[Review by the French Glaucoma Society on the roles of new surgical techniques in glaucoma]. / Mise au point de la Société française du glaucome sur la place des nouvelles techniques chirurgicales dans le glaucome.

The surgical management of glaucoma has been enriched in recent years by the arrival of new surgical techniques as a group known as MIGS (minimally invasive glaucoma surgery). The objective of these new techniques is to reduce intraocular pressure (IOP) while limiting the risk of complications of conventional filtering surgery and allowing faster visual recovery. MIGS can be classified into three main categories depending on the route used to promote the outflow of aqueous humor: the trabecular route, the suprachoroidal route and the subconjunctival route. MIGS using the subconjunctival route are also called minimally invasive bleb surgery (MIBS). These new techniques do not replace conventional filtering surgery, which remains the gold standard technique, but now offer new alternatives for the surgical management of glaucoma patients in combination with cataract surgery or as stand-alone procedures.

[Visual field progression in glaucoma: cluster analysis]. / Progression du champ visuel dans le glaucome: intérêt de l'analyse de l'évolution des clusters.

BACKGROUND: Visual field progression analysis is one of the key points in glaucoma monitoring, but distinction between true progression and random fluctuation is sometimes difficult. There are several different algorithms but no real consensus for detecting visual field progression. The trend analysis of global indices (MD, sLV) may miss localized deficits or be affected by media opacities. Conversely, point-by-point analysis makes progression difficult to differentiate from physiological variability, particularly when the sensitivity of a point is already low. The goal of our study was to analyse visual field progression with the EyeSuite™ Octopus Perimetry Clusters algorithm in patients with no significant changes in global indices or worsening of the analysis of pointwise linear regression. PATIENT AND METHOD: We analyzed the visual fields of 162 eyes (100 patients - 58 women, 42 men, average age 66.8 ± 10.91) with ocular hypertension or glaucoma. For inclusion, at least six reliable visual fields per eye were required, and the trend analysis (EyeSuite™ Perimetry) of visual field global indices (MD and SLV), could show no significant progression. The analysis of changes in cluster mode was then performed. In a second step, eyes with statistically significant worsening of at least one of their clusters were analyzed point-by-point with the Octopus Field Analysis (OFA). RESULTS: Fifty four eyes (33.33%) had a significant worsening in some clusters, while their global indices remained stable over time. In this group of patients, more advanced glaucoma was present than in stable group (MD 6.41 dB vs. 2.87); 64.82% (35/54) of those eyes in which the clusters progressed, however, had no statistically significant change in the trend analysis by pointwise linear regression. CONCLUSION: Most software algorithms for analyzing visual field progression are essentially trend analyses of global indices, or point-by-point linear regression. This study shows the potential role of analysis by clusters trend. However, for best results, it is preferable to compare the analyses of several tests in combination with morphologic exam.

[Ocular blood flow in glaucoma]. / Le flux sanguin oculaire dans le glaucome.

In clinical practice, the vascular factor seems to be essential in glaucoma. Nevertheless, the various studies investigating the relations between the changes in ocular blood flow and risk of glaucoma often have diverse and contradictory conclusions. The variety of the methods in studies on ocular blood flow, the absence of a reference examination, and the absence of large clinical studies probably explain the problems bringing to light an indisputable relation. However, it remains essential, in any glaucoma, to look for and treat the vascular risk factor and most particularly to decrease intraocular pressure, the treatment that currently remains the most reliable to improve ocular blood flow.

[Ocular intolerance to antiglaucoma medications is underestimated]. / Tolerance locale des medications antiglaucomateuses un probleme sous-estime.

Since about 20 years, the large panel of the antiglaucoma eyedrops has drastically changed the management of glaucoma. Indications for filtering surgery had decreased in frequency. A great number of patients are controlled only by medications. However ocular intolerance and side effects have been reported until in 50% of the cases with 10% of severe manifestations of intolerance. Ocular side effects to topical medications may very often alter compliance. Ocular intolerance had been shown to be secondary to immunological mechanisms and direct or indirect toxicity. The immunological or allergic mechanisms are induced by a type I or IV hypersensibility and only represent 3% to 10% of all the side effects induced by topical medications. Toxic effect can be a direct through different mechanisms: pure toxic effect, acid pH, osmolarity of the solution, photosensibilisation. This will induce inflammatory reaction that will produce fibrosis in the long term. This toxic effect can be worsened by eye dryness or rosacea. Toxicity can also be indirect through an alteration of the conjunctival microbial flora and/or the lacrymal secretion. Concomitant obstruction of the lacrymal ducts may also contribute to this effect. These mechanisms could have been elucidated thank to histological studies from conjunctival mark, and more recently with confocal HRT, which gives an analysis of the ocular surface in vivo. Appropriate and early detection of intolerance to antiglaucoma medications is mandatory to adjust management strategies accordingly. These are based on the suppression or the reduction of conservative agents whenever possible, the use of fixed combinations, the reduction of the number of the instillations and the associated treatment of the ocular surface.

[Intraocular pressure measurement in children]. / La mesure de la pression intra-oculaire chez l'enfant.

Intraocular pressure (IOP) measurement in children is often difficult to perform because younger children are non-compliant and resisting the examination. Normal IOP in children is not well established yet because in the studies reporting about IOP, the instruments used and clinical conditions have varied. Non contact tonometer often overestimates IOP in blinking children and is not always reliable. But all the others measurement techniques use contact (GAT, Perkins, Tono-Pen, ORA, RBT), and are not always suitable and easy-touse. Under general anaesthesia, mean IOP measured with Perkins applanation tonometer is under 8 mmHg before age of 3 months and under 12 mmHg between ages of 6 and 9 months. After, IOP shows an increasing trend with age of 1 mmHg per year up to 12 years. Some studies have proposed as normal pediatric IOP: To=0.71 x age (years) +10, up to age 10. Then, IOP tends to approach adult levels by 12 years of age. However pediatric glaucoma is rare: congenital glaucoma, before age of 3 years, autosomal dominant juvenile glaucoma, with family history of glaucoma and elevated IOP, or secondary glaucoma with special context. Thus, hypertony has to be confirmed by another measurement technique, correlated to central corneal thickness, and clinical examination (optic nerve head and visual field).

[Long term follow-up of bleb reconstruction after glaucoma filtering surgery]. / Réfection de bulle de filtration après chirurgie du glaucome. Résultats tonométriques à moyen terme.

PURPOSE: To study the long term outcomes of surgical bleb reconstruction after glaucoma filtering surgery. METHOD: A retrospective study of 46 eyes (43 patients, mean age 67.9 years +/-12.2, 30 women, 13 men) that underwent surgical bleb reconstruction for leaking bleb (56.53%), major bleb dysesthesia (17.39%), or extend bleb over cornea (26.08%). Bleb resection associated with the covering of filtering surgery site with conjunctival flap was performed 38.5 months (+/- 45.2) after initial filtering surgery. RESULTS: After a follow up of 24.3 months (+/- 17.9), intra ocular pressure was increased in 85.2% eyes: +3.56 mmHg (+/- 4.3, p<0,001), and a new hypotonic medication was needed in 26 %. Bleb dysesthesia was reduced in any case and none of the bleb was leaking any more. CONCLUSION: Bleb excision with conjunctival advancement is a safe and effective procedure for the treatment of late bleb leak or major bleb dysesthesia. However in most cases, intra ocular pressure increase after reconstruction and new hypotensive medication may be required.

[Clinical factors favoring excessive subconjunctival fibroblastic proliferation after glaucoma surgery]. / Facteurs cliniques favorisant la cicatrisation conjonctivale excessive après chirurgie du glaucome.

PURPOSE: To understand risk factors for failure of glaucoma filtering surgery. PATIENTS: A retrospective study of 67 eyes (16 nonpenetrating trabeculectomies, 51 trabeculectomies [31 with 5FU and 20 with mitomycin]) of 61 patients in whom 5FU bleb revision was needed because of increasing intraocular pressure. Postoperative incidents were analyzed to explain excessive subconjunctival fibroblastic proliferation. RESULTS: In eight cases, IOP increased after 6.16 months (+/-2) and for 59 eyes, after 33.5 days after surgery (+/-11.4). Postoperative incidents were 24 (35.9%) bleb leaks, nine cases (13.4%) of hypotony with choroidal detachment, six (9.0%) iris incarcerations, seven (10.4%) cystic blebs, and 21 (31.3%) inflammatory flat blebs. After a mean follow-up of 27 months +/- 18, the success of bleb 5FU revision was 84.6% for nonpenetrating trabeculectomy (without glaucoma treatment, 69.2%; with medical treatment, 15.4%) and 73.9% for trabeculectomy (47.8% and 32.6%). CONCLUSION: Postoperative outcomes favor an inner or outer obstacle to conjunctival filtration. Aqueous humor can no longer remain in the subconjunctival spaces, increasing the risk of glaucoma surgery failure. Early follow-up of glaucoma surgery is crucial to obtaining long-lasting filtration.

[What should we think? Is pneumotonometry still reliable?]. / Que faut-il en penser? La tonométrie à air est-elle encore fiable?

UNLABELLED: Noncontact tonometer (NCT) is an applanation tonometry, as is Goldmann tonometry. Numerous studies have shown the reliability of this technique but problems still exist. METHOD: We measured intraocular pressure (IOP) in 340 patients (668 eyes) with NCT and Goldmann tonometer (GAT). To evaluate the influence of central corneal thickness (CCT), we classified the patients according to their CCT (<500 microm; between 520 and 580 microm, and>600 microm). RESULTS: The mean difference between the two IOP measurements was -1.4 mmHg +/- 2.67 (-12 to +7), p<0,0001 for the thinner corneas, +0.13 mmHg +/- 2.67 (-8 to +8), p=0.445 for the regular corneas, and + 3.04 mmHg +/- 3.2 (-7 to +13) p<0.0001 for the thicker corneas. CCT influences NCT and GAT, but the difference between the two techniques is higher for thicker CCTs, higher IOPs, and in younger patients. CONCLUSION: NCT is good for glaucoma screening but is less reliable than GAT for glaucoma follow-up if CCT and IOP are far from regular values.

[Diode laser in "Malignant Glaucoma" treatment]. / Le laser Diode dans le traitement du "Glaucome Malin".

UNLABELLED: Malignant glaucoma remains one of the most dramatic complications of ocular surgery. It can occur after glaucoma surgery but also after iridotomy, capsulotomy, or cataract extraction. However, the mechanisms remain unclear. PURPOSE: to evaluate diode laser cyclodestruction as a complementary treatment in refractory malignant glaucoma. PATIENTS: Seven women with malignant glaucoma with onset several months before (mean, 43 months; range, 12-96 months), in whom shallow anterior chamber and high IOP (25 mmHg +/- 5.5 treated with 2.86 +/- 0.9 topical and systemic medications) persisted despite prior surgical treatment (mean, 2; range, 1-5). Controlateral eyes had hyperopia (mean, +3.7 D, range, +1 to +6), five had shallow anterior chamber and high IOP. UBM detected plateau iris in four women. METHODS: Seven eyes with malignant glaucoma and three controlateral eyes underwent cyclodestruction with diode laser (Viridis Twin Quantel Medical, laser, 810 nm), 22 burns around 270 degrees , 2 mm from the limbus for glaucomatous eyes and 15 inferior burns for controlateral eyes. RESULTS: Resolution of malignant glaucoma, with lower pressure (mean, 35%; range, 10%-70%), lower levels of medications (64%), final IOP at 13.2 mmHg (+/- 4.7), and deepening anterior chamber was achieved in all cases (mean follow-up, 18 months; range, 12-22). Cycloplegic topical treatment was stopped in 70% of cases. CONCLUSION: Diode laser cyclodestruction can help to resolve refractory malignant glaucoma. Larger UBM studies could help us to better understand the mechanisms of malignant glaucoma.

Regulation of optic nerve head blood flow in normal tension glaucoma patients.

PURPOSE: To investigate the regulation of the optic nerve blood flow (Fonh) in response to an increase of the perfusion pressure (PPm) in normal tension glaucoma (NTG) patients and in age-matched normal volunteers. METHODS: Measurements were performed in 16 eyes of NTG patients and in 10 eyes of age-matched controls. Laser Doppler flowmetry (LDF) was applied to calculate the relative flux of red blood cells at the temporal rim of the optic nerve head (ONH) in response to increases in PPm. PPm was raised through an increase in systemic blood pressure induced by isometric exercise. Before being tested, all patients had 3 weeks of washout of any local medication. RESULTS: In the NTG group, mean ophthalmic arterial blood pressure increased during isometric exercise from 73 to 89 mmHg (22%), resulting in a 29% increase of the PPm. This increase did not induce any significant change in mean Fonh. For the control group, the 28% increase of PPm also did not significantly affect Fonh. There was a trend for a greater increase in vascular resistance during isometric exercise in the NTG than in the normal control group (47% versus 25%). CONCLUSIONS: The LDF parameters, measured in the ONH, did not indicate an abnormal Fonh regulation in response to an increase of the PPm in either normal subjects or NTG patients. The maintenance of constant blood flow is achieved by an increase in local vascular resistance. Our data show a greater percent increase in vascular resistance in the NTG patients compared to the normal subjects for a similar percent increase in PPm in both groups during squatting. This suggests some alteration of the vessel tone regulatory mechanisms in NTG patients.

[HRT and glaucoma surgery follow-up]. / HRT et suivi des glaucomateux opérés.

Heidelberg Retina Tomography (HRT) analysis of the optic nerve might be temporarily modified after glaucoma surgery. However, optimal follow-up of glaucoma patients requires comparing reliable optic nerve images. The aim of this study was to define the consequences of glaucoma surgery on HRT measurements. Results showed temporary modifications until at least the third month, suggesting that it is better to wait 6 months after surgery to obtain reliable measurements.

[Color Doppler ultrasonography of short para-optic ciliary arteries in vascular glaucoma]. / Echo-Doppler couleur des artères ciliaires courtes para-optiques dans le glaucome vasculaire.

PURPOSE: To study color Doppler imaging in orbital vessels, especially para-optic short ciliary arteries, in patients with vascular glaucoma. PATIENTS AND METHODS: Twenty vascular normal or moderate elevated pressure glaucoma patients (6 with bilateral glaucoma, 9 with unilateral glaucoma et 5 with asymmetric glaucoma) underwent a color Doppler imaging (Accusson 128XP) in orbital arteries: common carotid, ophthalmic artery, central retinal artery, short para-optic ciliary arteries. Systolic and diastolic blood flow velocities were measured, and resistance index of Pourcelot and ratios between different parameters were calculated. RESULTS: In patients with unilateral glaucoma, ratios of systolic velocities between para-optic ciliary artery and common carotid, and ratio of Pourcelot index between para-optic ciliary artery and ophthalmic artery were increased in glaucomatous eyes. And Pourcelot index were statistically significant increased in all glaucomatous patients of the study compared with normal subjects. DISCUSSION AND CONCLUSION: Comparison of Pourcelot index and ratios between parameters makes color Doppler imaging more reliable, especially when analyse short para-optic ciliary arteries, which vascularize optic nerve. In these arteries Pourcelot index was increased in vascular glaucoma patients. Vascular risk factor should be taken into consideration in this form of glaucoma.

[Role of arterial blood pressure in the development of glaucomatous lesions]. / Rôle de la tension artérielle dans l'évolutivité des lésions glaucomateuses.

PURPOSE: In a significant number of glaucoma patients, progression of visual field loss occurs despite adequate intraocular pressure (IOP) control. Other factors, mainly vascular, seem to play a role in the pathogenesis of these glaucomas. The purpose of this study was to investigate the role of blood pressure (BP) as one of the vascular risk factors for progression of glaucomatous damage. METHODS: Eighty-three glaucoma patients were categorizated as to whether their visual field defect were stable or progressive in the face of clinically stable IOP; all patients were followed for at least two years. The mean systolic and diastolic BP were determined, using a 24-hour ambulatory recording device, during diurnal (6 am-10 pm) and nocturnal (10 pm-6 am) periods. For each patient, the nocturnal systolic and diastolic dips, and the BP variability (i.e. standart deviation, and percentage decrease from maximal to minimal readings) were determined. RESULTS: Forty-three patients had stable visual fields (25 females, 58.9 years old +/- 6.88; 18 males, 58.6 years old +/- 11), while 40 patients showed progressive visual field loss (23 females, 67.4 years old +/- 9.98; 17 males, 64.5 years old +/- 9.44). In the progressive group, women were older (p = 0.017), systolic (p = 0.0375) and diastolic (p = 0.0083) dips were greater, as also BP variability: systolic standard deviation was greater (p = 0.027) as percentage decrease from maximal systolic readings (p = 0.034). There were no difference for systolic, diastolic, diurnal or nocturnal mean BP in these two groups. CONCLUSIONS: The finding in this study suggests that age, decreased nocturnal BP and high BP variability may be additional risk factors for progression of glaucomatous field loss.

[Is trabeculectomy without danger in case of threatened fixation?]. / La trabéculectomie est-elle sans danger en cas de menace sur le point de fixation?

PURPOSE: This study examined the impact of trabeculectomy on the central visual field in patients in which field loss threatens fixation. METHODS: Fifty eyes in 45 patients demonstrating a visual field loss threat to fixation underwent trabeculectomy. All patients underwent visual field assessment before and within two months of surgery, using both the 24-2 quantitative program on the Humphrey Field Analyser, and the macular program which measures the threshold sensitivity three times per 16 points distributed in the central 5 degrees centrally at 2 degrees intervals. For inclusion in the study, each eye had to show involvement of at least two contiguous points in the central macular program, with a decrease in sensitivity to 15 dB or less, in a quadrant corresponding to a well-defined visual field defect shown on program 24-2. RESULTS: The average post-operative follow-up was 7.1 months (+/- 5.52). Overall intraocular pressure reduction was 40%. Visual acuity decreased on an average of half line. None of the eyes showed loss of fixation. The average number of points with decreased sensitivity in the central 5 degrees (15 dB sensitivity or less) was 6.06 points (+/- 3.36) pre-operatively and 5.78 points (+/- 3.85) post-operatively (p = NS). Mean Defect (MD) was noted to decrease by 1 dB (p = 0.0295) whereas Corrected Pattern Standard Deviation (CPSD) and Foveal Sensitivity (FS) was essentially stable. CONCLUSION: Based on the study, it appears that trabeculectomy can be safely offered to patients for surgical reduction of intraocular pressure even in those cases where central fixation is threatened by loss of vision within the five degrees of fixation.

[Arterial hypotension in glaucoma of normal or moderately high pressure]. / Hypotension artérielle dans le glaucome à pression normale ou modérément élevée.

BACKGROUND: Arterial hypotension, by decreasing blood flow in the optic nerve head, may be a risk factor for glaucomatous damage. The purpose of this study was to compare blood pressure in different types of glaucoma patients, using ambulatory recording. METHODS: An ambulatory blood pressure recording was performed in 55 glaucoma patients over a 24-hour period. Two groups of patients could have been differentiated according to pretreatment intra-ocular pressure level: a group of 38 patients (GPNM) with normal or moderately elevated intra-ocular pressure, and a group of 17 patients (GPH) with high intra-ocular pressure. RESULTS: A statistically significant different lower blood pressure was found in group GPNM for: diastolic mean blood pressure (76.4 versus 81.4 mmmHg p = 0.05), diastolic nocturnal (71.8 versus 78.1 mmHg p = 0.025), and for some hourly intervals: from 2:00 to 3:00 (p = 0.008), 8:00 to 9:00 (p = 0.01) and 15:00 to 18:00 (p = 0.03). The mean lowest readings were lower (p < 0.05) in group GPNM (95.8/54.4 versus 102/59.9 mmHg). The percentage of low readings (9.9% versus 5.1% p = 0.01) and systolic drops (0.226 versus 0.192 p = 0.018) were also higher in this group. CONCLUSION: Hypoperfusion of optic nerve head may be a significant factor in glaucomatous damage by compromising blood supply. It is important to identify arterial hypotension when examining of normal or moderately elevated pressure glaucoma patients, and ambulatory monitoring of blood pressure is currently the best test. These episodes should be taken into consideration, especially when initiating systemic antihypertensive therapy, in order to maintain, as well as possible, perfusion of the optic nerve head.

Diurnal and nocturnal blood pressure drops in patients with focal ischemic glaucoma.

BACKGROUND: The purpose of this study was to assess the role of arterial hypotension in the pathogenesis of certain types of glaucoma. METHODS: We compared diurnal and nocturnal fluctuations in blood pressure by using an ambulatory recording over a 24-h period in two different groups of patients: one of 16 patients with focal ischemic glaucoma (FIG) and another of 16 patients with primary open angle glaucoma (POAG). RESULTS: In patients with FIG, compared to those with POAG, we found: lower diastolic blood pressure (BP; 75.7 vs 82.5 mmHg, P < 0.05), systolic BP (121.7 vs 131.2 mmHg, P < 0.05) and mean BP (90.5 vs 101.5 mmHg, P < 0.05) over 24 h; lower diurnal diastolic BP (78.1 vs 85.5 mmHg, P < 0.05), and systolic BP (124.6 vs 134.2 mmHg, P < 0.05); greater nocturnal systolic BP variability (8.2% vs 6.2%, P < 0.05); and a greater percentage of diurnal low readings (14.53% vs 2.8%, P < 0.05), compared with the literature limits (101/61 mmHg). However, the number of nocturnal low readings was not different for either group. CONCLUSION: It is important to detect arterial hypotension - one of the components of the vascular factor - during examination of a patient with normal-pressure glaucoma. This is one element in preserving the best possible perfusion of the optic nerve.