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Glucocorticoid-induced glaucoma is a secondary open-angle glaucoma. About 40% of the general population may develop elevated intraocular pressure on prolonged glucocorticoid treatment secondary to damages in the trabecular meshwork (TM), a tissue that regulates intraocular pressure. Therefore, identifying the key molecules responsible for glucocorticoid-induced ocular hypertension is crucial. In this study, Dickkopf-related protein 1 (Dkk1), a canonical Wnt signaling inhibitor, was found to be elevated in the aqueous humor and TM of glaucoma patients. At the signaling level, Dkk1 enhanced glucocorticoid receptor (GR) signaling, whereas Dkk1 knockdown or Wnt signaling activators decreased GR signaling in human TM cells as indicated by luciferase assays. Similarly, activation of the GR signaling inhibited Wnt signaling. At the protein level, glucocorticoid-induced extracellular matrix was inhibited by Wnt activation using Wnt activators or Dkk1 knockdown in primary human TM cells. In contrast, inhibition of canonical Wnt signaling by β-catenin knockdown increased glucocorticoid-induced extracellular matrix proteins. At the physiological level, adenovirus-mediated Wnt3a expression decreased glucocorticoid-induced ocular hypertension in mouse eyes. In summary, Wnt and GR signaling inhibit each other in the TM, and canonical Wnt signaling activators may prevent the adverse effect of glucocorticoids in the eye.

Purpose This study reports long-term outcomes of bleb revision with ologen™ Collagen Matrix (Aeon Astron Europe BV, the Netherlands) for the surgical management of various bleb-related issues including persistent bleb leaks with or without associated hypotony, bleb dysesthesia, overhanging blebs, or hypotony after filtering glaucoma surgery. Materials and methods A retrospective chart review was performed for patients who underwent ologen bleb revision from 2012 to 2019 at Glaucoma Associates of Texas. Results The study included 23 eyes of 22 patients undergoing bleb revision with the ologen implant. Mean age was 74.0 ± 11.3 years, 16 (69.6%) were female, and 13 (56.5%) were White. Indications for bleb revision included bleb leak (78.3%), dysesthesia (13.0%), and hypotony from an overfiltering bleb (8.7%). Mean preoperative intraocular pressure was 6.8 ± 4.1 mmHg and the number of medications was 0.3 ± 0.9. Median follow-up was 24 months (range: 12–84 months); all patients had at least 12 months of follow-up. At 1 year, mean intraocular pressure was 10.9 ± 4.6 mmHg on 0.2 ± 0.5 medications, and at last follow-up, mean intraocular pressure was 10.4 ± 3.6 mmHg on 0.3 ± 0.7 medications. Bleb morphology remained low, diffuse, and posterior. One patient developed kissing choroidal effusions requiring surgical drainage with subsequent stabilization of intraocular pressure and bleb function, and three patients required additional surgery due to persistent leaks or bleb failure; there were no other vision-threatening complications. Conclusions Use of the ologen implant during surgical bleb revision is a useful surgical technique that confers long-term improvements in bleb morphology and stability of function.

Purpose To report a series of 3 eyes of 3 children with congenital glaucoma receiving the XEN gel stent implant. Patients and methods An interventional case series is reported. Results Three eyes underwent implantation of the gel stent. In 2 cases, the gel implant procedure was performed after failed trabeculotomy, while in the third eye, primary gel stent implantation was performed. One eye received 2 implants. Three procedures were performed via an ab interno approach while the fourth was performed ab externo. No device-related complications were observed. In all 3 eyes, intraocular pressure was controlled without the use of topical medications through 6 to 24 months of follow-up. Conclusions The gel stent implant can be safely used in children with congenital glaucoma and effectively lowers intraocular pressure in these eyes. This procedure is a viable follow-up to, or replacement for, traditional angle surgery in eyes with congenital glaucoma.

Although there is a currently a revolution in angle-based procedures, subconjunctival filtration surgery with mitomycin C (MMC) wound modification remains a vital skill for glaucoma surgeons. MMC is a potent antifibrotic agent that has been an invaluable adjunct for successful glaucoma filtration surgery for over 20 years, but it must be used judiciously to avoid serious complications, including hypotony, corneal decompensation, bleb avascularity, bleb leaks, blebitis, and endophthalmitis. The purpose of this report is to describe the historical lessons learned from MMC use, along with updated methods of MMC delivery during primary trabeculectomy, bleb needling at the slit lamp, bleb revisions in the operating room, and newer and less invasive ab-interno filtering procedures. Information for the review was gathered using an extensive search on PubMed, a review of all available peer-reviewed literature, and the authors' personal clinical judgment and experience.

Purpose To develop a vision-targeted health-related quality-of-life instrument for patients with glaucoma who are candidates for minimally invasive glaucoma surgery (MIGS). Design Development of a health-related quality-of-life instrument. Participants Twelve practicing ophthalmologists and 41 glaucoma patients. Methods A questionnaire was constructed to assess functional limitations, vision-related symptoms, aesthetics, psychosocial issues, and surgical satisfaction for MIGS candidates. Questions were drafted after a review of the literature and subsequently refined based upon input from 1 physician and 4 patient focus groups. Nineteen cognitive interviews were used to ensure that questions were understandable to respondents. Results The focus group identified the following key issues and concerns as being important to glaucoma patients: functional limitations (eg, driving), bodily discomfort (eg, stinging from drops), changes in appearance (eg, drooping eyelid), and psychosocial concerns (eg, mental burden associated with a diagnosis of glaucoma, financial burden of treatment). Cognitive interviews resulted in the following improvements to the questionnaire: changes in wording to clarify lighting conditions, and additional questions addressing psychosocial issues, such as job loss, severity of disease, and perception of MIGS. Conclusions A patient-reported outcomes instrument, the Glaucoma Outcomes Survey, was developed to evaluate MIGS for patients with mild to moderate glaucoma. Next steps include electronic administration to patients selected from the American Academy of Ophthalmology Intelligent Research in Sight (IRIS) registry. An electronic patient-reported outcomes platform will be used to administer the questionnaire before and after MIGS. The questionnaire will improve understanding of how surgical interventions such as MIGS impact vision-targeted health-related quality-of-life in glaucoma patients.

Purpose: The purpose of this study was to inform ophthalmic surgeons in a timely manner of the hidden problem of clear intraluminal cellular debris as a cause for XEN-45 failure and to describe low energy neodymium-doped yttrium aluminum garnet (Nd:YAG) laser revision with periluminal anterior chamber tip shockwave treatment to improve flow to the bleb. Patients and Methods: Six patients with visibly patent stent lumen post XEN-45 surgery. These eyes developed rising intraocular pressure (IOP) with a history of excellent prior bleb formation and were treated successfully with Nd:YAG laser shockwave therapy to disperse assumed intraluminal cellular debris. The laser was aimed just anterior and axial to the intracameral tip of the gel stent through a gonioscopy lens. Results: Six patients with an average age of 75 years (60 to 90 y), preoperative IOP of 30 mm Hg (16 to 52 mm Hg) on an average of 2 antiglaucoma medications (0 to 4) underwent periluminal anterior chamber tip shock wave at an average of 12 months (1 to 38 mo) from XEN-45 surgery. The IOP was immediately reduced to an average of 15 mm Hg (8 to 23 mm Hg) and last IOP averaged 15 mm Hg (10 to 23 mm Hg) on 1.5 medications (0 to 4) at 4 months post periluminal anterior chamber tip shock wave. Conclusion: Nd:YAG laser revision of hidden blockage of a XEN-45 gel implant with periluminal anterior chamber tip shockwave treatment can disperse invisible intraluminal cellular debris and improve flow in a failing XEN-45 microstent, especially when distal fibrosis is not excessive.

This is a descriptive case series of 3 patients with uncontrolled intraocular pressure that developed reticular corneal changes after initiating netarsudil (0.02%). In all cases, upon observing reticular corneal edema, netarsudil (0.02%) was stopped followed by disappearance of corneal honeycombing. With the increasing use of this novel glaucoma medication, potentially more rare side effects will be observed. Reticular corneal edema or corneal honeycombing is an ocular examination finding that can rarely occur after initiating netarsudil (0.02%) regardless of prior corneal edema status. In our experience, the reticular changes resolve upon cessation of netarsudil.

In this review, we aimed to provide, in a structured format, an evidenced based review of the current state of minimally invasive surgical glaucoma management. Numerous studies, mostly non-comparative, have demonstrated several new, safe, effective, and minimally invasive surgeries for the management of various stages of open-angle glaucomas. These surgeries can either be combined with cataract surgery or performed in isolation of cataract surgery. Most of the newer minimally invasive procedures ensure safety with a mild to moderate intraocular pressure (IOP) lowering effect. Two novel shunts, the InnFocus MicroShunt and XEN45, however, can provide substantial IOP reduction in a relatively safe fashion. The future of glaucoma surgery is very bright, and there continue to be several safe, effective, and novel procedures for the management of various types of glaucomas.

To report outcomes for a novel ab interno bleb revision technique and spatula.This is a retrospective chart review.A total of 21 eyes of 21 patients underwent ab interno bleb revision with the Grover-Fellman biplanar sclerostomy spatula. Mitomycin C was given at least 1 week preoperation. The mean age of the patients and blebs were 67 and 6.75 years, respectively. The mean follow-up is 10.6 months (range: 3 to 17 mo). Mean preoperative intraocular pressure (IOP) (SD) was 21.9 (9.1) mm Hg on 3.7 (1.2) glaucoma medications. At 12 months follow-up, the mean IOP was 12.1 mm Hg on 0.86 medications. Four eyes failed due to uncontrolled IOP needing a tube shunt. One eye failed due to uncontrolled IOP but was lost to follow-up before a tube shunt could be performed. All failures occurred within 3 months. Two eyes had an IOP of5 mm Hg after 1 month with no evidence of hypotony maculopathy. These cases resolved after 3 months without surgical intervention. All successful cases had blebs that were low, diffuse, and posterior.After a failed filtration surgery, a low-diffuse bleb was reestablished by pretreating with subconjunctival mitomycin C followed by ab interno bleb revision with the Grover-Fellman biplanar sclerostomy spatula, decreasing further more invasive glaucoma procedures.

In glaucoma, lowered intraocular pressure (IOP) confers neuroprotection. Elevated IOP characterizes glaucoma and arises from impaired aqueous humor (AH) outflow. Increased resistance in the trabecular meshwork (TM), a filter-like structure essential to regulate AH outflow, may result in the impaired outflow. Flow through the 360° circumference of TM structures may be non-uniform, divided into high and low flow regions, termed as segmental. After flowing through the TM, AH enters Schlemm's canal (SC), which expresses both blood and lymphatic markers; AH then passes into collector channel entrances (CCE) along the SC external well. From the CCE, AH enters a deep scleral plexus (DSP) of vessels that typically run parallel to SC. From the DSP, intrascleral collector vessels run radially to the scleral surface to connect with AH containing vessels called aqueous veins to discharge AH to blood-containing episcleral veins. However, the molecular mechanisms that maintain homeostatic properties of endothelial cells along the pathways are not well understood. How these molecular events change during aging and in glaucoma pathology remain unresolved. In this review, we propose mechanistic possibilities to explain the continuum of AH outflow control, which originates at the TM and extends through collector channels to the episcleral veins.

In 2018, the American Glaucoma Society (AGS), the world’s largest professional society of glaucoma subspecialists, convened a 12-member task force of experts to craft a position statement about microinvasive glaucoma surgery (MIGS). The main objective of this position statement is to provide a succinct overview of these procedures and to address some misconceptions about MIGS. The members of the task force were selected by the AGS Board of Directors and include AGS members with expertise in developing MIGS, teaching MIGS, performing research on use and outcomes of these procedures, and working with the United States Food and Drug Administration (FDA) and other regulatory agencies about developing criteria to evaluate the efficacy and safety of these devices. Each of the sections of the position statement was prepared by subgroups of the task force, and then the material from the various sections was aggregated, and the leader of the task force (J.D.S.) merged the material into a cohesive draft. This draft was shared with the AGS Executive Committee and other members of the AGS Board of Directors for additional input.

Purpose The purpose of this study was to describe downstream patterns of outflow with the episcleral venous fluid wave (EVFW) in the living human eye adjacent to microinvasive glaucoma surgery (MIGS) and determine if the EVFW supports existing ex-vivo laboratory outflow research. Design Retrospective, noncomparative case series. Patients A total of 10 eyes of 10 patients who underwent phaco-Trabectome and 10 eyes of 10 patients who underwent phaco-iStent consecutively at Glaucoma Associates of Texas for cataract and uncontrolled glaucoma who demonstrated an episcleral wave. Methods The EVFW was visualized and recorded during irrigation and aspiration. To describe the hydrodynamic properties of the fluid wave, its degrees, extent, and characteristics were measured with a protractor in Photoshop. Results The incised Trabectome arc produced adjacent episcleral blanching of 134±11 degrees (range, 112 to 150 degrees) with an additional 54 degrees of marginal recruitment (41 degrees inferonasal plus 13 degrees superonasal) adjacent to the ends of the Trabectome incision. The mean episcleral blanch for the iStent was 51±19 degrees (range, 19 to 90 degrees), comprised of 29 degrees inferonasal plus 22 degrees superonasal. Conclusions Downstream episcleral flow in the living human eye adjacent to the iStent is variable and mainly confined to 2 clock hours indicating a lack of significant circumferential flow in glaucomatous eyes. Flow distal to the Trabectome site encompasses the Trabectome incisional arc with an additional 2 clock hours of lateral fluid wave favoring the inferonasal over superonasal quadrant 3 to 1. These in-vivo findings made visible with MIGS, corroborate recent in-vivo and long-standing ex-vivo laboratory research that outflow is largely segmented, favored inferonasally and conserved distally.

Canine glaucoma is a group of disorders that are generally associated with increased intraocular pressure (IOP) resulting in a characteristic optic neuropathy. Glaucoma is a leading cause of irreversible vision loss in dogs and may be either primary or secondary. Despite the growing spectrum of medical and surgical therapies, there is no cure, and many affected dogs go blind. Often eyes are enucleated because of painfully high, uncontrollable IOP. While progressive vision loss due to primary glaucoma is considered preventable in some humans, this is mostly not true for dogs. There is an urgent need for more effective, affordable treatment options. Because newly developed glaucoma medications are emerging at a very slow rate and may not be effective in dogs, work toward improving surgical options may be the most rewarding approach in the near term. This Viewpoint Article summarizes the discussions and recommended research strategies of both a Think Tank and a Consortium focused on the development of more effective therapies for canine glaucoma; both were organized and funded by the American College of Veterinary Ophthalmologists Vision for Animals Foundation (ACVO‐VAF). The recommendations consist of (a) better understanding of disease mechanisms, (b) early glaucoma diagnosis and disease staging, (c) optimization of IOP‐lowering medical treatment, (d) new surgical therapies to control IOP, and (e) novel treatment strategies, such as gene and stem cell therapies, neuroprotection, and neuroregeneration. In order to address these needs, increases in research funding specifically focused on canine glaucoma are necessary.

PURPOSE The purpose of this study was to provide 24-month follow-up on surgical success and safety of an ab interno circumferential 360-degree trabeculotomy. METHODS Chart review of patients who underwent a gonioscopy-assisted transluminal trabeculotomy (GATT) procedure was performed by 4 of the authors (D.S.G., O.S., R.L.F., and D.G.G.). The surgery was performed in adults with various types of open-angle glaucoma with preoperative intraocular pressures (IOPs) of ≥18 mm Hg. RESULTS In total, 198 patients aged 24 to 89 years underwent the GATT procedure with at least 18 months follow-up. Patients with primary open-angle glaucoma had an average IOP decrease of 9.2 mm Hg at 24 months with an average decrease of 1.43 glaucoma medications. The mean percentage of IOP decrease in these primary open-angle glaucoma groups at 24 months was 37.3%. In secondary open-angle glaucoma, at 24 months there was an average decrease in IOP of 14.1 mm Hg on an average of 2.0 fewer medications. The mean percentage of IOP decrease in the secondary open-angle glaucoma groups at 24 months was 49.8%. The cumulative proportion of failure at 24 months ranged from 0.18 to 0.48, depending on the group. In all 6 study groups, at all 5 postoperative time points (3, 6, 12, 18, and 24 mo) the mean IOP and reduction in glaucoma medications was significantly reduced from baseline (P

To compare the outcomes of combined cataract surgery with trabecular microbypass stents and ab interno trabeculotomy in patients with open-angle glaucoma.University of Toronto, Toronto, Ontario, and University of Montreal, Montreal, Quebec, Canada, and Glaucoma Associates of Texas, Dallas, Texas, USA.Retrospective case series.Patients with primary open-angle, pseudoexfoliative, or pigmentary dispersion glaucoma were included. Primary outcome measures were intraocular pressure (IOP), postoperative medications, success (IOP ≤18 mm Hg, no glaucoma medications or reoperations), and postoperative adverse events.The average patient age was 76.5 years ± 12 [SD]. Forty-nine eyes had phacoemulsification and 2 had stent implantations; 52 eyes had phacoemulsification and trabeculotomy surgery with a 12-month postoperative follow-up. The analysis of variance indicated a significant reduction in mean IOP from baseline to 12 months for stent (19.6 ± 5.3 mm Hg to 14.3 ± 3.1 mm Hg; P.001) and trabeculotomy (20.6 ± 6.8 mm Hg to 17.3 ± 6.5 mm Hg; P.001) and lower mean IOP at 12 months in the stent group (P = .01). The median number of glaucoma medications decreased from baseline to 12 months in both groups and was lower in the stent group at 3, 6, and 12 months. Thirty-nine percent (19 eyes) in the stent group and 14% (7 eyes) in the trabeculotomy group achieved success at 12 months (P = .006). The incidence of hyphema was lower in the stent group (P = .008).Both types of surgery achieved a significant reduction in IOP and medication use at 12 months, with the stent group achieving higher success and a reduced incidence of postoperative hyphema.Dr. Ahmed is a consultant to and investigator for Glaukos Corp., Ivantis, Inc., Transcend Medical, Inc., and Aquesys, Inc., and has received speaker honoraria from Neomedix, Inc. Dr. Saheb has received travel funding from Glaukos Corp., Ivantis, Inc., and Transcend Medical, Inc., and a research grant from Ivantis, Inc. Dr. Harasymowycz has received a research grant from Ivantis, Inc. Dr. Fellman is a consultant to Endo Optiks, Inc., and has received honoraria from Optous and research funds from Ivantis, Inc., Glaukos Corp., and Transcend Medical, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

The authors have designed a muscle hook speculum that simultaneously allows the surgeon to isolate and expose both rectus muscles (either the superior and temporal or medial and inferior) for ease of placement of a 350-mm Baerveldt implant. This instrument facilitates the exposure and subsequent placement of either a superior-temporal tube or an infero-nasal tube in a more independent manner. By using the dual muscle hook speculum, an individual surgeon, without a glaucoma-trained assistant, can hook typically both the superior and lateral recti muscles while gaining simultaneous exposure of the quadrant. The purpose of this report is to describe the instrument, how it is used, and how it can improve efficiency in the operating room.

Purpose To introduce a minimally invasive, ab interno approach to a circumferential 360-degree trabeculotomy and to report the preliminary results. Design Retrospective, noncomparative cases series. Participants Eighty-five eyes of 85 consecutive patients who sought treatment at Glaucoma Associates of Texas with uncontrolled open-angle glaucoma and underwent gonioscopy-assisted transluminal trabeculotomy (GATT) for whom there was at least 6 months of follow-up data. Methods Retrospective chart review of patients who underwent GATT by 4 of the authors (D.S.G., D.G.G., O.S., R.L.F.) between October 2011 and October 2012. The surgery was performed in adults with various open-angle glaucomas. Main Outcome Measures Intraocular pressure (IOP), glaucoma medications, visual acuity, and intraoperative as well as postoperative complications. Results Eighty-five patients with an age range of 24 to 88 years underwent GATT with at least 6 months of follow-up. In 57 patients with primary open-angle glaucoma, the IOP decreased by 7.7 mmHg (standard deviation [SD], 6.2 mm Hg; 30.0% [SD, 22.7%]) with an average decrease in glaucoma medications of 0.9 (SD, 1.3) at 6 months. In this group, the IOP decreased by 11.1 mmHg (SD, 6.1 mmHg; 39.8% [SD, 16.0%]) with 1.1 fewer glaucoma medications at 12 months. In the secondary glaucoma group of 28 patients, IOP decreased by 17.2 mmHg (SD, 10.8 mmHg; 52.7% [SD, 15.8%]) with an average of 2.2 fewer glaucoma medications at 6 months. In this group, the IOP decreased by 19.9 mmHg (SD, 10.2 mmHg; 56.8% [SD, 17.4%]) with an average of 1.9 fewer medications (SD, 2.1) at 12 months. Treatment was considered to have failed in 9% (8/85) of patients because of the need for further glaucoma surgery. The cumulative proportion of failure at 1 year ranged from 0.1 to 0.32, depending on the group. Lens status or concurrent cataract surgery did not have a statistically significant effect on IOP in eyes that underwent GATT at either 6 or 12 months ( P > 0.35). The most common complication was transient hyphema, seen in 30% of patients at the 1-week visit. Conclusions The preliminary results and safety profile for GATT, a minimally invasive circumferential trabeculotomy, are promising and at least equivalent to previously published results for ab externo trabeculotomy.

To report on outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in eyes with prior incisional glaucoma surgery.A retrospective review was performed for all patients who underwent a GATT procedure with a history of prior incisional glaucoma surgery.Thirty-five eyes of 35 patients were treated. The mean age was 67.7 years. Nineteen eyes had a prior trabeculectomy, 13 eyes had a prior glaucoma drainage device, 4 eyes had a prior trabectome, and 5 eyes had prior endocyclophotocoagulation. Mean follow-up time was 22.7 months. For all eyes, the mean preoperative intraocular pressure (IOP) (SD) was 25.7 (6.5) mm Hg on 3.2 (1.0) glaucoma medications and at 24 months, the mean IOP (SD) was 15.4 (4.9) mm Hg on 2.0 (1.4) glaucoma medications (P0.001). The prior trabeculectomy group had a preoperative IOP (SD) of 24.6 (6.4) mm Hg on 3.2 (1.0) medications and at month 24, the mean IOP (SD) was 16.7 (5.6) mm Hg on 2.1 (1.4) glaucoma medications. In the prior glaucoma drainage device group, the mean preoperative IOP (SD) was 27.0 (7.1) mm Hg on 3.4 (1.1) glaucoma medications and at 24 months, the mean IOP (SD) was 12.9 (2.6) mm Hg on 2.1 (1.2) glaucoma medications. At 24 months, the cumulative proportion of failure was 0.4 and the cumulative proportion of reoperation was 0.29.GATT appears to be safe and successful in treating 60% to 70% of open-angle patients with prior incisional glaucoma surgery. When considering all eyes, there was a significant decrease in IOP and required glaucoma medications at 24 months. This surgery should be considered in certain patients with open angles who have failed a primary traditional glaucoma surgery.

Gonioscopy Assisted Transluminal Trabeculotomy (GATT) is a novel technique that allows for the performance of circumferential trabeculotomy via an ab-interno approach. The procedure offers several distinct advantages to traditional glaucoma filtering procedures in the treatment of adult and developmental glaucomas. Importantly, the procedure is performed via clear corneal incisions and therefore spares conjunctival tissue. Important preoperative considerations include the degree of corneal clarity, intraocular lens stability, and gonioscopic view of the anterior chamber angle. The procedure may be performed with either a suture or an illuminated microcatheter. Postoperatively, patients are treated with topical steroidal, nonsteroidal, and antibiotic eyedrops. Intraocular pressure (IOP)-lowering eyedrops may also be used as necessary. In a recent study reporting on results achieved with the GATT procedure, 57 patients with POAG achieved an IOP reduction of 7.7 mmHg [(SD, 6.2 mmHg) or 30.0 % (SD, 22.7 %)] with an average decrease in glaucoma medications of 0.9 (SD, 1.3) at 6 months. The GATT procedure is a minimally invasive, conjunctival sparing surgical technique that improves upon conventional ab externo trabeculotomy in adults and children. Success rates are at least equivalent to previously published studies of ab externo circumferential trabeculotomy.

Objective To compare the safety and intraocular pressure (IOP)-lowering efficacy of once-daily travoprost (0.0015% and 0.004%) to twice-daily timolol 0.5%. Design Prospective, 6-month, randomized, controlled, multicenter, double-masked, phase III study. Participants Six hundred five patients with open-angle glaucoma or ocular hypertension. Methods Patients with an 8 am IOP between 24 to 36 mmHg in at least one eye (the same eye) at two eligibility visits received either travoprost 0.0015%, travoprost 0.004% (dosed every day), or timolol 0.5% (dosed twice daily). Main outcome measures Mean IOP at 8 am , 10 am, and 4 pm in the patient’s eye with the higher baseline IOP. Results The mean IOP was significantly lower for both concentrations of travoprost compared with timolol. Travoprost was statistically superior to timolol at 9 of 13 visits, with differences in IOP reductions ranging from 0.9 to 1.8 mmHg (0.0015%) and 10 of 13 visits with differences in IOP reductions from 0.9 to 2.4 mmHg (0.004%). Mean IOP changes from baseline ranged from −6.0 to −7.5 mmHg (0.0015%), −6.5 to −8.0 mmHg (0.004%), and −5.2 to −7.0 mmHg for timolol. Hyperemia was experienced at rates of 29.2% (59 of 202) for travoprost 0.0015%, 42.8% (86 of 201) for travoprost 0.004%, and 8.9% (18 of 202) for timolol. Iris pigmentation changes were observed in 1.0% (2 of 200) of patients receiving travoprost 0.004% with no changes noted in the travoprost 0.0015% group or the timolol group. A decrease in pulse and systolic blood pressure was observed in the timolol group. There were no other clinically relevant or statistically significant changes from baseline in ocular signs or laboratory values, and no serious, related, unexpected adverse events were reported for any group. Conclusions Travoprost (0.0015% and 0.004%), dosed once daily in the evening, is statistically superior or equal to timolol 0.5% dosed twice daily at all treatment visits during this 6-month study. IOP reductions of up to 2.0 mmHg greater than timolol were found in the travoprost 0.004% pooled data group. Travoprost is safe and well tolerated in patients with open-angle glaucoma or ocular hypertension.

Background/aims To introduce a novel ab interno 360° trabeculotomy for treating primary congenital glaucoma (PCG) and juvenile open angle glaucoma (JOAG) and report preliminary results. Methods A retrospective chart review of patients who underwent a gonioscopy assisted transluminal trabeculotomy (GATT) procedure by four of the authors (DSG, OS, RLF and DGG) between October 2011 and October 2013. The surgery was performed in patients ≤30 years old with a dysgenic anterior segment angle and uncontrolled PCG and JOAG. Results Fourteen eyes of 10 patients underwent GATT with follow-up >12 months (12–33 months; mean 20.4). Patients ranged in age from 17 months to 30 years (mean=18.4 years), and five (50%) were female patients. No complications occurred during or following surgery except for early postoperative hyphema in five (36%) of eyes, all cleared by 1 month. The mean intraocular pressure (IOP) decreased from 27.3 to 14.8 mm Hg and the mean number of medications required decreased from 2.6 to 0.86. Five eyes had a drop in IOP ≥15 mm Hg (range 15–39). Conclusions The preliminary results and safety for GATT, a minimally invasive conjunctival sparing circumferential trabeculotomy, are promising and at least equivalent to previous results for ab externo trabeculotomy for the treatment of PCG and JOAG. All eyes in the study were considered a clinical success.

To evaluate the pattern of losses associated with glaucomatous injury in patients with progressing glaucoma, functional losses were examined in 14 patients with progressing glaucoma using tests for which detection should be selectively mediated by one of three psychophysical mechanisms. Red-on-white increments, blue-on-white increments and critical flicker frequency were used to isolate the responses of the red–green chromatic mechanism, the blue-on chromatic mechanism, and the high-frequency flicker achromatic mechanism. For our 3.1° circular stimuli, chromatic defects were found in a greater number of the patients with glaucoma than were achromatic defects. We evaluated these defects in terms of two existing hypotheses: preferential loss and reduced redundancy. The greater sensitivity to glaucomatous injury of chromatic tests, compared to achromatic tests, found in this and other studies and the apparent discrepancy between anatomical and psychophysical studies can be parsimoniously explained by differences in cortical summation of ganglion cell responses for the chromatic and achromatic pathways.

PURPOSE To describe a new technique for revising oversized blebs after trabeculectomy. METHODS A chart review of consecutive patients undergoing bleb window cryopexy was conducted. Patients with symptomatic oversized blebs were candidates for the technique, regardless of the intraocular pressure. Under topical anesthesia, the bleb was incised and a 3 mm x 3 mm conjunctival window was removed using 0.12 forceps and Vannas scissors. Light cryotherapy was applied to the sclera through the window. A soft bandage contact lens was then placed for compression, and a patch was applied. All patients were given antibiotic drops the first day after surgery. Topical corticosteroid drops were used to minimize postoperative inflammation. Outcome measures included relief of symptoms, adequate control of intraocular pressure, and restoration of filtering bleb function without further antiglaucoma medication or surgical bleb revision. RESULTS Nine patients met the inclusion criteria. All patients had flattening of the bleb with symptomatic relief within 2 weeks. No loss of bleb function occurred. One patient developed aqueous misdirection after the procedure. CONCLUSION Early results showed that bleb window cryopexy is safe and effective. This minimally invasive technique can be useful for selected patients with large. symptomatic, overhanging blebs.

The EX-PRESS shunt (Alcon Laboratory) is a stainless steel implant designed to shunt aqueous from the anterior chamber to the subconjunctival space. The device is placed under a scleral flap, with the lumen ideally positioned parallel to the iris. A properly positioned EX-PRESS shunt creates a controlled communication between the anterior chamber and the bleb. 1 Several shunt-specific complications have been described elsewhere, including blockage, extrusion or exposure, and anterior dislocation. 2-4 In addition to these complications, malpositioning of the shunt can occur but, to our knowledge, has never been reported as a source of debilitating chronic eye pain requiring shunt removal. We describe a new technique for gonioscopy-assisted ab interno removal of an EX-PRESS shunt. We also report findings in a patient with severe eye pain due to indentation and chafing of the superior iris stroma caused by an iris-embedded shunt. The patient’s eye pain resolved completely after successful ab interno removal of the malpositioned shunt. In a second patient, the ab interno technique was used to remove a nonfunctioning shunt during

Purpose: To report the observation of a perilimbal and/or episcleral vessel fluid wave seen during trabectome surgery, newly termed episcleral venous fluid wave. Patients and Methods: In 4 consecutive patients undergoing phacotrabectome surgery, the authors observed the nasal perilimbal and episcleral collector vessels for an anticipated wave of fluid adjacent to the trabeculotomy site. The wave of fluid was elicited during the irrigation and aspiration phase of cataract surgery at the time of low intraocular pressure with no infusion (foot pedal position 0) to maximum irrigation (foot pedal position 2), creating a maximal pressure gradient for balanced salt solution (BSS) to surge into the anterior chamber and potentially out of the newly cleaved canal venous collector system. Results: During the anterior chamber surge of BSS, the authors observed in 4 cases, 2 types of fluid waves, one episcleral and sectorial in distribution and the other through the perilimbal conjunctival vessels. There was a correlation between the location of retrograde reflux of blood into the anterior chamber during the low-pressure phase and a wave of BSS into the immediate adjacent collector. Conclusions: The authors believe the fluid wave signifies intraoperative structural patency of the conventional outflow system from the anterior chamber to the episcleral and conjunctival distal collectors. The fluid wave is a sign that the collector system is at least anatomically functional, however, not necessarily physiologically functional. The presence or absence of a fluid wave may better explain canal-based surgical outcomes and could be a prognostic indicator for success after a trabectome surgery.

The use of trypan blue is increasing in complicated cataract, retina, and glaucoma surgeries. We report on the use of trypan blue to help visualize the capsule over a glaucoma drainage implant and to assess adequate flow in different situations involving both valved and nonvalved implants. These cases demonstrate 3 key points. One, when completing the second stage of a tube, it is essential to prime the tube to ensure adequate flow. Two, when extensive conjunctival scarring is present, trypan blue can be used to stain the capsule around the plate and confirm adequate flow. Three, if one is concerned of the functionality of a valved glaucoma implant, trypan blue can be used to both confirm and reestablish functionality of the valve mechanism.

Glaucoma patients who require incisional glaucoma surgery and who neither are optimal candidates for filtering surgery nor need an intraocular pressure (IOP) as low as 10 mmHg may be candidates for trabeculotomy. Trabeculotomy ab externo is an anterior chamber angle procedure designed to increase conventional trabecular outflow. IOP is lowered without creating a filtering bleb. Patients with only mild to moderate disc damage and with uncontrolled IOPs greater than 21 mmHg may do well with postoperative IOPs in the mid- to late teens and perhaps just one antiglaucoma medication - the typical scenario post-trabeculotomy surgery (Fig. 66.1a, b).

This retrospective study reviews the results of 35 keratoplasty patients with complex corneal and glaucoma disease, who received Molteno-type (n = 25) or anterior chamber tube shunt to encircling band (ACTSEB)-type (n = 10) implant for the treatment of difficult glaucomas. The implant was placed before the keratoplasty in 14 eyes, during the keratoplasty procedure in 6 eyes, and subsequent to the corneal surgery in 15 eyes. Mean follow-up for the keratoplasty was 25.46 months (range, 6-58 months) and 24.74 months (range, 7-42 months) for the seton procedure. Graft rejection occurred in 12 (34%) of 35 eyes and was progressive in 9 eyes. Nonimmunologic failure was seen in 9 (26%) of 35 eyes. Grafts were repeated in ten eyes with eight of these (80%) remaining clear at a mean of 14.4 months. Considering the results of the repeat grafts, 25 (71%) of 35 eyes achieved clear transplants. Overall, 46% of patients had final visual acuities of 20/100 or better and 69% had final visual acuities of 20/400 or better. The mean preoperative intraocular pressure (IOP) of 34.54 mmHg (range, 14-68 mmHg; standard deviation [SD], 11.51) was lowered to a mean of 14.65 mmHg (range, 6-30 mmHg; SD, 4.49). In the final analysis, 30 (86%) of 35 eyes were judged successful from a glaucoma standpoint. We conclude that the Molteno- and ACTSEB-type implants are viable treatment alternatives in this difficult glaucoma group.

Purpose To determine whether the characteristics of an intraoperative episcleral venous fluid wave (EVFW), a potential indicator of trabecular outflow patency, correlates with Trabectome (NeoMedix Corp, Tustin, CA) outcomes. Design Retrospective, observational study. Participants A total of 68 eyes of 49 patients with glaucoma who underwent phaco-Trabectome (63 eyes) or Trabectome alone (5 eyes). Methods The EVFW was evaluated in a masked fashion for wave degree (0–4) and clock hours (0–6). A diffuse EVFW (4, 5, 6 clock hours) was a near complete blanching of the episcleral vasculature, and a poorly defined wave was minimal change in the vasculature. Patients were grouped into wave categories to determine whether there was a correlation with postoperative intraocular pressure (IOP). Patients requiring further glaucoma surgery were considered failures. Main Outcome Measures Degree and extent of EVFW, IOP, and glaucoma medications. Results For all eyes, there was a statistically significant correlation between wave clock hours and postoperative IOP at month 1 ( P = 0.043) and month 3 ( P = 0.002), but not a statistically significant correlation at month 6 ( P = 0.12) or 1 year ( P = 0.86). A strong correlation was found among IOP, medications, and EVFW in eyes with an extensive EVFW when compared with eyes with a poorly defined EVFW. At 12 months, the mean IOP in the extensive EVFW group was 13.3±2.7 mmHg on 1.4±1.2 medications compared with an IOP of 18.4±3.1 mmHg on 2.9±0.9 medications in the poorly defined group (both P = 0.001). Overall, 5 of 68 eyes (7%), required further glaucoma surgery. Eyes with a poorly defined EVFW had a higher likelihood of further glaucoma surgery (36%). Conclusions The EVFW is an intraoperative gauge of patency through the trabecular outflow pathway. Absence of the EVFW implies obstruction in the collector channel–intrascleral aqueous outflow pathway, preventing flow to the visible episcleral veins. In contrast, eyes with a diffuse EVFW had sufficient flow through their collector channels, had a lower IOP, required fewer glaucoma medications, and had a lower requirement for further glaucoma surgery. The characteristics of an EFVW may be able to predict surgical outcomes after Trabectome surgery.

PURPOSE: Increased serum immunoreactivity to retinal proteins may have a role in the disease process of some glaucoma patients. We describe a patient with normal- pressure glaucoma whose serum immunoreactivity to retinal proteins regressed after methotrexate treatment for rheumatoid disease. METHOD: Case report. RESULTS: In a 66-year-old white female with normal-pressure glaucoma and rheumatoid disease, sequential Western blots using patient sera against retinal proteins demonstrated a decrease in the immunoreactive bands after treatment. During the treatment period of 3 years, her visual fields appeared to have improved. Optic disk examination during the short periods without treatment, however, disclosed new, bilateral splinter hemorrhages on the optic disks. CONCLUSION: These observations suggest a potential role for immune-based intervention in similar patients.

This retrospective study evaluated the safety and efficacy of the forniceal conjunctival pedicle flap for repair of conjunctival-deficient tube erosions. Additionally, we report the split-lid technique, a procedural improvement if fornix access is difficult. We identified 15 eyes of 14 consecutive patients with complex tube erosions. The mean age was 72.8 years and 33.3% had diabetes mellitus. Most patients were functionally monocular and 80% had undergone 4 or more prior ocular surgical procedures. There was no difference between the following preoperative and postoperative values: visual acuity, intraocular pressure, or number of glaucoma medications. The mean follow-up time after pedicle flap repair was 49 months. There were no recurrent erosions allowing for preservation of the drainage implant with excellent intraocular pressure control. This study demonstrates the relative long-term safety and success of this novel technique.

Evaluation of tritan defects is potentially useful for early diagnosis and evaluation of treatment of glaucoma, but the clinical utility of tests such as the Farnsworth-Munsell 100 hue has been limited due in part to effects of individual variations in pupil size and extent of lens yellowing. S-cone contrast sensitivity has been proposed as a more useful tritan test, but it is not known precisely how S-cone contrast sensitivity measured with a computer monitor is influenced by variations in mean S-cone quantal catch due to individual differences in pupil size and lens density. We measured S-cone contrast sensitivity of patients with glaucoma, using 1.0 cycle/degree blue grating superimposed on a bright yellow background. Sensitivity was measured at a range of mean luminances, and pupil size was monitored with a closed-circuit video system. Inter-subject variability was reduced by plotting S-cone contrast sensitivity vs. retinal illuminance rather than stimulus luminance, indicating that much of the variability was due to differences in pupil size. Each patient’s data were fit with a threshold versus retinal illuminance (TVR) function. The TVR analysis suggested that additional variability was due to prereceptoral filters. These results indicate that reductions in S-cone contrast sensitivity at luminances available from computer monitors may reflect, in part, effects of pupillary miosis or lens yellowing, rather than optic nerve damage.

Purpose: The Baerveldt glaucoma implant is a new commercially available aqueous drainage device. Clinical data on the performance of the implant are relatively limited. The purpose of this investigation is to explore potential advantages and disadvantages of this implant over the more widely used Molteno implant. Methods: Retrospective analysis was performed on 37 eyes of 36 patients with refractory glaucoma who underwent placement of a mid-sized Baerveldt 350-mm 2 implant. Patient selection was based on previous failure of conventional medical, laser, and surgical management, with poor prognosis for further glaucoma surgery and adjunctive antifibrosis therapy. Results: Significant postoperative extraocular motility restriction and heterotropia were found in the operated eyes. Twenty-three (77%) of 30 eyes measured have significant heterotropia in primary gaze and restriction of gaze into the quadrant of the implant. As a result, 11 (65%) of 17 functionally binocular patients have diplopia in primary gaze. Conclusions: Pending further study, the authors are avoiding placement of the Baerveldt 350-mm 2 implant in both binocular and monocular patients due to the high frequency of induced heterotropia and motility restriction.

Purpose: To report two cases in which cystoid macular edema developed after initiation of topical latanoprost for glaucoma. Methods: Case reports. One pseudophakic eye in each of two patients treated with latanoprost for glaucoma developed decreased vision and cystoid macular edema. Latanoprost was discontinued, and the cystoid macular edema was treated with topical corticosteroids and ketorolac. Results: After discontinuing latanoprost and starting corticosteroids and ketorolac, visual acuity improved from counting fingers to 20/60 in one patient’s left eye and from 20/100 to 20/25 in the other patient’s right eye. The macular edema resolved in both eyes. Conclusions: Topical latanoprost may be associated with cystoid macular edema; this may be related to a prostaglandin–like action.

Objective To describe an alternative method to repair exposed glaucoma drainage devices (GDDs) when conventional attempts have failed. Methods Four eyes, from 3 patients, with severe ocular surface disease were included in the study. All eyes had previously received a Baerveldt GDD for uncontrollable intraocular pressure and postoperatively had exposed GDDs. The conjunctival defects were unrepairable with a scleral patch or pericardium, conjunctival advancement, or a conjunctival patch graft. Two eyes had chemical burns, one eye had extensive scarring from multiple surgical procedures, and one patient had rheumatoid arthritis. Each patient provided informed consent, and was given the option of removing the GDD and undergoing diode cyclophotocoagulation or attempting to save the GDD by a conjunctival pedicle flap. An interpolated conjunctival pedicle flap was taken from the cul-de-sac (fornix). The conjunctiva and Tenon capsule were incised radially to the tube, rotated from the fornix at a 90° angle, and sutured to the remaining healthy conjunctiva to cover the exposed tube. Results Postoperatively, all eyes had vascularized flaps that showed viable tissue. All eyes retained the GDDs, and the intraocular pressure has been under control during follow-up (7, 13, 25, and 27 months). Conclusion Interpolated conjunctival pedicle flaps seem to be a viable alternative to repairing exposed GDDs when other methods are impractical or impossible.

PURPOSE: To study operated-related variability in images obtained by laser polarimetry of the nerve fiber layer, a new imaging technique that attempts to estimate thickness of the nerve fiber layer by using the fact that it is birefringent. METHODS: Measurements were made using a commercial device, the Nerve Fiber Analyzer (Laser Diagnostic Technologies, San Diego, CA), which uses a dedicated scanning laser ophthalmoscope to produce a retardation map of the retina adjacent to the optic nerve head. Four trained operators tested 11 subjects twice each, resulting in 88 images. Standard circles were placed around the optic disk for analysis. We analyzed five indices computed from these images: mean thickness in each of four quadrants and mean thickness under the entire circle. RESULTS: Repeated-measures analyses of variance showed significant effects of operator for four of these indices. Mean values for a given index varied by 11-14 muUm across operators, and the maximum difference across operators was approximately 22 of the mean value across subjects. CONCLUSIONS: The clinical usefulness of the device will be limited until it has been shown that new modifications successfully reduce interoperator variability.

A 28-year-old man with iridocorneal endothelial syndrome and three failed trabeculectomies received two treatments of noncontact neody-mium-YAG transscleral cyclophotocoagulation. Four weeks afterwards he presented with the clinical signs of sympathetic ophthalmia in the unoperated eye. Intense topical and subtenons corticosteroids caused resolution of his symptoms without necessitating enucleation of the inciting eye. This represents the third reported case of presumed sympathetic ophthalmia following cyclophotocoagulation.

Argon laser trabeculoplasty (ALT) was performed in 232 eyes of 180 patients affected by uncontrolled primary open-angle glaucoma (POAG), exfoliation syndrome glaucoma (ESG) or pigment dispersion syndrome glaucoma (PDSG). Mean follow-up was 9 months (3-22). Mean IOP change was -21.6% (±19) from the initial value. The effect of IOP was larger in patients with ESG, PDSG, and in POAG cases with more pigmented trabecular meshwork. No relationship was found between IOP changes and age or refraction of patients; the association with iridoplasty did not influence final results. An Octopus computerized perimeter was used for pre and post-treatment visual field tests. In 113 eyes Octopus exams met the requirements for quantitative analysis. In this group 17% of visual field improved, 64% remained stable and 19% worsened. A good functional response was more frequent among the eyes with less advanced disease.

All patients with primary open-angle or primary angle-closure glaucoma requiring trabeculectomy between January 1982 and January 1983 were entered into a randomized prospective study to evaluate the effect of postoperative corticosteroids. Twenty-three eyes in Group 1 received a cycloplegic and topical antibiotic. Twenty-nine eyes in Group 2 received the same treatment, with the addition of topical 1% prednisolone acetate. Twenty-three eyes in Group 3 received the same treatment as Group 2, with the addition of systemic prednisone. Success rate was significantly improved with the use of topical corticosteroids. Systemic steroids did not prove to be of any added benefit over topical use alone.

Argon laser tarabeculoplasty (ALT) was performed on 232 eyes of 168 patients. Indication for treatment was progression of visual field loss due to glaucoma, despite maximum tolerated medical treatment. Mean percentage IOP change was -21.6% (± 19); mean F.U. was 9 months (3–21). Visual field were obtained with an Octopus computerized perimeter, using programs 31 or 32. Quantitative analysis of functional results was done only on eyes without significant amount of false answers or visual acuity changes or pupil size changes. 113 eyes met these requirements. IOP variations secondary to ALT were similar to those observed in the total group of treated eyes. Mean F.U. was 10 months (4–21). A visual field change was considered significant when a 15% variation of the mean quadrantic sensitivity was observed and the initial mean sensitivity was greater than 10 dB. When initial mean sensitivity was less than lOdB a 40% change was required to be considered significant. In our sample visual fields improved in 17% of patients, remained unchanged in 55% and worsened in 28%. Although visual field changes and IOP changes did not overlap always as expected there is a good correspondence between hydro dynamic and functional success. Patients with less advanced disease were more likely to have good functional results. The last decades have witnessed much debate regarding how, when, and, even, whether elevated intraocular pressure is responsible for glaucomatous optic nerve damage. Traditionally, treatment has largely been based on lowering intraocular pressure to a level which will no longer compromise an eye. Since the report of Wise and Witter argon laser trabeculoplasty (ALT) has been used successfully to decrease intraocular pressure in patient affected by primary open angle glaucoma (POAG) (7–10). The long-term effect of ALT on the natural history of glaucomatous disease, that is, on the functional visual ability of patients with POAG is, however, not established. We report here information regarding the course of visual field changes in patients undergoing ALT. The data are analyzed to determine possible relationships between change in IOP and change in the visual field.

Argon laser trabeculoplasty (ALT) was performed in 232 eyes of 180 patients affected by uncontrolled primary open angle glaucoma (POAG), exfoliation syndrome glaucoma (ESG) or pigment dispersion syndrome glaucoma (PDSG). Mean follow-up was 9 months (3, 22). Mean IOP change was — 21.6% (± 19) from the initial value. The effect on IOP was larger in patients with ESG, PDSG, and in POAG cases with more pigmented trabecular meshwork. No relationship was found between IOP changes and age of patients. An Octopus,computerized perimeter was used for pre- and post-treatment visual field tests. In 113 eyes Octopus exams met the requirements for quantitative analysis. In this group 17% of visual fields improved, 55% remained stable and 28% worsened. A good functional response was more frequent among the eyes with less advanced disease.