Effect of COVID-19 pandemic on glaucoma surgical practices in the UK.

BACKGROUND/AIM: The aim of the study was to examine the effect of the COVID-19 pandemic on glaucoma surgical practices within the UK. METHODS: A cross-sectional online survey was distributed to all consultant glaucoma specialists who are on the UK and Eire Glaucoma Society contact list. Participants were asked specific questions regarding preferences in glaucoma surgical practices and whether these had changed subsequent to the onset of the COVID-19 pandemic. RESULTS: Trabeculectomy was the procedure of choice for 61 (87%) glaucoma specialists. A total of 51 (73%) respondents reported performing minimally invasive glaucoma surgery (MIGS) procedures before the COVID-19 pandemic. The most commonly performed MIGS procedure was the iStent inject (51%), followed by XEN 45 (36%) and Preserflo (17%). Forty-three (61%) respondents reported modifying their glaucoma surgery practice subsequent to the onset of the COVID-19 pandemic. Of the glaucoma specialists who modified their surgical practices, 21 (43%) specifically reduced the number of trabeculectomies performed. In combination, diode laser (both micropulse and conventional trans-scleral cyclodiode) was the most common alternative procedure. Glaucoma drainage devices, deep sclerectomy and Preserflo were also commonly chosen alternatives. CONCLUSION: Although trabeculectomy remains the most commonly performed established glaucoma surgery, it is being performed with reduced frequency during the COVID-19 pandemic due to the number of postoperative visits and procedures required. Alternatives such as conventional and micropulse diode laser, glaucoma drainage devices, deep sclerectomy and Preserflo appear to be the favoured alternative procedures.

Outcomes of Primary Trabeculectomy From Two Same-centre Cohorts 10 Years Apart.

PRECIS: Trabeculectomy can effectively lower intraocular pressure (IOP). A more junior surgeon profile is emerging. Mitomycin C (MMC) has replaced 5-fluorouracil (5-FU) intraoperatively with comparable success rates and a decrease in postoperative antimetabolite administration. PURPOSE: We compare 2-year outcomes for primary trabeculectomy in 2 cohorts, 10 years apart, performed at a large UK teaching hospital. METHODS: Consecutive case series of trabeculectomies at Manchester Royal Eye Hospital between 2004-2005 (Cohort 1/C1) and 2014-2015 (Cohort 2/C2). Preoperative and postoperative data was collected for IOP outcomes and complications. Success was defined as IOP ≥6 and ≤21, ≤18, ≤16, ≤14, or ≤12 mm Hg with/without a ≥20% decrease from preoperative IOP. The need for and absence of postoperative antihypertensive medication defined qualified and complete success, respectively. RESULTS: A total of 186 cases were analyzed [52 (C1), 134 (C2)]. Mean preoperative IOP was 24±10 mm Hg (C1) and 21±7 mm Hg (C2) (P=0.01). Overall, 34 (79%), 33 (77%), 33 (77%), 29 (67%), and 25 (58%) patients in C1 and 88 (70%), 82 (65%), 73 (58%), 64 (51%), and 40 (32%) patients in C2 achieved complete success for IOP ≤21 mm Hg (P=0.33), ≤18 mm Hg (P=0.22), ≤16 mm Hg (P=0.04), ≤14 mm Hg (P=0.09), or ≤12 mm Hg (P=0.004). Similarly, 43 (93%), 40 (87%), 40 (87%), 35 (76%), and 27 (59%) in C1 and 123 (98%), 116 (92%), 106 (84%), 87 (69%), and 58 (49%) in C2 achieved qualified success (P=0.34, 0.37, 0.83, 0.48, and 0.19). In all, 32 (74%), 31 (72%),31 (72%), 28 (65%), and 24 (56%) in C1 and 64 (51%), 63 (50%), 61 (48%), 54 (43%), and 39 (31%) in C2 achieved complete success with ≥20% reduction from preoperative IOP and IOP of ≤21 mm Hg (P=0.01), ≤18 mm Hg (P=0.02), ≤16 mm Hg (P=0.01), ≤1 mm Hg (P=0.02), or ≤12 mm Hg (P=0.006). By same definition, 37 (80%), 36 (78%), 36 (78%), 33 (72%), and 26 (57%) in C1 and 94 (75%), 93 (74%), 90 (71%), 75 (60%), and 58 (46%) in C2 achieved qualified success (P=0.55, 0.69, 0.48, 0.20, and 0.30). Mean IOP at 2 years was 13±5 mm Hg (C1) and 13±4 mm Hg (C2) (P=0.35). Overall, 62% had intraoperative 5-FU in C1; only MMC was used in C2 (P<0.0001). Postoperative 5-FU was administered in 54% versus 22% in C1 and C2, respectively (P<0.0001). Needling rates were not statistically different [42% (C1), 54% (C2)] (P=0.22). CONCLUSIONS: Trabeculectomy is effective in lowering IOP with success comparable across various definitions. MMC replaced 5-FU as intraoperative antimetabolite resulting in reduced need for postoperative antimetabolite but not increased complications.

Precipitants of 5-Fluorouracil in Trabeculectomy Bleb Management: A Comparative Laboratory Study.

AIM: Concerns regarding 5-Fluorouracil (5-FU) corneal toxicity have resulted in various ways of reducing its corneal exposure during post-operative trabeculectomy bleb manipulation. This study investigates the properties of various topical agents used to induce the precipitation of this compound. MATERIALS AND METHODS: This is a double-blind, descriptive, laboratory study comparing five different potential precipitants of 5-FU (proxymetacaine (proxy), oxybuprocaine (oxy), ametho-caine (ameth), fluorescein (flor), proxymetacaine + fluorescein (proxy-flor) to a control group (normal saline). A 0.01 mL of each anonymized agent was applied next to a clear round comparison marker in a transparent sterile container set on a dark background. 5-FU (0.01 mL of 50 mg/mL) was subsequently applied to each agent. The induced changes in transparency were imaged and compared to the transparency of the central marker. For each application, pH changes were also noted. RESULTS: Proxy, flor and proxy + flor did not result in any discernible 5-FU precipitation. Oxy resulted in a moderate visible change, and ameth produced very significant precipitation. Application of proxy, oxy, ameth, and proxy + flor resulted in the neutralization of the 5-FU's alkaline pH. CONCLUSION: We propose using a cotton-tipped bud dipped in ameth applied at the injection site as the recommended method to avoid 5-FU corneal exposure in these cases. CLINICAL SIGNIFICANCE: Practitioners should be aware of the differences in precipitation of 5-FU by different types of topical anesthetics and modify techniques of anesthesia and 5-FU administration accordingly.How to cite this article: Mercieca KJ, Fenerty CH, Steeples LR, Drury B, Bhargava A. Precipitants of 5-Fluorouracil in Trabeculectomy Bleb Management : A Comparative Laboratory StudyJ Curr Glaucoma Pract 2018;12(2):64-66.