Quality of life in glaucoma patients: Comparison of medical therapy, trabeculectomy, and glaucoma drainage device surgery.

Purpose: To compare the quality of life (QoL) in patients with glaucoma on medical therapy and after trabeculectomy and glaucoma drainage device (GDD) using vision, glaucoma, and surgery-specific questionnaires. Methods: This cross-sectional study enrolled 30 patients of moderate to severe glaucoma, each in medical, trabeculectomy, and GDD groups. National Eye Institute Visual Function Questionnaire 25 (NEIVFQ-25), Glaucoma Quality of Life (GQL-15), and Surgery Specific Questionnaire (SSQ) were administered, and cumulative scores were compared. Results: The mean age of the participants was 58.95 ± 13.6 years with a male preponderance (73.3%, n = 66). The mean scores (SD) in the medical, trabeculectomy, and GDD groups using NEIVFQ-25 were 68.97 (6.98), 72.83 (7.81), and 75.20 (8.77), respectively, those using GQL-15 were 20.63 (6.00), 26.23 (9.12), and 28.43 (7.74), respectively, and for the SSQ, they were 74.33 (8.75) and 72.10 (5.92) in trabeculectomy and GDD groups, respectively. NEIVFQ-25 showed a better QoL in the GDD group compared to the medical group, whereas GQL-15 showed a better QoL in the medical group and comparable QoL in trabeculectomy and GDD. Both these QoL scores correlated to the LogMAR visual acuity. SSQ scores did not show a significant difference in the QoL across both surgical groups. Conclusion: NEIVFQ-25 questionnaire scores provided a holistic measure of QoL. GQL-15 assessed the activity limitation and visual disability of the patients but did not take into account the general health and psychological factors influencing the QoL. We did not find a significant difference between trabeculectomy and GDD using the SSQ. For QoL assessment in medically or surgically treated glaucoma, vision-specific and disease-specific questionnaires should always be used in conjunction.

Surgical outcomes of Glaucoma associated with Axenfeld-Rieger syndrome.

BACKGROUND: The surgical management of glaucoma associated with Axenfeld-Rieger Syndrome (ARS) is poorly described in the literature. The goal of this study is to compare the effectiveness of various glaucoma surgeries on intraocular pressure (IOP) management in ARS. METHODS: Retrospective cohort study at a university hospital-based practice of patients diagnosed with ARS between 1973 and 2018. Exclusion criterion was follow-up less than 1 year. The number of eyes with glaucoma (IOP ≥ 21 mmHg with corneal edema, Haabs striae, optic nerve cupping or buphthalmos) requiring surgery was determined. The success and survival rates of goniotomy, trabeculotomy±trabeculectomy (no antifibrotics), cycloablation, trabeculectomy with anti-fibrotics, and glaucoma drainage device placement were assessed. Success was defined as IOP of 5-20 mmHg and no additional IOP-lowering surgery or visually devastating complications. Kaplan-Meier survival curves and the Wilcoxon test were used for statistical analysis. RESULTS: In 32 patients identified with ARS (median age at presentation 6.9 years, 0-58.7 years; median follow-up 5.4 years, 1.1-43.7 years), 23 (71.9%) patients were diagnosed with glaucoma at median age 6.3 years (0-57.9 years). In glaucomatous eyes (46 eyes), mean IOP at presentation was 21.8 ± 9.3 mmHg (median 20 mmHg, 4-45 mmHg) on 1.0 ± 1.6 glaucoma medications. Thirty-one eyes of 18 patients required glaucoma surgery with 2.2 ± 1.2 IOP-lowering surgeries per eye. Goniotomy (6 eyes) showed 43% success with 4.3 ± 3.9 years of IOP control. Trabeculotomy±trabeculectomy (6 eyes) had 17% success rate with 14.8 ± 12.7 years of IOP control. Trabeculectomy with anti-fibrotics (14 eyes) showed 57% success with 16.5 ± 13.5 years of IOP control. Ahmed© (FP7 or FP8) valve placement (8 eyes) had 25% success rate with 1.7 ± 1.9 years of IOP control. Baerveldt© (250 or 350) device placement (8 eyes) showed 70% success with 1.9 ± 2.3 years of IOP control. Cycloablation (4 eyes) had 33% success rate with 2.7 ± 3.5 years of IOP control. At final follow-up, mean IOP (12.6 ± 3.8 mmHg, median 11.8 mmHg, 7-19 mmHg) in glaucomatous eyes was significantly decreased (p < 0.0001), but there was no difference in number of glaucoma medications (1.6 ± 1.5, p = 0.1). CONCLUSIONS: In our series, greater than 70% of patients with ARS have secondary glaucoma that often requires multiple surgeries. Trabeculectomy with anti-fibrotics and Baerveldt glaucoma drainage devices showed the greatest success in obtaining IOP control.

Clear Lensectomy, Goniosynechiolysis and Hydrus Microstent in a Patient with Mixed Mechanism Glaucoma.

PURPOSE: To report a case of a patient with mixed mechanism glaucoma and a clear lens who was successfully surgically treated with combination cataract extraction, goniosynechiolysis and the Hydrus stent. OBSERVATION: A 59-year-old Afro-Latino woman with a history of mixed mechanism glaucoma. She was taking latanoprost OU QHS. Best corrected visual acuities were 20/25 OU. Her intraocular pressures were 18 mmHg OU. Anterior segment examination revealed pigment on the lens zonules, and intermittent peripheral anterior synechiae in the angle. Optic nerves revealed glaucomatous cupping OU. After discussion of the risks and benefits, she agreed to undergo combined lensectomy, goniosynechiolysis, and Hydrus stent to lower the intraocular pressure on less medical therapy. Her vision improved to 20/20 with a mean IOP in the right eye during the 6 months follow up period was 12 mmHg on no medication. CONCLUSION: and Importance: Patients mixed mechanism glaucoma may benefit from earlier cataract extraction, goniosynechiolysis and Hydrus stent placement to lower intraocular pressure and reduce medication burden.

Dynamics of structural reversal in Bruch's membrane opening-based morphometrics after glaucoma drainage device surgery.

PURPOSE: Structural reversal of disc cupping is a known phenomenon after trabeculectomy. The aim of this retrospective, longitudinal, cross-sectional analysis was to evaluate the postoperative dynamics of Bruch's membrane opening-based morphometrics of the optic nerve head following glaucoma drainage device surgery. METHODS: Forty-three eyes, treated by glaucoma drainage device surgery, were included in the study. Individual changes in the spectral domain optic coherence tomography (SD-OCT) parameters Bruch's membrane opening minimum rim width (BMO-MRW), Bruch's membrane opening minimum rim area (BMO-MRA) and peripapillary retinal nerve fiber layer (RNFL) thickness as well as mean defect in 30-2 perimetry were analyzed. Changes were correlated to postoperative intraocular pressure levels over time. Available follow-up visits were aggregated and grouped into a short-term follow-up (20 to 180 days after surgery), a midterm follow-up (181 to 360 days after surgery) and a long-term follow-up (more than 360 days after surgery). RESULTS: In short-term follow-up, BMO-MRW and BMO-MRA increased significantly (p <= 0.034). This increase correlated negatively with the intraocular pressure at the time of the follow-up (Pearson's rho = - 0.49; p = 0.039). From 6 months after surgery on, there was no statistically significant change in BMO-MRW and BMO-MRA (p >= 0.207). RNFL thickness and mean defect of 30-2 perimetry showed no significant changes after GDD implantation (p >= 0.189). CONCLUSIONS: Lowering of intraocular pressure by glaucoma drainage device surgery leads to an increase of Bruch's membrane opening based parameters in the first 6 months after surgery. These changes have to be taken into account when evaluating patients' longitudinal follow-up after glaucoma drainage device implantation.

The shrinking eye: dimensional changes in the young child's eye after glaucoma drainage device implantation for refractory childhood glaucoma.

PURPOSE: To investigate the magnitude of reduction in the axial length (AL) and corneal diameter following glaucoma drainage device (GDD) placement and intraocular pressure (IOP) reduction in glaucoma patients <3 years of age at surgery. METHOD: The medical records of consecutive childhood glaucoma patients who underwent GDD implantation at a single practice between 2013 and 2018 and were <3 years of age at surgery were reviewed retrospectively. Demographics, glaucoma diagnoses, surgical details, and pre- and post-procedure measurements of AL, IOP, corneal diameter, central corneal thickness, presence of corneal edema, and cup:disk ratio were analyzed. RESULTS: A total of 16 eyes of 10 patients were included. Before GDD placement, mean AL was 23.49 ± 3.05 mm. Mean AL reduction after placement was 0.80 ± 0.85 mm (P = 0.001); median AL reduction, 0.93 mm (range, -3.05 to +0.59). Mean IOP reduction after GDD placement was 15.0 ± 6.0 mm Hg (P < 0.0001). IOP reduction and AL reduction were significantly related (P = 0.0013). Mean corneal diameter before GDD placement was 13.0 ± 1.6 mm; mean corneal diameter reduction after placement was 0.3 ± 0.3 mm (P = 0.012). Reduction of corneal diameter and of AL were significantly related (P = 0.03); corneal diameter and IOP were not (P = 0.40). Objective cupping reversal after GDD was noted in 50% of eyes with documented cup:disk ratio. CONCLUSIONS: In this study cohort, reduction in AL, corneal diameter, and cup:disk ratio was found to be correlated with reduced IOP after GDD placement. This result merits consideration during surgical planning for glaucoma patients <3 years of age.

Cutting the subconjunctival fragment of the XEN gel implant during needling procedure.

PURPOSE: To describe the case and the follow-up of an inadvertently damaged XEN gel implant during needling procedure. METHODS: Case report. RESULTS: A 60-year-old African American patient underwent an uncomplicated combined phacoemulsification with the insertion of a XEN gel implant. Two months postoperatively, a needling procedure was required. During the needling procedure, a fragment of the XEN gel implant was inadvertently damaged. One month postoperatively, the intraocular pressure was still controlled and the bleb was functioning well. CONCLUSION: This case report reveals a previously unreported complication concerning XEN gel implant. It is important for the surgeon to pay attention during needling procedure, especially if there is a subconjunctival hemorrhage impairing the view, to defer the procedure until good visibility exists.

Efficacy of Needling Revision After XEN Gel Stent Implantation: A Prospective Study.

INTRODUCTION: The XEN gel stent is currently the only minimally invasive glaucoma surgical device that targets the subconjunctival outflow pathway through an ab interno placement. It has demonstrated a significant intraocular pressure (IOP)-lowering potential and a favorable safety profile compared with traditional filtering surgery. However, despite a less invasive approach, the presence of a filtering bleb inevitably implies some risk of complications. The most commonly reported bleb-related complication, with rates as high as 45%, is bleb fibrosis associated with raised IOP. To restore filtration in those failing blebs, needling revision is considered the procedure of choice. In this study, we present the results of mitomycin C-augmented needling after XEN implantation. METHODS: This was a prospective, interventional study, conducted at a single tertiary glaucoma center. Fifty-one eyes of 51 patients with raised IOP associated with either a fibrotic or shallow bleb or increased vascularity following XEN gel stent implantation at the investigation site between January 2015 and June 2016 were enrolled in this study. Patients with other identified causes of filtration failure (stent malposition, internal ostium obstruction, retained viscoelastic) were excluded. Included patients who underwent mitomycin C-augmented needling revision, and follow-up examinations were conducted at 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months. The primary outcome was the magnitude of IOP reduction following needling revision at the last follow-up visit. Secondary outcome measures were the number of needling procedures carried out in all patients, the rate of patients requiring further filtering surgery following needling revision, and the rate of intraoperative and postoperative complications associated with needling revisions. RESULTS: The average age was 74.4±9.6 years; 66.7% (n=34) were female individuals. Primary open-angle glaucoma was the most common diagnosis (n=21, 41.2%). A total of 78 needling procedures were performed over the 24-month follow-up. Overall 20 of 51 eyes (39.2%) required >1 needling revision, and 14 eyes (24.5%) eventually required reoperation to maintain IOP within their desired target range. Before XEN implantation, mean preoperative IOP was 22.3±8.2 mm Hg and decreased to 14.1±8.0 mm Hg at day 1 postoperatively (-36.8%). The last measured IOP before the first needling revision was on average 23.6±8.9 mm Hg, which reduced to a mean 12.1±4.2 mm Hg at the first postrevision appointment (-48.7%). At the last follow-up appointment, on average 17.0±7.0 months after the first needling, the mean IOP was 14.3±4.1 mm Hg (-35.9% and -39.4% from preoperative and prerevision baselines, respectively). Complications associated with needling revisions were partial amputation of the XEN implant during needling (n=2, 3.9%), hypotony with choroidal detachment (n=1, 2%), and failure to achieve target IOP requiring subsequent surgery (n=14, 27.5%). No association was found between any of the recorded characteristics and the number of needling revisions performed or their outcomes. DISCUSSION: The present study shows that needling revision following XEN gel stent implantation is a relatively safe and efficient intervention to restore filtration in failing blebs, with a significant and durable IOP-reduction potential.

XEN Implant Fracture During Needling Procedure.

PURPOSE: The XEN implant is a small hydrophilic stent designed to be implanted permanently for the treatment of glaucoma. As with other bleb-forming surgical procedures, needling is part of postoperative care. We describe 3 cases of XEN fracture of the subconjunctival portion that occurred during the needling procedure. METHODS: The purpose of this study was to describe the clinical and anatomic outcomes in 3 cases of XEN fracture caused by the needling procedure. RESULTS: In our case series of XEN procedures (n=170), bleb needling has been performed in 98 cases (57.6%). In 3 cases (3.1%), we observed unintentional damage to the implant after the procedure.The mean distal segment length of the fractured XEN measured 0.83 (range: 0.7 to 1) mm. Despite the adverse event, the mean IOP changed from 25.0 (range: 21 to 30) mm Hg before needling to 12.0 (range: 10 to 14) after needling, with a mean follow-up of 15.3 (range: 11 to 18) months. No vision-threatening complications were recorded during the entire follow-up. CONCLUSIONS: XEN fracture related to the needling procedure should be considered as a possible adverse event of bleb management. Because XEN is composed of a soft and flexible gelatin material, it could be easily damaged by the needle. The fracture does not seem to impair the efficacy of the draining device. As a matter of fact, according to Poiseuille's laws, shortening of the implant's length decreases the resistance while increasing the flow rate. Despite our positive results, it is recommended to preserve the integrity of the implant.

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.

Glaucoma surgery preferences when the surgeon adopts the role of the patient.

BACKGROUND/OBJECTIVES: To survey the members of the American Glaucoma Society (AGS) to determine which glaucoma procedures they would prefer to have performed on themselves. SUBJECTS/METHODS: We distributed an anonymous, electronic survey via the AGS listserv. The participants were asked to adopt the role of a patient with primary open angle glaucoma with progressive visual field loss in need of glaucoma surgery. Three preoperative intraocular pressure (IOP) levels were provided (>26 mmHg, 21-26 mmHg, and <21 mmHg), and the participants were asked to choose a glaucoma procedure they would prefer performed on themselves under each preoperative IOP levels from a list of fifteen procedures. RESULTS: Out of 289 responses (representing 27.4% of active and provisional AGS members), the most preferred procedures were ab interno trabeculotomy (20.3%), Xen gel stent (18.6%), iStent with two devices (14.3%) and traditional trabeculectomy augmented with mitomycin C (14.1%). 17.6% and 6.9% of participants preferred a trabeculectomy performed or a glaucoma drainage device (GDD) implanted on themselves, which is a lower than what would be offered to a hypothetical patient. Significant proportions of participants prefer non-bleb forming or conjunctiva-sparing procedures, even with low preoperative IOP levels. Older participants were more likely to prefer traditional trabeculectomy and having a single procedure across all levels of preoperative IOP. CONCLUSIONS: The majority of AGS participants in the survey would prefer micro-invasive glaucoma surgery over traditional trabeculectomy or a GDD performed on themselves as a primary glaucoma procedure, and most would prefer non-bleb forming and conjunctiva-sparing procedures.

Effects of the Numbers and the Shapes of Venting Slits on Intraocular Pressure after Baerveldt Glaucoma Drainage Implant.

Purpose: Venting slits are widely used as an effective method to avoid the high intraocular pressure (IOP) phase immediately after the implantation of non-valved glaucoma drainage devices. However, there have been no detailed reports comparing the types of needles used and the numbers of slits made. In this study we investigated the effects of different needle types and the number of venting slits. Methods: IOP was measured using a Keyence NR-600 transducer connected to the limbus of a pig eye with a 27G needle. A microsyringe pump was also connected to the corneal limbus using a 27 G needle to make a continuous perfusion system at the rate of 200 µl/hr. The silicone tube of a Baerveldt glaucoma drainage implant (BG101-350) was ligated near the plate and then implanted in the anterior chamber of the pig eye. The tube was covered with scleral tissue of another pig eye after 1 or 3 venting slits were created in the middle of the outer diameter using different types of needles (7-0 Vicryl®, 7-0 PDSⅡ®, 5-0 PDSⅡ®, 3-0 PDS Plus®). IOP measurement was started from 50 mmHg and then we monitored the chronological changes of IOP for 15 minutes. Results: The IOPs at 15 minutes after continuous perfusion with the venting slits made using 7-0 Vicryl needles were 29.0 ± 2.5 mmHg (1 slit) and 23.1 ± 8.3 mmHg (3 slits). The IOPs were 23.1 ± 3.1 mmHg and 23.5 ± 4.7 mmHg with 7-0 PDS needles (1 slit and 3 slits, respectively), 21.8 ± 2.2 mmHg and 20.8 ± 4.3 mmHg with 5-0 PDS needles (1 slit and 3 slits, respectively), and with 3-0 PDS needles they were 12.2 ± 3.0 mmHg for one slit and 13.2 ± 3.5 mmHg for 3 slits. Conclusions: Usage of a round (PDS) needles produces more predictable IOP than a spatulated (Vicryl) needle.

Glaucoma Drainage Device Coated with Mitomycin C Loaded Opal Shale Microparticles to Inhibit Bleb Fibrosis.

Excessive fibrosis is the topmost factor for the defeat of surgical glaucoma drainage device (GDD) implantation. Adjuvant drug approaches are promising to help reduce the scar formation and excessive fibrosis. Opal shale (OS), as a natural state and noncrystalline silica substance with poriferous nature and strong adsorbability, is highly likely to undertake drug loading and delivery. Here, we employed OS microparticles (MPs) by ultrasound and centrifugation and presented an innovative and improved GDD coated with OS MPs, which were loaded with mitomycin C (MMC). MMC-loaded OS MPs were physically absorbed on the Ahmed glaucoma valve surface through OS' adsorbability. About 5.51 µg of MMC was loaded on the modified Ahmed glaucoma valve and can be released for 18 days in vitro. MMC-loaded OS MPs inhibited fibroblast proliferation and showed low toxicity to primary Tenon's fibroblasts. The ameliorated drainage device was well tolerated and effective in reducing the fibrous reaction in vivo. Hence, our study constructed an improved Ahmed glaucoma valve using OS MPs without disturbing aqueous humor drainage pattern over the valve surface. The modified Ahmed glaucoma valve successfully alleviated scar tissue formation after GDD implantation surgery.

Changes in Australian practice patterns for glaucoma management.

IMPORTANCE: The demand for glaucoma care is projected to increase significantly with the ageing population. BACKGROUND: To characterize trends in Australian practice patterns for glaucoma management over the 15-y period between 2003 and 2017. DESIGN: Retrospective audit. SAMPLES: The Medicare eligible population. METHODS: Audit of Medicare Benefits Schedule item number reimbursements in the private healthcare sector, and dispensed Pharmaceutical Benefits Scheme (PBS) prescriptions. MAIN OUTCOME MEASURES: Number, unadjusted cost and services per capita in the enrolled population. RESULTS: The number of medication prescriptions peaked in 2015, but then declined by 14.9%. PBS expenditure on glaucoma medications has been falling since 2012. There was a 9.2-fold increase in fixed-combination prescriptions and 281-fold increase in unpreserved medication prescriptions. In 2017, optometrists generated 1.86% of glaucoma prescriptions. Reimbursements for computerized perimetry increased dramatically for optometrists, and in 2017 optometrist-initiated perimetry exceeded ophthalmologist-initiated perimetry by 35.3%. There were significant increases in laser procedure rates, including laser trabeculoplasty (4.61-fold), laser iridotomy (2.55-fold) and cyclodestructive procedures (2.33-fold). There was a 3.83-fold increase in glaucoma drainage device insertions. Ab interno trabecular microbypass procedures increased 715% from 2014 to 2017. Adjusted for Medicare population, trabecular microbypass is performed at more than twice the rate of primary filtering operations. CONCLUSIONS AND RELEVANCE: This is the first time that glaucoma medication use and expenditure have declined since auditing began in 1992. Glaucoma laser procedures, drainage device implantation and trabecular microbypass increased substantially over the study period. In contrast, the rate of primary filtering operations increased in proportion to population growth. The increase in overall cost of glaucoma care has primarily been driven by computerized perimetry; however, this has been partially offset by a decline in medication expenditure.

Effect of mitomycin c and 5-flurouracil adjuvant therapy on the outcomes of Ahmed glaucoma valve implantation.

BACKGROUND: To examine the effect of mitomycin c and 5-flurouracil on treatment outcomes following Ahmed glaucoma valve implantation. DESIGN: Retrospective consecutive case series. PARTICIPANTS: Fifty patients who received Ahmed glaucoma valve implantation from 1999 to 2013 in the San Francisco Veterans Administration Hospital. METHODS: The +INJECTION group received intraoperative mitomycin c followed by postoperative mitomycin c and/or 5-flurouracil, whereas the -INJECTION group did not. MAIN OUTCOME MEASURES: Primary outcome was treatment success at 1 year post-implantation. Intraocular pressure, hypertensive phase, and the number of glaucoma medications were also examined. RESULTS: Twenty-six patients/eyes in the +INJECTION group and 24 patients/eyes in the -INJECTION group were included. Treatment success was higher in the +INJECTION compared with the -INJECTION group (86 vs. 58%; P = 0.04). Intraocular pressure was lower in the +INJECTION compared with the -INJECTION group at 1, 3, 6 and 12 months (P ≪ 0.00001, P = 0.00003, 0.0008 and 0.024). Hypertensive phase occurred less often in the +INJECTION compared with the -INJECTION group (3.8 vs. 54%; P = 0.021). The +INJECTION group required fewer medications compared with the -INJECTION group (P = 0.02, 0.002, 0.003 and 0.008 at 1, 3, 6 and 12 months). Complication rates were comparable between groups (46.2 and 54.2%; P = 0.63). CONCLUSIONS: Adjuvant treatment with antifibrotics following Ahmed glaucoma valve implantation decreased the hypertensive phase and improved surgical outcomes without impacting complication rates at 1 year. This study postulates a role for antifibrotics in the postoperative management of Ahmed glaucoma valves.

Modified Scleral Tunnel to Prevent Tube Exposure in Patients With Refractory Glaucoma.

PURPOSE: To present and evaluate modified scleral tunnel in prevention of tube exposure following Ahmed valve implantation in refractory glaucoma. METHODS: In the Affiliated Eye Hospital of Shandong University of Traditional Chinese Medicine, a retrospective study was conducted in 36 eyes of 34 patients who were diagnosed with refractory glaucoma and underwent Ahmed glaucoma valve implantation. In the surgery, the modified scleral tunnel was done to prevent tube exposure. RESULTS: At the end of follow-up (mean 21.68±9.25 mo), there was no conjunctival tube exposure in all 36 eyes. The mean intraocular pressure was 18.3±6.79 mmHg, and 8 eyes needed 1 to 3 types of drugs to decrease intraocular pressure. CONCLUSIONS: The modified scleral tunnel technique in Ahmed glaucoma valve implantation is able to prevent conjunctival tube exposure in the patients with refractory glaucoma.

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.

Needle Revision With 5-fluorouracil for the Treatment of Ahmed Glaucoma Valve Filtering Blebs: 5-Fluoruracil Needling Revision can be a Useful and Safe Tool in the Management of Failing Ahmed Glaucoma Valve Filtering Blebs.

PURPOSE: To determine the outcome of needling with adjunctive 5-fluorouracil (5-FU) in patients with a failing Ahmed glaucoma valve (AGV) implant, and to identify predictors of long-term intraocular pressure (IOP) control. METHODS: A prospective observational study was performed on consecutive patients with medically uncontrolled primary open-angle glaucoma (POAG) with AGV encapsulation or fibrosis and inadequate IOP control. Bleb needling with 5-FU injection (0.1 mL of 50 mg/mL) was performed at the slit-lamp. Patients were examined 1 week following the needling, and then at months 1, 3, and 6. Subsequent follow-up visits were scheduled at 6-month intervals for at least 2 years. Needling with 5-FU was repeated no more than twice during the first 3 months of the follow-up. Procedure outcome was determined on the basis of the recorded IOP levels. RESULTS: Thirty-six patients with an encapsulated or fibrotic AGV underwent 67procedures (mean 1.86 ± 0.83). Complete success, defined as IOP ≤ 18 mm Hg without medications, was obtained in 25% at 24 months of observation. The cumulative proportion of cases achieving either qualified (ie, IOP ≤ 18 mm Hg with medications) or complete success at 24 months of observation was 72.2%. In a univariate Cox proportional hazards model, age was the only variable that independently influenced the risk of failing 5-FU needling revision. Fourteen eyes (38.8%) had a documented complication. CONCLUSIONS: Needling over the plate of an AGV supplemented with 5-FU is an effective and safe choice in a significant proportion of POAG patients with elevated IOP due to encapsulation or fibrosis.

Trends in glaucoma surgical procedures in Ontario: 1992-2012.

OBJECTIVE: To analyze trends in the surgical management of glaucoma in Ontario over the past 2 decades. DESIGN: Retrospective analysis of health records. METHODS: Ontario Health Insurance Plan billing service claims between 1992 and 2012 were analyzed for the yearly number of glaucoma laser and incisional surgical procedures. The yearly number of Ontarians with primary open-angle glaucoma (POAG) was estimated by applying composite prevalence curves to published population data and the yearly number of procedures per 1000 Ontarians with POAG was calculated. RESULTS: Per 1000 people with POAG, laser trabeculoplasty (LT) rates increased nearly 2-fold (185%) from 1992 to 2012, with the rates stabilizing between 2008 and 2012, and total glaucoma filtration procedure (GFP) rates (trabeculectomy, aqueous shunts, and combined GFP and cataract extraction) in 2012 were similar to those in 1992, with a peak rate noted in 1996. Shunts represented 0.9% of GFP in 1992 and 33% in 2012. Data for combination codes billed on the same day for the same patient were available from 2000. From 2000 to 2012 the rates of trabeculectomy alone remained unchanged, the number of aqueous shunts alone increased more than 5-fold, combined trabeculectomy and cataract extraction decreased 81%, whereas combined shunts and cataract extraction increased from 6 in 2000 to 420 in 2012. Combined aqueous shunts and cataract extraction represented 0.4% of combined cataract extractions in 2000 and 26.3% in 2012. CONCLUSIONS: Over the past 2 decades there was an overall increase in the rate of LT, no change in the rate of trabeculectomies, and a significant increase in aqueous shunt surgery.

Combined posterior chamber intraocular lens, vitrectomy, Retisert, and pars plana tube in noninfectious uveitis.

OBJECTIVE: To assess the safety and efficacy of combined cataract extraction, posterior chamber intraocular lens placement, pars plana vitrectomy, fluocinolone acetonide intravitreal implant (Retisert), and Ahmed valves with pars plana tube (CPR-PT) in eyes with chronic, posterior, noninfectious uveitis. METHODS: Retrospective study of patients who underwent CPR-PT. Outcome measures included visual acuity, intraocular pressure, inflammation, and complications. RESULTS: Eight eyes were included, with a mean follow-up of 18 months. Mean visual acuity improved from 1.89 to 0.14 logMAR (Snellen, counting fingers at 2 ft [0.6 m]) to 20/30; P=.01). Mean intraocular pressure remained stable at 16 to 17 mm Hg (P=.35). The number of glaucoma medications per eye decreased from 2.9 to 0.25 (P=.01). Systemic prednisone therapy was discontinued in all patients by 9 months postoperatively. Inflammation was well controlled in all eyes. CONCLUSION: The CPR-PT procedure allows rapid visual rehabilitation without major short-term complications.

Adjunctive bevacizumab in patients undergoing Ahmed valve implantation: a pilot study.

BACKGROUND AND OBJECTIVE: To report on preliminary findings of adjunctive subconjunctival bevacizumab (SCB) injections in patients undergoing Ahmed valve implantation (AVI) (New World Medical, Rancho Cucamonga, CA). PATIENTS AND METHODS: The study was approved by the institution's ethics committee. Patients were prospectively recruited during a 1-month period and randomized to receive AVI with postoperative SCB (days 1 and 7, n = 7) or AVI without SCB (n = 6). RESULTS: Baseline intraocular pressure (IOP) in the treatment (AVI+SCB) group was 19.4 ± 8.6 mm Hg, whereas baseline IOP in the control (AVI) group was 32.1 ± 17.7 mm Hg (P = .119). Final IOP was 13.8 mm Hg (n = 7) for the treatment group and 12.7 mm Hg for the control group (n = 5, P = .790). One eye in the control group required further glaucoma intervention at day 45 and was considered a failure. The pre-massage postoperative IOP was significantly lower for the treatment group only at day 45 (16.1 vs 26.0 mm Hg, P = .012). Mean post-massage IOP was significantly lower in the treatment group at day 15 (11.28 vs 17.16 mm Hg, P = .004), day 30 (11.28 vs 20.83 mm Hg, P = .015), and day 45 (12.16 vs 21.33 mm Hg, P = .001), and similar at month 3. Mean change in bleb area was 11.4 mm(2) in the treatment group and -0.4 mm(2) in the control group (P = .036 and P = .361, respectively, Student's paired samples t test). CONCLUSION: Bevacizumab was associated with a less aggressive hypertensive period as measured by post-massage IOP measurements, postoperative glaucoma medications, and cross-sectional bleb area by ultrasound. Further prospective studies are needed to better understand the utility of SCB at the time of AVI surgery.