Endothelial cell loss 5 years after Preserflo MicroShunt implantation: About two cases.

PURPOSE: Preserflo MicroShunt is a minimally-invasive glaucoma drainage micro-tube used to shunt aqueous humor from the anterior chamber to the subtenon space. The safety of the procedure was considered satisfactory with a majority of minor side effects. OBSERVATION: We describe the 5 year endothelial cell loss after Preserflo implantation in 2 primary open angle glaucoma patients. The case 1 presented a device-cornea touch after a backward migration of the device. The case 2 presented a modified aspect of the device compatible with an inflammatory reaction. Both cases were explanted. CONCLUSION: As described in Ahmed glaucoma valve, Xen gel stent and Cypass, Preserflo MicroShunt can lead to endothelial cell loss in some cases. A long-term prospective study with pre and postoperative endothelial cell count and AS-OCT or UBM evaluation of the device positioning would be of great interest to assess the real impact of Preserflo MicroShunt and risk factors for endothelial cell loss.

Safety and Effectiveness of the PRESERFLO® MicroShunt in Primary Open-Angle Glaucoma: Results from a 2-Year Multicenter Study.

PURPOSE: To assess the safety and effectiveness of the PRESERFLO® MicroShunt (formerly InnFocus MicroShunt) in patients with primary open-angle glaucoma (POAG). DESIGN: The MicroShunt, a controlled ab externo glaucoma filtration surgery device, was investigated in a 2-year, multicenter, single-arm study. PARTICIPANTS: Eligible patients were aged 18-85 years with POAG inadequately controlled on maximal tolerated medical therapy with intraocular pressure (IOP) ≥18 and ≤35 mmHg or when glaucoma progression warranted surgery. METHODS: The MicroShunt was implanted as a stand-alone procedure with adjunctive use of topical mitomycin C (MMC; 0.2-0.4 mg/ml) for 2-3 minutes. MAIN OUTCOME MEASURES: The primary effectiveness outcome was IOP reduction and success (not requiring reoperation or pressure failures [IOP > 21 mmHg and < 20% reduction in IOP]) at year 1. Additional end points at year 2 included IOP reduction, success, glaucoma medications, adverse events (AEs), and reoperations. Results are reported in the overall population and subgroups of patients receiving 0.2 or 0.4 mg/ml MMC. RESULTS: In 81 patients, mean (± standard deviation [SD]) IOP decreased from 21.7 ± 3.4 mmHg at baseline to 14.5 ± 4.6 mmHg at year 1 and 14.1 ± 3.2 mmHg at year 2 (P < 0.0001). Overall success (with and without supplemental glaucoma medication use) at year 1 was 74.1%. Mean (± SD) number of medications decreased from 2.1 ± 1.3 at baseline to 0.5 ± 0.9 at year 2 (P < 0.0001), and 73.8% of patients were medication free. Most common nonserious AEs were increased IOP requiring medication or selective laser trabeculoplasty (25.9%) and mild-to-moderate keratitis (11.1%). There were 6 (7.4%) reoperations and 5 (6.2%) needlings by year 2. In an analysis (post hoc) according to MMC concentration, overall success was 78.1% (0.2 mg/ml) and 74.4% (0.4 mg/ml; P = 0.710). In the 0.2 and 0.4 mg/ml MMC groups, 51.9% and 90.3% of patients were medication free, respectively (P = 0.001). There was a trend toward lower IOP and higher medication reduction in the 0.4 mg/ml MMC subgroup. CONCLUSIONS: In this study, mean IOP and glaucoma medication reductions were significant and sustained over 2 years postsurgery. No long-term, sight-threatening AEs were reported. Further studies may confirm potential risk/benefits of higher MMC concentration.

Efficacy and safety at 6 months of the XEN implant for the management of open angle glaucoma.

The purpose of this study is to evaluate the efficacy and complications of the XEN implant as a solo procedure or in association with cataract surgery in patients with open angle glaucoma (OAG). All patients who received a XEN implant between June 2017 and June 2018 were included in the study. The primary and secondary outcomes were: the reduction of the intraocular pressure (IOP) at 6 months postoperatively, the decrease of the glaucoma medications 6 months after surgery, the clinical success rate (eyes (%) achieving ≥20% IOP reduction on the same or fewer medications without secondary surgical intervention), the frequency and type of postoperative interventions as well as the complication rate. We included one hundred and seven eyes from 97 patients with primary OAG (79%), or secondary OAG (21%). Seventy-seven patients (72%) received a standalone XEN implantation and 30 (28%) underwent XEN implantation combined with phacoemusification. The IOP decreased from 20.4 mm Hg ± 6.4 preoperatively to 15.4 mm Hg ± 5.3 six months after the surgery, which represented a reduction of 24.5% (P = 1.4.10-7). It was associated with a lowering of glaucoma medications from 2.8 ± 1.0 preoperatively to 0.6 ± 1.0 six months postoperatively (P = 3.6.10-34). The clinical success rate was 67.2% six months after the surgery. The most frequent complications were: IOP spikes >30 mmHg (16.8%), improper position or angled drain (14.0%) and transient minimal hyphema (<1 week) (11.2%). During the follow-up, the needling was required in 34.6% of cases and a total of 10 eyes (9.4%) required a new glaucoma surgery. To conclude XEN implantation appears to be an effective short- and mid-term surgical technique to control IOP in OAG with a low risk of complication. However postoperative maneuvers were frequently required to maintain efficiency.

Comparative Effectiveness and Tolerance of Subliminal Subthreshold Transscleral Cyclophotocoagulation With a Duty Factor of 25% Versus 31.3% for Advanced Glaucoma.

PRéCIS:: Subliminal subthreshold transscleral cyclophotocoagulation (SS-TSCPC) with duty cycles 25% and 31.3% seems to be an effective approach to reduce intraocular pressure (IOP) in glaucoma that is refractory to medical management. OBJECTIVE: The objective of this study was to compare the effectiveness and the tolerance of SS-TSCPC with a duty cycle of 25% versus 31.3% with Supra 810 nm Subliminal Quantel Medical laser stimulation for advanced glaucoma. MATERIALS AND METHODS: This was a retrospective, single-center, comparative case series of patients treated by SS-TSCPC between January 2017 and July 2017. The diagnostic and inclusion criteria were patients with advanced and refractory glaucoma, defined as IOP >21 mm Hg on maximal tolerated medical therapy with or without previous glaucoma surgical procedures, a minimum follow-up of 12 months, and patients who refused or were poor candidates for additional filtering surgery or implantation of glaucoma drainage devices. The primary endpoint was surgical success defined as an IOP of 6 to 21 mm Hg or a reduction of IOP by 20% from baseline without an increase in glaucoma medication from baseline. The secondary endpoints were the mean IOP and best visual corrected acuity best-corrected visual acuity at 12 months after surgery, retreatment outcomes, glaucoma medications, and complications such as inflammation, uveitis, cataract, mydriasis, and phthisis. RESULTS: Forty eyes of 32 patients were included: 20 eyes were subjected to SS-TSCPC with 31.3% duty cycle and 20 eyes with a 25% duty cycle. The surgical success of the TSCPC 12 months after the first procedure was better in the 31.3% duty cycle group (83.5%) than in the 25% duty cycle group (65%). The most common complications were inflammation (50%, 1 mo after surgery) and IOP spikes (increase in IOP of >25% from baseline within 1 mo of laser) in both groups. Inflammation was higher in the 31.3% duty cycle group. CONCLUSIONS: SS-TSCPC at 31.3% and 25% duty cycle seems to be an effective approach to reduce IOP in glaucoma that is refractory to medical management. SS-TSCPC at 31.3% duty cycle is more effective than the 25% duty cycle SS-TSCPC. However, the 31.3% duty cycle SS-TSCPC induces more inflammation than the 25% duty cycle SS-TSCPC. Each procedure should be considered on a case by case basis.

Argon Laser Iridoplasty For Plateau Iris Syndrome: Long-Term Outcomes of 48 Eyes.

PRECIS: Argon laser peripheral iridoplasty (ALPI) was performed on 48 eyes with plateau iris syndrome (PIS). Indentation gonioscopy was used to monitor the opening of the iridocorneal angle. Mean intraocular pressure (IOP) at 5 years decreased from 15.9 to 14.4 mm Hg. None of the eyes required trabeculectomy. PURPOSE: The purpose of this article was to report the long-term outcomes of ALPI for PIS. MATERIALS AND METHODS: A retrospective chart review was performed on all patients with PIS treated with ALPI from 2001 to 2012. The study included 48 eyes from 28 patients with PIS after peripheral iridotomy, with a follow-up of at least 5 years. Patients with advanced glaucoma requiring initial surgical treatment (pathologic discs and IOP above the target IOP despite medical treatment) were excluded. The primary outcomes were the effect on the number of IOP medications, and the need for complementary selective laser trabeculoplasty (SLT) or surgery (trabeculectomy and/or phacoemulsification). Secondary outcomes were optic nerve head changes and adverse events. RESULTS: The mean IOP statistically decreased after ALPI (15.91±2.62 vs. 14.35±2.18 mm Hg, P>0.001). The mean number of IOP-lowering medications statistically increased after ALPI (0.81±0.94 vs. 1.2±1.04, P>0.001). Mean follow-up was 92.4±26.5 months. At the end of the follow-up, 12 (25%) eyes had no medications, 20 (42%) had 1 medication, 11 (23%) had 2 medications, 3 (6%) had 3 medications, and 2 (4%) had 4. Ten (21%) eyes underwent SLT, 6 (10%) underwent phacoemulsification, and no trabeculectomy was necessary during follow-up. The change in cup to disc ratio from pre-ALPI to latest follow-up was not statistically significant, and no adverse events were reported. CONCLUSIONS: ALPI is relatively effective and safe to prevent angle-closure glaucoma and avoid trabeculectomy in patients with PIS. This procedure often helps to control IOP, although SLT and additional medical treatments are frequently necessary to maintain the target IOP.

[Glaucoma treatment]. / Traitement des glaucomes.

Glaucomas treatment. Glaucoma is the first cause of blindness in Europe. The purposes of its treatment are lowering intraocular pressure (IOP), but also getting a good patient compliance with a good tolerance and a good ratio cost/effectiveness. Glaucoma treatment should stop optic nerve fiber layer loss and stabilize visual field defects. Medical topic treatment is the first line of treatment, with possible association of drops and absence of benzalkonium chloride for some of them. Four therapeutic classes are available: beta blockers, prostaglandins , alpha-2 agonists and carbonic anhydrase inhibitors. Laser peripheral iridotomy (LPI) can treat occludable angles or angle closure when there is no or only localized peripheral anterior synechia. Laser iridoplasty is indicated in plateau iris when remains an appositional angle closure after LPI. Selective laser trabeculoplasty is an effective tool in lowering IOP and decrease IOP fluctuation. It can be successfully used as primary or adjunctive therapy for the management of both early and advanced glaucoma in primary open angle glaucoma or in angle closure glaucoma after LPI. Surgical approach should be considered after medical and/or laser treatment when glaucomatous visual field defects still progress. Filtering surgeries (non penetrating deep sclerectomy or trabeculectomy) or glaucoma valve implantation are well known for their effectiveness but bleb complications lead to develop blebless procedures called MIGS (mini invasive glaucoma surgery) or, in refractory glaucoma, non invasive surgery devices such as High-intensity focused ultrasound which consist in ultrasonic circular cyclo-coagulation of ciliary body, leading to less long term complication than diode transscleral cyclocoagulation.

Traitement des glaucomes. Le glaucome est la première cause de cécité en Europe. Les buts du traitement sont d'abaisser au maximum la pression intraoculaire, mais également d'aboutir à une bonne observance du traitement, avec une bonne tolérance et un coût minimal en termes de santé publique. Ce traitement doit permettre de stopper la perte en fibres optiques et stabiliser le déficit du champ visuel. Le traitement médical par collyre est le traitement de 1re intention. Quatre classes thérapeutiques sont disponibles (bêtabloquants, prostaglandines, alpha-2 agonistes et inhibiteurs de l'anhydrase carbonique). On peut les administrer seuls ou en association, et avec ou sans conservateurs selon le traitement choisi. L'iridotomie périphérique ou iridotomie laser traite les angles susceptibles de fermeture ou les angles fermés pour lesquels il n'existe pas, ou de façon localisée, de synéchies antérieures périphériques. L'iridoplastie laser est indiquée pour le traitement des iris en plateau chez lesquels persiste une apposition iridotrabéculaire après iridotomie périphérique. La trabéculoplastie sélective par laser permet de diminuer la pression intraoculaire et les pics pressionnels ; le laser peut être utilisé comme traitement de 1re intention ou traitement adjuvant d'un traitement médical, quel que soit le stade du glaucome, dès lors que l'angle est ouvert (de façon primitive ou après iridotomie périphérique). Les indications chirurgicales sont réservées aux échecs des traitements médicaux et/ou par laser. Du fait de complications inhérentes à la bulle de filtration, de nouvelles techniques dites mini-invasives ou non perforantes, telles que la cyclocoagulation par ultrasons, voient le jour afin d'essayer de suppléer aux chirurgies filtrantes « classiques ¼ (sclérectomie profonde non perforante et trabéculectomie), voire aux implantations par valve.