Bleb morphology of glaucoma drainage devices on magnetic resonance imaging.

PURPOSE: To evaluate bleb morphology features of different glaucoma drainage devices (GDD) using magnetic resonance imaging (MRI). MATERIALS AND METHODS: Prospective cohort study of GDD and bleb morphology in consecutive glaucoma patients implanted with Ahmed Glaucoma Valve (AGV), Paul Glaucoma Implant (PGI), Baerveldt Glaucoma Implant (BGI) and Ahmed ClearPath (ACP) devices. Thirty-six eyes from 30 consecutive patients underwent standardized GDD implantation followed by MRI at least 1 month after surgery. Main outcomes included bleb volume and endplate position relative to the optic nerve. Secondary outcomes included intraocular pressure (IOP), medication and surgical complications during a 12-month follow-up. RESULTS: Seven eyes were implanted with the AGV (19%), 5 with BGI (14%), 16 with PGI (44%) and 8 with ACP (22%). MRI scans were obtained 85 ± 66 days after surgery. Mean total bleb volume was 563 ± 390 mm3 . This bleb volume was inversely correlated with early post-operative IOP (day 7; rs = -0.3326, p = 0.0475) but positively correlated with IOP at 12 months (rs = 0.3592, p = 0.0341). No significant difference in total bleb volume was found between GDD types (p = 0.1223). A double-layered bleb was observed in 34 eyes (94%). The inferior bleb volume was significantly larger in PGI devices versus other GDD types (380 ± 205 vs. 193 ± 161 mm3 ; p = 0.0043). Distance from the endplate to the optic nerve was 9.5 ± 4.0 mm, similar across GDDs (p = 0.2519). CONCLUSIONS: Double-layered blebs are a common finding with GDDs. Bleb volume showed different correlations with IOP at distinct timepoints and the PGI device formed larger blebs. A standardized GDD implantation technique ensures a safe distance from the GDD endplate to the optic nerve.

Glaucoma triage system: results of implementing a virtual clinic.

PURPOSE: This study describes the virtual clinic triage system implementation process at Hospital Santa Maria-Centro Hospitalar Universitário Lisboa Norte (HSM-CHULN) and analyzes its results regarding healthcare outcomes for the patients and the system. METHODS: A retrospective analysis was performed, comparing two cohorts (pre-virtual cohort; virtual triage cohort). Outcomes related to waiting time, number of hospital visits, decisions at first contact, and ancillary exam-based decisions were reported. RESULTS: Two hundred and ninety-two charts were reviewed (pre-virtual cohort: 132; virtual cohort: 160). Mean waiting time between referral and the first medical contact with the glaucoma department decreased on average by 71.3 days (human contact: 286.6 days; virtual triage contact: 215.3 days). Triage system significantly decreased waiting time for glaucoma patients, with an average decrease of 326.8 days between referral and treatment decision. Triage staging allowed to label 107 (66.9; 95% confidence intervals (CI): 59.6%, 74.2%) as non-urgent; 30 (18.8%; 95% CI: 12.7%, 24.9%) as urgent, and 23 (14.3%; 95% CI: 8.9%, 19.7%) as immediate contact, with the scheduling of future appointments reflecting National Institute for Health and Care Excellence (NICE) guidelines in every patient. Moreover, the number of visits to perform the same exams and obtain the same clinical decisions was reduced by 63.6%. CONCLUSION: Our virtual screening strategy significantly decreased waiting time, number of hospital visits, and increased chances of data-assisted clinical decision. While results can be further improved, this system can add value in an overburdened healthcare system, where triage systems with remote decision-making may be valuable tools in optimizing glaucoma care, even without allocation of extra resources.

Trabeculectomy with mitomycin C alone or coupled with intracamerular bevacizumab? A 2-year comparative study.

PURPOSE: To compare outcomes of primary trabeculectomy using either mitomycin C (MMC) alone versus MMC augmented with intracamerular bevacizumab in patients with open-angle glaucoma. METHODS: Retrospective, cohort, two-centre, comparative study. Patients' data were screened between October 2015 and March 2019, with inclusion requiring a minimum follow-up of 24 months. Primary outcome was intraocular pressure (IOP) lowering at 24 months, with surgical success defined with different maximum IOP targets (≤18, ≤16 and ≤14 mm Hg) and at least 30% reduction and higher than 5 mm Hg. Absolute success was achieved if no IOP-lowering medication was needed and a qualified success if otherwise. Safety outcomes were analysed. RESULTS: A total of 110 eyes underwent trabeculectomy with MMC, 51 of these combined with intracamerular bevacizumab. Both strategies were effective in terms of IOP lowering (baseline vs 2 years postoperatively: 24.4 (8.0) mm Hg vs 12.1 (5.3) mm Hg in the MMC group; 25.1 (8.7) vs 10.8 (3.8) mm Hg in the MMC+bevacizumab group; p<0.001 in both comparisons). The MMC+bevacizumab group had a significant difference towards higher efficacy on absolute success rates at all targets (IOP≤14 or ≤16 or ≤18 mm Hg; p=0.010, p=0.039 and p=0.007, respectively). The large majority (93%) of the MMC+bevacizumab group was drop-free at 24 months, and 41% had IOP below 10 mm Hg. Complication rates were low and similar between groups, with no systemic adverse events. CONCLUSIONS: Intracamerular bevacizumab in MMC-augmented primary trabeculectomy increases the chances of obtaining low IOP outcomes. This strategy may be useful when planning for surgeries aiming at target pressures in the low teens. TRIAL REGISTRATION NUMBER: ISRCTN93098069.

High intensity focused ultrasound for glaucoma: 1-year results from a prospective pragmatic study.

BACKGROUND: Ciclo plasty using high-intensity focused ultrasound (HIFU) technology acts through the selective coagulation of the ciliary body. Our aim was to evaluate the safety and efficacy profiles of 8-s probe HIFU cyclocoagulation using the EyeOP1 device. METHODS: Prospective pragmatic trial. INCLUSION CRITERIA: adult glaucoma patients with uncontrolled IOP despite optimised medical therapy, and/or intolerant to medical therapy required to achieve target IOP. PRIMARY OUTCOME: surgical success defined as IOP reduction from baseline >20% with final IOP ≤21 mmHg, without adding any IOP-lowering drugs, and without loss of light perception; or decreased use of IOP-lowering drugs with stable/decreased IOP, without loss of light perception. SECONDARY OUTCOMES: mean IOP, intra and postoperative complications, best-corrected visual acuity (BCVA) and number of IOP-lowering drugs at each visit. Outcome data were collected preoperatively and at postoperative day 1, and months 1, 3, 6 and 12. RESULTS: Forty-nine eyes of forty-nine patients (28 male) with a mean age of 70 ± 14 years were enroled. Pre-operative IOP was 26.9 ± 7.4 mmHg under 2.8 ± 0.9 topical medications, decreasing to 17.8 ± 6.4 mmHg under 2.3 ± 1 drugs at 12 months (p < 0.01). One-year surgical success was achieved in 71.4% of patients (IOP-reduction criteria: 59.2%; decreased use of IOP-lowering drugs: 38.8%). Eight patients were ultimately submitted to other glaucoma surgical interventions. Five patients experienced serious adverse events (loss of light perception n = 5; hypotony n = 1). CONCLUSIONS: This innovative non-invasive technology seems to be effective in decreasing IOP and/or the number of administered drops in patients with refractory glaucoma. It seems a valuable tool to delay or preclude the need for filtering procedures in the majority of the patients.

Outcomes of phacoemulsification combined with two iStent inject trabecular microbypass stents with or without endocyclophotocoagulation.

AIM: Comparing outcomes after combined phacoemulsification, two iStents insertion and endocyclophotocoagulation (ECP) versus phacoemulsification-iStents alone. METHODS: This is a longitudinal retrospective 12 months study in eyes with ocular hypertension or early-to-moderate open angle glaucoma. Level of disease, intraocular pressure (IOP) and tolerance of glaucoma medication were considered before planning surgery. Best-corrected visual acuity (BCVA-logMAR), IOP (mm Hg), number of medications were assessed at baseline, week 1, week 5, month 3, 6, 12 postop. MAIN OUTCOME: percentage (%) in IOP reduction at 12 months vs medicated baseline. SECONDARY OUTCOMES: absolute values of IOP/medication reduction, BCVA and postop complications. RESULTS: The ICE2 (two iStents-cataract extraction-ECP) group included 63 eyes and Phaco-iStent group included 46 eyes. Baseline IOP was higher in the ICE2 than phaco-iStent group (19.97±4.31 mm Hg vs 17.63±3.86 mm Hg, p=0.004) and mean deviation was lower (-7.20±2.58 dB vs -4.94±4.51 dB, p=0.037). Number of medications were comparable at baseline: 2.22±1.06 (ICE2) vs 2.07±1.02 (phaco-iStent), p=0.442. At month 12 postop, IOP in the ICE2 group decreased 35% from baseline vs 21% in the phaco-iStent group (p=0.03); absolute IOP reduction was significantly lower than baseline in each group (p<0.001), yet final IOP was lower in the ICE2 group than phaco-iStent group (13.05±2.18 mm Hg vs 14.09±1.86 mm Hg, p=0.01). Similar results were found for glaucoma medication (1.24±1.05 in ICE2 group vs 1.39±1.03 in phaco-iStent group, p=0.01). Final BCVA was 0.11±0.18 (phaco-iStent group) vs 0.08±0.08 (ICE2 group), p=0.309. Safety outcomes were comparable between groups. CONCLUSION: ICE2 procedure offers better results in IOP/medication reduction at 12 months than phacoemulsification-iStents alone.