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The mutual relationship among medical therapy, ocular surface (OS) and filtration surgery (FS) represents one of the most crucial issues in glaucoma management. As the long-term use of intraocular pressure-lowering medications significantly affect the OS health, patients with an uncontrolled disease frequently undergo glaucoma surgery in less-than-ideal conditions. As we known, OS changes strongly affect the post-operative bleb filtration capability. Therefore, improving the OS conditions before proceeding with FS is needed. Currently, given the rapid diffusion of new surgical procedures, this need is even more perceived. Nevertheless, despite surgeons retain the OS preparation of primary importance, and recognize the OS disease (OSD) as the only modifiable risk factor for filtration failure, there is no agreement on which strategies should be preferred to prepare patients. This is largely due to the lack of validated guidelines, which forces clinicians to adopt personal approaches based on evidence derived from low-quality studies. In this review, we provided an overview of risk factors involved in the FS failure, with particular attention to those depending on OS changes, and how OSD negatively affects the aqueous humor resorption after surgery. Moreover, we reported the most exploited measures to mitigate the OSD before surgery, the possible reasons underlying the absence of shared approaches, and the upcoming area of intervention to preserve the OS health during glaucoma management. Finally, based on the current evidence, we proposed a pre-operative outline reporting the main risk factors that should be considered before surgery, and the therapeutical options available to improve the OS.

Purpose To evaluate the 10-year follow-up efficacy and safety of gold micro shunt (GMS) in patients with refractory glaucoma, and the potential risk factors for failure. Methods Retrospective data analyses based on medical records from 55 patients who underwent GMS implant for refractory glaucoma between March 2007 and April 2008. The primary outcome measure was the cumulative probability of success defined as intraocular pressure (IOP) below 21 mmHg together with a 33% lowering of the baseline IOP with (qualified) or without (complete) topical medications, no reoperation for glaucoma or loss of light perception. Results Mean IOP 10 years after the GMS implantation was 21.6 ± 5.1 mmHg with 2.7 ± 0.7 drugs. Qualified success was achieved in 8/55 patients (14.5%) with a mean of 2.9 ± 0.8 drugs at 5 years and in 2/55 patients (3.6%) with a mean of 2.7 ± 1.0 drugs at 10 years. None of the patients reached complete success at five years from surgery. The cumulative probability of complete success was 14%, 9% and 0% at 1, 2 and 5 years, respectively, and 72%, 67%, 36% and 3.6% at 1, 2, 5 and 10 years, respectively, for qualified success criterion. Baseline IOP for complete success, number of baseline medication for qualified success and age at the time of GMS implantation for both criteria were risk factors significantly associated with failure. Conclusion A very low long-term survival rate of GMS in refractory glaucoma was found. Most patients did not reach the IOP success criteria of the study, even with the re-introduction of medications, leading to the need for further surgical procedures.

Purpose: To compare the diagnostic accuracy of minimum rim width (MRW), peripapillary retinal nerve fibre layer (pRNFL) and multilayered macular analysis by Spectralis SD-OCT (Heidelberg Engineering, Germany) in discriminating perimetric glaucoma at different stages of the disease from healthy eyes. Methods: In this multicentre, prospective, evaluation of diagnostic tests study, multilayered macular analysis and MRW and pRNFL were obtained from one eye of 197 glaucoma (76 early, 68 moderate and 53 advanced) and of 83 healthy controls from the Multicenter Italian Glaucoma Imaging Study (MIGIS). The reference standard for classifying eyes as glaucomatous and for staging thedisease was the visual field. The main outcome measures were area under the ROC curve (AUC) and sensitivity at fixed specificity (95%). Results: Average MRW and average pRNFL showed the highest and similar diagnostic accuracy in both the whole study population (AUC 0.968 and 0.939) and early glaucoma (AUC 0.956 and 0.929). Among the macular parameters, the three innermost retinal layers combined as the Ganglion Cell Complex provided the highest diagnostic accuracy (AUC 0.931) in the whole population, which was statistically similar to that of average pRNFL but inferior to that of average MRW. Compared to both average MRW and pRNFL, all macular parameters showed statistically significant lower accuracy in early glaucoma, but accuracy in moderate and advanced glaucoma showed no statistically significant differences among three protocols. Conclusion: The diagnostic accuracy of MRW, pRNFL and macular analysis by Spectralis SD-OCT is overall good. MRW and pRNFL analysis performs statistically and clinically better than macular analysis to discriminate early glaucoma from healthy eyes.

Purpose To compare the reproducibility of peripapillary retinal nerve fiber layer (RNFL) measurements of 2 optical coherence tomography (OCT) systems. Methods Fifty-seven healthy individuals were prospectively selected. Only one eye was randomly chosen. All participants had intraocular pressure less than 21 mmHg and normal standard automated perimetry. Peripapillary RNFL thicknesses were measured with the Cirrus (Carl Zeiss Meditec, Dublin, Ca) and Spectralis (Heidelberg Engineering, Heidelberg, Germany) OCTs. The same operator acquired 3 consecutive series of scans. Left eye data were converted to a right eye format. Intraclass correlation coefficient (ICC), coefficient of variation (COV), and test-retest variability were calculated for all parameters. Results Mean age was 58.3±11.3 years. The ICC was higher than 0.92 for all parameters of both OCTs. The COV ranged from 1.8% (average thickness, Spectralis) and 2.5% (average thickness, Cirrus) to 5,8% (nasal inferior segment, Spectralis) and 6.4% (2 o’clock segment, Cirrus). Test-retest variability was lower than 12.2 µm for Cirrus parameters and lower than 10.9 µm for Spectralis parameters. Conclusion Both OCT systems had similar reproducibility of peripapillary RNFL measurements.

Purpose To determine the relationship between the indices of frequency-doubling perimetry (FDT) and the optic disc parameters measured with the Heidelberg Retina Tomograph (HRT) 3 in glaucoma patients. Methods 74 eyes of 74 glaucoma patients were prospective and consecutively selected. All of them had intraocular pressure higher than 21 mmHg, and reproducible glaucomatous visual field loss in standard automated perimetry. FDTs were performed with a Humphrey FDT perimeter using the C-20-5 full threshold strategy. Participants underwent imaging of the optic disc with the HRT3. The Kolmogorov Smirnov test was applied to check the data were normally distributed. Pearson correlations were calculated between FDT indices (mean deviation and pattern standard deviation) and global stereometric HRT3 parameters. Results Mild to moderate significant correlations (p