Micropulse Cyclophotocoagulation: A Multicenter Study of Efficacy, Safety, and Factors Associated With Increased Risk of Complications.

PRéCIS:: Micropulse cyclophotocoagulation (MPCP) lowered intraocular pressure (IOP) in the short-term but nearly half required additional intervention. Mydriasis was the most common complication (11%); 15% lost ≥3 Snellen lines of acuity; 11% had persistent complications at last follow-up. PURPOSE: The purpose of this study was to evaluate the efficacy and complications of MPCP in a large series of patients with all stages of glaucoma. DESIGN: Multicenter, retrospective chart review of patients from 3 clinical sites. PARTICIPANTS: One hundred sixty-seven eyes of 143 patients. METHODS: MPCP was performed with 2000 mW energy, 31.3% duty cycle and 2 to 4 180-degree applications of 80 seconds duration each per treatment. The procedure was considered a failure if any of the following occurred: additional IOP lowering intervention, <20% IOP reduction from baseline at the last follow-up (with or without medication), or severe complications. RESULTS: Mean age was 71 years, 53% were female, and 53% were Asian. 60% of eyes had POAG, 63% were pseudophakic, 38% had prior glaucoma surgery, and 51% had Snellen visual acuity (VA) of 20/40 or better. Mean follow-up time was 11.9±7.8 months. Mean IOP was 21.9±8.4 mm Hg before intervention, and 17.4±7.2 mm Hg at last follow-up (P<0.0001). There was no change in mean logMAR VA (P=0.0565) but 15% lost ≥3 Snellen lines of VA. The success rate was 36.5% (61/167 eyes) at last follow-up. The probability of survival by Kaplan-Meier analysis was 82%, 71%, and 57% at 3, 6, and 12 months after the procedure, respectively. The reasons for failure were additional intervention in 47%, inadequate IOP reduction in 14%, and severe complication in 1.8%. In a multivariable Cox proportional hazard model, female sex was associated with a 56% decrease in failure rate compared with males (P<0.0001), while a unit increase in baseline IOP corresponded with a 5.7% increase in failure rate (P<0.0001). If repeat MPCP was allowed then success rate increased to 58%. There were no complications in 73% (122/167) but 11% (18/167) had persistent complications at the last follow-up and half of these 18 eyes had decrease in VA of 1 to 6 Snellen lines. Asian race (odds ratio 13.5, P=0.0131) and phakic status (odds ratio 3.1, P=0.0386) were associated with higher odds of developing mydriasis, which was the most common complication. CONCLUSIONS: MPCP lowered IOP in the short-term but nearly half required additional IOP lowering intervention. Potential complications should be discussed in detail especially when the procedure is being considered for those with good VA and early stage disease.

Repeatability of selective laser trabeculoplasty for open-angle glaucoma.

BACKGROUND: To analyze the results of repeat selective laser trabeculoplasty (SLT). INCLUSION CRITERIA: participants with primary or secondary open-angle glaucoma (excluding uveitic) who had undergone SLT 360° (SLT 1) with diminution of response over time followed by repeat SLT 360° (SLT 2). Six months of follow-up were required and at least 6 months in between SLT 1 and 2. The main outcome measures were IOP reduction at 6 and 12 months and a comparison of the response between SLT 1 and 2. RESULTS: One hundred thirty-seven patients met the inclusion criteria. If only one eye had repeat treatment, that eye was chosen; if both eyes qualified, one was chosen at random. The baseline intraocular pressure (IOP) for SLT 1 = 20.3+/- 5.2 mmHg and SLT 2 = 19.4 +/- 5.0 was reduced to 16.4 +/- 3.9 and 16.7 +/- 4.7 at 1 year, respectively (p < .001). Medication use was not significantly changed, and was 2.2 +/- 1.2 at baseline for SLT 1 and 2.1 +/- 1.3 for SLT 2, and at 1 year was 1.9 +/- 1.3 and 2.2 +/- 1.2, respectively. A subanalysis of 62 patients matched for equivalent baselines showed a baseline IOP = 18.7 +/- 3.8 for SLT 1 and 18.7 +/- 3.5 for SLT 2, reduced to 16.0 +/- 4.3 and 15.3 +/- 3.8 at 1 year (p < .001). CONCLUSION: Repeat SLT laser (360-degree treatment, followed by a loss of effect over time, then a second 360-degree treatment) in this population resulted in IOP lowering similar to that of the initial treatment.

Blebitis After EX-PRESS Glaucoma Filtration Device Implantation-A Case Series.

PURPOSE: To present the management and outcomes of blebitis in patients who underwent EX-PRESS Glaucoma Filtration Device (GFD) implantation. DESIGN: Retrospective case series. PARTICIPANTS: The study included 5 patients who developed blebitis following EX-PRESS GFD implantation. METHODS: Charts of all patients who underwent EX-PRESS GFD implantation at the Glaucoma Center of San Francisco between 2007 and 2013 were reviewed. Five patients with blebitis were identified and their clinical course was recorded. MAIN OUTCOME MEASURES: Clinical course of blebitis. RESULTS: Of 325 eyes that underwent EX-PRESS GFD implantation, 5 eyes (1.5%) with blebitis were identified. The mean interval between EX-PRESS GFD surgery and blebitis was 2.3±0.8 years. Four of the 5 eyes with blebitis had potential risk factors for bleb-related infection; 1 had chronic blepharitis, 2 had contact lens use, and one had 2 episodes of bleb leak before blebitis. All patients were treated with topical antibiotics; in addition, 3 received oral antibiotics and 1 received intravitreal antibiotics. None of the patients developed endophthalmitis. One patient had recurrent blebitis, which was treated with topical, oral, and intravitreal antibiotics. None of the patients had the device removed. The mean follow-up time after blebitis was 16.8±8.9 months (range, 10 to 32 mo). CONCLUSIONS: This case series suggests that blebitis after EX-PRESS GFD implanted under a scleral flap may be treated without removal of the device. Further study is required to determine the optimal method of treating this condition.

Long-term effect of phacoemulsification on intraocular pressure using phakic fellow eye as control.

PURPOSE: To investigate the long-term effect of phacoemulsification on intraocular pressure (IOP) in patients with ocular hypertension and open-angle glaucoma. SETTING: Three multispecialty ophthalmology practices and one glaucoma specialty group. DESIGN: Retrospective comparative case series. METHODS: Review of medical records of patients with open-angle glaucoma or ocular hypertension who had had unilateral phacoemulsification (without other prior or concurrent ophthalmic procedure) with the fellow eye remaining phakic at least 3 years postoperatively. RESULTS: Preoperatively, the IOP in the surgical and fellow eyes in the 29 patients was 15.66 mm Hg ± 3.33 (SD) and 15.64 ± 4.23 mm Hg (P=.98), respectively. Postoperatively, it was 13.56 ± 2.04 mm Hg and 14.92 ± 2.85 mm Hg, respectively, at 4.5 months (P=.06); 14.88 ± 3.20 mm Hg and 15.27 ± 3.19 mm Hg, respectively, at 1 year (P=.67); 14.16 ± 2.61 mm Hg and 14.95 ± 2.79 mm Hg, respectively, at 2 years (P=.37); and 14.68 ± 3.44 mm Hg and 14.68 ± 2.68 mm Hg at 3 years (P=1.00), respectively. There was no significant difference in the mean number of IOP-lowering medications used in the surgical eyes (1.96 ± 1.40) and fellow eyes (2.08 ± 1.44) postoperatively (P=.77). CONCLUSIONS: In a cohort of ocular hypertensive and glaucoma patients, uncomplicated phacoemulsification had no significant IOP-lowering effect compared with the phakic fellow eye for up to 3 years postoperatively. There was also no difference between the mean number of postoperative IOP-lowering medications used in the surgical and fellow eyes. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of the efficacy of the fixed-combination timolol/dorzolamide versus concomitant administration of timolol and dorzolamide.

The purpose of this study was to compare the efficacy of the fixed-combination solution of timolol 0.5%/dorzolamide 2% with the concomitant administration of its components, timolol 0.5% twice a day and dorzolamide 2% twice a day. Ninety-eight patients adequately controlled with a concomitant regimen of timolol and dorzolamide were switched to the fixed-combination regimen of the same components. Intraocular pressures at baseline and 4 weeks after the change in regimen were recorded. The mean baseline intraocular pressure (IOP) was 16.0 +/- 5.6 mmHg. Four weeks after the change in medication to the fixed-combination regimen, the mean IOP was 14.5 +/- 5.6 mmHg. The mean IOP change from baseline was -1.5 +/- 3.9 mmHg. The difference between the two treatment modalities was found to be statistically significant (p-value < 0.001). Eighty-one (83%) patients were considered successfully switched after 4 weeks of fixed-combination therapy, and seventeen eyes (17%) were deemed unsuccessful because a rise in IOP was detected. In conclusion, the fixed combination of timolol 0.5%/dorzolamide 2% twice a day provided equivalent or better intraocular pressure reduction in most patients who were successfully controlled on concomitant administration of its components, timolol and dorzolamide.

Long-term results of noncontact neodymium:yttrium-aluminum-garnet cyclophotocoagulation in neovascular glaucoma.

PURPOSE: To determine the long-term efficacy and safety of noncontact transscleral neodymium:yttrium-aluminum-garnet (Nd:YAG) cyclophotocoagulation (CP) for the treatment of neovascular glaucoma (NVG). DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: One hundred fifteen eyes of 111 subjects treated from December 1987 to January 2001. METHODS: Eyes with uncontrolled NVG underwent noncontact Nd:YAG CP. Treatment parameters and pretreatment and posttreatment intraocular pressures (IOP) were reviewed. Preoperative and postoperative IOP were compared using a paired Student's t test. Success was defined as an IOP

Transconjunctival mitomycin-C in needle revisions of failing filtering blebs.

PURPOSE: To report the efficacy and safety of transconjunctival mitomycin-C as an adjunct to needle revision of failing filtering blebs. DESIGN: Retrospective, consecutive, noncomparative interventional case series. PARTICIPANTS: Forty-one patients (42 eyes) undergoing bleb revisions by a single surgeon at a single institution from May 1997 to January 2001. METHODS: The authors retrospectively reviewed charts of 42 eyes that underwent needle revision of the failing filtering bleb using transconjunctival application of mitomycin-C. Needling of the bleb was performed with a 25-gauge needle. The site of the needle puncture was sutured and followed by application of transconjunctival mitomycin-C (0.5 mg/ml) by means of a sponge left in contact with the conjunctival epithelium for 6 minutes. A group of patients received additional subconjunctival injections of 5-fluorouracil in the postoperative period. Success was defined as a reduction in intraocular pressure of 30% without the use of antiglaucoma medications and no further surgical procedures to control intraocular pressure. MAIN OUTCOME MEASURES: Intraocular pressure, visual acuity, complications, number of glaucoma medications used at the final visit. RESULTS: Mean preoperative intraocular pressure was 22.1 +/- 8.0 mmHg, which was reduced by 9.6 +/- 7.9 mmHg to a mean postoperative intraocular pressure of 12.5 +/- 6.1 mmHg. Mean follow-up was 17.6 +/- 13.5 months. Kaplan-Meier survival analysis showed a probability of continued success at 12 months of 76.1%, and at 24 months of 71.6%. The most common complication was hyphema in 7.1% of patients. Twenty-six eyes also received postoperative injections of 5-fluorouracil. CONCLUSIONS: Transconjunctival mitomycin-C may enhance success of the needling procedure in failing filtering blebs.

Long-term follow-up of initially successful trabeculectomy with 5-fluorouracil injections.

PURPOSE: To study the long-term results (1-14 years) of trabeculectomies with 5-fluorouracil injections that were successful at 1 year. DESIGN: A retrospective noncomparative case series. INTERVENTION/PARTICIPANTS: We identified 87 patients (87 eyes) who had trabeculectomies with 5-fluorouracil injections from 1984 to 1989 that were successful at 1 year and had a follow-up range of 1.0 to 14.7 years (mean, 8.1, standard deviation of 4.4 years). All patients had previously failed glaucoma surgery (66.7%), cataract surgery (47.1%), or other diagnoses making them at high risk for failure. MAIN OUTCOME MEASURES: Successful control of intraocular pressure (IOP) was defined as IOP less than 21 mmHg or a reduction of 33% if preoperative pressure was less than 21 mmHg. Statistical analysis was performed using Kaplan-Meier life table analysis. RESULTS: If an eye is considered successful by IOP at 1 year, the probability of successful control is 61% at 5 years, 44% at 10 years, and 41% at 14 years. CONCLUSIONS: Despite successful IOP control at 1 year, trabeculectomies with 5-fluorouracil injections show a continual loss of IOP control over time.

Filtering bleb modification with a THC:YAG (Holmium) laser.

OBJECTIVE: To present a method for remodeling oversized blebs using the THC:YAG laser and describe its use in treating hypotony and bleb leaks. METHODS: Retrospective medical record review of 13 patients who underwent holmium laser bleb revision. RESULTS: Thirteen eyes of 13 patients were analyzed. All the patients had an oversized bleb and 2 patients presented an associated late-onset leaking bleb. Mean preoperative IOP was 4.1 mm Hg. THC:YAG laser energy was applied to the bleb to remodel and/or close the leak. After a mean follow up of 17.3 months, the mean IOP was 7.84 mm Hg +/- 2.3. Postsurgery complications included hyphema and the inadvertent rupture of a conjunctival microcyst. Visual acuity improved in 9 of the eyes and remained stable in 4 of the eyes. CONCLUSION: The THC:YAG laser can be used effectively to sculpt large blebs, reduce symptoms associated with large blebs, increase IOP in hypotonous eyes, and under specific circumstances, close bleb leaks.