Michele Ushida

Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors

ABSTRACT Aim To investigate surgical outcomes and success predictors of transconjunctival scleral flap resuturing for the management of hypotony due to overfiltration following trabeculectomy with mitomycin C. Materials and methods Noncomparative, retrospective, interventional case series in which all glaucoma patients from two glaucoma services undergoing transconjunctival scleral flap resuturing between May 2012 and July 2016 were enrolled. Included eyes had to have hypotony [intraocular pressure (IOP) < 6 mm Hg] and/or hypotony maculopathy caused by excessive filtration following trabeculectomy. Key exclusion criteria were wound/bleb leaking and postoperative ocular trauma or infection. Preoperative and postoperative IOP, best-corrected visual acuity (BCVA), fundus imaging, surgical complications, and any subsequent related events or procedures were recorded. Rates of postsurgical hypotony and/or maculopathy resolution and possible success predictors were investigated. Results A total of 22 patients (22 eyes) with a mean age of 56.4 ± 15.2 years were included. Median follow-up was 245 days [interquartilerange (IR); 120-817 days] and mean IOP was increased from 2.9 ± 1.5 mm Hg (1-6 mm Hg) to 8.5 ± 3.1 mm Hg (2-16 mm Hg) at the last follow-up visit (p < 0.01). Approximately 75% of the cases (16 out of 22) had an IOP between 7 and 18 mm Hg at the end of the follow-up period. Median BCVA (log MAR) at last follow-up visit [0.1 (IR; 0.0- 0.3)] was significantly better than preoperative BCVA [0.4 (IR; 0.11.0); p < 0.01]. Hypotony resolved in 81% of the cases, while maculopathy resolution was found in 85% of the cases. Time interval between trabeculectomy and flap resuturing was the only factor significantly associated with patient’s IOP at last follow-up visit (R2 = 0.23; p = 0.036). Success rates (IOP > 6 mm Hg at last follow-up visit) were halved in those left untreated for more than 6 months. No serious adverse event was recorded. Conclusion Our findings support the use of transconjunctival scleral flap resuturing as an effective and safe alternative for hypotony management due to overflitration following trabeculectomy. As time interval seems to influence the odds of hypotony resolution, early intervention is recommended. How to cite this article Scoralick ALB, Almeida I, Ushida M, Dias DT, Dorairaj S, Prata TS, Kanadani FN, Hypotony Management through Transconjunctival Scleral Flap Resuturing: Analysis of Surgical Outcomes and Success Predictors. J Curr Glaucoma Pract 2017;11(2):58-62.

Selective laser trabeculoplasty as an initial treatment option for open-angle glaucoma

Although eye drops are frequently used as an initial treatment option for open angle glaucoma (OAG), side effects, and poor adherence, among others, may compromise treatment efficacy. In this scenario, laser trabeculoplasty is an interesting therapeutic option for open angle glaucoma cases. Commonly used for many years as a last alternative prior to glaucoma incisional surgery, laser trabeculoplasty has been changing its indication after the advent of selective laser trabeculoplasty (SLT). In the current review, we critically evaluated the published data regarding the use of laser trabeculoplasty as a first treatment option for open angle glaucoma patients. Studies using SLT as a first-line treatment have encouraging findings. One-year efficacy results are comparable to those obtained with prostaglandin analogues, with a good safety profile. Although the laser´s effect is known to be transitory, recent data suggest it can be successfully repeated in cases with good response to the first SLT treatment.

Cataract surgery alone cannot be considered an IOP-lowering procedure for open-angle glaucoma patients: an evidence-based perspective.

Due to the significant coexistence of cataract and glaucoma, cataract surgery has become a routine procedure in a glaucoma surgeon’s practice. The indication of cataract surgery in glaucoma patients usually differs from that in ordinary cases, either because of the intraoperative technique and perioperative care or because of the expected results. The approach also varies significantly among patients with glaucoma, depending on various factors such as disease stage, preoperative intraocular pressure (IOP), number of medications, gonioscopy appearance, patient’s age, previous ocular surgery, comorbidities, and others. Therefore, it is essential that every surgeon recognizes the influence of cataract surgery on IOP control in each type of glaucoma, aiming, above all, to mitigate the risk of losing control of the disease. The relationship between glaucoma and cataract surgery has been investigated in several glaucoma studies. More recently, the topic began to be approached by cataract specialists in original articles, editorials, and meetings. In this context, much has been discussed about the hypotensive effect of cataract surgery in patients with glaucoma or ocular hypertension. On analyzing the literature carefully, we found that most of the articles that evaluated the effects of phacoemulsification with intraocular lens implantation in patients with glaucoma included eyes with angle-closure glaucoma (either the chronic or acute form of the disease). Although little has been studied about the hypotensive effect of cataract surgery in eyes with open-angle glaucoma until now, the consistently good results reported on average in cases of angle-closure led to the idea that cataract surgery would be an effective IOP-lowering procedure for all cases of glaucoma. In our opinion, this assumption seems dangerous, and to date, has no strong basis in the literature. When focusing on previous articles that include patients with open-angle glaucoma, we come across scant data and few good studies. Most of the available studies are based on non-comparative case series with retrospective analysis. In general, a modest IOP reduction was observed after uncomplicated phacoemulsification in these patients. Among the more rigorous studies, the mean long-term changes in IOP values varied between 1.5 and 2 mmHg. For example, in a recent study by Slabaugh et al., over 150 patients with open-angle glaucoma controlled with medication underwent cataract surgery. After one year of follow-up, IOP was reduced by an average of 1.8 ± 3.1 mmHg. Although significant from a statistical point of view, it is questionable whether this percentage reduction in IOP is clinically meaningful. When compared with the preoperative period, there was no significant change in the number of medications after cataract surgery. In this study, perhaps the most alarming report was the fact that almost 40% of these glaucoma patients lost IOP control during the first year after cataract surgery either because they needed more medication (or laser) or because of an IOP increase (in cases where there was no change in medication regimen). Very similar results had previously been demonstrated by Shingleton et al. in a study with fewer patients but with longer follow-up time (average of 5 years). Finally, we must also highlight the effects of cataract surgery on IOP in the first few days after surgery. Patients with glaucoma, even when stabilized on topical medications, are more likely to experience IOP spikes (defined as IOP >30 mmHg) immediately after uncomplicated cataract surgery than controls; this increase being sustained during the first three days. In relation to other published articles, we believe that it is difficult to extract good guidelines for cases of coexisting cataract and open-angle glaucoma. In two relatively recent articles, Walland et al. emphasized the lack of randomized controlled trials providing adequate evidence regarding the benefit of cataract surgery in these cases. This fact, although significant, is not the most serious issue, in our opinion. For instance, some of the studies that included patients with open-angle glaucoma did not even use gonioscopy as an inclusion (or exclusion) criteria. Finally, two important points should be highlighted. First, there appears to be a clear positive

Factors associated with the presence of parafoveal scotoma in glaucomatous eyes with optic disc hemorrhages

PurposeGlaucomatous eyes with disc hemorrhage (DH) have a greater risk of paracentral visual field (VF) loss. However, not every DH eye presents with parafoveal scotoma (PFS), and contributing factors are still to be determined. In the present study, we investigated clinical and ocular factors associated with the presence of PFS in glaucomatous eyes with DH.MethodsA case-control study was carried out. One hundred thirty glaucomatous patients with DH were enrolled. They were divided into two groups based on two reliable 24-2 VF tests: those with PFS (defined as ≥3 adjacent points with p < 5% within the central 10 degrees of fixation, ≥1 point with p < 1% lying at the innermost paracentral points, in the same hemifield) and those without PFS. Clinical and ocular data from the time of DH detection were compared between groups. Factors associated with the presence of PFS were investigated through logistic regression.ResultsThe PFS group had a higher prevalence of Caucasian patients (82 vs. 47%; p < 0.01). Eyes with PFS had a more negative spherical equivalent and worse VF mean deviation (MD) index (p ≤ 0.01). There was a marginally significant intraocular pressure (IOP) difference between eyes with (15 mmHg) and without PFS (18 mmHg) at the time of DH detection (p = 0.10). Univariable analysis revealed PFS to be significantly associated with Caucasian race (OR, 3.02; p = 0.004), myopia (<−3 diopters; OR, 3.44; p = 0.039), and lower IOP (≤16 mmHg; OR, 2.10; p ≤ 0.047). Multivariable analysis, controlling for VF MD, revealed that only Caucasian race and myopia (as a continuous or categorical variable) remained significant in this model (p ≤ 0.038).ConclusionsCaucasian race and the presence and magnitude of myopia were found to be significantly associated with the presence of PFS in glaucomatous eyes with DH. Our results may help clinicians in the identification and surveillance of these eyes at higher risk of central VF loss.

Intraocular Pressure Spikes within First Postoperative Hours following Standard Trabeculectomy: Incidence and Associated Factors

Purpose: To evaluate the incidence of intraocular pressure (IOP) spikes within the first postoperative hours following trabeculectomy (TRAB) and to determine possible associated factors. Methods: An observational study was carried out. We enrolled consecutive patients undergoing standard TRAB with mitomycin C. They were examined twice within the first few postoperative hours (hours 1-2 and 4-6) and 3 times after TRAB (on days 1, 7, and 30). Demographic and ocular data were collected. Main outcome measurements were postoperative IOP values at each time point and the frequency of IOP spikes, defined as IOP ≥25 mm Hg. Results: A total of 40 eyes of 40 patients were included (mean age 59.62 ± 13.37 years). Although IOP was significantly reduced to 11.14 ± 7.99 mm Hg at hours 1-2 (p < 0.01) and to 11.52 ± 7.30 mm Hg at hours 4-6 (p < 0.01), IOP spikes were documented in 3 patients (7.5%). In the group of patients with IOP spikes, we noted that there was a high incidence of black patients and that the surgeries had been performed by fellow surgeons. Conclusion: Although the majority of the cases (92.5% of the patients) did not present IOP spikes, 7.5% of our patients presented the event. In selected cases, such as those with advanced disease, fixation threat, and of black race, IOP should be monitored during the first few postoperative hours for the identification and adequate management of potential IOP spikes, preventing undesirable outcomes.

Eyes with Suspicious Appearance of the Optic Disc and Normal Intraocular Pressure: Using Clinical and Epidemiological Characteristics to Differentiate Those with and without Glaucoma.

Among all glaucoma suspects, eyes with optic nerve head features suspicious or suggestive of early glaucoma are probably those that offer the greatest challenge for clinicians. In contrast with the robust longitudinal data published on ocular hypertension, there is no specific management guideline for these patients. Therefore, evaluating eyes with suspicious optic disc appearance and normal intraocular pressure (IOP), we sought to investigate potential differences in clinical and epidemiological characteristics to differentiate those with normal-tension glaucoma (NTG) from those with presumed large physiological optic disc cups (pLPC). In this observational case-control study, we consecutively enrolled individuals with pLPC and NTG. All eyes had vertical cup-to-disc ratio (VCDR)≥0.6 and untreated IOP<21 mmHg. Glaucomatous eyes had reproducible visual field defects. Eyes with pLPC required normal visual fields and ≥30 months of follow-up with no evidence of glaucomatous neuropathy. Clinical and epidemiological parameters were compared between groups. Eighty-four individuals with pLPC and 40 NTG patients were included. Regarding our main results, NTG patients were significantly older and with a higher prevalence of Japanese descendants (p<0.01). Not only did pLPC eyes have smaller mean VCDR, but also larger optic discs (p≤0.04). There were no significant differences for gender, central corneal thickness, and spherical equivalent (p≥0.38). Significant odds ratios (OR) were found for race (OR = 2.42; for Japanese ancestry), age (OR = 1.05), VCDR (OR = 5.03), and disc size (OR = 0.04; p≤0.04). In conclusion, in patients with suspicious optic disc and normal IOP, those with older age, Japanese ancestry, smaller optic discs, and larger VCDR are more likely to have NTG, and therefore, deserve deeper investigation and closer monitoring.