Journal of Current Glaucoma Practice

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2018 | September-December | Volume 12 | Issue 3

EDITORIAL

Shibal Bhartiya, Tarek Shaarawy

The Quest for the Holy Grail of Glaucoma Surgery: Does Cypass Herald the End?

[Year:2018] [Month:September-December] [Volume:12] [Number:3] [Pages:3] [Pages No:99 - 101]

PDF  |  DOI: 10.5005/jp-journals-10078-1231  |  Open Access |  How to cite  | 

ORIGINAL ARTICLES

David C Sousa, Nuno P Ferreira, Carlos Marques-Neves, Alix Somers, Evelien Vandewalle, Ingeborg Stalmans, Luís Abegão Pinto

High-intensity Focused Ultrasound Cycloplasty: Analysis of Pupil Dynamics

[Year:2018] [Month:September-December] [Volume:12] [Number:3] [Pages:5] [Pages No:102 - 106]

Keywords: Glaucoma, Intraocular pressure, Pupillometry, Ultrasound cystoplasty

PDF  |  DOI: 10.5005/jp-journals-10078-1232  |  Open Access |  How to cite  | 

Abstract

Aim: High-intensity focused ultrasound cystoplasty (UCP) aims to noninvasively and selectively target the ciliary body, thus lowering intraocular pressure (IOP). To be used on a large scale, the safety of the UCP procedure should be studied. Therefore, its effect on pupil behavior is important to better inform patients and to help physicians predict possible treatment side effects. This study aimed to evaluate to what extent UCP procedure (EyeOP-1®) affects pupil dynamics. Materials and methods: Consecutive glaucoma patients with uncontrolled IOP despite optimal medication scheduled for UCP treatment were recruited and followed for 6 months. Pupillometry (PlusoptiX® S04) was performed at baseline, and 1, 3 and 6 months after UCP procedure at scotopic and mesopic conditions. The difference between pupil diameter (PD) in both lighting conditions was calculated at the three follow-up visits. Demographic, clinical characteristics and specific ocular parameters (anterior chamber depth and volume, white-to-white measurement, axial length, phakic status) were registered. Statistical analysis was performed using STATA 14.1. Results: Sixteen eyes of 16 patients with a mean age of 69 ± 11 years were included. Mean preoperative IOP and number of medications were 23.6 ± 3.0 mm Hg and 2.4 ± 1.3, respectively. Mean baseline scotopic and mesopic PD were 4.8 ± 0.8 mm and 4.4 ± 0.9 mm, respectively (difference = 0.38 ± 0.30 mm; range 0.1 to 1.2 mm). At month-1, the pupil diameter (PD) change between scotopic (4.6 ± 0.7 mm) and mesopic (4.5 ± 0.8 mm) conditions decreased to 0.03 ± 0.34 mm, p = 0.01. On the longer follow-up periods, however, the amplitude difference in PD compared to baseline was no longer significant (month-3: 0.28 ± 0.49 mm; month 6: 0.23 ± 0.41 mm; p > 0.05). At the end of follow-up, mean scotopic and mesopic PD were 4.7 ± 1.0 mm and 4.4 ± 0.9 mm, respectively. Conclusion and clinical significance: In the early postoperative period after UCP treatment, most patients present with a less light-reactive pupil, which seems to normalize with time.

ORIGINAL ARTICLES

Michelle M Hui, Colin I Clement

Evaluation of the Early to Mid-term Efficacy and Safety of Deep Sclerectomy without an Intrascleral Spacer for Open-angle Glaucoma in an Australian Population

[Year:2018] [Month:September-December] [Volume:12] [Number:3] [Pages:6] [Pages No:107 - 112]

Keywords: Australia, Deep sclerectomy, Glaucoma, Nonpenetrating glaucoma surgery, Open-angle glaucoma

PDF  |  DOI: 10.5005/jp-journals-10078-1233  |  Open Access |  How to cite  | 

Abstract

Purpose: This study aims to evaluate the early to the midterm efficacy of deep sclerectomy (DS) without an intra-scleral spacer for open-angle glaucoma (OAG) patients. Materials and methods: Retrospective study of 99 eyes (88 patients) with open-angle glaucoma who underwent DS were recruited in a consecutive order following informed consent. Intraocular pressure (IOP) was collected up to 60 months post operation (mean 19.87 ± 15.13 months). Criteria of success were defined as the qualified success (QS) or complete success (CS) with IOP level less than 21, 18 and 15 mm Hg and a reduction of more than 20% IOP from baseline. QS includes additional medication post-DS, while CS requires no other medications or surgery post-DS. Further analysis includes comparing the criteria of success based on several factors. The data were analyzed using statistical package for social sciences (SPSS version 21) statistical software. Results: The QS at 60 months for IOP less than 21, 18 and 15 mm Hg is 71.3% (45.12 ± 2.46), 63.9% (40.41 ± 2.75) and 48.7% (35.62 ± 2.85), respectively. The CS at 60 months for IOP less than 21, 18 and 15 mm Hg are 69.3% (47.51 ± 2.77), 57.9% (40.41 ± 2.75) and 45.2% (35.62 ± 2.85), respectively. There was no significant difference between QS and DS post-DS based on the level of experience of the surgeons; intraoperation complication; age and gender. There was a significant reduction in IOP post operation (p < 0.001). Conclusion: DS is observed to be an effective surgical method with a favorable safety profile to manage patients with open-angle glaucoma. It has a better safety profile compared to trabeculectomy (TE) and can be performed by surgeons of different experience safely and successfully. Clinical significance: To our knowledge, this is the first report of DS in an Australian population with up to 60 months of follow-up. It is an effective procedure for IOP control in patients with OAG and has fewer complications compared to TE. DS is less popular than TE primarily due to a perceived steep learning curve, but most of the literature on DS describe single surgeon results. Our study compared the outcome of five surgeons with a variety of experience and found no significant differences in the rate of success for all levels of IOP.

ORIGINAL ARTICLES

Jessica Olayanju, Teresa Borras, Bahjat Qaqish, David Fleischman

OutƒPow Facility in Tube Shunt Fenestration

[Year:2018] [Month:September-December] [Volume:12] [Number:3] [Pages:6] [Pages No:113 - 118]

Keywords: Venting slit,Aqueous shunt, Baerveldt, Fenestration

PDF  |  DOI: 10.5005/jp-journals-10078-1234  |  Open Access |  How to cite  | 

Abstract

Aim: Determination of the effect of varying fenestration technique, and simulated patch graft on outflow facility for Baerveldt tube. Materials and methods: Silicone tubing similar to Baerveldt implant (AMO, Santa Ana, CA) with different fenestrations techniques was connected to a digital manometer in a closed system with a fluid-filled syringe on a stand to adjust pressure. The venting slits included: (A) 4 piercings with 7–0 TG140-8 needle; (B) a 2-mm slit with a 15° blade; (C) 4 piercings with a 15° blade; (D) 9–0 Nylon on CS140-6 needle with suture stenting the fenestration. Results: For pressures of 10, 20, 30, 40 mm Hg in groups A to D, the average outflow facility (mL/min/mm Hg) were group A: 0.11, 0.20, 0.28, 0.40; group B: 0.30, 0.69, 0.98, 0.93; group C: 0.73, 0.80, 0.81, 0.88; group D: 0.58, 0.65, 0.80, 0.87. For external compression with 10 gram weights at pressures of 10, 20, 30, 40 mm Hg, outflow were group A: 0.0, 0.18, 0.20, 0.53; group B: 0.75, 0.70, 0.97, 1.21. Group C: 0.18, 0.03, 0.57, 0.04. Group D: 0.73, 0.90, 1.13, 0.91. Conclusion: Effectivity of venting slits in maintaining adequate IOP in the early postoperative period for non-valved glaucoma implant is variable, multifactorial and largely intraocular pressure (IOP) dependent. Clinical significance: This study explores methods of producing fenestration and the effects on outflow at different pressures in an attempt to determine which fenestration technique has more reproducible results that can be made applicable in clinical practice. This is also the first study to evaluate the effect of external pressures similar to scleral patch graft on the tube fenestrations.

RESEARCH ARTICLE

Rick E Bendel, Michael T Patterson

Long-term Effectiveness of Trabectome (Ab-interno Trabeculectomy) Surgery

[Year:2018] [Month:September-December] [Volume:12] [Number:3] [Pages:6] [Pages No:119 - 124]

Keywords: Intraocular pressure, Minimally invasive glaucoma surgery, Trabectome, Trabeculectomy, Retrospective chart review

PDF  |  DOI: 10.5005/jp-journals-10078-1235  |  Open Access |  How to cite  | 

Abstract

Aim: To evaluate the long-term safety and efficacy of ab-interno trabeculectomy with trabectome for the treatment of glaucoma. Materials and methods: Data collected for 339 eyes which included demographics, intraocular pressure (IOP) measurements using Goldmann applanation tonometry, best-corrected visual acuity (BCVA), visual field results, optic nerve status, gonioscopic findings, prior glaucoma procedures, number of glaucoma medications and pain level. The main data points of interest were preoperative IOP vs. postoperative IOP and BCVA, medication use, pain status, and complications. Results: Of the 339 eyes that underwent trabectome, we found a statistically significant reduction in IOP (p < 0.01) at final follow-up (average = 18.35 months) of nearly 23%, with a complication rate of 5.86%. Furthermore, this reduction was maintained up to 8 years post procedure. LogMAR visual acuity was significantly improved in 69% of eyes at the final visit (p < 0.05), while only 1.77% of cases saw a significant reduction. Based on these findings, we determined a success rate of around 80% to 100 months following trabectome. Conclusion: Trabectome is a safe and effective long term for most forms and severities of glaucoma.

REVIEW ARTICLE

Dimitrios Kalogeropoulos, Velota CT Sung

Pathogenesis of Uveitic Glaucoma

[Year:2018] [Month:September-December] [Volume:12] [Number:3] [Pages:14] [Pages No:125 - 138]

Keywords: Ocular hypertension/hypotony, Ocular inflammation, Uveitis, Uveitic glaucoma,Glaucoma, Intraocular pressure

PDF  |  DOI: 10.5005/jp-journals-10078-1236  |  Open Access |  How to cite  | 

Abstract

Uveitic glaucoma consists one of the most serious complications of intraocular inflammation and, despite its rarity, is considered as one of the leading causes of preventable loss of vision worldwide. It has been associated with a wide spectrum of inflammatory diseases, but its pathogenesis is still not fully comprehended. It appears that the type of inflammation, the steroid-response and the anatomical alterations of the anterior chamber play a pivotal role. To our knowledge, the mechanisms may be both acute and chronic. The main targets of the treatment are to control the inflammation and reduce the intraocular pressure (IOP). The management of glaucoma associated with uveitis remains an extremely challenging condition for ophthalmologists. The successful treatment of uveitic glaucoma is inextricably correlated with prompt and immediate therapeutic decisions. Very often a solid collaboration between clinicians from different specialties may be required for treating the underlying disease. Further understanding of its pathogenesis can indicate therapeutic targets and may lead to the development of new and more efficient therapeutic approaches. New glaucoma surgical modalities may ameliorate the prognosis after surgical intervention, but this calls for further evaluation. This study aims to highlight the complexity of uveitic glaucoma analyzing the main pathogenetic mechanisms and the correlations with the inflammatory response.

CASE REPORTS

Nuno P Ferreira, Joana M Pinto, Filipa Teixeira, Luís A Pinto

XEN Gel Stent Early Failure-dye-enhanced Ab-externo Revision

[Year:2018] [Month:September-December] [Volume:12] [Number:3] [Pages:3] [Pages No:139 - 141]

Keywords: Complications, Glaucoma surgery, Minimally invasive glaucoma surgery, XEN stent

PDF  |  DOI: 10.5005/jp-journals-10078-1237  |  Open Access |  How to cite  | 

Abstract

The XEN gel stent is an ab-interno minimally invasive glaucoma surgery device that reduces intraocular pressure by creating a subconjunctival drainage pathway. XEN intents to provide a safer and less invasive mean of lowering intraocular pressure. As with any new device, there is still some lack of experience and knowledge concerning efficacy, technique, and complications. We report a novel surgical approach for early bleb failure after XEN implantation.

CASE REPORTS

Marko Popovic, Matthew B Schlenker

Angle-closure Glaucoma in a Myopic Patient Precipitated by Sexual Excitation: A Case Report

[Year:2018] [Month:September-December] [Volume:12] [Number:3] [Pages:3] [Pages No:142 - 144]

Keywords: Acute angle-closure glaucoma, Endocyclophotoplasty, Goniosynechialysis, Myopia, Optical coherence tomography

PDF  |  DOI: 10.5005/jp-journals-10078-1238  |  Open Access |  How to cite  | 

Abstract

Aim: Herein, we report a case of a 55-year-old male who presented with intermittent acute-on-chronic angle-closure glaucoma triggered by sexual excitation. Background: Sexual excitation is an uncommon cause of pupillary block and angle closure attack. Case description: A 55-year-old male with a history of myopic laser in situ keratomileusis (LASIK) presented with a volatile intraocular pressure (IOP) and blurred vision over the last seven years. He was particularly symptomatic following sexual excitation. Examination revealed an IOP of 36 mm Hg and best-corrected vision of 20/80 OD, with bilateral closed angles and a double hump sign on gonioscopy. There were advanced glaucomatous changes OD and mild-to-moderate changes OS on optical coherence tomography. Following an exploration of potential options, it was chosen to proceed with OD lens-based surgery, goniosynechialysis and endocyclophotoplasty. During OD recovery, the patient reported an episode of visual blurring OS secondary to sexual excitation, which was consistent with pupillary block and angle closure attack on examination. Initially managed with acetazolamide and laser peripheral iridotomy, he eventually underwent the same surgical procedure OS as for OD. Over 1-year of follow-up, he has achieved a stable IOP and excellent visual acuity bilaterally. Conclusion and clinical significance: This case highlights the importance of a thorough history, with the understanding that sexual excitation can precipitate angle-closure glaucoma. Gonioscopy must be performed even in the setting of myopia and a deep anterior chamber, and the double hump sign must be assessed. Appropriate education surrounding the risks of sexual activity in angle closure suspects is advised.

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