Gonioscopy-assisted transluminal trabeculotomy is an effective surgical treatment for uveitic glaucoma

Highlighting the limited efficacy of gonioscopy-assisted transluminal trabeculectomy in Fuchs uveitis syndrome: a case series

BACKGROUND

This study aimed to investigate the outcomes of gonioscopy-assisted transluminal trabeculectomy (GATT) surgery in patients with Fuchs' uveitis syndrome (FUS) related glaucoma.

CASE PRESENTATION

The clinical and surgical records of 4 FUS patients who underwent GATT surgery between 2021 and 2023 were retrospectively reviewed. The preoperative process, clinical course under medical treatment, postoperative clinical course, intraocular pressures (IOP), glaucoma medication requirements, need for additional surgeries, visual outcomes, and surgical success results were evaluated for each patient GATT surgery was performed as the first intervention for glaucoma control in FUS patients under 50 years of age with IOP above 20 mm Hg despite multiple different medications. The average follow-up period after GATT surgery was 12 months. Despite reaching the maximum level of antiglaucomatous treatment in any of the patients, the target IOP was not achieved. On average, 6 months later, mitomycin-C trabeculectomy (MMC-trab) was performed as a conventional surgical option in three of the patients, and diode laser cyclophotocoagulation was applied to one patient with poor visual prognosis.

CONCLUSIONS

In FUS, which causes low-grade inflammation, has a low likelihood of synechial formation, and relatively affects a younger age group, GATT surgery, a minimally invasive glaucoma surgery (MIGS) method, was considered a good alternative as an initial surgical option. However, it was observed that the surgical success was limited.

Uveitic Flare-Ups After Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Patients with Uveitic Glaucoma

PURPOSE

To assess the risk of gonioscopy-assisted transluminal trabeculotomy (GATT) inducing an uveitic flare-up in patients with uveitic glaucoma (UG).

METHODS

This retrospective study included consecutive UG patients who underwent GATT at a single medical center between June 2020 and September 2022. The main outcome measure was the occurrence of a surgery-related uveitic complication defined as either an uveitic flare-up defined by the Standardization of Uveitis Nomenclature (SUN) criteria, or the appearance of cystoid macular edema (CME) from 2 weeks to 3 months after surgery.

RESULTS

A total of 25 eyes of 22 patients were included in the study. Age ranged from 10-78 and 64% were women. The most common uveitic etiologies were juvenile idiopathic arthritis (JIA, 24%) and herpetic infection (24%). A total of 48%of the patients were on systemic immunosuppressants prior and unrelated to surgery. Eight eyes (32%) had severe glaucomatous damage prior to surgery, and 20% of the patients had undergone previous glaucoma surgery. Two cases (8%) demonstrated uveitic flare-up in the early postoperative period: a case of mild anterior chamber reaction and a case of CME with persistent edema prior to surgery. Average intraocular pressure (IOP) was reduced from 26.7 mm Hg on four medications to 12.2 on 1.1 after 1 year. One patient required reoperation for IOP control.

CONCLUSIONS

With careful pre and postoperative care, GATT seems to be a low-risk procedure for uveitic flare-ups in patients with UG.

Gonioscopy-Assisted Transluminal Trabeculotomy in Uveitis-Related Ocular Hypertension and Glaucoma

PRCIS

Gonioscopy-assisted transluminal trabeculotomy (GATT) may be an effective first-line surgery for decreasing intraocular pressure (IOP) and medication burden in patients with uveitis-related ocular hypertension (OHT) or glaucoma.

OBJECTIVE

The purpose of the study is to determine the efficacy of GATT in lowering IOP in uveitis-related OHT or glaucoma.

METHODS

Retrospective case series that included patients with uveitis-related OHT or glaucoma who underwent GATT with or without concomitant cataract extraction and intraocular lens implantation at 2 Canadian academic centres from July 2018 to May 2022. Primary outcomes were: complete (no medications) and qualified success (with medication), and failure defined as (1) IOP >21 mm Hg with maximal medical therapy, (2) the need for additional glaucoma procedure, (3) loss of light perception secondary to glaucoma, and (4) IOP <6 mm Hg for 3 months.

RESULTS

Twenty-one eyes from 18 patients were included with a mean preoperative IOP of 26.2 ± 7.3 mm Hg on 4.3 ± 0.7 classes of glaucoma drops. The average follow-up was 29.2 ± 17.6 months and 76% of eyes (n = 16) had reached at least 12 months of follow-up. At the 12-month follow-up visit, there was a significant decrease in average IOP by 9.9 ± 7.9 mm Hg (38%, P = 0.005) and a decrease of 1.9 in glaucoma medication classes ( P = 0.002). Of eyes, 14% achieved complete success, whereas 80% of eyes achieved qualified success. Six eyes failed (29%) and 5 patients (24%) required additional glaucoma surgery. The most common postoperative complication was hyphema (n = 9; 43%).

CONCLUSION

This small case series suggests that GATT may be an effective first-line surgery for decreasing IOP and medication burden in patients with uveitis-related OHT or glaucoma. Further studies with longer follow-ups should be conducted to assess its long-term outcomes.

Update on Diagnosis and Treatment of Uveitic Glaucoma

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

Outcomes of Goniotomy With or Without Secondary Intraocular Lens Implantation in Pediatric Glaucoma Following Cataract Surgery: A Prospective Pilot Study

PURPOSE

To report the outcomes of a 120-degree goniotomy (GT) with or without secondary intraocular lens (IOL) implantation in glaucoma following cataract surgery (GFCS).

DESIGN

Prospective, observational study.

METHODS

Pediatric patients with GFCS who underwent standalone 120-degree GT or 120-degree GT combined with secondary IOL implantation (GT+IOL) from March 2022 to August 2022 at the Zhongshan Ophthalmic Center were recruited. Primary outcomes were intraocular pressure (IOP) and the number of ocular hypotensive medications. A secondary outcome was the surgical success rate. Success was defined as a postoperative IOP within the range of 5-21 mm Hg. Complete and qualified successes were defined, as the above, without and with ocular hypotensive medications, respectively.

RESULTS

Thirty-two eyes of 22 patients were included. The mean age at the time of GT was 68.5 ± 29.3 months. The mean follow-up duration was 12.2 ± 2.3 months (9-15 mo). Mean IOP decreased from 30.9 ± 4.8 mm Hg on 2 (interquartile range = 1) medications at baseline to 15.8 ± 3.6 mm Hg on 0 (interquartile range = 1.5) medication at the latest visit in all eyes. The overall complete and qualified success rates were 68.8% and 90.6%, respectively. There were no significant differences in IOP, number of medications, and complete and qualified success rates between the standalone GT and GT+IOL groups at the latest follow-up at 9 months postoperatively.

CONCLUSIONS

To reduce the need for additional surgery, 120-degree GT was a safe and effective surgical treatment for GFCS in children, which could be combined with secondary IOL implantation in aphakic eyes with GFCS.

The Efficacy and Safety of the GATT Procedure in Open-Angle Glaucoma-6-Month Results

AIM

The aim of the study was to retrospectively evaluate the efficacy and safety of GATT during a 6-month observation period.

MATERIAL AND METHODS

The studied group consisted of 69 open-angle glaucoma patients treated with GATT as the only procedure or in combination with cataract surgery. Patients were assessed 1 day, 10 days, 1 month, 3 months, and 6 months after the surgery via standard ophthalmic examination including VF, IOP, and BCVA. The number of medications taken daily and possible complications were checked. Two criteria of success were established (S1: IOP decrease by 30% and S2: IOP lower than 18 mm Hg).

RESULTS

Before the surgery, the mean IOP was 26.94 mmHg and significantly decreased after GATT to 15.59 mmHg at 6M. BCVA did not significantly differ between the visits. The mean MD did not change significantly within the 6-month observation period (-8.20 dB vs. -8.16 dB, p = 0.9824), similar to the mean VFI (64.31% vs. 63.05%, p = 0.8571). A 30% IOP decrease at 6M visit was obtained in 95.6% of patients, and 37.7% needed medications to stabilize IOP. An IOP lower than 18 mmHg at 6M was obtained in 91.3% of studied patients after the GATT procedure, and in 58.0% without additional medications. The mean number of medications received daily decreased significantly at 6M compared to preoperative results (2.59 at inclusion vs. 0.76 at 6M, p = 0.0004). The most frequent complication after surgery was hyphema, which resolved spontaneously within 10 days.

CONCLUSION

The 6-month observation showed that GATT is a minimally invasive glaucoma-surgery technique that enables an effective and safe IOP decrease.