Changing trends in glaucoma surgery within Australia

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Nationwide Analysis of Glaucoma Surgeries in Fiscal Years of 2014 and 2020 in Japan

Nationwide trends in glaucoma surgical procedures were assessed by using the NDB Open Data 2014 and 2020. In Japan, 33,340 non-laser, 54,569 laser, and 88,019 total glaucoma surgeries were performed in 2014. In 2020, 60,108 non-laser, 60,547 laser, and 120,655 total glaucoma surgeries were performed. The rates from 2014 to 2020 were 180%, 111%, and 137%, respectively. In each procedure, angle surgery (326%), tube shunt surgery (383%), ciliary coagulation (489%), and gonio-laser (225%) were remarkably increased, while iridectomy (75%) and iris laser (77%) decreased during the same period. An increase in laser surgery was seen in young age groups, namely, 55-59 years old and younger, while non-laser surgery was increased in old age groups, namely, 45-49 years old and older. In 2020, 47.6 non-laser, 48.0 laser, and 95.6 total glaucoma surgeries were performed per 100,000 persons. None of the vital statistics, including prefectural population, mean age, and rate of ≥65-year-old people, were significantly associated with the number of glaucoma surgeries. Glaucoma practice patterns changed each time a new device or procedure was introduced. The results of the current study reflected the use of new procedures, such as minimally invasive glaucoma surgery, tube shunt, selective laser trabeculoplasty, and micropulse cyclophotocoagulation.

Real-World Outcomes of Glaucoma Filtration Surgery Using Electronic Health Records: An Informatics Study

PRCIS

Utilizing an automated pipeline for data extraction from electronic health records provides real-world information on the success of various glaucoma procedures, with tube shunt implantation associated with increased failure rates compared with trabeculectomy.

BACKGROUND

We aimed to evaluate the long-term survival of glaucoma surgeries using an automated pipeline for extraction of outcomes from electronic health records.

METHODS

A retrospective observational study from a single academic center. Patients undergoing trabeculectomy, Ex-PRESS shunt, Baerveldt, and Ahmed tube shunt insertion from 2009 to 2018 were identified from electronic health record procedure codes. Patient characteristics were identified from structured and unstructured fields using a previously validated natural language processing pipeline.

RESULTS

Five hundred twelve patients underwent 711 glaucoma surgeries: 287 trabeculectomies, 47 Ex-PRESS shunts, 274 Baerveldt and 103 Ahmed tube implantations. The Median follow-up was 359 days. The mean baseline IOP was 24.4 mm Hg (SD 10.9), and 73.1% were on ≥3 medications. Compared with trabeculectomy, tube shunt surgery had a higher risk of failure (Baerveldt: Hazard Ratio (HR) 1.44, 95% CI 1.02 to 2.02; Ahmed: HR 2.01, 95% CI 1.28 to 3.17). Previous glaucoma surgery was associated with increased failure (≥2 previous surgeries: HR 2.74, 95% CI 1.62 to 4.64), as were fewer baseline medications (<3 medications: HR 2.96, 95% CI 2.12 to 4.13) and male sex (HR 1.40, 95% CI 1.03 to 1.90). At 1 year, tube shunt patients had a 2.53 mm Hg ( P =0.002) higher IOP compared with trabeculectomy patients.

CONCLUSIONS

Baerveldt and Ahmed tube shunt implantation was associated with increased failure compared with trabeculectomy. Fewer baseline medications, previous glaucoma surgeries, and male sex were also risk factors for failure. These results demonstrate the utility of applying an informatics pipeline to electronic health records to investigate key clinical questions using real-world evidence.

Current practice of trabeculectomy in a cohort of experienced glaucoma surgeons in Australia and New Zealand

BACKGROUND/OBJECTIVES

To evaluate current routine trabeculectomy technique preferences among Australian and New Zealand Glaucoma Society surgeons regularly performing trabeculectomy surgery.

SUBJECTS/METHODS

Survey of experienced surgeons who perform trabeculectomy.

RESULTS

Forty-nine surgeons (33 male:16 female) participated in the survey. Trabeculectomy was performed as day surgery (39/47, 83.0%) under local anesthesia (44/47, 93.6%). The surgical techniques most commonly used were a corneal traction suture (44/47, 93.6%), fornix-based conjunctival flap (43/47, 91.5%) and half-thickness scleral flap (38/47, 81.0%). Mitomycin C antifibrotic agent was used in routine cases by 45/46 (97.8%) surgeons. Surgeons applied the antifibrotic agent under the Tenon layer with a pledget (36/46, 78.2%) with a concentration of 0.02% (37/46, 80.4%) for 2 (11/46, 23.9%) or 3 min (30/46, 65.2%). The Kelly (26/46, 56.5%) and the Khaw Descemet (19/46, 41.3%) punches were used to perform the sclerostomy. Most surgeons performed a peripheral iridectomy in all phakic patients (46/47, 97.9%), but less commonly in pseudophakic patients (34/47, 72.3%). Techniques for closure of the limbal conjunctival edge were quite varied with a combination of suturing including purse string (21/47, 57.4%), wing (20/47, 42.6%) and horizontal mattress sutures (33/47, 70.2%). Surgeons reviewed their routine patients four times in the first month (29/47, 61.7%) and continued the postoperative topical steroids for 3-4 months (28/47, 59.6%).

CONCLUSIONS

Although a wide range of techniques for trabeculectomy exists among surgeons, there are consistent procedures currently in use to optimize patient outcomes. This report will assist surgeons in choosing which surgical techniques fit their best practice.