Download Abstract Book

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