Primary congenital glaucoma: An updated review.

Aim To evaluate the therapeutic effect of continuous treatment with topical dorzolamide (a carbonic anhydrase inhibitor) for cystoid macular oedema (CME) associated with retinitis pigmentosa (RP). Methods 18 eyes in 10 patients with CME secondary to RP were included. Baseline visual acuity, visual field and optical coherence tomography (OCT) measurements were obtained for all patients. All patients used 1% dorzolamide three times daily in each affected eye. Patients underwent follow-up examinations at 1, 3, 6, 12 and 18 months after treatment. The response to treatment was monitored by the Humphrey field analyser (HFA: the central 10-2 program); in addition, foveal thickness was measured by OCT. Evaluation of ‘macular sensitivity’ was calculated by HFA as the average of 12 central points. Results The ‘macular sensitivity’ in 10 eyes in which CME was almost completely resolved was significantly improved (p<0.05). In eight of the nine eyes in which CME was almost completely resolved within 6 months, the therapeutic efficacy persisted through 18 months. Five eyes which were almost completely resolved or showed an initial response within 6 months experienced recurrence of CME. Conclusions The prolonged (longer than 1 year) use of topical dorzolamide is effective for the treatment of CME in patients with RP. Therefore, we propose topical dorzolamide treatment as a first choice.

Therapeutic Effect of Prolonged Treatment with Topical Dorzolamide for Cystoid Macular Edema in Patients with Retinitis Pigmentosa

Purpose Continuous-wave cyclophotocoagulation (CW-CPC) is often preferred to medical and surgical treatments for managing refractory glaucoma. This review summarizes diode CW-CPC indications, history, histopathology, methods, efficacy and safety. It also provides an overview of the latest data available on micropulse transscleral laser treatment (MP-TLT) that uses repetitive micropulses of diode laser energy in an off-and-on cyclical fashion. Methods A literature review was conducted on transscleral CW-CPC (CW-TSCPC), endoscopic CPC (ECP) and MP-TLT. Relevant series of adult and paediatric patients were included for assessing the procedures. Results Regarding CW-TCPC, highly variable success rates are reported in the literature, depending on the definition of success, type of underlying glaucoma, energy settings, follow-up duration and retreatment rates. CW-CPC often needs to be repeated, especially in paediatric patients. CW-CPC exposes to risks of inflammation and chronic ocular hypotony or phthisis with irreversible visual loss. CW-TSCPC has mainly been used in very severe forms of glaucoma, in painful eyes with limited visual potential or after filtering surgery failure. Published data on ECP are more limited but overall good success rates have been reported. Through the direct visualization of the targeted ciliary body in anatomically abnormal eyes, ECP is the preferred surgical procedure in paediatric refractory glaucoma. Complication rates are relatively low after ECP; however, large studies with long-term follow-up are needed. ECP may be used in difficult, refractory cases, but it is often used earlier when combined with cataract surgery. Despite limited data on the exact mechanism of action of MP-TLT and a lack of standardization of laser settings, the first data from heterogeneous case series shows that it has a similar efficacy and a better safety profile compared to CW-TSCPC in the medium term. Conclusion Although they may lead to sight-threatening complications, both CW-TSCPC and ECP seem effective. ECP appears to be superior to CW-TSCPC in paediatric refractory glaucoma. Unlike ECP combined with cataract surgery, evidence supporting a wider use of CW-TSCPC and MP-TLT in earlier stages of neuropathy is lacking. While it now appears that the safety profile of MP-TLT is superior to that of CW-CPC, robust prospective comparative studies including homogeneous and well-defined cohorts of patients are still needed to confirm an at least comparable efficacy in the long term.

An update on continuous-wave cyclophotocoagulation (CW-CPC) and micropulse transscleral laser treatment (MP-TLT) for adult and paediatric refractory glaucoma.

The Xen Gel Stent lowers intraocular pressure by shunting aqueous humor to the subconjunctival space. While published studies include both open conjunctiva and closed conjunctiva approaches, most publications feature a closed conjunctiva, ab interno approach. While this approach is widely used, other approaches may be preferred for some patients. This paper provides details on surgical steps and tips for enhancing outcomes for an open conjunctiva technique for the implantation of the Xen Gel Stent, as well as reasoning as to when this approach should be used.

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XEN Gel Stent Open Conjunctiva Technique: A Practical Approach Paper.

Cyclodestruction aims to reduce aqueous humor production through the coagulation or destruction of the ciliary body and has been an important treatment choice for glaucoma since the 1930s. The purp...

https://www.tandfonline.com/doi/pdf/10.1080/08820538.2020.1810711

A Review of Cyclodestructive Procedures for the Treatment of Glaucoma.

Purpose:To evaluate the intermediate-term efficacy and safety of micropulsed diode laser cyclophotocoagulation in recurrent pediatric glaucoma.Patients and Methods:A prospective interventional stud...

Micropulsed diode laser cyclophotocoagulation in recurrent pediatric glaucoma.

PURPOSE To evaluate the preliminary results of biodegradable collagen matrix implant (Ologen) designed to improve outcome in patients with infantile glaucoma undergoing combined trabeculotomy and trabeculectomy. METHODS A biodegradable collagen matrix (OculusGen) was placed in the subconjunctival space, partially over the scleral flap and the sclera in 20 eyes of 11 patients with infantile glaucoma who underwent combined trabeculotomy and trabeculectomy. Patients were examined preoperatively and on the first postoperative day with multiple postoperative follow-up visits within 12 months after surgery. Examination included measurements of intraocular pressure (IOP), corneal diameter, and axial length, bleb evaluation, and funduscopy. Ultrasound biomicroscopy of bleb (bleb presence, wall reflectivity, and scleral route visibility) was done at 1, 3, and 6 months and the last follow-up visit. Any complication was recorded. Data analysis was performed using paired-samples t test. RESULTS Mean patient age was 5.7 ± 5.69 months. Mean duration of follow-up was 10.05 ± 1.15 months. Mean preoperative IOP was 25.9 ± 3.08 mm Hg with 1.75 ± 0.55 IOP-lowering medications and mean final postoperative IOP was 17.7 ± 3.51 mm Hg with 0.55 ± 0.69 IOP-lowering medications. Overall success at last follow-up was 80%. None of the patients experienced systemic or ocular complication related to OculusGen. By the 6th month, complete Ologen degradation was evident in all cases. CONCLUSIONS The short-term preliminary results of this study indicate that the combined trabeculotomy and trabeculectomy with Ologen implantation could potentially provide a safe and effective procedure in the infantile age group but longer duration of follow-up in larger number of patients is needed.

Safety and efficacy of collagen matrix implantation in infantile glaucoma.

Objective To evaluate the use of perforated punctal plugs with adjuvant application of mitomycin-C in the management of acquired external punctal stenosis grades 0 and 1. Methods This is a prospective interventional case series including 30 eyes of 30 patients with acquired external punctal stenosis of the lower punctum of grades 0 and 1 presenting with epiphora. They were examined to exclude other causes of lacrimation and epiphora: Slit-lamp assessment of the stenosed punctum and grading was done, probing was done to exclude associated canalicular stenosis, and syringing was done to exclude nasolacrimal duct obstruction. For all cases, dilatation was done, followed by application of mitomycin-C, and perforated punctal plugs were then inserted. Plugs were removed after 6 months, and anatomical and functional success were assessed and followed during and for 6 months after removal of the plugs. Results The study included 30 patients with acquired external punctal stenosis: 9 males (30%) and 21 females (70%) with a mean age of 62.83 ± 8.3 years. Punctal stenosis grade 0 (no punctum) occurred in 9 cases (30%), and grade 1 (the punctum is covered by a membrane) occurred in 21 cases (70%). Six months after removal of the plugs, epiphora improved in 93.3% of patients, and fluorescein dye disappearance test results improved in 90% of patients; 6.7% of cases had early extrusion of the plug, and 3.3% had granuloma formation. Conclusions Application of perforated punctal plugs combined with mitomycin-C is a simple and efficient technique in the management of tight acquired external punctal stenosis.

Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.

Purpose To evaluate the efficacy of supra-Tenon capsule implantation of an Ahmed glaucoma valve (AGV) as a measure to decrease the fibrotic potential of the Tenon capsule on bleb formation and its subsequent effect on intraocular pressure (IOP) control in children with refractory glaucoma. Setting Mansoura Ophthalmic Centre, Faculty of Medicine, Mansoura University, Egypt. Design A prospective interventional study. Patients and methods Twenty-two eyes of 12 children with refractory glaucoma underwent supra-Tenon capsule implantation of AGV. Ophthalmic examinations under general anesthesia including measurement of the corneal diameter and the IOP with Perkin's tonometer were performed preoperatively, on the first postoperative day, the first postoperative week, weekly for the first month, 2-weekly for the following 3 months, and monthly for at least 18 months. Postoperative complications and the number of glaucoma medications used preoperatively and postoperatively were recorded. The paired Student t test was used to compare preoperative and postoperative data. Results There were 12 eyes (54.6%) with refractory congenital glaucoma, 7 eyes (31.8%) with refractory pseudophakic glaucoma, and 3 eyes (13.6%) with refractory aphakic glaucoma. Patients included 10 male (83.3%) and 2 female (16.7%) children with a mean age of 16.3±9.7 months. The mean follow-up duration was 24.1±4.3 months. There was a statistically significant difference between the mean preoperative IOP (30.7±2.88 mm Hg) and the mean postoperative IOP (16.1±3.60 mm Hg) (t=16.22 and P=0.000, with a mean decrease in the IOP by 47.6%). The difference between the mean number of antiglaucoma medications before surgery (1.86±0.4) and after surgery (1.0±0.9) was also statistically significant (t=4.31 and P=0.000). Total success was achieved in 18 eyes (81.9%). Postoperative complications included tube exposure and slippage (10%), hypotony (10%), and hyphema (5%). Conclusions Supra-Tenon capsule implantation of the AGV was successful in controlling the IOP with few postoperative complications in the management of children with refractory glaucoma.

Supra-Tenon Capsule Implantation of the Ahmed Glaucoma Valve in Refractory Pediatric Glaucoma.

Aim To evaluate the long-term results and complications of Ahmed glaucoma valve (AGV) implantation in a cohort of Egyptian patients. Methods A retrospective study of 124 eyes of 99 patients with refractory glaucoma who underwent AGV implantation and had a minimum follow-up of 5y was performed. All patients underwent complete ophthalmic examination and intraocular pressure (IOP) measurement before surgery and at 1d, weekly for the 1st month, 3, 6mo, and 1y after surgery and yearly afterward for 5y. IOP was measured by Goldmann applanation tonometry and/or Tono-Pen. Complications and the number of anti-glaucoma medications needed were recorded. Success was defined as IOP less than 21 mm Hg with or without anti-glaucoma medication and without additional glaucoma surgery. Results Mean age was 23.1±19.9y. All eyes had at least one prior glaucoma surgery. IOP was reduced from a mean of 37.2±6.8 to 19.2±5.2 mm Hg after 5y follow-up with a reduced number of medications from 2.64±0.59 to 1.81±0.4. Complete and qualified success rates were 31.5% and 46.0% respectively at the end of follow-up. The most common complications were encapsulated cyst formation in 51 eyes (41.1%), complicated cataract in 9 eyes (7.25%), recessed tube in 8 eyes (6.45%), tube exposure in 6 eyes (4.8%) and corneal touch in 6 eyes (4.8%). Other complications included extruded AGV, endophthalmitis and persistent hypotony. Each of them was recorded in only 2 eyes (1.6%). Conclusion Although refractory glaucoma is a difficult problem to manage, AGV is effective and relatively safe procedure in treating refractory glaucoma in Egyptian patients with long-term follow-up. Encapsulated cyst formation was the most common complication, which limits successful IOP control after AGV implantation. However, effective complications management can improve the rate of success.

Eman M. Elhefney

Papers

Micropulsed diode laser cyclophotocoagulation in recurrent pediatric glaucoma.

Safety and efficacy of collagen matrix implantation in infantile glaucoma.

Perforated punctal plugs with adjuvant use of mitomycin-C in management of acquired external punctal stenosis grades 0 and 1.

Supra-Tenon Capsule Implantation of the Ahmed Glaucoma Valve in Refractory Pediatric Glaucoma.

Long-term results of Ahmed glaucoma valve implantation in Egyptian population.