoma patients with co-existing cataract.