Choroidal Effusions after Glaucoma Drainage Implant Surgery: Risk Factors and Surgical Management.

OBJECTIVE: To report the incidence of patients who developed choroidal effusions after glaucoma drainage implant (GDI) surgery and determine risk factors for and outcomes of surgical intervention. DESIGN: Retrospective case series. SUBJECTS: Medical records of 605 patients who underwent GDI surgery from January 1, 2017 to June 7, 2021 at New York University Langone Health and New York Eye and Ear Infirmary of Mount Sinai were reviewed. METHODS: Preoperative, intraoperative, and postoperative clinical data were obtained. Multivariate logistic regression evaluated the factors associated with the need for surgical intervention. Patient records were analyzed for effusion resolution, intraocular pressure (IOP), visual acuity (VA), and complications across treatment modalities. MAIN OUTCOME MEASURES: Incidence of choroidal effusion development and need for surgical intervention. RESULTS: Choroidal effusions developed in 110 (18%) patients (110 eyes). Surgical intervention to drain the effusion or ligate the implant tube was performed in 19 (17%) patients. The average time to surgical intervention was 47.6 days. Among patients who developed postoperative effusions, risk factors for requiring surgical intervention included history of selective laser trabeculoplasty (SLT) (P = 0.004; odds ratio [OR], 14.4), prior GDI surgery (P = 0.04; OR 8.7), 350-mm2 Baerveldt glaucoma implant placement (P = 0.05; OR, 4.8), and anterior chamber shallowing (AC; P < 0.001; OR, 25.1) in the presence of effusions. The subgroup that required multiple surgeries for effusion resolution had a significantly lower mean IOP at the most recent follow-up compared with those who received medical management only (P < 0.001). A higher percentage of patients who required surgical intervention lost VA at the most recent follow-up compared with patients whose effusions resolved with conservative management (i.e., medical management, AC viscoelastic injection). CONCLUSIONS: Choroidal effusions after GDI surgery resolved with conservative management in most patients. A history of SLT or GDI placement, implantation of a BGI-350, and the presence of a shallow chamber were risk factors for surgical intervention. Although interventions, such as surgical drainage are at times necessary, a better understanding of their impacts can help guide postoperative decisions. The risks and benefits of these procedures must be carefully considered in these high-risk eyes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Risk factors and management of choroidal effusions.

PURPOSE OF REVIEW: Choroidal effusions are recognized as a common early postoperative complication of glaucoma surgery, and although often benign, they may cause significant ocular morbidity. This article aims to summarize current research on the risk factors and management of choroidal effusions. RECENT FINDINGS: Glaucoma drainage device (GDD) implantation and trabeculectomy are the most commonly performed surgeries for the management of moderate to severe glaucoma. Common postoperative complications of these procedures include hypotony and the development of choroidal effusions. Choroidal effusions have recently been associated with the oral administration of certain drugs, including select monoclonal antibody, antiseizure and bisphosphonate medications. Risk factors for effusion development include specific patient characteristics such as pseudoexfoliative glaucoma, older age and hypertension. Although choroidal effusions typically resolve with medical therapy alone, surgical intervention may be required. Various methods of surgical intervention, such as surgical drainage or GDD tube ligation, can be utilized to treat choroidal effusions when conservative management with medical treatment fails, but themselves carry alternative risks that must be considered. SUMMARY: Minimizing the incidence and duration of hypotony following ophthalmic surgery and careful monitoring of patients starting certain oral medications are important in limiting the occurrence of choroidal effusions. Risk factors for choroidal effusions have been recently identified in the literature. A better understanding of these risk factors, as well as the outcomes of choroidal effusion management, can help to reduce the occurrence of effusions overall and minimize ocular morbidity.

"Persistence of Memory" - Multimodal imaging of delayed sympathetic ophthalmia.

Purpose: To describe a case of late post-surgical sympathetic ophthalmia documented with multimodal imaging. Observations: A 74-year-old male presented to the urgent care of the New York Eye and Ear Infirmary with blurry vision and discomfort in his left eye for three weeks. His vision was 20/50, with intraocular pressure of 13 mmHg, and slit lamp examination was significant for conjunctival congestion, 1+ anterior segment cell and flare, and diffuse keratic precipitates. His right eye was no light perception with a condensed hyphema, intraocular lens and inferonasal tube. His medical history included coronary artery bypass, prostate cancer, hyperlipidemia, and hypertension. His ocular history included blunt trauma to the right eye at age 11 with development of a traumatic macular hole and later rhegmatogenous retinal detachment at age 53, repaired with multiple vitreoretinal procedures. He developed glaucoma in the right eye and was treated with a tube shunt and ultimately transscleral cyclophotocoagulation (TSCPC) 7 years later, 13 years prior to his presentation of the left eye. Dilated fundus examination of his left eye revealed diffuse chorioretinal folds in the macula without any discrete chorioretinal lesions. Ultrasound of the right showed serous macular detachments with scleral thickening. Presumptive diagnosis of sympathetic ophthalmia was made and oral corticosteroid therapy was initiated. Subsequent SD-OCT and en-face OCT-A demonstrated Dalen-Fuchs nodules within the macula underlying areas of resolved serous detachment, after 6 weeks of oral steroids and initiation of immunomodulatory therapy (IMT). Conclusions: Sympathetic ophthalmia may rarely present with very delayed onset, and TSCPC is an uncommon inciting event. These patients may develop serous detachment, choroidal folds and inflammatory nodules identifiable on exam and multimodal imaging, which can resolve when treated appropriately. OCT-A may provide utility in monitoring response to immunosuppressive treatment in these patients.

How glaucoma care changed for the better after the pandemic.

PURPOSE OF REVIEW: The current article reviews enhancements to the delivery of glaucoma care that developed in response to the coronavirus disease 19 (COVID-19) pandemic and are likely to persist beyond its resolution. RECENT FINDINGS: Literature from the review period (2020-2021) includes reports highlighting contributions of the ophthalmology community to global health during the pandemic. Glaucoma practices worldwide have instituted more robust infection control measures to mitigate severe acute respiratory syndrome coronavirus 2 transmission in the outpatient setting, and many of these modifications will endure in the post-COVID era. Operational adjustments have led to the provision of more efficient glaucoma care. A hybrid care model involving technician-based diagnostic testing and subsequent virtual consultation with a glaucoma specialist has evolved as a useful adjunct to traditional face-to-face encounters with patients. SUMMARY: Glaucoma specialists, patients, and staff have adapted to a 'new normal' of glaucoma care delivery during the COVID-19 pandemic. Although innovation has propelled several improvements to glaucoma care during this global health crisis, significant barriers to more widespread implementation of teleglaucoma still exist. Whether, and in what capacity, the pandemic has permanently altered glaucoma practice patterns remains to be seen.

Glaucoma care during the coronavirus disease 2019 pandemic.

PURPOSE OF REVIEW: The current article reviews the impact of the coronavirus disease 2019 (COVID-19) pandemic on the delivery of ophthalmic, and specifically, glaucoma care. RECENT FINDINGS: Literature from the review period includes case series demonstrating the presence of severe acute respiratory syndrome coronavirus 2 RNA in the conjunctival secretions of patients with laboratory-confirmed COVID-19. The global ophthalmology community published reports outlining the enhanced infection control measures undertaken by different institutions around the world to mitigate transmission of the novel coronavirus. Telemedicine has been increasingly implemented in glaucoma practices to reduce in-office patient volume. New data regarding the efficacy and feasibility of tools for home monitoring of intraocular pressure, virtual visual field testing, and remote disc photography are reviewed. SUMMARY: COVID-19 has posed a global public health threat due to the severity of its contagion and associated morbidity and mortality. Glaucoma specialists have responded to the pandemic with innovative modifications to reduce viral transmission and optimize patient and staff safety in the office and operating room. The role of teleglaucoma has expanded and will continue to evolve as remote diagnostic devices undergo further refinement and validation.

The Effect of Phacoemulsification on Intraocular Pressure in Eyes with Preexisting Glaucoma Drainage Implants.

PURPOSE: To study the effect of phacoemulsification on intraocular pressure (IOP) control in patients with preexisting glaucoma drainage implants (GDIs). DESIGN: Retrospective, observational case series. PARTICIPANTS: A total of 45 patients (51 eyes) with previously placed GDIs who underwent phacoemulsification between January 2013 and March 2018. METHODS: The list of patients was obtained from billing records. Clinical data were retrieved from the corresponding electronic medical records. MAIN OUTCOME MEASURES: Intraocular pressure, number of glaucoma medications before and after phacoemulsification (postoperative day 1, week 1, months 1, 3, 6, 12, 18, and 24), rate of failure (failure defined as IOP >18 mmHg and IOP increase >20% at 2 consecutive visits after month 1, need for additional glaucoma surgery, or loss of light perception vision), and postoperative complications. RESULTS: Mean follow-up was 23.0 ± 11.1 months. The average interval between GDI surgery and phacoemulsification was 9.4 ± 6.7 months. An Ahmed glaucoma valve (AGV; New World Medical) was implanted in 12 eyes, a Baerveldt glaucoma implant (BGI; Johnson & Johnson Surgical Vision) was implanted in 36 eyes, and a Molteno (Molteno Ophthalmic Limited) glaucoma implant was implanted in 3 eyes. Before phacoemulsification, the mean IOP was 14.4 ± 4.4 mmHg on 2.1 ± 1.3 glaucoma medications. At postoperative month 24, the mean IOP was 12.6 ± 4.4 mmHg (n = 29, P = 0.519) on 2.0 ± 1.6 (P = 0.457) glaucoma medications. The reduction in IOP was significant only at postoperative week 1 (P = 0.031). The cumulative failure rate was 3.9% at 1 year and 11.8% at 2 years. The AGV group had a significantly higher mean IOP before phacoemulsification than the BGI group (P = 0.016). Analysis of covariance, taking the baseline IOP as a covariate, revealed no differences in postoperative IOP and number of glaucoma medications between groups, except for month 18 (1 patient in the BGI group had uncontrolled IOP requiring surgery). Postoperative complications included cystoid macular edema (10%), corneal decompensation (6%), and choroidal effusion (4%). CONCLUSIONS: Phacoemulsification after GDI surgery resulted in a transient reduction in IOP at postoperative week 1. Patients with previously placed AGVs had similar postoperative outcomes compared with those with BGIs.

Virtual Ophthalmology: Telemedicine in a COVID-19 Era.

PURPOSE: To discuss the effects of the severe acute respiratory syndrome coronavirus 2 betacoronavirus on ambulatory ophthalmology practices, the value proposition of telemedicine, teleophthalmology implementation methodologies, and the accelerated future of telemedicine. DESIGN: Review of the current telehealth landscape including usage, policies, and techniques for ambulatory practice integration. METHODS: We provide author-initiated review of recent trends in telehealth, governmental recommendations for health care delivery during the COVID-19 pandemic, and a PubMed Central query for telemedicine in ophthalmology or teleophthalmology. In addition, the authors' comprehensive experience in telemedicine design and implementation is provided. RESULTS: We provide a summary describing the present state of telehealth, teleophthalmology modeling, care delivery, and the proposed impact of telehealth surges on the future of ophthalmology practice. CONCLUSION: Recent patient and provider interest in telemedicine, the relaxation of regulatory restrictions, increased remote care reimbursement, and ongoing social distancing practices compel many ophthalmologists to consider virtualizing services.

Downsizing a Baerveldt Glaucoma Implant For the Management of Persistent Postoperative Hypotony: A Case Series.

PURPOSE: The purpose of this study was to describe a surgical technique for treating persistent hypotony after Baerveldt glaucoma implant (BGI) surgery. MATERIALS AND METHODS: The medical records of 10 patients with persistent postoperative hypotony who underwent truncation of one or both wings of a previously placed BGI, combined with external ligation of the tube using a polypropylene suture, were retrospectively reviewed. RESULTS: All 10 eyes that underwent BGI truncation and placement of a single, external, nonabsorbable (polypropylene) tube ligature exhibited resolution of hypotony within 24 hours and resolution of choroidal effusions within the first 2 postoperative weeks. The median time interval between primary BGI surgery and truncation was 5 months (range, 1.5 mo to 8 y). Median postrevision follow-up time was 12 months (range, 5 mo to 16.2 y). The mean preoperative intraocular pressure (IOP) was 2.1±1.0 mm Hg, and the mean IOP rose to 29.2±13.9 mm Hg on postoperative day 1. Mean IOP at week 1, month 1, and month 3 was 20.5±10.4, 19.7±11.8, and 18.0±8.2 mm Hg, respectively, using an average of 1.4±1.4 glaucoma medications at postoperative month 3. Ligature release after BGI revision was performed in 9 (90%) of the 10 patients. The median time to ligature release was 1.5 months (range, 3 wk to 4 y). There was no recurrence of hypotony in any of these patients. At most recent follow-up, the mean IOP was 12.9±6.0 mm Hg on an average of 1.5±1.3 glaucoma medications. Five patients demonstrated improvement in visual acuity from their prerevision best-corrected visual acuity. CONCLUSIONS: Truncation of one or both wings of a BGI and complete closure of the tube with nonabsorbable, but releasable, suture ligature is an effective and safe method for reversing persistent postoperative hypotony while maintaining IOP control.

The African Descent and Glaucoma Evaluation Study (ADAGES) III: Contribution of Genotype to Glaucoma Phenotype in African Americans: Study Design and Baseline Data.

PURPOSE: To describe the study protocol and baseline characteristics of the African Descent and Glaucoma Evaluation Study (ADAGES) III. DESIGN: Cross-sectional, case-control study. PARTICIPANTS: Three thousand two hundred sixty-six glaucoma patients and control participants without glaucoma of African or European descent were recruited from 5 study centers in different regions of the United States. METHODS: Individuals of African descent (AD) and European descent (ED) with primary open-angle glaucoma (POAG) and control participants completed a detailed demographic and medical history interview. Standardized height, weight, and blood pressure measurements were obtained. Saliva and blood samples to provide serum, plasma, DNA, and RNA were collected for standardized processing. Visual fields, stereoscopic disc photographs, and details of the ophthalmic examination were obtained and transferred to the University of California, San Diego, Data Coordinating Center for standardized processing and quality review. MAIN OUTCOME MEASURES: Participant gender, age, race, body mass index, blood pressure, history of smoking and alcohol use in POAG patients and control participants were described. Ophthalmic measures included intraocular pressure, visual field mean deviation, central corneal thickness, glaucoma medication use, or past glaucoma surgery. Ocular conditions, including diabetic retinopathy, age-related macular degeneration, and past cataract surgery, were recorded. RESULTS: The 3266 ADAGES III study participants in this report include 2146 AD POAG patients, 695 ED POAG patients, 198 AD control participants, and 227 ED control participants. The AD POAG patients and control participants were significantly younger (both, 67.4 years) than ED POAG patients and control participants (73.4 and 70.2 years, respectively). After adjusting for age, AD POAG patients had different phenotypic characteristics compared with ED POAG patients, including higher intraocular pressure, worse visual acuity and visual field mean deviation, and thinner corneas (all P < 0.001). Family history of glaucoma did not differ between AD and ED POAG patients. CONCLUSIONS: With its large sample size, extensive specimen collection, and deep phenotyping of AD and ED glaucoma patients and control participants from different regions in the United States, the ADAGES III genomics study will address gaps in our knowledge of the genetics of POAG in this high-risk population.

Suture Stenting of a Tube Fenestration for Early Intraocular Pressure Control After Baerveldt Glaucoma Implant Surgery.

PURPOSE: To evaluate the efficacy and safety of a tube fenestration stented with a 10-0 polyglactin suture for controlling early postoperative intraocular pressure (IOP) after Baerveldt glaucoma implant (BGI) surgery. METHODS: The medical records of 110 patients (119 eyes) who underwent BGI surgery with a tube fenestration stented with a 10-0 polyglactin suture anterior to an occlusive tube ligature were retrospectively reviewed. Main outcome measures included IOP and number of glaucoma medications at postoperative day 1, week 1, and weeks 2 to 3 as well as complications occurring before ligature release. RESULTS: Mean±SD preoperative IOP was 30.9±9.3 mm Hg using an average of 3.8±1.1 glaucoma medications. A statistically significant reduction in IOP and glaucoma medications was observed at all timepoints during the first 3 postoperative weeks compared with baseline (P<0.001). Mean IOP on postoperative day 1, week 1, and weeks 2 to 3 was 18.4±12.2 mm Hg on no medication, 15.9±9.4 mm Hg on 1.0±1.3 medications, and 16.7±8.2 mm Hg on 1.2±1.5 medications, respectively. In total, 44 eyes (37%) achieved IOP control without glaucoma medication during period of tube occlusion. CONCLUSIONS: The use of a single, monofilament 10-0 polyglactin suture to stent a fenestration proximal to the occlusive ligature of a BGI tube is effective in controlling IOP in the early postoperative period. Hypotony-related complications were infrequent and resolved in all cases with in-office interventions.

Vitreous Occlusion of a Glaucoma Drainage Implant-Surgical Management.

Vitreous occlusion of a glaucoma drainage implant (GDI) can lead to failure of the device and severely elevated intraocular pressure. The pathophysiology of tube obstruction is related to central and anterior displacement of vitreous that is drawn into and condenses within the proximal lumen of the tube. This can occur from days to years following GDI surgery. Successful management of vitreous-tube obstruction generally requires manual removal of the condensed vitreous plug with end-grasping forceps. This technique achieves reversal of tube blockage and restoration of GDI function. Amputation of the incarcerated vitreous alone with vitrectomy or neodymium:yttrium-aluminum-garnet vitreolysis does not consistently restore GDI function and risks persistent intraluminal tube obstruction.

Long-term Outcomes and Complications of Pars Plana Baerveldt Implantation in Children.

PURPOSE OF THE STUDY: The purpose of the study was to report long-term outcomes and complications of Baerveldt glaucoma implant (BGI) surgery with pars plana tube insertion in children. MATERIALS AND METHODS: The medical records of consecutive aphakic and pseudophakic children (<16 y of age) who underwent BGI surgery with pars plana tube insertion between 1990 and 2013 were retrospectively reviewed. Main outcome measures were intraocular pressure and number of glaucoma medications. Postoperative complications were recorded. Failure was defined as an intraocular pressure <5 or ≥21 mm Hg (with or without glaucoma medications), loss of light perception, or need for additional glaucoma surgery. RESULTS: Thirty-seven children were identified with a mean age of 6.0±4.7 years (range, 4 mo to 14.5 y). Mean follow-up after pars plana BGI surgery was 6.5±3.4 years (range, 9 mo to 12.8 y) for patients who met success criteria. Mean intraocular pressure and mean number of glaucoma medications at most recent follow-up for patients with successful intraocular pressure control were 13.8±4.1 and 2.3±1.9 mm Hg, respectively. The Kaplan-Meier survival analysis revealed 1-, 3-, 5-, and 7-year success rates of 94.5%, 74.6%, 65.0%, and 45.8%, respectively. Complications included tube exposure in 1 patient (2.7%), tube obstruction in 8 patients (21.6%), and retinal detachment in 9 patients (24.3%). Seventeen patients (45.9%) failed due to inadequate intraocular pressure control, of whom 9 (24.3%) required additional glaucoma surgery. CONCLUSIONS: Although pars plana BGI surgery is a reasonable option for managing refractory glaucoma in aphakic and pseudophakic children, surgeons must be aware of the potential need for additional glaucoma surgery and/or posterior segment complications with extended follow-up.

Transconjunctival Revision With Mitomycin-C Following Failed Trabeculectomy.

PURPOSE: To evaluate the efficacy of transconjunctival revision (TCR) with mitomycin-C (MMC) following failed trabeculectomy. MATERIALS AND METHODS: The medical records of 27 patients (27 eyes) who underwent TCR with subconjunctival injection of MMC by a single surgeon between September 2001 and August 2013 were retrospectively reviewed. The same surgical protocol was followed for all patients. Revision was performed using a microvitreoretinal blade through a small conjunctival incision. Main outcome measures included visual acuity, intraocular pressure (IOP), and number of glaucoma medications. Failure was defined as an IOP<5 or >14 mm Hg, loss of light perception, or need for additional glaucoma surgery. RESULTS: Mean interval between trabeculectomy and TCR was 56.4±57.2 months. Mean preoperative IOP was 21.9±6.8 mm Hg using 4.0±1.2 glaucoma medications. Fifteen (55.6%) patients met success criteria. At most recent follow-up, mean IOP and number of glaucoma medications for successful patients were 9.7±3.8 mm Hg and 0.6±1.1, respectively. Kaplan-Meier analysis revealed 1-, 2-, and 3-year success rates of 62%, 58%, and 53%, respectively. Three additional patients achieved success after undergoing a second TCR, and 1 patient achieved success after a third TCR. Postoperative complications included transient choroidal effusion (n=8), shallow anterior chamber requiring reformation (n=5), 5-fluorouracil-related corneal epitheliopathy (n=10), and bleb leak (n=1). CONCLUSIONS: TCR with adjunctive MMC is a safe and effective procedure following failure of a trabeculectomy. More than 1 revision may be necessary to achieve long-term IOP reduction.

Postoperative management of trabeculectomy and glaucoma drainage implant surgery.

PURPOSE OF REVIEW: This article describes important aspects of postoperative management after trabeculectomy and glaucoma drainage implant surgery. RECENT FINDINGS: Postoperative management of glaucoma drainage implant surgery includes stabilization of intraocular pressure, possible ligature release, and management of complications such as corneal edema, and tube/plate exposure. Postoperative management of trabeculectomy includes evaluation of bleb encapsulation, management of hypotony, and assessment of need for adjuvant therapy. Recent advances in surgical techniques, device/tissue availability, and imaging continue to shape the postoperative course. SUMMARY: Careful preoperative planning and postoperative care may decrease the likelihood of complications in tube surgery or trabeculectomy.

Rapidly growing iris melanocytoma with secondary glaucoma in a 6-year-old child.

PURPOSE: To describe an unusual case of pediatric iris melanocytoma with pigment dispersion glaucoma that resolved after resection of the primary tumor. METHODS: Retrospective case review of the clinical record, ultrasonographic images, and histopathology. RESULTS: A 6-year-old Asian girl, with a dark iris tumor, pigment dispersion, and secondary glaucoma, was initially treated with topical antiglaucoma medication and observation. Rapid growth prompted biopsy, revealing melanocytoma. As the tumor continued to grow, excision of the primary tumor was performed. Surgery proved curative in that the pigment dispersion slowly reabsorbed and her glaucoma resolved. CONCLUSIONS: In this case, rapid growth did not indicate malignant transformation. Initial observation for growth and judiciously timed surgical intervention prevented progression, loss of vision, and potentially the loss of the eye.

Clinical impact of 8 prospective, randomized, multicenter glaucoma trials.

PURPOSE: To determine the impact of 8 multicenter randomized clinical trials (RCTs) on glaucoma practice. METHODS: An electronic survey was distributed to the members of the American Glaucoma Society (AGS). Each participant was asked 2 study-specific questions and 1 standard question common to all 8 RCTs assessing the study's impact on clinical practice. RCTs included in the survey were the Advanced Glaucoma Intervention Study (AGIS), Collaborative Initial Glaucoma Treatment Study (CIGTS), Collaborative Normal Tension Glaucoma (CNTG) Study, European Glaucoma Prevention Study (EGPS), Early Manifest Glaucoma Trial (EMGT), Glaucoma Laser Trial (GLT), Ocular Hypertension Treatment Study (OHTS), and Tube Versus Trabeculectomy (TVT) Study. A 5-point Likert scale was used for rating all responses. The practice setting and duration of glaucoma practice was determined for all AGS members who responded. RESULTS: A total of 206 (23.0%) of 894 AGS members participated in the survey. Among those who responded, 46.4% were self classified as academic practitioners and 53.6% worked in a private practice setting. Mean Likert scores for the standard question evaluating the overall impact of the RCT were OHTS 4.47, CNTG Study 4.13, AGIS 3.78, TVT Study 3.53, EMGT 3.48, CIGTS 3.44, GLT 3.39, and 2.69 EGPS. CONCLUSIONS: Substantial differences were observed in the clinical impact of several RCTs in glaucoma. The reported impact of each study likely reflects several factors including study timing, design, conduct, and interpretation of results.

Transscleral diode laser cyclophotocoagulation after baerveldt glaucoma implant surgery.

PURPOSE: To evaluate the safety and efficacy of transscleral cyclophotocoagulation (TSCPC) in patients requiring intraocular pressure (IOP) reduction despite prior Baerveldt glaucoma implant (BGI) surgery. PARTICIPANTS AND METHODS: Twenty eyes of 20 patients who had previously undergone BGI placement and subsequently underwent TSCPC with the red (810 nm) diode laser between April 2005 and January 2010 were retrospectively reviewed. RESULTS: All patients underwent BGI placement an average of 34.7±24.2 months before TSCPC. The mean follow-up period after TSCPC was 25.6±17.4 months (range, 2.3 to 56.5 mo). IOPs were reduced from a mean of 21.8±4.6 to 10.8±3.2 mm Hg at the most recent follow-up, which represents a 50.2% reduction in mean IOP. Successful postoperative IOP control was achieved in 16 (80%) of 20 patients. The number of glaucoma medications decreased from 4.2±0.6 to 2.2±1.2. The life-table success rate was 78.6% at 12, 24, and 36 months. Postoperative complications included persistent corneal edema in 1 patient and both persistent corneal edema and cystoid macular edema in another patient. Both patients sustained a >2 line reduction in Snellen visual acuity. CONCLUSIONS: TSCPC is safe and effective in the management of patients requiring IOP reduction after BGI surgery. Although our sample size was limited, the safety profile of TSCPC after BGI seems promising.

Angle closure after Boston keratoprosthesis.

PURPOSE: To evaluate changes in the anterior chamber angle after Boston keratoprosthesis (KPro) placement. PATIENTS/METHODS: Ten patients were serially imaged with anterior segment optical coherence tomography after Boston KPro surgery. Angles were judged to be open or closed in the horizontal axis. RESULTS: Seven of 10 patients had open angles before KPro placement. Within 4 months, 4 of 7 patients developed angle closure. Contact between the iris and the backplate was seen in 3 of these patients. Two of the 4 eyes demonstrated progressive angle closure. Intraocular pressure was elevated in 3 patients postoperatively due to the obstruction of a glaucoma drainage device tube (1 eye) and angle closure (2 eyes). CONCLUSIONS: After Boston KPro surgery, patients must be carefully monitored for the onset or progression of glaucoma. Progressive angle closure can occur after placement of a Boston KPro and may be seen in conjunction with irido-backplate touch.

Combined Baerveldt glaucoma implant and scleral buckling surgery for patients with retinal detachment and coexisting glaucoma.

PURPOSE: To report on the usefulness of combined Baerveldt glaucoma implantation (BGI) and scleral buckling surgery for patients with glaucoma requiring a scleral buckle for retinal detachment repair. METHODS: Retrospective, consecutive, noncomparative, and interventional case series of 30 eyes (30 patients) that underwent simultaneous scleral buckle and BGI surgery, using a staged (group 1, n=21 patients) or nonstaged (group 2, n=9 patients) approach to BGI implantation. Successful intraocular pressure (IOP) control was defined as 6 mm Hg≤IOP≤18 mm Hg. RESULTS: Although not statistically significant, mean best corrected visual acuity (LogMAR) improved from 2.0 before surgery to 1.7 after surgery (P=0.13) with a mean follow-up of 27.7 months. Of the 21 patients in group 1, only 13 (62%) required second-stage tube insertion at a mean of 7.0±8.0 months (range, 1 to 24 mo) postoperatively. For these eyes combined with group 2 eyes, mean IOP was reduced from 31.1±10.8 to 12.7±6.0 mm Hg (P<0.0001), and the mean number of glaucoma medications was reduced from 2.9±1.4 to 1.2±1.3 (P<0.001). Life table rates of successful IOP control were 90% and 80% at 12 and 24 months, respectively. CONCLUSIONS: Combined scleral buckle and BGI is an effective technique for managing coexisting glaucoma and retinal detachment and provides the clinician with a useful surgical option while minimizing surgical risk.

Scleral fistula closure at the time of glaucoma drainage device tube repositioning: a novel technique.

Repositioning a glaucoma drainage device tube from the anterior chamber to the ciliary sulcus or pars plana can be a challenging procedure owing to the difficulty in obtaining tight closure of the original limbal fistula. Failure to achieve watertight and airtight closure of the fistula can result in substantial difficulty in completing other key portions of the surgery and may lead to postoperative hypotony and associated complications. A novel technique using a Tutoplast scleral plug, polyglactin sutures, and, in certain cases, fibrin tissue sealant to close a limbal fistula at the time of glaucoma drainage device tube repositioning is described. This technique can be replicated with ease and provides a tight seal so that other concurrent surgical procedures can safely be completed and postoperative hypotony is avoided.