Clinical Results of the MINIject Implant for Suprachoroidal Drainage.

Objective: This retrospective study evaluated the safety and efficacy of the new minimally invasive MINIject implant placed in the suprachoroidal space. The aim was to assess its impact on intraocular pressure (IOP) reduction and complication rate. Methods: 18 eyes from 18 patients with insufficiently controlled glaucoma received the implant using topical medications. Outcomes were changes in IOP, change in IOP medication, need for other glaucoma surgery, and rate of adverse events. Results: IOP reduced by 15% (p < 0.05) following MINIject implantation. IOP medication decreased from 3 to 1 agent (p < 0.05). Four patients (22%) required other glaucoma surgery while we did not observe any clinically relevant adverse event. Conclusions: This retrospective study indicates that MINIject implants may be a safe and effective means of reducing IOP together with a reduction in IOP medications in most patients. Larger prospective studies with longer follow-ups are necessary to confirm our results, though.

[Wound healing after trabeculectomy : What and when in postoperative aftercare?] / Wundheilung nach Trabekulektomie : Was wann in der postoperativen Nachsorge?

Excessive wound healing in filtering glaucoma surgery is a key factor for a failed surgery. After the introduction of trabeculectomy in the 1960s many factors associated with an increased fibrotic reaction were recognized and methods were developed to influence postoperative wound healing. These range from the perioperative use of anti-inflammatory drugs and antimetabolites to the use of newer chemical compounds that influence the morphology of postoperative fibroblast growth. In the routine clinical practice, the fine tuning of therapeutic decisions plays a decisive role in the success or failure of filtration surgery.

Reassessing Trabeculectomy: A Long-Term Study with Stringent Success Criteria.

Background: The aim was to evaluate the long-term outcome and efficacy of primary trabeculectomy with adjunctive mitomycin c (MMC) for treating glaucoma. Methods: We examined the medical records of 286 eyes that underwent trabeculectomy between 2008 and 2009 at the University Eye Hospital in Freiburg, Germany. Preoperative and follow-up data were collected, including intraocular pressure (IOP) measurements, surgical glaucoma interventions, and prescribed glaucoma medication. The first success criterion was defined as IOP ≤ 15 mmHg with no use of pressure-lowering medication by the patient, the second criterion was defined as the absence of surgical revision, and the third criterion as no further IOP-lowering surgery excluding early revisions following trabeculectomy. Statistical analyses comprised Cox regression and Kaplan-Meier survival estimations. Results: The mean follow-up duration was 1841 days (5 years). The mean preoperative IOP was 26.1 mmHg. Evaluating the success criteria at the time of average follow-up yielded a success rate of only 25% for the first criterion but 80% for both the second and third success criteria. Conclusions: The findings suggest that trabeculectomy with adjunctive MMC can be an effective procedure for permanently lowering IOP. However, surgical revisions and/or further glaucoma surgeries might still be needed. The long-term success rate is lower in comparison to previous research, which may be explained by the stricter success criteria in our study.

XEN®-45 implantation for refractory uveitic glaucoma.

PURPOSE: To evaluate the efficacy of XEN®-45 gel stent ab interno implantation for medically uncontrolled uveitic glaucoma. METHODS: Retrospective analysis of 25 eyes receiving XEN® gel stent for medically uncontrolled uveitic glaucoma from February 2019 to February 2023 with recording of intraocular pressure (IOP) values, ocular hypotensive medication, requirement for revision or secondary surgery and complications. Prerequisites for XEN® implantation were a clear cornea, an open iridocorneal angle and an unscarred, mobile conjunctiva at the implantation site. Minimum follow-up required for inclusion was 3 months. The primary outcome measure was IOP compared to baseline. Complete and qualified success were defined as final IOP of ≤ 18 mmHg without or with topical antiglaucomatous treatment, respectively. Failure was defined as IOP > 18 mmHg on two consecutive visits, IOP reduction < 20%, persisting complications from hypotony and open conjunctival bleb revision. Further glaucoma surgical intervention was defined as complete failure. RESULTS: Mean preoperative IOP was 35.3 ± 10.9 mmHg on 2.9 ± 0.9 topical antiglaucomatous agents. 19 of 25 patients (76%) received additional oral acetazolamide. 19 eyes were pseudophakic, 5 eyes phakic and 1 aphakic. Early postoperatively, mean IOP reduced to 7.7 ± 3.0 mmHg (75.8% reduction). At final follow-up (mean 17.7 months) mean IOP was 12.0 ± 3.8 mmHg (62.5% reduction) on 0.2 ± 0.6 medications. Six eyes (24%) required bleb revision at mean 28 weeks and therefore were categorized as failure. One eye failed despite bleb revision and restart of topical ocular hypotensive medication. Three other eyes (12%) had IOP spikes with uveitis flare-ups. Transient hypotony complications occurred in 32%. At final follow-up, 18 eyes (72%) achieved complete success and one eye (4%) qualified success. CONCLUSION: The XEN® gel stent effectively reduced IOP in uncontrolled uveitic glaucoma, with 72% complete success. Bleb revision was required in 24%. IOP spikes occurred in 12% despite functioning blebs. Further follow-up is needed to determine long-term outcomes.

Slow Interstitial Fluid Flow Activates TGF-ß Signaling and Drives Fibrotic Responses in Human Tenon Fibroblasts.

BACKGROUND: Fibrosis limits the success of filtering glaucoma surgery. We employed 2D and 3D in vitro models to assess the effects of fluid flow on human tenon fibroblasts (HTF). METHODS: HTF were exposed to continuous or pulsatile fluid flow for 48 or 72 h, at rates expected at the transscleral outflow site after filtering surgery. In the 2D model, the F-actin cytoskeleton and fibronectin 1 (FN1) were visualized by confocal immunofluorescence microscopy. In the 3D model, mRNA and whole cell lysates were extracted to analyze the expression of fibrosis-associated genes by qPCR and Western blot. The effects of a small-molecule inhibitor of the TGF-ß receptor ALK5 were studied. RESULTS: Slow, continuous fluid flow induced fibrotic responses in the 2D and 3D models. It elicited changes in cell shape, the F-actin cytoskeleton, the deposition of FN1 and activated the intracellular TGF-ß signaling pathway to induce expression of fibrosis-related genes, such as CTGF, FN1 and COL1A1. ALK5-inhibition reduced this effect. Intermittent fluid flow also induced fibrotic changes, which decreased with increasing pause duration. CONCLUSIONS: Slow interstitial fluid flow is sufficient to induce fibrosis, could underlie the intractable nature of fibrosis following filtering glaucoma surgery and might be a target for antifibrotic therapy.

XEN®-63 Compared to XEN®-45 Gel Stents to Reduce Intraocular Pressure in Glaucoma.

The XEN® gel stent reduces intraocular pressure (IOP) in glaucoma. XEN®-45 is widely used; the newer XEN®-63 has a larger lumen targeting potentially lower IOP outcomes. We retrospectively compared the first 15 XEN®-63 cases to 15 matched XEN®-45 controls. With a preoperative IOP of 18.1 ± 3.9 mmHg (mean ± SD) and a final IOP of 9.1 ± 2.0 mmHg, XEN®-63 implantation resulted in an IOP reduction of 44.6 ± 16.5%. Similarly, with a preoperative IOP of 18.3 ± 4.5 mmHg and a final IOP of 10.3 ± 2.1 mmHg, XEN®-45 implantation resulted in an IOP reduction of 40.1 ± 17.2%. The median follow-up period was 204 days (range 78-338 days) for the XEN®-63 group and 386 days (range 99-1688 days) for the XEN®-45 group. In total, 5/15 eyes of each group underwent open conjunctival bleb revision within the period of observation. Three eyes of the XEN®-63 group had secondary glaucoma surgery. One eye in the XEN®-63 group and three eyes in the XEN®-45 group required a restart of antiglaucomatous medication. In conclusion, both stents effectively lower IOP and medication. XEN®-63 achieved a slightly lower IOP over a short follow-up. Complication and revision rates were similar.

[Primary Open Angle Glaucoma]. / Das primäre Offenwinkelglaukom.

Primary open angle glaucoma is the most frequent type among the glaucomas. It is characterized by a progressive loss of retinal ganglion cells and a corresponding visual field loss. Risk factors include older age, ethnicity, family history of glaucoma and, most important, an elevated intraocular pressure (IOP). The IOP is the only modifiable risk factor for glaucoma progression. Therapeutic approaches aim to lowering the IOP and incorporate topical pressure lowering medication, laser treatment, and different surgical approaches. Surgery aims to reducing the outflow resistance of the aqueous humor. This may be achieved by surgically opening the trabecular meshwork or Schlemm's canal. Penetrating glaucoma surgery comprises classic trabeculectomy and other draining devices.

[Angle closure-glaucoma]. / Das Winkelblockglaukom.

Angle-closure glaucoma is a less common form of glaucoma in Europe than open-angle glaucoma. Nevertheless, the clinical picture should also be known here since it can lead to severe visual disturbances and even blindness within a short time. It is divided into primary and secondary forms and can be further categorized depending on the presence of a pupillary block. In all cases, therapy is initially based on resolving the cause of the angle-closure and treating any underlying disease that may be present. In addition, intraocular pressure reduction must be achieved. This can be effectuated conservatively or surgically. Depending on the specific subtype of angle-closure, different treatments are promising.

Comparison between Intraocular Pressure Profiles over 24 and 48 h in the Management of Glaucoma.

(1) Background: Due to significant variation, sporadic IOP measurements often fail to correctly assess the IOP situation in glaucoma patients. Thus, diurnal-nocturnal IOP profiles can be used as a diagnostic tool. The purpose of this study is to determine the additional diagnostic value of prolonged IOP profiles. (2) Methods: All diagnostic 48 h IOP profiles from a large university hospital, between 2017 and 2019, were reviewed. Elevated IOP > 21 mmHg, IOP variation > 6 mmHg and nocturnal IOP peaks were defined as IOP events of interest and counted. The analysis was repeated for the first 24 h of every IOP profile only. The Chi2 test was used for statistical analysis. (3) Results: 661 IOP profiles were included. Specifically, 59% of the 48 h IOP profiles revealed IOP values above 21 mmHg, and 87% showed IOP fluctuation greater than 6 mmHg. Nocturnal peaks in the supine position could be observed in 51% of the patients. In the profiles censored for the first 24 h, the fractions were 50%, 71% and 48%, (p < 0.01, p < 0.01 and p = 0.12) respectively. (4) Conclusions: the 48 h IOP profiles identified more patients with IOP events of interest than the 24 h IOP profiles. The additional diagnostic value must be weighed against the higher costs.

A comparison of long-term results after Baerveldt 250 implantation in advanced uveitic vs. other forms of glaucoma.

INTRODUCTION: Uveitic glaucoma remains challenging despite medical and surgical advancements and can potentially lead to blindness if left uncontrolled. Conservative alternatives as well as microinvasive surgeries can postpone the necessity of a highly invasive intervention. However, such procedures are still necessary to treat some refractive glaucoma cases. Since previous studies have reported excellent results following the primary implantation of glaucoma drainage devices, it was our study's aim to evaluate long-term results following a Baerveldt 250 implantation in highly complex and surgically burdened uveitic glaucoma eyes (UG) and compare these to a similar population suffering from other forms of glaucoma (OFG). MATERIAL AND METHODS: We performed a retrospective analysis of all eyes (UG vs. OFG) following a Baerveldt 250 implant between 2013 and 2019. Efficacy parameters as well as post-operative complication data were extracted from our electronic data system for statistical analysis. RESULTS: A total of 62 eyes were included in our study (24 UG and 38 OFG). UG baseline mean IOP was 35.04 mmHg (± 11.85 mmHg) with 3.08 (± 1.13) topical agents, and OFG was 32.63 mmHg (± 7.74 mmHg) with 2.68 (± 1.28) topical agents. A majority of eyes also required systemic acetazolamide (UG: 79% OFG: 87%) and had undergone at least one glaucoma-related operation prior to the Baerveldt 250 implant ((UG: 1.21 (± 0.66)), OFG: 1.74 (± 1.33)). At the median follow-up period (UG 592, OFG 764 days), 52.5%/32.5% of UG/OFG cases showed qualified success (IOP below 21 mmHg with either topical or/and systemic medication), 15%/30% no longer required topical medication, and 47.5% /47.5% were free of acetazolamide systemically. Moreover, 75%/72.5% of eyes experienced no further pressure-related surgical event. Although sight-threatening complications such as corneal and macular edema were reported in both groups, most either maintained or improved their visual acuity at the last follow-up (58.33%/57.89%). CONCLUSION: The Baerveldt 250 implant is shown to be both effective and safe for advanced glaucoma cases in uveitis and other forms. No further glaucoma-related surgery is required in the majority of eyes in either group within a follow-up period of almost 2 years. Despite sight-threatening complications such as macular and corneal edema, visual acuity can be either maintained or improved in most eyes.

Acute Closed-Angle Glaucoma-an Ophthalmological Emergency.

BACKGROUND: Acute closed-angle glaucoma has an incidence of 2.2-4.1 cases per 100 000 persons per year in Europe. It is an ophthalmological emergency in which markedly elevated intraocular pressure can damage vision permanently. Because the acute symptoms are not always clearly referable to the eyes, patients often present to physicians who are not ophthalmologists. METHODS: This review is based on pertinent articles retrieved by a selective search in PubMed. RESULTS: The diverse symptoms of acute closed-angle glaucoma include eye redness, worsening of vision and other visual disturbances, headache, and nausea. Acute closed-angle glaucoma has multiple causes. Not all predisposing factors have been definitively identified; above all, there are certain anatomical configurations of the eye that make it more likely to arise. The goals of treatment are to reduce the elevated intraocular pressure rapidly, which usually leads to marked symptom relief, as well as to eliminate the situation that led to closed-angle glaucoma. For proper treatment, the patient should be seen by an ophthalmologist without delay, on the day of symptom onset if possible. CONCLUSION: Primary prevention of acute closed-angle glaucoma is not always possible. Even physicians who are not ophthalmologists can diagnose markedly elevated intraocular pressure by palpation of the globe. Proper, specific treatment can help patients rapidly and lastingly.

[Secondary Angle Closure Glaucoma]. / Sekundäre Winkelblockglaukome.

Secondary angle closure glaucoma is a very heterogeneous subtype of glaucoma with a variety of possible causes leading to a blockade of the regular aqueous humour flow or outflow. A distinction is made between secondary pupillary block, angle closure with "pulling" or angle closure with "pushing" mechanisms. For each of these three subgroups, there are different causes, which in turn require individual therapy. Treatment of the underlying cause should always take priority whenever possible. Reduction of the intraocular pressure is often a symptomatic therapy with surgical, pressure lowering procedures showing a limited success rate in many forms of secondary angle closure glaucoma. This article intends to provide an overview of the different causes of secondary angle closure, diagnostic approaches and targeted therapies of exemplary causes of each subgroup.From the group of secondary pupillary block, mechanical causes, iris bombé, and intraoperative air or oil input are addressed, from the group of "pulling" causes, angle neovascularization, post-inflammatory angle changes, and iridocorneal endothelial syndrome and for the group of "pushing" mechanisms, gas endotamponade, retroiridal neoplasms and aqueous misdirection syndrome.While secondary angle closure is one of the most challenging glaucoma subgroups for treatment it is crucial to know the different subgroups and their development to choose the right treatment.

A comparison of optic disc area measured by confocal scanning laser tomography versus Bruch's membrane opening area measured using optical coherence tomography.

BACKGROUND: Precise optic disc size measurements based on anatomically exact disc margins are fundamental for a correct assessment of glaucoma suspects. Computerized imaging techniques, such as confocal-scanning-laser-tomography (CSLT), which applies operator defined boundaries and optical-coherence-tomography (OCT), which incorporates an alternative detectable landmark (Bruch's-membrane-opening (BMO)), have simplified the planimetry of the optic disc and BMO-area, respectively. This study's objectives are to compare both modalities for area and to define a threshold for macro-BMO using BMO-OCT. METHODS: Retrospectively, patients that simultaneously received CSLT and BMO-OCT scans were included. Their images were correlated and agreement was determined using Bland-Altman-analysis. The diagnostic power of a macro-BMO threshold using OCT was derived after creating a receiver-operating-characteristics-curve using the well-established analogous CSLT threshold (2.43 mm2). RESULTS: Our study included 373 eyes with a median optic disc area by CSLT/ BMO-area by OCT of 2.56 mm2 and 2.19 mm2 respectively. The Bland-Altman-analysis revealed a systematic deviation with a diverging tendency with increasing area, which enabled the creation of the following mathematical relation: disc-area (CSLT)*0.73 + 0.3 = BMO-area (OCT). BMO-area of 2.19 mm2 showed the best diagnostic power for identifying macro-BMOs using OCT (sensitivity: 75%, specificity: 86%). CONCLUSIONS: Area measurements (CSLT optic disc area vs. BMO-area by OCT) showed a systematic deviation with a divergent tendency with increasing size. Our mathematical equation offers an estimated comparison of these anatomically diverse entities. Considering BMO-OCT´ anatomical accuracy, the 2.19 mm2 threshold may improve discernment between glaucoma suspects and norm variants.

[Chronification of malignant glaucoma after cataract surgery]. / Chronifiziertes malignes Glaukom nach Kataraktoperation.

The occurrence of malignant glaucoma several years after cataract surgery is a very rare delayed complication. An increasing myopic shift can be an early hint for the formation. A surgical intervention is often inevitable; however, intraocular pressure can also be successfully managed with conservative treatment as in the case described. Therefore, treatment should be adapted to the situation and individually decided how invasive the treatment must be and whether a vitrectomy is absolutely necessary.

Thinner temporal peripapillary retinal nerve fibre layer in Stargardt disease detected by optical coherence tomography.

PURPOSE: To evaluate peripapillary retinal nerve fibre layer (RNFL) thickness measured by spectral domain optical coherence tomography (OCT) in patients with Stargardt disease (STGD). METHODS: A cross-sectional, monocentric, observational case-control study. Twenty patients (39 eyes) with ABCA4 mutations graded according to the Fishman STGD classification were included. RNFL measurement was performed using Heidelberg Spectralis SD-OCT. RNFL thickness in STGD patients was compared to age-matched data of healthy individuals provided by the device's manufacturer. A manual readjustment of the optic disc-fovea angle was performed when needed. RESULTS: The mean age at first diagnosis of STGD was 22.9 years (range 9 to 50) and 39.1 years (range 18 to 74) at the time of examination. Thirty-nine percent of eyes (15 eyes) needed manual adjustment of the optic disc-fovea angle due to malfixation of the patients during OCT. The temporal quadrant corresponding to the macula showed a RNFL 16% thinner than controls (mean - 12 µm, 95%CI - 9 to -15 µm). However, global RNFL thickness did not differ from controls due to increased RNFL thickness of 12% in the nasal sectors. Duration and stage of STGD were not correlated to thinner RNFL. CONCLUSION: STGD seems to be associated with thinner peripapillary RNFL in the sector of axons projecting to the degenerated macular area. It is yet unclear as to whether this results from anterograde transneuronal degeneration of direct injury to retinal ganglion cells.

Prevention of Ocular Tenon Adhesion to Sclera by a PDMAA Polymer to Improve Results after Glaucoma Surgery.

The authors describe a process that may eventually reduce the risk of scar formation after glaucoma surgery. For this, a thin hydrogel coating is photochemically generated and linked to the sclera surface at the surgical site. This coating is generated from a photoreactive prepolymer containing anthraquinone groups, which is administered as a thin pad to the sclera surface. Short UV irradiation leads to a reaction of the photogroups with neighboring chains via C-H insertion crosslinking, thus transforming the precursor polymer into a hydrogel. Simultaneously, a reaction between the photogroups and the underlying sclera tissue occurs, so that the hydrogel patch becomes covalently linked to the tissue. The authors show that the resulting thin coating is strongly cell repellent and hinders tenon fibroblasts to form tenon tissue at the site of the coating and is suitable for inclusion into a surgical procedure.