Short-Term Outcomes of Bimatoprost Sustained-Release Intracameral Implant in Glaucoma.

PRCIS: This retrospective study found a statistically significant reduction in mean intraocular pressure (IOP) and the number of medications after intracameral Bimatoprost sustained release (SR) injection in patients with glaucoma. A history of selective laser trabeculoplasty (SLT) did not impact treatment outcomes. PURPOSE: To determine outcomes of Bimatoprost SR on IOP and the number of topical IOP-lowering medications in patients with glaucoma. A secondary objective was to determine the outcomes of Bimatoprost SR in patients with a prior history of SLT. METHODS: Retrospective case series. One hundred eighteen eyes from 84 patients that received Bimatoprost SR by 6 glaucoma specialists at Wills Eye Hospital from March 2020 to September 2021 were examined. The intervention was a single injection of intracameral Bimatoprost SR. The main outcome measures included IOP and the number of medications. RESULTS: The most recent mean follow-up time for all eyes was 27.8 ± 18.6 weeks. The mean posttreatment IOP at the most recent follow-up of 16.6 ± 5.3 mm Hg was significantly lower than the mean under-therapy pretreatment IOP of 18.5 ± 5.7 mm Hg for all eyes ( P < 0.01). The mean posttreatment number of medications at the most recent follow-up of 1.3 ± 1.3 decreased compared with the number of pretreatment medications of 2.1 ± 1.4 for all eyes ( P < 0.01). Analysis of multilevel models controlling for demographic variables demonstrated a statistically significant reduction in IOP and number of medications posttreatment ( P < 0.01). A prior history of SLT (n = 54) had no impact on treatment for both IOP and the number of medications ( P > 0.1 for both). CONCLUSIONS: Intracameral Bimatoprost SR reduced IOP and decreased the number of medications. Prior history of SLT did not impact Bimatoprost SR treatment outcomes.

Outcomes of Selective Laser Trabeculoplasty After Prior Incisional Surgery for Open Angle Glaucoma.

PRCIS: This retrospective case series of patients with open angle glaucoma and prior trabeculectomy or tube shunt surgery found that selective laser trabeculoplasty (SLT) resulted in significant intraocular pressure (IOP) reductions in the intermediate follow-up period in select cases. PURPOSE: The purpose of this study was to assess the IOP-lowering effect and tolerability of SLT after prior trabeculectomy or tube shunt surgery. MATERIALS AND METHODS: Open angle glaucoma patients at Wills Eye Hospital who previously underwent incisional glaucoma surgery and subsequently received SLT between 2013 and 2018 were included, along with an age-matched control group. Baseline characteristics, procedural data, and post-SLT data were recorded at 1, 3, 6, 12 months, and most recent visit. The primary success of SLT treatment was defined as IOP reduction of 20% or greater without the use of additional glaucoma medications compared to pre-SLT IOP. Secondary success was defined as IOP reduction ≥20% with the use of additional glaucoma medications compared to pre-SLT IOP. RESULTS: There were 45 eyes in the study group and 45 eyes in the control group. In the study group, IOP decreased from a baseline of 19.5±4.7 mm Hg on 2.2±1.2 medications to 16.7±5.2 mm Hg ( P =0.002) on 2.2±1.1 glaucoma medications ( P =0.57). In the control group, IOP decreased from 19.5±4.2 mm Hg on 2.4±1.0 medications to 16.4±5.2 mm Hg ( P =0.003) on 2.1±1.3 medications ( P =0.36). There was no difference in IOP reduction or change in number of glaucoma medications after SLT at any postoperative visit between the 2 groups ( P ≥0.12 for all). Primary success rates at 12 months were 24.4% for the control group and 26.7% for the prior incisional glaucoma surgery group with no significant difference between the groups ( P =0.92). There were no persistent complications after SLT treatment in either group. CONCLUSION: SLT may effectively lower IOP in patients with open angle glaucoma who have had previous incisional glaucoma surgery and should be considered in select cases.

XEN Gel Stent to Treat ICE Syndrome: 4 Cases.

PRéCIS:: This case series reports safe, effective implantation of XEN gel stents to treat iridocorneal endothelial (ICE) syndrome. The stents continue to function well and have not been occluded by membranes or peripheral anterior synechiae, but continued follow-up is necessary. PURPOSE: ICE syndrome-related glaucoma is often refractory to medical treatment, and traditional surgical treatment has lower success rates than typical for other types of glaucoma. We present a series of patients who were treated with XEN gel stent implantation. PATIENTS AND METHODS: Retrospective case series of 4 patients with ICE syndrome who underwent XEN with subconjunctival mitomycin C injection. RESULTS: Average preoperative intraocular pressure was 28.5 mm Hg on 3.8 glaucoma medications, and average postoperative intraocular pressure was 10.5 mm Hg on 1.0 medication. No patients required return to the operating room for additional procedures over an average of 6.9 months of follow-up. One patient had shallow anterior chamber that resolved with conservative management. Another had shallow anterior chamber that resolved with anterior chamber reformation with viscoelastic and developed nonappositional choroidal effusions that had resolved at most recent follow-up of 7 months after surgery. No XEN implants have been occluded by membrane formation or peripheral anterior synechiae. CONCLUSIONS: XEN is a safe and effective option for surgical management of ICE syndrome-related glaucoma. Further follow-up surveillance is necessary.

Trypan Blue for the Assessment of Filtering Bleb Function During Cataract Surgery.

PURPOSE: Phacoemulsification has been cited as a possible cause of bleb failure in eyes with prior trabeculectomy. No method has been developed to directly evaluate the risk of bleb failure after phacoemulsification. We investigate the use of trypan blue during cataract surgery in the setting of a preexisting trabeculectomy to evaluate the functional status of the bleb and predict postoperative bleb function. MATERIALS AND METHODS: In total, 14 patients contributing 1 eye each with a history of prior trabeculectomy with mitomycin C undergoing phacoemulsification with intraocular lens implantation were enrolled in this prospective, nonrandomized clinical trial. At the time of phacoemulsification, trypan blue was instilled into the anterior chamber before capsulorhexis creation. Staining of the bleb was grouped as being mild or diffuse using intraoperative photographs. These eyes were followed for 1 year postoperatively and evaluated for intraocular pressure (IOP) control. RESULTS: The change in IOP was not significantly different between the 2 groups (P=0.14). A trend towards greater need for IOP-lowering medications was noted (P<0.10) in eyes with mild bleb staining. No statistically significant difference in rates of decreased bleb function was noted at 1-year follow-up after phacoemulsification. CONCLUSION: The intensity of bleb staining with trypan blue during phacoemulsification is not associated with changes in IOP postoperatively. A trend towards decreased need for IOP-lowering medications was noted in eyes with diffuse bleb staining at 1 year after cataract surgery.

Pilot Study Assessing the Use of High-density Polyethylene (Su-Por) for Tube Shunt Patch Grafts.

PURPOSE: To assess the viability of a manufactured high-density polyethylene patch graft material (Su-Por) for prevention of tube shunt exposure. MATERIALS AND METHODS: Retrospective review of the first 11 patients from the Wills Eye Hospital Glaucoma Service to receive the high-density polyethylene patch graft during tube shunt surgery. RESULTS: Four patients (36.3%) experienced an extrusion of the Su-Por patch without a leak within 2.5 months of postoperative follow-up. All 4 patients developed either symptomatic or progressive extrusion. Operative repair was completed with Su-Por removal and replacement with a new human donor patch graft. No patient developed any sign of infection despite the extrusions. The remaining 7 patients had an uneventful postoperative course and continue to have no complications from the Su-Por patch with 9 months of follow-up. CONCLUSIONS: Given the high rate of extrusion of the Su-Por graft, this material seems to be an inadequate alternative for covering tube shunts. Harvested human tissue or other more flexible, manufactured grafts remain the standard of care for covering tube shunts.

Ahmed Versus Baerveldt Glaucoma Drainage Implantation in Patients With Markedly Elevated Intraocular Pressure (≥30 mm Hg).

PURPOSE: Glaucoma patients with markedly elevated intraocular pressure (IOP) are at risk for developing severe hypotony-related complications. The goal of this study was to compare the surgical outcomes of the Ahmed Glaucoma Valve (AGV) and the Baerveldt Glaucoma Implant (BGI) in this patient population. METHODS: Patients with preoperative IOP≥30 mm Hg were included. Outcome measures were: (1) surgical failure (IOP>21 mm Hg or <30% reduction from baseline or IOP≤5 mm Hg on 2 consecutive follow-up visits after 3 mo, or additional glaucoma surgery, or loss of light perception) and (2) surgical complications. RESULTS: A total of 75 patients were included: 37 in the AGV group and 38 in the BGI group. The mean±SD follow-up was 2.3±1.6 years for the AGV group and 2.4±1.7 years for the BGI group (P=0.643). Mean preoperative IOP was 38.7±6.5 mm Hg for the AGV group and 40.8±7.6 mm Hg for the BGI group. At the last follow-up, 10 (27.0%) patients failed in the AGV group compared with 6 (15.8%) patients in the BGI group (P=0.379). The BGI group had higher rate of flat or shallow anterior chamber (n=4, 10%) compared with the AGV group (n=0, 0%) (P=0.043). CONCLUSIONS: Failure rates of AGV and BGI in patients with IOP≥30 mm Hg were comparable. There were more early hypotony-related complications in the BGI group; however, none were vision threatening. Both glaucoma drainage implants were effective in treating patients with uncontrolled glaucoma in an emergency setting.

The Wills Eye Glaucoma App: Interest of Patients and Their Caregivers in a Smartphone-based and Tablet-based Glaucoma Application.

PURPOSE: To evaluate the interest of glaucoma patients and their caregivers in a smartphone-based and tablet-based glaucoma application (App), developed by the Wills Eye Glaucoma Research Center in collaboration with Drexel University. MATERIALS AND METHODS: Cross-sectional survey of patients with glaucoma and their caregivers. Main outcome measures are answers to survey questions regarding how receptive participants are to using the Glaucoma App. RESULTS: Fifty subjects completed the survey. The mean age (SD) was 59.5 (±17.3) years. A total of 88.6% of the participants lived in a household with access to a smartphone or tablet. The majority (72.3%) of participants would consider downloading the Glaucoma App, and younger participants (<65 y) were more likely to do so compared with their older (≥65 y) counterparts, P=0.025. Participants were more likely to download the App if it was free of charge, compared with a version that costs $3, P=0.018. Although only about one third (37.8%) of participants used eye drop reminders, nearly 3 of 4 (72.9%) participants were receptive to using the automated reminder feature of the Glaucoma App. CONCLUSIONS: Glaucoma patients and their caregivers were very interested in using a Glaucoma App; however, many were not willing to spend $3 for an App they seem to value. The free Wills Eye Glaucoma App currently available on the Apple store, includes educational videos, eye drop and appointment reminders, medical and ocular data storage, visual field tutorial, and intraocular pressure tracker. These features aim to increase patients' level of knowledge about glaucoma and improve their adherence to medication and follow-up appointment recommendations.

Outcomes of Sequential Glaucoma Drainage Implants in Refractory Glaucoma.

PURPOSE: To describe the outcomes of eyes that have undergone a second glaucoma drainage implant (GDI) surgery. METHODS: A retrospective review of eyes that underwent a second GDI surgery from 2006 to 2013 was conducted. Primary outcome measures included intraocular pressure (IOP) reduction and success rates. Secondary outcome measures included glaucoma medication use, visual acuity, and number of reoperations. Success was defined as 6 ≤ IOP ≤ 21 with at least 20% IOP reduction, and no increase in the number of glaucoma medications from baseline at 3 months of follow-up or more. RESULTS: Sixty-five eyes (63 patients) had a mean follow-up of 22.4 ± 19.9 months. The most frequently placed second GDIs were an Ahmed FP7 (49%) or a Baerveldt 250 (26%) in the inferotemporal (46%) or inferonasal (35%) quadrant. At 3-year follow-up, IOP was reduced from 25.8 ± 7.7 to 17.4 ± 9.9 mm Hg (P = 0.004) and the number of glaucoma medications decreased from 3.6 ± 1.2 to 2.5 ± 1.4 (P = 0.01) compared with baseline. The median time to failure was 24.7 ± 5.8 months. There was no significant difference in failure rates for type of sequential GDI (P = 0.80) or plate location (P = 0.34). There was no significant difference in visual acuity between baseline and 3-year follow-up (P = 1.0). The most common postoperative complication was corneal edema (n = 9, 14%). CONCLUSIONS: Most eyes undergoing a second GDI achieve adequate IOP control with fewer antiglaucoma medications. Failure rates were similar regardless of quadrant selection or GDI type.

Initial Experience With the New Ahmed Glaucoma Valve Model M4: Short-term Results.

PURPOSE: To evaluate the clinical outcomes of the new Ahmed glaucoma valve (AGV) model M4. The device consists of a porous polyethylene shell designed for improved tissue integration and reduced encapsulation of the plate for better intraocular pressure (IOP) control. METHODS: Medical records of patients with an AGV M4 implantation between December 1, 2012 and December 31, 2013 were reviewed. The main outcome measure was surgical failure, defined as either (1) IOP<5 mm Hg or >21 mm Hg and/or <20% reduction of IOP at last follow-up visit, (2) a reoperation for glaucoma, and/or (3) loss of light perception. RESULTS: Seventy-five eyes of 73 patients were included. Postoperative IOP at all follow-up visits significantly decreased from a baseline IOP of 31.2 mm Hg (P<0.01). However, IOP increased significantly at 3 months (20.4 mm Hg), 6 months (19.3 mm Hg), and 12 months (20.3 mm Hg) compared with 1 month (13.8 mm Hg) postoperatively (P<0.05). At 6 months and 1 year, the cumulative probability of failure was 32% and 72%, respectively. CONCLUSIONS: The AGV M4 effectively reduced IOP in the first postoperative month, but IOP steadily increased thereafter. Consequently, failure rates were high after 1 year of follow-up.

Comparing Gonioscopy With Visante and Cirrus Optical Coherence Tomography for Anterior Chamber Angle Assessment in Glaucoma Patients.

PURPOSE: The aim of this study was to compare gonioscopy with Visante and Cirrus optical coherence tomography (OCT) for identifying angle structures and the presence of angle closure in patients with glaucoma. A secondary objective was to assess interrater agreement for gonioscopy grading among 3 independent examiners. METHODS: Gonioscopy grading using Spaeth Classification and determination of angle-closure risk was performed on 1 randomly selected eye for 50 phakic patients. Images of the same eye using both Visante and Cirrus OCT were obtained in both light and dark conditions. Agreement of angle closure among 3 devices and interrater agreement for gonioscopy were determined using Cohen's κ (K) or Kendall's coefficient of concordance (W). RESULTS: Of the 50 patients, 60% were female, 64% were white, and the mean age was 62 years. Angle closure was detected in 18%, 16%, and 48% of quadrants with Visante, Cirrus, and gonioscopy, respectively. The scleral spur was identified in 56% and 50% of quadrants with Visante and Cirrus OCT, respectively. Visante and Cirrus OCT showed moderate agreement in detecting angle closure (K=0.42 light, K=0.53 dark) but slight-to-fair agreement with gonioscopy (Visante K=0.25, Cirrus K=0.15). Gonioscopy demonstrated substantial agreement in angle closure (K=0.65 to 0.68) and angle-closure risk assessment (W=0.83) among 3 examiners. CONCLUSIONS: Visante and Cirrus OCT imaging may have limited ability to identify angle closure because of difficulty identifying angle structures. Gonioscopy by well-trained clinicians had remarkably consistent agreement for identifying angle-closure risk.

Needle bleb revision with bevacizumab and mitomycin C compared with mitomycin C alone for failing filtration blebs.

PURPOSE: To report the 6-month comparative outcomes and bleb morphology for needle revision with bevacizumab and mitomycin C (MMC) versus MMC alone of failed trabeculectomy and ExPRESS shunt blebs. METHODS: Patients undergoing bleb needle revision procedures were enrolled in this study. All patients received a subconjunctival injection of 0.1 mL MMC (0.4 mg/mL) mixed with 0.1 mL preservative-free lidocaine (1%) at the beginning of the procedure. The patients were randomized into 2 cohorts assigned to receive either 1.0 mg (0.04 mL of 25 mg/mL) subconjunctival bevacizumab (treatment group) or 0.04 mL of balanced salt solution (control group) injected in an identical manner posterior to the bleb after the bleb needling. Success was defined as ≥20% reduction in intraocular pressure (IOP) without any IOP-lowering medications. Qualified success was defined as ≥20% reduction of IOP with IOP-lowering medications. Failure was defined as IOP>21 mm Hg, IOP reduction <20%, or need for additional surgery. Bleb morphology was classified using the Indiana Bleb Appearance Grading Scale. RESULTS: Six months postoperatively, in treatment group (n=29), 57% of patients achieved complete success, and 43% failed. In control group (n=29), 41% of patients achieved complete success, 7% achieved qualified success, and 52% failed. The difference in success rates between the 2 groups was not statistically significant (P=0.35). At 6 months, the mean IOP was 11.52 in treatment group and 12.83 in control group (P=0.45); patients in treatment group were on a mean of 0.16 medications as compared with 0.58 medications in control group (P=0.058). For bleb morphology of treatment group compared with control group, the blebs had less vascularity (0.76 vs. 1.20, respectively, on a scale of 0 to 4, P<0.05) and greater extent (2.68 vs. 2.36, on a scale of 0 to 3, P=0.022) in treatment group. CONCLUSIONS: There was no significant difference between the success rates and IOPs at postoperative month 6 between treatment and control groups. Postoperative blebs in the treatment group were less vascular and had greater extent.

Evaluation of Risk Factors for Glaucoma Drainage Device-related Erosions: A Retrospective Case-Control Study.

PURPOSE: To identify risk factors for glaucoma drainage device (GDD) erosions. PATIENTS AND METHODS: In a retrospective comparative case series, medical records of 1013 patients who underwent GDD surgery performed by 5 surgeons between 2006 and 2011 were reviewed. The outcome measures assessed included age, race, sex, contact lens wear, seasonal allergies, medical comorbidities, glaucoma diagnosis, preoperative oral and topical medications, type and number of preoperative surgeries and lasers, concomitant surgeries, tube type and position, patch graft material, and intraoperative use of Avastin, mitomycin-C, or Triescence. The association of variables with erosion status was evaluated using the Fisher exact test for categorical variables and the exact Wilcoxon rank-sum test for continuous variables. RESULTS: Charts were included from 339 eyes that had complete data sets and at least 6 months of follow-up. Twenty-eight eyes (8.3%) developed conjunctival erosions. The median follow-up time was 2.03 years for the erosion group and 1.71 years for nonerosion group. Erosion was only associated with the presence of concomitant surgical procedures at the time of GDD implantation (35.7% erosion group vs. 17.4% nonerosion group, P=0.02, OR=2.64). The majority of concomitant surgeries were composed of pars plana vitrectomy (35.0%) and cataract surgery (32.0%). Variables that were suggestive of association with erosion (P<0.20) included smoking (OR=2.14), pseudoexfoliation glaucoma (OR=2.71), and history of dry eye syndrome (OR=2.22). CONCLUSION: History of concomitant intraocular surgery with GDD implantation may be a potential risk factor for future erosions.

Explantation of the novel Ahmed glaucoma valve M4 implant.

PURPOSE: To report a series of cases involving Ahmed Glaucoma Valve M4 (AGV) explantation and to discuss the surgical technique to remove the drainage device. METHODS: Four cases were identified that presented with AGV M4 postoperative complications necessitating tube shunt removal. Three patients presented with conjunctival erosion and 1 patient with persistent diplopia. AGV M4 implants were removed successfully between 1.5 and 9 months after implantation. RESULTS: Successful explantation of the AGV M4 novel implant was achieved in all cases without intraoperative or postoperative complications. CONCLUSIONS: If necessary, AGV M4 explantation can be successfully performed in the early postoperative period.

A prospective study of consecutive patients undergoing full-thickness conjunctival/scleral hypotony sutures for clinical ocular hypotony.

PURPOSE: To describe a modified suturing technique for the treatment of hypotony. METHODS: A prospective case series of 15 patients with hypotony from an overfiltering trabeculectomy underwent full-thickness hypotony sutures. The technique involves placing several radial interrupted 10-0 nylon sutures in the area of the prior trabeculectomy. The suture pass starts at the limbus, travels through the conjunctiva, and full-thickness sclera before exiting the conjunctiva. The sutures were selectively removed postoperatively to titrate the intraocular pressure (IOP). Hypotony resolution, IOP, visual acuity, and complications were assessed on postoperative visits. RESULTS: Before surgery, the mean IOP was 3.3 mm Hg. The mean IOP 1 day after surgery was 23.5 mm Hg, which settled to 12.9 mm Hg 3 months after surgery. Hypotony was reversed in 100% of patients and 87% achieved a goal IOP. Suture removal was performed in 73%, most within the first week after surgery. CONCLUSIONS: Placing full-thickness hypotony sutures is an effective way to treat ocular hypotony. Sutures can be removed postoperatively to titrate the IOP.

O uso intraoperatório de mitomicina C em glaucomas refratários / Topical intraoperative mitomycin C in refractory glaucomas

Foram revistos os prontuários de 42 pacientes portadores de glaucoma refratário submetidos a trabeculectomia associada ao uso intra-operatório de mitomicina C (0.4 mg/ml) entre outubro de 1991 e maio de 1992 no Serviço de Glaucoma do Wills Eye Hospital (Philadelphia, EUA). Dos 42 olhos, 34 puderam ser seguidos por pelo menos 6 meses. Dentre estes 34, 29 (83,5 por cento) apresentaram controle pressórico adequado ao final de um período de seguimento médio de 7,2 +ou- 1,4 meses. As principais complicaçöes pós-operatórias, entre as quais, descolamento da coróide (16,6 por cento), câmara anterior rasa (9,5 por cento) e maculopatia por hipotonia (4,8 por cento) estäo relacionadas ao excesso de filtraçäo observado no pós-operatório. Este estudo sugere que a mitomicina C é um potente inibidor do processo de cicatrizaçäo, altamente eficaz em prevenir a falência da cirurgia filtrante em olhos com glaucomas refratários. A reduçäo da dosagem e do tempo de exposiçäo à mitomicina C podem resultar em um menor número de complicaçöes secundárias ao excesso de filtraçäo. Estudos prospectivos e randomizados estäo sendo realizados para investigar esta possibilidade