New suture probe canaloplasty combined with suprachoroidal collagen implantation.

PURPOSE: To present the modified surgery technique of new suture probe canaloplasty with a specially prepared monofilament 4.0 polypropylene suture combined with suprachoroidal drainage (ScD) and collagen sheet implantation for non-penetrating glaucoma surgery. METHODS: Prospective study with a twelve months follow-up. A standard 4/0 polypropylene suture (ProleneTM by Ethicon; thickness: approximately 250 m) is cut and shaped with an ophthalmic knife (MANI® Crescent Knife, Mani Inc 8-3 Kiyohara Industrial Park, Utsunomiya, Tochigi 321-3231, Japan) to create a blunt end without sharp or compressed edges. This improves suture probe canaloplasty by providing a more stable and smoother probing device. Schlemm's canal is prepared using the standard technique of canaloplasty with suprachoroidal drainage. Then, instead of using the canaloplasty microcatheter or the previously published 6/0 double-helix suture, Schlemm's canal is probed with the blunt ending of the 4/0 Prolene suture. After successful 360-degree probing, a doubled 10/0 polypropylene tension suture is threaded through the tip of the 4/0 suture. The 4/0 suture is then pulled back and the 10/0 tension sutures are tied at both ends to tension Schlemm's canal. A special collagen sheet (Ologen®) is placed in suprachoroidal space, and the scleral flap is firmly sewed. RESULTS: 115 eyes were included in this prospective study. In 113 cases the Schlemm's canal could completely be probed with the suture probe and canaloplasty with ScD and collagen sheet implantation succeeded. In two cases the intervention was transformed to 360-degree suture trabeculotomy due to an intraoperative cheese-wiring. Twelve months after successful new suture probe canaloplasty with ScD and Collagen Implantation the IOP had decreased by 37.1% (from 21.6 ± 6.0 mmHg with 3.3 different IOP lowering eye drops to 13.5 ± 3.5 mmHg with 1.0 eye drops). 16 Patients did not achieve sufficient IOP levels and underwent 360-degree suture trabeculotomy during the follow-up. One patient had to be treated with further glaucoma surgery to achieve a sufficient IOP level. Complications were hyphema, postoperative IOP elevation and transient hypotony. No serious or sight-threatening complications occurred. CONCLUSION: New suture probe canaloplasty with ScD and collagen sheet implantation yields the opportunity to conduct a cost-effective canaloplasty easier and less complicated than with the previously described method with the twisted 6/0 suture. The safety profile and IOP lowering effect is comparable. In cases where complete probing fails, there is still the opportunity to switch to suture trabeculotomy over the majorly probed part of Schlemm's canal. The pressure lowering effect of the deep sclerectomy with ScD and suprachoroidal collagen sheet implant seems to have an additional impact on the sufficient pressure lowering procedure.

Our Experience of Deep Sclerectomy at a Tertiary Center in the United Kingdom Over 14 Years.

Background Deep sclerectomy (DS) is a non-penetrating surgical procedure for glaucoma, reducing the resistance to aqueous outflow and lowering intraocular pressure while maintaining a physiological barrier between the anterior chamber and the sub-scleral space. This offers a lower complication profile than penetrating procedures, though with less intraocular pressure (IOP) reduction. Methods We retrospectively reviewed the electronic record for all DS undertaken at our hospital (a tertiary care center) over 14 years, collecting data on demographics, diagnosis, IOP, visual acuity, complications, medications, and further procedures required. Results Eighty eyes of 69 patients underwent DS, with a mean follow-up period of 53.5 months. The mean pre-operative IOP was 23.55 mmHg (range 11-52, standard deviation 8.46); the mean final IOP was 13.61 mmHg (range 5-35, SD 4.73), with a mean reduction of 42.21%. The mean change in glaucoma medications was -1.64. 78.40% experienced a reduction in glaucoma treatment. Post-operatively, 43.80% had no complications; this improved to 85.0% when numerical hypotony and raised IOP without visual sequelae were excluded. Further procedures required included Nd:YAG goniopuncture (10%), bleb needling (13.75%) or revision (7.5%), iridectomy (3.75%), goniosynechiolysis (1.25%), and autologous blood injection (1.25%). Two eyes were converted to trabeculectomy peri-operatively, with seven overall (8.75%) requiring trabeculectomy over the course of follow-up. 3.75% underwent glaucoma drainage device implantation, and 3.75% underwent cyclodiode laser. Conclusion We have found DS to be a safe, effective procedure for selected patients where trabeculectomy has a high likelihood of failure or where a higher IOP can be tolerated.

Trabeculectomy: Does It Have a Future?

The trabeculectomy (TRAB) procedure has undergone various modifications to increase the long-term surgical success and safety profiles. The main issues with TRAB include short and long-term complications, that are more common with the concomitant use of anti-fibrotic agents. While many surgeons have predicted the demise of trabeculectomy amidst newer non-penetrating glaucoma surgeries, it is still the gold standard procedure for patients with an advanced or rapidly progressing disease and for those patients who need very low intraocular pressures. This review article is unique in summarizing the evolution of trabeculectomy and its efficacy compared to neoteric shunt procedures while trying to predict if trabeculectomy has a future in the modern surgical world. We have compared the outcomes and complications of trabeculectomy to all the surgical procedures available to date and have tried to evolve an algorithm to help surgeons to decide on their preferred technique.

Outcomes of Deep Sclerectomy following Failed XEN Gel Stent Implantation in Open-Angle Glaucoma: A Prospective Study.

Background: The purpose of this study is to evaluate the outcome of deep sclerectomy (DS) as a secondary procedure following failed ab-interno XEN gel stent implantation in patients with open-angle glaucoma. Methods: Prospective, single-center, non-randomized, interventional study. Consecutive eyes that underwent mitomycin C (MMC) augmented XEN gel stent surgery, with uncontrolled intraocular pressure (IOP) or signs of disease progression, were included to undergo MMC-augmented DS. Primary efficacy outcome was surgical success, defined as complete when the unmedicated IOP was 12 mmHg or less, or 15 mmHg or less and 20% lower than at the timing of XEN failure and defined as qualified when the IOP fulfilled the same conditions with fewer medications than before deep sclerectomy. Secondary measures were mean reduction in IOP and in the number of medications, and the rates of complications. Results: Seventeen eyes were enrolled with a mean age of 72.1 ± 8.2 years (66.7% women). The mean follow-up was 20.1 ± 4.9 months, with more than 12-month data available from 15 eyes. Following DS, IOP decreased significantly from 22.6 ± 5.3 mmHg to 12.3 ± 5.5 (45.6%; p < 0.001). Antiglaucoma medications dropped from 1.1 ± 0.9 to 0.3 ± 0.7. Complete success was obtained in 40% of eyes using the threshold of 12 mmHg or less and a 20% decrease of IOP, and in 60% using the 15 mmHg or less threshold. Adverse events were observed in 20% of eyes (bleb leakage (13.3%); hypotony (6.7%)). No cases of choroidal detachment or hypotony maculopathy were reported. Conclusions: Failed XEN gel stent implantation does not seem to negatively affect the safety and efficacy of subsequent deep sclerectomy surgery.

Canaloplasty - Efficacy and Safety in an 18-Month Follow Up Period, and Analysis of Outcomes in Primary Open Angle Glaucoma Pigmentary Glaucoma and Pseudoexfoliative Glaucoma.

PURPOSE: Open-angle glaucoma (OAG), accounting for 90% of all glaucoma cases, is a progressive optic nerve neuropathy. It may lead to irreversible loss of visual field and complete blindness. When conservative treatment becomes insufficient to stop OAG progression, a surgical intervention is considered. Currently, canaloplasty procedure is being introduced instead of conventional trabeculectomy for invasive OAG treatment. The aim of the study is to asses safety and efficacy of canaloplasty. METHODS: This prospective study included 67 eyes that received 360° canaloplasty with placement of a tensioning suture. Primary OAG (n = 35), secondary OAG in pseudoexfoliative syndrome (n = 13), and pigmentary glaucoma (n = 19) patients were included. Control check-ups were conducted pre-operatively and in a 18-month follow-up time. Study endpoints involved reduction in IOP values and in the number of glaucoma medications after the intervention. RESULTS: The intervention led to a significant 38% reduction in IOP value from the preoperative baseline to 18 months after the intervention. The number of medications decreased significantly by 89%. At 18 months postoperative, 79% eyes did not require any glaucoma medications. The incidence of complications after canaloplasty was low, and none of the adverse effects were vision threatening. A surgically-induced astigmatism was the most frequent complication. Pigmentary glaucoma patients were the most beneficial subgroup, with 50% reduction in IOP, the highest success rate, and 98% reduction in the number of medications used. CONCLUSION: This study proved that canaloplasty is an efficient and safe procedure in OAG eyes.

Long-term outcomes of viscocanalostomy and phaco-viscocanalostomy in patients with narrow angle glaucoma.

PURPOSE: To assess the outcomes of viscocanalostomy and phaco-viscocanalostomy in patients with narrow angle glaucoma at a single tertiary eye centre. METHOD: All patients undergoing viscocanalostomy for narrow angle glaucoma between June 2010 and June 2017 with a minimum follow-up of 12 months were included. Data was analysed from a prospectively maintained surgical outcome database. Primary outcome was a change in intraocular pressure (IOP). Secondary outcomes were changes in LogMAR visual acuity, number of eye drops, post-operative complications and further surgical interventions. Success was defined at two IOP cut-off points: IOP ≤ 21 mmHg and IOP ≤ 15 mmHg with (qualified success) or without (complete success) drops. Failure was any repeat glaucoma surgery or loss of light perception. RESULTS: Seventy eyes of 46 patients with a mean follow-up of 41.31 months (range 12-60 months) were included. Mean IOP changed from 25.7 ± 9.6 to 15.2, 15.6, 14.6, 13.8 and 14.0 mmHg at 1, 2, 3, 4 and 5 years post-operatively. Drops reduced from 3.2 ± 1.1 pre-operatively to 0.5 at 1 year and 1.1 at all time points thereafter. Qualified success for an IOP ≤ 21 mmHg was achieved in 94.2%, 88.1%, 92.5%, 91.1% and 92.0% and complete success in 63.8%, 37.3%, 30.2%, 22.2% and 24.0% in years 1 to 5, respectively. Qualified success for an IOP ≤ 15 mmHg was achieved in 53.6%, 60.9%, 69.8%, 68.9% and 64.0% and complete success in 39.1%, 26.9%, 22.6%, 20.0% and 8.0% in years 1 to 5, respectively. IOP was significantly lower at all examined post-operative time points (41.1%, 39.3%, 43.3%, 46.4% and 45.3% at years 1 to 5, respectively, p < 0.001 at all time points). Four eyes (5.7%) failed to meet any of the success criteria. Of these, 3 eyes (4.3%) required further glaucoma surgery and one eye (1.4%) progressed to no perception of light at 48 months. No patients had an IOP ≤ 5 mmHg on two consecutive occasions after 3 months. CONCLUSION: Viscocanalostomy and phaco-viscocanalostomy are a safe and effective surgical option in the management of chronic narrow angle glaucoma.

Efficacy and safety of non-penetrating glaucoma surgery with phacoemulsification versus non-penetrating glaucoma surgery: a Meta-analysis.

AIM: To compare the clinical efficacy and safety of non-penetrating glaucoma surgery (NPGS) plus phacoemulsification (Phaco-NPGS) and NPGS-alone. METHODS: We systematically searched various databases and reviewed studies that had evaluated the effects of Phaco-NPGS or NPGS-alone for patients with glaucoma. Primary outcomes included postoperative intraocular pressure (IOP) and the number of postoperative antiglaucoma medications. Secondary outcomes were the prevalence of complications, incidence of needling or goniopuncture, and surgical success rate. RESULTS: In total, 380 and 424 eyes in NPGS-alone and Phaco-NPGS groups respectively were included. Both postoperative IOP and number of medications were significantly lowered in the Phaco-NPGS group than that in the NPDS-alone group [weighted mean difference (WMD)=-1.12, 95% confidence interval (CI): -2.11 to -0.12, P=0.03; WMD=-0.31, 95%CI: -0.53 to -0.09, P=0.006]. Moreover, Phaco-NPGS had a significantly lower prevalence of complications and postoperative procedures compared to NPGS-alone, while no significant difference existed for surgical success. CONCLUSION: Phaco-NPGS superior to NPGS-alone in the reduction of IOP and medications. Phaco-NPGS can be recommended for glaucoma patients with coexisting cataracts owing to its superior efficacy, fewer complications, and postoperative procedures.

Espolonectomía: una nueva modificación de la esclerectomía profunda no perforante / Spurectomy: A novel modification of non-penetrating deep sclerectomy

Objetivos Evaluar los resultados de una nueva modificación de la esclerectomía profunda no perforante (EPNP) denominada espolonectomía. Métodos Estudio retrospectivo no aleatorizado y comparativo que incluyó 98 ojos (grupoA) operados con espolonectomía, que consiste en la combinación de la escisión del espolón escleral con EPNP. El grupo control (B) incluyó 53 ojos operados con EPNP clásica. Durante 12meses se estudiaron la presión intraocular (PIO), los medicamentos antiglaucomatosos que requirieron y las complicaciones. Resultados La PIO media disminuyó de 25,69±8,11 preoperatoria a 15,73±4,16mmHg después de la cirugía en el grupoA (p<0,001). En el grupoB disminuyó de 26,66±5,93 preoperatoria a 18,19±5,93mmHg postoperatoria (p<0,001). Las diferencias entre grupos de la PIO postoperatoria fue estadísticamente significativa (p<0,001). A los 12meses después de la cirugía, el 13,27 y el 52,83% de ojos en los gruposA yB requirieron tratamiento antihipertensivo tópico (p<0,001). La tasa de éxito absoluto después de la cirugía fue del 87,5 y del 47,17% en los gruposA yB, con una tasa significativamente mayor de éxito relativo en el grupoB (p<0,001). No hubo diferencias significativas entre los grupos en la tasa de complicaciones (p=0,960). La complicación postoperatoria más frecuente fue la microperforación de la membrana trabeculo-descemética en ambos grupos. Conclusiones La espolonectomía es una técnica segura y eficaz en comparación con la EPNP convencional y parece una alternativa prometedora en el tratamiento quirúrgico del glaucoma, optimizando la eficacia del tratamiento y minimizando las complicaciones (AU)

Purpose To evaluate the outcomes of a novel modification of the non-penetrating deep sclerectomy (NPDS) approach for glaucoma management called spurectomy. Methods Observational comparative non-randomized retrospective study including 98 glaucomatous eyes of 76 patients operated on with the spurectomy technique consisting of the combination of the excision of the scleral spur with NPDS (groupA). A control group (groupB) including 53 glaucomatous eyes of 43 patients operated on with classical NPDS was also included. Changes in intraocular pressure (IOP) and medications required as well as complications were recorded in a 12-month follow-up. Results Mean IOP decreased from 25.69±8.11 preoperatively to 15.73±4.16mm Hg postoperatively in groupA (p<0.001). In groupB, mean IOP decreased from 26.66±5.93 preoperatively to 18.19±5.93mm Hg postoperatively (P<.001). Differences between groups in postoperative IOP was statistically significant (P<.001). At 12months after surgery, 13.27% and 52.83% of eyes in groupsA andB required topical antihypertensive therapy (P<.001). The rate of absolute success after surgery was 87.5% and 47.17% in groupsA andB, with significantly higher rate of relative success in groupB (P<.001). No significant differences among groups were found in the complication rate (P=.960). The most common postoperative complication was microperforation of the trabeculo-descemetic membrane in both groups. Conclusions Spurectomy is a safe and effective technique when compared with conventional NPDS and seems a promising alternative in the surgical management of glaucoma, optimizing the efficacy of the treatment and minimizing complications (AU)

[Results of filtering trabeculotomy (FTO) compared to conventional trabeculectomy (TE)-a matched case control study]. / Ergebnisse der filtrierenden Trabekulotomie (FTO) im Vergleich zur konventionellen Trabekulektomie (TE) ­ eine gematchte Fall-Kontroll-Studie.

OBJECTIVE: The aim of this study was to examine the 2­year results of filtering trabeculotomy (FTO) compared to conventional trabeculectomy (TE) in primary open-angle glaucoma, pseudoexfoliation glaucoma, and pigmentary glaucoma. PATIENTS AND METHODS: Thirty consecutive patients after FTO and 87 patients after TE were included in the study. Both groups were matched 1:3 according to age and intraocular pressure (IOP). The primary endpoint was reaching the target IOP after 2 years. An IOP without medication of ≤ 18 mm Hg and an IOP reduction of ≥ 30% were defined as complete success, and as qualified success with medication. Secondary endpoints were mean IOP reduction, resulting visual acuity, complications and subsequent operations. The surgical technique of the FTO is available as a video for this article. RESULTS: The 2­year data from 27 patients with FTO and 68 patients with TE were evaluated. The patients in both groups were matched according to age and IOP but were also homogeneous with respect to visual acuity, gender, and medication. The preoperative IOP with glaucoma medication was 23.0 mm Hg in both groups. According to the defined criteria, a qualified 2­year success was achieved in 70.4% of the FTO group and in 77.6% of the TE group (p = 0.60) and a complete 2­year success in 33.3% of the FTO group and 56.7% of the TE group (p = 0.07). The IOP was significantly reduced after 24 months in both surgical groups (p < 0.001) and was 12.8 mm Hg in the FTO group and 11.0 mm Hg in the TE group. Visual acuity was moderately reduced postoperatively but did not differ significantly between the two groups. Complication and reoperation rates were low and not different between both groups. CONCLUSION: The results of FTO and TE are largely similar after 2 years in terms of complete and qualified success rate, lowering of IOP, visual acuity, and complications.

Five-year results of non-penetrating deep sclerectomy with demineralized cancellous bone xenogenically derived collagen glaucoma implant.

PURPOSE: To investigate the long-term effectiveness of non-penetrating deep sclerectomy (NPDS) with xenogenically derived cancellous bone collagen glaucoma implant (XCB-CGI) implantation in patients with primary open-angle glaucoma (POAG). MATERIALS AND METHODS: Retrospective chart review of patients with POAG stages 2 and 3 was treated with NPDS and XCB-CGI. Follow-up was at 6 months, 1, 2, 3, 4 and 5 years after surgery. Main outcomes were intraocular pressure (IOP) and medication burden. Secondary outcomes were visual acuity, corneal hysteresis (CH), visual field (VF) and optical coherence tomography (OCT) parameter analysis. RESULTS: Among 71 patients (71 eyes), the mean age was 72.7 ± 9.8. Average initial IOP was 27.7 ± 7.9 and average initial med load was 2.36 ± 0.99. At 6 months, 1, 2, 3, 4 and 5 years, the average IOP was 14.9 ± 3.3 mm Hg (46.2% reduction), 15.3 ± 4.0 mm Hg (44.7% reduction), 14.2 ± 3.8 mm Hg (48.7% reduction), 15.2 ± 3.3 mm Hg (45.0% reduction), 15.5 ± 3.3 mm Hg (44.0% reduction) and 14.2 ± 2.8 mm Hg (48.7% reduction), respectively. In 5 years, the success rate was 34% and 67%, without, and with medications (1.8 ± 0.8 meds required), respectively. Visual acuity was not significantly different (P > .05) at all follow-up visits from baseline. Mean CH increased by 2.1 ± 0.8 (P = .05). No glaucomatous deterioration of the VF and OCT parameters was detected in 56 eyes at the 5-year follow-up. CONCLUSION: NPDS with XCB-CGI implantation is an effective procedure to normalize the level of IOP, stabilize glaucomatous changes and decrease the number of meds needed for glaucoma control.

Spurectomy: A novel modification of non-penetrating deep sclerectomy. / Espolonectomía: una nueva modificación de la esclerectomía profunda no perforante.

PURPOSE: To evaluate the outcomes of a novel modification of the non-penetrating deep sclerectomy (NPDS) approach for glaucoma management called spurectomy. METHODS: Observational comparative non-randomized retrospective study including 98 glaucomatous eyes of 76 patients operated on with the spurectomy technique consisting of the combination of the excision of the scleral spur with NPDS (groupA). A control group (groupB) including 53 glaucomatous eyes of 43 patients operated on with classical NPDS was also included. Changes in intraocular pressure (IOP) and medications required as well as complications were recorded in a 12-month follow-up. RESULTS: Mean IOP decreased from 25.69±8.11 preoperatively to 15.73±4.16mm Hg postoperatively in groupA (p<0.001). In groupB, mean IOP decreased from 26.66±5.93 preoperatively to 18.19±5.93mm Hg postoperatively (P<.001). Differences between groups in postoperative IOP was statistically significant (P<.001). At 12months after surgery, 13.27% and 52.83% of eyes in groupsA andB required topical antihypertensive therapy (P<.001). The rate of absolute success after surgery was 87.5% and 47.17% in groupsA andB, with significantly higher rate of relative success in groupB (P<.001). No significant differences among groups were found in the complication rate (P=.960). The most common postoperative complication was microperforation of the trabeculo-descemetic membrane in both groups. CONCLUSIONS: Spurectomy is a safe and effective technique when compared with conventional NPDS and seems a promising alternative in the surgical management of glaucoma, optimizing the efficacy of the treatment and minimizing complications.

Access to Schlemm's canal for canaloplasty: an intra-individual comparison of two dissection techniques.

PURPOSE: To compare a modified incision technique with classic scleral flap dissection for canaloplasty with canal expander regarding efficacy and safety. METHODS: In a prospective randomized pilot study of 32 eyes of 16 patients with primary open-angle glaucoma, access to Schlemm's canal was created by deep lamellar dissection (scleral flap excision, group 1) or by vertical cut-down incision (group 2). Following canal opening and viscodilation with microcannula and sodium hyaluronate, two Stegmann Canal Expanders were implanted, and the scleral flap or vertical incision, respectively, was closed watertight. RESULTS: Mean preoperative intraocular pressure (IOP) was 34.9 mmHg ± 6.7 [standard deviation (SD)] in group 1 and 33.8 mmHg ± 7.7 (SD) in group 2 (p = 0.66); mean postoperative IOP without medications was 14.3 mmHg ± 2.9 (SD) in group 1 and 14.8 mmHg ± 5.2 (SD) in group 2 at 1 month (p = 0.76), and 14.4 mmHg ± 1.9 (SD) in group 1 and 16.8 mmHg ± 3.1 (SD) in group 2 at 12 months (p = 0.01). Overall, there was a significant preoperative-postoperative IOP difference between groups (19.4 mmHg ± 10.1, group 1; 16.6 mmHg ± 8.9, group 2; p = 0.02). Surgery type had a significant effect when adjusted for preoperative IOP, cup-disc ratio, eye side, follow-up number and surgery type (p < 0.01, anova). No filtering bleb was observed in either group. Intra- and postoperative complications were rare and included peripheral Descemet's membrane detachment (3), microhyphema (2) and cannulation into the anterior chamber (1). CONCLUSIONS: In this intra-individual comparative study of ab externo canaloplasty with the canal expander, IOP reduction was substantial in both groups and slightly greater in the group with deep scleral flap excision. Additional IOP reduction by transscleral drainage through the Descemet's membrane window and intrascleral lake is suggested.

Flap-sparing canaloplasty: a modified approach to Schlemm's canal.

PURPOSE: To present a modified surgical technique for canaloplasty with the Stegmann Canal Expander obviating the need for lamellar scleral dissection. METHODS: After limbal peritomy of the conjunctiva, the sclera is not dissected in the classic lamellar fashion with superficial and deep scleral flaps but is successively 'scratched' down by radial incision until Schlemm's canal (SC) is opened (trench cut). Following canal opening and viscodilation with a microcannula and sodium hyaluronidate, one Stegmann Canal Expander is implanted on either side of the canal ostia and the scleral incision is closed watertight. RESULTS: Twenty-seven eyes with primary open-angle glaucoma (POAG) were consecutively operated on using this modified technique. In all eyes, SC was successively opened, but exposure of the choroid and rupture of trabeculo-Descemet's membrane with iris prolapse or filtering blebs were not found. Adverse events included trimming of the expander in one eye for incomplete implantation during surgery, and transient microhyphaema in five eyes post-surgery. Mean intraocular pressure (IOP) was 31.9 mmHg ± 6.0 (SD) before surgery and 14.0 mmHg ± 2.5 (SD) 6 months and 15.2 mmHg ± 1.95 (SD) 12 months after surgery. CONCLUSIONS: The flap-sparing, trench-cut incision technique may reduce the risk of complications in canaloplasty with the Stegmann Canal Expander while effectively lowering IOP in POAG patients.

Modified viscocanalostomy in the Chinese population with open angle glaucoma: a 10-year follow-up results.

AIM: To study the long-term efficacy and safety of modified viscocanalostomy in Chinese people with open angle glaucoma (OAG). METHODS: This retrospective study included a total of 100 eyes from 100 Chinese patients with medically uncontrolled OAG. All the patients underwent modified viscocanalostomy with injection of viscoelastic material in the surgically created ostia of Schlemm's canal (SC). The modifications included peeling of the inner wall of SC and the juxtacanalicular meshwork, use of mitomycin C, and loosely suturing the superficial scleral flap. Intraocular pressure (IOP), visual acuity, number of medications, laser goniopuncture data and complications were recorded. The definition of complete (qualified) success was an IOP equal to or lower than 21, 18, 16 mm Hg without (with or without) anti-glaucoma medications. RESULTS: The mean IOP was 33.5±9.9 mm Hg before surgery, 15.2±3.6 mm Hg (mean IOP reduction of 51%) at 5y after surgery, and 15.6±2.8 mm Hg (mean IOP reduction of 49.9%) at 10y after surgery (P<0.001). The number of anti-glaucoma medications dropped from 2.39±0.5 preoperatively to 0.47±0.8 at 5y and 0.67±0.8 at 10y postoperatively (P<0.001). The follow-up period was 104.5±37.0mo. The qualified success rate for an IOP of 21, 18 or 16 mm Hg or less was 84% [95% confidence interval (CI): 0.80-0.88], 73% (95%CI: 0.68-0.78), and 59% (95%CI: 0.52-0.66) after 5y, and 80% (95%CI: 0.76-0.84), 69% (95%CI: 0.64-0.74), 51% (95%CI: 0.44-0.58) after 10y, respectively. There was a relationship between age, preoperative IOP and success rate (P<0.01, P<0.05). A total of 31 eyes (31.3%) in 31 patients underwent laser goniopuncture, decreasing the IOP from 22.9±4.3 mm Hg to 16.3±2.5 mm Hg (P<0.01). Neither blebitis nor endophthalmitis occurred. CONCLUSION: Modified viscocanalostomy could be performed to lower IOP, decrease multiple anti-glaucoma drops use as well. It's a safe procedure with less complications over 10y in Chinese individuals with OAG.

Catheter-independent suture probe canaloplasty with suprachoroidal drainage.

PURPOSE: To introduce the novel technique of suture probe canaloplasty with suprachoroidal drainage (SCD) as a catheter-independent and cost-saving method to perform non-penetrating glaucoma surgery. METHODS: Prospective interventional study with a 12-month follow-up. A standard 6/0 polypropylene suture is twisted in a special manner to create a double helix with a small loop at its end. Then canaloplasty with SCD is performed, but instead of using the standard canaloplasty catheter, Schlemm's canal is probed with the twisted suture. After 360° probing, a 10/0 polypropylene suture is thread through the loop and the twisted 6/0 suture is pulled backwards through Schlemm's canal. The 10/0 suture in Schlemm's canal is tied firmly and hyaluronic acid is injected into the suprachoroidal space. RESULTS: In total, 74 eyes that underwent suture probe canaloplasty with SCD were included. In 57 cases, probing of Schlemm's canal with the twisted 6/0 suture succeeded. Seventeen eyes had adhesions in Schlemm's canal which made probing with the suture impossible so that the surgeon switched in 12 cases to microcatheter-guided canaloplasty with SCD. While this was successful in five further cases, the adhesions seemed surely not be overcome and SCD with collagen sheet implantation was directly performed. In four additional cases after successful probing, the suture cut through trabecular meshwork; hence a 360° suture trabeculotomy was performed. After successful suture probe canaloplasty with SCD, intraocular pressure (IOP) decreased by 39.2% (from 19.8 ± 4.3 mmHg with 3.4 ± 0.7 different IOP-lowering eye drops to 12.0 ± 1.9 mmHg with 0.6 ± 0.9 eye drops). Three patients did not achieve sufficient IOP levels and, therefore, underwent 360° suture trabeculotomy during follow-up. No serious or sight-threatening complications occurred. CONCLUSION: Suture probe canaloplasty + SCD yields the opportunity to conduct canaloplasty with SCD more cost-effectively with a safety profile and IOP-lowering effect comparable to conventional canaloplasty. In cases where probing with the suture fails. there still remains the option to use a conventional microcatheter or to switch to SCD with collagen sheet implantation.

Outcomes of viscocanalostomy and phaco-viscocanalostomy in patients with advanced glaucoma.

PURPOSE: To determine the medium-term outcomes for patients with advanced glaucoma undergoing viscocanalostomy. METHODS: All patients with advanced glaucoma (mean deviation (MD) - 12.00 dB or above) and patients with poor visual acuity secondary to advanced glaucoma which precluded formal visual field assessment undergoing viscocanalostomy (VC) and phaco-viscocanalostomy between 2010 and 2014 under the care of a single surgical team were included. Intraocular pressure (IOP), visual acuity (VA) and visual field outcomes were assessed from data prospectively collected into a surgical outcome database. Success was defined at two IOP cut-off points: IOP ≤ 21 and ≤ 16 mmHg with (qualified) or without (complete) medications. RESULTS: One hundred thirty-five patients were included. Mean IOP changed from 23.6 ± 6.4 mmHg pre-operatively to 15.3, 15.8 and 14.8 mmHg at 1, 2 and 3 years, a change of 35, 33.5 and 39% respectively. Qualified success for an IOP ≤ 21 mmHg was achieved in 95.66, 90.6 and 80% and complete success in 52.5, 48.6 and 30.6% at year 1, 2 and 3. Qualified success for an IOP ≤ 16 mmHg was achieved in 66.6, 66.05 and 60% and complete success in 44.8, 37.6 and 30.6% at year 1, 2 and 3. The cumulative probability for achieving an IOP ≤ 21 mmHg with or without drops was 86.1, 81.4 and 81.4% at 12, 24 and 36 months. Eleven patients (8.1%) failed to achieve adequate IOP control and needed further surgical intervention. Eleven (8.1%) patients needed an intervention (Yag goniopuncture) following VC. Four patients (2.9%) had some post-operative complications, which resolved within 2 weeks following surgery. Nine patients (6.7%) lost more than 2 Snellen lines. There was no significant change in the MD across time points. CONCLUSION: Viscocanalostomy and viscocanalostomy combined with phacoemulsification is a safe and effective method of controlling IOP in the medium term in patients with advanced glaucoma.

Evaluation of the learning curve of non-penetrating glaucoma surgery.

PURPOSE: To evaluate the learning curve of non-penetrating glaucoma surgery (NPGS). METHODS: The study included 32 eyes of 27 patients' (20 male and 7 female) with medically uncontrolled glaucoma. Non-penetrating glaucoma surgeries performed by trainees under control of an experienced surgeon between 2005 and 2007 at our tertiary referral hospital were evaluated. Residents were separated into two groups. Humanistic training model applied to the one in the first group, he studied with experimental models before performing NPGS. Two residents in the second group performed NPGS after a conventional training model. Surgeries of the residents were recorded on video and intraoperative parameters were scored by the experienced surgeon at the end of the study. Postoperative intraocular pressure, absolute and total success rates were analyzed. RESULTS: In the first group 19 eyes of 16 patients and in the second group 13 eyes of 11 patients had been operated by residents. Intraoperative parameters and complication rates were not statistically significant between groups (p > 0.05, Chi-square). The duration of surgery was 32.7 ± 5.6 min in the first group and 45 ± 3.8 min in the second group. The difference was statistically significant (p < 0.001, Student's t test). Absolute and total success was 68.8 and 93.8% in the first group and 62.5 and 87.5% in the second group, respectively. The difference was not statistically significant. CONCLUSIONS: Humanistic and conventional training models under control of an experienced surgeon are safe and effective for senior residents who manage phacoemulsification surgery in routine cataract cases. Senior residents can practice these surgical techniques with reasonable complication rates.

Evaluation of the Early to Mid-term Efficacy and Safety of Deep Sclerectomy without an Intrascleral Spacer for Open-angle Glaucoma in an Australian Population.

PURPOSE: This study aims to evaluate the early to the midterm efficacy of deep sclerectomy (DS) without an intra-scleral spacer for open-angle glaucoma (OAG) patients. MATERIALS AND METHODS: Retrospective study of 99 eyes (88 patients) with open-angle glaucoma who underwent DS were recruited in a consecutive order following informed consent. Intraocular pressure (IOP) was collected up to 60 months post operation (mean 19.87 ± 15.13 months). Criteria of success were defined as the qualified success (QS) or complete success (CS) with IOP level less than 21, 18 and 15 mm Hg and a reduction of more than 20% IOP from baseline. QS includes additional medication post-DS, while CS requires no other medications or surgery post-DS. Further analysis includes comparing the criteria of success based on several factors. The data were analyzed using statistical package for social sciences (SPSS version 21) statistical software. RESULTS: The QS at 60 months for IOP less than 21, 18 and 15 mm Hg is 71.3% (45.12 ± 2.46), 63.9% (40.41 ± 2.75) and 48.7% (35.62 ± 2.85), respectively. The CS at 60 months for IOP less than 21, 18 and 15 mm Hg are 69.3% (47.51 ± 2.77), 57.9% (40.41 ± 2.75) and 45.2% (35.62 ± 2.85), respectively. There was no significant difference between QS and DS post-DS based on the level of experience of the surgeons; intraoperation complication; age and gender. There was a significant reduction in IOP post operation (p < 0.001). CONCLUSION: DS is observed to be an effective surgical method with a favorable safety profile to manage patients with open-angle glaucoma. It has a better safety profile compared to trabeculectomy (TE) and can be performed by surgeons of different experience safely and successfully. CLINICAL SIGNIFICANCE: To our knowledge, this is the first report of DS in an Australian population with up to 60 months of follow-up. It is an effective procedure for IOP control in patients with OAG and has fewer complications compared to TE. DS is less popular than TE primarily due to a perceived steep learning curve, but most of the literature on DS describe single surgeon results. Our study compared the outcome of five surgeons with a variety of experience and found no significant differences in the rate of success for all levels of IOP. HOW TO CITE THIS ARTICLE: Hui MM, Clement CI. Evaluation of the Early to Mid-term Efficacy and Safety of Deep Sclerectomy without an Intrascleral Spacer for Open-angle Glaucoma in an Australian Population. J Curr Glaucoma Pract 2018;12(3):107-112.

Suprachoroidal drainage with collagen sheet implant- a novel technique for non-penetrating glaucoma surgery.

PURPOSE: Our purpose was both to introduce the new technique of suprachoroidal drainage with collagen sheet implantation as a novel technique of non-penetrating glaucoma surgery and to present first results of a prospective pilot study. METHODS: A superficial rectangular sclera flap of half-scleral thickness sized 4 × 4.5 mm is dissected anteriorly until clear cornea. Then, a second scleral flap is created underneath the first one sized 3.5x4mm and is cut down full-thickness to the choroid exposing the suprachoroidal space. The flap is then bluntly prepared until the scleral spur is reached. Sharp dissection above the sclera spur exposes Schlemm's canal, which is located directly anteriorly. Schlemm's canal is unroofed, juxtacanalicular meshwork is peeled and the deep flap is cut off at its base. An absorbable collagen sheet (Ologen®, Dahlhausen, Cologne, Germany) is placed into the suprachoroidal space at the level of the ciliary body, and the superficial sclera flap is sutured tightly to prevent leakage. RESULTS: We prospectively analyzed 65 eyes that underwent suprachoroidal drainage with collagen sheet implantation. Mean reduction of intraocular pressure after 3 months was 35.1% (from 21.0 ± 4.3 mmHg to 13.5 ± 3.4 mmHg)(p < 0.01) and after 12 months 35.6% (from 21.0 ± 4.3 mmHg to 13.5 ± 3.0  mmHg)(p < 0.01). The number of topical IOP-reducing medication decreased significantly from 3.5 ± 0.7 to 0.6 ± 0.9 and to 0.9 ± 1.1 after 3 and 12 months, respectively (p < 0.01). No serious complications occurred. CONCLUSION: Suprachoroidal drainage with collagen sheet implantation seems to be a safe and effective surgical technique for non-penetrating glaucoma surgery that yields the opportunity of a sufficient IOP reduction for eyes unsuitable for canaloplasty.

Canaloplasty with Stegmann Canal Expander for primary open-angle glaucoma: two-year clinical results.

PURPOSE: To examine longer-term postsurgical safety and efficacy of a new expander for Schlemm's canal. METHODS: In a non-comparative, prospective study, 42 White patients with medically uncontrolled primary open-angle glaucoma (POAG) underwent primary canaloplasty with >2-year follow-up. The bleb-independent procedure comprised catheter-assisted canaloplasty and implantation of two Stegmann Canal Expanders to maintain trabecular distension and canal patency over 180°. Intraocular pressure (IOP), glaucoma medication use and complications were assessed. RESULTS: Mean IOP was 26.8 ± 5.6 mmHg presurgery, 12.8 ± 1.5 mmHg at 6 months, 13.2 ± 1.2 mmHg at 12 months and 13.3 ± 2.5 mmHg at 24 months (p < 0.001). Rate of complete success, defined as IOP ≤21, ≤18 and ≤16 mmHg and a ≥ 30% IOP reduction, was 85% (95% CI: 0.76-0.95), 85% (0.76-0.95) and 82% (0.70-0.96) at 12 months and 83% (0.73-0.94), 80% (0.70-0.92) and 80% (0.70-0.92) at 24 months. Preoperative factors were not significant predictors of ≤16 mmHg IOP reduction: IOP (hazard ratio [HR]: 0.68; 95% CI: 0.44-1.04; p = 0.08), mean visual defect (1.06; 0.90-1.20; p = 0.47), number of medications (0.59; 0.17-2.14; p = 0.42) and age (0.96; 0.87-1.13; p = 0.41). Number of medications dropped from 2.8 ± 0.4 presurgery to 0.2 ± 0.5 postsurgery (p < 0.001). Mean preoperative best-corrected visual acuity was 0.19 ± SD 0.21 (range: 0-1.6), and logMAR was similar to 0.23 ± 0.16 (range: 0-1.6; p = 0.42) after a mean follow-up of 27.4 months. Complications included peripheral Descemet's membrane detachment (7.2%) and trimming of the expander (4.7%) during surgery, and transient microhyphaema (23.8%) and IOP elevation (7.2%) postsurgery. CONCLUSION: Canaloplasty with the Stegmann Canal Expander was a safe and effective procedure to reduce IOP in White patients with moderate to advanced POAG.