XEN gel implant versus gonioscopy-assisted transluminal trabeculotomy for the treatment of open-angle glaucoma.

OBJECTIVES: To compare successes and complications of XEN GEL Stent implantation and gonioscopy-assisted transluminal trabeculotomy (GATT) surgery in patients with open-angle glaucoma (OAG). METHODS: The multicentre, non-randomized, comparative, interventional, retrospective chart review study included 114 eyes undergoing XEN implantation and 107 eyes undergoing GATT for treatment of OAG. A comprehensive ophthalmic examination consisting of best-corrected LogMAR visual acuity (BCVA), Goldmann Applanation Tonometry, biomicroscopy, fundoscopy and gonioscopy was performed, and then, clinical findings, complications and number of antiglaucomatous medications were noted at the 3-, 6-, 12-, 18- and 24-month postoperative visits. Surgical success was defined as IOP ≤ 21 mmHg and 20% ≥ IOP reduction from baseline with (qualified success) or without (complete success) further medication, and without any further IOP-lowering surgery. RESULTS: The mean ages were 65.8 ± 10.6 and 59.1 ± 14.3 in XEN and GATT groups, respectively (p = 0.001). In XEN group, the percentage of IOP reduction and need of medication were significantly more improved than those in GATT group. The complete surgical success rates were 34.2% and 50.5% in XEN and GATT groups, respectively (p = 0.039), with a success rate of 41.1% in total. Qualified surgical success rates were 97.4% and 89.7% in XEN and GATT groups, respectively (p = 0.025), with a success rate of 93.7% in total. Transient hyphema, the most observed postoperative complication in both groups, cleared in a few days. CONCLUSIONS: Both MIGS have good efficacy and safety outcomes in lowering IOP and need of medication in patients with OAG. XEN Gel Stent implantation may be preferred in patients with lower IOP values targeted.

Intravitreal dexamethasone implant as an option for anti-inflammatory therapy of tuberculosis uveitis.

INTRODUCTION: Tuberculosis-associated uveitis remains a diagnostic and therapeutic challenge. After diagnosis of tuberculosis and initiation of anti-tuberculosis therapy for tuberculosis uveitis, the clinical responses are favorable. However, at 4-6 weeks of the therapy, there commonly occurs paradoxical deterioration due to an increase in inflammation which is often accompanied by cystoid macular edema. Thus, adjuvant administration of anti-inflammatory regimen should be considered. For this purpose, systemic and periocular steroids, systemic and intravitreal immunosuppressive agents have been tested. Nevertheless, there is no report in the literature about intravitreal dexamethasone slow-release implants for the treatment of this inflammatory condition. METHODS: Case presentation. RESULTS: We presented a tuberculosis uveitis case whose ocular inflammation is partially modified by systemic and periocular steroid injections and then well controlled by the intravitreal dexamethasone implant. CONCLUSION: Intravitreal dexamethasone implant injection seems to be a safe and potent option for the treatment of macular edema secondary to tuberculosis uveitis.

An unusual complication of combined gonioscopy-assisted transluminal trabeculotomy and phacoemulsification: vision loss due to intracapsular hematoma.

PURPOSE: To report two cases with an acute vision loss due to intracapsular hemorrhage (hematoma) after an uncomplicated gonioscopy-assisted transluminal trabeculotomy (GATT) combined with phacoemulsification surgery. METHODS: Case report. RESULTS: Seventy-six-year-old male and 75-year-old female patients with cataract and pseudoexfoliative glaucoma (XFG) uncontrolled with maximum medical therapy both underwent GATT combined with phacoemulsification. Shortly after the surgery, intracapsular hematoma behind the intraocular lens (IOL) were noted in both patients. Hematoma cleared in both of them via IOL extraction-anterior vitrectomy and YAG-laser capsulotomy, respectively. Hematoma cleared in both patients without any surgical complications. CONCLUSIONS: Vision loss due to unclearing intracapsular hematoma might be an early complication of combined GATT and phacoemulsification surgery.

The effects of tamsulosin and alfuzosin on iris morphology: an ultrasound biomicroscopic comparison.

CONTEXT: It is well known that Alpha-1 adrenergic receptor antagonists affect the receptors in the prostate and also iris dilator muscle, leading to loss of iris muscle tone. OBJECTIVE: To compare morphological alterations of iris secondary to tamsulosin and alfuzosin use. PARTICIPANTS: Patients included in the study were grouped as follows: 16 patients treated with tamsulosin (Group 1), 14 patients treated with alfuzosin (Group 2) and 18 untreated controls (Group 3). MATERIALS AND METHODS: All patients underwent ultrasound biomicroscopic and pupillometric examination. Iris thickness was measured at the dilator muscle region (DMR; measured at half of the distance between the scleral spur and the pupillary margin) and sphincter muscle region (SMR; Standardized at 0.75 mm from the pupillary margin). DMR/SMR was also calculated for each patient. Differences among groups were analysed. Main outcome measures were DMR, SMR, DMR/SMR and pupillary diameter. RESULTS: Mean duration of treatments were 2.4 ± 0.96 years (1-4) and 2.3 ± 1.01 years (1-4) in Groups 1 and 2. Pupillary diameters were reduced in Groups 1-2 compared to Group 3 (p < 0.001, p < 0.001). The SMR was similar in Groups 1 and 2 (p: 0.114). These values were not significantly different from that of Group 3 (p: 0.196, p: 0.209). However, thickness in the DMR in Groups 1-2 were significantly lower than that of controls (Group 3) whereas there was no significant difference between Groups 1 and 2 (p: 0.041, p: 0.039 and 0.986, respectively). Mean DMR/SMR ratios were significantly lower in Groups 1-2 than that of Group 3 (p: 0.040 and p: 0.040, respectively). CONCLUSIONS: In patients using these medications, the iris seems to be thinner at the dilator muscle region, but preserving the sphincter muscle region.

Ciliary body toxicities of systemic oxcarbazepine and valproic acid treatments: electron microscopic study.

Ciliary body is responsible for humour aqueous production in posterior chamber. Valproic acid (VPA) has been widely used for the treatment of epilepsy and other neuropsychiatric diseases such as bipolar disease and major depression. Oxcarbazepine (OXC) is a new anti-epileptic agent that has been used recently for childhood epilepsies such as VPA. In this study, we aimed to investigate the effects of VPA and OXC treatments used as antiepileptic in ciliary body by electron microscopy. In our study, 40 Wistar rats (21 days old) were divided equally into four groups which were applied saline (group 1), VPA (group 2), OXC (group 3) and VPA + OXC (group 4). The as-prepared ocular tissues were characterized by transmission electron microscopy (TEM) technique in scanning and transmission electron microscopy (SEM-TEM) (Carl Zeiss EVO LS10). The results confirmed that VPA caused dense ciliary body degeneration. Additionally, ciliary body degeneration in group 4 was supposed to be due to VPA treatment. Ciliary body damage and secondary outcomes should be considered in patients with long-term VPA therapy.

Fungal keratitis secondary to Scedosporium apiospermum infection and successful treatment with surgical and medical intervention.

To report a rare case of severe fungal keratitis caused by Scedosporium apiospermum, which was treated with a penetrating tectonic keratoplasty and aggressive medical treatment. A 62-year-old woman with a history of soil contamination of the right eye while planting vegetables presented with a severe corneal abscess and ocular pain. The patient received medical treatment and underwent tectonic keratoplasty. Both corneal scrapings and the corneal button were evaluated microscopically. The samples were sent for aerobic and anaerobic bacterial and fungal cultures. Microbiological examinations showed S. apiospermum. The isolate was sensitive to amphoterycine B, caspofungin, voriconazole, and resistant to fluconazole. No clinical improvement was achieved with topical voriconazole, vancomycin, ceftazidime, and systemic voriconazole. A penetrating tectonic keratoplasty and lensectomy with continuation of anti-fungal therapy achieved satisfactory results. A fungal etiology should be suspected in a progressive and untreatable corneal abscess. Microbiological investigation is very important in early diagnosis. Despite early diagnosis and aggressive treatment, in selected cases removing the infected tissue surgically is vital in preserving the ocular globe and vision.

Congenital glaucoma as an ophthalmic manifestation of Frank-Ter Haar syndrome.

We report on a patient with Frank-Ter Haar syndrome that is associated with high intraocular pressures. A 21-day-old male patient was referred to our clinic for surgical treatment of congenital glaucoma. On ophthalmic examination, he had buphthalmos, mild corneal edema and high IOP readings in both eyes. The patient underwent uneventful trabeculotomy surgery, bilaterally. Marked bilateral anterior iris insertion was noted during the surgery. Childhood glaucoma may be associated with Frank-Ter Haar syndrome.

Is GATT the Answer?

How to cite this article: Bhartiya S, Aktas Z, Ichhpujani P. Is GATT the Answer? J Curr Glaucoma Pract 2023;17(4):167-168.

Current surgical techniques for the management of pediatric glaucoma: A literature review.

Pediatric glaucoma surgery is challenging due to its diverse and complex pathophysiology, altered anterior segment anatomy, greater potential for failure, and complications compared to adult patients. Moreover, numerous challenges are associated with long-term postoperative management. Thus, when dealing with childhood glaucoma, it is important to consider the potential complications in addition to the benefits of each intervention. The purpose of this article is to review recently published literature to shed light on the most recent surgical techniques for the safe and effective treatment of childhood glaucoma. Current literature shows that goniotomy and trabeculotomy are the first choices for the management of primary congenital glaucoma. Although older children with phakic eyes seem to benefit from trabeculectomy with adjunctive mitomycin C, it carries a long-term risk of bleb-related endophthalmitis. Glaucoma drainage devices may be preferred for patients with secondary or refractory glaucoma. However, hypotony or tube-related complications are common and encountered more often in children than in adults. Cyclodestructive procedures are also an option for cases in which filtering surgery has failed, but they can also be used as a temporizing measure to reduce the rate of complications in high-risk patients. However, their outcomes can be unpredictable, in terms of efficiency and complications. Finally, minimally invasive glaucoma surgery (MIGS) as the sole alternative treatment or as an adjunctive surgical procedure is a relatively new path for pediatric patients.

Efficacy and Safety of Gonioscopy-Assisted Transluminal Trabeculotomy for Primary Congenital Glaucoma.

PRCIS: Gonioscopy-assisted transluminal trabeculotomy (GATT) provided effective intraocular pressure (IOP) control in primary congenital glaucoma (PCG). Also, approximately two third of patients did not need antiglaucoma medication at an average follow-up of 1 year after surgery. PURPOSE: The purpose of this study was to assess the safety and efficacy of GATT surgery in eyes with PCG. MATERIALS AND METHODS: This study is a retrospective review of patients who underwent GATT surgery for PCG. Outcome measures were changes in IOP and number of medications at all time points (1, 3, 6, 9, 12, 18, 24, and 36 mo after surgery), and success rates. Success was defined as IOP<21 mm Hg with at least a 30% reduction from the baseline, complete if without medications, or qualified if with or without medications. Cumulative success probabilities were analyzed using the Kaplan-Meier survival analyses. RESULTS: Twenty-two eyes of 14 patients diagnosed with PCG were enrolled in this study. The mean IOP reduction was 13.1 mm Hg (57.7%) with a mean decrease of 2 glaucoma medications at the final follow-up. All mean IOP readings during postoperative follow-up were significantly lower than baseline ( P <0.05 for all). Cumulative probability of qualified success was 95.5% and the cumulative probability of complete success was 66.7%. CONCLUSION: GATT was safe and successfully lowered IOP in patients with PCG with the advantage of avoiding conjunctival and scleral incisions.

Clinical Characteristics of Patients with Intraocular Lens Calcification after Pars Plana Vitrectomy.

AIM: To determine the clinical risk factors that may increase the occurrence of intraocular lens (IOL) calcification in patients who had undergone pars plana vitrectomy (PPV). METHODS: The medical records of 14 patients who underwent IOL explantation due to clinically significant IOL opacification after PPV were reviewed. The date of primary cataract surgery, technique and implanted IOL characteristics; the time, cause and technique of PPV; tamponade used; additional surgeries; the time of IOL calcification and explantation; and IOL explantation technique were investigated. RESULTS: PPV had been performed as a combined procedure with cataract surgery in eight eyes and solely in six pseudophakic eyes. The IOL material was hydrophilic in six eyes, hydrophilic with a hydrophobic surface in seven eyes and undetermined in one eye. The endotamponades used during primary PPV were C2F6 in eight eyes, C3F8 in one eye, air in two eyes and silicone oil in three eyes. Two of three eyes underwent subsequent silicone oil removal and gas tamponade exchange. Gas in the anterior chamber was detected in six eyes after PPV or silicone oil removal. The mean interval between PPV and IOL opacification was 20.5 ± 18.6 months. The mean BCVA in logMAR was 0.43 ± 0.42 after PPV, which significantly decreased to 0.67 ± 0.68 before IOL explantation for IOL opacification (p = 0.007) and increased to 0.48 ± 0.59 after the IOL exchange (p = 0.015). CONCLUSIONS: PPV with endotamponades in pseudophakic eyes, particularly gas, seems to increase the risk for secondary IOL calcification, especially in hydrophilic IOLs. IOL exchange seems to solve this problem when clinically significant vision loss occurs.

Surgical outcomes of posterior persistent fetal vasculature syndrome: cases with tent-shaped and closed funnel-shaped retinal detachment.

BACKGROUND/OBJECTIVES: To determine the role of vitreoretinal surgery (VRS) for two different forms of posterior persistent fetal vasculature syndrome (PFVS); with tent-shaped tractional retinal detachment (TRD) and closed funnel-shaped TRD. SUBJECTS/METHODS: Retrospective, single surgeon, consecutive case series of 52 eyes of 44 patients with posterior PFVS who underwent VRS. Cases were divided into "tent-shaped TRD" and "funnel-shaped TRD" groups based on the preoperative TRD configuration. Associated anomalies, functional and anatomical outcomes were evaluated. The cosmetic appearance was defined as poor if there was phthisis bulbi, gross buphthalmos, or corneal opacification; acceptable if there was apparent leukocoria; and excellent if none were noted at the last follow-up. RESULTS: Thirty eyes of 29 patients presented with tent-shaped TRD; 70% of which obtained counting fingers or better vision and 90% showed significant reversal of tenting achieving retinal reattachment. The cosmetic appearance was excellent in 87%. Two eyes (7%) became phthisic. Twenty-two eyes of 15 patients presented with funnel-shaped TRD and leukocoria; 45% achieved LP vision and 70% of patients with bilateral pathology had LP in at least one eye. The cosmetic appearance was acceptable to excellent in 73%. Three eyes (14%) became phthisic, one (5%) of which required enucleation. The median follow-up time was 16 (6-71) months. CONCLUSIONS: VRS often provides functional vision and anatomy in posterior PFVS with tent-shaped TRD morphology. In the funnel-shaped TRD morphology, where no treatment has historically been recommended, surgery may be considered with an aim of restoring light perception and globe preservation, particularly in bilateral cases.

Gonioscopy-assisted transluminal trabeculotomy for congenital glaucoma secondary to Klippel-Trenaunay-Weber Syndrome: A case report.

Purpose: To describe the case of a 9-year-old boy with congenital glaucoma secondary to Klippel - Trenaunay - Weber Syndrome (KTW) with a history of trabeculotomy in both eyes (BE) and further trabeculectomy in the left eye (LE) presented with high intraocular pressure (IOP) and progression in the LE despite maximum tolerated medical therapy. Observations: GATT surgery was performed firstly in the LE, followed by the right eye (RE) two months apart since the IOP in the RE started to increase later on. First post-operative day the IOP was under 15 mmHg. In the last visit, 6 months after the first surgery, IOPs were 10 and 11 mmHg RE and LE, on one fixed combination; slit lamp examinations were normal with wide open angles and a good view of the Schlemm's Canal (SC) posterior wall. Conclusions and Importance: GATT surgery can be done after failed incisional surgery in children with glaucoma secondary to KTW syndrome.

Surgical Treatment of a Patient with Recurrent Bleb Leak and Glaucoma: Bleb Excision Combined with Gonioscopy-Assisted Transluminal Trabeculotomy.

Here we present a case of intermittent bleb leakage with increased intraocular pressure (IOP) during recovery periods that was treated with gonioscopy-assisted transluminal trabeculotomy (GATT) combined with avascular bleb excision. A 60-year-old woman exhibiting simultaneous leaking bleb and glaucoma underwent GATT and bleb revision. At her final visit, the bleb leakage had resolved and IOP was under control without any further antiglaucoma medication. GATT may be useful for glaucoma patients exhibiting intermittent bleb leakage after failed trabeculectomy.

Risk Factors for Trabeculotomy Failure in Primary Congenital Glaucoma.

PRCIS: This study demonstrates that a baseline corneal diameter >12.25, initial age <4 months at diagnosis, higher baseline IOP than 24 mm Hg, bilaterality, or inability to perform circumferential trabeculotomy, increases the risk of surgical failure of trabeculotomy in patients with primary congenital glaucoma (PCG). PURPOSE: The aim of this study was to identify clinical predictive factors for surgical failure and to evaluate potential prognostic factors affecting surgical success in patients with PCG who underwent trabeculotomy. PATIENTS AND METHODS: The medical charts of 123 eyes of 75 patients who underwent trabeculotomy surgery for the treatment of PCG were retrospectively reviewed. At baseline and each visit, intraocular pressure (IOP), corneal diameter, cup to disc ratio, axial length, number of medications, and need for further glaucoma surgery were noted. Surgical success was defined as an IOP ≤18 mm Hg and 20% IOP reduction from baseline with (qualified) or without (complete) medication and without any further IOP-lowering surgery. RESULTS: The mean age at surgery was 4.2±6.6 months and the mean follow-up time was 60.0±37.6 months. The receiver operating characteristic curve showed 4 following best cutoff values to predict surgical failure: the first for age at surgery was 4.5 months; the second baseline IOP was 24.0 mm Hg; the third for baseline cup to disc ratio was 0.4; and the fourth for baseline corneal diameter was 12.25 mm. Multivariate logistic regression analysis revealed that baseline IOP more than 24 mm Hg increased the risk of surgical failure by 2 times, baseline mean corneal diameter >12.25 mm did by 4.2 times, younger age than 4 months did by 2.5 times, bilaterality did by 1.5 times. CONCLUSIONS: A higher baseline IOP, younger age, larger corneal diameter, and bilaterality were identified as risk factors for trabeculotomy failure in congenital glaucoma. The presence of one or more of these should be considered in the decision-making process when considering surgical options to manage glaucoma in these patients.

Outcomes of Prolene Gonioscopy Assisted Transluminal Trabeculotomy in Primary Open Angle Glaucoma and Pseudoexfoliation Glaucoma: A Comparative Study.

PRCIS: Gonioscopy-assisted transluminal trabeculotomy (GATT) provides greater intraocular pressure (IOP) reduction in pseudoexfoliative glaucoma (PXG) than in primary open angle glaucoma (POAG) in the first year of surgery; however, the difference between groups equalizes in the long term. PURPOSE: To compare outcomes of GATT in eyes with POAG and PXG. METHODS: Single-center, retrospective, comparative case-series. A total of 202 eyes (91 eyes of POAG; 111 eyes of PXG) were included. GATT was performed as a standalone procedure or in combination with cataract extraction. Outcome measures were change in IOP and number of medications at all time points (1, 3, 6, 9, 12, 18, 24, and 36 mo after surgery), success rate (IOP reduction ≥20% from baseline or IOP between 6 and 21 mmHg, without further glaucoma surgery), and complication rate. Cumulative success probabilities were compared using Kaplan-Meier survival analyses. RESULTS: The mean IOP decreased by 8.8 mmHg (34.4%) in the POAG group with a mean decrease of 2 glaucoma medications at final visit. In the PXG group, the mean IOP decreased by 12.8 mm Hg (44.6%) on 2.3 fewer medications. Mean IOP reduction was significantly higher in PXG than POAG at all time points up to 2-year visit ( P <0.05 for all), after which the difference was not significant. Cumulative success probability during the first year was significantly higher in PXG (97.6%) than in POAG (86.8%) ( P =0.01); no significant difference was found at 2-year ( P =0.07) and 3-year visits ( P =0.24). CONCLUSION: GATT was safe and effectively reduced the IOP and medication burden in patients with POAG and PXG. In the first year after GATT, a significantly higher success rate was noted in PXG compared with POAG; however, in subsequent years, the success rate was similar at ~75%.

Outcomes of Osteosarcoma in Children Without High-Dose Methotrexate: Could It Be Less Toxic Without Effecting Survival Rates?

Background: Osteosarcoma (OS) is the most common primary bone sarcoma in childhood. High-dose methotrexate, doxorubicine, cisplatin, and/or ifosfamide combinations are used as standard treatment in chemotherapy and could cause serious toxicity. Another alternative chemotherapy protocol is consisting of epirubicin, ifosfamide, and cisplatin (ECI), which we use in our center. The aim of this study was to evaluate the patients with OS who were treated with ECI protocol, retrospectively. Methods: Forty-three patients with OS diagnosed at our center between December 1995 and September 2017 were evaluated retrospectively. Results: The mean follow-up period was 31 months (5-145 months). Recurrence was detected in 15 of 43 patients. When the factors affecting relapse are examined, recurrence was higher in patients who were older than 10 years at the time of diagnosis, upper extremity involvement, osteoblastic, and chondroblastic subgroups, but there was no statistically significant difference. Five-year and 10-year overall survival rates were 67.4% and 58.9%, and event-free survival rates were 54% and 47.3%, respectively. While 5-year overall survival rate was 86.7% in nonrecurrent cases, this rate was 40.9% in recurrent cases and this difference was statistically significant (p = 0.023). Just two patients died because of the toxicity. Conclusion: The prognosis of OS is still poor in relapse cases, so the choice of chemotherapy for neoadjuvant and adjuvant therapy is vital. When the risk of toxicity is also considered, the first step of ECI protocol is seen as a preferable treatment option because the survival rates are similar to the literature.

Effect of light backscattering from anterior segment structures on automated flare meter measurements.

BACKGROUND: To evaluate effect of maximal anterior cortical lens density, iris scatter and anterior chamber depth on laser flare photometry. METHODS: Patients diagnosed with clinical uveitis were enrolled in the study. Clinical flare gradings were recorded upon the Standardization of Uveitis Nomenclature. Aqueous flare was measured with an automated device (Kowa FM-700). Back-scattering from anterior cortical lens and anterior iris surface was calculated from Scheimpflug images. A curvilinear regression model was used to calculate estimated values for each clinical grade. These values were used to split cases in Group I (laser flare photometry lower than estimated) and Group II (laser flare photometry higher than estimated). Mean anterior chamber depth, pupil aperture, maximal anterior cortical lens density and iris scatter values were compared between two groups. A stepwise multiple regression analysis was performed to determine the effect of clinical flare gradings and ocular parameters on aqueous flare measurements. RESULTS: The study included 228 eyes of 114 cases. Scheimpflug images were obtained from 105 eyes. Estimated aqueous flare measurements (in photons/milliseconds) were 4.87, 8.50, 14.81, 25.83, 45.04 and 136.93 for 0, 0.5+, 1+, 1.5+, 2+ and 3+ clinical flare respectively. Group II had higher maximal anterior cortical lens density than Group I (96.6 ± 37.1 vs 77.9 ± 17.1 pixel unit, p = 0.001). The measured aqueous flare was significantly related to clinical flare, maximal anterior cortical lens density and pupil aperture (adjusted R2: 0.480, p < 0.001). CONCLUSION: The back-scattered light from anterior cortical lens could affect laser flare photometry measurements. This effect might be quantified by Scheimpflug imaging.