The Effect of Selective Laser Trabeculoplasty on Intraocular Pressure in Patients with Dexamethasone Intravitreal Implant-Induced Elevated Intraocular Pressure.

INTRODUCTION: To assess the safety and efficacy of selective laser trabeculoplasty (SLT) for ocular hypertension (OHT) induced by a dexamethasone (DEX) intravitreal implant. MATERIALS AND METHODS: We performed a retrospective study of patients who underwent an SLT procedure for ocular hypertension induced by injection of a DEX intravitreal implant. Patients had, at least, one injection of the DEX-implant for symptomatic macular edema. SLT was delivered to 360° of the trabecular meshwork in two sessions. The primary outcome was a decrease in IOP, evaluated at one, three, and six months after the SLT procedure. RESULTS: Twenty-six eyes of 22 patients were included. The mean intraocular pressure (IOP) measured after DEX-implant injection was 25.4 ± 5.4 mmHg, and the mean increase in IOP was 35.8 ± 14.6%. The mean follow-up after SLT was 18.3 ± 7.7 months. After SLT, the mean IOP dropped by 30.9% at one month (16.9 ± 4.5 mmHg, p=0.01), 33.6% at three months (16.0 ± 2.7 mmHg, p < 0.01), and 34.9% at six months (15.6 ± 2.1 mmHg, p < 0.01). Each patient had a minimum follow-up of 6 months after SLT. Eight eyes (31%) received a second DEX-implant injection after the SLT procedure without experiencing an increase in the IOP above 21 mmHg or >20%. No glaucoma surgery was required during the follow-up. The mean number of medications (1.65 ± 1.36) was significantly reduced at one (1.19 ± 1.20, p=0.04), three (0.96 ± 1.03, p < 0.01), and six months (0.77 ± 0.95, p < 0.01) after SLT. CONCLUSION: SLT is an effective and safe procedure to control OHT following DEX-implant intravitreal injection.

Cataract and glaucoma combined surgery: XEN® gel stent versus nonpenetrating deep sclerectomy, a pilot study.

BACKGROUND: To compare the efficacy of phacoemulsification (PKE) combined with nonpenetrating deep sclerectomy (NPDS) with mitomycin C (MMC) versus XEN® gel stent with MMC. METHODS: In this nonrandomized, retrospective, comparative, single-center pilot study, 105 consecutive eyes of 75 patients with uncontrolled primary open-angle glaucoma (POAG) and cataract who underwent PKE combined with either XEN implantation (n = 47) or NPDS (n = 58) between May 2013 and November 2018 were included. The primary outcome was complete success at 9 months, which was defined as intraocular pressure (IOP) ≤18, 15 or 12 mmHg without treatment; qualified success was IOP ≤18, 15 or 12 mmHg with antiglaucoma medications. Secondary outcome measures included the number of antiglaucoma medications, visual acuity (VA), and postoperative adverse events. RESULTS: Using the 18 mmHg threshold, complete or qualified success was achieved in 69.6 and 89.1% in the PKE + XEN group, and 63.8 and 89.7% in the PKE + NPDS group (p = .54 and p = .93), respectively, at 9 months. The mean IOP decreased from 20.8 ± 6.8 mmHg to 16.2 ± 2.8 mmHg in the PKE + XEN group (p < .001, 18.9% mean drop), and from 21.5 ± 8.9 mmHg to 14.9 ± 3.9 mmHg in the PKE + NPDS group (p < .001, 25.6% mean drop). Best-corrected VA significantly improved (p < .001) in both groups. The mean number of antiglaucoma medications was significantly reduced from 2.66 ± 1.1 to 0.49 ± 1.0 in the PKE + XEN group (p < .001) and from 2.93 ± 0.9 to 0.69 ± 1.2 in the PKE + NPDS group (p < .001). CONCLUSIONS: The XEN stent combined with PKE seemed to be as effective and safe as PKE + NPDS at 9 months in this pilot study.

Changes in choroidal thickness and optic nerve head morphology after filtering surgery: nonpenetrating deep sclerectomy versus trabeculectomy.

BACKGROUND: The purpose of this study was to evaluate the changes in choroidal thickness and lamina cribrosa position after nonpenetrating deep sclerectomy (NPDS) and trabeculectomy. METHODS: Twenty-three eyes with glaucoma that required filtering surgery were included (12 NDPS and 11 trabeculectomies) in this prospective observational study. OCT-enhanced depth imaging (OCT-EDI) was used to measure choroidal thickness, prelaminar tissue thickness and lamina cribrosa position before and 7 days and 1 month after surgery. All results are shown as median (interquartile range values). RESULTS: Intraocular pressure (IOP) was significantly lower 1 week after surgery than at baseline (7 (6/10) mmHg vs. 21 (18/26) mmHg; p < 0.001) with a mean 64% decrease. IOP remained significantly lower at 1 month with a 55% mean decrease as compared to baseline (10 (8/12) mmHg; p < 0.001). One week after surgery, the subfoveolar choroidal thickness (SFCT) significantly increased (372 (306/523) µm vs. 317 (227/413) µm; p = 0.04) and the prelaminar tissue (PLT) was significantly thicker (269 (162/360) µm vs. 138 (87/268) µm; p = 0.02) as compared to preoperative measurements. These changes were not statistically significant at one month. There were no differences concerning these parameters between the NPDS and trabeculectomy groups. During the first week, the SFCT increase was correlated with IOP reduction (r = - 0.41; p = 0.04). CONCLUSIONS: OCT-EDI allowed the visualization of structural changes at the level of the optic nerve and choroidal vascularization during acute IOP changes. No difference was observed between NPDS and trabeculectomy concerning these structural modifications.

Risk assessment of sudden visual loss following non-penetrating deep sclerectomy in severe and end-stage glaucoma.

BACKGROUND/OBJECTIVES: To assess the risk of immediate sudden visual loss ("wipe-out" phenomenon) following non-penetrating deep sclerectomy (NPDS) for end-stages glaucoma within the first 6-months postoperative period. SUBJECTS/METHODS: Monocenter database study. We reviewed the results for 73 eyes with severe or end-stage glaucoma that underwent NPDS. End-stage glaucoma (stage 5) was defined by the inability of patients to perform the Humphrey visual field test or by a visual acuity <20/200 due to glaucoma, according to the Glaucoma Staging System classification. Severe glaucoma (stage 4) was defined by a mean deviation (MD) <-20 dB by the preoperative 24-2 Humphrey visual field assessment. All eyes had a severe defect on the central 10° visual field: only a central island of vision remained. "Wipe-out" was defined as the permanent postoperative reduction of visual acuity to <20/200 or to "counting fingers" or less if preoperative visual acuity was <20/200. RESULTS: The mean age was 60 years (range 22-86). Before surgery, the average MD (Humphrey 24-2) was -25.6 ± 3.8 dB, the MD (Humphrey 10-2) -19.9 ± 7.0 dB, and the VFI 24.6 ± 13%. There were no cases of postoperative flat anterior chamber. No patients experienced "wipe-out" within the first 6 months following surgery. At the six-month visit, intraocular pressure (IOP) had decreased significantly from 22.0 ± 8.8 to 13.5 ± 4.5 mmHg (P<0.001). There were no significant changes in mean visual acuity after 6 months (P = 6). CONCLUSIONS: In our study, NPDS provided considerable IOP decrease with no occurrences of "wipe-out" and few other complications. Consideration of NPDS in end-stage and severe glaucoma is advisable given its low risk of intraoperative and postoperative complications and the low risk of wipe out. This surgery should probably be offered with less apprehension about the risk of "wipe-out" in end-stages glaucoma.

Outcomes of Laser Goniopuncture Following Nonpenetrating Deep Sclerectomy With Mitomycin C: A Large Retrospective Cohort Study.

PURPOSE: To report on the frequency, efficacy, and safety of laser goniopuncture (LGP) in lowering intraocular pressure (IOP) following mitomycin-C-augmented nonpenetrating deep sclerectomy (NPDS) in a large cohort of eyes. MATERIALS AND METHODS: This is a monocenter database retrospective study. We reviewed records of 350 eyes that underwent NPDS between 2009 and 2015, at the National Ophthalmology Center of XV-XX (Paris, France). We recorded the incidence of LGP, the time between NPDS and LGP, IOP efficacy, and the occurrence of complications. The success of the LGP was defined by an IOP<15 mm Hg without hypotonic treatment. RESULTS: The mean postoperative follow-up period was 19±15.9 months after the NPDS (range, 6 to 58). LGP was performed in 125 eyes (35.7%) in a mean time after NPDS of 7.4±7.6 months (range, 1 d to 36 mo). Most LGP procedures were performed during the first year (97 eyes, 77.6%). The survival analysis using the Kaplan-Meier method showed a 50% incidence of LGP by 2 years. The mean IOP before LGP was 23.8±7.1 mm Hg. LGP resulted in immediate (day 8) and significant IOP lowering by up to 15±6.8 mm Hg. This decrease was maintained throughout the follow-up period, and the Kaplan-Meier survival success rate at 2 years was 48.9% (95% confidence interval, 39.4-60.8). The most common complication was iris incarceration, which occurred in 22 eyes of 125 LGP (17.6%). CONCLUSIONS: Most of the eyes that underwent NPDS may require LGP to reduce the IOP to below the target value. Most often, this procedure was performed in the first year after NPDS (77.6%). LGP lowered IOP<15 mm Hg without any hypotonic medication for at least 2 years in 50% of cases. Goniopuncture is associated with potentially significant complications, of which the most common is iris incarceration. We identified 2 predicting factors for iris incarceration: high IOP before LGP and early LGP after NPDS.

Central 10-degree visual field change following non-penetrating deep sclerectomy in severe and end-stage glaucoma: preliminary results.

PURPOSE: To report the impact of non-penetrating deep sclerectomy (NPDS) in severe and end-stage glaucoma treatment on the central 10° visual field progression (mean deviation, four central points, foveal threshold) and assess the risk of sudden visual loss. METHODS: Monocenter database study. We reviewed records of 34 eyes with severe or end-stage glaucoma that underwent NPDS between 2009 and 2015, at the National Ophthalmology Center of XV-XX (Paris, France). Severe and end-stage glaucoma were defined according to the Bascom Palmer Modified Glaucoma Staging System classification. All eyes had a constricted visual field < 10° (severe injury by the Humphrey visual field automated (HVFA) 10-2). Visual fields were recorded every 6 months after the procedure. Data from the last visit was used for the statistical analysis. RESULTS: The mean follow-up duration was 29 months (range 6 to 54) and 33 (97%) eyes were followed for more than 1 year. There were no cases of postoperative sudden visual loss. The intraocular pressure (IOP) decreased from 21.9 ± 8.1 to 15.0 ± 5.4 mmHg (P < .001). Twenty-eight (82%) eyes had an IOP < 21 mmHg and 19 (56%) an IOP < 16 mmHg. The MD 10-2 remained stable (- 19.8 ± 7.4 to - 19.4 ± 8.1 dB, non-significant improvement of + 0.4 dB, P = .1). The MD 10-2 slope showed an insignificant improvement of + 0.25 ± 1.8 dB per year (dB/y) (P = 0.1), but this slope was significantly better when the IOP was reduced to < 16 mmHg than when the IOP was ≥ 16 mmHg at the last visit (+ 0.84  1.2 versus - 0.48 ± 2.2 dB/y, P = .05). The mean number of the four central test points with sensitivity ≤ 5 dB and the change in mean sensitivity of the four central field points remained stable. There were no significant changes in the VFI (from 25.4% ± 13 to 25.8% ± 20) and in foveal threshold. CONCLUSION: NPDS appears to provide stability of the central 10° visual field (with a trend towards improvement but non-significant) with no occurrence of "wipe-out" phenomenon and few other complications. Consideration of NPDS in end-stage and severe glaucoma is advisable given its low risk of complications and its considerable IOP decrease with a relative stability of the central visual field.

Miniaturized high-intensity focused ultrasound device in patients with glaucoma: a clinical pilot study.

PURPOSE: To evaluate the relative safety and potential efficacy of high-intensity focused ultrasound cyclocoagulation by a miniaturized annular device containing six piezoceramic transducers in patients with refractory glaucoma. METHODS: This was a three-center prospective interventional pilot study. Twelve eyes of 12 patients with refractory glaucoma were insonified using a ring-shaped probe containing six miniaturized high-frequency transducers operating at 21 MHz. Ultrasound biomicroscopy (UBM) and a complete ophthalmic examination were performed before the procedure and at 1 day, 1 week, 1 month, and 3 months after the procedure. Additional visits were performed 6 and 12 months after the procedure. RESULTS: Intraocular pressure was significantly reduced (P < 0.01) from a mean preoperative value of 37.9 ± 10.7 mm Hg to a mean postoperative value of 27.3 ± 12.4, 25.2 ± 11.3, 25.2 ± 7.7, 24.8 ± 9.8, and 26.3 ± 5.1 mm Hg at 1 day, 1 week, 1 month, 3 months, and 6 months, respectively, and to a mean value of 24.7 ± 8.5 at the last follow-up visit. No major intraoperative or postoperative complications occurred. Minor postoperative corneal complications developed in four patients with previous corneal abnormalities: superficial punctate keratitis (n = 3) and central superficial corneal ulceration (n = 1). UBM showed cystic involution of the ciliary body in 9 of the 12 eyes and a suprachoroidal fluid space in 8 of the 12 eyes. CONCLUSIONS: Ultrasonic circular cyclocoagulation using high-intensity focused ultrasound delivered by a circular miniaturized device containing six piezoceramic transducers seems to be an effective and well-tolerated method to reduce intraocular pressure in patients with refractory glaucoma.