Outcomes of Trabeculectomy and Ahmed Glaucoma Valve Implantation in Patients with Iridocorneal Endothelial Syndrome.

PRECIS: Our study highlights the long-term success of trabeculectomy or AGV surgery in subjects with glaucoma secondary to ICE syndrome. However, many of ICE syndrome cases may need multiple glaucoma surgeries to achieve controlled IOP, with/without concomitant corneal graft surgery. PURPOSE: To evaluate the long-term outcome of trabeculectomy and Ahmed glaucoma valve (AGV) implantation in iridocorneal endothelial syndrome (ICE). METHODS: Patients with glaucoma secondary to ICE syndrome who underwent either trabeculectomy or AGV surgery with intraoperative adjunctive MMC from 2009 to 2020 were included in this study. All patients were followed for at least 6 months after initial surgery. The main outcome measures were intraocular pressure (IOP), number of IOP lowering medications and surgical success. Surgical success was defined as complete according to the levels of IOP (<18) and at least 20% reduction from preoperative IOP without medications and qualified as complete success but with medications, where the number of medications was less than preoperative numbers. Cumulative success was the sum of the qualified and complete success. RESULTS: Twenty-nine eyes of 29 patients were included. Trabeculectomy was done in 13 patients (group A, 44.8%) and 16 patients underwent AGV surgery (group B, 55.2%). The median age was 50(42-56.50) and 47(36.75-52.75) years in groups A and B, respectively (P value=0.10). All patients completed at least 2 years of follow up. Mean IOP was not significantly different between groups preoperatively (P=0.70) and the effect of the type of surgery on IOP was not statistically significant at multiple follow-up time points (repeated measures ANOVA, P=0.44). The mean IOP decreased from 35.76±6.36 mmHg preoperatively to 16.00+3.10 in group A and from 36.12+8.11 mmHg to 17.00+3.75 in group B (P=0.449) at year 2 of follow-up. The effect of the type of surgery was not significant on the total number of IOP lowering medications used throughout the study (repeated measures ANOVA, P=0.81). Kaplan-Meier analysis show complete success in 14 patients (48.3%), 11 patients (37.9%) and 7 patients (24.1%) at 6-month, 1 year and 2 years follow-up, respectively. Cumulative success rate was 95% at two years follow-up for all patients. CONCLUSIONS: In 2 year follow up, trabeculectomy or AGV could significantly reduce the IOP in glaucoma patients secondary to ICE syndrome.

Analysis of the outer retinal thickness pixel maps for the screening of hydroxychloroquine retinopathy.

PURPOSE: To describe the findings and new interpretation methods of retinal thickness maps in the setting of hydroxychloroquine (HCQ) therapy. METHODS: A case series of 27 patients with a history of HCQ intake of more than 5 years and 21 normal subjects as the control group were studied. Patients were tested using swept-source optical coherence tomography (OCT). Custom-made 10 × 10 retinal thickness pixel maps of the 6 mm⨯6 mm area centered on the fovea were created for the full, inner, and outer retina of each eye and normal values obtained from the control group were used to calculate the statistical significance of each pixel and highlight suspicious pixels. A pixel was shown with light or dark gray color if its p value was ≤ 0.05 or ≤ 0.01, respectively. Cross-sectional OCT images and visual fields were examined as well and used to confirm the diagnosis of HCQ retinopathy. RESULTS: The pixel outer retinal thickness maps appeared accurate in detecting lesions even in eyes with unremarkable full retina thickness maps. The size and location of atrophic retinal defects were shown on pixel maps. Outer retinal thickness maps were able in differentiating outer retinal thinning from inner retinal thinning as the hallmark of HCQ retinopathy. CONCLUSION: Outer retinal thickness pixel maps can be used for the screening of HCQ retinopathy.

Early Macular Thickness Changes after Trabeculectomy and Combined Phaco-Trabeculectomy.

Purpose: To assess postoperative changes in central retinal thickness (RT) following trabeculectomy and combined phaco-trabeculectomy using spectral domain-optical coherence tomography. Methods: In a prospective interventional comparative study, 64 consecutive glaucoma patients who underwent trabeculectomy (32 eyes) or phaco-trabeculectomy (32 eyes) were included. A macular thickness map using the Early Treatment Diabetic Retinopathy Study circles of 1 mm, 3 mm, and 6 mm was the standard to evaluate the 9-subfield thickness preoperatively and again at 1 and 3 months after surgery. Four subfields in each of the 3 mm and 6 mm rings were considered parafoveal and perifoveal regions, respectively. Results: Preoperative measurements were similar in the two groups, except patients in the combined group which were older (P = 0.002). The mean RT in the combined phaco-trabeculectomy group at month 1 was significantly higher than baseline measurements at central subfield retinal thickness (CSRT) (P = 0.01), temporal (P = 0.001), and inferior (P = 0.04) parafoveal and temporal (P = 0.01), superior (P = 0.02), and nasal (P < 0.001) perifoveal quadrants; however, RT changes in the trabeculectomy-only group were not statistically significant at months 1 and 3 (P > 0.05). The increase in the temporal perifoveal RT of the combined phaco-trabeculectomy group persisted at month 3 (P = 0.01), while the RT in other sectors returned to preoperative values. The two treatment groups did not differ in terms of changes in the CSRT over time (P = 0.37). In addition, no difference was observed between the treatment groups regarding the parafoveal RTs at each time points (0.06 ≤ P ≤ 0.29). Conclusions: There was no significant difference in the pattern of changes of CSRT and parafoveal RT between trabeculectomy and combined phaco-trabeculectomy treatment groups up to 3 months after surgery. Some detectable increase in RT in the combined phaco-trabeculectomy will reverse to baseline values 3 months after surgery, except in the temporal perifoveal region.

Trans-Scleral Cyclophotocoagulation in Refractory Pigment Dispersion-Like Glaucoma Secondary to Ciliary Body Melanoma.

Purpose: To report a case of ciliary body melanoma with acute high intraocular pressure (IOP) due to pigment dispersion, treated by limited trans-scleral cyclophotocoagulation (TSCPC) and plaque radiotherapy. Methods: A 33-year-old woman was referred to clinic with acute ocular pain and decreased visual acuity from 1 week before presentation. The IOP was 55 mmHg accompanied by red eye, perilimbal injection, mild corneal edema (stromal and epithelial), scattered pigment dust on central corneal endothelium, 4+ anterior chamber pigments, and pigmented cells. Gonioscopy revealed a bulging mass posterior to the iris root, about 2 o'clock width alongside a heavy dark brown pigmentation of all angle structures. Ultrasound biomicroscopy confirmed a ciliary body mass of about 4.5 mm × 4 mm × 3.3 mm in the superior ciliary region, in favor of melanoma. Due to no response to maximal antiglaucoma therapy, a limited TSCPC in the inferior hemisclera was done. After control of the IOP, plaque radiotherapy with Ru-106 was done. Results: Three days after the cyclophotocoagulation, IOP decreased to 18 mmHg. Visual acuity reached to 20/25 and IOP remained 18 mmHg, with timolol/dorzolamide drop twice a day. Anterior chamber pigments gradually decreased, and antiglaucoma and steroid drops were tapered during 1 month, thereafter. The IOP was 14-16 mmHg with timolol/dorzolamide bid at months 3 and 6 of follow-up and 21-22 mmHg without any drop at months 12 and 18, with no sign of glaucomatous optic neuropathy. Conclusion: Limited cyclophotocoagulation may be a good choice for controlling the high refractory IOP in cases of intraocular neoplasms such as ciliary body melanoma, which are planned for salvage therapy such as plaque radiotherapy.

Trabeculectomy in patients with diabetes: subconjunctival Mitomycin C with or without intravitreal bevacizumab.

BACKGROUND/AIMS: To evaluate the success of Mitomycin C (MMC) augmented trabeculectomy with or without intravitreal bevacizumab in patients with diabetes without neovascular glaucoma. METHODS: Fifty-six patients with diabetes who needed trabeculectomy were randomised to either combination of 2.5 mg intravitreal bevacizumab and subconjunctival MMC (group A, 28 eyes) or subconjunctival MMC alone (group B, 28 eyes). The main outcome measures were intraocular pressure (IOP), number of antiglaucoma medications, bleb morphology and success probability. Surgical success was defined as complete according to two levels of IOP (≤18 and <15 mm Hg) and at least 20% reduction from preoperative IOP without antiglaucoma medications and qualified as complete success but with antiglaucoma medications. Total success was the sum of complete and qualified success. RESULTS: The mean age was 65.2±12.9 and 67.4±10.2 years in groups A and B, respectively (p=0.50). All patients completed at least 1 year of follow-up. The mean 1-year IOP decreased from 25.2±12.0 mm Hg to 10.1±2.8 in group A and from 26.4±11.6 mm Hg to 15.2±6.9 in group B (all p<0.001). Overall, postoperative IOP measurement was statistically significantly lower in group A at month 12 (p=0.001). The number of medications in groups A and B at month 12 was 0.3±0.8 and 1.0±1.2, respectively (p=0.02). The cumulative probability of success at month 12 was not statistically significant (89.3% group A, 78.6% group B; p=0.27). CONCLUSION: In patients with diabetes with primary trabeculectomy, combined administration of intravitreal bevacizumab and subconjunctival MMC resulted in lower IOP and number of antiglaucoma medication compared with subconjunctival MMC alone.

Unilateral and Spontaneous Complete Anterior Dislocation of the Crystalline Lens in a Patient With Homocystinuria.

Homocystinuria is a metabolic disorder caused by a deficiency of cystathionine beta-synthase with autosomal recessive inheritance. Clinically it is characterized by lens subluxation, skeletal abnormalities, and thromboembolic accidents. We present a 6-year-old boy who was a known case of homocystinuria. The patient had a previous history of thrombotic cerebrovascular infarction at the age of 3. He had mild and vague pain in the left eye two weeks before presentation without being exposed to trauma. Ophthalmic examination revealed the dislocation of the crystalline lens into the anterior chamber with diffuse corneal stromal edema in the affected eye. The patient was treated with topical atropine and betamethasone eye drops, but due to the corneo-lenticular contact and corneal edema, he underwent lens extraction and placement of iris-fixated intraocular lens after 48 hours. Corneal edema exhibited improvement at follow-up visits. Early age onset and unilateral complete lens dislocation to the anterior chamber in the absence of a history of trauma is a less common presentation of homocystinuria. In patients with systemic diseases including homocystinuria that cause zonulysis, lens dislocation is usually symmetric and bilateral. Nevertheless, in unilateral cases especially in those who did not have any history of trauma, evaluation for systemic diseases like homocystinuria is necessary for early diagnosis and prevention from other systemic involvements.

Effect of trabeculectomy on optic nerve head and macular vessel density: an optical coherence tomography angiography study.

PURPOSE: To investigate the effect of trabeculectomy on peripapillary and macular vessel density (VD) using optical coherence tomography angiography (OCT-A) in patients with primary open-angle glaucoma. METHODS: This is a prospective, interventional study on 32 glaucoma eyes (21 patients) who underwent trabeculectomy. Optic nerve head (ONH) and macular structural and OCT-A scans were performed before surgery and at one and six months postoperatively with the Avanti device (AngioVue System, Optovue Inc., Fremont, CA). The primary outcomes of interest were changes in global and regional peripapillary and macular VD. RESULTS: The average (standard deviation) age and visual field mean deviation of the sample were 58.9(9.9) years and -14.5(9.0) dB, respectively. The average (standard deviation) baseline intraocular pressure significantly decreased from 24.5(10.4) mmHg to 9.6(2.1) mmHg, 6 months after the surgery (P< 0.001). The mean (standard deviation) whole image VD of ONH had increased from 37.6(8.3)% to 40.5(9.1)% at 6 months after the surgery (P = 0.01) while its changes were not significant at month 1 (38.1(9.5)%, P = 0.64). The average of radial peripapillary circle (RPC) VD increased from 36.5(10.3)% to 39.3(10.8)% at 6 months (P = 0.04) compared to 1-month post-trabeculectomy (37.0(11.4)%, P = 0.71). Similar patterns at postoperative months 1 and 6 were also observed in RPC VD at superior and inferior hemifields as well as nasal and temporal quadrants. The observed changes in VD of macular, foveal, peri-, and parafoveal were not significant at superficial or deep slabs at 1 and 6 months after trabeculectomy (all P values > 0.05). CONCLUSION: Our study demonstrated significant improvements in peripapillary vessel density at 6-month following trabeculectomy.

Postoperative Blepharoptosis after Trabeculectomy versus Ahmed Glaucoma Valve Implantation.

PURPOSE: To investigate the frequency of persistent postoperative ptosis (PP) following trabeculectomy or Ahmed glaucoma valve (AGV) implantation and to analyze the associated factors. METHODS: It is a prospective observational study on glaucoma patients who underwent trabeculectomy or AGV implantation from October 2015 to June 2017 in a tertiary center. Margin reflex distance 1 and 2 (MRD1 and 2) and levator function were measured before and at least 6 months, postoperatively. Clinically significant ptosis was defined as ≥2 mm drop of MRD1. RESULTS: One hundred and fourteen patients (124 eyelids) including 76 patients (87 eyelids) with trabeculectomy and 35 patients (37 eyelids) with AGV implantation were included. The mean age was 55.50 (standard deviation = 17.54) years. Most of the surgeries were performed under general anesthesia (87.9%, 109/124) between 30 and 60 min (53.2%, 66/124) by residents (39.5%, 49/124). Trabeculectomy and AGV groups did not differ in terms of pre, intra, and postoperative variables (0.1≤ P ≤0.9) except duration of surgery (P = 0.01) and sex (P = 0.04). Clinically significant persistent PP was observed in 12.9% (16/124) in total, 13.7% (12/87) in the trabeculectomy group, and 10.8% (4/37) in the AGV group (P = 0.6). Male gender (ß coefficient = 2.56, 95% confidence interval (CI) = 4.76-0.36, P = 0.02) and a higher preoperative MRD1 (ß coefficient = 1.24, 95% CI = 0.52-1.95, P = 0.001) were the only factors affecting the frequency of clinically significant PP. CONCLUSIONS: Postoperative blepharoptosis occurred in 12.9% of eyes after glaucoma procedures. Male gender and higher preoperative MRD1 were significantly associated with a higher frequency of postglaucoma surgery blepharoptosis.

Ocular biometric changes after Ahmed glaucoma valve implantation.

PURPOSE: To investigate the ocular biometric changes after uneventful Ahmed glaucoma valve implantation. METHODS: Patients with refractory glaucoma who were candidate for Ahmed valve surgery were prospectively included in this study. Patients with a history of any kinds of corneal surgery were excluded. Refractive status, intraocular pressure, axial length, anterior chamber parameters including anterior and posterior mean keratometry, central corneal thicknesses, and anterior chamber depth, anterior chamber volume, and anterior chamber angle were evaluated at baseline and 1 and 3 months after surgery. RESULTS: A total of 20 eyes from 20 patients were included. Mean intraocular pressure at baseline was 33.4 ± 12.3 mm Hg that significantly decreased to 14.6 ± 6.2 mm Hg at 1 month and 13.5 ± 4.3 mm Hg at 3 months after Ahmed glaucoma valve implantation (p < 0.001). Mean number of medications was 3.6 ± 1.3 at baseline which significantly decreased to 1.0 ± 1.3 at 3 months after Ahmed glaucoma valve implantation (p < 0.001). Axial length decreased significantly from 23.69 ± 1.95 to 23.47 ± 1.91 mm (p < 0.001) at month 3. There were no significant changes in other parameters such as mean spherical equivalent, anterior chamber volume, anterior chamber angle, anterior chamber depth, and keratometry at the end of month 3 after surgery (p > 0.05 in all). CONCLUSION: Ahmed glaucoma valve implantation had a significant effect on axial length at 3 months after surgery but its effect on keratometry and other anterior chamber parameters was not significant.

Vision-related quality of life in patients with a history of congenital glaucoma.

PURPOSE: To assess the vision-related quality of life in adult patients with a history of primary congenital glaucoma. METHODS: In a cross-sectional hospital-based study eligible patients with a history of primary congenital glaucoma aged more than 18 were recruited in the study. Patients with secondary glaucoma and monocular patients were excluded. All patients underwent a complete ophthalmologic examination. The subjects were requested to answer a Persian approved version of the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) questionnaire. RESULTS: A total of 23 congenital glaucoma patients have enrolled in the study. The mean age was 29.22 (9.3 SD) and mean IOP was 13.82 (5.19 SD) and 15.69 (5.26 SD) in right and left eyes, respectively. The mean number of medications was 1.13 (1.25 SD) in the right and 1.30 (1.18 SD) in the left eyes. Among all scores of NEI-VFQ-25, the lowest score belonged to mental health 53.71 (29.72) and the highest score was color vision score 83.69 (20.79). We found a significant influence of visual field defect on many subscales including general health and general vision (p = 0.007, R = +0.65) and (p = 0.002, R = +0.71) respectively. The Mean Defect (MD) was associated with low social functioning and peripheral vision too (p = 0.035, R = +0.53) and (p = 0.001, R = +0.76) respectively. Age had a negative impact on the general vision subscale (p = 0.003, R = -0.59). CONCLUSION: Our study showed that visual field defect was strongly associated with many subscales scores in (NEI VFQ-25) questionnaire.

Effects of fasting on peripapillary capillary density, peripapillary nerve fiber layer, intraocular pressure and central corneal thickness.

PURPOSE: To investigate the effects of fasting on intraocular pressure (IOP), central corneal thickness (CCT), radial peripapillary capillary (RPC) density and retinal nerve fiber layer (RNFL) thickness during Islamic fasting month of Ramadan. METHODS: Twenty-seven healthy fasting volunteers were enrolled. All subjects underwent full ophthalmic examination and optical coherence tomography angiography (OCTA) of both eyes. All measurements were recorded first in the morning (8:00-10:00 a.m.) and then in the evening (4:00-6:00 p.m.). The first visit was performed during the second and third week of Ramadan and then two months later in a nonfasting routine day. RESULTS: Mean age of participants was 40.07 ± 9.29 years. A significant decrease was found for evening IOP (11.17 ± 2.29 mmHg) in comparison with morning IOP (12.00 ± 2.28) (p = 0.00) only on fasting days. A decrease was observed for CCT both on fasting (6 µm) and nonfasting days (3 µm) (p = 0.00 and p = 0.02, respectively) in the evening. There was a significant increase in whole and peripapillary RPC density (%) on fasting days (48.79 ± 3.08 morning, 49.72 ± 2.85 evening for whole and 50.57 ± 4.06 morning, 51.64 ± 3.71 evening for peripapillary) (p = 0.00). Average RNFL thickness was decreased from morning to evening both on fasting days (0.80 µm) and nonfasting days (1.25 µm) (p = 0.00). Optic nerve head (ONH) vertical cup/disc (C/D) ratio was greater on fasting days (0.30 ± 0.25 morning, 0.31 ± 0.24 evening) in comparison with nonfasting days (0.27 ± 0.25 morning, 0.28 ± 0.25 evening) (p = 0.02). CONCLUSION: Fasting decreases the IOP and CCT in healthy subjects. OCTA revealed significant difference in RPC vessel density, RNFL thickness and ONH vertical C/D ratio during fasting hours in comparison with nonfasting days.

Observational Outcomes of Initial Trabeculectomy With Mitomycin C in Patients of African Descent vs Patients of European Descent: Five-Year Results.

Importance: There is evidence that patients of African descent (AD) experience higher surgical failure rate after trabeculectomy without antimetabolites. Objective: To compare outcomes of initial trabeculectomy with mitomycin C in AD patients with those of patients of European descent (ED) and to identify prognostic factors for failure. Design, Setting, and Participants: In this retrospective matched cohort study, 135 eyes of 105 AD patients were matched with 135 eyes of 117 ED patients by age (within 5 years), surgeon, lens status, and follow-up time (within 1 year) from a single tertiary academic center. Interventions: Initial trabeculectomy with mitomycin C. Main Outcomes and Measures: Criteria A, B, and C defined qualified success rates as final intraocular pressure of 18 mm Hg or less, 15 mm Hg or less, and 12 mm Hg or less, respectively, in addition to 20% or more, 25% or more, and 30% or more reduction of intraocular pressure or reduction of 2 or more medications. Kaplan-Meier survival curves were compared with log-rank test in AD and ED patients, and Cox proportional hazard models were used to estimate the influence of race/ethnicity on surgical success accounting for confounding variables. Results: Of the 105 AD patients, 56 (53.3%) were female, and the mean (SD) age was 67.5 (10.4) years; of the 117 ED patients, 64 (54.7%) were female, and the mean (SD) age was 68.2 (10.0) years. For AD patients compared with ED patients, the qualified success rates at 5 years for criteria A were 61% and 67%, respectively (difference, 7.3%; 95% CI, 4.4-10.4); for criteria B, 43% and 60% (difference, 17.6%; 95% CI, 15.2-20.0); and for criteria C, 25% and 40% (difference, 15.8%; 95% CI, 11.1-20.5). On multivariable Cox regression analyses, AD was associated with higher failure rate with criteria B and C for qualified success and with all criteria for complete success (ie, no need for medications). Incidence of bleb leaks was higher in the AD group (29 vs 11 eyes; P = .002). Additionally, AD patients required additional glaucoma surgeries more often than ED patients (47 vs 26 eyes; P = .004). Conclusions and Relevance: African descent was associated with higher failure rates and higher incidence of bleb leaks after initial trabeculectomy with mitomycin C compared with European descent. If this is subsequently shown to be a cause and effect, the findings need to be considered when surgical treatment of glaucoma is contemplated in AD patients.

Effect of subconjunctival Bevacizumab injection on the outcome of Ahmed glaucoma valve implantation: a randomized control trial.

IMPORTANCE: The effect of subconjunctival Bevacizumab injection on the outcome of Ahmed glaucoma valve (AGV) implantation. BACKGROUND: Evaluation of efficacy and safety of subconjunctival Bevacizumab injection adjunctive to AGV implantation. DESIGN: Prospective and randomized clinical trial. PARTICIPANTS: Fifty eyes of 50 patients with diagnosis of glaucoma that were candidate for AGV surgery were included. METHODS: In 25 eyes, conventional AGV surgery (group 1) and in 25 eyes AGV surgery with subconjunctival Bevacizumab (group 2) was performed by block randomization MAIN OUTCOME MEASURES: The primary outcome measure was surgical success. Outcome measures were compared at postoperative month 3, 6 and 12. RESULTS: Mean age of patients was 58.76 ± 12.11 and 51.36 ± 15.44 years in group 1 and 2 respectively (P = 0.06). Mean intraocular pressure (IOP) at baseline was 24.88 ± 7.62 mmHg in group 1 and 27.52 ± 8.57 mmHg in group 2 which decreased to15.4 ± 4.4 mmHg in group 1 and 13.42 ± 2.9 mmHg in group 2 (P < 0.00) at last follow up. Surgical success was defined in two level: postoperative IOP ≤ 21 mmHg with at least 20% reduction in IOP (Criterion A), either with no medication (complete success) or with no more than two medications (qualified success) and criterion B with the same definition but the IOP ≤ 18 mmHg The cumulative success according to criterion A and B was 77.8%, 72.2% in group 1 and 89.5% in group 2, respectively, at the end of follow-up. CONCLUSIONS AND RELEVANCE: Subconjunctival injection of Bevacizumab adjunctive to AGV implantation leads to higher success rate compared with AGV alone in one year follow-up.

THE RELATIONSHIP BETWEEN FOVEAL AVASCULAR ZONE AREA, VESSEL DENSITY, AND CYSTOID CHANGES IN DIABETIC RETINOPATHY: AN OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY STUDY.

PURPOSE: To measure the foveal avascular zone (FAZ) areas and vessel densities of patients with diabetic retinopathy and to study their relationship with diabetic cystoid changes and retinal thickness. METHODS: Prospective case series of 51 eyes of 31 patients with diabetic retinopathy. The eyes were grouped based on the presence or absence of cystoid edema and evaluated using optical coherence tomography angiography. The FAZ areas and vessel density were compared. RESULTS: The FAZ area at the superficial capillary plexus level was equal between the eyes with and without cystoid edema. Vessel density did not differ as well. There was no correlation with retinal thickness. In eyes with cystoid changes, FAZ area changes at the deep capillary plexus level were difficult to interpret. CONCLUSION: The FAZ area and vessel density at the superficial capillary plexus level are reproducible and independent of the presence of cystoid edema.

Comparison of the long-term outcomes of resident versus attending performed trabeculectomy.

PURPOSE: To compare the long-term outcomes obtained by residents and attending surgeons performing trabeculectomy. METHODS: After reviewing medical records of the patients, 41 residents performing trabeculectomy under supervision of attendings were compared to 41 attendings performing trabeculectomy. The primary outcome measure was the surgical success defined in terms of intraocular pressure (IOP) ≤ 21 mmHg (criterion A) and IOP ≤ 16 mmHg (criterion B), with at least 20% reduction in IOP, either with no medication (complete success) or with no more than 2 medications (qualified success). IOP, number of glaucoma medications, surgical complications, and visual acuity were analyzed as secondary outcome measures. RESULTS: Mean age of the patients was 59.5 ± 8.6 years in the resident group and 59.6 ± 12.31 years in the attending group (P = 0.96). Furthermore, mean duration of the follow-up was 62.34 ± 5.51 months in the resident group and 64.80 ± 7.80 months in the attending group (P = 0.10). The cumulative success according to criterion A was 87.8% in the resident group and 85.3% in the attending group (P = 0.50). Moreover, according to criterion B, it was 87.8% and 83% in the resident and attending groups, respectively (P = 0.62). Repeated glaucoma surgery was required in 12.2% and 2.4% of the patients in the resident and attending groups, respectively (P = 0.09). Rate of complications was 12.2% and 4.8% in the resident and attending groups, respectively (P = 0.23). CONCLUSION: There were comparable results with respect to success rates and complications between residents and attending surgeons performing trabeculectomy in the long-term follow-up.

Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma.

PURPOSE: To provide efficacy and safety of surgery with Trabectome combined with phacoemulsification in primary open-angle glaucoma. METHODS: In this interventional case series, 30 consecutive eyes that have had combined phacoemulsification with Trabectome were included. The main outcome measures were change in intraocular pressure (IOP), glaucoma medication use, and the rate of complications. RESULTS: Mean IOP was 18.25 ± 3.28 mmHg preoperatively which decreased to 13.50 ± 2.53 mmHg at 1 year. (P < 0.05). There was a corresponding drop in glaucoma medications from 2.52 ± 0.60 at baseline to 1.40 ± 0.53 at 12 months (P < 0.01). The preoperative BCVA (Log Mar) was improved from 0.68 ± 0.26 pre-operatively to 0.26 ± 0.19, 0.18 ± 0.13, 0.17 ± 0.13, 0.11 ± 0.12, at 5 days and 2, 6, and 12 months, respectively (P < 0.01). The only frequent complication was transient blood reflux resolving spontaneously within a few days. No vision-threatening complication occurred. CONCLUSION: Combined phacoemulsification and Trabectome significantly lowered IOP and medication use, with early visual rehabilitation in the majority of patients.

Macular SD-OCT Outcome Measures: Comparison of Local Structure-Function Relationships and Dynamic Range.

PURPOSE: We tested the hypothesis that the macular ganglion cell layer (GCL) thickness demonstrates a stronger structure-function (SF) relationship and extends the useful range of macular measurements compared with combined macular inner layer or full thickness. METHODS: Ninety-eight glaucomatous eyes and eight normal eyes with macular spectral domain optical coherence tomography (SD-OCT) volume scans and 10-2 visual fields were enrolled. Inner plexiform layer (IPL), GCL, macular retinal nerve fiber layer (mRNFL), ganglion cell-inner plexiform layer (GCIPL), ganglion cell complex (GCC), and full thickness (FT) measurements were calculated for 8 × 8 arrays of 3° superpixels. Main outcome measures were local structure-function relationships between macular superpixels and corresponding sensitivities on 10-2 fields after adjusting for ganglion cell displacement, dynamic range of measurements, and the change point (total deviation value where macular parameters reached measurement floor). RESULTS: Median (interquartile range [IQR]) mean deviation was -7.2 (-11.6 to -3.2) dB in glaucoma eyes. Strength of SF relationships was highest for GCIPL, GCL, GCC, and IPL (ρ = 0.635, 0.627, 0.621, and 0.577, respectively; P ≤ 0.046 for comparisons against GCIPL). Highest SF correlations coincided with the peak of GCL thickness, where the dynamic range was widest for FT (81.1 µm), followed by GCC (65.7 µm), GCIPL (54.9 µm), GCL (35.2 µm), mRNFL (27.5 µm), and IPL (20.9 µm). Change points were similar for all macular parameters (-7.8 to -8.9 dB). CONCLUSIONS: GCIPL, GCL, and GCC demonstrated comparable SF relationships while FT, GCC, and GCIPL had the widest dynamic range. Measurement of GCL did not extend the range of useful structural measurements. Measuring GCL does not provide any advantage for detection of progression with current SD-OCT technology.

Local Variability of Macular Thickness Measurements With SD-OCT and Influencing Factors.

PURPOSE: To compare the intrasession variability of spectral-domain optical coherence tomography (SD-OCT)-derived local macular thickness measures and explore influencing factors. METHODS: One hundred two glaucomatous eyes (102 patients) and 21 healthy eyes (21 subjects) with three good quality macular images during the same session were enrolled. Thickness measurements were calculated for 3° superpixels for the inner plexiform (IPL), ganglion cell (GCL), or retinal nerve fiber layers (mRNFL), GC/IPL, ganglion cell complex, and full macular thickness. Spatial distribution and magnitude of measurement errors (ME; differences between the 3 individual superpixel values and their mean) and association between MEs and thickness, age, axial length, and image quality were explored. RESULTS: MEs had a normal distribution with mostly random noise along with a small fraction of outliers (1.2%-6.6%; highest variability in mRNFL and on the nasal border) based on M-estimation. Boundaries of 95% prediction intervals for variability reached a maximum of 3 µm for all layers and diagnostic groups after exclusion of outliers. Correlation between proportion of outliers and thickness measures varied among various parameters. Age, axial length, or image quality did not influence MEs (P > 0.05 for both groups). CONCLUSIONS: Local variability of macular SD-OCT measurements is low and uniform across the macula. The relationship between superpixel thickness and outlier proportion varied as a function of the parameter of interest. TRANSLATIONAL RELEVANCE: Given the low and uniform variability within and across eyes, definition of an individualized 'variability space' seems unnecessary. The variability measurements from this study could be used for designing algorithms for detection of glaucoma progression.