Trabeculectomy with Suprachoroidal Derivation in Eyes with Uncontrolled Glaucoma: A Case Series with a 24-Month Follow-up.

INTRODUCTION: The aim of this study was to evaluate the efficacy of trabeculectomy with suprachoroidal derivation in eyes with uncontrolled glaucoma after a 24-month follow-up period. METHODS: This was a prospective uncontrolled non-randomized case series. All patients scheduled for a trabeculectomy due to uncontrolled glaucoma at the "Instituto de Glaucoma y Catarata" (Lima, Peru) between 2011 and 2014 were included. Thee patients underwent trabeculectomy with mitomycin C and suprachoroidal derivation with two autologous scleral flaps. Postsurgical follow-up visits took place on day 1, and at 1, 6, 12, 18 and 24 months. Best corrected visual acuity (BCVA), intraocular pressure (IOP) and complications at each control were registered. Main outcome measures were IOP reduction, number of glaucoma medications and complication rate. Postoperative IOP of > 21 mmHg, < 5 mmHg, additional glaucoma surgery or severe complications were considered as indications of failure. RESULTS: Thirty-three participants (41 eyes) were included in the study, of whom 27 (81.82%) (31 eyes [75.61%]) finished the 24 months of follow-up. At the end of the follow-up, mean IOP had decreased by 11.29 ± 9.32 mmHg (p < 0.001), and glaucoma medication usage in 25 (25/31; 80.65%) eyes had stopped. Ten (10/41; 24.39%) patients complained of blurred vision, and 15 (15/41; 36.59%) patients referred to foreign body sensation the first day after surgery; both sensations resolved spontaneously after 1 week in all cases. No failures, significant changes in BCVA (p = 0.387) or severe complications were found. CONCLUSIONS: In this case series, trabeculectomy with suprachoroidal derivation exhibited high efficacy and safety after a 24-month follow-up. A larger sample with a control group is needed to confirm our initial findings.

Level of agreement among Latin American glaucoma subspecialists on the diagnosis and treatment of glaucoma: results of an online survey.

PURPOSE: The aim of this research was to assess the level of agreement among glaucoma experts in Latin America on key practices related to treatment and diagnosis of glaucoma. METHODS: An online questionnaire was sent to a multinational panel of glaucoma experts. The questionnaire contained 107 statements on the medical treatment (Part 1) and diagnosis (Part 2) of glaucoma, and was developed in Spanish and translated into English. Agreement was defined as >70% of respondents. RESULTS: Fifty participants from 14 countries completed the questionnaire. For the medical treatment of glaucoma, nearly all respondents (98% or greater) confirmed that medical treatment as first-line therapy is preferred to surgery, prostaglandin analogs are the medication of first choice for primary open-angle glaucoma (POAG), longitudinal monitoring of efficacy should include intraocular pressure, structural and functional status, as well as if patients' quality of life is impaired by the high cost of medication. For the diagnosis of glaucoma section, all respondents confirmed that, after initial examination, gonioscopy should be repeated over time, standard automated perimetry is the most important functional examination for diagnosis and monitoring of primary open-angle glaucoma, central corneal thickness is important in assessment of glaucoma, and computerized imaging tests help in clinical evaluation of optic disc. CONCLUSIONS: This survey shows a high level of agreement on most aspects of glaucoma diagnosis and treatment among Latin American glaucoma experts. Areas of disagreement highlight the need for further evidence or education. These findings will be useful for guiding future efforts to optimize glaucoma practice by clinicians in Latin America.

Level of agreement among Latin American glaucoma subspecialists on the diagnosis and treatment of glaucoma: results of an online survey / Nível de concordância entre subespecialistas de glaucoma latino-americanos sobre o diagnóstico e tratamento do glaucoma: resultados de uma pesquisa digital

PURPOSE: The aim of this research was to assess the level of agreement among glaucoma experts in Latin America on key practices related to treatment and diagnosis of glaucoma. METHODS: An online questionnaire was sent to a multinational panel of glaucoma experts. The questionnaire contained 107 statements on the medical treatment (Part 1) and diagnosis (Part 2) of glaucoma, and was developed in Spanish and translated into English. Agreement was defined as >70% of respondents. RESULTS: Fifty participants from 14 countries completed the questionnaire. For the medical treatment of glaucoma, nearly all respondents (98% or greater) confirmed that medical treatment as first-line therapy is preferred to surgery, prostaglandin analogs are the medication of first choice for primary open-angle glaucoma (POAG), longitudinal monitoring of efficacy should include intraocular pressure, structural and functional status, as well as if patients' quality of life is impaired by the high cost of medication. For the diagnosis of glaucoma section, all respondents confirmed that, after initial examination, gonioscopy should be repeated over time, standard automated perimetry is the most important functional examination for diagnosis and monitoring of primary open-angle glaucoma, central corneal thickness is important in assessment of glaucoma, and computerized imaging tests help in clinical evaluation of optic disc. CONCLUSIONS: This survey shows a high level of agreement on most aspects of glaucoma diagnosis and treatment among Latin American glaucoma experts. Areas of disagreement highlight the need for further evidence or education. These findings will be useful for guiding future efforts to optimize glaucoma practice by clinicians in Latin America.

OBJETIVO: Avaliar o nível de concordância entre os especialistas de glaucoma na América Latina sobre as práticas mais importantes relacionadas ao tratamento e diagnóstico de glaucoma. MÉTODOS: Um questionário digital foi enviado a um painel multinacional de especialistas em glaucoma. O questionário continha 107 declarações sobre o tratamento médico (Parte 1) e diagnóstico (Parte 2) de glaucoma, e foi desenvolvido em espanhol e traduzido para o Inglês. Concordância foi definida como > 70% dos entrevistados. RESULTADOS: Cinquenta participantes de 14 países responderam ao questionário. Para o tratamento médico de glaucoma, quase todas as respostas (98% ou mais), confirmaram que o tratamento médico como terapia de primeira linha é preferido para a cirurgia, os análogos das prostaglandinas são os medicamentos de primeira escolha para o glaucoma primário de ângulo aberto (GPAA), a monitoração longitudinal eficácia deve incluir a pressão intraocular o estado estrutural e funcional além da qualidade de vida do paciente ser prejudicada pelo alto custo da medicação. Para a seção sobre o diagnóstico de glaucoma, todos os entrevistados confirmaram que, após análise inicial, a gonioscopia deve ser repetida ao longo do tempo, a perimetria automatizada padrão é o exame funcional mais importante para o diagnóstico e monitoramento do glaucoma primário de ângulo aberto, a espessura corneana central é importante na avaliação do glaucoma e exames de imagem computadorizados ajudam na avaliação clínica do disco óptico. CONCLUSÕES: Este estudo mostra um alto nível de concordância na maioria dos aspectos do diagnóstico e tratamento de glaucoma entre os especialistas em glaucoma latino-americanos. Áreas de desacordo destacam a necessidade de novas evidências ou educação. Estes resultados serão úteis para orientar futuros esforços na otimização de práticas em relação ao glaucoma por médicos da América Latina.

An eight-week, multicentric, randomized, interventional, open-label, phase 4, parallel comparison of the efficacy and tolerability of the fixed combination of timolol maleate 0.5%/brimonidine tartrate 0.2% versus fixed combination of timolol maleate 0.5%/dorzolamide 2% in patients with elevated intraocular pressure.

PURPOSE: To compare the efficacy and tolerability of the fixed combination of timolol maleate 0.5%/brimonidine tartrate 0.2% versus fixed combination of timolol maleate 0.5%/dorzolamide 2% in patients with elevated intraocular pressure (IOP) over 8 weeks. PATIENTS AND METHODS: This 8-week, multicentric, interventional, randomized, open-label, parallel group study was conducted at 4 centers in Brazil and 1 center in Argentina. Patients with open-angle glaucoma or ocular hypertension were randomized to receive bilaterally fixed combination of brimonidine/timolol maleate 0.5% or fixed combination of dorzolamide 2%/timolol 0.5% twice daily at 8:00 AM and 8:00 PM. A modified diurnal tension curve (8:00 AM, 10:30 AM, 02:00 PM, and 4:00 PM) followed by the water drinking test (WDT), which estimates IOP peak of diurnal tension curve, were performed in the baseline and week-8 visits. Adverse events data were recorded at each visit. RESULTS: A total of 210 patients were randomized (brimonidine/timolol, n=111; dorzolamide/timolol, n=99). Mean baseline IOP was 23.43+/-3.22 mm Hg and 23.43+/-4.06 mm Hg in the patients treated with brimonidine/timolol and dorzolamide/timolol, respectively (P=0.993). Mean diurnal IOP reduction after 8 weeks were 7.02+/-3.06 mm Hg and 6.91+/-3.67 mm Hg, respectively (P=0.811). The adjusted difference between groups (analysis of covariance) at week 8 was not statistically significant (P=0.847). Mean baseline WDT peak was 27.79+/-4.29 mm Hg in the brimonidine/timolol group and 27.68+/-5.46 mm Hg in the dorzolamide/timolol group. After 8 weeks of treatment, mean WDT peaks were 20.94+/-3.76 mm Hg (P<0.001) and 20.98+/-4.19 (P<0.001), respectively. The adjusted difference between groups (analysis of covariance) was not statistically significant (P=0.469). No statistical difference in terms of adverse events was found between groups. CONCLUSIONS: Both fixed combinations were capable of significantly reducing the mean diurnal IOP, mean diurnal peak, and mean WDT peak after 8 weeks of treatment. Also, both fixed combinations are well tolerated with few side effects.

Concave trabeculo-Descemet's membrane as an early sign of viscocanalostomy failure.

PURPOSE: To correlate trabeculo-Descemet's membrane (TDM) changes with a late rise in intraocular pressure (IOP) in patients with successful viscocanalostomy. SETTING: Consultores Oftalmológicos, Hospital Oftalmológico Santa Lucía, and Centro de Estudios Médicos e Investigación, Buenos Aires, Argentina. METHODS: Patients who had a viscocanalostomy between July 1998 and September 2001 were retrospectively studied. Gonioscopy was performed in all patients. A subgroup of patients who had a late increase in IOP and were successfully treated with neodymium:YAG (Nd:YAG) laser goniopuncture were studied to correlate gonioscopic findings. Ultrasound biomicroscopy was performed in 10 cases. Intraocular pressure measurements were taken before viscocanalostomy and before and after Nd:YAG treatment. RESULTS: Sixty-eight eyes of 48 patients had a viscocanalostomy to control IOP. Twenty-six eyes had a late increase in IOP and were successfully treated with Nd:YAG laser goniopuncture. Before goniopuncture, 17 eyes (65.30%) had a concave TDM. The mean IOP in these patients increased from 14.27 mm Hg to 18.73 mm Hg (range 14 to 27 mm Hg). Goniopuncture was performed a mean of 10.7 months (range 1 to 36 months) after surgery. After Nd:YAG treatment, the TDM was flat in all patients who had a concave TDM before treatment. At the last examination, the mean IOP was 13.8 mm Hg, a mean decrease of 52.24% from the baseline preoperative IOP; 61.5% of eyes had a final IOP of 14.0 mm Hg or lower. CONCLUSIONS: A concave TDM was associated with a late IOP rise. The TDM was flat after laser goniopuncture and normalization of IOP.

Midterm ultrasound biomicroscopy findings in eyes with successful viscocanalostomy.

PURPOSE: To show tissue changes using ultrasound biomicroscopy (UBM) in eyes with controlled intraocular pressure (IOP) after viscocanalostomy. SETTING: Consultores Oftalmológicos, Fundación Oftalmológica Argentina Jorge Malbran and Hospital Santa Lucía, Buenos Aires, Argentina. METHODS: This retrospective noncomparative case series comprised 23 eyes of 19 patients with uncontrolled open-angle glaucoma who had viscocanalostomy and UBM and a mean follow-up of 20 months +/- 5.9 (SD) (range 12 to 30 months). The UBM measurements were taken a mean of 6.8 +/- 5.9 months (range 3 to 14 months) after the viscocanalostomy. In 7 eyes, UBM was again performed a mean of 7.8 +/- 4.6 months (range 7 to 9 months) after the first study. All patients had preoperative and postoperative IOP measurements. RESULTS: The mean IOP at last examination was 13.3 +/- 2 mm Hg (range 8 to 17 mm Hg). One eye had evidence of a subconjunctival bleb. All eyes had a nonreflective scleral chamber and posterior to it, a hyporeflective zone. In 7 eyes in which 2 UBMs were performed, the scleral chamber was unchanged 7 to 9 months after the first study. CONCLUSIONS: The presence of a scleral chamber and absence of a subconjunctival filtering bleb are the usual UBM findings in eyes with adequate control of IOP several months after viscocanalostomy. These findings suggest that viscocanalostomy is successful when a continuous aqueous flow through the trabeculo-Descemet's membrane is present, maintaining a scleral chamber.

Biomicroscopía ultrasónica en ojos con aceite de silicón / UBM in eyes with silicon-oil

Objetivo: establecer patrones de imágenes de UBM, característicos de la presencia y comportamiento del aceite de silicón y de la proliferación vitreoretinal periférica en ojos sometidos cirugíavitreoretinal con inyección de aceite de silicón. Métodos: El diseño del estudio es una serie de casos. Se realizó UBM en 34 ojos de 34 pacientes entre 20 y 68 años. Para ser considerada patrón de UBM la imágen debe: ser reproducible en el mismo ojo, y ser observada en más de un ojo. Resultados: Se describieron los siguientes patrones principales: partículas de silicón, imágenes fantasma, pintado o impregnación de la superficie del iris y del ángulo de la cámara anterior, y proliferación vitreoretinal (PVR). Un tipo de imágen fantasma es el reflejo secundario de la córnea, cuando desaparece la interfase acuoso-aceite de silocón, en caso de desplazamiento masivo del aceite de silicón a la cámara anterior. La proliferación vitreoretinal produce imágenes en embudo y en tienda que podrían representar alteraciones tempranas. Hay una estrecha correspondencia entre estos patrones y los hallazgos aftalmológicos efectuados previamente. Conclusión: Fácilmente reconocibles, los distintos patrones de UBM son característicos de las condiciones encontradas en los ojos con aceite de silicón.

Biomicroscopía ultrasónica en ojos con aceite de silicón / UBM in eyes with silicon-oil

Objetivo: establecer patrones de imágenes de UBM, característicos de la presencia y comportamiento del aceite de silicón y de la proliferación vitreoretinal periférica en ojos sometidos cirugíavitreoretinal con inyección de aceite de silicón. Métodos: El diseño del estudio es una serie de casos. Se realizó UBM en 34 ojos de 34 pacientes entre 20 y 68 años. Para ser considerada patrón de UBM la imágen debe: ser reproducible en el mismo ojo, y ser observada en más de un ojo. Resultados: Se describieron los siguientes patrones principales: partículas de silicón, imágenes fantasma, pintado o impregnación de la superficie del iris y del ángulo de la cámara anterior, y proliferación vitreoretinal (PVR). Un tipo de imágen fantasma es el reflejo secundario de la córnea, cuando desaparece la interfase acuoso-aceite de silocón, en caso de desplazamiento masivo del aceite de silicón a la cámara anterior. La proliferación vitreoretinal produce imágenes en embudo y en tienda que podrían representar alteraciones tempranas. Hay una estrecha correspondencia entre estos patrones y los hallazgos aftalmológicos efectuados previamente. Conclusión: Fácilmente reconocibles, los distintos patrones de UBM son característicos de las condiciones encontradas en los ojos con aceite de silicón. (AU)