Intraoperative Customized Reduction in Baerveldt Implant Plate Size in Elderly Patients with Glaucoma and Short Eyes.

Purpose: Larger surface area glaucoma drainage implant plates are associated with greater IOP reduction. Older age and short axial length of the eye have been reported to be risk factors for postoperative hypotony and suprachoroidal hemorrhage after glaucoma surgery. This pilot study, the first of its type, was conducted to determine the clinical outcome of intraoperative Baerveldt implant plate size reduction in elderly patients (≥80 years) with short axial length (<22 mm). Methods: This was a retrospective study with a minimum 18-month follow-up involving 24 consecutive uncontrolled glaucoma patients who had previously undergone Baerveldt implantation with implant plate size reduction. Success was defined as intraocular pressure (IOP) < 21 mmHg with at least a 30% reduction in IOP from baseline on two consecutive follow-up visits, IOP > 5 mm Hg on two consecutive follow-up visits, and neither reoperation of glaucoma nor loss of light perception. The distance between the rectus muscles at the equator of the eyeball was measured using a surgical caliper. The Baerveldt implant plate was cut with straight dissecting scissors considering the distance between the muscles. Results: The mean ±SD preoperative IOP before GDI was 30.2 ± 6.9 mmHg, and the mean IOP at the last follow-up visit was 13.3 ± 5.1 mmHg, the mean pressure drop being 16.9 mmHg (56%) (P<0.001). The number of antiglaucoma medications declined from mean 3.7 ± 1.0 (range 2-5) to 1.6 ± 1.1 (range 0-3) at the last visit (P<0.001). The success rate at the last follow-up visit was 79% (19 of 24 eyes). Fourteen (58%) eyes were classified as qualified success and five eyes (21%) were complete success. Complications included intraoperative suprachoroidal hemorrhage (1) and postoperative hyphema (2). Conclusion: Baerveldt implantation with customized plate downsizing can be an effective treatment option for difficult glaucoma in elderly people with short eyes.

Intraluminal deposits: A rare cause of glaucoma drainage implant total obstruction.

PURPOSE: To report the unforeseen complication of total obstruction of a glaucoma drainage implant (GDI) tube lumen by white deposit material and to present a preliminary report identifying the composition of this material. METHODS: Two subjects with a high IOP due to total obstruction of a GDI tube were reviewed. Both patients had a long history with brinzolamide and timolol maleate eye drops. The GDI tube was swept with a 5-0 polypropylene suture stent in order to open the tube. The intraluminal solid sample was successfully collected from the implant tube in one patient. High-performance liquid chromatography-mass spectrometry (HPLC-MS) was used to determine the origin of the intraluminal sample. RESULTS: Intraluminal deposits containing components of antiglaucoma drugs e.g., timolol and brinzolamide are a rare cause of total obstruction of GDI tubes. CONCLUSIONS: Our study describes a new cause of total obstruction GDI tubes. The long-term use of timolol maleate and brinzolamide and their presence in the intraluminal solid sample collected from the blocked GDI tube suggest that the glaucoma medication may have a role in the pathogenesis. However, the exact mechanism is unknown and requires further studies.

A novel surgical technique for the treatment of a filtration bleb extending over 180° after Xen gel stent implantation.

PURPOSE: To describe a novel surgical treatment option for managing a symptomatic filtration bleb extending into the three quadrants with adequate IOP control after Xen gel stent implantation. METHODS: A 62-year-old female with pseudoexfoliative glaucoma with an IOP of 34 mmHg underwent implantation of a Xen to reduce the IOP in her right eye. The IOP responded well to the procedure, but the patient developed a persistent giant filtration bleb with foreign body sensation and pain. A huge filtering bleb of over 180° after Xen implant surgery was managed by splitting the giant bleb into two parts, posterior dissection into the intermuscular space, a biodegradable collagen device implantation, and suturing the conjunctiva in two parts with absorbable and nonabsorbable sutures. RESULTS: Before the operation for treatment of a giant bleb, the patient had an IOP of 12 mmHg, a best-corrected visual acuity (BCVA) of 20/40, corneal dellen, and no antiglaucoma medication. Following the bleb recession procedure, the IOP was 16 mmHg, BCVA improved to 20/20, there were no corneal dellen and the patient reported resolution of her bleb discomfort. The IOP and BCVA remained stable through 18 months of follow-up and no antiglaucoma medications or additional surgical procedures were required. CONCLUSION: The novel technique described here can be one option to treat this rare (over 180°) bleb formation after Xen Gel Stent implantation without adversely affecting IOP control.

Effect of glaucoma drainage implant surgery on corneal topography: a prospective study.

PURPOSE: To study the effect of glaucoma drainage implant (GDI) surgery on corneal topography during the first postoperative year. METHODS: Twenty-one adult glaucoma patients were implanted with a Molteno3 or a Baerveldt 250 GDI. Corneal topography measurements were taken preoperatively and at 6 and 12 months after surgery. Untreated opposite eyes served as controls. RESULTS: In the surgical group, the mean ± SD simulated average keratometry values were 44.36 ± 1.69 D, 44.08 ± 1.29 D (p = 0.266) and 44.15 ± 1.32 D (p = 0.554) before and 6 and 12 months after surgery, respectively. The corresponding simulated keratometry astigmatism values were 1.11 ± 1.11 D, 1.20 ± 1.01 D (p = 0.687) and 1.16 ± 0.71 D (p = 0.177). Posterior astigmatism and posterior average keratometry remained unchanged after GDI surgery as well. The mean ± SD central corneal thickness (CCT) was 530 ± 46 µm, 535 ± 56 µm (p = 0.049) and 536 ± 45 µm (p = 0.080) at 0, 6 and 12 months, respectively. A trend towards increased corneal thickness (CT) in response to GDI surgery was also seen in both the average peripheral and the tube-quadrant peripheral CT values. At 12 months postoperatively, the mean endothelial cell density (ECD) had decreased by 8% centrally and by 9% peripherally. Corneal topography parameters, CT and ECD did not significantly change in the control group during follow-up. CONCLUSION: Glaucoma drainage implant (GDI) surgery did not significantly alter corneal keratometry parameters and thus seems to be an astigmatically neutral procedure. However a slight, although seemingly transient, increase in CCT was observed after GDI implantation.

Cataract surgery in patients with glaucoma drainage implants: the hooked tube technique.

PURPOSE: Cataract surgery has been reported to adversely affect the IOP control in eyes with the glaucoma drainage implant (GDI). One reason might be the flow of lens debris/viscoelastic material through the GDI tube into the bleb. This pilot study was conducted to determine the clinical results of a novel technique for temporary occlusion of the GDI tube with an iris retractor hook during phacoemulsification. METHODS: Retrospective analysis of 15 patients (control group) who underwent phacoemulsification between January 2005 and December 2010 and 17 patients (treatment group) who underwent phacoemulsification with the hooked tube technique between January 2011 and April 2016 with a minimum 1-year follow-up. RESULTS: The IOP remained within 4 mmHg of the preoperative level in all eyes of the treatment group. Three eyes exhibited IOP spikes (≥ 10 mmHg) among controls. The mean postoperative IOP at 1 month was statistically significantly increased in the control group compared with the treatment group (P = 0.040). The number of antiglaucoma medications at 3 and 6 months was significantly increased in the control group (1.4 ± 1.1 vs. 1.7 ± 1.1; P = 0.041, 1.4 ± 1.1 vs. 2.3 ± 1.2; P = 0.017, respectively). After phacoemulsification, there was a significant increase in the mean number of antiglaucoma medications used at 6 months in the control group compared with the treatment group (P = 0.049). In both groups, one eye developed corneal decompensation. CONCLUSIONS: The hooked tube technique seems to provide an effective way to reduce the risk of the IOP spikes after cataract surgery in eyes with GDI.

Xen Gel Stent to Resolve Late Hypotony After Glaucoma Drainage Implant Surgery: A Novel Technique.

PURPOSE: To describe a new surgical method for treating late profound hypotony in 2 patients with glaucoma drainage implant (GDI). PATIENTS AND METHODS: Two patients, an 85-year-old woman and a 44-year-old woman, presented with choroidal effusions secondary related to chronic hypotony after GDI surgery. A novel technique was performed in both cases to narrow the lumen size of the GDI tube. The GDI tube was exposed and ligated temporarily with a polyglactin suture in both cases. The anterior part of the capsule wall was opened. The Xen stent was removed from its injector and pushed through the posterior orifice of the GDI tube. The whole Xen stent was inserted inside the tube to narrow the lumen size of the GDI tube. Once the Xen had been placed inside the tube lumen, a silk suture was tied around the GDI tube to secure the Xen in position. The ligation suture of the GDI tube was removed and suturing of the conjunctiva was performed. RESULTS: Before restriction of aqueous flow through the GDI, both patients had an intraocular pressure (IOP) of 2 mm Hg and blurry vison of 20/40 to 20/200. Following the Xen implant insertion, IOP ranged between 8 and 20 mm Hg and choroidal effusions resolved, and visual acuity improved. In both cases, IOP remained stable through 1 year of follow-up and no choroidal effusions or macular folds were noticed. CONCLUSIONS: A Xen implant placed inside the GDI tube offers an option for the treatment of chronic hypotony in eyes with GDI.

Matrix metalloproteinases (MMP-1, MMP-2, MMP-3 and MMP-9, and TIMP-1, TIMP-2 and TIMP-3) and markers for vascularization in functioning and non-functioning bleb capsules of glaucoma drainage implants.

PURPOSE: To investigate and compare functioning versus non-functioning glaucoma drainage implant (GDI) capsules for selective markers of extracellular matrix degradation and vascularity. METHODS: In three samples of both functioning and non-functioning blebs, immunohistochemistry was used to determine the expression of MMP-1, MMP-2, MMP-3, MMP-9, TIMP-1, TIMP-2, TIMP-3 and CD31. A non-functioning bleb was defined as IOP >21 mmHg or <20% reduction in IOP from baseline with maximal tolerated medication. The samples were classified into five grades based on immunostaining: no staining, no significant staining, mild, moderate or marked staining. RESULTS: Expression of MMP-1, MMP-2 and MMP-3 was mostly low in both functioning and non-functioning blebs. However, immunostaining of MMP-9 was marked in samples taken from functioning GDIs and correlated with the presence of vascular profiles in the luminal bleb. CD31 immunoreactivity was more intense in the outer layers of the bleb than in the inner layers. In non-functioning blebs, immunoreactivity for TIMP-3 was significant through the whole bleb wall, but only mild in the inner zone of functioning blebs. TIMP-1 and TIMP-2 were barely detectable. CONCLUSION: Staining of TIMP-3 was seen to be lower in the vicinity of the small blood vessels. In avascular bleb wall, increased expression of TIMP-3 suggests its potential role in the inhibition of angiogenesis as reported previously in vivo. The abundance of MMP-9 in bleb capsule wall of relatively old patients might lead to weakened bleb capsule wall architecture and increasing filtration of aqueous humour through the capsule, which are reflected in a lower IOP.

Pilot study of glaucoma drainage implant surgery supplemented with reticulated hyaluronic acid gel in severe glaucoma.

PURPOSE: This pilot study, the first of its type, was conducted to determine the clinical outcome of glaucoma drainage implant (GDI) surgery supplemented with injectable crosslinked hyaluronic acid (HA) in patients with severe glaucoma. METHODS: This was a retrospective chart study involving 10 eyes of 10 patients with severe glaucoma (glaucomatous visual field loss worse than -20 dB) who had previously undergone GDI surgery supplemented with crosslinked HA with a 2-year follow-up. Surgical success was defined as intraocular pressure (IOP) <21 mm Hg with a reduction of ≥40% (definition A) or ≥50% (definition B) from baseline IOP on 2 consecutive follow-up visits, IOP >5 mm Hg on 2 consecutive follow-up visits, and neither reoperation of glaucoma nor loss of light perception vision. RESULTS: The mean ± SD baseline IOP before GDI was 38.5 ± 10.7 mm Hg, and the mean IOP at the last follow-up visit was 13.0 ± 5.0 mm Hg, with a mean pressure drop of 24.4 ± 10.9 mm Hg (62%; p = 0.005). According to definition A, life-table analysis showed an overall success rate of 80%, while according to definition B, the success rate was 50% after 24 months of follow-up. Complications were infrequent and not serious. No complications resulting from the reticulated HA therapy itself were observed. CONCLUSIONS: In eyes with severe glaucoma, the intraoperative application of crosslinked sodium HA gel may improve the efficacy of GDI surgery.

Molteno3 implantation as primary glaucoma surgery.

Purpose. To determine the outcome of Molteno3 implantation as primary glaucoma surgery and to analyze the factors influencing the surgical outcome. Methods. This is a retrospective clinical study of 106 consecutive eyes (97 patients) with no previous glaucoma surgery. Surgical failure was defined as an IOP > 21 mmHg or less than a 20% reduction below baseline, or IOP ≤ 5 mmHg, on two consecutive visits after 3 months follow-up, or reoperation for glaucoma or loss of light perception. Results. At the end of the follow-up (mean, 35 months; range, 12-71 months), the mean postoperative IOP (14.2 ± 4.4 mmHg) was statistically significantly lower than the preoperative IOP (35.2 ± 9.7 mmHg) (P < 0.001). Life-table success rates were 97%, 94%, and 91% after follow-up of 12, 24, and 36 months, respectively. Success rate for an IOP ≤ 18 mmHg was 77% at the last visit. Success was not influenced by previous cataract surgery, sex, age, laser trabeculoplasty (LTP), preoperative IOP, or number of antiglaucoma medications. Forty-seven eyes had 66 postoperative complications. Conclusions. The primary Molteno3 implant provided significant IOP lowering with minimal and manageable complications in uncontrolled glaucoma. Neither previous cataract surgery nor LTP had any detrimental effect on surgical success.

Immunohistochemical analysis of extracellular matrix bleb capsules of functioning and non-functioning glaucoma drainage implants.

PURPOSE: To detect by immunohistochemical means the changes in bleb capsules at the cellular level between functioning and non-functioning glaucoma drainage implants (GDIs). METHODS: Three samples each of functioning (1 Baerveldt and 2 Molteno implants) and non-functioning filtration blebs (1 Molteno and 2 Ahmed implants) were studied. A non-functioning bleb was defined as an intra-ocular pressure (IOP) >21 mmHg or a <20% reduction in IOP from baseline on three consecutive follow-up visits with maximal tolerated medication. The capsules were obtained between 6 and 108 months after GDI insertion for medical reasons only. Primary antibodies were used to stain fibronectin, tenascin, laminin, collagen IV and smooth muscle actin (SMA). The samples were graded on the basis of the intensity and quantity of immunohistochemical staining into four categories as follows: no staining or a mild, moderate or marked staining. RESULTS: The non-functioning blebs expressed more fibronectin, tenascin and SMA through the whole capsule wall than the functioning blebs. In the functioning blebs, tenascin was found mainly in the inner layer of the capsule. More type IV collagen and laminin were also found in the non-functioning bleb capsules than in the functioning blebs. No difference was found between the bleb capsules irrespective of whether they had been perfused with aqueous humour immediately after surgery (Ahmed) or after a delay (Molteno, Baerveldt). CONCLUSION: Accumulation of extracellular matrix components and activated fibroblasts in the bleb capsules of non-functioning GDI indicates the presence of an active wound healing process, suggesting a possible reduction in filtration through the bleb wall.

[Restoration of vision by retinal prosthesis]. / Näkö takaisin verkkokalvoistutteella.

Retinitis pigmentosa and age-related macular degeneration destroy photoreceptor cells within the eye in the outermost layer of the retina, whereas cells of the inner layers of the retina often remain intact. Retinal prosthesis aims to replace the faded function of photoreceptor cells by means of microelectronics. The aim of the prostheses being developed is to bypass the atrophied layers of the retina and to convey visual information to the functional portion of the retina. A retinal prosthesis is not able to restore normal vision, but will make orientation easier and thus greatly facilitate the daily activities of a blind person.

Micropulse diode laser trabeculoplasty -- 180-degree treatment.

PURPOSE: To evaluate the outcome of 180° micropulse diode laser trabeculoplasty (MDLT) in patients with open-angle glaucoma. METHODS: A retrospective review of 40 eyes of 29 MDLT-treated patients with a minimum follow-up time of 6 months. Successful outcome was defined as follows: (i) a ≥20% or (ii) a ≥3-mmHg decrease of intraocular pressure (IOP), no further need for laser- or incisional surgery and the number of glaucoma medication was the same or less than preoperative. These definitions will from now on be referred to as definition one and definition two. RESULTS: Life-table analysis showed an overall success rate of 2.5% (1/40) and 7.5% (3/40) (according to definitions one and two, respectively) after up to 19 months of follow-up. The average time for failure was by definition one 2.9 months (standard deviation, SD ± 3.5, range 1-12 months) and by definition two 3.3 months (SD ± 3.9, range 1-16 months). There were no intra- or postoperative complications caused by MDLT. Postoperative inflammatory reaction, cells and flare, was scanty. CONCLUSION: Our results suggest that 180° MDLT is a safe but ineffective treatment in patients with open-angle glaucoma.

Effects of pegaptanib injections on intraocular pressure with and without anterior chamber paracentesis: a prospective study.

PURPOSE: To investigate how prophylactic anterior chamber paracentesis affects the intraocular pressure (IOP) after intravitreal pegaptanib injections. METHODS: In this prospective study, 41 eyes of 41 patients receiving intravitreal pegaptanib injections were randomly assigned either to receive anterior chamber paracentesis prior to the injection (Group A, 20 patients, n = 35 injections) or not (Group B, 21 patients, n = 38 injections). IOP was measured before the pegaptanib injection (T0) and 2 min (T1), 30 min (T2) and 1 week (T3) after the injection. A four-point scale was used to evaluate the subjective pain experienced during the procedure. RESULTS: The mean IOP at T1 was 15.3 ± 7.5 mmHg in group A and 47.1 ± 24.1 mmHg in group B (difference -31.85 mmHg, 95% Confidence interval -40.13 to -23.56; p < 0.0001). In 45% of the injections without paracentesis, IOP was higher than 50 mmHg 2 min after the pegaptanib injection. No significant difference in IOP was observed at T0, T2 and T3 between the two study groups. The mean pain scores did not differ significantly (0.97 in group A versus 1.32 in group B; p = 0.08). CONCLUSIONS: The results suggest that prophylactic anterior chamber paracentesis helps to prevent the high postoperative IOP spike without causing patients any additional pain.

The outcome of 270-degree selective laser trabeculoplasty.

Purpose. To evaluate the reduction of intraocular pressure (IOP) by a single-session 270° selective laser trabeculoplasty (SLT) in pseudoexfoliation glaucoma (PXFG) and primary open angle glaucoma (POAG) patients. Methods. A successful outcome was defined as an IOP reduction ≥20% from baseline with no further need for laser or incisional surgery. The preoperative pharmaceuticals were maintained unchanged throughout the course of the study. 70-80 nonoverlapping pulses were distributed around 270° in the trabecular band. Results. Sixty-six eyes of 42 patients with PXFG (30 eyes) or POAG (36 eyes) met the inclusion criteria. The mean ± standard deviation preoperative IOP was 23.7 ± 4.5 mmHg and at the end of the followup was 19.0 ± 4.5 mmHg with a pressure drop of 4.7 ± 3.1 mmHg (20%) (P < 0.001, 95% confidence interval 3.94-5.46). The cumulative probability of success was 39% (26 of 66 eyes) after 6 months of followup. Statistically significant differences in success rates were observed between the PXFG and POAG groups (27% versus 50%; P = 0.025). Postoperative inflammatory reaction was scanty. Conclusions. 270-degree SLT is useful in lowering IOP in PXFG and POAG, but the average reduction of IOP seems to be within the same range as reported with 180-degree SLT previously.

Surgical management of glaucoma with Molteno3 implant.

PURPOSE: To evaluate the outcome of 40 consecutive patients with Molteno3 implantation in uncontrolled glaucoma with at least a 6-month follow-up. MATERIALS AND METHODS: Nonrandomized, interventional, and retrospective clinical study. Failure was defined as IOP >21 mm Hg or less than 20% reduction of intraocular pressure (IOP) from baseline on 2 consecutive follow-up visits, IOP ≤5 mm Hg on 2 consecutive follow-up visits, reoperation of glaucoma or loss of light perception vision. RESULTS: The mean preoperative IOP was 34.3±9.1 mm Hg, and the mean postoperative IOP at the last follow-up visit was 16.8±7.5 mm Hg with a pressure drop of 19.1±11.5 mm Hg (56%) (P=0.000; 95% CI 13.5-21.4). The Kaplan-Meier life-table analysis showed a 95% success rate after 6 months and a 71% success rate after 12 months of follow-up. Postoperative complications included cataract (6 eyes), choroidal detachment (3 eyes), flat anterior chamber (2 eyes), malignant glaucoma (2 eyes), encapsulated bleb (2 eyes), corneal decompensation (2 eyes), hyphaema (1 eye), uveitis (1 eye), retinal detachment (1 eye), suprachoroidal hemorrhage (1 eye), tube erosion (1 eye), and phthisis bulbi (1 eye). CONCLUSION: The Molteno3 dual-chamber implant is useful and well tolerated in controlling IOP, but it does not seem to reduce the risk of postoperative hypotony.

Viscoanaesthesia in cataract surgery: a prospective, randomized clinical trial.

PURPOSE: We aimed to compare viscoanaesthesia (VisThesia) with intracameral lidocaine in cataract surgery carried out under topical anaesthesia. METHODS: In this prospective study 98 patients were randomly assigned to receive VisThesia (group 1, n = 49) or 0.5 cc of 1% unpreserved lidocaine (group 2, n = 49). All surgery was carried out by one surgeon using clear corneal technique. Pachymetry, the status of the cornea and anterior chamber, and intraocular pressure (IOP) were checked pre- and postoperatively. RESULTS: Mean pain scores were 0.12 (maximum: 3) in group 1 and 0.37 in group 2; the difference between the groups was not statistically significant (95% confidence interval [CI] 0.003-0.487; p = 0.05). A total of 48 patients in group 1 (98%) and 49 in group 2 (100%) reported no discomfort or only mild discomfort. No significant differences in flare and cells in the anterior chamber or IOP were found between the two study groups. There was a significantly greater frequency of corneal oedema in group 1 (p = 0.001). Postoperative central corneal thickness values were also significantly higher in group 1 (95% CI 11.64-57.24; p = 0.003). CONCLUSIONS: Results suggest that viscoanaesthesia provides a level of comfort during cataract surgery under topical anaesthesia similar to that facilitated by intracameral lidocaine. However, patients who are given viscoanaesthesia may have increased risk for postoperative corneal oedema.

Fibrin glue for preventing immediate postoperative hypotony following glaucoma drainage implant surgery.

PURPOSE: To prevent a leak of aqueous around the tube in the immediate postoperative period after glaucoma drainage implant (GDI) surgery. METHODS: A total of 42 eyes of 34 consecutive patients with refractory glaucoma requiring single-plate Molteno implantation were retrospectively reviewed. Peritubular filtration was checked intraoperatively in all filtered eyes. Fibrin glue was used over the scleral flap intraoperatively in every eye with peritubular leakage. All Molteno tubes were completely closed with an absorbable ligature. RESULTS: Peritubular filtration was detected in 11 eyes of 11 patients. All 11 eyes maintained intraocular pressure (IOP) >or= 16 mmHg in the immediate postoperative phase. The mean IOP on the first postoperative day was 30.5 +/- 10 mmHg. After an average follow-up of 6 months, the mean IOP in these 11 eyes was 19.1 +/- 6 mmHg. No complications or Seidel-positive aqueous leak were observed during the follow-up period. CONCLUSIONS: Results suggest that intraoperative use of fibrin glue is a viable option for reducing peritubular filtration and preventing immediate postoperative hypotony after GDI surgery.