Journal of Current Glaucoma Practice

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2019 | May-August | Volume 13 | Issue 2

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Deepika Dhingra, Tarek Shaarawy

Revisiting Results of Conventional Surgery: Trabeculectomy, Glaucoma Drainage Devices, and Deep Sclerectomy in the Era of MIGS

[Year:2019] [Month:May-August] [Volume:13] [Number:2] [Pages:5] [Pages No:45 - 49]

   DOI: 10.5005/jp-journals-10078-1248  |  Open Access |  How to cite  | 


Original Article

Maria EV Guimarães, Bernardo de Pádua Soares Bezerra, Frederico de Miranda Cordeiro, Christiano HS Carvalho, Daniella N Danif, Tiago S Prata, Syril K Dorairaj, Fábio N Kanadani

Glaucoma Surgery with Soaked Sponges with Mitomycin C vs Sub-Tenon Injection: Short-term Outcomes

[Year:2019] [Month:May-August] [Volume:13] [Number:2] [Pages:5] [Pages No:50 - 54]

Keywords: Glaucoma, Mitomycin C, Outcome, Surgery, Trabeculectomy

   DOI: 10.5005/jp-journals-10078-1254  |  Open Access |  How to cite  | 


Aim: The aim of this study is to compare the outcomes, success rates, complications, and number of interventions of the trabeculectomy surgery with mitomycin C (MMC) in two different techniques: conventional soaked sponges and sub-Tenon injection. Materials and methods: An observational retrospective study was performed with 79 eyes of 64 participants who underwent a glaucoma surgery with MMC. The conventional sponge soaked with MMC 0.03% for 3 minutes over the scleral flap (group I) and the subtenon injection of 0.1 mL of MMC 0.03% (group II) techniques were used to deliver the MMC. The data collected were patient demographics, preoperative intraocular pressure (IOP), central corneal thickness (CCT), number of pre- and postoperative ocular hypotensive drugs, postoperative complications, number of interventions, and need of further glaucoma surgery. Results: Seventy-nine eyes were divided into two: 39 eyes (49.37%) in group I and 40 eyes (50.63%) in group II. Trabeculectomy was performed in 53.17% and phacotrabeculectomy in 46.83%. The IOP decreased from 18.0 ± 11.0 mm Hg at the baseline to 10.0 ± 3.0 mm Hg at the last visit in group I and, in group II, from 16.0 ± 10.0–13.0 ± 6.0 mm Hg (median ± ID), p < 0.001. There were no significant differences between the groups regarding demographics, median follow-up, IOP in baseline, CCT, drugs reduction, success criteria adopted, postsurgical interventions, surgical complications, and need for new procedures (p > 0.05). Conclusion: Sub-Tenon injection of MMC is a safe and as effective as the conventional soaked sponge method in trabeculectomies. This method reduces surgical time and sponge-related risks with equivalent surgical efficacy. Clinical significance: As trabeculectomy is still the most common surgical procedure to reduce IOP and scar formation is one of the main causes of surgical failure, it is important to develop surgical techniques to improve its outcomes.


Original Article

Naoki Tojo, Atsushi Hayashi, Mitsuya Otsuka

Evaluation of Early Postoperative Intraocular Pressure for Success after Ex-Press Surgery

[Year:2019] [Month:May-August] [Volume:13] [Number:2] [Pages:7] [Pages No:55 - 61]

Keywords: Choroidal detachment, Ex-Press, Target intraocular pressure, Trabeculectomy

   DOI: 10.5005/jp-journals-10078-1252  |  Open Access |  How to cite  | 


Aim: The aim of this study is to identify target levels of early postoperative intraocular pressure (IOP) associated with successful trabeculectomy using an Ex-Press glaucoma shunt. Materials and methods: This was a retrospective single-facility study. We enrolled 158 glaucoma patients who underwent trabeculectomy with Ex-Press and were followed for >1 year, and investigated risk factors for the failure of Ex-Press surgery. We examined age, sex, central corneal thickness (CCT), number of preoperative glaucoma medications, simultaneous performance of cataract surgery, history of trabeculotomy, hypertension (HT), diabetes mellitus (DM), subtype of glaucoma, and early postoperative IOP (minimum, 2 weeks, 1 month, and 3 months). Results: Ex-Press surgery could significantly decrease IOP. Success rates at 1, 2, 3, and 4 years were 91.1, 86.1, 82.5, and 78.1%, respectively. Factors significantly affecting the success rate included age, the number of preoperative glaucoma medications, and early postoperative IOP. The IOP cutoff values of minimum IOP for the success of Ex-Press surgery was 5 mm Hg. Conclusions: Younger age, a high number of preoperative glaucoma medications, and high IOPs in the early postoperative period were found to be the risk factors for failure of Ex-Press surgery. Considering hypotonic complications, it is desirable to control the minimum IOP from 3–5 mm Hg within 2 weeks after surgery. According to our calculations, target IOPs at 2 weeks, 1 month, and 3 months after Ex-Press surgery should be 8 mm Hg, 10 mm Hg, and 14 mm Hg, respectively. Clinical significance: We thought that Ex-Press surgery might require lower IOP in the early postoperative period than conventional trabeculectomy.


Original Article

Albert R Bargoud, Hardik Parikh, Neil Kalbag, Patricia Greenberg

Outcomes of Complex Cataract Surgery in Patients with Primary Open-angle Glaucoma

[Year:2019] [Month:May-August] [Volume:13] [Number:2] [Pages:6] [Pages No:62 - 67]

Keywords: Cohort study, Glaucoma, Intraocular pressure, Phacoemulsification, Small pupil

   DOI: 10.5005/jp-journals-10078-1250  |  Open Access |  How to cite  | 


Aim: Whether pupillary expansion during phacoemulsification causes a change in postoperative intraocular pressure (IOP) is currently unknown. However, a growing proportion of patients can present with concurrent glaucoma and cataracts, which poses an increased risk of having small pupils and makes finding the answer to this question imperative for treating physicians. Materials and methods: This was a retrospective, observational cohort study which utilized data from 2008 to 2016 from the University Hospital, Newark, New Jersey, USA. All patients with primary open-angle glaucoma (POAG) who underwent phacoemulsification with pupillary expansion were considered for inclusion. Cases were subsequently excluded if they had prior incisional glaucoma surgery, if phacoemulsification was combined with another surgery, or if they had any incisional surgery in the eye 1 year preoperatively or postoperatively. The control group was made up of patients without POAG. The primary outcome was IOP. Results: Thirty-seven eyes from 31 glaucoma patients and 29 eyes from 28 control patients met inclusion criteria. The mean IOP in the POAG group increased from 15.0 ± 4.6 mm Hg to 15.9 ± 3.5 mm Hg after 1 year, whereas the control group decreased from 14.1 ± 3.6 mm Hg to 11.9 ± 3.9 mm Hg. Multivariate analysis showed that glaucoma was associated with a 5.56 mm Hg increase in IOP at 12 months postoperatively. The average number of glaucoma medications decreased significantly from 1.7 ± 1.4 at the baseline to 1.3 ± 1.3 after 1 year. Conclusion: In contrast with non-POAG patients, no significant drop in the mean IOP was noted after complex cataract surgery for this cohort of glaucoma patients, although medication burden significantly decreased and VA improved significantly. Clinical significance: Phacoemulsification with intraoperative pupillary expansion in POAG patients may not decrease IOP after 12 months but it can decrease the number of anti-glaucoma medications they take.



Ayse E Bahadir Kilavuzoglu, Cemile B Cosar, Ali RC Celebi, Ugur E Al Parmak

Intraocular Pressure Based on Dynamic Bidirectional Applanation and Air-puff Tonometry: A Comparative Study

[Year:2019] [Month:May-August] [Volume:13] [Number:2] [Pages:6] [Pages No:68 - 73]

Keywords: Air-puff tonometry, Corneal hysteresis, Corneal resistance factor, Intraocular pressure, Ocular response analyzer

   DOI: 10.5005/jp-journals-10078-1251  |  Open Access |  How to cite  | 


Aim: The aim of this study is to compare intraocular pressure (IOP) in healthy eyes measured via dynamic bidirectional applanation and air-puff tonometry, and to evaluate the effect of age, gender, the spherical equivalent (SE), mean keratometry (Kmean), corneal hysteresis (CH), and the corneal resistance factor (CRF) on IOP measurements. Materials and methods: IOP measured in 956 healthy eyes using the ocular response analyzer (ORA) and air-puff tonometer was compared in this cross-sectional retrospective study. Correlations between IOP, and age, gender, SE, Kmean, CH, and CRF were investigated using univariate and multivariate analyses. Bland–Altman plots were used to determine the level of agreement between the IOP values obtained with the two devices: IOP via air-puff tonometer (IOP-air-puff) and corneal-compensated IOP (IOPcc) using ORA (ORA-IOPcc). Linear mixed modeling was used to evaluate the effects of the study parameters on IOP. Intermethod reliability was established by calculating intraclass correlation coefficients (r). Results: The mean age of the patients was 39.56 ± 14.44 years. The mean IOPair-puff and ORA-IOPcc were 16.72 ± 2.37 mm Hg and 13.75 ± 3.12 mm Hg, respectively (p < 0.001). The mean CH and CRF were 11.14 ± 1.61 mm Hg and 10.53 ± 1.65 mm Hg, respectively. Multivariate analysis showed that both CH and CRF were significantly correlated with IOP-air-puff and ORA-IOPcc (p < 0.001). The 95% limit of agreement for IOP-air-puff and IOPcc was −2.843 to 8.784. There was a significant correlation between IOP-air-puff and ORA-IOPcc (r = 0.443, p < 0.001); the R2 value was 0.196. Conclusion: A low degree of agreement was noted between IOP-air-puff and ORA-IOPcc. The present findings show that air-puff tonometry overestimates IOP, as compared to ORA. Clinical significance: IOP based on air-puff tonometry must be interpreted in conjunction with other ophthalmologic findings and the same IOP measuring device should be used for follow-up evaluations.



Ann Shue, Russell M Levine, Gregory M Gallousis, Christopher C Teng

Cyclodialysis Cleft Associated with Kahook Dual Blade Goniotomy

[Year:2019] [Month:May-August] [Volume:13] [Number:2] [Pages:3] [Pages No:74 - 76]

Keywords: Ab-interno trabeculotomy, Argon laser photocoagulation, Cyclodialysis cleft, Goniotomy, Hypotony, Microinvasive glaucoma surgery, MIGS, Minimally invasive glaucoma surgery, Kahook dual blade

   DOI: 10.5005/jp-journals-10078-1255  |  Open Access |  How to cite  | 


Aim: The aim of this study is to report cyclodialysis cleft creation during Kahook dual blade (KDB) goniotomy. Background: No known reports of cyclodialysis clefts have been published to the authors’ knowledge after KDB goniotomy. Case description: A 55-year-old myopic male with primary open angle glaucoma in both eyes (OU) underwent routine cataract extraction and intraocular lens implant with KDB goniotomy in the right eye (OD). Preoperative intraocular pressures (IOP) OD were in the low 20 mm Hg range on timolol and bimatoprost. Postoperative IOP was 4 mm Hg, with a moderate depth anterior chamber. Gonioscopy was slit in all quadrants, with no structures visible, and no improvement on indentation. Mild macular choroidal folds were present OD. Ultrasound biomicroscopy (UBM) revealed an area of supraciliary fluid. Anterior chamber reformation with viscoelastic was performed and repeat gonioscopy revealed a cyclodialysis cleft from 2:00 to 3:00. Treatment with multiple sessions of argon laser photocoagulation successfully closed the cleft. Conclusion: KDB goniotomy may be complicated by cyclodialysis cleft formation and hypotony maculopathy. Visualization of a cleft on gonioscopy may require anterior chamber reformation. Clinical significance: With an increasing use of KDB for goniotomy, previously unreported complications may arise including cyclodialysis cleft and resultant hypotony maculopathy. Because cleft following KDB goniotomy is rare, suspicion may be low and diagnosis could be delayed in the setting of postoperative hypotony with closed angles.



Amado Rivero-Santana, David Pérez-Silguero, Miguel A Pérez-Silguero, Pablo Encinas-Pisa

Pupil Ovalization and Accommodation Loss after High-intensity Focused Ultrasound Treatment for Glaucoma: A Case Report

[Year:2019] [Month:May-August] [Volume:13] [Number:2] [Pages:2] [Pages No:77 - 78]

Keywords: Accommodation loss, Glaucoma, High-intensity focused ultrasound, Pupil ovalization

   DOI: 10.5005/jp-journals-10078-1256  |  Open Access |  How to cite  | 


Aim: The aim of this study is to present a complication derived from high-intensity focused ultrasound (HIFU) not described previously in the literature. Background: HIFU has shown to be an effective technique for reducing intraocular pressure (IOP) in the treatment of glaucoma, enabling the selective coagulation of the ciliary body. Published trials have not observed major intra- or postoperative complications, or serious adverse events derived from this technique. Case description: We present the case of a 65-year-old phakic patient with open-angle glaucoma and no previous filtration surgery. He was treated in both eyes with HIFU. After the intervention, the patient presented mild uveitis for 10 days, which remitted with the application of topical cycloplegic and corticosteroid treatment. After that, he reported a loss of near vision and examination showed pupil ovalization. It persisted 6 months later, with an accommodation loss of one diopter. Conclusion: Phakic patients treated with HIFU might be at risk of pupil ovalization with accommodation loss. Clinical significance: The complications described in this article should be included in the informed consent for patients with glaucoma who are offered HIFU as a treatment option.



Zaria C Ali, Dawnn I Khoo, Francessco Stringa, Vikas Shankar

Migration of XEN45 Implant: Findings, Mechanism, and Management

[Year:2019] [Month:May-August] [Volume:13] [Number:2] [Pages:3] [Pages No:79 - 81]

Keywords: Complications, Minimally invasive procedure, Surgical treatment, XEN

   DOI: 10.5005/jp-journals-10078-1253  |  Open Access |  How to cite  | 


Aim: The aim of this study is to report the mechanism of XEN migration and its management. Background: Over the past decade, new less invasive surgical approaches for glaucoma have been devised and carried out successfully. One such technique is the use of the XEN gel stent. We present a rare and relatively unknown complication of XEN migration and present in detail the likely mechanism by which this occurs, and its subsequent management. Case description: A 73-year-old male with primary angle closure on maximal medical treatment presented with an intraocular pressure of 30 mm Hg in the left eye. The visual acuity was 6/5, iridocorneal angles were open in all four quadrants, and the cup disc ratio was 0.4. As phacoemulsification alone was unlikely to adequately lower intraocular pressures, the patient underwent combined phacoemulsification and XEN implantation. Although the patient had a good postoperative result with pressures lowered to 11 mm Hg, 4 months after the operation, the XEN was found to have migrated 4 mm into the anterior chamber, associated with a low-grade uveitis. The patient subsequently had the XEN explanted a new XEN inserted. Pressures lowered 1 month postoperatively to 14 mm Hg. Conclusion: XEN migration is likely due to a combination of mechanical and frictional forces. If the XEN is positioned such that more than 2 mm is in the subconjunctival space, the XEN is likely to be angled upward and, therefore, be more susceptible to these forces and undergo migration. Clinical significance: It is essential that XEN implants are correctly sited and that this is confirmed intraoperatively to prevent the need for further procedures.


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