Glaucoma drainage devices in children: an updated review.

Implantation of glaucoma drainage devices is a valuable therapeutic option, particularly in children with glaucoma refractory to primary surgical treatment. Glaucoma drainage devices are typically used when conjunctival scarring hampers filtration surgery or prior angle procedures are not effective in controlling intraocular pressure. Despite known complications, the use of glaucoma drainage devices in children has increased in recent years, even as the primary surgical option. In this review, we evaluate the results of recent studies involving the implantation of glaucoma drainage devices in children, discussing new advances, and comparing the success rates and complications of different devices.

Circumlimbal suture and laser burns: Comparison between two different chronic glaucoma models. / çŽ¯è§’è†œç¼˜ç¼åˆä¸Žæ¿€å ‰å ‰å‡æ¨¡åž‹ï¼šä¸¤ç§æ ¢æ€§é«˜çœ¼åŽ‹æ¨¡åž‹çš„æ¯”è¾ƒï¼ˆè‹±æ–‡ï¼‰.

OBJECTIVES: Glaucoma is a multifactorial optic neuropathy with a high rate of irreversible visual loss, and its pathogenesis is complex and still unclear. Elevated intraocular pressure (IOP) is well recognized as the sole modifiable risk factor for the development of glaucoma in the majority of cases. This study aims to compare 2 different methods of inducing chronic ocular hypertension by circumlimbal suture or by laser burns in degree and lasting time of the IOP, different status of the retina and retinal ganglion cells (RGCs), and changes of the microstructure of neurons. METHODS: The chronic ocular hypertension models were induced by 2 different ways. One kind of the models was built by unilateral circumlimbal suture (10/0) implantation (suture group), another kind of model was built by laser burns at trabecular meshwork and episcleral veins (laser group). The untreated contralateral eye served as the control group. Changes in IOP were observed and regularly monitored in the 2 groups of rats. HE staining was applied to observe the retinal and optic nerve pathology. Transmission electron microscope (TEM) was used to observe the mitochondrial morphology. RGCs were specifically labeled with Brn3b antibody and counted. The expression of caspase-3 was detected by Western blotting to clarify the apoptosis of RGCs. RESULTS: Compared with the control group, IOP were significantly increased in the suture group and the laser group (both P<0.05). The suture group induced a 1.5-fold elevation of IOP, and sustained for 8 weeks. The laser group induced a 2-fold elevation of IOP for 12 weeks. Both methods could cause RGCs loss (both P<0.05), which were verified by pathology and immune staining of Brn3b. The expressions of caspase-3 were also increased (both P<0.05). The mitochondrial morphology became more fragment, which changed from long shape to round and small one under TEM in 2 models. For comparison, the pathology changes of retinal structure in suture group were not obviously than those in the laser group. CONCLUSIONS: Circumlimbal suture can build an effective model of chronic elevated IOP and induce glaucomatous pathologic changes similar to those in the laser photocoagulation, but the pathologic changes are milder than those in laser photocoagulation. Compare with translimbal laser photocoagulation, equipment and skill demand for circumlimbal suture is less.

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

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

Iris neovascularization and neurotrophic keratopathy following ultrasound cycloplasty in refractory glaucoma: case series.

BACKGROUND: Ultrasound cycloplasty is a noninvasive surgery used to reduce intraocular pressure in patients with glaucoma, with fewer severe complications. This report presents several cases of iris neovascularization and neurotrophic keratopathy following ultrasound cycloplasty. CASE PRESENTATION: Six patients diagnosed with refractory glaucoma underwent ultrasound cycloplasty at our clinic. Three cases developed iris neovascularization at postoperative day 3, week 2 and week 4 respectively, with intraocular pressure ranging from 12 to 24 mmHg. The other three cases developed neurotrophic keratopathy at postoperative week 3, week 6 and week 8 which completely healed within 60 days. CONCLUSIONS: Iris neovascularization and neurotrophic keratopathy can be triggered after ultrasound cycloplasty, which are uncommon and self-limited but potentially vision-threatening. Preoperative risk assessment and regular postoperative follow-up are recommended to manage complications effectively.

Outcomes of iStent inject combined with cataract surgery in Asian eyes: Australian data from the Fight Glaucoma Blindness international registry.

PURPOSE: To analyse real-world outcomes in Asian eyes of iStent inject, a second-generation trabecular micro-bypass stent, combined with phacoemulsification. METHODS: This is a multi-centre, observational study of glaucomatous Asian eyes that have undergone iStent inject implantation combined with cataract surgery. Patient data were extracted from the Fight Glaucoma Blindness! Registry. Outcome measures included those of IOP reduction, glaucoma medication reduction, and adverse events including the need for secondary surgery. RESULTS: 123 eyes of 86 patients with a mean age of 68.4 ± 9.3 years underwent iStent inject implantation with phacoemulsification. At baseline, the mean ± SD preoperative intraocular pressure (IOP) was 16.0 ± 4.4 mmHg, and the mean preoperative number of topical glaucoma medications was 1.9 ± 1.4. At 12 months 30.8% of eyes demonstrated a reduction in IOP greater than 20%, the mean IOP reduction was 12.5% with an additional reduction of 0.7 glaucoma medications. 40% of eyes were using no medications at 12 months compared to 16.3% preoperatively. 8.2% of eyes required a subsequent procedure within the 12-month follow-up window. CONCLUSION: iStent inject implantation combined with phacoemulsification in Asian eyes showed a reduction of IOP and glaucoma medication use in a real-world clinical setting. The safety profile of the device is good with minimal adverse outcomes, however, a subset of patients required secondary procedures within the 12 month follow up.

Outcome of illuminated microcatheter-assisted circumferential trabeculotomy following failed angle surgery in PAX6 aniridic glaucoma: a case report and literature review.

BACKGROUND: Aniridia is a rare eye disorder with a high incidence of glaucoma, and surgical intervention is often needed to control the intraocular pressure (IOP). Here, we reported a case of illuminated microcatheter-assisted circumferential trabeculotomy (MAT) performed on an aniridic glaucoma patient following a previous failed angle surgery. The surgical procedures for aniridic glaucoma were also reviewed. CASE PRESENTATION: A 21-year-old man, diagnosed with aniridic glaucoma, came to our hospital consulting for the poor control of left eye's IOP despite receiving goniotomy surgery 3 years ago. The IOP was 26 mmHg with maximum topical antiglaucoma eyedrops. The central cornea was opaque and the majority of iris was absent. The gonioscopy and ultrasound biomicroscopy (UBM) demonstrated that 360° anterior chamber angle was closed. The whole exome sequencing of peripheral blood confirmed a 13.39 Mb copy number loss at chromosome 11p15.1p13, containing PAX6 and WT1 gene. The 360° MAT surgery was performed on his left eye. At 1-year follow-up, the IOP was 19mmHg with 2 kinds of topical antiglaucoma medications, and the postoperative UBM demonstrated the successful incision of the anterior chamber angle. CONCLUSIONS: The case presented here exhibited a case of aniridic glaucoma treated by MAT surgery. The MAT surgery may be an effective option for IOP control in aniridic glaucoma patients following a previous failed angle surgery.

The gonio scratch study: methodology of a multicenter clinical trial establishing a new minimally invasive glaucoma surgery.

There are numerous surgical procedures for glaucoma. Minimally invasive glaucoma surgery is becoming popular; however, the disadvantage is the high incidence of anterior chamber hemorrhage. Heavy bleeding can also lead to increased intraocular pressure (IOP) postoperatively. Gonio scratch is a surgical procedure that improves aqueous humor outflow by rubbing off deposits on the trabecular meshwork with a Diamond Dusted Sweeper. As the conjunctiva and trabecular meshwork are not incised, no postoperative bleeding is expected, and the IOP spike will be minimal. We designed this study to determine the efficacy and safety of gonio scratch. This is an on-going multicenter, prospective, clinical trial. Patients who are scheduled for glaucoma surgery with or without cataract surgery are being enrolled. A total of 80 eyes will be recruited in the Hiroshima University Hospital, Miyoshi Eye Clinic, Yokoyama Retina Clinic, and Kusatsu Eye Clinic. All patients will undergo gonio scratch. When combined with cataract surgery, gonio scratch is performed after the intraocular lens is inserted. The primary study endpoint is the change in IOP from baseline to 1 year after surgery. The secondary endpoints are complications, number of glaucoma medications, surgical time, and changes in visual acuity and the visual field. This study protocol was approved by the institutional review board of Hiroshima University. The trial results will be shared with the scientific community at international conferences and by publication in a peer-reviewed journal. Trial registration number is jRCTs062200003.

Bilateral total iris atrophy, corneal decompensation and glaucoma following bilateral cosmetic artificial iris implantation: A case report of severe sequela and successful management.

PURPOSE: Cosmetic iris implants have a record of high ocular complications and are no longer in use. These complications include glaucoma, corneal decompensation, iris atrophy, uveitis, cataract and retinal detachment. CASE PRESENTATION: We report a case of a 44-year-old lady presented with bilateral total iris atrophy, glaucoma and corneal decompensation after cosmetic artificial iris implantation. The patient underwent bilateral artificial iris removal, glaucoma drainage device for the right eye, and micropulse laser for the left eye. In addition, she underwent phacoemulsification with iris-diaphragm intraocular lens implant for the right. The cornea of the right eye ended up with successful Boston keratoprosthesis after rejection of previous 2 grafts. CONCLUSIONS: To the best of our knowledge, we describe the first report of bilateral total iris atrophy following a cosmetic iris implant accompanied by bilateral glaucoma and corneal decompensation.

A comparative study of cystoid macula edema following glaucoma drainage device surgery versus trabeculectomy.

PURPOSE: To assess and compare the risk for development of cystoid macula edema (CME) after glaucoma drainage device (GDD) implantation versus conventional trabeculectomy with mitomycin (trab) for glaucoma. METHODS: Retrospective review of consecutive patients receiving trab or GDD implantation between 2016 and 2018. Inclusion criteria were availability of pre- and postoperative spectral domain optical coherence tomography (SD-OCT) of the macula. SD-OCT images were evaluated for presence of CME qualitatively, central subfield thickness (CST) and macular volume (MV). RESULTS: 73 eyes could be included, 42 received trab and 31 GDD surgery. Eyes receiving trab on average had 0.8 ± 0.8 previous intraocular operations, while eyes with GDD implantation had 3.1 ± 1.9 (p < 0.001). Occurrence of postoperative CME was significantly more frequent after GDD implantation (6 out of 31 (19.4%)) than after trab (2 out of 42 eyes = 4.8%), (p = 0.049). Mean preoperative CST as well as MV was comparable in both groups (CST before trab: 282.7 ± 23.0 µm, CST before GDD 284.2 ± 27.3 µm, p = 0.287; MV before trab: 7.8 ± 1.1 mm3, MV before GDD: 8.0 ± 0.8mm3, p = 0.305). Mean postoperative CST and MV were significantly higher after GDD (CST 338.5 ± 129.3 µm, MV 8.8 ± 2.6 mm3) than after trabeculectomy (CST 290.6 ± 60.2 µm, p = 0.038; MV 7.8 ± 1.2mm3, p = 0.039). CONCLUSIONS: In real-life conditions, GDD surgery seems to be associated with a higher risk to develop CME when compared to conventional trabeculectomy. This information may be helpful for glaucoma surgeons to advise the patients on postoperative risks of surgery.

Factors and outcomes associated with corneal edema and Haabs striae in primary congenital glaucoma.

PURPOSE: To identify specific factors and outcomes associated with corneal edema and Haabs striae in primary congenital glaucoma (PCG). METHODS: The medical records of patients with PCG from 2011 to 2023 with >3 months' follow-up were reviewed retrospectively. Preoperative details and final outcomes were compared between eyes with and without corneal findings. The right eye of bilateral cases and the affected eye in unilateral cases were included. RESULTS: A total of 58 patients (104 eyes, 69% male) underwent initial angle surgery at an average age of 297 ± 368 (median, 134) days. Corneal edema and Haabs striae were present preoperatively in 72 (69%) eyes of 41 patients and 68 (65%) eyes of 39 patients, respectively. Patients with corneal edema presented at a younger age (P < 0.0001) and with shorter axial length (P = 0.01) than those without edema. Univariate analysis showed that corneal edema was associated with worse visual acuity at final follow-up (OR = 4.4; 95% CI, 1.2-25.3). Patients with Haabs striae were older than those without striae (P = 0.04). After angle surgery, corneal edema was present at 1 month in 71% (95% CI, 52-84), at 2 months in 26% (95% CI, 12-42), at 3 months in 16% (95% CI, 6-30), and at 1 year in 3% (95% CI, 0-13). Corneal opacification did not resolve in 4 eyes of 3 patients after >4 years of follow-up. CONCLUSIONS: In our study cohort, corneal edema resolved in the majority of PCG cases within 2-3 months of initial angle surgery but was associated with younger age at presentation and worse visual acuity at final follow-up.

XEN® 45 en el manejo quirúrgico del glaucoma en fases tempranas: estudio nacional de consenso según metodología Delphi / XEN-45 in the management of Early Glaucoma Surgery: A National Delphi Consensus Study

Antecedentes y objetivo: Las recomendaciones sobre el manejo general del glaucoma y el uso de cirugías mínimamente-invasivas y microincisionales en fases tempranas son limitadas. El objetivo de este estudio fue establecer un consenso sobre el manejo del glaucoma, centrándose en el implante XEN 45 (AbbVie Inc., North Chicago, IL, EE. UU.). Métodos: Se utilizó un método Delphi. El comité científico dirigió el estudio, identificó el panel de expertos y participó en la elaboración del cuestionario. Se invitó a 51 expertos a completar, en una escala Likert de 9 puntos, un cuestionario de 89 ítems que cubría 3 bloques temáticos. Se realizaron 2 rondas Delphi. Se logró consenso si≥66,6% de los expertos llegaron a un acuerdo o desacuerdo. Resultados: Los panelistas acordaron 84 ítems relacionados con la calidad de vida, el algoritmo terapéutico y el perfil del paciente, y el manejo quirúrgico pre y postoperatorio. Los panelistas consideraron el implante XEN idóneo para tratar el glaucoma en diferentes etapas y para diferentes perfiles de pacientes: pacientes jóvenes/ancianos/con comorbilidades-significativas, glaucoma-miópico, pacientes con fracaso quirúrgico previo y con postoperatorio complejo. El implante XEN se consideró un paso terapéutico previo a la cirugía filtrante clásica y una posible primera opción quirúrgica en pacientes ancianos con comorbilidades y presión intraocular descontrolada. El implante XEN permite al paciente retomar sus actividades diarias más rápidamente que las cirugías filtrantes convencionales y reducir y/o eliminar los tratamientos tópicos. Conclusiones: Este consenso según la metodología Delphi proporcionó una serie de recomendaciones generales para el tratamiento del glaucoma, incluidas aquellas relacionadas con la calidad de vida del paciente, el algoritmo terapéutico y el perfil del paciente, y específicas con respecto al uso del implante XEN.(AU)

Background and objective: Recommendations on general glaucoma management and the use of early minimally invasive and microincisional surgeries are limited. This study aimed to establish consensus regarding glaucoma management, focusing on the XEN-45 gel stent implant. Methods: A Delphi consensus-driven process was used. The scientific committee led the study, identified the expert panel, and participated in elaborating the questionnaire. Fifty-one panelists were invited to complete, on a nine-point Likert scale, an 89-item questionnaire covering three topic blocks. Two Delphi rounds were performed. Consensus was achieved if ≥66.6% of panelists reached agreement or disagreement. Results: Panelists agreed on 84 items related to the patients’ quality of life, the therapeutic algorithm and patient profile, and surgical and pre- and post-operative management. Panelists agreed on the suitability of XEN stent implants to treat glaucoma at different stages and for different patient profiles: young patients, elderly or with significant comorbidities, and with myopic glaucoma, patients who failed previous surgeries, and with previous poor post-operative experience. XEN surgery was considered a therapeutic step prior to classic filtering surgery and a possible first surgical option in elderly patients with comorbidities and uncontrolled intraocular pressure. XEN surgery allows the patient to return to routine daily activities faster than conventional filtering surgeries and to reduce and/or eliminate topical treatments. Conclusions: This Delphi-driven consensus resulted in a series of general recommendations for glaucoma management, including those related to patient quality of life, therapeutic algorithm, and patient profile, and specific ones regarding the use of XEN stent gel surgery.(AU)

Complicated trabeculectomy converted into ab externo cyclodialysis.

The creation of a scleral flap during trabeculectomy can be complicated by a buttonhole, partial amputation at the limbus, and extensive thinning. In some cases, the procedure must be aborted to prevent more serious postoperative complications. This report describes a technique of converting complicated trabeculectomy into ab externo cyclodialysis. A 41-year-old patient with congenital glaucoma presented with a perforated scleral wall with the choroidal tissue exposed during the dissection of the partial-thickness scleral flap. By using a Barraquer cyclodialysis spatula through the scleral perforation, the choroid was separated from the sclera up to the scleral spur over 30° into the anterior chamber. The sclera and conjunctiva/Tenon were sutured with 10-0 nylon single sutures. Two months later, the intraocular pressure was reduced to 16 mmHg with no hypotensive topical medications. This case illustrates an alternative approach to managing a flap-related perioperative complication in trabeculectomy, which yielded good early results.

Nonsuperotemporal quadrant implantation of the Ahmed glaucoma valve using modified long scleral tunnel technique for intraocular pressure control.

PURPOSE: As superotemporal implantation of the Ahmed glaucoma valve is not always feasible in cases of refractory glaucoma, this study examined the characteristics and surgical outcomes of cases in which the valve was implanted in a nonsuperotemporal quadrant using a modified long scleral tunnel technique. METHODS: This retrospective case-control study included 37 eyes with nonsuperotemporal quadrant--Ahmed glaucoma valve implantation in Group 1 and 69 eyes with superotemporal Ahmed glaucoma valve implantation in Group 2. The demographic characteristics of these groups, surgical outcomes, including complications, further surgical interventions, and surgical success rates were compared. Surgical success was defined as an intraocular pressure not exceeding 21 mmHg, accompanied by a minimum reduction of 20% in intraocular pressure from the baseline without any additional intraocular pressure-lowering procedures, and the absence of light perception loss or phthisis bulbi. RESULTS: Group 1 had significantly higher numbers of eyes with secondary glaucoma and preoperative surgical procedures than Group 2 (p<0.05). Both groups had mean preoperative intraocular pressure values, and mean intraocular pressure values at the last visit of 34.2 and 27.9 months, 35.5 ± 1.5 and 35.8 ± 1.2 mmHg, and 14.5 ± 5 and 14.9 mmHg, respectively. Although both groups had 70.2% and 75.8% as their five-year cumulative probability of success, respectively, the rates of complications, revisional surgery, and additional surgical procedures did not differ significantly (p>0.05). CONCLUSION: The modified long scleral tunnel technique for Ahmed glaucoma valve implantation in nonsuperotemporal quadrants achieves intraocular pressure control and complication rates comparable to superotemporal implantation.

Neurotrophic Keratopathy in Marfan Syndrome Patient After Micropulse Transscleral Cyclophotocoagulation: A Call for Risk Stratification.

BACKGROUND Micropulse transscleral cyclophotocoagulation is a non-invasive, widely employed procedure that uses diode laser to target the ciliary body to lower the intraocular pressure. Despite its acknowledged efficacy, certain complications are recognized, with neurotrophic keratopathy being a rare yet serious consequence. This report seeks to shed light on a potential high-risk subgroup susceptible to neurotrophic keratopathy, exemplified by our patient with Marfan syndrome, a condition characterized by thin sclera. CASE REPORT Our patient, who was confirmed to have Marfan syndrome with pseudophakic glaucoma, underwent micropulse transscleral cyclophotocoagulation due to high intraocular pressure bilaterally and subsequently quickly manifested neurotrophic keratopathy in both eyes postoperatively. Swift initiation of management involved a comprehensive approach, including topical antibiotics, preservative-free lubrication, medroxyprogesterone acetate 1%, serum balanced salt solution (BSS) 50%, and the application of bandage contact lenses to expedite healing. Fortunately, the left eye demonstrated resolution within 10 days, while the right eye exhibited delayed healing, leading to subsequent scarring. CONCLUSIONS This report highlights the critical importance of recognizing populations predisposed to neurotrophic keratopathy before subjecting them to micropulse transscleral cyclophotocoagulation. Such awareness allows for the fine-tuning of procedural parameters, offering a strategic approach to mitigate the risk of neurotrophic keratopathy development. By further exploring and recognizing potential risk factors, clinicians can enhance patient outcomes and refine the safety profile of micropulse transscleral cyclophotocoagulation.

Secondary intervention after failed initial intervention for primary congenital glaucoma.

AIM: To report on the outcome of subsequent interventions after failed initial intervention for primary congenital glaucoma (PCG). METHODS: Retrospective chart review of children presenting with PCG and failed the initial glaucoma surgery in Alexandria Main University Hospital from 2005 to 2017. The data included demographics, preoperative, operative and postoperative clinical characteristics. Success was defined as IOP<16mmHg and <20% from the presenting IOP and C/D ratio like or better than presentation. RESULTS: The charts of 531 (260 right, 49%) eyes of 360 (224 males, 62%) children presenting with PCG and failed the initial glaucoma surgery (58 [31 right, 53%] eyes [10.9%] of 50 [28 males, 56%] children) revealed that at initial presentation, the mean±standard deviation (range, median) of the age of the children subjected to one successful glaucoma procedure and the study children was 8.6±11.7 (0.6-109, 5.2) and 4.9±6.1 (0.5-34.4, 3.0) months, respectively. Each of the study eyes was subjected to 2.6±0.8 (2-5.2) glaucoma procedures. The mean±standard deviation (range, median) duration between the initial and second glaucoma surgery and the duration of follow-up was 6.9±7.8 (0.7-39,3.9) and 61.5±32.1 (12.0-139.1, 60.1) months, respectively. At the final follow-up visit success was reported in 41 (70.1%) eyes by IOP<16mmHg criterion, 39 (67.2%) eyes by IOP>20% reduction criterion and in 28 (out of 35 eyes, 80.0%) by the optic nerve condition (C/D ratio) criterion. Success by all 3 criteria was reported in 25 (out of 35 eyes, 71%) eyes. CONCLUSIONS: A repeat glaucoma surgical procedure maybe needed in up to 11% of operated PCG eyes, with the subsequent glaucoma surgical procedures being successful by about 70%.

Minimally Invasive Bleb Surgery for Glaucoma: A Health Technology Assessment.

Background: Glaucoma is the term for a group of eye disorders that causes progressive damage to the optic nerve, which can lead to visual impairment and, potentially, irreversible blindness. Minimally invasive bleb surgery (MIBS) reduces eye pressure through the implantation of a device that creates a new subconjunctival outflow pathway for eye fluid drainage. MIBS is a less invasive alternative to conventional/incisional glaucoma surgery (e.g., trabeculectomy). We conducted a health technology assessment of MIBS for people with glaucoma, which included an evaluation of effectiveness, safety, the budget impact of publicly funding MIBS, and patient preferences and values. Methods: We performed a systematic literature search of the clinical evidence. We assessed the risk of bias of each included study using the Cochrane Risk of Bias 1.0 tool for randomized controlled trials (RCTs) and the Risk of Bias Assessment tool for Nonrandomized Studies (RoBANS) for comparative observational studies, and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We conducted an economic literature search and we estimated the budget impact of publicly funding MIBS in Ontario. We did not conduct a primary economic evaluation due to the limited long-term effectiveness data. We summarized the preferences and values evidence from previous health technology assessments to understand the perspectives and experiences of patients with glaucoma. Results: We included 41 studies (2 RCTs and 39 comparative observational studies) in the clinical evidence review. MIBS may reduce intraocular pressure and the number of medications used, but we are uncertain if MIBS results in outcomes similar to trabeculectomy (GRADE: Moderate to Very low). Compared with trabeculectomy, MIBS may result in fewer follow-up visits and interventions, and adverse events (GRADE: Moderate to Very Low). MIBS may also reduce intraocular pressure and the number of antiglaucoma medications used, compared with other glaucoma treatments, but the evidence is uncertain (GRADE: Very low). Our economic evidence review identified two directly applicable studies. The results of these studies indicate that the cost-effectiveness of MIBS is highly uncertain, and the cost of glaucoma interventions are likely to vary across provinces. The annual budget impact of publicly funding MIBS in Ontario ranged from $0.11 million in year 1 to $0.67 million in year 5, for a total 5-year budget impact estimate of $1.93 million. Preferences and values evidence suggests that fear of ultimate blindness and difficulty managing medication for glaucoma led patients to explore other treatment options such as MIBS. Glaucoma patients found minimally invasive glaucoma surgery (MIGS) procedure beneficial, with minimal side effects and recovery time. Conclusions: Minimally invasive bleb surgery reduces intraocular eye pressure and the number of antiglaucoma medications needed, but we are uncertain if the outcomes are similar to trabeculectomy (GRADE: Moderate to Very low). However, MIBS may be safer than trabeculectomy (GRADE: Moderate to Very low) and result in fewer follow-ups (GRADE: Moderate to Very low). MIBS may also improve glaucoma symptoms compared with other glaucoma treatments, but the evidence is very uncertain (GRADE: Very low).We estimate that publicly funding MIBS would result in an additional cost of $1.93 million over 5 years. Patients who underwent MIGS procedures found them to be generally successful and beneficial, with minimal side effects and recovery time. We could not draw conclusions about specific MIBS procedures or long-term outcomes.

A computational fluid dynamics investigation of endothelial cell damage from glaucoma drainage devices.

Glaucoma drainage devices (GDDs) are prosthetic-treatment devices for treating primary open-angle glaucoma. Despite their effectiveness in reducing intraocular pressures (IOP), endothelial cell damage (ECD) is a commonly known side-effect. There have been different hypotheses regarding the reasons for ECD with one being an induced increase in shear on the corneal wall. A computational fluid dynamics (CFD) model was used to investigate this hypothesis in silico. The Ahmed Glaucoma Valve (AGV) was selected as the subject of this study using an idealised 3D model of the anterior chamber with insertion angles and positions that are commonly used in clinical practice. It was found that a tube-cornea distance of 1.27 mm or greater does not result in a wall shear stress (WSS) above the limit where ECD could occur. Similarly, a tube-cornea angle of 45° or more was shown to be preferable. It was also found that the ECD region has an irregular shape, and the aqueous humour flow fluctuates at certain insertion angles and positions. This study shows that pathological amounts of WSS may occur as a result of certain GDD placements. Hence, it is imperative to consider the associated fluid force interactions when performing the GDD insertion procedure.

Twelve-month outcomes of Kahook dual blade goniotomy combined with cataract surgery in Latino patients.

PURPOSE: To evaluate 12 month surgical outcome of Kahook Dual Blade (KDB) goniotomy in combination with cataract surgery in Latino patients with open angle glaucoma (OAG) and ocular hypertension (OHT). METHODS: This retrospective study included 45 eyes of 40 patients who underwent KDB goniotomy combined with cataract extraction from January 2016 to September 2020 at two centers in South America. Primary outcome was surgical success defined as ≥ 20% intraocular pressure (IOP) reduction or ≥ 1 medication reduction from preoperative without additional IOP-lowering procedures and an IOP ≥ 5 mmHg or ≤ 21 mmHg. Additionally, we used 2 cutoffs values for success of IOP ≤ 18 and ≤ 15 mmHg. Secondary outcomes included: IOP, medication use, best corrected visual acuity, complications and failure-associated factors. RESULTS: Success rates at 12 months with cutoff limits of 21, 18 and 15 mmHg were 84.3%, 75.6% and 58.7%, respectively. At 12 months, mean preoperative IOP significantly decreased from 19.23 ± 0.65 mmHg on 2.3 ± 1.0 medications to 14.33 ± 0.66 mmHg on 0.6 ± 0.9 medications (p < 0.001) , with 62% of eyes free of hypotensive medication. Eyes that developed postoperative IOP spikes showed a higher risk for failure using the cutoff limit of IOP ≤ 18 mmHg with a hazard ratio of 3.6 (95% confidence interval [CI], 1.80-7.13; p < 0.001). There were no serious ocular adverse events. CONCLUSIONS: KDB combined with cataract extraction showed safety and efficacy for decreasing IOP in OAG and OHT Latino patients. Additionally, dependence on medications was reduced significantly after surgery.