Purpose: The study purpose was to assess patient survival after tube shunt implant or cyclodestructive procedure for neovascular glaucoma and to determine whether specific preoperative factors are predictive of survival. Materials and methods: A retrospective chart review was performed on patients with neovascular glaucoma who underwent tube shunt implant and/or cyclodestructive procedure between January 2002 and December 2019 at the Minneapolis Veterans Affairs Health Care System. Patient survival was compared to the age and gender-matched Minnesota population. Cox regression analyses were performed to evaluate preoperative parameters and survival. Results: Tube shunt alone was implanted in 30 eyes, cyclodestruction alone was performed in nine eyes, and two eyes underwent both (n = 41 eyes, 39 patients). The postoperative 5-year survival rate was 62% in neovascular glaucoma patients compared to 80% in controls. Survival did not differ significantly based on neovascular glaucoma etiology. Preoperative best-corrected visual acuity of the neovascular glaucoma-affected eye (p = 0.05) and Charlson Comorbidity Index (p = 0.02) were associated with survival, but preoperative maximum intraocular pressure, hemoglobin A1c, and creatinine were not. The mean intraocular pressure at 6 months postprocedure was 14 mm Hg for tube shunt and 27 mm Hg for cyclodestruction (p = 0.03). Conclusion: Neovascular glaucoma patients have reduced survival, but the majority survived at least 5-year postprocedure. Ophthalmologists should consider patient survival and factors predictive of survival when planning procedures for neovascular glaucoma. Clinical significance: Our findings provide an updated perspective on survival in the setting of neovascular glaucoma and can help ophthalmologists provide patient-centered and holistic care.

Aim: Our study aims to report the 2 years outcomes of the XEN implant in a single unit, single surgeon setting with minimal bleb needling. Methods: A retrospective cohort study was conducted. Inclusion criteria were patients who underwent implantation with a XEN device between May 2016 and December 2017. This included patients who underwent both combined phacoemulsification and intraocular lens implantation alongside XEN implantation and those who underwent XEN implantation alone. Data gathered included basic demographic data, best-corrected visual acuity (LogMAR), intraocular pressure (IOP) in mm Hg, mean deviation from their visual field test, and the number of IOP-lowering medications they were on. This information was recorded for their preoperative visit, and then at 6, 12, 18 and 24 months postoperatively. The primary outcome assessed was a complete success when the patient was without glaucoma medications and had an IOP of 18 mm Hg or less, but more importantly, this also had to equate to a 20% reduction in IOP compared to baseline. Qualified success was defined as the same change in IOP but with medications. Surgical failure is defined as those who required additional glaucoma surgery or those who did not obtain an IOP of 18 mm Hg alongside a 20% reduction in IOP compared to baseline. Results: At 24 months follow-up 82.5% of patients were surgical successes. Complete surgical success was achieved in 27% of patients. Qualified surgical success was achieved in 55.6% of patients. Subgroup analysis of those undergoing XEN implantation on its own and those combined with phacoemulsification + IOL were similar. The rate of bleb needling was low at 4.5%. Complication rates were acceptable at 9.5%. Conclusion: It is possible to get good IOP control with minimal postoperative bleb needling in patients who have undergone XEN implantation. Similar success rates are found in those undergoing combined procedures. Clinical Significance: Bleb needling carries its own risks. Minimizing the number of bleb needling allows procedures to be reserved at a later date. Furthermore, our study shows that success rates are not affected by doing a combined procedure with phacoemulsification.

Purpose: To report the efficacy of the XEN45 implant in advanced to end-stage glaucoma patients, after a 6 months follow-up. Methods: Retrospective, noncomparative electronic health record audit of patients who had undergone an XEN45 procedure. The main outcome measures were intraocular pressure (IOP) reduction and the number of antihypertensive medications. Secondary outcome measures were the rates of early postoperative complications. Complete and qualified success; failure and hypotony were defined according to the World Glaucoma Association guidelines (Shaarawy TM et al.). Needling rates and short-term complications were assessed and a subgroup analysis was performed. Results: A total of 39 eyes with advanced to end stage-glaucoma were included. Twenty eyes (51%) had undergone combined cataract surgery and 19 (49%), the XEN45 procedure alone. Mean IOP decreased from 19.67 ± 7.87 mm Hg to 13.18 ± 6.09 mm Hg; the number of medications decreased from a median use of 4 (IQR 2–5) to 0 (IQR 0–1). Complete success was achieved in 24 (61.5%) of the eyes, qualified success in 10 (25.6%), and failure in five (12.82%). Needling was required in 15 (38.46%) of the eyes at 6 months. Choroidal detachment occurred in eight (20.51%) eyes, numerical hypotony (IOP ≤ 5 mm Hg) at day 1 was noted in seven (17.95%) eyes with a full resolution by 2 weeks. Conclusion: In this short-term follow-up, we have seen that XEN45 is a viable, effective, and safe procedure utilized in advanced to end-stage glaucoma patients. Treating cases of significant hypotony using AC reformation with sulfur hexafluoride (SF6) is a safe and effective procedure.

Aim: To describe our first experience with the efficacy of micropulse transscleral cyclophotocoagulation (MP-TSCPC) procedure in the treatment of different glaucoma subtypes refractory to topical medication using a standard protocol. Materials and methods: Retrospective, interventional study in a series of 35 eyes of 34 patients with refractory glaucoma who underwent MP-TSCPC. Treatment success was defined as an intraocular pressure (IOP) reduction of at least 20% compared to baseline with or without IOP-lowering medication or eventual retreatment. Results: Mean age was 78.0 years. The glaucoma subtypes included pseudoexfoliative (PSXG) (16), neovascular (NVG) (9), primary open-angle (POAG) (7), congenital (1), aphakic (1), and secondary glaucoma (1). The mean preoperative IOP was 31.8 ± 10.5 mm Hg and at month 12 was 21.9 ± 10.6 mm Hg (p < 0.05). The average baseline number of glaucoma medications pretreatment was 3.0 ± 1.0 and at month 12 was 2.3 ± 1.2 (p = 0.114). At month 12, success was achieved in 15 eyes (42.9%) with an IOP-lowering effect of 31.1%. PSXG was correlated with IOP reduction (p = 0.037) and had a higher likelihood of success (p = 0.031). As complications, there was one case of prolonged hypotony and another case of developed postoperative neurotrophic keratopathy. Conclusion: Using our standardized protocol, MP-TSCPC seems a safe and relatively effective treatment in the medium-term for refractory glaucoma, achieving good results in PSXG. Clinical significance: There are few studies published about MP-TSCPC. The results of our study contribute to expanding on the short evidence reported at present, emphasizing our considerable percentage of PSGX.

Aim: To investigate whether steady state pattern electroretinogram (ssPERG) could identify retinal ganglion cell (RGC) dysfunction, and to assess the relationship between ssPERG with optical coherence tomography (OCT) measurements in glaucoma suspects (GS). Materials and methods: This was a prospective cohort study of GS, identified based on suspicious optic disk appearance and glaucoma risk factors. Complete eye exam, Standard automated perimetry, OCT, and ssPERG were performed. Magnitude (Mag), Magnitude D (MagD), and MagD/Mag ratio were subsequently used in the correlation and linear regression analyses between ssPERG parameters and the RNFL, GCL/IPL, and macular thicknesses measurements. Results: Forty-nine eyes of 26 patients were included. Mag and MagD were significantly correlated with the superior, inferior, and average RNFL thicknesses (avRNFLT). All ssPERG parameters were significantly correlated with the average and minimum GCL/IPL thicknesses and the inner macular sector thicknesses. Mag and MagD significantly predicted the superior, inferior, and avRNFLT in the regression analysis. All ssPERG parameters were predictive of GCL/IPL thickness in all sectors as well as the average and minimum GCL/IPL thicknesses. All ssPERG parameters were predictive of all inner macular sector thicknesses and MagD was also predictive of some outer macular sector thicknesses as well. Conclusion: ssPERG has significant correlations with and is predictive of RNFL, GCL/IPL, and macular thicknesses in glaucoma suspects. Clinical significance: ssPERG may serve as a useful objective functional tool for identifying and following the progression of disease in glaucoma suspects.

Aim: To describe the efficacy and safety of iStent implantation prior to phacoemulsification in manual as well as femtosecond laser-assisted cataract surgery (FLACS), and highlight this approach as a reasonable, if not necessary, step to advance one's ability and confidence in the use of microinvasive glaucoma surgery (MIGS) technology in phakic patients. Methods: A retrospective consecutive case series of patients with open angle glaucoma or ocular hypertension who underwent iStent inject implantation followed by cataract surgery (manual or FLACS). All cases underwent postoperative video review and were assessed and classified for intraoperative lens injury and hyphaema. Postoperative data included intraocular pressure (IOP), medication usage and adverse events. Results: Sixty-three eyes (n = 40 manual, n = 23 FLACS) were analyzed. Preoperatively, the mean IOP was 19.2 ± 4.9 mm Hg on 1.4 ± 0.96 mean medications, with 100% of eyes treated with medication. Intraoperatively, no lens injury was identified, and no significant hyphaema that impeded surgery occurred. At 6 months postoperative, mean IOP was 14.2 ± 1.8 mm Hg (38% reduction: p < 0.001), and >90% of eyes had IOP ≤ 16 mm Hg. The mean number of medications reduced to 0.11 ± 0.3 (92% reduction: p < 0.001), with 89% of eyes medication free. Safety was excellent for both manual and FLACS, with two iStents implanted in all eyes, and no cases of significant hyphaema or lens injury. Conclusion: Early implantation is safe, maximizes corneal clarity and angle visualization, avoids the risk of non-implantation due to surgical complications, and has a high success rate in both manual cataract surgery and the setting of FLACS. Clinical significance: The conventional recommended approach of iStent implantation following cataract extraction has been adopted by many, however, with the advent of stand-alone procedures and concern about potential lens injury, there is an opportunity to gain experience with minimal risk in patients undergoing MIGS procedures combined with cataract surgery by implanting iStents at the start of the procedure. There is currently little emphasis or data published in the literature on an early approach to implantation to guide surgeons.

Aim: To identify the ideal treatment protocol and success predictors for double-session micropulse transscleral (MP3) laser for glaucoma management. Materials and methods: Patients who underwent double-session MP3, with a minimum follow-up of 6 months, were retrospectively investigated. Logistic regression analysis was used to verify preoperative success predictors. The following comparisons were made: (1) Between eyes that obtained surgical success vs failure, (2) According to the time required for MP3, and (3) Considering only eyes that required retreatment. Results: A total of 191 eyes from 148 patients were included. The preoperative intraocular pressure (IOP) was significantly higher than at last follow-up visit (27.3 ± 6.9 vs 14.6 ± 6.0 mm Hg, p < 0.001). Success was observed in 90.5% of the eyes. On logistic regression analysis with preoperative IOP and MP3 time as independent variables, only previous IOP was identified as a statistically significant factor (p = 0.004), with lower IOP relating to higher success. Eyes that required lower MP3 time underwent more MP3 procedures than those with higher MP3 time (1.2 ± 0.5 vs 1.1 ± 0.3, p = 0.03). In the 36 eyes that underwent retreatment, preoperative IOP was higher (31.6 ± 7.4 vs 26.3 ± 6.4 mm Hg, p < 0.001); eyes with successful IOP treatment had a higher MP3 treatment time at the first surgery than eyes with failed IOP correction (364.1 ± 68.2 vs 330.0 ± 18.0 seconds, p = 0.02). Conclusion: Thus, an ideal double-session MP3 protocol should use a high laser energy at the first surgery, and a high preoperative IOP can be considered as a predictor of surgical failure. Clinical significance: This is the first study to give special attention to the double-session MP3 protocol and success predictors.

Aim: To identify clinical criteria that are easily achievable with follow-up tests and can identify subjects not suitable for driving. Patients and methods: We recruited 194 subjects with a clear diagnosis of glaucoma, with no other conditions that could affect the visual field (VF), and who performed a reliable VF examination. All patients underwent a full ophthalmologic evaluation and a questionnaire considering driving habits. An integrated visual field (IVF) was built using both monocular VF charts; the number of missed points (NoMP) within the central 20°, the average sensitivity (AS), and the better eye mean deviation (BEMD) were evaluated. Results: A total of 128 subjects showed a valid driving license (DL); 61.7% of drivers did not show missed points within the central 20° of the IVF, 27.4% presented one to three missed points, and 10.9% had four or more missed points. Best corrected visual acuity (BCVA) was highly above the legal criteria. Stratifying drivers by their BEMD (−7, −10, and −14 dB), we confirmed that the BEMD decrease corresponds to an increased NoMP and a decreased AS. Conclusion: Better eye mean deviation can be useful in clinical practice to identify patients at increased risk of being unsuitable for driving. Nevertheless, it is important to set specific cut-offs based on on-road driving performance. IVF evaluation may also be implemented in perimeter analysis software so that the composition of IVF, the BEMD, and the AS could directly describe the patient's binocular VF, excluding recourse to the Esterman visual field test (EVFT). Clinical significance: This new methodology will allow every physician—not just ophthalmologists—even if not an expert in evaluating a VF test, in assessing the ability to drive of glaucomatous patients.

Aim: To evaluate the efficacy of selective laser trabeculoplasty (SLT) in Southeast Asian eyes with primary open-angle glaucoma (POAG) vs primary angle-closure glaucoma after peripheral iridotomy (PACG-PI). Materials and methods: Records of glaucoma patients who underwent SLT and had a 24-month follow-up were reviewed. Pre- and post-treatment intraocular pressure (IOP), percentage of IOP reduction in POAG, and PACG-PI groups, and probability of failure were analyzed. SLT failure was defined as any eye that did not have IOP lower than 20% compared to the baseline or had an IOP higher than the baseline on two consecutive visits. Adding medication, repeating SLT, or surgical intervention to control IOP was also considered a failure. Results: Sixty-three POAG and 12 PACG-PI eyes were eligible. The mean (standard deviation [SD]) age was 62.9 (10.2) years in POAG and 60.3 (6.2) years in PACG-PI. Mean (SD) prelaser IOP in POAG was 19.0 (4.4) mm Hg and 20.7 (4.7) mm Hg in PACG-PI. At 24 months post-SLT, mean (SD) IOP was 14.1 (4.7) mm Hg and 13.6 (2.0) mm Hg in POAG and PACG-PI, respectively. There was no significant difference in percentage of IOP reduction (22.8 ± 23.0% for POAG and 30.7 ± 19.5% for PACG-PI, p = 0.96), or failure probability (p = 0.10) between both groups. Conclusion: The efficacy of SLT at 24 months was comparable between POAG and PACG-PI. Clinical significance: Selective laser trabeculoplasty may be an option to further lower IOP in eyes with angle closure with visible trabecular meshwork (TM) after iridotomy, especially in highly pigmented eyes of Southeast Asians.

Aim: To report an ocular juvenile xanthogranuloma (JXG) case presented with buphthalmos, corneal cloudiness, and normal intraocular pressure (IOP) in the neonatal period and treated with Ahmed glaucoma valve (AGV) implantation. Background: JXG is a rare disorder predominantly seen in infants, but the neonatal presentation is extraordinary. Although spontaneous hyphema is a common presenting sign in JXG, buphthalmos and corneal opacity in the neonatal period were reported only in one case, which had high IOP values at presentation. Case presentation: Sixteen-day-old male patient presented with buphthalmos, diffuse corneal clouding, and 11 mm Hg of IOP value in the right eye. IOP increased to 28 mm Hg three weeks later, and spontaneous hyphema developed, which did not respond to antiglaucomatous medications and topical corticosteroids. AGV was implanted, and the IOP decreased to 13 mm Hg postoperatively. In the follow-ups, numerous firm yellowish nodules were noticed on the patient's skin during the examination under general anesthesia. Histopathological examination of the skin nodules was compatible with the diagnosis of JXG. Lens subluxation and phacodonesis were developed during the follow-up and were managed with pars plana lensectomy. After a silent period of 3 months, epithelial ingrowth was determined around the side port entrance. Unfortunately, the ingrowth did not respond to cryotherapy and resulted in phthisis bulbi. Pathological evaluation of the enucleated phthisic eye revealed posterior segment involvement. Conclusion: Ocular JXG can be present with buphthalmos, corneal opacity, and normal IOP values without any skin lesions in the neonatal period. Neonatal presentation of JXG may be associated with limited medical therapy response and aggressive disease course. Clinical significance: This case report introduces the second ocular JXG case, which presented with buphthalmos and corneal cloudiness, and the third pathologically proven posterior segment involvement of JXG in the literature.

Aim: To describe a case of a patient on anticoagulation who underwent XEN45 (XEN) gel stent placement and subsequently developed kissing suprachoroidal hemorrhages (SCHs) requiring surgical drainage. Background: Minimally invasive glaucoma surgery (MIGS) aims to achieve effective control of intraocular pressure (IOP) while minimizing the complications associated with traditional glaucoma surgeries. Rarely, a severe complication of intraocular surgery is SCH, which can result from early postoperative hypotony. The XEN gel stent is a MIGS device that theoretically avoids the risk of hypotony due to its outflow resistance properties. However, cases of SCH associated with XEN gel stents have been reported. Case description: A monocular 86-year-old Caucasian male with glaucoma and atrial fibrillation on rivaroxaban underwent routine XEN gel stent placement with mitomycin C in his only seeing eye. On postoperative day 3, he presented with severe eye pain and worsening vision. He was found to have a SCH that gradually progressed to kissing suprachoroidals that required surgical drainage. After extensive discussion, the decision was made to hold the patient's rivaroxaban given his monocular status. The patient subsequently had a cerebral vascular accident (CVA) 1 week after drainage, but his symptoms gradually resolved after restarting anticoagulation. Two months after drainage, the patient's SCH had completely resolved, and he had recovered baseline visual acuity with excellent IOP control-off medications. Conclusion: This case highlights the importance of quick and appropriate management of complications following glaucoma surgery, as well as discussion with patients regarding risks of treatments and return precautions. It also is a reminder that although many new surgical interventions are “minimally invasive,” those like the XEN that are more effective at IOP control may have a similar risk profile to more traditional surgeries like trabeculectomy. As such, risk factors like anticoagulation use and older age should be considered in anticipation of surgical intervention. Clinical significance: The XEN gel stent is a new surgical option for glaucoma patients that asserts a better safety profile than traditional surgeries like trabeculectomy, but our case of kissing SCHs requiring surgical intervention following XEN placement reminds us that even minimally invasive surgeries can have devastating complications.

Aim: To present a case of rapid onset on neovascular glaucoma following the Coronavirus disease 2019 (COVID-19). Background: COVID-19 has various ocular manifestations such as conjunctivitis, uveitis, retinal vasculitis, and so on. However, to date, the development of neovascular glaucoma has not been reported in COVID-19. Case description: A 50-year-old male with a history of COVID-19 3 weeks ago presented with left eye (OS) central retinal artery occlusion (CRAO) and right eye (OD) cystoid macular edema with disc and microvascular leakage on multimodal imaging. After being managed conservatively for 2 weeks, the patient developed OD neovascular glaucoma with intraocular pressure (IOP) of 44 mm Hg and angle neovascularization (NVA) on gonioscopy. The patient was started on topical antiglaucoma medications (AGM) with panretinal photocoagulation (PRP) and responded well with complete regression of NVA, CME, and normal IOP after 3 weeks. Conclusion: This is the first reported case of rapid onset of NVG secondary to COVID-19-induced retinal vasculitis. COVID-19-associated prothrombotic state with secondary retinal vascular involvement can potentially trigger such NVG. Such NVG responds well with topical AGM and PRP therapy. Clinical significance: Given the global COVID-19 pandemic, it is imperative to be vigilant regarding the various vision-threatening manifestations associated with the disease such as the NVG.