Prevalence of Dry Eye Disease in Laser-Assisted In Situ Keratomileusis Candidates.

OBJECTIVE: To evaluate the prevalence of dry eye disease (DED) in laser-assisted in situ keratomileusis (LASIK) candidates. METHODS: A chart review of consecutive LASIK candidates who underwent full ocular surface work-up was performed, including ocular surface disease index (OSDI), noninvasive tests (noninvasive tear breakup time [ni-TBUT], tear meniscus height, lipid layer thickness, and meibography), and invasive tests (Schirmer test I, fluorescein TBUT, corneal staining, and meibomian gland [MG] expressibility). The prevalence of DED was calculated according to the Dry Eye Workshop II (DEWS II), and Japanese and Asia Dry Eye Society (JDES/ADES) criteria. RESULTS: In total, 135 patients (270 eyes) were evaluated. The mean age was 32.6±8.3 years, and 62.9% were women (n=85); 19 patients (15.4%) wore contact lenses, and 31 patients (23.8%) used artificial tears. The mean OSDI was 18.2±16.9, which was abnormal in 54.1% (n=62). Inferior lid MG dropout was the sign with the highest percentage of abnormal results (61.5%; n=83). There were no differences between men and women in any test except for ni-TBUT (6.3±0.3 and 7.2±0.2, respectively; P=0.002). Dry eye disease prevalence was 25.9% and 53.3%, according to JDES/ADES and DEWS II criteria, respectively. The only significant risk factor for DED was artificial tear use for both DEWS II (odds ratio [OR]=3.5, confidence interval [CI] [1.35-9.39]) and JDES/ADES (OR=2.58, CI [1.03-6.48]). CONCLUSIONS: This study found a high prevalence of DED and abnormalities in LASIK candidates and highlights the importance of ocular surface evaluation before photorefractive surgery.

Dupilumab induced ocular surface disease: A prospective case series.

PURPOSE: To identify the incidence, risk factors, demographics, and clinical profile of dupilumab-induced ocular surface disease (DIOSD) in patients with atopic dermatitis (AD), propose a standardised treatment protocol (STP) and evaluate the response. METHODS: Prospective case series of AD patients treated in the Dermatology Department, Royal Victoria Infirmary, Newcastle upon Tyne, UK developing ocular symptoms after commencing Dupilumab between September 2018 and February 2020. A standard history and examination protocol were used including subjective symptom severity grading and Ocular Surface Disease Index (OSDI) questionnaire on each visit. Standard treatment was prescribed, and response evaluated. RESULTS: 32 of 113 included patients (28.31%) developed DIOSD, of which 20 (62.5%) were referred to the Cornea Service. Median age was 38.0 years (IQR 26.8; range 19-74). Male to female ratio was 1:1. Average time to onset of ocular symptoms from starting dupilumab was 9.2 weeks (IQR 8.8; range 0.1-40). 90% patients had bilateral conjunctival inflammation and blepharitis at presentation. Significant improvement in the subjective severity scale and the median OSDI score (from 34.0 to 10.2) was noted in response to topical eye treatment. Dupilumab was discontinued in none. CONCLUSIONS: DIOSD is not uncommon although, with timely referral and appropriate topical treatment better clinical outcome and patient satisfaction can be achieved without the need to discontinue Dupilumab. Prior allergic conjunctivitis did not affect the incidence or severity of DIOSD. Further prospective studies with longer follow-up and more focus on possible disease mechanism such as goblet cell related changes and immune response are needed.

Outcomes of N-butyl-2-Cyanoacrylate Tissue Adhesive Application in Corneal Perforation Disorders: Consecutive Case Series.

INTRODUCTION: The purpose of this study was to report the success and long-term outcomes of cyanoacrylate tissue adhesive (CTA) application in the management of corneal perforation disorders. METHODS: This retrospective case series describes the profile and outcomes of eyes that underwent CTA for corneal perforation over an 11-year period from January 2009 until January 2020 at a tertiary eye centre in the United Kingdom. RESULTS: In total, 25 eyes underwent CTA application during the study period. Non-traumatic sterile corneal melt was responsible in more than half of the cases (56.0%; n = 14) followed by infection (32.0%; n = 8) and trauma (12.0%; n = 3). Median size of perforation was 2.0 mm (interquartile range, IQR 1.0-3.0). The most common anatomical location of corneal perforation was central (56.0%; n = 14). Ocular surface disease was seen in almost all eyes except two (92.0%; n = 23) with dry eye disease being the most common (48.0%; n = 12). Amongst 23 eyes that completed follow-up (median 27 months; IQR 9.5-46.5), single CTA application was successful in achieving intact globe in 13 (56.5%) eyes and repeat gluing sealed total of 20 (86.9%) eyes. Survival analysis showed cumulative success of 71.0% and 51.2% at 90 and 250 days, respectively. The CTA was retained in the eyes for median of 94.0 days (IQR 30.0-140.5). A total of five patients developed adverse events, including endophthalmitis (n = 2), following CTA application. CONCLUSIONS: CTA was highly effective in sealing corneal perforations in acute setting and showed moderate long-term success. However, multiple applications are often required.

Ocular surface disease: a known yet overlooked side effect of topical glaucoma therapy.

Ocular surface disease (OSD), a disorder affecting the lacrimal and meibomian glands and the corneal and conjunctival epithelium, is a well-known complication of topical glaucoma therapy. OSD can present as a new or pre-existing condition that virtually any anti-glaucoma formulation can exacerbate. As such, both glaucoma and OSD frequently coexist. Typical OSD symptoms include ocular discomfort, redness, burning, and dryness, whereas signs include periorbital and eyelid skin pigmentation, conjunctival scarring, and superficial punctate keratitis. Pressure-lowering eyedrops can cause toxic, allergic, and inflammatory reactions on the ocular surface. The latter can result from either preservatives or direct toxicity from the active molecule. Although usually mild, OSD can cause significant symptoms that lead to poor quality of life, decreased compliance to therapy, glaucoma progression, and worse visual outcomes. Given the chronic nature of glaucoma, lack of curative therapy, and subsequent lifelong treatment, addressing OSD is necessary. This manuscript aims to provide an up-to-date overview of OSD's signs, symptoms, and pathogenic mechanisms from glaucoma therapy toxicity.

International survey on dry eye diagnosis by experts.

Purpose: To evaluate patterns and opinion from international experts with respect to dry eye disease (DED) diagnosis in clinical practice. Methods: An online survey was distributed to worldwide DED experts. The use of diagnosis tests was evaluated including: symptoms questionnaires, functional tests, tear stability, tear volume, tear composition, surface damage and inflammation, and eyelid assessment. After the subjective importance of symptoms, tear break up time (TBUT), non-invasive TBUT, Schirmer's test, tear meniscus height, tear osmolarity, tear metalloproteinase 9, blepharitis assessment and non-contact meibography was evaluated according to likert scale. Results: The survey was sent to 109 experts, and 77 completed the questionnaire (rate of response = 70.6%). Most of the participants were from North America (27%) and Europe (40%). A majority of respondents (73%) diagnose DED using clinical signs and symptoms, but not fulfilling a specific criteria. Seventy-six participants (98.7%) use symptoms questionnaires. All participants evaluate damage to ocular surface, and fluorescein staining is the most frequent method used (92%). Also, all the respondents perform meibomian gland and blepharitis assessment. On the other hand, only 69.8% evaluate tear composition, being osmolarity the most common test used (66.2%). Regarding to the importance of tests, TBUT (p = 0.002) and Schirmer's (p = 0.021) were found to be more important to experts from Europe than North America. No differences were found in any other test (p > 0.05). Conclusions: This survey offers updated and day-to-day diagnostic clinical practice by DED worldwide experts. The results highlight the importance of symptoms and clinical signs, but not necessarily following a strict criteria.

Tips to optimize digital education in ophthalmology: Results from ESASO survey.

PURPOSE: To identify audience and faculty preferences to optimize digital education sessions in ophthalmology. METHODS: We distributed an online survey to ophthalmology trainees and specialists worldwide. The survey investigated respondents' preferences on various findings of hypothetical digital educational sessions. Data were analyzed using descriptive statistics, Fisher's exact probability and ANOVA tests. RESULTS: The survey was completed by 655 respondents, from 53 different countries. According to most respondents, the optimal duration and timeframe for a valuable digital education session would be 30-60 min, without a break (52%), in the evening time-slot (6-8 p.m.) (45%) of a weekday (Monday-Thursday) (46%), regardless of age (p-value = 0.84, 0.39, 0.89, respectively) and job position (p-value = 0.31, 0.29, 0.08, respectively). The availability of webinars and recorded surgical videos/clinical cases, associated with live discussion, represented the most important opportunity of digital educational channels for 46% and 42% of respondents, respectively. CONCLUSION: Appropriate planning of timing and structure of digital educational ophthalmology sessions may optimize their effectiveness. Using multiple e-learning formats may be helpful to ensure the continuity of learning activities, also in view of a long-term replacement of traditional in-person education.

High frequency of digital eye strain and dry eye disease in teleworkers during the coronavirus disease (2019) pandemic.

Objectives. This study aimed to evaluate visual display terminal (VDT)-related digital eye strain (ES) and dry eye disease (DED) symptoms in subjects whose work was changed to teleworking (TW) during the coronavirus pandemic. Methods. A digital self-reported survey was conducted on subjects in TW, including demographics, medical history, VDT time and ES-related symptoms before and during the pandemic and DED (dry eye questionnaire 5 [DEQ-5] questionnaire). Results. A total of 1797 questionnaires were analyzed. Mean age was 40.5 (SD 11.1) years, and 69.9% were female. The mean number of TW weeks was 10.2 (SD 3.0). The total VDT total hours increased from 7.4 (SD 3.3) to 9.5 (SD 3.3) (p < 0.001). All ES symptoms presented a significant increase (p < 0.001). The mean DEQ-5 score was 8.3 (SD 4.9). The oldest group presented lower values, and women had a higher score (p < 0.001). Additionally, 28.6% of the subjects were classified with severe DED, and the variables associated with a logistic regression model were total VDT hours, female gender, refractive surgery, rosacea, depression, previous DED, keratoconus and blepharitis. Conclusions. The number of VDT hours seemed to be a relevant factor for increase in ES symptoms and a high prevalence of DED during the pandemic period.

Dry Eye and Visual Display Terminal-Related Symptoms among University Students during the Coronavirus Disease Pandemic.

PURPOSE: To evaluate dry eye (DE) and subjective visual display terminal (VDT)-related symptoms in university students who moved their classes online due to the COVID-19 pandemic. METHODS: Cross-sectional study of students who were taking online classes. In May 2020, the participants completed a Dry Eye Questionnaire (DEQ-5) and a self-report survey, which included demographics, medical history, information on the use of VDT and presence of VDT-related symptoms. Participants were classified as having mild/moderate (7-12) or severe (>12) DE symptoms based on their DEQ-5 score. The associations between severe DE symptoms and relevant factors were also evaluated. RESULTS: The data of 1450 eligible students were analyzed. The mean age of the participants was 21.1 (2.7) years. 42.8% of the participants had mild/moderate DE symptoms, whereas 34.7% had severe symptoms. Associated factors for severe DE were female sex (OR = 2.57, CI [1.97-3.35]), allergic disease (OR = 1.63, CI [1.24-2.13]), previous dry eye diagnosis (OR = 13.49, CI [7.10-25.63]), keratoconus (OR = 5.56, CI [1.27-24.44], contact lens use (OR = 1.77, CI [1.24-2.53]) and duration of VDT use (OR = 1.02, CI [1.01-1.05]). Prior to the pandemic, the mean reported duration of VDT use was 9.8 (4.7) hours; this increased to 15.9 (5.8) hours during the online classes (p < .001). 80.6% of the participants reported a global increase in VDT-related symptoms. CONCLUSION: Students taking online classes had a high frequency of DE symptoms. They also reported a significant increase in VDT-related symptoms. DE should be considered as an emerging health problem among the young population, which is probably related to the recent changes in lifestyle.

Referral Patterns of Patients with Limbal Stem Cell Deficiency to a Specialized Tertiary Center in the United Kingdom.

INTRODUCTION: Limbal stem cell deficiency (LSCD) is a potentially blinding disease; hence, referral to a specialist service is becoming increasingly common. Our aim was to investigate the referral patterns and associated details. METHODS: We conducted an audit of 100 consecutive patients with LSCD who were referred to our service from 2011 to 2018. Patient demographics, geographical location, cause of LSCD, coexisting ocular diseases, best corrected visual acuity (BCVA), and extent of LSCD were recorded. The following two subgroups were further analyzed: (1) burns and (2) other causes of LSCD. RESULTS: Out of the 100 patients (138 eyes), 70% were male, with a mean age of 45 years (SD 19). LSCD was unilateral in 62% of the cases. The most common ocular comorbidity was glaucoma, in 21 patients (33 eyes). Burns were the most frequent cause of referral (61%). The mean BCVA of the involved eye was 1.22 (SD 0.8) LogMAR, and total LSCD was present in 75 eyes (54%). There were statistically significant age, gender and eye-involved differences between the burns group and other causes group, mean 39 (SD 17) and 53 (SD 19) years (p < 0.001); 85% were men versus 48.7%, (p = 0.001); and 82% were unilateral versus 31% (p < 0.001), respectively. CONCLUSIONS: LSCD was more common in men and usually unilateral. Overall, the main cause of LSCD was burns. There were significant differences between the burns group and other causes of LSCD group in terms of age, gender and unilateral involvement that may help to guide management decisions.

[Validation of the Ocular Surface Disease Index Questionnaire for Chilean patients]. / Adaptación cultural y validación del cuestionario Ocular Surface Disease Index en una población chilena.

BACKGROUND: Ocular Surface Disease Index (OSDI) is the most commonly used questionnaire worldwide to detect dry eye disease. Although it is massively used in clinical practice in Chile, its use has not been validated yet in the country. AIM: To develop a cultural adaptation and to validate the OSDI questionnaire for the Chilean population. MATERIAL AND METHODS: For cultural adaptation, a translation, retro-translation and an expert panel review was carried out. The resulting questionnaire was applied to a pilot group of twelve participants and their comments were considered for the final questionnaire version. The final questionnaire was applied to a non-random sample of 200 patients aged 53 ± 17 years (75% women). Internal consistency and construct validity were evaluated by Cronbach's alpha and exploratory factor analysis respectively. RESULTS: According to the OSDI score, 81% of respondents had dry eye (55% severe). Reliability was 0.91 and factor analysis resulted in three factors explaining 75.4% of the total variance. CONCLUSIONS: The OSDI questionnaire version obtained in this study demonstrated excellent internal consistency values and adequate construct validity making it applicable to clinical practice and dry eye research.

Adaptación cultural y validación del cuestionario Ocular Surface Disease Index en una población chilena / Validation of the Ocular Surface Disease Index Questionnaire for Chilean patients

Background: Ocular Surface Disease Index (OSDI) is the most commonly used questionnaire worldwide to detect dry eye disease. Although it is massively used in clinical practice in Chile, its use has not been validated yet in the country. Aim: To develop a cultural adaptation and to validate the OSDI questionnaire for the Chilean population. Material and Methods: For cultural adaptation, a translation, retro-translation and an expert panel review was carried out. The resulting questionnaire was applied to a pilot group of twelve participants and their comments were considered for the final questionnaire version. The final questionnaire was applied to a non-random sample of 200 patients aged 53 ± 17 years (75% women). Internal consistency and construct validity were evaluated by Cronbach's alpha and exploratory factor analysis respectively. Results: According to the OSDI score, 81% of respondents had dry eye (55% severe). Reliability was 0.91 and factor analysis resulted in three factors explaining 75.4% of the total variance. Conclusions: The OSDI questionnaire version obtained in this study demonstrated excellent internal consistency values and adequate construct validity making it applicable to clinical practice and dry eye research.

Isolated conjunctival granuloma as a first manifestation of Parinaud's oculoglandular syndrome: A case report.

PURPOSE: Parinaud's oculo-glandular syndrome (POGS) is the most frequent manifestation of ocular bartonellosis, and usually presents with local lymphadenopathies and systemic symptoms. We present a case of isolated conjunctival granuloma as the sole manifestation of ocular bartonellosis. OBSERVATIONS: A 67-year-old female presented to the authors' eye clinic with complaints of a 2-week history of unilateral red eye and chemosis. Slit lamp examination revealed an isolated bulbar conjunctival granuloma. The remainder of the eye examination was unremarkable. Topical treatment with gatifloxacin and prednisolone acetate was started. Etiological work-up was performed. General laboratory tests revealed only a mild leukocytosis, and interferon gamma-release assay and chest computed tomography were normal. Serological testing for Bartonella henselae was positive at titers of 1:1024. Three weeks after initial symptoms, lymphadenopathies, malaise, and fever appeared. Systemic azithromycin was added, which resulted in complete regression of the disease. CONCLUSION AND IMPORTANCE: Conjunctival granulomas present a wide range of differential diagnoses to the practitioner. Ocular bartonellosis is a relevant cause of conjunctival granuloma. POGS should be suspected in cases of conjunctival granulomata non-responsive to local therapy. It is important to consider that other agents to treat POGS have been described and are available, and that appropriate serological tests should be performed.

Use of Autologous Serum Tears for the Treatment of Ocular Surface Disease From Patients With Systemic Autoimmune Diseases.

PURPOSE: To describe the safety and efficacy of autologous serum tears (AST) in managing ocular surface disease resistant to conventional therapy in patients with systemic autoimmune disease(s). DESIGN: Retrospective, interventional case series. METHODS: Records of patients from 2009 to 2015 with systemic autoimmune disease treated with AST (20%-50%) for chronic surface disease were analyzed. Standardized measures of subjective dry eye symptoms, objective dry eye staining of the cornea, and slit-lamp findings including punctate epithelial erosion (PEE), filamentary keratopathy (FK), and corneal epithelial defects (KED) were compared during first and last visit. We attempted to standardize outcomes by creating a scale from 1 to 4 for subjective and objective components: worsening (1), no improvement (2), partial improvement (3), and complete resolution (4). RESULTS: Fifty-one patients (101 eyes) were included. The mean age was 59.8 ± 13.2 years (72.5% female). Average use of AST was 14.3 ± 11.7 months. Complete objective improvement of initial slit-lamp findings was achieved in 30% and partial improvement in 55% of eyes. Presence of PEE, FK, and KED decreased from 92.1% to 52.5% (P < .001), from 22.8% to 9.9% (P = .02), and from 5% to 2% (P = .44) of the eyes, respectively. Full subjective improvement of symptoms was achieved in 34.6%, partial in 50.5%, and none in 14.9% of patients. No adverse side effects were noted during follow-up. CONCLUSIONS: AST are a safe and effective adjunct therapy in improving both objective signs and subjective symptoms of ocular surface disorders associated with systemic autoimmune disease(s).

Algorithm approach for revision surgery following late-onset bleb complications after trabeculectomy: long-term follow-up.

PURPOSE:: The aim of this study was to introduce a reproducible algorithm for the surgical management of late-onset (>2 months) bleb complications after trabeculectomy with mitomycin C. METHODS:: We performed a retrospective review of eyes treated using a reproducible algorithm approach by a single surgeon for the surgical management of late-onset bleb complications from July 2006 to April 2014. Exclusion criteria were bleb revision with less than 3 months of follow-up or bleb revision combined with other glaucoma procedures at the time of surgery. Success was evaluated using the Kaplan-Meier survival method and defined as achieving all of the following criteria: primary surgery indication resolved, no additional surgery required for decreasing the intraocular pressure (IOP), and IOP of ≥6 mmHg and ≤18 mmHg. RESULTS:: Twenty-three eyes from 20 patients were evaluated. Indications for bleb revision were hypotonic maculopathy (47.8%), bleb leak (30.4%), and dysesthetic bleb (21.7%). The overall primary outcome success rate calculated using the Kaplan-Meier survival method was 65.2% at 48 months. When the IOP target was changed to ≤15 mmHg, the bleb survival rate was 47.8% at 48 months. At the most recent postoperative visit, 95.7% of eyes had an IOP of ≤15 mmHg and 56.5% were being treated with an average of one medication per eye. One eye (4.3%) required a second bleb revision for persistent hypotony and two eyes required glaucoma surgery to reduce IOP during follow-up. CONCLUSIONS:: An algorithm approach for the surgical management of late-onset bleb complications with a success rate similar to those reported in specialized literature is proposed. Randomized trials are needed to confirm the best surgical approach.

Zone I of Tear Microdesiccates Is a Lipid-Containing Structure.

PURPOSE: Morphological features of tear microdesiccates on glass surfaces have been associated with tear fluid status. Tear-film lipids play a critical role in the pathophysiology of some ocular surface disorders. Tear microdesiccates display 4 distinctive morphological domains (zones I, II, III, and transition band). In this study, we investigated the lipid location in tear microdesiccates. METHODS: Tear from individual healthy eyes (assessed by symptoms, signs, and slit-lamp examination) was collected using absorbing minisponges. One-µL aliquots were allowed to dry under ambient conditions on microscope slides. Tear microdesiccates were examined by various transmitted light microscopy methods. Tear lipids were located both by partition experiments using 2 lipophilic dyes (Oil red O and Nile blue A) mixed with tear fluid under conditions preserving morphological features of microdesiccates and by assessing the effect of 2 solvents markedly differing in polarity (water and ethanol) on the morphology of particular domains of preformed microdesiccates. RESULTS: During desiccation, both Nile blue A and Oil red O became preferentially located in the outermost domain of tear microdesiccates (zone I) without affecting the formation of major fern-like crystalloids (zones II and III). Low volumes of water drastically affected fern-like crystalloids, whereas the gross morphology of zone I was maintained. Contrarily, ethanol, a less polar solvent, was a fixative for fern-like crystalloids, although it markedly affected the bulk of zone I by extracting liquid droplets out of microdesiccates and visibilizing some filamentous subcomponents. CONCLUSIONS: Zone I is a hydrophobic domain, whereas zones II and III are highly hydrophilic domains of tear microdesiccates. Zone I represents a lipid-rich structure.

Algorithm approach for revision surgery following late-onset bleb complications after trabeculectomy: long-term follow-up / Algoritmo de abordagem para cirurgia de revisão nas complicações da bolha de início tardio após trabeculectomia: acompanhamento de longo prazo

ABSTRACT Purpose: The aim of this study was to introduce a reproducible algorithm for the surgical management of late-onset (>2 months) bleb complications after trabeculectomy with mitomycin C. Methods: We performed a retrospective review of eyes treated using a reproducible algorithm approach by a single surgeon for the surgical management of late-onset bleb complications from July 2006 to April 2014. Exclusion criteria were bleb revision with less than 3 months of follow-up or bleb revision combined with other glaucoma procedures at the time of surgery. Success was evaluated using the Kaplan-Meier survival method and defined as achieving all of the following criteria: primary surgery indication resolved, no additional surgery required for decreasing the intraocular pressure (IOP), and IOP of ≥6 mmHg and ≤18 mmHg. Results: Twenty-three eyes from 20 patients were evaluated. Indications for bleb revision were hypotonic maculopathy (47.8%), bleb leak (30.4%), and dysesthetic bleb (21.7%). The overall primary outcome success rate calculated using the Kaplan-Meier survival method was 65.2% at 48 months. When the IOP target was changed to ≤15 mmHg, the bleb survival rate was 47.8% at 48 months. At the most recent postoperative visit, 95.7% of eyes had an IOP of ≤15 mmHg and 56.5% were being treated with an average of one medication per eye. One eye (4.3%) required a second bleb revision for persistent hypotony and two eyes required glaucoma surgery to reduce IOP during follow-up. Conclusions: An algorithm approach for the surgical management of late-onset bleb complications with a success rate similar to those reported in specialized literature is proposed. Randomized trials are needed to confirm the best surgical approach.

RESUMO Objetivo: Descrever um algoritmo reprodutível para o tratamento cirúrgico das complicações da bolha de início tardio (>2 meses) após trabeculectomia com mitomicina-C. Métodos: Revisão retrospectiva de olhos que foram submetidos a um algoritmo reprodutível para o tratamento cirúrgico das complicações da bolha de início tardio por um único cirurgião, de julho de 2006 a abril de 2014. Os critérios de exclusão foram revisão de bolha com menos de 3 meses de seguimento ou revisão de bolha combinado com outro procedimento antiglaucomatoso no momento da cirurgia. O sucesso foi avaliado pelo método de sobrevida de Kaplan-Meier e definidos como ter atingido todos os seguintes critérios: indicação de cirurgia primária resolvido, nenhuma cirurgia adicional necessária para diminuir a pressão intraocular (IOP), IOP ≥6 mmHg e ≤18 mmHg. Resultados: Vinte e três olhos de 20 pacientes foram incluídos. Indicações para revisão bolha foram maculopatia hipotônica (47,8%), extravasamento da bolha (30,4%) e bolha elevada (21,7%). A taxa de sucesso do resultado primário global calculada pelo método de sobrevivência de Kaplan-Meier foi de 65,2% aos 48 meses. Quando a IOP foi diminuída para ≤15mmHg, a taxa de sobrevivência bolha foi de 47,8% em 48 meses. Na visita pós-operatória mais recente, 95,7% dos olhos apresentavam PIO ≤15mmHg e 56,5% estavam sob tratamento com uma média de um medicamento por olho. Um olho (4,3%) necessitou de uma segunda revisão da bolha para hipotonia persistente e dois olhos necessitaram cirurgia de antiglaucomatosa para reduzir a IOP durante o seguimento. Conclusões: Um algoritmo de abordagem para o tratamento cirúrgico das complicações tardias da bolha com uma taxa de sucesso semelhante aos relatados na literatura especializada é proposto. Ensaios clínicos randomizados são necessários para confirmar a melhor abordagem cirúrgica.