Tarek Shaarawy

Deep sclerectomy with collagen implant in one eye compared with trabeculectomy in the other eye of the same patient.

PurposeTo study the efficacy and safety of deep sclerectomy with collagen implant in one eye versus trabeculectomy in the other eye of the same patient. MethodsThe authors conducted a nonrandomized prospective trial of 20 patients with medically uncontrolled primary and secondary open-angle glaucoma. Patients with bilateral medically uncontrolled glaucoma who had previously undergone trabeculectomy in one eye were selected for the study, and a deep sclerectomy with collagen implant was performed in the second medically uncontrolled glaucomatous eye. Trabeculectomy was studied retrospectively whereas deep sclerectomy with collagen implant was studied prospectively. Visual acuity, intraocular pressure, and slit-lamp examinations were performed before and after surgery, at 1 and 7 days, and at 1, 3, 6, 9, 12, 18, and 24 months. Visual fields were repeated every 6 months. ResultsThe mean follow-up period for both groups was 24.3 ± 19.1 months. The mean intraocular pressure at 24 months was 13.9 ± 4.5 mm Hg for deep sclerectomy with collagen implant and 12.9 ± 4.8 mm Hg for trabeculectomy. At 24 months, IOP was reduced by 39.7% in the deep sclerectomy with collagen implant group (13.8 mm Hg vs. 22.9 mm Hg), and by 55.9% in the trabeculectomy group (12.9 mm Hg vs. 29.3 mm Hg). Forty percent of the deep sclerectomy with collagen implant eyes and 45% of the trabeculectomy eyes achieved a pressure of less than 21 mm Hg without treatment (complete success rate). The deep sclerectomy with collagen implant group showed 50% less hyphema and choroidal detachment than the trabeculectomy group. ConclusionsDeep sclerectomy with collagen implant is another surgical treatment option in the management of glaucoma, showing pressure results comparable with trabeculectomy but with a lower rate of early postoperative complications.

Continuous intraocular pressure monitoring with a wireless ocular telemetry sensor: initial clinical experience in patients with open angle glaucoma

The authors report their initial clinical results with a novel wireless ocular telemetry sensor (OTS) (Sensimed AG, Switzerland) for continuous intraocular pressure (IOP) monitoring in patients with open angle glaucoma. This was a prospective, observational cohort of 15 patients. The OTS is a disposable silicone contact lens with an embedded micro-electromechanical system, which measures changes in corneal curvature induced by variations in IOP. An antenna, mounted around the eye, receives the data, which are then transmitted to a recorder. A signal was recorded in all patients. Thirteen (87%) patients completed 24-h IOP monitoring: one patient discontinued IOP monitoring due to device intolerance, and incomplete recordings were obtained in a second patient due to technical device malfunction. In 9/13 (69%) patients, the highest signals were recorded during the nocturnal period. No serious adverse events were recorded. The OTS shows good safety and functionality to monitor IOP fluctuations in patients over 24 h. This technology has the potential to provide hitherto unobtainable data on the chronobiology of IOP, possibly leading to improved care of glaucoma patients.

Five-year results of deep sclerectomy with collagen implant

Purpose: To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI), a nonpenetrating filtration procedure. Setting: Glaucoma Unit, Department of Ophthalmology, Hôpital Ophtalmique Jules Gonin, University of Lausanne, Lausanne, Switzerland. Methods: This nonrandomized prospective trial comprised 105 eyes of 105 patients with medically uncontrolled primary or secondary open‐angle glaucoma. Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before and after surgery at 1 and 7 days and 1, 3, 6, 9, 12, 18, 24, 30, 36, 48, 54, 60, and 66 months. Visual field examinations were repeated every 6 months. A qualified success was defined as IOP below 21 mm Hg with or without medication. A complete success was defined as IOP lower than 21 mm Hg without medication. Results: The mean follow‐up was 43.2 months ± 14.3 (SD). The mean IOP was 26.8 ± 7 mm Hg preoperatively, 5.1 ± 3 mm Hg 1 day postoperatively, and 11.8 ± 3 mm Hg 60 months postoperatively. At 60 months, the qualified success rate was 94.8% and the complete success rate, 61.9%. The IOP was lower than 21 mm Hg with medication in 32.1% of patients at 60 months; 48 patients (45.7%) had an IOP of 15 mm Hg or lower without medication. No patient developed a shallow or flat anterior chamber, endophthalmitis, or surgery‐induced cataract. However, 23 (21.9%) had progression of a preexisting senile cataract. Injections of 5‐fluorouracil were given to 25 patients (23.8%) who had DSCI to salvage encysted blebs. The mean number of medications per patient was reduced from 2.30 ± 0.76 to 0.49 ± 0.72. Conclusion: Deep sclerectomy with collagen implant provided reasonable IOP over a long‐term follow‐up with few immediate postoperative complications.

Long-term results of deep sclerectomy with collagen implant

Purpose: To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI). Setting: Glaucoma Unit, Department of Ophthalmology, Hôpital Ophtalmique Jules Gonin, University of Lausanne, Lausanne, Switzerland. Methods: This nonrandomized prospective trial comprised 105 eyes of 105 patients with medically uncontrolled primary and secondary open‐angle glaucoma. Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before surgery and after surgery at 1 and 7 days, and 1, 3, 6, 9, 12, 18, 24, 30, 36, 48, 54, 60, 66, 72, 78, 84, 90, and 96 months. Visual field examinations were repeated every 6 months. Results: Mean follow‐up period was 64 months ± 26.6 (SD). Mean preoperative IOP was 26.8 ± 7.7 mm Hg, and mean postoperative IOP was 5.2 ± 3.35 mm Hg at day 1 and 12 ± 3 mm Hg at month 78. At 96 months, the qualified success rate (ie, patients who achieved IOP <21 mm Hg with and without medication) was 91%, and the complete success rate (ie, IOP <21 mm Hg without medication) was 57%. At 96 months, 34% of patients had an IOP <21 mm Hg with medication. Fifty‐one patients (49%) achieved an IOP ≤15 mm Hg without medication. Neodymium:YAG goniopuncture was performed in 54 patients (51%); mean time of goniopuncture performance was 21 months, and mean IOP before goniopuncture was 20 mm Hg, dropping to 11 mm Hg after goniopuncture. No shallow or flat anterior chamber, endophthalmitis, or surgery‐induced cataract was observed. However, 26 patients (25%) showed a progression of preexisting senile cataract (mean time 26 months; range 18 to 37 months). Injections of 5‐fluorouracil were administered to 25 patients (23%) who underwent DSCI to salvage encysted blebs. Mean number of medications per patient was reduced from 2.3 ± 0.7 to 0.5 ± 0.7 (signed rank P<.0001). Conclusion: Deep sclerectomy with collagen implant appears to provide stable and reasonable control of IOP at long‐term follow‐up with few immediate postoperative complications.

Nonpenetrating Glaucoma Surgery

Nonpenetrating glaucoma surgeries have been developed in recent years in order to improve the safety of conventional filtering procedures. The goal of nonpenetrating filtering procedures is to reduce intraocular pressure by enhancing the natural aqueous outflow channels, while reducing outflow resistance located in the inner wall of the Schlemms canal and the juxtacanalicular trabecular meshwork. In the last few years viscocanalostomy and deep sclerectomy with external trabeculectomy have become the most popular nonpenetrating filtering procedures. Both involve removal of a deep scleral flap, the external wall of Schlemms canal and corneal stroma behind the anterior trabeculum and Descemets membrane, thus creating an intrascleral space. The aqueous humour leaves the anterior chamber through the intact trabeculo-Descemets membrane into the scleral space, from where it will egress into different pathways. The technique is associated with a long learning curve. Published clinical trials comparing nonpenetrating glaucoma surgery to full-thickness trabeculectomy have a consensus on the superior safety profile of nonpenetrating glaucoma surgery but are not in agreement when it comes to efficacy, where conflicting results have been found. This article reviews the nonpenetrating surgical techniques, mechanisms of action, indications, contraindications, complications, and results.

Comparative study between deep sclerectomy with and without collagen implant: long term follow up.

Aim: To identify the value of using collagen implant in deep sclerectomy. Methods: A prospective randomised trial of 104 eyes (104 patients) with medically uncontrolled primary and secondary open angle glaucoma. All patients had deep sclerectomy (DS), half of them with and the other half without a collagen implant (CI) sutured in the scleral bed. The main outcome measures were intraocular pressure (IOP), visual acuity, number of treatments preoperative and postoperative, and Nd:YAG goniopunctures. Results: Mean follow up period was 44.5 (SD 21) months for the DS group and 43.9 (SD 14) months for the deep sclerectomy with a collagen implant (DSCI) group. The mean preoperative IOP was 23.3 (SD 7.2) mm Hg for the DS group and 25.6 (SD 4.9) mm Hg for the DSCI group. The mean IOP at the first postoperative day was 6.1 (SD 4.21) mm Hg for the DS group and 5.1 (SD 3.3) mm Hg for the DSCI group. At 48 months IOP was reduced by 40% (14 versus 23.3 mm Hg) for the DS group and by 50% (12.7 versus 25.6 mm Hg) for the DSCI group. Complete success rate, defined as IOP lower than 21 mm Hg without medication, was 34.6% (18/52 patients) at 48 months for the DS group, and 63.4% (33/52 patients) for the DSCI group. Qualified success rate; patients who achieved IOP below 21 mm Hg with or without medication, was 78.8% (41/52 patients) at 48 months and 94% (49/52 patients) for the DSCI group. The mean number of medications was reduced from 2.1 (SD 0.8) to 1.0 (SD 1) after DS, and was reduced from 2.2 (SD 0.7) to 0.4 (SD 0.6) in the DSCI group (p = 0.001) Conclusion: The use of a collagen implant in DS enhances the success rates and lowers the need for postoperative medication.

Five year results of viscocanalostomy

Aim: To prospectively study the success rate and complications of viscocanalostomy, a non-penetrating glaucoma surgery. Methods: Prospective non-randomised consecutive case series of 57 eyes (57 patients) with medically uncontrolled primary and secondary open angle glaucoma. Viscocanalostomy was performed on all participants with injection of viscoelastic in the surgically created ostia of Schlemm’s canal as well as in the scleral bed, the superficial scleral flap was loosely sutured. Intraocular pressure, visual acuity, and number of goniopunctures were measured. Results: The mean follow up period was 34.1 months. The mean preoperative intraocular pressure (IOP) was 24.6 mm Hg; while the mean postoperative IOP was 5.6 mm Hg at day 1 and 13.9 mm Hg at 36 month. Patients who achieved IOP below 21 mm Hg with or without medication were 90% at 60 months, complete success rate (IOP<21 mm Hg without medication) was 60% at 60 months. 21 patients (37%) needed Nd:YAG goniopuncture postoperatively to control raised IOP, mean time for goniopuncture application was 9.4 months, mean pre-goniopuncture IOP was 20.4 mm Hg and mean postgoniopuncture IOP was 12.6 mm Hg (p <0.0001). Conclusion: Viscocanalostomy appears to be a promising modification of filtering surgery.

Deep sclerectomy with collagen implant in patients with glaucoma and high myopia

Purpose: To study prospectively the success rate and complications of deep sclerectomy with collagen implant (DSCI), a nonpenetrating filtration procedure, in patients with glaucoma and high myopia. Setting: Glaucoma Unit, Hôpital Ophtalmique Jules Gonin, Lausanne, Switzerland. Methods: This nonrandomized prospective trial comprised 21 eyes of 21 highly myopic patients with medically uncontrolled primary or secondary open‐angle glaucoma. Visual acuity, intraocular pressure (IOP), and slitlamp examinations were performed before as well as 1 and 7 days and 1, 3, 6, 9, 12, 18, 24, 30, 36, 42, 48, 54, 60, and 66 months postoperatively. Visual field examinations were repeated every 6 months. Exclusion criteria were known allergy to collagen, advanced lens opacity, and eye surgery or laser trabeculoplasty fewer than 6 months before enrollment. Results: The mean follow‐up was 44.0 months ± 17.1 (SD). The mean preoperative IOP of 26.4 ± 5.9 mm Hg dropped to 10.4 ± 6.1 mm Hg at 48 months. Eighty‐one percent of patients achieved an IOP below 21 mm Hg with or without medication at 48 months. Thirty‐eight percent had an IOP below 21 mm Hg without medication. The mean number of medications per patient was reduced from 2.30 ± 0.85 to 0.86 ± 0.91. Conclusions: Deep sclerectomy with collagen implant provided reasonable control of IOP in patients with glaucoma and high myopia over a long‐term follow‐up. There were relatively few postoperative complications.

Ten years follow-up after deep sclerectomy with collagen implant.

PurposeTo evaluate the long-term success rate and complications of nonpenetrating deep sclerectomy with collagen implant in open-angle glaucoma. Patients and MethodsClinical, prospective, monocentric, nonrandomized, unmasked study on 105 patients with medically uncontrolled glaucoma. A standard procedure deep sclerectomy with collagen implant was performed. Complete examinations were performed before surgery and postoperatively at 1 and 7 days; 1, 2, 3, 6, 9, and 12 months and then every 6 months during the 10 following years. ResultsThe mean follow-up was 101.5±43.1 (3 to 144) months [mean±SD, (range)]. The preoperative intraocular pressure (IOP) was 26.8±7.7 (14 to 52) mm Hg and the best-corrected visual acuity 0.71±0.33 (0.02 to 1.5). Ten years after surgery IOP was 12.2±4.7 (6 to 20) mm Hg and best-corrected visual acuity 0.63±0.34 (0.01 to 1.2) (number of remaining patients=52). The mean number of medications per patient went from 2.3±0.7 (1 to 4) down to 1.3±1.1 (0 to 3). An IOP ≤21 mm Hg without medication was achieved in 47.7% patients and in 89% with or without treatment. One major complication was reported. Goniopuncture was performed in 61 eyes (59.8%), 5-fluorouracil treatment given to 25 patients postoperatively and included needling (n=5). ConclusionsOn the basis of a 10-year follow-up deep sclerectomy with collagen implant demonstrated its efficacy in controlling IOP with few postoperative complications.

Quality of diurnal intraocular pressure control in primary open-angle patients treated with latanoprost compared with surgically treated glaucoma patients: a prospective trial

Purpose: To compare the intraocular pressure (IOP) diurnal fluctuations of glaucoma patients treated with latanoprost 0.005% once a day with patients with controlled IOP after deep sclerectomy or trabeculectomy. Methods: The trial included 60 prospectively recruited subjects with primary open-angle glaucoma. The medical group consisted of 20 patients with controlled IOP (<18 mm Hg) under latanoprost 0.005% monotherapy and with no history of previous intraocular surgery or argon laser trabeculoplasty; the surgical groups included 20 patients after trabeculectomy, and 20 patients after deep sclerectomy with collagen implant (DSCI). The patients in the surgical groups had a controlled IOP without any ocular hypotensive medications. All patients underwent a diurnal tension curve (08:00–17:00/three-hour intervals), followed by a water-drinking test (WDT) with the last IOP measurement taken at 21:00 hours. The between-group differences were tested for significance by means of analysis of variance (ANOVA). Results: Baseline IOP was significantly different between the trabeculectomy group (10.1 mm Hg (3.4 SD)), the DSCI group (13.9 mm Hg (2.8)) and the latanoprost group (15.5 mm Hg (2.0); p = 0.005). The average IOP during the diurnal tension curve (10.1, 13.7, and 15.7 mm Hg, respectively, for the trabeculectomy, DSCI, and latanoprost groups) differed significantly between groups (ANOVA; p<0.0001), but the variation was comparable in the three groups (ANOVA; p = 0.13). After the WDT, elevation of IOP was significantly greater among patients treated with latanoprost (p = 0.003). Conclusion: Trabeculectomy patients had a statistically significant lower average IOP in the diurnal tension curve compared with the other two groups. No wider variation in diurnal IOP with latanoprost compared with the surgical procedures was found. The IOP increase during the WDT was most marked in patients under latanoprost therapy.