A prospective, comparative study between endoscopic cyclophotocoagulation and the Ahmed drainage implant in refractory glaucoma

PURPOSE: To compare endoscopic cyclophotocoagulation (ECP) and the Ahmed drainage implant in the treatment of refractory glaucoma. METHODS: Sixty-eight eyes of 68 patients with refractory glaucoma were prospectively assigned to either ECP or Ahmed tube shunt implantation. All procedures were performed by a single surgeon. Eyes that were included were pseudophakic with a history of at least one trabeculectomy with antimetabolite, an intraocular pressure (IOP) equal to or above 35 mm Hg on maximum tolerated medical therapy, and a visual acuity better than light perception. Exclusion criteria included eyes that had had previous glaucoma drainage device implantation or a cyclodestructive procedure. Success was defined as an IOP more than 6 mm Hg and less than 21 mm Hg, with or without topical anti-hypertensive therapy. RESULTS: The mean follow-up was 19.82 +/- 8.35 months and 21.29 +/- 6.42 months, for the Ahmed and ECP groups, respectively (P = 0.4). The preoperative IOP, 41.32 +/- 3.03 mm Hg (Ahmed) and 41.61 +/- 3.42 mm Hg (ECP) (P = 0.5), and the mean postoperative IOP, at 24 months follow-up, 14.73 +/- 6.44 mm Hg (Ahmed) and 14.07 +/- 7.21 mm Hg (ECP) (P = 0.7), were significantly different from baseline in both groups (P < 0.001). Kaplan-Meier survival curve analysis showed a probability of success at 24 months of 70.59% and 73.53% for the Ahmed and ECP groups, respectively (P = 0.7). Complications included choroidal detachment (Ahmed 17.64%, ECP 2.94%), shallow anterior chamber (Ahmed 17.64%, ECP 0.0%), and hyphema (Ahmed 14.7%, ECP 17.64%). CONCLUSION: There was no difference in the success rate between the Ahmed Glaucoma Valve and ECP in refractory glaucoma. The eyes that underwent Ahmed tube shunt implantation had more complications than those treated with ECP.     

眼内窥镜下睫状体光凝对角膜植片存活的影响

目的探讨对穿透性角膜移植术（PKP）后眼压升高且药物不能控制的患者,采用眼内窥镜直视下睫状体光凝术（ECP）进行治疗的疗效和对角膜植片存活的影响。方法选择2000年3月至2004年4月期间,于中山大学中山眼科中心就诊的34例（34只眼）PKP术后眼压升高且药物不能控制患者,在眼内窥镜直视下,行半导体激光睫状体光凝术（12例）或联合玻璃体切除术（22例）（ECP组）。选择26例（26只眼）患者作为对照,采用经巩膜面半导体激光睫状体光凝术（TCP）（TCP组）。术前、术后随访观察视力、眼压、植片透明度、内皮细胞密度及前房反应,超声活体显微镜（UBM）检查睫状突和房角情况,注意术后并发症等。结果ECP组术后3个月和6个月时,分别有13例（38．2％）和23例（67．7％）眼压低于21mmHg。TCP组术后3个月和6个月时,分别有10例（38．5％）和8例（30．8％）眼压低于21mmHg。两组之间术后眼压控制率比较,在3个月时差异无统计学意义（X^2=0．0003,P=0．986）,但6个月时差异有统计学意义（X^2=8．024,P=0．005）。ECP组和TCP组术后植片内皮细胞密度分别为（1013±170）个／mm^2和（847±136）个/mm^2,差异有统计学意义（t=-0．009,P=0．033）。ECP组和TCP组术后分别有9例（26．5％）和21例（80．8％）出现反应性虹膜炎,两组之间比较差异有统计学意义（x^2=17．376,P=0．001）。结论ECP对降低PKP术后青光眼患者眼压的远期疗效优于TCP。ECP对角膜植片内皮细胞的损伤和引起术后葡萄膜炎的程度均较TCP轻,相对提高了PKP术后角膜植片的生存质量。     

内窥镜下睫状体光凝和减压阀植入术治疗角膜移植术后青光眼的疗效对比

目的:探讨内窥镜下睫状体光凝和减压阀植入术治疗角膜移植术后青光眼的疗效和安全性。方法:设计回顾性研究,对46例46眼角膜移植术后继发青光眼患者分别进行内窥镜下睫状体光凝和减压阀植入术,术后1,7d;1,6mo观察两组病例视力、眼压和角膜内皮以及术后并发症等情况结果:术后两组患者随访眼压在1,7d;1mo时间点进行t检验,均显示无统计学差异,但是在第6mo时间点时ECP组眼压为平均14.1±8.4mmHg,Ahmed组眼压平均18.2±7.6mmHg,两者之间显示有统计学差异。而两组中4个随访时间的眼压值与手术前眼压进行Dunnett-t检验显示均有统计学的差异。术前ECP组平均使用降眼压药物2.3种,术后下降到0.8种,Ahmed组平均使用降眼压药物2.4种,术后下降到0.7种,两者之间显示无统计学差异。ECP组手术后4眼出现渗出膜,5眼出现前房出血。渗出性脉络膜脱离2眼,低眼压2眼。Ahmed组2眼术后出现渗出膜,3眼术后出现前房出血,浅前房5眼,脉络膜脱离6眼,低眼压3眼。结论:ECP和引流阀植入术对于角膜移植术后继发青光眼的治疗均有可靠的疗效。但ECP降眼压的远期效果较引流阀植入术好,同时适应证广,并发症少。     

Long-term outcome of aqueous shunt surgery in ten patients with iridocorneal endothelial syndrome.

PURPOSE: To report the long-term outcome of ten patients with iridocorneal endothelial (ICE) syndrome who underwent aqueous shunt surgery for uncontrolled glaucoma. DESIGN: Noncomparative, retrospective case series. PARTICIPANTS: The authors reviewed charts of ten patients with ICE syndrome-related glaucoma who underwent aqueous shunt surgery at one institution between 1987 and 1996. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), number of glaucoma medications, and further surgical interventions were measured. RESULTS: With a median follow-up of 55 months, four eyes had adequate IOP control (IOP <21 mm Hg) with one or two medications after the initial aqueous shunt surgery. An additional three eyes achieved adequate IOP control after one or more tube repositionings or revisions of the initial aqueous shunt. In this series, the aqueous shunt surgery most often failed because of blocking of the tube ostium by iris, ICE membrane, or membrane-induced tube migration. CONCLUSION: Aqueous shunt surgery appears to be an effective method for IOP lowering in some eyes with ICE syndrome-related glaucoma when medical treatment or conventional filtration surgeries fail, but additional glaucoma procedures and/or aqueous shunt revisions and tube repositionings are not uncommon.     

Outcomes of sequential tube shunts in complicated glaucoma

OBJECTIVE: To evaluate intraocular pressure (IOP) control, change in visual acuity, and complications in eyes that have undergone a second glaucoma tube shunt procedure. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-two eyes of 22 patients that have undergone sequential tube implants for management of glaucoma. METHODS: Parameters analyzed included IOP, visual acuity, and number of hypotensive agent before each shunt procedure and at last follow-up visit. The overall IOP lowering effect attributable to each tube shunt was calculated. Any ocular complications after the second tube shunt were recorded. Success was defined as an IOP between 6 and 21 mm Hg and a 20% reduction in IOP from the second tube shunt procedure. Qualified successes met one of these two requirements at the last follow-up visit. Total failures did not meet any of the above criteria, required additional surgical intervention to lower IOP, or both. MAIN OUTCOME MEASURES: Intraocular pressure control, visual acuity preservation, and complications. RESULTS: At the last follow-up visit, the average percent reduction in IOP from both tube shunt procedures was 42+/-21%. The average percent IOP reduction from the second tube shunt was 33+/-17%. Eleven (50%) patients met the criteria for success, 8 (36.4%) patients were qualified successes, and 3 (13.6%) were failures. The median number of hypotensive agents decreased from two to one. Ten patients experienced new or worse pseudophakic bullous keratopathy after the second tube shunt, six of whom underwent penetrating keratoplasty. Thirteen (59%) patients maintained visual acuity within one line of their second tube shunt pre-operative Snellen visual acuity. Seven (32%) patients lost more than 2 lines, and one patient lost light perception. CONCLUSIONS: Although corneal morbidity is a common complication, a second tube shunt does not cause higher-than-expected rates of other complications associated with tube shunt surgery. Eyes that undergo a second tube shunt procedure can achieve pressure control, require fewer hypotensive agents, and may maintain stable visual acuity.     

Phacoemulsification in patients with Baerveldt tube shunts

PURPOSE: To investigate the effects of phacoemulsification in glaucomatous eyes with functioning Baerveldt tube shunts. SETTING: Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA. METHODS: This retrospective analysis followed 9 eyes of 8 patients with functioning Baerveldt tube shunts who had clear corneal phacoemulsification. Intraocular pressure (IOP), number of glaucoma medications, corneal thickness, visual acuity, and additional glaucoma surgery were measured. RESULTS: The mean follow-up was 21 months +/- 3 (SD) (range 17 to 25 months). The mean change in IOP and the number of glaucoma medications used did not significantly change at 1 month (P>.19), 1 year (P>.17), or the last follow-up (P>.17). At the last examination, 2 eyes had IOP increases of 2 to 4 mm Hg, 3 eyes had no change, and 4 eyes had decreases of 4 to 7 mm Hg. Intraocular pressure increased in 1 eye at 8 months and required a tube shunt revision. No eye developed corneal decompensation. Visual acuity improved in 8 eyes; the mean improvement was 4 +/- 3 Snellen lines. CONCLUSION: In most cases, phacoemulsification in glaucomatous eyes with a functioning Baerveldt tube shunt improved vision and maintained control of IOP.     

The efficacy of a modified ACTSEB (anterior chamber tube shunt to an encircling band) procedure

PURPOSE: To evaluate the efficacy of a modified anterior chamber tube shunt to an encircling band (ACTSEB) procedure for treating intractable glaucoma after scleral buckling procedure. METHODS: A retrospective review of medical records was performed on 7 eyes of 5 patients who underwent a modified ACTSEB procedure to treat intractable glaucoma after an encircling procedure. The modified ACTSEB procedure was performed using a silicone tube with its distal end inserted into the fibrous capsule around a scleral buckle and its proximal end inserted into the anterior chamber. Preoperative and postoperative intraocular pressure (IOP), number of antiglaucoma medications, visual acuity, and complications were recorded. Success was defined as a final IOP of >6 mm Hg and <21 mm Hg with or without medication. Among them qualified success was defined as a final IOP of <22 mm Hg with antiglaucoma medication, and complete success as the same IOP without medication. RESULTS: The overall success rate was 86% (6/7). Qualified success rate was 71% (5/7), and the complete success rate 14% (1/7). No case of hypotony, shallow anterior chamber, fibrous tube occlusion, tube obstruction by lens or iris, conjunctival wound leak, hyphema, or epithelial ingrowth occurred. The only complication was of inferior migration of the silicone tube into the anterior chamber in 2 cases. One of these led to corneal decompensation and subsequent tube removal due to tube migration, and the other underwent tube repositioning at 14 months postoperatively. CONCLUSIONS: The modified ACTSEB procedure provides an efficient means of treating intractable glaucoma after scleral buckling procedure.     

Shunt revision versus additional tube shunt implantation after failed tube shunt surgery in refractory glaucoma

PURPOSE: To compare tube shunt revision with additional tube shunt after failed tube shunt surgery. METHODS: We identified 281 patients who underwent a primary tube shunt procedure from 1985 to 1998 at Indiana University and reviewed 33 eyes of 33 patients that had failed and required further surgery. Shunt revision was performed in 12, whereas an additional shunt was placed in 21 eyes. Intraocular pressure, antiglaucoma medications, visual acuity, and complications were noted. Success was defined as at least a 25% reduction in intraocular pressure that was deemed clinically adequate. Qualified success was defined as a 25% intraocular pressure reduction but with additional medications or a significant reduction in medications with stable intraocular pressure for preoperative intraocular pressure less than 21 mm Hg. RESULTS: Preoperative intraocular pressures (mean +/- 95% confidence interval) for the revision and additional tube groups were 28.8 +/- 5.8 mm Hg and 29.8 +/- 2.7 mm Hg (P =.73), with an average follow-up period of 25.2 months (range, 3 to 108 months) and 34.8 months (range, 6 to 84 months), respectively. Final mean intraocular pressure was 25.3 +/- 6.7 mm Hg for the revision group and 17.7 +/- 3.4 mm Hg for the additional tube group (P =.037). Forty-two percent in the revision group versus 62% in the additional tube group achieved at least a qualified success (P =.30, Fisher exact test). Corneal edema was a common complication, especially in the additional tube group. Limitations of this study include the small sample sizes and the uneven distribution of neovascular glaucoma between the two groups (six of 12 in the revision group vs two of 21 in the additional tube group; P =.015, Fisher exact test). CONCLUSIONS: Our series showed that after failed tube shunt surgery, an additional tube shunt offers better intraocular pressure control than revision by excision of an encapsulated bleb.     

A novel approach to suprachoroidal drainage for the surgical treatment of intractable glaucoma

PURPOSE: In glaucoma surgery, scarring of the artificial fistula is the limiting factor for long-term control of intraocular pressure (IOP). Several devices and surgical techniques have been developed for artificial aqueous humor drainage in intractable glaucoma. The authors describe a novel surgical technique that uses a silicone tube as a shunt for aqueous flow from the anterior chamber to the suprachoroidal space. PATIENTS AND METHODS: Thirty-one eyes of 31 patients with uncontrollable refractory glaucoma were included in this prospective consecutive case-control study. Each eye had undergone an average of 3.5+/-1.9 previous interventions for glaucoma. The baseline IOP was 44.25+/-8.7 mm Hg despite maximum therapy. As in trabeculectomy, a limbus-based scleral flap was prepared. The suprachoroidal space was accessed via a deep posterior scleral flap. The silicone tube was inserted as an intrascleral connection from the anterior chamber to the suprachoroidal space. Cyclodialysis was avoided by this surgical approach. Success was defined as a lowering of IOP to below 21 mm Hg without the need for further medication or intervention. RESULTS: The mean functional shunt survival was 55.9+/-45.6 weeks. IOP was reduced to 12.9+/-5.2 mm Hg in 70% of all eyes after 30 weeks postoperatively. After 52 weeks, 60% of the eyes could be classified as representing success, and 76 weeks after surgery, 40% of the eyes still showed controlled IOP. In none of the eyes were severe postoperative hypotony or suprachoroidal bleeding observed. No localized or general inflammation or infection was seen in connection with the silicon tube. Two patients needed anterior chamber lavage because of bleeding. In 2 patients the tube had to be removed because of corneal endothelial contact. Shunt failure of the tube was caused in some cases by connective tissue formation at the posterior lumen of the tube. CONCLUSION: This novel surgical approach and the placement of the silicone tube described here have several advantages. Its intrascleral course minimizes the risk of conjunctival erosion and associated infections. No cyclodialysis is performed. Connection to the suprachoroidal space exploits the resorptive capability of the choroid. It guarantees drainage but also provides a natural counterpressure, avoiding severe postoperative hypotony. The suprachoroidal shunt presented here achieves good follow-up results in terms of IOP control. No serious complications have been observed. This new method promises to be an effective surgical technique and presents a new therapeutic option in intractable glaucoma. Fibroblast reaction obstructing the posterior lumen, seemed to be the only factor limiting drainage. Further studies and experiments will be needed to elucidate the exact physiologic mechanisms underlying the draining, the capacity and duration of the draining effect, and the histologic background of suprachoroidal scarring.     

Combined cataract-glaucoma surgery using the intracanalicular Eyepass glaucoma implant: first clinical results of a prospective pilot study

PURPOSE: To study prospectively the safety and pressure-reducing efficacy of the Y-shaped Eyepass glaucoma implant (GMP Vision Solutions, Inc.). SETTING: Departments of Ophthalmology, University of Cologne, Cologne, and University of Erlangen, Erlangen, Germany. METHODS: This study comprised 12 patients with primary open-angle or exfoliative glaucoma and cataract who had phacoemulsification with endocapsular implantation of a foldable intraocular lens and intracanalicular implantation of an Eyepass glaucoma implant. The implant is a silicone microtube shunt that bypasses the trabecular meshwork and connects the lumina of Schlemm canal with the anterior chamber in combined cataract-glaucoma surgery. Perioperative complications, intraocular pressure (IOP), and pressure-reducing topical medications were monitored over a preliminary follow-up. RESULTS: Perforation of the trabecular meshwork during Eyepass implantation occurred in 2 eyes; the antiglaucoma procedure was converted to trabeculotomy after the shunt was explanted, and both eyes were excluded from further follow-up. In the remaining 10 eyes, the mean maximum IOP was 30.4 mm Hg +/- 7.5 (SD) (range 21 to 46 mm Hg) preoperatively, 12.0 +/- 6.1 mm Hg (range 2 to 20 mm Hg) 1 day postoperatively, 17.2 +/- 4.1 mm Hg (range 12 to 27 mm Hg) at 4 weeks, and 18.3 +/- 4.5 mm Hg (range 12 to 25 mm Hg) at the end of the preliminary follow-up. The mean number of topical medications was 3.2 +/- 0.8 preoperatively and 0.9 +/- 0.7 at the end of follow-up (mean 7.1 months). Although there were no major complications requiring surgical revision, 4 eyes had an IOP of 18 or higher at the end of follow-up. CONCLUSION: Combined cataract surgery with Eyepass shunt implantation was safe and appeared to be beneficial in glaucomatous eyes with cataract not requiring a low target IOP.     

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 (IOP) measurement before surgery and at 1d, weekly for the 1st month, 3, 6mo, and 1y after surgery and yearly afterward for 5y. IOP 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 IOP 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. IOP 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 IOP control after AGV implantation. However, effective complications management can improve the rate of success.     

Clinical experience of e-PTFE membrane implant surgery for refractory glaucoma

AIMS: To evaluate the clinical efficacy of membrane tube implant made of expanded polytetrafluoroethylene (e-PTFE, Gore-Tex) membrane and silicone tube in treating refractory glaucoma. METHODS: A retrospective chart review was performed on 43 eyes of 40 patients who underwent glaucoma tube shunt implant surgery using double layered e-PTFE membrane and silicone tube to treat refractory glaucoma. The surgeries were performed from May 1991 to September 1995, and the subjects were patients with terminal glaucoma without useful vision on the study eye. RESULTS: The mean follow up period was 32.9 months. The Kaplan-Meier survival for intraocular pressure (IOP) control (IOP between 6 and 21mm Hg without significant complication) was 80.9% at 1 year, 73.9% at 2 years, and 62.2% at 3 years after surgery. After excluding three eyes of three patients who were dropped within 3 months after surgery and did not have any serious complication or problem in IOP control, the average preoperative IOP was 42.5 (SD 14.6) mm Hg and IOP on the last visit was 17.3 (10.2) mm Hg (p = 0.000, n = 40). The number of antiglaucoma medications before surgery (2.2 (0.6)) was reduced to 0.5 (0.8) on the last visit (p = 0.000). The IOP was controlled within the range of 6-21 mm Hg in 26 eyes (65.0%). In the remaining 14 eyes (35%), we could not control the IOP or additional surgery was needed to control the IOP or to treat severe complications. Two cases of endophthalmitis and three of phthisis were found as serious complications. The other complications were similar to those of other commercially available glaucoma implants. CONCLUSION: A comparable clinical result was obtained with this new implant as with the other commercially available implants. This implant with a thin and non-rigid reservoir has a potential to reduce some complications associated with the large volume and rigid consistency of the other implants, although it is not yet proved. This membrane tube implant may be considered as another substitute in the surgery of refractory glaucoma.     

Treatment outcomes in the tube versus trabeculectomy study after one year of follow-up

PURPOSE: To report one-year results of the Tube Versus Trabeculectomy (TVT) Study. DESIGN: Multicenter randomized clinical trial. METHODS: Setting: 17 Clinical Centers. Study Population: Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract extraction with intraocular lens implantation and uncontrolled glaucoma with intraocular pressure (IOP) > or =18 mm Hg and < or =40 mm Hg on maximum tolerated medical therapy. Interventions: 350 mm(2) Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC). Main Outcome Measures: IOP, visual acuity, and reoperation for glaucoma. RESULTS: A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in the trabeculectomy group. At one year, IOP (mean +/- SD) was 12.4 +/- 3.9 mm Hg in the tube group and 12.7 +/- 5.8 mm Hg in the trabeculectomy group (P = .73). The number of glaucoma medications (mean +/- SD) was 1.3 +/- 1.3 in the tube group and 0.5 +/- 0.9 in the trabeculectomy group (P < .001). The cumulative probability of failure during the first year of follow-up was 3.9% in the tube group and 13.5% in the trabeculectomy group (P = .017). CONCLUSIONS: Nonvalved tube shunt surgery was more likely to maintain IOP control and avoid persistent hypotony or reoperation for glaucoma than trabeculectomy with MMC during the first year of follow-up in the TVT Study. Both surgical procedures produced similar IOP reduction at one year, but there was less need for supplemental medical therapy following trabeculectomy with MMC.     

The use of a "cheese-wire" suture in trabeculectomy

AIM: To report a preliminary study on the safety and efficacy of the use of a cheese-wire suture in trabeculectomy. Patients and methods: The case notes of 32 eyes of 25 patients with medically uncontrolled glaucoma who underwent trabeculectomy with cheese-wire suture at Stobhill Hospital, Glasgow, UK, between July 2001 and September 2002 were studied retrospectively. Diagnoses included primary open angle glaucoma (n = 24), normal tension glaucoma (n = 3), angle closure glaucoma (n = 2), ocular hypertension (n = 1), angle recession glaucoma (n = 1) and combined mechanism glaucoma (n = 1). The mean presenting intraocular pressure (IOP) was 29.5 mm Hg and mean intraocular pressure before operation was 23.5 mm Hg OUTCOME MEASURES: Success was defined as lowering of IOP by at least 15% compared with IOP before removal. RESULTS: A total of 20 eyes (62%) underwent removal of the cheese-wire suture. 17 eyes (85%) underwent removal for therapeutic reasons (failing/failed blebs) and three eyes (15%) underwent suture removal as the suture loops were exposed. The timing of removal was between 2 weeks and 12 months following surgery. A successful outcome was seen in 12/17 (70%) eyes in the eyes that had therapeutic suture removal. 15 eyes had undergone previous surgical interventions (trabeculectomy n = 12, extracapsular cataract extraction n = 1 and laser peripheral iridotomies n = 2). Mean IOP before removal was 23.66 mm Hg and mean IOP immediately following removal was 11.33 mm Hg. Of the 32 eyes that underwent trabeculectomy with cheese-wire suture, 24 eyes had intraoperative mitomycin C and one eye had 5-fluorouracil. The remaining seven eyes did not have any antimetabolites. Early complications related to the surgical procedure included conjunctival haematoma in one eye (3%), corneal abrasion in one eye (3%), wound leak in five eyes (15%), shallow anterior chamber in one eye (3%), hyphaema in six eyes (18%), choroidal effusion in six eyes (18%) and raised IOP in two eyes (6%). Late complications of suture exposure occurred in three eyes (9%). Complications related to removal of the cheese-wire suture included suture breakage in two eyes (10%), hypotony in one eye (5%) and transient hyphaema in one eye (5%). CONCLUSION: The use of cheese-wire suture in trabeculectomy appears to be safe and may provide an alternative strategy in the management of bleb failure.     

Outcomes of chronic angle-closure glaucoma treated by phacoemulsification and endocyclophotocoagulation with or without endoscopically goniosynechialysis

AIM: To investigate the surgical outcomes of patients with chronic angle-closure glaucoma (CACG) treated with phacoemulsification (phaco)/endocyclophotocoagulation (ECP) with and without endoscopic goniosynechialysis (E-GSL). METHODS: A retrospective, nonrandomized, comparative case series was conducted. Patients with CACG who underwent phaco in combination with either ECP alone (ECP group) or GSL with ECP (E-GSL group) from 2018 to 2019 were followed for 12mo and reviewed. Clinical features and outcomes were identified and analyzed. The ECP and E-GSL groups were matched in age and baseline intraocular pressure (IOP). Changes in IOP, mean of visual acuity (VA), peripheral anterior synechiae (PAS) formation, and the number of glaucoma medications was examined. RESULTS: The ECP group included 32 eyes of 27 patients, and the E-GSL group included 32 eyes of 26 patients. The preoperative baseline IOP was 22.18±6.48 mm Hg in the ECP group and 22.95±6.71 mm Hg in the E-GSL group (P=0.644). The mean IOP reduction was 26.2% in the ECP group and 41.6% in the E-GSL group at 12mo. The mean postoperative VA (logMAR units) at 12mo was 0.47 in the ECP group and 0.36 in the E-GSL group. The reduction in PAS formation and the number of glaucoma medications was also higher in the ECP group than E-GSL group at 12mo. CONCLUSION: The phaco/ECP and phaco/E-GSL groups both achieve a significant reduction in IOP without complications associated with traditional glaucoma filtration surgeries.     

Cataract and combined cataract/glaucoma surgery as intraocular pressure-reducing procedure in eyes with relative anterior microphthalmos

PURPOSE: Eyes with relative anterior microphthalmos (RAM) (normal [> 20.0 mm] axial length but disproportionally small anterior segment [horizontal corneal diameter < 11 mm]) often present with increased intraocular pressure. Under these difficult conditions cataract surgery alone or in combination with a glaucoma filtering procedure is often required. PATIENTS AND METHODS: We retrospectively reviewed the records of 71 patients (108 eyes) with RAM in whom cataract only (n = 72) or combined cataract/glaucoma surgery (n = 36) was performed. Preoperative clinical and biometric findings, intraoperative complications and postoperative results (visual acuity and intraocular pressure) were analysed. RESULTS: Median preoperative values were 7.46 mm for corneal curvature, 2.53 mm for anterior chamber depth and 22.44 mm for axial length. The implanted lens had a median 25.0 dioptric power. The IOP was reduced from 15.6 +/- 3.9 mm Hg to 13.5 +/- 3.1 mm Hg with cataract surgery alone and from 22.4 +/- 5.5 mm Hg to 15.4 +/- 4.0 mm Hg with combined surgery. Mean best corrected visual acuity improved from 0.4 +/- 0.2 to 0.79 +/- 0.25 with cataract surgery and from 0.5 +/- 0.3 to 0.81 +/- 0.24 with combined surgery. Intraoperatively only 3 eyes had a rupture of the posterior capsule and postoperatively 2 eyes developed malignant glaucoma in the combined group. CONCLUSIONS: The results show that, in eyes with RAM, cataract surgery alone or in combination with glaucoma surgery can be performed with excellent results and low complication rate if adequate precautions are taken (especially the use of hyperosmotic agents).     

Anterior chamber tube shunt to an encircling band in the treatment of neovascular glaucoma

A new procedure for neovascular glaucoma that has reduced intraocular pressure (IOP) significantly and has caused relatively few postoperative complications is introduced. Aqueous is shunted to the reservoir of an encircling no. 20 silicone band from which fluid is postulated to diffuse into the orbit. The anterior chamber tube shunt to an encircling band (ACTSEB) procedure was conducted in 19 eyes with neovascular glaucoma. After surgery 18 of the 19 eyes (95%) followed for periods ranging between five and 26 months (mean: 59 weeks) had controlled IOP using less than or equal to 20 mm Hg as normal, and one eye had partial control (eye 9) at 26 mm Hg. Despite the preoperative use of atropine sulfate, timolol maleate, acetazolamide, and 20% mannitol, the patients' average preoperative IOP was 54.1 mm Hg. After surgery the average IOP fell, dramatically, to 16.2 mm Hg. The mean change in IOP was 37.9 +/- 9.8 (SD). This change is statistically significant by the paired t-test, P less than 0.01. Minimal postoperative medications were required for pressure control. Postoperative complications included hyphema (21%), prolonged flat chamber (74%), localized peripheral lens opacity (5%), localized corneal opacity (5%), and possible acceleration of progressive cataract formation (25%). Results of current surgical procedures used to manage neovascular glaucoma are compared to the ACTSEB results.     

Long term results of diode laser cycloablation in complex glaucoma using the Zeiss Visulas II system.

AIM: To investigate the safety and efficacy of the Zeiss Visulas II diode laser system in the reduction of intraocular pressure (IOP) in patients with complex glaucoma. METHODS: The authors analysed the medical records of patients who underwent trans-scleral diode laser cycloablation (TDC) at the Manchester Royal Eye Hospital during a 34 month period. 55 eyes of 53 patients with complex glaucoma were followed up for a period of 12-52 months (mean 23.1 months) after initial treatment with the Zeiss Visulas II diode laser system. RESULTS: Mean pretreatment IOP was 35.8 mm Hg (range 22-64 mm Hg). At the last examination, mean IOP was 17.3 mm Hg (range 0-40 mm Hg). After treatment, 45 eyes (82%) had an IOP between 5 and 22 mm Hg; in 46 eyes (84%) the preoperative IOP had been reduced by 30% or more. The mean number of treatment sessions was 1.7 (range 1-6). At the last follow up appointment, the mean number of glaucoma medications was reduced from 2.1 to 1.6 (p<0.05). In 10 eyes (18%), post-treatment visual acuity (VA) was worse than pretreatment VA by 2 or more lines. CONCLUSIONS: Treatment with the Zeiss Visulas II diode laser system can be safely repeated in order to achieve the target IOP. Treatment outcomes in this study were similar to those from previously published work using the Iris Medical Oculight SLx laser.     

【In Press】 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 (IOP) measurement before surgery and at 1d, weekly for the 1, 3, 6mo, and 1y after surgery and yearly afterward for 5y. IOP 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 IOP 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. IOP was reduced from a mean of 37.2±6.8 mm Hg 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 IOP control after AGV implantation. However, effective complications management can improve the rate of success.     

Results of phacoemulsification in eyes with preexisting glaucoma filters

PURPOSE: To evaluate the intraocular pressure (IOP), best corrected visual acuity (BCVA), and glaucoma medication requirements in patients having phacoemulsification after preexisting glaucoma filters. SETTING: Ophthalmic Consultants of Boston, Boston, Massachusetts, USA. METHODS: A retrospective analysis of 58 eyes that had temporal phacoemulsification via a clear corneal (32 eyes) or a scleral tunnel (26 eyes) approach after filtration surgery was performed with a minimum follow-up of 12 months. Two-tailed homoscedastic t tests were used for statistical analysis. RESULTS: The mean preoperative IOP in all eyes was 11.8 mm Hg +/- 4.2 (SD), and the mean final postoperative IOP was 13.7 +/- 4.6 mm Hg (P<.022). The mean preoperative logMAR equivalent BCVA was 0.8 +/- 0.4, which improved to a mean of 0.4 +/- 0.4 postoperatively (P<.0000002). There was no statistically significant change in glaucoma medication requirements postoperatively. The differences in IOP, BCVA, and postoperative glaucoma medication requirements were not statistically significant between the clear corneal group and the scleral tunnel group or between patients who received mitomycin at the time of filtration surgery and those who did not. There were no intraoperative complications; 1 patient required additional glaucoma surgery. CONCLUSION: Clear corneal or scleral tunnel phacoemulsification in the setting of a preexisting glaucoma filter was associated with improved BCVA, a small but statistically significant increase in IOP, and stability in the number of glaucoma medicines required for IOP control over a minimum follow-up of 1 year.