Twenty-Four-Month Outcome of Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Eyes With Prior Corneal Transplant Surgery.

PURPOSE: Glaucoma is a well-known sequelae of corneal transplant surgery and is a leading cause of visual loss in this patient group. We evaluated the performance and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in this population. DESIGN: Noncomparative retrospective case series. PARTICIPANTS: Consecutive eyes of patients receiving the GATT procedure for uncontrolled intraocular pressure (IOP) following corneal transplant surgery from 2016 to 2019. METHODS: Retrospective analysis of eyes with a history of prior corneal transplant undergoing GATT at Glaucoma Associates of Texas between 2016 and 2019 was performed. Data included IOP, patient demographics, preoperative and postoperative medications, preoperative and postoperative corneal procedures, complications, and need for reoperation for IOP control. MAIN OUTCOME MEASURES: IOP reduction and medication use following the procedure. RESULTS: Thirty-nine eyes of 32 patients with prior corneal transplant surgery underwent a GATT procedure. Prior corneal surgery included penetrating keratoplasty (59.0%), Descemet's stripping endothelial keratoplasty (35.9%), Descemet's membrane endothelial keratoplasty (2.6%), and deep anterior lamellar keratoplasty (2.6%). Patient age ranged from 24 to 94 years (mean 68.0 y) with 44% female and 81% Caucasian. The majority of patients had secondary open angle glaucoma (64.1%). There was a significant reduction in IOP and number of medications at all postoperative time points after censoring patients requiring reoperation to control IOP (P<0.001). At 24 months the pressure decreased from baseline of 30.9±11.5 to 13.9±4.7 mm Hg. Medications decreased from 4.2±1.0 medications at baseline to 0.6±1.0 at 24 months. Visual acuities decreased significantly over the first postsurgical month (all P<0.05), but these recovered at subsequent follow-up visits with 2-Snellen line improvements exceeding losses from month 3 to 36. Seven eyes required reoperation for uncontrolled glaucoma at a median of 8.5 months (range: 1.6 to 16.2 mo) after GATT. The cumulative proportion of eyes undergoing repeat cornea surgery was 2.6%, 2.6%, and 14.3% at 12, 24, and 36 months post-GATT, respectively. CONCLUSIONS: This case series describes a group of glaucoma patients, with a history of prior corneal surgery, that were safely and successfully treated with GATT. While classically traditional glaucoma surgeries are considered the standard of care for eyes following corneal transplant surgery, GATT should be considered as a reasonable, safe and effective alternative for surgically lowering IOP.

Outcomes of bleb revision with ologen following filtering glaucoma surgery.

PURPOSE: This study reports long-term outcomes of bleb revision with ologen™ Collagen Matrix (Aeon Astron Europe BV, the Netherlands) for the surgical management of various bleb-related issues including persistent bleb leaks with or without associated hypotony, bleb dysesthesia, overhanging blebs, or hypotony after filtering glaucoma surgery. MATERIALS AND METHODS: A retrospective chart review was performed for patients who underwent ologen bleb revision from 2012 to 2019 at Glaucoma Associates of Texas. RESULTS: The study included 23 eyes of 22 patients undergoing bleb revision with the ologen implant. Mean age was 74.0 ± 11.3 years, 16 (69.6%) were female, and 13 (56.5%) were White. Indications for bleb revision included bleb leak (78.3%), dysesthesia (13.0%), and hypotony from an overfiltering bleb (8.7%). Mean preoperative intraocular pressure was 6.8 ± 4.1 mmHg and the number of medications was 0.3 ± 0.9. Median follow-up was 24 months (range: 12-84 months); all patients had at least 12 months of follow-up. At 1 year, mean intraocular pressure was 10.9 ± 4.6 mmHg on 0.2 ± 0.5 medications, and at last follow-up, mean intraocular pressure was 10.4 ± 3.6 mmHg on 0.3 ± 0.7 medications. Bleb morphology remained low, diffuse, and posterior. One patient developed kissing choroidal effusions requiring surgical drainage with subsequent stabilization of intraocular pressure and bleb function, and three patients required additional surgery due to persistent leaks or bleb failure; there were no other vision-threatening complications. CONCLUSIONS: Use of the ologen implant during surgical bleb revision is a useful surgical technique that confers long-term improvements in bleb morphology and stability of function.

The Canonical Wnt Signaling Pathway Inhibits the Glucocorticoid Receptor Signaling Pathway in the Trabecular Meshwork.

Glucocorticoid-induced glaucoma is a secondary open-angle glaucoma. About 40% of the general population may develop elevated intraocular pressure on prolonged glucocorticoid treatment secondary to damages in the trabecular meshwork (TM), a tissue that regulates intraocular pressure. Therefore, identifying the key molecules responsible for glucocorticoid-induced ocular hypertension is crucial. In this study, Dickkopf-related protein 1 (Dkk1), a canonical Wnt signaling inhibitor, was found to be elevated in the aqueous humor and TM of glaucoma patients. At the signaling level, Dkk1 enhanced glucocorticoid receptor (GR) signaling, whereas Dkk1 knockdown or Wnt signaling activators decreased GR signaling in human TM cells as indicated by luciferase assays. Similarly, activation of the GR signaling inhibited Wnt signaling. At the protein level, glucocorticoid-induced extracellular matrix was inhibited by Wnt activation using Wnt activators or Dkk1 knockdown in primary human TM cells. In contrast, inhibition of canonical Wnt signaling by ß-catenin knockdown increased glucocorticoid-induced extracellular matrix proteins. At the physiological level, adenovirus-mediated Wnt3a expression decreased glucocorticoid-induced ocular hypertension in mouse eyes. In summary, Wnt and GR signaling inhibit each other in the TM, and canonical Wnt signaling activators may prevent the adverse effect of glucocorticoids in the eye.

Reticular Corneal Edema or Corneal Honeycombing in Eyes Treated With Netarsudil: A Case Series.

This is a descriptive case series of 3 patients with uncontrolled intraocular pressure that developed reticular corneal changes after initiating netarsudil (0.02%). In all cases, upon observing reticular corneal edema, netarsudil (0.02%) was stopped followed by disappearance of corneal honeycombing. With the increasing use of this novel glaucoma medication, potentially more rare side effects will be observed. Reticular corneal edema or corneal honeycombing is an ocular examination finding that can rarely occur after initiating netarsudil (0.02%) regardless of prior corneal edema status. In our experience, the reticular changes resolve upon cessation of netarsudil.

XEN Gel Stent in Pediatric Glaucoma.

PURPOSE: To report a series of 3 eyes of 3 children with congenital glaucoma receiving the XEN gel stent implant. PATIENTS AND METHODS: An interventional case series is reported. RESULTS: Three eyes underwent implantation of the gel stent. In 2 cases, the gel implant procedure was performed after failed trabeculotomy, while in the third eye, primary gel stent implantation was performed. One eye received 2 implants. Three procedures were performed via an ab interno approach while the fourth was performed ab externo. No device-related complications were observed. In all 3 eyes, intraocular pressure was controlled without the use of topical medications through 6 to 24 months of follow-up. CONCLUSIONS: The gel stent implant can be safely used in children with congenital glaucoma and effectively lowers intraocular pressure in these eyes. This procedure is a viable follow-up to, or replacement for, traditional angle surgery in eyes with congenital glaucoma.

Early Results of Goniotomy with the Kahook Dual Blade, a Novel Device for the Treatment of Glaucoma.

PURPOSE: To report the outcomes of patients who underwent goniotomy with the Kahook Dual Blade (KDB) either as a standalone procedure or in combination with cataract extraction. PATIENTS AND METHODS: This retrospective chart review included 111 eyes of 90 patients who underwent KDB goniotomy from January to November 2016 at Glaucoma Associates of Texas. KDB goniotomy was combined with cataract surgery in 100 eyes. The main outcome measures were postoperative intraocular pressure (IOP) and number of IOP lowering medications. RESULTS: Preoperatively, mean IOP was 17.1 ± 4.7 mmHg (range 8-34 mmHg) and mean number of IOP lowering medications was 2.4 ± 1.3 (range 0-6). Postoperatively, mean IOP was 14.9 mmHg, 13.9 mmHg, 14.1 mmHg, 14.4 mmHg, and 14.7 mmHg at 1, 3, 6, 9, and 12 months follow-up, respectively (all p <0.004). Mean numbers of IOP lowering medications were 0.8, 1.0, 1.0, 1.0, and 1.6 at 1, 3, 6, 9, and 12 months follow-up, respectively (all p <0.001). The cumulative reoperation rates for uncontrolled IOP after KDB were 0%, 1.0%, 2.1%, and 4.6% at 3, 6, 9, and 12 months, respectively. Eyes with a preoperative IOP >21 mmHg were significantly more likely to undergo reoperation (p = 0.038, log-rank test). There were no serious complications at any time point in the follow-up period. CONCLUSION: The Kahook Dual Blade results in a reduction in IOP and use of glaucoma medications after one year of follow-up. Further prospective studies are needed to fully characterize safety and efficacy.

Gonioscopy-assisted Transluminal Trabeculotomy: An Ab Interno Circumferential Trabeculotomy: 24 Months Follow-up.

PURPOSE: The purpose of this study was to provide 24-month follow-up on surgical success and safety of an ab interno circumferential 360-degree trabeculotomy. METHODS: Chart review of patients who underwent a gonioscopy-assisted transluminal trabeculotomy (GATT) procedure was performed by 4 of the authors (D.S.G., O.S., R.L.F., and D.G.G.). The surgery was performed in adults with various types of open-angle glaucoma with preoperative intraocular pressures (IOPs) of ≥18 mm Hg. RESULTS: In total, 198 patients aged 24 to 89 years underwent the GATT procedure with at least 18 months follow-up. Patients with primary open-angle glaucoma had an average IOP decrease of 9.2 mm Hg at 24 months with an average decrease of 1.43 glaucoma medications. The mean percentage of IOP decrease in these primary open-angle glaucoma groups at 24 months was 37.3%. In secondary open-angle glaucoma, at 24 months there was an average decrease in IOP of 14.1 mm Hg on an average of 2.0 fewer medications. The mean percentage of IOP decrease in the secondary open-angle glaucoma groups at 24 months was 49.8%. The cumulative proportion of failure at 24 months ranged from 0.18 to 0.48, depending on the group. In all 6 study groups, at all 5 postoperative time points (3, 6, 12, 18, and 24 mo) the mean IOP and reduction in glaucoma medications was significantly reduced from baseline (P<0.001) with the exception of one time point. CONCLUSIONS: The 24-month results demonstrate that GATT is relatively safe and effective in treating various forms of open-angle glaucoma. The long-term results for GATT are relatively equivalent to those previously reported for GATT and ab externo trabeculotomy studies.

Micropulse Cyclophotocoagulation: Initial Results in Refractory Glaucoma.

PURPOSE: The purpose of this study is to evaluate the use of micropulse transscleral cyclophotocoagulation (MP-TSCPC), a new and increasingly popular treatment, in patients with uncontrolled glaucoma. METHODS: A retrospective chart review was performed for all patients who underwent a MP-TSCPC at the Glaucoma Associates of Texas. RESULTS: A total of 84 eyes were treated with MP-TSCPC in this study with a mean follow-up time of 4.3 months. The mean age of treated patients was 74 years and 48 (57%) were female. Preoperatively, mean intraocular pressure (IOP) was 27.7 mm Hg and mean number of ocular antihypertensive medications used was 3.3. Mean postoperative IOP at months 1, 3, 6, and 12 were lowered to 16.3 mm Hg (41.2% reduction), 14.6, 13.0, and 11.1 mm Hg, respectively. Postoperative ocular antihypertensive medication use was also lowered to 1.9, 2.0, 2.0, and 2.3 medications at months 1, 3, 6, and 12, respectively. Five patients required further laser or surgical intervention for adequate IOP control. Complications included hypotony, IOP spike, hyphema, serous choroidal detachment, persistent inflammation, and vision loss. At 3 months, inflammation was still present in 46% of eyes and vision loss of at least 1 line was present in 41% of eyes. CONCLUSIONS: MP-TSCPC is effective at lowering IOP and decreasing the need for ocular antihypertensive medications. Eyes with limited visual potential or at high risk for incisional glaucoma surgery can successfully be treated with MP-TSCPC as a reasonable and effective alternative to traditional CPC. These results present short-term data and both longer follow-up and further studies are necessary.

Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Eyes With Prior Incisional Glaucoma Surgery.

PURPOSE: To report on outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in eyes with prior incisional glaucoma surgery. PATIENTS AND METHODS: A retrospective review was performed for all patients who underwent a GATT procedure with a history of prior incisional glaucoma surgery. RESULTS: Thirty-five eyes of 35 patients were treated. The mean age was 67.7 years. Nineteen eyes had a prior trabeculectomy, 13 eyes had a prior glaucoma drainage device, 4 eyes had a prior trabectome, and 5 eyes had prior endocyclophotocoagulation. Mean follow-up time was 22.7 months. For all eyes, the mean preoperative intraocular pressure (IOP) (SD) was 25.7 (6.5) mm Hg on 3.2 (1.0) glaucoma medications and at 24 months, the mean IOP (SD) was 15.4 (4.9) mm Hg on 2.0 (1.4) glaucoma medications (P<0.001). The prior trabeculectomy group had a preoperative IOP (SD) of 24.6 (6.4) mm Hg on 3.2 (1.0) medications and at month 24, the mean IOP (SD) was 16.7 (5.6) mm Hg on 2.1 (1.4) glaucoma medications. In the prior glaucoma drainage device group, the mean preoperative IOP (SD) was 27.0 (7.1) mm Hg on 3.4 (1.1) glaucoma medications and at 24 months, the mean IOP (SD) was 12.9 (2.6) mm Hg on 2.1 (1.2) glaucoma medications. At 24 months, the cumulative proportion of failure was 0.4 and the cumulative proportion of reoperation was 0.29. CONCLUSIONS: GATT appears to be safe and successful in treating 60% to 70% of open-angle patients with prior incisional glaucoma surgery. When considering all eyes, there was a significant decrease in IOP and required glaucoma medications at 24 months. This surgery should be considered in certain patients with open angles who have failed a primary traditional glaucoma surgery.

Collagen matrix vs mitomycin-C in trabeculectomy and combined phacoemulsification and trabeculectomy: a randomized controlled trial.

BACKGROUND: Antifibrotic agents are commonly utilized to enhance the success rates of trabeculectomy. Novel approaches to further improve success rates and reduce the risks of complications are needed. The purpose of this study was to compare intraocular pressure (IOP)-lowering efficacy and safety of trabeculectomy or combined phacoemulsification and trabeculectomy with mitomycin-C (MMC) vs. Collagen Matrix (CM). METHODS: A prospective, multicenter, randomized controlled trial was performed. Ninety-five eyes of 94 patients with uncontrolled glaucoma despite medical therapy, without previous incisional glaucoma surgery underwent trabeculectomy (85 eyes) or combined phacoemulsification and trabeculectomy (10 eyes) and were randomized to MMC or CM. One eye of each subject was analyzed. Patients were followed for 24 months. The criteria for complete success were IOP >5 and ≤21 mmHg with at least a 20% reduction below medicated baseline without additional glaucoma surgery or medications. The main outcome measures were complete success rates at 24 months with Kaplan-Meier analysis and incidence of adverse events. RESULTS: The baseline IOPs were 20.4 ± 6.0 mmHg and 21.2 ± 6.1 (mean ± standard deviation, p = 0.49) on 3.2 ± 1.1 and 3.1 ± 1.0 medications (p = 0.53) compared to 11.8 ± 5.2 and 12.8 ± 3.7 (p = 0.36) on 0.5 ± 0.8 and 0.6 ± 1.0 medications (p = 0.63) at 2 years in the MMC and CM groups, respectively. Kaplan-Meier analysis demonstrated complete success rates were similar in both groups at 24 months: 38.4 ± 7.6% with MMC and 56.2 ± 7.9% with CM (mean ± standard error, p = 0.112, log rank test); however, a significantly higher incidence of failure due to persistent hypotony was observed with MMC (p = 0.002). CONCLUSIONS: Use of the CM implant at the time of trabeculectomy or combined phacoemulsification and trabeculectomy is associated with similar complete success rates compared to adjunctive MMC; however, the risk of persistent hypotony is higher with MMC. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT01440751 . Registered 9/14/11.

Postoperative Complications in the Ahmed Baerveldt Comparison Study During Five Years of Follow-up.

PURPOSE: To compare the late complications in the Ahmed Baerveldt Comparison Study during 5 years of follow-up. DESIGN: Multicenter, prospective randomized clinical trial. METHODS: setting: Sixteen international clinical centers. STUDY POPULATION: Two hundred seventy-six subjects aged 18-85 years with previous intraocular surgery or refractory glaucoma with intraocular pressure of >18 mm Hg. INTERVENTIONS: Ahmed Glaucoma Valve FP7 or Baerveldt Glaucoma Implant BG 101-350. MAIN OUTCOME MEASURES: Late postoperative complications (beyond 3 months), reoperations for complications, and decreased vision from complications. RESULTS: Late complications developed in 56 subjects (46.8 ± 4.8 5-year cumulative % ± SE) in the Ahmed Glaucoma Valve group and 67 (56.3 ± 4.7 5-year cumulative % ± SE) in the Baerveldt Glaucoma Implant group (P = .082). The cumulative rates of serious complications were 15.9% and 24.7% in the Ahmed Glaucoma Valve and Baerveldt Glaucoma Implant groups, respectively (P = .034), although this was largely driven by subjects who had tube occlusions in the 2 groups (0.8% in the Ahmed Glaucoma Valve group and 5.7% in the Baerveldt Glaucoma Implant group, P = .037). Both groups had a relatively high incidence of persistent diplopia (12%) and corneal edema (20%), although half of the corneal edema cases were likely due to pre-existing causes other than the aqueous shunt. The incidence of tube erosion was 1% and 3% in the Ahmed Glaucoma Valve and Baerveldt Glaucoma Implant groups, respectively (P = .04). CONCLUSIONS: Long-term rates of vision-threatening complications and complications resulting in reoperation were higher in the Baerveldt Glaucoma Implant than in the Ahmed Glaucoma Valve group over 5 years of follow-up.

Gonioscopy assisted transluminal trabeculotomy: an ab interno circumferential trabeculotomy for the treatment of primary congenital glaucoma and juvenile open angle glaucoma.

BACKGROUND/AIMS: To introduce a novel ab interno 360° trabeculotomy for treating primary congenital glaucoma (PCG) and juvenile open angle glaucoma (JOAG) and report preliminary results. METHODS: A retrospective chart review of patients who underwent a gonioscopy assisted transluminal trabeculotomy (GATT) procedure by four of the authors (DSG, OS, RLF and DGG) between October 2011 and October 2013. The surgery was performed in patients ≤30 years old with a dysgenic anterior segment angle and uncontrolled PCG and JOAG. RESULTS: Fourteen eyes of 10 patients underwent GATT with follow-up >12 months (12-33 months; mean 20.4). Patients ranged in age from 17 months to 30 years (mean=18.4 years), and five (50%) were female patients. No complications occurred during or following surgery except for early postoperative hyphema in five (36%) of eyes, all cleared by 1 month. The mean intraocular pressure (IOP) decreased from 27.3 to 14.8 mm Hg and the mean number of medications required decreased from 2.6 to 0.86. Five eyes had a drop in IOP ≥15 mm Hg (range 15-39). CONCLUSIONS: The preliminary results and safety for GATT, a minimally invasive conjunctival sparing circumferential trabeculotomy, are promising and at least equivalent to previous results for ab externo trabeculotomy for the treatment of PCG and JOAG. All eyes in the study were considered a clinical success.

Five-year treatment outcomes in the Ahmed Baerveldt comparison study.

PURPOSE: To compare the 5-year outcomes of the Ahmed FP7 Glaucoma Valve (AGV) (New World Medical, Cucamonga, CA) and the Baerveldt 101-350 Glaucoma Implant (BGI) (Abbott Medical Optics, Abbott Park, IL) for the treatment of refractory glaucoma. DESIGN: Multicenter, randomized, controlled clinical trial. PARTICIPANTS: A total of 276 patients, including 143 in the AGV group and 133 in the BGI group. METHODS: Patients aged 18 to 85 years with previous intraocular surgery or refractory glaucoma and intraocular pressure (IOP) of ≥18 mmHg in whom glaucoma drainage implant (GDI) surgery was planned were randomized to implantation of an AGV or a BGI. MAIN OUTCOME MEASURES: Surgical failure, IOP, visual acuity (VA), use of glaucoma medications, and complications. RESULTS: At 5 years, IOP (mean ± standard deviation [SD]) was 14.7±4.4 mmHg in the AGV group and 12.7±4.5 mmHg in the BGI group (P = 0.015). The number of glaucoma medications in use at 5 years (mean ± SD) was 2.2±1.4 in the AGV group and 1.8±1.5 in the BGI group (P = 0.28). The cumulative probability of failure during 5 years of follow-up was 44.7% in the AGV group and 39.4% in the BGI group (P = 0.65). The number of subjects failing because of inadequately controlled IOP or reoperation for glaucoma was 46 in the AGV group (80% of AGV failures) and 25 in the BGI group (53% of BGI failures; P = 0.003). Eleven eyes in the AGV group (20% of AGV failures) experienced persistent hypotony, explantation of implant, or loss of light perception compared with 22 eyes (47% of failures) in the BGI group. Change in logarithm of the minimum angle of resolution VA (mean ± SD) at 5 years was 0.42±0.99 in the AGV group and 0.43±0.84 in the BGI group (P = 0.97). CONCLUSIONS: Similar rates of surgical success were observed with both implants at 5 years. The BGI produced greater IOP reduction and a lower rate of glaucoma reoperation than the AGV, but the BGI was associated with twice as many failures because of safety issues.

Three-year treatment outcomes in the Ahmed Baerveldt comparison study.

PURPOSE: To compare 3-year outcomes and complications of the Ahmed FP7 Glaucoma Valve (AGV) (New World Medical, Cucamonga, CA) and the Baerveldt Glaucoma Implant (BGI) 101-350 (Abbott Medical Optics, Abbott Park, IL) for the treatment of refractory glaucoma. DESIGN: Multicenter, randomized, controlled clinical trial. PARTICIPANTS: A total of 276 patients: 143 in the AGV group and 133 in the BGI group. METHODS: Patients aged 18 to 85 years with refractory glaucoma and intraocular pressures (IOPs) ≥ 18 mmHg in whom an aqueous shunt was planned were randomized to an AGV or a BGI. MAIN OUTCOME MEASURES: The IOP, visual acuity (VA), supplemental medical therapy, complications, and failure (IOP >21 mmHg or not reduced by 20% from baseline, IOP <5 mmHg, reoperation for glaucoma or removal of implant, or loss of light perception vision). RESULTS: At 3 years, IOP (mean ± standard deviation) was 14.3 ± ± 4.7 mmHg (AGV group) and 13.1 ± 4.5 mmHg (BGI group) (P = 0.086) on 2.0 ± 1.4 and 1.5 ± 1.4 glaucoma medications, respectively (P = 0.020). The cumulative probabilities of failure were 31.3% (standard error [SE], 4.0%) (AGV) and 32.3% (4.2%) (BGI) (P = 0.99). Postoperative complications associated with reoperation or vision loss of >2 Snellen lines occurred in 24 patients (22%) (AGV) and 38 patients (36%) (BGI) (P = 0.035). The mean change in the logarithm of the minimum angle of resolution VA at 3 years was similar (AGV: 0.21 ± 0.88, BGI: 0.26 ± 0.74) in the 2 treatment groups at 3 years (P = 0.66). The cumulative proportion of patients (SE) undergoing reoperation for glaucoma before the 3-year postoperative time point was 14.5% (3.0%) in the AGV group compared with 7.6% (2.4%) in the BGI group (P = 0.053, log rank). The relative risk of reoperation for glaucoma in the AGV group was 2.1 times that of the BGI group (95% confidence interval, 1.0-4.8; P = 0.045, Cox proportional hazards regression). CONCLUSIONS: Implantation of the AGV was associated with the need for significantly greater adjunctive medication to achieve equal success relative to implantation of the BGI and resulted in a greater relative risk of reoperation for glaucoma. More subjects experienced serious postoperative complications in the BGI group than in the AGV group.

Gonioscopy-assisted transluminal trabeculotomy, ab interno trabeculotomy: technique report and preliminary results.

PURPOSE: To introduce a minimally invasive, ab interno approach to a circumferential 360-degree trabeculotomy and to report the preliminary results. DESIGN: Retrospective, noncomparative cases series. PARTICIPANTS: Eighty-five eyes of 85 consecutive patients who sought treatment at Glaucoma Associates of Texas with uncontrolled open-angle glaucoma and underwent gonioscopy-assisted transluminal trabeculotomy (GATT) for whom there was at least 6 months of follow-up data. METHODS: Retrospective chart review of patients who underwent GATT by 4 of the authors (D.S.G., D.G.G., O.S., R.L.F.) between October 2011 and October 2012. The surgery was performed in adults with various open-angle glaucomas. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), glaucoma medications, visual acuity, and intraoperative as well as postoperative complications. RESULTS: Eighty-five patients with an age range of 24 to 88 years underwent GATT with at least 6 months of follow-up. In 57 patients with primary open-angle glaucoma, the IOP decreased by 7.7 mmHg (standard deviation [SD], 6.2 mm Hg; 30.0% [SD, 22.7%]) with an average decrease in glaucoma medications of 0.9 (SD, 1.3) at 6 months. In this group, the IOP decreased by 11.1 mmHg (SD, 6.1 mmHg; 39.8% [SD, 16.0%]) with 1.1 fewer glaucoma medications at 12 months. In the secondary glaucoma group of 28 patients, IOP decreased by 17.2 mmHg (SD, 10.8 mmHg; 52.7% [SD, 15.8%]) with an average of 2.2 fewer glaucoma medications at 6 months. In this group, the IOP decreased by 19.9 mmHg (SD, 10.2 mmHg; 56.8% [SD, 17.4%]) with an average of 1.9 fewer medications (SD, 2.1) at 12 months. Treatment was considered to have failed in 9% (8/85) of patients because of the need for further glaucoma surgery. The cumulative proportion of failure at 1 year ranged from 0.1 to 0.32, depending on the group. Lens status or concurrent cataract surgery did not have a statistically significant effect on IOP in eyes that underwent GATT at either 6 or 12 months (P > 0.35). The most common complication was transient hyphema, seen in 30% of patients at the 1-week visit. CONCLUSIONS: The preliminary results and safety profile for GATT, a minimally invasive circumferential trabeculotomy, are promising and at least equivalent to previously published results for ab externo trabeculotomy.

Diagnostic performance of optical coherence tomography ganglion cell--inner plexiform layer thickness measurements in early glaucoma.

PURPOSE: To evaluate the glaucoma diagnostic performance of ganglion cell inner-plexiform layer (GCIPL) parameters used individually and in combination with retinal nerve fiber layer (RNFL) or optic nerve head (ONH) parameters measured with Cirrus HD-OCT (Carl Zeiss Meditec, Inc, Dublin, CA). DESIGN: Prospective cross-sectional study. PARTICIPANTS: Fifty patients with early perimetric glaucoma and 49 age-matched healthy subjects. METHODS: Three peripapillary RNFL and 3 macular GCIPL scans were obtained in 1 eye of each participant. A patient was considered glaucomatous if at least 2 of the 3 RNFL or GCIPL scans had the average or at least 1 sector measurement flagged at 1% to 5% or less than 1%. The diagnostic performance was determined for each GCIPL, RNFL, and ONH parameter as well as for binary or-logic and and-logic combinations of GCIPL with RNFL or ONH parameters. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR). RESULTS: Among GCIPL parameters, the minimum had the best diagnostic performance (sensitivity, 82.0%; specificity, 87.8%; PLR, 6.69; and NLR, 0.21). Inferior quadrant was the best RNFL parameter (sensitivity, 74%; specificity, 95.9%; PLR, 18.13; and NLR, 0.27), as was rim area (sensitivity, 68%; specificity, 98%; PLR, 33.3; and NLR, 0.33) among ONH parameters. The or-logic combination of minimum GCIPL and average RNFL provided the overall best diagnostic performance (sensitivity, 94%; specificity, 85.7%; PRL, 6.58; and NLR, 0.07) as compared with the best RNFL, best ONH, and best and-logic combination (minimum GCIPL and inferior quadrant RNFL; sensitivity, 64%; specificity, 100%; PLR, infinity; and NPR, 0.36). CONCLUSIONS: The binary or-logic combination of minimum GCIPL and average RNFL or rim area provides better diagnostic performances than those of and-logic combinations or best single GCIPL, RNFL, or ONH parameters. This finding may be clinically valuable for the diagnosis of early glaucoma.

Forniceal conjunctival pedicle flap for the treatment of complex glaucoma drainage device tube erosion.

This retrospective study evaluated the safety and efficacy of the forniceal conjunctival pedicle flap for repair of conjunctival-deficient tube erosions. Additionally, we report the split-lid technique, a procedural improvement if fornix access is difficult. We identified 15 eyes of 14 consecutive patients with complex tube erosions. The mean age was 72.8 years and 33.3% had diabetes mellitus. Most patients were functionally monocular and 80% had undergone 4 or more prior ocular surgical procedures. There was no difference between the following preoperative and postoperative values: visual acuity, intraocular pressure, or number of glaucoma medications. The mean follow-up time after pedicle flap repair was 49 months. There were no recurrent erosions allowing for preservation of the drainage implant with excellent intraocular pressure control. This study demonstrates the relative long-term safety and success of this novel technique.

Glaucoma diagnostic accuracy of ganglion cell-inner plexiform layer thickness: comparison with nerve fiber layer and optic nerve head.

PURPOSE: To determine the diagnostic performance of macular ganglion cell-inner plexiform layer (GCIPL) thickness measured with the Cirrus high-definition optical coherence tomography (HD-OCT) ganglion cell analysis (GCA) algorithm (Carl Zeiss Meditec, Dublin, CA) to discriminate normal eyes and eyes with early glaucoma and to compare it with that of peripapillary retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) measurements. DESIGN: Evaluation of diagnostic test or technology. PARTICIPANTS: Fifty-eight patients with early glaucoma and 99 age-matched normal subjects. METHODS: Macular GCIPL and peripapillary RNFL thicknesses and ONH parameters were measured in each participant, and their diagnostic abilities were compared. MAIN OUTCOME MEASURES: Area under the curve (AUC) of the receiver operating characteristic. RESULTS: The GCIPL parameters with the best AUCs were the minimum (0.959), inferotemporal (0.956), average (0.935), superotemporal (0.919), and inferior sector (0.918). There were no significant differences between these AUCs and those of inferior quadrant (0.939), average (0.936), and superior quadrant RNFL (0.933); vertical cup-to-disc diameter ratio (0.962); cup-to-disc area ratio (0.933); and rim area (0.910), all P>0.05. CONCLUSIONS: The ability of macular GCIPL parameters to discriminate normal eyes and eyes with early glaucoma is high and comparable to that of the best peripapillary RNFL and ONH parameters. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.