Outcomes and Baseline Predictors of Failure in Primary Standalone Xen45 Gel Stent versus Trabeculectomy for Glaucoma.

PURPOSE: To compare safety, effectiveness, and baseline predictors of failure in standalone primary Xen45 gel stent (Xen) versus trabeculectomy (Trab) in glaucoma. DESIGN: Retrospective study. SUBJECTS: Subjects that underwent primary Xen or Trab augmented by mitomycin-C with at least 12 months follow-up. METHODS: Multinational observational study of eyes in the Fight Glaucoma Blindness international registry MAIN OUTCOME MEASURES: The primary outcome was success at 12 months defined by intraocular pressure (IOP) reduction ≥ 20% from baseline and ≤ threshold IOPs of 15, 18, and 21 mmHg with (qualified) or without (complete) medications and without secondary glaucoma surgery. Multivariable mixed effects Cox regression models were used to identify risk factors for failure in each cohort. RESULTS: A total of 701 eyes (Xen, 308; Trab, 393) of 596 subjects were included with baseline IOP being significantly higher (22.4 vs. 19.9 mmHg, P < 0.001) and baseline medications significantly lower in the Xen versus the Trab group (2.9 vs. 3.4, P < 0.001). Baseline visual field mean deviation was less severe in the Xen group (-9.47 vs. -13.04 dB, P < 0.001). The proportion of complete surgical success was significantly lower in the Xen versus Trab group across the 3 upper IOP limits at 12 months; 32% versus 52% at 15 mmHg, 37% versus 54% at 18 mmHg, and 39% versus 55% at 21 mmHg (P < 0.001). The incidence of postoperative numerical and symptomatic hypotony was lower in the Xen versus Trab group. In the Xen cohort, a higher failure rate was associated with Asian ethnicity (hazard ratio [HR], 1.97; 95% confidence interval (CI), 1.03-3.79) and use of oral acetazolamide at baseline (HR, 1.74; 95% CI, 1.13-2.70), whereas a lower failure rate was associated with diagnosis of ocular hypertension/open-angle glaucoma suspect (HR, 0.40; 95% CI, 0.20-0.82) and secondary open-angle glaucoma (HR, 0.46; 95% CI, 0.26-0.82). Exposure to prostaglandin analog was associated with greater failure in the Trab group (HR, 2.66; 95% CI, 1.18-6.01). CONCLUSIONS: There was significantly greater complete success at 12 months across all complete success definitions for Trab compared with Xen, whereas the rate of postoperative hypotony was significantly lower in the Xen group. Asian ethnicity and use of oral acetazolamide at baseline were associated with greater failure in Xen, whereas exposure to prostaglandin analog was associated with greater failure in Trab patients. Such baseline predictors of success and failure may help guide patient selection for subconjunctival minimally invasive glaucoma surgery in patients undergoing surgical intervention. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Five-Year Outcomes of Trabeculectomy and Phacotrabeculectomy.

Purpose The purpose of this study is to examine five-year outcomes of trabeculectomy and compare the stand-alone procedure when combined with phacoemulsification. Patients and methods This study included 123 eyes of 109 patients, with 79 patients in the trabeculectomy group and 44 patients in the phacotrabeculectomy group. Non-randomized comparative cohort study with data collected retrospectively from an existing database compiled by a single surgeon operating in Sydney, Australia from 2007 to 2019. The primary outcome measure was intraocular pressure. Secondary outcome measures were a number of glaucoma medications, treatment success rates, best-corrected visual acuity, bleb morphology, post-operative complications, and re-operation rate. Results The mean intraocular pressure was 10.6 ± 2.7 mm Hg in the trabeculectomy group (pre-operative mean intraocular pressure of 28.0 ± 9.8) and 12.0 ± 3.0 mm Hg in the phacotrabeculectomy group (pre-operative mean intraocular pressure of 23.4 ± 7.9) after five years (P = 0.052). The number of glaucoma medications required was 0.3 ± 0.7 in the trabeculectomy group (pre-operative mean of 3.7 ± 1.1) and 1.3 ± 1.2 in the phacotrabeculectomy group (pre-operative mean of 3.1 ± 1.0, P < 0.001). Conclusions Intraocular pressure reduction post-operatively over five years was similar between trabeculectomy and phacotrabeculectomy as determined by mean intraocular pressure, and intraocular pressure reduction from baseline. However, fewer supplemental glaucoma medications were required following trabeculectomy as compared to the combined procedure.

Outcomes: Trabeculectomy Bleb Needle Revision With 5-Fluorouracil.

PURPOSE: To evaluate outcomes of trabeculectomy bleb needle revision with 5-fluorouracil augmentation performed in the operating theater. METHODS: Retrospective study of all patients undergoing trabeculectomy bleb needle revisions in the operating theater performed by a single surgeon in a metropolitan hospital in Australia. A total of 51 needle revisions were performed on 33 eyes over a mean follow-up time of 1.81±1.56 years. RESULTS: A total of 29% achieved intraocular pressure (IOP) ≤20 mm Hg off all glaucoma medications, and an additional 39% achieved qualified success with the addition of glaucoma medications, giving overall success of 68%. Analyzing success rate for target IOP≤16 mm Hg, 24% achieved target off all glaucoma medications, 35% achieved qualified success with the addition of glaucoma medications, giving an overall success rate of 59%. There was a statistically significant improvement in IOP, as compared with preoperative levels, at all timepoints postoperatively (P<0.05). However, number of glaucoma medications remained unchanged (P>0.05) contributing to the high percentage of qualified successes. Visual acuity remained unchanged and there were no major postoperative complications. The Kaplan-Meier survival shows a survival rate of 60% with IOP≤20 mm Hg and 40% for IOP≤16 mm Hg at 5 years. CONCLUSIONS: Trabeculectomy needle revision is a useful option for the management of elevated IOP in the presence of a failed or failing trabeculectomy bleb. However, as with trabeculectomy, there tends to be a failure rate over time. This often leads to reinstitution of glaucoma medications and/or further needle revisions to maintain IOPs at target level. The procedure itself is minimally invasive with an acceptable safety profile.

Retrospective review of pars plana versus anterior chamber placement of Baerveldt glaucoma drainage device.

PURPOSE: To evaluate outcomes of pars plana (PP) versus anterior chamber (AC) placement of Baerveldt glaucoma drainage device (GDD). METHODS: This study is a nonrandomized, retrospective case series evaluating 63 eyes that underwent GDD insertion with Baerveldt 350 device under the supervision of 2 surgeons at 5 centers. The drainage tube was either inserted into the AC or through the PP into the vitreous cavity where eyes had been vitrectomized. Surgery was conducted between 2003 and 2010 with minimum patient follow-up of 6 months. Data on postoperative intraocular pressure (IOP), visual acuity, number of hypotensive medications, and surgical complications were recorded. RESULTS: Of the 63 drainage device surgeries, 34 tubes were placed in the AC and 29 were placed into the posterior segment through the PP. Preoperative mean IOP was 32.3±20.3 mm Hg in the AC group and 32.8±18.4 mm Hg in the PP group. Postoperative mean IOP was reduced at all follow-up time points in both the groups. Postoperative mean IOP in the anterior tube group was 14.0, 12.9, and 14.0 mm Hg and in the PP group was 14.2, 14.2, and 14.0 mm Hg, at the 1-, 2-, and 3-year follow-up, respectively. The qualified success rate at 2 years was 94% for the PP group and 91% for the AC group, whereas absolute success was 35% for the PP group and 27% for the AC group at 2-year follow-up. CONCLUSIONS: Insertion of the tube of the Baerveldt GDD into the PP is a safe and effective method for IOP control in aphakic, pseudophakic, and vitrectomized eyes where there is a need to avoid anterior tube placement such as coexisting corneal pathology. IOP control results appear comparable to conventional AC placement.

Seamless integration of dose-response screening and flow chemistry: efficient generation of structure-activity relationship data of ß-secretase (BACE1) inhibitors.

Drug discovery is a multifaceted endeavor encompassing as its core element the generation of structure-activity relationship (SAR) data by repeated chemical synthesis and biological testing of tailored molecules. Herein, we report on the development of a flow-based biochemical assay and its seamless integration into a fully automated system comprising flow chemical synthesis, purification and in-line quantification of compound concentration. This novel synthesis-screening platform enables to obtain SAR data on b-secretase (BACE1) inhibitors at an unprecedented cycle time of only 1 h instead of several days. Full integration and automation of industrial processes have always led to productivity gains and cost reductions, and this work demonstrates how applying these concepts to SAR generation may lead to a more efficient drug discovery process.

Bilateral homonymous superior quadrantanopia after traumatic attempts to remove a cockroach impacted in the external auditory canal.

Visual field defects typically caused by lesions in the optic nerve or optic chiasm may be caused indirectly by subdural haematomas. A 61-year-old man survived transtentorial herniation caused by subdural haematomas that resulted from shaking his head in an attempt to remove a cockroach impacted in his external auditory canal. Bilateral incomplete posterior cerebral artery infarction of both inferior tips of the occipital lobe resulted in bilateral superior quadrantanopia. There are no previous reports of tentorial herniation causing this permanent outcome.

Primary trabeculectomy with mitomycin C: safety and efficacy at 2 years.

PURPOSE: To examine the rates of intermediate-term intraocular pressure (IOP) control after trabeculectomy with adjunctive mitomycin C (MMC) and assess for associated complications. METHODS: Medical records of patients undergoing primary trabeculectomy with MMC at Concord Repatriation Hospital, Sydney between January 1997 and December 2005 were reviewed. All eyes with a minimum of 2-year follow up were included. Follow-up data were collected in a standardized form on postoperative IOP, bleb-related and other complications. Success was measured as IOP ≤ 18 mmHg and ≥ 6 mmHg (criteria 1) with (qualified success) or without (absolute success) the use of glaucoma medications. A secondary outcome measure was an IOP reduction of greater than 20% from baseline (criteria 2). Eyes with preoperative IOP of 18 mmHg or less were included, but also analysed separately to those eyes with preoperative IOP above 18 mmHg. RESULTS: Sixty eyes from 42 patients were included in the study, with 3-year follow up on 48 eyes. Mean preoperative IOP was 25.3 mmHg (range 8-45) and mean postoperative IOP was 14.0 mmHg at 1- and 2-year follow up, and 14.7 mmHg at 3 years (ranges: 3-31, 4-30 and 8-45 mmHg respectively). Cumulative success for criteria 1 was 85.0% at 2 years and 83.3% at 3 years, and for criteria 2 it was 80.0% and 79.2%, respectively. The number of eyes on glaucoma medications was reduced from 51 preoperatively to 30 at 3 years. Complications were infrequent. There was one eye with a shallow anterior chamber beyond the immediate postoperative period. One eye required cataract surgery at 1-year follow up. Subgroup analysis was performed using the first operated eye only, and results did not differ significantly from overall results. CONCLUSION: MMC-augmented trabeculectomy can significantly reduce IOP in the short and intermediate term, with a favourable safety profile.

Outcome of bleb revision using scleral patch graft and conjunctival advancement.

PURPOSE: To evaluate our surgical technique of bleb revision using scleral patch graft and conjunctival advancement, the long-term outcome and the ability to maintain adequate intraocular pressure (IOP) control. PATIENT AND METHODS: Retrospective review. RESULTS: Eighteen patients were identified. The mean age was 72.1+/-4.3 years (95% confidence limits). In 12 of the 18 cases, the posterior edge of scleral patch graft was secured with fixed sutures, in another 3 with releasable sutures and in the remaining 3 with adjustable sutures. The mean follow-up period was 23.7+/-5.4 months (95% confidence limits). The mean preoperative IOP was 7.6+/-3.0 mm Hg (95% confidence limits), increased to 13.1+/-1.6 mm Hg (P=0.02) postoperatively. Twelve of the 18 patients had a minimum of 2-year follow-up. At this time point, 7 out of 12 (58%) patients had IOP <21 mm Hg without any medication, 9 out of 12 (75%) patients had IOP <21 mm Hg with medication, 7 out of 12 (58%) patients had IOP <16 mm Hg without medication, and 9 out of 12 (75%) had IOP <16 mm Hg with medication. The mean number of 5-fluorouracil injections with or without needling was significantly higher in the success group than in the failure group (P=0.035). CONCLUSIONS: This series illustrates a useful technique using a scleral patch graft in cases of full-thickness scleral defect encountered during bleb revisions. The success rates achieved are comparable to those in the published literature, and furthermore our successful cases achieved lower IOPs appropriate for patients with advanced glaucoma.

Life-threatening haematological disorders presenting with opthalmic manifestations.

Three cases are reported where life-threatening haematological disorders requiring urgent medical intervention presented initially to the ophthalmologist. Case one, chronic myeloid leukaemia, presented with bilateral leukaemic retinopathy and central retinal vein obstruction due to hyperviscosity. Case two, acute myeloid leukaemia, presented with bilateral haemorrhagic retinopathy. Case three, aplastic anaemia, presented with bilateral retinopathy due to anaemia and thrombocytopaenia resembling bilateral central retinal vein occlusion. In all three cases the presence of simultaneous bilateral retinal vascular involvement and white-centred haemorrhages suggested an underlying haematological disorder and differentiated them from typical retinal venous obstruction. Prompt identification of the underlying haematological disorder allows timely referral for potentially life-saving treatment.