Sameh Mosaed

Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma: Initial results

PURPOSE: To provide an update of the short‐term results of combined phacoemulsification and trabeculotomy by the internal approach with a follow‐up to 21 months. SETTING: Universities and private practices in the United States. METHODS: This prospective interventional case series comprised 304 consecutive eyes with open‐angle glaucoma and cataract having combined phacoemulsification and trabeculotomy with a Trabectome (NeoMedix Inc.). The Trabectome is designed to open a direct pathway for aqueous to flow from the anterior chamber into Schlemm canal collector channels. Under gonioscopic control, bipolar cautery was applied by a purpose‐designed footplate to ablate the trabecular meshwork and inner wall of Schlemm canal. The main outcome measures were intraocular pressure (IOP), glaucoma medication use, and complications. RESULTS: The mean IOP was 20.0 mm Hg ± 6.3 (SD) preoperatively, 14.8 ± 3.5 mm Hg at 6 months, and 15.5 ± 2.9 mm Hg at 1 year. There was a corresponding drop in glaucoma medications from 2.65 ± 1.13 at baseline to 1.76 ± 1.25 at 6 months and 1.44 ± 1.29 at 1 year. Subsequent secondary glaucoma procedures were performed in 9 patients. The only frequent complication, blood reflux in 239 patients (78.4%), resolved within a few days. CONCLUSIONS: Combined phacoemulsification and trabeculotomy by the internal approach using the Trabectome lowered IOP and medication use in the majority of patients. Complications were minimal and comparable to those in an earlier series of Trabectome‐only procedures.

Corneal epithelial VEGF and cytochrome P450 4B1 expression in a rabbit model of closed eye contact lens wear

Purpose. The similar and overlapping activity of VEGF and the potent corneal-derived angiogenic eicosanoid 12(R)-HETrE calls for a study of the temporal relationship in the expression of these two autocoids. Since recent evidence suggests that hypoxia induces the expression of a CYP4B1 mRNA which might be involved in the conversion of arachidonic acid to 12(R)-HETrE, we determined its time-dependent expression and correlated it to that of VEGF mRNA in the rabbit model of closed eye contact lens-induced injury. Methods. Rabbit eyes were fitted with contact lenses followed by a silk suture tarsorrhaphy. The anterior surface was analyzed at 2-, 4- and 7-days by slit lamp biomicroscopy, subjective inflammatory scoring and corneal pachymetry. Corneal epithelium was scraped and CYP4B1 and VEGF mRNA levels were measured by Southern hybridization of RT-PCR products amplified from a single cornea with specific primers. Results. Corneal thickness and inflammatory scores increased in a time dependent manner in the model of closed eye contact lens induced hypoxic injury. Corneal epithelial CYP4B1 and VEGF mRNAs, as well as the production of the angiogenic eicosanoid, 12-HETrE, increased in a time-dependent manner and correlated with the in situ inflammatory response. Conclusions. The present study documents the increased expression of CYP4B1 isoform in the corneal epithelium during hypoxic injury in vivo. It also demonstrates the presence of VEGF mRNA in the corneal epithelium and its increased expression in this model of hypoxic injury. All together, the results of this study raise the possibility of interaction between these autocoids, VEGF and CYP4B1-12(R)-HETrE, in mediating the neovascularization response induced by the prolonged hypoxic state brought about by closed eye contact lens wear.

Effect of a failed trabectome on subsequent trabeculectomy.

PurposeTo determine the effect of a failed trabectome on the outcomes of a subsequent trabeculectomy. Patients and MethodsA cohort study of eyes that underwent trabeculectomy after a failed trabectome procedure (study) compared with eyes that underwent trabeculectomy as an initial surgical procedure (control). Inclusion criteria were open-angle glaucoma, age ≥18 years, and uncontrolled glaucoma with maximally tolerated medical therapy. Exclusion criteria were concurrent surgery and follow-up less than 6 months. Outcome measures were intraocular pressure (IOP), success rate, and occurrence of complications. Failure was the occurrence of additional glaucoma surgery, loss of light perception vision, or IOP >21 mm Hg, ⩽5 mm Hg, or <20% reduction below baseline on 2 consecutive follow-up visits after 1 month. ResultsMean follow-up was 15.4 months and 18.6 months for study (n=34) and control (n=42) groups, respectively. IOP decreased from 27.6±11.8 mm Hg at baseline to 10.6±2.6 mm Hg at 2 years in study group, and 29.2±11.4 mm Hg to 11.0±5.4 mm Hg in the control group. The success rates at 2 years were 60.2% and 55.5% in the study and control groups, respectively (P=0.895). Systemic hypertension [P=0.009; adjusted hazard ratio, 4.03; 95% confidence interval, 1.41-11.53] and number of the preoperative antiglaucoma medications (P=0.005; 2.29; 1.28 to 4.11) were significant risk factors for failure in the multivariate analysis. Failed trabectome was not associated with trabeculectomy failure (P=0.899). Postoperative complications were similar. ConclusionsA failed trabectome did not affect the success rate of a subsequent trabeculectomy.

Association of Central Corneal Thickness and 24-hour Intraocular Pressure Fluctuation

PurposeTo evaluate the association between office-hour central corneal thickness (CCT) and 24-hour intraocular pressure (IOP) fluctuation in patients with glaucoma. DesignObservational case-control study. MethodsMeasurements of IOP were obtained every 2 hours during a 24-hour period from 52 untreated glaucoma patients and 29 age-matched normal control subjects housed in a sleep laboratory. Habitual IOP measurements were obtained using a pneumatonometer in the sitting positions during the diurnal/wake period (7 AM to 11 PM) and in the supine position during the nocturnal/sleep period (11 PM to 7 AM). CCT was measured in all subjects using ultrasound pachymetry once during office hours. The association between IOP fluctuation (peak IOP-trough IOP) during the 24-hour period and the office-hour CCT was assessed in both glaucoma patients and healthy age-matched controls using Spearman rank order correlation. ResultsThere was no statistically significant correlation between IOP fluctuation and CCT in glaucomatous (P=0.405) and normal subjects (P=0.456). ConclusionsTwenty-four–hour IOP fluctuations were not correlated with single CCT measurements taken during office hours in glaucoma patients.

Results of Trabectome Surgery Following Failed Glaucoma Tube Shunt Implantation: Cohort Study

Abstract To evaluate the safety and efficacy of Trabectome after failed tube shunt surgery. Twenty patients with prior failed tube shunt surgery who underwent Trabectome alone were included. All patients had at least 3 months of follow-up. Outcomes measured included intraocular pressure (IOP), glaucoma medications, and secondary glaucoma surgeries. The success for Kaplan–Meier survival analysis is defined as IOP ⩽21 mm Hg, IOP reduced by at least 20% from preoperative IOP, and no secondary glaucoma surgery. Mean preoperative IOP was 23.7 ± 6.4 mm Hg and mean number of glaucoma medications was 3.2 ± 1.5. At 12 months, IOP was reduced to 15.5 ± 3.2 mm Hg (P = 0.05) and number of medications was reduced to 2.4 ± 1.5 (P = 0.44). Survival rate at 12 months was 84% and 3 patients required additional glaucoma surgery with 15 patients reaching 12 months follow-up. Other than failure of IOP control and transient hypotony (IOP < 3 mm Hg) day 1 in 2 cases, there were no adverse events. Trabecular bypass procedures have traditionally been considered an approach appropriate for early-to-moderate glaucoma; however, our study indicates benefit in refractory glaucoma as well. Eyes that are prone to conjunctival scarring and hypertrophic wound healing, such as those who have failed tube shunt surgery, may benefit from procedures that avoid conjunctival incision such as Trabectome. This study indicates potential benefits in this patient population. Trabectome was safe and effective in reducing IOP at 1-year follow-up in patients with prior failed tube shunt surgery, but not effective in reducing medication reliance in these patients.

Aqueous shunts in the treatment of glaucoma

The main goal of surgical glaucoma treatment is to reduce the intraocular pressure. The standard procedure over the past 40 years has been trabeculectomy, first described in 1968. This procedure comes with a very high risk profile, and results in moderate long-term results at best. Tube shunt devices were introduced as an alternate means to divert fluid out of the glaucomatous eye, attempting to improve upon the poor long-term outcomes of trabeculectomy, particularly in refractory cases that had failed attempts at prior glaucoma surgeries. They are currently available in a handful of different designs and have evolved from representing a second- or third-line treatment in refractory cases, to their current standing of accepted first-line surgical intervention for many surgeons. The designs of the aqueous shunts are simple and installation involves straightforward principles of ophthalmic surgery. Recent additions to the literature, as well as the development of the Ex-PRESS Miniature Shunt, are changing the way shunts are employed in the treatment algorithm for surgical glaucoma. The outcomes of these procedures are encouraging, and support their use as first-line surgical options for the treatment of adult and juvenile glaucoma.

Prostaglandin-Induced Cystoid Macular Edema Following Routine Cataract Extraction

To our knowledge, we are reporting the first case of a 59-year-old man who developed recurrent CME with three separate trials of three different prostaglandin class drugs following uncomplicated phacoemulsification with intraocular lens implantation. Despite multiple reports of individual prostaglandin (PG) analogues being suggested as the cause of CME, there are no recommendations regarding withholding these medications in the perioperative period. Our patient first developed CME OD 4-months post uncomplicated cataract extraction. XALATAN (Latanoprost) had been restarted after surgery and discontinued at onset of CME. While off XALATAN (Latanoprost), the patients CME resolved, but his IOP rose. The patient was started on LUMIGAN (Bimatoprost) to control the IOP, but within weeks his CME recurred. The patients CME was again treated and his IOP remained acceptable, but then progressively increased. TRAVATAN (Travoprost) was attempted, but he presented with a third round of CME. Definitive conclusions about causal relationships cannot be made without well-designed, prospective clinical trials addressing this issue.

The First Decade of Global Trabectome Outcomes

Purpose: To present available primary outcome results of global Trabectome experience for patients receiving Trabectome procedure including cases with up to 90 months of follow-up. Method: A total of 5,435 cases were included in the study. Baseline demographics were collected and outcome measures included intraocular pressure (IOP), number of glaucoma medications and secondary glaucoma surgery, if any. Survival analysis was performed and success was defined as IOP ≤21 mmHg, at least 20 % of IOP reduction from baseline, and no additional glaucoma surgery. Results: At 90 months, IOP was reduced from 23.0±7.9 mmHg to 16.5±3.8 mmHg (29 %) and the number of glaucoma medications was reduced from 2.6±1.3 to 1.6±1.3 (38 %). At 90 months, the survival rates were 60 % for all cases, 76 % for combined cases and 50 % for Trabectome alone cases. Discussion: These results are generally consistent with previously published outcome results for patients receiving the Trabectome procedure. Conclusion: Considering this outcome analysis of the available global Trabectome experience in combination with outcome data surveyed from the literature, patients receiving Trabectome on average have about a 30 % reduction in IOP and a 60 % reduction in glaucoma medication. The Trabectome procedure can be considered for initial glaucoma therapy, as well as for end-stage patients who have been refractory to other surgical and medical treatments.

Critical evaluation of latanoprostene bunod in the treatment of glaucoma

Latanoprostene bunod (LBN) is a novel nitric oxide-donating prostaglandin F2α receptor agonist in clinical development for intraocular pressure lowering in open-angle glaucoma and ocular hypertension. Currently in Phase III clinical trials in the USA, European Union, and Japan, LBN has demonstrated promising efficacy while maintaining safety and tolerability. We review preclinical and clinical developmental efforts and evaluate the potential role of LBN monotherapy in the management of open-angle glaucoma and ocular hypertension. The current LBN clinical development program comprises eight trials, four of which have resulted in publication of complete methodology and outcomes. We additionally pool adverse events data to determine incidences across three pivotal studies. Evidence thus far indicates that LBN may be a safe and effective ocular hypotensive agent, although the potential neuroprotective effects and the impact on visual field loss remain to be evaluated.

Outcome of primary trabeculotomy ab interno (Trabectome) surgery in patients with steroid-induced glaucoma

AbstractTo determine the efficacy and safety of Trabectome surgery on patients with steroid response, ranging from ocular hypertension refractory to maximal medical therapy to the development of steroid-induced glaucoma.A nonrandomized, nonblinded, retrospective study of 20 subjects with steroid response was conducted. All 20 eyes underwent Trabectome surgery alone. Nine subjects had steroid response with unremarkable visual field, 3 had mild steroid-induced glaucoma, and 8 had advanced steroid-induced glaucoma. Outcome measures included intraocular pressure (IOP), number of glaucoma medications, need for secondary glaucoma surgery, and steroid regimen. Mann–Whitney U test was used to compare postoperative IOP and number of medications to preoperative IOP and number of medications. Kaplan–Meier was used for survival analysis, and success was defined as: IOP reduced by 20% or more on any 2 consecutive visits after 3 months; IOP ⩽21 mm Hg on any 2 consecutive visits after 3 months; and no secondary glaucoma surgery.The average preoperative IOP was 33.8 ± 6.9 mm Hg and average preoperative glaucoma medication usage was 3.85 ± 0.75 medications. At 12 months, the IOP was reduced to 15.00 ± 3.46 mm Hg (P = 0.03) and glaucoma medication was reduced to 2.3 ± 1.4 (P < 0.01). The survival rate at 12 months was 93%. At 12 months, 10 patients were continued on their preoperative steroid treatments, 5 were on tapered steroid treatments, and 5 had ceased steroid treatments entirely. One patient required secondary glaucoma surgery (glaucoma drainage device). No other complications were noted.The Trabectome procedure is safe and highly effective for steroid-response glaucoma, even in the context of continued steroid treatment.