A Retrospective Comparison of Phaco-Tube vs. Phaco-Trabeculectomy in Glaucoma Patients.

PURPOSE: To compare surgical outcomes of phacoemulsification combined with Baerveldt implantation (phaco-tube) or trabeculectomy with mitomycin-C (MMC) (phaco-trab) in patients without prior incisional ocular surgery. DESIGN: Single-center, retrospective, comparative case series. PARTICIPANTS: A total of 90 patients underwent surgical treatment, including 45 patients in the phaco-tube group and 45 patients in the phaco-trab group. METHODS: Eligible patients were identified using current procedural terminology (CPT) codes, and their medical records were retrospectively reviewed. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of surgical failure (IOP ≤5 mmHg or >21 mmHg or reduced <20% from baseline on two consecutive study visits after 3 months, reoperations for glaucoma, or experienced loss of light perception vision). Patients who had successful surgical outcomes without use of glaucoma medications were classified as complete successes, while those that used glaucoma medications were classified as qualified successes. Secondary outcome measures were visual acuity (VA), visual field mean deviation (VFMD), intraocular pressure (IOP), glaucoma medication use, and complications. RESULTS: The cumulative probability of failure was 6.7% in the phaco-tube group and 32.8% in the phaco-trab group after 3 years (P= 0.005; Restricted Mean Survival Time = 5.9 months, 95% CI = 1.4 to 10.4 months). IOP was 13.1 ± 3.4 mmHg in the phaco-tube group and 13.3 ± 6.2 mmHg in the phaco-trab group at 3 years (P= 0.90), and the number of glaucoma medications was 2.6 ± 1.5 in the phaco-tube group and 1.7 ± 1.3 in the phaco-trab group (P= 0.015). LogMAR VA was 0.39 ± 0.58 in the phaco-tube group and 0.43 ± 0.73 in the phaco-trab group at 3 years (P= 0.82) and VFMD was -18.3 ± 9.0 dB in the phaco-tube group and -14.1 ± 7.0 dB in the phaco-trab group (P= 0.16). Postoperative complications developed in 21 patients (47%) in the phaco-tube group and 15 patients (33%) in the phaco-trab group (P= 0.28). CONCLUSIONS: Phaco-tubes had a significantly lower rate of surgical failure compared to phaco-trabs after 3 years of follow-up. However, phaco-trabs used significantly fewer glaucoma medications at multiple postoperative timepoints and had a higher proportion of complete success.

Visual Field Outcomes in the Primary Tube Versus Trabeculectomy Study.

PURPOSE: To describe visual field outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. DESIGN: Cohort analysis. PARTICIPANTS: A total of 155 eyes (155 subjects) randomly assigned to treatment with tube shunt surgery (n = 84) or trabeculectomy with mitomycin C (n = 71). METHODS: The PTVT Study was a multicenter randomized clinical trial comparing the safety and efficacy of trabeculectomy and tube shunt surgery in eyes without previous intraocular surgery. Subjects underwent standard automated perimetry (SAP) at baseline and annually for 5 years. Standard automated perimetry tests were deemed reliable if the false-positive rate was ≤ 15%. Tests were excluded if visual acuity was ≤ 20/400 or loss of ≥ 2 Snellen lines from baseline because of a nonglaucomatous etiology. Linear mixed-effects models were used to compare rates of change in SAP mean deviation (MD) between the 2 groups. Intraocular pressure (IOP) control was assessed by percentage of visits with IOP < 18 mmHg and mean IOP. MAIN OUTCOME MEASURES: Rate of change in SAP MD during follow-up. RESULTS: A total of 730 SAP tests were evaluated (average of 4.7 tests per eye). The average SAP MD at baseline was -12.8 ± 8.3 decibels (dB) in the tube group and -12.0 ± 8.4 dB in the trabeculectomy group (P = 0.57). The mean rate of change in SAP MD was -0.32 ± 0.39 dB/year in the trabeculectomy group and -0.47 ± 0.43 dB/year in the tube group (P = 0.23). Eyes with mean IOP 14 to 17.5 mmHg had significantly faster rates of SAP MD loss compared with eyes with mean IOP < 14 mmHg (-0.59 ± 0.13 vs. -0.27 ± 0.08 dB/year; P = 0.012), and eyes with only 50% to 75% of visits with IOP < 18 mmHg had faster rates than those with 100% of visits with IOP < 18 mmHg (-0.90 ± 0.16 vs. -0.29 ± 0.08 dB/year; P < 0.001). Multivariable analysis identified older age and worse IOP control as risk factors for faster progression in both treatment groups. CONCLUSIONS: No statistically significant difference in mean rates of visual field change was observed between trabeculectomy and tube shunt surgery in the PTVT Study. Worse IOP control was significantly associated with faster rates of SAP MD loss during follow-up. Older patients were also at risk for faster progression.

An Analysis of Solicitations From Predatory Journals in Ophthalmology.

PURPOSE: To evaluate trends associated with email communication from potentially predatory publishers to faculty in ophthalmology. DESIGN: Cross-sectional study METHODS: Ophthalmologists (n = 14) from various subspecialties and institutions were recruited to participate. Participants identified unsolicited emails that they had received originating from publishers in May 2021. Information collected included details on email contents and publisher organizations. Trends in communications from predatory publishers were evaluated. RESULTS: Over a 30-day study period, a total of 1813 emails were received from 383 unique publishers and 696 unique journals, with a mean (SD) of 4.73 (2.46) emails received per day per participant. Of the 1813 emails identified, 242 (13%) emails were invitations to conferences, whereas 1440 (80%) were solicitations for article submissions to open-access, pay-to-publish journals. A total of 522 (29.0%) emails were related to ophthalmology, and reference to a prior publication of the participant occurred in 262 emails (14%). Of the 696 unique journals identified, 174 (25%) journals were indexed on PubMed and 426 (61%) were listed on Beall's list. When comparing journals that were listed on PubMed vs those that were not, PubMed indexed journals had a higher impact factor (2.1 vs 1.5, P = .002), were less likely to use "greetings" (76% vs 91%, P < .001), had fewer spelling/grammar errors (40% vs 51%, P = .01), and were less likely to offer rapid publication (16% vs 25%, P = .02). CONCLUSIONS: Unsolicited requests to publish occur frequently and may diminish the quality of the scientific literature. We encourage individuals in ophthalmology to be aware of these trends in predatory publishing.

Difficult decisions, filtration surgery, and the heartbreak of the numerator.

A 70-year-old man had progressive and severe glaucoma in each eye. He was intolerant to dorzolamide, brimonidine, and netarsudil. Each eye had prior selective laser trabeculoplasty (SLT) as well as phacoemulsification plus minimally invasive glaucoma surgery (MIGS) 6 years before current presentation (iStent [Glaukos Corp.] in the right eye and Cypass [Alcon Laboratories, Inc.] in the left eye). Postoperative acuities were 20/20 and 20/25 in the right and left eyes, respectively. When his left eye progressed with loss of central acuity despite peak intraocular pressures (IOPs) in the middle to upper teens, neuro-ophthalmology consultation was obtained (Figure 1JOURNAL/jcrs/04.03/02158034-202401000-00017/figure1/v/2023-12-22T124801Z/r/image-tiff). That workup included magnetic resonance imaging scan and hematologic screening, but all results were negative, and the neuro-ophthalmic consultant concluded that the vision loss was likely on the basis of glaucoma. Accordingly, a trabeculectomy was performed in the left eye achieving consistent IOPs in the range of 7 to 10 mm Hg without medications, rending the left eye stable since the filtration surgery nearly 2 years previously. The right eye continued to progress both subjectively and objectively, and on recent examination, the IOP measured 20 mm Hg and 09 mm Hg in the right and left eyes, respectively (Figure 2JOURNAL/jcrs/04.03/02158034-202401000-00017/figure2/v/2023-12-22T124801Z/r/image-tiff). Medications included timolol and latanoprostene bunod in the right eye only. Central corneal thickness was 526 µm and 527 µm in the right and left eyes, respectively. The visual acuity now measured 20/25 in the right eye and 20/250 in the left eye. The vertical cup-to-disc ratio was 0.9 in the right eye and 1.0 in the left eye. Gonioscopy revealed a wide open angle in each eye with a patent sclerostomy superiorly in the left eye. The conjunctiva and sclera were healthy and without scarring in the right eye. The bleb in the left eye was diffuse, lightly vascularized, and seidel negative. Axial length (AL) was 26.88 µm in the right eye and 26.77 µm in the left eye. The patient was in good health and was not anticoagulated. An extensive discussion ensued about the best course of action for the right eye. How would you proceed in managing definite progression in this individual's right eye, knowing that he had lost fixation in his left eye at similar pressures?

Tube Versus Trabeculectomy IRIS Registry Study: 1-Year Secondary Treatment Outcomes.

PURPOSE: To describe 1-year secondary outcomes in the Tube Versus Trabeculectomy IRIS® (Intelligent Registry In Sight) Registry Study (TVTIRIS), and to compare to the TVT randomized controlled trial (TVTRCT). DESIGN: TVTIRIS was a retrospective cohort study. METHODS: The 2013-2017 IRIS Registry was used to identify eyes that received a tube shunt (tube) or trabeculectomy after a previous trabeculectomy and/or cataract surgery and had 1 year of follow-up. The TVTRCT compared a Baerveldt 350-mm2 glaucoma implant to trabeculectomy in similar eyes. RESULTS: In the TVTIRIS cohort, the tube (n = 236, 56.3%) and trabeculectomy (n = 183, 43.7%) groups had similar and significant reductions in intraocular pressure (IOP) from baseline to 1 year. In the tube group, IOP (mean ± SD) decreased from 26.6 ± 6.5 mm Hg at baseline to 14.3 ± 4.8 mm Hg at 1 year. In the trabeculectomy group, IOP decreased from 25.3 ± 6.4 mm Hg at baseline to 13.5 ± 5.2 mm Hg at 1 year. The trabeculectomy groups from both studies had similar 1-year IOP reduction (P = .18), although the TVTRCT cohort used fewer medications at all time points (P < .01). There were more pronounced differences in the mean IOP and medications between the tube groups in the 2 studies, presumably due to the inclusion of valved tubes in TVTIRIS. More reoperations occurred in TVTIRIS. CONCLUSIONS: The TVTIRIS tube and trabeculectomy groups had comparable 1-year IOP reduction, although trabeculectomy eyes used fewer glaucoma medications. The trabeculectomy group in TVTIRIS and TVTRCT had similar IOP and medication reduction at 1 year. Randomized controlled trials and electronic health record data both provide invaluable insight into surgical outcomes.

Pattern Electroretinogram in Ocular Hypertension, Glaucoma Suspect and Early Manifest Glaucoma Eyes: A Systematic Review and Meta-analysis.

Topic: To provide standardized confidence limits of the transient pattern electroretinogram (tPERG) P50 and N95 and steady state pattern electroretinogram (ssPERG) amplitudes in normal controls as compared to ocular hypertension (OHT), glaucoma suspect (GS), or early manifest glaucoma (EMG) eyes. Clinical Relevance: The identification of standardized confidence limits in the context of pattern electroretinogram (PERG) might overcome the high intrinsic variability of the measure, and it might lead to a more intuitive understanding of the results as well as to an easier comparison of data from multiple tests, sites, and operators. Methods: The study protocol was prospectively registered on the International Prospective Register of Systematic Reviews (ID: CRD42022370032). A literature search was conducted on PubMed, Web of Science, and Scopus. Studies comparing PERG raw data in normal control eyes as compared to OHT, GS, or EMG were included. The risk of bias was assessed using the National Institute for Health and Clinical Excellence quality assessment tool. The main outcome was the P50, N95, and ssPERG amplitude difference between the control and the study groups' eyes. The standardized mean difference was calculated as a measure of the effect size for the primary outcome. A subanalysis was conducted based on the type of electrodes adopted for the PERG measurements (invasive vs. noninvasive). Results: Of the 4580 eligible papers, only 23 were included (1754 eyes). Statistically significant amplitude differences were found in the P50, N95, and ssPERG amplitudes between normal controls and OHT, GS, and EMG eyes. The highest standardized mean difference values were observed in the ssPERG amplitude in all 3 sets of comparison. The subanalysis did not reveal any statistically significant differences between invasive and noninvasive recording strategies. Conclusions: The use of standardized values as the main outcome measures in the context of the PERG data analysis is a valid approach, normalizing several confounding factors which have affected the clinical utility of PERG both for individual patients and in clinical trials. Steady state PERG apparently better discriminates diseased eyes compared to tPERG. The adoption of skin-active electrodes is able to adequately discriminate between healthy and diseased statuses. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

Results from the Primary Tube Versus Trabeculectomy Study and translation to clinical practice.

PURPOSE OF REVIEW: The Primary Tube Versus Trabeculectomy (PTVT) Study is a multicenter randomized clinical trial comparing the safety and efficacy of tube shunt surgery and trabeculectomy with mitomycin C (MMC) in eyes without previous incisional ocular surgery. This article reviews results from the PTVT Study and suggests how they may be translated to clinical practice. RECENT FINDINGS: Tube shunt surgery had a higher failure rate than trabeculectomy with MMC in the PTVT Study, and the difference was statistically significant at 1 year but not at 3 years and 5 years. Both surgical procedures reduced intraocular pressure (IOP) to the low teens throughout 5 years of follow-up. Mean IOPs were lower after trabeculectomy with MMC compared with tube shunt implantation, and the differences were statistically significant during the first postoperative year and at 3 years. The greater IOP reduction after trabeculectomy with MMC was achieved with significantly fewer glaucoma medications relative to tube shunt placement. Surgical complications were common in the PTVT Study, but most were transient and self-limited. The incidence of early postoperative complications was significantly higher after trabeculectomy with MMC than tube shunt surgery. The rates of late postoperative complications, cataract progression, and vision loss were similar with both surgical procedures. Serious complications producing vision loss and/or requiring a reoperation to manage the complication developed more frequently after trabeculectomy with MMC compared with tube shunt surgery, and the difference was statistically significant at 1 year but not at 3 years and 5 years postoperatively. SUMMARY: Tube shunt implantation and trabeculectomy with MMC are both viable surgical options for managing glaucoma in patients without previous incisional ocular surgery. Results from the PTVT Study support further expansion of tube shunt use beyond refractory glaucomas.

Outcomes of Glaucoma Reoperations in the Primary Tube Versus Trabeculectomy Study.

PURPOSE: To describe the incidence and outcomes of reoperations for glaucoma in the Primary Tube Versus Trabeculectomy (PTVT) Study. DESIGN: Cohort study of patients in a multicenter randomized clinical trial. PARTICIPANTS: The PTVT Study enrolled 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery. METHODS: Randomization assigned 125 patients to placement of a tube shunt (350-mm2 Baerveldt glaucoma implant) and 117 patients to trabeculectomy with mitomycin C (MMC, 0.4 mg/ml for 2 minutes). Data were analyzed from patients who underwent additional glaucoma surgery. MAIN OUTCOME MEASURES: Outcome measures included intraocular pressure (IOP), use of glaucoma medications, visual acuity, surgical complications, and failure (IOP > 21 mmHg or reduced by <20%, IOP ≤ 5 mmHg, additional glaucoma surgery, or loss of light perception vision). RESULTS: Additional glaucoma surgery was performed in 21 patients in the tube group and 12 patients in the trabeculectomy group in the PTVT Study, and the 5-year cumulative reoperation rate for glaucoma was 18.0% in the tube group and 10.4% in the trabeculectomy group (P = 0.15). Follow-up (mean ± standard deviation [SD]) after additional glaucoma surgery was 35.1 ± 17.7 months in the tube group and 30.1 ± 17.6 months in the trabeculectomy group (P = 0.44). At 3 years after glaucoma reoperation, IOP (mean ± SD) was 15.5 ± 4.8 mmHg in the tube group and 16.6 ± 7.3 mmHg in the trabeculectomy group (P = 0.71). The number of glaucoma medications (mean ± SD) after 3 years of follow-up was 2.1 ± 1.7 in the tube group and 1.7 ± 1.0 in the trabeculectomy group (P = 0.58). The cumulative probability of failure at 3 years after a glaucoma reoperation was 37.8% in the tube group and 21.3% in the trabeculectomy group (P = 0.47). CONCLUSION: No significant difference in the rate of reoperation for glaucoma was observed after tube shunt implantation and trabeculectomy with MMC in the PTVT Study. Similar surgical outcomes were observed after additional glaucoma surgery, irrespective of the initial procedure to which the patient was randomized. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Assessment of visual field progression in glaucoma.

PURPOSE OF REVIEW: Perimetry plays an important role in the diagnosis and management of glaucoma. This article discusses the assessment of visual field progression in patients with glaucoma. RECENT FINDINGS: Selecting the best visual field test strategy and establishing a baseline of visual fields will assist clinicians in the detection of glaucomatous progression. Repeat testing serves to confirm or refute changes on visual field testing. More frequent testing after initial diagnosis is recommended to establish a baseline and to identify patients with rapid progression who may need more aggressive management. Statistically significant changes on event analysis can prompt examination of a patient's trend analysis to determine whether clinically significant deterioration may be occurring. Future applications of machine learning can complement existing methods of visual field interpretation. SUMMARY: Many treated patients with glaucoma will experience visual field progression. Optimal utilization of visual field testing strategy and analytical software can help clinicians identify patients with glaucomatous progression likely to cause functional visual disability.

Long-term surgical outcomes of Aurolab aqueous drainage implant in pediatric eyes with primary congenital glaucoma versus aphakic glaucoma.

PURPOSE: To compare the outcomes of the Aurolab aqueous drainage implant (AADI) placed in eyes with refractory primary congenital glaucoma (PCG) versus aphakic glaucoma (APG). DESIGN: Retrospective comparative interventional case series. METHODS: Case files of consecutive eyes with PCG or APG that underwent AADI surgery between January 2013 and December 2016 and had a minimum 4 years follow-up were extracted from a computerised database. Failure was defined as intraocular pressure (IOP)>21 mm Hg or reduced<20% below baseline on two consecutive follow-up visits after 3 months, IOP≤5 mm Hg on two consecutive follow-up visits after 3 months, reoperation for glaucoma or a complication, or loss of light perception. RESULTS: Eighty-nine eyes underwent AADI placement, including 42 eyes (47%) with PCG and 47 eyes (53%) with APG. Both groups were comparable at baseline. At 1 year, the APG group had lower mean IOP (13.6±8.1 mm Hg vs 17.6±7.5 mm Hg, p=0.02) with use of fewer IOP-lowering medications (0.8±1.0 vs 1.5±1.0, p=0.01) than the PCG group. The cumulative failure rate at 4 years was 57% (95% CI 43% to 72%) in PCG versus 40% (95% CI 28% to 56%) in the APG eyes (p=0.11). Eyes with PCG had greater tube-related complications (48% vs 38%, p=0.07) and number of reoperations (40% vs 32%, p=0.02) compared with eyes with APG. CONCLUSIONS: Eyes with APG had relatively better outcomes after AADI placement compared with PCG during 4 years of follow-up. Reoperations accounted for more than 70% of the failures.

Survey of the American Glaucoma Society Membership on Current Glaucoma Drainage Device Placement and Postoperative Corticosteroid Use.

Purpose: To assess practice patterns and opinions of glaucoma specialists regarding glaucoma drainage device tube shunt placement and post-operative anti-inflammatory medication use. We also assess the perceived need for a randomized control trial to compare them. Patients and Methods: An online survey was distributed to a group of glaucoma specialists from the American Glaucoma Society via the American Glaucoma Society forum from April to August 2021. Results: One hundred and twenty-eight responses were included. Ninety percent placed tubes in the anterior chamber. Sixty-one percent reported that evidence suggested the superiority of sulcus tube placement over the anterior chamber, whereas 34% reported there was not enough evidence to suggest superiority of either in preventing endothelial cell loss. Comparing these techniques for intraocular pressure control, 49% reported evidence suggested sulcus tube placement superiority whereas 46% reported there was not enough evidence. Over 40% of respondents reported that they were either unfamiliar with literature or that there was not enough evidence to support the superiority of difluprednate 0.05% over prednisolone 1% for post-operative use in preventing endothelial cell loss and for intraocular pressure control. Ninety percent and 81% of respondents respectively would benefit from randomized control trials comparing outcomes of anterior chamber vs sulcus tube placement and post-operative corticosteroid usage. Conclusion: Most glaucoma specialists surveyed place glaucoma drainage device tube in the anterior chamber over the sulcus. A randomized control trial to determine optimal tube placement and post-operative anti-inflammatory medication use for preventing endothelial cell loss would change current glaucoma drainage device practice patterns.

Acute-onset postoperative endophthalmitis after cataract surgery performed by resident and attending physicians at a university teaching hospital.

PURPOSE: To evaluate acute-onset postoperative endophthalmitis following cataract surgery and to compare rates between resident and attending physician-performed cohorts. SETTING: Bascom Palmer Eye Institute, Miami, Florida. DESIGN: Retrospective chart review. METHODS: Records of patients diagnosed with endophthalmitis within 6 weeks of surgery performed by attending and resident physicians between January 1, 2015, and December 31, 2020, were reviewed. Total cataract volume was obtained from institutional records, and resident case totals were obtained from case logs. Endophthalmitis cases were obtained from billing records and confirmed with chart review. RESULTS: There were 22 cases of endophthalmitis among 32 505 cases (0.068%). Endophthalmitis occurred in 6 of 6447 (0.093%) resident cases and 16 of 26 058 (0.061%) attending cases ( P = .55). The most common bacterial isolates were coagulase-negative Staphylococcus (8/22, 36.3%) and Streptococcus species (3/22, 13.6%), with negative cultures in 10 (10/22, 45.5%). Initial treatment with vitreous tap and injection of intravitreal antibiotics was performed in 21 eyes (21/22, 95.4%) and vitrectomy with intravitreal antibiotic injection in one (1/22, 4.5%). Vitrectomy was performed secondarily in 9 patients (9/22, 40.9%). Corrected distance visual acuity (CDVA) at last follow-up was ≥20/40 in 13 eyes (13/22, 59%) and ≤hand motions in 3 eyes (3/22, 13.6%). CDVA (logMAR mean ± SD) was 1.22 ± 1.16 in resident and 0.49 ± 0.79 in attending cases ( P = .11). CONCLUSIONS: In the current study, acute-onset postoperative endophthalmitis developed infrequently following cataract surgery. The rates and visual outcomes of endophthalmitis were similar in resident and attending cases.

Postoperative Complications in the Primary Tube Versus Trabeculectomy Study During 5 Years of Follow-up.

PURPOSE: To describe postoperative complications encountered in the Primary Tube Versus Trabeculectomy (PTVT) Study during 5 years of follow-up. DESIGN: Multicenter randomized clinical trial. PARTICIPANTS: A total of 242 eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 patients in the tube group and 117 patients in the trabeculectomy group. METHODS: Patients were enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC, 0.4 mg/ml for 2 minutes). MAIN OUTCOME MEASURES: Surgical complications, reoperations for complications, visual acuity, and cataract progression. RESULTS: Early postoperative complications occurred in 24 patients (19%) in the tube group and 40 patients (34%) in the trabeculectomy group (P = 0.013). Late postoperative complications developed in 27 patients (22%) in the tube group and 32 patients (27%) in the trabeculectomy group (P = 0.37). Serious complications producing vision loss and/or requiring a reoperation were observed in 3 patients (2%) in the tube group and 9 patients (8%) in the trabeculectomy group (P = 0.11). Cataract progression was seen in 65 patients (52%) in the tube group and 52 patients (44%) in the trabeculectomy group (P = 0.30). Surgical complications were not associated with a higher rate of treatment failure (P = 0.61), vision loss (P = 1.00), or cataract progression (P = 0.77) CONCLUSIONS: A large number of surgical complications were observed in the PTVT Study, but most were transient and self-limited. The incidence of early postoperative complications was higher following trabeculectomy with MMC than with tube shunt surgery. The rates of late postoperative complications, serious complications, and cataract progression were similar with both surgical procedures after 5 years of follow-up. Surgical complications did not increase the risk of treatment failure, vision loss, or cataract progression.

Treatment Outcomes in the Primary Tube Versus Trabeculectomy Study after 5 Years of Follow-up.

PURPOSE: To report 5-year treatment outcomes in the Primary Tube Versus Trabeculectomy (PTVT) Study. DESIGN: Multicenter randomized clinical trial. PARTICIPANTS: A total of 242 eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 patients in the tube group and 117 patients in the trabeculectomy group. METHODS: Patients were enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC) (0.4 mg/ml for 2 minutes). MAIN OUTCOME MEASURES: The primary outcome measure was the rate of surgical failure, defined as intraocular pressure (IOP) > 21 mmHg or reduced < 20% from baseline, IOP ≤ 5 mmHg, reoperation for glaucoma, or loss of light perception. Secondary outcome measures included IOP, glaucoma medical therapy, and visual acuity. RESULTS: The cumulative probability of failure after 5 years of follow-up was 42% in the tube group and 35% in the trabeculectomy group (P = 0.21; hazard ratio = 1.31; 95% confidence interval = 0.86-2.01). At 5 years, IOP (mean ± standard deviation) was 13.4 ± 3.5 mmHg in the tube group and 13.0 ± 5.2 mmHg in the trabeculectomy group (P = 0.52), and the number of glaucoma medications (mean ± standard deviation) was 2.2 ± 1.3 in the tube group and 1.3 ± 1.4 in the trabeculectomy group (P < 0.001). CONCLUSIONS: Trabeculectomy with MMC and tube shunt surgery produced similar IOPs after 5 years of follow-up in the PTVT Study, but fewer glaucoma medications were required after trabeculectomy. No significant difference in the rate of surgical failure was observed between the 2 surgical procedures at 5 years.

The Effect of Changing Fellowship Interview Format on Candidate Ranking Variabilities: The COVID-19 Experience.

Purpose: This study investigated the effect of interview format changes (in-person to virtual, one-to-one to multiple-to-one) necessitated by the COVID-19 travel restrictions on preliminary fellowship candidate ranking variabilities. Design: Cross-sectional observational study. Method: In 2018 and 2019, the glaucoma fellowship interviews were conducted in-person in a one-to-one format, whereas in 2020, interviews were virtual and in a multiple (interviewers)-to-one (candidate) format. We compared ranking ranges of interviewers within the same virtual room (WSR) and not within the same virtual room (NWSR) to assess the effect of WSR versus NWSR on ranking variabilities. We also compared ranking categories ("accept," "alternate," and "pass") agreements between 2018, 2019, and 2020 to assess the effect of virtual versus in-person interviews on ranking variabilities. Results: NWSR and WSR mean rankings differed by 1.33 (95% confidence interval difference 0.61 to 2.04, p = 0.0003), with WSR interviewers having less variability than NWSR pairs. The variability between 2018/2019 (in-person interviews) and 2020 (virtual interviews) showed no differences between in-person and virtual interviews (weighted Kappa statistic 0.086 for 2018, 0.158 for 2019, and 0.101 for 2020; p < 0.05 for all years). The overall least attractive candidate has the lowest variability; the most attractive candidate has the second lowest variability. Conclusion: Grouping interviewers WSR during the interview decreased ranking variabilities compared to NWSR, while a change from in-person to virtual interview format did not increase the ranking variabilities. This suggests that the decreased nonverbal interactions in virtual interviews do not decrease interviewers' perceptions as applied to preliminary rankings.

Risk Factors for Failure of Tube Shunt Surgery: A Pooled Data Analysis.

PURPOSE: To identify the risk factors associated with failure of tube shunt surgery. DESIGN: Pooled analysis of 3 prospective multicenter, randomized clinical trials. METHODS: A total of 621 patients with medically uncontrolled glaucoma were enrolled, including 276 from the Ahmed Baerveldt Comparison Study, 238 from the Ahmed Versus Baerveldt Study, and 107 from the tube group of the Tube Versus Trabeculectomy Study. Patients were randomized to treatment with an Ahmed glaucoma valve (model FP7) or Baerveldt glaucoma implant (model 101-350). The associations between baseline risk factors and tube shunt failure were assessed using a Cox proportional hazards regression model. The primary outcome measure was the rate of surgical failure defined as intraocular pressure (IOP) > 21 mmHg or reduced < 20% from baseline, IOP ≤ 5 mmHg, loss of light perception vision, reoperation for glaucoma, or removal of implant. RESULTS: The cumulative probability of failure after tube shunt surgery was 38.3% after 5 years. In multivariable analyses, baseline factors that predicted tube shunt failure included preoperative IOP (≤ 21 mmHg compared to IOP > 21 and ≤ 25 mmHg; HR, 2.34; 95% CI, 1.52-3.61; P < .001), neovascular glaucoma (HR, 1.79; 95% CI, 1.28-2.52; P = .001), randomized treatment (for Ahmed glaucoma valve; HR, 1.36; 95% CI, 1.04-1.78; P = .025), and age (for 10 year decrease in age; HR, 1.19; 95% CI, 1.09-1.31; P < .001). CONCLUSIONS: Lower preoperative IOP, neovascular glaucoma, Ahmed implantation, and younger age were predictors of tube shunt failure. This Study provides the largest prospectively collected dataset on tube shunt surgery.

Glaucoma Cascade Screening in a High Risk Afro-Caribbean Haitian Population: A Pilot Study.

PRCIS: Glaucoma cascade screening in first-degree relatives (FDRs) of young Haitian glaucoma patients had high yield for diagnosing manifest and suspected glaucoma in 30.8% of those screened despite modest participation. PURPOSE: To evaluate the outcomes of glaucoma cascade screening in FDRs (parents, siblings, and offspring) of Haitian juvenile open-angle glaucoma (JOAG) patients. PATIENTS AND METHODS: Consecutive index patients (Haitians with JOAG) were identified, and the number/type of FDRs residing in South Florida were recorded. These FDRs were invited for free glaucoma screening, which included a comprehensive ophthalmic exam, gonioscopy, automated visual field testing and optical coherence tomographic analysis of the retinal nerve fiber layers. FDR characteristics and clinical findings from screening are reported. RESULTS: A total of 77 FDRs were invited, 26 (33.8%) agreed to undergo screening (18 females, 9 males), which revealed 2 (7.7%) with manifest glaucoma (mean age 77.5 y; one of whom was previously unaware of his glaucoma diagnosis), 6 (23.1%) with suspected glaucoma (mean age 29.8±18.3 y), and 18 (69.2%) without manifest or suspected glaucoma (mean age 37.2±21.8 y). Siblings of index patients were least likely to participate in cascade glaucoma screening when compared with index patients' parents or offspring. FDR eyes with manifest glaucoma had significantly worse best-corrected visual acuities, higher intraocular pressures, thinner central corneal thicknesses, and thinner circumferential papillary retinal nerve fiber layer thicknesses than those without glaucoma. CONCLUSION: Glaucoma cascade screening of Haitian JOAG patients' FDRs revealed that 30.8% had suspected or manifest glaucoma. Future efforts centered on provider-initiated recruitment and improving public glaucoma awareness and education may increase screening participation.