Glaucoma drainage device implantation and cyclophotocoagulation in the management of refractory glaucoma after Descemet-stripping automated endothelial keratoplasty

AIM:To compare the surgical outcomes of glaucoma drainage device implantation(GDI)and trans-scleral neodymium:YAG cyclophotocoagulation(CPC)in the management of refractory glaucoma after Descemetstripping automated endothelial keratoplasty(DSAEK).METHODS:This retrospective study on observational case series enrolled 29 patients who underwent DSAEK and posterior anti-glaucoma surgery(15 with GDI and 14 with CPC).The main outcome measures were intraocular pressure(IOP),glaucoma surgery success rate(defined as IOP of 6–21 mm Hg without additional anti-glaucoma operation),number of glaucoma medications,endothelial graft status,and best-corrected visual acuity(BCVA).RESULTS:The mean follow-up time was 34.1 and 21.0mo for DSAEK or glaucoma surgeries,both for the GDI and CPC groups.Both groups showed significant IOP reduction after glaucoma surgery.The GDI group presented a significantly higher success rate in IOP control than the CPC group(60%vs 21.4%,P=0.03).Both procedures significantly decreased the number of glaucoma medications(P=0.03).Forty percent and 57%of cases in the GDI and the CPC group,respectively,experienced endothelial graft failure during follow-up(P=0.36).Significantly worse BCVA after surgery was observed in the CPC group but not in the GDI group.CONCLUSION:Both GDI and CPC significantly decrease IOP in eyes with glaucoma after DSAEK.GDI is preferable to CPC in refractory glaucoma cases after DSAEK,as it manifests a significantly higher success rate for IOP control,similar endothelial graft failure rate,and relatively preserves BCVA than CPC.

Dellen-like keratopathy associated with glaucoma drainage devices

To report the first case of dellen-like keratopathy with superior corneal thinning associated with implantation of glaucoma drainage devices. A 70-year-old male with a history of primary open angle glaucoma and dry eye disease underwent placement of glaucoma drainage devices with antimetabolite application in both eyes. Prior to placement, minimal refractive error was noted on manifest refraction. Several years later, the patient was referred for decreased vision and corneal irregularity. Examination showed pathologic corneal curvature, superior corneal thinning, and epithelial demarcation lines immediately anterior to the glaucoma drainage devices in both eyes. The epithelium remained intact with no evidence of limbal stem cell deficiency. Manifest refraction revealed a large change in both eyes. Topography was used to confirm the presence of irregular corneal curvature anterior to the glaucoma drainage devices. Dellen-like keratopathy with superior thinning is a rare sequela after implantation of a glaucoma drainage device that must be considered in elderly patients who undergo glaucoma surgery. It is likely related to a combination of tear film alteration related to previously large anterior blebs, antimetabolite application, and aqueous humor flow patterns around the drainage devices. Treatment should focus on lubrication.

Binocular disturbance after glaucoma drainage device implantation

Binocular vision disturbance is a well-described complication of glaucoma drainage device(GDD) implantation. The pathophysiology is not well-understood, but may involve bulk effects from the implant and surrounding bleb, as well as modulation of muscle function due to surgical trauma and post-operative inflammation, resulting in a combined resection/posterior fixation effect. Retrospective studies have found the risks of motility disorder and diplopia vary widely, estimated to be 56%-86% and 57%-75%, respectively. More recently, cross-sectional studies and prospective trials estimate post-GDD incidence to be approximately 1%-44%, with the incidence in newer generation of implants designed to limit bleb size likely lower at 1%-5%. Suggested methods of management strategies include prismatic spectacles, monocular occlusion, extreme monovision, and strabismus surgery.

Glaucoma drainage implants

Glaucoma drainage devices have traditionally been reserved for refractory glaucoma.However,there is an increasing body of evidence to suggest the use of these implants at an earlier stage in the surgical management of glaucoma.We describe the mechanics behind their function as well as the various implants available.The implants vary in size,surface area and composition and hence the surgical implantation of these devices are described in detail.The knowledge of such devices and their potential complications is fundamental for the successful management of patients who undergo aqueous-shunt surgery.Careful patient selection and optimal postoperative management is critical to the successful patient outcomes.

Long-term Outcomes of Domestic Hunan Aqueous-Drainage Implantation in Refractory Glaucoma

Purpose:To evaluate the long-term outcomes of a non-valved,.Chinese-made Hunan aqueous drainage device(HAD) in patients with refractory glaucoma,.compared to trabeculectomy.Methods:This was a retrospective observational case series,including 27 patients with refractory glaucoma who either underwent HAD implantation (n=11) or trabeculectomy (n=16).The mean follow-up was 27.9±13.5 (mean±SD) months.Intraocular pressure(IOP),visual acuity and postoperative complications were measured.Results:IOP was significantly lower at the last follow-up in both two groups compared with the baseline IOP (HAD:58.4 to 19.0 mmHg,P<0.001;trabeculectomy:58.4 to 23.7 mmHg,P<0.001).One week,1 month and 1 year after the operation,the average IOP of the HAD group was significantly lower than that of trabeculectomy group(P<0.05 at all time points).However,the IOP did not differ significantly between the two groups at the time of last follow-up.Conclusion:HAD implantation serves as a good option to control IOP in refractory glaucoma.

HA-Mg引流片兔眼前房植入对眼压控制的有效性和安全性

目的评估羟基磷灰石涂层镁基(HA-Mg)青光眼引流片植入兔眼后的安全性和有效性。方法使用配对比较法将12只SPF级3~4月龄新西兰白兔随机分为HA-Mg引流片植入组和小梁切除术组,每组6只,均取右眼进行相应操作;12只左眼均不行任何操作,作为正常对照组。术后1、3、5个月,采用裂隙灯显微镜及前置镜观察术后各组眼部情况;采用超声生物显微镜检查引流片于前房与结膜下间隙固定情况。术后5个月,采用角膜内皮细胞计数仪测量HA-Mg引流片植入组角膜内皮细胞数量;术前和术后每周采用Tonopen眼压计测量眼压,连续监测21周;采用锥虫蓝前房注入法验证房水引流通道通畅性;采用苏木精-伊红染色法评估HA-Mg引流片完全降解后房水引流通道与周围组织情况。结果术后实验兔均未出现全身及眼部异常或不良反应,6枚HA-Mg引流片均于术后约4个月完全降解,4枚引流片位置固定良好,2枚引流片出现少量旋转移位,无引流片落入前房;术后5个月,HA-Mg引流片植入组和正常对照组角膜内皮细胞数量分别为(2535.2±274.4)和(2521.0±175.8)个,差异无统计学意义(t=0.073,P=0.857)。手术前后不同时间点各组眼压总体比较,差异均有统计学意义(F组别=26.409,P<0.001;F时间=7.843,P<0.001),其中小梁切除术组和正常对照组术后不同时间点眼压均高于HA-Mg引流片植入组,HA-Mg引流片植入组术后不同时间点眼压均低于术前,差异均有统计学意义(均P<0.05)。引流通道通畅性实验发现,HA-Mg引流片植入术后5个月,蓝色染色剂仍可从前房引流到结膜下。术后6个月引流片已完全降解,巩膜层间可见线状房水引流通道及虹膜前粘连,各组织均未见明显炎性细胞浸润。结论HA-Mg引流片植入兔眼后可有效降低眼压,安全性较好。

Combined pars plana vitrectomy and Baerveldt glaucoma implant placement for refractory glaucoma

AIMTo evaluate outcomes of combined pars plana vitrectomy and Baerveldt glaucoma implant (PPV-BGI) placement for refractory glaucoma.METHODSThe medical records of 92 eyes (89 patients) that underwent PPV-BGI were retrospectively reviewed, including 43 eyes with neovascular glaucoma (NVG) and 49 eyes with other types of glaucoma (non-NVG).RESULTSOutcome measures were visual acuity (VA), intraocular pressure (IOP), glaucoma medical therapy, complications, and success [VA&#x0003e;hand motions (HM), IOP&#x02265;6 mm Hg and &#x02264;21 mm Hg, no subsequent glaucoma surgery]. Cumulative success rates for the non-NVG group and NVG group were 79% and 40% at 1y, respectively (P=0.038). No difference in the rates of surgical success were found between pars plana and anterior chamber tube placement. Preoperative IOP (mean&#x000b1;SD) was 30.3&#x000b1;11.7 mm Hg in the Non-NVG group and 40.0&#x000b1;10.6 mm Hg in the NVG group, and IOP was reduced to 15&#x000b1;9.5 mm Hg in the non-NVG group and 15&#x000b1;10.5 mm Hg in the NVG at 1y. Number of glaucoma medications (mean&#x000b1;SD) decreased from 2.7&#x000b1;1.3 in the non-NVG group and 2.8&#x000b1;1.3 in the NVG group preoperatively to 0.76&#x000b1;1.18 in the non-NVG group and 0.51&#x000b1;1.00 in the NVG group at 1y. Improvement in VA of &#x02265;2 Snellen lines was observed in 25 (27%) eyes, although only 33% of non-NVG eyes and 2.3% of NVG eyes maintained VA better than 20/200 at 1y. Nonclearing vitreous hemorrhage was the most common postoperative complication occurring in 16 (17%) eyes, and postoperative suprachoroidal hemorrhages developed in 5 (5.4%) eyes.CONCLUSIONPPV-BGI is a viable surgical option for eyes with refractory glaucoma, but visual outcomes are frequently poor because of ocular comorbidities, especially in eyes with NVG. The location of tube placement does not influence surgical outcome and should be left to the discretion of the surgeon.

Glaucomatous optic neuropathy treatment options:the promise of novel therapeutics,techniques and tools to help preserve vision

Peripheral vision loss followed by ＂tunnel vision＂ and eventual irreversible blindness is the fate of patients afflicted by various forms of glaucoma including primary open-angle glaucoma（POAG） and normotensive glaucoma（NTG）.These complex and heterogeneous diseases are characterized by extensive death of retinal ganglion cells（RGCs） accompanied by retraction and severance of their axonal connections to the brain and thus damage to and thinning of the optic nerve.Since patients suffering from this glaucomatous optic neuropathy（GON） first notice visual impairment when they have lost 〉 40% of their RGCs,early diagnosis is the key to retard the progression of glaucoma.Elevated intraocular pressure（IOP）,low cerebrospinal and/or low intracranial fluid pressure,advancing age,and ethnicity are major risk factors associated with POAG.However,retinal vascular abnormalities and a high sensitivity of RGCs and optic nerve head components to neurotoxic,inflammatory,oxidative and mechanical insults also contribute to vision loss in POAG/GON.Current treatment modalities for POAG and NTG involve lowering IOP using topical ocular drugs,combination drug products,and surgical interventions.Two recently approved multi-pharmacophoric drugs（e.g.,rho kinase inhibitor,Netarsudil;a drug conjugate,Latanoprostene Bunod） and novel aqueous humor drainage devices（i Stent and Cy Pass） are also gaining acceptance for treating POAG/NTG.Neuroprotective and regenerative agents,coupled with electroceutical,mechanical support systems,stem cell transplantation and gene therapy are emerging therapeutics on the horizon to help combat GON.The latter techniques and approaches hope to rejuvenate RGCs and repair the optic nerve structures,thereby providing a gain of function of the visual system for the glaucoma patients.

Bio-modulation of scaring Glaucoma Filtration Surgery using a novel application of coated magnesium

Filtration surgery still plays a mainstream role of treatment for glaucoma.Postoperative scarring is the main cause of surgical failure.This study evaluated the biocompatibility and anti-proliferative properties of pure magnesium with three different coatings,which are hydroxyapatite(HA),dicalcium phosphate dihydrate(DCPD)and DCPD+stearic acid(SA),in a primary culture of human tenon's capsule fibroblasts(HTCFs)and in rabbit Glaucoma Filtration Surgery.Titanium and glass were used as controls in vitro,and trabeculectomy was used as control in vivo.The results show the number and shape of HTCFs seeded on different coatings showed less quantity and poor cell morphology.Each type of coated magnesium demonstrated significantly decreased metabolic activity of HTCFs.DCPD+SA showed higher cytotoxicity than the other coatings.Significant inhibition of proliferation was observed with the DCPD+SA coating.The expression ofα-SMA was decreased in the cells when seeded on all of the coated magnesium disks.In vivo,no obvious adverse effects were observed after operation.No significant difference existed for any of the different samples regarding different ion concentrations in the aqueous humor.The inflammatory response in the titanium,DCPD and DCPD+SA treated eyes was more intense than in the trabeculectomy alone and HA groups.Western Blot analysis showed that collagen-1 andα-SMA expression was significantly lower in the titanium,HA,DCPD and DCPD+SA groups compared with the control.Different coatings on magnesium were able to affect the corrosive properties,which in turn,influenced the morphology and function of HTCFs.HA coated magnesium may be considered a very promising biodegradable material for the next generation of glaucoma drainage devices.

Dealing with pediatric glaucoma: from medical to surgical management-a narrative review

Pediatric glaucoma is a potentially sight-threatening disease and is considered the second leading cause of treatable childhood blindness.Pediatric glaucoma is a clinical entity including a wide range of conditions:primary congenital glaucoma,glaucoma secondary to ocular(e.g.,aniridia,Peter’s anomaly),or systemic disease(e.g.,Sturge Weber)and glaucoma secondary to acquired condition(pseudophakic,traumatic,uveitic glaucoma).The treatment algorithm of childhood glaucoma is a step-by-step approach,often starting with surgery,as in primary congenital glaucoma cases.Medical therapy is also crucial in the management of pediatric glaucoma.Here we reported the results of the randomized,controlled,clinical trials carried out in children treated with topical anti-glaucoma drugs.It is worth knowing that prostaglandin analogues showed an excellent systemic safety profile,while serious systemic events have been reported in children taking topical beta-blockers.Angle surgery is the first surgical option in patients diagnosed with primary congenital glaucoma,with ab interno and ab externo approaches showing similar outcomes.Trabeculectomy in children can be troublesome,as mitomycin C(MMC)can lead to bleb complications and a higher endophthalmitis rate than in adults.Glaucoma drainage devices(GDD)are no longer a last resort and can be considered a suitable option for the management of uncontrolled pediatric glaucoma after angle surgery failure.

青光眼的微创手术治疗和引流装置

青光眼是一类严重危害人类健康的疾病,医学界一直在探索治疗青光眼新方法,其中微创青光眼手术(MIGS)联合植入引流装置的治疗方式和传统小梁切除术相比更为安全有效,并发症较少。根据MIGS类手术治疗方法和实现途径的不同,在科学界的不断努力下,发明出多种不同的微创手术引流装置,保障了青光眼手术的治疗效果。本文就近年MIGS手术使用的多种流行的和先进的引流装置进行综述。

微创青光眼手术在儿童青光眼治疗中的应用现状和展望

儿童青光眼是一类难治性青光眼,微创青光眼手术(MIGS)为儿童青光眼提供了安全有效的治疗选择。多数已发表的研究倾向于支持应用全周内路小梁切开术,其治疗儿童青光眼的安全性和有效性与非MIGS的全周外路小梁切开术相似。关于KDB刀、小梁消融术和Xen凝胶支架的研究较为有限,但在某些特定的病例中可能有其各自的优势。每一种MIGS手术在考虑其优势之处的同时须特别权衡每种手术方法的长期效果。此外,还需要更多的前瞻性和比较性研究、更大的样本量和更长的随访时间来验证MIGS手术治疗儿童青光眼的安全性和有效性。

XEN凝胶引流装置治疗青光眼的研究进展

近年来,微创青光眼手术(MIGS)在降低眼压和减少术后并发症中显示出良好的前景。XEN凝胶引流装置植入术作为一种新型的MIGS,在材料特质、房水引流功能以及降眼压机制等方面展现出区别于其他青光眼引流阀装置的独特优势。XEN凝胶引流装置植入术与传统的复式小梁切除术在降低眼压、减少药物使用数量等方面的治疗结果类似,但XEN凝胶引流装置植入术的术后并发症相对较少,安全性更高。因此,XEN凝胶引流装置植入术可能是难治性青光眼持续性高眼压的一种治疗方案。

P50型与P200型Ex-PRESS引流器植入术对开角型青光眼疗效及安全性的随机对照研究

背景 目前国外对Ex-PRESS引流器植入术治疗开角性青光眼的临床应用效果已有报道,在中国临床上使用的Ex-PRESS引流器有内径分别为50μm和200μm的P50型和P200型,但2种类型引流器的临床效果是否有所不同,目前国内外报道较少. 目的 对比观察P50型与P200型Ex-PRESS引流器植入术治疗开角型青光眼的早期临床疗效和安全性. 方法 采用随机对照临床研究设计,纳入2012年3月至2013年4月在广州军区武汉总医院行Ex-PRESS引流器植入术的开角型青光眼患者69例80眼,采用随机数字表法将患者分为基线特征匹配的2个组,分别实施P50型Ex-PRESS引流器植入术（35例40眼）和Ex-PRESS引流器植入术（34例40眼）,比较2个组患者的病种构成比、最佳矫正视力恢复时间、理论住院天数、手术前后的眼压变化及并发症的发生情况.结果 P50组和P200组术眼手术前后眼压平均下降幅度分别为（21.19±11.22）和（24.35±12.27）mmHg（1 mmHg=0.133 kPa）,差异无统计学意义（t=-1.201,P＞0.05）.P50组患者的理论住院天数和最佳矫正视力恢复时间分别为（3.65±0.92）d和（2.85±0.95）d,明显少于P200组的（4.90±0.81）d和（3.40±0.96）d,差异均有统计学意义（t=-6.444,P＜0.01;t=-2.584,P＜0.05）.P50组和P200组术眼术后并发症发生率分别为6.06％和25.00％,差异有统计学意义（x2=9.800,P＜0.05）,P50组术眼发生低眼压和浅前房的跟数少于P200组.结论 P50型和P200型Ex-PRESS引流器植入术对开角性青光眼的降眼压作用接近,与P200型Ex-PRESS引流器植入术比较,P50型Ex-PRESS引流器植入后早期患者的视力恢复快,并发症的发生率低.

两种房水引流植入装置降眼压效果比较

目的观察并比较两种房水引流装置植入术降眼压的效果。方法选择健康新西兰白兔40只,单眼进行房水引流装置植入术。根据不同的植入物,分为NADI组和Ahmed组,每组20只实验兔。结果术后各组均未出现浅前房。NADI组术后8周眼压比术前下降19.4%;Ahmed组术后8周眼压下降幅度为15.7%。术后8周内,各组间眼压值统计对比,均有显著性差异(P<0.05),且NADI组的眼压值下降幅度要明显大于Ahmed组。结论 NADI组比Ahmed组的眼压值下降幅度大,且下降时间维持较长,表明此新型房水引流植入物NADI降眼压效果明显,具有很好的临床应用前景。

青光眼房水引流装置的研究进展

青光眼房水引流装置植入术是目前临床上广为推崇的一种治疗难治性青光眼的有效方法。各引流装置在设计、材料、引流盘的面积和形状及有无阀门或限流器上存在差异。现就临床常用的青光眼房水引流装置的结构特点、作用机制、并发症、不足之处以及当前研究进展做一简要概述。

青光眼引流装置植入术在治疗难治性青光眼中的作用

难治性青光眼是主要的致盲眼病之一，目前青光眼引流装置植入术已成为治疗难治性青光眼的主要方法，因其具有安全、有效、并发症较少等优点，青光眼引流装置在临床已得到广泛应用。通过近几年大量临床应用与青光眼微创手术的创新发展，青光眼引流装置植入术展现出良好的治疗前景。本文总结分析了青光眼外引流装置（Molteno、Schocket、Baerveldt、国产HAD房水引流物、Krupin、Ahmed、Joseph、Whites、Optimed房水引流物）及青光眼微创手术（Ex—PRESS青光眼引流器、Xen凝胶支架、CyPass微型支架、小梁消融术、Schlemm管支架、iStent引流器、SOLX Gold Shunt等）的结构特点和临床疗效，就青光眼引流装置植入术在治疗难治性青光眼中的作用进行综述。

内窥镜睫状体光凝术与青光眼阀植入术治疗难治性青光眼的对比研究

目的:对比内窥镜睫状体光凝术(endoscopic cyclophotocoagulation,ECP)和青光眼阀植入术治疗难治性青光眼疗效。方法:回顾性分析难治性青光眼99眼,分为ECP组50眼(A组)和青光眼阀植入组49眼(B组)。观察两组术后眼压、视力、术中、术后并发症。结果:(1)眼压:两组最后复诊眼压下降较术前差异均有统计学意义(t=2.47、t=2.51,P<0.05)。除术后2 d及7 d外,余时间点两组眼压差异无统计学意义(t=0.92、t=0.89、t=0.95,P>0.05)。(2)视力:末次随访两组视力差异无统计学意义(x^2=37.85,P>0.05)。(3)并发症:A组早期并发症:前房反应性渗出、短期高眼压、前房积血。B组早期并发症:浅前房、前房积血、阀口阻塞性高眼压、迟发型爆发性脉络膜上腔出血、脉络膜脱离。中期并发症:引流盘纤维包裹性高眼压;远期并发症:引流管排斥、暴露和移位、感染性眼内炎、结膜增殖性病变。结论:内窥镜睫状体光凝术与青光眼阀植入术均能降低难治性青光眼眼压。内窥镜睫状体光凝术术后并发症少。

抗VEGF联合Ex-press青光眼引流器植入治疗新生血管性青光眼

目的:观察玻璃体腔注射抗VEGF联合Ex-press青光眼引流器植入术对新生血管性青光眼的临床疗效。方法:回顾性分析我院收治的新生血管性青光眼患者20例20眼,15眼行玻璃体腔注射抗VEGF及Ex-press青光眼引流器植入联合PPV术,术中行全视网膜光凝术。另5眼行玻璃体腔注射抗VEGF及Ex-press青光眼引流器植入术,术后7d行全视网膜光凝。分别观察20例患者术中及术后并发症情况,以及术后1wk,1、3、6mo后的视力、眼压、虹膜新生血管消退情况。结果:治疗前平均眼压为47±5.6mmHg,治疗后1wk,1、3、6mo时平均眼压分别为13.4±3.6、15.3±4.2、16.9±5.3、18.7±6.9mmHg,治疗后各随访时间点眼压较治疗前差异具有统计学意义(P<0.05)。Ex-press青光眼引流器植入术术中及术后并发症主要有早期浅前房、引流管阻塞,经适当治疗后均恢复。滤过泡瘢痕化8眼,但眼压稳定在正常范围。结论:玻璃体腔注射抗VEGF联合Ex-press青光眼引流器植入术可以有效治疗新生血管性青光眼,降低新生血管性青光眼患者的眼压。

Ex-press青光眼引流器植入术治疗难治性青光眼的疗效及并发症

目的：探讨Ex-press青光眼引流器植入术治疗难治性青光眼的临床疗效及并发症。方法：随机选取本院2013-02/2014-08收治行Ex-press青光眼引流器植入术治疗的难治性青光眼53例56眼,男39例41眼,女14例15眼,平均年龄52.63±10.58岁;新生血管性青光眼25例26眼,滤过手术失败后青光眼16例18眼,玻璃体切除术后继发青光眼6例6眼以及复杂眼外伤后青光眼6例6眼。观察术后1、12mo视力、眼压、前房深度、角膜内皮细胞密度及并发症等情况,并与术前进行分析比较。结果：术后12mo,完全成功率为62%（35眼）,部分成功率为14%（8眼）,总成功率为77%。其中新生血管性青光眼有效率为85%,滤过手术失败后青光眼有效率为56%,复杂眼外伤后青光眼100%,玻璃体切除术后青光眼83%。术后1mo视力较术前提高者28眼（50%）,视力不变18眼（32%）,视力降低10眼（18%）。术后12mo视力较术前提高者19眼（34%）,视力不变18眼（32%）,视力降低19眼（34%）。术前平均眼压29.58±8.66mm Hg,术后1mo平均眼压12.75±5.66mm Hg,与术前比较差异有统计学意义（P〈0.05）,其中56例患眼眼压均表现为降低（100%）。术后12mo眼压为9.8~28.4（平均15.42±4.09）mm Hg,与术前比较差异有统计学意义（P〈0.05）,其中眼压较术前增高者2眼,眼压不变0眼,眼压降低54眼（96%）。术后1、12mo内皮细胞计数分别为1958.22±168.30、1793.99±201.55个/mm2,与术前的2113.47±80.56个/mm2比较,差异有统计学意义（P〈0.01）。术后总并发症发生率为29%,其中术后早期发生浅前房低眼压4眼,暂时性高眼压3眼,引流管阻塞5眼,前房出血3眼。后期并发症有局部隆起的包裹的囊状泡1眼。结论：Ex-press青光眼引流器植入术治疗难治性青光眼,虽然存在一定的术后并发症,但仍可取得较好的临床疗效,是目前治疗难治性青光眼的有效方法。