Intraluminal Suture Placement for Management of Hypotony After Glaucoma Drainage Device Surgery.

PRCIS: Intraluminal 3-0 Supramid stent placement can be an effective long-term solution for hypotony after glaucoma drainage device surgery. This procedure may obviate the need for conjunctival dissection. In some cases, additional procedures are required. PURPOSE: To describe the utility of implantation of a multifilament polyamide suture (Supramid) in the tube lumen to reverse hypotony after glaucoma drainage device (GDD) surgery. PATIENTS: Patients who underwent tube revision with intraluminal placement of a 3-0 Supramid stent, with or without external ligature, to manage hypotony following GDD surgery between January 2010 and October 2020. METHODS: Resolution of hypotony was defined as IOP >5 mm Hg and the absence of hypotony-related structural abnormalities. Overall success was the absence of failure criteria (IOP ≤5 mm Hg, >21 mm Hg, or <20% reduction below baseline IOP after 3 months for 2 consecutive study visits; additional glaucoma surgery; or loss of light perception), with or without adjunctive ocular hypotensive therapy. RESULTS: Nine eyes of 9 patients underwent placement of a 3-0 Supramid stent with a resolution of hypotony in all eyes with a mean follow-up duration of 33.3 ±24.0 months. Overall success was achieved in 7 of 9 eyes. Four eyes required intervention after stent placement: 1 eye required selective laser trabeculoplasty followed by replacement of the original stent with a shorter 3-0 Supramid suture and external ligature; 1 eye underwent revision for tube exposure; and 2 eyes underwent laser suture lysis to release an external suture ligature. CONCLUSIONS: In cases of hypotony after GDD, particularly when it is desirable to reduce the extent of additional conjunctival dissection, intraluminal placement of a 3-0 Supramid stent via an intracameral approach can be an effective long-term solution. Postoperative adjustments were required in many cases.

Rates of visual field change and functional progression in glaucoma following trabecular microbypass implantation of iStent technologies: a meta-analysis.

BACKGROUND/AIM: While intraocular pressure (IOP) remains the only modifiable risk factor for glaucoma progression, the ultimate goal of glaucoma management is to preserve patients' functional vision and quality of life. To this end, minimally invasive glaucoma surgeries (MIGSs) aim to reduce IOP with minimal eye trauma. Commonly used MIGS devices include iStent technologies, which have well-documented IOP-reducing potential and favourable safety profiles. However, no study concluded on their effect on the rates of visual field (VF) changes. The aim of this meta-analysis is to determine the long-term effect of iStent technology implantation on glaucoma functional progression. METHODS: Electronic medical literature databases were searched to identify studies reporting on iStent technologies. Reports with follow-up durations <12 months, retention rates <75% and missing VF data were excluded. Fifteen studies reporting on 1115 eyes were identified. The overall weighted mean VF mean deviation (MD) progression, IOP reduction and follow-up duration were calculated. RESULTS: Weighted mean IOP at baseline was 19.0±3.1 mm Hg. At the end of a 37.9-month mean follow-up (range 12-96 months), a weighted mean 26.6% IOP reduction was achieved (range 15.2%-42.3%). Over the same duration, the weighted mean VF MD progression rate was -0.02±0.34 dBs/year, from a mean baseline of -5.76±5.68 dBs. CONCLUSION: In this review, which examines functional stability of 1115 eyes, iStent technologies achieved a mean rate of progression of -0.024 dBs/year with serial standard automated perimetry, which is similar to that reported in non-glaucomatous eyes and slower than that reported in medically treated glaucoma.

Long-term follow-up of laser trabeculoplasty in multi-treated glaucoma patients.

PURPOSE: To evaluate the long-term effect of laser trabeculoplasty (LTP) in patients randomized to multi-treatment in the Glaucoma Intensive Treatment Study (GITS). METHODS: Patients with untreated newly diagnosed open-angle glaucoma were treated with three intraocular pressure (IOP)-lowering substances for 1 week and then 360° argon or selective LTP was performed. IOP was measured just before LTP and repeatedly during the 60-month study period. Our previous report on 12 months follow-up data revealed no effect of LTP in eyes having an IOP <15 mmHg before the laser treatment. RESULTS: Before LTP, the mean IOP ± standard deviation in all 152 study-eyes of 122 multi-treated patients was 14.0 ± 3.5 mmHg. Three eyes of three deceased patients were lost to follow-up during the 60 months. After exclusion of eyes that received increased therapy during follow-up, the IOP was significantly reduced at all visits up to 48 months in eyes with pre-LTP IOP ≥15 mmHg; 2.6 ± 3.1 mmHg at 1 month and 1.7 ± 2.8 mmHg at 48 months, n = 56 and 48, respectively. No significant IOP reduction was seen in eyes with pre-LTP IOP <15 mmHg. Seven eyes, i.e., <13%, with pre-LTP IOP ≥15 mmHg at baseline had required increased IOP-lowering therapy at 48 months. CONCLUSION: LTP performed in multi-treated patients may provide a useful IOP reduction that is maintained over several years. This was true on a group level when the initial IOP was ≥15 mmHg, but if the pre-laser IOP was lower than that, chances of LTP success were small.

The effect of axial length on the short-term outcomes of cataract surgery combined with ab interno trabeculotomy.

PURPOSE: Minimally invasive glaucoma surgery is safer and effective surgical modality for patients with glaucoma. To compare the effect of axial length (AL) on the surgical outcomes of combined cataract surgery and ab interno trabeculotomy (phaco-LOT), a retrospective, non-randomized comparative study was performed. METHODS: In total, 458 eyes of 458 open-angle glaucoma patients who underwent phaco-LOT and were followed-up without any intervention for at least 6 months were enrolled. All were divided into a long-AL group (AL ≥ 26.0 mm, 123 eyes) and a not-long-AL group (AL < 26.0 mm, 335 eyes). The principal outcomes were the changes in intraocular pressure (IOP) and medication scores. We also sought a correlation between postoperative IOP spike and hyphema. RESULTS: Significant postoperative reductions in IOP and medication scores were apparent in all subjects. The IOP reductions were significant at all timepoints in the not-long-AL group, but not until 1 month postoperatively in the long-AL group, and the IOP change was significantly lower in the long-AL group from postoperative day 1 to 3 months. On subanalysis of subjects by age, the microhook used, the pre-operative IOP, and the medication score, a significantly higher incidence of IOP spike was observed in the long-AL group in weeks 1 and 2 (both p < 0.05), but this did not correlate with hyphema status, implying that a different mechanism was in play. CONCLUSION: Phaco-LOT was effective regardless of AL, but the postoperative IOP decrease was lower and the early postoperative incidence of IOP spike was higher in long-AL eyes.

Short-Term Efficacy and Safety of Phacoemulsification Associated With iStent Inject W in Patients With Controlled Open Angle Glaucoma.

PRCIS: The iStent inject W implanted during phacoemulsification effectively reduces IOP. PURPOSE: The purpose of this study was to evaluate the efficacy and safety of iStent inject W combined with phacoemulsification in patients with controlled open angle glaucoma undergoing cataract surgery. PATIENTS AND METHODS: We conducted a retrospective, bicentric study of patients with controlled chronic open angle glaucoma who underwent phacoemulsification combined with the injection of 2 iStent inject Ws. Patient characteristics, including intraocular pressure (IOP) and the number of glaucoma medications, were evaluated preoperatively and 1 week, 1 month, and 6 months postoperatively. The primary end point was IOP reduction, and the secondary end point was the reduction in the number of glaucoma medications. RESULTS: In this study, 85 eyes were included. The majority of patients had primary open angle glaucoma (85% of eyes). Preoperative mean IOP was 16.1±2.0 mm Hg with a mean of 2.3±0.5 glaucoma medications. At 1 week postoperatively, the mean IOP was 16.7±3.1 mm Hg with a mean of 2.0±0.7 hypotensive medications. At 1 and 6 months, the mean IOP was 14.2±2.1 and 13.0±1.5 mm Hg, with a mean of 2.0±0.6 and 1.8±0.5 glaucoma medications, respectively. The percentage IOP reduction at 1 and 6 months was 11.6% ( P =0.001) and 19.3% ( P <0.0001), respectively. Regarding glaucoma medications, at 1 and 6 months, the reduction in the number of medications was 12.9% ( P =0.025) and 22.4% ( P =0.003), respectively. The most frequent significant postoperative adverse events were corneal edema in 7%, IOP spikes in 6%, and hyphema in 6% of eyes, which resolved spontaneously. CONCLUSIONS: The iStent inject W implanted during phacoemulsification effectively reduces IOP and the number of glaucoma medications needed at 6 months of follow-up, with a favorable safety profile in patients with controlled open angle glaucoma.

"Pinch and Stretch" technique to overcome ocular hypotony during scleral suturing of recti muscles.

During extraocular muscle surgery, an uneventful scleral suture pass is very essential. In presence of normal intraocular tension, the surgery is quite predictable and safe. However, in the presence of significant hypotony, it becomes challenging. Therefore, to mitigate complication rate in these cases, we have adopted a simple technique, that is, the "pinch and stretch" technique. The surgical steps of this technique are as follows: In eyes with significant ocular hypotony, the surgery is initiated with a routine forniceal/limbal peritomy, following which the muscle is sutured and dis-inserted. Using three tissue fixation forceps, the scleral surface is stabilized. Using first forceps, the surgeon rotates the globe toward themself from the muscle stump, and with the remaining two forceps, the assistant pinches and stretches the episcleral tissue in an outward and upward direction just beneath the intended marks. This creates a flat scleral surface with significant firmness. Sutures are passed over this rigid sclera and the surgery is completed without any complications.

Outcomes of iStent Inject Versus Kahook Dual Blade Surgery in Glaucoma Patients Undergoing Cataract Surgery.

PRCIS: iStent Inject implantation (iStent) or Kahook Dual Blade goniotomy (KDB) in combination with phacoemulsification have a similar IOP-lowering effect in all stages of glaucoma, and medications are significantly reduced, especially after KDB. PURPOSE: To compare the 2-year efficacy and safety of iStent or KDB in combination with phacoemulsification in eyes with mild to advanced open angle glaucoma. METHODS: A retrospective chart review of 153 patients that received iStent or KDB in combination with phacoemulsification at a single center between March 2019 and August 2020. The main outcome parameters at 2 years were: (1) intraocular pressure (IOP)-reduction ≥20%, with a postoperative IOP ≤18 mm Hg, and (2) a reduction of ≥1 medication. Results were stratified by glaucoma grade. RESULTS: After 2 years, mean IOP was reduced from 20.3±6.1 to 14.2±4.1 mm Hg in the phaco-iStent group ( P <0.001) and from 20.1±6.1 to 14.7±3.6 mm Hg in the phaco-KDB group ( P <0.001). The mean number of medications was reduced from 3.0±0.9 to 2.6±1.1 in the Phaco-iStent group ( P =0.001) and from 2.3±1.0 to 1.5±1.3 in the Phaco-KDB group ( P <0.001). Success regarding IOP-reduction ≥20% with a postoperative IOP ≤18 mm Hg was met by 46% in the phaco-iStent group and by 51% in the phaco-KDB group. A reduction of ≥1 medication was met by 32% in the phaco-iStent group and by 53% in the phaco-KDB group ( P =0.013). Eyes with mild to moderate and advanced glaucoma responded equally well to the success criteria. CONCLUSIONS: iStent and KDB, in combination with phacoemulsification, both lowered IOP effectively in all stages of glaucoma. More medications were reduced after KDB, suggesting that it may be a more effective procedure compared with iStent.

Excessive conjunctival and scleral retraction during trabeculectomy: an unusual intraoperative complication.

Aim: Trabeculectomy is the gold standard surgery for achieving target intraocular pressure (IOP) in glaucoma. Besides the efficiency of trabeculectomy, intraoperative or postoperative complications such as, suprachoroidal hemorrhage, vitreous loss, malignant glaucoma, flat anterior chamber, hypotony, choroidal detachment, endophthalmitis, are also quite important. We present the management of excessive conjunctival and scleral retraction during trabeculectomy: an unusual intraoperative complication. Case report: A 66-year-old woman was referred to our glaucoma unit with progression of primary open angle glaucoma. No known systemic disease was observed in her history except hypertension. The best-corrected visual acuity was 20/ 63 in the right eye and 20/ 20 in the left eye. IOP was 27 mmHg and 19 mmHg (with bimatoprost timolol fixed combination and brimonidine tartrate) in the right and left eyes, respectively. We planned trabeculectomy with mitomycin C for the right eye of the patient. Excessive conjunctival and scleral retraction occurred during surgery. Autograft conjunctival tissue was prepared to cover for bare sclera area. No complications were observed in postoperative period. Seronegative spondyloarthropathy (HLA-B27-negative) was diagnosed postoperatively as a result of consultations. Discussion: Conjunctival retraction is observed as a postoperative complication after trabeculectomy. Postoperative conjunctival retraction can cause bleb leakage and hypotony, as well as predispose to infection. Nowadays, micro invasive glaucoma surgery (MIGS) is gaining popularity, especially because of its reduced complication rate compared to trabeculectomy. However, considering the IOP reduction rates, MIGS has been indicated in mild and moderate glaucoma. Conclusions: We presented the management of excessive conjunctival and scleral retraction during trabeculectomy, which has not been reported earlier. Conjunctival autograft transplantation is useful to manage this complication.

Outcomes of Partial Versus Complete Goniotomy With or Without Phacoemulsification for Primary Open Angle Glaucoma: A Multicenter Study.

PRCIS: Goniotomy (GT) 120 degrees with or without phacoemulsification was sufficient to lower the intraocular pressure (IOP) and reduce hyphema for primary open angle glaucoma. PURPOSE: To compare the surgical outcomes and safety profiles of 120 degrees and 360 degrees GT with or without phacoemulsification cataract extraction and intraocular lens implantation (PEI) for primary open angle glaucoma. PATIENTS AND METHODS: This multicenter retrospective study consisted of 139 eyes and was divided into 4 groups: (1) 120 degrees GT, (2) 360 degrees GT, (3) PEI + 120 degrees GT, and (4) PEI + 360 degrees GT. IOP, number of topical hypotensive medications, and complications were recorded and evaluated at baseline and at the final visit. The complete and qualified success rate and their potential associated factors were also investigated. The effectiveness and safety profile of the surgery were compared between different subgroups. RESULTS: After a mean follow-up of 8.6 months, the IOP reduction was 13.2 ± 8.3 (38.8 ± 28.8%), 12.4 ± 8.3 (41.6 ± 18.2%), 12.8 ± 9.9 (39.4 ± 34.5%), and 13.8 ± 7.2 (46.0±17.1%) mm Hg in 120 degrees, 360 degrees, PEI + 120 degrees GT group, and PEI + 360 degrees GT, respectively. No significant difference was found in IOP, a decline of IOP from baseline, topical hypotensive medication, and complete or qualified success between either standalone 120 degrees versus 360 degrees GT, or PEI + 120 degrees versus PEI + 360 degrees GT (all P s > 0.05). The PEI + 120 degrees GT group had a lower final IOP than the 120 degrees GT group ( P = 0.0002) whereas there was no difference between PEI + 360 degrees GT and 360 degrees GT group ( P = 0.893). Both 360 degrees GT and PEI + 360 degrees GT group had a significantly higher incidence of hyphema than the 120 degrees GT and PEI + 120 degrees GT groups (all P s < 0.0001). CONCLUSIONS: GT of 120 or 360 degrees lowered IOP equally with or without cataract surgery, and hyphema was most commonly noted after complete GT. Partial GT alone or in combination with cataract surgery was an effective and safe approach to manage patients with open angle glaucoma.

Oral Ibuprofen is Associated With Reduced Likelihood of Early Bleb Failure After Trabeculectomy in High-Risk Glaucoma Patients.

PRCIS: Individuals prescribed ibuprofen after trabeculectomy have better postoperative intraocular pressure (IOP) control and a higher chance of bleb survival despite being at a higher risk of scarring. PURPOSE: To investigate the effects of early adjunctive oral ibuprofen treatment on IOP and bleb failure in eyes at high risk of scarring. METHODS: In these retrospective analyses, 288 eyes of 273 patients (mean ± SD age: 68.56 ± 10.47 y; 32.60% females) with primary glaucoma who underwent trabeculectomy/phacotrabeculectomy at the Singapore National Eye Centre between April 2020 and April 2021 with a follow-up duration ≥1 year were included. Of these, 77 (26.7%) eyes deemed to be at high risk of scarring were administered oral ibuprofen ≥3 months postoperatively (mean ± SD ibuprofen administration duration: 4.08 ± 2.28 wk). Participant's IOPs at baseline and at postoperative weeks 1, 2-3; and months 1, 2, 3, 6, and 12 were recorded. Bleb failure was defined as 2 consecutive IOP readings of >21, >18, and >15 mm Hg, and/or requiring remedial postoperative laser or surgery. RESULTS: The ibuprofen group experienced significantly greater postoperative IOP reductions at week 1 [mean difference, 95%CI: -2.89 (-5.22, -0.56) mm Hg] and month 1 [-2.29 (-4.53, -0.05) mm Hg]; and substantially lower odds of bleb failure at the >18 mm Hg [odds ratio, 95% CI: 0.39 (0.20-0.79)] and >15 mm Hg [0.52 (0.29-0.94)] thresholds, compared with the non-ibuprofen group. No differences in adverse ocular hypotony events were observed. CONCLUSION: Early adjunctive oral ibuprofen administered to individuals at high risk of posttrabeculectomy scarring is associated with greater IOP reductions and reduced likelihood of bleb failure. Our results suggest that oral nonsteroidal anti-inflammatory drugs may be a safe way of improving trabeculectomy survival in high-risk eyes.

Efficacy and Safety of Gonioscopy-Assisted Transluminal Trabeculotomy for Primary Congenital Glaucoma.

PRCIS: Gonioscopy-assisted transluminal trabeculotomy (GATT) provided effective intraocular pressure (IOP) control in primary congenital glaucoma (PCG). Also, approximately two third of patients did not need antiglaucoma medication at an average follow-up of 1 year after surgery. PURPOSE: The purpose of this study was to assess the safety and efficacy of GATT surgery in eyes with PCG. MATERIALS AND METHODS: This study is a retrospective review of patients who underwent GATT surgery for PCG. Outcome measures were changes in IOP and number of medications at all time points (1, 3, 6, 9, 12, 18, 24, and 36 mo after surgery), and success rates. Success was defined as IOP<21 mm Hg with at least a 30% reduction from the baseline, complete if without medications, or qualified if with or without medications. Cumulative success probabilities were analyzed using the Kaplan-Meier survival analyses. RESULTS: Twenty-two eyes of 14 patients diagnosed with PCG were enrolled in this study. The mean IOP reduction was 13.1 mm Hg (57.7%) with a mean decrease of 2 glaucoma medications at the final follow-up. All mean IOP readings during postoperative follow-up were significantly lower than baseline ( P <0.05 for all). Cumulative probability of qualified success was 95.5% and the cumulative probability of complete success was 66.7%. CONCLUSION: GATT was safe and successfully lowered IOP in patients with PCG with the advantage of avoiding conjunctival and scleral incisions.

Outcomes of Selective Laser Trabeculoplasty After Prior Incisional Surgery for Open Angle Glaucoma.

PRCIS: This retrospective case series of patients with open angle glaucoma and prior trabeculectomy or tube shunt surgery found that selective laser trabeculoplasty (SLT) resulted in significant intraocular pressure (IOP) reductions in the intermediate follow-up period in select cases. PURPOSE: The purpose of this study was to assess the IOP-lowering effect and tolerability of SLT after prior trabeculectomy or tube shunt surgery. MATERIALS AND METHODS: Open angle glaucoma patients at Wills Eye Hospital who previously underwent incisional glaucoma surgery and subsequently received SLT between 2013 and 2018 were included, along with an age-matched control group. Baseline characteristics, procedural data, and post-SLT data were recorded at 1, 3, 6, 12 months, and most recent visit. The primary success of SLT treatment was defined as IOP reduction of 20% or greater without the use of additional glaucoma medications compared to pre-SLT IOP. Secondary success was defined as IOP reduction ≥20% with the use of additional glaucoma medications compared to pre-SLT IOP. RESULTS: There were 45 eyes in the study group and 45 eyes in the control group. In the study group, IOP decreased from a baseline of 19.5±4.7 mm Hg on 2.2±1.2 medications to 16.7±5.2 mm Hg ( P =0.002) on 2.2±1.1 glaucoma medications ( P =0.57). In the control group, IOP decreased from 19.5±4.2 mm Hg on 2.4±1.0 medications to 16.4±5.2 mm Hg ( P =0.003) on 2.1±1.3 medications ( P =0.36). There was no difference in IOP reduction or change in number of glaucoma medications after SLT at any postoperative visit between the 2 groups ( P ≥0.12 for all). Primary success rates at 12 months were 24.4% for the control group and 26.7% for the prior incisional glaucoma surgery group with no significant difference between the groups ( P =0.92). There were no persistent complications after SLT treatment in either group. CONCLUSION: SLT may effectively lower IOP in patients with open angle glaucoma who have had previous incisional glaucoma surgery and should be considered in select cases.

Comparative outcomes of phacoemulsification combined with micro-invasive glaucoma surgery plus: Schlemm canal microstent versus Ab interno trabecular excision.

PURPOSE: To report the relative efficacy of combining phacoemulsification with a Schlemm's canal microstent (Phaco/Hydrus) or dual blade trabecular excision (Phaco/KDB). DESIGN: Retrospective study. METHODS: One hundred and thirty-one eyes of 131 patients who underwent Phaco/Hydrus or Phaco/KDB procedures from January 2016 to July 2021 at a tertiary care center were included and assessed for up to 36months postoperatively. Primary outcomes were intraocular pressure (IOP) and number of glaucoma medications, evaluated by generalized estimating equations (GEE). Two Kaplan-Meier estimates (KM) assessed survival without additional intervention or pressure lowering medication while maintaining: (1) IOP≤21mmHg and≥20% IOP reduction or (2) IOP≤preoperatively designated goal. RESULTS: Mean preoperative IOP was 17.70±4.91 (SD) mmHg on 0.28±0.86 medications in the Phaco/Hydrus cohort (n=69) and 15.92±4.34mmHg on 0.19±0.70 medications in the Phaco/KDB cohort (n=62). At 12months, mean IOP was reduced to 14.98±2.77mmHg on 0.12±0.60 medications after Phaco/Hydrus and 13.52±4.13mmHg on 0.04±0.19 medications after Phaco/KDB. GEE models of IOP (P<0.001) and medication burden (P<0.05) showed significant patterns of reduction across all timepoints in both cohorts. There were no differences in IOP reduction (P=0.94), number of medications (P=0.95) or survival (P=0.72 by KM1, P=0.11 by KM2) between procedures. CONCLUSIONS: Both Phaco/Hydrus and Phaco/KDB resulted in significantly reduced IOP and medication burden for over 12months. Phaco/Hydrus and Phaco/KDB confer similar outcomes in terms of IOP, medication burden, survival, and procedural time in a population with predominantly mild and moderate open-angle glaucoma.

MicroPulse Transscleral Laser Therapy Dosimetry Utilizing the Revised P3 Delivery Device: A Randomized Controlled Trial.

PURPOSE: To compare the long-term effectiveness and safety outcomes of 2 treatment dosages of the MicroPulse Transscleral Laser Therapy (MPTLT) procedure on intraocular pressure (IOP) control in patients with primary open-angle glaucoma. DESIGN: Single-blinded randomized controlled trial. SUBJECTS: A total of 19 patients with POAG without prior history of incisional glaucoma surgery. METHODS: Subjects randomized into 2 treatment groups, 100-second (total energy 78.25 joules [J], fluence 109.2 J/cm2) or 120-second (total energy 93.9 J, fluence 131.0 J/cm2) total treatment duration, underwent the MPTLT procedure with the revised P3 delivery probe delivering 2.5 W energy, 31.3% duty cycle, applied in 3 sweeps per hemisphere, avoiding 3 and 9 o'clock. All subjects were followed at 1, 3, 6, 9, and 12 months to compare reduction in IOP and medication. MAIN OUTCOME MEASURES: Absolute and percentage IOP reduction at 6 months. RESULTS: The treatment groups were similar in age, sex, and stage of glaucoma at baseline (all P > 0.05). The 120-second group had significantly better baseline best-corrected visual acuity (BCVA) and a higher percentage of patients with prior MPTLT therapy (ranging from 4-19 months before study). Significantly greater IOP reduction was noted in the 120-second group compared with the 100-second group at 3 months, with mean IOP reduction of 7.3 ± 4.2 mmHg (vs. 0.9 ± 2.5 mmHg, P = 0.006) and percentage IOP reduction of 32.2% ± 18.3% (vs. 4.1% ± 13.7%, P = 0.007). The 120-second group continued to outperform at 6-month follow-up: mean IOP reduction of 9.0 ± 4.8 mmHg (vs. 0.8 ± 2.5 mmHg, P = 0.016) and percentage IOP reduction of 37.8% ± 19.8% (vs. 3.6% ± 13.3%, P = 0.021). At 12 months, 37.5% and 18.2% of the 100- and 120-second groups, respectively, required an additional IOP-lowering procedure (P = 0.35); however, Kaplan-Meier analysis of time to intervention was not significantly different (P = 0.38). There were no vision-threatening complications or changes in BCVA during the study period. CONCLUSIONS: This study demonstrates a dose-response relationship with improved IOP control and excellent safety profile in patients treated with higher treatment total energy and fluence using the revised MPTLT probe. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Reduction of Intraocular Pressure and Aqueous Outflow Resistance After Modified 360-degree Suture Trabeculotomy.

PRCIS: Decreasing aqueous outflow resistance at trabecular meshwork is the main mechanism of modified 360-degree suture trabeculotomy (ST), and the preoperative C-value, which shows aqueous outflow resistance, is likely to be useful for predicting intraocular pressure (IOP) reduction. PURPOSE: To clarify the mechanism of IOP reduction and the preoperative prognostic predictor of modified 360-degree ST. MATERIALS AND METHODS: Forty-three eyes of 32 patients with glaucoma who underwent ST at Hokkaido University Hospital between April 2017 and February 2020 were enrolled. The records of postoperative IOP and coefficient of aqueous outflow (C-value) after ST were reviewed from clinical charts retrospectively. Preoperative IOP and C-values were also reviewed and considered as the baseline. RESULTS: Although the differences were not significant, IOP decreased to 15.4±3.3 mm Hg at 3 months ( P =0.10) and 16.1±3.8 mm Hg at 6 months ( P =0.21). In addition, there were significant decreases in anti-glaucoma medication scores at both 3 and 6 months after surgery ( P <0.01). The C-value increased significantly to 0.24±0.11 µL/min/mm Hg at 3 months ( P <0.01) and increased significantly to 0.27±0.14 µL/min/mm Hg at 6 months ( P <0.01). The rates of change in IOP were negatively correlated with that in the C-value at 3 months ( r =-0.49 P <0.01) and 6 months ( r =-0.46 P <0.01). The success rate (IOP<21 mm Hg, IOP reduction>20%) was greater in the low baseline C-value group (≤0.17) than high baseline C-value group (>0.17) ( P <0.05), and the baseline IOP and C-values were statistically significant in association with the success ( P <0.05) at 6 months. CONCLUSIONS: Increased conventional outflow by the elimination of the aqueous outflow resistance at the trabecular meshwork is the main mechanism of IOP reduction after ST. Preoperative examination of tonographic outflow facility may be useful for predicting the IOP reduction and outcome of ST.

Ab-externo intraluminal stent for prolonged hypotony and choroidal detachment after Preserflo implantation.

PURPOSE: To describe a case of prolonged hypotony and choroidal detachment following insertion of a Preserflo™ MicroShunt in a patient with primary open-angle glaucoma (POAG). CASE REPORT: An 84-year-old Caucasian man with medically uncontrolled POAG developed refractory hypotony and choroidal detachment following a mitomycin C augmented Preserflo MicroShunt (PMS) insertion. Initial medical treatment with Dexamethasone 2 mg/mL and Atropine 1% for the hypotony (4 mmHg) and choroidal detachment was unsuccessful, BCVA decreased from the preoperative 20/28 to 20/60. After 90 days, surgery revision was carried out by inserting a 10-0 nylon monofilament suture through the distal end of the PMS reaching the opposite end of the tube. The free end of the nylon suture was exposed from the conjunctiva in the inferotemporal quadrant close to the fornix to ensure access to the occlusive stent. After one month intraocular pressure (IOP) was 7 mmHg, the choroidal detachment was completely regressed, and best corrected visual acuity (BCVA) increased to 20/28, at that time the exposed part of the stent was trimmed. 6 months after the revision surgery IOP was 14 mmHg, BCVA was 20/25, and the nylon stent was retained side to side inside the PMS lumen. CONCLUSION: The management of hypotony and choroidal detachment after a glaucoma drainage device (GDD) implantation is still unstandardized. The ab externo insertion of a nylon suture grants multiple advantages over the other techniques when performed on a PMS tube.

Stand-Alone Xen Gel Microstent Implantation Compared With Kahook Dual Blade Goniotomy.

PRCIS: Both Xen gel Microstent implantation and Kahook Dual Blade (KDB) goniotomy are safe and effective as stand-alone procedures, but the Xen Gel Microstent was associated with more postoperative interventions and achieved higher success at a lower intraocular pressure threshold. PURPOSE: To evaluate outcomes of stand-alone Xen Gel Microstent implantation compared with stand-alone KDB goniotomy for moderate to severe glaucoma. METHODS: A retrospective, single-center, case-series analysis comparing outcomes of Xen Gel Microstent implantation and KDB goniotomy stand-alone cases in 75 eyes. Primary outcomes included intraocular pressure (IOP) reduction, glaucoma medication reduction, surgical success, and complications. Surgical success was defined using IOP<21 mm Hg and IOP<18 mm Hg thresholds, with or without glaucoma medications, and without further glaucoma surgery. Subjects were followed for at least 24 months after surgery. RESULTS: Mean baseline IOP was comparable between the Xen Gel Microstent and KDB goniotomy groups (23.7±8.4 and 25.9±7.9 mm Hg, respectively, P =0.32). At 24 months after surgery, the mean IOP after Xen Gel Microstent was 14.7±3.2 mm Hg (32.7% reduction from baseline, P =0.018) and KDB goniotomy was 16.7±3.2 mm Hg (40.4% reduction from baseline, P =0.049). Although the mean IOP was significantly lower during the first month after Xen Gel Microstent implantation, no difference in mean IOP was observed between the 2 treatment groups at 24 months after surgery ( P =0.416). At 24 months after surgery, the percent reduction of IOP from baseline was not significantly different between the 2 groups. The mean reduction of glaucoma medications from baseline at 24 months was 1.69 drops after Xen Gel Microstent implantation ( P =.008) and 1.67 drops after KDB goniotomy ( P =0.038). Postoperative complications were nonvision-threatening and were not significantly different between the 2 groups ( P =0.550). Interventions not included with complications were needling performed in 21 (37%) of eyes in the Xen Gel Microstent group and Nd:YAG goniopuncture in 1 (5.6%) eye after KDB goniotomy. With an IOP threshold <21 mm Hg, surgical success was not significantly different between the 2 groups ( P =0.06). At a lower IOP threshold (<18 mm Hg), surgical success was higher after Xen Gel Microstent implantation compared with KDB goniotomy ( P =0.001). CONCLUSIONS: Both stand-alone Xen Gel Microstent implantation and KDB goniotomy can effectively and safely reduce IOP for moderate to severe glaucoma. The Xen Gel Microstent was associated with a higher need for postoperative interventions and achieved greater success at a lower IOP threshold.

Outcomes of Prolene Gonioscopy Assisted Transluminal Trabeculotomy in Primary Open Angle Glaucoma and Pseudoexfoliation Glaucoma: A Comparative Study.

PRCIS: Gonioscopy-assisted transluminal trabeculotomy (GATT) provides greater intraocular pressure (IOP) reduction in pseudoexfoliative glaucoma (PXG) than in primary open angle glaucoma (POAG) in the first year of surgery; however, the difference between groups equalizes in the long term. PURPOSE: To compare outcomes of GATT in eyes with POAG and PXG. METHODS: Single-center, retrospective, comparative case-series. A total of 202 eyes (91 eyes of POAG; 111 eyes of PXG) were included. GATT was performed as a standalone procedure or in combination with cataract extraction. Outcome measures were change in IOP and number of medications at all time points (1, 3, 6, 9, 12, 18, 24, and 36 mo after surgery), success rate (IOP reduction ≥20% from baseline or IOP between 6 and 21 mmHg, without further glaucoma surgery), and complication rate. Cumulative success probabilities were compared using Kaplan-Meier survival analyses. RESULTS: The mean IOP decreased by 8.8 mmHg (34.4%) in the POAG group with a mean decrease of 2 glaucoma medications at final visit. In the PXG group, the mean IOP decreased by 12.8 mm Hg (44.6%) on 2.3 fewer medications. Mean IOP reduction was significantly higher in PXG than POAG at all time points up to 2-year visit ( P <0.05 for all), after which the difference was not significant. Cumulative success probability during the first year was significantly higher in PXG (97.6%) than in POAG (86.8%) ( P =0.01); no significant difference was found at 2-year ( P =0.07) and 3-year visits ( P =0.24). CONCLUSION: GATT was safe and effectively reduced the IOP and medication burden in patients with POAG and PXG. In the first year after GATT, a significantly higher success rate was noted in PXG compared with POAG; however, in subsequent years, the success rate was similar at ~75%.

Energy Dose-Response in Selective Laser Trabeculoplasty: A Review.

PRCIS: A literature review of selective laser trabeculoplasty (SLT) energy dose-response found no definitive relationship between intraocular pressure (IOP) reduction with respect to total or pulse energy, race, pigmentation, or application pattern. PURPOSE: SLT is a safe and effective treatment for lowering IOP. Although evidence is mounting for the advantage of its use as a first-line treatment for IOP reduction, the SLT procedures in use vary widely. The purpose of this literature review was to investigate whether there were any relationships between SLT energy and efficacy for lowering IOP in the published literature. METHODS: A literature review was undertaken that included studies in which energy levels required for successful SLT treatment were investigated: in general, with respect to angle pigmentation, race or ethnicity, and treatment arc extent. RESULTS: There was no indication that higher (or lower) energy used in the treatment leads to greater (or less) IOP reduction. Similar results were obtained regarding the level of trabecular meshwork pigmentation. Race was not found to be associated with altered dose response in SLT. There were indications that treating the full 360 degrees, as opposed to smaller arcs, could be beneficial for more IOP reduction. IOP reduction from SLT was found to be similar to that provided by topical medications. CONCLUSIONS: The optimal energy level of SLT needed for IOP reduction has not yet been definitively established, with all reported pulse energies resulting in similar IOP reduction. Furthermore, similar lack of conclusive findings exists regarding optimal SLT energy dosage for use in different races and degrees of trabecular meshwork pigmentation. This parameter and each of the abovementioned factors requires further research.

Surgical Advancement of Tenon's Layer During Trabeculectomy Improves Bleb Morphology.

Trabeculectomy surgery remains the gold standard incisional glaucoma surgical procedure in many practices, particularly for patients requiring intraocular pressure (IOP) in the low teens or below. However, trabeculectomy surgery is associated with complications including leakage, over filtration, or fibrosis of the surgical bleb. Morphology of the surgical bleb is an important predictor of surgical success defined as long-term IOP reduction with minimal to no complications. There have been many, often subtle, variations in the surgical technique in hopes of improving long-term IOP reduction. However, fewer changes have been implemented specifically to modify bleb morphology. In our surgical practice, we began performing a thorough dissection and advancement of Tenon's layer with incorporation into the conjunctival closure in a 2-layered manner. This technique allowed flow of aqueous to a delineated potential space between sclera and Tenon's layer. Our clinical observations were improved bleb morphology characterized by diffuse, low-lying blebs with nonischemic overlying conjunctiva compared with those performed with a more traditional trabeculectomy technique. Since we incorporated this change into our practice at a defined time, we have a small number of patients in our practice that had a more traditional trabeculectomy technique in the fellow eye. Therefore, in our surgical practice, a small number of patients had trabeculectomy in 1 eye before implementation of this new technique, and then had trabeculectomy in the fellow eye after this technique was adopted, providing opportunity for comparison of bleb morphology with and without Tenon advancement. In series we present two representative, index cases and describe our surgical technique.