Outcome of combined Ahmed glaucoma valve implant and penetrating keratoplasty in refractory congenital glaucoma with corneal opacity

PURPOSE: To investigate surgical outcomes following simultaneous Ahmed glaucoma valve implant and penetrating keratoplasty (PKP) in the management of refractory congenital glaucoma with corneal opacity. METHODS: A retrospective review was undertaken of pediatric patients who underwent simultaneous Ahmed glaucoma valve implant and PKP at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, between January 1994 and September 1999. RESULTS: Twenty eyes of 17 patients were included in the study. Cumulative probabilities of success by Kaplan-Meier analysis showed 85%, 44%, and 33% IOP control and 85%, 43%, and 17% graft success at 2, 24, and 48 months. The most common cause of glaucoma failure that required subsequent surgery was subconjunctival scarring, which resulted in loss of long-term IOP control. Main graft-related complications included failure (13/20) and graft ulceration (6/20), and in 4/6 ulcerated grafts, Streptococcus pneumoniae was cultured positively. Subsequent surgery was the only significant clinical factor associated with poor outcome of glaucoma. However, low graft survival rate was significantly associated with delinquency of follow-ups, corneal ulcer, subsequent surgery, and postoperative complications. CONCLUSIONS: The long-term success of simultaneous Ahmed glaucoma valve implant and PKP in refractory congenital glaucoma associated with corneal opacity is low, and the complication rate is high.     

Viscocanalostomy combined with trabeculotomy for management of refractory primary congenital glaucoma

PurposeTo investigate the outcome of viscocanalostomy combined with trabeculotomy (VCO+tbo) in primary congenital glaucoma (PCG) with history of failed trabeculotomy.MethodsIn this prospective study, VCO+tbo was performed in 75 eyes of 46 patients with PCG who had not responded adequately to one angle surgery. Success was defined as intraocular pressure (IOP) of 6–21 mm Hg and at least 20% IOP drop at the last postoperative visit with (qualified) or without (complete) glaucoma medications.ResultsPatients completed a mean follow-up of 31 ± 11 months. Complete success was achieved in 6 eyes (8%); qualified success, in 38 eyes (51%). In the 44 successfully treated eyes, IOP was reduced from a preoperative mean of 29.0 ± 5.8 to 15.7 ± 2.6 mm Hg, and the number of medications dropped from 2.6 ± 0.9 to 2.0 ± 1.0 (P < 0.001). In univariate analysis, the success rate was lower in patients with neonatal onset disease than subjects whose age at onset was 1-12 months (HR = 0.22; 95% CI, 0.05-0.93; P = 0.039). Children whose disease was first diagnosed after 1 year of age responded better than neonatal onset patients but worse than those with age of onset of 1-12 months; however, the difference was not statistically significant. Hyphema occurred in 27 eyes (36%) on day 1 and resolved spontaneously. Iatrogenic cyclodialysis occurred in one eye, which was surgically repaired after 1 month of treatment with cycloplegic agents.ConclusionsIn our study cohort, VCO+tbo was associated with successful outcomes in the majority of treated eyes.

     

两种术式植入Ahmed青光眼阀治疗难治性青光眼的疗效比较

目的：：探讨两种不同术式植入Ahmed青光眼阀治疗难治性青光眼的有效性和安全性。方法：采用回顾病例对照研究,收集2011-06/2014-09在我院行Ahmed 阀植入术的难治性青光眼患者资料。根据引流管进入前房的术式不同分为直接巩膜隧道穿刺组和自体巩膜瓣组。观察并比较两组患者手术持续时间、术后手术成功率、眼压、术后抗青光眼用药的数目、术后最佳矫正视力以及并发症。结果：两组患者随访1a时,两组患者在术后眼压,术后抗青光眼药物数目在所有随访时间点均较术前明显降低,差异有显著统计学意义(P<0.01)。术后各个随访时间点两组之间在眼压,抗青光眼用药数目,最佳矫正视力方面,差异均无统计学意义。卡普兰-迈耶( Kaplan-Meier)生存曲线显示：在随访1a时,直接巩膜隧道穿刺组和自体巩膜瓣组手术总成功率分别为79%和80%,差异无统计学意义(P=0.932)。在并发症方面,直接巩膜隧道穿刺组浅前房的发生率(6%)明显低于自体巩膜瓣组(24%),差异有统计学意义(P=0.032)。结论：Ahmed青光眼房水引流阀植入是治疗难治性青光眼安全有效的方法,两种不同术式有相似的疗效,但直接巩膜隧道穿刺组发生浅前房的机会更低,耗时更短。     

Genetic analysis of patients with primary congenital glaucoma

Purpose

To determine the common gene mutation in patients with primary congenital glaucoma (PCG) in the Southeast region of Turkey via genetic analysis and to evaluate whether there were other gene mutations in these patients.

Methods

A total of 25 patients with PCG were included in this study. We performed sequence analysis including all exons of cytochrome p450 1B1 (CYP1B1), myocilin (MYOC), forkhead box C1 (FOXC1), and paired-like homeodomain 2 (PITX2) genes of the obtained samples. Further, we analyzed the results using the Nextgen analysis program.

Results

The CYP1B1 gene mutation was detected in 20 (80%) of 25 patients, and FOXC1 gene mutation was detected in one (4%) patient. The mutation site of nine (45%) of the 20 CYP1B1 genes was found in the second exon. The pathogenic variant (p.Gly61Glu) was observed in 12 (60%) patients (in the first and second exons); the mutation type of six (50%) of these patients was homozygous. The mutation site of one patient with FOXC1 gene mutation was found to be in the first exon; its pathogenic variant was p.Met400lle. The mutation type in this gene was observed to be heterozygous. Lastly, there were no mutations in the MYOC, FOXC1, and PITX2 genes in combination with the CYP1B1 gene mutation.

Conclusion

The most common cause of PCG in our region is the CYP1B1 gene mutation, and the most frequent pathogenic variant is c.182G?>?A (p.Gly61Glu). We also determined that the CYP1B1 gene mutation was alone and did not occur with other gene mutations (MYOC, FOXC1, and PITX2).

     

Clinical study of the pars plana Ahmed glaucoma valve implant in refractory glaucoma patients

PURPOSE: To evaluate the effect of pars plana implantation of the Ahmed glaucoma valve on refractory glaucoma. METHOD: Five patients (5 eyes) (3 men, 2 women) were fitted with the Ahmed glaucoma valve. Mean age was 51.8 21.3 years, and mean follow-up was 9.4 +/- 2.6 months. Among the 5 eyes studied, 4 eyes were in neovascular glaucoma patients. Of these 4 eyes, 2 eyes were in diabetic retinopathy patients and 2 eyes were in a patient with central retinal vein occlusion. The remaining eye was in a developmental glaucoma patient. As a surgical procedure after pars plana vitrectomy, the inlet tube of the Ahmed glaucoma valve was placed in the posterior chamber. RESULT: The mean preoperative IOP of 46.8 +/- 15.7 mmHg (30-64 mmHg) under maximum tolerable medication was reduced to 16.0 +/- 2.0 mmHg (14-19 mmHg) after surgery. Postoperative visual acuity improved in 3 eyes, and the mean visual acuity in these eyes improved from 0.05 +/- 0.09 (sl.-0.07) to 0.17 +/- 0.3(0-0.7). A reduction in visual acuity was observed in 2 eyes; in one, due to retinal detachment, and in the other, due to transient high IOP and vitreous hemorrhage. The visual acuity improved in 60% of patients and the IOP controlled in 80% of patients. CONCLUSION: The implantation of the Ahmed glaucoma valve for refractory glaucoma was effective in our study.     

Collagen implant in refractory glaucoma surgery

The problem of surgical treatment of refractory glaucoma (RG) in patients with corneal disease is studied. Glaucoma prior to penetrating keratoplasty is a significant risk factor for postkeratoplastic glaucoma that results in graft failure. The main tendency of RG surgery is implantation of draining devices. The aim of our study was to evaluate the efficacy of glaucoma surgery with collagen implant in patients with RG associated with severe corneal disease. 42 operations were analyzed. This operation technique let us achieve persistent hipotensive effect and corneal improvement. The insertion of collagen implant is absolutely safe in terms of corneal graft survival and it prevents scaring in surgery zone.     

Molteno implant surgery in refractory glaucoma

In recent years aqueous drainage implants have become a useful adjuvant in the treatment of refractory glaucomas. The Molteno implant is one of the most widely used devices for providing a permanent channel of aqueous flow from the anterior chamber to a collecting reservoir in the posterior subconjunctival space. Recently, modifications in design and surgical technique of the Molteno implant have enhanced its success rate, with a reduction in complications such as prolonged hypotony, anterior chamber flattening, and tube-corneal touch. These modifications include intracamerally injecting hyaluronic acid, using a needle track to provide an opening into the anterior chamber for the tube, performing the operation in two stages, using a double plate, temporarily ligating the tube, using a donor scleral patch, and giving adjunctive antifibrotic therapy. The rationale for application of the Molteno implant, the indications, techniques, results, and complications are described.     

Ab interno gel implant in patients with primary open angle glaucoma and pseudoexfoliation glaucoma

Purpose

To compare efficacy and safety results of an ab interno gel implant in patients with pseudoexfoliation glaucoma (PXG) and primary open angle glaucoma (POAG).

Methods

Retrospective analysis of the medical records of 110 consecutive eyes with open angle glaucoma who had received a XEN45 gel implant between March 2014 and June 2015. Intraocular pressure course, number of glaucoma medications, the need for additional intervention (including needling) and complications were evaluated until 12?months postoperatively.

Results

Data of 67 eyes with POAG and 43 eyes with PXG were analyzed. At 12?months postoperatively, the mean IOP had significantly decreased by 54.0% from preoperatively 31.85?±?8.5?mmHg to 13.99?±?2.6?mmHg in the POAG group, (p?=?0.000; Wilcoxon test), and by 55.2% from 31.63?±?9.0?mmHg to 13.28?±?3.1?mmHg in the PXG group (p?=?0.000; Wilcoxon test). The mean number of anti-glaucoma medications had significantly decreased from 3.25?±?0.8 at baseline to 0.3?±?0.7 medications at 12?months postoperatively in POAG eyes (p?=?0.000; Wilcoxon test), and from 3.05?±?1.0 to 0.3?±?0.6 medications in PXG eyes (p?=?0.000; Wilcoxon test). Hypotony (IOP?≤?6?mmHg) was observed in 2 POAG eyes (3.0%) and in 5 PXG eyes (11.7%) at 1?month but normalized in all eyes at 12?months postoperatively. Severe complications were not observed. No statistically significant differences were found between PXG eyes and POAG eyes.

Conclusion

Our data indicate that the XEN45 gel implant provides significant and comparable reduction in IOP and anti-glaucoma medication during the one-year follow-up period in POAG as well as PXG eyes. This suggests that it may be a noteworthy alternative to traditional filtering procedures in patients with POAG and PXG respectively.

     

Results of the modified trabeculotomy in the treatment of primary congenital glaucoma.

PURPOSE: To evaluate the effect of trabeculotomy employing probes with curvatures more closely corresponding to variable course of Schlemm's canal. METHODS: Forty-six children with primary congenital glaucoma who underwent trabeculotomy with newly designed probes between 1990 and 1998 were evaluated retrospectively. One set of the newly designed instruments consists of 3 pairs of trabeculotomy probes, the curvatures of which correspond to corneal diameters of 10, 12, and 14 mm. The criteria for surgical success were intraocular pressure (IOP) below 21 mmHg and simultaneous absence of cup to disc (C/D) ratio progression and of disproportional enlargement of the cornea. RESULTS: Forty-six children who underwent surgery over the course of 7 years were evaluated in a follow-up period from 7 to 83 months (38.4 +/- 22.5 months). A total of 102 trabeculotomies were performed in a total of 78 eyes, with the following complications: 8 large intraoperative hemorrhages, 3 small iris prolapses, 2 small descemetolyses, and 1 short iridodialysis. Postoperatively, glaucoma was successfully controlled in 68 eyes (87%), IOP fell in average from 30.81 +/- 6.55 mmHg to 16.32 +/- 5.13 mmHg (P <.00005). Visual acuity was better than 0.4 in 50 eyes and worse than 0.1 in 5 eyes at the end of the study. CONCLUSION: The probing of the Schlemm's canal was feasible in all procedures and the number of complications was low. The success rate of surgery was high. Adaptation of the trabeculotomy probes to the Schlemm's canal curvature seems to make probing easier and safer.     

A clinical study of the Ahmed glaucoma valve implant in refractory glaucoma

OBJECTIVE: To assess clinical outcomes of the Ahmed glaucoma valve implant in patients with refractory glaucoma. PARTICIPANTS: 15 patients (16 eyes), including 7 women and 8 men; patients with glaucoma: phakic- 10 eyes, pseudophakic - 4 eyes, and aphakic - 2 eyes, average age: 47.2 (18-72 years old), average IOP before the intervention: 47 mmHg (32-71 mmHg), average number of medications taken before the intervention: 3.0. MAIN OUTCOME MEASURES: Success was defined as IOP less than or equal to 21 mmHg and no need to perform another surgical intervention. Average period of observation was 23.2 months (6-42 months). RESULTS: Intervention was successful in 12 out of 16 eyes. Average number of medicaments taken after the intervention decreased to 1.2. 4 out of 16 patients had a hypertensive phase. Cumulative probabilities of success at 1 and 2 years were 88% and 72% respectively. Complications: hyphema - 4 eyes (25%), tube exposure - 1 eye (6.25%), corneal graft failure - 4 eyes (25%), hypertensive phase - 4 eyes (25%) anterior chamber shallowing - 2 eyes (12.5%) CONCLUSIONS: The Ahmed glaucoma valve implant is an effective way of treating the patients with refractory glaucoma.     

Correlations of genotype with phenotype in Indian patients with primary congenital glaucoma

PURPOSE: To establish the genotype-phenotype correlations of various CYP1B1 (human cytochrome P450) mutations in patients in India with primary congenital glaucoma (PCG). METHODS: The study cohort comprised 146 patients with PCG from 138 pedigrees. Patients were analyzed for six distinct CYP1B1 mutations by sequencing and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) methods. A severity index for grading various PCG phenotypes was constructed based on clinical parameters. RESULTS: Six mutations were identified in 45 patients analyzed and genotype-phenotype correlations were established for 43 of them. The percentages of severe phenotypes associated with various mutations in at least one eye were: frameshift, 100%; G61E, 66.7%; P193L, 62.5%; E229K, 80%; R368H, 72%; R390C, 83.3%. The frameshift mutation resulted in blindness. Based on the severity index, the disease severity was graded from normal to severe and the prognosis from good to very poor (blind). De novo mutation was identified in one family. CONCLUSIONS: This is the first study to attempt to devise a severity index for grading various PCG phenotypes and to use genotype as an indicator to predict the prognoses of the disorder. This index may help guide therapy and counseling of the afflicted family regarding the progression of the disorder. All patients with severe phenotypes showed poor prognoses (r = 0.976; P < 0.0001). The data derived from this study could be used as an added clinical tool in disease management. Integrated management of PCG that makes use of a genetic approach could yield better results than medical, surgical, and rehabilitation interventions alone.     

Surgical outcomes of combined phacoemulsification and glaucoma drainage implant surgery for Asian patients with refractory glaucoma with cataract

PURPOSE: To examine the safety and efficacy of combined phacoemulsification and glaucoma drainage implant surgery in providing reduction of intraocular pressure (IOP) and visual rehabilitation in eyes with refractory glaucoma and cataract. DESIGN: Interventional case series. METHODS: A retrospective chart review was performed on all subjects who underwent combined phacoemulsification with intraocular lens implantation and glaucoma drainage implant surgery by a single surgeon at the National University Hospital, Singapore. The implants used were the 185 mm2 Ahmed glaucoma valve and the 350 mm2 Baerveldt glaucoma implant. In terms of IOP, a complete success was defined as IOP of between 6 to 21 mm Hg without medication, qualified success as IOP between 6 to 21 mm Hg with one or more medication, and failure as a sustained IOP of >21 mm Hg or <6 mm Hg with or without one or more medication on two or more visits. RESULTS: A total of 32 combined phacoemulsification and glaucoma implant surgeries in 32 patients was performed. All patients were of Asian origin, and the mean age was 58 +/- 16 years (range, 20-78 years). The Baerveldt glaucoma implant and Ahmed glaucoma valve implant were inserted in 16 eyes each. With a mean follow-up of 13 +/- 5 months (range 6 to 22 months), IOP was reduced from a mean of 28.0 +/- 11.5 mm Hg to 15.2 +/- 6.0 mm Hg postoperatively (P <.0001), whereas the number of antiglaucoma medications decreased from a mean of 2.4 +/- 1.4 to.3 +/-.7 (P <.0001) at last follow-up. Overall, there were 24 eyes (75%) that were classified as complete successes, 4 eyes (12.5%) that were qualified successes, and 4 eyes that failed (12.5%). Twenty-three eyes (72%) had improvement of visual acuity, while only one eye had a loss of more than 1 line of Snellen acuity. There was no case that encountered an intraoperative complication, and postoperative complications occurred in 12 eyes (38%), the most common of which was hypotony (in six eyes, 19%). CONCLUSION: For subjects with refractory glaucoma and cataract, combined phacoemulsification and glaucoma drainage implant surgery provide good visual rehabilitation and control of IOP, with low incidence of complications.