[Clinical study on the efficacy and safety of glaucoma drainage implants in the treatment of different types of glaucoma].

Objective: To evaluate the efficacy and safety of glaucoma drainage implants(XEN-45 Gel Stent) for glaucoma treatment. Methods: A prospective study was conducted to continuously collect the clinical data of patients who were diagnosed with glaucoma and underwent XEN-45 Gel Stent implantation in the Ophthalmology Department of Peking University People's Hospital from January 2022 to August 2023. The visual acuity, intraocular pressure, number of glaucoma medications, and success rate of the patients were analyzed before and after surgery at 1 day, 1 week, 1 month, 3 months, 6 months, 12 months, and 18 months. The differences in intraocular pressure and number of glaucoma medications among primary open-angle glaucoma, primary angle closure glaucoma, secondary glaucoma, and different implantation methods of XEN-45 Gel Stent among patients with primary open-angle glaucoma were compared. The intraoperative and postoperative complications were observed, and the risk factors for needling and surgical complete success were analyzed. Results: A total of 48 eyes from 48 patients were included in this study, comprising 27 males and 21 females, with a mean age of (54.4±18.0) years and the disease duration was 36.0(7.3, 81.0) months.There were 28 cases of primary open-angle glaucoma, 4 cases of primary angle closure glaucoma, and 16 cases of secondary glaucoma.The follow-up period was 8.0 (3.0, 12.0) months. At 12 months after surgery, the intraocular pressure decreased from 20.5 (17.0, 26.0) mmHg to (13.5±3.3) mmHg (P<0.05), and the number of glaucoma medications decreased from 3.0 (3.0, 4.0) to 0.0 (0.0, 0.0) (P<0.05). The complete success rate and qualified success rate were 73.9% (17/23) and 91.3% (21/23), respectively. The most common postoperative complications were shallow anterior chamber in 6 cases (12.5%), hypotony in 3 cases (6.3%), and blocked stent in 3 cases (6.3%). The most common postoperative treatment was needling in 27 cases (56.3%). There was no significant difference in intraocular pressure among different types of glaucoma. In the comparison of postoperative effects of different surgical implantation methods for primary open-angle glaucoma, there were no statistically significant differences in intraocular pressure and the number of glaucoma medications at other follow-up time points except 1 month after surgery (P<0.05). Univariate logistic regression analysis did not find any risk factors associated with needling and surgical complete success. Conclusions: XEN-45 Gel Stent implantation is an effective and safe surgical option for different types of glaucoma patients in China, which can significantly reduce intraocular pressure and the use of glaucoma medications and has a high success rate. However, some patients may need needling or other treatments after surgery.

Clinical Presentation and Treatment Outcomes of Pupillary Block Glaucoma Following Vitreoretinal Surgery.

PURPOSE: To describe the clinical presentation and treatment outcomes of pupillary block glaucoma (PBG) following vitreoretinal surgery (VR surgery). MATERIAL AND METHODS: Retrospective observational study of 6941 patients, who underwent VR surgery at a tertiary eye care centre in South India between January 2015 and December 2019. Amongst them, clinical data of 61 patients who developed PBG were taken for statistical analysis. RESULTS: Mean (SD) age was 53.90 (13.4) years and the incidence of PBG was .87%. Median (IQR) time of onset of PBG following VR surgery was 3.33 (1.1-6.6) months and majority were pseudophakic (75%). PBG resolved with Nd:YAG laser peripheral iridotomy (LPI) alone in 50 (82%) patients, whereas 11(18%) patients required additional interventions like surgical iridectomy, trabeculectomy or diode laser cyclophotocoagulation (CPC) either as a stand-alone procedure or in combination with silicone oil removal (SOR). Mean (SD) intraocular pressure at the onset of PBG was 41.61 (14.5) mmHg, which reduced drastically following LPI to 24.28 (14.9) mmHg which further dropped significantly at 6 months follow up to 20.34 (13.9) mmHg. CONCLUSIONS: Incidence of secondary PBG after VR surgery was .87%, and we observed diabetes mellitus, combined cataract and VR surgery, use of 1000cs SO endotamponade, intraoperative endolaser and multiple VR surgical interventions as common associations. Majority of the patients with PBG after VR procedures resolved with LPI and medical management. Few individuals (18%) required additional laser or surgical intervention for IOP control.

Treat the individual and not the angle.

BACKGROUND: Glaucoma, the silent thief of sight, is one of the most common vision-threatening conditions. Even though POAG (primary open angle glaucoma) is more common, PACG (primary angle closure glaucoma) is the dreaded variant. ISGEO (International Society for Geographical and Epidemiological Ophthalmology) has classified primary angle closure as PACS (primary angle closure suspect), PAC (primary angle closure), and PACG (primary angle closure glaucoma. The inconspicuous nature of PACS makes its diagnosis and treatment very tricky. PURPOSE: To determine which cases are best suited for laser peripheral iridotomy. SYNOPSIS: Laser peripheral iridotomy is the gold standard for acute primary angle closure glaucoma treatment. But there is a lot of confusion regarding its use in PACS as a prophylactic measure. We have tried to throw light on laser peripheral iridotomy, a much debatable topic. The video focuses on various trials regarding laser peripheral iridotomy, the indications, side effects, and contraindications. We have also discussed its use as a therapeutic and prophylactic procedure. HIGHLIGHTS: The video highlights that the approach of laser peripheral iridotomy should be on a case-by-case basis. VIDEO LINK: https://youtu.be/kiEYI9ct2Oo.

Bleb characteristics assessed by ultrasound biomicroscopy correlate with intraocular pressure after Ahmed glaucoma valve surgery in dogs.

OBJECTIVE: To assess the characteristics of blebs formed after Ahmed glaucoma valve (AGV) surgery in dogs using ultrasound biomicroscopy (UBM) and to analyze their correlation with postoperative intraocular pressure (IOP). ANIMALS: 16 eyes (13 dogs) were diagnosed with primary angle-closure glaucoma and were followed up after AGV surgery from June 2021 to September 2023. METHODS: In this prospective study, UBM examinations were performed to assess bleb characteristics, including bleb wall thickness and reflectivity. IOP at the time of UBM imaging and the duration from AGV surgery to UBM imaging were recorded. Histological examination of an enucleated eye removed due to uncontrolled IOP leading to blindness was also conducted. RESULTS: A significant correlation was observed between IOP and relative reflectivity (Pearson r = 0.60; P = .01), and a negative correlation was observed between bleb wall thickness and relative reflectivity (Pearson r = -0.72; P = .002). No significant correlation was observed between the duration from AGV surgery to UBM imaging and either bleb wall thickness or relative reflectivity, respectively. Histological examination of the enucleated eye revealed collagen-rich fibrous encapsulation of the bleb wall, including myofibroblasts that exhibited positive α-smooth muscle actin immunostaining. CLINICAL RELEVANCE: In dogs that underwent AGV surgery, less dense, thick-walled blebs on UBM tended to maintain IOP within the normal range. However, denser, thinner-walled blebs showed IOP levels above the normal range despite the use of antiglaucoma medications. UBM is a useful tool for evaluating bleb characteristics and their influence on IOP regulation after AGV surgery in dogs.

Angle-closure glaucoma associated with vitreous prolapse after neodymium-doped yttrium-aluminumgarnet laser posterior capsulotomy.

Capsulotomy with neodymium-doped yttriumaluminum-garnet (Nd:YAG) laser is an effective treatment for posterior capsule opacification following cataract surgery. A wide opening of the posterior capsule associated with the ruptured anterior hyaloid can cause anterior chamber vitreous prolapse. Two patients who developed angle-closure glaucoma associated with vitreous prolapse following Nd:YAG laser posterior capsulotomy were successfully treated with antiglaucoma medication and peripheral iridotomies. Patient identification for potential risk factors and a careful postoperative follow-up are essential to avoid these serious complications.

Lensectomy as treatment for refractory or progressive retinopathy of prematurity narrow-angle glaucoma.

We present the case of a patient with a history of laser-treated retinopathy of prematurity (ROP) who developed narrow angles and intermittent angle closure. Despite laser peripheral iridotomy/iridoplasty, 1 year later, the patient had recurrent narrowing that resolved following clear lens extraction with intraocular lens placement. This case highlights the importance of continued monitoring for narrow angles in patients with ROP history.

Influence of anterior chamber depth and vault on anterior chamber angle morphology after phakic posterior chamber intraocular lens implantation.

PURPOSE: This study aims to investigate the influence of anterior chamber depth (ACD) and vault on the anterior chamber angle (ACA) morphology in myopic individuals implanted with posterior chamber phakic intraocular lenses. METHODS: This retrospective case series involved 231 eyes receiving a 13.2-mm implantable collamer lens (ICL). Preoperative anterior chamber anatomy was assessed using anterior segment optical coherence tomography (AS-OCT) and optical tomography, while postoperative evaluation employed AS-OCT. ACA morphology was characterized pre- and postoperatively through trabecular iris angle (TIA750), ACA distance opening (AOD750) and trabecular iris space area (TISA750). The influence of ACD and vault was examined by categorizing the sample into ACD (shallow, average and deep) and vault (low, optimal and high) groups. RESULTS: Preoperative ACA morphology varied based on ACD, with shallower ACDs exhibiting narrower TIA750, smaller AOD750 and TISA750. ICL implantation induced greater ACA narrowing more in the deep ACD group (TIA750 = 20.1 degrees; AOD750 = 0.82 mm and TISA750 = 0.44 mm2) compared to the shallow ACD group (TIA750 = 15.2 degrees; AOD750 = 0.44 mm and TISA750 = 0.21 mm2). Postoperatively, deeper ACDs showed larger ACAs. Increasing vault magnitude led to increased ACA narrowing, with the low vault group exhibiting smaller closure (TIA750 = 14.3 degrees; AOD750 = 0.56 mm and TISA750 = 0.29 mm2) compared to the high vault group (TIA750 = 20.8 degrees; AOD750 = 0.73 mm and TISA750 = 0.36 mm2). The magnitude of ACA narrowing associated with the vault had a consistent effect across different ACD groups. CONCLUSIONS: Posterior chamber intraocular lens implantation results in ACA narrowing, the extent of which is contingent upon preoperative anterior chamber and ACA morphology, with additional influence from vault magnitude.

The Effects of Lens Extraction Surgery on Intraocular Pressure and Anterior Segment Parameters in Primary Angle-Closure Glaucoma.

Objectives: To investigate the effects of phacoemulsification with intraocular lens implantation (phaco+IOL) surgery on intraocular pressure (IOP) and anterior segment parameters in patients with cataract and primary angle-closure glaucoma (PACG). Materials and Methods: Fifty-five patients with PACG undergoing phaco+IOL surgery were evaluated in terms of best corrected visual acuity (BCVA), IOP, anterior chamber depth (ACD), aqueous depth (AD), and lens thickness (LT) measured by optical biometry preoperatively and at the 6-month postoperative visit. They were compared with 34 healthy age-and gender-matched cataract patients who underwent phaco+IOL surgery. Results: Preoperative evaluation revealed higher IOP, shorter axial length, shallower ACD and AD, and greater LT in the PACG group (p<0.001 for all). Postoperative evaluation in the PACG group showed an increase in BCVA, a significant decrease in IOP, an increase in ACD and AD, and a decrease in LT (p<0.001 for all). Additionally, a reduction in the average number of antiglaucomatous medications used postoperatively was observed in the PACG group (p<0.001). The changes in IOP, ACD, AD, and LT between preoperative and postoperative assessments were significantly greater in the PACG group compared to the control group (p<0.0001 for all). Conclusion: Phaco+IOL surgery in PACG patients leads to a significant increase in ACD compared to the control group and allows better control of IOP with fewer antiglaucomatous medications after surgery.

Phacoemulsification combined with goniosynechialysis versus phacoemulsification alone for patients with primary angle­closure disease: A meta-analysis.

This meta-analysis aims to systematically compare the efficacy between phacoemulsification (PE) combined with goniosynechialysis (GSL) and PE alone for primary angle-closure disease (PACD) patients. All the data were searched from the PubMed, EMBASE and the Cochrane Library. The Cochrane Handbook was used to evaluate the quality of the included studies. Additionally, this meta-analysis was performed by using the Revman 5.4 software. Nine randomized controlled trials (RCTs) were included in this study. Compared with PE alone group, PE+GSL could result significant reduction in the IOP (MD, 1.81; p = 0.002). In the instrumental subgroup, also more reduction of IOP was shown in the PE+GSL group (MD, 2.11; p = 0.02). In the viscogonioplasty (VGP) subgroup, there was not no statistical difference between PE alone group and PE+GSL group (MD, 1.53; p = 0.11). Also, more reduction of peripheral anterior synechiae (PAS) was shown in the PE+GSL group (MD,59.15; p<0.00001). For the change in angle open distance (AOD)500, AOD 750, trabecular-iris space (TISA)500, number of glaucoma medications and best corrected visual acuity (BCVA), there was no difference between two groups (p = 0.25, 0.35, 0.17, 0.56, 0.08). For TISA 750, more improvement was shown in the PE+GSL group (p<0.00001). Instrumental separation had better effect on lowering IOP when it combined with PE. Both instrumental separation and VGP could reduce postoperative PAS. The operation of GSL has no obvious effect on postoperative vision.

Long-Term Efficacy of Selective Laser Trabeculoplasty in Primary Angle-Closure Disease After Laser Peripheral Iridotomy.

PURPOSE: To evaluate the long-term efficacy of selective laser trabeculoplasty (SLT) in eyes with primary angle-closure (PAC) and primary angle-closure glaucoma (PACG) following a laser peripheral iridotomy (LPI). METHOD: In this prospective cross-sectional study, 45 eyes of 34 patients with PAC/PACG diagnosis, uncontrolled intraocular pressure (IOP), and visible pigmented trabecular-meshwork (TM) at least 180° on gonioscopy following a LPI were recruited. Following a detailed baseline ophthalmic evaluation, all eligible eyes underwent SLT, and the patients were examined on day1, at 1 week, 1-, 3-, and 6-months, and 1-, 2-, 3-, 4-, and 5-year subsequently. The main outcomes measured were IOP, number of IOP-lowering agents, and complications. RESULTS: The mean age of the cohort was 57.80 ± 6.44 years, the male-female ratio was 8:26, and 17 eyes were PACG, and 28 were PAC. The baseline IOP was 23.81 ± 1.78 mm Hg, and was significantly declined at all follow-ups (p < .0001). The cumulative probability of overall success was 91% and 84% at 2-, and 5-year, respectively. At 5-year SLT provided drug-freedom in 80% of PAC and 23% of PACG eyes. Six eyes had IOP spike at 1-week and two patients underwent repeat SLT after 1-year. No other complications, such as pain/discomfort, inflammation, an increase in peripheral anterior synechiae and cystoid-macular-edema, were noted. CONCLUSIONS: SLT appears a safe and cost-effective procedure in PAC/mild- moderate PACG eyes with uncontrolled IOP after laser iridotomy. The long-term effectiveness of SLT as adjuvant treatment was good, but need large sized randomized studies for more validation.

Phacogoniotomy versus phacotrabeculectomy for advanced primary angle-closure glaucoma with cataract: A randomized non-inferiority trial.

PURPOSE: To investigate the effectiveness and safety of phacogoniotomy versus phacotrabeculectomy (PVP) among patients with advanced primary angle-closure glaucoma (PACG) and cataracts. DESIGN: Multicenter, randomized controlled, non-inferiority trial. METHODS: A total of 124 patients (124 eyes) with advanced PACG and cataracts were enrolled, with 65 in the phacogoniotomy group and 59 in the phacotrabeculectomy group. Patients were followed up for 12 months with standardized evaluations. The primary outcome was the reduction in intraocular pressure (IOP) from baseline to 12 months postoperatively, of which a non-inferiority margin of 4 mmHg was evaluated. Secondary outcomes included the cumulative surgical success rate, postoperative complications, and changes in the number of glaucoma medications. RESULTS: After 12 months, phacogoniotomy demonstrated non-inferiority to phacotrabeculectomy in terms of IOP reduction, with mean IOP reductions of - 26.1 mmHg and - 25.7 mmHg (P = 0.383), respectively, from baseline values of around 40 mmHg. Both groups experienced a significant reduction in the mean number of medications used postoperatively (P < 0.001). The cumulative success rate was comparable between the groups (P = 0.890). However, phacogoniotomy had a lower rate of postoperative complications and interventions (12.3% and 4.6%) compared to phacotrabeculectomy (23.7% and 20.3% respectively). The phacogoniotomy group reported shorter surgery time (22.1 ± 6.5 vs. 38.8 ± 11.1 min; P = 0.030) and higher quality of life (EQ-5D-5 L) improvement at 12 months (7.0 ± 11.5 vs. 3.0 ± 12.9, P = 0.010) than the phacotrabeculectomy group. CONCLUSIONS: Phacogoniotomy was non-inferior to phacotrabeculectomy in terms of IOP reduction for advanced PACG and cataracts. Additionally, phacogoniotomy provided a shorter surgical time, lower postoperative complication rate, fewer postoperative interventions, and better postoperative quality of life.

Dysphotopsia and location of laser iridotomy: a systematic review.

This systematic review aimed to clarify the relationship between the location of laser peripheral iridotomy (LPI), a common procedure to prevent or treat angle-closure glaucoma, and the incidence of post-procedure visual disturbances known as dysphotopsias. Understanding this relationship is crucial due to the high frequency of LPIs performed and the significant impact dysphotopsia can have on vision and quality of life. Articles investigating the relationship between LPI location and dysphotopsia in at least five patients were identified via a literature search of OVID MEDLINE (1946-November 19, 2022) and EMBASE (1946-November 19, 2022). Non-comparative and non-English studies were excluded. Studies did not require a control group to be included. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and Cochrane Risk of Bias 2 (RoB2) tool were used to appraise included studies. Our review included three studies encompassing 1756 eyes from 878 patients. The location of LPI was grouped into superior (604 patients, 889 eyes), inferior (150 patients, 150 eyes), and nasal/temporal (443 patients, 717 eyes). The analysis showed no significant difference in the incidence of any new dysphotopsia types among the location groups post-LPI. Overall, the incidence of lines, ghost images, and blurring significantly increased after LPI, while halos and glare significantly decreased. In conclusion, the current literature suggests that the location of LPI has no significant relationship to the types and rates of dysphotopsia experienced thereafter. While there is a 2-3% risk of linear dysphotopsia after LPI regardless of location, LPI may also resolve pre-existing halos and glare.

Long-Term Risk and Prediction of Progression in Primary Angle Closure Suspect.

Importance: Identifying primary angle closure suspect (PACS) eyes at risk of angle closure is crucial for its management. However, the risk of progression and its prediction are still understudied in long-term longitudinal studies about PACS. Objective: To explore baseline predictors and develop prediction models for the 14-year risk of progression from PACS to primary angle closure (PAC). Design, Setting, and Participants: This cohort study involved participants from the Zhongshan Angle Closure Prevention trial who had untreated eyes with PACS. Baseline examinations included tonometry, ultrasound A-scan biometry, and anterior segment optical coherence tomography (AS-OCT) under both light and dark conditions. Primary angle closure was defined as peripheral anterior synechiae in 1 or more clock hours, intraocular pressure (IOP) greater than 24 mm Hg, or acute angle closure. Based on baseline covariates, logistic regression models were built to predict the risk of progression from PACS to PAC during 14 years of follow-up. Results: The analysis included 377 eyes from 377 patients (mean [SD] patient age at baseline, 58.28 [4.71] years; 317 females [84%]). By the 14-year follow-up visit, 93 eyes (25%) had progressed from PACS to PAC. In multivariable models, higher IOP (odds ratio [OR], 1.14 [95% CI, 1.04-1.25] per 1-mm Hg increase), shallower central anterior chamber depth (ACD; OR, 0.81 [95% CI, 0.67-0.97] per 0.1-mm increase), and shallower limbal ACD (OR, 0.96 [95% CI, 0.93-0.99] per 0.01 increase in peripheral corneal thickness) at baseline were associated with an increased 14-year risk of progression from PACS to PAC. As for AS-OCT measurements, smaller light-room trabecular-iris space area (TISA) at 500 µm from the scleral spur (OR, 0.86 [95% CI, 0.77-0.96] per 0.01-mm2 increase), smaller light-room angle recess area (ARA) at 750 µm from the scleral spur (OR, 0.93 [95% CI, 0.88-0.98] per 0.01-mm2 increase), and smaller dark-room TISA at 500 µm (OR, 0.89 [95% CI, 0.80-0.98] per 0.01-mm2 increase) at baseline were identified as predictors for the 14-year risk of progression. The prediction models based on IOP and central and limbal ACDs showed moderate performance (area under the receiver operating characteristic curve, 0.69; 95% CI, 0.63-0.75) in predicting progression from PACS to PAC, and inclusion of AS-OCT metrics did not improve the model's performance. Conclusions and Relevance: This cohort study suggests that higher IOP, shallower central and limbal ACDs, and smaller TISA at 500 µm and light-room ARA at 750 µm may serve as baseline predictors for progression to PAC in PACS eyes. Evaluating these factors can aid in customizing PACS management.

Outcomes of Filtering Surgery Versus Clear Lens Extraction in Young Patients With Angle-Closure Glaucoma.

PURPOSE: To compare the effect of filtering surgery versus clear lens extraction in young patients with medically uncontrolled angle-closure glaucoma (ACG). DESIGN: Retrospective, nonrandomized, comparative, interventional study. METHODS: We reviewed the medical charts of patients with the following scenarios: (1) age ≤40 years; (2) diagnosis of ACG without cataract, including primary angle-closure glaucoma (PACG), nanophthalmic ACG, and ACG combined with retinal dystrophies; and (3) ACG undergoing filtering surgery or clear lens extraction. The main outcomes including intraocular pressure (IOP), number of medications, best-corrected visual acuity, and severe complications were extracted at the postoperative early (within 1 week) and late stage (>3 months) follow-up. RESULTS: Data from 160 eyes of 130 young patients with ACG were available. Eyes with 76 PACG, 12 nanophthalmic ACG, and 26 ACG with retinal diseases underwent filtering surgery, whereas eyes with 22 PACG, 12 nanophthalmic ACG, and 12 ACG with retinal diseases received clear lens extraction. Overall, filtering surgery and clear lens extraction resulted in significant but comparable IOP and drug reductions at the postoperative late stage in each ACG subgroup, with similar complete success rates between 2 treatments (all P > .05). Regarding the safety, filtering surgery and patients with retinal diseases were independent factors associated with postoperative malignant glaucoma (P < .05 in both multivariable logistic regression models). CONCLUSIONS: This study highlights that the efficacy of clear lens extraction is comparable to that of filtering surgery in medically uncontrolled ACG in young patients, but clear lens extraction is safer, especially for young patients with ACG comorbid with retinal diseases.