Long-Term Surgical Outcomes of Glaucoma Drainage Implants in Eyes with Preoperative Intraocular Pressure Less than 19 mmHg.

Background: This retrospective review reports on patients who underwent glaucoma drainage implant (GDI) surgery and had baseline intraocular pressure (IOP) of ≤18 mmHg with at least one year of follow-up. Methods: Clinical data of 67 eyes of 67 patients were collected from patients' charts, and the outcomes of GDI were evaluated until 7 years. GDI failure was defined as IOP reduction of less than 20% from the baseline at two consecutive visits three months after surgery, decline to no light perception, or if additional glaucoma surgery was performed. Results: The average age was 65.9 ± 13.2 years. Most cases were male (52.2%), White (53.7%), and had primary open-angle glaucoma (62.7%). Forty-four eyes had prior glaucoma surgery (68.6%) and 46 (68.6%) had severe glaucoma. Though postoperative (postop) IOP changes were insignificant, the average postop number of medications dropped from 2.4 ± 1.4 to 1.9 ± 1.2 medications two years after surgery (p = 0.0451). Postop complications (23.9%) included GDI exposure (7.5%), inflammation (4.5%), shallow anterior chamber (4.5%), and strabismus (1.5%). Hypotony was observed in 4 eyes (5.9%), none of which developed hypotony maculopathy. The cumulative one-year failure rate was 56.7%, most of which were due to failure to lower IOP. Conclusion: In patients with baseline IOP ≤18 mmHg who had GDI surgery, though the change in IOP was not statistically significant, the number of medications dropped and visual field progression slowed in a subset of patients with adequate perimetric data. Due to a relatively high rate of complications and limited effectiveness in lowering IOP, GDI should be cautiously used in these eyes.

Persistent Mydriasis Following Gonioscopy-Assisted Transluminal Trabeculotomy.

Herein we describe 2 cases of persistent mydriasis after gonioscopy-assisted transluminal trabeculotomy for open angle glaucoma. Both surgeries were uneventful, but the patients experienced postoperative hyphema and intraocular pressure elevation. They then developed persistent fixed and dilated pupils resistant to pilocarpine that led to intolerable photosensitivity and glare. An iris cerclage pupilloplasty was performed with adequate relief of symptoms in one case.

Early Postoperative Aqueous Suppression Therapy and Surgical Outcomes of Ahmed Tube Shunts in Refractory Glaucoma.

PURPOSE: To compare early vs. delayed use of aqueous suppressants on Ahmed glaucoma valve (AGV) outcomes. DESIGN: Single-center retrospective comparative case series. PARTICIPANTS: Patients who underwent AGV surgery at Wills Eye Hospital in the period between 2016 and 2021. METHODS: Retrospective review of AGV surgery at Wills Eye Hospital 2016 to 2021 for refractory glaucoma. Two groups were created: group 1 or those who received early aqueous suppressant therapy in the first 2 weeks postoperatively whenever the intraocular pressure (IOP) was > 10 mmHg, and group 2 or those who received delayed treatment after 2 weeks whenever the IOP exceeded the target pressure. Aqueous suppressant therapy included topical beta blockers, carbonic anhydrase inhibitors, and/or alpha agonists. MAIN OUTCOME MEASURES: The primary outcome measures were the frequency of hypertensive phase (HP) defined as IOP > 21 mmHg in first 3 months after an initial reduction to 21 mmHg or less in the first postoperative week not caused by tube obstruction or retraction, and month-12 surgical failure defined as 5 ≥ IOP > 21 mmHg on 2 consecutive visits, vision decline to no light perception (NLP), or glaucoma reoperation. Secondary outcome measures included changes in visual acuity (VA), IOP, and glaucoma medications at 12 months. Predictive factors for surgical failure were also identified. RESULTS: A total of 407 eyes of 391 patients (260 in group 1, 147 in group 2) with similar baseline characteristics were included. Hypertensive phase was more common in group 2 than 1 (41.5% vs. 18.5%; P < 0.001). At month 12 (N = 303 eyes), group 1 was less likely to fail than group 2 (21.2% vs. 36.8%, P = 0.003). Multivariate regression analysis showed that HP (odds ratio [OR] = 10.47, P < 0.001), delayed aqueous suppression use (OR = 2.17, P = 0.003), and lower baseline VA (OR = 1.56, P = 0.015) were the strongest predictors of month-12 failure. CONCLUSIONS: Early use of aqueous suppressants may lower the risk of HP and improve AGV outcomes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

10-Year Clinical Outcomes of Tube Shunt Surgery at a Tertiary Care Center.

PURPOSE: To report 10-year clinical outcomes of tube shunt (TS) surgery at a tertiary care center. DESIGN: Retrospective cohort study. METHODS: Eyes were included that underwent a first TS surgery between January 2005 and December 2011 at a tertiary referral eye hospital and with at least 10 years of follow-up. Demographic and clinical data were collected. Failure was defined as reoperation to lower intraocular pressure (IOP), IOP > 80% of baseline for two consecutive visits, or progression to no light perception. RESULTS: Eighty-five eyes of 78 patients were included in the Study Group; 89 eyes were selected as a Comparison Group. Mean follow-up was 11.9 ± 1.7 years. Fifty-one valved (60%), 25 non-valved (29%), and nine unknown (11%) TS were placed. At the final visit, mean IOP was reduced from 29.2 ± 10.4 mmHg on 3.1 ± 1.2 medications to 12.6 ± 5.8 mmHg on 2.2 ± 1.4 (p<0.001 for each). Forty-eight eyes (56%) failed; 29 eyes (34%) underwent additional glaucoma surgery; eight eyes (10%) progressed to no light perception; and 34 eyes (40%) also required TS revision. Best corrected visual acuity (BCVA) logMAR (minimal angle of resolution) worsened from 0.8 ± 0.7 (20/125) to 1.4 ± 1.0 (20/500) at the last visit (p<0.001). Average visual field MD was -13.9 ± 7.5 dB at baseline and -17.0 ± 7.0 dB at last follow-up (P=0.0605). CONCLUSIONS: Many eyes maintained IOP control 10 years following TS, but 56% met failure criteria, 39% had substantial vision loss, and 34% underwent additional surgery. Outcomes did not differ with TS model. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Outcomes of Selective Laser Trabeculoplasty After Prior Incisional Surgery for Open Angle Glaucoma.

PRCIS: This retrospective case series of patients with open angle glaucoma and prior trabeculectomy or tube shunt surgery found that selective laser trabeculoplasty (SLT) resulted in significant intraocular pressure (IOP) reductions in the intermediate follow-up period in select cases. PURPOSE: The purpose of this study was to assess the IOP-lowering effect and tolerability of SLT after prior trabeculectomy or tube shunt surgery. MATERIALS AND METHODS: Open angle glaucoma patients at Wills Eye Hospital who previously underwent incisional glaucoma surgery and subsequently received SLT between 2013 and 2018 were included, along with an age-matched control group. Baseline characteristics, procedural data, and post-SLT data were recorded at 1, 3, 6, 12 months, and most recent visit. The primary success of SLT treatment was defined as IOP reduction of 20% or greater without the use of additional glaucoma medications compared to pre-SLT IOP. Secondary success was defined as IOP reduction ≥20% with the use of additional glaucoma medications compared to pre-SLT IOP. RESULTS: There were 45 eyes in the study group and 45 eyes in the control group. In the study group, IOP decreased from a baseline of 19.5±4.7 mm Hg on 2.2±1.2 medications to 16.7±5.2 mm Hg ( P =0.002) on 2.2±1.1 glaucoma medications ( P =0.57). In the control group, IOP decreased from 19.5±4.2 mm Hg on 2.4±1.0 medications to 16.4±5.2 mm Hg ( P =0.003) on 2.1±1.3 medications ( P =0.36). There was no difference in IOP reduction or change in number of glaucoma medications after SLT at any postoperative visit between the 2 groups ( P ≥0.12 for all). Primary success rates at 12 months were 24.4% for the control group and 26.7% for the prior incisional glaucoma surgery group with no significant difference between the groups ( P =0.92). There were no persistent complications after SLT treatment in either group. CONCLUSION: SLT may effectively lower IOP in patients with open angle glaucoma who have had previous incisional glaucoma surgery and should be considered in select cases.

Glaucoma Surgical Outcomes in Patients with a History of Scleritis.

PURPOSE: To assess the outcomes of glaucoma surgery in patients with a history of scleritis at a tertiary medical center. METHODS: The retrospective case series included patients with a history of scleritis who required glaucoma surgery between 4/2006 and 8/2021. RESULTS: Two hundred and eighty-one eyes of 259 patients had glaucoma and scleritis with 28 eyes (10%) of 25 patients requiring glaucoma surgery. Post-operatively, one eye (4%) had infectious scleritis. Eleven (39%) surgeries failed: 5 tube shunts, 5 cyclophotocoagulation, and 1 gonioscopy-assisted transluminal trabeculotomy. Five (18%) eyes required tube revisions due to tube exposures without infection (3), iris blocking the tube (1), or to shorten tube length (1). CONCLUSIONS: Patients with a history of scleritis have a low risk of scleritis recurrence or scleral perforation after glaucoma surgery but should be counseled appropriately on the higher risk of reoperation.

The effectiveness and tolerability of fixed-dose combination netarsudil 0.02%/latanoprost 0.005% at a tertiary glaucoma center.

PURPOSE: To assess real-world effectiveness and tolerability of fixed-dose combination netarsudil 0.02%/latanoprost 0.005% (FCNL) in management of glaucoma patients in a tertiary eye care center. METHODS: This retrospective cohort study included glaucoma patients initiated on FCNL from January 2018 to July 2021 with at least 1-month follow-up. Demographic and clinical data were collected at baseline and at follow-up visits through 12 months. Patient-solicited side effects were recorded at each visit. Maximum glaucoma pharmacotherapy was defined as surgery/laser being the next treatment option following an intensive pharmacotherapy regimen, or when pharmacotherapy could not be increased due to allergy/intolerance or all pharmacologic mechanisms already being in use. RESULTS: Seventy-nine eyes of 47 patients were included. Mean age was 67.7 ± 14.7 years. Baseline IOP was 18.7 ± 4.9 mmHg; mean change in IOP (∆IOP) each study visit compared to baseline ranged from - 1.6 ± 3.5 to - 4.4 ± 4.1 mmHg (all p < 0.05). The eyes on maximum glaucoma pharmacotherapy (73.4%) had similar ∆IOP compared to those on non-maximal therapy at each visit (p > 0.2 for all). Forty-three (54.4%) eyes were switched from a prostaglandin analog alone, producing a 1-month IOP reduction of - 4.7 ± 3.9 mmHg at 1 month which remained significant at each visit for the 12-month study period (all p < 0.05). Across all study visits, conjunctival hyperemia was documented in 26 (32.9%) eyes. Subjective blurry vision was reported in 22 (27.8%) eyes without significant worsening of visual acuity at any visit (all p > 0.05). Six (7.6%) and 7 (8.9%) eyes required further medical or surgical/laser intervention, respectively. Kaplan-Meier analysis revealed no significant difference in the need for subsequent medical or surgical intervention between those on maximum and non-maximal pharmacotherapy (p > 0.4). CONCLUSION: FCNL was well-tolerated and demonstrated a significant and sustained reduction in IOP, even as last-line therapy before incisional or laser surgery in those on maximum glaucoma pharmacotherapy. FCNL is a viable treatment option for glaucomatous eyes before consideration of surgical intervention.

PREVALENCE, CHARACTERISTICS, AND OUTCOMES OF RHEGMATOGENOUS RETINAL DETACHMENT IN EYES WITH TRABECULECTOMY OR GLAUCOMA DRAINAGE DEVICES.

PURPOSE: To describe the prevalence, management, and outcomes of rhegmatogenous retinal detachment (RRD) after incisional glaucoma filtering surgery. METHODS: All patients with a history of trabeculectomy or glaucoma drainage device surgery who were subsequently diagnosed with an RRD from January 1, 2016, to January 1, 2021, at the Wills Eye Hospital were identified. RESULTS: Forty-six eyes met the inclusion criteria. The mean age was 60.7 ± 19.6 years, and 15 patients (32.6%) were female. Of all eyes, 34 (73.9%) were diagnosed with primary open-angle glaucoma. The mean time from most recent incisional glaucoma surgery to RRD diagnosis was 1,133 ± 1,644 days. There were 19 eyes (41.3%) with preoperative proliferative vitreoretinopathy (9 eyes [19.6%] with Grade C proliferative vitreoretinopathy) and 35 eyes (76.1%) had macula-off RRD at the time of presentation. At RRD presentation, 4 eyes (8.7%) had concomitant endophthalmitis, 5 (10.9%) had concurrent choroidal detachment, and 2 (4.7%) had concurrent vitreous hemorrhage. Primary vitrectomy was performed in most (91.3%) cases. Silicone oil tamponade was often required (71.1%). The single surgery success rate was 65.2% (30 of 46). The mean preoperative logarithm of the minimum angle of resolution visual acuity was 1.72 ± 0.78 (Snellen acuity 20/1,050), and the mean final postoperative logarithm of the minimum angle of resolution was 1.59 ± 0.89 (20/778, P = 0.2853). Of glaucoma surgeries performed, the 5-year prevalence of RRD was 0.71% (26 of 3,664, 95% Poisson confidence interval 0.48%-1.04%). CONCLUSION: The 5-year prevalence of RRDs after trabeculectomy or glaucoma drainage device was 0.71%. Most patients presented with macula-involving detachments, often with proliferative vitreoretinopathy. Anatomical and visual outcomes were poor.

Outcomes of eyes with retinal vein occlusion that are lost to follow-up after antivascular endothelial growth factor therapy.

BACKGROUND/AIMS: To evaluate the outcomes of eyes with macular oedema due to retinal vein occlusion (RVO) that are lost to follow-up (LTFU) after antivascular endothelial growth factor (VEGF) injections. METHOD: A retrospective, single-centre, consecutive case series of RVO patients receiving injections who were LTFU >6 months was conducted. Data were collected from the visit before LTFU; return visit; 3 months, 6 months and 12 months after return; and the final visit. RESULTS: Ninety eyes of 83 patients were included. Fifty (55.5%) eyes had branch RVO and 40 (44.5%) had central RVO. Mean LTFU duration was 277.8 days with additional mean follow-up for 748.1 days after return. Mean logarithm of the minimum angle of resolution visual acuity (VA) (Snellen) at the visit before LTFU was 0.72 (20/105) which worsened on return [1.04 (20/219), p<0.001) and remained worse at all timepoints after return: 0.92 (20/166) at 3 months (p<0.001), 0.97 (20/187) at 6 months (p<0.001), 0.94 (20/174) at 12 months (p<0.001) and 1.01 (20/205) at final visit (p<0.001). Mean central foveal thickness (CFT) increased from 252 µm at the visit before LTFU to 396 µm at the return visit (p<0.001). No difference in CFT was noted by 3 months (258 µm, p=0.71), 6 months (241 µm, p=0.54) or 12 months after return (250 µm, p=0.95). CFT was thinner at the final visit (215 µm, p=0.018). CONCLUSION: RVO patients receiving anti-VEGF injections who were LTFU experienced a decline in VA that did not return to the levels seen before LTFU despite improvement in CFT after restarting therapy, underscoring the importance of ongoing treatment.