Efficacy of Selective Laser Trabeculoplasty on Circadian Intraocular Pressure Following Trabeculectomy in Advanced Primary Open-angle Glaucoma.

PRCIS: In about 50% of post-trabeculectomy (TE) eyes, selective laser trabeculoplasty (SLT) is effective in further lowering intraocular pressure (IOP). PURPOSE: To investigate the efficacy and safety of SLT in post-TE eyes, uncontrolled on maximum tolerated medication, and/or with progression of visual field loss. PATIENTS AND METHODS: This retrospective study consecutively included post-TE eyes of patients diagnosed with primary open-angle glaucoma who had been treated with 360 degrees SLT and had a follow-up after 12 months. Primary endpoints were the reduction of mean diurnal intraocular pressure (mdIOP, mean of 6 measurements), peak IOP, and diurnal IOP fluctuations. Secondary outcomes were factors influencing IOP reduction, SLT success, and failure rates. RESULTS: Forty-three eyes of 43 patients were included. During the first year, 10 eyes (23%) needed additional procedures to reduce mdIOP and were accounted as failures and excluded from final analysis. Of the remaining 33 eyes (77%) mdIOP [Q25, Q75] dropped from 15.2 [12.2 to 16.5] to 13.2 [11.6 to 15.3] mm Hg (P=0.027), 23 eyes (54%) showed a sufficient mdIOP reduction, 1 year after SLT. CONCLUSION: SLT is effective and safe in lowering mdIOP to target IOP in about 50% of eyes after prior incisional glaucoma surgery.

One-Year Follow-up of Pars Plicata Versus Pars Plana Application of Transscleral Micropulse Cyclophotocoagulation.

PURPOSE: To compare the efficacy and safety of micropulse transscleral cyclophotocoagulation applied at the level of the pars plicata transscleral micropulse cyclophotocoagulation (PLI-MPC) versus the pars plana transscleral micropulse cyclophotocoagulation (PLA-MPC). METHODS: This prospective interventional case series included 44 eyes of 31 medically treated primary open-angle glaucoma patients scheduled for micropulse transscleral cyclophotocoagulation to achieve further intraocular pressure (IOP) reduction. In total, 22 eyes underwent PLI-MPC and PLA-MPC each. Primary endpoints were the reduction of 24-hour mean diurnal IOP (mean of 6 measurements), diurnal IOP fluctuations, and peak IOP, after 3 and 12 months. Secondary outcomes were postoperative complications, a possible deterioration in visual acuity and field, factors influencing IOP reduction, and the number of dropouts. RESULTS: In the PLI-MPC group, IOP was reduced from 15.9±3.4 mm Hg to 13.6±3.1 mm Hg (n=16; P<0.001) and 12.9±3.7 mm Hg (n=13; P<0.001) at 3 and 12-month follow-up. In the PLA-MPC group, IOP decreased from 16.4±3.5 mm Hg to 12.3±2.6 mm Hg (n=15; P<0.001) and 11.8±2.2 mm Hg (n=14; P<0.001), respectively. At 12 months, 59% of the PLI-MPC and 63% of the PLA-MPC group had a sufficient IOP reduction to reach the individual target pressure. No complications were seen in either group. A higher preoperative IOP was recognized as the only factor influencing the postoperative IOP reduction. CONCLUSIONS: PLI-MPC and PLA-MPC seem to be safe and effective in further lowering the IOP in about 60% of patients with primary open-angle glaucoma who did not reach target pressure despite maximally tolerated IOP-lowering medication. Although the IOP-lowering effect was not statistically significantly different between groups the pars plicata application was superior and easier to perform and should be recommended as the preferred method of application.

Comparison of the diurnal efficacy and safety of cyclocryocoagulation and cyclophotocoagulation in patients with refractory glaucoma.

PURPOSE: To compare the diurnal IOP-lowering efficacy and safety of cyclocryocoagulation (CCC) and cyclophotocoagulation (CPC) in patients with refractory glaucoma. METHODS: Forty eyes of 40 Caucasian patients with advanced primary or secondary glaucoma with only tunnel vision left were included in this retrospective, comparative interventional case series. Twenty eyes treated with CCC were compared with 20 eyes treated with CPC. Primary endpoint was the reduction of 24 h mean diurnal intraocular pressure (IOP; mean of 6 measurements), peak IOP and diurnal IOP fluctuations 3 and 6 months post-treatment. Secondary outcomes were the occurrence of postoperative complications and the identification of factors influencing the postoperative IOP reduction. RESULTS: In the CCC group (mean age 70.6 ± 13.4 years), mean diurnal IOP was significantly reduced from 20.0 ± 4.5 mmHg to 14.7 ± 2.5 (p < 0.001) at 3 months and 13.9 ± 3.34 mmHg at 6-month follow-up (p < 0.001). In the CPC group (mean age 74.9 ± 9.0 years), mean diurnal IOP significantly decreased from 18.2 ± 3.1 mmHg to 13.2 ± 2.2 (p < 0.001) at 3 months and 13.1 ± 2.6 mmHg (p < 0.001) at 6 months. At 6 months, 75% of the CCC and 63% of the CPC group had mean diurnal IOP reductions of 20% or more. The most frequent complication (25%) was a transient IOP increase during the first days after CCC. A higher preoperative mean diurnal IOP was recognized as the only factor influencing the postoperative IOP reduction after CCC and CPC. CONCLUSIONS: Both cyclodestructive methods seem to be reasonably safe and effective in lowering 24 h mean diurnal IOP in the perspective of 6 months in patients with refractory glaucoma. The IOP-lowering effect after CCC was better but not statistically significantly different compared to CPC. A higher rate of complications was observed in the CCC group, however.

Comparison of Central Corneal Thickness Measurements Using Optical and Ultrasound Pachymetry in Glaucoma Patients and Elderly and Young Controls.

PRéCIS:: Optical and ultrasound pachymetry cannot be used interchangeably in young, healthy adults. In elderly, healthy and glaucoma patients the speed of ultrasound in the cornea increases because of changing corneal biomechanical characteristics in age and disease and the different devices could be used interchangeably. PURPOSE: The purpose of this study was to compare central corneal thickness (CCT) using optical and ultrasound pachymetry in patients with open-angle glaucoma and young as well as elderly, healthy controls. Further to investigate whether the devices could be used interchangeably. METHODS: In total, 69 eyes of 41 glaucoma patients, 51 eyes of 32 elderly and 50 eyes of 25 young controls were consecutively included in this cross-sectional observational study. Optical CCT measurements were obtained using the noncontact Specular Microscope CEM-530 (NCSM). Ultrasound pachymetry (USP) was measured using the Pachy Meter SP 3000. RESULTS: In young subjects (27.2±4.8 y), the mean CCT taken with NCSM and USP was 562.1±33.6 µm and 565.8±35.8 µm, respectively. This was significantly different (USP>NCSM, P=0.019). In elderly subjects (70.6±10.7 y) CCT measured with NCSM (562.5±27.8 µm) compared to USP (564.9±27.1 µm) was not statistically significantly different (P= 0.121). In glaucoma patients (65.0±11.1 y), USP measured thinner CCT values compared to NCSM, without significant differences between the devices (NCSM 525.3±32.3 µm; USP 522.9±33.15 µm; P=0.067). CCT was significantly thinner in comparison to both healthy groups (P< 0.001). CONCLUSIONS: In young subjects, ultrasound pachymetry measurements are higher than they are with optical pachymetry. This difference is no longer observed in elderly subjects and is even reversed in glaucoma patients. A higher speed of ultrasound in the cornea due to changing corneal biomechanical properties in the elderly and glaucoma patients could explain this. The devices could be used interchangeably in older and glaucoma patients, but not in young individuals.

Bleb Morphology After Mitomycin-C Augmented Trabeculectomy: Comparison Between Clinical Evaluation and Anterior Segment Optical Coherence Tomography.

PURPOSE: The main aim of this article was to study the longitudinal correlation between the clinical, morphological appearance of filtering blebs with anterior segment optical coherence tomography (AS-OCT) in the early postoperative period. METHODS: Thirty eyes of 30 glaucoma patients scheduled for first-time trabeculectomy with 0.02% mitomycin-C were consecutively enrolled. The filtering blebs were evaluated clinically according to a grading system and with AS-OCT at day 1 and weeks 1, 2, 3, 4, and 12 following surgery. Bleb wall thickness (BWT) and bleb cavity height (BCH) were analyzed by means of horizontal and vertical AS-OCT scans. RESULTS: Nineteen eyes (63%) had functioning blebs without any further surgical intervention. intraocular pressure changed from 18.4±1.3 mm Hg with preoperatively applied glaucoma medication to a mean of 9.75±1.4 mm Hg at all follow-ups postoperatively without medication. Mean BWT during follow-up was 575±47 µm; mean BCH was 295±72 µm. Nine filtering blebs (30%) showed encapsulation requiring a bleb needling. This was recognized clinically at week 3 in 4, and at week 4 in 5 cases. The tendency towards encapsulation was seen much earlier with AS-OCT, already showing a statistically thinner BWT (P=0.036) at week 1 and a higher BCH (P=0.005) at week 2 postsurgery, compared with the group with functioning blebs. As of week 3, intraocular pressure increased and was statistically significantly higher (P=0.016) compared with the group with functioning blebs. Two patients (7%) showed early scarring. CONCLUSION: AS-OCT allows an analysis of the clinically invisible deeper layers of the filtering bleb. Characteristics of encapsulation, like higher blebs with thinner bleb walls, are sooner recognized than the clinical appearance. This might benefit the management of the postoperative period after trabeculectomy and the long-term outcome.