Risk Factors for Failure in Glaucoma Patients Undergoing Microshunt Implantation.

PURPOSE: To evaluate risk factors for failure of Microshunt in glaucoma patients. DESIGN: Multicenter retrospective cohort study. METHODS: The study included 220 eyes from 220 consecutive glaucoma patients undergoing Microshunt implantation at six glaucoma units. Four intraocular pressure (IOP) success criteria were defined: (A) IOP ≤21 mm Hg with ≥20% IOP reduction; (B) IOP ≤18 mm Hg with ≥20% IOP reduction; (C) IOP ≤15 mm Hg with ≥25% IOP reduction; and (D) IOP ≤12 mm Hg with ≥30% IOP reduction from baseline. Kaplan-Meier analysis was used to estimate success rates according to the criteria above, and multivariable Cox models were used to identified risk factors for failure according to criterion A. RESULTS: Success rates varied based on different criteria, ranging from 43.3% to 62.5% (overall success for criteria D and A, respectively) and from 35.3% to 44.4% (complete success for criteria D and A, respectively) at 1-year follow-up. Higher intraoperative MMC concentration was associated with reduced risk of failure to maintain complete (0.4 vs 0.2 mg/mL: hazard ratio [HR] = 0.441, P < .001) and overall (0.4 vs 0.2 mg/mL: HR = 0.360, P = .004) success. For complete success, other risk factors for failure were pseudoexfoliation glaucoma/pigmentary glaucoma (HR = 1.641, P = .004), primary angle closure glaucoma (HR = 1.611, P < .001), and previous non-glaucomatous ocular surgeries (HR = 2.301, P = .002). For overall success, other risk factors for failure were lower preoperative IOP (for 1-mm Hg increase, HR = 0.934, P = .005), higher number of preoperative antiglaucoma agents (HR = 1.626, P < .001), and Microshunt combined with cataract surgery (HR = 1.526, P = .033). CONCLUSIONS: This study identified risk factors for Microshunt failure, highlighting the importance of high intraoperative MMC dose and careful patient selection to optimize surgical success.

Treatment of Open-Angle Glaucoma and Ocular Hypertension with the Fixed-Dose Combination of Preservative-Free Tafluprost/Timolol: Clinical Outcomes from Ophthalmology Clinics in Italy.

Introduction: The VISIONARY study examined the intraocular pressure (IOP)-lowering efficacy and tolerability of the preservative-free fixed-dose combination of tafluprost (0.0015%) and timolol (0.5%) (PF tafluprost/timolol FC) in a real-world setting. The country-level data reported herein comprise the largest and first observational study of PF tafluprost/timolol FC therapy in Italy. Methods: An observational, multicenter, prospective study included adult Italian patients with open-angle glaucoma (OAG) or ocular hypertension (OHT) demonstrating insufficient response or poor tolerability with topical prostaglandin analogue (PGA) or beta-blocker monotherapy. Treatment was switched to PF tafluprost/timolol FC therapy at baseline. Primary endpoint was the absolute mean IOP change from baseline at Month 6. Exploratory and safety endpoints included change in IOP at Weeks 4 and 12, ocular signs, symptom severity and reporting of adverse events (AEs). Results: Overall, 160 OAG/OHT patients were included. Mean ± standard deviation IOP was reduced from 19.6 ± 3.6 mmHg at baseline to 14.5 ± 2.6 mmHg at Month 6 (reduction of 5.1 ± 3.7 mmHg; 24.1%; p < 0.0001). IOP reduction was also statistically significant at Week 4 (23.1%; p < 0.0001) and Week 12 (24.7%; p < 0.0001). Based on data cutoff values for mean IOP change of ≥20%, ≥25%, ≥30% and ≥35%, respective Month 6 responder rates were 68.1%, 48.7%, 36.2% and 26.9%. Most ocular signs and symptoms were significantly reduced in severity from baseline at Month 6. Two non-serious and mild AEs were reported during the study period, among which, one AE was treatment-related (eyelash growth). . Conclusion: Italian OAG and OHT patients demonstrated a significant IOP reduction from baseline at Week 4 that was maintained over a 6-month period following a switch from topical PGA or beta-blocker monotherapy to PF tafluprost/timolol FC therapy. Severity of most ocular signs and symptoms was significantly reduced during the study period, and PF tafluprost/timolol FC was generally well tolerated.

Comparison of Retinal Nerve Fiber Layer and Ganglion Cell-Inner Plexiform Layer Thickness Values Using Spectral-Domain and Swept-Source OCT.

Purpose: To compare peripapillary retinal nerve fiber layer (pRNFL) and macular ganglion cell-inner plexiform layer (mGCIPL) thickness measurements obtained with spectral domain optical coherence tomography (SD-OCT) and swept-source OCT (SS-OCT) using an OCT-angiography scanning protocol, and their ability to distinguish among patients with glaucoma, glaucoma suspects (GS), and healthy controls (HC). Methods: Cross-sectional study of 196 eyes (81 glaucoma, 48 GS, and 67 HC) of 119 participants. Participants underwent peripapillary and macular OCT with SD-OCT and SS-OCT. Parameters of interest were average and sector-wise pRNFL and mGCIPL thickness. Inter-device agreement was investigated with Bland-Altman statistics. Conversion formulas were developed with linear regression. Diagnostic performances were evaluated with area under the receiver operating characteristic curves. Results: Both SD-OCT and SS-OCT detected a significant pRNFL and mGCIPL thinning in glaucoma patients compared to HC and GS for almost all study sectors. A strong linear relationship between the two devices was present for all quadrants/sectors (R2 ≥ 0.81, P < 0.001), except for the nasal (R2 = 0.49, P < 0.001) and temporal (R2 = 0.62, P < 0.001) pRNFL quadrants. SD-OCT and SS-OCT measurements had a proportional bias, which could be removed with conversion formulas. Overall, the two devices showed similar diagnostic abilities. Conclusions: Thickness values obtained with SD-OCT and SS-OCT are not directly interchangeable but potentially interconvertible. Both devices have a similar ability to discriminate glaucoma patients from GS and healthy subjects. Translational Relevance: OCT-Angiography scans can be reliably used to obtain structural metrics in glaucoma patients.

A case of endophthalmitis following needling procedure after PRESERFLO® Micro Shunt implantation.

PURPOSE: To report a case of endophthalmitis following bleb needling in a patient previously implanted with a PRESERFLO® MicroShunt. METHODS: Case report. RESULTS: A 40-year-old woman with bilateral malformative glaucoma repeatedly operated on in childhood underwent PRESERFLO® MicroShunt implantation in her right eye and six needling revisions (NRs) and a surgical revision due to unsatisfactory intraocular pressure (IOP) control due to bleb encapsulation. About 3 months after the surgical revision the bleb encapsulation relapsed and she underwent a further NR with betamethasone. About 4 days after the last NR, she experienced visual acuity reduction and was therefore advised to come immediately to the hospital for an unscheduled visit, showing up with hypopyon and diffuse vitreous haze. A clinical diagnosis of endophthalmitis (later confirmed by bacteria culture tests) was made and she was treated with pars-plana vitrectomy with silicone oil and intravitreal antibiotics. Preoperative visual function was luckily completely restored. CONCLUSIONS: Endophthalmitis can occur after NR in an eye with PRESERFLO® MicroShunt implant which therefore does not prevent reflux of bacteria from a filtering bleb to the anterior chamber.

Combining Structural and Vascular Parameters to Discriminate Among Glaucoma Patients, Glaucoma Suspects, and Healthy Subjects.

Purpose: Compare the ability of peripapillary and macular structural parameters, vascular parameters, and their integration to discriminate among glaucoma, suspected glaucoma (GS), and healthy controls (HCs). Methods: In this study, 196 eyes of 119 patients with glaucoma (n = 81), patients with GS (n = 48), and HCs (n = 67) underwent optical coherence tomography (OCT) and OCT angiography to measure peripapillary retinal nerve fiber layer (pRNFL), macular ganglion cell-inner plexiform layer (mGCIPL) thicknesses, radial peripapillary capillary perfusion density (RPC-PD), and macular GCIPL perfusion density (GCIPL-PD). Parameters were integrated regionally with logistic regression and globally with machine learning algorithms. Diagnostic performances were evaluated with area under the receiver operating characteristic (AUROC) curves. Results: Patients with glaucoma had mild to moderate damage (median, -3.3 dB; interquartile range, -6.5 to -1.4). In discriminating between patients with glaucoma and the HCs, pRNFL thickness had higher AUROC curve values than RPC-PD for average (0.87 vs. 0.62; P < 0.001), superior (0.86 vs. 0.54; P < 0.001), inferior (0.90 vs. 0.71; P < 0.001), and temporal (0.65 vs. 0.51; P = 0.02) quadrants. mGCIPL thickness had higher AUROC curve values than GCIPL-PD for average (0.84 vs. 0.68; P < 0.001), superotemporal (0.76 vs. 0.65; P = 0.016), superior (0.72 vs. 0.57; P = 0.004), superonasal (0.70 vs. 0.56; P = 0.01), inferotemporal (0.90 vs. 0.72; P < 0.001), inferior (0.87 vs. 0.69; P < 0.001), and inferonasal (0.78 vs. 0.65, P = 0.012) sectors. All structural multisector indices had higher diagnostic ability than vascular ones (P < 0.001). Combined structural-vascular indices did not outperform structural indices. Similar results were found to discriminate glaucoma from GS. Conclusions: Combining structural and vascular parameters in a structural-vascular index does not improve diagnostic ability over structural parameters alone. Translational Relevance: OCT angiography does not add additional benefit to structural OCT in early to moderate glaucoma diagnosis.

Needle revision outcomes after glaucoma filtering surgery: survival analysis and predictive factors.

PURPOSE: To evaluate the efficacy and safety of needle revision and examine factors predictive of failure. METHODS: In total, 157 eyes of 131 patients that underwent needle revision augmented with either 5-fluorouracil or betamethasone for trabeculectomy failure were included in this retrospective study. Complete failure was defined as additional glaucoma surgery, ciliodestructive procedures, loss of light perception, sight-threatening complications, hypotony maculopathy, and surgical bleb revision. Success was defined as intraocular pressure ⩽ 18 (criterion A), ⩽15 (criterion B), and ⩽12 mmHg (criterion C) reached with (qualified) or without (complete) medications, and absence of any criteria of complete failure. RESULTS: The median (interquartile range) follow-up was 25.0 (41.0) months. Complete failure rates were 19%, 26%, and 31% at 1, 2, and 3 years, respectively. For criterion A, qualified and complete success rates were, respectively, 77% and 69% at 1 year, 66% and 51% at 2 years, and 60% and 47% at 3 years. For criterion B, qualified and complete success rates were, respectively, 67% and 61% at 1 year, 48% and 42% at 2 years, and 44% and 39% at 3 years. For criterion C, qualified and complete success rates were, respectively, 43% and 41% at 1 year, 27% and 25% at 2 years, and 24% and 23% at 3 years. High baseline intraocular pressure and primary surgery were associated with higher and lower risks of complete failure, respectively. CONCLUSION: Needle revision is an effective and safe procedure to rescue failing trabeculectomy postponing or avoiding further glaucoma surgery. Eyes with low target intraocular pressure may have poor long-term outcomes.

Comparison of methods to quantify macular and peripapillary vessel density in optical coherence tomography angiography.

PURPOSE: To compare macular and peripapillary vessel density values calculated on optical coherence tomography angiography (OCT-A) images with different algorithms, elaborate conversion formula, and compare the ability to discriminate healthy from affected eyes. METHODS: Cross-sectional study of healthy subjects, patients with diabetic retinopathy, and glaucoma patients (44 eyes in each group). Vessel density in the macular superficial capillary plexus (SCP), deep capillary plexus (DCP), and the peripapillary radial capillary plexus (RCP) were calculated with seven previously published algorithms. Systemic differences, diagnostic properties, reliability, and agreement of the methods were investigated. RESULTS: Healthy eyes exhibited higher vessel density values in all plexuses compared to diseased eyes regardless of the algorithm used (p<0.01). The estimated vessel densities were significantly different at all the plexuses (p<0.0001) as a function of method used. Inter-method reliability and agreement was mostly poor to moderate. A conversion formula was available for every method, except for the conversion between multilevel and fixed at the DCP. Substantial systemic, non-constant biases were evident between many algorithms. No algorithm outperformed the others for discrimination of patients from healthy subjects in all the retinal plexuses, but the best performing algorithm varied with the selected plexus. CONCLUSIONS: Absolute vessel density values calculated with different algorithms are not directly interchangeable. Differences between healthy and affected eyes could be appreciated with all methods with different discriminatory abilities as a function of the plexus analyzed. Longitudinal monitoring of vessel density should be performed with the same algorithm. Studies adopting vessel density as an outcome measure should not rely on external normative databases.

22q11.2 microduplication syndrome and juvenile glaucoma.

BACKGROUND: 22q11.2 microduplication is a relatively recently recognized syndrome. Findings in affected individuals range from apparent normality to a wide variety of systemic and ocular conditions. We describe the association between 22q11.2 microduplication and juvenile glaucoma in two brothers. MATERIALS AND METHODS: We reviewed ophthalmological, genetic, and hematological medical records of two patients and their unaffected mother. RESULTS: A 2.07 Mb interstitial duplication in 22q11.21 and a smaller 182 kb duplication in 22q11.23 were identified in both subjects. Patient 1 showed an initial intraocular pressure (IOP) of 15 mmHg in right eye (RE) and 32 mmHg in left eye (LE) under maximum medical treatment. Deep sclerectomy surgery in LE was converted to trabeculectomy due to a macroperforation of the trabeculo-descemetic membrane. Postoperatively, the patient developed persistent hypotony with retinal folds, while IOP in RE increased to 28 mmHg. Trabeculectomy in RE was also complicated by persistent hypotony. Autologous blood injection was performed, resulting in an increase in both visual acuity and IOP. Patient 2 presented with an IOP of 29 mmHg in RE and 33 mmHg in LE. We planned an elective trabeculectomy and added orally administered acetazolamide. The patient developed bilinear cytopenia that contraindicated the surgical procedure. After hematologic normalization, the patient underwent trabeculectomy in LE, causing persistent hypotony. We performed deep sclerectomy surgery in RE, without any significant intra- or post-operative complications. CONCLUSIONS: 22q11.2 microduplication syndrome can be associated with juvenile glaucoma. Trabeculectomy may be complicated by persistent hypotony. Deep sclerectomy appears to be a better surgical option, although the presence of a thin sclera may result in conversion to trabeculectomy.

Optical Coherence Tomography Angiography Macular and Peripapillary Vessel Perfusion Density in Healthy Subjects, Glaucoma Suspects, and Glaucoma Patients.

Purpose: To evaluate macular and peripapillary vessel perfusion density (VD) in glaucoma suspects (GS) and glaucoma patients; to correlate ganglion cell-inner plexiform layer (GCIPL) and retinal nerve fiber layer (RNFL) thicknesses with macular and peripapillary VD; and to evaluate the diagnostic accuracy of the structural and vascular parameters. Methods: A consecutive series of GS, glaucoma patients, and healthy subjects was prospectively recruited from July 1, 2016, to January 31, 2017. All subjects underwent standard automated perimetry, spectral-domain optical coherence tomography (OCT), and 6 × 6-mm optical coherence tomography angiography (OCT-A) centered on the fovea and optic nerve. Results: Forty controls, 40 GS, and 40 glaucoma patients were enrolled. Peripapillary RNFL, GCIPL, and macular RNFL thicknesses significantly decreased in the glaucoma group compared to controls and GS (P < 0.01). Peripapillary VD in average and in the superior and inferior quadrants decreased in the glaucoma group (P ≤ 0.001); conversely, macular VD was not statistically different across groups (P > 0.05). At the peripapillary area, a correlation between RNFL thickness and VD was found; conversely, no statistically significant correlation was found between GCIPL thicknesses and macular VD (all P > 0.05) in all groups. Peripapillary RNFL and GCIPL showed higher diagnostic capacity compared to peripapillary and macular VDs. Conclusions: Structural damage is evident both in the peripapillary and in macular areas. Vascular damage seems to be less prominent, as it was seen only for the glaucoma group and at the radial peripapillary plexus. Diagnostic abilities are excellent for structural variables, less so but still good for peripapillary VD, and poor for macular VD.

Postoperative Management of Penetrating and Nonpenetrating External Filtering Procedures.

Correct postoperative management is fundamental to prevent and treat complications and to optimize the success of filtering surgery. Timely control visits and appropriate actions and prescriptions ensure the best outcomes, allow recovery from a number of untoward events, and can reestablish filtration when failure seems imminent. In contrast, a slack follow-up and wrong interventions or prescriptions can lead to the failure of any surgery, no matter how accurately it was carried out, sometimes jeopardizing vision and even the anatomy of the globe. The purpose of this review is to present a rational approach to postoperative follow-up and to synthetically describe how to prevent, recognize and address the most common complications of filtering surgery, pointing out the most common pitfalls in the management of the operated eye.

Optical coherence tomography angiography features of chorioretinal folds: a case series.

PURPOSE: To report 3 cases of ocular chorioretinal folds from different etiologies and their aspect with the new imaging technology of optical coherence tomography (OCT) angiography (OCT-A). METHODS: Baseline data, investigational process on etiology, and follow-up data of patients referred for chorioretinal folds to the Medical Retina & Imaging Unit of San Raffaele Hospital in the period January-March 2016 were collected. Multimodal imaging evaluation, comprehensive of infrared, fundus autofluorescence, multicolor, spectral-domain OCT, and OCT-A, was performed on all patients. RESULTS: Four eyes of 3 men, 65, 46, and 50 years of age, showed chorioretinal folds secondary to central serous chorioretinopathy, postoperative hypotony (after deep sclerectomy), and anisometropia with unilateral hyperopia, respectively. In all cases, OCT-A imaging showed a signal reduction in the choriocapillaris layer in correspondence of the folds. Due to this signal reduction, the en face reconstruction of choriocapillaris layer showed, in all cases, a peculiar tigroid aspect. The aspect of the folds at OCT-A remained unchanged during the 3-month follow-up in all patients. CONCLUSIONS: Optical coherence tomography angiography shows a typical linear signal reduction in the choriocapillaris layer in correspondence of the fold with a tigroid pattern. We hypothesize this aspect could be explained by blood flow alteration at the choriocapillaris level in correspondence of the fold.

Nd:Yag laser goniopuncture for deep sclerectomy: efficacy and outcomes.

PURPOSE: To report on the safety and efficacy of Nd: YAG laser goniopuncture (LGP) for postsurgical intraocular pressure increase after deep sclerectomy (DS) in a consecutive cohort of open-angle glaucoma patients. METHODS: This case series included 56 eyes from 49 consecutive patients who underwent LGP between November 2008 and March 2015. Prior to LGP, patients had undergone DS augmented with mitomycin C and injectable cross-linked hyaluronic acid implant between October 2008 and May 2014. Demographic variables, type of glaucoma, prior phacoemulsification, intraocular pressure (IOP), best-corrected visual acuity, execution of post-LGP maneuvres, and post-LGP complications were analyzed. The success rate of the procedure was analyzed using the Kaplan-Meier survival curve. Univariate and multivariate analyses were performed using the Cox proportional hazard regression model in order to highlight variables associated with a failure to achieve surgical success. RESULTS: Mean IOP was 23.0 mmHg prior to LGP, and 12.5, 11.8, and 10.5 mmHg at 6, 12, and 24 months after LGP respectively. Post-laser IOP was significantly lower than pre-laser IOP at every time point. For an IOP ≤ 15 mmHg, success rates were 85 % at 6 months, 76 % at 1 year, and 62 % at 2 years. Thirty-eight eyes underwent prophylactic iridotomy and iridoplasty prior to LGP. Iris prolapse into the trabeculo-descemetic window following LGP occurred in 6/18 eyes (33.3 %) of the non-pretreated and in 1/38 eyes (2.6 %) of the pretreated group. One case of choroidal detachment and one delayed suprachoroidal hemorrhage occurred after LGP execution in two non-pretreated eyes. CONCLUSIONS: LGP is a relatively safe and effective complementary adjunct to deep sclerectomy that makes it possible to further lower IOP and avoid additional filtering surgery. Prophylactic iridotomy and localized iridoplasty may permit the frequency of post-LGP complications to be reduced.

Deep Sclerectomy With Mitomycin C and Injectable Cross-linked Hyaluronic Acid Implant: Long-term Results.

PURPOSE: To evaluate the long-term efficacy and safety of deep sclerectomy (DS) augmented with mitomycin C (MMC) and injectable cross-linked hyaluronic acid implant (Healaflow) in medically refractory glaucoma patients. MATERIALS AND METHODS: Our study included 96 eyes of 83 consecutive patients with open-angle glaucoma undergoing MMC-DS with injectable cross-linked hyaluronic acid implant. Mean follow-up was 28.6±20.0 months. Variables analyzed were: intraocular pressure (IOP), best-corrected visual acuity, mean number of antiglaucomatous drugs, execution of postoperative maneuvres (goniopuncture, bleb needling, and laser lysis of scleral flap sutures). Tonometric success was defined by 2 different thresholds, specifically IOP≤21 mm Hg (criterion A) and ≤15 mm Hg (criterion B). The procedure was defined as a qualified success if reached with medication and as a complete success if reached without. RESULTS: For criterion A, qualified and complete success rates were 96% and 94%, respectively, at 12 months, 95% and 92% at 24 months, and 92% and 89% at 36 months. For criterion B, qualified and complete success rates were 75% and 75%, respectively, at 12 months, 62% and 60% at 24 months, and 59% and 58% at 36 months. Goniopuncture was performed in 56 eyes (58%), bleb needling with 5-fluorouracil injection in 4 eyes (5.1%), and laser release of scleral flap sutures in 4 eyes (4%). Six eyes required additional filtering surgery. CONCLUSION: DS with Healaflow and MMC seems to be an effective and safe technique to lower IOP in patients affected by open-angle glaucoma, with few postoperative complications.

Delayed suprachoroidal hemorrhage following Nd:YAG laser goniopuncture: a case report.

PURPOSE: To report a delayed suprachoroidal hemorrhage following Nd:YAG laser goniopuncture (LGP) in an eye with a previous deep sclerectomy. METHODS: Case report. RESULTS: A 75-year-old woman with advanced primary open-angle glaucoma underwent LGP due to unsatisfactory intraocular pressure (IOP) in her left eye, 1 month after undergoing deep sclerectomy in the same eye. Delayed suprachoroidal hemorrhage occurred the day after LGP execution. CONCLUSIONS: Nd:YAG laser goniopuncture is often performed to enhance IOP control following deep sclerectomy. Although LGP is usually effective and safe, severe complications, such as delayed suprachoroidal hemorrhage, may occur after its execution.

Glaucoma: present challenges and future trends.

The authors indicate four key issues which, in their opinion, represent the most stimulating challenges in the field of glaucoma today, and describe the present approaches and the developments that can be expected or advised in the near future: (1) Glaucoma is often undiagnosed or diagnosed too late. Accurate detection is crucial to correctly recognize and treat affected subjects, thus reducing the disability and the social burden of the disease. Is glaucoma screening advisable and cost-effective? What strategies can be implemented to achieve an earlier diagnosis? (2) What role can genetics play in glaucoma clinics? (3) What are the fundamentals and the limits of medical hypotensive and nonhypotensive treatment of glaucoma today, and what novelties could be introduced in the next few years? (4) What are the current and future options for glaucoma surgery? Should we aim at reducing aqueous production or at enhancing aqueous outflow? What are the success figures and the pros and cons of ab externo procedures with external filtration (trabeculectomy, nonpenetrating techniques and glaucoma drainage devices) and of ab externo techniques with internal filtration (viscocanalostomy and canaloplasty)? Will microinvasive procedures ever play a role in the treatment of the disease? These questions and the possible future developments in the management of glaucoma are discussed critically, based on the current clinical state of the art, on a review of the literature, and on an everyday experience in a busy university hospital glaucoma service.

Postoperative management of penetrating and nonpenetrating external filtering procedures.

Correct postoperative management is fundamental to prevent and treat complications and to optimize the success of filtering surgery: timely control visits and appropriate actions and prescriptions ensure the best outcomes, allow recovery from a number of untoward events, and can reestablish filtration when failure seems imminent. In contrast, a slack follow-up and wrong interventions or prescriptions can lead to failure of any surgery, no matter how accurately it had been carried out, sometimes jeopardizing vision and even the anatomy of the globe. The purpose of this review is to present a rational approach to postoperative follow-up and to synthetically describe how to prevent, recognize and address the most common complications of filtering surgery, pointing out the most common pitfalls in the management of the operated eye.

Viscocanalostomy in patients with glaucoma secondary to uveitis: preliminary report.

PURPOSE: To assess the efficacy of viscocanalostomy in eyes with uncontrolled glaucoma secondary to uveitis. SETTING: Immunology and Uveitis Service, Department of Ophthalmology and Visual Sciences, University Hospital San Raffaele, Milan, Italy. METHODS: All consecutive patients with glaucoma secondary to uveitis and inadequate intraocular pressure (IOP) control (IOP >21 mm Hg) under maximum-tolerated medical therapy had viscocanalostomy. Patients with active uveitis at the time of surgery, peripheral anterior synechias in the upper quadrant, previous ocular surgery, or sight in only 1 eye were excluded. Eleven eyes of 11 patients with a mean age of 52.2 years +/- 19.9 (SD) were operated on. The etiology of the uveitis was recorded. The ocular variables were IOP, best corrected visual acuity, number of antiglaucoma medications, and complications. Success was defined as an IOP between 6 mm Hg and 21 mm Hg (inclusive) without medication (complete success), or with 1 or more antiglaucoma medications and/or goniopuncture (qualified success). The mean follow-up was 45.9 +/- 11.6 months (range 23 to 56 months). RESULTS: Viscocanalostomy significantly reduced IOP from a mean baseline value of 35.1 +/- 7.0 mm Hg (range 23 to 48 mm Hg) to a mean final value of 18.1 +/- 4.9 mm Hg (range 12 to 30 mm Hg) (P<.0001). Complete success was achieved in 6 eyes (54.5%) and qualified success, in 10 eyes (90.9%). The mean number of preoperative and final antiglaucoma medications was 3.4 +/- 0.8 (range 2 to 4) and 0.7 +/- 1.2 (range 0 to 3), respectively (P =.0004). Complications were minor and included transient hyphema and postoperative IOP spike. CONCLUSION: This preliminary study suggests that viscocanalostomy is a safe, effective surgical alternative for treating glaucoma in patients with uveitis.

Viscocanalostomy versus trabeculectomy in white adults affected by open-angle glaucoma: a 2-year randomized, controlled trial.

PURPOSE: To compare the effectiveness and safety of viscocanalostomy and trabeculectomy in adults with uncontrolled open-angle glaucoma. DESIGN: Single-masked, parallel-group, prospective, randomized 24-month trial, with 90% power to detect a clinically important difference between groups. PARTICIPANTS: Fifty consecutive patients (50 eyes) with primary open-angle or pseudoexfoliative glaucoma. INTERVENTION: Eyes were assigned randomly to either viscocanalostomy (group 1) or trabeculectomy (group 2) with no intraoperative antifibrotics in the study eye. In group 1, no further intervention was allowed, whereas trabeculectomy eyes could receive subconjunctival 5-fluorouracil (5-FU) injections or laser suture lysis after surgery. MAIN OUTCOME MEASURES: Success rate based on intraocular pressure (IOP), visual acuity, discomfort, and other complications. RESULTS: At the end of the 24-month follow-up, IOP of 21 mmHg or less and more than 6 mmHg was achieved in 76% in group 1 (n = 19) and in 80% in group 2 (n = 20; log-rank P = 0.60); an IOP between 6 and 16 mmHg was obtained in 56% in group 1 (n = 14) and in 72% in group 2 (n = 18; log-rank P = 0.17; Kaplan-Meier cumulative probability of success). Complications of viscocanalostomy included one intraoperative conversion into trabeculectomy; microruptures in Descemet's membrane in five eyes; three cases of iris incarceration in the Decemet's window, two of which caused early failure of the procedure requiring reoperation; and a 1-mm to 2-mm transient self-resolving hyphema in three cases. Complications of trabeculectomy included one case of postoperative bleb bleeding with early transient IOP spike; one early hyphema; five cases of postoperative hypotony, two of which had a positive Seidel test from the conjunctival suture; three cases of transient choroidal detachment, two of which had shallow anterior chamber. No patient required reoperation. Two eyes required argon laser suture lysis, and nine underwent one or more 5-FU injections, which caused punctate keratopathy in three eyes. CONCLUSIONS: Viscocanalostomy is an effective IOP-lowering procedure in white adults affected by open-angle glaucoma. Trabeculectomy with postoperative 5-FU can probably provides lower IOPs but, with more numerous complications, greater discomfort, and more intensive postoperative management.