Kateki Vinod

Practice Preferences for Glaucoma Surgery: A Survey of the American Glaucoma Society

Purpose: The purpose of this study is to assess surgical practice patterns among the American Glaucoma Society (AGS) membership. Methods: An anonymous online survey evaluating the use of glaucoma surgeries in various clinical settings was redistributed to AGS members. Survey responses were compared with prior results from 1996, 2002, and 2008 to determine shifts in surgical practice patterns. Questions were added to assess the preferred approach to primary incisional glaucoma surgery and phacoemulsification combined with glaucoma surgery. Results: A total of 252 of 1091 (23%) subscribers to the AGS-net participated in the survey. Percentage use (mean±SD) of trabeculectomy with mitomycin C (MMC), glaucoma drainage device (GDD), and minimally invasive glaucoma surgery (MIGS) as an initial surgery in patients with primary open angle glaucoma was 59%±30%, 23%±23%, and 14%±20%, respectively. Phacoemulsification cataract extraction alone was the preferred surgical approach in 44%±32% of patients with primary open angle glaucoma and visually significant cataract, and phacoemulsification cataract extraction was combined with trabeculectomy with MMC in 24%±23%, with MIGS in 22%±27%, and with GDD in 9%±14%. Although trabeculectomy was selected most frequently to surgically manage glaucoma in 8 of 8 clinical settings in 1996, GDD was preferred in 7 of 8 clinical settings in 2016. Conclusions: The use of GDD has increased and that of trabeculectomy has concurrently decreased over the past 2 decades. Trabeculectomy with MMC is the most popular primary incisional surgery when performed alone or in combination with phacoemulsification cataract extraction. Surgeons frequently manage coexistent cataract and glaucoma with cataract extraction alone, rather than as a combined cataract and glaucoma procedure.

Update on pigment dispersion syndrome and pigmentary glaucoma

Purpose of review The present article reviews the clinical features and pathogenesis of pigment dispersion syndrome and pigmentary glaucoma and provides an update regarding their diagnosis and management. Recent findings Newer imaging modalities including ultrasound biomicroscopy and anterior segment optical coherence tomography facilitate visualization of the iris concavity characteristic of eyes with pigment dispersion syndrome and pigmentary glaucoma. Patients with pigmentary glaucoma may be distinguished from those with other glaucoma types by the presence of typical symptoms, personality type, and patterns of diurnal intraocular pressure fluctuation. Although laser iridotomy has been shown to alter iris anatomy in pigmentary glaucoma, it is not proven to slow visual field progression. Multiple trials have validated the safety and efficacy of filtering surgery in treating pigmentary glaucoma, with fewer studies published on the role of micro-invasive glaucoma surgery. Summary Literature from the review period has further defined the unique clinical characteristics of pigment dispersion syndrome and pigmentary glaucoma. Laser surgery has a limited role in the management of these entities, whereas trabeculectomy remains an acceptable first-line surgical treatment. Further studies are needed to define the potential application of the newer micro-invasive glaucoma procedures in pigmentary glaucoma.

Vitreous Occlusion of a Glaucoma Drainage Implant-Surgical Management

Vitreous occlusion of a glaucoma drainage implant (GDI) can lead to failure of the device and severely elevated intraocular pressure. The pathophysiology of tube obstruction is related to central and anterior displacement of vitreous that is drawn into and condenses within the proximal lumen of the tube. This can occur from days to years following GDI surgery. Successful management of vitreous-tube obstruction generally requires manual removal of the condensed vitreous plug with end-grasping forceps. This technique achieves reversal of tube blockage and restoration of GDI function. Amputation of the incarcerated vitreous alone with vitrectomy or neodymium:yttrium-aluminum-garnet vitreolysis does not consistently restore GDI function and risks persistent intraluminal tube obstruction.

Transconjunctival Revision With Mitomycin-C Following Failed Trabeculectomy.

Purpose:To evaluate the efficacy of transconjunctival revision (TCR) with mitomycin-C (MMC) following failed trabeculectomy. Materials and Methods:The medical records of 27 patients (27 eyes) who underwent TCR with subconjunctival injection of MMC by a single surgeon between September 2001 and August 2013 were retrospectively reviewed. The same surgical protocol was followed for all patients. Revision was performed using a microvitreoretinal blade through a small conjunctival incision. Main outcome measures included visual acuity, intraocular pressure (IOP), and number of glaucoma medications. Failure was defined as an IOP<5 or >14 mm Hg, loss of light perception, or need for additional glaucoma surgery. Results:Mean interval between trabeculectomy and TCR was 56.4±57.2 months. Mean preoperative IOP was 21.9±6.8 mm Hg using 4.0±1.2 glaucoma medications. Fifteen (55.6%) patients met success criteria. At most recent follow-up, mean IOP and number of glaucoma medications for successful patients were 9.7±3.8 mm Hg and 0.6±1.1, respectively. Kaplan-Meier analysis revealed 1-, 2-, and 3-year success rates of 62%, 58%, and 53%, respectively. Three additional patients achieved success after undergoing a second TCR, and 1 patient achieved success after a third TCR. Postoperative complications included transient choroidal effusion (n=8), shallow anterior chamber requiring reformation (n=5), 5-fluorouracil-related corneal epitheliopathy (n=10), and bleb leak (n=1). Conclusions:TCR with adjunctive MMC is a safe and effective procedure following failure of a trabeculectomy. More than 1 revision may be necessary to achieve long-term IOP reduction.

Long-term Outcomes and Complications of Pars Plana Baerveldt Implantation in Children.

Purpose of the Study: The purpose of the study was to report long-term outcomes and complications of Baerveldt glaucoma implant (BGI) surgery with pars plana tube insertion in children. Materials and Methods: The medical records of consecutive aphakic and pseudophakic children (<16 y of age) who underwent BGI surgery with pars plana tube insertion between 1990 and 2013 were retrospectively reviewed. Main outcome measures were intraocular pressure and number of glaucoma medications. Postoperative complications were recorded. Failure was defined as an intraocular pressure <5 or ≥21 mm Hg (with or without glaucoma medications), loss of light perception, or need for additional glaucoma surgery. Results: Thirty-seven children were identified with a mean age of 6.0±4.7 years (range, 4 mo to 14.5 y). Mean follow-up after pars plana BGI surgery was 6.5±3.4 years (range, 9 mo to 12.8 y) for patients who met success criteria. Mean intraocular pressure and mean number of glaucoma medications at most recent follow-up for patients with successful intraocular pressure control were 13.8±4.1 and 2.3±1.9 mm Hg, respectively. The Kaplan-Meier survival analysis revealed 1-, 3-, 5-, and 7-year success rates of 94.5%, 74.6%, 65.0%, and 45.8%, respectively. Complications included tube exposure in 1 patient (2.7%), tube obstruction in 8 patients (21.6%), and retinal detachment in 9 patients (24.3%). Seventeen patients (45.9%) failed due to inadequate intraocular pressure control, of whom 9 (24.3%) required additional glaucoma surgery. Conclusions: Although pars plana BGI surgery is a reasonable option for managing refractory glaucoma in aphakic and pseudophakic children, surgeons must be aware of the potential need for additional glaucoma surgery and/or posterior segment complications with extended follow-up.

Primary Open Angle Glaucoma: Is It Just One Disease?

Purpose of ReviewThis article reviews evidence from the literature suggesting that primary open angle glaucoma (POAG) represents a group of heterogeneous diseases with varying clinical features rather than a single disease.Recent FindingsA growing body of evidence has been made available recently indicating that POAG behaves differently in different subpopulations. Although normal tension glaucoma has long been regarded as a diagnosis distinct from POAG, a considerable degree of overlap exists in their pathophysiology and clinical characteristics and suggests that intraocular pressure alone is not a reliable means of separating POAG into different subtypes. Meanwhile, POAG patients with initial paracentral visual field defects rather than early peripheral defects more often exhibit systemic vascular dysregulation, regardless of whether their intraocular pressures are high or low. Patients of African and Afro-Caribbean heritage develop a subtype of POAG that manifests at an earlier age, displays a more rapid disease course, and leads to blindness more frequently than do patients of European descent.SummaryRecognizing the existence of various POAG subtypes differentiated by factors other than intraocular pressure alone will allow clinicians to diagnose glaucoma more accurately and provide more individualized care.

Navigating a new direction in micro-invasive glaucoma surgery: results from the COMPASS trial

Recent innovations and technological advances have ushered in a new era of surgical approaches to glaucoma management. Our options have expanded beyond traditional incisional glaucoma surgery (i.e., trabeculectomy and tube shunts) to include newer procedures that can be implemented earlier in patients with milder disease. Many of these recently introduced operations can be classified as micro-invasive glaucoma surgery (MIGS), for which five defining criteria have been proposed: an ab interno approach; minimal tissue trauma; at least modest efficacy; high safety; and rapid recovery (1). Candidates for currently available MIGS are generally those with early glaucoma whose disease does not require very low intraocular pressure (IOP) to retard progression and/or who may benefit from reduction in medical therapy.