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PURPOSE OF REVIEW: The current article reviews enhancements to the delivery of glaucoma care that developed in response to the coronavirus disease 19 (COVID-19) pandemic and are likely to persist beyond its resolution. RECENT FINDINGS: Literature from the review period (2020-2021) includes reports highlighting contributions of the ophthalmology community to global health during the pandemic. Glaucoma practices worldwide have instituted more robust infection control measures to mitigate severe acute respiratory syndrome coronavirus 2 transmission in the outpatient setting, and many of these modifications will endure in the post-COVID era. Operational adjustments have led to the provision of more efficient glaucoma care. A hybrid care model involving technician-based diagnostic testing and subsequent virtual consultation with a glaucoma specialist has evolved as a useful adjunct to traditional face-to-face encounters with patients. SUMMARY: Glaucoma specialists, patients, and staff have adapted to a 'new normal' of glaucoma care delivery during the COVID-19 pandemic. Although innovation has propelled several improvements to glaucoma care during this global health crisis, significant barriers to more widespread implementation of teleglaucoma still exist. Whether, and in what capacity, the pandemic has permanently altered glaucoma practice patterns remains to be seen.

Sub-Tenon's implantation of the Xen Gel stent resulted in significant intraocular pressure (IOP) lowering along with a low rate of postoperative bleb needling, and a favorable bleb morphology on anterior segment optical coherence tomography (AS-OCT).The aim was to assess clinical outcomes and bleb morphology following sub-Tenon's implantation of the Xen Gel Stent.The medical records of patients who underwent sub-Tenon's Xen Gel Stent implantation with intraoperative mitomycin-C through an open conjunctival approach were reviewed. Postoperative IOP and number of glaucoma medications at 1, 3, 6, 9, and 12 months were assessed. Bleb morphology was analyzed at various timepoints using AS-OCT (Topcon DRI OCT version 1.1.1).Twenty-six eyes were included in the study. Mean age was 69.4±8.0 years. Mean preoperative IOP was 28.1±7.8 mm Hg on an average of 3.5±0.9 glaucoma medications. Mean IOP at postoperative month 12 (n=23 eyes) was 12.9±4.0 mm Hg (P0.01) on an average of 0.3±0.6 (P0.01) glaucoma medications. Three eyes (12%) required postoperative needle revision. Bleb morphology in the early postoperative period (≤3 mo) was characterized by multiple small subconjunctival microcysts on AS-OCT. At the intermediate (6 to 12 mo) and long-term (12 mo) timepoints, reduction in microcysts with multiple internal parallel layers of aqueous flow and a uniform pattern were more frequently noted. All functional blebs were characterized by the presence of a posterior episcleral fluid lake. Failed blebs showed absence of aqueous humor around the distal end of the microshunt.Following an open conjunctival approach, sub-Tenon's placement of the Xen Gel Stent with significant IOP lowering was achieved. In eyes with good shunt function, bleb morphology by AS-OCT showed a posterior episcleral fluid lake similar to findings following trabeculectomy.

Purpose To study the effect of phacoemulsification on intraocular pressure (IOP) control in patients with preexisting glaucoma drainage implants (GDIs). Design Retrospective, observational case series. Participants A total of 45 patients (51 eyes) with previously placed GDIs who underwent phacoemulsification between January 2013 and March 2018. Methods The list of patients was obtained from billing records. Clinical data were retrieved from the corresponding electronic medical records. Main Outcome Measures Intraocular pressure, number of glaucoma medications before and after phacoemulsification (postoperative day 1, week 1, months 1, 3, 6, 12, 18, and 24), rate of failure (failure defined as IOP >18 mmHg and IOP increase >20% at 2 consecutive visits after month 1, need for additional glaucoma surgery, or loss of light perception vision), and postoperative complications. Results Mean follow-up was 23.0 ± 11.1 months. The average interval between GDI surgery and phacoemulsification was 9.4 ± 6.7 months. An Ahmed glaucoma valve (AGV; New World Medical) was implanted in 12 eyes, a Baerveldt glaucoma implant (BGI; Johnson & Johnson Surgical Vision) was implanted in 36 eyes, and a Molteno (Molteno Ophthalmic Limited) glaucoma implant was implanted in 3 eyes. Before phacoemulsification, the mean IOP was 14.4 ± 4.4 mmHg on 2.1 ± 1.3 glaucoma medications. At postoperative month 24, the mean IOP was 12.6 ± 4.4 mmHg (n = 29, P = 0.519) on 2.0 ± 1.6 (P = 0.457) glaucoma medications. The reduction in IOP was significant only at postoperative week 1 (P = 0.031). The cumulative failure rate was 3.9% at 1 year and 11.8% at 2 years. The AGV group had a significantly higher mean IOP before phacoemulsification than the BGI group (P = 0.016). Analysis of covariance, taking the baseline IOP as a covariate, revealed no differences in postoperative IOP and number of glaucoma medications between groups, except for month 18 (1 patient in the BGI group had uncontrolled IOP requiring surgery). Postoperative complications included cystoid macular edema (10%), corneal decompensation (6%), and choroidal effusion (4%). Conclusions Phacoemulsification after GDI surgery resulted in a transient reduction in IOP at postoperative week 1. Patients with previously placed AGVs had similar postoperative outcomes compared with those with BGIs.

Purpose of review The current article reviews the impact of the coronavirus disease 2019 (COVID-19) pandemic on the delivery of ophthalmic, and specifically, glaucoma care. Recent findings Literature from the review period includes case series demonstrating the presence of severe acute respiratory syndrome coronavirus 2 RNA in the conjunctival secretions of patients with laboratory-confirmed COVID-19. The global ophthalmology community published reports outlining the enhanced infection control measures undertaken by different institutions around the world to mitigate transmission of the novel coronavirus. Telemedicine has been increasingly implemented in glaucoma practices to reduce in-office patient volume. New data regarding the efficacy and feasibility of tools for home monitoring of intraocular pressure, virtual visual field testing, and remote disc photography are reviewed. Summary COVID-19 has posed a global public health threat due to the severity of its contagion and associated morbidity and mortality. Glaucoma specialists have responded to the pandemic with innovative modifications to reduce viral transmission and optimize patient and staff safety in the office and operating room. The role of teleglaucoma has expanded and will continue to evolve as remote diagnostic devices undergo further refinement and validation.

Purpose The purpose of this study was to describe a surgical technique for treating persistent hypotony after Baerveldt glaucoma implant (BGI) surgery. Materials and methods The medical records of 10 patients with persistent postoperative hypotony who underwent truncation of one or both wings of a previously placed BGI, combined with external ligation of the tube using a polypropylene suture, were retrospectively reviewed. Results All 10 eyes that underwent BGI truncation and placement of a single, external, nonabsorbable (polypropylene) tube ligature exhibited resolution of hypotony within 24 hours and resolution of choroidal effusions within the first 2 postoperative weeks. The median time interval between primary BGI surgery and truncation was 5 months (range, 1.5 mo to 8 y). Median postrevision follow-up time was 12 months (range, 5 mo to 16.2 y). The mean preoperative intraocular pressure (IOP) was 2.1±1.0 mm Hg, and the mean IOP rose to 29.2±13.9 mm Hg on postoperative day 1. Mean IOP at week 1, month 1, and month 3 was 20.5±10.4, 19.7±11.8, and 18.0±8.2 mm Hg, respectively, using an average of 1.4±1.4 glaucoma medications at postoperative month 3. Ligature release after BGI revision was performed in 9 (90%) of the 10 patients. The median time to ligature release was 1.5 months (range, 3 wk to 4 y). There was no recurrence of hypotony in any of these patients. At most recent follow-up, the mean IOP was 12.9±6.0 mm Hg on an average of 1.5±1.3 glaucoma medications. Five patients demonstrated improvement in visual acuity from their prerevision best-corrected visual acuity. Conclusions Truncation of one or both wings of a BGI and complete closure of the tube with nonabsorbable, but releasable, suture ligature is an effective and safe method for reversing persistent postoperative hypotony while maintaining IOP control.

Purpose To find genetic contributions to glaucoma in African Americans. Design Cross-sectional, case-control study. Participants One thousand eight hundred seventy-five primary open-angle glaucoma (POAG) patients and 1709 controls, self-identified as being of African descent (AD), from the African Descent and Glaucoma Evaluation Study (ADAGES) III and Wake Forest School of Medicine. Methods MegaChip genotypes were imputed to Thousand Genomes data. Association of single nucleotide polymorphisms (SNPs) with POAG and advanced POAG was tested by linear mixed model correcting for relatedness and population stratification. Genetic risk scores were tested by receiver operator characteristic curves (ROC-AUCs). Main Outcome Measures Primary open-angle glaucoma defined by visual field loss without other nonocular conditions (n = 1875). Advanced POAG was defined by age-based mean deviation of visual field (n = 946). Results Eighteen million two hundred eighty-one thousand nine hundred twenty SNPs met imputation quality of r2 > 0.7 and minor allele frequency > 0.005. Association of a novel locus, EN04, was observed for advanced POAG (rs185815146 β, 0.36; standard error, 0.065; P Conclusions A novel association with advanced POAG in the EN04 locus was identified putatively in persons of AD. In addition to this finding, this genome-wide association study in POAG patients of AD contributes to POAG genetics by identification of novel signals in prior loci (9p21), as well as advancing the fine mapping of regions because of shorter average LD (FNDC3B). Although not useful without confirmation and clinical trials, the use of genetic risk scores demonstrated that considerable AD-specific genetic information remains in these data.

PURPOSE:To describe the study protocol and baseline characteristics of the African Descent and Glaucoma Evaluation Study (ADAGES) III. DESIGN:Cross-sectional, case-control study. PARTICIPANTS:Three thousand two hundred sixty-six glaucoma patients and control participants without glaucoma of African or European descent were recruited from 5 study centers in different regions of the United States. METHODS:Individuals of African descent (AD) and European descent (ED) with primary open-angle glaucoma (POAG) and control participants completed a detailed demographic and medical history interview. Standardized height, weight, and blood pressure measurements were obtained. Saliva and blood samples to provide serum, plasma, DNA, and RNA were collected for standardized processing. Visual fields, stereoscopic disc photographs, and details of the ophthalmic examination were obtained and transferred to the University of California, San Diego, Data Coordinating Center for standardized processing and quality review. MAIN OUTCOME MEASURES:Participant gender, age, race, body mass index, blood pressure, history of smoking and alcohol use in POAG patients and control participants were described. Ophthalmic measures included intraocular pressure, visual field mean deviation, central corneal thickness, glaucoma medication use, or past glaucoma surgery. Ocular conditions, including diabetic retinopathy, age-related macular degeneration, and past cataract surgery, were recorded. RESULTS:The 3266 ADAGES III study participants in this report include 2146 AD POAG patients, 695 ED POAG patients, 198 AD control participants, and 227 ED control participants. The AD POAG patients and control participants were significantly younger (both, 67.4 years) than ED POAG patients and control participants (73.4 and 70.2 years, respectively). After adjusting for age, AD POAG patients had different phenotypic characteristics compared with ED POAG patients, including higher intraocular pressure, worse visual acuity and visual field mean deviation, and thinner corneas (all P < 0.001). Family history of glaucoma did not differ between AD and ED POAG patients. CONCLUSIONS:With its large sample size, extensive specimen collection, and deep phenotyping of AD and ED glaucoma patients and control participants from different regions in the United States, the ADAGES III genomics study will address gaps in our knowledge of the genetics of POAG in this high-risk population.

Purpose To discuss the effects of the severe acute respiratory syndrome coronavirus 2 betacoronavirus on ambulatory ophthalmology practices, the value proposition of telemedicine, teleophthalmology implementation methodologies, and the accelerated future of telemedicine. Design Review of the current telehealth landscape including usage, policies, and techniques for ambulatory practice integration. Methods We provide author-initiated review of recent trends in telehealth, governmental recommendations for health care delivery during the COVID-19 pandemic, and a PubMed Central query for telemedicine in ophthalmology or teleophthalmology. In addition, the authors' comprehensive experience in telemedicine design and implementation is provided. Results We provide a summary describing the present state of telehealth, teleophthalmology modeling, care delivery, and the proposed impact of telehealth surges on the future of ophthalmology practice. Conclusion Recent patient and provider interest in telemedicine, the relaxation of regulatory restrictions, increased remote care reimbursement, and ongoing social distancing practices compel many ophthalmologists to consider virtualizing services.

Vitreous occlusion of a glaucoma drainage implant (GDI) can lead to failure of the device and severely elevated intraocular pressure. The pathophysiology of tube obstruction is related to central and anterior displacement of vitreous that is drawn into and condenses within the proximal lumen of the tube. This can occur from days to years following GDI surgery. Successful management of vitreous-tube obstruction generally requires manual removal of the condensed vitreous plug with end-grasping forceps. This technique achieves reversal of tube blockage and restoration of GDI function. Amputation of the incarcerated vitreous alone with vitrectomy or neodymium:yttrium-aluminum-garnet vitreolysis does not consistently restore GDI function and risks persistent intraluminal tube obstruction.

PURPOSE OF THE STUDY The purpose of the study was to report long-term outcomes and complications of Baerveldt glaucoma implant (BGI) surgery with pars plana tube insertion in children. MATERIALS AND METHODS The medical records of consecutive aphakic and pseudophakic children (

This article describes important aspects of postoperative management after trabeculectomy and glaucoma drainage implant surgery.Postoperative management of glaucoma drainage implant surgery includes stabilization of intraocular pressure, possible ligature release, and management of complications such as corneal edema, and tube/plate exposure. Postoperative management of trabeculectomy includes evaluation of bleb encapsulation, management of hypotony, and assessment of need for adjuvant therapy. Recent advances in surgical techniques, device/tissue availability, and imaging continue to shape the postoperative course.Careful preoperative planning and postoperative care may decrease the likelihood of complications in tube surgery or trabeculectomy.

PURPOSE: To describe the study protocol and baseline characteristics of the “African Descent and Glaucoma Evaluation Study (ADAGES) III: Contribution of Genotype to Glaucoma phenotype in African Americans”. DESIGN: Cross-sectional, case-control study PARTICIPANTS: There were 3266 glaucoma patients and controls without glaucoma of African or European descent recruited from five study centers in different regions of the United States. METHODS: Individuals of African descent (AD) and European descent (ED) with primary open angle glaucoma (POAG) and control subjects completed a detailed demographic and medical history interview. Standardized height, weight and blood pressure measurements were obtained. Saliva and blood samples to provide serum, plasma, DNA and RNA were collected for standardized processing. Visual fields, stereoscopic disc photographs, and details of the ophthalmic examination were obtained and transferred to the University of California-San Diego Data Coordinating Center for standardized processing and quality review. MAIN OUTCOME MEASURES: Participant gender, age, race, body mass index, blood pressure, history of smoking and alcohol use in POAG patients and controls are described. Ophthalmic measures included intraocular pressure, visual field mean deviation, central corneal thickness, glaucoma medication use or past glaucoma surgery. Ocular conditions including diabetic retinopathy, age-related macular degeneration and past cataract surgery were recorded. RESULTS: The 3266 ADAGES III study participants in this report include 2146 AD POAG patients, 695 ED POAG patients, 198 AD controls and 227 ED controls. AD POAG patients and controls were significantly younger (both 67.4 years) than ED POAG patients and controls (73.4 and 70.2 years, respectively). After adjusting for age, AD POAG patients had different phenotypic characteristics compared to ED POAG patients, including higher intraocular pressure, worse visual acuity and visual field mean deviation, and thinner corneas (all p

PURPOSE To evaluate the efficacy and safety of a tube fenestration stented with a 10-0 polyglactin suture for controlling early postoperative intraocular pressure (IOP) after Baerveldt glaucoma implant (BGI) surgery. METHODS The medical records of 110 patients (119 eyes) who underwent BGI surgery with a tube fenestration stented with a 10-0 polyglactin suture anterior to an occlusive tube ligature were retrospectively reviewed. Main outcome measures included IOP and number of glaucoma medications at postoperative day 1, week 1, and weeks 2 to 3 as well as complications occurring before ligature release. RESULTS Mean±SD preoperative IOP was 30.9±9.3 mm Hg using an average of 3.8±1.1 glaucoma medications. A statistically significant reduction in IOP and glaucoma medications was observed at all timepoints during the first 3 postoperative weeks compared with baseline (P

PURPOSE To describe an unusual case of pediatric iris melanocytoma with pigment dispersion glaucoma that resolved after resection of the primary tumor. METHODS Retrospective case review of the clinical record, ultrasonographic images, and histopathology. RESULTS A 6-year-old Asian girl, with a dark iris tumor, pigment dispersion, and secondary glaucoma, was initially treated with topical antiglaucoma medication and observation. Rapid growth prompted biopsy, revealing melanocytoma. As the tumor continued to grow, excision of the primary tumor was performed. Surgery proved curative in that the pigment dispersion slowly reabsorbed and her glaucoma resolved. CONCLUSIONS In this case, rapid growth did not indicate malignant transformation. Initial observation for growth and judiciously timed surgical intervention prevented progression, loss of vision, and potentially the loss of the eye.

Ocular decompression retinopathy (ODR) presents as retinal hemorrhages following acute lowering of the intraocular pressure (IOP). We review 32 articles published from 1992 to 2011 and address the pathogenesis, clinical features, management, and outcomes of ODR. ODR is defined as a multifocal hemorrhagic retinopathy that results from acute lowering of IOP and is not explained by another process. Hemorrhages occur in all retinal layers, and most patients are asymptomatic. The mean drop in IOP in ODR is 33.2 ± 15.8 mm Hg (range, 4-57 mm Hg). Eighty-two percent are diagnosed by the first postoperative day, all within 2 weeks. ODR resolved in a mean of 13 ± 12.4 weeks (range, 2-72 weeks). Vitrectomy was required for vitreous and subhyaloid hemorrhage in 14% of cases. Visual outcomes are generally good, with 85% of eyes returning to baseline vision. Although ODR infrequently results in significant ocular morbidity, gradual reduction in IOP might prevent this complication.

Purpose To evaluate the efficacy of transconjunctival revision (TCR) with mitomycin-C (MMC) following failed trabeculectomy. Materials and methods The medical records of 27 patients (27 eyes) who underwent TCR with subconjunctival injection of MMC by a single surgeon between September 2001 and August 2013 were retrospectively reviewed. The same surgical protocol was followed for all patients. Revision was performed using a microvitreoretinal blade through a small conjunctival incision. Main outcome measures included visual acuity, intraocular pressure (IOP), and number of glaucoma medications. Failure was defined as an IOP 14 mm Hg, loss of light perception, or need for additional glaucoma surgery. Results Mean interval between trabeculectomy and TCR was 56.4±57.2 months. Mean preoperative IOP was 21.9±6.8 mm Hg using 4.0±1.2 glaucoma medications. Fifteen (55.6%) patients met success criteria. At most recent follow-up, mean IOP and number of glaucoma medications for successful patients were 9.7±3.8 mm Hg and 0.6±1.1, respectively. Kaplan-Meier analysis revealed 1-, 2-, and 3-year success rates of 62%, 58%, and 53%, respectively. Three additional patients achieved success after undergoing a second TCR, and 1 patient achieved success after a third TCR. Postoperative complications included transient choroidal effusion (n=8), shallow anterior chamber requiring reformation (n=5), 5-fluorouracil-related corneal epitheliopathy (n=10), and bleb leak (n=1). Conclusions TCR with adjunctive MMC is a safe and effective procedure following failure of a trabeculectomy. More than 1 revision may be necessary to achieve long-term IOP reduction.

PURPOSE To determine the outcomes of inferonasal Baerveldt glaucoma implant (BGI) surgery. PATIENTS AND METHODS A retrospective, non-comparative case series of 182 eyes of 182 patients who underwent inferonasal placement of a Baerveldt glaucoma implant. The main outcome measures included intraocular pressure, number of glaucoma medications, best corrected visual acuity, and complications. RESULTS Patients were followed for an average (+/- SD) of 19 +/- 15 months. Median Snellen visual acuity was unchanged at last follow-up. Intraocular pressure was reduced from a mean (+/- SD) of 28.6 +/- 11.5 mm Hg preoperatively to 13.4 +/- 5.7 mm Hg at most recent follow-up (P < 0.001). The number of antiglaucoma medications was reduced from a mean (+/- SD) of 2.7 +/- 1.3 preoperatively to 1.1 +/- 1.1 at most recent follow-up. Nineteen eyes met our criteria for failure, yielding a cumulative percent survival of 92% at 12 months, 88% at 24 months, and 77% at 44 months. The most common complications were hyphema (14 eyes, 8%), choroidal effusion (12 eyes, 7%), and corneal decompensation (19 eyes, 10%). Endophthalmitis and diplopia occurred rarely (1 eye

Purpose To determine the efficacy and associated complications of glaucoma drainage implant (GDI) surgery with pars plana tube insertion and penetrating keratoplasty (PK) in eyes with glaucoma and corneal disease. Design Retrospective, interventional case series. Participants All patients who underwent both GDI surgery with pars plana tube insertion and PK before September 1997 were included. Methods The medical records of 34 consecutive patients (34 eyes) who had undergone GDI (Baerveldt, Pharmacia & Upjohn, Kalamazoo, MI; Molteno, IOP Inc., Costa Mesa, CA; Krupin, Hood Laboratories, Pembroke, MA; or Ahmed, New World Medical, Rancho Cucamonga, CA) insertion before, concurrent with, or after PK were reviewed retrospectively. All corneal grafts were clear before GDI surgery for patients who underwent glaucoma surgery after PK. Outcomes were evaluated using Kaplan–Meier life-table analysis. Main outcome measures Clinical outcome assessment included corneal graft clarity, intraocular pressure (IOP), visual acuity, and identification of complications. Results Mean follow-up after completion of both GDI surgery and PK was 12.1 ± 8.4 months (range, 0–31.8 months). Twelve- and 24-month life-table rates for complete success after both GDI and PK were 63% and 33%, respectively. Twelve- and 24-month life-table success rates for IOP control and corneal graft clarity were 85% and 62%, and 64% and 41%, respectively. Final postoperative visual acuity was the same as or better than (≥2 Snellen lines) the preoperative level in 29 patients (85%). One or more posterior segment complications occurred in 15 (44%) patients. Conclusions Pars plana tube insertion of GDIs is a reasonable option for patients who have undergone PK or in whom PK is anticipated, despite the need for a complete pars plana vitrectomy. Although complications related to limbal tube placement are avoided, the incidence of posterior segment complications may be higher for pars plana insertion. The potential for enhanced corneal graft survival with pars plana versus anterior segment tube placement warrants further investigation.

* BACKGROUND AND OBJECTIVE: To investigate the outcome and complication rates of trabeculectomy following the combined use of intraoperative, topical 5-fluorouracil (5-FU) and low-dose, postoperative subconjunctival 5-FU injections. * PATIENTS AND METHODS: Forty-one eyes of 41 patients with advanced, medically uncontrolled glaucoma underwent trabeculectomy with intraoperative episcleral application of 5-FU (50 mg/ml for 5 minutes). A variable number of subconjunctival 5-FU injections were administered postoperatively at the discretion of the operating surgeon. * RESULTS: Six-, 12-, and 15-month life-table success rates (5 mm Hg ≤ intraocular pressure [IOP ≤ 21 mm Hg) were 100%, 97%, and 83%, respectively. Mean postoperative IOP was 12.1 ± 4.3 mm Hg. An average of 2.2 ± 1.6 (range 0 to 7) supplemental subconjunctival 5-FU injections were administered postoperatively. Corneal epithelial erosions developed in 7 (17%) of the eyes. Five of 7 patients who underwent subsequent surgical procedures maintained successful control of IOP at an average of 11.0 ± 4.8 (range 5 to 16) months after the secondary surgery. * CONCLUSION: Trabeculectomy with intraoperative 5-FU is effective in controlling IOP while possibly minimizing the need for frequent postoperative injections and the occurrence of corneal epitheliopathy. [Ophthalmic Surg Lasers 1998;29:552-561.]

* BACKGROUND AND OBJECTIVE: The authors investigated the role of ultrasound biomicroscopy after ocular trauma. * PATIENTS AND METHODS: Ultrasound biomicroscopy was performed in six eyes of six patients at the New York Eye and Ear Infirmary after a variety of traumatic ocular injuries. * RESULTS: Eyes with angle recession, iridodialysis, cyclodialysis, hyphema, an intraocular foreign body, scleral laceration, and subluxed crystalline lens were imaged without complication. Ultrasound biomicroscopy aided in the diagnosis when visualization was limited by media opacities or distorted anterior segment anatomy. * CONCLUSION: Ultrasound biomicroscopy is a safe and effective adjunctive tool for the clinical assessment and management of ocular trauma, especially when visualization is limited and multiple traumatic injuries are involved. [Ophthalmic Surg Lasers 1997;28:201-207.]

To determine the impact of 8 multicenter randomized clinical trials (RCTs) on glaucoma practice.An electronic survey was distributed to the members of the American Glaucoma Society (AGS). Each participant was asked 2 study-specific questions and 1 standard question common to all 8 RCTs assessing the study's impact on clinical practice. RCTs included in the survey were the Advanced Glaucoma Intervention Study (AGIS), Collaborative Initial Glaucoma Treatment Study (CIGTS), Collaborative Normal Tension Glaucoma (CNTG) Study, European Glaucoma Prevention Study (EGPS), Early Manifest Glaucoma Trial (EMGT), Glaucoma Laser Trial (GLT), Ocular Hypertension Treatment Study (OHTS), and Tube Versus Trabeculectomy (TVT) Study. A 5-point Likert scale was used for rating all responses. The practice setting and duration of glaucoma practice was determined for all AGS members who responded.A total of 206 (23.0%) of 894 AGS members participated in the survey. Among those who responded, 46.4% were self classified as academic practitioners and 53.6% worked in a private practice setting. Mean Likert scores for the standard question evaluating the overall impact of the RCT were OHTS 4.47, CNTG Study 4.13, AGIS 3.78, TVT Study 3.53, EMGT 3.48, CIGTS 3.44, GLT 3.39, and 2.69 EGPS.Substantial differences were observed in the clinical impact of several RCTs in glaucoma. The reported impact of each study likely reflects several factors including study timing, design, conduct, and interpretation of results.

Ocular hypotony in the early postoperative period following tube shunt surgery is relatively common. The pressure level at which structural compromise of the eye and resultant secondary complications (e.g., shallow/ flat anterior chamber, serous and/or hemorrhagic choroidal detachment, chorioretinal folds, corneal folds) occur varies considerably. Some patients may tolerate extremely low pressures well for extended periods of time. However, an increased amount of secondary complications is often seen with intraocular pressures (IOPs) below 6 mm Hg. For the purpose of the ensuing discussion, we will adopt a definition of hypotony based solely on this pressure criterion without regard to the clinical state of the eye. An understanding of the causes of hypotony is critical to its prevention as well as its treatment. The etiologies of hypotony can be broken down into 2 broad categories: general (Table 34.1) and device-specific (Table 34.2). The device-specific causes can be further categorized into those that occur with valved devices and those that occur with non-valved devices. Aqueous flow around the tube at the scleral insertion site may result in early postoperative hypotony regardless of the type of tube shunt used. A 23-gauge needle generally creates a tight track in an area of normal sclera with little potential for excess flow around the tube. Rarely, however, the scleral entry track can be significantly wider than the external diameter of the tube, resulting in peri-tube flow and a low IOP, which are particularly likely to occur following excessive manipulation of the scleral opening as it is created or during tube insertion. The use of a 22-gauge or wider needle will increase the risk of peri-tube flow. Leak around the tube may also occur when a 23-gauge needle is used to create the fistula through an area of abnormally thin, ectatic sclera. Additionally, when 2 or more scleral openings are made in an effort to optimize tube placement, aqueous flow through an unused scleral entry site may result in overfiltration and early postoperative hypotony if the sclerostomy is not tightly closed. Aqueous hyposecretion secondary to ciliary body dysfunction may also result in transient ocular hypotony in the early postoperative period.

Purpose: To describe the authors' clinical experience with intracameral tissue plasminogen activator (tPA) after glaucoma surgery. Methods: Retrospective review of medical records of all patients who received intracameral tPA after glaucoma surgery at the Doheny Eye Institute from November 4, 1992, to June 14, 1994. There were 20 tPA administrations (18 eyes of 17 patients) in doses ranging from 6 to 25 μg. Indication for tPA administration was decreased bleb function secondary to blood/fibrin clot in aqueous outflow pathway. Results: Tissue plasminogen activator was given after trabeculectomy (5 drug administrations) and combined cataract extraction/trabeculectomy procedures (9 drug administrations), with increased filtration in 12 (86%). There were five (36%) instances of hyphema and three (21%) of hypotony. All hyphemas occurred after doses of 25 μg. Final IOP of 18 mmHg or lower and 6 mmHg or higher was achieved in 11 (92%) of 12 patients after a mean follow-up interval of 4.2 ± 4.7 months. The six remaining tPA irrigations were done in five patients after glaucoma drainage implant surgery (n = 4) or surgical/needle revision of a filtering bleb (n = 2). Conclusions: Aqueous outflow obstruction from blood/fibrin clot after glaucoma surgery may be treated effectively with intracameral tPA in doses of 6 to 25 μg. The authors recommend using a dose of less than or equal to 6 to 12.5 μg to minimize the risk of hyphema.

Purpose To evaluate the safety and efficacy of transscleral cyclophotocoagulation (TSCPC) in patients requiring intraocular pressure (IOP) reduction despite prior Baerveldt glaucoma implant (BGI) surgery. Participants and methods Twenty eyes of 20 patients who had previously undergone BGI placement and subsequently underwent TSCPC with the red (810 nm) diode laser between April 2005 and January 2010 were retrospectively reviewed. Results All patients underwent BGI placement an average of 34.7±24.2 months before TSCPC. The mean follow-up period after TSCPC was 25.6±17.4 months (range, 2.3 to 56.5 mo). IOPs were reduced from a mean of 21.8±4.6 to 10.8±3.2 mm Hg at the most recent follow-up, which represents a 50.2% reduction in mean IOP. Successful postoperative IOP control was achieved in 16 (80%) of 20 patients. The number of glaucoma medications decreased from 4.2±0.6 to 2.2±1.2. The life-table success rate was 78.6% at 12, 24, and 36 months. Postoperative complications included persistent corneal edema in 1 patient and both persistent corneal edema and cystoid macular edema in another patient. Both patients sustained a >2 line reduction in Snellen visual acuity. Conclusions TSCPC is safe and effective in the management of patients requiring IOP reduction after BGI surgery. Although our sample size was limited, the safety profile of TSCPC after BGI seems promising.

Purpose To compare perfused peripapillary capillary density in primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), and normal patients using optical coherence tomography angiography (OCT-A). Methods A retrospective review of POAG, NTG, and normal patients imaged with OCT-A was performed. En face OCT angiograms identifying peripapillary vessels were obtained using a spectral-domain OCT system (Avanti RTVue-XR). A custom image analysis approach identified perfused peripapillary capillaries, quantified perfused capillary density (PCD), and generated color-coded PCD maps for 3.5- and 4.5-mm-diameter scans. We compared PCD values, PCD maps, standard automated perimetry (Humphrey visual field [HVF]) parameters, and OCT retinal nerve fiber layer (RNFL) thickness analyses across all groups. Results Forty POAG, 26 NTG, and 26 normal patients were included. Annular PCD in POAG (34.24 ± 6.76%) and NTG (37.75 ± 3.52%) patients was significantly decreased compared to normal patients (42.99 ± 1.81%) in 4.5-mm scans (P < 0.01 and P < 0.01, respectively). Similar trends and statistical significances were seen in 3.5-mm scans. Linear regression analysis resulted in moderate correlations between annular PCD values and other glaucomatous parameters. Pearson coefficients comparing annular PCD from 4.5-mm scans in POAG and NTG groups to HVF mean deviation, HVF pattern standard deviation, and average RNFL thickness all showed statistical significance (P < 0.05). Color maps showed that POAG and NTG patients had a reduction of perfused capillaries that progressed in size when comparing early, moderate, and severe glaucoma groups. Conclusions Optical coherence tomography angiography can uniquely identify changes in peripapillary PCD in glaucoma patients. Optical coherence tomography angiography may offer insights into the pathophysiology of glaucomatous damage and risk factors for disease progression.

Purpose: The authors present a retrospective study designed to assess the effectiveness of the Baerveldt glaucoma implant in controlling intraocular pressure (10P) and maintaining visual function in eyes with neovascular glaucoma. Methods: The medical records of all 36 patients (36 eyes) who underwent Baerveldt glaucoma implantation for medically uncontrolled neovascular glaucoma between February 1991 and December 1992 were reviewed. Results: Eighteen patients received Model 350 implants, 16 received Model 500 implants, and 2 received Model 200 implants. The 12- and 18-month life-table success rates (success defined as 6 mmHg ≤ final IOP ≤ 21 mmHg without additional "glaucoma surgery or devastating complication) were 79% and 56%, respectively. Visual acuity remained stable or improved in 10 (31 %) patients. Postoperative complications included flat anterior chamber, serous choroidal detachment, and obstruction of the proximal tube tip with fibrovascular tissue, each of which occurred in four (11 %) patients. Eleven (31 %) patients lost light perception. There were no significant differences between the groups receiving the Model 350 and Model 500 implants with respect to life-table success rates, percentage of postoperative IOP reduction, or complication rates. Patients in the Model 500 implant group required significantly fewer antiglaucoma medications postoperatively, but also demonstrated a significantly greater mean visual acuity reduction. Better preoperative visual acuity and increased patient age were positively correlated with a successful outcome. Conclusions: Baerveldt implantation is effective in controlling IOP elevation associated with neovascular glaucoma. Postoperative visual loss, despite adequate IOP control, is common. Young patient age and poorer preoperative visual acuity are significant predictors of surgical failure.

Repositioning a glaucoma drainage device tube from the anterior chamber to the ciliary sulcus or pars plana can be a challenging procedure owing to the difficulty in obtaining tight closure of the original limbal fistula. Failure to achieve watertight and airtight closure of the fistula can result in substantial difficulty in completing other key portions of the surgery and may lead to postoperative hypotony and associated complications. A novel technique using a Tutoplast scleral plug, polyglactin sutures, and, in certain cases, fibrin tissue sealant to close a limbal fistula at the time of glaucoma drainage device tube repositioning is described. This technique can be replicated with ease and provides a tight seal so that other concurrent surgical procedures can safely be completed and postoperative hypotony is avoided.

To evaluate changes in the anterior chamber angle after Boston keratoprosthesis (KPro) placement.Ten patients were serially imaged with anterior segment optical coherence tomography after Boston KPro surgery. Angles were judged to be open or closed in the horizontal axis.Seven of 10 patients had open angles before KPro placement. Within 4 months, 4 of 7 patients developed angle closure. Contact between the iris and the backplate was seen in 3 of these patients. Two of the 4 eyes demonstrated progressive angle closure. Intraocular pressure was elevated in 3 patients postoperatively due to the obstruction of a glaucoma drainage device tube (1 eye) and angle closure (2 eyes).After Boston KPro surgery, patients must be carefully monitored for the onset or progression of glaucoma. Progressive angle closure can occur after placement of a Boston KPro and may be seen in conjunction with irido-backplate touch.

PURPOSE To report on the usefulness of combined Baerveldt glaucoma implantation (BGI) and scleral buckling surgery for patients with glaucoma requiring a scleral buckle for retinal detachment repair. METHODS Retrospective, consecutive, noncomparative, and interventional case series of 30 eyes (30 patients) that underwent simultaneous scleral buckle and BGI surgery, using a staged (group 1, n=21 patients) or nonstaged (group 2, n=9 patients) approach to BGI implantation. Successful intraocular pressure (IOP) control was defined as 6 mm Hg≤IOP≤18 mm Hg. RESULTS Although not statistically significant, mean best corrected visual acuity (LogMAR) improved from 2.0 before surgery to 1.7 after surgery (P=0.13) with a mean follow-up of 27.7 months. Of the 21 patients in group 1, only 13 (62%) required second-stage tube insertion at a mean of 7.0±8.0 months (range, 1 to 24 mo) postoperatively. For these eyes combined with group 2 eyes, mean IOP was reduced from 31.1±10.8 to 12.7±6.0 mm Hg (P

Background: The Baerveldt glaucoma implant is a large equatorial aqueous shunting device that is installed through a single-quadrant conjunctival incision. The intermediateterm results of a randomized study comparing the 350- and 500-mm 2 Baerveldt implants are reported. Methods: Seventy-three patients with medically uncontrollable, nonneovascular glaucomas associated with aphakia, pseudophakia, or failed filters were enrolled in a randomized, prospective study comparing 350- and 500-mm 2 Baerveldt implants. Surgical success was defined as 6 mmHg ≤ final intraocular pressure ≤ 21 mmHg without glaucoma reoperation or devastating complication. Results: Of patients with 350- and 500-mm 2 implants, 93% and 88%, respectively, achieved surgical success (18-month life-table analysis, P = 0.93). The 500-mm 2 implants afforded intraocular pressure control with significantly fewer medications (0.7 versus 1.3; P = 0.006). The postoperative visual acuities remained within one line of the preoperative visual acuities or improved in 62% and 66% of patients in the 350- and 500mm 2 groups, respectively (P = 0.93). Complication rates were statistically similar. The most frequent ones in the 350- and 500-mm 2 groups, respectively, were serous choroidal effusion (16% and 32%), strabismus (16% and 19%), anterior uveitis (14% and 11 %), and corneal or corneal graft edema (11 % each). Conclusion: The intermediate-term results of the 350- and 500-mm 2 Baerveldt implants were statistically comparable with respect to surgical and visual outcomes, as well as complications, although the larger implant was associated with a higher rate of some complications. However, the 500-mm 2 Baerveldt implant afforded intraocular pressure control with fewer medications than the 350-mm 2 implant.

Purpose: The treatment of glaucoma after scleral buckling surgery is often problematic. The authors investigated a series of patients in whom a silicone tube was implanted to shunt aqueous from the anterior segment to the fibrous capsule surrounding a previously placed silicone episcleral encircling element. Methods: Thirteen patients were retrospectively reviewed. In each patient, a silicone tube was inserted through a small incision into the fibrous capsule overlying the scleral explant. In most patients, no attempt was made to secure the distal end of the tube to the silicone band. The proximal end of the tube was inserted into the eye via a needle track. Results: Successful control of intraocular pressure (IOP) (6 mmHg ≤ final IOP ≤ 21 mmHg with or without medication) was ultimately achieved in 11(85%) of 13 patients (3 of the successful patients underwent one or more surgical revisions to relieve obstruction of the proximal and/or distal tube opening). Follow-up in these patients ranged from 8 to 49 months (mean ± standard deviation, 21.7 ± 14.1 months). The final postoperative visual acuities were within one line of the preoperative visual acuities or had improved in 11 (85%) patients. Complications included serous choroidal detachment (3 patients; 23%), conjunctival wound leak (2 patients; 15%), hyphema (1 patient; 8%), and tube obstruction by lens, iris, vitreous, or episcleral fibrous tissue (4 patients; 31 %). Conclusion: Aqueous tube shunt to a pre-existing episcleral encircling element is useful in treating complicated glaucomas after scleral buckling surgery. Fibrous obstruction of the external tube opening is a frequent complication in the early postoperative period, but it may be relieved by surgical revision.

The implantation of non-valved aqueous shunting devices in children is often complicated by intraocular pressure elevation in the early postoperative period, during which time the tube is closed with a temporary suture ligature to avoid hypotony. Release of a polyglactin suture ligature using conventional laser lysis is not possible in young children in the clinic setting. The authors describe a minimally invasive technique using a portable green diode (532-nm) laser delivered through a standard endoprobe and a Hoskins laser suture lysis lens to disrupt a polyglactin suture ligature following pars plana aqueous shunt implantation in a young child.

PURPOSE The purpose of this study was to report recurrent hemolacria, or "bloody tears," as a sign of scleral buckle (SB) infection. METHODS This is an interventional case series of three eyes of three patients with hemolacria after SB placement. RESULTS Two men and one woman were treated for recurrent hemolacria after SB placement for a rhegmatogenous retinal detachment. Two patients had an encircling silicone sponge placed, one 6 years and the other 3 years before presentation. The third patient had a segmental solid silicone element placed 3 months before presentation. Two of the patients reported between 6 to 10 episodes of hemolacria occurring for "years" before referral and diagnosis. In all three patients, hemolacria originated from an occult conjunctival fistula overlying or adjacent to an exposed SB. Microbiological cultures grew Staphylococcus aureus in two eyes and polymicrobial growth in the other. Hemolacria resolved with explantation of the SB in two patients and with long-term continuous topical antibiotics in the other patient. CONCLUSION Hemolacria can be a sign of a SB infection and should raise a high level of suspicion for the presence of an occult conjunctival fistula with exposure of the underlying scleral buckling element when frank exposure is not seen.

PURPOSE To evaluate the effectiveness and associated complications of Baerveldt glaucoma implant (BGI) surgery with pars plana tube insertion in aphakic and pseudophakic children. PATIENTS AND METHODS The medical records of 30 patients (30 eyes) younger than 18 years old with uncontrolled glaucoma associated with aphakia or pseudophakia who underwent pars plana BGI surgery were retrospectively reviewed. Clinical outcome assessment included the measurement of intraocular pressure (IOP) and visual acuity and the identification of complications. Success was defined as 5 mm Hg

To evaluate the efficacy of a second glaucoma implant in eyes with prior glaucoma implant surgery and inadequate intraocular pressure (IOP) control.Retrospective observational cohort study.Patients undergoing a second glaucoma implant surgery from 1996 to 2008 were included. Outcome measures included visual acuity, IOP, glaucoma medication use, and complications. Success was defined as IOP21 mm Hg (criterion 1) and IOP17 mm Hg (criterion 2), with at least 25% reduction in IOP and no prolonged hypotony.Forty-three eyes (43 patients) had a mean follow-up of 32.6 +/- 21.6 months. Life-table analysis demonstrated success rates of 93%, 89%, and 83% using criterion 1 and 83%, 75%, and 75% using criterion 2 at 1, 2, and 3 years, respectively. At last follow-up, mean IOP (13.6 +/- 4.6 vs 24.7 +/- 7.5 mm Hg; P.001) and mean number of medications (1.4 +/- 1.2 vs 3.9 +/- 1.2; P.001) were lower following the second implant. There was no difference in preoperative and most recent logarithm of the minimal angle of resolution (logMAR) visual acuities (0.86 +/- 0.13 vs 1.1 +/- 0.13; P = .07). The most frequently used second implants were similar in percentage IOP reduction (Baerveldt implant, 45 +/- 19%; Ahmed valve, 40 +/- 18%; P = .4).A second glaucoma implant may effectively lower IOP in eyes with refractory glaucoma.

We examined 14 patients from nine families referred with the diagnosis of Treacher Collins syndrome. We noted seven significant ocular findings including the following: a subnormal horizontal palpebral fissure length and inferomedial displacement of the lateral canthus in primary gaze; further medial displacement (4.0 mm or more) of the lateral canthus with resultant shortening of the horizontal fissure length on forced eyelid closure (fissure narrowing sign); partial-thickness eyelid colobomata localized to the nasal one half to two thirds of the lower eyelids; bilateral absence of the inferior lacrimal puncta; bilateral blepharoptosis; inferior displacement of the palpebral fissures; and regular astigmatism without any consistent orientation of the axis of astigmatism relative to the lower eyelid defects, blepharoptosis, or lateral canthus. The fissure narrowing sign correlates with known anatomic deficiencies in the Treacher Collins syndrome and may prove valuable in confirming the diagnosis in patients who lack certain typical features.

Glaucoma in children is characterized by marked intraocular pressure (IOP) elevation with resultant atrophy of the optic nerve and loss of retinal ganglion cells. In very young children, secondary expansion of the globe with damage to anterior segment structures, such as the cornea and zonule, often occurs. Permanent, severe visual dysfunction may result from optic nerve damage as well as from amblyopia arising from anisometropia and corneal opacification. The treatment of childhood glaucoma often involves surgery. Goniotomy and trabeculotomy remain the first line surgical procedures for open-angle glaucoma in children. Trabeculectomy with adjunctive antifibrosis therapy, aqueous shunt surgery, and cyclodestructive procedures are undertaken when angle surgery fails to control the IOP or is unlikely to succeed. The choice of surgical procedure is individualized according to factors such as the age of the patient, the specific type of glaucoma, the number of prior surgical procedures, and the visual potential of the eye. Achieving and maintaining an adequate IOP to prevent progressive optic nerve damage, avoiding complications, and preserving vision are the goals that must be considered in deciding on a surgical plan.

PURPOSE: To describe focal obstruction of drainage tubes by kinking at the scleral entry site after pars plana insertion. METHODS: Case study. RESULTS: Three eyes of three patients underwent uncomplicated placement of a Baerveldt implant into the vitreous cavity at the time of pars plana vitrectomy. Intraocular pressure remained increased after the procedure without evidence of flow. Surgical exploration and modification of the tube placement resulted in immediate intraocular pressure reduction. Compression of the tube at the scleral entry site was confirmed intraoperatively in all eyes by ultrasound biomicroscopy. CONCLUSION: Kinking of the tube at its scleral entry site should be recognized as a possible cause of increased intraocular pressure without bleb formation after pars plana insertion of a glaucoma drainage implant.

Purpose To evaluate the effectiveness and safety of trabeculectomy with mitomycin-C (MMC) in the management of childhood glaucomas. Design Retrospective, noncomparative case series. Participants All patients less than 18 years of age who underwent trabeculectomy with MMC from June 1991 through October 1997 were included. Methods The medical records of 29 consecutive patients (29 eyes) were reviewed. Data collected during routine patient follow-up were analyzed. Surgical outcome was evaluated using Kaplan-Meier life-table analysis. Main outcome measures Clinical outcome assessment included intraocular pressure (IOP) control, visual acuity, and identification of complications. Successful IOP control was defined as 5 mmHg ≤ final IOP ≤ 21 mmHg, with or without antiglaucoma medications and without further glaucoma surgery or loss of light perception. Outcomes for the group of patients with primary infantile glaucoma were compared with those for the group with secondary glaucomas. Results Mean patient age was 6.4 ± 4.4 years (range, 0.2–15.3 years). A variety of primary and secondary glaucomas were represented. Mitomycin-C (0.5 mg/ml) on a surgical sponge was applied to the episcleral surface for an average of 3.8 ± 1.0 minutes (range, 1.5–5.0 minutes). Mean follow-up time for patients categorized as successes was 25.1 ± 16.0 months (range, 5.5–59.7 months). The 12-, 24-, and 36-month life-table success rates for IOP control were 82%, 59%, and 59% respectively. There was no difference between the primary infantile glaucoma group and the secondary glaucoma group with respect to length of follow-up, rate of successful IOP control, and incidence of complications. Five patients (17%) experienced late bleb-related infection (BRI) at an average of 27.9 ± 18.1 months (range, 5.4–55.5 months) after surgery. Other complications included hyphema, retinal detachment, late-onset bleb leak, flat anterior chamber, chronic hypotony, decompression retinopathy, suture abscess, and phthisis. Conclusions Trabeculectomy with MMC may be useful in the management of childhood glaucomas in which goniotomy, trabeculotomy, or both have failed. However, the high incidence of BRI in this series over an extended follow-up interval dictates caution in using MMC as an adjunct in pediatric trabeculectomy.

Objective: The purpose of the study is to report the clinical course of bleb-related ocular infection in children after trabeculectomy with adjunctive mitomycin C. Design: The study design was a retrospective review of all patients with a diagnosis of bleb-related ocular infection after trabeculectomy with adjunctive mitomycin C. Participants: Three children were identified in whom late postoperative bleb-related ocular infection developed. Intervention: Treatment consisted of vitreous biopsy with intravitreous antibiotic and corticosteroid injection and/or bleb culture with topical and intravenous antibiotic administration. Main Outcome Measures: Visual acuity and intraocular pressure were measured. Results: Bleb-related ocular infection developed an average of 16.7 ± 10.9 months after trabeculectomy (range, 4–23 months). The mean age at presentation was 7.0 ± 2.6 years (range, 4–10 years). Vitreous cultures were positive for staphylococci in two cases. A bleb culture from the third case also grew staphylococcus. All of the children recovered their initial vision after treatment of infection. However, one lost six lines of vision after a subsequent retinal detachment. Additional glaucoma surgery was required in one patient. Conclusions: Late bleb-related ocular infection may occur in children after trabeculectomy with mitomycin C and is characterized by abrupt onset, bleb infiltration, and rapid progression. Despite early preservation of vision after treatment of infection, significant late visual loss can occur.

To evaluate the timing, efficacy, and complications of laser suture lysis (LSL) after mitomycin C trabeculectomy in patients with glaucoma at high risk for failure of filtering surgery.The authors retrospectively reviewed the charts of 62 consecutive patients who underwent a total of 66 sessions of LSL after trabeculectomy with mitomycin C.The interval from surgery to LSL ranged from 2 to 65 days (mean +/- standard deviation, 17.9 +/- 14.9 days). The average intraocular pressure (IOP) reduction after LSL was 11.9 +/- 8.9 mmHg (range, 3-40 mmHg). A longer interval to LSL was correlated with a lesser degree of pressure reduction (P=0.0004, Wilcoxon rank-sum test). After LSL, hypotony developed in 13 (21%) patients (IOP6 mmHg on 2 consecutive measurements at least 24 hours apart). This resolved spontaneously after 7 to 304 days (104.1 +/- 109.1 days) in 12 (92%) of the 13 patients. Life-table success rates (success defined as 6 mmHg/= final IOP/= 21 mmHg) for the hypotony and no hypotony groups were 100% and 86% (at 6 months) and 96% and 86% (at 12 months), respectively. The final visual acuity worsened in a significantly greater percentage of patients in the hypotony group (46%) compared with the no-hypotony group (18%) (P = 0.06), Fisher's exact test).Laser suture lysis is safe and effective in augmenting aqueous filtration after mitomycin C trabeculectomy. A longer time interval between surgery and LSL may result in both a lesser degree of IOP reduction and a lower incidence of subsequent hypotony.

Background: The Krupin Eye Valve with Disk (Krupin disk) is a glaucoma shunt that incorporates a slit valve intended to minimize early postoperative hypotony. Methods: The medical records of all patients who have undergone Krupin disk implantation at the Doheny Eye Institute between July 1990 and December 1992 (25 eyes of 25 patients) were reviewed. Results: Intraocular pressure (IOP) was reduced from a mean of 36.1 ± 11.5 mmHg to 15.3 ± 7.5 mmHg at follow-up intervals of 4 to 19 months (mean, 13.2 months). On the first postoperative day, IOPs ranged from 0 to 40 mmHg. In two eyes (8%), the IOP was less than 6 mmHg, and in five eyes (20%) the IOP was more than 21 mmHg. Serous choroidal effusion and/or choroidal hemorrhage occurred in seven patients (28%). Sixand 12-month life-table success rates (6 ≤ IOP ≤ 21 mmHg) were 84% and 66%, respectively. Conclusion: The Krupin disk lowers IOP in most patients; however, the presence of a slit valve does not eliminate either early postoperative hypotony with its attendant complications or early IOP spikes.

Background: The authors report four cases of conjunctival epithelial invasion into the fibrous capsule surrounding a Baerveldt glaucoma implant. All cases were associated with concurrent or recent prior scleral buckling surgery. Methods: Three patients had postoperative conjunctival wound leaks, one in the immediate postoperative period and the other two at 9 and 17 days postoperatively after release of the tube ligature. In the fourth patient, a fistulous tract developed over the implant after a first-stage insertion. Histopathologic confirmation of subconjunctival epithelialization was obtained in two of these patients. Results: Surgical revision was performed in all patients. Excision and debridement of all epithelium-lined subconjunctival tissues and extensive bipolar cautery were used in the three patients with wound leaks. Implant removal also was performed in one of these. Fistulectomy and bipolar cautery were used in the fourth patient. No recurrent wound leaks or other adverse sequelae were noted. Conclusions: Epithelial invasion of the subconjunctival space and inner bleb wall after implantation of glaucoma drainage devices can lead to breakdown of the conjunctival wound and persistent aqueous leak. Prior or concurrent scleral buckling surgery may predispose to this occurrence. Surgical revision involving epithelial debridement, cautery, and meticulous wound closure, with or without implant removal, has been used successfully in the management of this complication.

Glaucoma drainage implants provide a useful option in the management of complicated glaucomas for which the risk of failure of conventional filtering surgery is high. The basic design of these devices is similar; a silicone tube shunts aqueous humor from the anterior chamber to a fibrous capsule surrounding a synthetic plate or band positioned at the equatorial region of the globe. The capsule serves as a reservoir for aqueous drainage. Drainage implants have been used in the treatment of various refractory glaucomas, including those associated with aphakia and pseudophakia, prior unsuccessful filtering surgery, anterior segment neovascularization, trauma, youth, uveitis, epithelial downgrowth, iridocorneal endothelial syndrome, vitreoretinal disorders, and penetrating keratoplasty. Modifications in implant design and surgical technique have been developed to limit the occurrence of postoperative complications such as hypotony and its related sequelae, and strabismus.