Intraocular pressure profile following selective laser trabeculoplasty in pigmentary and primary open-angle glaucoma.

PURPOSE: To compare the intraocular pressure (IOP) profile and the incidence of IOP spikes following selective laser trabeculoplasty (SLT) between pigmentary glaucoma (PG) and primary open-angle glaucoma (POAG). MATERIALS AND METHODS: Retrospective comparative study of 65 PG eyes of 51 patients matched with 65 POAG eyes of 65 patients who received SLT. Matching was done based on age, gender, glaucoma severity, pre-laser IOP, and number of medications. Post-SLT IOP spike was defined as IOP elevation ≥5mmHg, 30-45 min after the laser. RESULTS: In PG and POAG groups, the average age was 62.33 ± 9.18 and 62.58 ± 9.19 years (p = 0.95). The glaucoma severity (p = 0.708), baseline IOP (PG = 21.61 ± 1.34mmHg vs. POAG = 21.13 ± 5.09mmHg, p = 0.943), and number of topical glaucoma medications(PG = 2.34 ± 1.34 vs. POAG = 2.1 ± 1.41, p = 0.342) were comparable. More PG patients were on oral acetazolamide (PG = 26.15% vs. POAG = 1.5%, p < 0.001). Average logMAR visual acuity was significantly higher in the POAG group (0.207 ± 0.3 vs. 0.192 ± 0.37, p = 0.012). Eyes with PG received lower laser energy (POAG = 63.65 ± 22.03 mJ vs. PG = 43.71 ± 25.68 mJ, p < 0.001). IOP spikes were recorded in 5 PG eyes (7.6%) and none in the POAG group (p = 0.058). Failure rates were similar (PG = 50.7% and POAG = 43.1%, p = 0.205). In multivariable analysis, only pre-laser IOP (coefficient = 2.154 [CI: 0.765-3.543], p = 0.003) was a significant predictor of IOP change percentage after 12 months. CONCLUSIONS: SLT was comparably effective in both PG and POAG. IOP spikes were observed only in the PG group, though the total laser energy was lower in this group compared with POAG.

Long-Term Surgical Outcomes of Glaucoma Drainage Implants in Eyes with Preoperative Intraocular Pressure Less than 19 mmHg.

Background: This retrospective review reports on patients who underwent glaucoma drainage implant (GDI) surgery and had baseline intraocular pressure (IOP) of ≤18 mmHg with at least one year of follow-up. Methods: Clinical data of 67 eyes of 67 patients were collected from patients' charts, and the outcomes of GDI were evaluated until 7 years. GDI failure was defined as IOP reduction of less than 20% from the baseline at two consecutive visits three months after surgery, decline to no light perception, or if additional glaucoma surgery was performed. Results: The average age was 65.9 ± 13.2 years. Most cases were male (52.2%), White (53.7%), and had primary open-angle glaucoma (62.7%). Forty-four eyes had prior glaucoma surgery (68.6%) and 46 (68.6%) had severe glaucoma. Though postoperative (postop) IOP changes were insignificant, the average postop number of medications dropped from 2.4 ± 1.4 to 1.9 ± 1.2 medications two years after surgery (p = 0.0451). Postop complications (23.9%) included GDI exposure (7.5%), inflammation (4.5%), shallow anterior chamber (4.5%), and strabismus (1.5%). Hypotony was observed in 4 eyes (5.9%), none of which developed hypotony maculopathy. The cumulative one-year failure rate was 56.7%, most of which were due to failure to lower IOP. Conclusion: In patients with baseline IOP ≤18 mmHg who had GDI surgery, though the change in IOP was not statistically significant, the number of medications dropped and visual field progression slowed in a subset of patients with adequate perimetric data. Due to a relatively high rate of complications and limited effectiveness in lowering IOP, GDI should be cautiously used in these eyes.

Early Postoperative Aqueous Suppression Therapy and Surgical Outcomes of Ahmed Tube Shunts in Refractory Glaucoma.

PURPOSE: To compare early vs. delayed use of aqueous suppressants on Ahmed glaucoma valve (AGV) outcomes. DESIGN: Single-center retrospective comparative case series. PARTICIPANTS: Patients who underwent AGV surgery at Wills Eye Hospital in the period between 2016 and 2021. METHODS: Retrospective review of AGV surgery at Wills Eye Hospital 2016 to 2021 for refractory glaucoma. Two groups were created: group 1 or those who received early aqueous suppressant therapy in the first 2 weeks postoperatively whenever the intraocular pressure (IOP) was > 10 mmHg, and group 2 or those who received delayed treatment after 2 weeks whenever the IOP exceeded the target pressure. Aqueous suppressant therapy included topical beta blockers, carbonic anhydrase inhibitors, and/or alpha agonists. MAIN OUTCOME MEASURES: The primary outcome measures were the frequency of hypertensive phase (HP) defined as IOP > 21 mmHg in first 3 months after an initial reduction to 21 mmHg or less in the first postoperative week not caused by tube obstruction or retraction, and month-12 surgical failure defined as 5 ≥ IOP > 21 mmHg on 2 consecutive visits, vision decline to no light perception (NLP), or glaucoma reoperation. Secondary outcome measures included changes in visual acuity (VA), IOP, and glaucoma medications at 12 months. Predictive factors for surgical failure were also identified. RESULTS: A total of 407 eyes of 391 patients (260 in group 1, 147 in group 2) with similar baseline characteristics were included. Hypertensive phase was more common in group 2 than 1 (41.5% vs. 18.5%; P < 0.001). At month 12 (N = 303 eyes), group 1 was less likely to fail than group 2 (21.2% vs. 36.8%, P = 0.003). Multivariate regression analysis showed that HP (odds ratio [OR] = 10.47, P < 0.001), delayed aqueous suppression use (OR = 2.17, P = 0.003), and lower baseline VA (OR = 1.56, P = 0.015) were the strongest predictors of month-12 failure. CONCLUSIONS: Early use of aqueous suppressants may lower the risk of HP and improve AGV outcomes. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Ahmed ClearPath vs. Baerveldt Glaucoma Implant: A Retrospective Noninferiority Comparative Study.

PURPOSE: To compare the efficacy and safety of 2 nonvalved glaucoma drainage devices (GDDs): Ahmed ClearPath (ACP) vs. Baerveldt glaucoma implant (BGI). DESIGN: Single-center, retrospective, comparative study. PARTICIPANTS: Consecutive patients who underwent ACP or BGI surgery for glaucoma (250 mm2 or 350 mm2 models), had ≥ 6 months of follow-up, and no prior GDD implantation. METHODS: Chart review of ACP or BGI surgery in patients with glaucoma at Wills Eye Hospital (2020-2023). MAIN OUTCOME MEASURES: The primary outcome measure was surgical failure at the end of follow-up, defined as intraocular pressure (IOP) > 21 or < 6 mmHg at 2 consecutive visits, progression to no light perception (NLP) vision, glaucoma reoperation, or implant removal. Secondary outcome measures included the rate of postoperative complications and changes in best corrected visual acuity (BCVA), IOP, and glaucoma medications. RESULTS: A total of 128 eyes of 113 patients (63 ACP, 65 BGI) with similar baseline characteristics and a mean follow-up duration of 19.6 ± 10.8 (median 20.5) months were included. Surgical failure occurred in 12 eyes (9.4%) with no significant difference between ACP and BGI eyes (9.5% vs. 9.2%, respectively; P = 0.810). Reasons for failure included IOP > 21 mmHg (3/12, 25.0%), glaucoma reoperation (5/12, 41.7%), and tube removal (4/12, 33.3%). No eyes progressed to NLP vision. Kaplan-Meier survival analysis showed similar cumulative rate of surgical failure in both groups (P = 0.871). Both groups achieved significant IOP and medication reduction compared to their baseline. Final IOP, BCVA, and complication rates were similar in both groups, but medication number was significantly lower in the ACP group (P = 0.012). Both the 250 mm2 and 350 mm2 models had similar outcomes, but diplopia was significantly associated with the 350 mm2 model of either implant (P = 0.012). Univariate logistic regression analysis did not identify either tube type or plate size as predictors of surgical failure. CONCLUSIONS: This study compares the recently approved ACP vs. BGI. Both implants had similar surgical failures and complication rates. Final IOP was similar in both groups, but ACP achieved lower medication number. Diplopia was significantly associated with the use of 350 mm2 model of either implant. Neither tube type nor plate size were significant predictors of surgical failure. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Hemorrhagic Complications Following Trabecular Bypass Microstent Surgery in the Setting of Antithrombotic Therapy.

PRCIS: In this retrospective study, the use of chronic antithrombotic therapy (ATT) did not increase the risk of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification. Stent type and female sex were associated with hyphema. PURPOSE: To report the incidence of hemorrhagic complications after trabecular bypass microstent surgery and phacoemulsification with and without (ATT). METHODS: Retrospective case series on glaucoma patients on chronic ATT who underwent trabecular bypass microstent surgery (iStent, iStent inject, and Hydrus) combined with phacoemulsification between 2013 and 2019 with ≥3-month follow-up. The primary outcome measure was the incidence of hemorrhagic complications within a 3-month postoperative period. Generalized estimating equations were created to account for inter-eye correlation and logistic regression analysis was performed to identify factors predictive of hemorrhagic complications. RESULTS: Of 333 patients (435 eyes), 161 patients (211 eyes) were on ATT and 172 patients (224 eyes) were not on ATT; both groups were similar in age and baseline ocular characteristics. The only hemorrhagic complication was hyphema, which occurred in 84 (19.3%) eyes (41 ATT, 43 non-ATT eyes; P = 1.00). Onset was at postoperative day 1 in 98.8% of eyes, with a duration of 1 week in 73.8% of eyes, without difference between ATT and non-ATT groups. Hyphema was most common with Hydrus microstent (36.4%) versus iStent (19.9%) and iStent inject (8.5%) ( P = 0.003). In the multivariate model, the female sex was a predictor of hyphema [hazard ratio (HR) = 2.062; P = 0.009], iStent inject was protective against hyphema (HR = 0.379; P = 0.033), whereas Hydrus did not reach statistical significance (HR = 2.007; P = 0.081). Age, systemic comorbidities, ATT use, and baseline ocular characteristics were not significant predictors. CONCLUSIONS: Hemorrhagic complications after trabecular bypass microstent surgery were limited to transient hyphema and were not associated with chronic ATT use. Stent type and female sex were associated with hyphema.

Glaucoma Surgical Outcomes in Patients with a History of Scleritis.

PURPOSE: To assess the outcomes of glaucoma surgery in patients with a history of scleritis at a tertiary medical center. METHODS: The retrospective case series included patients with a history of scleritis who required glaucoma surgery between 4/2006 and 8/2021. RESULTS: Two hundred and eighty-one eyes of 259 patients had glaucoma and scleritis with 28 eyes (10%) of 25 patients requiring glaucoma surgery. Post-operatively, one eye (4%) had infectious scleritis. Eleven (39%) surgeries failed: 5 tube shunts, 5 cyclophotocoagulation, and 1 gonioscopy-assisted transluminal trabeculotomy. Five (18%) eyes required tube revisions due to tube exposures without infection (3), iris blocking the tube (1), or to shorten tube length (1). CONCLUSIONS: Patients with a history of scleritis have a low risk of scleritis recurrence or scleral perforation after glaucoma surgery but should be counseled appropriately on the higher risk of reoperation.

The effectiveness and tolerability of fixed-dose combination netarsudil 0.02%/latanoprost 0.005% at a tertiary glaucoma center.

PURPOSE: To assess real-world effectiveness and tolerability of fixed-dose combination netarsudil 0.02%/latanoprost 0.005% (FCNL) in management of glaucoma patients in a tertiary eye care center. METHODS: This retrospective cohort study included glaucoma patients initiated on FCNL from January 2018 to July 2021 with at least 1-month follow-up. Demographic and clinical data were collected at baseline and at follow-up visits through 12 months. Patient-solicited side effects were recorded at each visit. Maximum glaucoma pharmacotherapy was defined as surgery/laser being the next treatment option following an intensive pharmacotherapy regimen, or when pharmacotherapy could not be increased due to allergy/intolerance or all pharmacologic mechanisms already being in use. RESULTS: Seventy-nine eyes of 47 patients were included. Mean age was 67.7 ± 14.7 years. Baseline IOP was 18.7 ± 4.9 mmHg; mean change in IOP (∆IOP) each study visit compared to baseline ranged from - 1.6 ± 3.5 to - 4.4 ± 4.1 mmHg (all p < 0.05). The eyes on maximum glaucoma pharmacotherapy (73.4%) had similar ∆IOP compared to those on non-maximal therapy at each visit (p > 0.2 for all). Forty-three (54.4%) eyes were switched from a prostaglandin analog alone, producing a 1-month IOP reduction of - 4.7 ± 3.9 mmHg at 1 month which remained significant at each visit for the 12-month study period (all p < 0.05). Across all study visits, conjunctival hyperemia was documented in 26 (32.9%) eyes. Subjective blurry vision was reported in 22 (27.8%) eyes without significant worsening of visual acuity at any visit (all p > 0.05). Six (7.6%) and 7 (8.9%) eyes required further medical or surgical/laser intervention, respectively. Kaplan-Meier analysis revealed no significant difference in the need for subsequent medical or surgical intervention between those on maximum and non-maximal pharmacotherapy (p > 0.4). CONCLUSION: FCNL was well-tolerated and demonstrated a significant and sustained reduction in IOP, even as last-line therapy before incisional or laser surgery in those on maximum glaucoma pharmacotherapy. FCNL is a viable treatment option for glaucomatous eyes before consideration of surgical intervention.

Outcomes of Valved and Nonvalved Tube Shunts in Neovascular Glaucoma.

PURPOSE: To determine the outcomes of Ahmed glaucoma valve (AGV; New World Medical Inc) and Baerveldt glaucoma implant (BGI; Advanced Medical Optics) surgery in the setting of neovascular glaucoma (NVG). DESIGN: Single-center, retrospective study. PARTICIPANTS: Consecutive patients who underwent AGV or BGI surgery for the treatment of NVG and had ≥6 months of follow-up. METHODS: Chart review of AGV and BGI surgical outcomes in patients with NVG. MAIN OUTCOME MEASURES: Progression to no light perception (NLP) vision and 6-month surgical failure, which was defined as intraocular pressure (IOP) >21 mmHg with medications or <5 mmHg at 2 consecutive visits, or glaucoma reoperation. RESULTS: A total of 152 eyes (91 AGV, 61 BGI) were included with an average follow-up of 29.6 ± 25.8 months. Baseline demographics and clinical characteristics were comparable between groups. At month 6, failure was similar between AGV and BGI eyes (21.6% vs. 25.9%; P = 0.552), but glaucoma medication use was lower in BGI eyes (P < 0.001). At the final visit, 18.7% of AGV and 14.8% of BGI eyes progressed to NLP vision (P = 0.530), and medication use was lower in BGI eyes (P < 0.0001). Multivariate analysis identified lower preoperative visual acuity (VA) (P = 0.001), failure to receive panretinal photocoagulation within 2 weeks of surgery (P = 0.003), and bilaterality of the underlying ischemic retinal pathology (P = 0.026) as the strongest predictors of NLP outcome. Age, sex, race, NVG etiology, tube type, preoperative IOP, extent of synechial angle closure preoperatively, preoperative hyphema, IOP at the first NLP visit, and final IOP were not significant predictors of NLP vision. CONCLUSIONS: Eyes with AGV and BGI had comparable outcomes in NVG, although fewer medications were required in BGI eyes to control IOP. Progression to NLP vision was associated with poor baseline VA, delayed retinal treatment, and bilaterality of the underlying ischemic retinal pathology.

Predictors of Success in Selective Laser Trabeculoplasty.

PURPOSE: Selective laser trabeculoplasty (SLT) is a common procedure to lower intraocular pressure (IOP) in patients with glaucoma. However, reports are conflicting regarding what factors contribute to SLT success. The purpose of this study was to determine predictors of SLT success. DESIGN: Retrospective case series. PARTICIPANTS: All patients treated with SLT between January 1, 2012, and June 30, 2018. METHODS: Baseline, demographic, procedural, and ophthalmic examination data were recorded at the time of first SLT treatment. Intraocular pressure and medication data were recorded at all follow-up visits. MAIN OUTCOME MEASURES: Selective laser trabeculoplasty success was defined as IOP decrease of 20% or more from baseline at the 3-month, 6-month, and 12-month follow-up visits. Eyes were considered to have failed and were censored when additional SLT or glaucoma surgery was performed. Patients were excluded if they had less than 3 months of follow-up. RESULTS: A total of 997 eyes from 677 patients were included in the study. Mean age was 70.2±11.5 years. Selective laser trabeculoplasty success was achieved in 227 eyes (22.8%), whereas 770 eyes (77.2%) did not meet success criteria. Intraocular pressure before SLT was 21.9±5.2 mmHg while taking 2.0±1.2 medications in eyes with successful SLT, compared with 19.0±5.0 mmHg (P < 0.0001) while taking 2.1±1.3 medications (P = 0.52) in eyes with SLT failure. At the 1-year follow-up, mean IOP in eyes with SLT success was 14.7±3.2 mmHg with 2.0±1.2 medications, compared with 16.3±4.7 mmHg (P = 0.008) with a mean of 1.9±1.3 medications (P = 0.37) in eyes with SLT failure. Eyes with SLT success more often showed greater angle pigment (P = 0.03). Age, glaucoma severity, total SLT power, type of glaucoma, severity of glaucoma, visual field mean defect, and retinal nerve fiber layer thickness were not found to correlate with success. No difference was found between the rate of success based on treatments before SLT, whether surgical or medical. CONCLUSIONS: In this large cohort of eyes undergoing SLT, greater IOP and angle pigment before SLT correlated positively with SLT success. Age, total SLT power, severity of glaucoma, and prior treatments were not associated with SLT success or failure.

Ahmed Versus Baerveldt Glaucoma Drainage Device in Uveitic Glaucoma: A Retrospective Comparative Study.

PRECIS: Baerveldt glaucoma drainage device demonstrated a greater reduction in intraocular pressure (IOP) than Ahmed in patients with uveitic glaucoma. The most common cause of failure was uncontrolled IOP in Ahmed and hypotony in the Baerveldt group. PURPOSE: To compare the efficacy and safety of Ahmed and Baerveldt glaucoma drainage devices in uveitic glaucoma. MATERIALS AND METHODS: The retrospective comparative study included patients with uveitic glaucoma who underwent Ahmed or Baerveldt glaucoma drainage device implantation with a minimum follow-up of 3 months. Success was defined as IOP ≥6 and ≤21 mm Hg and >20% reduction on 2 consecutive visits after the third month with (qualified success) or without (complete success) medications and no further glaucoma surgery or loss of vision. IOP, number of medications, visual acuity, complications, and interventions were compared between groups. RESULTS: In total, 137 eyes of 122 patients (67 Ahmed, 70 Baerveldt) were included. The preoperative IOP and number of medications in the Ahmed group (32.7±10.3 mm Hg; 4.1±1.3) were similar to Baerveldt (32.1±10.2 mm Hg; 4.3±1.3; P=0.73, 0.35). These at the last follow-up were (18.1±9.8 mm Hg; 2.1±1) in Ahmed and (12.7±6.9 mm Hg; 1.3±1.3) in Baerveldt groups (P=0.04, 0.01). The Baerveldt had greater IOP reduction (60.3% vs. 44.5%) and complete success rate (30% vs. 9%) with higher complication rate (51.4% vs. 20.9%) (all P≤0.05). The de novo glaucoma reoperation rate was 19% in the Ahmed group and 4% in the Baerveldt group (P=0.006). Hypotony resulted in failure in 7 eyes (10%) in the Baerveldt group and none in the Ahmed group (P=0.013). CONCLUSIONS: Higher complete success rate and significantly greater reduction in mean IOP and number of medications were observed in the Baerveldt group, but with a higher rate of complications including hypotony.

Vision-related Performance and Quality of Life of Patients With Rapid Glaucoma Progression.

PURPOSE: The purpose of this study was to determine how clinical measures, performance-based measures and subjective assessments of vision-related quality of life (VRQoL) are affected in patients with rapid glaucoma progression. METHODS: Prospective longitudinal study that included 153 patients diagnosed with moderate glaucoma. A subset of patients that presented with rapid glaucoma progression (n=22), defined as visual field (VF) mean deviation (MD) loss >2.0 dB/y, were compared with patients with nonrapid progression (n=131). Groups were compared using t tests, χ, or Fisher exact test. Main outcome measures were visual acuity (VA), VF MD, retinal nerve fiber layer thickness (RNFL), contrast sensitivity (CS), Compressed Assessment of Ability Related to Vision (CAARV), and Rasch calibrated National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) scores. RESULTS: At baseline, patients who progressed rapidly had lower measurements of VA (P=0.041), VF MD (P<0.001), Pelli-Robson score (P=0.004), Spaeth/Richman Contrast Sensitivity (SPARCS) score (P=0.001), RNFL thickness (P=0.009), CAARV total score (P<0.001), and NEI-VFQ-25 composite score (P=0.03). A multivariable logistic regression was performed and showed VF MD to be the only baseline independent predictor of rapid progression. After 1 year, patients who progressed rapidly also had a significant decrease in SPARCS score (P=0.04). CONCLUSIONS: Factors associated with rapid glaucoma progression included worse VF MD decreased scores of performance-based measures and subjectively worse VRQoL. After 1 year, rapid progressors had a significant reduction in contrast sensitivity as measured by SPARCS.

Fornix-Based Trabeculectomy Conjunctival Closure: Winged Sutures versus Modified Wise Closure.

PURPOSE: To compare the midterm safety and efficacy profile of winged sutures versus modified Wise closure for fornix-based trabeculectomy. DESIGN: Retrospective comparative study. PARTICIPANTS: Consecutive cases that underwent fornix-based trabeculectomy by a single surgeon between January 5, 2015, and May 8, 2017. METHODS: Potential cases were identified using the Current Procedural Terminology code, and their charts were reviewed thoroughly. Only 1 eye per patient was included. Demographic and clinical data were collected. MAIN OUTCOME MEASURES: Primary outcomes were bleb leak and subsequent surgical revision rates. Secondary outcomes included intraocular pressure (IOP), number of glaucoma medications (NGM), visual acuity (VA), and other complications. RESULTS: A total of 313 patients were identified, 157 with winged sutures and 156 with modified Wise closure. Baseline demographic and clinical characteristics were similar between the 2 groups. Twenty-six cases (16.6%) of winged sutures and 10 cases (6.4%) of modified Wise group developed bleb leak (P = 0.007), but only a total of 10 eyes needed bleb revision (P = 0.336). Other complications were similar in rates between the groups (P > 0.05). At 6 months, the modified Wise group had significantly greater IOP reduction (-3.10±1.29 [standard error], P = 0.016). Number of glaucoma medications reduction and VA evolution were similar between the 2 groups (P > 0.05). CONCLUSIONS: Fornix-based trabeculectomy with either closure technique was effective in lowering IOP and NGM with comparable safety profile at 6 months. Furthermore, modified Wise closure provided larger IOP reduction and lower bleb leak rate, suggesting a potential superiority to winged sutures. Our study was limited by mitomycin C (MMC) delivery method change near the time of conjunctival closure change, although MMC delivery methods did not show significance in any outcome model.

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.

Use of Gamma-Irradiated Cornea to Plug Sclerostomy Site During Tube Shunt Revision.

Tube shunt implantation is a common procedure for control of intraocular pressure (IOP). However, tube revision and repositioning must sometimes be performed, and this involves removing the tube from its sclerostomy site. This site is prone to leaking and this may cause postoperative hypotony. We describe a novel and cosmetically acceptable technique of plugging and covering the sclerostomy site with gamma-irradiated corneal tissue.