Glaucoma surgery experiments using digital microscope-integrated optical coherence tomography and OCT-compatible instruments

There is a certain failure rate in traditional glaucoma surgery because of the lack of depth information in microscope images.In this work,we present a digital microscope-integrated optical coherence tomography(MIOCT)system and several custom-made OCT-compatible instruments for glaucoma surgery.Sixteen ophthalmologists were asked to perform trabeculectomy and canaloplasty on live porcine eyes using the system and instruments.After surgery,a subjective feedback survey about the user experience was taken.The experiment results showed that our system can help surgeons easily locate important tissue structures during surgery.The custom-made instruments also solved the shadowing problem in OCT imaging.Surgeons preferred to use the system in their future practice.

Selective laser trabeculoplasty as adjunctive treatment for open-angle glaucoma vs following incisional glaucoma surgery in Chinese eyes

BACKGROUND Selective laser trabeculoplasty(SLT)is a relatively safe and effective therapy in lowering intraocular pressures(IOP)for glaucoma.AIM To study the long-term effects of SLT on IOP and number of glaucoma medications used in Chinese eyes.METHODS This is a retrospective study in which 75 eyes of 70 patients with open-angle glaucoma(OAG,n=36)and eyes with prior glaucoma surgery(PGS,n=39)were included.Changes in mean IOP and number of glaucoma medications used evaluated at 1 d,1 wk,1 mo,3 mo,6 mo,12 mo,and 36 mo after laser treatment.RESULTS All patients(33 male,37 female)were Chinese.The mean age was 44.34±16.14years.Mean pre-SLT IOP was 22.75±2.08 mmHg in OAG and 22.52±2.62 mmHg in PGS.Mean IOP was significantly reduced 1 d,1 wk,1 mo and 3 mo after laser treatment(P<0.05,respectively).Whereas,there were no significant differences between baseline and SLT treated groups at the 6th month both in OAG(P=0.347,P>0.05)and in PGS(P=0.309,P>0.05).Six months after SLT treatment,some patients received retreatment of SLT or were given more topical IOP-lowering medication to control the IOP.By the end of our study,the average IOP decreased to 20.73±1.82 mmHg in OAG and 20.49±1.53 mmHg in PGS groups.The number of glaucoma medications used was significantly reduced until the end of 3 years compared to baseline.CONCLUSION SLT could reduce IOP as adjunctive treatment both in OAG and PGS groups.SLT significantly reduced the number of glaucoma medications used 3-years following treatment in glaucoma patients.

Efficacy and safety of deep sclerectomy with uveoscleral implant plus collagen matrix implant overcoming the superficial scleral flap in glaucoma surgery

AIM:To assess the efficacy and safety of non-penetrating deep sclerectomy(NPDS)with uveoscleral implant plus subconjunctival and intrascleral collagen matrix overcoming the superficial scleral flap lips(modified deep sclerectomy technique,DS)and minimal use of mitomycin C in glaucoma surgery.METHODS:A retrospective review of 47 consecutive glaucoma patients who underwent NPDS with DS between January 2017 and May 2018.Best-corrected visual acuity,intraocular pressure(IOP),post-operative need for glaucoma medications,visual field mean deviation(MD),re-interventions,needling revisions and laser goniopuncture were noted.Absolute success was defined as IOP≤18 mm Hg without topical medication.Relative success was defined as the same criteria but with the addition of any antihypertensive medication.IOP over 18 mm Hg on two consecutive followup visits was considered as a failure.RESULTS:Fifty-two eyes of 47 patients were evaluated.Mean preoperative IOP was 25.37±6.47 mm Hg,and decreased to 15.04±4.73 at 12mo and 12.21±4.1 at 24mo(all P<0.0001).Requirement for topical medications dropped from a mean of 3.06±0.25 per patient to 0.51±0.99 and 1.11±1.23 respectively after 12 and 24mo(all P<0.0001).No medications were required in 45.5%of patients after 24mo.Relative and absolute success rate at 24mo were 85.5%±5%and 48.5%±7.4%,respectively.CONCLUSION:DS is a safe and effective nonpenetrating glaucoma surgery variation.It aims to retain the patency of all pathways created for aqueous humor drainage:the intrascleral bleb,the supraciliary space and the open communication between intrascleral and subconjunctival compartments.

A novel suturing technique for filtering glaucoma surgery:the accordion suture

AIM：To present a novel scleral flap suturing technique for filtering glaucoma surgery in order to control high postoperative intraocular pressure（IOP）.METHODS：Description of ‘the accordion suture＇ technique for mitomycin C augmented trabeculectomy.In cases of postoperative high IOP,pulling the loop of the suture helps to lift up the scleral flap by an even pressure on both edges.By means of this technique,the scleral flap opens up in an ‘‘accordion＇＇ manner,thus preventing flap obstruction and providing adequate aqueous flow.RESULTS：Our study group consisted of 8 eyes of 8 patients with neovascular glaucoma.Mean age of the subjects was 67.42±8.21 y and female/male ratio was 4/4.Mean preoperative IOP was 37±7.48 mm Hg.Mitomycin C augmented trabeculectomy was carried out on the subjects without any complications.The scleral flap closure is performed with three separate sutures;initially,our accordion suture through the center of the flap,and two releasable sutures on both corners.All the patients received removal of two side releasable sutures concomitant with pulling the accordion suture,without any complications.The average traction time was 3.5±0 wk postoperatively.The mean postoperative IOP was 11.37±2.72 mm Hg.No suture related complications were observed.CONCLUSION：This technique can be the suture of choice for filtering glaucoma surgery in experienced hands by its easy learning curve for precisely indicated patients.

Comparison of minimally invasive glaucoma surgery with trabecular micro-bypass stent and microhook ab interno trabeculotomy performed in conjunction with cataract surgery

AIM: To evaluate the effectuality and safety of cataract surgery combined with either ab interno trabeculotomy by the microhook(μLOT) or a single i Stent? trabecular bypass implantation(i Stent) in eyes with cataract and mild-tomoderate glaucoma. METHODS: This study enrolled subjects with mild-tomoderate open angle glaucoma with visually significant cataract who used two or more ophthalmic antiglaucoma agents between 60 and 90 y of age. Patients underwent cataract surgery cooperated with either implantation of an i Stent(i Stent-phaco) or excisional goniotomy with the μLOT(μLOT-phaco). Patients underwent μLOT-phaco in the eye with lower the mean deviation, according to the Humphrey field analyzer, while i Stent-phaco was carried out on the other eye. Intraocular pressure(IOP) pre-and post-surgery, alterations in anterior chamber flare(ACF), and corneal endothelial cell density(ECD) were estimated.RESULTS: Twenty subjects were enrolled(mean age: 73.6±7.3 y). The mean medicated preoperative IOP was 16.7 mm Hg in the μLOT and 16.2 mm Hg in the i Stent eyes. The mean final IOP at 12 mo was 13.6 mm Hg in the μLOT eyes and 13.6 mm Hg in the i Stent eyes, representing a 17.8% and 17.2% reduction, respectively. The preoperative ACF in the μLOT eyes was 9.5 pc/ms and it returned to normal in 30 d postoperatively, with a value of 11.4 pc/ms. In the i Stent eyes, ACF was 9.6 pc/ms preoperatively and it returned to normal by 7 d postoperatively(11.2 pc/ms atday 7), demonstrating that postoperative inflammation was less in the i Stent eyes. The corneal ECD in both groups was not significantly decreased.CONCLUSION: In this study, i Stent and μLOT are both effective through 12 mo of follow-up. Safety is more favorable in the i Stent eyes, based on early anterior chamber inflammation.

Evaluation of the Ex-PRESS~ P-50 implant under scleral flap in combined cataract and glaucoma surgery

AIM： To evaluate the efficacy and safety of glaucoma drainage device Ex-PRESS~ P-50 for combined cataract surgery and glaucoma.·METHODS： Patients having cataract and open angle glaucoma or patients with open advanced glaucoma which needed two or more antiglaucoma medications were included. Combined cataract surgery and glaucoma with Ex-PRESS~ P-50 model placed under scleral flap was performed.·RESULTS： Out of 40 eyes of 40 patients（55% male and45% female） completed the study during one-year follow-up. The mean of age was 76.6 ±11.02 y. The intraocular pressure（IOP） decreased significantly during the 12-month follow-up from 23.5 mm Hg to 16.8 mm Hg（Wilcoxon signed ranks test, P 〈0.001）. A 59.5% of patients did not need any topical treatment, 10.8% of them needed one active principle, 27% needed two active principles, and 2.7% of them needed three active principles for successful IOP control（〈21 mm Hg）.·CONCLUSION：Combinedsurgeryofphacoemulsification with Ex PRESS~ P-50 lowers IOP from the preoperative baseline and reduces significantly the number of antiglaucoma active principles for IOP control after the operation.

Efficacy and safety of non-penetrating glaucoma surgery with phacoemulsification versus non-penetrating glaucoma surgery:a Meta-analysis

AIM:To compare the clinical efficacy and safety of non-penetrating glaucoma surgery(NPGS)plus phacoemulsification(Phaco-NPGS)and NPGS-alone.METHODS:We systematically searched various databases and reviewed studies that had evaluated the effects of Phaco-NPGS or NPGS-alone for patients with glaucoma.Primary outcomes included postoperative intraocular pressure(IOP)and the number of postoperative antiglaucoma medications.Secondary outcomes were the prevalence of complications,incidence of needling or goniopuncture,and surgical success rate.RESULTS:In total,380 and 424 eyes in NPGS-alone and Phaco-NPGS groups respectively were included.Both postoperative IOP and number of medications were significantly lowered in the Phaco-NPGS group than that in the NPDS-alone group[weighted mean difference(WMD)=-1.12,95%confidence interval(CI):-2.11 to-0.12,P=0.03;WMD=-0.31,95%CI:-0.53 to-0.09,P=0.006].Moreover,Phaco-NPGS had a significantly lower prevalence of complications and postoperative procedures compared to NPGS-alone,while no significant difference existed for surgical success.CONCLUSION:Phaco-NPGS superior to NPGS-alone in the reduction of IOP and medications.Phaco-NPGS can be recommended for glaucoma patients with coexisting cataracts owing to its superior efficacy,fewer complications,and postoperative procedures.

Changes in macular thickness following glaucoma surgery

Dear Sir,Previous reports have illustrated reversible structural changes in optic disc cupping,the lamina cribrosa,and the retinal nerve fiber layer(RNFL)following glaucoma surgery[1-3].However,few studies have assessed changes in macular thickness following such intervention.Our aim was to investigate the impact of intraocular pressure(IOP)reduction after glaucoma surgery on total macular thickness

Micro-invasive glaucoma surgery – an interventional glaucoma revolution

The glaucoma surgical landscape has changed dramatically over the last decade with the introduction and integration of micro-invasive glaucoma surgery(MIGS)techniques.These modalities target physiologic outflow pathways or optimize previously utilized glaucoma surgical methods in order to deliver safety,efficacy,and individualized care to the patient.MIGS techniques can be classified based on anatomical location as well as method of intraocular pressure(IOP)reduction.This review will focus on MIGS optimizing the conventional outflow pathway via intervention at Schlemm’s canal,MIGS optimizing the uveoscleral outflow pathway via suprachoroidal shunting,and MIGS optimizing the transscleral or subconjunctival outflow pathway which has long been utilized by glaucoma surgeons performing traditional filtration procedures.The wide array of currently available MIGS modalities can be staggering to the glaucoma care provider,but an understanding of the landscape and the large classes of interventional strategies can allow for clinical decision making based on the specifics of the patient’s needs and the pathophysiology of their disease.

Trends in operating room-based glaucoma procedures at a single eye center from 2016–2020

AIM:To evaluate trends in glaucoma procedures at the Peking University Eye Center in 2016–2020.METHODS:A retrospective search of all glaucoma procedures performed at our institution were performed.Data were analyzed by calculating the absolute numbers and relative weightage of each procedure per year.RESULTS:The average age of glaucoma patients undergoing surgical procedures was 62.33±17.87y,and 55%were women.From 2016 to 2019,the number of surgical procedures performed in glaucoma patients showed an overall upward trend from 749 to 1460,although it decreased slightly in 2020(n=1393),probably due to the COVID-19 pandemic.The number of trabeculectomies did not change significantly in 2016(n=161)to 2018(n=164)but decreased in 2019(n=139)to 2020(n=121),indicating a reduction in its relative weightage among glaucoma procedures(from 21.50%to 8.69%).The number of glaucoma drainage device implantations and minimally invasive glaucoma surgeries both increased(50and 58 respectively in 2019),except in 2020.The number of transscleral cyclophotocoagulation procedures was relatively stable,increasing until 2017(n=218)and then decreasing.Cataract surgeries with or without glaucoma procedures accounted for a large number of the total surgeries,increasing from 247(32.97%)in 2016 to 967(69.42%),among which cataract extraction combined with goniosynechialysis was the most frequent.CONCLUSION:The overall increase in the number of operating room-based surgical procedures is significant.Trabeculectomy is one of the most commonly performed procedures,despite the relative decline in its weightage.Other procedures,including use of glaucoma drainage devices and mini shunts and minimally invasive glaucoma surgeries,are gaining greater acceptance.Notably,lensrelated surgery plays an important role in glaucoma management.

Exosome-mediated aptamer S58 reduces fibrosis in a rat glaucoma filtration surgery model

AIM:To confirm whether exosome-mediated delivery of aptamer S58(Exo-S58) has a better antifibrotic effect than naked S58 in human conjunctival fibroblasts(HCon Fs) and a rat glaucoma filtration surgery(GFS) model.METHODS:To enhance the effective reaction time of aptamer S58 in vivo, we loaded aptamer S58 into exosomes derived from HEK293 T cells by PEI transfection to determine the effect of Exo-S58 in HCon Fs and a rat GFS model.RESULTS:Exo-S58 can significantly reduce cell proliferation, migration and fibrosis in TGF-β2-induced HCon Fs. In an in vivo experiment, Exo-S58 treatment prolonged filtering bleb retention and reduced fibrosis compared with naked S58 treatment in GFS rats.CONCLUSION:The exosomes are safe and valid carriers to deliver aptamers. Furthermore, Exo-S58 exhibited superior antifibrotic effect than naked S58 both in HCon Fs cells and rat GFS models.

Meta-analysis of the efficacy and safety of combined surgery in the management of eyes with coexisting cataract and open angle glaucoma

AIM： To conduct a systematic review and quantitative Meta-analysis of the efficacy and safety of combined surgery for the eyes with coexisting cataract and open angle glaucoma.METHODS： We performed a systematic search of the related literature in the Cochrane Library, PubM ed, EMBASE, Web of Science databases, CNKI, CBM and Wan Fang databases, with no limitations on language or publication date. The primary efficacy estimate was identified by weighted mean difference of the percentage of intraocular pressure reduction（IOPR%） from baseline to end-point, the percentage of number of glaucoma medications reduction from pre-to post-operation, and the secondary efficacy evaluations were performed by odds ratio（OR） and 95% confidence interval（CI） for complete and qualified success rate. Besides, ORs were applied to assess the tolerability of adverse incidents. Meta-analyses of fixed or random effect models were performed using Rev Man software 5.2 to gather the consequences. Heterogeneity was evaluated by Chi^2 test and the I^2 measure.RESULTS： Ten studies enrolling 3108 patients were included. The combined consequences indicated that both glaucoma and combined cataract and glaucoma surgery significantly decreased IOP. For deep sclerectomy vs deep sclerectomy plus phacoemulsification and canaloplasty vs phaco-canaloplasty, the differences in IOPR% were not all statistically significant while trabeculotomy was detected to gain a quantitatively greater IOPR% compared with trabeculotomy plus phacoemulsification. Furthermore, there was no statistical significance in the complete and qualified success rate, and the rates of adverse incidents for trabeculotomy vs trabeculotomy plus phacoemulsification.CONCLUSION： Compared with trabeculotomy plus phacoemulsification, trabeculectomy alone is more effective in lowering IOP and the number of glaucoma medications, while the two surgeries can not demonstrate statistical differences in the complete success rate, qualified success rate, or incidence of adverse incidents.

A narrative review of ocular surface disease considerations in the management of glaucoma

s from those searches were screened for relevance to our review topics.Publications were included if the subjects included glaucoma patients,and if ocular surface outcomes were described.Non-English papers were excluded.Key Content and Findings:Topical glaucoma medications frequently cause adverse effects on the ocular surface,both through direct action of the medications themselves as well as through toxicity from their associated preservatives.Optimization of the ocular surface may improve medication compliance rates.Traditional surgical treatments for glaucoma,such as trabeculectomy,can exacerbate OSD by disrupting the ocular surface but can also reduce the need for chronic medications.Optimization of ocular surface health is imperative in reducing trabeculectomy complication rates,while also potentially reducing the need for trabeculectomy in patients that are able to achieve intraocular pressure control through improved drop tolerability.The introduction of MIGS represents a promising alternative to existing therapies and has been shown to alleviate the overall medication burden.It would be reasonable to assume that decreasing the medication burden could reduce OSD prevalence and severity.However,more research is needed to directly assess the extent of improvement seen after MIGS.Conclusions:A comprehensive understanding of the importance of OSD in medical and surgical management of glaucoma is essential in optimizing patient care and improving outcomes.

Outcomes of Ahmed valve surgery for refractory glaucoma in Dhahran, Saudi Arabia

AIM: To evaluate the outcomes of Ahmed glaucoma valve(AGV) implantation surgery for refractory glaucoma.METHODS: This one-armed historical cohort study was conducted in 2011. Refractory glaucoma was defined as eyes with an intraocular pressure(IOP) greater than21 mm Hg with maximally tolerated glaucoma medications, failed surgeries, or both. For all eyes with refractory glaucoma that underwent AGV implantation,data were collected on IOP, the best corrected visual acuity(BCVA) and glaucoma medications preoperatively and 4, 6, 12, 24 and 56 wk postoperatively. Logarithm values of IOP were calculated and compared. RESULTS: The study group was comprised of 30patients(30 eyes, 16 males and 14 females) with refractory glaucoma. Mean preoperative IOP was 39.3 ±13.8 mm Hg. Postoperative mean IOP was 15.7±7.1 mm Hg,19.6 ±12.8 mm Hg and 13.9 ±14.2 mm Hg at 12, 24 and56 wk respectively. BCVA was ≥6/60 in 11 eyes preoperatively, and five eyes had BCVA ≥6/60 at 56 wk postoperatively. Preoperatively, more than four medications were used to treat glaucoma in 21 eyes. At12 wk postoperatively, no medications were required to control IOP in 20 eyes. At 56 wk postoperatively, at least one medication was required to control IOP in 10 eyes.Over the entire follow up period, four eyes were treated with yttrium aluminium garnet(YAG) laser and 14 eyes required a second surgery. The AGV was removed in four eyes.CONCLUSION: AGV implantation reduced IOP and the number of medications required to control refractory glaucoma. However, there was a higher risk of decreased vision. Long-term follow up and prompt intervention are recommended.

XEN® Gel Implant for Glaucoma;Prospective Cohort Study in a High-Volume Department

Purpose: To evaluate the 3-year efficiency and safety of XEN® 45 gel stent implantation in a heterogenous group of open angle glaucoma patients. Methods: In this prospective, non-randomized observational study we identified patients who had undergone either stand-alone XEN® implantation (XEN solo) or XEN® implantation in combination with phacoemulsification (XEN combi). All patients who had undergone an implantation during the period 01.04.17-31.10.19 at the Department of Ophthalmology, Drammen Hospital, Norway, were asked to participate. Success was defined as IOP between 5 - 18 mmHg and 20% pressure reduction without medications. Qualified success required the same pressure interval and reduction but allowed medications. The procedure was deemed as failure if pressure requirements were not met, vision was reduced to light perception or worse, or if there was a converion to secondary glaucoma surgery. Results: Out of 115 patients and 133 eyes identified, 87 patients and 99 eyes consented to participate. All patients were Caucasians with a mean age of 73.6 years. The study had a mean (range) follow-up of 38.9 (28 - 54) months. The mean medicated baseline (SD) was reduced from 22.6 (7.9) mmHg on 3.2 (1.1) medications to 14.2 (5.6) mmHg on 1.4 (1.6) medications. Success and qualified success were achieved in 22.2% and 21.2%, respectively. Needling was performed in 34 eyes. Conclusion: XEN® 45 gel stent implantation is a safe procedure, offering a significantly lower IOP and number of medications in a subset of patients with open angle glaucoma.

Effect of long-term topical latanoprost medication on conjunctival thickness in patients with glaucoma

AIM： To investigate the effect of long-term use of topically administered latanoprost on conjunctival thickness（CT） and conjunctival epithelium thickness（CET） in the patients with glaucoma. METHODS： A series of 106 glaucomatous patients were included. Of the 106 eyes, 55 eyes were treated with latanoprost eye drops once a day（latanoprost group）, while 51 eyes were treated with carteolol hydrochloride eye drops（carteolol group）. All the included patients completed a 2-year follow-up. CT and CET were measured with optical coherence tomography（OCT） in all patients at presentation and at 2-year visit, respectively. Statistical analysis was then performed to compare the change in CT and CET. RESULTS： At presentation, there was no difference in CET（t=0.400, P=0.689） or CT（t=1.14, P=0.259） between the two groups. No significant difference was found in CET（61.65±5.35 μm at baseline, 60.36±6.36 μm at 2-year follow-up, respectively; t=1.977, P=0.0531）, while there was a significant decrease in CT from 201.45±14.99 μm at baseline to 167.81±14.57 μm at 2-year visit（t=14.1407, P〈0.001） in the latanoprost group. At 2-year follow-up, no statistically difference was found in CET（62.24±5.27 μm; t=1.086, P=0.282） or CT（201.23±12.45 μm; t=1.44, P=0.154） compared to it at baseline（CET： 61.23±5.42 μm; CT： 198.76±13.68 μm, respectively） in the carteolol group. CONCLUSION： A significant decrease in conjunctival thickness is found in glaucoma patients treated with long-term topical latanoprost; its potential effect on the outcome of filtration surgery should be considered.

Performances of glaucoma operations with Kahook Dual Blade or iStent combined with phacoemulsification in Japanese open angle glaucoma patients

AIM:To compare surgical outcomes of phacoemulsification combined with glaucoma surgical techniques performed with either Kahook Dual Blade(KDB)or iStent for Japanese patients with either primary open angle glaucoma or exfoliation glaucoma.METHODS:We retrospectively evaluated the surgical outcomes of 129 eyes of 84 Japanese patients with glaucoma who underwent KDB or 44 eyes of 34 patients who underwent phacoemulsification with iStent procedures combined with cataract surgery.The primary outcome was surgical success or failure[with surgical failure being indicated by<20%reduction from preoperative intraocular pressure(IOP)or IOP>18 mm Hg as criterion A;IOP>14 mm Hg as criterion B on two consecutive study visits;or reoperation requirement].In addition,we assessed the number of postoperative glaucoma medications and the resulting complications.RESULTS:The probability of success was significantly higher in the KDB group than in the iStent group for criterion A(60.2%vs 46.4%,P=0.019).In the KDB group,the mean preoperative IOP of 19.8±7.3 mm Hg decreased significantly to 13.0±3.1 mm Hg(P<0.01),and the mean number of glaucoma medications at 2.5±1.4 decreased significantly to 1.6±1.6(P<0.01)12 mo postoperatively.In the iStent group,the mean preoperative IOP of 17.8±2.9 mm Hg significantly decreased to 14.3±2.3 mm Hg(P<0.01),and the mean number of glaucoma medications at 2.2±1.1 decreased significantly to 0.9±1.4(P<0.01)12 mo postoperatively.The overall IOP reduction percentage was higher in the KDB group(26.2%)than in the iStent group(19.0%)12 mo postoperatively(P=0.03).Hyphema occurred significantly more frequently in the KDB group(16.3%)than in the iStent group(2.3%,P=0.017).CONCLUSION:KDB and iStent procedures combined with cataract surgery both result in significant IOP and glaucoma medication reductions after the 12-month followup.The patients in the KDB group have a higher success rate for the target IOP of less than 18 mm Hg and a higher complication rate than those in the iStent group.

Comparison of surgical outcome of trabeculectomy and phacotrabeculectomy in Chinese glaucoma patients

Our study retrospectively reviewed the surgical outcomes up to 3 mo of 38 consecutive Chinese glaucoma patients who underwent trabeculectomy（n=18） or phacotrabeculectomy（n=20）.Baseline age,visual acuity,and intraocular pressure were comparable.Intraocular pressure from post-operative 1 d to 3 mo were similar between 2 groups.Complete success was achieved in 65% of phacotrabeculectomy,and 66.7% of trabeculectomy cases;while failure occurred in 16.7% of phacotrabeculectomy,and 10% of trabeculectomy cases at 3 mo.Phacotrabeculectomy group consistently showed better improvement in visual acuity.Diffuse blebs occurred in 65% of phacotrabeculectomy and 83% of trabeculectomy eyes;and flat blebs in 35% of phacotrabeculectomy,but none after trabeculectomy.There was more hypotony（5% vs 0） after phacotrabeculectomy.To conclude,phacotrabeculectomy and trabeculectomy demonstrated comparable intraocular pressure control up to 3 mo post-operatively.However,phacotrabeculectomy patients had better visual acuity improvement.Nonetheless,more diffuse bleb and less hypotony were present following trabeculectomy.

Efficacy and safety of XEN 45 gel stent alone or in combination with phacoemulsification in advanced open angle glaucoma patients: 1-year retrospective study

AIM:To assess the effectiveness of the XEN 45 gel stent,either alone or combined with cataract surgery,in advanced stage open angle glaucoma(OAG)patients.METHODS:Retrospective and single-center study conducted on consecutive OAG patients who underwent a XEN 45 gel stent implantation surgery,between July 2017 and September 2018.The primary efficacy end-point was the mean intraocular pressure(IOP)reduction at the end of the follow-up period.Success was defined as an IOP reduction of at least 20%and an IOP value≤18 mm Hg without(complete)or with(qualified)hypotensive medication.RESULTS:Seventy-four patients(80 eyes)were included in the study.In the overall study sample,XEN implant significantly reduced IOP from 21.0(19.8 to 22.1)mm Hg at baseline to 9.3(8.2 to 10.4),10.7(9.6 to 11.9),13.4(12.2 to 14.7),14.5(13.6 to 15.4),14.7(13.8 to 15.6),and 14.7(13.9 to 15.4)mm Hg at 1 d,1 wk,1,3,6,and 12 mo of follow-up,respectively(P<0.0001 each).In the overall study population,at the end of the study the mean IOP reduction was 27.4%(23.3%to 31.5%).Adjusted IOP reduction was similar in XEN and XEN+phacoemulsification groups[30.0(23.4 to 36.4)mm Hg vs 24.8(18.4 to 31.2)mm Hg,respectively,P=0.2939].At the last follow-up visit,52(65.0%)eyes were considered success,29(36.3%)eyes as complete success and 23(28.7%)as qualified success.Mean number of hypotensive medications was significantly reduced from 2.8(2.7 to 3.0)at baseline to 1.1(0.8 to 1.3),P<0.0001.Kaplan-Meier survival analysis did not find any difference in the success rate between XEN and XEN+PHACO,mean hazard ratio 0.56,95%CI 0.26 to 1.23;P=0.1469.Needling was performed in 7(8.8%)eyes at months 1(n=3);3(n=2);4(n=1)and 11(n=1).Eleven(13.8%)eyes presented adverse events.CONCLUSION:XEN implant,either alone or in combination with phacoemulsification,significantly reduced the IOP and the number of hypotensive medications in patients with OAG in advanced stage.

Outcomes after combined excisional goniotomy and manual small incision cataract surgery

AIM: To report the long-term outcomes of combined excisional goniotomy and manual small incision cataract surgery(MSICS).METHODS: This is a retrospective case series of patients with open angle glaucoma and visually significant cataracts that underwent combined excisional goniotomy and MSICS with one-year follow-up. The medical history, demographic information, and clinical characteristics of each case were recorded. Data regarding changes in vision, intraocular pressure(IOP), the number of glaucoma medications, and the evolution of the disease after surgery were reported. RESULTS: Three patients, with open angle glaucoma and cataracts underwent combined excisional goniotomy and MSICS without adverse events. All patients had improvement in vision compared to baseline measurements. The range of IOP at baseline was from 14 to 18 mm Hg and decrease to a range of 10 to 14 mm Hg after one year of follow-up. Additionally, two patients also decreased their dependence on IOP-lowering medications at the last follow up visit with one patient maintaining baseline level of medication use.CONCLUSION: A combination of excisional goniotomy and MSICS illustrates both the safety and efficacy to treat patients with visually significant cataract and glaucoma. This procedure allows for a more cost-effective surgical approach that matches the needs of resource strained territories around the globe.