Gonioscopy-assisted transluminal trabeculotomy (GATT) outcomes in eyes with open-angle glaucoma resistant to maximum treatment / Resultados da técnica de trabeculotomia transluminal assistida por gonioscopia em olhos com glaucoma de ângulo aberto resistentes ao tratamento máximo

ABSTRACT Purpose: To report the initial 2 years' learning curve on gonioscopy-assisted transluminal trabeculotomy performed using the thermally blunted suture technique and review the factors that could potentially affect the outcome. Methods: This retrospective study evaluated 100 eyes from 89 participants with glaucoma resistant to maximum clinical treatment, which was defined as having an intraocular pressure >21 mmHg in addition to three or four different hypotensive drugs. Intraocular pressure values at baseline, 1 week, and at 1, 2, 3, 6, 12, and 24 months of follow-up and details regarding the need of antiglaucoma medication and further glaucoma surgery were recorded. Eyes that required further surgical intervention for intraocular pressure control were considered as failure. Results: A total of 51 eyes were subjected to isolated gonioscopy-assisted transluminal trabeculotomy, and 49 eyes were subjected to gonioscopy-assisted transluminal trabeculotomy + cataract extraction at the same surgical time. A statistically significant difference was observed between overall mean follow-up intraocular pressure and mean preoperative intraocular pressure (p<0.001) in all follow-up visits. When the extent of treatment was evaluated, patients with an extension of 360° did not exhibit statistically significantly lower mean intraocular pressure than those with other extensions. Hyphema was the only complication presented in 50 eyes (50%), but all had spontaneous resolution within 4 weeks. A total of 26 eyes (26%) required additional conventional trabeculectomy due to uncontrolled intraocular pressure, especially those who previously underwent vitreoretinal surgery. Conclusions: Gonioscopy-assisted transluminal trabeculotomy, besides being an apparently safe procedure, results in satisfactory success rates even during the surgeon's initial learning curve. The technique was effective in decreasing intraocular pressure and medication burden.

RESUMO Objetivo: Reportar a curva de aprendizado dos 2 anos iniciais da trabeculotomia transluminal assistida por gonioscopia, usando a técnica de sutura termicamente atenuada e revisar os fatores que podem afetar o resultado. Métodos: Este estudo retrospectivo incluiu 100 olhos de 89 participantes com glaucoma resistente ao tratamento clínico máximo, definido como tendo pressão intraocular superior a 21mmHg, além de três ou quatro drogas hipotensoras diferentes. Pressão intraocular inicial, 1 semana, primeiro, segundo, terceiro, sexto, 12 e 24 meses de acompanhamento; necessidade de medicação antiglaucoma; necessidade de mais cirurgias anti-glaucomatosas foram registradas. Olhos que necessitaram de intervenção cirúrgica adicional para o controle da pressão intraocular foram considerados como insucesso. Resultados: Cinquenta e um olhos foram submetidos à trabeculotomia transluminal assistida por gonioscopia isolado e 49 olhos à trabeculotomia transluminal assistida por gonioscopia associado à extração de catarata no mesmo tempo cirúrgico. Houve diferença estatisticamente significativa entre a pressão intraocular média global no acompanhamento e a pressão intraocular média pré-operatória (p<0,001) em todas as visitas do acompanhamento. Ao avaliar a extensão do tratamento, os pacientes com extensão de 360 graus não apresentaram pressão intraocular média menor estatisticamente significativa em comparação com outras extensões. O hifema foi a única complicação presente em 50 olhos (50%), contudo todos tiveram resolução espontânea em quatro semanas. Um total de 26 olhos (26%) teve que ser submetido a trabeculectomia convencional adicional devido à pressão intraocular descontrolada, principalmente aqueles previamente submetidos à cirurgia vitreorretiniana. Conclusões: A trabeculotomia transluminal assistida por gonioscopia, além de ser um procedimento aparentemente seguro, apresenta taxas de sucesso satisfatórias, mesmo durante a curva de aprendizado inicial do cirurgião. A técnica foi efetiva em reduzir a pressão intraocular e uso de medicamentos.

An innovation in glaucoma surgery: XEN45 gel stent implantation / Uma inovação na cirurgia de glaucoma: implante de endoprótese de gel XEN45

ABSTRACT Purpose: To report follow-up data for patients who underwent XEN45 gel stent implantation, a new method of minimally invasive glaucoma surgery. Methods: Fifteen eyes in fifteen patients who underwent XEN45 gel stent implantation surgery were investigated in the study. All patients were examined preoperatively and at the following postoperative time points: 1 day; 1 and 2 weeks; and 1, 2, 3, 6, and 12 months. Intraocular pressure (IOP) was measured via Goldmann applanation tonometry. Combined surgical procedures (XEN45 + phacoemulsification + intraocular lens) were performed in patients who that had cataracts in addition to glaucoma. Results: The mean IOP values were significantly lower than the preoperative values at all postoperative visits (p<0.001). In two patients, the IOP exceeded 20 mmHg 12 months after surgery. These IOP increases were controlled by medical therapy, and none of the patients needed another surgical procedure. Conclusion: XEN45 gel stent implantation is a minimally invasive glaucoma surgery that ensures the effective reduction of IOP. This new treatment modality also avoids the destructive complications encountered in other invasive surgical procedures. However, further studies with greater numbers of patients and longer follow-up periods are needed to clarify certain points.

RESUMO Objetivo: Relatar os dados de acompanhamento dos pacientes que apresentaram implante de endoprótese de gel XEN45, um novo método de cirurgia de glaucoma minimamente invasiva. Métodos: Foram investigados quinze olhos de quinze pacientes que tiveram cirurgia de implante de endoprótese de gel XEN45 no estudo. Todos os pacientes foram examinados no pré-operatório e nos seguintes pontos de tempo pós-operatório: 1 dia; 1 e 2 semanas; E 1, 2, 3, 6 e 12 meses. A pressão intraocular foi medida pela tonometria de aplanamento de Goldmann. Procedimentos cirúrgicos combinados (XEN 45 + facoemulsificação + lente intraocular) foram realizados nos casos que apresentavam catarata além do glaucoma. Resultados: Os valores médios de PIO foram significativamente menores em todas as visitas pós-operatórias quando comparados aos valores pré-operatórios (p<0,001). Em 2 casos, os valores da pressão intraocular foram superiores a 20 mmHg aos 12 meses pós-operatório. Estes aumentos da pressão intraocular foram controlados por terapia médica, e nenhum dos pacientes necessitou de outro procedimento cirúrgico. Conclusão: Implantação de endoprótese de gel XEN45 é uma cirurgia de glaucoma minimamente invasiva que garante a redução efetiva da pressão intraocular. Esta nova modalidade de tratamento também evita as complicações destrutivas encontradas em outros procedimentos cirúrgicos invasivos. No entanto, estudos adicionais com um maior número de pacientes e períodos de acompanhamento mais longos são necessários para esclarecer certos pontos.

Selective laser trabeculoplasty as an initial treatment option for open-angle glaucoma / Trabeculoplastia seletiva como opção terapêutica inicial para o tratamento do glaucoma de ângulo aberto

ABSTRACT Although eye drops are frequently used as an initial treatment option for open angle glaucoma (OAG), side effects, and poor adherence, among others, may compromise treatment efficacy. In this scenario, laser trabeculoplasty is an interesting therapeutic option for open angle glaucoma cases. Commonly used for many years as a last alternative prior to glaucoma incisional surgery, laser trabeculoplasty has been changing its indication after the advent of selective laser trabeculoplasty (SLT). In the current review, we critically evaluated the published data regarding the use of laser trabeculoplasty as a first treatment option for open angle glaucoma patients. Studies using SLT as a first-line treatment have encouraging findings. One-year efficacy results are comparable to those obtained with prostaglandin analogues, with a good safety profile. Although the laser´s effect is known to be transitory, recent data suggest it can be successfully repeated in cases with good response to the first SLT treatment.

RESUMO Embora a terapia tópica seja frequentemente usada como primeira opção para o tratamento inicial do glaucoma de ângulo aberto (GAA), efeitos colaterais, baixa adesão, entre outros fatores podem comprometer a eficácia do tratamento. Nesse cenário, a trabeculoplastia a laser surge como uma opção terapêutica interessante. Comumente usada como última alternativa antes da cirurgia antiglaucomatosa incisional por muitos anos, a trabeculoplastia a laser tem sido indicada cada vez mais cedo com o advento da trabeculoplastia seletiva a laser (SLT). Nessa revisão, nós avaliamos criticamente as publicações sobre trabeculoplastia a laser como primeira opção para glaucoma de ângulo aberto. Os estudos de SLT como primeira opção terapêutica têm apresentado dados animadores. Os resultados de um ano de acompanhamento mostram eficácia semelhante àquela obtida com análogos de prostaglandinas. Embora o efeito do laser seja transitório, estudos recentes sugerem que o procedimento pode ser repetido com sucesso nos casos que tiveram boa resposta ao primeiro tratamento com SLT.

Medical therapy versus trabeculectomy in patients with open-angle glaucoma / Tratamento clínico versus trabeculectomia em pacientes com glaucoma de ângulo aberto

ABSTRACT Purpose: To compare therapeutic outcomes between trabeculectomy and medical therapy in patients with open-angle glaucoma. Methods: In the present retrospective comparative study, the medical charts of 284 patients (eyes) newly diagnosed with open-angle glaucoma who had received conventional medications (n=188) or undergone fornix-based trabeculectomy (n=96) at a teaching eye hospital were reviewed. Results: At a mean follow-up of 6.6 years, post-treatment changes in intraocular pressure (IOP), visual field (VF), best spectacle-corrected visual acuity (BSCVA), and number of required drugs were significantly more favorable in the surgical group (P<0.001 for all comparisons). However, the frequency of clinically desirable IOP (≤21 mmHg) at the endpoint was comparable between the surgical and medical groups (87.2% vs. 82.3%; P=0.26). The rate of conversion to surgical therapy was 34% in the medical group. A greater baseline requirement for anti-glaucoma drugs (two or more) was the only independent predictor of treatment failure in the present study. Conclusions: Although more severe cases naturally receive trabeculectomy, the surgical approach had greater efficacy than conventional medical therapy in patients with open-angle glaucoma. An initial requirement for two or more anti-glaucoma drugs may predict failure of medical therapy.

RESUMO Objetivo: Comparar o resultado terapêutico de trabeculectomia versus terapia médica em pacientes com glaucoma de ângulo aberto. Método: Neste estudo comparativo retrospectivo, prontuários médicos de 284 pacientes (olhos), de um hospital de ensino oftalmológico, com diagnóstico recente de glaucoma de ângulo aberto que receberam medicamentos convencionais (n=188) ou foram submetidos a trabeculectomia de base fórnice (n=96) foram revisados. Resultados: Com seguimento médio de 6,6 anos, as mudanças pós-tratamento da pressão intraocular (PIO), campo visual (VF), melhor acuidade visual corrigida por óculos (BSCVA), e o número de medicações necessárias foram significativamente mais favorável ao grupo cirúrgica (p<0,001 para todas as comparações). No entanto, os grupos foram comparáveis para a frequência de PIO clinicamente desejável (≤21 mmHg) na visita final (87,2% vs. 82,3%, respectivamente; p=0,26). A taxa de conversão para o tratamento cirúrgico foi de 34% no grupo médico e a necessidade inicial de mais drogas antiglaucomatosas (2 ou mais) foi o único preditor independente desta conversão. Conclusões: Embora os casos mais graves de glaucoma são naturalmente designados o grupo de trabeculectomia, esta abordagem cirúrgica se mostrou mais eficaz do que a terapia médica convencional em pacientes com glaucoma de ângulo aberto. Uma necessidade inicial de 2 ou mais medicações antiglaucomatosas pode prever a falha em terapia médica.

Percepção do paciente portador de glaucoma e os diferentes tipos de tratamento (clínico versus cirúrgico) / Patient’s perception on glaucoma and different types of treatment (medical versus surgical treatment)

Objetivo: Identificar a percepção dos pacientes sobre o significado de ser portador de glaucoma e a percepção que tem sobre o tratamento clínico ou cirúrgico. Métodos: Para a coleta dos dados utilizou-se a pesquisa qualitativa através da estratégia de grupos focais realizados com pacientes em tratamento clínico (grupo 1) e pacientes submetidos à cirurgia antiglaucomatosa (grupo 2). A análise e a interpretação dos resultados foram feitas pela técnica da análise de conteúdo. Resultados: O medo da cegueira e a desinformação sobre a doença foram os aspectos negativos mais encontrados com relação a ser portador de glaucoma. O grupo cirúrgico preferiu a situação atual quando comparada à necessidade do uso de medicação. Verificou-se que tanto o glaucoma quanto o seu tratamento impactaram profundamente esses pacientes e que, embora a preocupação com a doença ainda persista, os pacientes operados demonstraram apresentar menos impacto no seu cotidiano. Foram determinantes para a aceitação da indicação da cirurgia a falta de controle da doença e a confiança no médico, sendo esta última considerada um fator primordial nos dois grupos pesquisados, o que aponta para sua importância, independente da decisão tomada pelo paciente na convivência com sua doença. Conclusão: Identificaram-se os aspectos negativos mais relevantes com relação ao glaucoma e ao seu tratamento. A confiança na correta indicação do tipo de tratamento, clínico ou cirúrgico, e uma relação sólida entre o paciente e o médico são os fatores determinantes para uma maior tranquilidade dos pacientes em tratamento de glaucoma (clínico ou cirúrgico).

Objective: To identify the meaning and impact on their quality of life of having glaucoma and to understand the patients’ perception on the different types of treatment (medical or surgical). Methods: Through a qualitative research, focus groups were conducted with patients in clinical treatment (group 1) and patients who underwent glaucoma surgery in both eyes and were without medication (group 2). The responses were analyzed using the technique of content analysis. Results: Fear of blindness and lack of information about the disease were the most cited issues in relation to how it is like to having glaucoma. Medication costs, impact of drops on patients’ daily lives and the side effects were the main points discussed in relation to medical treatment. All patients in the surgical group preferred the current situation (without medication) when compared to the need for chronic use of medication. In the two groups, both glaucoma and its treatment had a profound impact on people, not only from a psychological standpoint, but also affecting their daily lives. Patients operated on for glaucoma appear to have less impact on their daily lives, but the concern about the disease persists. Conclusion: We identified the most significant negative aspects of glaucoma and its treatment from patients’ perspectives. Confidence in the correct indication of the type of treatment, clinical or surgical, and a solid relationship between the patient the doctor are determining factors for extra peace of mind of patients being treated for glaucoma.

Early effectiveness of P50 and P200 Ex-PRESS glaucoma drainage device implantation for open angle glaucoma:a randomized controlled study / 中华实验眼科杂志

Background Ex-PRESS glaucoma drainage device implantations have been clinically applied worldwide.In China,50 type and 200 type of Ex-PRESS glaucoma drainage devices are used for different types of open angle glaucoma.However,whether the clinical outcomes are similar between 50 type and 200 type of Ex-PRESS glaucoma drainage devices are not elucidated.Objective This study was to compare the therapeutic efficacy and security of Ex-PRESS implantation between PS0 type and P200 type of Ex-PRESS glaucoma drainage devices for open angle glaucoma Methods A randomized,parallel-group trial was designed,and written informed consent was obtained from each patient prior to entering in the cohort.Eighty eyes of 69 patients with various types of open angle glaucoma were included from March 2012 to April 2013 in Wuhan General Hospital of Guangzhou Military Command.The patients were randomized into 2 groups according to randomized digital table.The P50 type Ex-PRESS glaucoma drainage device was implanted in 40 eyes of 35 patients in the P50 group,and P200 type was implanted in 40 eyes of 34 patients in the patients of the P200 group.The disease composition,best corrected visual acuity (BCVA) recovery time,theoretical hospitalization days,lowing intraocular pressure (IOP) range and postoperative complications were compared between the two groups.Results The average lowing-IOP ranges of the P50 type group and P200 type group were (21.19±11.22) and (24.35±12.27) mmHg,respectively,with an insignificant difference between them (t =-1.201,P＞0.05).The theoretical hospitalization days and BCVA recovery time in the of P50 type group were (3.65±0.92) days and (2.85±0.95)days,and those in the P200 type group were (4.90±0.81) days and (3.40± 0.96) days,showing significant decreases in the P50 type group (t =-6.444,P＜0.01 ;t =-2.584,P＜ 0.05).The incidence of postoperative complications were 6.06％ and 25.00％ in P50 type group and P200 type group,respectively,with a significant difference between the two groups (.x2 =9.800,P＜0.05).Conclusions Although P50 and P200 Ex-PRESS implantation provide a similar effect in lowing IOP,P50 type Ex-PRESS implantation can restore BCVA more rapidly and lessen complications in comparison with P200 type Ex-PRESS implantation in the early postoperative stage.

Clinical outcome evaluation of selective laser trabeculoplasty as the initial therapy for primary open angle glaucoma / 中华实验眼科杂志

Background Selective laser trabeculoplasty (SLT) is one of common therapies for early-stage primary open angle glaucoma (POAG).However,it always been used as a method of treating medically uncontrolled open angle glaucoma in China.So the assessment of efficacy of SLT as the initial therapy for POAG is still lack.Objective This clinical study was to compare the efficacy of SLT in early-stage POAG eyes with or without primary medical therapy.Methods A prospective non-randomized controlled study was designed.Sixty-five eyes of 37 patients with early-stage POAG were divided into without pre-treated group (30 eyes of 16 patients) and with pretreated group (35 eyes of 21 patients).SLT was performed on the inferior trabecular meshwork of 180° in all the patients aged 12-57 years old using a 532 nm frequency-doubled,Q-switched Nd:YAG laser with the pulse 3 ns,spot diameter 400 μm.The emitting energy was set from an initial energy of 0.6 mJ to decreased energy successively at 0.1 mJ interval till bubbles coming out.The following-up was 6 months.Primary outcome of SLT included the changes of intraocular pressure (IOP) and effective rate,and the secondary outcome included the perimetry and C/D value.The safety index was evaluated as the incidence of irritative symptom.Results After SLT 1 day to 6 months,the IOP was lower than that before SLT in all the patients (all at P＜0.05).The IOP was (24.03± 3.76)mmHg and (19.18±3.86)mmHg respectively at preoperation and postoperative 1 month in without pretreated group,with a mean decreasing value of (4.85 ±4.31)mmHg,in with pretreated group,the IOP was (23.63±4.29)mmHg at preoperation and (17.07±4.15)mmHg at postoperative 1 month,with a mean difference of (6.28±3.57)mmHg,with a significant difference in the IOP lowing value between the two groups (P =0.045),but there were no significant differences in the IOP lowing value between without and with pretreated groups in 1 hour,1 day,3 months and 6 months after SLT (all at P＞0.05).The effective rate was 75.00％ and 76.67％ in without and with pretreated groups respectively at the end of following-up (P =0.882).No obvious changes were seen in visual field and C/D value before and after SLT in both groups.Also,no serious complication was found in the patients during the following-up duration.Conclusions SLT has a good outcome in lowing-IOP for early stage POAG.There is no obvious impact to the clinical efficacy of SLT whether with or without the primary administration of anti-glaucomatous eye drops.Long-term effect of SLT remains to be observed.

Selective laser trabeculoplasty :up-to-date choice for glaucoma treatment / 中华实验眼科杂志

The management of open-angle glaucoma is a long-term,even lifelong procedure.A right medical decision can gain better efficacy and economic benefit and effectively avoid medical risk.Selective laser trabeculoplasty (SLT) is a therapy approved by FDA of USA and has been applied in China over decade.However,the clinical efficacy assessment is still controversial in China.For re-evaluation of the indication,methodology,technical parameters,and the efficacy of SLT will give full play to its advantage of the potential sufficient control of intraocular pressure (IOP) in glaucomatous treatment.The development of history,mechanism and effectiveness in control IOP,security and operation of SLT are reviewed.The suitable population,technique parameters,multiple centers clinical trial and the cost-effectiveness of SLT for Chinese glaucomatous patients are also proposed.

A primary report on modified trabeculectomy for primary open angle glaucoma / 眼科

Objective To introduce an anti-glaucoma filtering surgery, modified trabeculectomy, which may have a continuous drainage of the aqueous. Design Retrospective, comparative case series. Participants 41 patients (51eyes) with primary open angle glaucoma. Methods Remove a perpendicular scleral flap along with the trabecular meshwork and followed with a peripheral iridectomy and tenonnectomy. The excision of a portion of Tenon's capsule ensures that the superior end of the tunnel remains open. Patients were followed over one year period. The therapeutic efficacy of the modified operation versus traditional operation were compared. Main Outcome Measures Pre-and post-operative intraocular pressure(IOP), un-corrected visual acuity(UCVA), best-corrected visual acuity (BCVA), postoperative bleb formation and postoperative complications. Results A total of 41 patients (51eyes) were included in this study. Chronic open angle glaucoma was the most common type of glaucoma. During the one year follow-up, 97.2% (25/26) of the mod ified operation treated eyes achieved IOP below 20mmHg and 76.0% (19/25) of traditional operative procedure, below 21mmHg. The postoperative BCVA in both groups did not show significant changes. Conclusion In the modified surgery, a perpendicular sclera strip with trabecular meshwork was excised. Postoperative IOP was reduced and visual acuity remained stable. IOP may be controlled for a long term in modified trap procedure, which seems to be a safer and more effective treatment for open angle glaucoma.