Changes in corneal endothelial cells after trabeculectomy and EX-PRESS shunt: 2-year follow-up.

BACKGROUND: To compare trabeculectomy and EX-PRESS device implantation procedures for treating glaucoma and evaluate changes in corneal endothelial cell density (CECD). METHODS: This study prospectively evaluated changes in the CECD in 60 eyes of 60 patients who underwent trabeculectomy and 50 eyes of 45 patients who underwent EX-PRESS device implantation. Baseline patient data recorded included age at surgery, sex, type of glaucoma medications, and lens status. Using a noncontact specular microscope, corneal specular microscopy was performed preoperatively at the central cornea and then at 6, 12, 18 and 24 months after surgery. CECD before and after surgery was compared using a paired t-test. RESULTS: There was a significant decrease in the IOP and number of antiglaucoma medications in both groups after the surgery. The mean CECD in the trabeculectomy group was 2505 ± 280 cells/mm2 at baseline, while it was 2398 ± 274 cells/mm2 (P < 0.001), 2349 ± 323 cells/mm2 (P < 0.001), 2293 ± 325 cells/mm2 (P < 0.001), and 2277 ± 385 cells/mm2 (P = 0.003) at 6, 12, 18, and 24 months, respectively. However, the CECD in the EX-PRESS group was 2377 ± 389 cells/mm2 at baseline, while it was 2267 ± 409 cells/mm2 (P = 0.007), 2292 ± 452 cells/mm2 (P = 0.043), 2379 ± 375 cells/mm2 (P = 0.318), and 2317 ± 449 cells/mm2 (P = 0.274) at 6, 12, 18, and 24 months, respectively. CONCLUSIONS: As compared to trabeculectomy, EX-PRESS device implantation appears to be a safer procedure with regard to the endothelial cell loss risk.

Visual acuity and corneal higher-order aberrations after EX-PRESS or trabeculectomy, and the determination of associated factors that influence visual function.

PURPOSE: This study investigated postoperative visual acuity and corneal higher-order aberrations following EX-PRESS or trabeculectomy. METHODS: Out of 56 eyes of 56 patients analyzed, 30 eyes were treated using trabeculectomy, while 26 eyes were treated with EX-PRESS. Visual acuity and corneal higher-order aberrations were analyzed in both groups before and at 2 weeks, 1, 2, and 3 months after the surgeries. Risk factors that could potentially influence corneal higher-order aberrations were evaluated. RESULTS: Significant reductions in the IOP were observed at 3 months after the surgery in both groups. Although a significant decrease in the visual acuity (logMAR) was observed at 2 weeks after the surgery in both groups, at 1 month after the surgeries, there were no significant differences found for the vision as compared to the baseline. At each study visit in the trabeculectomy group, significantly higher corneal higher-order aberrations compared to baseline were noted. In the EX-PRESS group, however, these aberrations were no longer significantly different from the baseline at month 2 (P = 0.36). Analysis of the risk factors indicated that hypotony could influence corneal higher-order aberrations after surgery. CONCLUSIONS: Corneal higher-order aberrations were significantly increased at 1 month after EX-PRESS treatment, with levels returning to baseline by 2 months. After trabeculectomy, however, corneal higher-order aberrations remained significantly increased at 3 months after the procedure.

Vision-related quality of life following glaucoma filtration surgery.

BACKGROUND: To evaluate vision-related quality of life (VR-QOL) following glaucoma filtration surgery. METHODS: A total of 103 glaucoma patients scheduled to undergo glaucoma filtration surgery. Prior to and at three months after glaucoma filtration surgery, trabeculectomy or EX-PRESS, all patients completed the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25). A total of 48 patients underwent combined cataract and filtration surgery. The clinical data collected pre- and postoperatively included best-corrected visual acuity (BCVA) and intraocular pressure (IOP). RESULTS: The IOP decreased significantly from 19.0 ± 8.1 mmHg to 9.7 ± 3.9 mmHg (P < 0.001). Preoperative VFQ-25 composite score (65.8 ± 15.6) was similar to the postoperative score (67.8 ± 16.6). A significantly improved VFQ-25 composite score (pre: 63.2 ± 17.1, post: 67.7 ± 17.8; P = 0.001) was observed in the patients who underwent combined cataract and filtration surgery. There was a significant association between the BCVA changes in the operated eye and the changes in the VFQ-25 composite score (r = -0.315, P = 0.003). CONCLUSIONS: Although glaucoma filtration surgery by itself did not decrease the VR-QOL in glaucoma patients, there was significant improvement in the VR-QOL after the patients underwent combined cataract and glaucoma filtration surgery.

Effect of trabeculectomy on corneal endothelial cell loss.

AIM: To investigate changes in corneal endothelial cell density (CECD) after trabeculectomy. METHODS: This prospective, observational study followed 117 eyes of 117 patients for 2 years after trabeculectomy. The central cornea was examined by corneal specular microscopy prior to and at every 6 months after the surgery. Survival analysis of patients who exhibited a 10% or less reduction of the postoperative CECD compared with preoperative levels was assessed using the Kaplan-Meier survival curve. A Cox proportional hazards model was used to evaluate prognostic factors for decreasing CECD. RESULTS: At baseline, the mean CECD was 2420±357 cells/mm2, while at 6, 12, 18 and 24 months after surgery, the mean CECD was 2324±373 cells/mm2 (p<0.001), 2276±400 cells/mm2 (p<0.001), 2290±398 cells/mm2 (p<0.001) and 2267±446 cells/mm2 (p<0.001), respectively. At 6, 12, 18 and 24 months after surgery, the results of the Kaplan-Meier survival analysis of the 10% loss of CECD from baseline were 91%, 85%, 83% and 77%, respectively. Uveitic glaucoma was a significant prognostic factor for decreasing CECD (p=0.041). CONCLUSIONS: CECD significantly and continuously decreased after trabeculectomy.

Retinal Nerve Fiber Layer Thickness Progression after Robotic-Assisted Laparoscopic Radical Prostatectomy in Glaucoma Patients.

PURPOSE: To investigate the effect of the steep Trendelenburg position surgical procedure on the retinal structure and function during robotic-assisted laparoscopic radical prostatectomy (RALP) in glaucoma patients. METHODS: At 1 month and 1 day before and at 1 and 2 months after the RALP operation, 10 glaucoma patients underwent standard automated perimetry and optical coherence tomography. After placing patients in a supine position, intraocular pressure (IOP) was measured at 5 min after intubation under general anesthesia (T1), at 5 discrete time points (5, 30, 60, 120, and 180 min; T2-6) and at 5 min after returning to a horizontal supine position (T7). The Guided Progression Analysis software program was used to assess serial retinal nerve fiber layer (RNFL) thicknesses and visual field progression. RESULTS: Eight additional patients were newly diagnosed in addition to the two previous glaucoma patients. Average IOP (mmHg) at each time point was as follows: T1 = 11.2 ± 3.8, T2 = 19.0 ± 4.4, T3 = 23.3 ± 6.3, T4 = 25.1 ± 4.3, T5 = 25.5 ± 5.1, T6 = 28.3 ± 4.8, and T7 = 22.6 ± 5.4. IOP significantly increased during RALP. RNFL thickness progressed in two eyes of two patients after the surgery, even though there was no progression of the visual field. CONCLUSIONS: Two eyes of two patients exhibited significant RNFL thickness progression. Since an increased IOP during the surgery was the probable cause of the changes, ophthalmologic examinations should be performed before and after RALP, especially in glaucoma patients.

Influence of Disc Size on the Diagnostic Accuracy of Cirrus Spectral-Domain Optical Coherence Tomography in Glaucoma.

PURPOSE: To examine the influence of optic disc size on the diagnostic accuracy of optic nerve head (ONH) parameters determined by Cirrus spectral-domain optical coherence tomography (Cirrus HD-OCT). METHODS: A total of 51 eyes of 51 normal participants and 71 eyes of 71 glaucoma patients were examined. ONH imaging was obtained by Cirrus HD-OCT. Sensitivity at a fixed 90% specificity along with the area under the receiver operating characteristic curve (AUC) for continuous parameters were analyzed. We also examined the coefficients of variation (CoV) for sensitivity estimates, as these have been used to test and quantify the influence of optic disc size on diagnostic accuracy. The influence of optic disc size on the glaucoma diagnosis was assessed by the likelihood ratio chi-square test. RESULTS: Among the continuous parameters, the best diagnostic accuracy was seen for the average rim area, which had an AUC of 0.96. The most reliable factor across the disc size groups was the rim area (CoV, 2.8%). The diagnostic accuracy of the rim area did not appear to be influenced by optic disc size (P = 0.17). CONCLUSIONS: The high diagnostic accuracy of the rim area demonstrated by Cirrus HD-OCT for the quantitative assessment of the ONH was not significantly affected by disc size in this study.

Changes in choroidal area after intraocular pressure reduction following trabeculectomy.

PURPOSE: To investigate changes of the macular and peripapillary choroidal areas after trabeculectomy. METHODS: This prospective and interventional study examined 74 eyes of 74 patients with glaucoma uncontrolled by medical therapy. Enhanced depth imaging optical coherence tomography (EDI-OCT) recorded macular and peripapillary choroidal images at 1 day before trabeculectomy and at 2 weeks after surgery. The Niblack method was used to covert luminal and interstitial areas to binary images. RESULTS: At baseline, the mean intraocular pressure (IOP) was 17.6±6.3 mmHg, while it was 6.5±2.9 mmHg after trabeculectomy (P < 0.001). Increases were observed for the macular choroidal area after the surgery, with the total area increasing from 317,853±95,728 µm2 to 368,597±104,393 µm2, while the luminal area increased from 210,355±73,650 µm2 to 249,464±77,195 µm2, and the interstitial area increased from 107,498±27,613 µm2 to 119,133±31,811 µm2 (all P < 0.001). Increases were also observed after the surgery for the peripapillary choroidal area, with the total area increasing from 1,629,440±460,429 µm2 to 1,974,289±500,496 µm2, while the luminal area increased from 920,141±328,690 µm2 to 1,179,843±357,601 µm2, and the interstitial area increased from 709,299±153,179 µm2 to 794,446±169,029 µm2 (all P < 0.001). There was a significant increase in the ratio of the luminal to choroidal area in the macular area (67.2%) and in the peripapillary area (59.1%). Factors associated with the changes in the peripapillary choroidal area included decreases in the diastolic blood pressure and IOP. CONCLUSIONS: A reduction in the IOP after trabeculectomy led to increases in the macular and peripapillary choroidal areas. Observed changes in the choroidal area after trabeculectomy are primarily due to increases in the luminal areas.

Oxygen venular saturation correlates with a functional loss in primary open-angle glaucoma and normal-tension glaucoma patients.

PURPOSE: To investigate whether there are differences in retinal oxygen saturation in upper and lower visual field hemispheres in primary open-angle glaucoma (POAG) and in normal-tension glaucoma (NTG). METHODS: This study enrolled POAG and NTG patients exhibiting differences between the upper and lower total deviation (TD) that were either more than 10 or <5 dB. Retinal oxygen saturation measurements in these patients with glaucoma were performed by a non-invasive spectrophotometric retinal oximeter. The Student's t-test was used for statistical analysis. RESULTS: Evaluations of the worse and better hemifields in the patients with POAG who exhibited differences in the upper and lower hemifield TD that was <5 dB (n = 25) showed that there were no statistically significant differences for the retinal venous saturation of oxygen (SaO2 ). However, there was a higher mean SaO2 in the worse (57.0 ± 7.5%) versus the better (54.3 ± 7.0%) hemifield in the patients with NTG (n = 22; p = 0.007). Evaluations of the patients with more than a 10-dB difference in the upper and lower hemifield TD showed statistically significant differences for the retinal venous SaO2 in the venous vessels between the POAG (n = 19) and the NTG (n = 26) patients. CONCLUSION: Although there was no significant difference in retinal SaO2 in the venules between the better and worse hemifield when the difference between the better and worse hemifield in the patients with POAG was <5 dB, there was a higher SaO2 in the venous vessels in the worse hemifield in the patients with NTG.

The Effect of Steep Trendelenburg Positioning on Retinal Structure and Function during Robotic-Assisted Laparoscopic Procedures.

PURPOSE: Robotic-assisted laparoscopic radical prostatectomy (RALP) has become a standard treatment choice for localized prostate cancer. RALP requires a steep Trendelenburg position, which leads to a significant increase in intraocular pressure (IOP). This study evaluated the effect on the retinal structure and function in patients undergoing RALP. METHODS: Standard automated perimetry (SAP) and optical coherence tomography (OCT) were performed in 20 males scheduled for RALP at 1 month and 1 day before the operation and at 1 and 3 months after the operation. IOP measurements were made in the supine position at 5 min after intubation under general anesthesia (T1), at 6 discrete time points (5, 30, 60, 120, 180, and 240 min; T2-7), and at 5 min after returning to a horizontal supine position (T8). Serial retinal nerve fiber layer (RNFL) thicknesses and visual field progression were assessed using the guided progression analysis software program. RNFL thickness progression and visual field progression were evaluated by event analysis. RESULTS: Average IOP (mmHg) for each time point was as follows: T1 = 12.3 ± 2.6, T2 = 20.4 ± 4.2, T3 = 23.3 ± 3.8, T4 = 24.0 ± 3.2, T5 = 24.3 ± 3.4, T6 = 27.1 ± 7.2, T7 = 29.8 ± 8.7, and T8 = 20.1 ± 4.4. During RALP, IOP significantly increased. There was no progression of the visual field and RNFL thickness after surgery or any other ocular complications found. CONCLUSIONS: Although IOP significantly increased during RALP, there were no significant changes in the retinal structure and function between the pre- and postoperation observations.

Retinal oxygen saturation before and after glaucoma surgery.

PURPOSE: This study compared retinal vessel oxygen saturation before and after glaucoma surgery. METHODS: Retinal oxygen saturation in glaucoma patients was measured using a non-invasive spectrophotometric retinal oximeter. Adequate image quality was found in 49 of the 108 consecutive glaucoma patients recruited, with 30 undergoing trabeculectomy, 11 EX-PRESS and eight trabeculotomy. Retinal oxygen saturation measurements in the retinal arterioles and venules were performed at 1 day prior to and at approximately 10 days after surgery. Statistical analysis was performed using a Student's t-test. RESULTS: After glaucoma surgery, intraocular pressure (IOP) decreased from 19.8 ± 7.7 mmHg to 9.0 ± 5.7 mmHg (p < 0.001). Although oxygen saturation in retinal arterioles remained unchanged before and after surgery (104.7 ± 10.6% before and 105.4 ± 9.3% after surgery, p = 0.58), the oxygen saturation in the venules increased from 54.9 ± 7.4% to 57.4 ± 5.7% (p = 0.01). CONCLUSION: Intraocular pressure (IOP) decreases caused by glaucoma surgery had an effect on the retinal venous oxygen saturation.

Additive Intraocular Pressure Lowering Effects of the Rho Kinase Inhibitor, Ripasudil in Glaucoma Patients Not Able to Obtain Adequate Control After Other Maximal Tolerated Medical Therapy.

INTRODUCTION: The aim of this study is to investigate the additive intraocular pressure (IOP)-lowering effects and safety of the selective Rho kinase inhibitor, 0.4% ripasudil, in patients with glaucoma not adequately controlled by other maximal tolerated medical therapies. METHODS: We retrospectively reviewed 92 glaucoma patients who received ripasudil as an additive glaucoma treatment. In spite of receiving prior maximal tolerated medical therapies, all patients had uncontrolled glaucoma before receiving ripasudil. IOP was recorded at all follow-up dates. RESULTS: The study population consisted of 43 primary open-angle glaucoma (POAG), 28 normal-tension glaucoma (NTG), ten secondary glaucoma, seven exfoliation glaucoma, and four developmental glaucoma patients. After ripasudil administration, there was a significant decrease in the IOP. The mean pre-administration IOP and % IOP reduction at the last follow-up were 19.7 ± 4.9 mmHg and 6.5 ± 17.0% for POAG, 15.5 ± 2.0 mmHg and 2.3 ± 10.4% for NTG, 22.8 ± 8.3 mmHg and 19.1 ± 13.5% for secondary glaucoma, 22.5 ± 4.4 mmHg and 2.1 ± 14.5% for exfoliation glaucoma, and 20.2 ± 8.9 mmHg and 11.4 ± 23.1% for developmental glaucoma, respectively. Side effects led to ripasudil discontinuation in 13 patients, with five exhibiting an allergic reaction, six developing blepharitis, and two having a burning sensation. CONCLUSIONS: Use of ripasudil as an adjunctive therapy resulted in lowering of the IOP. Ripasudil was well tolerated. FUNDING: Grant-in-Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science, and Technology of Japan (26462689).

Comparison of Macular Integrity Assessment (MAIA ™), MP-3, and the Humphrey Field Analyzer in the Evaluation of the Relationship between the Structure and Function of the Macula.

PURPOSE: This study was conducted in order to compare relationships between the macular visual field (VF) mean sensitivity measured by MAIATM (Macular Integrity Assessment), MP-3, or Humphry field analyzer (HFA) and the ganglion cell and inner plexiform layer (GCA) thicknesses. METHODS: This cross-sectional study examined 73 glaucoma patients and 19 normal subjects. All subjects underwent measurements for GCA thickness by Cirrus HD-OCT and static threshold perimetry using MAIATM, MP-3, or HFA. VF and OCT in the retinal view were used to examine both the global relationship between the VF sensitivity and GCA thickness, and the superior hemiretina and inferior hemiretina. The relationship between the GCA thickness and macular sensitivity was examined by Spearman correlation analysis. RESULTS: For each instrument, statistically significant macular VF sensitivity (dB) and GCA thickness relationships were observed using the decibel scale (R = 0.547-0.687, all P < 0.001). The highest correlation for the global (R = 0.682) and the superior hemiretina (R = 0.594) GCA thickness-VF mean sensitivity was observed by the HFA. The highest correlation for the inferior hemiretina (R = 0.687) GCA thickness-VF mean sensitivity was observed by the MP-3. Among the three VF measurement instruments, however, no significant differences were found for the structure-function relationships. CONCLUSIONS: All three VF measurement instruments found similar structure-function relationships in the central VF.

Estimating the rate of retinal ganglion cell loss to detect glaucoma progression: An observational cohort study.

This study aimed to evaluate the relationship between glaucoma progression and estimates of the retinal ganglion cells (RGCs) obtained by combining structural and functional measurements in patients with glaucoma.In the present observational cohort study, we examined 116 eyes of 62 glaucoma patients. Using Cirrus optical coherence tomography (OCT), a minimum of 5 serial retinal nerve fiber layer (RNFL) measurements were performed in all eyes. There was a 3-year separation between the first and last measurements. Visual field (VF) testing was performed on the same day as the RNFL imaging using the Swedish Interactive Threshold Algorithm Standard 30-2 program of the Humphrey Field Analyzer. Estimates of the RGC counts were obtained from standard automated perimetry (SAP) and OCT, with a weighted average then used to determine a final estimate of the number of RGCs for each eye. Linear regression was used to calculate the rate of the RGC loss, and trend analysis was used to evaluate both serial RNFL thicknesses and VF progression.Use of the average RNFL thickness parameter of OCT led to detection of progression in 14 of 116 eyes examined, whereas the mean deviation slope detected progression in 31 eyes. When the rates of RGC loss were used, progression was detected in 41 of the 116 eyes, with a mean rate of RGC loss of -28,260 ±â€Š8110 cells/year.Estimation of the rate of RGC loss by combining structural and functional measurements resulted in better detection of glaucoma progression compared to either OCT or SAP.

Relationship between oxygen saturation of the retinal vessels and visual field defect in glaucoma patients: comparison with each hemifield.

PURPOSE: This study aimed to elucidate the relationship between visual field defects in the upper and lower hemifields and the corresponding oxygen saturation of the retinal vessels in patients with glaucoma. METHODS: Patients with glaucoma (n = 44) exhibiting more than a 10 dB difference between the upper and lower total deviation (TD) were enrolled in the study. After measuring the retinal vessel oxygen saturation by a non-invasive spectrophotometric retinal oximeter, the hemifields in one eye of each patient were divided into worse (worse TD) and better (better TD) hemifield areas. We additionally evaluated a separate group of 40 patients with glaucoma who exhibited less than a 5 dB difference between the upper and lower TD. Statistical analysis was performed using a Student's t-test. RESULTS: A higher mean venous saturation of oxygen (SaO2 ) was observed in the worse (59.0 ± 8.0%) hemifield compared to the better (55.4 ± 7.2%) hemifield (p < 0.01). The mean arteriovenous difference in the SaO2 was lower in the worse (44.4 ± 9.0%) hemifield compared to the better (48.6 ± 11.4%) hemifield (p = 0.02). However, when we evaluated the worse and better hemifields in the patients who had less than a 5 dB difference in the upper and lower hemifield TD, we found no statistically significant differences for either the retinal SaO2 in the venous vessels or the arteriovenous difference. CONCLUSIONS: Advanced glaucomatous visual field defects were associated with increased SaO2 in the venous vessels and a decreased arteriovenous difference in the SaO2 . The present results suggest there is a reduced retinal oxygen extraction in eyes with glaucomatous damage due to retinal ganglion cell loss.