Hypotony Failure Criteria in Glaucoma Surgical Studies and Their Influence on Surgery Success.

PURPOSE: Review hypotony failure criteria used in glaucoma surgical outcome studies and evaluate their impact on success rates. DESIGN: Systematic literature review and application of hypotony failure criteria to 2 retrospective cohorts. PARTICIPANTS: A total of 934 eyes and 1765 eyes undergoing trabeculectomy and deep sclerectomy (DS) with a median follow-up of 41.4 and 45.4 months, respectively. METHODS: Literature-based hypotony failure criteria were applied to patient cohorts. Intraocular pressure (IOP)-related success was defined as follows: (A) IOP ≤ 21 mmHg with ≥ 20% IOP reduction; (B) IOP ≤ 18 mmHg with ≥ 20% reduction; (C) IOP ≤ 15 mmHg with ≥ 25% reduction; and (D) IOP ≤ 12 mmHg with ≥ 30% reduction. Failure was defined as IOP exceeding these criteria in 2 consecutive visits > 3 months after surgery, loss of light perception, additional IOP-lowering surgery, or hypotony. Cox regression estimated failure risk for different hypotony criteria, using no hypotony as a reference. Analyses were conducted for each criterion and hypotony type (i.e., numerical [IOP threshold], clinical [clinical manifestations], and mixed [combination of numerical or clinical criteria]). MAIN OUTCOME MEASURES: Hazard ratio (HR) for failure risk. RESULTS: Of 2503 studies found, 278 were eligible, with 99 studies (35.6%) lacking hypotony failure criteria. Numerical hypotony was predominant (157 studies [56.5%]). Few studies used clinical hypotony (3 isolated [1.1%]; 19 combined with low IOP [6.8%]). Forty-nine different criteria were found, with IOP < 6 mmHg, IOP < 6 mmHg on ≥ 2 consecutive visits after 3 months, and IOP < 5 mmHg being the most common (41 [14.7%], 38 [13.7%], and 13 [4.7%] studies, respectively). In both cohorts, numerical hypotony posed the highest risk of failure (HR, 1.51-1.21 for criteria A to D; P < 0.001), followed by mixed hypotony (HR, 1.41-1.20 for criteria A to D; P < 0.001), and clinical hypotony (HR, 1.12-1.04; P < 0.001). Failure risk varied greatly with various hypotony definitions, with the HR ranging from 1.02 to 10.79 for trabeculectomy and 1.00 to 8.36 for DS. CONCLUSIONS: Hypotony failure criteria are highly heterogenous in the glaucoma literature, with few studies focusing on clinical manifestations. Numerical hypotony yields higher failure rates than clinical hypotony and can underestimate glaucoma surgery success rates. Standardizing failure criteria with an emphasis on clinically relevant hypotony manifestations is needed. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

NONPERFORATING INTRASCLERAL STABBING FOR SUTURELESS 23G SCLEROTOMY CLOSURE.

PURPOSE: The need for suturing leaking sclerotomies have not been eliminated completely in transconjunctival sutureless vitrectomy (TSV). This study aims to describe a novel technique for 23-gauge (G) sclerotomy closure in TSV surgery and discuss its effectiveness. MATERIALS AND METHODS: Two hundred and thirty cases of 180 patients who underwent 23G TSV with various diagnoses were included to the study. Cases with connective tissue diseases, thin sclera, and significant conjunctival and scleral scarring were excluded. Nonperforating intrascleral stabbing (NIS) was performed to leaking 23G sclerotomies (n = 650) and 27G chandeliers (n = 84). Demographics, rate of sclerotomy closure with NIS procedure, the need for suturing, and complications of the procedure were recorded. RESULTS: The overall success of NIS was found to be 91.0% in sclerotomies. Although 9.1% of sclerotomies required sutures, 592 of the 650 sclerotomies could be closed with NIS procedure ( P < 0.001). Nonperforating intrascleral stabbing procedure helped close 98.8% of leaking 27G chandeliers. An average of 1.28 ± 0.52 NIS attempts were needed for successful sclerotomy closure. Closure of sclerotomies with the NIS technique were somewhat related to the location of the sclerotomy, history of TSV and NIS, duration of TSV, and type of endotamponade. Hypotonia and choroidal detachment were seen in one case. No additional interventions were needed to normalize intraocular pressure in any case. Subconjunctival hemorrhage happened to be the leading complication of the procedure. CONCLUSION: NIS procedure seems as a practical, reproducible, cost-effective, and uncomplicated approach, which significantly reduces the need to suture 23G sclerotomies. Further studies are required.

New Releasable Nonabsorbable Polypropylene 8.0 Suturing Technique for Sclerotomy Sealing in 23-Gauge Vitrectomy.

PURPOSE: We propose a new releasable 8.0 polypropylene suture for leaking sclerotomies at the end of vitrectomy. Characteristic of this suture is that it can be easily removed the day after surgery at the slit-lamp examination. METHODS: Patients undergoing 23-gauge pars plana vitrectomy with the need for at least 2 sclerotomy sutures and having a preoperative Ocular Surface Disease Index score <12 were consecutively allocated to sealing with either polyglactin 910 absorbable suture (VY GROUP) or nonabsorbable 8.0 polypropylene releasable suture (PR GROUP). Evaluation of adverse events, Ocular Surface Disease Index score, and conjunctival hyperemia (through the Efron scale) was performed at 1, 7, and 30 days postoperatively. RESULTS: Both methods effectively sealed sclerotomies. PR GROUP showed a significantly lower Ocular Surface Disease Index score and lower degree of conjunctival hyperemia at both 7 and 30 days follow-up. The Ocular Surface Disease Index score decreased significantly after 7 days in PR GROUP while in VY GROUP improved at 30 days postoperatively. PR GROUP showed a lower degree of conjunctival hyperemia both at 7 and 30 days follow-up. CONCLUSION: Polypropylene 8-0 releasable sutures proved to be effective in 23-gauge pars plana vitrectomy wound sealing while inducing less ocular surface inflammation and patient discomfort compared with the standard polyglactin 910 suture.

Rotational extraction of incarcerated iris (REII): a slit lamp technique to reduce incarcerated iris after nonpenetrating deep sclerectomy for glaucoma.

PURPOSE: Iris incarceration is a complication of glaucoma filtering surgery that often requires surgery. We describe a technique for reduction of incarcerated iris at the slit lamp, dubbed rotational extraction of incarcerated iris (REII). A retrospective analysis of visual function and intraocular pressure (IOP) was done in patients treated with REII after nonpenetrating deep sclerectomy. METHODS: We retrospectively evaluated a cohort of patients who received REII for iris incarceration after nonpenetrating deep sclerectomy for glaucoma. IOP (applanation) and visual acuity (VA) were measured day-of, and 1, 3, 6, and 12 months post-REII. Adverse events were recorded. Kaplan-Meier survival analysis was done with definitions of IOP control at 15, 18, and 21 mmHg. RESULTS: Forty-one eyes of 41 patients were treated with REII. Median time to iris incarceration from glaucoma surgery was 50 days (range 1-1906). Mean pre-REII IOP ± SD was 33.7 ± 14.1 mmHg, which reduced to 11.5 ± 6.1 mmHg day-of. LogMAR VA was 0.72 ± 0.8 log units at baseline and was unchanged at 12 months (P = 0.53). Survival analysis demonstrated varying efficacy depending on the definition of success. 79.0 to 92.2% of eyes achieved IOP control immediately after REII, 39.5 to 71.1% at 1 month, 26.3 to 52.6% at 3 months, 21.1 to 44.3% at 6 months, and 10.5 to 38.0% at 12 months. Nearly half (47.4%) of eyes required a tube shunt by 12 months. CONCLUSION: REII may be a safe, minimally invasive slit lamp procedure that can reduce incarcerated iris and delay more invasive intervention for 3-6 months in most eyes.

Minimally Invasive Micro Sclerostomy (MIMS) Procedure: A Novel Glaucoma Filtration Procedure.

PRCIS: Intermediate-term results suggest that ab interno Minimally Invasive Micro Sclerostomy (MIMS) stent-less subconjunctival filtration procedure is a promising treatment option for patients with open-angle glaucoma (OAG). PURPOSE: MIMS is a novel ab interno, stent-less, subconjunctival filtration procedure. This study set to investigate the safety, performance, and efficacy of MIMS in OAG patients. METHODS: Prospective, open-label, single arm clinical trial with intrasubject comparisons. Study participants were adults with OAG who were candidates for a filtration procedure. Patients were operated by a single surgeon (A.A.) in Chennai, India. Following mitomycin-C pretreatment, ab interno MIMS procedure was performed alone or combined with phacoemulsification surgery. Procedure-related complications and adverse events were assessed. Primary outcomes: patients (%) achieving an intraocular pressure (IOP) ≥5 mm Hg and ≤18 mm Hg, and an IOP reduction of >20% as compared with baseline, with or without hypotensive medications, with no need for recurrent surgery. RESULTS: Twenty-one phacoemulsification-MIMS and 10 standalone MIMS procedures were performed. Mean age was 63.94±6.33 years. Mean duration of MIMS was 1:58±0:25 (min:s). Scleral tunnels were achieved in all cases. No device malfunctions, intraoperative complications, or serious adverse events were reported. Five (16.12%) patients presented with iris clogging 1 to 24 weeks following procedure. Two were treated with laser and 3 required trabeculectomy. Mean IOP change from baseline at 24 weeks was 47.4% (31.2 to 16.4 mm Hg, P<0.0001, n=23). The mean difference was -14.8 mm Hg (95% confidence interval: -17.6, -11.9) with no statistically significant differences between groups. Qualified success was achieved in 21 (84%), 17 (74%), and 13 (93%) after 12, 24, and 52 weeks, respectively. Complete success was achieved in 17 (68%), 13 (57%), and 8 (57%) after 12, 24, and 52 weeks, respectively. CONCLUSIONS: The interim results suggest that MIMS procedure may be a simple and effective surgical option for early OAG patients requiring target IOP in high teens although iris clogging of incision site is the major concern with this procedure.

Lamellar sclerectomy augmented XEN gel stent glaucoma surgery.

PURPOSE: To describe a surgical technique to optimize XEN gel stent position and its outflow. METHODS: A small 1- to 1.5-mm square lamellar sclerectomy was created at the external tip of the XEN gel stent implant. The lamellar scleral tissue, served as a patch graft, was secured at the gel stent insertion site. RESULTS: Four sequential, unselected, patients with failed primary XEN gel stent surgeries underwent bleb revisions with the technique described. These four patients achieved unmedicated intraocular pressures between 10 and 12 mmHg and a favourable bleb morphology despite repeated mitomycin C applications at 6 months. CONCLUSION: Lamellar sclerectomy with auto-scleral graft augmented XEN gel stent surgery deliver successful short-term outcomes without major complications observed.

A Retrospective Case Series of Uveal Effusion Syndrome.

PURPOSE: This study aimed to describe the clinical findings and management of eyes affected by uveal effusion syndrome. METHODS: We retrospectively evaluated the charts of 13 eyes of 8 consecutive patients diagnosed with uveal effusion syndrome attending the Ophthalmology Unit of the University Hospitals Leuven, Belgium, between 2007 and 2018. The presenting features, investigations, management, and outcomes were analyzed for each case. RESULTS: Cataract surgery was the predisposing factor for uveal effusion in 6 eyes, 2 bilateral uveal effusions (4 eyes) were considered to be medication-induced, and in 3 eyes, the uveal effusion was described as idiopathic. Fundus examination of 5 of 13 eyes showed bullous choroidal detachment, treated with pars plana vitrectomy with superotemporal sclerectomy or transscleral punction. Fundoscopy showed uveal effusion without serous retinal detachment in 3 eyes. Serous retinal detachment accompanied by uveal swelling was observed in 3 eyes and the 2 remaining eyes presented with uveal swelling only. The 8 nonbullous choroidal detachments were treated in a conservative way. A rapid resolution of subretinal fluid and uveal effusion was observed in all cases. CONCLUSIONS: A conservative approach with acetazolamide treatment or just observation was used in our case series in choroidal detachment without substantial visual loss if, over time, slow improvement was documented. However, further studies are needed to verify the effectiveness of the reported therapy.

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.

Comparison of early versus late laser goniopuncture following deep sclerectomy for the management of open-angle glaucoma.

PURPOSE: To compare the outcome of early versus late Nd:YAG laser goniopuncture (LGP) after deep sclerectomy with mitomycin C (DSMMC) for open-angle glaucoma (OAG). METHODS: A retrospective study of consecutive OAG eyes that underwent a LGP following DSMMC was recruited between June 2012 and November 2015. Success was defined as intraocular pressure (IOP) less than 21, 18 or 15 mm Hg with a reduction of more than 20% IOP from baseline without (complete success) or with medications (qualified success). RESULTS: 99 eyes with OAG that underwent DSMMC were recruited into the study. Of these, 49 eyes (49.49%) had undergone LGP post-DSMMC. IOP was significantly reduced following LGP from 28.4 to 11.8 mm Hg. Comparison of Kaplan-Meier survival curves out to 60 months after LGP showed a trend towards better outcomes in the late LGP group with the only statistically significant difference noted for qualified success with IOP target <15 mm Hg. Complications were few with no difference noted between early and late LGP groups. CONCLUSION: There appears to be a trend towards late LGP being more effective after DSMMC when compared with early LGP; this however was not significant. This study corroborates previous published data confirming LGP is an effective and safe procedure for lowering IOP post-DSMMC procedure.

Modified CO2 Laser-assisted Sclerectomy Surgery in Chinese Patients With Primary Open-Angle Glaucoma and Pseudoexfoliative Glaucoma: A 2-Year Follow-up Study.

PRECIS: A modified CO2 laser-assisted sclerectomy surgery (CLASS) based on the characteristics of Chinese eyeball was carried out in Chinese patient and was confirmed to be effective and safe during long-term follow-up. PURPOSE: The purpose of this study was to study the long-term efficacy and safety of modified CLASS in Chinese patients with primary open-angle and pseudoexfoliative glaucoma. METHODS: We enrolled 25 medically uncontrolled primary open-angle and pseudoexfoliative glaucoma patients in this prospective, interventional case series. A combination of modified CLASS and preoperative laser iris management was administered to 29 eyes. Visual acuity, intraocular pressure (IOP), slit-lamp examinations, visual field, and gonioscopy were carried out at baseline and until 24 months postoperatively. Ultrasound biomicroscopy examinations were repeated at 3, 12, and 24 months postsurgically. RESULTS: Mean patient age was 53.92±12.08 years. Mean preoperative IOP was 30.66±10.41 mm Hg; and mean postoperative IOP was 8.17±3.76, and 13.25±2.73, 13.76±2.50, and 13.76±2.50 mm Hg at 1 day, and 6, 12, and 24 months, respectively. Proportional changes in IOP from baseline at 6, 12, and 24 months was 58.33%, 56.25%, and 58.97% (P<0.001), respectively. Complete postoperative success rates at 12 and 24 months were 62.07% and 48.28%. Qualified success rates at 12 and 24 months postoperatively were both 89.66%. Number of medications administered per patient reduced from 3 at baseline to 0 at 12 and 24 months (P<0.0001). Two patients demonstrated severe peripheral anterior synechiae (6.90%). Ultrasound biomicroscopy examination revealed a severe scleral lake diminution in 1 patient (3.40%) at 12 months and 2 patients (6.90%) at 24 months. CONCLUSION: Combination of modified CLASS and preventive laser iris management was effective and safe in the long-term treatment of primary open-angle glaucoma patients.

Prospective evaluation of penetrating deep sclerectomy in advanced open-angle glaucoma: Filtration surgery adapted to resource scarcity in developing countries.

PURPOSE: Two of the hurdles that are facing ophthalmologists in developing countries are scarcity of resources and patient follow-up. Deep sclerectomy (DS) has proven less costly and more effective than topical therapies and has a more favorable safety profile than trabeculectomy. The main factors preventing its use in developing countries are the need to perform laser goniopuncture in 40-80% of cases to maintain filtration and the risk of postoperative iris incarceration. The purpose of this study is to assess the efficacy and safety profile in advanced open-angle glaucoma of a relatively new surgical technique designed to overcome this limitation: penetrating DS. SETTING: This was an investigator-initiated, prospective, interventional study, conducted at a single ophthalmology center in Kinshasa, Congo. The study was conducted in full compliance with the Declaration of Helsinki. METHODS: Fifty-one eyes (34 patients) with uncontrolled advanced primary open-angle glaucoma (visual field mean deviation<-10 dBs) were enrolled between October 2012 and June 2016. Age, gender, comorbidities (hypertension/diabetes), best-corrected visual acuity, topical medications, medicated and unmedicated intraocular pressure (IOP) were recorded. All patients underwent penetrating DS, during which, following standard dissection of the scleral flaps, the anterior chamber was penetrated through the trabeculo-Descemet membrane and an iridectomy was performed. Patients attended postoperative appointments at months 1, 3, 6 and 12. Surgical success was defined as a 20% reduction of IOP from baseline in conjunction with a 12-month unmedicated IOP≤12mmHg. RESULTS: The mean age was 64.5±14.0 years (44.1% female, 100% African). Mean IOP decreased from 20.2±6.1 (medicated) and 30.7±9.8mmHg (unmedicated) preoperatively to 12.1±4.1 at 12 months. Concomitantly, the number of topical medications decreased from 1.5±0.7 to 0.0. Complete surgical success was achieved in 64.7%. Four eyes (7.8%) were considered surgical failures due to uncontrolled IOP. None of the eyes lost light perception or required additional surgery. A significant association between surgical failure and hypertension was observed (HR=1.49; P=0.008). There were no intraoperative complications. Postoperatively, 4 bleb encapsulations (7.8%) and 1 iris incarceration (2%) were observed. CONCLUSIONS: The present study demonstrates that penetrating DS achieved similar efficacy and safety results to traditional non-penetrating DS. In addition, it showed a lower potential for intraoperative complications, which might be associated with a more benign surgical learning curve. Finally, the rates of serious postoperative complications (iris incarceration, choroidal effusion and hypotony) were significantly lower than in DS and trabeculectomy, and this technique does not require subsequent Nd: YAG laser goniopuncture to maintain filtration, making frequent follow-up visits less critical. In view of these findings, perforating deep sclerectomy could offer a viable option for glaucoma management in developing countries as well as worldwide.

Effect of filtering bleb dimensions on postoperative intraocular pressure in deep sclerectomy with collagen implant: a comparative study.

INTRODUCTION: The mechanisms of intraocular pressure (IOP) lowering in deep sclerectomy (DS) are multiple. Using collagen implants is one of the proposed mechanisms of DS success. It has been established to work via maintenance of subscleral decompression lake. However, the relation to conjunctival bleb formation is not fully established. METHOD: This study is a retrospective review of the records of 40 eyes of 30 patients with chronic open-angle glaucoma. Patients were divided into two groups; 20 eyes with DS using the Ologen implant (group A), and 20 eyes with DS without implant (group B). The records of UBM that was done for all patients 1 and 6 months after surgery were assessed for the extent, height of conjunctival bleb, depth of AC, the presence of intrascleral bleb and presence of collagen implant. RESULTS: Extent and height of conjunctival bleb by UBM in group A at 1 and 6 months were 3.46 ± 0.77 mm, 1.6 ± 0.38 and 3.71 ± 1.24 mm, 1.6 ± 0.64, respectively. In group B, they were 2.4 ± 1.12 mm, 0.99 ± 0.69 and 2.69 ± 1.77 mm, 0.81 ± 0.67 mm, respectively; the difference was statistically significant. Correlation using Pearson's correlation coefficient test showed significant negative correlation between extension of the bleb at 6 months and 3rd month postoperative IOP (r = - 0.447, P value 0.048) and significant negative correlation of the height at 6 months to 5th month IOP (r = - 0.491, P 0.028). CONCLUSION: Using collagen implant in DS significantly increases conjunctival bleb dimensions, which reflects on lower postoperative IOP.

Rare cause of floaters: A motile live worm in vitreous cavity.

Ocular filariasis commonly presents as subconjunctival or eyelid nodules. We report a rare case of a live, motile worm causing floaters. The worm was isolated from the vitreous cavity and revealed to be Dirofilaria repens. Correct recognition of the worm is necessary as human dirofilariasis does not present as microfilaremia and does not require systemic therapy; in contrast to other causes of ocular filariasis, which require systemic therapy. As ophthalmologist may be the first physician to encounter such patients, a high index of suspicion is required for timely and adequate management.

Effects on ocular discomfort and tear film dynamics of suturing 23-gauge pars plana vitrectomies / Efeito da sutura da vitrectomia via pars plana de calibre 23 no desconforto ocular e na dinâmica do filme lacrimal

ABSTRACT Purpose: To evaluate the effects of suturing 23-gauge pars plana vitrectomies on ocular discomfort and tear film dynamics. Methods: This retrospective chart review involved data from 50 procedures in 50 patients who underwent 23-gauge pars plana vitrectomy from January to November 2016. We divided the eyes into two groups according to the presence or absence of sutures; 35 eyes underwent sutureless vitrectomies (Group 1), and 15 eyes underwent vitrectomy with at least one sclerotomy suture site (Group 2). In each group, we assessed objective variables including tear film break-up time, Schirmer test I, corneal surface grading with Oxford system, and a quantitative method evaluating subjective dry eye symptoms using ocular surface disease index questionnaires preoperatively 1 week, and 1 and 3 months after surgery. Results: The tear film break-up time showed a significant difference at the 3-months follow-up (p=0.026). The Schirmer test I and corneal surface staining score showed no statistically significant differences between two groups at any time after the operations. The ocular surface disease index score was significantly lower in Group 1 than in Group 2 at 1 week (p=0.032), 1 month (p=0.026), and 3 months (p=0.041) after the operation. Conclusion: Sclerotomy suturing caused ocular discomfort and had a negative effect on tear film dynamics during the late postoperative period. Sclerotomies without suturing seem to reduce the ocular surface changes.

RESUMO Objetivo: Avaliar os efeitos da sutura da vitrectomia via pars plana de 23-gauge sobre o desconforto ocular e a dinâmica do filme lacrimal. Métodos: Esta revisão retrospectiva de prontuários envolveu dados de 50 casos em 50 pacientes submetidos à vitrectomia via pars plana de 23-gauge, de janeiro a novembro de 2016. Dividimos os olhos em dois grupos de acordo com a presença ou ausência de suturas; 35 olhos foram submetidos à vitrectomia sem sutura (Grupo 1) e 15 olhos foram submetidos à vitrectomia com pelo menos um ponto de sutura no local da esclerotomia (Grupo 2). Em cada grupo, avaliamos variáveis objetivas incluindo tempo de ruptura do filme lacrimal, teste de Schirmer I, gradação da superfície corneana com o sistema Oxford e um método quantitativo avaliando sintomas subjetivos de olho seco usando questionários de índice de doença da superfície ocular nos períodos: 1 semana do pré-operatório, 1 mês e 3 meses após a cirurgia. Resultados: O tempo de ruptura do filme lacrimal apresentou diferença significativa no seguimento de 3 meses (p=0,026). O teste de Schirmer I e o escore da coloração da superfície da córnea não mostraram diferenças estatisticamente significativas entre os dois grupos em nenhum momento após as operações. O escore do índice de doença da superfície ocular foi significativamente menor no Grupo 1 em relação ao Grupo 2 no período de 1 semana (p=0,032), 1 mês (p=0,026) e 3 meses (p=0,041) após a cirurgia. Conclusão: A sutura da esclerotomia causou desconforto ocular e teve um efeito negativo na dinâmica do filme lacrimal durante o período pós-operatório. Esclerotomias sem sutura parecem reduzir as alterações da superfície ocular.

Effects on ocular discomfort and tear film dynamics of suturing 23-gauge pars plana vitrectomies.

PURPOSE: To evaluate the effects of suturing 23-gauge pars plana vitrectomies on ocular discomfort and tear film dynamics. METHODS: This retrospective chart review involved data from 50 procedures in 50 patients who underwent 23-gauge pars plana vitrectomy from January to November 2016. We divided the eyes into two groups according to the presence or absence of sutures; 35 eyes underwent sutureless vitrectomies (Group 1), and 15 eyes underwent vitrectomy with at least one sclerotomy suture site (Group 2). In each group, we assessed objective variables including tear film break-up time, Schirmer test I, corneal surface grading with Oxford system, and a quantitative method evaluating subjective dry eye symptoms using ocular surface disease index questionnaires preoperatively 1 week, and 1 and 3 months after surgery. RESULTS: The tear film break-up time showed a significant difference at the 3-months follow-up (p=0.026). The Schirmer test I and corneal surface staining score showed no statistically significant differences between two groups at any time after the operations. The ocular surface disease index score was significantly lower in Group 1 than in Group 2 at 1 week (p=0.032), 1 month (p=0.026), and 3 months (p=0.041) after the operation. CONCLUSION: Sclerotomy suturing caused ocular discomfort and had a negative effect on tear film dynamics during the late postoperative period. Sclerotomies without suturing seem to reduce the ocular surface changes.

[The effect of trabeculectomy combined with prophylactic sclerotomy as a treatment of late stage juvenile open angle glaucoma and primary congenital glaucoma patients: a primary observational study].

Objective: To evaluate the outcomes of trabeculectomy combined with a new prophylactic sclerotomy in late stage juvenile open angle glaucoma (JOAG) and primary congenital glaucoma (PCG) patients at high risks of intraoperative and postoperative suprachoroidal hemorrhage (SCH). Method: A retrospective case series study. Thirty-three eyes of 28 JOAG patients and 15 eyes of 12 PCG patients with high risk factors for severe choroidal effusion or SCH were enrolled from November 2006 to April 2012 at Eye and ENT Hospital of Fudan University. The standard trabeculectomy accompanied by prophylactic sclerotomy was performed (video attached). Ophthalmic examinations were performed before and after the surgery. Surgical outcome was assessed in terms of intraocular pressure (IOP), best-corrected visual acuity, optic nerve head cup disc ratio, visual field, and complications. All patients were followed up for at least 1 year. Complete success was defined as an IOP ≥6 mmHg (1 mmHg=0.133 kPa) but ≤18 mmHg without medication. Qualified success was defined as an IOP ≥6 mmHg but ≤18 mmHg with local application of medications. Kaplan-Meier survival curves were drawn for the success rate calculation. Results: The mean age of all 40 patients was (13.2±9.4) years old. And among them, 22 patients were male and 18 patients were female. The mean follow-up time was (31.8±15.9) months. At the postoperative 3(rd) year, the complete success rate was 75.8%, and the qualified success rate was 90.0%. In our case series, one eye had expulsive SCH intraoperatively and two eyes had delayed SCH postoperatively. All of them were successfully saved without further surgery and with no significant damage to visual function. Conclusion: Trabeculectomy combined with prophylactic sclerotomy is a promising technique developed to control IOP in late stage JOAG and PCG patients, which provides a potential intervention to reduce severe consequences of massive choroidal effusion or SCH. (Chin J Ophthalmol, 2019, 55: 347-354).

Extensive circumferential partial-thickness sclerectomy in eyes with extreme nanophthalmos and spontaneous uveal effusion.

AIM: To describe an extensive scleral excision technique to treat uveal effusion in nanophthalmic eyes. METHODS: This prospective, interventional series of eight eyes of five consecutive patients with nanophthalmos underwent scleral window surgeries. Ninety per cent of the scleral thickness, extending from immediately behind the extraocular muscle insertions to the vortex veins for 3 and 1/4 quadrants, was removed. The main outcome measure was resolution of the uveal effusions. RESULTS: Eight eyes of five patients (one female and four male) with a mean age of 46 years were studied. The mean (range) axial length was 16.1 mm (14.6-17.6 mm), and the mean refractive error was +13.6 dioptres (+10.75 to +16.00 dioptres). Following scleral excision surgery, all uveal effusions resolved within an average (±SD) of 13.9 (±8.7) days. The uveal effusion recurred in only one eye that had a vasoproliferative retinal tumour. The mean best corrected visual acuity improved from 0.69 logarithm of the minimum angle of resolution (logMAR) (Snellen equivalent: 20/97) at baseline to 0.51 logMAR (Snellen equivalent: 20/64; Wilcoxon paired t-test: p=0.016) after a mean follow-up of 35.6 months. CONCLUSION: The circumferential scleral window technique produces rapid resolution of uveal effusion in nanophthalmic eyes. No adverse effects were noted after surgery and the clinical effect was durable through 1 year. TRIAL REGISTRATION NUMBER: NCT03748732.

The EX-PRESS glaucoma shunt versus nonpenetrating deep sclerectomy with Esnoper implant in combined surgery for open-angle glaucoma: a prospective randomized study.

PURPOSE: To report 1-year treatment outcomes of P50 EX-PRESS implant versus nonpenetrating deep sclerectomy (NPDS) with Esnoper V2000 combined with phacoemulsification. DESIGN: Randomized, prospective and multicentre clinical trial. METHODS: Settings: Six clinical centres. POPULATION: Patients 54-89 years of age without previous filtering surgery with cataract and glaucoma who required lower levels of intraocular pressure (IOP). INTERVENTIONS: Phaco-EX-PRESS P50 or Phaco-NPDS with Esnoper V2000, both groups with mitomycin C (0.2 mg/ml for 2 min). MAIN OUTCOME MEASURES: IOP, complete success rate (IOP: ≥6 and ≤18 mmHg), visual acuity, use of medical therapy and systematic assessment of complications and postoperative interventions. RESULTS: A total of 98 eyes were enrolled, including 50 in the EX-PRESS group and 48 in the NPDS group. At 12 months, IOP (mean ± SD) was 13.9 ± 3.3 mmHg in EX-PRESS group and 13.3 ± 3.6 mmHg in NPDS group (p = 0.38). Success rate was 75% and 80% in EX-PRESS and NPDS groups, respectively (p = 0.53). The number of glaucoma medications (mean ± SD) was 0.2 ± 0.55 in EX-PRESS group and 0.17 ± 0.44 in NPDS group (p = 1.00). The total number of complications was 66 in 35 subjects in EX-PRESS group and 39 in 23 subjects in NPDS group (p = 0.02). The incidence of more than one complication was n = 13 (26%) versus n = 9 (18.8%) in EX-PRESS and NPDS groups, respectively (p = 0.38). The total number of required postoperative interventions was 59 and 26 in EX-PRESS and NPDS groups, respectively (p = 0.01). Visual acuity was similar in both groups at month 12 (p = 0.13). Surgical time (mean ± SD) was 52.6 ± 13.6 min in EX-PRESS group and 63.3 ± 19.4 min in NPDS group (p = 0.01). CONCLUSION: Phaco-EX-PRESS surgery had similar success rate compared to Phaco-NPDS during 1 year of follow-up. Both procedures were associated with similar IOP reduction and use of additional medical therapy at 12 months. EX-PRESS surgery required more postoperative interventions and had more complications, but needed less surgical time compared to NPDS.

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.

A Comparison of Deep Sclerectomy Trainer Versus Trainee Outcomes.

PURPOSE: The aim of this study was to compare the results of deep sclerectomy (DS) and combined deep sclerectomy with phacoemulsification (phaco-DS) performed by clinical fellows with those by an experienced glaucoma surgeon and DS trainer. PATIENTS AND METHODS: This is a retrospective nonrandomized study of 266 eyes of 226 consecutive patients who had DS or phaco-DS between March 2014 and December 2016 which were included from a database of all glaucoma surgery performed in our department. A minimum of 9 months follow-up was required. The cases were recorded as to whether a fellow or consultant performed the entire procedure. Overall, 114 surgeries were performed by the consultant and 164 surgeries were performed by the fellow, in which 91 cases received no assistance from the consultant. Intraocular pressure (IOP) success criteria were: (A) IOP<22 mm Hg and/or 20% decrease from baseline off any glaucoma medications and (B) IOP<16 mm Hg and/or 30% drop from baseline off any glaucoma medications. RESULTS: No statistically significant difference was noted by any criteria (P<0.05) between the 2 groups. The Kaplan-Meir IOP success rates at 2 years with criteria B (IOP<16 mm Hg without medications) were 64% for consultant, 76% for independent surgeries done by a fellow and 72% for surgeries with assistance from the consultant trainer (P=0.15). There were no significant differences between measured IOPs at any time after surgery. Intraoperative perforation of trabeculo-Descemet membrane was noted in 4 cases (3.5%) done by the consultant and 12 cases (7.3%) performed by fellows (Fisher exact P=0.19). CONCLUSIONS: IOP outcomes of DS and phaco-DS were not adversely affected if fellows performed surgery, whether under supervision or independently.