Comparison of safety and effectiveness of micropulse transscleral cyclophotocoagulation and "slow cook" diode laser transscleral cyclophotocoagulation in patients with refractory open-angle glaucoma

ABSTRACT Purpose: This study aimed to compare the safety and effectiveness of intraocular pressure reduction between micropulse transscleral cyclophotocoagulation and "slow cook" transscleral cyclophotocoagulation in patients with refractory primary open-angle glaucoma. Methods: We included patients with primary open angle glaucoma with at least 12 months of follow-up. We collected and analyzed data on the preoperative characteristics and postoperative outcomes. The primary outcomes were a reduction of ≥20% of the baseline value (criterion A) and/or intraocular pressure between 6 and 21 mmHg (criterion B). Results: We included 128 eyes with primary open-angle glaucoma. The preoperative mean intraocular pressure was 25.53 ± 6.40 and 35.02 ± 12.57 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The mean intraocular pressure was reduced significantly to 14.33 ± 3.40 and 15.37 ± 5.85 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups at the last follow-up, respectively (p=0.110). The mean intraocular pressure reduction at 12 months was 11.20 ± 11.46 and 19.65 ± 13.22 mmHg in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The median preoperative logMAR visual acuity was 0.52 ± 0.69 and 1.75 ± 1.04 in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p<0.001). The mean visual acuity variation was −0.10 ± 0.35 and −0.074 ± 0.16 in the micropulse- and "slow cook" transscleral cyclophotocoagulation, respectively (p=0.510). Preoperatively, the mean eye drops were 3.44 ± 1.38 and 2.89 ± 0.68 drugs in the micropulse- and "slow cook" transscleral cyclophotocoagulation groups, respectively (p=0.017), but those were 2.06 ± 1.42 and 1.02 ± 1.46 at the end of the study in the "slow cook" and micropulse transscleral cyclophotocoagulation groups, respectively (p<0.001). The success of criterion A was not significant between both groups. Compared with 11 eyes (17.74%) in the "slow cook" transscleral cyclophotocoagulation group, 19 eyes (28.78%) in the micropulse transscleral cyclophotocoagulation group showed complete success (p=0.171). For criterion B, 28 (42.42%) and 2 eyes (3.22%) showed complete success after micropulse- and "slow cook" transscleral cyclophotocoagulation, respectively (p<0.001). Conclusion: Both techniques reduced intraocular pressure effectively.

Effect of tobacco smoking on outcomes of trabeculectomy / Efeito do tabagismo nos desfechos da trabeculectomia

ABSTRACT Purpose: To evaluate the effect of tobacco smoking on trabeculectomy outcomes. Methods: Charts of patients with glaucoma who underwent trabeculectomy performed by a single surgeon between 2007 and 2016 were retrospectively reviewed. Charts were screened for a documented history of smoking status before surgery. Demographic and clinical preoperative variables were recorded. Based on smoking history, subjects were divided into two groups: smokers and nonsmokers. Any bleb-related interventions (e.g., 5-flourouracil injections ± laser suture lysis) or bleb revision performed during the postoperative period were noted. Success was defined as an intraocular pressure >5 mmHg and <21 mm Hg without (complete success) or with (qualified success) the use of ocular hypotensive medications. Failure was identified as a violation of the criteria mentioned above. Results: A total of 98 eyes from 83 subjects were included. The mean age of the subjects was 70.7 ± 11.09 years, and 53% (44/83) were female. The most common diagnosis was primary open-angle glaucoma in 47 cases (47.9%). The smokers Group included 30 eyes from 30 subjects. When compared with nonsmokers, smokers had a significantly worse preoperative best-corrected visual acuity (p=0.038), greater central corneal thickness (p=0.047), and higher preoperative intraocular pressure (p=0.011). The success rate of trabeculectomy surgery at 1 year was 56.7% in the smokers Group compared with 79.4% in the Group nonsmokers (p=0.020). Smoking presented an odds ratio for failure of 2.95 (95% confidence interval, 1.6-7.84). Conclusion: Smokers demonstrated a significantly lower success rate 1 year after trabeculectomy compared with nonsmokers and a higher requirement for bleb-related interventions.

RESUMO Objetivo: Avaliar o efeito do tabagismo nos desfechos da trabeculectomia. Métodos: Uma revisão retrospectiva do gráfico de pacientes com glaucoma submetidos à trabeculectomia foi realizada por um único cirurgião entre 2007 e 2016. Os gráficos foram examinados para uma história documentada de condição de fumante antes da cirurgia. Variáveis pré-operatórias clínicas e demográficas e clínicas foram registradas. Os pacientes foram divididos em dois grupos de acordo com sua história de tabagismo em fumantes e não fumantes. Quaisquer Intervenções relacionadas à bolha, por exemplo, injeções de 5-fluorouracil + lise de sutura com laser, ou revisão da bolha realizada durante o período pós-operatório foram observadas. O sucesso foi definido como pressão intraocular > 5 mmHg e < 21 mm Hg sem (sucesso completo) ou com (sucesso qualificado) medicamentos hipotensores oculares. A falha foi identificada como violação dos critérios mencionados acima. Resultados: O estudo incluiu 98 olhos de 83 pacientes com idade média de 70,7 ± 11,09 anos, sendo 53% (44/83) dos pacientes do sexo feminino. O diagnóstico mais comum foi o glaucoma de ângulo aberto primário com 47 casos (47,9%). O Grupo de fumantes incluiu 30 olhos de 30 pacientes. Os fumantes, quando comparados aos não fumantes, apresentaram uma melhor acuidade visual pré-operatória significativamente pior (p=0,038), maior espessura central da córnea (p=0,047) e maior pressão intraocular pré-operatória (p=0,011). A taxa de sucesso de um ano para a cirurgia de trabeculectomia foi de 56,7% no Grupo de fumantes contra 79,4% no Grupo de não fumantes (p=0,020). O tabagismo apresentou razão de chances para falha de 2,95 95% de IC (1,6-7,84). Conclusão: Os fumantes demonstraram uma taxa de sucesso significativamente menor em um ano após a trabeculectomia em comparação com os não fumantes e uma maior necessidade de intervenções relacionadas à bolha.

Saccadic movements during an exploratory visual search task in patients with glaucomatous visual field loss

ABSTRACT Purpose: To evaluate the saccadic movements of patients with visual field loss due to primary open-angle glaucoma. Methods: Thirteen patients with good visual acuity (0.2 logMAR or better) (seven patients with primary open-angle glaucoma 65 ± 13 years) and six controls (51 ± 6 years) yielded a comprehensive ophthalmological examination, including Humphrey Visual Field tests (SITA-Standard 24-2), and performed a monocular, exploratory digital visual search task that quantifies the duration for finding the number "4" on a random array of digits distributed on the screen. After individual adjustments of the angle and distance positioning, the screen was spatially matched with the 24-2 visual field, and divided into five areas for analysis. During the task, saccades were simultaneously recorded in the same eye with a video-based eye tracker. Results: The patients with primary open-angle glaucoma showed a significantly higher number of saccades/screen (median ± interquartile range, 59.00 ± 29.00 vs. 32.50 ± 19.75 saccades (p=0.027) and visual search time per screen (38.50 ± 60.14 vs. 23.75 ± 8.90 seconds (p=0.035) than the controls did. Although the univariate analysis indicated a significant correlation with visual field mean deviation (coefficient=26.19 (p=0.02), only the visual search time/screen was significantly associated with the number of saccades/screen in the multivariate regression model (coefficient=0.55 (p<0.001). Overall, no significant correlation was observed between the sectorial number of saccades and the sensitivity of the five visual field areas. Conclusions: The patients with primary open-angle glaucoma show impaired search performance and showed a higher number of saccades needed to find stimuli when performing the exploratory visual task.

Resultados iniciais de mundo real do XEN® 45 Gel Stent na população brasileira / Real-world initial results of the XEN® 45 Gel Stent in the Brazilian population

RESUMO Objetivo Avaliar os resultados preliminares em médio prazo (até 6 meses) do uso isolado ou em combinação com a cirurgia de catarata do dispositivo XEN® Gel Stent na população brasileira. Métodos Realizou-se um estudo longitudinal retrospectivo de olhos portadores de glaucoma primário de ângulo aberto consecutivamente submetidos à cirurgia de implante de XEN® Gel Stent isolada (Grupo XEN®) ou em combinação com a cirurgia de catarata (Grupo Faco-XEN®) no mesmo centro entre abril e dezembro de 2023. Analisou-se a capacidade de redução da pressão intraocular e da quantidade de medicamentos hipotensores oculares, além das intercorrências intra e pós-operatórias. O critério de sucesso foi pressão intraocular < 18 mmHg e pelo menos 20% de redução da pressão intraocular pré-operatória (sucesso absoluto: sem medicação; sucesso relativo: com ou sem medicação). Avaliou-se ainda a duração do procedimento cirúrgico ao longo da curva de aprendizado. Resultados Foram incluídos 37 olhos no estudo (15 no Grupo Faco-XEN® e 22 no Grupo XEN®). A pressão intraocular média reduziu de 19,35 mmHg, no pré-operatório, para 13,05 mmHg, ao fim do acompanhamento (p < 0,001). Já a quantidade de medicamentos caiu de 2,95 para 0,22 por olho, no mesmo período (p < 0,001). A maioria dos pacientes (83%) chegou ao fim do acompanhamento livres de colírios. Não houve diferenças entre os dois grupos em relação à capacidade de redução pressórica e dos colírios. A taxa de sucesso absoluto foi de 81,2 e 86,7% nos Grupos XEN® e Faco-XEN®, respectivamente (p = 0,532). Seis olhos apresentaram falência da bolha e necessitaram de reintervenção cirúrgica. Houve uma redução significativa do tempo de cirurgia ao longo do acompanhamento. Conclusão O dispositivo XEN® Gel Stent foi efetivo, tanto em cirurgia isolada quando combinada, em reduzir a pressão intraocular e a quantidade de medicamentos, com elevado perfil de segurança na população brasileira.

ABSTRACT Objective To evaluate the preliminary medium-term results (up to 6 months) of the stand-alone use of XEN® Gel Stent implantation or in combination with cataract surgery in the Brazilian population. Methods A retrospective longitudinal study was carried out on eyes with primary open-angle glaucoma consecutively submitted to XEN® Gel Stent implantation surgery alone (XEN® Group) or in combination with cataract surgery (Phaco-XEN® Group) in the same center between April and December 2023. The ability to reduce intraocular pressure and the amount of ocular hypotensive medications were analyzed, in addition to intra- and postoperative complications. The success criterion was intraocular pressure < 18 mmHg and at least 20% reduction from the preoperative intraocular pressure (absolute success: without medication; relative success: with or without medication). The duration of the surgical procedure was also evaluated throughout the learning curve. Results Thirty-seven eyes were included in the study (15 in the Phaco-XEN® group and 22 in the XEN® group). The mean intraocular pressure was reduced from 19.35 mmHg preoperatively to 13.05 mmHg at the end of the follow-up (p < 0,001). The amount of medication decreased from 2.95 to 0.22 per eye in the same period (p < 0,001). Of the patients, 83% reached the end of follow-up without no need for eye drops. There were no differences between the two groups in terms of intraocular pressure reduction capacity and eye drops. The absolute success rate was 81.2 and 86.7% in the XEN® and Phaco-XEN® Groups, respectively (p = 0.532). Six eyes presented bleb failure and required surgical reintervention. There was a significant reduction in surgery time throughout follow-up. Conclusion The XEN® gel stent implantation was effective, both in stand-alone and in combined surgery, in reducing intraocular pressure and the medication burden, with a high safety profile in the Brazilian population.

Glaucoma suspects referred by general ophthalmologists to a tertiary center in Brazil: outcomes of the glaucoma specialist assessment / Suspeitos de glaucoma encaminhados do oftalmologista geral para um centro terciário no Brasil: resultados da avaliação do especialista em glaucoma

ABSTRACT Purpose: To characterize patients with suspected glaucoma who were referred to the clinic for suspected glaucoma in a tertiary public hospital in southern Brazil and to evaluate differences in functional and structural damages between patients diagnosed with different types of glaucoma, those with normal eye examination results, and those who remained as glaucoma suspects. Methods: This is a cohort study of patients referred by general ophthalmologists to the clinic for suspected glaucoma at Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil, between March 2016 and December 2018. The patients were followed up until they had undergone reliable examinations (eye examination, visual field screening, and optic coherence tomography for classification as normal and having a suspected glaucoma, glaucoma with an elevated intraocular pressure, normotensive glaucoma, or ocular hypertension. Results: A total of 135 patients were included in this study. Of the patients, 117 subjects completed all examinations and met the inclusion criteria. Most patients were normal (36.8%), followed by those with suspected glaucoma (25.64%), normal tension glaucoma (18.8%), glaucoma with elevated intraocular pressure (12%), and ocular hypertensive (6%). The main reason for referral was increased optic nerve head cupping. The patients with normal tension glaucoma were older than the other subjects on average (p=0.03). In addition, the normal tension glaucoma group had a significantly worse baseline visual field index and mean deviation of the visual field than the normal, glaucoma suspect, and ocular hypertensive groups. The circumpapillary retinal nerve fiber layer on OCT was thinner on average in the normal tension glaucoma group than in the normal and glaucoma suspect groups (p<0.002) but did not significantly differ between the glaucoma group with elevated intraocular pressure and the other groups. Conclusions: Patients with normal tension glaucoma tend to be diagnosed later because of their normal intraocular pressures; thus, the optic nerve cupping must be greater to raise the suspicion of glaucoma. In this study, we found that the patients with normal tension glaucoma had worse disease at the time of diagnosis.

RESUMO Objetivo: Caracterizar a população com suspeita de glaucoma encaminhada a um centro público terciário no sul do Brasil e avaliar diferenças no dano dos parâmetros funcionais e estruturais entre os pacientes diagnosticados com diferentes tipos de glaucoma e aqueles classificados como normais e aqueles mantidos como suspeitos de glaucoma. Métodos: Esta é uma coorte dos pacientes encaminhados para o setor de glaucoma suspeito do Hospital Nossa Senhora da Conceição, Porto Alegre - BR, no período de março de 2016 a dezembro de 2018. Os pacientes foram acompanhados até obterem exames confiáveis (exame oftalmológico completo, campimetria visual, tomografia de coerência óptica) para serem classificados como: normal, glaucoma suspeito, glaucoma com pressão intraocular elevada, glaucoma de pressão normal ou hipertenso ocular. Resultados: Um total de 135 pacientes foram incluídos neste estudo, sendo que destes, 117 pacientes completaram todos os exames e foram incluídos neste estudo. A maioria dos pacientes foi considerada normal (36,8%), seguido por glaucoma suspeito (25,64%), glaucoma de pressão normal (18,8%), glaucoma com pressão intraocular elevada (12%) e hipertensão ocular (6%). A principal razão para encaminhamento foi escavação do nervo óptico aumentada. Pacientes com glaucoma de pressão normal eram em média mais velhos que os demais (p=0,03). Esses também apresentavam índice de campo visual e desvio médio da campimetria visual piores que sujeitos normal, com suspeita de glaucoma e hipertensos oculares, e tinham a camada de fibra nervosa medida pela tomografia de coerência óptica mais fina que normais e suspeitos de glaucoma (p<0,002). Os pacientes com glaucoma de pressão elevada não diferiram significativamente dos outros grupos. Conclusão: Pacientes com glaucoma de pressão normal tendem a ser diagnosticados mais tardiamente devido ao fato da pressão intraocular não estar elevada, logo a escavação do disco óptico deve ser maior para gerar a suspeita de glaucoma. Neste estudo, paciente com glaucoma de pressão normal apresentaram doença mais avançada no momento do diagnóstico em comparação com os outros grupos.

Trabecular microbypass as replacement therapy in pharmacologically controlled open-angle glaucoma patients / Implante de by-pass trabecular como alternativa aos colírios em portadores de glaucoma de ângulo aberto controlados com tratamento clínico

ABSTRACT Purpose: To assess the outcomes of the trabecular bypass as replacement therapy for medications in pharmacologically controlled vs. pharmacologically uncontrolled open-angle glaucoma patients. Methods: This was a retrospective study of eyes treated with first- (iStent) or second-generation (iStent inject) trabecular bypass. Group 1 consisted of eyes with pharmacologically controlled intraocular pressure <18 mmHg and Group 2 consisted of eyes with pharmacologically controlled intraocular pressure ≥18 mmHg. The main outcomes measured were qualified (with or without medications) and unqualified or complete (without medications) success rates at different target intraocular pressures, mean reduction (%) in medication use, and proportion of medication-free eyes. Results: The mean age was 70.4 years in Group 1 (n=105) and 68.1 years in Group 2 (n=65). Qualified success rates for intraocular pressure <18 mmHg, intraocular pressure <15 mmHg, and intraocular pressure <12 mmHg were similar between the groups (Group 1: 96.2%, 88.6%, and 32.4%, respectively; Group 2: 93.8%, 78.5%, and 21.5%, respectively; all p>0.05). Complete success rates were significantly higher in Group 1 than in Group 2: for intraocular pressure <18 mmHg (76.2% vs. 47.7%), intraocular pressure <15 mmHg (73.3% vs. 40.0%), and intraocular pressure <12 mmHg (14.3% vs. 4.6%). The mean reduction in medication use was higher in Group 1 than in Group 2. At the end of follow-up, 79.0% of eyes in Group 1 and 47.7% of eyes in Group 2 became medication-free. Conclusions: Both groups showed high qualified success rates, but eyes with baseline pharmacologically controlled intraocular pressure <18 mmHg showed higher complete success rates and greater chances of achieving no need for medications.

RESUMO Objetivo: Avaliar os resultados dos implantes de by-pass trabecular como terapia de substituição aos colírios em pacientes com glaucoma de ângulo aberto controlados com medicação vs. não controlados com medicação. Métodos: Este foi um estudo retrospectivo de olhos submetidos a cirurgia de implante de by-pass trabecular de primeira (iStent) ou segunda geração (iStent inject). O Grupo 1 consistiu em olhos com pressão intraocular medicada <18 mmHg e o Grupo 2 consistiu em olhos com pressão intraocular medicada ≥18 mmHg. Os principais desfechos foram as taxas de sucesso relativo (com ou sem medicamentos) e completo (sem medicamentos) em diferentes pressões intraoculares-alvo, redução média (%) no uso de medicamentos e proporção de olhos sem medicamentos. Resultados: A média de idade foi de 70,4 anos no Grupo 1 (n=105) e 68,1 anos no Grupo 2 (n=65). As taxas de sucesso relativo para pressão intraocular <18 mmHg, pressão intraocular <15 mmHg e pressão intraocular <12 mmHg foram semelhantes entre os grupos (Grupo 1: 96,2%, 88,6% e 32,4%, respectivamente; Grupo 2: 93,8%, 78,5% e 21,5%, respectivamente; todos p>0,05). As taxas de sucesso completo foram significativa mente maiores no Grupo 1 do que no Grupo 2: pressão intraocular <18 mmHg (76,2% vs. 47,7%); pressão intraocular <15 mmHg (73,3% vs. 40%); pressão intraocular <12 mmHg (14,3% vs. 4,6%). A redução média no uso de medicamentos foi maior no Grupo 1 do que no Grupo 2. Ao final do acompanhamento, 79,0% dos olhos do Grupo 1 e 47,7% dos olhos do Grupo 2 estavam livres medicamentos. Conclusões: Ambos os grupos mostraram altas taxas de sucesso relativo, mas olhos com pressão intraocular medicada pré-operatória <18 mmHg apresentaram taxas de sucesso completo mais elevadas, bem como maiores chances de se tornarem livres de medicamentos para glaucoma.

The curative effect of endoscopic cyclophotocoagulation combined with trabeculectomy for primary open angle glaucoma / 中国医师进修杂志

Objective:To investigate the curative effect of endoscopic cyclophotocoagulation combined with trabeculectomy for primary open angle glaucoma.Methods:From January 2020 to May 2021, 30 eyes of 30 patients with advanced primary open angle glaucoma with cataract who underwent endoscopic cyclophotocoagulation combined with trabeculectomy in the Municipal Hospital Affiliated to Xuzhou Medical University were retrospectively analyzed. The preoperative best corrected visual acuity, preoperative intraocular pressure (IOP) and numbers of anti-glaucoma medication were recorded. IOP, numbers of anti-glaucoma medication at 1 day, 3 months, 6 months and 1 year after operation, postoperative complications, the numbers of absolute success and qualified success were recorded.Results:All cases were followed up for 1 year. The best corrected visual acuity improved by more than one line in 26 eyes at 1 year after operation. Preoperative visual acuity was maintained in 3 eyes visual acuity decreased in 1 eye. The IOP and numbers of anti-glaucoma medication at 1 day, 3 months, 6 months and 1 year after operation were significantly different from those before operation ( P<0.01). At 1 year after operation, 8 patients were qualified successful and 17 patients were absolutely successful. Early hyphema in 30 eyes, transient ocular hypertension in 3 eyes ciliary body detachment in 0 eyes, corneal edema in 9 eyes, and anterior chamber exudation in 8 eyes. Conclusions:In this small sample size of study with follow-up for 12 months, the results showed that endoscopic cyclophotocoagulation combined with trabeculectomy in the treatment of advanced open angle glaucoma has good preliminary efficacy and safety. However, a large sample of cases is still needed to further study its long-term safety and efficacy.

Search for potential target genes in dexamethasone-induced open-angle glaucoma by bioinformatics / 中华实验眼科杂志

Objective:To predict potential target genes in dexamethasone-induced open-angle glaucoma via bioinformatics technology.Methods:The GEO datasets GSE16643, GSE37474, and GSE124114 were used to analyze the differentially expressed genes by GEO2R.Gene Set Enrichment Analysis (GSEA) was performed on the differentially expressed genes between GSE37474 and GSE124114.Intersection of the three datasets were displayed by Venn diagram.The annotation and enrichment analysis of the intersection genes were performed through Gene Ontology (GO)/Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis and then were compared with normal tissue in GTEx Portal database.The corresponding protein interaction network was obtained by STRING.Finally, the candidate genes were searched for their transcription factors in UCSC and JASPAR.Primary human trabecular cells were divided into dexamethasone group and control group, treated with 2 ml 500 nmol/L dexamethasone and the same amount of ethanol, respectively.The expression of BDKRB1 and TAGLN in trabecular cells was detected by Western blot.Results:Differential genes between GSE37474 and GSE124114 datasets enriched in complement and coagulation cascade by GSEA.There were 89 intersecting genes of the three datasets.These genes mainly regulated the formation of extracellular matrix by GO analysis.The gene with the highest enrichment score and collagen-containing extracellular matrix was found to be associated with fibroblasts in GTEx Portal database.ACTA2, MYL9, TAGLN, and LMOD1 were closely related in STRING protein-protein interaction network.Transcription factor SP1 in UCSC and JASPAR according to related genes, BDKRB1, NID1, MFGE8 and TAGLN.The relative expression levels of BDKRB1 and TAGLN proteins were 1.32±0.14 and 0.44±0.09 in dexamethasone group, respectively, which were significantly higher than 1.00±0.00 and 0.20±0.10 in the control group, respectively ( t=-3.61, 2.89; both at P<0.05). Conclusions:Bioinformatics analysis showed that transcription factor SP1 may play a role in human trabecular meshwork cells to myofibroblasts transition after dexamethasone treatment.

Optic nerve head vascular variations in pseudoexfoliative and primary open-angle glaucoma / Variações vasculares da cabeça do nervo óptico no glaucoma pseudoesfoliativo e primário de ângulo aberto

Abstract Purpose: The purpose of this study was to assess the optic nerve head microvascular changes in pseudoexfoliative and primary open-angle glaucoma and define the relationship between vessel density and retinal nerve fiber layer thickness. Methods: This observational cross-sectional study assessed 72 eyes with primary open-angle glaucoma, 41 eyes with pseudoexfoliative glaucoma, and 60 healthy eyes. On the basis of optic nerve head-centered, 4.5 mm × 4.5 mm scan size images, we evaluated the vessel density, as well as the peripapillary sector, inside disk, and all sectoral quadrants. Results: Both glaucoma Groups had lower vessel density in all regions compared with the healthy Group (p<0.05 for all variables). Vessel densities of the nasal inferior, inferior nasal, and inferior temporal sectors in both glaucoma Groups showed similar results (p=0.157, p=0.128, p=0.143, respectively). Eyes with pseudoexfoliative glaucoma had significantly lower vessel densities than eyes with primary open-angle glaucoma in all other regions (p<0.05 for all variables). For both glaucoma Groups, the average retinal nerve fiber layer thickness positively correlated with vessel density in all peripapillary sectors (p<0.05 for all variables). Conclusions: Reduction in vessel density correlated with the thinning of retinal nerve fiber layer in both glaucoma Groups. Decreased vessel density in the optic nerve head can be used to demonstrate the microvascular pathologies and possible ischemic changes that lead to faster progression and worse prognosis in pseudoexfoliative glaucoma.

Resumo Objetivo: Atribuir variações microvasculares à cabeça do nervo óptico no glaucoma pseudoesfoliativo e primário de ângulo aberto, e definir a relação entre a densidade dos vasos e a espessura da camada de fibras nervosas da retina. Métodos: Este estudo foi projetado como observacional e transversal. Foram incluídos 72 olhos com glaucoma primário de ângulo aberto, 41 olhos com glaucoma pseudoesfoliativo e 60 olhos saudáveis. Foram obtidas imagens do nervo óptico centralizadas na cabeça do nervo com 4,5 × 4,5 mm de tamanho de varredura. A densidade vascular foi avaliada em toda a imagem, na área peripapilar, dentro do disco óptico e em todos os quadrantes setoriais. Resultados: Em todas as regiões, a densidade vascular foi menor em ambos os grupos com glaucoma que nos olhos saudáveis (p<0,05 para todas as variáveis). Em ambos os grupos com glaucoma, a densidade vascular mostrou resultados semelhantes nos setores nasal inferior, inferior nasal e temporal inferior (respectivamente, p=0,157, p=0,128 e p=0,143). Os olhos com glaucoma pseudoesfoliativo mostraram densidade vascular acentuadamente menor que nos olhos com glaucoma primário de ângulo aberto em todas as outras regiões (p<0,05). A espessura média da camada de fibras nervosas da retina demonstrou uma correlação positiva com a densidade vascular em todos os setores peripapilares em ambos os grupos com glaucoma (p<0,05 para todas as variáveis). Conclusões: A redução da densidade vascular foi correlacionada a uma redução da espessura da camada de fibras nervosas da retina em ambos os grupos com glaucoma. A densidade vascular reduzida na cabeça do nervo óptico poderia ser usada para provar patologias microvasculares e possíveis alterações isquêmicas responsáveis por uma evolução mais rápida e um prognóstico pior no glaucoma pseudoesfoliativo.

Custo-utilidade do tratamento primário não farmacológico do glaucoma de ângulo aberto / Cost-utility of primary non-pharmacological treatment of open-angle glaucoma

RESUMO Objetivo: Avaliar o impacto econômico de iniciar o tratamento do glaucoma primário de ângulo aberto com estratégias não farmacológicas nos centros de referência para o tratamento do glaucoma no Sistema Único de Saúde. Métodos: A população foi oriunda de uma coorte hipotética de pacientes aos 60 anos de idade, portadores de glaucoma primário de ângulo aberto inicial. A estratégia 1 se baseou apenas em uso de colírios. As estratégias 2 e 3 tiveram como tratamento inicial a trabeculoplastia seletiva a laser. Na estratégia 2, após a falência do laser, foi realizado o implante de dispositivo trabecular (iStent inject®), seguido de uso de colírios. A estratégia 3 iniciou-se com o tratamento medicamentoso logo após a falência do laser. O modelo desenvolvido foi o de Markov. Foi usada a razão de custo-utilidade incremental como medida de desfecho. Resultados: As estratégias 2 e 3 geraram ganho de qualidade de vida e foram dominantes em relação à estratégia 1, sendo mais efetivas e baratas. Porém a relação custo-efetividade da estratégia 2 sofreu um impacto significativo, de acordo com a idade de entrada no modelo. Conclusão: As estratégias não farmacológicas do glaucoma primário de ângulo aberto inicial foram custo-efetivas sob a perspectiva do Sistema Único de Saúde em um horizonte da expectativa de vida da população.

ABSTRACT Objective: To evaluate the economic impact of starting the treatment of primary open angle glaucoma with non-pharmacological strategies within the scope of reference centers for the treatment of glaucoma in the Unified Health System. Methods: The population of this study comes from a hypothetical cohort of patients aged 60 years with initial primary open angle glaucoma. The reference strategy (strategy 1) is based only on the use of eye drops, following the guidelines of the clinical protocol of the Brazilian Ministry of Health. Strategies 2 and 3 have the same initial treatment, with selective laser trabeculoplasty. In strategy 2, after laser failure, a trabecular device (iStent inject®) is implanted, followed by the use of eye drops as needed, and in strategy 3, it starts with the drug treatment right after the failure of the laser. The model developed for the cost-utility analysis was the Markov model. The incremental cost-utility ratio was used as an outcome measure. Results: Strategies 2 and 3 generated a gain in quality of life and were dominant over strategy 1, being at the same time more effective and less costly in relation to clinical treatment. The two non-pharmacological strategies (2 and 3) proved to be cost-effective; however, the cost-effectiveness of strategy 2 suffers a significant impact according to the age of entry into the model. Conclusion: It is concluded that the initial non-pharmacological treatment strategies of the initial primary open angle glaucoma are cost-effective from the perspective of the Unified Health System in a horizon of the life expectancy of the population.

Phacoemulsification with Kahook Dual Blade goniotomy in eyes with medically treated glaucoma: analysis of surgical outcomes and success predictors / Facoemulsificação combinada à goniotomia com Kahook Dual Blade em olhos com glaucoma tratado clinicamente: análise dos resultados cirúrgicos e preditores de sucesso

ABSTRACT Purpose: The purpose of this study was to investigate the postoperative outcomes and evaluate the success predictors of phacoemulsification with Kahook Dual Blade goniotomy for cataract and glaucoma management in eyes with primary open-angle glaucoma. Methods: This was a retrospective, non-comparative; inter ventional case series in which all patients with primary open-angle glaucoma who underwent phacoemulsification with Kahook Dual Blade goniotomy between June 2018 and April 2019 were enrolled. All the participants had a minimum follow-up period of 6 months. Preoperative and postoperative intraocular pressure values (at 1, 3, and 6 months), number of antiglaucoma medications, best-corrected visual acuity, surgical complications, and any subsequent related events or procedures were recorded. A logistic regression analysis was performed to investigate the association between the different variables and surgical outcomes. Results: A total of 47 patients (57 eyes) were included (mean age, 70.5 ± 7 years). The mean intraocular pressure was reduced from 15.5 ± 4.2 mmHg to 12.2 ± 2.4 mmHg at the last follow-up visit (p<0.001). The mean number of antiglaucoma medications decreased significantly from 1.9 ± 1.0 to 0.6 ± 1.0 during the same period (p<0.001). On the basis of the predefined criterion (intraocular pressure reduction ≥20% and/or reduction ≥1 medication), the 6-month success rate was 86%. A higher preoperative intraocular pressure value (odds ratio [OR]= 2.01; p=0.016) and greater percentage of initial (30 days) intraocular pressure reduction (OR= 1.02; p=0.033) were sig nificantly associated with surgical success. Conclusion: Our findings suggest that phacoemulsification with Kahook Dual Blade goniotomy is an effective and safe alternative for cataract management in eyes with primary open-angle glaucoma that positively impacts intraocular pressure control and medication burden. Eyes with higher baseline intraocular pressure and a more pronounced initial response to the procedure appeared to present better outcomes at 6 months. Further studies are needed to evaluate the long-term efficacy and safety profile of the procedure.

RESUMO Objetivo: Investigar os resultados pós-operatórios e avaliar os preditores de sucesso da facoemulsificação combinada à goniotomia com o Kahook Dual Blade para o tratamento da catarata e do glaucoma em olhos com glaucoma primário de ângulo aberto. Métodos: Série de casos retrospectivos, não comparativos e intervencionistas, em que todos os pacientes com glaucoma primário de ângulo aberto submetidos ao procedimento de facoemulsificação combinada à goniotomia com o Kahook Dual Blade entre junho de 2018 e abril de 2019 foram inscritos. Todos os participantes tiveram um acompanhamento mínimo de 6 meses. Foram registrados os valores de pressão intraocular pré e pós-operatória (em 1, 3 e 6 meses), número de medicamentos antiglaucomatosos, melhor acuidade visual corrigida, complicações cirúrgicas e quaisquer eventos ou procedimentos subsequentes relacionados. A análise de regressão logística foi usada para investigar a associação entre diferentes variáveis e resultados cirúrgicos. Resultados: Um total de 57 olhos de 47 pacientes foram incluídos (média de idade, 70,5 ± 7 anos). A pressão intraocular média reduziu de 15,5 ± 4,2 mmHg para 12,2 ± 2,4 mmHg na última visita de acompanhamento (p<0,001). O número médio de medicamentos antiglaucomatosos diminuiu significativamente de 1,9 ± 1,0 para 0,6 ± 1,0 durante o mesmo período (p<0,001). Com base no critério predefinido (redução da pressão intraocular ≥20% e/ou redução de ≥1 medicamento), a taxa de sucesso em 6 meses foi de 86%. Um valor de pressão intraocular pré-operatório mais alto (OR= 2,01; p=0,016) e maior porcentagem de redução da pressão intraocular inicial (30 dias) (OR= 1,02; p=0,033) foram significativamente associados ao sucesso cirúrgico. Conclusão: Nossos resultados sugerem que o procedimento de facoemulsificação combinada à goniotomia com o Kahook Dual Blade é uma alternativa eficaz e segura para o manejo da catarata em olhos com glaucoma primário de ângulo aberto, impactando positivamente no controle da pressão intraocular e no número de medicamentos. Olhos com pressão intraocular basal mais alta e resposta inicial mais pronunciada ao procedimento parecem apresentar melhores resultados em 6 meses. Mais estudos são necessários para avaliar a eficácia em longo prazo e o perfil de segurança.

Short-term endothelial cell density changes after gonioscopy-assisted transluminal trabeculotomy / Alterações de curto prazo na densidade celular endotelial associadas à trabeculotomia transluminal assistida por gonioscopia

ABSTRACT Purpose: To investigate the reduction in corneal endothelial cell density associated with gonioscopy-assisted transluminal trabeculotomy (GATT) in a short-term follow-up period. Methods: A retrospective analysis of the medical charts of patients with open-angle glaucoma who underwent gonioscopy-assisted transluminal trabeculotomy isolated or combined with phacoemulsification (phaco-gonioscopy-assisted transluminal trabeculotomy) was conducted. Patients who underwent phacoemulsification alone were included as controls. The endothelial cell density data (assessed using a specular microscope) before and at the first month after operation were collected and then compared. Results: Sixty-two eyes previously treated with gonioscopy-assisted transluminal trabeculotomy (gonioscopy-assisted transluminal trabeculotomy, n=39 eyes; phaco-gonioscopy-assisted transluminal trabeculotomy, n=23 eyes) fulfilled the inclusion criteria. The mean age of the study patients was 61.3 ± 18.4 years in the stand-alone gonioscopyassisted transluminal trabeculotomy group and 60.4 ± 11.9 in phaco-gonioscopy-assisted transluminal trabeculotomy group. Men comprised 66.6% of the patients in the isolated gonioscopyassisted transluminal trabeculotomy group and 56.5% of those in the phaco-gonioscopy-assisted transluminal trabeculotomy group. The mean visual field defects (mean deviation index) were -13.9 ± 9.2 and -10.3 ± 7.7 dB in the isolated gonioscopy-assisted and phaco-gonioscopy-assisted transluminal trabeculotomy groups, respectively. The patients in the former group presented a mean endothelial cell density reduction of 28.8 cells/mm² (1.31%; p=0.467). In the latter group, the mean endothelial cell density loss was 89.4 cells/mm² (4.36%; p=0.028). The control eyes (23 patients) presented a mean endothelial cell density change of 114.1 ± 159.8 cells/mm² (4.41%; p=0.505). The endothelial cell density reduction in the phaco-gonioscopy-assisted transluminal trabeculotomy group was not significantly different from that in the controls (p=0.81). Conclusions: Gonioscopy-assisted transluminal trabeculotomy appears to be a safe procedure for the corneal endothelial cell layer when performed either isolated or combined with cataract extraction in a short-term follow-up period.

RESUMO Objetivo: Investigar a redução na densidade celular endotelial corneana associada à trabeculotomia transluminal assistida por gonioscopia (GATT) em curto prazo. Métodos: Análise retrospectiva de prontuários médicos de pacientes com glaucoma de ângulo aberto que foram submetidos à trabeculotomia transluminal assistida por gonioscopia isolada ou combinada com facoemulsificação. Pacientes que foram submetidos à facoemulsificação isolada foram incluídos como controles. Dados da densidade celular endotelial corneana (avaliada através de microscópio especular) pré-operatória e ao primeiro mês pós-operatório foram coletados e comparados. Resultados: Sessenta e dois olhos que foram submetidos à trabeculotomia transluminal assistida por gonioscopia (trabeculotomia transluminal assistida por gonioscopia=39 olhos; faco com trabeculotomia transluminal assistida por gonioscopia=23 olhos) passaram pelos critérios de inclusão. A idade média dos pacientes estudados era 61,3 ± 18,4 anos no grupo trabeculotomia transluminal assistida por gonioscopia isolada e 60,4 ± 11,9 anos no grupo faco com trabeculotomia transluminal assistida por gonioscopia. Homens eram 66,6% do grupo trabeculotomia transluminal assistida por gonioscopia isolada e 56,5% do grupo faco com trabeculotomia transluminal assistida por gonioscopia. O defeito perimétrico médio (Mean Deviation) era -13,9 ± 9,2 dB e -10,3 ± 7,7 dB nos grupos trabeculotomia transluminal assistida por gonioscopia isolada e faco com trabeculotomia transluminal assistida por gonioscopia respectivamente. O grupo que fora submetido à trabeculotomia transluminal assistida por gonioscopia isolada apresentou redução média da densidade celular endotelial corneana de 28,8 células/mm² (1,31%; p=0,467). No grupo faco com trabeculotomia transluminal assistida por gonioscopia, a redução média da densidade celular endotelial corneana foi de 89,4 células/mm² (4,36%; p=0,028). Olhos controle (23 olhos) apresentaram redução média da densidade celular endotelial corneana de 114,1 ± 159,8 células/mm² (4,41%; p=0,505). A redução na densidade celular endotelial corneana no grupo faco com trabeculotomia transluminal assistida por gonioscopia não foi significativamente diferente do grupo controle (p=0,81). Conclusões: A trabeculotomia transluminal assistida por gonioscopia parece ser segura para a camada endotelial corneana em um curto prazo quando realizada de forma isolada ou combinada com cirurgia de catarata.

Comparison of macular vessel density changes in early primary open-angle glaucoma with central visual field defects and peripheral visual field defects / 中华实验眼科杂志

Objective:To compare the change of macular microvasculature in early primary open-angle glaucoma (POAG) patients with central visual field defects (CVFDs) and peripheral visual field defects (PVFDs).Methods:A cross-sectional study was performed.Sixty-six eyes of 66 consecutive patients with early POAG were enrolled in Beijing Tongren Hospital from June to December 2020.The patients were divided into CVFDs group (25 eyes) and PVFDs group (41 eyes) according to their visual field defect.Another 55 eyes of 55 age-, gender- and spherical equivalent-matched healthy people were set as a normal control group.All subjects underwent routine ophthalmic examination.Humphrey 24-2 visual field test was carried out.Macular vessel density (VD) and perfusion density (PD) of an area of 6 mm×6 mm were measured by optical coherence tomography angiography (OCTA), and the area was divided into 3 rings and 9 zones, including center, inner ring (superior, inferior, temporal and nasal sectors), and outer ring (superior, inferior, temporal and nasal sectors) according to ETDRS ring.The relationship among VD, PD, and visual field defect was analyzed.This study adhered to the Declaration of Helsinki.The research protocol was approved by an Ethics Committee of Beijing Tongren Hospital, Capital Medical University (No.TRECKY2020-103). Written informed consent was obtained from each subject before any examination.Results:The total macular VD of normal control group, CVFDs group and PVFDs group was 18.20 (17.50, 18.50), 17.10 (16.30, 17.85), and 17.20 (16.25, 17.90)mm/mm 2, respectively, and there was a significant difference ( H=20.84; P<0.001). The total macular PD of normal control group, CVFDs group and PVFDs group was 0.45 (0.43, 0.46), 0.42 (0.40, 0.44), and 0.43 (0.40, 0.44)mm 2/mm 2, respectively, with a significant difference ( H=16.15; P<0.001). The total macular VD and PD of CVFDs and PVFDs groups were significantly lower than those of normal control group, with statistically significant differences (all at P<0.05). Significant differences were found in VD and PD of superior, inferior, temporal, and nasal sectors of the outer ring among three groups (all at P<0.05). VD of the outer ring and PD of superior, inferior, and nasal sectors of the outer ring were reduced in CVFDs group than normal control group, showing significant differences (all at P<0.05). VD and PD of the superior, inferior, and temporal sectors of the outer ring were reduced in PVFDs group compared with normal control group, with significant differences (all at P<0.05). A significant difference was found in macular PD of the outer-nasal sector between CVFDs and PVFDs groups ( P=0.035). Conclusions:Macular VD and PD are reduced in early POAG.Compared with POAG patients with CVFDs, the macular PD of the outer-nasal sector of POAG patients with CVFDs is lower.

Observation on the structural characteristics of optic discs in high myopia combined with primary open-angle glaucoma / 中华眼底病杂志

Objective:To observe and analyze the structural characteristics of the optic discs in high myopia (HM) combined with primary open-angle glaucoma (POAG) and the optic disc parameters with diagnostic efficacy.Methods:A cross-sectional study. From August 2020 to March 2021, a total of 114 eyes of 68 patients with POAG, HM and healthy volunteers who were diagnosed by Department of Ophthalmology, The First Affiliated Hospital of Kunming Medical University were included in the study. Among them, 21 POAG patients (39 eyes) were divided into H+P group (9 patients, 18 eyes) and non-H+P group (12 patients, 21 eyes) according to whether or not HM was combined; 26 HM patients (37 eyes) were selected as HM group; 21 healthy volunteers (38 eyes) were selected as normal control group. The subjects included 31 males (51 eyes) and 37 females (63 eyes), whose average age was 36.93±12.60 years old. Diopter, central corneal thickness (CCT) and axial length (AL) were measured. There was no significant difference in age ( F=8.333), sex composition ratio ( χ2=0.863), and CCT ( F=1.425) among the four groups ( P>0.05); while, there were significant differences in AL ( F=69.956), diopter ( F=37.711), visual field index (VFI) ( F=43.254) and mean defect (MD) ( F=49.793) among the four groups ( P<0.01). Enhanced depth imaging using optical coherence tomography was used to obtain the tilt parameters, the disc rim parameters, the lamina cribrosa parameters and the retinal nerve fiber layer (RNFL) thickness. The tilt parameters included optic disc horizontal diameter, optic disc vertical diameter, optic disc ellipse index (horizontal diameter/vertical diameter); the disc rim parameters included Bruch’s membrane opening-minimal rim width (BMO), optic cup area, optic disc area, disc rim area, cup-disc area ratio; the lamina cribrosa parameters included anterior laminar insertion depth (ALID), prelaminar neural tissue (PLNT), and lamina cribrosa thickness. The pairwise comparison between groups were performed by ANOVA test. Pearson correlation analysis was used to analyze the correlation between disc tilt parameters, disc rim parameters, lamina cribrosa parameters and visual field parameters, as well as between disc rim parameters and RNFL thickness. According to receiver operating characteristic (ROC) curve and area under the curve (AUC), the predictive value of those above related factors for HM combined with POAG was evaluated. Results:Tilt parameters: compared with the optic disc horizontal diameter of non-H+P group, those of normal control group, HM group and H+P group were significantly decreased ( P<0.05), the ellipse indices of HM group and H+P group were significantly lower than those of normal control group and non-H+P group ( P<0.05). The results of correlation analysis showed that the optic disc horizontal and vertical diameters were negatively correlated with MD ( r=-0.302,-0.235; P=0.002, 0.017), and negatively correlated with VFI ( r=-0.291,-0.246; P=0.003, 0.013). Disc rim parameters: the disc cup area and cup-disc area ratio of non-H+P group and H+P group were significantly larger than those of normal control group and HM group ( P<0.05). The disc rim area and the average BMO of HM group, non-H+P group and H+P group were significantly smaller than those of normal control group ( P<0.05). The results of correlation analysis showed that the cup-disc area ratio ( r=-0.584), the average BMO ( r=0.650) had the highest correlation with the average RNFL thickness ( P<0.001). The superior, inferior, nasal and temporal BMO were all positively correlated with the corresponding quadrant RNFL thicknesses ( r=0.431, 0.656, 0.362, 0.375; P<0.05); the optic disc rim area, the average BMO were positively correlated with MD ( r=0.449, 0.618) and VFI ( r=0.449, 0.605) ( P<0.05), among which the correlation of the average BMO was the highest; the optic cup area and cup-disc area ratio were negatively correlated with MD ( r=-0.346,-0.559) and VFI ( r=-0.312,-0.548) ( P<0.001), among which the correlation of the cup-disc area ratio was the highest. Lamina cribrosa parameters: ALID of non-H+P group and H+P group were significantly deeper than those of normal control group and HM group ( P<0.05). LC of non-H+P group and H+P group were significantly thinner than those of normal control group and HM group ( P<0.05). The results of correlation analysis showed that ALID was negatively correlated with MD and VFI ( r=-0.402, P<0.001), VFI ( r=-0.405, P=0.001); LC was positively correlated with MD and VFI ( r=0.403, P<0.001), VFI ( r=-0.401, P=0.015). Comparison of diagnostic efficiency between various optic disc parameters: the results of ROC analysis showed that the cup-disc area ratio had the highest diagnostic performance (AUC=0.847, P=0.007), the maximum Youden index was 0.563, the sensitivity and specificity were 0.833 and 0.730, respectively, and the best critical value was 0.340. Conclusions:Optic disc tilt is more pronounced in HM combined with POAG; BMO in each quadrant could objectively reflect the disc rim defect of HM combined with POAG; the thinning and the backward shift of the lamina cribrosa were consistent with the aggravation of the visual field defect. Among them, the cup-disc area ratio had better diagnostic performance.

Assessment of Risk Factors for Advanced Open Angle Glaucoma Presentation among Patients Visiting Jimma University Medical Center, Jimma, Ethiopia

Glaucoma is the predominant cause of irreversible blindness, particularly the late presentation. The purpose of this study is to identify the risk factors associated with late presentation in Jimma University Medical Center METHODS: A case-control study was done among patients newly diagnosed to have open angle glaucoma (of any type) at Jimma University Medical Center from July 2014 ­ January 2019. Cases were patients/eyes diagnosed to have any type of open angle glaucoma with advanced glaucomatous disc features, whereas controls were patients diagnosed with early and moderate stages of glaucoma. RESULTS: There were 205 (116 cases and 89 controls) participants. The mean age of the participants at the time of diagnosis was 58.3±13.4yrs. Family history of blindness, presenting IOP, type of glaucoma and age were independently associated with late presentation. Patients with family history of blindness had late advanced glaucoma five times higher than those with no family history of blindness. The presence of late glaucoma among patients with presenting intra ocular pressure < 30mmHg is lower than those having ≥30mmHg (Adjusted Odds Ratio= 0.136). Primary open-angle glaucoma patients were less likely to present with advanced glaucoma than pseudo exfoliative glaucoma patients (Adjusted Odds Ratio=0.39). The chance of presenting with late glaucoma was increased by 3.4% for every one-year increment of age. CONCLUSIONS: Presence of family history of blindness, high presenting intraocular pressure, pseudo exfoliative glaucoma and old age are risk factors for late presentation of glaucoma

Procedimentos Minimamente Invasivos para Glaucoma: uma revisão atualizada da literatura / Minimally Invasive Glaucoma Surgery (MIGS): an updated literature review

RESUMO O glaucoma é considerado a maior causa de cegueira irreversível no mundo, e o aumento da pressão intraocular constitui seu principal fator de risco. Usualmente, a terapia inicial do glaucoma consiste na redução da pressão intraocular a partir da instilação de drogas hipotensoras tópicas, estando as cirurgias antiglaucomatosas reservadas, na maioria das vezes, para casos em que o controle da doença não é atingido clinicamente. Classicamente, o tratamento cirúrgico do glaucoma é realizado a partir dos procedimentos filtrantes: trabeculectomia e implante de dispositivos de drenagem. O acrônimo MIGS (do inglês minimally invasive glaucoma surgery, procedimentos minimamente invasivos para glaucoma) corresponde a um grupo de procedimentos cirúrgicos pouco invasivos, que propõem a redução pressórica de maneira mais segura e previsível, quando comparada às técnicas cirúrgicas antiglaucomatosas convencionais.

ABSTRACT Glaucoma is considered the biggest cause of irreversible blindness in the world and the increase in intraocular pressure is its main risk factor. Usually, the initial therapy for glaucoma consists of reducing IOP through the instillation of topical hypotensive drugs, with antiglaucoma surgeries being normally reserved for cases in which disease control is not clinically achieved. Classically, the surgical treatment of glaucoma is performed using filtering procedures: trabeculectomy; non-penetrating sclerotomy and glaucoma drainage devices. The acronym MIGS (Minimally Invasive Glaucoma Surgery) corresponds to a group of minimally invasive surgical procedures that provide a safer and more predictable pressure reduction when compared to conventional antiglaucoma surgical techniques.

Postoperative anterior uveitis in a patient submitted to combined treatment with cataract surgery and iStent inject®. How to manage? / Uveíte anterior no pós-operatório de facectomia combinada com implante de iStent inject®. Como manejar?

ABSTRACT Minimally invasive glaucoma surgeries are surgical treatment alternatives for glaucoma aimed at reducing intraocular pressure with a better safety profile compared to traditional trabeculectomy. However, in spite of less invasive techniques, complications may develop in any surgical procedure. To the best of our knowledge, this is the first case report of anterior uveitis following combined treatment with cataract surgery and iStent inject® which addresses the management of postoperative inflammation.

RESUMO As cirurgias minimamente invasivas para glaucoma consistem em uma opção de tratamento cirúrgico para glaucoma, a qual promove redução da pressão intraocular com melhor perfil de segurança do que a trabeculectomia. Todavia, complicações são inerentes à realização de procedimentos cirúrgicos, apesar do uso de técnicas menos invasivas. Este é o primeiro relato que apresenta um caso de uveíte anterior após cirurgia combinada de catarata e iStent inject®, além de orientações quanto ao manejo do quadro inflamatório.

A Brazilian cost-utility analysis of trabecular micro-bypass with iStent inject® for the treatment of open-angle glaucoma / Análise de custo-utilidade do implante trabecular iStent inject® para o tratamento do glaucoma de ângulo aberto no Brasil

ABSTRACT Purpose To evaluate the cost-utility of the iStent inject® for the treatment of mild-to-moderate open-angle glaucoma (OAG) within the Brazilian Unified Health System (SUS). Methods A Markov model was developed, in which the effectiveness outcome measure was the incremental cost-effectiveness ratio (ICER: R$ / QALY quality-adjusted life-year). Direct medical costs were obtained from the SUS perspective. The base case comprised of a hypothetical cohort of patients with OAG using topical medication and being managed according to the Clinical Protocol and Therapeutic Guidelines (PCDT) and a real-world setting based on data from Datasus. The model's robustness through sensitivity analyses was tested. Results In the PCDT base case setting, the trabecular micro-bypass implant provided gains of 0.47 QALYs and an ICER of R$7,996.66/QALY compared to treatment with topical medication. In the real-world setting based on data from Datasus, the trabecular micro-bypass implant, provided gains of 0.47 QALYs and an ICER of R$4,485.68/QALY compared to treatment with topical medication. The results were robust to sensitivity analyses. Conclusion Incorporating iStent inject® to SUS provides an improvement in the patient's quality of life with an additional cost that warrants the benefit provided to patients. Results may be considered cost-effective compared to topical medication.

RESUMO Objetivo Avaliar a relação custo-utilidade do iStent inject® para o tratamento do glaucoma de ângulo aberto leve a moderado no Sistema Único de Saúde. Métodos Foi desenvolvido um modelo de Markov, no qual a medida de resultado de efetividade foi a razão custo-efetividade incremental (razão de custo-efetividade incremental: R$/ano de vida ajustado pela qualidade). Os custos médicos diretos foram obtidos por meio da perspectiva do Sistema Único de Saúde. O caso base foi composto de uma coorte hipotética de pacientes com glaucoma de ângulo aberto em uso de medicação tópica tratados de acordo com o Protocolo Clínico e Diretrizes Terapêuticas e um cenário do mundo real baseado em dados do Departamento de Informática do Sistema Único de Saúde. Foi testada a robustez do modelo por meio de análises de sensibilidade. Resultados No cenário base do Protocolo Clínico e Diretrizes Terapêuticas, o implante trabecular micro-bypass proporcionou ganhos de 0,47 ano de vida ajustado pela qualidade e razão de custo-efetividade incremental de R$7.996,66/ano de vida ajustado pela qualidade em relação ao tratamento com medicação tópica. No cenário real baseado em dados do Departamento de Informática do Sistema Único de Saúde, o implante trabecular proporcionou ganhos de 0,47 ano de vida ajustado pela qualidade e razão de custo-efetividade incremental de R$ 4.485,68/ano de vida ajustado pela qualidade em relação ao tratamento com medicação tópica. Os resultados foram robustos para análises de sensibilidade. Conclusão A incorporação do iStent inject® ao Sistema Único de Saúde proporciona melhora na qualidade de vida do paciente com um custo adicional que garante o benefício proporcionado a eles. Os resultados podem ser considerados custo-efetivos em comparação com a medicação tópica.

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.

Use of machine learning to predict the risk of early morning intraocular pressure peaks in glaucoma patients and suspects / Uso de aprendizado de máquina para predizer o risco de picos de pressão intraocular no início da manhã em pacientes com glaucoma e suspeitos

ABSTRACT Purpose: To use machine learning to predict the risk of intraocular pressure peaks at 6 a.m. in primary open-angle glaucoma patients and suspects. Methods: This cross-sectional observational study included 98 eyes of 98 patients who underwent a 24-hour intraocular pressure curve (including the intraocular pressure measurements at 6 a.m.). The diurnal intraocular pressure curve was defined as a series of three measurements at 8 a.m., 9 a.m., and 11 a.m. from the 24-hour intraocular pressure curve. Two new variables were introduced: slope and concavity. The slope of the curve was calculated as the difference between intraocular pressure measurements at 9 a.m. and 8 a.m. and reflected the intraocular pressure change in the first hour. The concavity of the curve was calculated as the difference between the slopes at 9 a.m. and 8 a.m. and indicated if the curve was bent upward or downward. A classification tree was used to determine a multivariate algorithm from the measurements of the diurnal intraocular pressure curve to predict the risk of elevated intraocular pressure at 6 a.m. Results: Forty-nine (50%) eyes had intraocular pressure measurements at 6 a.m. >21 mmHg, and the median intraocular pressure peak in these eyes at 6 a.m. was 26 mmHg. The best predictors of intraocular pressure measurements >21 mmHg at 6 a.m. were the intraocular pressure measurements at 8 a.m. and concavity. The proposed model achieved a sensitivity of 100% and a specificity of 86%, resulting in an accuracy of 93%. Conclusions: The machine learning approach was able to predict the risk of intraocular pressure peaks at 6 a.m. with good accuracy. This new approach to the diurnal intraocular pressure curve may become a widely used tool in daily practice and the indication of a 24-hour intraocular pressure curve could be rationalized according to risk stratification.

RESUMO Objetivo: Utilizar aprendizado de máquina para predizer o risco de picos de pressão intraocular às 6 AM em pacientes com glaucoma primário de ângulo aberto e suspeitos. Métodos: Esse estudo observacional transversal incluiu 98 olhos de 98 pacientes submetidos à curva de 24 horas de pressão intraocular (incluindo as medidas às 6 AM). A curva diurna de pressão intraocular foi definida como uma série de três medidas da curva de 24 horas de pressão intraocular às 8 AM, às 9 AM e às 11 AM. Duas novas variáveis foram apresentadas: inclinação e concavidade. A inclinação da curva às 8 AM foi calculada como a diferença entre pressão intraocular às 9 AM e 8 AM e reflete a variação da pressão intraocular na primeira hora. A concavidade da curva foi calculada como a diferença entre as inclinações às 9 AM e às 8 AM e pode ser para cima ou para baixo. Uma árvore de classificação foi usada para determinar um algoritmo multivariado a partir das medidas da curva diurna para prever o risco de pressão intraocular elevada às 6 AM. Resultados: Quarenta e nove (50%) olhos apresentaram pressão intraocular às 6 AM >21 mmHg e a mediana do pico de pressão intraocularPIO foi 26 mmHg. Os melhores preditores de pressão intraocular às 6 AM >21 mmHg foram a pressão intraocular às 8 AM e a concavidade. O modelo proposto apresentou uma sensibilidade de 100% e uma especificidade de 86%, com uma acurácia de 93%. Conclusões: A abordagem de aprendizado de máquina foi capaz de prever o risco de picos de pressão intraocular às 6 AM com uma boa acurácia. Essa nova abordagem para a curva diurna de pressão intraocular pode se tornar uma ferramenta amplamente utilizada na prática clínica e a indicação da curva de 24 horas de pressão intraocular pode ser racionalizada de acordo com a estratificação de risco.