Characteristics and Treatment Outcomes of Hypotony Maculopathy Post-Glaucoma Filtering Surgery: An Optical Coherence Tomography-Based Study

PURPOSE

This study assesses morphological characteristics using SD-OCT in patients with hypotony maculopathy (HM) following glaucoma filtering surgery and evaluates the results of its treatment.

MATERIAL AND METHODS

Retrospective analysis of all HM patients between January 2019 and March 2023. Inclusion criteria consisted of both pre-operative and post-revision SD-OCT images of the macula and the presence of HM as observed on OCT images preoperatively. HM was graded according to its appearance in OCT both pre- and post-revision surgery. Change in visual acuity and IOP were assessed.

RESULTS

45 eyes of 45 patients were included. 21 eyes had HM limited to retinal pigment epithelium (RPE), 18 eyes had involvement of RPE and photoreceptor layers and 6 eyes had additional intra- or subretinal edema. After revision surgery with IOP elevation, 64% of eyes had complete HM regression with no HM signs in OCT imaging. 80% of patients achieved at least one grade improvement in HM. Preoperative visual acuity increased from 0.7±0.4 (logMAR) to 0.4±0.4 at 2 weeks postoperatively, over the course of an increase of IOP from 3.5±1.8 mmHg to 17.1±10.6 mmHg at day one. Eyes with complete HM regression had higher IOP at day 1 compared to those without improvement (P=0.04). The median time between HM onset and revision was 10.0 days for those with complete regression and 27 days for those without improvement (P=0.04).

CONCLUSIONS

Bleb revision procedures for HM following glaucoma filtering surgery show promising outcomes, including notable improvements in visual acuity and IOP. The timing of revision surgery appears to influence outcome. In our study earlier intervention was associated with better results. Even delayed surgeries can lead to an improvement, although complete morphological restoration may not be achieved in advanced grades of HM.

SUBFOVEAL CHOROIDAL TUBERCULOMA IN A HEALTHY YOUNG WOMAN CAUSED BY MYCOBACTERIUM BOVIS

PURPOSE

To describe a case of a macular tuberculoma in a young and healthy woman after developing a tuberculous lymphadenitis caused by Mycobacterium bovis .

METHODS

Retrospective case report.

RESULTS

Tuberculous lymphadenitis caused by M. bovis was detected after biopsy and histological examination as well as polymerase chain reaction test testing of cervical lymph nodes in a 20-year-old patient. An interferon gamma was positive. Shortly starting antitubercular therapy, the patient developed visual deterioration caused by a single yellowish subretinal structure in the macula of the right eye. Optical coherence tomography showed a dome-shaped, hyperreflective, subfoveal choroidal lesion with subtle subretinal fluid. Antitubercular therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide was performed, and the deescalation therapy with isoniazid and rifampicin was extended to 7 months. Further examinations showed regression of choroidal tuberculoma to a scar.

CONCLUSION

This is the first reported case of choroidal tuberculoma after tuberculous lymphadenitis caused by M. bovis .

[Real-world outcomes of glaucoma surgical procedures for open-angle glaucoma]

This article provides an overview of real-world outcomes in glaucoma surgical procedures. While randomized clinical trials provide valuable insights, they do not fully reflect real-world clinical practice. Real-world studies enable the evaluation of outcomes in uncontrolled settings and play a crucial role in counselling and decision-making for glaucoma treatment. By examining real-world data the article aims to identify rare adverse events that may go unnoticed in controlled clinical trials. The focus is on assessing the effectiveness and safety of glaucoma surgical procedures beyond the controlled trial setting.

Outcomes of Open Bleb Revision After PreserFlo MicroShunt Failure in Patients With Glaucoma

PRCIS

After the open bleb revision following PreserFlo, the mean postoperative intraocular pressure (IOP) was lowered from 26.4 ± 9.9 mm Hg to 12.9 ± 5.6 mm Hg at 1 month and 15.9 ± 4.1 mm Hg at 12 months.

PURPOSE

The purpose of this study was to evaluate the effectiveness and safety of an open bleb revision with mitomycin- C (MMC) for bleb fibrosis after PreserFlo MicroShunt implantation.

PATIENTS AND METHODS

We performed a retrospective analysis of 27 consecutive patients with bleb fibrosis after PreserFlo MicroShunt Implantation that underwent an open revision with MMC 0.2 mg/mL applied for 3 minutes at the Department of Ophthalmology of the Mainz, University Medical Center, Mainz, Germany. Demographic data, such as age, sex, glaucoma type, number of glaucoma medications, IOP before and after PreserFlo implantation and revision, complications, and reoperations within 12 months, were analyzed.

RESULTS

Twenty-seven patients (27 eyes) received an open revision after previous PreserFlo Microshunt implantation and consecutive bleb fibrosis. The mean preoperative IOP was 26.4 ± 9.9 mm Hg before revision, 7.0 ± 2.7 mm Hg ( P < 0.001) in the first week after the revision, and 15.9 ± 4.1 mm Hg at 12 months ( P = 0.02). Four patients needed IOP-lowering medication after 12 months. One patient had a positive Seidel test and needed a conjunctival suture. Four patients required a second procedure due to recurring bleb fibrosis.

CONCLUSIONS

At 12 months, open revision with MMC for bleb fibrosis after failed PreserFlo implantation effectively and safely reduced IOP with a similar medication burden.

Semi-automated quantification of vitreal hyperreflective foci in SD-OCT and their relevance in patients with peripheral retinal breaks

BACKGROUND

Retinal breaks (RB) are emergencies that require treatment to prevent progression of rhegmatogenous retinal detachment. Vitreal hyperreflective foci (VHF) representing migration of RPE cell clusters or interphotoreceptor matrix from the RB are potential biomarkers. The aim of this study is to investigate VHF in RB-patients using SD-OCT.

METHODS

The retrospective cross-sectional study included RB patients from our Department of Ophthalmology, HSK Wiesbaden who underwent macular SD-OCT (SPECTRALIS®, Heidelberg Engineering, Germany) on both eyes. VHF, defined and quantified as foci that differ markedly in size and reflectivity from the background speckle pattern, were assessed for presence and frequency. The RB-affected eyes were the study group (G1), the partner eyes the control group (G2).

RESULTS

160 consecutive patients with RB were included. Age was 60 ± 10.2 years (52% female). 89.4% of G1 and 87.5% of G2 were phakic (p = 0.73). 94.4% (n = 151) were symptomatic. Symptom duration was 8.0 ± 10.1 days in G1, 94.4% (n = 151) showed VHF versus 5.6% (p < 0.0001) in G2, of which 75% (n = 6) showed asymptomatic lattice degenerations. Detectable VHF showed a strong association of OR = 320 (95% CI, 110-788, p < 0.0001)) with respect to symptomatic RB. Sensitivity and specificity were 94.7% and 94.7%, respectively.

CONCLUSIONS

Most eyes with symptomatic RB show vitreal VHF in SD-OCT. Detected VHF are strongly associated with RB, and our semi-automated greyscale reflectivity analysis indicates that VHF likely originate from photoreceptor complexes torn out of the RB area that migrate into the vitreous cavity. The presence of VHF may indicate RB and should lead to a thorough fundus examination in both symptomatic and asymptomatic cases.

Influence of different primary surgical techniques on long-term intraocular pressure and medication in glaucoma after congenital cataract surgery

PURPOSE

To assess long-time results of primary surgical treatment in children with glaucoma after congenital cataract surgery.

METHODS

A retrospective study of 37 eyes from 35 children with glaucoma after congenital cataract surgery, who underwent surgery between 2011 and 2021 at the Childhood Glaucoma Center, University Medical Center Mainz, Germany. Only children, who received a primary glaucoma surgery in our clinic within the given time (n = 25) and had at least one-year follow-up (n = 21), were included in the further analysis. The mean follow-up time was 40.4±35.1 months. The primary outcome was the mean reduction in IOP (in mmHg) from baseline to follow-up visits after the surgery, measured with Perkins tonometry.

RESULTS

8 patients (38%) were treated with probe trabeculotomy (probe TO), 6 (29%) with 360° catheter-assisted trabeculotomy (360° TO) and 7 (33%) with cyclodestructive procedures. IOP was significantly reduced after probe TO and 360° TO after 2 years, from 26.9 mmHg to 17.4 mmHg (p<0.01) and 25.2 mmHg to 14.1 mmHg (p<0.02), respectively. There was no significant IOP reduction after cyclodestructive procedures after 2 years. Both, probe TO and 360° TO led descriptively to eye drops reduction after 2 years, from 2.0 to 0.7 and 3.2 to 1.1. The reduction was not significant.

CONCLUSIONS

In glaucoma after congenital cataract surgery, both trabeculotomy techniques, lead to good reduction of IOP after 2 years. There is a need for a prospective study with comparison to the use of glaucoma drainage implants.

Combined vitrectomy, near-confluent panretinal endolaser, bevacizumab and cyclophotocoagulation for neovascular glaucoma - a retrospective interventional case series

Background: Neovascular glaucoma (NVG) is a severe, potentially blinding disease and a therapeutic challenge. The purpose of this study was to evaluate the safety and efficacy of an integrative surgical approach to neovascular glaucoma. Methods: Retrospective analysis of a one-year follow-up of a consecutive interventional case series of NVG. Eyes underwent transscleral cyclophotocoagulation, pars plana vitrectomy, near-confluent panretinal photocoagulation, and intravitreal bevacizumab. Phakic eyes underwent concomitant cataract surgery. Best-corrected visual acuity (BCVA, logMAR), intraocular pressure (IOP, mmHg), number of glaucoma medication, visual analog pain scale (VAPS, 0-10) were recorded at baseline, and 1, 3, 6, and 12 months. Blind eyes were excluded. Results: Seventy-seven eyes of 77 patients (45 male, 32 female, mean age 73.6±12.2 years) were included. NVG underlying conditions included retinal vein occlusion (41.6%), proliferative diabetic retinopathy (35.1%), central retinal artery occlusion (19.5%), and ocular ischemic syndrome (3.9%). Mean IOP decreased postoperatively from 46.3±10.1 mmHg to 14.5±7.9 mmHg (p<0.001), glaucoma medication from 4.7±1.3 to 1.8±1.8 (p<0.001), and VAPS from 6.0±1.8 to 0. BCVA remained unchanged. Postoperative intraocular inflammation had resolved in all eyes at the one-month follow-up. 71.4% (55/77) eyes did not require additional major interventions during follow-up. Conclusions: A single, comprehensive surgery session lowered IOP significantly, reduced GMS, and controlled pain.

Combined vitrectomy, near-confluent panretinal endolaser, bevacizumab and cyclophotocoagulation for neovascular glaucoma - a retrospective interventional case series

Background: Neovascular glaucoma (NVG) is a severe, potentially blinding disease and a therapeutic challenge. The purpose of this study was to evaluate the safety and efficacy of an integrative surgical approach to neovascular glaucoma. Methods: Retrospective analysis of a one-year follow-up of a consecutive interventional case series of NVG. Eyes underwent transscleral cyclophotocoagulation, pars plana vitrectomy, near-confluent panretinal photocoagulation, and intravitreal bevacizumab. Phakic eyes underwent concomitant cataract surgery. Best-corrected visual acuity (BCVA, logMAR), intraocular pressure (IOP, mmHg), number of glaucoma medication, visual analog pain scale (VAPS, 0-10) were recorded at baseline, and 1, 3, 6, and 12 months. Blind eyes were excluded. Results: Seventy-seven eyes of 77 patients (45 male, 32 female, mean age 73.6±12.2 years) were included. NVG underlying conditions included retinal vein occlusion (41.6%), proliferative diabetic retinopathy (35.1%), central retinal artery occlusion (19.5%), and ocular ischemic syndrome (3.9%). Mean IOP decreased postoperatively from 46.3±10.1 mmHg to 14.5±7.9 mmHg (p<0.001), glaucoma medication from 4.7±1.3 to 1.8±1.8 (p<0.001), and VAPS from 6.0±1.8 to 0. BCVA remained unchanged. Postoperative intraocular inflammation had resolved in all eyes at the one-month follow-up. 71.4% (55/77) eyes did not require additional major interventions during follow-up. Conclusions: A single, comprehensive surgery session lowered IOP significantly, reduced GMS, and controlled pain.

Results of First In Vivo Trial of an Acoustic Self-Tonometer

Purpose

Glaucoma is the world's most common cause of irreversible blindness, which makes early diagnosis, with the goal of preserving vision, essential. The current medical intervention is to reduce intraocular pressure (IOP) to slow down progression of the disease. The main goal of this study was to test a novel handheld acoustic self-tonometer on humans.

Methods

A sound pressure pulse generated by a loudspeaker causes the eye to vibrate. A pressure chamber is placed on the human orbit to form a coupled system comprised of the patient's eye, the enclosed air, and the loudspeaker. A displacement sensor in front of the loudspeaker membrane allows the dynamic behavior of the entire system to be detected.

Results

For this clinical trial series, a prototype of the acoustic self-tonometer principle was applied. The resulting membrane oscillation data showed sensitivity of patient IOP, but direct allocation of the measured damping and frequency to the IOP was not significant. For this reason, an artificial neural network was used to find relationships among the subjects’ biometric eye parameters in combination with the self-tonometer data for the IOP reference. An expanded measurement uncertainty (k_p = 2) equal to 6.53 mm Hg was determined for the self-tonometer in a Bland–Altman analysis using Goldmann applanation tonometer reference measurements.

Conclusions

The usability and success rate of producing valid measurement values with the device during self-measurements by test subjects was nearly 92%. The cross-sensitivities observed require compensation in a possible redesign phase to reduce the measurement uncertainty by at least 25% to the maximum of 5 mm Hg required to seek medical device approval.

Translational Relevance

Building on successful laboratory experiments with pig eyes, this article reports the results of testing the acoustic tonometer on humans.

[Glaucoma Drainage Devices: Tube versus Trabeculectomy Study]

While trabeculectomy with mitomycin C has previously been the gold standard in penetrating glaucoma surgery, glaucoma drainage implants used early within glaucoma surgery were examined in the course of the tube versus trabeculectomy (TVT) study. Glaucoma drainage implants are now being used earlier, as materials are tissue-compatible and surgery has been improved. While in the past, the use of such implants was often carried out after multiple preoperations, implants are now being used at an earlier stage. Glaucoma drainage implants are typically still used in the pseudophakic eye, where 1-2 glaucoma preoperations (e.g. trabeculectomy) have already been performed.