Selective Laser Trabeculoplasty as a Substitute for Medications in Patients with Mild-to-moderate Glaucoma in the Brazilian Public Health System.

PRCIS: Selective laser trabeculoplasty can be used as a substitute for medications in patients with mild-to-moderate glaucoma, reducing the cost of eye drop distribution in the Brazilian public health system. PURPOSE: To observe the effectiveness of selective laser trabeculoplasty (SLT) as a substitute for eye drops in patients with open angle glaucoma in the Brazilian Public Health System. MATERIALS AND METHODS: SLT was performed bilaterally after medication washout. This is a prospective interventional study comparing intraocular pressure (IOP) when using eye drops at baseline (post-washout), and at 12-month follow-up after SLT. Medication was added if the target IOP was not achieved, following the Brazilian Public Health System eye drops protocol, based on medication costs. Absolute (without eye drops) and qualified (with eye drops) success were measured with IOP ≤ 21, IOP ≤ 18, IOP ≤ 15 and IOP ≤ 12 mm Hg. Besides IOP evolution, the ability to reduce IOP (in %), and eye drops reduction were evaluated. RESULTS: Ninety-two eyes of 46 patients were included, 70 eyes with mild glaucoma and 22 with moderate glaucoma; the mean number of eye drops was 2.26±1.06 (82.6% were using a prostaglandin analogue), and post-washout IOP of 21.10±5.24 mm Hg. There was relative success at IOP ≤18 mm Hg, where the mild group had greater success than the moderate group (88.1% vs. 71.4%, P =0.824). The average IOP reductions were 23.04% and 25.74% at 6 and 12 months, respectively. The average number of eye drops was 1.02, with 1.1% using a prostaglandin analogue. Furthermore, 68.19% of the patients had a decrease in the quantity of eye drops used. CONCLUSION: SLT is effective in reducing IOP and replacing eye drops in patients in the Brazilian Public Health System. Moreover, there was a significant reduction in the use of prostaglandin analogues.

Visco-Circumferential-Suture-Trabeculotomy Versus Rigid-Probe Viscotrabeculotomy in Neonatal-Onset Primary Congenital Glaucoma.

PRCIS: Angle procedures are safe and relatively effective for neonatal onset PCG. Watchful delay in intervention to close to the second month of life is helpful in ensuring diagnosis and making surgery more successful and easier. PURPOSE: The purpose of this study was to compare the surgical outcomes of visco-circumferential-suture-trabeculotomy (VCST) to rigid-probe double-entry viscotrabeculotomy (DEVT) and rigid-probe single-entry viscotrabeculotomy (SEVT) in infants with neonatal-onset primary congenital glaucoma (PCG). DESIGN: This was a retrospective chart review. PATIENTS AND METHODS: Retrospective chart review of 64 eyes of 64 infants with neonatal-onset PCG referred to Mansoura Ophthalmic Center in Mansoura, Egypt between February 2008 and November 2018. Study groups included VCST, DEVT, and SEVT, and follow-up covered 4 postoperative years. Complete (qualified) success was defined as intraocular pressure (IOP) ≤18 mm Hg and with 35% IOP reduction from baseline without (with) IOP-lowering medications or further surgical interventions, and without any sign of progression in corneal diameter, axial length, or optic disc cupping and without visual devastating complications. RESULTS: The mean±SD age at presentation and at the surgery of the study children was 3.63±1.74 and 55.23±1.60 days, respectively. The mean±SD IOP and cup/disc ratio of all study eyes at presentation and at final follow-up were 34.91±0.82 mm Hg and 0.70±0.09 and 17.04±0.74 mm Hg and 0.63±0.08, respectively. Complete success was achieved in 54.5%, 43.5%, and 31.6% in the VCST, DEVT, and SEVT groups, respectively. A self-limited hyphema was the commonest complication in all groups. CONCLUSIONS: Angle procedures are safe and marginally effective for the surgical treatment of neonatal-onset PCG, bringing IOP under control for at least 4 years of follow-up. Circumferential trabeculotomy as a first-line treatment has more favorable outcomes than rigid-probe SEVT. Rigid-probe viscotrabeculotomy offers an alternative to the noncompleted circumferential procedure.

The case for standalone micro-invasive glaucoma surgery: rethinking the role of surgery in the glaucoma treatment paradigm.

PURPOSE OF REVIEW: To highlight progress in glaucoma therapy challenging the traditional medication-first approach and present evidence supporting early standalone surgery in the era of micro-invasive glaucoma surgery (MIGS). RECENT FINDINGS: Medical therapy is limited by well documented poor adherence that compromises the quality of intraocular pressure reduction. Results from modern clinical trials demonstrate advantages of selective laser trabeculoplasty and MIGS procedures in terms of both IOP control and progression risk. SUMMARY: The MIGS options for pseudophakic or precataractous patients are limited by regulatory rules that require the performance of some procedures only at the time of cataract surgery. These include the iStent/iStent Inject and the Hydrus implants. Nonbleb-forming procedures currently available for standalone use in eyes with mild-moderate primary open-angle glaucoma include gonioscopy-assisted transluminal trabeculotomy (which lowers IOP by 28-61% and medication use by 38-73% in various studies), trabecular ablation with the Trabectome (23-39% and 21-43%, respectively), excisional goniotomy with the Kahook Dual Blade (15-36% and 15-40%, respectively), ab interno canaloplasty (35% and 57%, respectively), and combined canaloplasty and trabeculotomy using the OMNI system (39-40% and 64-73%, respectively). For patients who would benefit from early standalone surgery, these procedures offer meaningful reductions in both IOP and medication burden.

Results of modified CO2 laser-assisted sclerectomy monotherapy versus trabeculectomy combination therapy in the eyes with uveitic glaucoma.

This study compared the efficacy of modified CO2 laser-assisted sclerectomy surgery (CLASS) with combined CLASS and trabeculectomy (CLASS-TRAB) in patients with uveitic glaucoma (UG). UG patients who underwent CLASS-TRAB between August 2015 and April 2019 were retrospectively compared with a control group who underwent a modified CLASS standalone procedure during the same period. Visual acuity, intraocular pressure (IOP), use of supplemental medical therapy and postoperative complications were recorded at baseline, 1 week, 3 months, 6 months and 12 months. Forty patients (40 eyes) were enrolled, and each group had 20 patients (20 eyes). The age and sex distribution were matched between groups (P > 0.05). Both the preoperative IOP (CLASS: 34.9 ± 9.3 mmHg, CLASS-TRAB: 36.8 ± 8.7 mmHg; P > 0.05) and number of glaucoma medications (CLASS: 3.3 ± 0.4, CLASS-TRAB: 3.5 ± 0.5; P > 0.05) were relatively higher in the CLASS-TRAB group than in the CLASS group. At the final follow-up, the IOP (CLASS: 12.9 ± 3.4 mmHg, CLASS-TRAB: 11.2 ± 2.5 mmHg) and number of glaucoma medications (CLASS: 0.4 ± 0.7 and CLASS-TRAB: 0.2 ± 0.5) significantly decreased in both groups (P < 0.01). Both the complete success rate and qualified success rate were comparable between the two groups (CLASS versus CLASS-TRAB: 55% versus 80%, P = 0.09; 80% versus 95%, P = 0.34). CLASS-TRAB is as efficient as modified CLASS in terms of the IOP-lowering effect, providing a new option for patients with UG that is severe and ineligible for other treatments.

Outcomes of Combined Ahmed Glaucoma Valve and Trabeculectomy Revision With Adjunctive Antimetabolite.

PURPOSE: Evaluate the intraocular pressure (IOP) control in combined Ahmed Glaucoma Valve (AGV) implantation and trabeculectomy revision with adjunctive antimetabolite compared with AGV alone in patients who failed prior trabeculectomy. METHODS: Consecutive cases of combined AGV implantation and trabeculectomy revision with adjunctive antimetabolite (combined group) after January 3, 2014 were case-matched to cases of AGV implantation alone (AGV-alone group) before January 3, 2014. Primary outcome measures were qualified success with stratified IOP targets based on criteria: (A) IOP≤18 mm Hg and 20% IOP reduction; (B) IOP≤15 mm Hg and 25% IOP reduction; (C) IOP≤12 mm Hg and 30% IOP reduction, and hypertensive phase (HP) rate. Secondary outcome measures were 1-year postoperative IOP and number of glaucoma medications and complications. RESULTS: Twenty eyes (20 patients) in each group were included. Cumulative success for combined group and AGV-alone group at 1-year were: 74.0% versus 59.2% (criterion A, P=0.221), 61.9% versus 49.5% (B, P=0.183), and 54.2% versus 30.0% (C, P=0.033), respectively. In total, 50% (10 eyes) in the AGV-alone group developed HP compared with 15% (3 eyes) in the combined group (P=0.041). At 1-year follow-up, combined group had statistically significantly lower IOP than AGV-alone group (10.1±4.4, 13.3±2.9 mm Hg, respectively; P=0.028). There were no cases of bleb-related infections, choroidal effusion or hemorrhage, persistent hypotony, or hypotony maculopathy in either group. CONCLUSIONS: Combining AGV implantation with trabeculectomy revision with antimetabolite was associated with better tonometric success compared with AGV implantation alone in patients with previously failed trabeculectomy, particularly when a low IOP target (≤12 mm Hg) is required. Revised trabeculectomy may provide complimentary outflow facility to AGV.

Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial.

BACKGROUND: Primary open angle glaucoma and ocular hypertension are habitually treated with eye drops that lower intraocular pressure. Selective laser trabeculoplasty is a safe alternative but is rarely used as first-line treatment. We compared the two. METHODS: In this observer-masked, randomised controlled trial treatment-naive patients with open angle glaucoma or ocular hypertension and no ocular comorbidities were recruited between 2012 and 2014 at six UK hospitals. They were randomly allocated (web-based randomisation) to initial selective laser trabeculoplasty or to eye drops. An objective target intraocular pressure was set according to glaucoma severity. The primary outcome was health-related quality of life (HRQoL) at 3 years (assessed by EQ-5D). Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness, and safety. Analysis was by intention to treat. This study is registered at controlled-trials.com (ISRCTN32038223). FINDINGS: Of 718 patients enrolled, 356 were randomised to the selective laser trabeculoplasty and 362 to the eye drops group. 652 (91%) returned the primary outcome questionnaire at 36 months. Average EQ-5D score was 0·89 (SD 0·18) in the selective laser trabeculoplasty group versus 0·90 (SD 0·16) in the eye drops group, with no significant difference (difference 0·01, 95% CI -0·01 to 0·03; p=0·23). At 36 months, 74·2% (95% CI 69·3-78·6) of patients in the selective laser trabeculoplasty group required no drops to maintain intraocular pressure at target. Eyes of patients in the selective laser trabeculoplasty group were within target intracoluar pressure at more visits (93·0%) than in the eye drops group (91·3%), with glaucoma surgery to lower intraocular pressure required in none versus 11 patients. Over 36 months, from an ophthalmology cost perspective, there was a 97% probability of selective laser trabeculoplasty as first treatment being more cost-effective than eye drops first at a willingness to pay of £20 000 per quality-adjusted life-year gained. INTERPRETATION: Selective laser trabeculoplasty should be offered as a first-line treatment for open angle glaucoma and ocular hypertension, supporting a change in clinical practice. FUNDING: National Institute for Health Research, Health and Technology Assessment Programme.

One-month IOP in mitomycin C-augmented trabeculectomy can predict long-term IOP control in chronic primary angle-closure glaucoma.

PURPOSE: To investigate the predictors of long-term intraocular pressure (IOP) in chronic primary angle-closure glaucoma (CPACG) treated with primary trabeculectomy. METHODS: This study systematically reviewed cases of CPACG treated with primary trabeculectomy. The scleral flaps in all cases were sutured with two stitches in situ and two releasable sutures to ensure watertight under normal IOP conditions during surgery. Mitomycin C was used in all eyes. All patients were followed for 2 years. Digital massage of the bulbus and removal of the releasable suture were performed according to the IOP and shape of the filtering bleb. Demographic data and clinical outcomes were recorded. Factors predicting long-term IOP were identified. RESULTS: A total of 72 patients (88 eyes) with a mean age of 58.51 ± 10.60 years were included in this study. The complete success rate was 89.77% after 2 years. The IOP began to stabilize after 7 days and reached its lowest point at the 1-month follow-up. The preoperative and early postoperative high or low IOP does not affect long-term effects (P > 0.05). There was a positive correlation between postoperative IOP at the 1-month and 2-year follow-ups (r = 0.64, P < 0.001). CONCLUSION: In CPACG patients undergoing primary trabeculectomy, scleral flaps sutured watertightly with two stitches in situ and two releasable sutures under normal IOP conditions can ensure controllable, effective and safe treatment of CPACG. The preoperative and early postoperative high or low IOP does not affect long-term effects. One-month postoperative IOP can be used as a predictor of long-term IOP control.

Suprachoroidal hemorrhage after removal of releasable suture with globe massage post-trabeculectomy.

A 19-year-old female, having aniridia with secondary glaucoma, presented with uncontrolled intraocular pressure (IOP) in the right eye (RE) on maximal topical and systemic medications. On examination, RE had a subluxated cataractous lens with advanced cupping. She underwent trabeculectomy with mitomycin C. On postoperative day 1, as the IOP was 32 mmHg, one releasable suture was removed followed by gentle bleb massage. On postoperative day 2, suprachoroidal hemorrhage was noted, for which the patient underwent two drainage procedures. Hemorrhagic choroidals resolved completely 4 weeks after drainage.

Impact of ab-interno trabeculectomy on Bruch's membrane opening-based morphometry of the optic nerve head for glaucoma progression analysis.

PURPOSE: To analyze the longitudinal change in Bruch's membrane opening minimal rim width (BMO-MRW) and circumpapillary retinal nerve fiber layer (RNFL) thickness using spectral domain optical coherence tomography (SD-OCT) after glaucoma surgery via ab-interno trabeculectomy in adult glaucoma patients. METHODS: Retrospective audit of 65 eyes of 65 participants undergoing ab-interno trabeculectomy using electroablation of the trabecular meshwork. In 53 eyes, surgery was combined with phacoemulsification and posterior chamber lens implantation. Pre- and postoperative SD-OCT examinations of the optic nerve head (ONH), intraocular pressure (IOP), and visual field data were analyzed. Longitudinal change in morphometric SD-OCT parameters of the ONH was compared and correlated to change in IOP and visual field function. RESULTS: BMO-MRW increased significantly between baseline (BL) and follow-up (FU) within the first 6 months after surgery (BL = 167.85 ± 90 µm; FU = 175.59 ± 89 µm; p = 0.034). This increase correlated with postoperative lowering of IOP (rho = - 0.41; p = 0.016). Nine months after surgery (range, 7-12 months), there was no significant change in BMO-MRW (BL = 196.79 ± 79; FU = 196.47 ± 85 µm; p = 0.95), while in later follow-up, a decrease of BMO-MRW was found (BL = 175.18 ± 78; FU = 168.65 ± 72; p = 0.05). RNFL thickness was unchanged in early (p > 0.16) and significantly decreased in later follow-up (p = 0.009). Mean deviation (MD) of visual field function did not show a significant change before and after surgery. CONCLUSION: Electroablative ab-interno trabeculectomy leads to a significant transient mild increase in BMO-MRW. This increase was shown to correlate with IOP lowering. Significant loss of BMO-MRW in later follow-up may reflect insufficient IOP reduction by surgery. The parameters RNFL thickness and MD seem less impacted directly by surgery.

Role of trabeculectomy in advanced glaucoma: Whether we stand to consider it a bane or a boon today?

PURPOSE: To elucidate the role of trabeculectomy in advanced glaucoma. MATERIALS AND METHODS: Only patients with primary open-angle glaucoma were selected. All patients who had cup-disc ratio of 0.9 or a near-total cupping were given a trial of aggressive maximum medical therapy for IOP control for at least 4 weeks. Target IOP was defined as ≤ 12 mm Hg. Patients who showed progression were included in the study. A total of 10 patients were selected. Trabeculectomy was performed using limbal-based conjunctival flap. Patients were followed up for a period of 2 years for visual acuity, intraocular pressure, visual fields, slit-lamp biomicroscopy and bleb morphology. RESULTS: Mean preoperative intraocular pressure on five drugs was 21.7 ± 3.8 mm Hg (range 18-27 mm Hg) on maximum medical therapy. Mean post-operative intraocular pressure was 11 ± 1.78 mm Hg (range 9-13 mm Hg) and 11 ± 1.92 mm Hg (range 9-14 mm Hg) at 1 month and 6 months post-operatively, respectively. Post-operatively, the visual acuity remained stable in 17 patients. It dropped by 1 Snellen line in 2 patients and 2 Snellen lines in 1 patient, respectively, over a period of 6 months and later improved to 6/6P following cataract surgery. There was no defined visual field progression in any of the 20 patients. CONCLUSION: Besides being a cost-effective alternative to medical management, trabeculectomy not only provides a better IOP control but also has a high safety profile when performed by an experienced surgeon.

Could adverse effects and complications of selective laser trabeculoplasty be decreased by low-power laser therapy?

Selective laser trabeculoplasty (SLT) has been used for treatment of primary open-angle glaucoma, ocular hypertension, pigmenter and pseudoexfoliative glaucoma being considered a low-risk procedure. Therefore, transitory and permanent adverse effects have been reported, including corneal changes, subclinical edema, and reduction in endothelial cells and in central corneal thickness. Despite rarer, serious corneal complications after SLT can be permanent and lead to visual impairment, central corneal haze, opacity and narrowing. The mechanism involves increase of vasoactive and chemotactic cytokines causing inflammatory infiltrate, destruction of stromal collagen by fibroblasts and increase of matrix metalloproteinases type 2, which impair reepithelization. SLT also increases free radical production and reduces antioxidant enzymes, resulting in endothelium damages. Low-power laser therapy (LPLT) has been used in regenerative medicine based on its biostimulatory and anti-inflammatory effects. Biostimulation occurs through the interaction of laser photons with cytochrome C oxidase enzyme, which activates intracellular biochemical cascades causing synthesis of a number of molecules related to anti-inflammatory, regenerative effects, pain relief and reduction in edema. It has been showed that LPLT reduces gene expression related to pro-inflammatory cytokines and matrix metalloproteinases, and it increases expression of growth factors related to its proliferative and healing actions. Although radiations emitted by low-power lasers are considered safe and able to induce therapeutic effects, researches based on experimental models for glaucoma could bring important data if LPLT could be an alternative approach to improve acceptation for patients undergoing SLT.

Comparison between 90-degree and 360-degree selective laser trabeculoplasty (SLT): A 2-year follow-up.

PURPOSE: To compare the effect of 90- and 360-degree selective laser trabeculoplasty (SLT) as primary or supplement therapy in patients with glaucoma and ocular hypertension (OHT). METHODS: Patients (>30 years old) with OHT, primary open-angle glaucoma (OAG), pigmentary glaucoma or pseudoexfoliative glaucoma were enrolled in a prospective randomized clinical trial. Patients were sequentially randomized to either 90- or 360-degree SLT. Their intraocular pressure (IOP) was monitored. RESULTS: The survival periods (in days) of the two extents (90 or 360 degrees) of treatment were not statistically significantly different (p = 0.85); only pretreatment IOP level could predict survival of treatment (p = 0.02). CONCLUSION: The 90-degree SLT is as effective as 360-degree SLT. Further studies are warranted to confirm the findings. High baseline IOP could be a factor that predicts treatment success.

Primary trabeculotomy compared to combined trabeculectomy-trabeculotomy in congenital glaucoma: 3-year study.

PURPOSE: To compare the outcome of primary trabeculotomy with that of combined trabeculectomy-trabeculotomy (CTT) with mitomycin C (MMC) in children with congenital glaucoma. METHODS: This is a prospective comparative study, carried out on a cohort of 28 eyes (28 infants) with congenital glaucoma. Infants with proved congenital glaucoma [based on intra-ocular pressure (IOP), cup/disc (C/D ratio), corneal diameter and axial length measurements] were randomly allocated to either group A (trabeculotomy) or group B (CTT with MMC). Postoperatively, all patients were followed regularly for 3 years; for IOP and C/D evaluation. Criteria for successful outcome included resolution of corneal oedema, reversal of disc cupping, and IOP 18 mmHg or less. RESULTS: Success rate in each group was 85.7% (p = 1.00). All preoperative parameters, including horizontal corneal diameter, axial length, IOP and C/D ratio, were not statistically significantly different between the two groups. Also, postoperative C/D ratio, IOP, IOP difference and percentage difference (compared to preoperative values), at different follow-up visits, were not statistically significantly different between both surgical techniques. Comparing preoperative to postoperative IOP and C/D ratio in each group was statistically significant. CONCLUSION: Both primary trabeculotomy and CTT with MMC had similar outcomes, which could mean that trabeculotomy could be resorted to first.

Management of Primary Angle-Closure Glaucoma.

Primary angle-closure glaucoma (PACG) is a progressive optic nerve degeneration and is defined as a glaucomatous optic neuropathy with associated characteristic enlargement of optic disc cupping and visual field loss that is secondary to ocular hypertension caused by closure of the drainage angle. Angle closure is caused by appositional approximation or adhesion between the iris and the trabecular meshwork. The main treatment strategy for PACG lies in the reduction of intraocular pressure, reopening of the closed angle, and possible prevention of further angle closure. There is no universally agreed best surgical treatment for PACG. Trabeculectomy, goniosynechialysis (GSL), glaucoma implant, and cyclodestructive procedures are effective surgical options. Each of them plays an important role in the management of PACG with its own pros and cons. Accumulating evidence is available to show the effectiveness of visually significant and visually nonsignificant cataract extraction in the treatment of PACG. Trabeculectomy and GSL are often combined with cataract extraction, which may offer additional pressure control benefits to patients with PACG. This review article will discuss laser peripheral iridotomy, argon laser peripheral iridoplasty, and surgeries such as GSL, phacoemulsification, and phaco plus glaucoma surgeries that lower intraocular pressure and also alter the anterior segment and/or drainage angle anatomy. Currently, glaucoma implants and cyclodestruction are mainly reserved for PACG patients who have failed previous filtering operations. Their role as initial surgical treatment for PACG will not be discussed.

Trabeculectomy Under Augmented Topical Anesthesia: Study on Pain Evaluation and Surgical Feasibility.

PURPOSE: Performing trabeculectomy under topical anesthesia using lignocaine jelly with intracameral anesthesia may offer painless surgery with immediate visual gain and avoid the increase in intraocular pressure associated with locally injected anesthesia. In this context, we evaluated topical anesthesia using 2% lignocaine jelly with intracameral 1.0% lignocaine for trabeculectomy in terms of pain during surgery and the surgeon's experience. DESIGN: This was a tertiary care center-based interventional case series. METHODS: Patients scheduled for trabeculectomy as the first surgery for medically controlled glaucoma underwent standard ab externo trabeculectomy under topical anesthesia. Pain evaluation was done using a visual analog scale with the modified Wong-Baker FACES Pain Rating Scale, within 1 hour after surgery. RESULTS: Fifteen eyes of 14 patients were included in the study with a mean (SD, range) age of 61.3 (17.54, 40-90, distributed normally) years. Patients' pain score analysis showed a mean (SD, range) visual analog scale score of 0.73 (0.59, 0-2) on a scale of 0 to 10. The mean (SD, range) surgeon's satisfaction score was 3.2 (0.4, 3-4) on a scale of 3 to 9. The intraocular pressure of all patients was well controlled at 2 weeks [mean (SD, range), 9.2 (2.9, 4-16)] and at 4 weeks [mean (SD, range), 13.2 (1.2, 11-15)] postoperatively without any topical or systemic antiglaucoma medications. CONCLUSIONS: Trabeculectomy can be done under augmented topical anesthesia, which provides adequate analgesia for acceptable patient and surgeon comfort with favorable outcomes. Anesthesia provided by topical application of lignocaine 2% jelly and intracameral 1.0% lignocaine is sufficient for safe trabeculectomy surgery with acceptable discomfort to the patient.

Long-term Surgical Outcomes of 180-Degree Suture Trabeculotomy in Korean Patients With Primary Congenital Glaucoma.

PURPOSE: To investigate the surgical outcomes of 180-degree suture trabeculotomy in Korean patients with primary congenital glaucoma (PCG). PATIENTS AND METHODS: This retrospective study included 21 eyes of 17 children with PCG who underwent 180-degree suture trabeculotomy as a first surgical procedure. Surgical success was defined as (1) an intraocular pressure (IOP)<22 mm Hg with or without medication; (2) no additional intraocular surgery; and (3) no evidence of progressive optic disc cupping. The main outcome measure was the success rate of 180-degree suture trabeculotomy. Secondary outcome measures were IOP, number of glaucoma medications, and occurrence of complications. RESULTS: Of the 21 eyes included, 18 (85.7%) were classified as having achieved success at the final visit (mean last follow-up or failure time, 54.91±45.68 mo). Median age at surgery was 11.97 months with mean IOP 29.8±9.6 mm Hg, on average of 1.52 medications. The mean IOP at the final visit was 16.9±5.6 mm Hg on an average of 0.38 medications. The surgical success rate of 180-degree suture trabeculotomy at 1, 3, and 5 years was 95.0%, 87.7%, and 78.9%, respectively (Kaplan-Meier analysis). Three eyes underwent second operations and the mean time to failure was 29.39±19.75 months. Hyphema was observed in 10 eyes, but it cleared up within 7.6 days. CONCLUSION: The 180-degree suture trabeculotomy performed for PCG had a significant IOP-lowering effect and caused no remarkable complications.

Long-Term Outcomes of Trabeculectomy Augmented with Mitomycin C Undertaken within the First 2 Years of Life.

PURPOSE: To evaluate the long-term effectiveness and safety of mitomycin C (MMC)-augmented trabeculectomy undertaken within the first 2 years of life for the surgical management of glaucoma. DESIGN: Retrospective, consecutive, noncomparative case series. PARTICIPANTS: All children who underwent MMC-augmented trabeculectomy within 2 years of birth between May 2002 and November 2012. METHODS: The medical records of 40 consecutive eyes of 26 children who underwent surgery by a single surgeon were reviewed. Data collected during routine clinical care were analyzed. MAIN OUTCOME MEASURES: Assessment of clinical outcomes included intraocular pressure (IOP), final visual acuity, bleb morphology, surgical complications (early and late), postoperative interventions, and further glaucoma surgery performed. Surgical success was defined as final IOP of 5 mmHg or more and of 21 mmHg or less, with anti-glaucoma medications (qualified success) and without (complete success), stable ocular dimensions and optic disc cupping, and no further glaucoma surgery (including needling) or loss of light perception. Surgical outcomes were evaluated using Kaplan-Meier life table analysis. RESULTS: Forty eyes of 26 children were studied over a mean follow-up period of 62.8 months. Most cases (80%) were of primary congenital glaucoma after failed goniotomy surgery. Cumulative probabilities of survival at 1, 5, and 7 years were 78%, 67%, and 60%, respectively. Of eyes regarded as successful, 96% (25/26 eyes) had controlled IOP without topical medication and 44% achieved visual acuity of 20/40 or better. In only 1 of the 40 eyes did a cystic avascular bleb develop, with all the other eyes being non-cystic in nature (diffuse and elevated or flat) at final follow-up. Sixty-four percent (9/14 eyes) of cases regarded as failures ultimately underwent glaucoma drainage device implantation. CONCLUSIONS: A contemporary pediatric trabeculectomy technique augmented with MMC is an effective procedure in the management of glaucoma within the first 2 years of life, as shown by the successful long-term outcomes and low incidence of sight-threatening complications. Trabeculectomy after failed goniotomy surgery or as a primary surgical intervention may offer a phakic infant with glaucoma an excellent opportunity to achieve long-term control of IOP without medications and may be associated with optimal visual outcomes.

Comparison of 360-degree versus traditional trabeculotomy in pediatric glaucoma.

PURPOSE: To compare intraocular pressure (IOP) control of pediatric glaucoma patients undergoing traditional trabeculotomy (<360 degrees or partial) with those receiving 360-degree circumferential trabeculotomy. METHODS: The medical records of pediatric glaucoma patients receiving trabeculotomy at a single institution from 2000 to 2012 were retrospectively reviewed. Patients were divided into two groups: a traditional trabeculotomy group and 360-degree trabeculotomy group. IOP at baseline and at 1, 3, 6, and 12 months' follow-up were compared within and each groups. RESULTS: A total of 77 eyes of 56 patients (age at surgery, 1.52 ± 2.68 years) in the traditional group and 14 eyes of 10 patients in the 360-degree group (age at surgery, 0.61 ± 0.42 years) were included. Mean baseline IOP was similar in both groups (traditional, 28.75 ± 8.80 mm Hg; 360-degree, 30.35 ± 6.04 mm Hg; t test; P = 0.43). Mean 1-year IOP was 17.05 ± 5.92 mm Hg in the traditional group and 11.0 ± 2.31 mm Hg in the 360-degree group. At 1-year, the surgical success rate was 58.44% in the traditional group and 85.71% in the 360-degree group; 32 eyes in the former and 2 eyes in the latter required another glaucoma procedure within 1 year for IOP control. For both groups, compared to baseline values, IOP decreased significantly with all postoperative measurements (paired t test, all P < 0.01). The 360-degree group had significantly lower IOP compared to the traditional group at 1-year (t test, P < 0.01). CONCLUSIONS: Both 360-degree and traditional trabeculotomy significantly reduced IOP in children through 1 year's follow-up, although the former procedure shows better 1-year postoperative IOP control, with higher rate of surgical success.

Proparacaine hydrochloride topical drop and intracameral 0.5% lignocaine for phacotrabeculectomy in patients with primary open angle glaucoma.

AIM: To compare the efficacy and safety of 0.5% intracameral lignocaine to 1% intracameral lignocaine prior to phacotrabeculectomy. STUDY DESIGN: Prospective, comparative, observational, and interventional study. SETTING: Tertiary eye care center in central India. MATERIALS AND METHODS: This study was comprised of 79 patients (79 eyes) with primary open angle glaucoma scheduled for phacotrabeculectomy. Patients were assigned to 1 of 2 Groups receiving proparacaine 0.5% eye drops and 1% intracameral lignocaine just prior to phacotrabeculectomy (Group 1, n = 39) and 0.5% intracameral lignocaine after completion of phacoemulsification just prior to trabeculectomy (Group 2, n = 40). The visual analogue scale was used to record intraoperative and postoperative pain. Patient comfort, intraoperative painful sensations perceived by the patient, supplemental anesthesia, complications, and surgeon discomfort were noted. An anesthetist also noted the vital parameters and the requirement for intravenous medications. RESULTS: There was no significant difference in the intraoperative pain score (P = 0.0733) or supplemental anesthesia (P = 0.372) between Groups. Postoperative pain score was statistically significant in Group 2 (P < 0.0001). The overall operating conditions in both Groups were comparable (P = 0.7389). A greater number of patients in Group 2 (88.57%) preferred the same anesthetic technique for combined surgery in the fellow eye. There was no difference in inadvertent eye movements and lid squeezing between Groups and they did not interfere with surgery. CONCLUSION: Topical anesthetic drops supplemented with 0.5% intracameral lignocaine before performing trabeculectomy is as effective as 1% intracameral lignocaine given at the beginning of phacotrabeculectomy for primary open angle glaucoma.

[Methods used and abandoned in glaucoma]. / Metode încercate si abandonate în glaucom.

The discovery of the disease called glaucoma dates back to the 17th century. Its important role as a cause of blindness has been known since the 19th century. Initial comprehension of this pathogenesis and treatment belong to the 20th century. Its prevention will hopefully be the work of the 21st century.