Efficacy and safety of first-line or second-line selective laser trabeculoplasty for normal-tension glaucoma: a multicentre cohort study.

BACKGROUND/AIMS: This study aimed to investigate and compare the efficacy and safety of first-line and second-line selective laser trabeculoplasty (SLT) in Japanese patients with normal-tension glaucoma (NTG). METHODS: 100 patients with NTG were enrolled in this study. Patients were treated with SLT as a first-line or second-line treatment for NTG. Main outcome measures were intraocular pressure (IOP) reduction rate, outflow pressure improvement rate (ΔOP), success rate at 1 year and complications. Success was defined as ΔOP≥20% (criterion A) or an IOP reduction ≥20% (criterion B) without additional IOP-lowering eye-drops, repeat SLT or additional glaucoma surgeries. The incidence of transient IOP spike (>5 mm Hg from the pretreatment IOP), conjunctival hyperaemia, inflammation in the anterior chamber and visual impairment due to SLT were assessed. RESULTS: A total of 99 patients (99 eyes) were initially enrolled in this study, including 74 eyes assigned to the first-line SLT group and 25 eyes to the second-line SLT group. The mean IOP of 16.3±2.1 mm Hg before SLT decreased by 17.1%±9.5% to 13.4±1.9 mm Hg at 12 months after SLT in the first-line group (p<0.001), and the mean IOP of 15.4±1.5 mm Hg before SLT decreased by 12.7%±9.7% to 13.2±2.0 mm Hg at 12 months after SLT (p=0.005) in the second-line group. Both groups showed significant reductions in IOP. Higher pre-SLT IOP and thinner central corneal thickness were associated with greater IOP reduction. The success rate at 1 year was higher in the first-line compared with the second-line group, with lower pretreatment IOP and the use of IOP-lowering medication before SLT being associated with treatment failure. Most post-treatment complications were minor and transient. CONCLUSIONS: SLT may be an effective and safe treatment option for NTG, as either a first-line or second-line treatment. TRIAL REGISTRATION NUMBER: The study was registered in the UMIN-CTR (UMIN Test ID: UMIN R000044059).

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.

Ab Interno Ahmed Glaucoma Valve Plugs In An Eye With Persistent Hypotony.

PURPOSE: This case report aims to describe a new method for increasing intraocular pressure (IOP) in patients with acute hypotony resulting from uveitis flare-ups and preexisting glaucoma drainage devices. The temporary glaucoma tube plug method described is effective and safe. METHODS: This case report presents a 47-year-old female patient with a history of chronic panuveitis and secondary glaucoma, who had 2 previously implanted Ahmed glaucoma valves. The patient developed panuveitis flare-up and persistent hypotony. A novel method of ab interno plugging of the glaucoma tubes using 2-0 prolene suture plugs was performed. Following treatment, the IOP increased successfully and remained within the normal range. CONCLUSION: The temporary ab interno glaucoma tube plug method effectively increased IOP in a patient with 2 preimplanted Ahmed glaucoma valves with persistent low IOP due to uveitis.

Comparison of clinical outcomes between gonioscopy-assisted transluminal trabeculotomy and trabeculectomy in advanced-stage pseudoexfoliation glaucoma.

PURPOSE: To compare clinical outcomes between gonioscopy-assisted transluminal trabeculotomy (GATT) and trabeculectomy (TRAB) in patients with advanced-stage pseudoexfoliation glaucoma (PEXG). METHODS: This comparative study comprised 62 patients who underwent GATT (N = 31) or TRAB (N = 31) for advanced-stage PEXG. Primary outcome was cumulative probability of surgical success at the end of 12-month follow-up. Success was determined as intraocular pressure (IOP) reduction ≥ 30% from baseline, IOP between 6 and 18 mmHg and IOP upper limits for IOP < 15 mmHg and < 12 mmHg, separately. Secondary outcomes were IOP reduction, antiglaucoma medication (AGM) use, and complications in the study. RESULTS: Age, sex, cup/disc ratio, mean deviation, pattern standard deviation, and retinal nerve fiber layer thickness did not significantly differ between the groups (p > 0.05 for all). The probability of cumulative surgical success at the end of 12 months was similar between the two groups for IOP < 15 mmHg and < 18 mmHg but significantly higher after TRAB (92.0%) than GATT (82.5%) for IOP < 12 mmHg (log-rank test p = 0.035). Percentage of IOP reduction from baseline was similar between the groups (53.1 ± 18.6% in GATT group and 53.0 ± 16.6% in TRAB group, p = 0.98) at the end of 12 months. No significant difference in the mean number of AGM was present at the 12-month visit (1.3 ± 1.4 in GATT and 1.1 ± 1.4 in TRAB, p = 0.65). CONCLUSION: At the end of 12 months, IOP reduction rate was similar between GATT and TRAB. Cumulative surgical success was higher after TRAB than GATT for IOP < 12 mmHg.

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.

Optimal Performance of Selective Laser Trabeculoplasty: Results from the Swedish Optimal SLT Multicenter Randomized Controlled Trial.

PURPOSE: Selective laser trabeculoplasty (SLT) is a first-line treatment for glaucoma and ocular hypertension. However, due to insufficient comparative evidence in efficacy and safety, several SLT treatment protocols are currently used in practice. The objective of this trial was to compare the clinical outcomes of the 4 most significant SLT variants. DESIGN: Prospective, multicenter, masked, randomized controlled trial (RCT). PARTICIPANTS: Four hundred patients with glaucoma or ocular hypertension. The cohort consisted of both treatment-naive patients and patients undergoing glaucoma treatment, at different stages of disease. METHODS: Selective laser trabeculoplasty was performed with 50 ± 5 laser spots in 180 degrees or with 100 ± 10 spots in 360 degrees. The laser power was titrated to either just below the cavitation bubble level ("standard energy") or to a level producing cavitation bubbles at 50% to 75% of laser applications ("high energy"). Thus, 4 different treatment protocols were included - 180/standard, 180/high, 360/standard, and 360/high. The study adhered as close as possible to regular clinical management, but within a scientific framework. MAIN OUTCOME MEASURES: Reduction of intraocular pressure (IOP) 1 to 6 months after SLT. The proportion of patients achieving a 20% IOP reduction without any further intervention. Time to glaucoma treatment escalation in a Kaplan-Meier survival analysis. RESULTS: SLT performed with the 360/high protocol was shown to be superior regarding all primary endpoints. The IOP reduction 1 to 6 months after SLT was 5.4 mmHg in the 360/high group, compared to 3.4, 3.2, and 4.2 mmHg with the 180/standard, 180/high, and 360/standard protocols, respectively (P < 0.001). Furthermore, the success rate after 6 months was significantly higher -58.3%, compared with 30.2%, 29.3%, and 41.7% (P < 0.001). The median time to glaucoma treatment escalation was more than twice as long with 360/high SLT -1323 days, compared to 437 days, 549 days, and 620 days (P < 0.001). Although postoperative discomfort was more frequent with the 360/high protocol, symptoms were generally mild and transient. Adverse events were rare in all groups. CONCLUSIONS: The magnitude and longevity of SLT results increases substantially if SLT is performed according to the 360/high protocol, without compromising safety. Therefore, we recommend that 360/high SLT be considered as standard treatment. FINANCIAL DISCLOSURES: The authors have no proprietary or commercial interest in any materials discussed in this article.

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.

Efficacy and Safety of Sutureless Deep Sclerectomy in Juvenile and Adult Open Angle Glaucoma: 2-Year Outcomes.

PRCIS: Sutureless deep sclerectomy (SDS) achieved significant reduction in primary open angle glaucoma (POAG) and juvenile open angle glaucoma (JOAG). PURPOSE: To assess long-term results of SDS in cases with POAG and JOAG. PATIENTS AND METHODS: A prospective interventional study included 84 eyes of 54 patients underwent SDS with the superficial scleral flap left un-sutured. Changes in intraocular pressure (IOP) were recorded over 2 years. Success was defined according to the world glaucoma association criteria: Criterion A: IOP ≤18 mmHg and IOP reduction ≥30% from the preoperative status without medications [complete success (A1)], with and without medications [qualified success (A2)]. Criterion B: IOP ≤15 mmHg and IOP reduction ≥40% from the preoperative status without medications [complete success (B1)], with and without medications [qualified success (B2)]. RESULTS: There was statistically significant reduction in IOP compared with the preoperative IOP (mean IOP = 26.21± 10.46 mmHg) starting from 1 st postoperative day (mean IOP = 7.18 ± 1.8 mmHg) till the end of follow-up period at 2 years (mean IOP = 15.85± 4.46) ( P < 0.001). Also, number of medications dropped significantly from 3.27 ± 1.14 to 0.82 ± 0.97 at the end of follow up period. At 2 years complete success (A1) was achieved in 57.1% and qualified success (A2) was achieved in 91.6% of cases. Subgroup analysis into males and females, POAG and JOAG showed no statistically significant difference between subgroups regarding IOP reduction. CONCLUSION: SDS is an effective and safe modification to deep sclerectomy in cases with POAG and JOAG.

"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.

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.

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.

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.

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.

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.

Efficacy of a Novel Zigzag Application Pattern for Micropulse Transscleral Cyclophotocoagulation for the Management of Glaucoma.

PRCIS: A zigzag mode of application effectively lowered IOP in glaucoma patients at 6 months with a low incidence of complications despite the longer application time. Comparative studies to assess the potential advantages of treating a larger area of ciliary body with this approach are needed. PURPOSE: The purpose of this study is to evaluate the clinical outcome of micropulse transscleral laser cyclophotocoagulation with zigzag mode of application in adult glaucomatous patients. SUBJECTS AND METHODS: A prospective single-arm clinical trial included a series of 34 eyes of 30 consecutive patients who underwent micropulse transscleral cyclophotocoagulation (MP-TSCPC) with zigzag technique at a private ophthalmology center. The trial was conducted from March 16, 2021 to April 12, 2021. Patients who had at least 6 months of follow-up were included. MP-TSCPC probe was moved for 2 mm perpendicular to a line 3 mm parallel to the cornea. This aims to cover the largest circumference of the area supposed to hinder the cilliary body. The probe is moved over 3 quadrants for 90 seconds for each quadrant (total 270 s). Defined as an intraocular pressure (IOP) of 6 to 21 mm Hg or a reduction of IOP by 30%. Failure was defined as an inability to meet the criteria for success or need for retreatment. RESULTS: The mean age of involved patients was 52.9 (±SD: 3.9) years old. The mean IOP before MP-TSCPC was 37.47 (±SD: 11.08) mm Hg, which was significantly reduced to 17.7 (±SD: 7.4) mm Hg in the last follow-up visit at 6 months. Number of medications showed significant reduction from mean 3.44 (±SD: 0.99) to 1.91 (±SD: 1.26) in the last follow-up. Success rate was found to be 88% (30 out of 34 eyes) at the final follow-up, where 9 cases showed complete success (26.5%), whereas 21 (61.8%) cases showed qualified success. Despite the relatively higher parameters used in our study, no cases reported postoperative complications apart from only 1 case of reduced visual acuity by 1 line. CONCLUSIONS: A zigzag mode of application effectively lowered IOP in glaucoma patients at 6 months with a low incidence of complications despite the longer application time. Comparative studies to assess the potential advantages of treating a larger area of ciliary body with this approach are needed.

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.