Search

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.

To describe a novel technique for thermally marking the tip of a suture, in preparation for a gonioscopy-assisted transluminal trabeculotomy.One patient was used as an example for this technique.Technique report.The authors introduce a modification of a novel surgical procedure (GATT) in which a suture is marked and thermally blunted allowing a proper visualization while performing an ab interno, minimally invasive, circumferential 360-degree suture trabeculotomy. The authors have previously reported on the GATT surgery with the use of an illuminated microcatheter, which allowed for visualization of the tip of the catheter as it circumnavigated Schlemm canal. This modification allows for similar visualization of the tip of the suture, however, is much more cost-effective while still maintaining similar safety.

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.

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.

Purpose. To compare the mean central corneal thickness (CCT) in patients with congenital aniridia to that of a group of age-matched control subjects. The findings of specular and confocal microscopy in a patient with aniridia are discussed. Methods. The mean values of five consecutive pachymetry measurements of patients with aniridia and control subjects were used for analysis. Statistical analysis was performed with a Mann–Whitney rank sum test. Specular microscopy was performed on one patient with aniridia using a Konan Specular Microscope Noncon ROBO CA (Hyogo, Japan). Confocal microscopy through focusing was performed with the Tandem Scanning Confocal Microscope (Reston, VA). Results. Mean CCT measured 691.8 75.4 m for patients with aniridia (16 eyes of 10 patients) and 548.2 21.2 m for control subjects (P0.001). Specular microscopy in a patient with aniridia showed normal endothelial cell counts and structure. Confocal microscopy through focusing of this patient showed normal-appearing keratocytes and a thick corneal stroma. Conclusions. Patients with congenital aniridia have significantly thicker corneas than do age-matched control subjects. This difference can have important implications for the treatment of those patients who develop secondary glaucoma. The increased CCT in patients with aniridia is not a result of endothelial dysfunction but appears to be the result of the production of a thickened but otherwise healthy cornea by the mutated PAX6 gene.

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.

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

Disruptive or ablative surgeries involving the trabecular meshwork and Schlemm’s canal, which have traditionally been applied to the developmental and congenital glaucomas, are currently receiving renewed interest in adult open-angle glaucoma because of the development of new technologies. The Trabectome® (NeoMedix Corporation, Tustin, California) procedure, canaloplasty with or without stent, direct trabecular bypass, excimer laser trabeculotomy (ELT), and other techniques in development are all based in their surgical approaches on classic trabeculotomy. Some of the proposed mechanisms of action, as well as the potential complications that occur in classic angle surgeries, are also likely quite similar. It is prudent to note that in some specific limited populations, adult trabeculotomy ab externo has long been employed. For example, in Japan trabeculotomy has been used in adult open-angle glaucoma, and even in North America there have been studies of trabeculotomy combined with cataract surgery. It is well accepted that any and all of the complications related to these procedures in congenital glaucoma can occur when applied to the adult eye, and mitigation and avoidance of them are likely very similar. Some specific complications may be more likely in adult eyes. By far the most common complication related to trabeculotomy, whether in adults or children, is hyphema. In fact it is expected, and some bleeding should be considered a sign that the procedure was done correctly rather than a complication. However, in several large clinical series from Japan, rates of clinically significant postoperative hyphema in adult trabeculotomy often approach 20%. It is thought that hyphema occurs due to disruption of the trabecular meshwork, as a barrier between retrograde flow of blood from the collector channel system into the anterior chamber is removed at least temporarily. Once the trabecular meshwork is disrupted, if the intraocular pressure (IOP) is lower than the episcleral venous pressure (EVP), retrograde flow of blood into the anterior chamber may result. One commonly employed technique to avoid significant hyphema in trabeculotomy is to temporarily “tamponade” the anterior chamber with viscoelastic.

Every intraocular surgery carries risk of a serious complication. One of the most worrisome is an intraoperative suprachoroidal hemorrhage. For a variety of reasons, especially hypotony, these hemorrhages occur more frequently in glaucoma patients, may develop at any time during the perioperative period, and may cause considerable visual loss. When a severe choroidal hemorrhage does occur, it can be visually devastating and may be very painful. A large perioperative choroidal effusion is also worrisome because it may be the initiating factor that precipitates a choroidal hemorrhage. Even after a “simple bleb needling” or postoperative suture lysis for uncontrolled intraocular pressure (IOP), a suprachoroidal hemorrhage may develop, leading to catastrophic visual loss. In spite of best efforts, choroidal events will still occur and should be managed in a highly expeditious fashion. Proper prevention and management of a choroidal event is the best chance for saving vision. An intraoperative choroidal event is typically a spontaneous collection of either fluid and/or blood in the suprachoroidal space. This potential space is located between the choroid and the sclera. The fluid within a chronic choroidal effusion typically has a straw color due to the accumulation of proteins. Choroidal events are most common following glaucoma surgery, and choroidal hemorrhage or effusion may lead to complicated surgery with resulting visual loss. A spontaneous intraoperative choroidal effusion may initiate a shallow anterior chamber and a firm eye. The mechanisms are complex and variable. A spontaneous collection of blood into the suprachoroidal space may occur when the IOP is low, as seen during filtration surgery. Severe bleeding that breaks through into the vitreous is typically associated with a poor prognosis, as are bleeds that reach the optic nerve head. These eyes commonly end up with a pale optic disc and poor visual function. Every attempt is made to avoid these situations (see Table 6.1); nevertheless, the surgeon must remain calm during such an event and immediately close the eye to minimize visual harm.

Purpose: The purpose of the study is to report the problem of a temporal visual field defect occurring after macular hole surgery. Methods: The authors reviewed the records of 13 patients found to have visual field defects after vitrectomy for macular holes. Fluorescein angiograms (13 patients), optic nerve photographs (13 patients), focal electroretinograms (3 patients), and nerve fiber analyses (8 patients) were performed in patients with visual field defects. Results: An absolute, temporal, usually inferior field defect was noted in 13 patients. In eight patients, the defect was detected because of specific reports or retrospective field examination results. Five patients examined in a prospective manner were found to have field defects. No history of abnormal intraocular pressure or direct trauma to the optic nerve or retinal vessels was identified. Four patients showed optic nerve pallor and three had an anomalous-appearing disc. Focal electroretinograms were of similar amplitude in the involved retina compared to corresponding areas in the healthy fellow eye. Nerve fiber analysis showed a reduction in nerve fiber layer thickness correlating to the visual field defect in those eight patients in which this test was used. Conclusion: A significant temporal field defect may occur in patients after otherwise uncomplicated surgery for macular holes. The cause is unclear; however, reductions in nerve fiber layer thickness from the superior and nasal peripapillary area suggest that acute surgical release of the posterior hyaloid and the use of long-acting intraocular gas may in certain patients result in visual field defects.

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.