Efficacy of glaucoma drainage devices in uveitic glaucoma and a meta-analysis of the literature.
ABSTRACT: PURPOSE:To assess the efficacy of glaucoma drainage devices (GDD) in uveitic glaucoma and non-uveitic glaucoma, and to perform a meta-analysis of previously published results to compare with our data. METHODS:Retrospective case-control study, in which all eyes that underwent GDD surgery were included from 2015 onwards. Cases were defined as patients with uveitic glaucoma. Patients with non-uveitic glaucoma served as controls. To compare our results, a review of the literature was performed using PubMed database. RESULTS:A total of 99 eyes were included (38 with uveitic glaucoma). The preoperative IOP was 25.9?±?7.7 mmHg and 27.9?±?9.6 mmHg for patients with and without uveitis (p =?0.277). No significant differences were found between patients with and without uveitis in the final IOP or reduction in IOP (44.9% vs. 42.8%, respectively). Within the first year after surgery, 13.2% of cases developed macular edema (vs. 6.6%; p =?0.267) and 15.8% a transient hypotony (vs. 8.2%; p =?0.242). A meta-analysis of 24 studies showed a postoperative weighted mean difference of -?17.8 mmHg and 2.2 lower number of IOP-lowering medications in uveitic glaucoma (compared to -?13.2 mmHg and 3.5 in the current study, respectively). CONCLUSION:GDD surgery in patients with uveitis has a similar effect on IOP as in patients without uveitis. The risks of developing macular edema and hypotony were slightly higher in patients with uveitis, but the results were not statistically significant. These findings are in line with previous reports, though data on the efficacy of GDD surgery and macular edema in uveitic glaucoma is scarce.
Project description:BACKGROUND:To assess the efficacy and safety of the second-generation probe of ultrasonic circular cyclocoagulation (UC3) in naive or refractory glaucoma, with a 6-month follow-up. METHODS:A retrospective consecutive case-series study included patients having a UC3 procedure with the second-generation probe of the EyeOP1 device, intraocular pressure (IOP) ? 21 mmHg and under maximum tolerated medical treatment, with or without previous glaucoma surgery. Surgical success was defined at the 6-month post-operative visit as IOP > 5 and ? 21 mmHg with IOP reduction ? 20% from baseline, without any reoperation, and visual acuity better than negative light perception. RESULTS:100 patients were included and 97 (97.0%; 97 eyes) attended the 6-month follow-up. At 6 months, surgical success was obtained in 48 eyes (49.5%). Intraocular pressure was reduced from a mean ± SD preoperative value of 28.0 ± 5.6 mmHg to 19.3 ± 7.1 mmHg at 6 months (p<0.0001). The proportion of eyes requiring oral acetazolamide decreased from 57.0% to 30.0% between baseline and 6 months after surgery (p = 0.0007). We observed 15 (15.0%) cases of postsurgical macular edema, 8 (8.0%) of hypotony, and 20 (20.0%) of visual acuity loss > 2 Snellen lines. Postsurgical macular edema was associated with a history of epiretinal membranes, uveitis or retinal detachment. Risk factors for hypotony were a history of diabetes or trabeculectomy. CONCLUSIONS:The second-generation UC3 probe significantly reduced IOP in eyes with naive and refractory glaucoma but severe post-operative complications were often observed. Further studies are needed to better identify responders and decrease the high risk for complications associated with the procedure.
Project description:The purpose of this study was to report the functional and anatomical outcomes of a prospective study resulting from repeated dexamethasone intravitreal implants in patients with uveitic refractory macular edema.Twelve eyes of 9 patients with intermediate and posterior noninfectious inflammatory uveitis complicated with refractory macular edema were regularly reviewed after a dexamethasone intravitreal implant. Patients were examined at baseline, 30, 90, 135, and 180 days with best-corrected visual acuity (BCVA), complete slit-lamp examination, intraocular pressure (IOP), optical coherence tomography, and fluorescein angiography. After 6 months of follow-up, eyes were reassessed to receive a second implant.BCVA significantly improved when comparing the baseline values after the first and second implant (16.2 and 25.8 letters, respectively, 9.6 letters improvements, p<0.05). BCVA was better after the second implant compared to the first one throughout the follow-up, but without statistical significance. Mean central macular thickness (CMT) was 446.3±129.9 ?m at baseline and was significantly reduced until day 135 (p<0.05). CMT reductions after the second injection showed a similar pattern, though differences were not statistically significant. Cataract progression was observed in 4 of 8 phakic eyes (50%) after the first implant, and in 2 of 3 phakic eyes following the second implant, with 1 eye requiring cataract surgery. One eye developed an IOP >30 mmHg 30 days after the second implant, treated topically.Repeated dexamethasone intravitreal implants in uveitic patients with refractory macular edema can be used effectively in a clinical setting with an acceptable safety profile.
Project description:<h4>Importance</h4>To investigate the safety, effectiveness and follow-up rates after transscleral diode laser cyclophotocoagulation as primary treatment for seeing eyes with primary open angle glaucoma in Bauchi, Nigeria.<h4>Background</h4>There is a high prevalence of primary open angle glaucoma in Africa where adherence to medical treatment and acceptance of surgery are poor.<h4>Design</h4>Prospective case series.<h4>Participants</h4>New glaucoma patients where surgical intervention was recommended.<h4>Methods</h4>A diode 810?nm laser G-probe was used under retrobulbar anaesthesia to deliver approximately 20 shots for 2000?ms, titrating the power. If both eyes were treated the first was the study eye. Repeat treatment offered if the intraocular pressure (IOP) was >21?mmHg on two consecutive visits.<h4>Main outcome measures</h4>IOP?<?22?mmHg, change in ?2 lines of Snellen visual acuity (VA), and complications.<h4>Results</h4>201 out of 204 eyes with complete data analysed. Mean age 52?years, 17 (8.3%) eyes were re-treated. Mean pre-treatment IOP was 39 (SD 11) mmHg. 106 (53%) attended at 12?months when the mean IOP was 19 (7-45) mmHg; 77 (73%) had IOP < 22?mmHg. VAs were better in 13 (12.3%) and worse in 23 (21.7%) eyes. Postoperative complications included mild uveitis (5.5%), corneal oedema (2.5%), severe uveitis (0.5%) and transient hypotony (2.0%). No hypotony at 12?months.<h4>Conclusions and relevance</h4>Transscleral diode laser cyclophotocoagulation controlled IOP in almost three quarters of eyes at 12?months with short-term preservation of vision and minimal complications. Poor follow-up in this setting highlights the need for an effective, safe and acceptable treatment where regular follow-up is less critical.
Project description:PURPOSE:To describe the risk and risk factors for ocular hypertension (OHT) in adults with noninfectious uveitis. DESIGN:Retrospective, multicenter, cohort study. PARTICIPANTS:Patients aged ?18 years with noninfectious uveitis seen between 1979 and 2007 at 5 tertiary uveitis clinics. METHODS:Demographic, ocular, and treatment data were extracted from medical records of uveitis cases. MAIN OUTCOME MEASURES:Prevalent and incident OHT with intraocular pressures (IOPs) of ?21 mmHg, ?30 mmHg, and increase of ?10 mmHg from documented IOP recordings (or use of treatment for OHT). RESULTS:Among 5270 uveitic eyes of 3308 patients followed for OHT, the mean annual incidence rates for OHT ?21 mmHg and OHT ?30 mmHg are 14.4% (95% confidence interval [CI], 13.4-15.5) and 5.1% (95% CI, 4.7-5.6) per year, respectively. Statistically significant risk factors for incident OHT ?30 mmHg included systemic hypertension (adjusted hazard ratio [aHR], 1.29); worse presenting visual acuity (?20/200 vs. ?20/40, aHR, 1.47); pars plana vitrectomy (aHR, 1.87); history of OHT in the other eye: IOP ?21 mmHg (aHR, 2.68), ?30 mmHg (aHR, 4.86) and prior/current use of IOP-lowering drops or surgery in the other eye (aHR, 4.17); anterior chamber cells: 1+ (aHR, 1.43) and ?2+ (aHR, 1.59) vs. none; epiretinal membrane (aHR, 1.25); peripheral anterior synechiae (aHR, 1.81); current use of prednisone >7.5 mg/day (aHR, 1.86); periocular corticosteroids in the last 3 months (aHR, 2.23); current topical corticosteroid use [?8×/day vs. none] (aHR, 2.58); and prior use of fluocinolone acetonide implants (aHR, 9.75). Bilateral uveitis (aHR, 0.69) and previous hypotony (aHR, 0.43) were associated with statistically significantly lower risk of OHT. CONCLUSIONS:Ocular hypertension is sufficiently common in eyes treated for uveitis that surveillance for OHT is essential at all visits for all cases. Patients with 1 or more of the several risk factors identified are at particularly high risk and must be carefully managed. Modifiable risk factors, such as use of corticosteroids, suggest opportunities to reduce OHT risk within the constraints of the overriding need to control the primary ocular inflammatory disease.
Project description:PURPOSE:This study examines the incidence of visually significant cystoid macular edema (CME) after glaucoma drainage implant (GDI) surgery and analyses risk factors associated with developing CME and prognosis with treatment. MATERIALS AND METHODS:In total, 185 eyes from 185 glaucoma patients (mean age, 72.46±13.94?y) who underwent GDI surgery at a tertiary eye institute were recruited. Patients were classified based on the presence (CME) or absence (No-CME) of CME. Pre-GDI and post-GDI best-corrected visual acuity, number of intraocular pressure (IOP)-lowering medications, IOP, standard automated perimetry and post-GDI complications, were recorded and compared between the 2 groups. Optical coherence tomography (OCT) was used to quantify retinal thickness and monitor CME. RESULTS:In total, 41 (22.2%) eyes developed visually significant CME after GDI surgery. Patients with CME had a higher incidence of pre-GDI nonsteroidal anti-inflammatory drug (P<0.01) use and higher number of prior glaucoma surgeries (P<0.01). CME patients had a higher (P<0.01) incidence of iritis, epiretinal membrane, and hypotony. CME eyes responded well to steroids, with resolving macular edema (458.4±151.9 vs. 322.0±92.0?µm, P<0.01) and improving visual acuity (0.73±0.48 vs. 0.56±0.56?logarithm of minimum angle of resolution, P<0.01). Both CME and non-CME groups had equivalent lowering of IOP and post-GDI glaucoma medications; with no significant elevation in IOP in the steroid-treated CME group. CONCLUSIONS:Post-GDI surgery visually significant CME rates are potentially higher in a real hospital scenario compared with controlled clinical trials. With diligent treatment, CME resolves effectively restoring visual acuity and central macular thickness.
Project description:To evaluate the efficacy and safety of ripasudil for treatment of secondary glaucoma, a historical cohort study was conducted at 18 centres in Japan. Adults (age ?20 years) who needed additional IOP reduction and received topical 0.4% ripasudil between 2014 and 2018 due to three secondary glaucoma subtypes, including uveitic glaucoma (UG), exfoliation glaucoma (EG) or steroid-induced glaucoma (SG) were assessed for mean IOP change from baseline prior to additional treatment with ripasudil. We further evaluated the IOP change in each glaucoma subtype, baseline characteristics of each cohort, course of uveitis-induced inflammation in UG eyes, and proportion of patients in each cohort with adverse events. In 332 eyes from 332 patients eligible for this study, the mean overall IOP reductions from baseline at 1, 3, and 6 months were -5.86?±?9.04?mmHg (-19.4?±?25.1%), -6.18?±?9.03?mmHg (-20.0?±?27.1%), and -7.00?±?8.60?mmHg (-23.4?±?25.6%), respectively. These changes were all statistically significant. Of 332 eyes, 109 eyes had UG, 181 had EG, and 42 eyes had SG. The IOP-lowering effects of ripasudil in UG and SG were significantly greater than those of EG at every time point. This finding could have been related to higher baseline IOP levels in UG and SG. UG patients exhibited significant decreases in mean cell score of the anterior segment after ripasudil treatment. No severe adverse events were reported. These findings suggest that treatment with ripasudil is a safe and effective therapeutic modality for IOP reduction in secondary glaucoma.
Project description:PurposeTo report the results of subconjunctival ologen Collagen Matrix implantation to manage ocular hypotony after filtration glaucoma surgery.Patients and methodsThis retrospective observational case series included 12 consecutive implantations of ologen in nine eyes of nine Japanese subjects (five men, four women; mean age±SD, 72.1±12.7 years) who underwent subconjunctival implantation of the device to treat hypotony after glaucoma filtration surgery. Demographic data and surgical results were collected by chart review.ResultsThe subjects included six patients who underwent trabeculectomy and three who underwent an EX-PRESS shunt surgery. The duration between the last glaucoma surgery and the initial ologen implantation was longer than 2 years in seven (78%) eyes. Bleb leakage in five (56%) eyes preoperatively stopped in all cases by 8 days after the device implantation. After the initial implantation, three (33.3%) eyes required a second implantation of ologen because of insufficient efficacy. After a mean follow-up of 12.6±6.8 months, the mean preoperative intraocular pressure (IOP) of 3.8±2.7?mmHg increased significantly (P=0.0001) to 9.0±3.2?mmHg; no eye required glaucoma medication to control the IOP. No vision-threatening complications developed in association with the treatment.ConclusionWhen conservative management failed, subconjunctival implantation of ologen Collagen Matrix in combination with bleb revision can be a useful therapeutic option for ocular hypotony after glaucoma filtration surgery.
Project description:The purpose of this study was to evaluate the real-world use, efficacy, and safety of one or more dexamethasone intravitreal implant(s) 0.7 mg (DEX implant) in patients with macular edema (ME).This was a retrospective cohort study of patients with ME secondary to retinal disease treated at ten Canadian retina practices, including one uveitis center. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure (IOP), glaucoma and cataract surgery, and safety data were collected from the medical charts of patients with ≥3 months of follow-up after the initial DEX implant.One hundred and one patient charts yielded data on 120 study eyes, including diagnoses of diabetic ME (DME) (n=34), retinal vein occlusion (RVO, n=30; branch in 19 and central in 11), and uveitis (n=23). Patients had a mean age of 60.9 years, and 73.3% of the study eyes had ME for a duration of ≥12 months prior to DEX implant injection(s). Baseline mean (± standard error) BCVA was 0.63±0.03 logMAR (20/86 Snellen equivalents) and mean CRT was 474.4±18.2 μm. The mean number of DEX implant injections was 1.7±0.1 in all study eyes; 44.2% of eyes had repeat DEX implant injections (reinjection interval 2.3-4.9 months). The greatest mean peak changes in BCVA lines of vision occurred in study eyes with uveitis (3.3±0.6, P<0.0001), followed by RVO (1.3±0.5, P<0.01) and DME (0.7±0.5, P>0.05). Significant decreases in CRT were observed: -255.6±43.6 μm for uveitis, -190.9±23.5 μm for DME, and -160.7±39.6 μm for RVO (P<0.0001 for all cohorts). IOP increases of ≥10 mmHg occurred in 20.6%, 24.1%, and 22.7% of DME, RVO, and uveitis study eyes, respectively. IOP-lowering medication was initiated in 29.4%, 16.7%, and 8.7% of DME, RVO, and uveitis study eyes, respectively. Glaucoma surgery was performed in 1.7% of all study eyes and cataract surgery in 29.8% of all phakic study eyes receiving DEX implant(s).DEX implant(s) alone or combined with other treatments and/or procedures resulted in functional and anatomic improvements in long-standing ME associated with retinal disease.
Project description:<h4>Introduction</h4>The purpose of this study was to determine whether the outcomes following placement of a fluocinolone acetonide implant (Retisert(®); Bausch & Lomb, Inc.) combined with an Ahmed™ glaucoma valve (New World Medical, Inc.) in eyes with uveitic glaucoma (UG Retisert) were different when compared to an Ahmed valve alone in eyes with uveitic glaucoma or primary open angle glaucoma (UG non-Retisert and POAG, respectively).<h4>Methods</h4>Retrospective, interventional study of consecutive uveitic and OAG eyes undergoing Ahmed valve (AV) implantation with or without combined Retisert insertion at a single academic center between 2009 and 2012. Surgical success was defined as intraocular pressure (IOP) between 5 and 18 mmHg and greater than 20% reduction of IOP at two consecutive visits without need for additional IOP-lowering medications or surgical procedures. Secondary outcome measures included IOP and number of glaucoma medications.<h4>Results</h4>Sixty eyes of 60 patients (22 UG Retisert, 16 UG non-Retisert, 22 POAG) were included. Mean ± standard deviation surgical success duration was significantly greater in UG Retisert eyes, 629 ± 53 days, compared to those with UG non-Retisert, 361 ± 37 days, and POAG, 472 ± 65 days (P = 0.034). At 24 months, the mean IOP was 11.7, 12.1, and 15.0 mmHg and the average patient was on 1.45, 0.71, and 2.00 medications in the UG Retisert, UG non-Retisert, and POAG valve groups, respectively.<h4>Conclusion</h4>Retisert implants when combined with AV in uveitic glaucoma had a longer duration of surgical success than uveitic or POAG treated with AV insertion alone.
Project description:Uveitis patients represent a unique subset of the population undergoing cataract surgery and pose several challenges that require special consideration and strategy. Maintenance of disease quiescence for at least three months prior to surgery maximizes postoperative outcomes, though these patients remain at increased risk for pseudophakic cystoid macular edema, which can be refractory to the traditional steroid treatments. In this review, we detail the pillars of preoperative optimization, intraoperative considerations, and postoperative management of uveitic cataracts, with special attention on the evidence surrounding prevention and treatment of refractory postoperative cystoid macular edema.