One-Year Outcomes of Micropulse Cyclophototherapy for Primary Open-angle Glaucoma.

PRECIS: In primary open-angle glaucoma (POAG), micropulse trans-scleral cyclophototherapy (MPTCP) is effective in lowering intraocular pressure (IOP), but its effects are not permanent. Hence, it can serve as a temporizing measure before definitive glaucoma surgery. PURPOSE: There is limited data on MPTCP in POAG. This is the first study that looks at MPTCP treatment specifically in POAG patients. PATIENTS AND METHODS: This is an interventional, single-institution exploratory case series with 55 eyes of 48 patients with POAG. Data was collected from clinical records, including patient demographics, clinical information, number of glaucoma medications, MPTCP laser settings, complications, and clinical outcomes. RESULTS: Patients had a mean age of 67.3±14.1 years with a preponderance of males. IOP was 24.8±1.0 mm Hg before MPTCP and decreased to 19.7±1.1, 21.9±1.1, and 21.8±1.1 mm Hg at postoperative month 3, 6, and 12 respectively. IOP remained below pretreatment levels throughout the postoperative period (P<0.05). Visual acuity and mean deviation remained stable before and after MPTCP. No eyes had complications. Number of glaucoma medications remained the same after MPTCP. Four eyes required additional oral acetazolamide at postoperative month 1 for IOP control. Seventeen eyes subsequently required further surgical intervention after 9.84 months. Maximal IOP decrease was greater when there were higher power settings, higher preoperative IOP, and better preoperative visual acuity. CONCLUSIONS AND RELEVANCE: The IOP lowering effect of MPTCP treatment in patients with POAG was found to be modest and transient with a similar medication burden, and definitive glaucoma surgery was needed in a number of patients.

Treatment Outcomes Using the PAUL Glaucoma Implant to Control Intraocular Pressure in Eyes with Refractory Glaucoma.

PURPOSE: To investigate efficacy 1 year after implantation of a novel glaucoma tube shunt, the PAUL Glaucoma Implant (PGI; Advanced Ophthalmic Innovations, Singapore, Republic of Singapore), in the treatment of eyes with refractory glaucoma. DESIGN: Clinical trial. PARTICIPANTS: Glaucoma patients who are recalcitrant to maximum tolerated medical therapy and require tube shunt surgery. METHODS: Interventional cohort study involving consecutive PGIs implanted at 6 international centers between December 1, 2017, and December 1, 2018. All the participants were followed up for 1 year after surgery. MAIN OUTCOME MEASURES: The primary outcome measure was failure, defined prospectively as intraocular pressure (IOP) of more than 21 mmHg or less than 20% reduction from the preoperative baseline on 2 consecutive visits, 3 months or more after surgery; persistent late hypotony, defined as IOP of less than 6 mmHg on 2 consecutive visits after 3 months; additional glaucoma surgery; loss of light perception vision; or removal of the implant for any reason. RESULTS: Of 82 patients enrolled, 74 (74 eyes) completed 12 months of follow-up. The mean age ± standard deviation at enrollment was 62.3±14.7 years, 73.0% were men, and 36.5% had secondary glaucoma. One year after surgery, 4 patients (5.4%) fulfilled the surgical criteria for failure, 68.9% (51/74 eyes) were deemed complete successes, and 93.2% (69/74 eyes) were considered qualified successes. Compared with the medicated preoperative IOP (23.1±8.2 mmHg), the postoperative IOPs at 6 and 12 months were 13.8±4.0 mmHg and 13.2±3.3 mmHg, respectively (P < 0.001). The mean number of IOP-lowering drugs used before surgery and after 12 months of follow-up were 3.3±0.9 and 0.3±0.6, respectively (P < 0.001). Significant postoperative complications included self-limiting shallow anterior chamber (n = 11; 14.9%), hypotony requiring intervention (n = 7; 9.5%), tube shunt occlusion (n = 5; 6.8%), tube exposure (n = 3; 4.1%), and endophthalmitis with resultant loss of vision (n = 1; 1.4%). CONCLUSIONS: The PGI demonstrated comparable efficacy with other currently available implants, with almost three quarters of the enrolled patients with refractory glaucoma achieving complete surgical success after 1 year of follow-up.

MP3 Plus: A Modified Micropulse Transscleral Cyclophototherapy Technique for the Treatment of Refractory Glaucoma.

PRéCIS:: In advanced refractory glaucoma which has failed prior MP3 laser, MP3 Plus is effective in reducing intraocular pressure (IOP) without significant complications. It is also useful as a temporizing procedure before incisional surgery. PURPOSE: To evaluate the efficacy and safety of MP3 Plus, a novel technique using modified micropulse transscleral cyclophototherapy (MPTCP) in eyes with refractory glaucoma or failed MPTCP treatment. METHODS: This is a retrospective interventional case series. In total, 32 consecutive eyes from 29 patients with uncontrolled IOPs who had previous MPTCP or refractory glaucoma underwent MP3 Plus, a modified MPTCP where additional discrete pulses are applied. The main outcome measurement was IOP at 1, 3, 6, and 12 months postprocedure, with success defined as a 20% reduction in baseline IOP, an IOP of 25 mmHg or less, and no need for further reoperation. We collected and analyzed visual acuity, number of glaucoma medications, and complications. RESULTS: The patients had an average of 1.4±0.9 glaucoma procedures before treatment, where 87.5% underwent one or more previous MPTCP with suboptimal response. Of the eyes presenting for follow-up, 51.6% (n=31), 37.0% (n=27), 35.7% (n=28), and 25.9% (n=27) achieved the primary outcome at 1, 3, 6, and 12 months, respectively. Baseline IOP was 33.7±11.6 mmHg (n=32 eyes) and posttreatment IOP at 1, 3, 6, and 12 months were 21.0±9.0 mmHg (n=31; P<0.0001), 26.2±10.8 mmHg (n=25; P<0.0001), 23.2±9.4 mmHg (n=20; P<0.05), and 24.6±9.8 mmHg (n=16; P<0.001), respectively. There was a reduction in glaucoma medications from 3.4±0.8 preoperatively to 2.8±1.2 (n=16; P<0.05) at 12 months. There were no cases of prolonged inflammation or hypotony. CONCLUSIONS: MP3 Plus is effective and safe in lowering IOP in eyes with refractory glaucoma after previous failed MPTCP.

Anticoagulation for Radiation-Induced Optic Neuropathy.

Radiation-induced optic neuropathy (RION) is a severely disabling complication of radiotherapy, without any known effective treatment. Three patients, one female and two males, aged 60, 34, and 45 years, respectively, developed progressive deterioration in visual acuity over 1 month, 8 years, and 2 months, starting 3, 12, and 9 years after radiotherapy for nasopharyngeal carcinoma. They received 70.15, 60.89, and 56.11 Gy over a period of 6-7 weeks, with fractionated doses of 2, 1.79, and 1.81 Gy, respectively. Ophthalmological examination revealed a relative afferent pupillary defect in the latter 2 patients, best-corrected visual acuity was 6/12 or better in all. Visual field charting showed a superior altitudinal field defect in the first two, and generalised visual loss in the third patient in the symptomatic eyes. Anticoagulation with heparin bridging and oral warfarin with an INR target of 2.0-3.0 was commenced within 2 months of symptom onset. All showed improvement in visual fields within 2 weeks, and remained stable for at least 2 years while on warfarin. Our encouraging findings will need to be confirmed in a randomised controlled clinical trial.

Case Series of Combined XEN Implantation and Phacoemulsification in Chinese Eyes: One-Year Outcomes.

PURPOSE: The outcome of XEN implantation in Chinese eyes has not been previously reported. The purpose of our study is to evaluate the efficacy and safety of combined cataract surgery and XEN implantation in Chinese eyes with glaucoma. METHODS: We conducted a prospective study of 31 consecutive Chinese patients who underwent combined phacoemulsification and XEN implantation at the National University Hospital (Singapore) in this study. Patients were assessed preoperatively and postoperatively on days 1 and 7, and months 1, 3, 6, and 12. The intraocular pressure (IOP), glaucoma medication use, Snellen visual acuity (VA), and complications were assessed at each visit. The Wilcoxon signed rank test for non-parametric data was used for the analysis of IOP and glaucoma medications at baseline versus 12 months after the procedure. RESULTS: The mean age of the patients was 70 ± 7.9 years and 48.4% were male. Twelve patients (38.7%) were diagnosed with primary open angle glaucoma and 19 patients (61.3%) were diagnosed with primary angle closure glaucoma. There was a significant decrease in IOP at 12 months (12.1 ± 2.6 mmHg) compared with preoperative medicated (15.6 ± 2.7 mmHg, p < 0.0001) and unmedicated IOP (22.1 ± 3.6 mmHg, p < 0.001). as well as a significant reduction in the number of glaucoma medications (1.4 ± 0.6 vs 0.1 ± 0.4, p < 0.0001). The most common complications were transient hypotony (12.9%) and ptosis (12.9%) and there were no sight-threatening intraoperative or postoperative complications. One patient required additional glaucoma surgery for uncontrolled IOP at 8 months after combined phacoemulsification and XEN implantation. CONCLUSION: Combined XEN implantation with cataract surgery was effective in lowering the IOP and the number of glaucoma medications in Chinese eyes for at least 12 months, with a favorable safety profile.

Evaluating the Laser Output of the Micropulse P3 Laser Delivery Device Following Repeated Use.

PRECIS: Repeated use of the Micropulse P3 (MP3) probe during micropulse transscleral cyclophotocoagulation is associated with an increase in laser output over time. PURPOSE: The purpose of this study was to examine the laser efficacy of the MP3 probe following repeated use. METHODS: This was an observational study carried out using Cyclo G6 Glaucoma Laser System with 6 MP3 laser delivery probes. Each probe was fired for 100 seconds, every 10 minutes until the probe was deactivated. The laser output was measured using a laser power meter. Maximum observed laser power output was also noted. RESULTS: All probes were deactivated after 90 minutes (9 cycles) of use. Mean laser output of all 6 probes was determined, and results suggested an increase in output with time. When examining the differences in total laser output for each cycle, no significant differences were observed for the first 4 cycles, but not for the remaining 5 cycles, wherein the increased laser outputs were found to be significantly different from baseline (cycle 1). CONCLUSION: Findings suggest a possible increase in laser output with repeated use, especially after 4 cycles, and clinicians need to be cautious if they intend to use the probes repeatedly.

Quantitative assessment of changes in anterior segment morphology after argon laser peripheral iridoplasty: findings from the EARL study group.

IMPORTANCE: Argon laser peripheral iridoplasty (ALPI) could be effective in widening residual angle closure following laser peripheral iridotomy (LPI). BACKGROUND: We investigated changes in angle parameters following ALPI and its safety profile in this study. DESIGN: Retrospective, observational case series. PARTICIPANTS: The records from a single centre, of 36 patients (60 eyes) who underwent ALPI, for residual angle closure following LPI, were reviewed. METHODS: We analysed anterior chamber parameters in anterior segment optical coherence tomography (ASOCT) images using customized software pre- and post-ALPI. Paired t-test was used to compare changes. MAIN OUTCOME MEASURES: ASOCT parameters analysed included angle opening distance (AOD 500 and 750), trabecular iris surface area (TISA 500 and 750), anterior chamber width (ACW), anterior chamber volume (ACV), angle recess area (ARA), anterior chamber area (ACA), anterior chamber depth (ACD) and lens vault (LV). RESULTS: There was a mean increase in AOD 500 (0.05 vs. 0.16 mm, P < 0.001), AOD 750 (0.15 vs. 0.27 mm, P < 0.001), TISA 500 (0.010 vs. 0.038 mm2 , P < 0.001), TISA 750 (0.039 vs. 0.102 mm2 , P < 0.001), ACV (89.76 vs. 102.25 mm3 , P = 0.01), ARA 500 (0.015 vs. 0.033 mm2 , P < 0.001) and ARA 750 (0.044 vs. 0.088 mm2 , P < 0.001). There was no significant change in ACW, ACD, ACA and LV. Mean intraocular pressure (IOP) decreased post-ALPI (17.2 vs. 15.7 mmHg, P = 0.002). The mean follow-up duration was 2.1 years (range 0.5-5 years). CONCLUSIONS AND RELEVANCE: ALPI results in changes to the angle morphology and lowered IOP in eyes with residual angle closure. Our findings suggest a possible role for ALPI in eyes with residual angle closure following peripheral iridotomy.

Predicting the outcome of laser peripheral iridotomy for primary angle closure suspect eyes using anterior segment optical coherence tomography.

PURPOSE: Develop an algorithm to predict the success of laser peripheral iridotomy (LPI) in primary angle closure suspect (PACS), using pretreatment anterior segment optical coherence tomography (ASOCT) scans. METHODS: A total of 69 eyes with PACS underwent LPI and time-domain ASOCT scans (temporal and nasal cuts) were performed before and after LPI. After LPI, success is defined as one or more angles changed from closed to open. All the pretreatment ASOCT scans were analysed using the Anterior Segment Analysis Program to derive anterior chamber angle (ACA) measurements. The measurements for each angle were ordered along with angle-independent measurements totalling to 42 measurements which serve as features for the prediction algorithm. Two masked glaucoma fellowship-trained ophthalmologists graded the pre-LPI ASOCT scans to determine whether LPI was likely to successful. RESULTS: There were 42 (60.9%) eyes that fulfilled the criteria for success after LPI. Iris concavity, angle recess area (750 µm) and iris concavity ratio showed the highest predictive score and were selected using correlation-based subset selection method. These features were classified into two ('successful' and 'unsuccessful') categories using a Bayes classifier. The algorithm predicted the success of LPI with 79.28% cross validation accuracy, which was superior to the predictive accuracy of the ophthalmologists (kappa 0.497 and 0.636 respectively). CONCLUSION: Using pretreatment ASOCT scans, our algorithm was superior to ophthalmologists in predicting the success of LPI for PACS eyes. This novel algorithm could aid decision making in offering LPI as a prophylaxis for PACS.

Outcomes and Complications of Ahmed Tube Implantation in Asian Eyes.

PURPOSE: There is a lack of long-term Asian studies on the efficacy and safety of Ahmed glaucoma valve (AGV) implantation. This study seeks to determine the outcomes and complications of AGV implantation in Asians. METHODS: A retrospective review of AGV surgeries performed at a single center in Singapore was conducted. A total of 76 patients with primary and secondary glaucoma who underwent their first AGV surgery from January 1, 2010 to December 31, 2012 were considered for our study. Primary outcomes evaluated were as follows: failure, intraocular pressure, best-corrected visual acuity, number of intraocular pressure (IOP)-lowering medications, and complications. Failure was defined by the following: IOP >21 mm Hg on 2 consecutive visits after 3 months, IOP≤5 mm Hg on 2 consecutive visits after 3 months, reoperation for glaucoma, removal of implant, or loss of light perception vision. RESULTS: Mean follow-up duration was 33.2±6.9 months. There was significant reduction in IOP (mean reduction, 25.9%; P<0.001) and number of IOP-lowering medications (mean reduction, 77.8%; P<0.001) at 3 years. Absolute failure rate was 23.9% at 3 years with no difference between eyes with or without previous trabeculectomy and between eyes with primary or secondary glaucoma. Occurrence of postoperative hyphema was a significant risk factor for failure. The commonest postoperative complications were hyphema and tube exposure. CONCLUSIONS: At 3 years after AGV surgery in Asian eyes, less than one-quarter of the eyes fulfilled the criteria for surgical failure.

Outcomes and Complications of Scleral-Fixated Intraocular Lens Combined with Ahmed Tube Surgery.

BACKGROUND: To evaluate the outcome and complications of transscleral suture-fixated posterior chamber intraocular lens (PCIOL) implantation combined with Ahmed glaucoma valve (AGV) surgery in Asian eyes. DESIGN: This was a retrospective study that included 22 eyes from 22 participants. The surgeries were performed at Singapore's National University Hospital. Participants underwent an Ahmed tube surgery, together with transscleral suture-fixated posterior chamber intraocular lens. MAIN OUTCOME MEASURES: Complete success was defined as 6 ≤ intraocular pressure (IOP) ≤ 21 mmHg without medications at the last follow-up visit, with no reoperation required and no progression to no perception of light (NPL). RESULTS: At the last follow-up, there was a significant reduction in mean IOP (22.4 ± 6.5 mmHg versus 13.9 ± 3.9 mmHg; p < 0.001) and mean number of intraocular pressure-lowering medications (2.45 ± 1.30 versus 0.05 ± 0.21; p < 0.001). There was no significant change in visual acuity [1.43 ± 1.21 (LogMAR) versus 1.09 ± 1.31 (p = 0.204)]. Sixteen eyes (72.7%) achieved complete success. The 3 commonest complications were bullous keratopathy, choroidal detachment, and displacement of intraocular lens. CONCLUSION AND RELEVANCE: This technique showed good success for intraocular pressure control and vision preservation. Postoperative complications were relatively common although most were self-limiting. Patients at increased risk of trabeculectomy failure may be suitable for this procedure.

Novel Automated Approach to Predict the Outcome of Laser Peripheral Iridotomy for Primary Angle Closure Suspect Eyes Using Anterior Segment Optical Coherence Tomography.

Develop an algorithm to predict the success of laser peripheral iridotomy (LPI) in primary angle closure suspect (PACS), using pre-treatment anterior segment optical coherence tomography (ASOCT) scans. A total of 116 eyes with PACS underwent LPI and time-domain ASOCT scans (temporal and nasal cuts) were performed before and 1 month after LPI. All the post-treatment scans were classified to one of the following categories: (a) both angles open, (b) one of two angles open and (c) both angles closed. After LPI, success is defined as one or more angles changed from close to open. In this proposed method, the pre and post-LPI ASOCT scans were registered at the corresponding angles based on similarities between the respective local descriptor features and random sample consensus technique was used to identify the largest consensus set of correspondences between the pre and post-LPI ASOCT scans. Subsequently, features such as correlation co-efficient (CC) and structural similarity index (SSIM) were extracted and correlated with the success of LPI. We included 116 eyes and 91 (78.44%) eyes fulfilled the criteria for success after LPI. Using the CC and SSIM index scores from this training set of ASOCT images, our algorithm showed that the success of LPI in eyes with narrow angles can be predicted with 89.7% accuracy, specificity of 95.2% and sensitivity of 36.4% based on pre-LPI ASOCT scans only. Using pre-LPI ASOCT scans, our proposed algorithm showed good accuracy in predicting the success of LPI for PACS eyes. This fully-automated algorithm could aid decision making in offering LPI as a prophylactic treatment for PACS.

Residual Angle Closure One Year After Laser Peripheral Iridotomy in Primary Angle Closure Suspects.

PURPOSE: To determine the incidence and baseline clinical and anterior segment optical coherence tomography (AS-OCT) predictors associated with residual angle closure as assessed by gonioscopy 1 year after laser peripheral iridotomy (LPI) in primary angle closure suspects (PACS). DESIGN: Subanalysis of randomized controlled trial data. METHODS: AS-OCT images from 181 PACS subjects ≥50 years of age were analyzed using customized software before and 1 year after LPI. Other parameters assessed were intraocular pressure (IOP) and axial length (Axl). Residual angle closure was defined as the inability to see the posterior trabecular meshwork for at least 2 quadrants on gonioscopy after LPI. Multivariate regression analysis determined the baseline predictors of residual angle closure 1 year after LPI. RESULTS: The mean age of participants was 62.4 (standard deviation 9.9) years. The majority were female (137, 75.7%) and Chinese (174, 96.1%). At 1 year post LPI, 148 (81.8%) subjects had gonioscopic residual angle closure. Univariate analysis showed that baseline Axl, anterior chamber area, anterior chamber volume, angle opening distance at 750 µm from the scleral spur, and angle recess area were smaller while baseline lens vault and iris curvature were larger in residual angle closure subjects (all P < .05). Multivariate analysis revealed that baseline iris volume (B = -0.08, P = .035) and baseline IOP (B = 0.23, P = .032) were predictors for residual angle closure. CONCLUSIONS: One year after LPI, >80% of PACS had gonioscopic residual angle closure. Greater baseline iris volume and higher IOP at baseline are independent risk factors for residual gonioscopic angle closure.

Surgical Treatment of Angle-Closure Glaucoma.

Advances in anterior segment imaging modalities have contributed new insights towards a better understanding of the various mechanisms of angle-closure glaucoma (ACG). This development is key to good decision making when confronted with angle-closure patients needing appropriate therapy. Surgical management of ACG remains an integral part of glaucoma patient care. The distinctive anatomy of angle-closure eyes and the few objective lines of evidence to support the effectiveness of the different surgical treatment options present a challenge to glaucoma surgeons.

Success rates of 2-site phacoemulsification combined with fornix-based trabeculectomy using mitomycin C for primary angle-closure glaucoma and primary open-angle glaucoma in an Asian population.

PURPOSE: To determine the long-term outcomes of 2-site phacoemulsification combined with fornix-based trabeculectomy using mitomycin C (MMC) for primary angle-closure glaucoma (PACG) and primary open-angle glaucoma (POAG) in an Asian population. METHODS: We reviewed the records of all patients with POAG or PACG who underwent phacoemulsification with trabeculectomy using MMC from January 2008 through December 2010 in a tertiary ophthalmology unit in Singapore. The primary outcome measure was cumulative success rates defined as complete [intraocular pressure (IOP) <21, 18, 15 mmHg without medication] and qualified (IOP <21, 18, 15 mmHg with at least 1 medication) success. RESULTS: In total, 168 eyes (110 POAG and 58 PACG) were included (43.5% female; mean age ± SD, 68.3 ± 8.2 years). The respective 3-year qualified success rates were 88.4, 79.3, and 52.5% for IOP <21, 18, and 15 mmHg. The corresponding complete success rates were 79.0, 70.9, and 51.1%. The mean 3-year postoperative IOP was 14.5 ± 4.4 mmHg, and the IOP reduction was significantly greater for PACG than for POAG eyes (P = 0.006). After surgery, the mean number of medications was significantly reduced and visual acuity, significantly improved (both P < 0.001). Occurrence of postoperative complications, higher number of topical medications, younger age, and presence of diabetes mellitus were significant risk factors for surgical failure. CONCLUSION: Two-site phacoemulsification combined with fornix-based trabeculectomy using MMC is a good surgical approach for Asian eyes with concomitant mild-to-moderate primary glaucoma and cataracts.

A study on the genetic relationships of Avena taxa and the origins of hexaploid oat.

KEY MESSAGE: Using next-generation DNA sequencing, it was possible to clarify the genetic relationships of Avena species and deduce the likely pathway from which hexaploid oat was formed by sequential polyploidization events. A sequence-based diversity study was conducted on a representative sample of accessions from species in the genus Avena using genotyping-by-sequencing technology. The results show that all Avena taxa can be assigned to one of four major genetic clusters: Cluster 1 = all hexaploids including cultivated oat, Cluster 2 = AC genome tetraploids, Cluster 3 = C genome diploids, Cluster 4 = A genome diploid and tetraploids. No evidence was found for the existence of discrete B or D genomes. Through a series of experiments involving the creation of in silico polyploids, it was possible to deduce that hexaploid oat likely formed by the fusion of an ancestral diploid species from Cluster 3 (A. clauda, A. eriantha) with an ancestral diploid species from Cluster 4D (A. longiglumis, A. canariensis, A. wiestii) to create the ancestral tetraploid from Cluster 2 (A. magna, A. murphyi, A. insularis). Subsequently, that ancestral tetraploid fused again with another ancestral diploid from Cluster 4D to create hexaploid oat. Based on the geographic distribution of these species, it is hypothesized that both the tetraploidization and hexaploidization events may have occurred in the region of northwest Africa, followed by radiation of hexaploid oat to its current worldwide distribution. The results from this study shed light not only on the origins of this important grain crop, but also have implications for germplasm collection and utilization in oat breeding.

Argon Laser Peripheral Iridoplasty for Primary Angle-Closure Glaucoma: A Randomized Controlled Trial.

PURPOSE: To determine the effectiveness of argon laser peripheral iridoplasty (ALPI) in primary angle closure (PAC) and primary angle-closure glaucoma (PACG). DESIGN: Randomized controlled trial. PARTICIPANTS: Eighty PAC or PACG subjects who underwent laser iridotomy (LI) and had at least 180° of persistent appositional angle closure and intraocular pressure (IOP) of more than 21 mmHg were enrolled. METHODS: Subjects were randomized to receive either 360° ALPI (Visulas 532s; Carl Zeiss Meditec, Jena, Germany) or medical therapy (Travoprost 0.004%; Alcon-Couvreur, Puurs, Antwerp, Belgium). Repeat ALPI was performed if the IOP reduction was less than 20% from baseline along with inadequate angle widening at the month 1 or month 3 visit. Intraocular pressure was controlled with systematic addition of medications when required. MAIN OUTCOME MEASURES: The primary outcome measure was success rates after ALPI at 1 year. Complete success was defined as an IOP of 21 mmHg or less without medication, and qualified success was defined as an IOP of 21 mmHg or less with medication. Failure was defined as an IOP more than 21 mmHg despite additional medications or requiring glaucoma surgery. RESULTS: Forty subjects (51 eyes) were randomized to ALPI and 40 subjects (55 eyes) were randomized to medical therapy. Complete success (IOP ≤21 mmHg without medication) was achieved in 35.0% eyes of the ALPI group compared with 85.0% of eyes in the prostaglandin analog (PGA) group (P < 0.001), and qualified success (IOP ≤21 mmHg with medication) was achieved in 35.0% and 7.5%, respectively (P = 0.003). The IOP decreased by 4.9 mmHg (95% confidence interval [CI], 3.5-6.3 mmHg) in the ALPI group (P < 0.001) and by 6.1 mmHg (95% CI, 5.1-7.1 mmHg) in the medication group (P < 0.001). A failure rate of 30.0% was noted in the ALPI group compared with 7.5% in the medication group (P = 0.01). No treatment-related complications were recorded in either group. CONCLUSIONS: After 1 year, ALPI was associated with higher failure rates and lower IOP reduction compared with PGA therapy in eyes with persistent appositional angle closure and raised IOP after LI.

Micropulse versus continuous wave transscleral diode cyclophotocoagulation in refractory glaucoma: a randomized exploratory study.

BACKGROUND: The aim of this study was to compare the efficacy and safety of micropulse and continuous wave diode transscleral cyclophotocoagulation in refractory glaucoma. DESIGN: Randomized, comparative, exploratory study in a tertiary hospital setting. PARTICIPANTS: Patients with refractory, end-stage glaucoma. METHODS: Forty-eight patients were randomized to either treatment. The intraocular pressure, visual acuity, number of medicines and repeat treatment were monitored for 18 months. Complications that include visual acuity decline, prolonged anterior chamber inflammation, phthisis bulbi, scleral thinning and ocular pain were noted. MAIN OUTCOME MEASURE: Intraocular pressure between 6 and 21 mmHg and at least a 30% reduction with or without anti-glaucoma medications after 18 months. RESULTS: A successful primary outcome was achieved in 75% of patients who underwent micropulse cyclophotocoagulation and 29% of patients who received continuous wave cyclophotocoagulation after 12 months (P < 0.01). At 18 months, successful outcome was 52% and 30% (P = 0.13), respectively. The mean intraocular pressure was reduced by 45% in both groups (P = 0.70) from a baseline of 36.5 mmHg and 35.0 mmHg (P = 0.50) after 17.5 ± 1.6 months (range 16-19) follow up. No significant difference in retreatment rates or number of intraocular pressure lowering medications was noted. The ocular complication rate was higher in continuous wave treated eyes (P = 0.01). CONCLUSION: Diode transscleral cyclophotocoagulation in both micropulse and continuous modes was effective in lowering intraocular pressure. The micropulse mode provided a more consistent and predictable effect in lowering intraocular pressure with minimal ocular complications.

Comparison of incidence of ptosis after combined phacotrabeculectomy with mitomycin C and phacoemulsification.

OBJECTIVE: To compare the incidence of upper eyelid blepharoptosis after combined phacotrabeculectomy with mitomycin C and phacoemulsification surgeries and the relationship of bleb morphology to the incidence of ptosis. DESIGN: Retrospective observation study. PARTICIPANTS: We included 46 patients after combined phacotrabeculectomy and 44 patients with phacoemulsification in the former group, and all eyes underwent a standardized two-site surgery with intra-operative mitomycin C. MATERIALS AND METHODS: Postoperative ptosis was defined as a reduction of upper marginal reflex distance 2 mm in the operated eye compared to the fellow eye. Trabeculectomy bleb measurements were carried out using anterior segment optical coherence tomography (Visante™, Carl Zeiss Meditec, Dublin, CA, USA) which included bleb height and total area of the bleb. RESULTS: There were 8 eyes (17.4%) and 5 eyes (11.4%) with postoperative ptosis in the phacotrabeculectomy and phacoemulsification groups, respectively (P = 0.342). In multivariate regression analysis, reduced total bleb area was significantly associated with upper eyelid ptosis after adjusting for age, gender, and type of anesthesia. The trend seemed to show that increased bleb height was also associated with ptosis, but this did not reach statistical significance. CONCLUSIONS: Incidence of persistent ptosis after phacoemulsification combined with trabeculectomy and mitomycin C is similar compared to stand alone phacoemulsification surgery in a multiethnic Asian population. Bleb morphology may play an important role in postoperative ptosis development and should be considered in the evaluation of upper eyelid blepharoptosis.

Longitudinal changes in anterior chamber depth and axial length in Asian subjects after trabeculectomy surgery.

BACKGROUND/AIMS: To investigate longitudinal changes in anterior chamber depth (ACD) and axial length (AXL) over 5 years after trabeculectomy surgery in Asian patients with primary glaucoma, and to identify factors associated with these changes. METHODS: In this prospective cohort study, phakic subjects with primary glaucoma who underwent trabeculectomy had ACD and AXL measured over 5 years. The effect of intraocular pressure (IOP) on ACD and AXL was determined. Subjects were divided into two groups (high or low fluctuation of ACD/AXL) and factors were compared to determine if there were factors associated with greater fluctuation. RESULTS: 122 subjects were analysed. The majority of subjects were male (75.4%) and Chinese (77%). ACD and AXL were shallower/shorter compared with baseline at all postoperative visits, with a mean decrease of 0.11 mm (95% CI 0.07 to 0.15 mm, p<0.01) and 0.16 mm (95%CI 0.11 to 0.20 mm, p<0.01), respectively. Patients with primary open angle glaucoma (POAG) had higher odds of fluctuations in longitudinal measurements of ACD (OR=8.74, p<0.01) and AXL (OR=5.60, p<0.01) compared with patients with primary angle closure glaucoma. For every 1 mm Hg decrease in IOP, ACD and AXL decreased by 0.02 mm (p<0.01) and 0.01 mm (p=0.03), respectively, for POAG patients with emmetropia or mild myopia. CONCLUSIONS: Trabeculectomy resulted in a decrease in both ACD and AXL, and these changes were persistent over a period of 5 years.