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.

Long-term success of ahmed glaucoma valve in refractory glaucoma

AIM:To evaluate the long-term results and complications of ahmed glaucoma valve (AGV) implantation in refractory glaucoma.· METHODS:A retrospective review of 13 patients (13 eyes) with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 18 months was performed.All patients underwent a complete ophthalmologic examination and intraocular pressure (IOP) measurement before surgery and at 1 month,3 months,6 months,1 year after surgery and yearly afterwards.Complications and the number of antiglaucoma medications needed were recorded.· RESULTS:Mean age was 27.3±16.0 years.All eyes (100%) had at least one prior incisional surgery.Mean follow-up was 61.3±30.8 months.IOP was reduced from a mean of 35.0±7.0mmHg to 18.2±7.9mmHg at 12 months and to 17.0±4.1mmHg at 96 months (P <0.05) with a lower number of medications from baseline,76.9% patients required additional procedures to achieve the success criteria set by previously published series.The most common complications were encapculated cyst formation in eight eyes (61.5%) and tube exposure in four eyes (30.8%).· CONCLUSION:Encapsulated cyst formation was the most common complication which hindered succesful IOP control after AGV implant insertion for refractory glaucoma.Despite cyst excision with anti-fibrotic agents,successful IOP reduction was not achieved in 76.9% of the patients without antiglaucoma medication.

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.

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.

Micropulse diode laser therapy in refractory glaucoma

Purpose:Description of safety and efficacy of micropulse lYanssderal cydophotocoagulation as a treatment option for refractory glaucoma.Mahods:This is a prospective study including 39 eyes of 31 patients foil owed for refractory glaucoma,who benefited from transsderal cyclophotocoagulation using a mic topi used laser.The main indication for tire pro­cedure was increased ocular pressure refractory to quadri therapy in various types of glaucoma.Ihe patients were tieated using iridex Cyclo G6 laser with a Micropulse P3 infrared probe with a wavelength of 810 nm.The pa­rameter for tire procedure were a duration of 90 s per hemisphere with a power of 2000 mW and an eneigy of 180 J.Both tire upper and lower hemispheres were treated in tire same procedure,sparing tire 3 o'clock and 9 o'clock meridians,and aD tire patients benefited from a single treatment session.The following parameters were evaluated;ocular pain and overall tolerance;visual acuity;and tire evolution of IOP postoperatively up to 9 months.Results:The glaucoma subtypes treated are as follows:primaty open-angle glaucoma(n=05),chronic angle-closure glaucoma(n=13),neovascular glaucoma(n=07),aphakic glaucoma(n=06),malignant glaucoma(n=04),post-traumatic angle recession(n=02),and inflammatoiy glaucoma(n=02).The mean pre-operative intraocular pressure was 42.3±5.2 mmHg and tire mean post operative intraocular pressure at 9 months was 16.9±1.9 mmHg The reduction in IOP was 49.9%.The average number of intraocular pressure-lowering medications used prior to surgery was four,and tire average number of medications used at tire 9-month post­operative visit was 2.0±1.2(703%of patients were on dual therapy).The overall success rate was 60.9%.Conclusions:Micropulse transsderal cydophotocoagulation appears to be a safe and effident treatment for re­fractory glaucoma.Its indications should therefore be broadened and proposed early in various situations.

A prospective comparative study on neovascular glaucoma and non- neovascular refractory glaucoma following Ahmed glaucoma valve implantation

Background Neovascular glaucoma is a refractory disease, and difficult to manage. The aim of this study was to evaluate the clinical outcomes of Ahmed glaucoma valve implantation （AGVI） in neovascular glaucoma （NVG） and non- NVG patients. Methods This prospective, non-randomized study included 55 eyes of 55 patients with refractory glaucoma; 27 had NVG （NVG group） and 28 had non-NVG （non-NVG group）. All of the patients underwent AGVI. The NVG group was adjunctively injected with intravitreal ranibizumab/bevacizumab （IVR/IVB） before AGVI. Intraocular pressure （lOP） was the primary outcome measure in this study. Surgical success rate, number of antiglaucoma medications used, best corrected visual acuity （BCVA）, and postoperative complications were analyzed between the groups. Results All of the patients completed the study （follow-up of 12 months）. Kaplan-Meier survival curve analysis indicated that the qualified success rates in the NVG and non-NVG groups at 12 months were 70.5% and 92.9%, respectively; this difference was significant （P=-0.036）. The complete success rates in the NVG and non-NVG groups at 12 months were 66.7% and 89.3%, respectively （P=0.049）. Compared with preoperative examinations, the postoperative mean lOP and use of medications were significantly lower at all follow-up time points in both groups （all P 〈0.05）. There were significant differences in BCVA between the two groups at the 12-month follow-up （X2=9.86, P=0.020）. Cox proportional hazards regression showed NVG as a risk factor for surgical failure （RR=15.08, P=0.033）. Postoperative complications were similar between the two groups. Conclusions AGVI is a safe and effective procedure in refractory glaucoma, but the success rate of surgery was related to the type of refractory glaucoma. The complete and qualified success rates of NVG patient adjunctive anti-vascular endothelial growth factor treatment are still lower than those of non-NVG patients.

A Case of Refractory Childhood Glaucoma Secondary to Weill-Marchesani Syndrome:Management with Combined CO_(2) Laser-Assisted Sclerectomy Surgery and Trabeculectomy

A 2-year-old girl was diagnosed as Weill-Marchesani syndrome with typical systemic features of short stature,short and stubby hands and feet,language disorders and mental retardation.He developed bilateral angle closure glaucoma,ectopia lentis and suffered visual loss from the ocular features of Weill-Marchesani syndrome.The child was successfully treated by combined CO_(2) laser-assisted sclerectomy surgery and trabeculectomy.

Long-term results of Ahmed glaucoma valve implantation in Egyptian population

AIM： To evaluate the long-term results and complications of Ahmed glaucoma valve （AGV） implantation in a cohort of Egyptian patients. METHODS： A retrospective study of 124 eyes of 99 patients with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 5y was performed. All patients underwent complete ophthalmic examination and intraocular pressure （lOP） measurement before surgery and at ld, weekly for the 1st month, 3, 6mo, and ly after surgery and yearly afterward for 5y. lOP was measured by Goldmann applanation tonometry and/or Tono-Pen. Complications and the number of anti-glaucoma medications needed were recorded. Success was defined as lOP less than 21 mm Hg with or without anti-glaucoma medication and without additional glaucoma surgery. RESULTS： Mean age was 23.1±19.9y. All eyes had at least one prior glaucoma surgery, lOP was reduced from a mean of 37.2±6.8 to 19.2±5.2 mm Hg after 5y follow-up with a reduced number of medications from 2.64±0.59 to 1.81±0.4. Complete and qualified success rates were 31.5% and 46.0% respectively at the end of follow-up. The most common complications were encapsulated cyst formation in 51 eyes （41.1%）, complicated cataract in 9 eyes （7.25%）, recessed tube in 8 eyes （6.45%）, tube exposure in 6 eyes （4.8%） and corneal touch in 6 eyes （4.8%）. Other complications included extruded AGV, endophthalmitis and persistent hypotony. Each of them was recorded in only 2 eyes （1.6%）. ~ CONCLUSION： Although refractory glaucoma is a difficult problem to manage, AGV is effective and relatively safe procedure in treating refractory glaucoma in Egyptian patients with long-term follow-up. Encapsulated cyst formation was the most common complication, which limits successful lOP control after AGV implantation. However, effective complications management can improve the rate of success.