Effectiveness and Safety of Trabeculectomy Versus Tube Shunt Implantation for Uveitic Glaucoma: A Systematic Review and Meta-Analysis.

PURPOSE: To evaluate the effectiveness and safety of trabeculectomy compared to glaucoma drainage devices (GDDs) in managing uveitic glaucoma (UG). DESIGN: Systematic review. METHODS: We searched seven electronic databases (PubMed, Scopus, Web of Science, ScienceDirect, EMBASE, CENTRAL, and Google Scholar) to compare trabeculectomy with various GDDs in UG. The primary outcome was intraocular pressure (IOP) reduction, and secondary outcomes included postoperative complications. We fitted a random effects model for meta-analysis and assessed the risk of bias using the National Institute of Health quality assessment tool. RESULTS: We included eight studies; 197 eyes underwent trabeculectomy, and 277 eyes had GDDs. The mean age of participants was 48.5 years, with ∼53.5% being male in the trabeculectomy group and 49.3% in the GDDs group. The meta-analysis revealed no significant difference in IOP reduction between trabeculectomy and GDDs (P = .48). Subgroup analyses revealed no significant difference in IOP reduction between trabeculectomy and either the Ahmed glaucoma drainage device group (P = .38) or the Baerveldt glaucoma implant group (P = .90). GDDs were associated with higher rates of complications such as cystoid macular edema (CME) (15% vs. 4%, P < .001), need for revision surgery (11% vs. 6%, P = .04), and uveitic flare (5% vs. 0%, P = .001). However, trabeculectomy had a higher risk of cataract progression (7% vs. 1%, P < .001). CONCLUSION: Trabeculectomy and GDDs demonstrated comparable effectiveness in reducing IOP or glaucoma medication reduction in UG. However, there were significant differences in their safety profiles; CME and revisions were higher in GDD, and cataract progression was higher after trabeculectomy.

Beliefs and Attitudes of Ophthalmologists Regarding SLT as First Line Therapy for Glaucoma.

PRECIS: Targeted educational interventions for physicians may be useful in increasing adoption of selective laser trabeculoplasty (SLT) as first line therapy for the treatment of glaucoma. PURPOSE: SLT is a safe and effective first line treatment for glaucoma, however, it is underutilized. To evaluate barriers for the widespread adoption of this procedure, we assessed the beliefs and attitudes of ophthalmologists. We developed an educational intervention directed to physicians to increase the consideration of SLT earlier in the glaucoma treatment paradigm. SUBJECTS AND METHODS: In this prospective study, an online survey and educational slide presentation was sent to a group of comprehensive ophthalmologists, ophthalmology residents, and glaucoma specialists. Subjects were asked to respond to questions regarding their beliefs and attitudes towards SLT before and after watching the educational slide presentation. RESULTS: A total of 53 subjects were enrolled. Before watching the slide presentation, 85% of subjects stated they offer SLT to newly diagnosed patients, although only 28% preferred it over medications. While 52% of physicians reported between 0% and 10% of their newly diagnosed patients receive laser therapy, 47% said they would use it as a first line therapy for all or most newly diagnosed glaucoma patients. Most subjects (94%) stated the educational slide presentation convinced them that SLT is appropriate as a first line therapy for treatment of open angle glaucoma. CONCLUSIONS: A better understanding of the barriers for utilizing SLT as a first line therapy provides valuable information to help increase the adoption of this safe and effective procedure. A targeted educational intervention may improve acceptance of SLT as first line therapy for open angle glaucoma.

Outcomes of trabecular microbypass surgery: Comparison of resident trainees and attending surgeons.

PURPOSE: To determine the efficacy, safety, and surgical outcomes of trabecular microbypass stent (iStent) surgery performed by resident trainees and attending surgeons. SETTING: Wills Eye Hospital, Philadelphia, Pennsylvania, USA. DESIGN: Retrospective case series. METHODS: Records of all patients who had microbypass stent surgery by a resident at Wills Eye Hospital were retrospectively reviewed. The attending-performed group included any patient who had a microbypass stent implanted by an attending surgeon on the same day a resident case was performed. RESULTS: Between 2016 and 2018, 31 microbypass stents were implanted by a resident supervised by an attending and 93 microbypass stents were implanted by an attending surgeon on the day a resident case was performed. The mean follow-up was 16.2 months ± 17.9 (SD). The mean intraocular pressure (IOP) decreased from 16.0 ± 4.6 mm Hg at baseline to 14.0 ± 3.1 mm Hg at most recent follow-up visit in the resident group (P = .02) and from 17.5 ± 4.8 mm Hg to 15.1 ± 4.3 mm Hg, respectively, in the attending group (P < .001). The final mean IOP and mean number of hypotensive medications were similar between the 2 groups (P = .83 and P = .12, respectively). Self-resolving hyphema occurred in 1 resident case and 2 attending cases. The resident group had 1 case of iridodialysis, which did not require additional surgery. One eye in the attending group ultimately required a trabeculectomy. CONCLUSION: Microbypass stent implantation by resident trainees with attending supervision had similar efficacy and safety as surgery performed by attending surgeons.

Effect of Anticoagulants and Surgeon-Related Factors on Short-term Outcomes of Laser Peripheral Iridotomy.

PURPOSE: To assess the effects of surgeon-related factors on laser peripheral iridotomy (LPI) outcomes by comparing residents and glaucoma specialists, and to look for demographic and clinical predictive factors associated with LPI complications. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients who underwent LPI performed by a resident physician were included as cases, and patients who underwent LPI performed by a glaucoma specialist were included as controls. In patients who underwent multiple sessions of laser therapy, only the information from the first session of each eye was included in the study. METHODS: Demographic and clinical information were gathered from the pre-LPI, 1-week, 1-month, and 3-month follow-up visits. The following information was recorded from the LPI session: total laser energy, presence of bleeding, and post-laser intraocular pressure (IOP). Information gathered from the follow-up visits included visual acuity (VA), IOP, hyphema, and need to repeat LPI. A logistic regression analysis with modification for rare events was used to examine the relationship between the dependent variables and the group, adjusted for the clinical and demographic characteristics of patients. MAIN OUTCOME MEASURES: The LPI procedure parameters (total energy), postoperative VA and IOP, risk for complications, and need for re-treatment were compared between groups using odds ratio (OR) measurements. RESULTS: A total of 333 eyes were included in the study. The residents used statistically significant higher total energy compared with the glaucoma specialists' group (P < 0.001). After adjusting for demographic characteristics, antiplatelet/anticoagulant use, and laser energy parameters, we found that the patients of the residents group had a significantly increased likelihood for re-treatment within 3 months (OR, 3.38; 95% confidence interval [CI], 1.31-8.73) and anterior chamber bleeding (OR, 7.48; 95% CI, 1.07-52.02). CONCLUSIONS: Although LPI is an effective and minimally invasive procedure, evidence shows that a higher level of experience leads to clinically and statistically significant better outcomes.

Update and review of Urrets-Zavalia syndrome.

For more than half a century, Urrets-Zavalia syndrome (fixed dilated pupil) has been described as a postoperative complication of ophthalmic surgery. Since first reported as a complication of penetrating keratoplasty for keratoconus in patients receiving atropine, the characteristic features of Urrets-Zavalia syndrome have been expanded. In previous literature, a total of 110 cases resulted in a fixed and dilated pupil. Increased intraocular pressure (IOP) in the immediate postoperative period, phakia, and air or gas in the anterior chamber appear to be the most important risk factors for Urrets-Zavalia syndrome following ophthalmic procedures. Mannitol, IOP control, the removal of air or gas in the anterior chamber, and iridectomy have all demonstrated utility in managing Urrets-Zavalia syndrome.

Update and review of Urrets-Zavalia syndrome / Atualizando e revisando a síndrome de Urrets-Zavalia

ABSTRACT For more than half a century, Urrets-Zavalia syndrome (fixed dilated pupil) has been described as a postoperative complication of ophthalmic surgery. Since first reported as a complication of penetrating keratoplasty for keratoconus in patients receiving atropine, the characteristic features of Urrets-Zavalia syndrome have been expanded. In previous literature, a total of 110 cases resulted in a fixed and dilated pupil. Increased intraocular pressure (IOP) in the immediate postoperative period, phakia, and air or gas in the anterior chamber appear to be the most important risk factors for Urrets-Zavalia syndrome following ophthalmic procedures. Mannitol, IOP control, the removal of air or gas in the anterior chamber, and iridectomy have all demonstrated utility in managing Urrets-Zavalia syndrome.

RESUMO Por mais de meio século, a síndrome de Urrets-Zavalia (pupila fixa e dilatada) foi descrita como uma complicação pós-operatória em oftalmologia. Desde o primeiro relato após ceratoplastia penetrante em pacientes portadores de ceratocone em uso de atropina, seu conceito foi ampliado. Na literatura, um total de 110 casos resultaram em pupila fixa e dilatada. Aumento da pressão intraocular (PIO) no pós-operatório imediato, facia, ar ou gás na câmara anterior parecem ser fatores de risco importantes para o aparecimento da síndrome. Sua prevenção pode ser alcançada com o uso de manitol, controle adequado da PIO e quantidade de ar ou gás na camâra anterior e iridectomia.