Modified deep sclerectomy combined with Ex-PRESS filtration device versus trabeculectomy for primary open angle glaucoma

AIM：To compare the efficacy of modified deep sclerectomy combined with Ex-PRESS shunt versus trabeculectomy in primary open angle glaucoma. METHODS：This is a prospective cohort comparative single-center study. Forty-nine eyes of 49 patients were enrolled in the study. Patients were randomly divided into two groups. Group A（22 patients） underwent classic trabeculectomy and group B（27 patients） underwent modified deep sclerectomy combined with insertion of Ex-PRESS model P50 drainage device. RESULTS：Mean age was 69±7y in group A and 64±8y in group B（P=0.03）. The mean reduction was 11.1±5.7 mm Hg in group A compared to 15.8±5.7 mm Hg in group B at 6mo（P=0.006）, and 9.8±4.9 mm Hg and 15.4±4.7 mm Hg respectively at 1y（P=0.0001）. Regarding the postoperative glaucoma medication, significant difference was observed between the two groups（in favour of group B） only at 6mo（P=0.017）. At the end of the follow-up period complete success rate in group A was 68.2% compared to 92.6% in group B（χ^2 test, P=0.07） and qualified success rate was 100% in both groups.CONCLUSION：Modified deep sclerectomy combined with Ex-PRESS shunt may provide comparable IOP reduction with fewer complications in management of primary open angle glaucoma.

Deep sclerectomy-trabeculectomy with mitomycin C in treating glaucoma:postoperative long-term results

AIM:To determine the long-term postoperative outcomes of deep sclerectomy-trabeculectomy(DST)with mitomycin C(MMC)in the treatment of glaucoma.METHODS:Patients who underwent DST with MMC between 2010 and 2017 were included in this retrospective observational study.Complete success was defined as postoperative intraocular pressure(IOP)≤21 mm Hg or 30%reduction of IOP from baseline without any topical IOP-lowering agent,and qualified success defined as IOP≤21 mm Hg or 30%reduction of IOP from baseline with/without single topical agent.We evaluated the surgical success rates and complication rates of this procedure,as well as described the IOP profiles,best corrected visual acuity(BCVA)profiles and mean deviations(MD)of Humphrey visual field(HVF)24-2 performance at each follow-up time point.Mixed linear regression models were constructed to determine estimated predictive values of demographic data,use of topical IOPlowering agents,baseline and postoperative IOP and optical profiles(e.g.,BCVA and MD).RESULTS:Totally 98 eyes(mean postoperative followup 67.5mo)showed mean IOP reduction at every followup interval.Both median BCVA and MD of visual fields were maintained throughout the follow-up intervals when comparing to baseline.The number of IOP-lowering medications decreased from 2.8±0.8 to 0.3±0.7(P=0.068).Totally 84(85.7%)eyes achieved complete success at final follow-up.Transient hyphaema and transient choroidal effusion developed in 15 eyes(15.3%)and 11 eyes(11.2%)respectively.Other complications included shallow anterior chamber in 5 eyes(5.1%),bleb leak in 4 eyes(4.1%),bleb revision in 7 eyes(7.1%),bleb needling in 9 eyes(9.2%)and repeat trabeculectomy in 1 eye(1.0%).There was no endophthalmitis,blebitis or macular oedema.There was no significant correlation between postoperative IOP control and postoperative BCVA.CONCLUSION:DST with MMC demonstrates effective and sustained long-term outcomes in the treatment of glaucoma with no major complication.

Effect of CO_2 laser sclerectomy with iridectomy on ocular hypertension in rabbits

AIM:To evaluate the efficiency and safety of an optimized CO2 Laser glaucoma surgery system for laser sclerectomy with iridectomy.METHODS:Rabbit trials were performed to evaluate the efficiency and safety.RESULTS:IOP was significantly decreased in laser group compared with trabeculectomy group(P<0.05) from 7th postoperative day to 60th day.Compared with trabeculectomy group,histopathology studies confirmed fewer complications and better effects were found in laser group.CONCLUSION:CO2 laser sclerectomy with iridectomy is effective and safe in terms of IOP lowering.

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.

Changes in peripapillary retinal nerve fiber layer thickness in patients with primary open-angle glaucoma after deep sclerectomy

AIM： To assess changes in peripapillary retinal nerve fiber layer （RNFL） thickness and visual field （VF） in patients with glaucoma after reduction of intraocular pressure （IOP）. METHODS： Thirty-five consecutive patients with bilat-eral high tension glaucoma were included in the study. Thirty-five eyes underwent monocular deep sclerectomy （surgery group） and the medically treated fellow eyes served as controls （control group）. Quantitative analyses of the peripapillary RNFL thickness by optical coherence tomography （OCT） and global VF indices by automated perimetry were performed before surgery and six months after surgery in both eyes. The changes in RNFL thickness overall and by quadrant were evalu-ated and studied with respect to age, best-corrected visual acuity （BCVA）, preoperative global VF indices, postoperative IOP changes, and postoperative changes in global VF indices. Changes observed in RNFL thickness and VF indices were compared between eyes after surgery and fellow eyes. RESULTS： Six months after surgery, the overall IOP decreased from a baseline mean of 24.5 ± 3.2 mmHg to 11.5 ± 2.7 mmHg （P 〈 0.001） at the time of OCT testing. A signifcant increase in the overall mean RNFL thickness was observed after surgery （P 〈 0.001）. The preoperative VF mean deviation was significantly cor-related with a postoperative increase in the RNFL thick-ness （P 〈 0.075）. No correlation was found between RNFL thickness changes and age, BCVA, or changes in the global VF indices. There was no significant difference between eyes with an IOP reduction of more than 50% and those with a reduction in IOP less than 30% （ P = 0.312）.CONCLUSION： A signifcant increase in the peripapil-lary RNFL thickness was associated with IOP reduction by glaucoma filtration surgery as measured by OCT.

Diagnosis and Treatment of Uveal Effusion Syndrome: a Case Series and Literature Review

Objective To explore the diagnosis, classification, and management of uveal effusion syndrome (UES). Methods The clinical data of 10 patients diagnosed with UES in our hospital between 1990-2010 were extracted from hospital records and analyzed, including ophthalmologic examination, ophthalmologic ultrasonography, ultrasound biomicroscopy (UBM), fundus fluorescence angiography (FFA), indocyanine green (ICG) angiography, surgical procedures, and outcomes. Results The fundus examination of all impacted eyes showed bullous retinal detachment shifting with head position, confirmed by ultrasonography revealing retinal and choroidal detachment. UBM showed annular peripheral ciliochoroidal detachment in all cases. FFA was performed in 5 patients and revealed leopard spots without leakage from choroid into subretinal space. ICG angiograpy was performed in 3 patients and demonstrated diffused granular marked hyperfluorescence in the choroidal fluorescence in the very early phase, which increased with time and persisted until the late phase. Four eyes of 2 patients underwent full-thickness sclerectomies and 1 eye of 1 patient underwent subscleral sclerectomy, all of whom achieved reattachment of the retina without recurrence during 1-year follow-up. Conclusions Comprehensive preoperative evaluation, including ophthalmologic ultrasonography, computed tomography, and magnetic resonance imaging, is crucial for accurate classification of UES and selection of proper management strategy. Surgical treatment can achieve optimal clinical outcomes for type 1 and type 2 UES.

Meta Analysis of Non-penetrating Trabecular Surgery versus Trabeculectomy for the Treatment of Open Angle Glaucoma

This study compared the efficacy of non-penetrating trabecular surgery and trabeculectomy for the treatment of open angle glaucoma. We searched the Cochrane Library, PUBMED （1966 to 2009）, Embase （1980 to 2009） and CMB-disk （1979 to 2009） for the randomized clinical trials （RCT） concerning the two treatment strategies. The reports, including the papers listed in bibliographies, were evaluated against a set of quality criteria and the RCTs that satisfied the criteria were selected and subjected to Meta analysis by employing the Cochrane Collaboration＇s RevMan 4.5 software package. A total of nine RCTs were included in the study. The analyses of the reports showed that, 12 months after surgery, there was significant difference in the reduction of interocular pressure （IOP） between non-penetrating trabecular surgery and trabeculectomy （Z=6.05 P0.00001）. There also existed statistically significant difference in the reduction of IOP at the censored time between the two procedures （Z=4.92, P0.00001）. Difference in the success rate was also found between the two surgeries （Z=3.82, P=0.0001）. It is concluded that, compared with the non-penetrating trabeculectomy, the traditional trabeculectomy could reduce IOP more and had higher success rate while the non-penetrating trabecular surgery is associated with lower postoperative complications.

Clinical characteristics and surgical treatment of idiopathic uveal effusion syndrome

AIM: To investigate the clinical characteristics of idiopathic uveal effusion syndrome(IUES) and to identify effective surgical modalities for its treatment.METHODS: This retrospective analysis included clinical data of 33 eyes from 26 patients with IUES at Beijing Tongren Hospital. Records of eye examinations, ocular ultrasound, ocular ultrasound biomicroscopy(UBM), and follow-up surgical treatment were reviewed and analyzed.RESULTS: Of 26 patients, 17(65.4%) were male and 9(34.6%) were female. The average age of disease onset was 46.8 y(range: 22-64 y). Seven patients(26.9%) showed retinal detachment in both eyes at presentation. B-ultrasound showed the presence of retinal detachment in one eye or both eyes. All patients had binocular ciliary leakage and detachment. Eyes with retinal detachment underwent four-quadrantic partial-thickness sclerectomy and sclerostomy. Subretinal fluid resolution was achieved within 6 mo. Recurrence was observed in three eyes and was resolved with re-operation.CONCLUSION: Ophthalmic ultrasound and UBM, among others, can be helpful in the diagnosis of IUES. Sclerectomy and sclerostomy are surgical modalities that can successfully treat the disease. Some patients may experience recurrence after surgery;reoperation remains safe and effective for them. Long-term follow-up is essential in such settings.

Scleral resection in chronic central serous chorioretinopathy complicated by exudative retinal detachment

Background:Effective therapeutic options are limited for the management of chronic central serous chorioretinopathy(CSCR)complicated by exudative retinal detachments(RD).The authors describe the resolution of one such case following partial thickness scleral resection with mitomycin C.Case presentation:This 39-year-old male presented with a unilateral inferior exudative RD in the right eye.There was no history of steroid use either locally or systemically.The fundus fluorescein angiogram showed window defects and leaks typical of chronic CSCR.The axial length was 21.06 mm in the right eye and 21 mm in the left eye.Thickening of the ocular coats was evident on ocular ultrasound.Considering an axial length in the borderline-low range inferotemporal and inferonasal partial thickness scleral resection with mitomycin C was performed.The exudative RD resolved at 4 months.Conclusion:Partial thickness scleral resection may be considered as an option for treating chronic CSCR patients with borderline-low axial length complicated by exudative RD.