Effect of selective laser trabeculoplasty on ocular haemodynamics in primary open-angle glaucoma

Real-World Outcomes of Canaloplasty and Trabeculotomy Combined with Cataract Surgery in Eyes with All Stages of Open-Angle Glaucoma

Purpose

To evaluate the long-term safety and efficacy of sequential canaloplasty and trabeculotomy combined with cataract surgery in patients with mild, moderate, and advanced open-angle glaucoma.

Patients and Methods

Case records of 171 consecutive patients (171 eyes) who had undergone cataract surgery followed by canaloplasty (≥180°) and trabeculotomy (≥90°) for mild, moderate, or advanced open-angle glaucoma (Shaffer grade ≥3) using the OMNI Surgical System (Sight Sciences, Inc., Menlo Park, CA) were analyzed retrospectively. Efficacy endpoints included change in mean IOP and number of medications from baseline to postoperative 12- and 24-months for the overall dataset and stratified by each stage of glaucoma. Kaplan-Meier survival analysis of success (eyes that did not require secondary surgical interventions (SSI)) by postoperative 24 months was also performed.

Results

Postoperatively, there was a statistically significant reduction in IOP (baseline of 17.2 mmHg on 1.3 medicines reduced to 14.3 on 0.8 medicines (12 months) and 14.0 on 0.9 medicines (24 months), p<0.001 for both time points). Eyes with advanced glaucoma (N=63) maintained significant IOP reduction (17.8 mmHg on 1.6 medicines at baseline reduced to 13.6 mmHg on 1.3 medicines (12 months) and 13.0 on 1.5 medicines (24 months), p<0.001). Kaplan-Meier analysis showed a 93.0% survival probability for the avoidance of SSI at 2 years after surgery.

Conclusion

Canaloplasty and trabeculotomy combined with cataract surgery provided effective IOP reduction for eyes with all stages of glaucoma at postoperative 12 and 24 months, and the procedure yielded a 93% survival rate for SSI avoidance at 2 years.

Vascular dysregulation in glaucoma: retinal vasoconstriction and normal neurovascular coupling in altitudinal visual field defects

Purpose

Vision loss in glaucoma is not only associated with elevated intraocular pressure and neurodegeneration, but vascular dysregulation (VD) is a major factor. To optimize therapy, an improved understanding of concepts of predictive, preventive, and personalized medicine (3PM) is needed which is based on a more detailed understanding of VD pathology. Specifically, to learn if the root cause of glaucomatous vision loss is of neuronal (degeneration) or vascular origin, we now studied neurovascular coupling (NVC) and vessel morphology and their relationship to vision loss in glaucoma.

Methods

In patients with primary open angle glaucoma (POAG) (n = 30) and healthy controls (n = 22), NVC was studied using dynamic vessel analyzer to quantify retinal vessel diameter before, during, and after flicker light stimulation to evaluate the dilation response following neuronal activation. Vessel features and dilation were then related to branch level and visual field impairment.

Results

Retinal arterial and venous vessels had significantly smaller diameters in patients with POAG in comparison to controls. However, both arterial and venous dilation reached normal values during neuronal activation despite their smaller diameters. This was largely independent of visual field depth and varied among patients.

Conclusions

Because dilation/constriction is normal, VD in POAG can be explained by chronic vasoconstriction which limits energy supply to retinal (and brain) neurons with subsequent hypo-metabolism ("silent" neurons) or neuronal cell death. We propose that the root cause of POAG is primarily of vascular and not neuronal origin. This understanding can help to better personalize POAG therapy of not only targeting eye pressure but also vasoconstriction to prevent low vision, slowing its progression and supporting recovery and restoration.

Trial registration

ClinicalTrials.gov, # NCT04037384 on July 3, 2019.

Efficacy of selective laser trabeculoplasty on lowering intraocular pressure fluctuations and nocturnal peak intraocular pressure in treated primary open-angle glaucoma patients

Purpose

To investigate the efficacy of adjunctive selective laser trabeculoplasty (SLT) in reducing 24-h intraocular pressure (IOP) fluctuations and nocturnal IOP peaks.

Methods

In this prospective interventional case series, 157 medically treated eyes of 157 patients with primary open-angle glaucoma (POAG) who were assigned SLT to further reduce IOP were consecutively included. Each patient had a complete glaucoma work-up and 24-h IOP monitoring (6 measurements, including one in the supine position) taken before and on average 6 months after SLT. The main outcome measures were the reduction of 24-h IOP fluctuations and nocturnal peak IOP. Secondary outcome measures were success rates, factors influencing the reduction of high 24-h IOP fluctuations and nocturnal peak IOP, complications, and severe adverse events.

Results

Medicated mean 24-h IOP (mmHg) was statistically significantly reduced from 15.1 ± 2.6 to 13.8 ± 2.4 (P < 0.001) and IOP fluctuations from 6.5 ± 2.7 to 5.4 ± 2.6 (P < 0.001) 6 months after SLT. Ninety-four eyes (59.9%) initially had high IOP fluctuations (more than 5 mmHg). These were reduced from 8.1 ± 2.3 to 5.6 ± 2.7 at 6 months (P < 0.001). Fifty-two eyes (55.3%) had fluctuations below 5 mmHg post-SLT which was defined as success. Fifty-one patients (32.5%) had nocturnal IOP peaks. In these cases, nocturnal IOP was reduced by 19.2% from 20.1 ± 3.4 to 16.2 ± 3.3 mmHg at 6 months (P = 0.001).

Conclusions

The current study demonstrates that adjunctive SLT not only reduces mean 24-h IOP in treated POAG patients, but also has an additional benefit in reducing IOP fluctuations and nocturnal peak IOP.

Trial registration

Clinical trial registration: NCT02959242.

Efficacy of Selective Laser Trabeculoplasty on Circadian Intraocular Pressure Following Trabeculectomy in Advanced Primary Open-angle Glaucoma

PRCIS

In about 50% of post-trabeculectomy (TE) eyes, selective laser trabeculoplasty (SLT) is effective in further lowering intraocular pressure (IOP).

PURPOSE

To investigate the efficacy and safety of SLT in post-TE eyes, uncontrolled on maximum tolerated medication, and/or with progression of visual field loss.

PATIENTS AND METHODS

This retrospective study consecutively included post-TE eyes of patients diagnosed with primary open-angle glaucoma who had been treated with 360 degrees SLT and had a follow-up after 12 months. Primary endpoints were the reduction of mean diurnal intraocular pressure (mdIOP, mean of 6 measurements), peak IOP, and diurnal IOP fluctuations. Secondary outcomes were factors influencing IOP reduction, SLT success, and failure rates.

RESULTS

Forty-three eyes of 43 patients were included. During the first year, 10 eyes (23%) needed additional procedures to reduce mdIOP and were accounted as failures and excluded from final analysis. Of the remaining 33 eyes (77%) mdIOP [Q25, Q75] dropped from 15.2 [12.2 to 16.5] to 13.2 [11.6 to 15.3] mm Hg (P=0.027), 23 eyes (54%) showed a sufficient mdIOP reduction, 1 year after SLT.

CONCLUSION

SLT is effective and safe in lowering mdIOP to target IOP in about 50% of eyes after prior incisional glaucoma surgery.

Efficacy of low-energy selective laser trabeculoplasty on the treatment of primary open angle glaucoma

AIM

To investigate the efficacy of low-energy selective laser trabeculoplasty (SLT) on the treatment of primary open angle glaucoma (POAG) patients.

METHODS

Outpatients with POAG who underwent 360-degree SLT using an initial energy of 0.3 mJ (total energy of 30-40 mJ) were reviewed retrospectively from September 2011 to January 2018.

RESULTS

Eight-six eyes of 44 POAG patients underwent 360-degree SLT using initial energy of 0.3 mJ and were followed up regularly. The total energy used was 32.5±2.5 mJ (23-40 mJ, 105±6 spots). The average pretreatment intraocular pressure (IOP) was 19.8±3.9 mm Hg. At 1, 3, 6mo, 1, and 2y, the post-SLT IOPs (mm Hg) were 16.9±3.3, 16.5±3.3, 17.1±3.4, 16.6±3.5, 16.5±2.8, which were significantly lower than that before treatment (P<0.001). The patients in the SLT success group were found to be younger than those in the SLT failure group. After SLT, 59 eyes that maintained pretreatment medications were defined as the drug retention group. The pre-SLT IOP was 20.1±3.7 mm Hg. At 1, 3, 6mo, 1, and 2y, the post-SLT IOPs (mm Hg) were 17.3±3.6, 16.6±3.5, 17.2±3.6, 16.9±3.8 and 16.5±2.9, respectively. Twenty-seven eyes that required reduced drugs were defined as the drug reduction group. The pre-SLT IOP was 19.2±4.4 mm Hg. At 1, 3, 6mo, 1, and 2y, the post-SLT IOPs (mm Hg) were 16.1±2.6, 16.5±3.1, 16.8±2.9, 16.0±2.6 and 16.3±2.4, respectively. Compared with the pretreatment IOPs, the post-SLT IOPs were significantly lower in drug retention group and drug reduction group. The patients in the drug reduction group were found to be younger than those in the drug retention group.

CONCLUSION

Low-energy SLT is safe and effective for POAG patients during a 2-year follow-up. Younger POAG patients may obtain better results after low-energy SLT treatment.