Primary trabeculectomy for advanced glaucoma: pragmatic multicentre randomised controlled trial (TAGS).

OBJECTIVE: To determine whether primary trabeculectomy or primary medical treatment produces better outcomes in term of quality of life, clinical effectiveness, and safety in patients presenting with advanced glaucoma. DESIGN: Pragmatic multicentre randomised controlled trial. SETTING: 27 secondary care glaucoma departments in the UK. PARTICIPANTS: 453 adults presenting with newly diagnosed advanced open angle glaucoma in at least one eye (Hodapp classification) between 3 June 2014 and 31 May 2017. INTERVENTIONS: Mitomycin C augmented trabeculectomy (n=227) and escalating medical management with intraocular pressure reducing drops (n=226) MAIN OUTCOME MEASURES: Primary outcome: vision specific quality of life measured with Visual Function Questionnaire-25 (VFQ-25) at 24 months. SECONDARY OUTCOMES: general health status, glaucoma related quality of life, clinical effectiveness (intraocular pressure, visual field, visual acuity), and safety. RESULTS: At 24 months, the mean VFQ-25 scores in the trabeculectomy and medical arms were 85.4 (SD 13.8) and 84.5 (16.3), respectively (mean difference 1.06, 95% confidence interval -1.32 to 3.43; P=0.38). Mean intraocular pressure was 12.4 (SD 4.7) mm Hg for trabeculectomy and 15.1 (4.8) mm Hg for medical management (mean difference -2.8 (-3.8 to -1.7) mm Hg; P<0.001). Adverse events occurred in 88 (39%) patients in the trabeculectomy arm and 100 (44%) in the medical management arm (relative risk 0.88, 95% confidence interval 0.66 to 1.17; P=0.37). Serious side effects were rare. CONCLUSION: Primary trabeculectomy had similar quality of life and safety outcomes and achieved a lower intraocular pressure compared with primary medication. TRIAL REGISTRATION: Health Technology Assessment (NIHR-HTA) Programme (project number: 12/35/38). ISRCTN registry: ISRCTN56878850.

Comparison of Intraocular Pressure, Usage of Topical Steroids, Need for Intraocular Pressure Lowering Drops, and Incidence of Glaucoma Surgery Up to 2 Years After Penetrating Keratoplasty and Endothelial Keratoplasty.

PRECIS: A retrospective review of 239 eyes comparing intraocular pressure (IOP), steroid needs, IOP-lowering drop needs, and incidence of glaucoma surgery between endothelial keratoplasty and penetrating keratoplasties (PKP) at multiple timepoints postoperatively up to 2 years. PURPOSE: The purpose of this study was to compare postoperative IOP, steroid use, IOP-lowering drop use, and need for glaucoma surgery between PKP, Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSEK). MATERIALS AND METHODS: A retrospective chart review of all PKP, DMEK, and DSEK surgeries was performed between July 1, 2012 and July 1, 2017 at the University of California, Irvine. Patients with a prior history of glaucoma, corneal or glaucoma surgery, concurrent major or emergent surgery, active infection, and eye disease with synechiae were excluded. A total of 239 patients who underwent PKP (N=127), DMEK (N=46), or DSEK (N=66) were included. IOP, steroid use, IOP-lowering drop use, and need for glaucoma surgery were compared at postoperative day 1, postoperative week 1 (POW1), and postoperative month 1 to 24 (POM1-24). RESULTS: IOP for PKP was higher than DMEK and DSEK at POW1, POM1, POM6, and POM24 (P<0.05). IOP for PKP was higher than DMEK at POM12 (P=0.028). There was no significant difference in IOP between DMEK and DSEK for all timepoints. PKP required more steroids than DSEK and DMEK at POM3, POM6, POM12, and POM24 (P<0.05). More IOP-lowering drops were required for DSEK than DMEK and PKP at postoperative day 1 and POW1 (P<0.05). More IOP-lowering medications were used for DSEK than DMEK at POM3 and POM12 (P<0.05). About 6% to 7% of patients needed glaucoma surgery by POM24. CONCLUSIONS: Endothelial keratoplasties had decreased IOP and steroid needs compared with PKPs postoperatively up to 2 years. The rate of glaucoma surgery and IOP-lowering drop needs were similar between the groups.

Clinical practice preferences for glaucoma surgery in Japan: a survey of Japan Glaucoma Society specialists.

PURPOSE: This study evaluated the surgical practice patterns of glaucoma management followed by glaucoma specialists in Japan. METHODS: A survey was administered to 50 glaucoma specialists who were councilors in the Japan Glaucoma Society about surgical preferences and postoperative glaucoma care. RESULTS: All 50 glaucoma specialists participated in the survey. Results show that, in 2019, compared to conventional trabeculotomy (4.6%), the frequency of minimally invasive glaucoma surgery (MIGS), combined with phacoemulsification, remarkably increased (79.0%) for non-operated eyes with mild open-angle glaucoma associated with cataract. Tube-shunt surgery was performed more often for open-angle glaucoma with previously twice failed trabeculectomy (65.8%) and neovascular glaucoma with previously once failed trabeculectomy (63.4%). In addition, during one year post-operatively, MIGS required less frequent follow-up visits compared to filtering surgery. CONCLUSION: Although glaucoma specialists in the Japan Glaucoma Society usually prefer trabeculectomy, in the past decade they have selected tube-shunt surgery more often to treat refractory glaucoma. MIGS is increasing remarkably as the choice primary glaucoma surgery.

Trends in glaucoma procedures and surgeries at the eye foundation hospital group, Nigeria.

AIMS: To review the trends in glaucoma procedural treatments from January 2009 to December 2017. METHODOLOGY: A retrospective search was carried out from the operating theater and laser room records of the Eye Foundation Hospitals in Lagos, Abuja, and Ijebu-Imushin. Consecutive glaucoma procedures for each year from January 2009 to December 2017 were recorded in the data sheet prepared for the study. Data were analyzed using SPSS version 25. RESULTS: From 2009 to 2017, trabeculectomy had been decreasing in frequency from 117 to 65 (44%), except for 2015. The frequency of use of glaucoma drainage device (GDD) has been steadily increasing from 1 in 2013 to 26 in 2017, but this is not statistically significant. The frequency of cataract extraction with trabeculectomy reduced drastically from 20 in 2009 to 3 (566%) in 2014. Bleb review (BR) increased from 2 in 2009 to 18 (800%) in 2015, however, it dropped to 6 in 2017 (66%). Among the laser procedures, transscleral cyclophotocoagulation (g-probe) is commonly done. It increased from 40 procedures in 2009 to 98 in 2014 (145%). There has been an increase in laser trabeculoplasty from 15 in 2009 to 44 in 2013 (193%). Laser iridotomy increased from 12 in 2009 to 26 in 2015 (116%). From 2009 to 2015, there was an increase in glaucoma procedures and surgeries - 206 to 325 (58%) but this declined by 27% from 2015 to 2017. CONCLUSION: Trabeculectomy is the most performed procedure at our centers. This is followed by g-probe and laser trabeculoplasty. The rate of trabeculectomy is on the decrease, while the rate of GDD is increasing. The laser procedures are also on the increase.

Trends in the characteristics of acute primary angle closure in Korea over the past 10-years.

PURPOSE: To investigate the changes in the demographic, clinical, and biometric characteristics of APAC patients in South Korea during the last decade. METHODS: Medical records of patients with APAC who visit the emergency department or the glaucoma clinic of Chonnam National University Hospital, a tertiary referral center in Gwangju, South Korea in 2007 and 2017 were analyzed. Demographics, clinical characteristics, and treatment modality were compared between the APAC patients in 2007 and 2017. RESULTS: The number of patients with APAC increased from 54 in 2007 to 68 in 2017. Female patients in their 60s were most common in both groups and there was no significant difference in IOP, cataract grade, gonioscopic grading, PAS, or optic nerve damage between the two groups at baseline visit (all P > 0.05). However, APAC eyes in 2017 had a shallower ACD (1.74 ± 0.28 mm vs 1.87 ± 0.35 mm; P = 0.024) and greater LV (1.05 ± 0.26 mm vs 0.93 ± 0.19 mm; P = 0.001) than those of APAC eyes in 2007. During one year follow-up, 25 patients (51.02%) received LPI only, and 18 patients (36.73%) required LE, and 6 patients (12.24%) required phacotrabeculectomy or sequential LE and trabeculectomy. However, in 2017, LPI alone was sufficient in 23 patients (38.33%), 29 patients (48.33%) required further LE, and 8 patients (13.33%) required phacotrabeculectomy or sequential LE and trabeculectomy for the treatment of APAC (P = 0.015). CONCLUSIONS: Compared to older cases of APAC, recent cases received LE more frequently, which suggests an increasing trend of LE as a treatment option for APAC. In addition, recent cases had a greater LV and shallower ACD than older cases and these biometric differences may be one of the reasons for increasing rate of LE in this study.

Glaucoma care in Nigeria: Is the current practice poised to tackle this emerging sight-threatening disease?

PURPOSE: To investigate the current practice on glaucoma care with the aim of highlighting its poise to tackle this emerging sight-threatening disease in Nigeria. METHODS: This was a cross-sectional, descriptive, population-based survey involving 88 ophthalmologists. Information on their demographic characteristics, practice profile, challenges and prospects on glaucoma care was collected using a semi-structured, self-administered questionnaire in August 2016. Data were analysed using SPSS 20. RESULTS: The participants are comprised of 46 (52.3%) males and 42 (47.7%) females, with a mean age of 42.2 ± 8.7 SD years. They were 45 (51.1%) consultants, 31 (35.2%) residents and 12 (13.6%) diplomates. Their years of practice were 8.8 ± 6.7 SD years. They worked mainly in government hospitals located at the southern part of Nigeria. The current practice was mainly comprehensive ophthalmology, 63 (71.6%). Only 2 (2.3%) had strict subspecialty practice. Others, 23 (26.1%), had combined practice. Eleven (12.5%) were glaucoma specialists and had combined practice. The majority of the participants, 57 (64.8%), were routinely diagnosed glaucoma properly. Sixty-three (71.6%) participants underwent trabeculectomy, 48 (54.5%) combined cataract surgery with trabeculectomy, 7 (8.0%) drainage implants, 5 (5.7%) laser trabeculoplasty, and 2 (2.3%) minimally invasive glaucoma surgery. Poor patients' acceptance and satisfaction, fear of complications, lengthy post-operative care and cost were the main deterrents to surgeries. Advocacy, public awareness, training of glaucoma specialists, provision of equipment and health insurance were the major recommendations on improving glaucoma care. CONCLUSION: Given the meagre number of specialists and lack of strict subspecialty practice, optimal glaucoma care in Nigeria is still far from reality.

Changes in glaucoma medication numbers after cataract and glaucoma surgery: A nationwide population-based study.

To determine whether cataract or glaucoma and combined cataract and glaucoma surgery (CGS) affect glaucoma medication usage.We recruited patients who received new diagnoses of glaucoma, either primary open-angle glaucoma (POAG) (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 365.1) or primary angle-closure glaucoma (PACG) (ICD-9-CM code 365.2), between 1998 and 2011 and had undergone cataract surgery alone (CS), glaucoma surgery alone (GS), or CGS under the National Health Insurance program in Taiwan. CS, GS, and CGS in all the patients were performed after the glaucoma diagnosis date. The patients were subdivided into CS, CGS, and GS groups. The number of glaucoma medications, including prostaglandin analogs, ß-blockers, carbonic anhydrase inhibitors, α-agonists, pilocarpine, and a combination of drugs, in each prescription, were compared before and after surgery.The mean number of glaucoma medications in each prescription before the surgery increased from approximately 0.5/1 (CS/CGS + GS) to a peak of 1.75/3 within 3 months before the index date. The mean number of glaucoma medications in each prescription reduced to 0 (CS group) and to approximately 0.5 (CGS and GS) at the end of the 3-year follow-up period. The mean number of glaucoma medications in each prescription significantly reduced at the time points within 6 months, between 6 months and 2 years, and during 2 to 3 years after surgery in each group. At the end of the 3-year period, the reduction effect was most evident in the CS group. Similar trends were also observed in the POAG and PACG group.CS, GS, and CGS significantly reduced the number of glaucoma medications used by the glaucoma patients.

[Selective laser trabeculoplasty in African blacks]. / Trabéculoplastie sélective chez le mélanoderme africain.

INTRODUCTION: The treatment of primary open angle glaucoma (POAG) is preferably medical. However, when medical therapy fails, alternative or complementary treatments may be considered. In this regard, selective laser trabeculoplasty is a widely popular procedural treatment whose accepted benefits have been very little studied in African blacks. The objective of this study was to assess the efficacy of selective laser trabeculoplasty on the reduction of intraocular pressure (IOP) in African blacks with POAG. METHODS: We conducted a retrospective study of black patients treated with selective laser trabeculoplasty between March 2010 and March 2011. All patients had POAG with trabecular meshwork accessible over 360°. The treatment protocol consisted of a 360°treatment in two sessions (180°/session) 15 days apart. Success was defined as decrease from the initial IOP≥3mm Hg without additional medications. RESULTS: We included 44 patients, corresponding to 82 eyes. The mean age of the patients was 55.94±11.66 years with extremes of 19 years and 76 years. The mean intraocular pressure before laser treatment (initial IOP) was 18.43±4.81mm Hg. After laser treatment, the mean pressure reduction was (i) 3.81mm Hg (20.67%) at 15 days ; (ii) 4.08mm Hg (22.14%) at 1 month; (iii) 4.45mm Hg (24.14%) at 3 months; and (iv) 4.95mm Hg (26.86%) at 6 months. The success rate after laser treatment was 67.60% at 15 days, 83.78% at 1 month, 72.09% at 3 months and 80.43% at 6 months. CONCLUSION: Selective laser trabeculoplasty is effective in African blacks. Its efficacy is comparable to that of a carbonic anhydrase inhibitor or even a prostaglandin. It could be a complementary or substitutive alternative to POAG medications in African blacks.

Clinical Characteristics and Outcomes of Malignant Glaucoma after Different Procedures Treated with Pars Plana Vitrectomy: A 10-Year Retrospective Study.

Background and objectives: Despite established common risk factors, malignant glaucoma (MG) remains a rare condition with challenging management. We aimed to analyze differences in risk factors for MG after different surgeries and outcomes after pars plana vitrectomy (PPV). Materials and Methods: This retrospective study included cases of MG treated with PPV between January 2005 and December 2015 in the Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas, Lithuania. Results: A total of 39 cases were analyzed: 23 (59%) after cataract surgery, 13 (33.3%) after trabeculectomy, and 3 (7.7%) after other interventions. Characteristics among the groups did not differ. Intraocular lens refractive power was significantly higher in the cataract group, in which intraocular pressure (IOP) before MG was significantly greater in the affected eye. Normotension was achieved in 92.3%, and a normal anterior chamber in 75%. Additional measures included eye drops (n = 24), trabeculectomy (n = 5), bleb revision (n = 2), synechiotomy (n = 4), and cyclophotocoagulation (n = 1). The proportion of drop-free patients significantly increased after PPV compared with that before MG development (38.5% versus 15.4%). Complications were observed in 11 cases: choroidal detachments with spontaneous resolution (n = 2); retinal detachment (n = 1); constant mydriasis (n = 1), neovascular glaucoma (n = 1); obstruction of filtrating zone by iris (n = 1) and by blood clot (n = 1); posterior synechia formation causing IOP rise (n = 4 (all resolved after synechiotomy)). The cataract group experienced significantly fewer complications than the trabeculectomy group (17.4% vs. 53.8%, respectively). Conclusions: There were no differences in the risk of MG among the different surgeries. However, higher IOP in the predisposed eye (versus contra-lateral eye) could indicate additional risk of MG after cataract surgery. PPV afforded reliable treatment for MG and the possibility for glaucoma patients to discontinue topical treatment.

Gonioscopy-assisted Transluminal Trabeculotomy: An Ab Interno Circumferential Trabeculotomy: 24 Months Follow-up.

PURPOSE: The purpose of this study was to provide 24-month follow-up on surgical success and safety of an ab interno circumferential 360-degree trabeculotomy. METHODS: Chart review of patients who underwent a gonioscopy-assisted transluminal trabeculotomy (GATT) procedure was performed by 4 of the authors (D.S.G., O.S., R.L.F., and D.G.G.). The surgery was performed in adults with various types of open-angle glaucoma with preoperative intraocular pressures (IOPs) of ≥18 mm Hg. RESULTS: In total, 198 patients aged 24 to 89 years underwent the GATT procedure with at least 18 months follow-up. Patients with primary open-angle glaucoma had an average IOP decrease of 9.2 mm Hg at 24 months with an average decrease of 1.43 glaucoma medications. The mean percentage of IOP decrease in these primary open-angle glaucoma groups at 24 months was 37.3%. In secondary open-angle glaucoma, at 24 months there was an average decrease in IOP of 14.1 mm Hg on an average of 2.0 fewer medications. The mean percentage of IOP decrease in the secondary open-angle glaucoma groups at 24 months was 49.8%. The cumulative proportion of failure at 24 months ranged from 0.18 to 0.48, depending on the group. In all 6 study groups, at all 5 postoperative time points (3, 6, 12, 18, and 24 mo) the mean IOP and reduction in glaucoma medications was significantly reduced from baseline (P<0.001) with the exception of one time point. CONCLUSIONS: The 24-month results demonstrate that GATT is relatively safe and effective in treating various forms of open-angle glaucoma. The long-term results for GATT are relatively equivalent to those previously reported for GATT and ab externo trabeculotomy studies.

Evaluation of preoperative speed of progression and its association with surgical outcomes in primary congenital glaucoma patients: a retrospective study.

BACKGROUND: Surgeries are inevitable for treating primary congenital glaucoma (PCG) and risk factors of surgical failure play a key role in surgical decision making. The aim of this study was to investigate the influence of delay of surgery and preoperative speed of progression (SP) on the surgical outcomes in these patients. METHODS: Medical records of 83 eyes of 51 PCG patients with trabeculotomy within 3 years were retrospectively observed. Surgical outcomes, demographic and clinical data were compared after separating the eyes into two groups based on the interval (between onset of PCG and trabeculotomy) and SP index (SPI) respectively. Student's t-test, Wilcoxon rank-sum test, Pearson's chi-square test and Kaplan-Meier survival analysis were used in the statistical analysis. RESULTS: Comparative analysis showed better outcomes in the group with longer interval and lower SPIs. Better intraocular pressure (IOP) control was found in patients with lower SPI at 1, 3, 6, 12 and 24 months postoperatively (19.54 ± 4.84 mmHg vs. 24.75 ± 8.87 mmHg, p = 0.004; 19.88 ± 7.78 mmHg vs. 23.19 ± 6.74 mmHg, p = 0.089; 17.45 ± 6.23 mmHg vs. 21.31 ± 7.28 mmHg, p = 0.031; 15.09 ± 6.21 mmHg vs. 19.18 ± 6.66 mmHg, p = 0.008; 14.95 ± 2.95 mmHg vs. 18.10 ± 3.96 mmHg, p = 0.004). The correlation between SPI and IOP at 1, 3, 6, 12 and 24 months postoperatively was 0.328 (CI = 0.105 to 0.529, p = 0.005), 0.192 (CI = -0.070 to 0.429, p = 0.149), 0.261 (CI = 0.010 to 0.481, p = 0.042), 0.046 (CI = -0.183 to 0.270, p = 0.70), and 0.230 (CI = -0.072 to 0.493, p = 0.134), respectively. Patients with lower SPI were less likely to fail (χ2 = 22.71, p = 0.000, OR: 0.174; 95%CI: 0.059-0.510). Kaplan-Meier analysis showed a much slower decline of success rate in patients with lower SPI (χ2 = 25.52, p = 0.000). CONCLUSIONS: In PCG patients, lower preoperative SPI was associated with better short-term IOP control and success rate. Evaluation of preoperative SPI may help with surgical decision. However, early detection and treatment are important given the same SPI.

Can Adapted Motivational Interviewing Improve Uptake of Surgical or Laser Treatment for Glaucoma in Nigeria: Randomized Controlled Trial.

PURPOSE: To assess whether adapted motivational interviewing (MI) has any impact on the proportion of participants who subsequently underwent surgery or laser treatment for glaucoma. MATERIALS AND METHODS: A single site randomized controlled trial in Bauchi, Nigeria. Participants were new patients with a confirmed diagnosis of primary open-angle glaucoma in 1 or both eyes, where surgery or laser was recommended. Intervention was a session of MI adapted for glaucoma and the local context, using an interview guide based on local qualitative research. Participants were randomly allocated to intervention or usual care. Usual care was routine explanation by an ophthalmologist and an educational pamphlet. After the interview, a 12-item Working Alliance Inventory questionnaire was administered to patient-interviewer pairs to assess the collaborative relationship. RESULTS: Two hundred seventy-six glaucoma patients participated; 70% males. One hundred thirty-five (49%) were assigned to adapted MI and 141 to usual care. All received the intervention as allocated. Uptake (ie, the proportion who underwent treatment) of laser or surgery in the MI group was 52% compared with 45% in the usual care group (risk difference 7.2%; 95% confidence interval, -4.5% to 18.9%). Mean Working Alliance Inventory scores were 68.0 for interviewers and 68.5 for participants with a combined reliability coefficient of 93.9% (ie, high internal consistency and reliability). CONCLUSIONS: We observed only a small increase in the uptake of surgery or laser with MI compared with usual care which was not statistically significant. Although only 1 in 2 patients accepted surgery or laser in this trial, this is a much higher proportion than in other studies.

Practice of trabeculectomy by ophthalmologists in Nigeria.

AIM: To assess the practice of trabeculectomy among ophthalmologists in Nigeria. MATERIALS AND METHODS: This was a cross-sectional study in which structured, self- administered questionnaires were distributed to 80 consenting ophthalmologists present during the 2010 annual scientific session of the Ophthalmological Society of Nigeria. All consenting ophthalmologists treat glaucoma patients. Information obtained were demographic characteristics, glaucoma outpatient load, number of trabeculectomies performed in the preceding 1 year and during residency training, and factors influencing trabeculectomy practice. Data were analyzed with Statistical Package for Social Science version 16.0. Relationships between variables were tested using the ×2 test for statistical significance. RESULTS: Sixty-five of the 80 consenting ophthalmologists responded to the questionnaires (81.3% response rate); 32 (53.3%) were females and 28 (46.7%) were males (5 non-responders). Ages ranged from 30 to 60 years with a mean of 44 years ± SD 7.7. Only 36 (57.1%) performed trabeculectomy in the 1 year preceding the study. There was an overall trabeculectomy rate of 0.9/ophthalmologist/month. Of the 15 respondents who performed more than 15 trabeculectomies during residency, 14 (93.3%) also performed the surgery in the year preceding this study (P = 0.001). The main limitation to the practice of the procedure was patients' unwillingness to accept surgery, as identified by 50 (89.3%) respondents. CONCLUSIONS: A low trabeculectomy rate of 0.9/ophthalmologist/month was found in this study. It was significantly associated with insufficient exposure to the surgery during residency training and patients' poor acceptance of the surgery.

Long-term efficacy of combined phacoemulsification plus trabeculectomy versus phacoemulsification plus excimer laser trabeculotomy.

Background Combined cataract and glaucoma procedures, and minimally-invasive glaucoma surgery in particular, have gained increasing interest over the past few years. The aim of this study was to compare the long-term efficacy of combined phaco-trabeculectomy (Phaco-Trab) and combined phacoemulsification plus excimer laser trabeculotomy (Phaco-ELT). Patients and Methods Retrospective, non-randomised, comparative, interventional case series of consecutive patients after Phaco-Trab and Phaco-ELT at the University Hospital of Zurich and the Talacker Eye Center Zurich in Switzerland. Inclusion criteria were diagnosis of glaucoma plus vision-impairing coexisting cataract. Primary outcome measures were change in intraocular pressure (IOP), number of anti-glaucoma drugs (AGDs), and best-corrected visual acuity (BCVA) 1 year and 4 years after the procedure. Secondary outcome measures were surgical complications and requirement of postoperative interventions. Success was defined based on the criteria of the Tube-versus-Trabeculectomy study. Results Mean age was 76.1 ± 8.6 years (29.2 % males; 47.8 % right eyes). Phaco-Trab (n = 62) decreased median IOP from 22.8 to 13.0 at 1 year and to 14.0 mmHg at 4 years. AGDs were reduced from 2 drugs to 0 AGDs at 1 year and 4 years. Median BCVA improved from 0.2 logMAR to 0.0 logMAR at 1 year and 4 years. Phaco-ELT (n = 51) lowered median IOP from 19.0 to 15.0 at 1 year and to 14.0 mmHg (p = 0.002) at 4 years. AGDs were reduced from 2 drugs to 1 AGD at 1 year and 4 years (p = 0.002). BCVA improved from 0.4 logMAR to 0.1 logMAR after 1 year and 4 years. If not stated otherwise, all changes compared to baseline were highly significant (p < 0.001). No perioperative complications occurred; postoperative interventions were performed in 74 % of Phaco-Trab patients. Conclusion Both surgical procedures reduced IOP and AGDs and improved BCVA significantly and persistently during the entire follow-up period of 4 years with a good safety profile. This study validates Phaco-ELT as an option when post-operative target pressure in the mid-teens would be adequate, whereas Phaco-Trab would be the treatment of choice when IOP in the low teens is desired.

Victorian trabeculectomy audit.

IMPORTANCE: This study highlights the efficacy and safety of trabeculectomy in Victoria, Australia. BACKGROUND: Trabeculectomy is currently the gold standard in glaucoma surgery. However, its role has been increasingly questioned because of its associated risks and complications. This audit aimed to assess the efficacy and safety of trabeculectomy surgery in the state of Victoria, Australia. DESIGN: A cross-sectional, retrospective and voluntary statewide audit of trabeculectomy surgery by individual surgeons in 2012 with 24 months follow-up. PARTICIPANTS: Twenty-four surgeons in the state of Victoria submitted data on 227 trabeculectomies. METHODS: Basic preoperative and perioperative data were collected. Post-operative data collected included intra-ocular pressure measurements, glaucoma medications, associated complications and subsequent surgery up to 24 months post-trabeculectomy. MAIN OUTCOME MEASURES: The main outcome measures were post-operative intra-ocular pressure and surgical complications. RESULTS: At 12 months, the mean intra-ocular pressure was 12.6 ± 4.1 mmHg (range 3-28 mmHg). A total of 91% of eyes had an intra-ocular pressure ≤18 mmHg with or without ocular hypotensive medications. One-third of eyes that were phakic at the time of trabeculectomy underwent cataract extraction within the 24 months of follow-up. Eyes that underwent combined cataract extraction and trabeculectomy (23% of trabeculectomies) had a significantly higher mean 12-month intra-ocular pressure than eyes that underwent trabeculectomy alone (13.9 vs. 12.2 mmHg, P = 0.01). At 24 months, there were no cases of blebitis/endophthalmitis. CONCLUSIONS AND RELEVANCE: The Victorian Trabeculectomy Audit demonstrates excellent efficacy and safety results that are comparable with international standards. Combined cataract extraction and trabeculectomy tended to result in a higher mean post-operative intra-ocular pressure than trabeculectomy alone.

Association of Repeated Intravitreous Bevacizumab Injections With Risk for Glaucoma Surgery.

Importance: Intravitreous injections of anti-vascular endothelial growth factor (VEGF) agents are associated with a sustained increase in intraocular pressure. This sustained elevated intraocular pressure could lead to higher rates of glaucoma surgery to lower this pressure. Objective: To determine the risk of glaucoma surgery following repeated intravitreous bevacizumab injections. Design, Setting, Participants: This nested, case-control study acquired and analyzed data from large, population-based, linked health databases supported by the British Columbia Ministry of Health in Canada. Study participants included all patients with ophthalmic issues in British Columbia, such as those of the Provincial Retinal Diseases Treatment Program, who had received intravitreous bevacizumab injections for exudative age-related macular degeneration between January 1, 2009, and December 31, 2013. Cases were identified using glaucoma surgical codes for trabeculectomy, complicated trabeculectomy, glaucoma drainage device, and cycloablative procedure. For each case, 10 controls were identified and matched for age, preexisting glaucoma, calendar time, and follow-up time. The number of intravitreous bevacizumab injections received per year-3 or fewer, 4 to 6, or 7 or more-was determined for both cases and controls. Data analysis was performed from February 23, 2016, to November 14, 2016. Main Outcomes and Measures: Risk of glaucoma surgery compared with the number of intravitreous bevacizumab injections per year in cases and controls. Rate ratios were adjusted for covariates (diabetes mellitus, myocardial infarction, stroke, and verteporfin use). Results: Seventy-four cases of glaucoma surgery and 740 controls were identified, with a mean (SD) age of 81.3 (8.4) years for cases and 81.4 (7.9) for controls. The case group had more males than the control group (38 [51.4%] vs 272 [36.8%]). The adjusted rate ratio of glaucoma surgery among those who received 7 or more injections per year was 2.48 (95% CI, 1.25-4.93). There was a 10.3% higher number of 7 or more injections among cases compared with controls. The adjusted rate ratio for those who received 4 to 6 injections per year compared with those who received 3 or fewer was 1.65% (95% CI, 0.84-3.23). Conclusions and Relevance: Findings from this large, pharmacoepidemiologic study suggest that 7 or more intravitreous injections of bevacizumab annually is associated with a higher risk of glaucoma surgery and that 4 to 6 injections per year show a nonstatistically significant rate ratio in the same direction.

Survey of glaucoma surgical preferences and post-operative care in the United Kingdom.

BACKGROUND: To evaluate the spectrum of glaucoma surgery and the post-operative follow-up regimes undertaken among glaucoma specialists in the United Kingdom. DESIGN: National survey. PARTICIPANTS: Seventy-five glaucoma specialists (consultants and fellows). METHODS: An eight-question survey was emailed to all glaucoma subspecialists members of the United Kingdom and Eire Glaucoma Society. MAIN OUTCOME MEASURES: Surgery undertaken, post-operative management, awareness of intervention tariff and handling of the follow-up burden generated through surgery. RESULTS: Almost all the participants (74/75: 99%) routinely performed trabeculectomy, 54 responders (72%) undertook tube surgery and Minimally Invasive Glaucoma Surgery (MIGS) was more frequently undertaken (33.0%) than non-penetrating surgery (23%). In general, for patients with advanced glaucoma requiring a low target intraocular pressure (IOP), the most frequent primary intervention was trabeculectomy (99%), followed by tubes (64%). Similarly, in patients with less advanced glaucoma requiring moderate target IOP, participants preferred trabeculectomy (99%), followed by MIGS (60%). By the first 6 months after the procedure, trabeculectomy and Baerveldt tube implant required a larger number of postoperative visits (9 and 7, respectively), than iStent® and non-penetrating deep sclerectomy (3 and 5, respectively). The majority of participants were not aware of the costs of their interventions. CONCLUSIONS: A wide variety of glaucoma surgery techniques are undertaken. Post-operative follow-up regimes are variable between techniques and for surgeons using the same technique. Trabeculectomy requires more follow-up than any other intervention. For patients requiring low IOP, trabeculectomy is the operation of choice for most surgeons.

Preoperative characteristics and compliance with follow-up after trabeculectomy surgery in rural southern China.

PURPOSE: To evaluate preoperative characteristics and follow-up in rural China after trabeculectomy, the primary treatment for glaucoma there. METHODS: Patients undergoing trabeculectomy at 14 rural hospitals in Guangdong and Guangxi Provinces and their doctors completed questionnaires concerning clinical and sociodemographic information, transportation, and knowledge and attitudes about glaucoma. Follow-up after surgery was assessed as cumulative score (1 week: 10 points, 2 weeks: 7 points, 1 month: 5 points). RESULTS: Among 212 eligible patients, mean preoperative presenting acuity in the operative eye was 6/120, with 61.3% (n=130) blind (≤6/60). Follow-up rates were 60.8% (129/212), 75.9% (161/212) and 26.9% (57/212) at 1 week, 2 weeks and 1 month, respectively. Patient predictors of poor follow-up included elementary education or less (OR=0.37, 95% CI 0.20 to 0.70, p=0.002), believing follow-up was not important (OR=0.62, 95% CI 0.41 to 0.94, p=0.02), lack of an accompanying person (OR=0.14, 95% CI 0.07 to 0.29, p<0.001), family annual income

[Surgical options before and after trabectome surgery : Impact of previous surgeries, possibilities of revision surgery and complication management]. / Chirurgische Optionen vor und nach Trabektomchirurgie : Einfluss von Voroperationen, Möglichkeiten der Revisionschirurgie und Komplikationsmanagement.

BACKGROUND: Trabectome surgery is a new method to lower intraocular pressure through ablation of the trabecular meshwork. Technically, it is an ab interno trabeculotomy. The goal of this review is to investigate the options after failed trabectome surgery and evaluate the possibilities of trabectome surgery after failed previous glaucoma surgery. OBJECTIVES: A literature review was performed to answer the following questions: (1) Is trabectome surgery an option after failed glaucoma surgery? (2) Is trabeculectomy an option after failed trabectome surgery? (3) Which postoperative constellations require early revision surgery after trabectome surgery? RESULTS: Trabectome surgery is an option after failed trabeculectomy or failed tube surgery. Performing a trabeculectomy after failed trabectome surgery did not show disadvantages. Hypotony or hyphema is rare and self-limiting and, therefore, does not require further surgery. CONCLUSIONS: Due to a lack of randomized studies, recommendations should be taken with caution.

Glaucoma Surgery Outcome in Rwanda.

PURPOSE: To assess long-term intraocular pressure (IOP) outcome after adult trabeculectomy surgery in Central Africa. PATIENTS AND METHODS: All adult glaucoma patients who underwent trabeculectomy surgery in the Kabgayi Eye Unit, Rwanda between August 2003 and March 2008 were invited for a follow-up visit. Surgical and clinical data were collected from medical records. At the study visit, best-corrected visual acuity was measured and Goldmann applanation tonometry and biomicroscopy were done. Good IOP outcome was defined as both an IOP<21 mm Hg and achieving ≥30% reduction from the preoperative IOP. Considering first operated eyes, univariate and multivariate logistic regression was used to investigate risk factors for failure. RESULTS: Of 163 individuals operated 3 had died, 118 (74%) participated. Preoperatively, the mean IOP was 31 mm Hg (SD=11; range, 12 to 60). At the time of the follow-up study visit the mean postoperative IOP was 13 mm Hg (SD=5; range, 4 to 35). Good IOP outcome was achieved in 132 eyes (84%). Univariate analysis suggested a protective effect against failure of use of antimetabolites [odds ratio (OR)=0.39; 95% confidence interval (CI), 0.14-1.11; P=0.07] and a decrease in success with length of follow-up (OR=3.57; 95% CI, 1.09-12.50; P=0.03). The latter remained borderline significant with multivariate analysis. Seven eyes went from previously better vision (at least hand movements) down to perception of light or no perception of light after trabeculectomy. Particularly a flat anterior chamber in the first postoperative week (OR=0.07; 95% CI, 0.01-0.49; P<0.001) and late hypotony (OR=0.04; 95% CI, 0.002-0.99; P=0.004) were significant risk factors for severe visual loss. CONCLUSIONS: Trabeculectomy with antimetabolites is one of the best available options for glaucoma management in Africa. However, the IOP control reduced at a follow-up duration beyond 2 years, highlighting the importance of regular long-term follow-up.