Long-Term Changes in Lamina Cribrosa Curvature Index After Trabeculectomy in Glaucomatous Eyes.

Purpose: This study aimed to evaluate both short-term and long-term changes in the lamina cribrosa curvature index (LCCI) following trabeculectomy and investigate the factors influencing these changes. Methods: In this retrospective, observational study, 40 eyes of 40 patients with glaucoma who underwent trabeculectomy and had a follow-up of at least 2 years were included. Optic nerve head area was scanned by using spectral-domain optical coherence tomography before surgery (Pre_OP), within 6 months postoperatively (Post_OP1), and at the last visit (Post_OP2). LCCI values calculated from B-scan images at six different planes (0°, 30°, 60°, 90°, 120°, and 150°) and their mean values were compared. Univariate and multivariate linear regression analyses were used to identify the clinical factors associated with the amount of LCCI changes. Results: The mean follow-up time was 38.3 ± 16.8 months. At Post_OP1, the mean LCCI decreased from 9.28 ± 2.58 to 7.91 ± 2.57 (P < 0.001), and the mean intraocular pressure decreased from 22.0 ± 7.6 mm Hg to 12.2 ± 3.8 mm Hg (P = 0.001). At Post_OP2, the mean LCCI was maintained at 7.74 ± 2.49 (P = 0.56 when compared to Post_OP1 and P < 0.001 when compared to Pre_OP). The mean intraocular pressure was 12.6 ± 5.4 mm Hg (P = 0.67 when compared to Post_OP1 and P < 0.001 when compared to Pre_OP). Long-term LCCI changes were associated with baseline age (P = 0.04), spherical equivalent (P = 0.02), mean IOP during follow-ups (P = 0.02), and preoperative LCCI (P = 0.04). Conclusions: Glaucomatous eyes undergoing trabeculectomy demonstrated reductions in the LCCI after a mean follow-up of over 3 years. Greater long-term LCCI reduction was associated with younger age, lower mean IOP during follow-up period, greater spherical equivalent refractive error, and preoperative LCCI.

Outcomes of Gonioscopy-Assisted Transluminal Trabeculotomy in Eyes With Prior Failed Glaucoma Surgery.

PRCIS: This study concludes that GATT can be an effective and safe surgical alternative for managing IOP in eyes with prior failed glaucoma surgeries, associated with minimal complications. PURPOSE: To report outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in eyes with prior failed glaucoma surgery. PATIENTS AND METHODS: A retrospective study involving 30 eyes of 30 patients, all of whom had open angles on gonioscopy, experienced prior glaucoma surgery failures, and subsequently underwent GATT. The primary outcome measure was success defined as complete when the intraocular pressure (IOP) was >5 and ≤21/16 mm Hg without glaucoma medications and qualified with medications. RESULTS: The mean age was 51.8±16.1 years. Twenty-one eyes underwent GATT and 9 eyes underwent phaco-GATT. Twenty-seven eyes had failed trabeculectomy and 3 eyes had failed glaucoma drainage device. Post-GATT, the IOP decreased from 27.1±7 to 16.9±6 mm Hg (P<0.001) at the end of 15 months, with a mean drop in AGM from 4.9±1.0 to 2±1.6. At postoperative 1 year, the probability of complete success was 20% (95% CI: 9-43) for an IOP criterion of both 21 and 16 mm Hg. The qualified success probability at 1 year was 82% (67-100) for an IOP criterion of 21 mm Hg and 57% (38-84) for an IOP criterion of 16 mm Hg. Risk factor for failure was older age [hazard ratio (HR): 1.03, 95% CI: 1.01-1.06]. The complications noted were hyphema in 14 eyes (46%), majority resolved within 1 week and all by 2 weeks. None needed any intervention. CONCLUSIONS: This study concludes that GATT can be an effective and safe surgical alternative for managing IOP in eyes with prior failed glaucoma surgeries, associated with minimal complications.

Surgery Outcomes of Prolene Suture Gonioscopy-Assisted Transluminal Trabeculotomy (GATT): Up to 4 Years Follow-Up and Prognostic Factors.

PRCIS: Long-term success was achievable after GATT. GATT performed at early stage of glaucoma had better surgery outcomes. Trabeculoplasty may compromise surgery success. PURPOSE: To evaluate the long-term effectiveness of prolene suture gonioscopy-assisted transluminal trabeculotomy (GATT) and identify factors that may affect surgical outcomes. PATIENTS AND METHODS: This is a retrospective cohort study of adult patients with prolene suture GATT performed by a single surgeon at 1 medical center. RESULTS: Of the 145 eyes from 124 patients studied, intraocular pressure was reduced from 22.1±7.8 to 15.1±3.2 and 15.1±3.5 mm Hg, and the number of glaucoma medications was reduced from 3.2±1.1 to 1.3±1.4 and 1.4±1.5 at postoperative years 3 and 4, respectively. Ninety-three and 71 eyes completed a 3- and 4-year follow-up, with 44% of the eyes at year 4 remaining medication free. Compared with eyes with combined GATT/cataract extraction (CE), eyes with GATT alone had significantly more preoperative medications and a higher reoperation rate (31% vs. 16.5%). Eyes with prior trabeculoplasty had a higher reoperation rate (28.8%) than those without (16.1%). Kaplan-Meier survival analysis revealed that GATT/CE eyes without trabeculoplasty had a longer median time to failure (48 mo) than GATT/CE eyes with trabeculoplasty (18 mo), and GATT eyes with or without trabeculoplasty (9 and 12 mo, respectively). CONCLUSION: Prolene suture GATT successfully reduced IOP. Eyes with more preoperative medications responded less well to GATT. Prior laser trabeculoplasty was associated with poorer outcomes. Further study is needed to verify these findings.

Ab-Externo XEN Gel stent implantation effectively treated refractory glaucoma with prior failed shunt tube.

PURPOSE: To assess the efficacy of a gelatin stent (XEN 45 Gel Stent; Allergan) implant in advanced glaucoma eyes that have failed prior aqueous shunt implantation. METHODS: We retrospectively reviewed 6 patients with refractory glaucoma, defined as persistently high IOP (> 21 mmHg) despite taking at least 3 IOP-lowering medications subsequent to undergoing a glaucoma drainage device (GDD) with or without a second GDD or cilioablative procedure. Eyes with previous failed GDD underwent subconjunctival 0.3 cc (0.4 mg/ml) mitomycin C, tenonectomy, and placement of an ab- externo XEN stent. The outcome measures included change in IOP and the number of glaucoma medications. Success was defined as patients achieving an IOP ≤ 18 mmHg with a percentage reduction of 25% or 15 mmHg and 40% mean IOP reduction from baseline while taking the same number or fewer medications. RESULTS: All six eyes with age of 77.6 ± 7.82 years who underwent XEN implantation following previous GDD surgery had primary open-angle glaucoma. The IOP decreased significantly from 32.33 ± 5.99 to 12.67 ± 3.27 mmHg (p < 0.001) with a follow-up of 13.9 ± 2 (11.7-16.7) months. Visual acuity and visual field remained stable after XEN placement. Compared to the baseline number of medications of 4.2 ± 0.8, all medication was discontinued except in one eye on two drops at the end of the follow-up. The overall surgical success rate was 100%. No complications, needling, or additional procedures were required. CONCLUSION: This study described successful implantation of the XEN stent following failed GDD. XEN Gel stent implantation associated with mitomycin C and tenonectomy can be considered a viable surgical option for patients with a history of previously failed tube shunt requiring further IOP lowering.

Comparison of safety and effectiveness of micropulse transscleral cyclophotocoagulation and "slow cook" diode laser transscleral cyclophotocoagulation in patients with refractory open-angle glaucoma.

PURPOSE: This study aimed to compare the safety and effectiveness of intraocular pressure reduction between micropulse transscleral cyclophotocoagulation and "slow cook" transscleral cyclophotocoagulation in patients with refractory primary open-angle glaucoma. METHODS: We included patients with primary open angle glaucoma with at least 12 months of follow-up. We collected and analyzed data on the preoperative characteristics and postoperative outcomes. The primary outcomes were a reduction of ≥20% of the baseline value (criterion A) and/or intraocular pressure between 6 and 21 mmHg (criterion B). RESULTS: We included 128 eyes with primary open-angle glaucoma. The preoperative mean intraocular pressure was 25.53 ± 6.40 and 35.02 ± 12.57 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The mean intraocular pressure was reduced significantly to 14.33 ± 3.40 and 15.37 ± 5.85 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups at the last follow-up, respectively (p=0.110). The mean intraocular pressure reduction at 12 months was 11.20 ± 11.46 and 19.65 ± 13.22 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The median preoperative logMAR visual acuity was 0.52 ± 0.69 and 1.75 ± 1.04 in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The mean visual acuity variation was -0.10 ± 0.35 and -0.074 ± 0.16 in the micropulse- and "slow cook" transscleral cyclophotocoagulation, respectively (p=0.510). Preoperatively, the mean eye drops were 3.44 ± 1.38 and 2.89 ± 0.68 drugs in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p=0.017), but those were 2.06 ± 1.42 and 1.02 ± 1.46 at the end of the study in the "slow cook" and micropulse transscleral cyclophotocoagulation groups, respectively (p<0.001). The success of criterion A was not significant between both groups. Compared with 11 eyes (17.74%) in the "slow cook" transscleral cyclophotocoagulation group, 19 eyes (28.78%) in the micropulse transscleral cyclophotocoagulation group showed complete success (p=0.171). For criterion B, 28 (42.42%) and 2 eyes (3.22%) showed complete success after micropulse- and "slow cook" transscleral cyclophotocoagulation, respectively (p<0.001). CONCLUSION: Both techniques reduced intraocular pressure effectively.

Open-angle glaucoma and Fuchs dystrophy.

A 62-year-old woman with a history of moderate myopia, long-standing open-angle glaucoma (OAG), and Fuchs dystrophy in both eyes was referred for consultative care. She had prior trabeculectomy in 1984 and 1992 in the left and right eyes, respectively. She is 3 months post-Descemet-stripping endothelial keratoplasty (DSEK) in the left eye, now referred with uncontrolled intraocular pressure (IOP) despite maximum tolerated medical therapy. Current medical therapy for IOP consists of acetazolamide 250 mg by mouth 2 times a day, brimonidine 2 times a day in the left eye, dorzolamide 2 times a day in the left eye, and timolol 2 times a day in the left eye. The patient has a history of presumed steroid response; however, her corneal surgeon has requested that the steroid be continued for the next several months because of the recent DSEK. The IOP in the left eye has ranged from the mid-20s to mid-30s since DSEK. The right eye has consistently had pressure in the low teens and below for many years without topical antihypertensive medications. Examination revealed stable visual acuity at 20/30 and 20/40 in the right and left eyes, respectively, IOP was 12 mm Hg in the right eye and 25 mm Hg in the left eye by Goldman applanation, irregular but reactive pupils without afferent defect, and full confrontational visual fields. Slitlamp examination showed superior low avascular bleb, moderate-to-severe guttae, and posterior chamber IOL in the right eye. The left eye showed superior low diffuse bleb, clear DSEK graft, quiet chamber, superonasal iridectomy, and posterior chamber IOL with an open posterior capsule. The conjunctiva was moderately scarred but a repeat trabeculectomy or Xen Gel stent (Abbvie) appeared possible. The angles were wide open in each eye. Fundus examination was normal aside from myopic, anomalous-appearing nerves with an approximate cup-to-disc ratio of 0.90 in both eyes. Humphrey visual field showed nonspecific changes on the right and moderate nasal defect on the left eye, stable to previous examinations dating back to 2018 (Figure 1JOURNAL/jcrs/04.03/02158034-202407000-00018/figure1/v/2024-07-10T174240Z/r/image-tiff and Figure 2JOURNAL/jcrs/04.03/02158034-202407000-00018/figure2/v/2024-07-10T174240Z/r/image-tiff). Optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) revealed moderated thinning in both eyes that was also stable to prior examinations (Figure 3JOURNAL/jcrs/04.03/02158034-202407000-00018/figure3/v/2024-07-10T174240Z/r/image-tiff). Her axial length measured 25.23 and 26.34 mm in the right and left eyes, respectively. Central corneal thickness was 553 µm in the right eye and 563 µm in the left eye before her DSEK procedure. What would be your approach to management of this patient's left eye, addressing the following: Rationale for your procedure of choice? Would you over-rule the corneal surgeon and stop the steroid in an attempt to obviate the need for glaucoma surgery? Does the age of onset of glaucoma affect your surgical decision making? Note that patient age at the time of trabeculectomy was 22 years. Are some procedures better suited for patients after DSEK surgery?

Comparison of corneal endothelial cell density reduction between primary open-angle glaucoma and pseudo-exfoliation glaucoma patients at 3 years after Ex-Press® surgery.

PURPOSE: We compared corneal endothelial cell (CED) loss after Ex-Press (EXP) surgery between patients with primary open-angle glaucoma (POAG) and pseudo-exfoliation glaucoma (PEX). PATIENTS AND METHODS: This was a single-facility retrospective study. We included glaucoma patients who had undergone EXP surgery and were followed up > 3 years. We measured the CED before and after (at 12, 24, and 36 months) EXP surgery by noncontact specular microscopy and compared the means of the CED values and CED survival ratios after EXP surgery by paired t-test. RESULTS: We included 119 eyes that underwent EXP surgery, including 60 POAG eyes and 59 PEX eyes. In the POAG group, the mean CED decreased from 2389 ± 321 at baseline to 2230 ± 424 cells/mm2 after 3 years. In the PEX group, the mean CED decreased from 2111 ± 510 at baseline to 1845 ± 628 cells/mm2 after 3 years. At the 3-year follow-up, the CED survival ratio was 93.3 ± 12.5% in the POAG group and significantly lower, at 85.0 ± 19.5%, in the PEX group (p = 0.0064). Two cases in the PEX group developed bullous keratopathy. CONCLUSIONS: EXP surgery decreased the corneal endothelial cell populations in PEX patients faster than POAG patients.

Corneal endothelial density loss in patients after gonioscopy­assisted transluminal trabeculotomy.

PURPOSE: To compare short-term changes in corneal endothelial cells after gonioscopy-assisted transluminal trabeculotomy(GATT). METHODS: This retrospective comparative study included 138 patients(138 eyes), and 98 of these patients underwent GATT procedure and 40 underwent SLT procedure as a control group. Changes in the corneal endothelium in patients who underwent GATT and SLT were analyzed retrospectively. Endothelial changes in the central cornea were examined using specular microscopy before and 6 months after the GATT and SLT procedure. Intraocular pressure(IOP), number of glaucoma medications, and side effects were evaluated at visits before and after two methods. RESULTS: One hundred and thirty-eight eyes of 138 patients with a mean age of 62.9±12.7 years in the SLT group and 62.5±11.8 years in the GATT group were included in this study. Pre-procedure mean ± SD IOP was 27.7±3.6 mmHg and 27.4±5.3 mmHg (p=0.173) 2.8±0.5 and 2.9±0.8 (p=0.204) glaucoma drugs are in the SLT and GATT group, respectively. The mean corneal endothelial cell density (CECD) in the SLT group was 2433.1±581.4 cells/mm2 before the procedure and 2435.1±585 cells/mm2 6 months after the procedure, a change of 0.1±0.6% which was not statistically significant (p>0.967).The mean CECD at baseline in the GATT group was 2443.4±508.2 cells/mm2 and decreased to 2290.2±527.7 cells/mm2 6 months after this procedure, representing a cell loss of 6,2±9,1% (p<0.001). CONCLUSION: GATT caused more CECD damage than SLT at the sixth month after the procedure. Considering the loss of CECD in candidates for GATT, sufficient number of endothelial cells in the central cornea is recommended.

Long-term effectiveness and safety of XEN45 in open-angle glaucoma patients.

BACKGROUND: To investigate the long-term effectiveness and safety of XEN45 implant, either alone or in combination with phacoemulsification, in eyes with open-angle glaucoma (OAG). METHODS: Retrospective and single center study conducted on consecutive OAG patients who underwent a XEN45 implant between February-2017 and December-2021. The primary endpoint was the mean intraocular pressure (IOP) lowering from preoperative values. Surgical success was defined as an IOP-lowering from preoperative values ≥ 20% and an IOP absolute value between 6 and 13 mm Hg, without (Complete-success) or with (Qualified-success) antiglaucoma medications. RESULTS: A total of 158 eyes (34 (21.5%) eyes XEN-solo and 124 (78.5%) XEN + Phaco) were included. The median follow-up time was 28.5 months. In the overall study population, the mean preoperative IOP was significantly lowered from 19.4 ± 6.5 mm Hg to 12.4 ± 5.0 mm Hg. The mean preoperative (95% confidence interval) IOP was significantly lowered from 21.3 (19.3-23.2) mm Hg and 18.8 (17.7-20.0) mm Hg to 12.0 (10.4-13.6) mm Hg and 12.5 (11.6-13.5) mm Hg in the XEN-Solo and XEN + Phaco groups, respectively (p < 0.0001 each, respectively). The mean number of ocular-hypotensive medications was significantly reduced in the overall study sample (from 3.4 ± 0.9 to 0.9 ± 1.3, p < 0.0001), XEN-Solo (from 3.5 ± 1.1 to 0.6 ± 1.0, p < 0.0001, and XEN + Phaco (from 3.4 ± 1.1 to 0.9 ± 1.3, p < 0.0001) groups. Eighty-four (53.2%) eyes were categorized as success, with 49 (58.3%) classified as complete success. Eighty-one (51.3%) eyes underwent needling and 15 (9.5%) eyes required an additional surgical procedure. One (0.6%) eye had endophthalmitis. CONCLUSION: XEN implant, either alone or in combination with phacoemulsification significantly lowered IOP and reduced the need of ocular-hypotensive medication, while maintaining a good safety profile.

Long-term outcomes of canaloplasty and phaco-canaloplasty in the treatment of open angle glaucoma: a single-surgeon experience.

PURPOSE: To evaluate and compare the long-term outcomes of canaloplasty and phaco-canaloplasty in the treatment of open angle glaucoma and assess the prognostic factors associated with surgical outcome. METHODS: A 48-month retrospective analysis was performed on n = 133 open angle glaucoma eyes treated with canaloplasty and n = 57 open angle glaucoma eyes treated with phaco-canaloplasty by a single surgeon. Surgical success was defined according to six criteria, achieving a target intraocular pressure (IOP) ≤ 21, 18 or 15 mmHg on glaucoma medications (qualified success) or without any further treatment (complete success), including laser therapy or surgery. Kaplan-Meier survival analysis and Cox regression analysis were performed to evaluate surgical success and preoperative factors associated with surgical outcome. Surgical complications in the early postoperative period were compared between canaloplasty and phaco-canaloplasty. RESULTS: Canaloplasty and phaco-canaloplasty significantly reduced postoperative IOP and number of glaucoma medications (p = 0.001 for both). Phaco-canaloplasty showed higher rates of cumulative surgical success over canaloplasty, but only for target IOP ≤ 21 and ≤ 18 (p = 0.018 and p = 0.011, respectively). A preoperative number of > 4 glaucoma medications predicted surgical failure. Phaco-canaloplasty was associated with a higher rate of IOP peaks in the first month compared with canaloplasty (40.4% vs 12.7%, p = 0.000). CONCLUSION: Canaloplasty and phaco-canaloplasty demonstrated long-term efficacy in the treatment of open angle glaucoma, with phaco-canaloplasty showing higher rates of surgical success compared to canaloplasty, but not for target IOPs lower than 16 mmHg. Patients on more than 4 preoperative glaucoma medications may not be good candidates for canaloplasty and may benefit from other surgical options.

Plasma rich in growth factors (PRGF) technology as adjuvant to Ab Externo trabeculectomy.

PURPOSE: Plasma rich in growth factors (PRGF) technology creates blood-derived products with growth factors that promote wound healing and regeneration. The goal of this study was to assess the potential role of PRGF products as wound modulators in trabeculectomy. Our premise is that due to PRGF's regenerative and antifibrotic properties, its use in trabeculectomy may produce a more physiological bleb, without altering IOP reduction. METHODS: A retrospective, longitudinal study was conducted in a Hospital in Portugal. Patients with eyes with open angle glaucoma were included. Trabeculectomy was performed on all patients using PRGF membrane (mPRGF) under the conjunctiva, as adjuvant. Data regarding patients' demographics and number of medications used, was collected. Intraocular pressure (IOP) before surgery, 8 days, 1 month, 3 month, 6 month, 9 month and 1 year after surgery was recorded. Bleb morphology was classified according to Moorfields Bleb Grading System 6 months after surgery. RESULTS: Nine eyes of 9 patients were enrolled. Mean age was 71 ± 5.1 years old. Six were male. Mean IOP decreased from 24.0 ± 8.8 mmHg pre-surgery to 12.9 ± 2.6 mmHg at one year follow-up. The number of hypotensive drugs (mean ± SD) was 4.3 ± 0.9 preoperatively and 0.8 ± 1.1 at 1-year. Complete success was defined as IOP equal to or less than 21 mm Hg without ocular hypotensive medications and qualified success as IOP equal to or less than 21 mm Hg with medications. Complete success was 66.7% and qualified success was 100% at 1 year follow-up. CONCLUSION: In our study, trabeculectomy with mPRGF demonstrated both safety and efficacy. Low values of bleb height (1.6 ± 0.8) were recorded. mPRGF could improve wound healing and produce a more well-tolerated, favourable bleb, avoiding antimetabolite complications.

Outcomes of bent ab interno needle goniectomy with phacoemulsification in moderate to severe primary open angle glaucoma.

PURPOSE: To assess the safety and efficacy of bent ab interno needle goniectomy (BANG) in moderate to severe primary open angle glaucoma (POAG) eyes undergoing phacoemulsification (phaco). DESIGN: Single-arm, prospective, interventional study. METHODS: POAG patients with medically uncontrolled intraocular pressure (IOP), >15 mmHg for moderate and >12 mmHg for severe POAG, with visually significant cataract were recruited. All patients underwent BANG using a 26-gauge needle to excise 30° of the trabecular meshwork, along with phaco. Primary outcome was IOP. Secondary outcomes were success rate, percentage reduction in IOP/antiglaucoma medications (AGMs), and intraoperative complications. Success at 12 months was defined as: criterion A: IOP <15 mmHg for moderate glaucoma or <12 mmHg for severe glaucoma with or without AGMs OR criterion B: reduction in number of AGMs by >1. RESULTS: Thirty-two eyes of 32 patients underwent BANG + phaco. Mean age of the participants was 62.7 ± 8.4 years and there were 25 males and seven females. At 12 months, a significant decrease was noted in both IOP (from 17.6 ± 3.6 to 12 ± 1.6 mmHg, 31.8%; P < 0.001) and AGMs (from 3.7 ± 0.9 to 2.8 ± 0.8, 24.3%; P < 0.001). Twenty percent or more reduction in IOP was achieved in 62.5% (20/32) of eyes. Overall success (meeting either of the criteria A or B) at 12 months was achieved in 87.5% eyes. Mild postoperative hyphema was noted in 10 (31.2%) eyes, and two eyes (6.2%) required additional filtration surgery at 7 months. CONCLUSION: A 30-degree BANG with phaco in patients of POAG appears to be a safe, effective and affordable MIGS for developing countries.

Effect of ripasudil after trabeculectomy with mitomycin C: a multicentre, randomised, prospective clinical study.

BACKGROUND: To investigate if there are improvements in trabeculectomy outcomes supporting filtration bleb formation caused by Rho-associated protein kinase (ROCK) inhibitors. METHODS: This prospective, multicentre, randomised, open-label clinical study examined open-angle glaucoma patients who underwent trabeculectomy or trabeculectomy combined with cataract surgery followed by 3-month postoperative ripasudil treatments. After randomly allocating patients to ripasudil-ROCK inhibitor (ripasudil) or without ripasudil (non-ripasudil) groups. Mean intraocular pressure (IOP) changes, success rate, and number of eyedrops were compared for both groups. RESULTS: A total of 17 and 15 subjects dropped out in the ripasudil group and non-ripasudil group, respectively. At baseline, the mean IOP was 16.8±5.0 mm Hg in the ripasudil group (38 patients) and 16.2±4.4 in the non-ripasudil group (52 patients). The IOP decreased to 11.4±3.2 mm Hg, 10.9±3.9 mm Hg and 10.6±3.5 mm Hg at 12, 24 and 36 months in the ripasudil group, while it decreased to 11.2±4.1 mm Hg, 10.5±3.1 mm Hg and 10.9±3.2 mm Hg at 12, 24 and 36 months in the non-ripasudil group, respectively. There was a significant decrease in the number of IOP-lowering medications after trabeculectomy in the ripasudil group versus the non-ripasudil group at 24 (p=0.010) and 36 months (p=0.016). There was no statistically significant difference between the groups for the 3-year cumulative probability of success. CONCLUSION: Although ripasudil application did not increase the primary trabeculectomy success rate, it did reduce IOP-lowering medications after trabeculectomy with mitomycin C.

Double implantation of Xen 45 gel stent in primary open-angle glaucoma: a pilot study.

PURPOSE: To describe the outcomes of double implantation of Xen 45 Gel Stent (Xen) using an ab externo approach with closed conjunctiva. METHODS: Retrospective single-centre case series of primary open-angle glaucoma patients with at least six months of follow-up after implantation of a second Xen in the same eye via ab externo technique without conjunctival opening. RESULTS: Eight pseudophakic eyes of 8 patients were included. Intraocular pressure (IOP) dropped from 30 ± 2.6 mmHg pre-operatively to 22.4 ± 2.3 mmHg one month after the first Xen implant (mean difference: -7.6 mmHg [95% confidence interval: -9.4, -5.9 mmHg], p = 0.0092). A second Xen was then implanted to achieve the target IOP. The procedure showed no significant intraoperative or postoperative complications. The IOP dropped to 16.1 ± 2.7 mmHg six months following this second implant (mean difference: -6.3 mmHg [95% confidence interval: -7.2, -5.3 mmHg], p = 0.0183); however, 3 patients needed medical therapy to further reduce the IOP towards the target value. CONCLUSION: Sequential implantation of two Xen 45 Gel Stents using an ab externo approach with closed conjunctiva appears a promising procedure that showed a favorable safety and efficacy profile in this small case series. This pilot data might pave the way for further studies to evaluate the safety and efficacy of the procedure.

Epithelial inclusion cyst secondary to glaucoma surgery: A case series.

Epithelial inclusion cysts (EIC) are a rare ocular disease and its physiopathology is not well-known. They consist on growths of ocular surface epithelial cells inside the anterior segment of the eye in the form of a cyst. To date several cases have been published in the literature, none of them related to glaucoma surgery. We describe two cases of EIC after glaucoma devices implantation. An 86 year-old male patient with primary open angle glaucoma develop an EIC in right eye three years after removal of PRESERFLO™ MicroShunt (Santen, Osaka, Japan) and a 9 year-old female patient with glaucoma secondary to uveitis for juvenile idiopathic arthritis develops an EIC under the tube of an Ahmed valve implant during postoperative period. EIC develop after ocular penetrating wounds and an inflammatory stimulus. They are benign proliferations, follow-up is necessary to detect space complications early, so less mutilating surgery is needed for removal.

Primary Practice Patterns for the Initial Management of Open Angle Glaucoma.

PRCIS: About one-fourth of survey respondents from an ASCRS database initiate treatment for primary open angle glaucoma (POAG) with laser trabeculoplasty. Factors impacting physicians' choice of laser versus topical treatment for POAG were explored. PURPOSE: To characterize primary treatment preferences (topical medication versus laser trabeculoplasty or intracameral sustained release implants) in primary open angle glaucoma (POAG) patients and determine factors related to primary intervention selection. METHODS: A 33-question survey was distributed to an American Society of Cataract and Refractive Surgery database on treatment choices made by ophthalmologists for POAG. Data collected included country of practice, years of practice, completion of glaucoma fellowship training, type of practice, and preference for the first line of treatment for POAG. Multiple logit regression was used to compare the effect of covariates on physicians' choice of either topical medication or laser trabeculoplasty for POAG. RESULTS: A total of 252 of 19,246 (1.3%) surveys were returned. Almost three-quarters of respondents used topical medication as the first line of treatment for POAG (73.6%), whereas 26.4% preferred to start with laser treatment. Significant variables associated with the selection of laser (vs. drops) are practicing in the United States (odds ratio [OR] 2.85; 95% CI, 1.33-6.10), the more recent completion of ophthalmology residency (OR 1.95; 95% CI, 1.00-3.77), the greater volume of minimally invasive glaucoma surgeries (MIGS) (OR 1.68; 95% CI, 1.18-2.40), and a glaucoma patient base greater than 25% (OR 2.21; 95% CI, 1.09-4.48). CONCLUSIONS: For the first-line treatment of POAG, laser trabeculoplasty is more likely to be preferred, over topical drops, by U.S. physicians who are relatively new in practice, who have a larger glaucoma patient base, and who perform more MIGS.

Predictive biomarkers of intra-ocular pressure decrease after cataract surgery associated with trabecular washout in patients with pseudo exfoliative glaucoma.

To investigate biomarkers of intra-ocular pressure (IOP) decrease after cataract surgery with trabecular washout in pseudo-exfoliative (PEX) glaucoma. A single-center observational prospective study in PEX glaucoma patients undergoing cataract surgery with trabecular washout (Goniowash) was performed from 2018 to 2021. Age, gender, visual acuity, IOP, endothelial cell count, central corneal thickness, medications, were collected over 16-month follow-up. Multivariable binomial regression models were implemented. 54 eyes (35 subjects) were included. Mean preoperative IOP (IOPBL) was 15.9 ± 3.5 mmHg. Postoperative IOP reduction was significant at 1-month and throughout follow-up (p < 0.01, respectively). IOPBL was a predictive biomarker inversely correlated to IOP decrease throughout follow-up (p < 0.001). At 1 and 12 months of follow-up, IOP decrease concerned 31 (57.4%) and 34 (63.0%) eyes with an average IOP decrease of 17.5% (from 17.6 ± 3.1 to 14.3 ± 2.2 mmHg) and 23.0% (from 17.7 ± 2.8 to 13.5 ± 2.6 mmHg), respectively. Performance (AUC) of IOPBL was 0.85 and 0.94 (p < 0.0001, respectively), with IOPBL threshold ≥ 15 mmHg for 82.1% and 96.8% sensitivity, 84.2% and 75.0% specificity, 1.84 and 3.91 IOP decrease odds-ratio, respectively. All PEX glaucoma patients with IOPBL greater than or equal to the average general population IOP were likely to achieve a significant sustainable postoperative IOP decrease.