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FREE PAPERS FP1 12 month results from a prospective, multicenter study of a nickel-titanium Schlemm’s canal scaffold for IOP reduction after cataract surgery in open angle glaucoma Norbert Pfeiffer1, Katrin Lorenz1 1 Department of Ophthalmology, University Medical Center, Mainz - Germany Purpose: The objective of the study was to evaluate the ability of the Hydrus™ Microstent (Ivantis, Inc. Irvine, California) to lower IOP in patients with mild to moderate open angle glaucoma. Methods: The study was conducted in 6 centers located in Germany, Austria, and Mexico. The study was performed under Medical Ethics Committee approvals. All subjects provided written informed consent in order to enter the study. Key inclusion criteria included a diagnosis of primary open angle glaucoma (POAG) or pseudoexfoliative glaucoma (PXF) confirmed by either visual field defect or nerve fiber layer imaging, an age related cataract, visual acuity worse than 20/40, and a screening IOP of 24 mmHg or less on no more than 4 medications. Secondary glaucoma, significant ocular pathology other than cataract and glaucoma, and prior glaucoma surgery were excluded. To control for medication confounding the endpoint, subjects were washed out of all glaucoma medications prior to surgery. Washed out IOP had to be between 22-32 mmHg based on Goldmann applanation tonometry. Post operatively, subjects were followed up at 1, 7, 30, 90, 180, and 365 days. Results: A total of 29 patients were recruited from 6 centers. Study subjects had a mean age of 70.9 ± 6.5 years and were 55% female. 76% of subjects were Caucasian and 21% were Hispanic. POAG was diagnosed in 79%, and the average mean deviation was -4.49 ± 4.62 and PSD was 4.92 ± 3.31 based on Humphrey visual field analysis. At screening, medicated IOP was 21.1 ± 5.6 mmHg treated with an average of 2.2 ± 1.4 glaucoma medications. Wash out resulted in an increase in IOP to 24.6 ± 5.3 mmHg. All surgeries resulted in successful Hydrus implantation. Surgical complications included one case of mild iris damage; there were no other complications. 100% of study subjects completed all the scheduled follow up visits through 6 months, and 13 patients completed 12 month follow up. At 6 monhts, the mean (± SD) IOP mean IOP decreased by 8.7 points from the wash out value while medication use only increased to an average of 0.2 meds/patient. Medication use was stable between 6 and 12 months. At 12 months, washed out IOP was 15.5 ± 3.3 mmHg (p < 0.05), a decrease of 9.1 mmHg. The remainder of the 12 month follow up will be complete by the date of the conference. Conclusion: The use of the implant resulted in significant drops in IOP and medication use from baseline values. At 12 months the mean washed out mean IOP was 15.5 mmHg, a reduction of 9.1 points from the mean baseline washed out value. There were no reports of hypotony, endophthalmitis, or shallow AC. There was one patient 1 with a small area of PAS at the inlet area of the device, and one patient with PCO. Overall safety was consistent with cataract surgery alone. A safe, permanent implant may offer a preferable means for IOP control in select patients. FP2 Histological features of gold micro shunt in patients with unsuccessful implantation Marek Rekas1, Beata Pawlik1 1 Ophthalmology Department, Military Institute of Medicine in Warsaw, Marki - Poland Purpose: To describe the histological features of failed Gold Micro Shunt implantation for primary open angle glaucoma patients. Material and methods: Four eyes of four patients with unsuccessful GMS implantation were included. All of them underwent shunt removal. The histological analysis was performed throughout the whole extent of the shunt describing inner and outer surface. Results: The mean intraocular pressure before GMS removal was 26.2 ± 5.3 mmHg on maximal tolerated therapy. The mean time of GMS removal was 29.7 ± 8.3 months. Verification of GMS position in the suprachoroidal space was confirmed by ultrasound and AS-OCT. None of case presented corneal endothelial or iris contact. In spite of this in three cases signs of corneal decompensation were observed. Characteristic histological findings were observed in each analysed devices. In all cases we did find a marked fibrous tissue colonization of the outer surface, inner channels and grid holes. Thick fibrous tissue was showed around the device. The inner channels were filled with loosely arranged tissue. Histological differences showed presence of inflammatory cell infiltration. In one case we found necrotic tissue. Conclusions: It’s a high probability that fibrous tissue development is important factor affecting the efficacy of this device as well as presence of inflammatory cells and their metabolic products. Understanding and knowledge of pathophysiological reactions around the gold device will let us eventually modify them in the future. FP3 Pars plana vitrectomy with capsulotomy communicating anterior chamber and vitreous cavity in surgical treatment of malignant glaucoma in pseudophakic eyes Marek Rekas1, Karolina Krix-Jachym1, Mariusz Kosatka1 1 Ophthalmology Department, Military Institute of Medicine in Warsaw, Warsaw - Poland Purpose: To investigate the results of partial PPV with peripheral lens capsule excision communicating anterior and posterior chamber in malignant glaucoma treatment. Material and methods: A case series study comprised 17 patients and 20 eyes after combined cataract and glaucoma surgery with malignant glaucoma diagnosis. PPV with peripheral lens capsule excision communicating anterior chamber and vitreous cavity was performed. IOP, number of medications and BCVA were examined. On the basis of the assessment of the anterior and posterior segments of the eye the character and also the degree of intensification of postoperative complications were established.Follow-up examinations were performed on days 1 and 7, and at 1, 3, 6, 12 months. The complete success rate was defined as IOP ≤21 mmHg without, and the qualified success rate as IOP ≤ 21 mmHg with and without antiglaucoma medications. Results: Mean time from malignant glaucoma diagnosis to PPV was 61.4 (range: 0-840 days), mean follow up was 405.4 (7-1440 days) Me 12 months. Mean IOP decreased by 49.3% (Me 55.8%) (range -11.8-80.8%) on the 1. day after surgery, 12 months after surgery mean IOP reduction was 43.0% (Me 45.3%) (range 5.8-72.3%). Mean IOP decreased from 30.4 ± 14.2 mmHg (Me 25 mmHg) to 14.6 ± 3.2 (Me 15 mmHg) 12 months after surgery (p < 0.00001). The mean number of medications was reduced from 3.3 ± 1.1 (Me 3) to 1.2 ± 1.1 (Me 1) (p = 0.002218). Complete and qualified success rates were 49.0 % and 85.7 %, respectively. Mean logMAR of BCVA changed from 0.9 ± 0.7 to 0.3 ± 0.5 (Me 0.2) (p = 0.00001). Among complications in the analyzed material increased IOP (5%), vitreous haemorrhage (10%), recurrence of malignant glaucoma (15%), CME (10%) and retinal detachment (5%) were noted. Conclusion: PPV with peripheral lens capsule excision allows effective IOP control in 12 months follow-up. In most cases there is a necessity of additional use of antiglaucoma drugs in order to obtain the desired level of IOP after surgery. Safety profile of PPV in this modification doesn’t differ from complications observed after penetrating surgeries. FP4 Conjunctival advancement flap for restoration of visual function while conserving filtration in dysfunctional antimetabolite blebs William Sponsel1, Sylvia Groth2, Randy Craven3 1 WESMDPA/UTSA Department of Biomedical Engineering, San Antonio, Texas - USA, 2University of Minnesota Medical School, Minneapolis, Minnesota - USA, 3Specialty Eye Care Associates, Denver, Colorado - USA Purpose: Mitomycin-C can reduce fibrovascular closure of filtering blebs, but occasionally antimetabolite blebs may develop diffuse oozing or full-thickness leaks, with or without hypotony. These changes can lead to altered vision from corneal irregularity and macular edema, with increased risk of endophthalmitis. In this consecutive case series, we investigated the long-term efficacy of a fornix-based teno-conjunctival advancement flap to close leaks, change limbal anatomy and relieve hypotony. Methods: This study was a 2-year observational case series of 44 eyes of 42 consecutive patients with Seidel-positive bleb leak, dysfunctional limbal anatomy or hypotony undergoing a fornix-based conjunctival advancement procedure. It was a quality assurance series with IRB approval. • All patients undergoing conjunctival advancement at each of the two study centers (Denver, Colorado and San Antonio, Texas) from January 2001- December 2011 satisfying the above inclusion criteria were included in this analysis. • Eyes undergoing any other concomitant procedure in the same eye, including cataract extraction, were excluded. • Outcome measures were ∆IOP, ∆acuity and ∆glaucoma medications. Results: Recovery from hypotony was immediate and sustained (p < 0.001), with associated significant improvement in visual acuity (p < 0.0001): Age (years) 70.6 ± 1.9 (sem) Mean follow-up 20.3 ± 1.0 months Pre-op IOP 4.09 ± 0.4 mmHg 6-month post-op IOP 10.3 ± 0.5 mmHg 12-month post-op IOP 12.0 ± 1.0 mmHg 24-month post-op IOP 11.1 ± 0.7 mmHg Pre-op meds 0.02 ± 0.02 12-month meds 0.3 ± 0.1 Conclusion: Conjunctival advancement over an intact bleb is very effective at closing bleb leaks and maintaining IOP at a safe and protective level through three years. Visual acuity improved significantly and the number of medications required remained minimal. Healing phenomena (e.g. tissue turgor, inflammation, and early fibrosis) may be responsible for the initial mid-normal range IOP at 1 month, later decreasing and remaining in the low-normal range at all subsequent intervals. FP5 Ex-PRESS mini-glaucoma shunt surgery: outcomes after four years of follow-up Orna Geyer1, Zoya Rabkin-Mainer1 1 Department of Ophthalmology, Carmel Medical Center, Haifa - Israel Purpose: To report 4-year outcomes of treatment by Ex-PRESS Mini-Glaucoma Shunt implantation in patients with previous ocular surgeries. Methods: This is a retrospective non-comparative case series study of patients with open-angle glaucoma and previous glaucoma or cataract surgeries, who underwent implantation of an Ex-PRESS Mini-Glaucoma Shunt (Model R 50) under scleral flaps. Outcome measures included intraocular pressure (IOP), number of antiglaucoma medications, and complications. Success was defined as an IOP of 5-21 mmHg with (“qualified”) or without (“complete”) the use of antiglaucoma medications and without reoperation for glaucoma. The more stringent target of IOP of 5-17 mmHg with or without antiglaucoma medications was also recorded. Results: A total of 65 implanted eyes (59 patients, mean age 70.7 ± 13.5 years, mean follow-up 30.4 ± 16.3 months) were evaluated. At last follow-up, success was complete in 15 eyes (23.1%) and qualified in 28 eyes (43.1%). The mean preoperative IOP of 32.8 ± 7.9 mmHg (range: 16-56 mmHg) with 3.7 ± 1.1 drugs declined postimplantation to 17.1 ± 5.7 mmHg with 2.2 ± 1.7 drugs 2 (p < 0.0001). Cumulative probabilities of success were 85.5%, 66.7%, 47.1% and 9.8%, at 1, 2, 3 and 4 years, respectively, for complete success, 76.9%, 56.9%, 45.2% and 31.4% at 1, 2, 3 and 4 years, respectively, for qualified success. They were 85.5%, 68.4%, 54.3% and 37.8% at 1, 2, 3 and 4 years, respectively, for achieving an IOP of 5-17 mmHg. The most frequent early postoperative complications (i.e., within one week following surgery) were choroidal detachment (18%), which resolved spontaneously, and flat anterior chamber necessitating intervention (15.4%). There was a total of 26 (40%) failed eyes (all due to uncontrolled IOP), and 17 (65%) of them underwent reoperation for glaucoma. Conclusion: The current study demonstrates significant short-term lowering of IOP in eyes with open-angle glaucoma following Ex-PRESS mini glaucoma shunt implantation under scleral flap. Long-term success, however, is much more limited. FP6 Three year results of the Ahmed Baerveldt Comparison (ABC) Study Renata Puertas1, Donald Budenz2, William Feuer3, Keith Barton1, Vital Costa4, David Godfrey5, Yvonne Buys6 1 Moorfields Eye Hospital, London - United Kingdom, 2 Ophthalmology, University of North Carolina, Chapel Hill - USA, 3Biostatistics, University of Miami-Bascom Palmer, Miami - USA, 4Ophthalmology, University of Campinas, Sao Paulo, - Brazil, 5Glaucoma Associates of Texas, Dallas - USA, 6Ophthalmology & Vision Sciences, University of Toronto, Toronto - USA Purpose: To compare the safety and efficacy of the Ahmed Glaucoma Valve (model FP7) to the Baerveldt Glaucoma Implant (model 101-350) in patients with refractory glaucoma after three years of follow-up. Methods: Patients 18 to 85 years of age with refractory glaucoma having intraocular pressure (IOP) of 18 mmHg or more in whom an aqueous shunt was planned were randomized to undergo implantation of either an Ahmed or a Baerveldt implant. The main outcome measures were IOP, visual acuity, use of supplemental medical therapy, complications, and failure (IOP > 21 mmHg or not reduced by 20%, IOP ≤ 5 mmHg, reoperation for glaucoma or removal of implant, or loss of light perception vision). Results: Retention rates at 18, 24, and 36 months respectively were 92%, 87%, and 75%. The risk of failure by any criterion was similar for the Ahmed and Baerveldt implants (risk ratio = 1.0, p = 0.88, 95% CI = 0.7, 1.6); however, the risk of reoperation for glaucoma was 2.0 times higher with the Ahmed implant than the Baerveldt implant (p = 0.074, 95% CI = 0.9, 4.4). At 36 months, mean (SD) IOP was 14.3 mmHg (4.9) in the Ahmed group and 12.9 mmHg (4.4) in the Baerveldt group (p = 0.049). The mean (SD) number of IOP lowering medicines was 1.9 (1.4) in the Ahmed group and 1.5 (1.4) in the Baerveldt group (p = 0.048). Conclusions: There was no difference in failure rates, but the modestly better intraocular pressure control with the Baerveldt implant compared to the Ahmed 3 implant seen at one year follow-up persisted through 3 years. FP7 Treatment outcomes in the tube versus trabeculectomy (TVT) study after five years of follow-up Poornima Rai1, Keith Barton1, Steven Gedde2, Joyce Schiffman2, William Feuer2, Leon Herndon3, James Brandt4, Donald Budenz2 1 Glaucoma. Moorfields Eye Hospital, London - United Kingdom, 2Department of Ophthalmology, Bascom Palmer Eye Institute, Miami - USA, 3Department of Ophthalmology, Duke University, Durham - USA, 4 Department of Ophthalmology, University of California, Davis, Sacramento - USA Purpose: To report 5-year treatment outcomes in the Tube Versus Trabeculectomy (TVT) Study Methods: Multicenter randomized clinical trial. Setting: 17 Clinical Centers. Study Population: Patients 18 to 85 years of age who had previous trabeculectomy, cataract extraction with intraocular lens implantation, or both and uncontrolled glaucoma on maximum tolerated medical therapy with intraocular pressure (IOP) ≥ 18 mmHg and ≤ 40 mmHg. Interventions: 350 mm2 Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC) 0.4 mg/ml for 4 minutes. Main Outcome Measures: IOP, use of glaucoma medications, failure (IOP > 21 mm Hg or not reduced by 20%, IOP ≤ 5 mmHg, reoperation for glaucoma, loss of light perception vision). Results: A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in the trabeculectomy group. At 5 years, IOP (mean ± SD) was 14.4 ± 6.9 mm Hg in the tube group and 12.6 ± 5.9 mm Hg in the trabeculectomy group (p = 0.12). The number of glaucoma medications (mean ± SD) was 1.4 ± 1.3 in the tube group and 1.2 ± 1.5 in the trabeculectomy group (p = 0.23). The cumulative probability of failure during the first 5 years of follow-up was 29.8% in the tube group and 46.9% in the trabeculectomy group (p = 0.002). The rate of reoperation for glaucoma was 9% in the tube group and 29% in the trabeculectomy group (p = 0.025). Conclusions: Tube shunt surgery had a higher success rate compared with trabeculectomy with MMC during the first 5 years of follow-up in the TVT Study. Both procedures were associated with similar IOP reduction and use of glaucoma medical therapy at 5 years. Additional glaucoma surgery was needed more frequently after trabeculectomy with MMC than tube shunt placement. FP8 Surgical complications in the tube versus trabeculectomy (TVT) study during the first five years of follow-up Poornima Rai1, Keith Barton1, James Brandt2, Donald Budenz3, Steven Gedde3, Joyce Schiffman3, William Feuer3, Leon Herndon4 1 Glaucoma Service, Moorfields Eye Hospital, London United Kingdom, 2Department of Ophthalmology, University of California, Davis, Sacramento - USA, 3 Department of Ophthalmology, Bascom Palmer Eye Institute, Miami - USA, 4Department of Ophthalmology, Duke University, Durham - USA Purpose: To describe postoperative complications encountered in the Tube Versus Trabeculectomy (TVT) Study during the first 5 years of follow-up. Methods: Multicenter randomized clinical trial. Setting: 17 Clinical Centers. Study Population: Patients 18 to 85 years of age who had previous trabeculectomy, cataract extraction with intraocular lens implantation, or both and uncontrolled glaucoma on maximum tolerated medical therapy with intraocular pressure (IOP) > 18 mm Hg and < 40 mm Hg. Interventions: 350 mm2 Baerveldt glaucoma implant or trabeculectomy with mitomcyin C (MMC) 0.4 mg/ml for 4 minutes. Main Outcome Measures: Surgical complications, reoperations for complications, visual acuity, and cataract progression. Results: Early postoperative complications occurred in 22 (21%) patients in the tube group and 39 (37%) patients in the trabeculectomy group (p = 0.012). Late postoperative complications developed in 36 (34%) patients in the tube group and 38 (36%) patients in the trabeculectomy group (p = 0.81). The rate of reoperation for complications was 22% in the tube group and 18% in the trabeculectomy group (p = 0.29). Cataract extraction was performed in 13 (54%) phakic eyes in the tube group and 9 (43%) phakic eyes in the trabeculectomy group (p = 0.43). Conclusions: There were a large number of surgical complications in the TVT Study, but most were transient and self-limited. The incidence of early postoperative complications was higher following trabeculectomy with MMC than tube shunt surgery. The rates of late postoperative complications, reoperation for complications, and cataract extraction were similar with both surgical procedures during the first 5 years of follow-up. FP9 Long terms outcomes of mitomycin-c-augmented needle revision of trabeculectomy and deep sclerectomy blebs Fayyaz Musa1, Nitin Anand1, Antigoni Koukkoulli1 1 Department of Ophthalmology, Calderdale & Huddersfield NHS Trust, Huddersfield - United Kingdom Introduction: DS is a conjunctival filtration bleb- dependent NPGS procedure. Like trabeculectomy, needle revision can be done to rejuvenate falling blebs. There is no report in the literature on the outcomes of NR with DS. Aim: To report long-term comparative outcomes for mitomycin C (MMC)-augmented needle revision (NR) of failing deep sclerectomy (DS) and trabeculectomy (trab). Methods: Retrospective database search of all needle revisions with MMC for trab and DS at our centre between 2002 and 2008. 111 eyes of 109 patients, 66 of DS and 45 of trab group were identified. Subconjunctival MMC 0.01- 0.02 mg was injected 15 minutes before the NR. Complete success was defined as an IOP less than 18 mmHg and a 20% decrease from baseline with no glaucoma medications or further surgical procedures to lower IOP. Results: Mean follow-up was 60.1 ± 22.5 months with no difference between groups. Mean baseline IOPs were 23.2 ± 6.9 mmHg in the DS and 22.4 ± 6.8 mmHg in the trab group (p = 0.5). The interval between index surgery and NR was 10.78 ± 8.84 in the DS group and 42.27 ± 52.51 months in the trab group (p = 0.002). KaplanMeier success rates were 64% and 73% at 6 months, 53% and 64% at 1 year and 47% and 45% at 3 years in the DS and trab groups respectively (p = 0.8). Early NRs, within 6 months of index glaucoma surgery, were more likely to fail by Cox’s regression analyses (Hazards Ratio 2.8, 95% CI 1.6- 5.0, p = 0.0003). There was no significant difference in the number of complications between the groups (51.5% for DS and 44.4% for trab group, p = 0.9). Conclusion: The long-term success rates of NR with MMC in DS and trabeculectomy are disappointing but statistically similar. Early needle revision appears to a negative prognostic factor for success. FP10 Measurement matters: a new method of direct measurement of surgical outflow and results in a rabbit tube shunt model with histology Michael Coote1, Craig Ross1, Dan Nguyen1, Jonathan Crowston2 1 Glaucoma Surgery Research Unit, Centre for Eye Research Australia, Melbourne, Australia, 2Centre for Eye Research Australia, Melbourne - Australia Purpose: Post-surgical IOP is determined by existing and surgically induced outflow. Surgically induced outflow is the key functional endpoint for clinical and experimental glaucoma surgery, but is not measured clinically or experimentally. Hydraulic engineering modelling suggests that the central determinant of outflow facility is the porosity of the fibrous cap [Gardiner et al 2010, PLoS ONE e13178]. Insufficient porosity leads to reduced outflow and higher IOP. It is therefore sensible to measure the porosity of the fibrous cap as an endpoint in glaucoma surgical experiments. We wished to develop a model of glaucoma surgery which directly measured the porosity of the fibrous cap and which linked the hydraulic conductivity of the peri-implant tissue to the histologic appearance. In order to isolate porosity of the fibrous cap we utilised an established animal model using a defined drainage area and a familiar tube and plate drainage device. Methods: Nine adult female New-Zealand White rabbits underwent insertion of a single-plate paediatric Molteno implant into the anterior chamber of the left eye. Right eyes were used as controls, and procedures were performed in accordance with the ARVO Statement for the use of Animals in Ophthalmic and Vision Research. Outflow measurements were performed either 7 days (group one; n = 5) or 28 days (group two; n = 4) after surgery, and the eyes collected for histological analysis of capsules. The outflow measurements were performed by cannulating the implant tube (ostium in-situ in the anterior chamber) with a 25-gauge needle attached to a pressure transducer and fluid column. The flow of balanced saline solution at 15 mmHg into the implant capsules was directly measured. After a steady rate of flow had been reached, the drop in height of the fluid column was 4 recorded every minute for 5 minutes. Six rabbits also underwent fluid outflow measurements on the control eyes via anterior chamber cannulation. Using the same fluid column apparatus, whole-eye fluid outflow rates were measured in the unoperated eyes (n = 6). Following outflow measurements at 7 or 28 days following surgery, rabbits were euthanized and the experimental eyes enucleated and fixed in 4% paraformaldehyde. Paraffinembedded implant capsules were sectioned, stained and examined for histological assessment of scarring. Results: Successful cannulation of the whole eye and the implant was possible with the implant in situ. Furthermore it is possible to reliably measure the hydraulic resistance of the implant fibrous cap and show changes with time from implantation. Histologic evaluation was aided by the underlying implant orientating the tissue sample. There is a significant decline in tissue hydraulic conductivity over the month of the experiment. At 7 days the implant has a similar outflow resistance as the whole (normal) eye, but at 28 days the outflow resistance has risen over 13 times. At 7 days post implant surgery capsule outflow was 1.76 ± 0.54 µL/min at 15 mmHg (mean ± SEM), whereas at 28 days it was significantly reduced to 0.13 ± 0.05 µL/min (p = 0.03, unpaired-t test). Control eyes had a whole-eye outflow of 2.03 ± 0.10 µL/ 5 min at 15 mmHg. Haematoxylin and Eosin (H&E) and Masson Trichrome (MT) staining of implant capsules at 7 days demonstrated an acute inflammatory/healing stage with thin and loosely arranged collagenous capsules. In comparison, implant capsules at 28 days were consistent with scar formation, with thicker and more densely arranged collagen in the fibrous capsule, and only scanty inflammatory cells. Conclusion: We developed a method of measuring the surgical outflow directly and thus the porosity of the fibrous cap in a rabbit tube shunt model. With this model we can clearly identify the histologic appearance associated with outflow function and observe changes with time and aqueous flow. Outflow is due to capsule porosity. Tissue porosity is known to be due to cellular and non-cellular elements, with the collagen and extracellular matrix (ECM) of greatest importance. Histology shows an increase in the collagen and ECM associated with the reduction of the measured hydraulic conductivity of the tissue. This model can be adapted to investigate the relationship between capsule function, clinical or histological assessment of scarring, intraocular pressure, and the contributors to reduced implant function. POSTER SESSION 1 ANGLE CLOSURE GLAUCOMA P1 The effectiveness of early lens extraction with intraocular lens implantation for the treatment of primary angle-closure glaucoma (EAGLE): baseline characteristics of enrolled participants Claire Cochran1, on behalf of The EAGLE Study Group 1 Health Services Research Unit, Univeristy of Aberdeen - United Kingdom Purpose: Angle-closure glaucoma is a leading cause of irreversible blindness. The current standard care for PACG is a stepped approach of a combination of laser iridotomy surgery (to open the drainage angle) and medical treatment (to reduce intraocular pressure). If these treatments fail, glaucoma surgery is indicated. It has been proposed that, because the lens of the eye plays a major role in the mechanisms leading to PACG, early lens extraction will improve glaucoma control by opening the drainage angle. This procedure might reduce the need for drugs and glaucoma surgery, maintain good visual acuity, and improve quality of life compared with standard care. EAGLE aims to evaluate whether early lens extraction improves patient-reported, clinical outcomes, and cost-effectiveness, compared with standard care. Methods: EAGLE is a multicentre pragmatic randomized trial. All people presenting to the recruitment centres in the UK, East Asia and Australia with newly diagnosed PACG and who are at least 50 years old were eligible. The primary outcomes are EQ-5D, intraocular pressure (IOP), and incremental cost per quality adjusted life year (QALY) gained. Follow-up time will be three years. 400 participants (200 in each group) were needed to have 90% power at 5% significance level to detect a difference in EQ-5D score between the two groups of 0·05, and a mean difference in IOP of 1·75 mmHg. The study would have 80% power to detect a difference of 15% in the glaucoma surgery rate. Results: Recruitment finished in December 2011 and a total of 419 participants were enrolled. There were more patients of non-Chinese (289, 72%) than Chinese race. Mean age was 67.0 (± 9.8) years, EQ-5D scores were 0.871 (± 0.18) and the mean IOP at baseline was 28.9 (± 9.7) mmHg. There was a balance in demographic and clinical measures assessed at enrolment. Conclusions: Follow-up of this well-characterized group of patients should provide well-rounded guidance, based on ophthalmic measures, patients’ perspectives, and economic outcomes, on how best to initially treat angleclosure glaucoma. P2 Comparison of the effects of phacoemulsification with iol alone vs. phacoemulsification with IOL and goniosynechialysis on outflow facility in patients with primary angle closure with or without glaucoma: randomised pilot study Pouya Alaghband1, Laura Beltran-Agullo1, Kin Sheng Lim1 1 Ophthalmology Department, St Thomas’ Hospital, London - United Kingdom 7 Purpose: To compare the effect of cataract surgery alone versus cataract surgery with goniosynechialysis (GSL) on tonographic outflow facility in patients with primary angle closure with or without glaucoma (PACG or PAC). Methods: Design of the study: Prospective randomized pilot study (NCT00719290). Randomization: Patients were randomized by using Excel random number generator and opaque sealed envelopes to 2 groups: 1) phacoemulsification with IOL implanation only (Phaco); 2) phacoemulsification with IOL and GSL (Phaco-GSL). Inclusion criteria: 1) Age ≥ 21 years old; 2) Diagnosis of PAC or PACG with ≥ 90 degree peripheral anterior synechiae (PAS) and with significant lens opacity ± glaucoma medications. Exclusion criteria: 1) Only eye; 2) Previous intraocular surgery or keratorefractive surgery; 3) Secondary angle closures i.e. trauma, uveitis, drug induced; 4) Patients on warfarin with INR > 3.0. Primary outcome measure: Success was defined as 20% reduction in IOP at 6 month compared to baseline and significant increase in outflow facility. Secondary outcome measure: Significant decrease in number of glaucoma medication at 6 month, long-term development of PAS and intra or post operative complications. Patients were reviewed at 1 day, 1 week, 3 month, 6 month and 12 month postoperatively. IOP was measured by Goldmann applanation tonometry and electronic Shiotz tonography was used to measure the outflow facility (TOF) at baseline, 3 month, 6 month and 12 month after surgery. Results: There are 11 patients in Phaco+GSL group and 10 patients allocated in the phaco only group. Baseline characteristics of each group is shown in Table 1. Overall, IOP was reduced by 70% in phacoemulsification group with 148% increase in TOF in 6 month. In comparison to phacoemulsification with GSL group where IOP was decreased by 59% and 128% enhancement. In phaoemulsification with GSL group amount of PAS from median baseline of 180 degree reduced significantly to median 90 degree at 6 month (p < 0.001). In contrast the amount of PAS in phaco group remained the same at 6 month (p = 0.7). All patients underwent uneventful cataract surgery. However, two cases in phaco-GSL group developed less than 1mm hyphaema postoperatively which was resolved with conservative management. Conclusion: Phacoemulsification with goniosynechialysis significantly decreases the IOP by increasing the tonographic outflow facility. Although TOF was increased in the phaco group, it didn’t reach statistical significance. The only variable which was reduced significantly was IOP in the phaco group. On the contrary, in phaco-GSL not only IOP but also TOF was significantly changed. When two groups (phaco and phaco-GSL) compared with each other there was no statistical difference between TOF increase and IOP decrease. However, a larger study should be conducted to provide further evidence. Table 1 - Baseline characteristcs Variable Phacoemulsification only group (n = 10) (mean ± SD) Age 66 ± 10.2 Gender, M:F 4:6 Intraocular pressure (mmHg) 19.8 ± 5.1 Tonographic outflow facility (μL/min/mmHg) 0.12 ± 0.06 CCT (μm) 552.8 ± 29.7 AXL (mm) 22.4 ± 0.6 ACD (mm) 2.51 ± 0.25 Number of IOP lowering medications (median, range) 1 (0-4) Phaco power 18.07 ± 4.85 Phaco time 5.37 ± 10.08 Phacoemulsification p value + GSL group (n = 11) (mean ± SD) 73 ± 8.1 0.62 2:9 0.26 25.6 ± 8.9 0.01* 0.06 ± 0.03 551.5 ± 33.1 22.08 ± 0.9 2.56 ± 0.36 0.19 0.74 0.5 0.86 2 (0-4) 15.38 ± 4.85 1.6 ± 1.3 0.79 0.24 0.9 Student t test was used to compare continuous variables between groups except number of IOP lowering medications that was compared using Wilcoxon Signed-Rank test as the variable did not follow the normality. Table 2 - Comparison between IOP and TOF in baseline and 6 month follow-up Variable Phacoemulsification group, n • intraocular pressure (mmHg) • tonographic outflow facility μL/ min/mmHg • number of medication Phacoemulsification + GLS, n • intraocular pressure (mmHg) • tonographic outflow facility μL/ min/mmHg • number of medication Baseline (mean ± SD) 6 months (mean ± SD) Mean difference 6 months (mean ± SD) p value 10 19.8 ± 5.1 8 13.93 ± 2.67 -5.03 ± 4.04 0.007* 0.12 ± 0.06 1 (0-4) 0.16 ± 0.1 1 (0-4) 0.04 ± 0.08 0 0.16 0.26 11 25.6 ± 8.9 0.06 ± 0.03 2 (0.4) 7 15.01 ± 2.6 -11.7 ± 9.1 0.002* 0.18 ± 0.07 2 (0.4) 0.11 ± 0.06 0 0.005* 0.007 * p value is statistically significant. 8 P3 Glutathione S-transferase M1 and T1 genetic polymorphisms in Iranian angle closure glaucom patients Gholamreza Shahsavari1, Fatemeh Kazemi Safa1, Arezoo Mifabtabi2 1 Department of Biochemistry, School of Medicine, Lorestan University of Medical Sciences, Khorramabad Iran, 2Department of Ophthalmology, Tehran University of Medical Sciences, Tehran - Iran Purpose: Glutathione S-transferases (GSTs) are members of multigenic family which have essential role in cells as an antioxidant. In the present study we investigated the polymorphism of GSTT1 and GSTM1 deletion genotypes (T0M1, T1M0, and T0M0) in Iranian PCAG (primary closed angle glaucoma ) patients compared to healthy human subjects. Methods: We conducted a study of 41 PCAG patients (24 women, 17 men) and 100 healthy subjects (57 women, 43 men) to determine the prevalence of GSTT1 and GSTM1 deletion genotypes and the risk of PCAG , which were determined by multiplex polymerase chain reaction. Results: GSTM1 and GSTT1 null deletions genotypes were determined in 22 (53.7%) and 7 (17.1%) patients with PCAG and 34 (34%) and 15 (15%) in healthy subjects. Comparison of patients and healthy subjects regarding GSTM1 and GSTT1 genotypes revealed increase of GSTM1 null deletions genotypes in patients with PCAG (p = 0.03). Conclusion: It was concluded that the increased frequencies of GSTM1 null in patients with PCAG could be associated with a risk factor for incidence of PCAG in the Iranian population. P4 Prospective comparative study of phacoemulsification versus peripheral YAG iridotomy in narrow angles Carmen Cabarga1, Francisco Jose Munoz-Negrete1, Alfonso Almendral Gomez1, Elena Jarrin2 1 Hospital Ramon y Cajal, IRYCIS, Madrid - Spain, 2 Hospital Rey Juan Carlos de Móstoles, Mostoles - Spain Purpose: To compare the changes induced in the anterior segment of the eye by one of the two procedures employed in the prevention of pupillary block: laser Nd:YAG iridotomy versus phacoemulsification, in eyes with occludable angles, and the efficacy of both techniques to low the intraocular pressure or to avoid the use of medication. Methods: A prospective study was performed in our centre from October 2010 to May, 2012. Patients with occludable angle (Shaffer modified classification 0-II) were included. They were split into two groups of treatment: cataract surgery and peripheral Nd:YAG iridotomy, depending on the degree of lens sclerosis, visual acuity and age. Visual acuity, biomicroscopic and funduscopic evaluation, tonometry and gonioscopy were obtained before the inclusion. Automated measurements of the anterior chamber depth, volume, and angle were also 9 performed with Pentacam rotating Scheimpflug camera (Oculus Inc.). This examination was repeated 1 and 3 months after the intervention. Results: Fifty-nine eyes of 39 patients were included. 27 of them underwent cataract surgery and 32 received laser YAG iridotomy. Both groups were comparable in all measured parameters but visual acuity and age, which mean values were higher in the iridotomy and cataract surgery group, respectively. Statistically significant reduction in intraocular pressure (IOP) was found in the phacoemulsification group one month after the intervention (16.07 ± 3.6mmHg, vs. 16.40 ± 2.84 mmHg, p = 0.039). This reduction could not be objectified in the third month. The anti-glaucoma medication was significantly higher in the iridotomy group in the 3-months follow-up (0.38 ± 0.87 drugs, vs. 0.11 ± 0.42, p < 0.01). The anatomical widening of the anterior chamber was consistently greater in the phacoemulsification group, both one and three months after the intervention. This fact became evident in Gonioscopy grading (3.07± 0.73 vs. 1.85 ± 0.73, p < 0.01 one month after the intervention and 3.48 ± 0.527 vs. 2.01 ± 0.91 after the third month, p < 0.01). The three parameters obtained from Pentacam camera were also significantly higher in this group in both postoperative examinations (anterior chamber depth: 3.7 ± 0.57 vs. 2.22 ± 1.68 after one month and 3.51 ± .55 vs. 1.93 ± 0.216 after three months; anterior chamber volume: 153.44 ± 24.86 vs. 88.05 ± 21.6 and 154.74 ± 27.56 vs. 89.75±17,9 in the first and third month examination respectively; iridocorneal angle: 43.61 ± 5.95 vs. 24.01 ± 4.24 after one month and 43.07 ± 5.02 vs 23.38 ± 4 after three months). Conclusion: Both iridotomy and phacoemulsification have been proven as effective techniques in prevention of pupillary block in occludable angles. Furthermore, the results of this study suggest that cataract surgery could be more effective in the anatomical widening of the iridocorneal angle, and also in the reduction of antiglaucoma drugs. The lack of superiority of long-term reduction in IOP in phacoemulsification group could be explained by the decrease in the use of topical medication. Further studies will be needed to confirm these results. P5 Effectiveness and safety of goniosynechialysis (GSL) for primary angle closure (PAC) with moderate to extensive peripheral anterior synechiae (PAS) Akash Raj1, Achilleas Mandalos1, Tina Parmar1, Pravin Pandey1, Velota Sung1 1 Birmingham & Midland Eye Centre, Birmingham - United Kingdom Purpose: To determine the safety and efficacy of GSL for PAC with significant PAS. Methods: Retrospective case-note reviews of consecutive cases of 28 eyes of 24 patients who have had acute PAC or chronic angle closure with more than 90 degrees of PAS treated with GSL over a 6 year-period. Success was defined as intraocular pressure (IOP) < 21 mmHg with or without glaucoma medications and no further glaucoma procedures performed. Statistical analysis was performed with Paired t-tests. Results: The mean pre-operative IOP and number of glaucoma medications were 22.60 (range 9-41) mmHg and 2.5 respectively. The mean period from PAC attack to GSL was 10.26 months (range 0.5 to 44 months). The mean pre-operative PAS was 284.4 degrees. GSL alone was performed on 5 eyes (18%) and was combined with phacoemulsification and IOLs on 23 eyes (82%). Mean follow-up was 19.96 months (range 3-60 months). Last follow-up visit showed significant reduction in the mean IOP and glaucoma medications (14.85 mmHg and 1.23 respectively, p < 0.0001). The mean PAS also improved significantly (77.4 degrees, p < 0.0001). All 28 eyes were classified as success (IOP under 21 mm Hg with or without medications); the qualified success rate was 64% (18/28 requiring medications). Post-operative complications including fibrinous uveitis (two eyes) and cystoid macular oedema (two eyes), chronic uveitis (one eye), fixed dilated pupil (one eye) and microhyphaema (in one eye) were recorded. Some eyes had more than one of those complications (a total of 5 eyes shared all the complications). Most of the complications resolved with treatments. Conclusions: GSL is an effective and safe procedure in controlling IOPs in patients with moderate to extensive PAS and could therefore delay or prevent glaucoma filtration surgery. POSTER SESSION 2 CATARACT AND GLAUCOMA SURGERY P6 Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma Arezoo Miraftabi1, Seyed Javad Hashemian1 1 Tehran University of Medical Sciences, Eye Research Center, Rasoul Akram Hospital, Tehran - Iran Purpose: To evaluate results of phacoemulsification combined with Trabectum on IOP In patients with glaucoma and cataract. Design: Prospective interventional case series. Main outcome measures: Change in IOP and number of medication and complications Methods: 21 adults (13 male, 8 female) with open angle glaucoma and cataract without previous surgery or laser treatment were recruited in the study. Phacoemulsification combined with internal trabeculotomy by Trabectum (NeoMedix Inc.) was performed in all of patients. Only patients with at least 6 months of follow up entered in study. Results: Medications decreased from 2.5 ± 0.6 before surgery to 0.95 ± 0.38 in 6 months (p < 0.000), N = 21. After one year number of medication was 1.14 ± 0.53 (p < 0.000), N = 14. The mean preoperative IOP was 18.24 ± 3.2 that decreased to 14.48 ± 2.3 in 6 months (p < 0.001). After one year IOP was 13.5 ± 2.5 (p < 0.000), N = 14. The most common complication was blood reflux which was observed in 90.7% of our patients and resolved spontaneously. Corneal edema was observed in one patient (4.8%) that resolved spontaneously. No prolonged hypotony or choroidal effusion occurred. Conclusion: Phaco combined with trabeculotomy by the internal approach decreased number of medications in majority of our patients without significant complications. Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma P7 Maintenance of IOP following phaco+IOL in SLT-treated eyes Ejaz Ansari1 1 Department of Ophthalmology, Maidstone United Kingdom Purpose: To assess whether the intraocular pressure (IOP) in SLT-treated eyes is maintained following subsequent phacoemulsification and lens implant (phaco+IOL). Methods: Retrospective single-centre review of 45 eyes of 35 patients who had open angle glaucoma (OAG) successfully treated by SLT by the same surgeon (EA), and then had routine phaco+IOL by same surgeon (EA). All patients had SLT first-line for the treatment of OAG. No patients were taking ocular hypotensive drops in addition. Time between SLT and phaco+IOL ranged between 2-36 months. IOP was measured at 3, 6 and 12 months following phaco+IOL. Results: The main outcome measures were baseline (SLTtreated) IOP and IOP at 3, 6 and 12 months following routine phaco+IOL. Secondary outcome measures were visual acuity pre and post phaco+IOL and any complications. The mean baseline IOP (SD) was 15.8 mmHg (1.8). At 3, 6 and 12 months post phaco+IOL, the mean IOP (SD) were 13.9 mmHg (1.5), 14.3 mmHg (1.7), 14.8 mmHg (1.8). All cases were routine with mean pre-op visual acuity of 6/18, improving to 6/9 + 2 at 12 months. Conclusion: IOP reduction with SLT is not significantly affected by subsequent phaco+IOL in patients with OAG. P8 Pseudoexfoliation washout combined with cataract surgery: a new surgical approach to lower intraocular pressure Van Tao Tran1, André Mermoud1 1 Clinique Montchoisi, Lausanne - Switzerland Purpose: Glaucoma with ocular hypertension can be caused by the presence of pseudoexfoliation (PEX) material and pigmented cells on the trabecular meshwork (TM) and at the irido-cornea angle (ICA). Accumulation of these materials that can be highlighted by slit lamp (SL) or ultrasoundbiomicroscopy (UBM) prevents aqueous humor from flowing out and thus induces intraocular pressure (IOP) elevation. A new technique using a special cannula for washing the TM and ICA, combined with cataract surgery can lower IOP and reduce number of drugs needed. Methods: Prospective study on 11 patients (13 eyes) presenting a PEX glaucoma. They all had cataract surgery combined with special washing technique. Visual acuity 10 and IOP were measured before, after surgery and during follow-up. Number of topical drugs needed was recorded too. Mean follow-up time was 34.42 months (range: 21.83-59.20). First case was revealed in 2007 with a 5 years follow-up time. Local status was checked by SL and UBM. Results: Mean age is 79.10 (range: 71.46-86.04). Mean visual acuity was 0.37 pre-op (range: 0.05-0.6) and 0.89 post-op (range: 0.05-1.0). Mean IOP before and after surgery was 32.85 ± 8.74 (range 20-53 mmHg) and 15.08 ± 3.5 (range 10-20 mmHg). Amount of drugs needed was 87% lower after surgery. No PEX material recurrence was seen with SL or UBM during the mean follow-up of 3 years. No complication was recorded in this study. Conclusion: Washout technique of TM and ICA to remove PEX material or pigmented cells combined with cataract surgery significantly lowers the IOP and the amount of drugs needed. Long term follow-up gives good result with no complication or recurrence. Eye status after surgery remains physiological and glaucoma surgery can be added if necessary. More research with higher number of patients should be initiated to confirm this technique. P9 Phacoemulsification in eyes with cataract and post-trabeculectomy chronic choroidal detachment Chrysostomos Dimitriou1, Artemios Kandarakis1, Stylianos Kandarakis1, Iordanis Chatziangellides1, Dimitrios Karagiannis1 1 A’ Department of Ophthalmiatreion, Athens Eye Hospital, Athens - Greece Introduction: Choroidal detachment is a complication of trabeculectomy and other glaucoma filtration surgical interventions that may have devastating sight-threatening consequences. The terms suprachoroidal, ciliochoroidal or choroidal effusion or detachment have been interchangeably used in the literature, all describing an abnormal accumulation of fluid into the suprachoroidal space. Hypotony leading to uveal effusion is the commonest underlying mechanism in the vast majority of trabeculectomy cases on the grounds of an over-filtrating bleb. In this clinical cohort study, we aimed to evaluate the potential for safe cataract extraction in eyes with coexisting chronic choroidal detachment after trabeculectomy. In all our cases choroidal detachment was an early post-operative complication attributed to hypotony. Decreased visual acuity (VA) of less than 1.0 LogMAR due to dense cataract was an absolute prerequisite for our cataract preoperative assessment. Patients and Methods: In this case series, four eyes of four patients with advanced primary open angle glaucoma (POAG) underwent trabeculectomy with intraoperative application of mitomycin-C (TRAB-MMC). They all developed early postoperative hypotony with intraocular pressure (IOP) between 3 and 5 mmHg recorded with Goldmann applanation tonometry. Within 3 months from initial surgery they developed a manifest choroidal detachment which was documented utilizing b-scan ultrasonography (BUS) and ultrasound biomicroscopy (UBM). They were all managed with tapering dose of systemic corticosteroids. Full-thickness sclerectomy 11 was not attempted. Twelve months later all eyes had a visual acuity of worse than 1.0 LogMAR. Spectral Domain Optical Coherence Tomography (Spectralis® V.5.0, Heidelberg Engineering) and Amsler Grid were applied to exclude hypotony maculopathy. Poor VA was mainly attributed to cataract progression. IOLMaster® V.5.4 (Carl Zeiss Meditec) was used for preoperative biometry taking into account axial length adjustments as proposed by Francis et al. In our study we found no significant change in axial length despite the presence of choroidal detachment. Case 1: A 67-year-old female patient with advanced POAG underwent TRAB-MMC. In the immediate postoperative period she developed a shallow anterior chamber and hypotony with an IOP of 3 mmHg. BUS (Figure 1) and UBM (Figure 2) revealed ciliochoroidal detachment that improved slowly over the next months with the aid of systemic corticosteroid treatment. Twelve months later her VA gradually dropped to counting fingers owing to dense cataract. Normal Amsler grid recordings and unremarkable SD-OCT aided in the exclusion of hypotony maculopathy. At that point decision for cataract surgery was made despite the presence of shallow ciliochoroidal detachment. A three-piece soft hydrophobic acrylic intraocular lens (PreciSALTM, Millenium Biomedical Inc.) was implanted in the capsular bag at the end of the case. A month later, VA was 0.4 LogMAR with IOP of 8mmHg. New BUS (Figure 3) and UBM (Figure 4) showed choroidal and ciliary body reattachment. Four months later VA increased to 0.1 LogMAR with IOP of 9-10 mmHg that remained stable over 1-year follow-up. Case 2: A 72-year-old male patient with advanced POAG underwent TRAB-MMC. In the immediate post-operative period he developed hypotony with a shallow anterior chamber and an IOP of 4 mmHg. Ultrasonographic assessment revealed ciliochoroidal detachment. Ten months later his VA gradually dropped to 1.0 LogMAR owing to dense cataract. We used Amsler grid recordings and SD-OCT to rule out hypotony maculopathy. Following consultation patient consented to proceed with cataract surgery. At the end of the case a three-piece hydrophobic acrylic intraocular lens (PreciSALTM, Millenium Biomedical Inc.) was implanted in the capsular bag. Six weeks later VA was 0.15 LogMAR with IOP of 12 mmHg. Three months later VA increased to 0.1 LogMAR with IOP of 10 mmHg, maintained over 1-year follow-up. Discussion: In this case series we have described the potential resolution of choroidal detachment following phacoemulsification. Appropriate preoperative assessment, intraoperative precautions and meticulous postoperative care are of paramount importance in delivering optimal results. We postulated that intraoperative elevation of IOP can lead to mechanical drainage of the suprachoroidal fluid whereas an in-the-bag three-piece IOL can possibly contribute to the reattachment of the ciliary boby enhancing IOP control. BUS and UBM are of indispensable value in identifying and evaluating ciliochoroidal detachment secondary to post-trabeculectomy hypotony which may frequently have a subclinical manifestation. References 1. Edmunds B, Thompson JR, Salmon JF, Wormald RP. The National Survey of Trabeculectomy. III. Early and late complications. Eye 2002; 16: 297-303. 2. Mathew RG, Murdoch IE. The Silent Enemy: a Review of Cataract in Relation to Glaucoma and Trabeculectomy Surgery. Br J Ophthalmol 2011; 95: 1350-4. 3. Elagouz M, Stanescu-Segall D, Jackson T. Uveal Effu- sion Syndrome. Major Review. Surv Ophthalmol 2010; 5: 134-45. 4. Chu TG, Green RL. Suprachoroidal Hemorrhage. Major Review Surv Ophthalmol 1999; 43: 471-86. 5. Francis BA, Wang M, Lei H, et al. Changes in axial length following trabeculectomy and glaucoma drainage device surgery. Br J Ophthalmol 2005; 89: 17-20. P10 Outcomes of sequential glaucoma drainage device versus cyclophotocoagulation after failure of primary drainage implant Monica A. Levine1, Helen Koenigsman1, Fran M. Smith1, Mark B. Sherwood1 1 Department of Ophthalmology, University of Florida, Gainesville - USA Purpose: The most common cause of glaucoma drainage device (GDD) failure is inadequate intraocular pressure (IOP) control despite the re-introduction of medication. The purpose of this study was to compare the IOP lowering efficacy and visual outcomes of implantation of a second tube versus cyclophotocoagulation (CPC) after the failure of an initial glaucoma drainage implant surgery. Methods: A retrospective chart review was conducted including patients that had received either a double plate Molteno implant or a Baerveldt implant. Those patients with inadequate control of IOP requiring an additional procedure were identified. In those cases of eyes that had both CPC and secondary tubes, we analyzed whichever procedure occurred first. Once all of the eligible patients were selected, charts were pulled and data on diagnosis, IOP, visual acuity (VA), number of hypotensive agents, and all ocular procedures was collected and analyzed. A total of 51 eyes of 47 patients were identified with 33 having CPC and the remaining 18 having an additional GDD. Results: Mean follow-up for patients after the second procedure was 77 months with a range 10-241 months. For patients treated with CPC follow up was approxi- 12 mately 5 years whereas that for the secondary tube patients was approximately 10 years. 41% of the total eyes failed to achieve long-term IOP control with their second procedure and required 3 or more total procedures. 33% of eyes that received CPC as their second procedure needed yet another intervention at a mean of 13 months post-op (3-40 months) while 50% of eyes that received a second drainage tube required another intervention a mean of 67 months post-operatively (5-173 months). 27% of patients receiving CPC and 44% of patients receiving a second tube had a decrease in VA of two lines or greater between their second glaucoma procedure and either their next procedure or their latest follow up appointment. Conclusions: A significant number of eyes that fail initial GDD surgery will long term fail either a second implant or CPC and require a third or even more interventions. With a mean follow-up of 10 years, IOP failure of second GDD’s appears to occur late (on average 5 - 6 years postoperatively). IOP failure of eyes receiving CPC following initial GDD failure tends to occur earlier (64% within the first year) with a mean follow-up of 5 years following CPC. P11 Risk factors for intra-operative complications during combined phaco-trabeculectomy surgery Tiakumzuk Sangtam1, Katherine Wan Xian Lun1, Lennard Thean2, Chee Chew Yip1, Benjamin Chang1 1 Department of Ophthalmology & Visual Sciences, Khoo Teck Puat Hospital, Singapore - Singapore, 2Department of Ophthalmology, National University Singapore, Singapore - Singapore Purpose: To identify ocular risk factors for intra-operative complications during combined phaco-trabeculectomy surgery. Methods: Retrospective data analysis of patients with intra-operative complications during combined phacotrabeculectomy. Zonulodialysis, posterior capsule rupture (PCR), vitreous loss, anterior vitrectomy, anterior chamber intraocular lens (ACIOL) placement and dislocation of lens fragments into the vitreous were defined as intra-operative complications. Patient ocular characteristics that were considered risk factors for these complications were identified. Results: Intra-operative complications were seen in four of 90 surgeries. The following complications were encountered, namely: zonulodialysis in two eyes (2.22%), PCR in two eyes (2.22%), vitreous loss in two eyes (2.22%), anterior vitrectomy in two eyes (2.22%) and ACIOL placement in one eye (1.11%). Of note, there was no dislocation of lens fragment into the vitreous. The two cases complicated by zonulodialysis were associated with soft cataract and deep-set eye, respectively. The two cases of PCR with vitreous loss needing anterior vitrectomy were associated with eyes having dense cataract, narrow palpebral aperture and positive vitreous pressure. Conclusion: Our observation suggests that patients with ocular characteristics, such as soft cataract, deep-set eye, dense cataract, narrow palpebral aperture and 13 positive vitreous pressure, may be at a higher risk of intra-operative complications during combined phacotrabeculectomy. Careful pre-operative assessment, identification and proper allocation to an experienced surgeon of such cases may pre-empt these complications. POSTER SESSION 3 CONGENITAL - PEDIATRIC GLAUCOMA P12 Paediatric glaucoma drainage implant surgery: long-term outcomes from a single tertiary referral centre Rajen Tailor1, Achilleas Mandalos1, Walter Andreatta1, Tina Parmar1, Velota Sung1 1 Birmingham and Midland Eye Centre, Birmingham United Kingdom Purpose: To evaluate the long-term outcomes of glaucoma drainage implant surgery in paediatric patients in a tertiary referral centre. Methods: Retrospective case series audit of all paediatric patients (aged less than 18 years at the time of surgery) who underwent glaucoma drainage implant surgery by a single surgeon through the period 2004-2011. Data was collected by review of case notes using a detailed audit proforma. Patients were identified through the operation listing books. Results: Case notes of 53 patients were reviewed and 62 glaucoma drainage implant procedures (53 Baerveldt tube and 9 Molteno tube) were identified. Mean age of patients at the time of surgery was 8.5 years (range 0.3-17 years). Aphakic and primary congenital glaucoma were the more common types of glaucoma. Preoperatively, mean intraocular pressure (IOP) was 28.2 mmHg and mean number of antiglaucoma medications was 3.5. At the last postoperative visit, mean IOP was 15.6 mmHg and mean number of medication had been reduced to 0.4. As we are currently updating our audit database, updated results will be presented at the meeting. Overall success (defined as IOP > 5 mmHg and < 22 mmHg with or without adjunctive medications, no devastating visual loss, no additional glaucoma surgery) was achieved in the vast majority of cases. Hypotony (defined as IOP < 6 mmHg on two consecutive visits) was the most common complication in the early (within 6 months) postoperative period, whereas bleb encapsulation was the most common late(beyond 6 months) postoperative complication. Conclusion: Glaucoma drainage implant surgery was highly successful in long-tem control of glaucoma in paediatric patients and had an acceptable safety profile. P13 Glaucoma in Sturge-Weber syndrome patients Iwona Helemejko1, Magdalena Koziorowska1, Malgorzata Mulak1, Anna Karasinska1, Bartlomiej Markuszewski1, Anna Fizia-Orlicz1, Marta Misiuk-Hojlo1 1 Department of Ophthalmology, Wroclaw Medical University, Wroclaw - Poland Purpose: The purpose is to present glaucoma surgery treatment course in two Sturge-Weber syndrome patients treated at the Ohthalmology Clinic of Wroclaw Medical University. Methods: Sturge-Weber syndrome belongs to dermatoneuropathic diseases, called phakomatosis or neuroectomezodermal dysplasia. It manifests by wine-red facial skin changes (port-wine naevus), haemangioma of pia matter on the same side and calcifications in the cerebral cortex. Upper lid haemangioma is often accompanied by glaucoma observed in 60% of 2 years old children. The causes of intraocular pressure can be anomalies in the iridocorneal angle and episcleral intravenous pressure increase. The two patients underwent trabeculectomy glaucoma surgery and were under observation due to complications following surgery. Results: The treatment options are complex, consist of glaucoma treatment, by the use of different methods such as eye drop administration, surgical and laser intervention. Choroid detachment with hypotonia was observed. Conclusion: The choice of surgical course for Sturge-Weber patient must be made carefully. Detailed long term observation is indicated in patients with Sturge-Weber syndrome following glaucoma surgery due to possible problematic choroid detachment. Lowering and stabilization of IOP was finally achieved following surgical intervention and post operative observation. P14 Three-year follow-up of the Ahmed glaucoma valve surgery in pediatric glaucoma Orna Geyer1, Alvit Wolf1 1 Department of Ophthalmology, Carmel Medical Center, Haifa - Israel Purpose: To report the effectiveness and safety of the Ahmed glaucoma valves (AGV) implantation in pediatric glaucoma. Methods: Retrospective medical records from 48 consecutive eyes of 39 patients, 33 eyes (24 patients) with PCG and 16 eyes (15 patients) with aphakic glaucoma who underwent AGV implantation between December 2004 and March 2011 were reviewed. The median age at time of surgery was 2 years (range: 1 months to 18 years). Criteria for success were intraocular pressure greater than 5 mmHg and less than 22 mmHg with or without medication, no need for further glaucoma surgery and the absence of visually threatening complications. Results: Mean follow-up time was 18.8 ± 15 months (range, 6 to 64 months). Intraocular pressure was reduced from a preoperative mean of 32.9 ± 7.8 mmHg to 18.1 ± 5.7 mmHg at the last follow-up examination (p < 0.001). The number of medications decreased from 2.6 ± 1.2 medications at baseline to 1.6 ± 1.1 at the final visit (p < 0.001). Cumulative probabilities of success for all eyes were 80%, 73.3%, and 73.3%, at 1, 2, and 3 years, respectively. On average, the AGV were successful for a period of 1.6 ± 1.25 years. There was no significant difference between PCG eyes and aphakic eyes in the postoperative intraocular pressure, number of glaucoma medications and cumulative success (p > 0.05). The most frequent complications were shallow anterior chamber (8%), tube-cornea touch (8%), tube exposure (12%) and retinal detachment resulting in loss of vision (6%). Tube related complications were more frequent in PCG eyes (27%) than in aphakic eyes (12.5%). Conclusion: Ahmed valves proved effective in controlling intraocular pressure in pediatric glaucoma. There is a risk of visual loss due to retinal detachment. POSTER SESSION 4 GLAUCOMA MEDICATIONS P15 Effect of gross saponins from Tribulus terrestris L (GSTT) on the concentration of glutamic acid in the retinal in rabbits with chronic high intraocular pressure (IOP) Li Na Huang1, Ping Zeng1, Nuo Li1 1 Shenzhen Eye Hospital, Shenzhen - China Purpose: Observe the effect of gross saponins from Tribulus terrestris L (GSTT) on the concentration of glutamic acid in the retinal in rabbits with chronic high intraocular pressure(IOP). Methods: New Zealand rabbits 24 only were randomized into control (A group), high intraocular pressure group (B group), Erigeron breviscapus (Vant.) Hand-Mazz (EBHM) treatment group (C group), GSTT treatment group (D group), the 20 g/L methylcellulose into anterior chamber of the high intraocular pressure group and the two treated groups, Group C, group D daily rabbit ears margin veins push note respectively EBHM 4.5 mg/kg, GSTT 5 mg/kg. High-performance liquid chromatography (HPLC) was utilized to measure the concentration of glutamic acid in retina after 4 weeks. Transmission electron microscope observe each group rabbit retina ganglion cells (RGCs) ultrastructural structure. Results: The concentration of glutamic acid in retina of rabbits in the high intraocular pressure group were significantly higher than those in control group and treated group (p < 0.05). Significant difference appeared between the treated group C and treated group D (p < 0.05). By electron microscopy RGCs ultrastructure of group B, C, D and A group of group compared all have degeneration necrosis, group C, D group degeneration necrosis light in group B. Conclusion: Higher concentration of glutamate damaging retina was induced by chronic high IOP. Extract of GSTT can significantly inhibit the retina glutamate concentration, to protect the retinal damage function. 14 Each group made 28 days after mode glutamic acid content comparison (x ± S) Group Control group (A) Eye Glutamic acid 6 32.15 ± 0.22 Model group (B) 6 132.26 ± 0.28 EBHM group (C) 6 65.28 ± 0.26 GSTT group (D) 6 66.26 ± 0.22 P16 Drops don’t work, because we don’t use them right? Shibal Bhartiya1, Parul Ichhpujani2 1 Glaucoma Service, Eye 7 Group of Hospitals, New Delhi - India, 2Department of Ophthalmology, Government Medical College and Hospital, Sector 32, Chandigarh India Aim: To evaluate the technique of eye drops administration in glaucoma patients. Methods: 200 patients on anti glaucoma therapy for a mean duration of 74.2 ± 91.2 months (range 2-360; median 120 months) were included in this observational, non interventional study. A 6 point proforma with binary end points was completed by one of the co-authors (SB, PI) to assesses drop administration technique as patients were applying eye drops, and evaluated subsequently. The level of statistical significance was set as p < 0.05. Results: Out of the 200 patients recruited for the study, 123 were females and 77 males. The mean age of the patients enrolled in this study was 73.7 + 8.8 years (75, range 52-93). 128 (64%) of the overall patients were unable to put the drops correctly, in spite of the patients’ assurances that they had received clear instructions from their treating ophthalmologist. With regard to patients who demonstrated an improper technique of drop administration, 32.0% (41/128) missed their eye and 47.7% (61/128) contaminated the bottle tip; overall, 53.9% demonstrated more than one mistake in drop instillation. A significant correlation was noticed between age and faulty administration of eye drops (p < 0.05). Number of women using an improper technique was found to be 75/123; as against 53/77 men, but the difference was not found to be statistically significant. The mistakes in eye drop instillation were not correlated with duration of disease, as assessed by Mann Whitney Rank Sum Test (p > 0.05). Conclusion: As many as sixty four percent patients did not instill their anti glaucoma medication properly, and this can potentially affect compliance. This may become increasingly relevant in an ageing population, as disease severity and the use of multiple medications becomes more frequent. Even patients who have been on therapy for a long duration are likely to benefit from continuing education and reinforcement of good technique. Therefore, glaucoma patients should be instructed on proper drop administration. 15 P17 Granulomatous anterior uveitis An uncommon and less well recognized side effect of topical α-adrenergic agonists Maria Moutsou1 , Saurabh Goyal1 1 Department of Ophthalmology, Queen Mary’s Hospital, Sidcup - United Kingdom Purpose: Topical α-adrenergic agonists are used as 2nd to 4th line agents in the management of glaucoma. Granulomatous anterior uveitis (GAU) is a rare but known side effect of Brimonidine but it has not been well described for Apraclonidine. Five cases of GAU seen in our glaucoma clinic in the last year are described. These patients had been on α-adrenergic drops elsewhere before referral to us for management of uncontrolled glaucoma. Methods: Retrospective chart review and anterior segment photos of these patients will be presented. Results: All patients were elderly (> 65 years). Three patients developed GAU after at least a year of exposure to Brimonidine. One of these 3 patients was being treated with topical steroids for some years as it was considered to be hypertensive uveitis on a background of primary glaucoma. One patient had previous history of GAU with Brimonidine and on challenge developed GAU within 6 weeks of restarting Brimonidine. One patient had hypersensitivity reaction to Brimonidine in the past and it was changed to Apraclonidine but developed GAU more than 6 months after the substitution to Apraclonidine. In all cases GAU was associated with some other signs of hypersensitivity like follicles, papillae, conjunctival congestion and periocular dermatitis. In all cases GAU settled after stopping the α-adrenergic agent. Conclusion: Clinicians dealing with management of glaucoma should be aware of GAU as a rare side effect of α-adrenergic agonists. POSTER SESSION 5 GLAUCOMA SURGICAL COMPLICATIONS P18 Management of nano silicon and nano silver (Masoud balloon) for treatment and prevent open angle glaucoma with optic nerve pathology and postoperative complications after vitreoretinal surgery Mehran Masoudnaseri1 1 Academy of Filatov, Odessa - Ukraine Purpose: To treatment and prevent glaucoma and postoperative complications with intraocular nano silicon balloon (anti virus, antibacterial, anti fungous) after vitrectomy in aphakic and pseudophakic eyes with optic nerve pathology in retinal detachment. Methods: After vitrectomy the syringe with silicon oil, with fixed nano silicon bubble (anti virus, antibacterial, with treats drugs) on it (v. 4-6 mm), injected through ora serrata into vitreous cavity. Then we filled the bubble with oil or (N-saline,BSS) up to normal pressure, and fixed on sclera. Upon total retina attachment to choroidea silicon oil or (N-saline) with bubble should be simultaneously removed in (1-3) month after surgery. Result: Injection of nano silicon bubble (in addition nano silver) (v. 4-6 mm) with silicon oil in vitreous cavity creates conditions where oil dose not penetrated anywhere A-Does not get to anterior chamber and contact with corneal epithelial layer B-to vessels D-oil does not get through valves, and holes behind the retina. E-interferes to penetration of oil into the ciliary body and prevents closing of a space for coming of liquid regulating IOP and prevents closing canal Schelmm. Avoid glaucoma and antimicrobial system nano silver avoids postoperative complication and optimized IOP on optic disc nerve and capillaries. Conclusion: This method help to provides total retinal attachment to choroidea and treatment and prevent glaucoma and post operative complication. P19 Management of biological material (Mehran, bio-lent) for treatment and avoid secondary glaucoma postoperative complication after scleral buckling surgery in retinal detachment Mehran Masoudnaseri1 1 Academy of Filatov, Odessa - Ukraine Purpose: For treatment and avoid glaucoma and postoperative complications and improve reattachment retina with Mehran bio-lent (biomaterial) after scleral buckling . Methods: Scleral buckle by Mehran bio-lent. that is a piece of biomaterial (trimethyl carbonate) that properties same as silicon material, the sclera toward the middle of the eye This buckling effect on the sclera relieves the pull (traction) on the retina, which difference is that have 4 pairs of holes in the end of the strip. And 16 on one its ends there is a split 1*5 mm, the head of the biomaterial can be ahead from the spilt than fix bio, lent with together on the sclera with nylon Succor. After 4-6 mount (after reattachment retina) automat these nylons and biomaterial will be observes, and step by step the eyeball will be as normal size. Result: Sclera buckling with Mehran bio-lent, surgeon able to control IOP, with regular bio lent, after resolve bio material, avoid of: A - Decrease blood circulation, and increase blood pressure. B - Choroidea ischemia, and reduced pulse amplitude. C - Change visual axis. D Avoid of glaucoma. E - avoid of rick myopia, strabismus, astigmatism. F - Avoid of vitreous hemorrhage. G - To change anterior segment deepness. H - Avoid of (IOP) and increase pressures on optical nervous, and avoid of retina edema, change biochemical process, scleral change diameter, change to microscopic layer retina, avoid vitreous proliferation, internal erosion, Conclusion: This method helps to provides total retinal attachment to choroidea and help to avoid glaucoma and post operative complication. In scleral buckling surgery. P20 Tayside experience with zonulo-hyaloidovitrectomy as management of malignant glaucoma Lai Ling Tan1, Caroline Cobb1 1 Department of Ophthalmology, Ninewells Hospital, Dundee - United Kingdom Purpose: To describe Tayside experience with zonulohyaloido-vitrectomy as management of malignant glaucoma. Methods: Retrospective case series of four patients with malignant glaucoma. Results: Three patients developed malignant glaucoma post trabeculectomy and one patient developed malignant glaucoma post cataract surgery. All four patients were refractory to medical management with Atropine and anti - glaucoma topical drops. All four patients underwent zonulo-hyaloido-vitrectomy resulting in resolution of the malignant glaucoma. The first two patients underwent a number of surgical procedures to break the aqueous misdirection including pars-plana vitrectomy, cataract surgery, YAG capsulotomy and anterior hyaloid fasciotomy. However, only the zonulo-hyaloido-vitrectomy was successful in treating malignant glaucoma. The third and fourth patient underwent a zonulo-hyaloido-vitrectomy as the primary procedure. Conclusion: A zonulo-hyaloido-vitrectomy involves the performance of zonulectomy, hyaloidectomy, and anterior vitrectomy (zonulo-hyaloido-vitrectomy) through a peripheral iridectomy or iridotomy via the anterior chamber. It was first described by Lois et al in 2000. Given the results in our cases we would now do a zonulohyaloido-vitrectomy as a primary surgical procedure for this condition as it is minimally invasive and appears to be effective. P21 Evaluation of background of patients who needed a subsequent trabeculectomy after a failed trabectome surgery Nobuyuki Shoji1, Kimiya Shimizu2, Tetsuya Morita2, 17 Masahide Takahashi2, Sonoko Tatsui2, Masayuki Kasahara2, Kazuhiro Matsumura2 1 Dept. of Orthoptics and Visual Sciences, 2 Dept. of Ophthalmology, Kitasato University, Kanagawa - Japan Purpose: To evaluate backgrounds of patients who needed a subsequent trabeculectomy within 3 months after a trabectome surgery. Subjects and Methods: Sixty one eyes of 54 Japanese patients with uncontrolled open-angle glaucoma (OAG) were performed trabeculotomy ab interno with the trabectome. IOP and adverse events were evaluated. Multivariate logistic regression analysis was performed using sex, type of glaucoma, history of selective laser trabeculoplasty (SLT) and the combination of trabectome with a phacoemulsification to determine which variables were associated with a failure of trabectome. Results: IOP was reduced from 29.3 mmHg to 18.0 mmHg with medications at 1 day, 20.2 mmHg at 1 week, 16.6 mmHg at 1 month, 16.1 mmHg at 3 months, and 18.1 mmHg at 6 months. Mean reduction ratio of IOP was 46, 46, 43, 41 and 28%, respectively. Blood reflux occurred in all eyes intraoperatively and decreased in several days. Six patients were performed a subsequent trabeculectomy within 3 months after a trabectome surgery. The odds of a failed trabectome with a prior SLT were 13.4 times the odds of a failed trabectome without a prior SLT (p = 0.032). No other statistically significant risk was found. Conclusion: A subsequent trabectome might be lesseffective for the patient with a failed SLT. It is unclear whether a previous SLT would affect an IOP control of a subsequent trabectome surgery or trabectome surgery would have no effect on the eye which had non-response to SLT. Further studies about the influence of SLT on the trabectome surgery should be needed. P22 Zonulectomy in the management of aqueous misdirection Ashraf Khan1, Hilary Devlin1 1 Princess Alexandra Eye Pavilion, Edinburgh - United Kingdom Purpose: Aqueous misdirection (AM) is a rare condition caused by aqueous being diverted posteriorly into the vitreous cavity. It most commonly occurs after glaucoma filtration surgery particularly in patients with a history of angle closure. It is characterised by central and peripheral shallowing of the anterior chamber (AC) with a patent iridotomy (PI) and no evidence of suprachoroidal haemorrhage or effusion. Unfortunately the failure rate for medical and laser therapy is high. Recent reports describe a technique of combined vitrectomy with zonulectomy. We report our case series of patients managed with a modified version of this technique. Methods: The study included seven cases of AM (seven eyes, five patients). Five eyes underwent pars plana vitrectomy combined with peripheral zonulectomy, two patients underwent a peripheral zonulectomy from an anterior approach. Surgical technique: patients under- went three port pars-plana core vitrectomy and anterior hyaliodectomy. Following this, the vitrector was angled upwards to perform a zonulectomy and a peripheral iridectomy from a posterior approach. Two patients underwent a zonulectomy and peripheral iridectomy from an anterior approach. Here the AC was deepened with viscoelastic and an AC maintainer was used. From a limbal incision the vitrector was angled backwards through the peripheral iridectomy to enlarge it and then moved further posteriorly to perform a zonulectomy. Results: Case 1: 71-year-old female with chronic angle closure glaucoma (CACG) underwent trabeculectomy surgery. Two weeks post op she had a raised pressure (34) and underwent laser suture lysis and bleb needling. Her pressure remained high after six months (28) and she underwent vitrectomy with zonulectomy. Her postoperative IOP was 22 has been maintained at 11 after three years. Case 2: 31-year-old male with plateau iris syndrome underwent difficult trabeculectomy surgery. AM was diagnosed one week post op. He underwent vitrectomy with subsequent AC deepening. 18 months later, his AC shallowed and his IOP was 52. He underwent a further vitrectomy combined with phacoemulsification of the lens. His AC progressively shallowed and his pressure increased to 44. He underwent an iridectomy, zonulectomy and anterior vitrectomy from an anterior approach with immediate AC deepening. Despite maintaining a deep AC his IOP increased to 40. He underwent revision of his iridectomy and anterior hyloidectomy from a posterior approach. His post-op IOP of 20 has been maintained for four years. Case 3: 77-year-old female with right CACG and a shallow AC in the left eye, underwent a right trabeculectomy. AM was diagnosed two months post-op. Her IOP rose over three years and she underwent vitrectomy with zonulectomy. Her IOP has been controlled at 18 after three years. Over the same time she had a left phaco with AM diagnosed two years post-op (IOP 34). She underwent vitrectomy and zonulectomy controlling her IOP after four years at 15. Case 4: 44-year-old female with plateau iris syndrome underwent a right trabeculectomy. The next day she was diagnosed with AM and underwent a vitrectomy and zonulectomy. The same month, the patient underwent a left phaco-trabeculectomy. AM was diagnosed on day one post-op and underwent a vitrectomy and zonulectomy. Unfortunately she developed left post-operative endophthalmitis and had a further vitrectomy with intravitreal antibiotics. Her latest IOP is 14 (right) and 12 (left) after one year. The vision in the left eye has reduced from 6/6 preop to 6/18. Case 5: 79-year-old female with CACG underwent a left trabeculectomy. One year later she underwent a right trabeculectomy complicated by AM one week postop. She had a vitrectomy and subsequent bleb needling two weeks later. Six months later she underwent a left phaco. After five years she had an elevated IOP and underwent a redo-trabeculectomy. AM was diagnosed one week post-op and she had a left peripheral iridectomy, zonulectomy and anterior vitrectomy from an anterior approach. Her AC deepened on the table and has remained deep since. Her latest IOP was 12 (right) and 10 (left). Conclusions: AM results from posterior flow of aqueous into the vitreous cavity. By creating a communication between the anterior chamber and vitreous cavity, aqueous flow can be re-established to the anterior chamber. Vitrectomy facilitates the flow of aqueous into the anterior chamber by disrupting the anterior hyaloids. Recurrence after vitrectomy may be due to difficulty in removing the anterior hyaloid face. In our case series most patients underwent a vitrectomy combined with hyaloido-zonulectomy. We feel this is the most important step as it establishes the unobstructed communication. Two patients underwent a zonulectomy from an anterior approach, with immediate deepening of the AC, further suggesting that this step is crucial in allowing the aqueous to flow into the AC. Vitrectomy combined with hyaloido-zonulectomy is an effective treatment for the management of AM, experienced anterior segment surgeons may consider performing a peripheral iridotomy and zonulectomy from an anterior approach. POSTER SESSION 6 LASERS P23 Clinical results of CO2-laser in deep sclerectomy; a 12-month follow-up Michael Feusier1, Delphine Bifrare1, André Mermoud1, Sylvain Roy1 1 Montchoisi Clinic, Lausanne - Switzerland Purpose: To evaluate the efficacy and safety profile of a CO2-laser ablation system in non-penetrating glaucoma surgery Methods: From July 2010 until December 2010 14 eyes from 14 patients suffering from glaucoma have been operated using a CO2-laser ablation system. After a superficial scleral flap was performed a square-shaped deep scleral space was created by CO2-laser ablation. Depth of ablation was limited before reaching the choroidal layer. For the ablation of the inner wall of Schlemm’s canal, an arc-shaped profile was used. Laser treatment was controlled upon oozing of aqueous humour. After sufficient tissue removal was achieved and an efficient drainage was obtained, the scleral flap and the conjunctiva were then sutured. The main outcomes were the mean intraocular pressure (IOP), the mean number of antiglaucoma medication, the number of postoperative complications. Results: For the 14 eyes the mean age at surgery was 71.5 ± 9.0 years, the mean follow-up was 12.4 ± 2.8 months, the mean preoperative IOP was 24.2 ± 7.3 mmHg, the mean visual acuity was 0.8 ± 0.3 and the mean number of antiglaucoma medication before surgery was 3.1 ± 1.2. At final follow-up visits, the mean IOP went down to 10.8 ± 2.8 mmHg (p < 0.005), the mean visual acuity was 0.7 ± 0.3 and the mean number of antiglaucoma medication was reduced to 0.2 ± 0.3 (p < 0.005). The filtering bleb was visible on 9 eyes (90%). 18 Overall 8 complications were reported, among which 6 were iris incarceration after goniopuncture, 1 was angle closure glaucoma, and 1 acute IOP spike. Complete success rate (IOP ≤ 18 mmHg without antiglaucoma medication) was 70% and the qualified success rate (IOP ≤ 18 mmHg with and without antiglaucoma medication) was 90%. One case (10%). Conclusion: A new technique using a CO2-laser ablation system allows precise and easy creation of the scleral space and ablation of Schlemm’s canal. This would render the deep-sclerectomy an easier glaucoma surgery with less complication. From this study the IOP was significantly lowered with less glaucoma medication. P24 A new technique for diode laser cyclophotocoagulation: short term results Mayerling M. Suriano1, Jorge Vila-Arteaga2, Oana Stirbu3 1 Hospital Clínico Universitario de Valencia, Valencia - Spain, 2Hospital Clínico Universitario de Valencia, Clínica Oftalmológica Dr. Vila, Valencia - Spain, 3Institut Comtal d’Oftalmologia, Barcelona - Spain Background: To evaluate the efficacy of a new technique for diode laser cyclophotocoagulation in refractory glaucoma. Methods: A consecutive case series of 8 eyes of 7 Caucasian patients who underwent gonioprism assisted diode laser cyclophotocoagulation (GADC). GADC with a peripheral corneal approach is a new surgical technique that employs a manual gonioprism, iris hooks, ophthalmic operating microscope and an 810 nm laser diode probe 19 usually utilized for retinal photocoagulation (Figs. 1-3). Results: The mean follow-up time was 5.9 months (range 3 to 11 months). Mean intraocular pressure (IOP) (±SD) was reduced from 24.5 ± 4.3 mmHg to 11.25 ± 1.7 mmHg. The mean number of IOP lowering eye drops (±SD) was reduced from 2.0 ± 0.8 preoperatively to 0.8 ± 0.5 postoperatively. The visual acuity remained unchanged in 7 of 8 eyes (87.5%) and deteriorated in 1 of 8 eyes (12.5%). Early complications included IOP spike in one patient. No major complications were encountered. No eyes required repeat cyclophotocoagulation. Conclusion: Gonioprism assisted diode laser cyclophotocoagulation with peripheral corneal approach appears to be an effective and safe surgical treatment of refractory glaucoma and has the advantage of no requiring of new endoscopic devices. P25 Photocoagulation laser trabeculoplasty as supplement to glaucoma medication in uncontrolled primary open angle glaucoma in Indian eyes: five year results Deven Tuli1, Sudhank Bharti2, Tanuj Dada3 1 Glaucoma Service, 2Ophthalmology Service, Bharti Eye Hospital, New Delhi - India, 3Glaucoma Service, All India Institute of Medical Sciences, New Delhi - India Purpose: To assess the efficacy of laser trabeculoplasty (LTP) as a supplement to antiglaucoma medication in Indian eyes. Methods: 50 eyes with primary open angle glaucoma (POAG) not meeting target pressure on 3 antiglaucoma medication (in 2 bottles) were included to undergo LTP using the 532 nm double frequency Nd:YAG laser. All procedures were done by single glaucomatologist. 60 spots (15 in each quadrant) of 50 micron each were equally spaced at the anterior trabecular meshwork and distributed over the 360 degree angle. With laser duration of 0.1 second, the energy ranged between 800-1500 mW. Patients younger than 40 years, with secondary glaucoma and with previous glaucoma laser or surgery were excluded. Results: Mean age was 62.4 years with 60% males. Mean pre-laser intraocular pressure (IOP) was 23.4 mmHg. Follow-up was 5 years in all eyes. Mean post laser IOP was 19.6 mmHg (16.2% reduction from pre-laser level) at 1 month, 15.1 mmHg (35.5% reduction, p < 0.05) at 6 months, 16.4 mmHg (30% reduction, p < 0.05) at 1 year, 17.2 mmHg (26.4% reduction) at 3 years and 18.0 mmHg (23% reduction) at 5 years. Target IOP was achieved in 100% at 1 year, 87% at 3 years and 76% at 5 years. 10 eyes that failed to achieve target with first LTP, underwent a second similar LTP and maintained target at 5 year follow up. In this series no patient required trabeculectomy to achieve target IOP. Transient IOP spike (range 4-8 mmHg) was the commonest reported adverse event. No patient during the five year follow up in this series was found to progress on periodic structural and functional optic nerve analysis. Conclusion: LTP should be considered to supplement glaucoma medication in patients not meeting target IOP on 3 drugs. Results in patients of Indian origin are com- parable with those reported in White and Black races. Maximum IOP reduction was seen at 6 months followed by a gradual rise in IOP suggesting a gradual decline in laser effect with follow up. Adverse events were negligible. This study also suggests that for patients on glaucoma medication with IOP much above target (> 30%), it may be correct practise to proceed straight with trabeculectomy. P26 The effectiveness and safety of laser suture stretch in the early postoperative management of trabeculectomy Marta Hovan1, Stephen Vernon1 1 Eye, Ear Nose and Throat Centre, Queens’ Medical Centre, Nottingham - United Kingdom Purpose: To assess the efficacy and safety of sub-threshold laser “stretching” rather than cutting of scleral flap sutures in the early postoperative period following trabeculectomy. Methods: Three year cohort case series review of all laser assisted suture adjustment treatments under the care of one glaucoma specialist. Primary outcome measures were reduction of IOP immediately after laser suture stretch (LSS) and at consecutive visits and complications. Secondary outcome measures included the need for other bleb manipulations, topical anti-glaucoma medications and the IOP at 3 months after trabeculectomy and at final visit. Results: 25 eyes from 24 patients required LSS. 15 had POAG, 8 NTG, 1 pseudoexfoliative glaucoma and 1 steroid induced glaucoma. Laser suture stretch was initiated at a median 8 days (range 1-30) following trabeculectomy. Laser treatments were delivered to 5 patients with a conventional Argon laser and 20 with the PASCAL Photocoagulator using shorter laser pulse duration and lower energy with the latter. 8 needed repeat LSS – 6 on the same day and 2 at the next outpatient visit. Mean pre-stretch IOP was 24.5 ± 6.2 mmHg reducing to 12.7 ± 4.2 mmHg on average 30 minutes after treatment. This IOP lowering effect was maintained at 10.0 ± 5.4 mmHg at mean 6.8 ± 4 days following the treatment. Only 3/25 (12%) eyes required suture lysis to obtain the desired 20 IOP lowering effect. In one further case treatment was aborted due to poor visibility of the sutures and was treated with topical IOP lowering agents followed by bleb needling with 5FU. One patient developed hypotony but did not require further intervention as he maintained 6/6 unaided vision over 8 months follow-up. Mean IOP measured 10.6 ± 6.2 mmHg at three months and 12.1 ± 4.8 mmHg at final follow up (median 12 months). 11 eyes required further bleb manipulation to keep their IOP at the desired level and/or improve their bleb morphology. Two eyes received 5 FU injections immediately following LSS and again 2 weeks later and 9 had 5FU or mitomycinC enhanced needling 1 week to 8 months following LSS. 4 eyes required topical anti-glaucoma medication commencing at 3, 7, 15 and 26 months after surgery. Conclusion: Laser suture stretch is a safe and effective method by which to enhance outflow in the early posttrabeculectomy period and avoids the need to use adjustable sutures. P27 SLT and cataract surgery: what should come first? Natalya Kurysheva1, Pavel Ryzhkov1 1 Ophthalmological Center of the Federal Medical and Biological Agency, Moscow - Russia It has been postulated recently that the long-term effectiveness of selective laser trabeculoplasty (SLT) is the same for phakic and pseudophakic patients (Werner M. et al., 2007; Shazly T. et al., 2011). Moreover, cataract extraction itself might be an intraocular pressure (IOP)lowering procedure (Issa A. et al., 2005; Bhallil S. et al., 2009). Purpose: The purpose of the study is to compare the effect of SLT performed prior to cataract surgery and following it in glaucoma patients. Methods: A retrospective chart review was performed on 147 eyes of 102 patients with mild to moderate primary open angle glaucoma (POAG) and uncontrolled IOP who underwent 180 degrees SLT (frequency-doubled Qswitched 532 nm Nd:YAG laser) in our clinic from 2005 to 2011. In the first group 89 patients (130 eyes) underwent SLT at the period of 2-3 months prior to phacoemulsification-assisted cataract excision surgery, in the second group (13 patients, 17 eyes) – 2-3 months after it. In all cases intracapsular lens implantation was performed successfully. In the second group, while IOP was controlled by a maximum amount of medications before the cataract surgery, it was uncontrolled after the operation, which became an indication for SLT. Patients were excluded if they required additional glaucoma medications, laser, or ocular surgery during the follow-up period. IOP measurements were carried out at scheduled intervals (1 day, 1 week, 1 month, 6 months and 12 months) of post-laser follow up. The figures were then compared with baseline IOP taken prior to SLT. Changes in IOP and statistical significance were determined at each followup period. Average decrease in IOP and success rates for phakic and pseudophakic eyes were compared statistically at each time period. An independent-samples t-test was used to compare the IOP reduction between 21 the phakic and pseudophakic groups. Perimetric indices (MD – mean deviation, and PSD – pattern standard deviation) were also analyzed while assessing the long-term effects of SLT. All patients underwent computer perimetry (Humphrey Visual Field Analyzer II, Humphrey Instruments, San Leandro, California, USA) prior to SLT and 1 year after the laser surgery. MD and PSD taken after the cataract surgery were chosen to represent the baseline in the pseudophakic patients. Changes in MD and PSD indices and statistical significance were calculated at the aforementioned periods in both groups. Results: IOP reduction in the pseudophakic group was 24.7% (1 day), 14.8% (1 week), 12.3% (1 month), 1.0% (6 months) and 12.6% (12 months). In phakic patients, the mean IOP reduction was 35.6% (1 day), 16.4% (1 week), 14.9% (1 month), 20.5% (6 months), 21.6% (12 months). The p value was 0.822 (1 day), 0.299 (1 week), 0.981 (1 month), 0.034 (6 months) and 0.048 (12 months) after SLT. One year post-SLT 72.4% of phakic patients and 90.5% of pseudophakic patients required IOP-lowering medications. The MD perimetric index decreased by 3.89 dB (from -7.63 to -11.52) in the pseudophakic group and increased by 0.65 dB (from -4.31 to -3.66) in the phakic group. The difference was found to be statistically insignificant with the p value being 0.316 in the pseudophakic group and statistically significant (p = 0.032) in the phakic group. The difference between the groups was 7.86 dB (p = 0.08). The PSD index remained stable in both groups showing neither improvement, not deterioration. Conclusions: SLT is more effective in lowering IOP if performed prior to cataract surgery. However it seems to be a safe and effective means of IOP reduction in pseudophakic glaucoma patients and can reasonably be applied as adjunctive therapy. SLT performed on phakic eyes might play a role in visual field improvement. This finding warrants future investigation. Perhaps further studies involving bigger groups of patients with more frequent visual field assessment post-SLT may shed light on this issue. P28 Transcleral cyclophotocoagulation using diode laser 980 nm Amr Eldib1 1 National Laser Institute for Enhanced Science Medical Center, Cairo University - Egypt Purpose: To examine the efficacy of 980 diodelaser cyclophotocoagulation CP following failure of glaucoma control on maximal medical therapy in treatment of refractory glaucoma. Methods: A nonrandomized retrospective chart review was conducted of 15 eyes contact diode CP (Group A), or 12 eyes non contact diode (Group B) with refractory glaucoma treated with following initial failed maximal medical therapy Success was defined as an intraocular pressure # 20 mmHg on medical therapy, no visually devastating complications, and no further glaucoma surgery performed or recommended. Results: Of the 15 eyes (Group A) and 12 eyes (Group B) underwent diode CP as a secondary procedure. analysis demonstrated a successful outcome at 1 month and 3 months Conclusions: Diode CP using 980 nm diode laser use in glaucoma showed high efficacy and low complication rates. However, Noncontact CP provides IOP reduction in eyes with medically uncontrolled glaucoma. Patients with history of prior ALT or any incisional ocular surgery other than cataract were excluded from the study. Success of the procedure was defined as 15% or more IOP reduction from baseline. Mean, SD, one way ANOVA followed by Tukey’s test were used for the analysis. Chi-square test was used to compare proportions. P values less than 0.05 were considered to be statistically significant. Results: Age, race, SLT parameters in pseudophakic and phakic group were not statistically different. Pre-treatment IOP did not differ between groups (19.2 ± 2.5 vs. 19.7 ± 3.2 mmHg before SLTI, p > 0.05; 19.2 ± 3.4 vs. 18.9 ± 4.6 mmHg before SLT II, p > 0.05). Time to repeat (months) was 26.4 ± 15 after SLT I (range: 11-65) in pseudophakic group, and 28.3 ± 12 (range: 11-54) in phakic group. Mean numbers of glaucoma medications did not change during 24 month follow-up in both groups as compared to baseline. The mean numbers of glaucoma medications in the pseudophakic group was significantly lower at 4 months after SLT I compare to the phakic group (p < 0.05). Mean IOP reductions were statistically significant in both groups after the first and repeat SLT up to 24 months. Percentage of pseudophakic and phakic eyes achieving ≥ 15% IOP reduction significantly differed only at 1 month after repeat SLT (Table). Conclusions: Percentage of successful IOP reduction from primary and repeat SLT in pseudophakic eyes was not significantly different from phakic eyes at 4-24 month after the intervention. These retrospective data suggest primary and repeat SLT were similarly effective in phakic and pseudophakic eyes after the first and repeat SLT. P29 Comparison of repeat selective laser trabeculoplasty efficacy in phakic and pseudophakic eyes Robert Fechtner1, Tamara Berezina1, Barry Maltzman1, Khelly Shah2, Albert Khouri1 1 The Institute of Ophthalmology and Visual Science, UMDNJ-New Jersey Medical School, Newark, NJ - USA, 2 Drexel University, Philadelphia, PA - USA Purpose: To compare the efficacy of first and repeat selective laser trabeculoplasty (SLT) in phakic and pseudophakic eyes. Methods: Retrospective review of electronic medical records from Hudson Eye Physicians and Surgeons Center affiliated with UMDNJ was performed. Patients with open angle glaucoma undergoing first and repeat 360-degree SLT for additional intraocular pressure (IOP) reduction between 6/2003 and 11/2007 were selected for analysis. Twenty three pseudophakic eyes from 19 patients who underwent cataract surgery at least six months prior to SLT were included. The first 23 phakic eyes from 19 patients selected from the database served as a control. Demographic data, SLT parameters, IOP and number of glaucoma medications were collected at baseline and at 1, 4, 8, 12, 18, and 24 months after the intervention. Table - Percentage of pseudophakic and phakic eyes achieving ≥ 15% IOP reduction after primary and repeat SLT Time point SLT I (mean energy 0.96 mJ) Pseudophakic Phakic 1 month P I-II* 52% (12/23) 73% (16/22) 4 month P I-II 63% (12/19) 8 month P I-II p value (phakic vs. pseudophakic) SLT II (mean energy 1.1 mJ) p value (phakic vs. pseudophakic) Pseudophakic Phakic 0.091 33% (7/21) 0.112 62% (13/21) 0.194 0.046 63% (12/19) - 40% (8/20) 0.092 56% (9/16) 0.248 0.168 70% (14/20) 55% (12/22) 0.151 53% (10/19) 0.142 67% (12/18) 0.191 0.183 12 month P I-II 62% (13/21) 52% (12/23) 0.195 43% (10/23) 0.116 44% (8/18) 0.164 0.248 18 month P I-II 57% (12/21) 48% (11/23) 0.197 65% (15/23) 0.209 53% (9/17) 0.238 0.189 24 month P I-II 41% (7/17) 67% (14/21) 0.079 50% (10/20) 0.226 63% (10/16) 0.261 0.202 22 P30 A randomized comparative study of the safety and efficacy of conventional versus micropulse diode laser transscleral cyclophotocoagulation in refractory glaucoma Maria Cecilia Aquino1, Anna Marie Tan1, Seng Chee Loon1, Paul Chew1 1 Department of Ophthalmology, National University Hospital, Singapore - Singapore Objective: To compare the efficacy and safety of micropulse and continuous wave diode transscleral cyclophotocoagulation in patients with refractory glaucoma. Design: Single center randomized clinical trial. Participants: Patients with refractory, end-stage glaucoma. Intervention: Patients were assigned randomly either to micropulse or continuous wave diode cyclophotocoagulation. Main Outcome Measures: The primary outcome measure was qualified success defined in two ways: (i) ≥ 30% IOP drop (ii) IOP between 6 - 21 mmHg from baseline at final follow-up with or without anti-glaucoma medications. Secondary outcome measures were complication rates, number of medications and repeat treatment. Methods: Patients with refractory glaucoma having IOP of > 21 mmHg on maximal tolerated medical therapy with or without previous surgical intervention and visual acuity of 6/60 or worse were randomized into two groups, micropulse diode transscleral cyclophotocoagulation (MCPC) and conventional, continuous wave diode CPC (CWCPC). Laser parameters were as follows: MCPC 2 Watt(W), 100 second(s) pulse envelop with 0.5ms ON and 1.1ms OFF delivering 62.6 Joules(J) per treatment; CWCPC 1.5 – 2 W, 2s exposure time per pulse, 20 - 28 pulses per eye delivering 60 - 112J per treatment. Both groups were followed up for 18 months. Retreatment was done when intraocular pressure reduction was less than 30% from baseline after 1 month. Results: Fifty patients with advanced glaucoma randomly received either MCPC or CWCPC. Mean pretreatment IOP was 41.58 mm Hg (CI 35.48, 47.67) and 37.92 mmHg (33.09, 42.74) (p = 0.337) respectively. Both groups responded to treatment with substantial decrease in IOP from baseline. At 12 months, MCPC treated eyes had significantly lower average IOP of 18.35 mmHg (CI16.55, 20.14) compared to 25.21 mmHg of CWCPC treated group (CI19.09, 31.33) (p = 0.035). At 18 months, no statistical difference in mean IOP was found (19.83 mm Hg MCPC, 25.56 mm Hg CWCPC; p = 0.067). When outcome measure was IOP reduction of ≥ 30%, qualified success was 88% for MCPC and 75% for CWCPC with no significant difference. But when success was equated to IOP of 6 21 mmHg with or without glaucoma eye drops at final visit, qualified success was remarkably higher in MCPC compared to CWCPC (81% versus 33% at 12 months; 61% versus 30% CWCPC at 18 months). Mean IOP reduction from baseline was 49.79% in MCPC and 35% in CWCPC (p = 0.013). The number of repeat treatment (mean[sd] MCPC 1.6 [± 0.75]; CWCPC 1.8 [± 0.82] p = 0.615) and IOP lowering medications (MCPC 1.15 [± 0.78]; CWCPC 1.17 [± 1.09] p = 0.132) were comparatively similar. Compli- 23 cation rates were higher in CWCPC group. There were 5 cases of hypotony, 5 prolonged uveitis, 1 phthisis bulbi, 4 scleral thinning and 6 cases of visual acuity deterioration. In MCPC group, 1 patient showed visual acuity decline and 1 had scleral thinning (2 out of 26 eyes MCPC vs. 21 out of 24 CWCPC; p < 0.001). Conclusion: Diode transscleral cyclophotocoagulation delivered in a micropulse mode was found to be effective and consistent in lowering IOP compared to conventional, continuous diode CPC with significantly less complications. It provided rapid IOP drop with better safety profile. P31 Analysis of anterior segment dynamics using anterior segment optical coherence tomography before and after laser peripheral iridotomy in primary angle closure eyes Ce Zheng1, Paul T.K. Chew1, Aung Tin1, Sim Heng Heng2, Celeste P. Guzman3, Carol Y. Cheung3 1 Department of Ophthalmology, 2Department of Bioengineering, NUHS, Singapore - Singapore, 3 Singapore Eye Research Institute, Singapore - Singapore Purpose: To evaluate changes in speed of pupil constriction (SPC) and anterior segment parameters after laser peripheral iridotomy (LPI) in patients with angle closure using anterior segment optical coherence tomography (ASOCT). Methods: This was a prospective observational study. Videos of pupil and anterior segment changes in response to illumination were captured with real-time video recording from ASOCT and analysed frame by frame before and after LPI. Customized software was used to measure SPC and changes in anterior chamber depth (ACD) and area (ACA); iris thickness at 750 microns from scleral spur (IT750), at the sphincter muscle region (ITSMR, 0.75mm from pupillary margin), and at the mid-iris location (ITMIL, at half of the distance between scleral spur and pupillary margin); pupil diameter (PD), angle opening distance and trabecular-iris space area 500 microns from scleral spur (AOD500 and TISA500, respectively) were determined. SPC was defined as the rate of PD change in response to illumination. Results: Twenty-nine patients were included. The majority were Chinese (89%) and female (62%). The ACA, AOD500 and TISA500 measurements were significantly higher post-LPI (p < 0.001). There was a significant increase in SPC after LPI (p < 0.005). In response to illumination, the rate of change in ITSMR and IT750 was faster after LPI (p < 0.05). Similarly, there was an increase in the speed of change of AOD500 in response to illumination after LPI (p < 0.05). Conclusions: In patients with angle closure, changes in dynamic irido-pupillary behaviour were found after LPI. The speed of pupillary constriction was faster after LPI. POSTER SESSION 7 MISCELLANEOUS P32 Relationship among photopic negative response, retinal nerve fiber layer thickness, and visual field between normal and POAG eyes Li Na Huang1 1 Shen Zhen Eye Hospital,Ji Nan University, Shen Zhen China Purpose: To determine the relationship among photopic negative response (PhNR) of the electroretinogram (ERG) , retinal nerve fiber layer (RNFL) thinkness and the Visual Field in normal and glaucomatous patients. Methods: Thirty-eight normal volunteers and One hundred twenty-four patients with Primary open-angle glaucoma (POAG)were enrolled in the study. The PhNR were elicited by white stimuli on a white background and red stimuli on a blue background. The visual field parameters was measured using the standard automated perimetry (SAP). The spectral domain optical coherence tomography (SD-OCT) was used to measure the retinal nerve fiber layer (RNFL) thickness around the optic disc. Results: The PhNR amplitudeW/W, B/R, MD and mean RNFL thickness in POAG eyes were significantly lower than normal eyes - p = 0.001). The R value in Normal+Glaucomatous group was higher than the only glaucomatous group. The R values of PhNR amplitude (B/R) with MD and RNFL were higher than PhNR amplitude (W/W). Significant linear association was found of the relationship between RNFL thickness and PhNR amplitude (B/R) (R2 = 0.5, p = 0.001). However, Significant curve association were found of the relationship between MD and PhNR amplitude (B/R), RNFL thickness (R2 = 0.525, 0.442, p = 0.001). Conclusions: The ganglion cell activity can be more efficiently evaluated with the PhNR elicited with a red than with a broadband stimulus. The linear relationship between the PhNR amplitude and RNFL thickness indicates that inner retinal function declines proportionately with neural loss in glaucomatous eyes. The PhNR and RNFLT are more objective tool to detect glaucomatous damage than visual field. P33 Development of core outcome measures for glaucoma interventions Rehab Ismail1, Augusto Azuara-Blanco1, Craig Ramsay1 1 Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen United Kingdom Purpose: Evidence from randomised controlled trials comparing interventions to guide glaucoma manage- ment is less useful than it might be expected because of uncertainty of what constitutes important outcomes and heterogeneity of outcomes that are reported. This is particularly true for glaucoma surgical trials. We aim to develop a standardised set of core outcomes for glaucoma randomised controlled trials which are important to all stakeholders to optimise decision-making. These ‘Core Outcome Sets’ should represent the minimum that should be measured and reported in all glaucoma trials, audits of practice or other forms of research. They do not imply that outcomes should be restricted to those in the core outcome set. Rather, there is an expectation that the core outcomes will be collected and reported to allow the results of trials and other studies to be compared, contrasted and combined as appropriate. This approach would reduce heterogeneity between trials, lead to research that is more likely to have measured relevant outcomes, and be of potential value to use in clinical audit. Importantly, it would enhance the value of evidence synthesis by reducing the risk of outcome reporting bias and ensuring that all trials contribute usable information. Therefore we aim to establish a framework for the development of a standardised set of core outcomes of interventions for glaucoma which will improve decision making by patients, clinicians and health policy makers. Methods: Collaboration between methodologists and clinicians following COMET guidelines. Results: The research will utilise a mixed methods approach of qualitative and quantitative studies. Phase 1 will identify and assess the range of reported outcomes and measures used and identify knowledge gaps, by way of systematic reviews. Phase 2 will refine and build on identified outcomes using a DELPHI study on glaucoma experts from the UK Europe & USA through respective glaucoma societies, and focus groups and semi-structured interviews with patients who have glaucoma. A list of core outcomes and the appropriate measures will be identified, assessed and tested for acceptability and utility using a questionnaire survey of glaucoma experts and patients with glaucoma. Based on the findings of phase 1 and 2, Phase 3 will test the shortlisted set of outcomes in a feasibility study with glaucoma patients in terms of their responsiveness to change of disease severity. Conclusion: Clinical trials are as reliable as their outcomes. Thus when designing a clinical trial, the decision as to which outcomes to measure is crucial. The selection of inappropriate outcomes can lead to wasted resources or information that overestimates, underestimates, or completely misses the potential benefits of an intervention. An important rationale for outcome development is that the outcomes reported in clinical trials fail to provide endpoints that are meaningful for patients. These issues could be addressed with the development and application of agreed standardised sets of outcomes. This approach would reduce heterogeneity between trials, lead to research that is more likely to have measured relevant outcomes, and be of potential value to use in clinical audit. Importantly, it would enhance the value of evidence synthesis by reducing the risk of outcome reporting bias and ensuring that all trials contribute usable. 24 P34 Long-term results of surgical treatment of refractory postburn glaucoma Stanislav Iakymenko1, Petro Kostenko1 1 State Institution «The Filatov Institute of Eye Diseases and Tissue Therapy of the National Academy of Medical Sciences of Ukraine», Odessa - Ukraine Purpose: To investigate the long-term effects of our antiglaucoma operations – autoscleral cyclogoniodrainage with the strip of autosclera (ACGD(S)) and its modifications - cyclogoniodrainage with the fold of autosclera (ACGD(F)) and ACGD(F) with the simultaneous implantation of the Ahmed glaucoma valve (ACGD(A)) (implantation is conducted in our method) in patients with refractory postburn glaucoma on maintenance of reduced intraocular pressure (IOP). Methods: This retrospective study analyzes 137 antiglaucoma operations performed in in 128 eyes between 2001 and 2011. ACGD(S) was performed in 30 eyes (32 operations), ACGD(F) in 67 eyes (74 operations) and ACGD(A) in 31 eyes (31 operations). All patients with refractory postburn glaucoma had the scarry changes in the front division of eye after a burn. Before the operation the intraocular pressure (IOP) level was increased in all patients - range 31-54 mmHg. Visual acuity in all patients equaled to light-perception. Different antiglaucoma operations previously were conducted in majority of patients. Definition of operation success was the compensation of IOP postoperative and in the follow-ups. Results: Compensation of IOP occurred in all patients following ACGD(S), ACGD(F) and ACGD(A) in early postoperative period (less then 3 months). The compensation of IOP in the follow-up period (up to 5 years) occurred in 59.4% of cases after ACGD(S), in 78.4% of cases after ACGD(F), and in 83.9% of cases after ACGD(A). The IOP was reduced because new ways of aqueous humor outflow from the anterior chamber to the suprachoroidal space was created and the aqueous humor production was oppressed. In all patients with compensated IOP the light-perception was preserved and painful symptom was removed. Keratoprosthesis was performed on 27 eyes, which restored vision in these patients. Conclusion: Use of ACGD(S), ACGD(F) and ACGD(A) allowed normalizing intraocular pressure and preserving visual functions in the majority of patients with refractory postburn glaucoma. However, we recommend ACGD(F) and ACGD(A) for these patients, because there is high risk of re-elevation of IOP after ACGD(S) within five years. P35 History of glaucoma surgical procedures Parul Ichhpujani1, Shibal Bhartiya2, George Spaeth3 1 Department of Ophthalmology, Government Medical College and Hospital, Sector 32, Chandigarh - India, 2 Glaucoma Service, Eye 7 Group of Hospitals, New Delhi - India, 3Glaucoma Service, Wills Eye Institute, Philadelphia - USA Purpose: To survey the literature and trace the history of various intraocular pressure reducing surgical techniques and their refinements over the past 150 years. Methods: A Literature search was conducted using Pub- 25 Med search engine, with no date limitation, describing various surgical techniques for glaucoma. Standard textbooks on glaucoma were also referred for additional information. Results: This study looks at the various surgeries and their refinements over the past two centuries, designed to increase the outflow or decrease the inflow of aqueous. Several new surgeries have been introduced since 1856, when von Graefe devised iridectomy. All surgical techniques adopt any of the four approaches: pupillary block disruption, internal filtration, external filtration, and ciliodestruction. Trabeculectomy, non-penetrating glaucoma surgeries and drainage devices are in vogue in the present era. Majority of new surgeries involve use of new implantable devices including SOLX, iStent, and Ex-PRESS shunt. Conclusion: The understanding of pathogenesis and subsequent management of Glaucoma has improved over past two centuries. To better ascertain future directions, we must know how we have arrived to the juncture where we stand today. P36 Evaluation of ocular surface disease in patients of primary glaucoma Sourabh Sharma1, Abhishek Dave1, Lalit Tejwani1, M. Vanathi1, Tanuj Dada1 1 Department of Ophthalmology, AIIMS, New Delhi - India Purpose: To evaluate the prevalence of ocular surface disease (OSD) in glaucoma patients on chronic topical ocular htpotensive therapy. Methods: Sixty four eyes of 64 cases with of primary glaucomas (POAG 30, PACG 34) on chronic topical therapy for more than 6 monthswere included. All patients underwent a detailed ocular surface evaluation (tear break -up time, schirmer, corneal and conjunctival rose bengal dye staining). Patients with secondary glaucoma or any other form of topical therapy were excluded. Results: Mean age of the patients was 56.4 + 8.2 years. A decreased schirmer’s value (< 10 mm) was seen in 54.7% of cases with 6.25% showing severe (< 5 mm) tear deficiency. Early tear break up (< 10 seconds) was found in 68.75% patients with 15.6% showing severe tear film (< 5 seconds) abnormality on TBUT. Corneal/ conjunctival vital staining was seen in 51.6% cases with 2 patients having severe OSD. Mean schirmer score was 12.43 ± 5.05 mm in eyes on 1 medication and 9.64 ± 3.58 mm in eyes on 2 medcations (p = 0.02). Conclusion: Ocular surface disease was found in more than half of the patients with primary adult glaucomas on chronical topical medical therapy. Evaluation of the tear film and ocular surface should be incorporated in the work up of glaucoma patients. P37 Measuring IOP. Corneal rigidity affects IOP measurements: a new simple method is described utilising a combination of Goldmann applanation with Icare rebound tonometry to evaluate rigidity Robert Harvey1, Rishi Sharma1 1 Department of Ophthalmology, Royal Alexandra Hospital, Paisley - United Kingdom Purpose: Raised IOP is the main risk factor in determining the likelihood of primary open angle glaucoma (POAG). Goldmann Tonometry (GT) is the gold standard of intraocular pressure (IOP) measurement utilising the principle of flattening the cornea. The new technique of Icare tonometry IT using the icare device (manufactured by Icare, Finland) offers new insights into glaucoma assessment. Goldmann applanation tonometry makes the fundamental assumption that the surface tension acting on the tonometer prism is counteracted by corneal rigidity. The test is essentially static. In contrast icare rebound tonometry is affected by corneal hysteresis because it is a dynamic test. Corneal pachymetry has a correlation with rigidity but the relationship is complex so no conversion formula is entirely reliable. Icare tonometry (IT) works by rebound tonometry and is a dynamic test compared to the relatively static Goldmann applanation. Results of IT may differ slightly from GT. The . We hypothesise that the difference is due to variations in corneal hysteresis. The Goldmann Icare Difference (GID) may be slightly positive or negative. Many studies have compared IT with GT and found comparable results overall. We have stratified the results depending on whether patients have established glaucoma or ocular hypertension. Then the difference between Goldmann and icare measurements reveals useful hidden information (corneal rigidity). Methods: 150 patients were in this study. We only enrolled one eye (the right). Standard assessment included visual acuity, Humphrey SITA visual fields were plotted. Goldmann tonometry (GT) then Icare tonometry (IT). Central corneal thickness to determine an approximate value of corneal rigidity. Gonioscopy. Subtracting IT from GT provides the GID or Goldmann Icare Difference. Patients were stratified into 3 groups based on the actual conversion to glaucoma (deterioration of visual field or decision to start treatment). Group A (n = 59) had established open angle glaucoma or normal tension glaucoma with progressive field defects. Group B (n = 43) had borderline glaucoma. Non-progressive field defects, suspicious optic discs or high IOP with normal fields and discs. Group C (n = 48) had ocular hypertension (IOP over 22 on 2 occasions but otherwise healthy eyes). Follow up at least 18 months. Results: The 95% limits of agreement between the two methods were calculated by the Bland-Altman method. The mean (M) and standard deviation (SD) of the difference in IOP between GT and IT were calculated (GID). See figure showing the 95% confidence limits. Overall we found no significant difference between Goldmann and Icare measurements when all the patients were aggregated. This is in agreement with other published studies. Interestingly when patients were stratified the GID 26 became significant. Group A patients had a mean GID of +1.5. Group C patients had a mean GID of -1.3. Using GID it becomes easier to categorise borderline patients, especially when the Goldmann and Icare measurements “disagree with each other”. This is a new previously unpublished finding. Conclusions: We found a significant difference in the 2 groups and so Icare was helpful in providing additional information when used in conjunction with Goldmann applanation. Icare is a quick simple test and when used in this way only has to be done once. It means patients with low risk of developing glaucoma (negative GID) have less need for hospital follow up. Similarly those with less rigid corneas (positive GID) need closer follow up as they are more likely to progress quickly. We postulate the GID figure provides a better correlation than pachymetry of the corneal rigidity. The measurements relate directly to pressure (mm of mercury) whereas pachymetry only measures thickness (not pressure). Further studies to confirm this finding using Reichert ORA technology would be useful. P38 Ocular vascular ischemic syndrome and glaucoma Laura Bortmann1, Maria Moussalli1 1 Department of Ophtalmology Hospital Italiano de Buenos Aires, Buenos Aires - Argentina Purpose: Report a clinical case of a patient with ocular vascular ischemic syndrome and comment on its management. Methods: We present the patient: Subject: Male, 73 years old with an acute cardiac infarct, diabetes and internal carotid artery stenosis of 80%. He had previous glaucoma surgery (trabeculectomy) and cataract surgery with intraocular lens in both eyes. His visual acuity lowered in a few days in his right eye and also, the IOP elevated with maximal medication in both eyes (24 mmHg). The Visual Acuity was 20/200 RE and 20/25 LE. The optic disc was pale and with 0.9 excavation in both eyes. At the slit lamp he had iris neovascularization in his RE, and at the gonioscopy, the ostium was closed with synechias. We treated the RE with an Ahmed Glaucoma Implant and we spoke with the cardiovascular surgeon to plan cardiovascular surgery as soon as possible. Results: The patient controlled the Diabetes and underwent carotid stenosis surgery. The postoperative IOP without medication was 10 mmHg the first day, 10 mmHg after one week, 11 mmHg after 1 month and 11 mmHg after 3 months. The rubeosis iridis disappeared and the 27 Visual Acuity was stable. His LE was treated with topical medication (dorzolamide and timolol and latanoprost) and the IOP remained stable at 17 mmHg. Conclusions: The ocular ischemic syndrome may cause a neovascular glaucoma. Our first priority is to lower the IOP to prevent further visual loss, particularly since in these eyes perfusion pressure in the ocular vascular bed is already low. Neovascular glaucoma is a severely blinding disease. To prevent or reduce the extent of visual loss caused by NVG, the first essential measure is to have a high index of suspicion of its development and see the general diseases, early diagnosis and aggressive control of high IOP. The Ahmed glaucoma Valve can control the IOP. Glaucoma drainage device has its own complications and limitations. Placing a glaucoma drainage device in an eye with synechiae is technically demanding and the fibrovascular membrane can occlude the tube. P39 Visual outcome and intraocular pressure control after extracapsular cataract extraction in phacomorphic glaucoma Ravi Bypareddy1, Mahesh Kumar1, Tanuj Dada1 1 All India Institute of Medical Science (AIIMS), New Delhi - India Purpose: To evaluate the effect of extra capsular cataract surgery (ECCE) in patients of phacomorphic glaucoma in terms of visual outcome, intra-ocular pressure control and to assess the correlation between time of presentation with IOP control and visual outcome. Methods: This was a prospective non-randomized interventional consecutive case series which included all patients presenting to the casualty and the out-patient department services of a tertiary care eye facility for a period of 1 year (June 2009-July 2010). Detailed history pertaining to onset of symptoms and time of presentation and cause for delayed presentation were noted. All patients underwent detailed slit lamp examination, applanation tonometry, gonioscopy and ultrasonography. Extracapsular cataract extraction (ECCE) with IOL implantation was performed in all the affected eyes. Sequential follow ups were done and best corrected visual acuity and IOP measurements were performed after 6 weeks of surgery. Result: A total of 70 eyes of 70 patients with phacomorphic glaucoma were included in this study. Mean age of presentation was 62.9 ± 7.11 yrs, with 41 (58.5%) males and 29 (51.5%) females. The mean time of presentation from onset of symptoms was 20.2 ± 17.41 days (2 days75 days) with 54 (77.14%) patients presenting beyond 7 days. Major reasons for late presentation being “poor accessibility” in 23 (32.8%), “no escort” 18 (25.7%) and ”lack of money” in 16 (22.8%). Pre-op mean IOP was 44.4 ± 7.57 mm Hg (3 2 mmHg - 56 mmHg) which reduced to 18.3 ± 3.08 mmHg (14 mmHg-24 mmHg) at 6 weeks post surgery (p < 0.0001). The BCVA at last follow up visit was more than 20/200 in 41 eyes (58.5%). Of the 38 (54.2%) patients presenting beyond 14 days, 28 (73.6%) had final visual outcome of hand movements or less, perception of light in 7 eyes (10%) and a total loss of perception of light in 3 eyes (4.2%). Main causes for poor vision being Optic atrophy in 24 (34.2%) eyes, corneal oedema in 14 (20%) eyes. Conclusion: ECCE is a safe and effective surgery in controlling IOP and achieving good functional visual outcome with minimal complications in managing phacomorphic glaucoma. However, patients showing delayed presentation carry poor visual prognosis. In developing countries, causes for delayed presentation being poor accessibility and financial constraints P40 Glaucoma surgery and social media, what can physicians and patients learn online? John Somner1, Freia McGregor2 1 Anglia Ruskin University, Cambridge - United Kingdom, 2 West Sussex Hospital, Bury St Edmunds United Kingdom Purpose: Many patients with eye problems are using the internet. Several online communities exist where patients can share information and experiences about their conditions. Little work has been done to analyse what use is being made of these online resources and what information is available in them. This study set out to evaluate the content of ophthalmic forums and to look at the online discussion of glaucoma surgery. Methods: Four online sources of ophthalmic information were analysed, the International Glaucoma Association (IGA) forum, Facebook, Twitter and PatientOpinion.org. uk. A total of 3279 items were scraped from the sites, collated and analysed using simple thematic analysis by two coders (511 Facebook posts, 1514 IGA posts, 717 Tweets and 527 Patient Opinion posts). Results: Analysis of these different online resources identified 15 principle themes. Of these 3 were of relevance to glaucoma surgery, experience of care (20% of all posts), promotions (18% of all posts) and treatment (23% of all posts). Only four posts discussing the experience of care related to glaucoma surgery, two related to communication around the time of surgery, one to lack of surgical equipment and one to a surgical complication. Promotions relating to surgery were similarly limited with only seven posts promoting particular surgical treatments (three canaloplasty, two trabecular meshwork shunts, one Trabectome and one a developing world eye service). Discussion about treatment was mostly directed at topical drops with 49% of posts on this theme, 34% of posts were on surgery while posts on complementary therapy (11%) and systemic medications (6%) made up the rest. The nature of the posts on glaucoma surgery for the two online forums is summarised in the following figure. Of the comments on medical and surgical management of glaucoma approximately 25% were negative while only 13% of comments on complementary therapy for glaucoma were negative. There was no significant difference between the number of positive or negative comments on medical or surgical glaucoma management (p = 0.2) however comments on complementary therapy were significantly more likely to be positive (p = 0.03) than either posts on medical or surgical management. There was only one potentially misleading post on surgery but this was unlikely to result in harm. Conclusion: Online forums contain a wealth of detailed, granular information on themes of importance to patients. Eight percent of discussion focussed on surgery, most of this was positive and similar amounts of negative posts were received by surgical and medical approaches to glaucoma. Patients ask questions, receive answers, tell personal stories, chat and support each other online. There was minimal misleading or dangerous information but certain less well established procedures were actively promoted online and complementary therapies were significantly more likely to receive positive posts. This study provides in depth information about the online descriptions of surgery provided by patients with glaucoma. It demonstrates that online social media can act as a useful resource for patients by highlighting both the positive and negative aspects of different treatment modalities. It may help physicians to understand the patient perspective on treatment options for glaucoma and could help to improve communication and support for patients considering or undergoing glaucoma surgery. P41 Intra-ocular pressure (IOP) reduction after scleral spacing procedure (SSP) in normotensive presbyopes (NTP) and primary open angle glaucoma (POAG) subjects John Samples1, David Schanzlin2, Barrie Soloway3 1 Department of Surgery, Rocky Vista University, Parker USA, 2Department of Ophthalmology, University of California, San Diego - USA, 3New York Eye and Ear Infirmary Vision Correction Center, New York - USA Purpose: To evaluate the IOP at intervals after SSP and PMMA implants (PresView Scleral Implants, Dallas, TX) (PSI) as compared to pre-operative, unmedicated IOP in NTP and medication controlled POAG subjects Methods: A retrospective study was performed which compared pre-operative IOP in normotensive presbyopes (NTP) enrolled in the USA FDA monitored IDE study of scleral implants (SSP with PSI) for presbyopia in the United States at up to 18 months post-operatively. This data was then compared to the early prospective results of SSP with PSI in subjects with primary open angle glaucoma (POAG) in the health Canada monitored study currently underway in Ontario Results: Pre-operative unmedicated mean IOP was 14.3 28 mmHg and 29.0 mmHg in the USA normotensive presbyopes and the Canadian POAG subjects respectively. Both groups showed an elevation at one day post-op with the mean IOP of 2.4 mmHg (+17%) and 4.1 mmHg (+14%) respectively. The normotensive cohort mean IOP decreased to 13.8 mmHg (-3%), 12.8 mmHg (-10%), 12.3 mmHg (14%), and 11.8 mmHg (-17%) at 1, 6, 12, and 18 months post-operatively. The POAG cohort resumed medications at one day post-op. By the 2 month post-operative visit, a mean reduction of one medication was found with 33% of the patients totally off medication to maintain IOP ≤ 18 mmHg was found. Conclusion: SSP with PSI reduces IOP in both NTP and POAG patients after 2 months post-operatively. The amount of reduction of IOP is directly correlated to the unmedicated pre-operative IOP. Long term reduction is seen in NTG subjects, however additional measurements are required to determine the continued efficacy in POAG patients. A number of potential mechanisms for this observation exist and will be discussed. P42 Minimally invasive glaucoma surgery. Strategies for success Daljit Singh1 1 Singh Eye Hospital, Amritsar - India My first glaucoma operation was Elliot trephine in 1957. After half a century, we are nowhere near a perfect filtration technique. The reason is that there are myriad of glaucoma situations that we try to handle with a single solution/technique like a gold standard trabeculectomy or its modifications. we make a large footprint of the surgery on the sclera, in the form of surgical dissection, bipolar cautery and mitomycin application. Failure is a problem, since re-surgery is doubly traumatic. Glaucoma filtration surgery has become a complicated battlefield in the hands of specialist glaucoma surgeons. Many implants and valves have only added to the confusion. Cryo cautery and diode laser are a manifestation of our desperation. There is uniform ignorance about the presence of a network of lymphatics that are responsible for the drainage of out coming aqueous. A new tool, Fugo blade became available to me in 1999, the same year I became aware of conjunctival lymphatics. Initially I used it for Transciliary Filtration (TCF), Soon I used Fugo blade to make small tracks in to the anterior chamber - Microtrack Filtration (MTF). Fugo plasma blade is an ablative tool that causes minimal collateral damage and there is no burning or charring.It works like excimer laser. It ablates surfaces and makes tracks, by removing the tissues in its path. Its unique ablative property lets us perform surgery across the tissue planes. For 12 years Fugo blade has been my sole tool to manage diverse glaucoma situations - primary or failed surgeries. The small foot print and the ability of the ablative tool to wriggle anywhere has been a great help and source of confidence in handling any situation. Failures with other techniques like Trabeculectomy and drainage valves are handled as easily. For many years, I have concentrated my attention to MTF. It is a one minute operation that connects the anterior chamber to the space under the 29 conjunctiva, close to its attachment at the limbus. There are minimal variables involved - a precise 250 micron track with an inner and an outer opening. Initially there is over filtration. The pupil is kept small with pilocarpine. A partial or a complete internal closure leads to shallowing of the bleb, deepening of the anterior chamber and a rise of IOP. The iris is cleared with a single shot of YAG laser. If need be it is repeated. Within one month the ac depth and the bleb get stabilized. To reduce the chances of outside closure by scarring, MMC 0.02 % is deposited under the conjunctiva at the end of the surgery. We have found that the conjunctival lymphatics are not damaged by MMC, the way it is used. Failure is not a big problem. About 1 in 15 cases need re-surgery by the same atraumatic technique and similar follow up. Our ultimate goal is to achieve an early and complete success, so as to match the un-paralleled success of phako in the field of cataract. The following strategies have been adopted: 1. Placing a bandage contact lens at the end of surgery. 2. Passing a trans-cameral suture over the iris to prevent it from moving forward and blocking the internal opening. 3. Putting cross linked sodium hyaluronate in the path of out coming aqueous, to reduce the speed of flow and reduce chances of shallow anterior chamber. One year experience with over 50 cases. 4. Placing collagen matrix under the conjunctiva to achieve the same as above.9 months experience with 62 cases. 5. Tying the conjunctiva (and the lymphatics contained under it) like a sheaf on two sides, before MTF is done. This increases outside resistance to aqueous flow. 6. Reducing the track size, so that there is less tendency for the iris to move forwards. 7. A combination of measures mentioned above. The main line glaucoma surgery of today is nowhere in my line of thinking. Since I am working all alone, my experience remains anecdotal. Yet, I never have to say that my surgery has failed, since it is so easy to redo it. However, a lot of work/research remains to be done, so that we can reach cherished goal of one time totally effective, adequate sized track, that is protected from over and under filtration, that saves the patient costly medication, and returns him to work early. Reference Singh D. Microtrack filtration. Ann Ophthalmol 2002; 34: 183-7. P43 The importance of conjunctival lymphatics Daljit Singh1 1 Singh Eye Hospital, Amritsar - India The lack of awareness about lymphatics is best reflected in Shield Text Book of Glaucoma, sixth edition, 2011. About the route of aqueous drainage it mentions ,”Aqueous in the filtering bleb usually filters through the conjunctiva and mixes with the tear film or is absorbed by vascular or perivascular conjunctival tissue”. My contention is 1.Passage through the conjunctiva means a leaking bleb. 2.Conjunctival tissue can not endlessly absorb the aqueous. The aqueous has to be drained all the time. The concept and reality of the existence of lymphatics solves the mystery of aqueous flow. i have demonstrated the conjunctival lymphatics in the following ways: 1.Routine slit lamp examination of the limbus shows lymphatics.. Presence of pigment at the limbus highlights the lymphatics. They enter the cornea singly but freely anastomose proximally. 2. Injuries causing subconjunctival haemorhage, push the blood in to the conjunctival lymphatics. 3. In the operation theater,mere twisting the limbal conjunctiva with a swab, makes the lymphatics prominent. 4. The network of conjunctival lymphatics can be demonstrated by injecting trypan blue at the limbus. 5. The conjunctival lymphatics do not show in the area of scarring. 6. Scleral lymphatics have been demonstrated by injecting the dye in the perilimbal sclera. These lymphatics are connected to the conjunctival network. 7. Yeni et al 2009, demonstrated the presence of lymphatics in the ciliary body. 8. I have demonstrated the presence of lymphatic network in the cornea. I have also demonstrated that the so called “lucid interval’ as seen in cases of arcus senilis is actually a channel. I have reasons to believe that “lucid interval canal” has connections with the canal of Schlemm. The picture that finally emerges is of a single network of channels in the anterior segment of the eye. The orbit too has lymphatics. They are responsible for quickly draining a large retrobulbar haemorrhage. Once convinced about the presence of a lymphatic network in the ocular tissues, it becomes our responsibility to preserve it during glaucoma surgery and allow it to naturally drain the out coming aqueous. I have my way to do atraumatic Microtrack Filtration, a one minute procedure with Fugo plasma blade to produce a filtration track of precise width of 150,200 or 250 microns. References 1. Singh D et al. The conjunctival Lymphatic system. Ann ophthalmol 2003; 35: 99-104. 2. Singh D. Letters: conjunctival lymphatic system. J Cataract Refrat Surg 2003; 29: 632-3. 3. Singh D, Kirmani T. The applications of fugo blade. Lippincots, Williams & Wilkens 2010; 79-82. 4. Singh D. Microtrack filtration. Ann Ophthalmol 2002; 34: 183-7. POSTER SESSION 8 GLAUCOMA DRAINAGE SERVICES P44 Ex-press drainage device in advanced glaucoma patients: long-term efficiency and safety Alexander Kuroyedov1, Victoriya Ogorodnikova1, Vitaliy Gorodnichiy1 1 Department of Ophthalmology, 2nd Mandryka Central Clinical Hospital, Moscow - Russia Purpose: To determine the long-term efficiency and safety of implantation Ex-PRESS shunt to patients at advanced stage of POAG. Methods: Seven male patients underwent penetrating filtering surgery with implantation of the Ex-PRESS shunt over the lack of stabilization of visual functions on hypotensive drugs. Results: Average monitoring of patients was 19.96 ± 9.73 months. IOP in postoperative period was 16.14 ± 3.67 mmHg (by Maklakov). The reduction of IOP was 12.72 mmHg (40.2%). Cell density didn’t differ from double (2879 ± 87 cell/mm2 и 2798 ± 67 cell/mm2, p > 0.05). Conclusion: Long-term gradual reduction of IOP and safety of implantation Ex-PRESS mini-shunt may be a reason of choice this type of surgery for patients at advanced stage. P45 Collagen matrix implant for treatment of refractory glaucoma (OloGen) in 25 pt in Sudan Mohamed Siddig1 1 Glaucoma Department, Khartuom Eye Hospital, Khartuom - Sudan Aims: Based on experience learned from earlier animal study, we describe a short term pilot study that evaluates the safety and efficacy of trabeculectomy with implantation of OloGen in refractory glaucoma patients. OloGen, by its characteristics, improves the regenerating tissue-remodeling and reduces scar formation by guiding fibroblast to grow through the matrix pores randomly. Material and methods: In this prospective and nonrandomized study, twenty five patients underwent trabeculectomy with new device in one eye for refractory glaucoma, which is defined as having previously failed medical, laser or surgical treatment, or some combination thereof. The OloGen was implanted on the top of the scleral flap at the limbus before closing the conjunctival wound during trabeculectomy operations. Intraocular pressure (IOP), number of medications and complication were assessed before and after surgery. Results: The mean preoperative IOP was 45.67 ± 7.45 mmHg with 2.07 ± 0.84 antiglaucoma medications. Postoperatively, the mean IOP at last follow up (4 months) for all eyes was 16.11 ± 3.17 mmHg (64.50% reduction) with 0.33 ± 0.18 antiglaucoma medications. There were no significant intra-operative complications in any patients. Transient postoperative completion, Postoperative iritis 1 patietn, cataract 4 patietns, dropping of vision 2 patients. 30 Conclusion: The preliminary results of this study indicate that the OculusGen implantation in trabeculectomy represents a new, safe, simple and effective therapeutic approach for treating refractory glaucoma. Normalization of subconjunctival wound healing by tissue engineering is applied to traditional filtering surgery, bringing a novel approach to anti-scarring. A larger-scale study with a longer follow-up period is required to confirm these observation. P46 Esnoper Clip®: a new glaucoma implant for deep sclerectomy Jordi Loscos Arenas1, Mª Àngels Parera Arranz1, Sandra Gómez Sánchez1 1 Hospital Universitari “Germans Trias i Pujol”, Department of Ophthalmology, Glaucoma Unit, Barcelona - Spain Purpose: To evaluate the effect and the safety of a new rigid , nonabsorbable HEMA implant, Esnoper Clip® (AJL, Alava, Spain), designed for increase the trabecular and uveoescleral outflow and achieved higher intrascleral blebs. Methods: Fifteen eyes with medically uncontrolled primary open-angle glaucoma were operated of non penetrating deep sclerectomy with Esnoper Clip® implant. The implant has two foots one, for the intrascleral lake and the other is placed between the sclera and the choroid and its fixed without suturing. The patients were follow-up during at least four months. During the examination slit lamp,tonometry visual acuity, funduscopy, anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopic (UBM) was done Results: The medium follow-up period was 6 months. At the last follow-up visit most of the patients achived IOP of 18 mmHg or less, without antiglaucoma medication. We evaluate postoperative the presence of suprachoroidal hyporeflective area with UBM and intrascleral bleb hight with AS-OCT and its relation to IOP control. Conclusion: The new HEMA implant, Esnoper Clip®, is easy to place and seems to offers success and few complications rates .It designs keep intrascleral and suprachoroidal space.and high intrascleral bleb. Further studies with higher numbers of patients and long-term follow-up are needed to study if the effect of its shape provides better beneffits than others. P47 Outcomes through one year after micro-invasive glaucoma surgery (MIGS) with implantation of two trabecular bypass stents in open-angle glaucoma Konrad Schargel Palacios1, Jose Belda Sanchis1 1 Department of Ophthalmology, Hospital de Torrevieja, Alicante - Spain Purpose: Micro-invasive glaucoma surgery (MIGS) in which single or multiple trabecular micro-bypass stents are implanted ab internally in conjunction with cataract surgery has been shown to result in significant IOP and ocular hypotensive use through one year. This prospective study involved implantation of two trabecular micro-bypass stents as the sole surgical procedure. This 31 evaluation by the MIGS study group was performed in patients who were diagnosed with open angle glaucoma not controlled with the use of two medications prior to surgery. Patients underwent stent implantation and were administered with one postoperative topical ocular hypotensive medication. IOP and medication use was assessed through one year. Methods: Initial criteria for subject enrollment were open-angle glaucoma, use of two topical ocular hypotensive medications, and medicated IOP greater than or equal to 18 mmHg and less than or equal to 30 mmHg. Both phakic and pseudophakic eyes were enrolled. Following a preoperative medication washout period, one additional qualification criterion was preoperative unmedicated IOP ranging between 22 mmHg and 38 mmHg. A total of 42 eyes that met all qualification criteria underwent MIGS implantation of two trabecular microbypass stents (iStent, Glaukos Corporation, Laguna Hills, CA) through a 1 mm clear corneal incision. Travoprost was administered postoperatively to all patients. Primary efficacy assessments included of IOP reduction ≥ 20% with reduction of one medication at one year, and IOP ≤ 18 mmHg with reduction of one medication at one year. Safety assessments at postoperative visits through 25 months included slit-lamp, gonioscopy fundus/optic nerve exam, surgical/postoperative complications and best corrected visual acuity. Results: To date, twenty-eight subjects have been followed through one year. Mean preoperative medicated IOP prior to washout of two medications was 22.3 mmHg (SD 2.5). Following medication washout, mean preoperative unmedicated IOP was 25.1 mmHg (SD 1.9). Following implantation of two stents and administration of one medication, postoperative IOP was 14.1mmHg (SD 2.6) at 1 month, 14.1 mmHg (SD 2) at 3 months, and 14.1 mmHg (SD 1.8) at 6 months. At one year, 89% of eyes achieved IOP reduction ≥ 20% with reduction of one medication, and 89% also achieved IOP ≤ 18 mmHg with reduction of one medication. Transient hypotony occurred at one week in one subject and resolved without intervention or further sequelae by 1 month. Conclusion: Significant IOP and medication reduction was achieved in a subset of subjects followed for one year in this study of MIGS implantation of two iStents as the only surgical procedure, followed by administration of one postoperative prostaglandin, in OAG subjects not controlled preoperatively on two medications. P48 STARfloTM, a new suprachoroidal drainage implant for glaucoma : 3 months clinical results Veva De Groot1, Nathalie Collignon2, Max Maginness3, Andrew Marshall3, Cecile Roy4, Michel Alvarez4, Pierre Geens4, Sayeh Pourjavan5 1 Universitair Ziekenhuis Antwerpen (UZA), Antwerpen Belgium, 2Centre Hospitalier Universitaire (CHU), Liège - Belgium, Healionics Corporation, Seattle - USA, 4iSTAR Medical, Isnes - Belgium, 5Cliniques Universitaires Saint Luc, Bruxelles - Belgium Purpose: STARfloTM is a medical grade silicone implant designed to reduce IOP in patients suffering from open angle glaucoma. STARfloTM is made entirely with STAR® Biomaterial, a flexible tissue-friendly, micro-porous structure designed to reduce fibrotic response and maximize long-term performance. Here we share our 3 months experience with the first 4 patients implanted with the STARfloTM glaucoma drainage device. The safety and performance endpoints of the study are: (1) feasibility of STARfloTM device implantation; (2) incidence of device and procedure related-complication and unanticipated adverse device effects; (3) reduction in intraocular pressure (IOP) from pre-operative baseline; (4) reduction in number of glaucoma medications from pre-operative baseline. Methods: Four patients (one female and 3 males) with advanced open angle glaucoma and pre-operative IOP higher than 21 mmHg underwent STARfloTM implantation in one eye. Under local or general anesthesia, a fornixbased conjunctival flap and a superficial scleral flap (8x3 mm and 50% depth) were created. A 7-8 mm incision in the second layer of sclera until choroid was performed to insert the body of the implant in the suprachoroidal space while the head of the implant was then inserted through a 3mm opening into the anterior chamber, parallel to the iris plane. The superficial scleral flap was sutured tight and conjunctiva was closed. Outcome measures included IOP, biomicroscopy, ophthalmoscopy and the number of anti-glaucomatous drugs were noted on day 1, week 1, month 1 and month 3 after surgery. In addition, the surgical success and the occurrence of ocular signs, symptoms and adverse events were documented. Results: Patient ages were 65.3 (SD 19.0) years (min–max = 43-83 years). All patients had poor visual acuity. Mean pre-operative IOP was 37.0 (SD 8.4) mmHg and mean pre-operative glaucoma medication was 2.5 (SD 1.0) intake/day. One month after surgery (4 cases), mean IOP decreased to 21.8 (SD 9.7) mmHg (a mean of 38.4% reduction per patient) and mean glaucoma medication decreased to 1.0 (SD 1.2) intake/day. At 3 months (3 cases), mean IOP was 25.0 (SD 11.3) mmHg (a mean of 33.1% reduction per patient) and mean glaucoma medication was 1.0 (SD 1.0) intake/day. No adverse events were reported during or immediately after the surgical procedure and no device-related (serious) adverse events were reported during follow-up. Early post-operative complications included: transient hypotony (IOP < 6 mmHg) for two patients at day 1 and for one patient at week 1, transient choroidal hemorrhage in one case at week 1, transient abnormal macula in one case at month 1. In 3 cases, bleb disappeared at month 1, and in one case it disappeared at month 3. No significant modification of the biomicroscopy score of the implanted eyes was noted between baseline and last observation carried forward. One patient, with posttraumatic COAG, was dropped out following a cytophoto-coagulation performed on the treated eye 4 months after implantation due to insufficient pressure lowering. Conclusions: Early clinical results for STARfloTM have met the safety and performance endpoints of the study. STARfloTM shows promise as a novel, suprachoroidal implant for bleb-free, intraocular pressure (IOP) reduction in refractory glaucoma. P49 Results through 12 months postoperative of ab interno suprachoroidal stent implantation and postoperative travoprost for the treatment of open angle glaucoma Anselm Juenemann1, Michaela Moelle1, Juliane Schlomberg1 1 Department of Ophthalmology, University of Erlangen-Nürnberg, Erlangen - Germany Purpose: The intraocular pressure (IOP) lowering effect of an ab interno suprachoroidal stent in conjunction with postoperative Travoprost was assessed in open angle glaucoma (OAG) subjects with IOP previously not controlled on two topical hypotensive medications. Methods: A suprachoroidal stent (Model G3) was developed by Glaukos to create a patent lumen from the anterior chamber into the suprachoroidal space to enhance aqueous outflow and reduce IOP in moderate to advanced OAG. In this prospective trial by the MIGS Study Group, 40 subjects underwent implantation of a single stent through a 1 mm temporal clear corneal incision under topical anesthesia. Preoperative medicated IOP was required to be between 18 mmHg and 30 mmHg on two medications. Preoperative IOP after medication washout was required to be between 22 mmHg and 38 mmHg. Travoprost was prescribed postoperatively and discontinued if IOP measured below 6 mmHg. Postoperative evaluations occurred at Day 1, Week 1, and Month 1, 3, 6, 12, 13, 18, 24 and 25. Results: Mean preoperative medicated diurnal IOP was 20.8 mmHg (SD 2.2), and unmedicated (baseline) IOP was 24.7 mmHg (SD 1.9). To date, twenty-five subjects have been followed through 12 months postoperative. Following uncomplicated implantation of a Model G3 suprachoroidal stent and administration of postoperative Travoprost, IOP decreased to 13.8 mmHg or less through the one year timeframe. Ninety-six percent of eyes with follow-up through one year met the primary efficacy endpoint of IOP reduction ≥ 20% with reduction in one medication. Furthermore, 24/25 eyes experienced IOP reduction of reduction ≥ 20%; IOP reduction in the remaining subject was 18.2%. All eyes met the secondary efficacy endpoint of IOP ≤ 18 mmHg with reduction of one medication; 80% achieved IOP ≤ 15 mmHg with reduction of one medication. No untoward postoperative sequelae have been observed to date. BCVA improved or maintained from preoperative BCVA in all subjects. Conclusions: These data through 12 months postoperative suggest that MIGS implantation of a suprachoroidal stent in OAG subjects previously uncontrolled on two topical hypotensive medications is feasible, safe and capable of significant reduction in IOP and medication burden. P50 Mid-term outcomes of trabecular bypass stent surgery (iStent®) in complex glaucoma patients Achilleas Mandalos1, Imran Masood1, Manjit Mehat1, Pravin Pandey1 1 Birmingham and Midland Eye Centre, Birmingham United Kingdom 32 Purpose: The micro-bypass trabecular stent (iStent®) is an innovative device designed to be implanted in the Schlemm’s canal via an ab interno approach. Its use has been studied in standard open angle glaucoma patients, however its role in complex glaucoma is not yet fully elucidated. The purpose of this study is to report the mid-term outcomes of iStent implantation with or without cataract surgery in a series of complex glaucoma patients. Methods: Ongoing, prospective, interventional case series involving 9 patients (7 males- 2 females, mean age 60 years) with complex or refractory glaucoma who underwent iStent surgery. Two patients had primary open angle glaucoma (POAG) with previously failed trabeculectomy and poor intraocular pressure (IOP) control, one had advanced pigmentary glaucoma and had undergone refractive surgery for high myopia, one patient had poorly controlled advanced pseudoexfoliative glaucoma in his only, highly myopic eye, while another had pseudophakic pigment dispersion syndrome with poorly controlled IOP. A patient with juvenile open angle glaucoma and previously failed trabeculectomy in his only eye was also included. Another POAG patient had Marfan syndrome and lens dislocation and had been fitted with a scleralfixated intraocular lens in his only eye. Further, a pseudophakic patient with a history of capsular phimosis and YAG laser anterior capsulotomy had developed medically uncontrolled inflammatory glaucoma as a result of retained anterior capsule remnants in the anterior chamber. Finally, the iStent was implanted in addition to surgical iridectomy in a patient with complex uveitic and angle closure glaucoma due to circumferential posterior synechiae secondary to recurrent episodes of acute anterior uveitis. Results: Overall mean (range) preoperative IOP on maximum tolerated topical medication was 27.7 (21-39.5) mmHg. Mean IOP (with or without topical medication) was reduced to 17.6 (13-23) mmHg, 23 (11-48) mmHg, 22.1 (9-36) mmHg, 17.6 (13-22) mmHg on day 1, week 1, month 1 and month 3-4, respectively. As this is an ongoing study, further results will follow. Patients’ dependence on antiglaucoma medication also dropped from a median of 3 medications preoperatively to 2 medications at last follow up. No intraoperative complications were noted and blood reflux upon iStent implantation was noticed in all cases, which was a reliable sign of proper placement of the device. No IOP spike in the immediate postoperative period was noted. Interestingly, however, steroid response was noted in 6 cases, but all cases improved after cessation of steroids. Conclusion: The iStent® seems to be an effective and safe option for selected patients with complex glaucoma at least in the short to medium term. Further studies are needed to evaluate its long-term efficacy in IOP control in such patients. P51 One year results with the minimally invasive aquecentesis procedure which inserts a trans-scleral durable soft gelatin aqueous drainage implant Paul Palmberg1 1 Department of Ophthalmology, University of Miami 33 Miller School of Medicine, Miami - USA Purpose: To establish the safety and effectiveness of the Aquecentesis procedure in reducing intraocular pressure in patients with primary open-angle glaucoma. In this international study, 118 patients undergoing either primary or secondary surgery were followed for 12 months and their outcomes for mean IOP, IOP change, and reduction of medications were recorded. Methods: The Aquecentesis procedure is a MIGS (Minimally Invasive Glaucoma Surgery) in which a novel inserter is passed across the anterior chamber, its hollow 25g needle tip penetrates the angle and sclera, and a twist of the handle withdraws the needle as it deposits a trans-scleral aqueous drainage implant which connects the anterior chamber to the subconjunctival space. The AqueSys implant is manufactured from a soft, flexible, permanent gelatin. Clinical ophthalmic examinations were performed at the preoperative visit and on postoperative day 1, weeks 1 and 2 and months 3, 6, 9, and 12. The exams included applanation tonometry, anterior chamber OCT imaging, visual acuity, visual field, and assessment of any complications. Effectiveness was evaluated by comparing the baseline and post-operative IOPs and reduction in glaucomatous medications. Results: The mean preoperative IOP was 23 mmHg. The mean postoperative IOP was: 15.4 at 12 months, a mean decrease of -7.6 (-33% reduction), and reduction in median medications from 3 to 1. (These results were obtained without adjunctive use of either 5-Fluorouracil or Mitomycin at the time of surgery and even lower pressures might be obtained with their use.) Conclusion: The Aquecentesis procedure is an effective surgical approach for controlling intraocular pressure in early, moderate, or refractory patients who have primary open-angle glaucoma. The mean IOP was reduced 33% at 12 months. The procedure bypasses all of the trabecular and scleral resistance to flow, but unlike other full thickness procedures provides an appropriate resistance to flow, due to the dimensions of the implant, and thus obviates the need to make any scleral flap or to perform any conjunctival dissection. P52 Biocompatibility evaluation of a novel nickel-titanium Schlemm’s canal scaffold Ian Grierson1 1 Department of Eye and Vision Science, Liverpool United Kingdom Purpose: A new implant (Hydrus™ Aqueous Implant, Ivantis, Inc.) made of Nitinol (nickel-titanium alloy) that reestablishes aqueous humor flow from the anterior chamber through Schlemm’s canal was implanted into rabbits and primates to assess the local tissue biocompatibility. Methods: New Zealand white rabbits were selected to evaluate the ocular biocompatibility of the Hydrus Aqueous Implant. Eight rabbits received implants inserted through the anterior chamber, into the sclera and subconjunctival space using a needle delivery system. The fellow eye underwent a sham procedure without implant. The rabbits were sacrificed after 6 months, the eyes were fixed and sent for histological evaluation. To assess the tissue response in Schlemm’s canal, Cynomolgus primates were selected due to dimensional similarities of their canal to humans. For the study, three primates received a scleral cut-down procedure to access Schlemm’s canal externally. Hydrus Implants were inserted into Schlemm’s canal in two of the primates, the third served as a surgical sham control. After 13 weeks the animals were sacrificed, the eyes were fixed and sent for histological and scanning electron microscopy (SEM) assessment. The histological slides were evaluated masked and unmasked by two independent assessors. Results: Histological examination of the rabbit eyes revealed minimal mononuclear cell infiltration and mild fibrotic response at the site of the implants. Histological and SEM analysis of the primates demonstrated that the implants were properly located in Schlemm’s canal. There was no evidence of an acute or chronic inflammatory response, granulation response or fibrosis in the outflow system or in adjacent tissues. There were minimal differences between study and control eyes. Conclusion: The Hydrus Aqueous Implant was associated with minimal inflammation in both rabbit and primate eyes with extended follow-up. In primate eyes, the implant was well placed within Schlemm’s canal with no evidence of device migration and no signs of fibrosis. It appears from these preclinical studies that the biocompatibility of the Hydrus implant is excellent and human studies are now now underway to corroborate these findings. month IOP was 10 mmHg with fixed combination medication, timolol and dorzolamide. In the case 2, the immediate IOP after surgery without medication was 5 mmHg, after 1 week 12, at 1st month and 12 mmHg at the 6th month. In the case 3 ,the immediate IOP after surgery without medication was 10 mmHg, after 1 week 15, at 1st month and 22 mmHg at the 6th month 25 mmHg, so we used fixed combination medication, timolol and dorzolamide and control IOP in 16 mmHg. Conclusions: The Ex-press r Glaucoma shunt had variable results in complicated glaucoma patients with previous surgery. The most common complication was blockage of the tube. The mean number of glaucoma medications preoperative and postoperative were similar. Results of long-term follow up studies are needed. P53 The Ex-Press r glaucoma shunt: considerations and results in complicated glaucoma Maria Moussalli1 1 Department of Ophtahlmology, Hospital Italiano de Buenos Aires, Capital Federal - Argentina Purpose: We know that the Ex-press r mini shunt are usually indicated for primary open angle glaucoma as a first surgical choice instead of trabeculectomy. The purpose of this presentation is to describe 3 cases of patients with refractive glaucoma and previous complicated cataract surgery. We will focus on success criterial results and will formulated conclusions. Methods: Descriptive study of 3 cases using this device. The patients average age was 75.2 males and one female. All of them pseudophakic and had undergone others previous surgery. The Ex-press r implanted under a 5 x 5mm scleral flap, with a 27G gauge-needle tract and viscoelastic inside the tract. The scleral flap was closed with 9.0 nylon suture. Antimetabolites were not used. Subject: All patients had previous IOP 27 (± 2 mmHg) with maximum medical treatment. There were pseudophakic. In the case 1, had a keratoplasty and vitrectomy. In case 2 trabeculectomy and vitrectomy and in case 3, panfotocaogulation and vitrectomy for central vein retinal occlusion. Results: In the case 1,the immediate IOP after surgery without medication was 10 mmHg, after 1 week 12 and 26 mmHg at the first month. The tube lumen was blockage with iris so we made 2 Yag laser iridotomy. At the 6th 34 P54 Glaucolight assisted canaloplasty vs. iTrack assisted viscocanaloplasty Gabor Scharioth1 1 Aurelios Augenzentrum, Recklinghausen - Germany Purpose: To compare results of Glaucolight assisted canaloplasty (DORC, The Netherlands) with iTrack assisted viscocanaloplasty (iScience, USA). Methods: Over the last few years we have used both microcatheters for canaloplasty. Twelve patients were identified with a minimum follow up of 12 months where in one eye first an iTrack assisted viscocanloplasty (group A) was performed and later in the second eye a Glaucolight assisted canaloplasty (group B) was performed. Results: Preoperative IOP was 23.4 mmHg in the group A and 21.2 mmHg in group B. In both groups preoperative antiglaucomatous therapy was 2.25 drugs. After 12 months IOP in group A was 14.7 mmHg and in group B 14.2 mmHg. In both groups after 12 months no eye required antiglaucomatous therapy. No serious complication occurred. Conclusion: Both microcatheters worked well. There was no significant difference in postoperative IOP after 12 months. It seems to be of no additional effect to perform viscocanaloplasty with 360° viscodilatation of Schlemm’s canal over simple simple canaloplasty. Furthermore simple canaloplasty reduces the risk for descemet membrane detachment. Glaucolight canaloplasty is more cost effective. P55 New technique of draining miniaturized glaucoma shunt under scleral flap with choroidal exposure Roberto Servadei1, Paolo Maria Fantaguzzi1, Edlira Bendo1 1 Department of Ophthalmology, Forlì - Italy Objective: The authors aims with the new technique to demonstrate the effectiveness of the miniaturized draining glaucoma shunt (Ex-press 200) through the choroidal exposure of a full-thickness scleral lake that favors a sovrachoroidal drainage Methods: The surgery of mini glaucoma shunt (Ex-press) is performed with the classical technique of scleral flap and lake according to Mermoud with application of MMC 0.5 mgs / ml for 3 minutes, subsequently the choroid is exposed through the removal of the residual scleral foil inside the scleral lake for about 50%. The selected patients are those already submitted to filtering glaucoma surgery that result ineffective. In these cases, and with this technique we opts for a sovrachoroidal posterior filtering without looking for a filtration from the bleb that often is flat because a scar formation. Results: We present the first results in 10 patients with a follow-up of 1 year in comparison with the results of previously operated patients with the same technique without choroidal exposure. Conclusions: The authors try to highlight a greater functional effectiveness in the control of the intraocular pressure with this surgical technique. During the surgery was not verified any complication and in the follow-up period no bleeding or choroidal detachment was present. 35 P56 Ahmed glaucoma valve versus gold micro shunt (GMS) implants - Five years results of a prospective randomized clinical trail Shlomo Melamed1 1 The Sam Rothberg Glaucoma Center, Tel Aviv University Medical School - Israel Purpose: To report 5-year treatment outcomes of Ahmed Glaucoma Valve (AGV) implantation Compared with the Gold Micro Shunt (GMS) implants. Methods: A total of thirty eyes of 30 patients with refractory glaucoma were prospectively assigned to either AGV or Gold Micro Shunt (GMS or GMS+) implantation. All procedures were performed by a single surgeon. Success was defined as an intra ocular pressure (IOP) more than 5 mm Hg and less than 22 mm Hg, with or without topical anti-hypertensive therapy. Results: At 5 years, IOP (mean ± SD) was 14.3 ± 6.9 mmHg in the AGV group (compared to pre operative IOP of 35.3 ± 13.8 mmHg , p = 0.008), 15.9 ± 7.3 mmHg in the GMS group (compared to pre operative IOP of 25.7 ± 1.4 mmHg , p = 0.005) and 17.2 ± 9.0 mmHg in the GMS+ group (compared to pre operative IOP of 34.4 ± 4.4 mmHg, p = 0.0001). No statistical difference was found in comparison of the delta IOP (p = 0.23). The number of glaucoma medications (mean ± SD) was 3 ± 1.1, 2.8 ± 2.0 and 2.1 ± 1.5 correspondingly (p = .62). The cumulative probability of failure during 5 years of follow-up was 12.5% in the AGV and the GMS group and 25% in the GMS+ group. Conclusions: There was no difference in the success rate between the AGV and GMS during 5 years of follow-up. Both procedures were associated with similar IOP reduction and use of supplemental medical therapy at 5 years. Lower success rate was found in the GMS+ group. POSTER SESSION 9 NON-PENETRATING SURGERY P57 NPDS with spurectomy and supraciliar implant Mayerling M. Suriano1, Emilio Vila Mascarell2, Jorge Vila-Arteaga1,2 1 Hospital Clínico Universitario de Valencia, Valencia Spain, 2Clínica Oftalmológica Dr. Vila, Valencia - Spain Background: To determine the safety and efficacy of the non penetrant deep sclerectomy (NPDS) with spurectomy and supraciliar Esnoper implant placement to facilitate aqueous humor outflow by suprachoroidal way. Methods: Retrospective observational descriptive study with 90 eyes of 78 patients that were performed nonpenetrating filtration surgery for glaucoma with spurectomy. The new technique consisted of a non-penetrating deep sclerectomy as the standard technique coupled with the spurectomy and supraciliar Esnoper implant. Results: The mean preoperative Intraocular pressure (IOP) was 27.97 mmHg, the postoperative IOP at one year of follow up was 16.28 mmHg, with a decrease in IOP of 44.76% (12.52 mmHg). Complete success was found in 50.6%, the relative success was 39.1% and 10.3% of failures. The mean number of glaucoma medications was of 3.28 and a year after surgery just 31 patients required treatment, with an average of 1.21. About complications we found 11.1% cases with hyphema, 3.33% of seidel, choroidal detachment in 1.1% and 4.4% with interlocking of the iris. Conclusions: This technique offers the suprachoroidal route like an alternative drainage for the intrascleral of the conventional process (Fig. 2), thereby enhancing the way out of the aqueous humor, with the benefit of no penetration into the anterior chamber of the regular surgery. P58 Cicatrization of incision after the non penetraiting deep sclerectomy among patients with glaucoma and diabetes mellitus Pavlo Bezditko1, Olesya Zavoloka1 1 Department of Ophthalmology, Kharkiv National Medical University, Kharkiv - Ukraine Purpose was to study the cicatrization of incision after the non penetraiting deep sclerectomy among patients with glaucoma and diabetic polyneuropathy. Methods: 22 patients with glaucoma and diabetic polyneuropathy and 27 patients with glaucoma without diabetes mellitus were made the non penetraiting deep sclerectomy. Research methods were Corneal Confocal Microscopy, esthesiometry, pupil cycle time, Schirmer, Jones and Norn test. Results: In patients with glaucoma and diabetic polyneuropathy the epithelization time and the degree of eye inflammation reaction on the non penetraiting deep sclerectomy were higher than in patients with glaucoma without diabetes mellitus (р = 0.007 and р = 0.01). Violations of vegetative innervation were also marked in patients with glaucoma and diabetic polyneuropathy due to an increase of pupil cycle time, decrease of corneal sensitivity, reducing of corneal nervous fibres, and also decrease of common tear Production. Conclusions: In patients with glaucoma and diabetic polyneuropathy the defeat of vegetative nervous fibres and an increase of epithelization time are noted after the non penetraiting deep sclerectomy. P59 Viscocanalostomy: an alternative safe, effective drainage procedure to trabeculectomy Divya Mathews1, Tafadzwa Zvandasara1 1 Stanley Eye Unit, Abergele - United Kingdom Purpose: To establish outcomes following Viscocanalostomy/Phaco-Viscocanalostomy and compare with other studies. Methods: Data was collected prospectively as part of a single surgeon’s audit. All patients undergoing viscocanalostomy for uncontrolled glaucoma were included. Choice of surgery was viscocanalostomy as a sole procedure or combined Viscocanalostomy with phacoemulsification plus intraocular lens implantation (phacoviscocanalostomy) for patients with concomitant cataract. All Patients with 12 month post-operative data available were included. Results: Data was available for 104 (98%) eyes at the 1 year follow up. Viscocanalostomy as a sole procedure was performed in 49% (n = 52) of eyes, whilst combined phacoviscocanalostomy (phacoemulsification and intraocular lens implantation combined with viscocanalostomy) in 51% (n = 54). The demographics and characteristics of the cases were 57% male and 49% female. The majority 53% (n = 56) of eyes had not undergone any prior Ophthalmic procedure. Previous Ophthalmic surgical procedures included cataract surgery 36% (n = 38), trabeculectomy 6% (n = 6) and 1% (n = 1) had undergone prior viscocanalostomy. Pre-operatively 104 eyes were on a glaucoma drop 98% (n = 104), the mean number of 36 glaucoma drops was 3.0. Duration of pre-op follow up was a mean of 8.7 years (SD 6.7). There was no significant difference between the type of Glaucoma and the outcome at m12, ANOVA (F = 1.687, df = 2, Sig. = 0.191). The mean preoperative highest IOP was 30.14 mmHg (95% CI 28.20-32.11), mean pre-operative listing IOP was 24.34 mmHg (95% CI 23.60-25.04), and the mean post op IOP was 14.8 mmHg (95% CI 14.5-15.1). Eyes achieving complete success (IOP ≤ 18 mmHg without treatment) was 76% (n = 76), and those with IOP ≤ 18 mmHg without or on 1 permanent glaucoma drop 88% (n = 88). A 30% IOP reduction compared to the highest recorded IOP without glaucoma drops, was achieved in 77% (n = 80)and a 30% drop in IOP compared to the highest IOP with or without 1 permanent glaucoma drop, achieved in 89% (n = 92). A 30% reduction in IOP c.f. the listing IOP was achieved in 61% (n = 63) of eyes without need for a drop, and a 30% drop in IOP with or without 1 permanent glaucoma drops in 65% (n = 67). An IOP ≤ 21 mmHg without drops was achieved in 91% (n = 95), whilst IOP ≤ 21mmHg with or without 1 permanent glaucoma drop in 95% (n = 99). Excluding NTG eyes (n = 16), IOP ≤ 21 mmHg without permanent drops was achieved in 90% (n = 79), and IOP ≤ 21 mmHg with or without a permanent drop in 94% (n = 83). There was no statistically significant difference in outcome between the two groups (viscocanalostomy and phacoviscocanalostomy), the t-test for Equality of Means (0.445, df 102, p = 0.657) for IOP at m 12. The commonest intra-operative complication was inadvertent perforation into the anterior chamber in 15% (n = 16), Early complications were defined as those observed within 2 weeks of surgery. Post-op (Day 1) hypotony defined as an IOP less than 5 with a shallow anterior chamber with or without choroidal detachment was evident in 1 case (1%) case. One phacoviscocanalostomy eye had developed Cystoid macular oedema at the 4 week post operative review which was responsive to medical treatment. Conclusion: The complications following viscocanalostomy and combined viscocanalostomy and phacoviscocanalostomy in this group are lower than those reported in the National trabeculectomy study. The low rates of complications were similar to those observed in other studies evaluating viscocanalostomy or phacoviscocanalostomy. In our evaluation both the procedures were highly successful at 1 year review. Viscocanalostomy demands sound surgical skill, but it is not impossible for most ophthalmic surgeons to master the technique. We strongly feel this procedure could provide a safer, effective alternative to trabeculectomy. We hope to further evaluate individual pre-operative characteristics and the success, to help advance knowledge on individual glaucoma types and outcomes. P60 Deep sclerectomy augmented with bevacizumab and mitomycin C - A comparative case-control study Antigoni Koukkoulli1, Fayyaz Musa1, Nitin Anand1 1 Calderdale & Huddersfield NHS Trust, Huddersfield United Kingdom Aim: To assess the comparative efficacy and safety of primary deep sclerectomy (DS) augmented with subcon- junctival bevacizumab and intraoperative mitomycin C (MMC). Methods: Retrospective comparative, case-control series of consecutive primary DSs between January 2008 and December 2010. 68 eyes of 66 patients were included, with 27 eyes in the MMC and 41 in the bevacizumab group. MMC (0.2 mg/ml for 2 minutes) was applied subconjunctivally before scleral flap dissection. Bevacizumab (2.5 mg in 0.1 ml) was injected subconjunctivally at the end of surgery. Complete success was IOP < 19 mmHg and a 20% decrease from baseline with no postoperative medications Results: There were no significant differences between the groups except for a significantly longer follow-up of 29.7 ± 10.8 months in the MMC group compared to 21.1 ± 6.6 months for the bevacizumab group (p = 0.00). Complete success rates were 93% and 85% at one year and 89% and 81% at two years after DS in the bevacizumab and MMC groups respectively (p = 0.1). Mean IOPs were significantly lower in the MMC group (p = 0.003) at 11-13 months but not at prior or subsequent measured timeperiods. At last follow-up, 3 eyes (11.1%) of MMC group and 1 eye (2.0%) of the bevacizumab group were on medications to control IOP (p = 0.6). Self-limiting complications were noted in 9 (22.0%) in bevacizumab and 7 (33.3%) in the MMC group (p = 0.8). Conclusion: Augmentation of primary DS with subconjunctival bevacuzimab injection appears to be as efficacious as MMC augmentation with no additional side effects. P61 Does the non absorbable implant Esnoper V-2000 from AJL works as good as the T-Flux from Zeiss in deep sclerectomy? 24 months follow-up Konrad Schargel Palacios1, Jose Belda Sanchis1 1 Department Of Ophthalmology, Hospital de Torrevieja, Alicante - Spain Purpose: To evaluate differences in intraocular pressure (IOP) and number of glaucoma medications between patients who have undertaken deep sclerectomy (DS) with non absorbable T-Flux Zeiss, Francia and Esnoper non absorbable implant V-2000 de AJL, Alava España devices, after 24 months of follow-up. Methods: Retrospective comparative study. We that included 128 patients that had diagnosis of Open angle glaucoma or pseudoexfoliation glaucoma not control with full treatment or signs of progression in visual field or optic nerve. The two groups were A T- Flux (60 patients) and the Groep B Esnoper (68 patients) All patient were done by two surgeons with experience in Deep sclerectomy, The surgery was in the standard way and both implants were place suprachoroidal and the sclera was close without suture just apposition. The only variation was the implants, selected in a randomize way T-flux or Esnoper devices were used as implants. The schedule visits were 1 week, 1, 3, 6, 12 and 24 months. IOP, Visual Acuity, progression of the glaucoma, Goniopunture and medication was register during following. Variables analyzed: IOP and number of drugs prior to and after surgery, need of goniopunture, needling and complications. 37 Results: The average time of follow-up was 24 ± 1 month. Primary open angle 108 patients (84.4%) and pseudoexfoliative glaucoma 10 patients (7.8%)and Normal tension Glaucoma 8 patients (6.3 %) were the most frequent diagnoses also 1 Uveitic glaucoma and 1 Pseudofaquic glaucoma were included. T-flux device was implanted in 60 eyes while Esnoper was implanted in 68 eyes. Antimetabolites were used in all cases. After one year of follow-up the mean IOP at baseline decreased from 25.42 ± 12.63 to 15.02 ± 3.48 for the T-flux group and from 23.33 ± 8.27 to 13.95 ± 3.92 for the Esnoper group,with a mean decrease in pressure of 45 % from inicial level showing no statistical difference between them (p > 0.05). The average number of glaucoma medications showed no statistical difference (p > 0.05) between both groups, decreasing from 2.81 ± 0.91 to 0.29 ± 0.70 for the T-flux group and from 2.66 ± 0.79 to 0.17 ± 0.51 for the Esnoper group. There was also no statistically significant difference in age, pachymetry, visual acuity, Axial Length or keratometry in both groups. Final IOP and the number of medications used by patients 24 months after surgery showed no statistically significant difference (p > 0.05) between both implants. Conclusions: According to the results of our study no significant difference between the use of T-flux and Esnoper implants was found after two years of deep sclerectomy The level of IOP is 1 mm Hg lower in the ESnoper groups. and function of the devices. The scleral flap itself hence is a suitable, yet less explored tissue surface that could be used to optimize safety and efficacy of glaucoma surgery. P62 The scleral flap - Alternative site for the fixation of drainage devices Gysbert van Setten1 1 St Eriks Eye Hospital, Stockholm - Sweden Purpose: Nonpenetrating deep sclerectomy (NPDS) can enhance drainage of aqueous humor without disrupting the trabecular endothelial layer, reducing risks of postoperative hypotony and hyphema. This study explores associations of angle morphology with surgical efficacy in eyes with open and obstructed angles. Methods: Eighty-nine consecutive eyes undergoing successful NPDS (non-implant, with 0.4 mg/ml mitomycin-C and limbus-based 2-layer closure) were studied in this IRB-approved retrospective quality assurance study. Postoperative complication frequency, IOP, glaucoma medications required, and acuity were monitored (baseline versus 3-,6-,9-,12-&18-month postoperative levels), along with 30-2 Humphrey MD and CPSD (baseline versus 6-,12-,&18-month postoperative values). Preoperative gonioscopy was compared with the subsequent requirement for specific postoperative interventions. Results: IOP at all 5 post-operative intervals was reduced [22 ± 0.9 to 12 ± 0.5 mmHg (p < 0.0001)]. No hyphemata were observed. Hypotony (IOP < 4) occurred rarely (8/445; 1.8%). Mean glaucoma medication use dropped from 3.1 ± 0.1 to 0.23 ± 0.1 at 18 months (p < 0.0001). Mean 30-2 MD improved by ~1.4 dB at 6, 12, & 18 months (p < 0.002); CPSD remained stable. Conclusions: Following NPDS, sustained IOP decrease of 10mmHg (45%) was attained, with stable acuity, increased perimetric generalized light sensitivity, and 90% reduction in medical therapy requirement. Morbidity risk was associated with narrow gonioscopic angle insertion and synechia, but not by shallow approach or trabecular pigmentation. Introduction: In deep sclerectomy the creation of a wound bed close to the uveal tract implies an increased difficulty to fixate drainage devices such as PDS sutures in the wound bed. Methods: A alternative site for the fixation of fixate drainage devices such as PDS sutures was searched in the wound area. It was discovered that the easiest accessible alternative site was the exposed inverted surface of the scleral flap. After exposure and de-roofing of the Schlemm’s canal a short section of PDS ™ (Ethicon , Johnson & Johnson) suture was fastened with 10-0 Ethilon™ (Ethicon, Johnson & Johnson) suture(s) without any problem. Then the flap was reversed and put into position. Results: We herewith report on the first cases operated with the alternative fixation site. The fixation of the PDS ™ suture was easily achieved. The repositioning was uneventful. Postoperatively the roof-fixed PDS ™ suture was usually not distinguishable from the bed-fixed. The clinical picture and effect was not different from the established bed-fixed filtration devices. Conclusion: Roof fixation of glaucoma drainage devices in techniques where a scleral flap is created does offer a safe alternative for some techniques. Depending on the fixation techniques also later fine positioning and suture tightening could be an option to optimize the location P63 Mitomycin-augmented nonpenetrating deep sclerectomy in primary and secondary glaucoma William Sponsel1, Sylvia Groth2 1 WESMDPA/UTSA Biomedical Engineering, San Antonio, Texas - USA, 2University of Minnesota Medical School, Minneapolis, Minnesota - USA 38 P64 Glaucolight assisted canaloplasty Gabor Scharioth1 1 Aurelios Augenzentrum, Recklinghausen - Germany Purpose: To report on one year experience with a new device for canaloplasty (Glaucolight, DORC Int., The Netherlands) Methods: Surgical technique and results of Glaucoligth assisted canalopalsty in our center will be presented. All surgeries were performed by one surgeon. IOP and antiglaucomatous medical therapy were analyzed preoperative, month one, three, six and twelve postoperatively. Results: Preoperative IOP was 25.1 mmHg and medication was 2.4 antiglaucomatous drugs. Postoperative IOP after 3 months was 15.6 mmHg and 0.29 antiglaucomatous drugs. After 12 months IOP was reduced to 15.0 mmHg and antiglaucomatous drugs 0.21. Four eyes required postoperative goiniopuncture (NdYAG descemetotomy) and one eye needed resurgery with implantation of Bearveldt shunt. In one eye a rupture of the trabecular meshwork during the retracktion of the microcatheter occurred. No other serious complication occurred. Conclusion: The Glaucolight microcatheter is a new device to assist canaloplasty. Results are comparable to reported results of iTrack assisted viscocanaloplasty. The procedure is safe, effective and more economical. POSTER SESSION 10 OCULAR IMAGING P65 Bulbar conjunctival and Tenon’s layer thickness measurement using optical coherence tomography (OCT) Kaveh Vahdani1, Jonathan Rossiter1, Jael Howlett2 1 Musgrove Park Hospital, Department of Ophthalmology, Taunton - United Kingdom, 2Royal Eye Infirmary, Plymouth - United Kingdom 39 Introduction: Observations made during glaucoma filtering surgery (trabeculectomy) suggest variability in the thickness of the bulbar conjunctival and Tenon’s layers between individuals which could influence the healing response. Purpose: We designed a pilot study using OCT to measure bulbar conjunctival and Tenon’s layer thickness. Methods: A total of 67 eyes of 48 patients were scanned using an Optovue Mode RT100 version 2.0 OCT machine. Cross-line CAM-L scans were taken and the combined bulbar conjunctival and Tenon’s layer thickness was measured 3 millimetres above the superior limbus. Conjunctiva and Tenon’s layers appeared as a hyper-reflective section as opposed to the hyporeflective underlying sclera. Measurements were taken using the inbuilt review software. Results: The age ranged from 23 to 91 years. There were 20 males and 28 females. The mean conjuncti- val and Tenon’s layer thickness was 393 ± 67 microns ranging from 194 to 573 microns. Conclusions: OCT Conjunctival and Tenon’s layer thickness measurements appear to vary significantly between individuals. We postulate that these measurements could be a surrogate marker for the risk of postoperative trabeculectomy failure; with patients most at risk perhaps having thicker conjunctival and Tenon’s layer measurements. Further assessment could establish cutoffs on which patients should receive intraoperative antimetabolites and/or Tenon’s layer excision. P66 Early morphological changes in lamina cribosa and prelaminar tissue after deep sclerectomy Francisco Jose Munoz-Negrete1, Gema Rebolleda1, Constanza Barrancos Julian1, Noelia Oblanca Llamazares1 1 Hospital Ramon y Cajal, IRYCIS, Madrid - Spain Purpose: To determine the early response of the lamina cribrosa (LC) and prelaminar tissue to acute reduction of intraocular pressure (IOP) in glaucoma patients after non penetrating glaucoma surgery using Spectral Domain Optical Coherence Tomography (SD-OCT) Methods: 23 eyes of 21 patients presenting primary open angle glaucoma who underwent deep sclerectomy were studied. SD-OCT scans using enhanced depth imaging technology were obtained before surgery and one week postoperatively (Spectralis OCT). The OCT device was set to image a 15 x 10 degrees vertical rectangle centered on the optic disc. From the 13 cross-section scans that were obtained, the scan closest to the center of the optic nerve head (ONH) that did not include the main vessels was selected for analysis (the same scan was studied pre and postoperatively). A line joining Bruch’s membrane opening was used as the reference line. The vertical distance between the reference line and the anterior prelaminar tissue surface and the anterior and posterior surfaces of the LC was measured at the center and thirds of the reference line. Results: Intraocular pressure (IOP) decreased from 19.21 ± 4.66 mmHg to 9.04 ± 3.78 mmHg one week after surgery. The mean reduction of ONH excavation was 75.00 ± 85.65 μm (p < 0.001). The mean anterior displacement of the anterior surface of LC was 26.92 ± 40.00 μm (p = 0.007). The thickness of prelaminar tissue significantly increased 18.33 ± 16.43% (p < 0.001). A non significant (p = 0.091) slight reduction in LC thickness was found (-6.72 ± 24.14%). In multivariate regression analysis the increase in prelaminar tissue thickness was positively correlated with IOP reduction (p = 0.183), lower mean deviation at perimetry (p = 0.140) and thicker pachimetry (p = 0.060). No correlation was found to younger age (p = 0.860) or longer axial length (p = 0.890). Conclusion: Morphological changes in the ONH one week after deep sclerectomy are predominantly dependant on displacement and increase of thickness of the prelaminar tissue. Anterior displacement of the LC contributes to the ONH postoperative modifications as well. 40 P68 Comparison of AS-OCT with gonioscopy in evaluating ostium patency in patients with failing trabeculectomy surgery Prolima Thacker1, Shalini Gupta1, Kirti Jaisingh1 1 Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi - India Purpose: To compare the utility of AS OCT, a non contact method, with gonioscopy in identifying the patency of the ostium in recent post op cases with failing blebs. Method: A prospective observational study was conducted in the Glaucoma Services, at a tertiary eye centre , where 20 patients of operated trabeculectomy with early failing bleb (6 to 8 weeks post op) who needed 5FU needling, were enrolled and ostium patency was checked both by gonioscopy and AS-OCT (OPTOVUE RTVUE-100 adapted for imaging the anterior chamber). Vertical ASOCT images passing through the region of the peripheral iridectomy were analyzed to see for ostium patency. Gonioscopy was done by a single observer in the same patients to see the sclerostomy site and its patency. Result: Out of the 20 patients examined, sclerostomy was found patent in all 20 of the patients. AS-OCT was able to pick ostium patency in 14 of these patients (70% of the patients). Conclusion: AS-OCT appears to be a promising imaging modality in recent pot op patients to assess for sclerostomy patency before 5FU needling in failing blebs. POSTER SESSION 11 TRABECULECTOMY P69 Anaesthetic techniques for trabeculectomy in Nigerian adults Bola Adekoya1 1 Department of Ophthalmology, Lagos State University Teaching Hospital / College of Medicine, Ikeja - Nigeria Purpose: To determine the current ocular anaesthetic practices for routine trabeculectomy among Nigerian adults. Methods: This was a cross sectional survey among Nigerian delegates (ophthalmologists, resident doctors, and ophthalmic medical officers) attending the 36th annual meeting and scientific conference of ophthalmological society of Nigeria, which held in Lagos, Nigeria, between 7th and 10th September, 2011. An ophthalmic medical officer is a medical graduate (MBBS) who has finished one year internship and mandatory one year national service (as a general medical officer), currently working in the eye department of a non-training institution (such as a secondary level hospital) under direct supervision of an ophthalmologist. One hundred and twenty self administered and anonymous questionnaires were distributed to participants and collated thereafter. Information in the questionnaire included type of institution, cadre, types of anaesthetic techniques used for trabeculectomy for adult patients, the individual who administers it, complications experienced from current techniques, and facial block techniques. The structured questionnai- Table 1 - Administration of regional ocular anaesthesia Retrobulbar Peribulbar Subtenon n % n % n % Consultant ophthalmologist 11 32.4 15 30.0 2 100.0 Resident doctor/ OMO 20 58.8 28 56.0 0 0.0 Ophthalmic Nurse 2 5.9 6 12.0 0 0.0 Anaesthetist 1 2.9 1 2.0 0 0.0 Total 34 100.0 50 100.0 2 100.0 OMO – Ophthalmic medical officer re was first pre-tested among resident doctors attending a clinical revision course five months before the annual meeting, and appropriate corrections were made as necessary. These were not included in the final analysis. Ethical approval was obtained from the ethical committee of Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos. Informed consent was also obtained from each participant. Data was entered and analyzed using SPSS version 17 (SPSS, Chicago, IL, USA). Results: A total of 120 questionnaires were distributed to eligible delegates, and 81 were returned (response rate 67.5%). Out of the 74 who indicated their cadre, 49 (66.2%) were consultant ophthalmologists, 22 (29.7%) were resident doctors, while 3 (7.1%) were ophthalmic medical officers (OMO). Of the 71 responders who indicated their type of institutions, 53 (74.7%) were from tertiary training institutions, 13 (18.3%) from secondary level centres, and 5 (7.0%) from private centres. Anaesthetic techniques for routine trabeculectomy among adults are shown in Figure 1. Twenty five respondents indicated the use more than one procedure. Retrobulbar 20 (58.8%) and peribulbar 28 (56.0%) anaesthesia are mostly performed by resident doctors or ophthalmic medical officers (Table 1). Ophthalmic nurses were re- ported to be involved in administration of retrobulbar and peribulbar in 2 (5.9%) and 6 (12.0%) of the cases respectively. Facial block techniques: Out of the 77 responders, most (25 / 32.5%) use a combination of Van Lints and Obrien methods of facial nerve block, while (18 / 23.4%) do not routinely give a separate facial block. Others use Van Lints (14 / 18.2%), Obrien (18 / 23.4%), and Nadbath (2 / 2.6%) techniques only. Anaesthetic complications: Twenty one (25.9%) participants gave a positive response of having experienced complications from retrobulbar anaesthesia within the previous year. Seven responders had at least two occurrences, while one responder experienced adverse effects from retrobulbar anaesthesia thrice. Retrobulbar haemorrhage was the commonest complication occurring in 27 (90.0%) out of the total 30 occurrences. Others are poor block 2 (6.7%), and globe perforation 1 (3.3%). Anaesthetic complications from peribulbar technique were reported by 13 (16.1%) participants, and four had two occurrences, with a total of 17 episodes. These reported complications were retrobulbar haemorrhage 9 (52.9%), subconjuctival haemorrhage 4 (23.5%), chemosis 2 (11.8%), poor block 1 (5.9%), and systemic injection 1 (5.9%). There were no reported complications from Figure 1. Anaesthetic techniques for routine trabeculectomy in Nigerian adults. 41 subtenon anaesthesia. Conclusion: Peribulbar block is the commonest anaesthetic technique for routine trabeculectomy among Nigerian adults. This is followed by retrobulbar block. Prevalence of use of subtenon block was very low. These regional blocks were mostly given by resident doctors or ophthalmic medical officers, with anaesthetists and ophthalmic nurses playing very minor roles. Van Lints and O’brien techniques were the commonest facial block methods employed, while a significant proportion do not routinely give a separate facial block. Retrobulbar haemorrhage was the commonest reported complication with retrobulbar and peribulbar blocks. P70 Age and cataract development post-trabeculectomy Fiona Watson1, Caroline Cobb2 1 University of Dundee Medical School, Dundee - United Kingdom, 2Department of Ophthalmology, Dundee United Kingdom Purpose: To determine whether the age of the patient at the time of surgery affects the incidence of cataract development post-trabeculectomy. Methods: Subjects were 76 glaucoma patients, 63 phakic at the time of surgery, who underwent trabeculectomy surgery between the years 2005 and 2010. A proforma was devised with categories relevant to the patient care and presentation during pre-, peri- and post-trabeculectomy periods. The information collected from 76 case notes was tabulated. Statistical analysis was performed by one-way analysis of variance on all 63 phakic subjects using VassarStats® . Results: The mean age at the time of surgery of all phakic glaucoma patients undergoing trabeculectomy was 66.6 years. The mean age of those who underwent trabeculectomy, but who did not have a documented cataract at the time of this study, was 66.4 years. 17 out of 63 subjects developed cataracts following trabeculectomy. The mean age of these subjects was 67.2 years. Comparison of the age at the time of surgery between the two groups using one-way analysis of variance statistical analysis returned a p-value of 0.792, not statistically significant. This study also revealed that of the phakic trabeculectomy subjects that received mitomycin C as a peri-operative metabolite, 44% developed a cataract compared to 18% with 5-flurouracil and 22% in those that did not receive any anti-metabolite. Conclusion: The age of the patient at the time of surgery did not affect the incidence of cataract development post-trabeculectomy in this study. Peri-operative anti-metabolite mitomycin C may increase the risk of cataract formation post-trabeculectomy and this should be considered when gaining consent for trabeculectomy surgery. These results are confined to one surgical team in one hospital. P71 Advantages and disadvantages of intraoperatively used 5-Fu during trabeculectomy Vesna Dimovska1 1 University Clinic of Eye Diseases, Skopje - Macedonia 42 Purpose: To evaluate and compare the outcome and postoperative complications of trabeculectomy performed with and without intraoperative use of 5-Fu. Methods: In the study participated 31 patient with performed trabeculectomy, separated in 2 groups: 15 patients with trabeculectomy without 5-Fu, and 16 patients with trabeculectomy supplemented with 5-Fu used intraoperatively. The subject of analysis were following parameters: postoperative hypotony, postoperative hyphema, IOP control, bleb morphology, fornix versus limbus-based conjunctival incision, and cataract formation. All the patients have been examined for: best corrected visual acuity, tonometry, slit-lamp examination, gonioscopy, C/D-ratio, and visual field assessment. 20 patients had undergone anterior segment OCT (AC-OCT) Results: The data analysis have shown the following: postoperative hypotony was more frequently associated with 5-Fu (4 patients); postoperative hyphema was registered only in 1 patient with 5-Fu. Regarding IOP control, although it was slightly better in the group with 5-Fu, there was no statistically significant difference between the groups. In our study was not found statistically significant difference regarding the type of conjunctival incision. Cataract formation was more related to the surgical technique than the antimetabolite use. Most significant difference between the groups occurred referring to bleb morphology: in the group without 5-Fu were registered mostly diffuse blebs, with 2 cystic blebs and 1 discomfort bleb. In the other group, bleb morphology have shown 4 cystic blebs, 1 encapsulated bleb and 1 bleb with late leakage. One patient in this group needed re-operation due to fistula obliteration. Conclusion: According to the results of our study, intraoperatively used 5-Fu, as it is already known, enables good IOP control, with slight number of postoperative complications. It is fully recommended for re-operations and glaucoma with high preoperative IOP. But, also, good surgical technique and suture material, have great impact on the amount and magnitude of postoperative complications following trabeculectomy. P72 Hybrid trabeculectomy - The advantage of a conjunctival frill Kadaba Rajkumar1, Hugh Jewsbury1 1 University Hospital Wales, Department of Ophthalmology, Cardiff - United Kingdom Purpose: 1. To establish hybrid trabeculectomy as the new name for trabeculectomy performed via creation of a conjunctival frill. 2. To present success, failure and complication rates of the technique in comparison to other trabeculectomy studies. Hybrid trabeculecomy (HT) combines the advantages of limbal and fornix based flaps by fashioning a 0.5-1mm conjunctival frill. The proposed advantages are low bleb leakage rates that require intervention, reduced limbal stem cell loss and bleb migration, and greater tolerance of rigid lens wear in the young myope. The overall result is a technique that provides high success and reduced failure rates. The procedure is further amenable to topical and superior sub-conjunctival anaesthesia, precluding need for a superior traction suture. Methods: Retrospective study of 40 consecutive mitomycin augmented hybrid trabeculectomies performed between 2007 - 2009. All procedures performed by one surgeon. Data collected using a pro forma in conjunction with patient notes. The inclusion criterion was diagnosis of POAG, NTG, PXF or PDS glaucoma. Exclusion criteria were any procedures previously performed on the bulbar conjunctiva and any combined trabeculectomy procedures. Data collected for twelve months post operatively. The primary outcome was a post-operative IOP at 12 months of less than two-thirds of the preoperative value. This was unqualified if achieved without pressure lowering medication and qualified if achieved with medication. Secondary outcomes included, the proportion of patients achieving a post-operative IOP at 12 months of < 14 mmHg, 14-17 mmHg and 18-21 mmHg, early complication rates (hyphaema, hypotony, bleb leak and choroidal detachment), late complication rates (loss of > 1 line snellen acuity and endophthalmitis) and frequency of bleb needling. Failure was defined as repeat trabeculectomy within 12 months. Results primarily compared to The National Survey of Trabeculectomy (NST) and additionally to Birmingham, MMC augmented, fornix based, trabeculectomy audit data (BA). Results: Comparison with NST data. Primary outcome: Percentage of patients with IOP less than two thirds of the pre-operative value. Unqualified success = 75.7% (HT) vs 66.6% (NST). Qualified success = 75.7% (HT) vs 71% (NST). Proportion of HT patients with post-operative IOP at 12 months < 14 mmHg = 87.5%, 14-17 mmHg = 10%, 18-21 mmHg = 2.5%. Mean pre-operative IOP 19 mmHG (HT) vs 28 mmHg (NST). Early complications: hyphaema 12% (HT) Vs 25% (NST), hypotony 39% (HT) vs 24% (NST), bleb leak 22% (HT) vs 18% (NST), choroidal detachment 20% (HT) Vs 14% (NST). Late complications: loss of vision > 1 snellen line 9.8% (HT) Vs 19% (NST). Endophthalmitis 0% (HT) vs 0.2% (NST). Bleb needling 12.2% (HT) Vs 1.7% (NST). Failure rate 0% (HT) Vs 6.6% (NST). Comparison with BA data. Mean Pre operative IOP for high-tension glaucoma patients = 19.7 mmHg (HT) vs 24.1 mmHg (BA). Mean pre-operative IOP for low-tension glaucoma patients = 16.6 mmHg (HT) vs 15.7 mmHg (BA). Mean percentage drop in IOP at 12 months for high-tension glaucoma patients = 46% (HT) Vs 45.5% (BA), low-tension glaucoma patients = 42% (HT) Vs 28% (BA). Clinically significant early hypotony (viscoelastic to AC or conjunctival/scleral suturing) = 7% (HT) Vs 5% (BA). Conclusion: Hybrid trabeculectomy demonstrates excellent results in comparison to national and regional standards with low rates of post-operative complications and visual loss. It provides an excellent alternative to traditional limbal or fornix based procedures. P73 Uveitic glaucoma - Results of surgical treatment Marek Fichtl1, Eva Růžičková1, Lucie Kondrová1 1 Department of Ophthalmology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague - Czech Republic Purpose: To assess results of surgical treatment of uveitic glaucoma. Methods: A retrospective chart review was carried out of 11 eyes operated for uncontrolled uveitic glaucoma. All patients underwent trabeculectomy. In 3 cases MMC was used, in 1 case Healaflow implant and in 4 cases Ologen implant was used. Main outcome criteria were IOP, complications and need for postoperative antiglaucoma medication. Results: Mean follow up was 13.72 months. Mean preoperative IOP was 35.11 torr (range from 24 to 45 torr). Mean postoperative IOP was 15.60 (7-30 torr). Number of antiglaucoma medications used before surgery 2.78 decreased to 1.08 after surgery. 72% of patients used acetazolamide orally before surgery. One patient was still progressing and IOP was not controlled after the surgery despite using maximal local antiglaucoma medication. This patient needed further antiglaucoma surgery – cyclophotocoagulation. Conclusions: Trabeculectomy especially using MMC or different types of implants lead to good postoperative IOP control in uveitic glaucoma. P74 A national survey of glaucoma specialists on the preoperative (trabeculectomy) management of the ocular surface Ruchi Batra1, Rajen Tailor1, Shabibir Mohamed1 1 Department of Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham - United Kingdom Purpose: Studies have shown that the preoperative (trabeculectomy) treatment of the ocular surface reduces post-operative interventions with improved trabeculectomy outcomes. To determine current routine pre-operative management of the ocular surface by Glaucoma specialists. Methods: A two-sided questionnaire with a cover letter was posted to all UK consultants with an interest in Glaucoma (146), the names of whom were obtained from the Royal College of Ophthalmologists. Responses were tabulated into a Microsoft excel spreadsheet. Results: The first time response rate was 43.8%. With regard to routine pre-operative management of patient undergoing a trabeculectomy: 40.6% of specialists would replace existing glaucoma drops with preservative free drops (6.2% routinely, 34.4% if there was conjunctival injection or evidence of allergy or intolerance); 29.7%% would commence a drop holiday (1.6% routinely and 28.1% if there was significant ocular surface disease [OSD]); 53% would advice lid hygiene; 42.1% would prescribe lubricants (10.9% routinely, 31.2% if there were signs and/or symptoms of dry eyes; 50% would prescribe topical steroids (10.9% routinely, 39.1% if there were signs of blepharoconjunctivitis, conjunctival inflammation or a history of uveitis or previous failed trabeculectomy); 7.8% would prescribe topical NSAID (1.6% routinely, 6.2% if known steroid responder), 34.4% would prescribe a systemic tetracycline (3.2% routinely, 31.2% if a patient had meibomian gland dysfunction). Pre-operatively if 43 there were signs of OSD 84.4% of specialists expressed that they would change their routine management. Preoperative optimisation of the ocular surface was seen as “necessary” by 48.4% of specialists and “beneficial” by 85.9% of specialists. Conclusion: Despite a wide variation in how specialists would routinely manage the ocular surface pre-operatively, the majority regard pre-operative optimization of the ocular surface as beneficial and a significant proportion as necessary. Hence, specialists would specifically tailor their management in the presence of OSD. P75 Trabeculectomy - Subconjunctival bevacizumab compared to intraoperative mitomycin C Pouya Alaghband1, Nitin Anand1 1 Calderdale & Huddersfield NHS Trust, Huddersfield United Kingdom Aim: To compare medium-term outcomes of trabeculectomy with subconjunctival Bevacizumab to intraoperative Mitomycin C application. Methods: Retrospective study on consecutive trabeculectomies and phacotrabeculectomies (phacotrab) performed in our centre from November 2007 to October 2011. Eyes with uveitic glaucoma were excluded. 67 eyes of 61 patients were included. Complete success was defined as an IOP < 19 mmHg and a 20% drop in IOP from baseline without medications, while partial success was IOP < 19 mmHg with glaucoma medications or subsequent needle revisions. Results: There were 35 eyes in the bevacizumab and 31 in the MMC group. Mean follow-ups were 25.4 ± 7.5 in the bevacizumab and 28.4 ± 15.7 months in the MMC group (p = 0.3) Seven eyes (19%) of the bevacizumab and 11 eyes (35%) in the MMC group had phacotrabs (p = 0.17). Five eyes (14%) of the bevacizumab and 4 eyes (13%) of the MMC group had previous incisional surgery (p = 1.0). IOP was 27.7 ± 7.7 mmHg and 27.4 ± 9.2 preoperatively and 15.1 ± 3.1 and 14.7 ± 3.0 mmHg after 2 years in the bevacizumab and MMC groups respectively, with no significant difference at any measured time interval between the groups. Complete success rates were 66% and 63% in the first year and 59% and 54% in the second year in the bevacizumab and MMC groups respectively (p = 0.9). Cox’s regression analyses showed no significant association of actuarial success to age, sex, MMC or bevacizumab, suture release, trab or phacotrab and previous incisional surgery. Post- surgery needle revision of the bleb was associated with failure (Hazard ratio 3.28, p = 0.006). Glaucoma medications were required to control IOP in 2 eyes (6%) of the bevacizumab and 4 eyes (13%) of the MMC group (p = 0.6). Needle revision was done in 5 eyes (14%) of the bevacizumab and 8 eyes (25%) of the MMC group (p = 0.4). Serious complications included hypotony with maculopathy in 2 eyes of the MMC group and blebitis in 1 eye of the bevacizumab group. Conclusions: Two-year IOP and safety outcomes of trabeculectomy supplemented with bevacizumab or MMC were similar in this cohort. P76 Outcomes of needling of trabeculectomy blebs with 5FU and avastin in a district hospital eye department Simran Mangat1, Suman Biswas1 1 Ophthalmology department, Burton hospital, Burton United Kingdom Purpose: To determine the outcomes of bleb needling on intraocular pressure, visual acuity, number of medication used, complications and requirement for eventual glaucoma surgery in our unit compared to published data. To identify a sub-set of patients receiving Bevacizumab (Avastin) and 5FU with needling and to establish if this provides a more favourable outcome. Methods: Retrospective notes review of all bleb needlings performed over a 12 month period from March 2011 to March 2012 in a district general hospital setting. All procedures performed by a single glaucoma surgeon. Dose of 5FU injected varied from 5mg to 15mg while Avastin dose was 1.25mg. Visual acuity measured using LogMAR values and intraocular pressure (IOP) using goldmann applanation tonometry. An absolute success was defined as IOP reduction of 20% from pre-needling baseline without further surgery and IOP below 22 mmHg while a qualified success was defined as achievement of the above with a reduction in the number of drops used. A two tailed t-test was used to compare pre-needling and post-needling IOP, visual acuity and number of drops used. Results: Mean age of sample was 72.3 years. Twenty one patients underwent needling, of which 20 were Primary open angle glaucoma (POAG), while one had narrow angle glaucoma. Of the initial trabeculectomies prior to needling, 15 were augmented with MMC, 3 with 5-FU and 3 were unaugmented. Sixteen first-time needlings were with 5FU and 5 with 5FU and avastin. Needling with avastin was indicated by the presence of grade 4-5 vascularisation in central and peripheral areas (Moorfields bleb grading). After the first needling procedure, 2 patients underwent a revision of trabeculectomy, 1 a re-do trabeculectomy, 3 underwent a second needling with 5FU and 3 had a second needling with 5FU and Avastin. One of the patients undergoing a second needling with 5FU and avastin underwent a revision of their trabeculectomy and another had a combined phacoemulsification needling procedure with just 5-FU. Mean first follow up was 3.1 days and mean longest follow up was 6.75 months. Mean pre-needling IOP was 25.1 mmHg, mean first follow up IOP was 16.7 mmHg (p < 0.05). Four patients had transient hypotony. Mean last follow up IOP was 21.5 mmHg (p < 0.05). Mean pre-needling vision 0.25 LogMAR. Mean first follow up LogMAR vision 0.36 (p < 0.05). Mean last follow up LogMAR vision 0.23 (p > 0.05). Mean preneedling number of drops was 1.2 and at last follow up 1.1 (p > 0.05). 40% of patients had at least a 20% reduction in IOP at last follow up however absolute success as defined above was achieved in 25%. Qualified success at last follow up was 5%. One case of an absolute success failed at 22 months. The one qualified success remains successful. The vascularity of the blebs decreased in all cases where avastin was used to grade 1 or less (Moor- 44 fields bleb grading). Of the 5 patients receiving avastin and 5-FU, none were absolute successes, but 1 was a qualified success. Repeat needling was required in 7 eyes. Additional glaucoma surgery like revision or repeat trabeculectomy was required in 3 of these eyes that required repeat needling. Conclusions: There was a statistically significant difference between the pre-needling IOP compared with the first and final follow up IOP (p < 0.05). At the first follow up there was a statistically significant reduction in visual acuity compared to pre-needling baseline (p < 0.05), however this did not persist up to the last follow up. Patients should be warned about transient reduction in vision after bleb needling. Bleb needling did not significantly reduce the mean number of drops over the time period of the follow-up. Our observation is that one needling procedure alone was inadequate in several patients, but better IOP control was observed after repeating the procedure once or twice, although further glaucoma surgeries like revision or repeat trabeculectomy may be required. Avastin appeared to decrease bleb vascularity, but this didn’t result in improved outcome of significantly lowered IOP for the patients in the small sample observed. P77 Needle revision with subconjunctival bevacizumab for late failure of trabeculectomy Nitin Anand1 1 Calderdale & Huddersfield NHS Trust, Huddersfield United Kingdom Background: Experimental evidence suggests that besides the well-known effect on angiogenesis, Bevacuzimab has an inhibitory effect on subconjunctival fibroblasts. The antifibrotic action may be equivalent to that of 5-Fluorouracil which is commonly used to suppress wound-healing after needle revision of trabeculectomy blebs. A detailed search of Medline© revealed a single case-report of needle revision enhanced with Bevacizumab. Purpose: To report outcomes of bleb needle revision with subconjunctival Bevacizumab for late failure of trabeculectomy. Methods: Retrospective case- series of eyes with late (> 6 months) of trabeculectomy. After needle revision (NR) Bevacizumab 2.5mg in 0.1 ml, was injected into the conjunctival filtration bleb. Postoperatively patients received topical steroids for 2 months. No further bevacizumab or antimetabolite injections were given. Complete success was defined as an IOP ≤ 18 mmHg and a 20% decrease from baseline IOP with no medications. Partial success was defined as a 20%m decrease in the IOP but with fewer medications than before needle revision. Results: 15 eyes of 14 patients were included. The procedure was done on the slit-lamp in 4 eyes and in the operating room in 11 eyes. One eye had an encapsulated bleb whilst the rest had subconjunctival and /or episcleral fibrosis. The interval between trabeculectomy and NR was 58.5 ± 52.9 (range 7-156) months. Mean followup after NR was 22.1 ± 8.6 (range 12-36) months. Mean 45 IOP at decision to perform NR was 23.0 ± 5.0 mmHg. The probability of complete and partial success at one year was 73% (54-100%, 95% Cis) and 80% (62-100%) respectively. By last follow-up 9 eyes (60%) and 10 (66.7%) had a successful or partially successful outcome respectively. No significant complications were noted after NR. Recurrence of encapsulation was noted in one eye. Subsequent procedures included Selective Laser Trabeculoplasty, phacoemulsification and trabeculectomy with Mitomycin C in one eye each. Conclusions: In this selected series of eyes with delayed trabeculectomy failure, NR with subconjunctival Bevacizumab was safe and reasonably effective in lowering IOP. P78 Ologen biodegradable collagen matrix implant for trabeculectomy revision surgery: a pilot trial Lucia Pelosini1, Ejaz Ansari1 1 Eye, Ear & Mouth Unit, Department of Ophthalmology, The Maidstone Hospital - United Kingdom Purpose: To investigate the safety and efficacy of ologen (OLO) implants for trabeculectomy revisions versus historical controls of trabeculectomy revisions with mytomicin C. Methods: This study was a prospective pilot trial with 6-months follow-up. Fourteen glaucoma patients underwent trabeculectomy revision with OLO. Primary outcome measures included postoperative target intraocular pressure (IOP), with or without medications. Secondary outcome measures included bleb evaluation, OCT imaging, number of medications, number of postoperative interventions and adverse events. All patients were reviewed postoperatively at day 1, 7, week 3, 7, 12 and 24. Results: The mean preoperative IOP was 22.3 (±4.1 mmHg), mean postoperative IOP was 14 (±5.8 mmHg). IOP reduction from baseline was statistically significant (p < 0.05). The bleb remained well formed and functioning in all patients at all postoperative reviews. OCT imaging allowed to monitor the position of OLO implant and showed a progressive decrease in thickness of the OLO implant from week 1 to week 7. No serious events were observed. Conclusions: The trial showed that trabeculectomy revision with OLO implant was safe and achieved a similar success rate to trabeculectomy with MMC from historical controls. POSTER SESSION 12 TUBE SHUNTS P79 Retrobulbar extension implant (REI) for encapsulated tube shunts William Sponsel1 1 WESMDPA/UTSA Department of Biomedical Engineering, San Antonio - USA Purpose: Encapsulated blebs severely impair the effective treatment of glaucoma after tube shunt implantation. Recent studies indicate that up to 20% of tube shunt reservoirs become encapsulated with a dense connective tissue complex that becomes impervious to aqueous humor egress, leaving a large but totally ineffective bleb. To preserve the encapsulated bleb as a functioning structure, the simple solution of transferring the aqueous to the retrobulbar space was devised. This study evaluates the efficacy of a new large-diameter poly-perforated retrobulbar seton for redirecting aqueous from encapsulated blebs via the subtenons space into the retrobulbar fat pad, a capacious and largely avascular hydrophobic milieu where further fibrosis may be less likely to occur. Methods: Nine eyes of adults with severe progressive visual field loss and bleb encapsulation underwent implantation of an REI silicone retrobulbar seton from the lumen of the encapsulated bleb into the retrobulbar space. All patients were on maximally tolerated medical therapy at the time of surgery. Post-implantation IOP and the number of antiglaucoma medications used were compared with pre-operative levels 1 week, and 1, 2, 4, 6, 8, 10, 12, 14 & 16 months post-op. Results: 6 of the patients receiving the new implant were male, and 3 were female. Their mean age at the time of implant was 57 ± 6.5 years. The mean pre-operative IOP level among eyes undergoing surgery was 31.8 ± 3.3 mmHg. Most eyes were intolerant to at least one standard class of antiglaucoma medication, and the mean number of medications in use preoperatively was 2.6 ± 0.3. Mean IOP at the 10 post-operative intervals was 12.8, 15.0, 15.3, 17.7, 14.8, 15.7, 13.3, 15.2, 16.0 & 13.2 [mean IOP 14.9 ± 0.47 mmHg (mean Δ -16.9 mmHg; -53%); p < 0.0001]. Medications in use at each of the for several eyes during the early post-operative phase to maintain anterior chamber depth and avoid iris incarceration into the original tube shunt orifice. Conclusion: With appropriate conservative clinical postoperative measures the new retrobulbar extension implant was highly effective in reducing IOP and eliminating medications, restoring normal IOP level and facilitating visual recovery. P80 Long-term results in 912 Ahmed valves without graft patch in Mexico Oscar Albis-Donado1, Felix Gil-Carrasco1, Rafael Castaneda-Diez1, Mauricio Turati-Acosta1, Magdalena Garcia-Huerta1, Jesus Jimenez-Roman1 1 Glaucoma Department, Asociacion Para Evitar la Ceguera en Mexico, Mexico - Mexico Purpose: We reviewed the records of 840 randomly selected of the approximately 8700 patients operated with an Ahmed valve between June 1993 and July 2009. Methods: A total of 912 Ahmed valve implants without using a tube-covering patch and their 8152 visits were analyzed for IOP control, complications and rate of failure. Failure was defined as IOP over 21 mmHg (with or without massage and/or medications) or under 5 mmHg on 2 consecutive visits at least 1 month apart, loss of light perception, or need of additional surgery for IOP lowering. Kaplan-Meier survival analysis and generalized estimating equations were used for multivariate analysis of risk factors for failure, adjusting for dependencies when both eyes of the same patient had been operated, repeated measures and missing data. Results: Mean age at first surgery was 56 (SD 19.6), mean preoperative IOP was 30.5 mmHg (SD 13.7), mean follow-up time was 29.3 months (range 1 day to 16 years). Success survival was 81.8% by 6 months, 76.4% at 1 year, 62.6% by 5 years, and 49% at 10 and 15 years. GEE analysis revealed coefficient B of failure is +0.73 for inferotemporal location (CI 0.5-1.4, p = 0.036), +0.13 per 10 mmHg above 30 of preoperative IOP (CI 0.01-0.25, p = 0.029) and -0.1 per decade over 56 years of age (CI 0.020.19, p = 0.016). Mean last recorded IOP was 16.9 before massage and 15.1 mmHg after massage. Complications included glaucoma-related loss of light perception (NLP) in 35 eyes (3.8%), non-glaucoma related NLP in 20 eyes (2.2%), valve removal in 10 eyes (1.1%), tube retraction in 7 eyes (0.8%), tube exposure 4 eyes (0.4%), phthisis bulbi 3 eyes (0.3%), unsolved hypotony 2 eyes (0.2%), malignant glaucoma 2 eyes and plate exposure 2 eyes. Conclusions: The long-term control of different glaucomas with Ahmed valves implanted without using patch grafts is very good. Higher initial IOP, younger age and inferotemporal locations were risk factors for failure. The rate of tube exposures is very low. 10 postoperative intervals dropped to 0, 0, 0, 0.1, 0.6, 0.1, 0.9, 1.3, 0.8 & 0.5 [mean 0.4 ± 0.1 medications; Δ -2.2 meds (-85%); p < 0.0001]. Viscoelastic reformations and tube flush maneuvers at the slit lamp were required 46 P81 Autologous scleral patch graft for the coverage of the Ahmed glaucoma valve implant tube Orna Geyer1, Oren Golan1, Yair Hod1 1 Department of Ophthalmology Carmel Medical Center, Haifa - Israel Purpose: Various heterologous materials have been used to cover glaucoma drainage implant tubes. They include sclera, corneoscleral rim, dura, pericardium, and fascia lata grafts. Since they all require donor materials, they are not readily available and add cost to the procedure. We tested autologous scleral patch grafts as an alternative approach for tube coverage. Methods: The study was conducted between October, 2004 and April, 2010, and included 53 consecutive eyes of 46 glaucoma patients (21 eyes of 15 pediatric glaucoma patients), mean age 33 years (range 2 months to 86 years). Surgery consisted of Ahmed glaucoma valve implantation using a free autologous scleral patch graft (one-half of the scleral thickness) to cover the limbal portion of the silicone tube. Occurrences of tube exposure, patch graft thinning and complications during and after surgery were evaluated. Results: The mean duration of follow-up was 44.1 ± 17.1 months. Two of the 53 studied eyes had tube erosion with exposure and conjunctival defect that required reoperation. One of those eyes was of a 7-month-old with congenital glaucoma who had undergone trabeculotomy surgery: the erosion occurred within 6 months of the drainage implant surgery. The other eye was of a 5-month-old with congenital glaucoma who had undergone repeat trabeculotomy surgery: the erosion occurred within 5 months of the drainage implant surgery. There was significant thinning of the autologous graft such that the tube was visible beneath intact conjunctiva in 16 eyes (30%), 6 of them in pediatric glaucoma. None of the eyes with patch thinning demonstrated any conjunctival defect. No other complications related to the autologous patch graft were encountered. Conclusion: Autologous scleral patch grafting appears to be inexpensive, easily available and effective for the coverage of Ahmed valve implant tubes. Tube exposure is apparently more likely to occur in pediatric glaucoma patients. 47 P81 bis Corneal endothelial cell loss associated with Ahmed valve implant assessment using HRT II – 4 years follow-up Youssr Louati1 1 Department of Ophthalmology, Glaucoma Sector, Geneva University Hospitals, Geneva - Switzerland Aims: To report mid-term and long-term corneal endothelial cell loss associated with Ahmed valve implant in eyes with refractory glaucoma. Methods: 10 eyes underwent Ahmed valve implant surgery and were followed-up for up to 4 years. Data collected included intraocular pressure (IOP), number of antiglaucoma medications and surgery-related complications. At 6, 12, 18 months, 3 and 4 years Heidelberg cornea tomography II (HRT II) was used to measure corneal endothelial cell density. Results: Mean (±SEM) preoperative IOP was 29.5 ± 4 mmHg. Mean postoperative IOP was 11.6 ± 2 mmHg at 12 months (p 0.01). Mean central corneal endothelial density loss was 7.7% ± 2.5 over a 6-month period, 15% over a 18-month period, 20.7% ± 2.5 over 3 years. Conclusions: Corneal endothelial cell loss following Ahmed valve implant surgery probably is a multifactorial phenomena, giving that it is not only associated with glaucoma drainage device implantation, that is persistent with time, questioning Ahmed Valve and other conventional glaucoma devices safety and leading the way to a flourish debate on their usefulness as well as to the development of a whole new generation of glaucoma devices that are in different stages of development and that probably need better biocompatible material. POSTER SESSION 13 WOUND HEALING MODULATION P82 Enhanced method of bleb needling using a slit blade Robert Harvey1 1 Ophthalmology Dept, Royal Alexandra Hospital, Paisley - United Kingdom Indications: If there is no response after 1 or 2 conventional needling attempts at the slit-lamp, consider using a slit-blade (1 to 1.2 mm width) in the controlled conditions of the operating theatre. The bulbar conjunctiva must not be fixed and scarred as otherwise there is excessive risk of inadvertently buttonholing the conjunctiva. Test conjunctival mobility in the clinic with the sterile tip of a “Minims” (unit dose proxymetacaine). Procedure: Topical anaesthesia with proxymetacaine and 2.5% phenylephrine to blanch the conjunctival vessels. Allow more time (10 minutes) than with routine phacoemulsification surgery for the anaesthetic to penetrate the sclera. Optional use a subconjunctival injection of 2% lignocaine inferiorly and milk it to the superior fornix with a blunt instrument such as a squint hook (this prevents excessive chemosis and means the supe- 48 rior conjunctiva is spared unnecessary trauma). Prepare with aqueous povidone iodine and drape. A Clarke’s style speculum provides good operative access. Figure 1: Ask the patient to look down towards their toes and keep looking down. “Walk” the superior conjunctiva towards the limbus by gathering superior conjunctiva with a pair of Moorfield’s or Colibri type atraumatic forceps. Then gather more with a second pair of forceps until a large amount of conjunctiva is gathered. Use an angled slit blade (1.0 or 1.2 mm in width) to puncture the superior conjunctiva as far from the limbus as possible. Figure 2: Pass an angled MVR or slit-blade towards the bleb being careful not to buttonhole the gathered conjunctiva. It may be possible to separate conjunctiva from Tenon’s capsule over the flap. Sweep gently to free the conjunctiva over the scleral flap. Figure 3: Next withdraw slightly then pass the blade beneath the flap (angling deeper initially, then return parallel to the scleral plane). The slit blade will cut any residual suture and scar tissue. When at the limbus advance through the sclerostomy so the tip of the blade is just visible in the anterior chamber. Figure 4: Be especially careful in phakic eyes not to touch the crystalline lens (otherwise a cataract operation will be mandatory)! The bleb should be seen to form when the blade is removed. The conjunctival entry wound retracts away from the bleb at least 12 mm. Pressure from the lid controls excessive leakage. Figure 5: Administer 0.2 ml of 25 mg/ml 5-FU temporally away from the bleb. This is to avoid the hazard of the chemical entering the relatively soft eye. The puncture wound is held closed by forceps whilst the 5-FU is milked superiorly with an iris repositor. Apply chloramphenicol ointment. Apply a cartella shield. G. Prednisolone acetate 1% or G. Dexamethasone 0.1% 6x daily and G. Chloramphenicol 0.5% 4x daily. Review in 1 day and again in 1 to 2 weeks. 11 patients (total number performed over 6 years). No exclusions. 14 eyes since 3 cases had Bleb blading subsequently of a second eye. 50% of patients had had trabeculectomy augmented by MMC previously. 6 cases were due to early bleb failure (within 2 months). 5 from late bleb failure. Results: Success (IOP under 21 without medications) = 8 (57%). Modified success IOP under 21 with 1 med = 2 (14%). Unsuccessful (Further intervention required) = 1 (cyclodiode) (7%). Hypotony (IOP < 6) on day 1 = 9 (64%). Hypotony (IOP < 6) on day 7 = 1. Long-term hypotony 0. It is not uncommon to find over-drainage at day 1 and a shallow AC after slit blading but this usually settles spontaneously. The cartella can be reapplied each night if hypotony is an issue. Conclusion: Blading has a higher success rate than ordinary needling with small but must take place in the theatre with an operating microscope to ensure good visibility and stable conditions. Augmented the proce- P83 HealaFlow™ for the modulation of postoperative healing after viscocanalostomy Sylvain Roy1, Alexandre Rizatto2, Gordana Sunaric-Megevand2 1 EPFL, Lausanne - Switzerland, 2Fundation Rothschild, Geneva - Switzerland dure with 5-FU to compensate for the trauma and possible bleeding. Although the procedure may cause a little subconjunctival haemorrhage this is usually less than would occur after conventional small needle bleb puncture. TIP: Make a long subconjunctival track to avoid prolonged hypotony. TIP: Passing the blade through the sclerostomy takes judgement. If the blade misses the sclerostomy the scleral wound is self-sealing and the procedure may need to be repeated. Caution: This procedure does not work without a preexisting trabeculectomy (even if non-functioning) but it saves many patients the hassle of redo surgery. Purpose: To evaluate the effect of a double cross-linked hyaluronic acid on the healing process after viscocanalostomy surgery. Methods: Classical viscocanalostomy (VCS) with injection of Healon GV™ into the Schlemm’s canal (14 eyes) was compared to the same surgical procedure but augmented with injection of HealaFlow™ (HF) under the superficial scleral flap (16 eyes). Surgeries were performed between September 2009 and September 2010 in eyes with primary open angle glaucoma (16 cases), pseudoexfoliation glaucoma (12 cases), primary angle closure glaucoma (1 case) and congenital glaucoma (1 case). Main outcomes were: intraocular pressure (IOP), number of antiglaucoma medication, and number of complications. Results: The mean age for the VCS group was 67.6 ± 9.6 years compared to 75.5 ± 7.7 years in the HF group. The mean follow-up was 18.5 ± 4.0 months in the VSC group and 18.4 ± 4.5 months in the HF group. The mean preoperative IOP was 21.4 ± 5.0 mmHg in the first group and 20.4 ± 3.7 mmHg in the second group, respectively, with a mean number of antiglaucoma medications of 2.7 ± 1.1 (VCS) and 2.6 ± 1.2 (HF), respectively. At final follow-up visits, the mean IOP was 13.2 ± 3.0 mmHg (p < 0.05) in the VCS group and 12.4 ± 2.1 mmHg (p < 0.05) in the HF group, the mean number of antiglaucoma medication being 0.6 ± 0.7 (VCS) (p < 0.005) and 0.3 ± 0.6 (HF) (p < 0.005), respectively. Twelve Nd:YAG goniopuncture was performed on 8 eyes in the VCS group and 3 on 3 eyes in the HF group. Two iris incarcerations were recorded in the VCS group whereas no complications occurred in the HF group. One eye required needling of the scleral flap in the VSC group. One eye required further surgical revision of the filtering site from the same VCS group. Complete and overall success rates were 57% and 79%, respectively, in the VCS group, while rates were 81% and 100%, respectively, in the HF group. Conclusion: HealaFlow™, a slow resorbable highly crosslinked sodium hyaluronate drainage implant, prevents postoperative fibrosis and maintains the intrascleral space created with VCS, improving aqueous humour outflow from the Schlemm’s canal through the intrascleral lake. During the first post-operative year the IOP was significantly lowered, no HF related complications were reported and there was less need for goniopuncture in the group of patients treated with HealFlow™. P84 HealaFlow™ for the modulation of postoperative healing after deep sclerectomy Michael Feusier1, Sylvain Roy2, Alexandre Rizatto3, André Mermoud1 1 Montchoisi Clinic, Lausanne - Switzerland, 2EPFL, Lausanne - Switzerland, 3Fundation Rothschild, Geneva - Switzerland 49 Purpose: To evaluate the effect of a double cross-linked hyaluronic acid on the healing process control after deep sclerectomy surgery Methods: Classical deep sclerectomy (DS) was performed between January and June 2010. The main diagnoses were primary open angle glaucoma, primary angle closure glaucoma and pseudoexfoliation. Surgeries were performed using HealaFlow™ and results were compared against the same surgeries (DS) using collagen implant. The outcomes were the intraocular pressure (IOP), the number of antiglaucoma medication, and the number of complications and bleb management. Results: For the group with HealaFlow (n = 13) the mean age at surgery was 60.1 ± 10.9 years, the mean followup was 19.7 ± 5.5 months, the mean preoperative IOP was 19.8 ± 4.8 mmHg, and the mean number of antiglaucoma medication was 3.0 ± 1.0. At final follow-up visits, the mean IOP was 10.7 ± 4.2 mmHg (p < 0.05), the mean number of antiglaucoma medication was 0.2 ± 0.4 (p < 0.005), with 6 complications (5 bleb leaks, 1 iris incarceration). Nd:YAG goniopuncture was performed on 7 eyes, and needling of the filtering bleb was done on 5 eyes. No eye required further surgery. In the group with collagen implant (n = 17) the mean age at surgery was 63.1 ± 11.0 years, the mean follow-up was 19.0 ± 5.7 months, the mean preoperative IOP was 18.5 ± 3.4 mmHg, and the mean number of antiglaucoma medication was 2.2 ± 1.2. At final follow-up visits, the mean IOP was 12.4 ± 4.9 mmHg (p < 0.05), the mean number of antiglaucoma medication was 0.4 ± 0.7 (p < 0.005), with 3 complications (1 bleb leak, 2 perforations). Nd:YAG goniopuncture was performed on 11 eyes, needling of the filtering bleb on 10 eyes. Two eyes required further surgical revision of the filtering site. Complete and overall success rates were 85% and 92%, respectively, in the HealaFlow™ group, while rates were 71% and 88%, respectively, in the DS group. Conclusion: The slow resorbable highly crosslinked sodium hyaluronate drainage implant HealaFlow™ prevents the postoperative filtering bleb fibrosis and helps in maintaining a functional filtration after glaucoma surgery. The IOP was significantly lowered with a few numbers of postoperative complications and a dramatic reduction in glaucoma medication. Postoperative bleb management was simpler with less goniopuncture and needling of the filtering bleb and no need for further surgeries in the group of patients operated with HealaFlow™. P85 Objective six month follow-up of bleb vascularisation after trabeculectomy with mitomycin C (MMC) and subconjunctival 5-FU vs bevacizumab using gray scale analysis Juliane Schlomberg1, Anselm Jünemann1 1 Department of Ophthalmology, Erlangen - Germany Purpose: Vascularisation of filtering blebs, fibroblast migration and proliferation are the major risk factors for bleb failure leading to postoperative conjunctival scarring. Several antifibrotic agents have been applied in combination with trabeculectomy to improve the outco- me. Aim of the present study was to compare the early outcome of trabeculectomy with MMC using adjunctive subconjunctival 5-FU vs bevacizumab by quantification of bleb vascularity. Methods: This retrospective study included 24 patients that underwent primary trabeculectomy with MMC and adjunctive subconjunctival 5-FU or bevacizumab postoperativly. One surgeon performed the trabeculectomy with mitomycin C (0.3mg/ml). In three consecutive examinations at 1 month, 3 months and 6 months post op, the bleb was documented using analog color photographs according to a standardized protocol (slit lamp photograph in down-gaze, 10fold magnification). The morphometric analysis of the bleb vascularisation was performed using a digital image analysis software (cell^F: Olympus Soft Imaging Solutions GmbH, Muenster, Germany). An optimized filter set was used for the detection of the vessels in the generated grey scale picture. The vascularisation of the bleb was given as percentage of the total bleb area. Results: The gray scale analysis was possible in all photographs. In the bevacizumab-group the vascularisation area decreased of from 14.4 ± 3.5 % (1 month) to 10.7 ± 2.7% (3 months) (p < 0.001) and to 8.2 ± 1.3 (6 months) (p < 0.001) (p < 0.001, 1 to 6 months). In the 5-FUgroup vascularisation area decreased from 11.0 ± 4.7% (1 month) to 7.0 ± 3.7% (3 months) (p = 0.139) and to 3.6 ± 1.6 % (6 months) (p = 0.190) (p = 0.001, 1 to 6 months). IOP decreased from praeop 23.5 ± 9.1 mmHg in the bevacizumab-group to 9.5 ± 4.8 mmHg (2 months), 9.7 ± 4.5 mmHg (3 months), 9.9 ± 5.0 mmHg (6 months). In the 5-FU-group IOP decreased from 23.1 ± 6.1 mmHg to 10.2 ± 3.0 mmHg (2 months), 9.2 ± 3.1 mmHg (3 months), 8.8 ± 2.3 mmHg (6 months). Conclusions: Between bevacizumab and 5-FU-group there is no statistical difference between bleb vascularity after 4 weeks of follow up, but statistically significant difference after 3 and 6 months of follow-up. IOP decreased after trabeculectomy with MMC and adjunctive bevacizumab or 5-FU with no statistical difference after 6 Months of follow up. P86 Histological characteristic and filtering function of bleb after trabeculectomy with mitomcin C Kun Zeng1, Linan Huang1 1 Shenzhen Eye Hospital, Shenzhen - China Purpose: To observe histological change of filtering bleb and correlate with filtering function after trabeculectomy with mitomcin C using in vivo confocal microscope. Methods: Morphological characteristics of 46 filtering blebs 1 month to 5 years postoperatively was observed by the Heidelberg Retina Tomograph III/Rostock Cornea Module. Results: Different types of blebs vary with histological characteristic. The intraepithelial microcysts quantity, subepithelial connective tissue density and vascularization were significantly correlated with filtering bleb function (p < 0.005). Conclusion: In vivo confocal microscope study of filtering blebs presents a microscopic architecture and cor- 50 relates well with filtering function. P87 Outcome of combination of low dose MMC trabeculectomy along with unaugmented bleb needling Amit Vikram Datta1, Soo Park1 1 Department of Ophthalmology, NHS Lanarkshire, Glasgow - United Kingdom Purpose: To evaluate the outcome of low dose Mitomycin C Trabeculectomy combined with postoperative bleb needling. Methods: Retrospective audit of cases from January 2007 to November 2008 to look at least 6 month follow up data. 24 eyes of 22 patients who have had trabeculectomy with mitomycin-C (0.2 mg/ml) applied for two minutes in this period were identified. All patients were operated by single surgeon. Results: The average age of the patients was 72.5 years (55 to 90 years). Female to male ratio was 1.4:1. The average follow-up was 11.3 months (7 to 21 months). Postoperative bleb needling was required in 83% of eyes. Postoperatively, 91.7% eyes had IOP < 21 mmHg, 58.3% had < 15 mmHg. Two eyes required reoperations. The most common complication was raised IOP (33%), late cataract (16%) and bleb leak (4%). Mean pre op and post op IOP was 23.9 and 13.62 mmHg respectively. Average topical medications dropped from 3.25/eye to 0.2/eye. There were no cases of hypotony, blebitis or bleb related endophthalmitis. Conclusion: Trabeculectomy with low-dose MMC shows low incidence of complications in the short to medium term. Close bleb and IOP monitoring and early intervention with needling only without augmentation can achieve target IOP. P88 Surgical outcome of trabeculectomy modulated with mitomycin C (MMC) and amniotic membrane transplantation (AMT) in patients of juvenile open angle glaucoma (JOAG) Usha Yadava1, Prolima Thacker1, Shalini Gupta1, Abhishek Goel1 1 Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi - India Purpose: To study the results of trabeculectomy with MMC and AMT augmentation in hypertensive juvenile open angle glaucoma. Method: A retrospective study was conducted in a tertiary care hospital where in patient records of 12 cases of Juvenile Glaucoma operated for trabeculectomy augmented with MMC and AMT from August 2010 to January 2011 were retrieved for the present study. Juvenile Glaucoma was defined as glaucoma presenting in the age group of 5 to 40 years, with gonioscopically open angles, presenting IOP of more than 21 mmHg on at least two occasions, glaucomatous optic neuropathy with its attendant visual field loss and exclusion of all secondary causes of glaucoma. Trabeculectomy was performed in patients not controlled on maximally tolerated topical anti glaucoma medications. Records were retrieved for pre and post-operative IOP, complications, interventions till the end of 1 year of follow up. The success of tra- 51 beculectomy surgery was assessed on the basis of IOP at the end of one year wherein complete success was defined as IOP < 21 mmHg, qualified success as IOP < 21 mmHg on single anti glaucoma medication and failure as IOP > 21 mmHg despite the use of a single anti glaucoma drug. Results: All patients of Juvenile glaucoma in this study had IOP ≥ 30 mmHg on maximal topical anti glaucoma medication and needed systemic medications for adequate lowering of IOP. The mean pre op IOP was 38.67 ±7.34 mmHg. Immediate mean post op IOP was 11.76 ± 2.5 mmHg on post op day one. Post op hypotony was seen in 5 out of 12 patients (41.67%) with hypotonous maculopathy seen in 2 of these patients (16.6%). Transient shallowing of anterior chamber occurred in 4 patients (33.3%) of which only 1 patient required anterior chamber reformation with Healon GV. 9 patients (75%) had uncontrolled IOP and underwent bleb needling with 5 Fluorouracil, of these, 4 patients did have initial hypotony after primary trabeculectomy. Post 5 FU needling, 4 patients showed adequate IOP control, 4 patients needed a single anti glaucoma drug for adequate IOP control and 1 patient could not achieve IOP control despite the use of a single anti glaucoma drug. Delayed reporting of choroidal detachment (CD) occurred in 1 patient (8.3%). At the end of 1 year mean IOP was 18.69 mmHg. 50% of the patients resulted in complete success, 4 patients had qualified success (33.3%) and 2 patients suffered failure (16.67%). Conclusion: Young age is a risk factor for trabeculectomy failure and makes the use of antifibrotic agents mandatory. In this small series of 12 uncontrolled patients suffering from JOAG, we used AMT with the purpose of delaying the inflammatory response and achieving target IOP and preventing early bleb failure. The critical role of AMT in offsetting extreme hypotony and the resulting sight threatening side effects of MMC was also studied, which was found to be reversible except in one patient who reported late with CD. Overall success was achieved in over 80% of patients indicating a possible benefit from concurrent use of AMT in these otherwise difficult to control subset of cases of glaucoma. VIDEO SESSION V1 Endoscopic vitreo-lensectomy with Baerveldt tube-shunt implant Velota Sung1 1 Birmingham and Midland Eye Centre, Birmingham United Kingdom A 42 years old lady with congenital rubella and bilateral opaque microcornea presented with very high intraocular pressures in both eyes. UBM scan showed obliteration of anterior chambers in both eyes with anterior displacement of crystalline lenses. A bilateral spontaneous aqueous misdirection was diagnosed. The opaque corneae do not allow enough visualisation for cataract extraction. An endoscopic vitreo-lensectomy was performed in conjunction with vitreo-retinal surgeon. A Baerveldt tube implant was also inserted for IOP control. This resulted in subjective improvement of vision and achieved good IOP control without medication. The same operation was performed in the other eye. The intraocular pressures were under well controlled without medication after 9-months of follow-up. V2 Non technical skills in eye surgery Bashar Mohammed1, Georgis Vakros1, Lucy Mitchell2, Rebecca Ford1, Augusto Azuara-Blanco1 1 Aberdeen Royal Infirmary, Aberdeen - United Kingdom, 2 Aberdeen University, Aberdeen - United Kingdom Purpose: Safe and efficient surgery requires more skills than good technique. Surgical errors can often be directly or indirectly associated with the lack of nontechnical skills such as communication, leadership, awareness or decision-making. Furthermore, the majority of ophthalmic operations including glaucoma surgery are done under local anaesthetic. Surgeons and trainee surgeons should master the necessary communication skills to deal with difficult circumstances such as dealing with surgical complications while the patient is awake. This video is to emphasise the importance of non-technical skills in ophthalmic surgery and show the possible consequences of lacking non-technical skills on patients and the team. These skills are generic to cataract, glaucoma and other ophthalmic surgery. The significance of structured and constructive feedback to surgical trainees is also illustrated. Methods: Scenarios that show an ophthalmic surgeon who lacks non-technical skills and the consequences of his behaviour are displayed in contrast with other scenarios in which the surgeon shows proper non-technical skills. The first scenario deals with issues of punctuality, organisation, leadership, planning and using the surgical safety checklist. The second scenario portraits the issues of good communication with all staff, using appropriate language and tone without distressing patients while managing a surgical complication and the importance of constructive feedback in surgical training. Result: Non-technical skills are essential to minimise surgical errors and to promote surgical excellence and optimal outcomes. Conclusion: Teaching non-surgical skills is an important part of surgical training. Using video scenarios is one possible method to do this task. V3 Combined phacoemulsification and CO2 laser-assisted sclerectomy surgery (CLASS) Daniel Cotlear1 1 The Sam Rothberg Glaucoma Center, Tel Hashomer & Barzilai Medical Center, Ashkelon, Tel Aviv - Israel Traditional combined cataract and glaucoma surgery involves Cataract surgery and trabeculectomy .This movie demonstrates a new technique of combined and Glaucoma surgery .Combined phacoemulsification and CLASS procedure, a new methodology of using the CO2 laser for unroofing of Schlemmms canal to perform a deep sclerectomy in Glaucoma patients. CO2 laser-assisted sclerectomy surgery (CLASS) is a proposed filtering procedure for the management of medically uncontrolled glaucoma. It offers an alternative to the penetrating trabeculectomy procedure, and is clinically similar to the manual procedure of nonpenetrating deep sclerectomy (NPDS). The latter, a procedure in current clinical use, is known to be associated with a reduced rate of postoperative complications [1-9], but is technically rather difficult to perform. A frequent complication of manual NPDS, however, is inadvertent perforation into the anterior chamber,necessitating conversion to a penetrating filtration procedure. Another frequent problem with NPDS, also related to technical difficulties, is insufficient tissue dissection, preventing effective fluid percolation and intraocular pressure (IOP) reduction [911]. A relatively long learning curve, highsurgical skills, and considerable experience are therefore required to consistently achieve good clinical results. CO2 laser irradiation, because of its unique characteristics, was suggested by Assia et al [10] and Assia [11] as a means of simplifying NPDS. Advantages of introducing this laser technique as part of the surgical procedure are the CO2 laser-associated photoablation of dry tissue and coagulation of bleeding vessels, as well as the effective absorption of laser energy by any water or aqueous solution present,even if only in a minimal amount. After the superficial flap is created, repeated laser applications cause progressive ablation of thin layers of scleral tissue until aqueous percolation is achieved. The percolating fluid absorbs the laser energy, preventing it from reaching the sclera. The ablation therefore ceases “automatically” and penetration through the remaining thinned scleral wall is avoided. CLASS procedure thus substantially simplifies the nonpenetrating operation, while retaining its safety characteristics. References 1. Russo V, Scott IU, Stella A, et al. Nonpenetrating deep sclerectomy with reticulated hyaluronic acid implant versus punch trabeculectomy: a prospective clinical trial. Eur J Ophthalmol. 2008; 18: 751-7. 2. Hondur A, Onol M, Hasanreisoglu B. Nonpenetrating glaucoma surgery: meta-analysis of recent results. J Glaucoma 2008; 17: 139-46. 52 3. Cillino S, Di Pace F, Casuccio A, et al. Deep sclerectomy versus trabeculectomy with low-dosage mitomycin C: four-year follow-up. Ophthalmologica 2008; 222: 817. [Epub February 22, 2008]. 4. Arnavielle S, Lafontaine PO, Bidot S, et al. Corneal endothelial cell changes after trabeculectomy and deep sclerectomy. J Glaucoma 2007; 16: 324-8. 5. Funnell CL, Clowes M, Anand N. Combined cataract and glaucoma surgery with mitomycin C: phacoemulsification-trabeculectomy compared to phacoemulsification-deep sclerectomy. Br J Ophthalmol 2005; 89: 694698. 6. Ambresin A, Shaarawy T, Mermoud A. Deep sclerectomy with collagen implant in one eye compared with trabeculectomy in the other eye of the same patient. J Glaucoma 2002; 11: 214-20. 7. Chiselita D. Non-penetrating deep sclerectomy versus trabeculectomy in primary open-angle glaucoma surgery. Eye 2001; 15: 197-201. 8. Mermoud A, Schnyder CC, Sickenberg M, et al. Comparison of deep sclerectomy with collagen implant and trabeculectomy in open-angle glaucoma. J Cataract Refract Surg 1999; 25: 323-31. 9. Efstratios Mendrinos E, Mermoud A, Shaarawy T. Nonpenetrating glaucoma surgery. Surv Ophthalmol 2008; 53: 592-630. 10. Assia EI, Rotenstreich Y, Barequet IS, et al. Experimental studies on nonpenetrating filtration surgery using the CO2 laser. Graefes Arch Clin Exp Ophthalmol 2007; 245: 847-54. 11. Assia EI. Non-penetrating surgery with the CO2 laser. In: Garg A (ed). Mastering the Techniques of Laser Applications in Ophthalmology. V4 Ahmed valve tube extension using 22-gauge Venflon Seen Nee Chia1, James F.T. Li Yim1, Donald Montgomery2 1 Department of Ophthalmology, Stobhill Hospital, Glasgow - United Kingdom, 2Department of Ophthalmology, Glasgow Royal Infirmary, Glasgow United Kingdom Purpose: Tube retraction is an important complication leading to failure of glaucoma drainage tube surgery. Different devices and methods for extending the tube had been described, including the Crawford tubes and the commercially available Tube Extender (New World Medical, Inc, Rancho Cucamonga, CA). We present our experience with the technique using a tube extender fashioned from the 22-gauge venflon. This method was originally described by Smith and Doyle [1]. Methods: Our patient is 69-year-old woman with a complex case of advanced glaucoma who underwent Ahmed valve implantation to both eyes. Two weeks following her right eye surgery, her tube retracted into the cornea and her IOP rose to 28 mmHg. Her tube was extended using 22-gauge angiocatheter (Venflon) cannula, combined with tutoplast patch graft. A fornix-based conjunctival flap was raised and the Ahmed valve tube was exposed by incising the superficial sclera. The tube was amputated at the distal end, and the cut ends connected to an extender segment prepared from Venflon cannula. 53 The Venflon extender is rigid, unlike the tube of Ahmed valve, and we found it easier to thread the distal end of the tube into the anterior chamber prior to connecting the extender. The extender also needs to be fashioned to an adequate length. The extender portion was partially buried in the sclera tunnel for snug fit, and secured to the sclera with 10-0 nylon sutures. Tutoplast patch graft is placed over the extender and tube to prevent erosion and conjunctiva closed. Results: At the first postoperative day, her IOP reduced to 6 mmHg. Her IOP remained adequately controlled on Ganfort at her last follow-up at 6 months post-operative. Conclusions: This video demonstrated that tube extension using the 22-gauge venflon is a useful option in the management of complex glaucoma with tube retraction. It is effective, safe, relatively inexpensive and obviates the need for technically difficult repositioning of the whole implant. Reference 1. Smith MF, Doyle JW. Results of another modality for extending glaucoma drainage tubes. J Glaucoma 1999; 8: 310-14. V5 Principles and methods of trabeculectomy bleb revision for early and late hypotony Saurabh Goyal1, Lesley Stuart1, Amir Mani1 1 Department of Ophthalmology, Queen Mary’s Hospital, Sidcup - United Kingdom Purpose: Hypotony after Trabeculectomy surgery is a sight threatening complication. Hypotony needing revision is seen in less than 5% of our Trabeculectomy surgical cases. This presentation describes the principles and surgical techniques for revision of bleb for early and late hypotony after Trabeculectomy drainage surgery. Methods: Video and case presentations for surgical techniques including anterior chamber reformation on slit lamp, transconjunctival flap resuturing, partial bleb excision, compression sutures, autologous blood injection and patch grafting will be described. Results: All seven patients covered in this presentation were treated with a varying combination of surgical procedures and needed a single visit to the operating room to reverse the hypotony and improve vision. Conclusions: A combination of surgical techniques when applied in the management of bleb revision can effectively reverse the hypotony and improve vision. V6 iStent implantation in a patient with juvenile open angle glaucoma, a failed trabeculectomy and a cataract Pravin Pandey1, Imran Masood2 1 Department of Ophthalmology, Birmingham & Midland Eye Centre - United Kingdom, 2Department of Ophthalmology, Birmingham - United Kingdom We present a video of a 29 year old male with a previous failed trabeculectomy, cataracts and uncontrolled intraocular pressures. He underwent cataract extraction combined with insertion of a single iStent. Intrao- peratively, greatly thickened pre-trabecular tissue was evident. Istent insertion technique was modified by increasing the angle of entry so as to gain access into Schlemm’s canal. Successful placement was confirmed by presence of blood around the stent. Post operatively the patient had a good stent position with well controlled intraocular pressures. V7 Deep sclerectomy our technique of choice, suprachoroidal placement of the implant plus no suture to close the sclerectomy Konrad Schargel Palacios1, Jose Belda Sanchis1 1 Department of Ophthalmology, Hospital de Torrevieja, Alicante - Spain Purpose: To show our surgical technique. Methods, Results and Conclusions: Our technique of choice for most of the glaucomas is the Deep Sclerectomy. Done with subtenon or peribulbar anesthesia, limbo or fornix base conjuntival flap, trapezoidal or square scleral flap, does not really matter where the difference are done commonly is in the trabeculo-descementic area and implant place. This is very safe techniques that allow us leave it with no suture. We make a description of the step we considered more important in our technique. In this video we do not show results because we register an Abstract that is related to that. V8 Canaloplastic surgery - Own experiance Iwona Helemejko1, Renata Ortyl-Markiewicz2, Bartlomiej Markuszewski1, Marta Misiuk-Hojlo1 1 Department of Ophthalmology, Wroclaw Medical University, Wroclaw - Poland, 2Department of Ophthalmology, Legnica Specialistic Hospital, Legnica Poland Purpose: The purpose of presentation is to show own experiances performing the non-penetrating open angle glaucoma surgery - canaloplasty. Methods: Patients underwent the new non-penetrating method for glaucoma surgery according to the Robert Stegmann technique. A microcatheter is used to circumferentially dilate the Schlemm’s canal. During insertion and retraction of catheter microvolumes of high viscosity ophthalmic sodium hyaluronate are injected. Following retraction of catheter a 10.0 prolene sutures are placed in the canal to apply permanent tension to trabecular meshwork. Results: Patients achieve stable lowering of IOP at the mid to long term observation. No filtrating bleb formation was observed. Conclusion: Surgical technique requires change of approach to glaucoma surgery. This non-penetrating glaucoma surgery allows for greater filtration through primary anatomic way - the trabecular meshwork. V9 Improving filtering surgeries: customized procedure Jorge Iglesias1, Bona Park1, Jorge Acosta2 1 Ophthalmology Service, Hospital Rivadavia, Buenos Aires - Argentina, 2CEMIC, Buenos Aires - Argentina Purpose: The innovation is driven by the unmet need for better and safer solutions for a constant IOP control. From full thickness perforating procedures to minimal invasive approach we have now, in our countries the possibility to choose which, in our opinion, is the appropriate technique, the devices or postop control according to each clinical situation. Methods: We can choose between: A) Bleb dependent surgery - Trabeculectomy Moorfields Safer Surgery System (SSS) - Deep Sclerectomy Posterior Way (D.S P-W) - Express Glaucoma filtration device (Minimally Invasive Surgery) B) Bleb Independent Surgery - Deep Sclerectomy - Deep Sclerectomy plus suprachoroidal outflow pathway (Esnoper device) - Viscocanalostomy - Canaloplasty and tensioning of Schlemmn´s Canal Results: Each technique, each indication and results on time are showed, including intra surgical change of technique in order to improve filtration and keep it on time. Conclusions: The technique, the device or postop control is a personalized challenge to evaluate before each clinical situation. The answer will depend on the surgeon´s confidence with the individual technique and safety considerations. (M.Sheerwod, USA. Geneva 2009). And taking into account: the ethics of surgical innovation (G.Spaeth, USA. International Glaucoma Review. 2010) V10 Surgical technique of augmented penetrating deep sclerectomy (APDS) Vishwas Kayarkar1 1 Department of Ophthalmology, Doncaster & Bassetlaw Hospitals, NHS Foundation Trust, Doncaster - United Kingdom Introduction: The gold standard to compare with in glaucoma surgery is Trabeculectomy, but it has significant postop complications like shallow/ flat anterior chamber (AC), hypotony with maculopathy, choroidal effusion, bleb problems, etc. Non-penetrating surgery of Deep Sclerectomy (DS) is considered safer, with almost as good results, but long term IOPs are generally not low enough. Many require YAG laser goniopuncture to drop IOP further. Some have filtration site blocked by iris incarceration at the Descemets window blocking off the drainage. APDS surgery addresses the problems associated with trabeculectomy and DS, improves the results of glaucoma surgery, while minimising the complications. Technique: Procedure done under a local (or general) anaesthetic; corneal traction suture applied. Fornixbased conjunctival flap with conjunctival frill left at the limbus. Site of DS and area around treated with 0.4 mg/ ml mitomycin-C (MMC). DS performed. 5 x 5 mm superficial and 4 x 4 mm deep scleral flaps done. After exposing the Descemets window and establishing the aqueous flow, and identifying and canulating the Schlems canal the deep scleral flap excised. The Descemets window is then ruptured and removed. Peripheral iridectomy 54 is done. Superficial scleral flap is then closed with 10-0 prolene sutures (2 fixed and 2 releasable). Conjunctiva closed with 10-0 vicryl. Patients seen postop one weekly for 4 weeks. Releasable sutures removed and/ or 5-Fluorouracil (5FU) subconjunctival injections given adjacent to filtration site as needed. Patients given predforte and chloramphenicol 6/day for 8 weeks. Additionally cyclopentolate 1% given 1/day to phakic patients for 1 week. Discussion: Following APDS low complication rate, and better results, are probably due to changed internal fluid dynamics with the improved uveoscleral flow through the deep sclerectomy site. Even when intraocular pressures (IOPs) are very low following surgery, APDS cases are not associated with flat/ shallow ACs, hypotonic maculopathy, bleb problems, choroidal effusion, unlike trabeculectomy. APDS cases do not require goniopuncture, tend to have low long term IOPs, and have no risk of iris incarceration, unlike DS. APDS gives excellent results can aim for IOPs less than 10 without risk of hypotonic maculopathy. So far with APDS no long term bleb leakage problems seen despite use of MMC & 5 FU use. APDS can be combined with phacoemulsification surgery. APDS gives very good results in complicated cases as well. Conclusion: Innovative technique. APDS combines best of trabeculectomy and DS. APDS does not have drawbacks of trabeculectomy or DS. Augmentation with MMC and %FU, and close supervision in first 4 postop weeks, allows manipulations of filtration site for weeks and also helps to achieve low IOP in the long term. APDS is a safe procedure, with excellent long-term glaucoma control, with hardly any postop problems associated with trabeculectomy or DS. V11 A novel technique for application of antimetabolite during trabeculectomy James Li Yim1, Kaleena Micheal1, Donald Montgomery1 1 Department of Ophthalmology, Glasgow Royal Infirmary, Glasgow - United Kingdom Purpose: To describe a novel technique which allows a more precise and reproducible delivery of antimetabolite with minimal contamination of the conjunctival edge during trabeculectomy Methods: We used an intraocular lens implant injector (UNFOLDER® Emerald delivery system handpiece with One Series cartridge implantation system - Abbott Medical Optics) to inject a length of antimetabolite soaked wick (BD Visidrain Eye Fluid Wick) under the fornix based conjunctival flap during trabeculectomy surgery. Injecting the wick allows a controlled and reproducible posterior placement while avoiding contamination of the conjunctival edge which may be a problem with conventional methods of inserting antimetabolite soaked sponges with forceps. A 2.5 cm length of wick is soaked in the mitomycin solution and inserted into the barrel of the cartridge with a pair of forceps. Once loaded into the injector, the wick is ejected slowly until it reaches the tip of the cartridge and any excess fluid is dabbed away. The tip of the injector is inserted under the conjunctiva in the superotemporal quadrant and the wick is ejected slowly. Once injected posteriorly, the wick tends not to prolapse forward which is common when placing the 55 wick into the subconjunctival space with forceps. Posterior placement of the wick can be seen through the conjunctiva during the leave-in period. To minimise contact with the anterior conjuctiva, the wick is removed with a pair of forceps while another uncontaminated pair of forceps is used to lift up the conjunctiva at the limbus. Results: To demonstrate the efficacy of this method we mixed trypan blue 0.1% (Oftal Blu) with mitomycin-C 0.4 mg/ml in a ratio of 1:1 to achieve a mitomycin C concentration of 0.2 mg/ml. This solution allowed the position of the wick and the resulting treatment area to be readily visualised. Conclusion: The use of trypan blue clearly demonstrates the precise and reproducible application of antimetabolite to the target area using this technique. Conjunctival spillage in this technique is minimised unlike conventional methods. V12 “Hybrid trabeculectomy” (HT). A combined fornix- and limbal-based approach to trabeculectomy Kadaba Rajkumar1, Mohammed Rashid1, Huw Jewsbury1 1 Department of Ophthalmology, University Hospital of Wales, Cardiff, Cardiff - United Kingdom Purpose: The long-term success of trabeculectomy depends largely on the controlled aqueous drainage from the anterior chamber through a partial thickness scleral flap formation of a filtration bleb. Cairns’ (1968) original procedure has undergone multiple modifications ever since in an attempt to reduce complications. A video presentation is used to describe a modified technique of trabeculectomy (hybrid trabeculectomy - HT) that combines the advantages of a fornix- and limbal-based conjunctival flap. Methods: Surgery is performed under topical anaesthesia to avoid conjunctival buttonhole and haemorrhage. The need for a corneal bridle suture was avoided. Subconjunctival injection of lidocaine 1% superiorly is used to raise a bleb. A fornix-based conjunctival flap with a 1-2mm frill at the limbus is created with minimal tissue handling. Tenon tissue is dissected. Antifibrotic agent is applied to the scleral surface and subtenon space. A 3x5mm scleral flap using angled incisions is fashioned at the limbus to direct posterior flow of aqueous. An oblique paracentesis is created parallel to the limbus. A fistula is created using a scleral punch, and a peripheral iridectomy is performed through the sclerotomy. Releasable sutures are applied to the flap. The conjunctiva is closed with purse-string sutures on round bodied needles. Results: This surgical approach results in a desirable diffuse trabeculectomy bleb. Results were compared to The National Survey of Trabeculectomy (NST) dataset. Mean pre-operative IOP 19mmHG (HT) Vs 28 mmHg (NST). Percentage of patients with IOP less than two thirds of the pre-operative value: Unqualified success = 75.7% (HT) Vs 66.6% (NST). Qualified success = 75.7% (HT) Vs 71% (NST). Proportion of HT patients with post-operative IOP at 12 months < 14 mmHg = 87.5%, 14-17 mmHg = 10%, 18-21 mmHg = 2.5%. Early complications: Hyphaema 12% (HT) Vs 25% (NST), Hypotony 39% (HT) Vs 24% (NST), Bleb leak 22% (HT) Vs 18% (NST), Choroidal detachment 20% (HT) Vs 14% (NST). Late complications: Loss of vision > 1 Snellen line 9.8% (HT) Vs 19% (NST). Endophthalmitis 0% (HT) Vs 0.2% (NST). Bleb needling 12.2% (HT) Vs 1.7% (NST). Failure rate 0% (HT) Vs 6.6% (NST). Conclusions: Continued development of trabeculectomy techniques will reduce complication rates. The use of a 1mm conjunctival frill does not compromise the results of trabeculectomy, allows preservation of limbal stem cell architecture and reduces early postoperative leakage and bleb dysesthesias. Our outcomes compare favourably with the NST dataset. V13 How to evaluate the patency of glaucoma tubes without the need to remove them Carolina Pallas1, Honorio Pallas2 1 Glaucoma Department, IMO, Barcelona - Spain, 2 Department of Ophthalmology, Hospital San Pedro De Logroño, Logroño (La Rioja) - Spain Purpose: To assess the effectiveness of the glaucoma tubes without having to remove them avoiding further surgery. Medical evidence shows that up to 5% of glaucoma surgery results in complications from the obstruction of drainage tubes and sometimes the surgery actually fails because of these obstructions. Usually whatever the cause of the obstruction (whether it be blood, vitreous humour, silicone oil, fibrosis of the valvular system or, excessive cyst formation of the perivalvular bleb) it is quite straightforward for a glaucoma surgeon to identify the degree of obstruction. An initial approach to address this situation is the removal of the tube inside the eyeball to check the patency of the tube. The problem with this technique is that it involves yet again the dissection of the conjunctiva and Tenon’s capsule which are already scarred and damaged by previous multiple surgeries. Methods: As a more practical and cost-effective alternative to this, we would like to describe the technique that we use at IMO where we insert a cannula from the anterior chamber. This technique is more effectively carried out using a vital stain called Trypan Blue. This is injected with a 30 gauge cannula to more effectively identify the position of a glaucoma tube blockage. Cur- rently there exists many ophthalmic uses of the vital stain called Trypan Blue including: the anterior capsule staining in cataract surgery, the visualization of epiretinal membranes; to check the outflow of aqueous humour during trabeculectomies and even to identify the area treated with antimetabolites in glaucoma surgery. Results: Now we would like to show you 4 short videos explaining our technique. In the first video, where Trypan Blue was not available, from the anterior chamber we introduce a 30 gauge cannula into the tube through a 25 gauge parecentesis and inject a saline solution. We realize that the tube works and so as you can see there is a bigger bled around the plate of the valve. In this second case, after making several forced attempts to insert the cannula with a saline solution I switched to using the Trypan Blue which has a clear advantage over the saline solution as it helps to identify the source of the obstruction. As you can see the stain continues all along the length of the tube but it is still impossible to see a bigger bleb and identify the Trypan Blue around the bleb. This then tells us that the problem is either due to fibrosis of the valvular system or excessive cyst formation in the walls of the bleb. We then carry out a needling of the cyst to rule out the cyst formation theory. As this didn’t result in the diffusion we expected we can hypothetically deduce that the problem can be found in either of the two valves. In the subsequent video, we show a new way of using the stain Trypan Blue to identify and restore the valvular flow. We can see how the tube is stained as are the walls of the cyst and how the perivalvular bleb has spread blow the conjunctiva. In the last video, we need to check the vitrectomy to rule out that the previously inserted tube, behind the iris of this aphakic post-vitrectomy patient, is obstructed by vitreous humour. We find that remains of vitreous stuck at the tip of the tube. We now have to try and dislodge the vitreous from the tip of the tube and to flush out any more vitreous that could be along the length of the tube. By using Trypan Blue we can not only displace the vitreous but we can also visualize the expulsion of the blockage. The image of the stained bleb shows the viability of the implant. Conclusion: The use of Trypan Blue enables us to more clearly identify the position of a blockage in glaucoma tubes. V14 Baerveldt glaucoma implants - A “belt and braces” approach Tom Betts1, Divya Mathews2, Magdalena Popiela2 1 Stanley Eye Hospital, 2Stanley Eye Unit, Abergele United Kingdom Purpose: This video presentation demonstrates the “belt and braces” technique we employ in Baerveldt tube surgery to reduce the risk of postoperative hypotony. Method: The videos shows the following “belt and braces” method undertaken for glaucoma shunt procedure. Surgery was performed under general anaesthesia in all patients by a glaucoma specialist. All patients undergo single stage Baerveldt 250 mm2 implantation. A 120 degree peritomy is performed in the supero-temporal or supero-nasal quadrant and the sclera exposed. The superior rectus and the lateral or medial rectus muscles 56 are hooked to create clear space for implantation of the glaucoma drainage device. Mitomycin-C (0.4-1.0 mg/ml) is applied for three minutes over the sclera. The plate is secured to the sclera with its anterior edge 8 mm posterior to the limbus using 9/0 Nylon sutures. The plate wings are tucked under the rectus muscles. After an anterior chamber maintainer is placed inferiorly, a scleral tunnel is created, starting 1.5 mm from the limbus using a 25 gauge needle. The anterior chamber (AC) is entered 0.25 mm posterior to the limbus with the needle directed parallel to and just anterior to the iris plane. The implant tube is trimmed with an anterior bevel to extend approximately 2mm into the AC. The tubes lumen is partially occluded by passing a 3/0 nylon suture (Supramid®) internally for about 3 mm. The lumen of the tube is then totally occluded with 6/0 Vicryl dissolvable suture tied externally over the tube beyond the Supramid®. The distal end of the Supramid® suture is tucked under the conjunctiva into the inferior fornix. The tube is inserted through the scleral tunnel into the anterior chamber aiming towards the centre of the pupil. The tube is secured to the underlying sclera with a 10-0 nylon suture in a box configuration. A “Sherwood” slit is made in the tube to allow egress of fluid with markedly raised IOP. A donor scleral patch covers the tube and is sutured to the sclera with 10/0 nylon sutures. The graft is placed with one end along the limbus and secured to the underlying sclera with 2 interrupted 10-0 nylon sutures. Further securing of the graft is done with 2 posterior sutures, which also prevents the plate from migrating forward. Conjunctival closure is performed using 8-0 Vicryl, suturing the peritomy extensions to the sclera in an interrupted fashion, to prevent anterior leaks. The conjunctiva is secured at the limbus with 10-0 nylon mattress sutures. Dexamethasone and cefuroxime are given subconjunctivally at the inferior fornix and one drop of atropine 1% instilled at the end of surgery. Conclusion: This video demonstrates the striking difference in our technique versus the majority of the published literature in the simultaneous use of all available safeguards to prevent early and medium term hypotony. We attribute our low incidence of hypotony, choroidal effusion and the need for repeated AC reformation to the “Belt and Braces” technique of using one standardized surgical 3/0 nylon suture (Supramid®) to partially occlude the tube lumen and the additional external ligation with 6/o vicryl. We suggest that the use of an anterior chamber maintainer throughout the surgical procedure helped prevent intraoperative hypotony and related complications. It also allows the surgeon to check for complete occlusion of the tube and assess drainage from the Sherwood slit. Leakage along the scleral tunnel around the sides of the tube was minimized by the use of a 25 G needle to enter the AC and the continuous use of anterior chamber maintainer helped for checking and remedying any minimal leakage also intraoperatively. A careful closure of the conjunctiva further minimises the incidence of leakage. 57 V15 Surgical decompression of an encapsulated Ahmed valve James Li Yim1, Donald Montgomery1, Paul Flavahan1 1 Department of Ophthalmology, Glasgow Royal Infirmary, Glasgow - United Kingdom Purpose: To describe the management of an encapsulated Ahmed valve after two previous failed capsule excisions in a patient with ICE Syndrome. Methods: A 45 year old woman with an Ahmed valve in the superotemporal fornix of her right eye had an intraocular pressure of 40mmHg. She had two failed previous attempts of surgical excision of the capsule, with the second excision augmented with 1.0mg/ml of mitomycin c. She had again developed a large, tight Tenon’s cyst over the Ahmed Valve. Options considered at this point included trans-scleral diode laser cycloablation and insertion of a further Ahmed valve. Previous diode laser treatment had resulted in transient hypotony with associated macular oedema while insertion of a second tube into the anterior chamber carries an additional risk of corneal decompensation. As the Ahmed valve was clearly draining it was considered logical to try to decompress the Tenon’s cyst by employing a 250 mm2 Baerveldt tube device with the draining tube inserted into the cyst. The Baerveldt valve was sutured in the superonasal fornix. The Tenon’s capsule was exposed and an opening large enough to pass the draining tube of the Baerveldt valve was made with a 15 degree blade. The tube was secured onto the sclera with 9/0 nylon sutures and was covered with Tutoplast before the conjunctiva was closed. Results: In the immediate post operative period the IOP measured 8 mm Hg. The results of follow up at 3 months will be reported in the video Conclusions: This is an alternative method to treat encapsulation of an Ahmed valve after failed capsule excision. The long term outcome still needs to be evaluated. V16 Surgical tube decompression of an encapsulated Ahmed valve Sikander Sidiki1, James Li Yim1 1Department of Ophthalmology, Gartnavel General Hospital, Glasgow - United Kingdom V17 Aqueous shunt implantation after retinal surgery Usman A. Sarodia1, Arosha I. Fernando1, Alan Lacey1, Keith Barton1 1 Moorfields Eye Hospital, London - United Kingdom Aqueous shunt implantation may offer the best chance of achieving intraocular pressure control in certain eyes with recalcitrant glaucoma after retinal surgery. However, there are often impediments to successful implantation. External placement of the plate may be hampered by excessive conjunctival scarring, the presence of scleral buckles, scleral thinning and previous trabeculectomy blebs. Inside the eye, peripheral anterior synechiae, silicone oil and expansile gas may complicate implantation. A number of modifications in technique have been described to circumvent these obstructions, and in this video the authors will illustrate how these may be used to achieve successful shunt implantation in eyes that have had retinal surgery. Purpose: To describe further management of a 17 year old boy with an s shape lid deformity due to a prominent Tenon’s cyst around an Ahmed valve. Methods: A 17 year old boy with juvenile glaucoma had an Ahmed valve in the superotemporal fornix. He had previously had two trabeculectomies which failed. His intraocular pressure was 19 mmHg after the Ahmed valve but required the topical use of Ganfort drops. The Ahmed valve was encapsulated with a prominent Tenon’s cyst giving rise to an S shape deformity of his upper lid. Two previous needling and two surgical excision of capsule failed to reduce his IOP. After careful discussion with the patient and his parents, a further attempt to decompress this cyst was attempted. Instead of excision of the capsule, the cyst was decompressed using only the draining tube of an Ahmed valve. This tube was sleeved over a hypodermic needle and then inserted into the cyst. Once within the fluid filled cyst, the needle was removed leaving the draining tube in situ. The other end of the tube was tunneled under the conjunctiva over the superior rectus muscle insertion. A nylon suture was used to secure this tube to the sclera. The conjunctiva was closed over this tube. Results: Twenty four hours later, the Tenon’s cyst was less prominent with the upper lid no longer having an S shaped configuration. One week later on, microcysts were visible at the end of the draining tube subconjunctivally. The intraocular pressure was lower at 16 mmHg. The lid position and IOP remain stable after three months. Conclusions: This technique appears to be a safe alternative way to manage an encapsulated Ahmed valve without having to remove it and replace it. 58