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Prcis: After the open bleb revision following PreserFlo, the mean postoperative intraocular pressure (IOP) was lowered from 26.4 ± 9.9 mm Hg to 12.9 ± 5.6 mm Hg at 1 month and 15.9 ± 4.1 mm Hg at 12 months., Purpose: The purpose of this study was to evaluate the effectiveness and safety of an open bleb revision with mitomycin- C (MMC) for bleb fibrosis after PreserFlo MicroShunt implantation., Patients and Methods: We performed a retrospective analysis of 27 consecutive patients with bleb fibrosis after PreserFlo MicroShunt Implantation that underwent an open revision with MMC 0.2 mg/mL applied for 3 minutes at the Department of Ophthalmology of the Mainz, University Medical Center, Mainz, Germany. Demographic data, such as age, sex, glaucoma type, number of glaucoma medications, IOP before and after PreserFlo implantation and revision, complications, and reoperations within 12 months, were analyzed., Results: Twenty-seven patients (27 eyes) received an open revision after previous PreserFlo Microshunt implantation and consecutive bleb fibrosis. The mean preoperative IOP was 26.4 ± 9.9 mm Hg before revision, 7.0 ± 2.7 mm Hg ( P < 0.001) in the first week after the revision, and 15.9 ± 4.1 mm Hg at 12 months ( P = 0.02). Four patients needed IOP-lowering medication after 12 months. One patient had a positive Seidel test and needed a conjunctival suture. Four patients required a second procedure due to recurring bleb fibrosis., Conclusions: At 12 months, open revision with MMC for bleb fibrosis after failed PreserFlo implantation effectively and safely reduced IOP with a similar medication burden., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To assess long-time results of primary surgical treatment in children with glaucoma after congenital cataract surgery., Methods: A retrospective study of 37 eyes from 35 children with glaucoma after congenital cataract surgery, who underwent surgery between 2011 and 2021 at the Childhood Glaucoma Center, University Medical Center Mainz, Germany. Only children, who received a primary glaucoma surgery in our clinic within the given time (n = 25) and had at least one-year follow-up (n = 21), were included in the further analysis. The mean follow-up time was 40.4±35.1 months. The primary outcome was the mean reduction in IOP (in mmHg) from baseline to follow-up visits after the surgery, measured with Perkins tonometry., Results: 8 patients (38%) were treated with probe trabeculotomy (probe TO), 6 (29%) with 360° catheter-assisted trabeculotomy (360° TO) and 7 (33%) with cyclodestructive procedures. IOP was significantly reduced after probe TO and 360° TO after 2 years, from 26.9 mmHg to 17.4 mmHg (p<0.01) and 25.2 mmHg to 14.1 mmHg (p<0.02), respectively. There was no significant IOP reduction after cyclodestructive procedures after 2 years. Both, probe TO and 360° TO led descriptively to eye drops reduction after 2 years, from 2.0 to 0.7 and 3.2 to 1.1. The reduction was not significant., Conclusions: In glaucoma after congenital cataract surgery, both trabeculotomy techniques, lead to good reduction of IOP after 2 years. There is a need for a prospective study with comparison to the use of glaucoma drainage implants., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Strzalkowska et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Glaucoma is one of the most frequent causes of irreversible blindness worldwide. The main risk factor of the disease is an individually too high intraocular pressure and pressure reduction is still the only established treatment. If conservative pressure reduction and adherence are insufficient, and if the patient is unable to tolerate conservative treatment, surgical procedures become necessary. There are nowadays more than a dozen different surgical procedures for lowering the pressure. This article presents and discusses the procedures that have a subconjunctival pre-equatorial drainage in common. These include trabeculectomy, the XEN-gel implant and the Preserflo microshunt., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: To evaluate the long-term outcomes of trabeculectomy (TE) surgery in a large cohort with a minimum follow-up of 3 years., Design: Retrospective cohort study., Setting: University Eye Hospital, Germany., Participants: Three hundred and seventy-nine patients with open-angle glaucoma underwent TE with mitomycin C (MMC) between January 2013 and February 2017 with a minimal follow-up of 3 years. Eligible patients were identified via an electronic surgical case register., Interventions: All patients had undergone TE with MMC following a set surgical protocol. To assess the influence of cataract surgery following TE, eyes which underwent cataract surgery at least 6 months after TE were matched 1:3 by sex and age to eyes who did not undergo cataract surgery during the follow-up period., Main Outcome Measures: Primary outcome was the proportion of surgical success based on intraocular pressure (IOP), surgical complications, the need for revision surgery, loss of light perception and the need for additional pressure-lowering medication., Results: The mean follow-up time was 6 (±0.8, IQR: 5.4-6.5) years. Seventy-three per cent of eyes achieved qualified surgical success at the last follow-up (IOP≥5 mm Hg and ≤18 mm Hg, without surgical complications or complete loss of vision) but necessitated additional medical therapy, complete surgical success with no additional medical therapy was achieved in 69% of eyes. There was no significant difference in the success probability between eyes that had undergone cataract surgery after TE and those that had not (p=0.45)., Conclusions: The results demonstrate a high and stable success rate of TE after a mean follow-up time of approximately 6 years, that is, not affected by later cataract surgery., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Trabeculectomy represents the glaucoma surgical procedure that achieves the greatest reduction in intraocular pressure and enables a low pressure regulation especially in normal pressure glaucoma. For the beginner the operation is challenging due to potential intraoperative and postoperative difficulties. With this in mind this article explains how to learn to perform a trabeculectomy and explains the various steps from assessing the indications via training, performing the surgery independently and follow-up care. The article points out the challenges during the procedure and the possible solutions and explains the individual aftercare using the Mainz treatment scheme as an example. In this way, the risk of serious complications can be reduced to a minimum and in the vast majority of patients a sufficient regulation of intraocular pressure can be achieved without the need for eye drops., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: To assess surgical success and the post-operative development of intraocular pressure between XEN45 ® gelstent, Preserflo ® MicroShunt and trabeculectomy with mitomycin C., Methods: Data from 105 eyes from 105 patients of matched cases with refractory open-angle glaucoma, who underwent surgery between January 2019, and August 2020, were evaluated. Patients underwent either stand-alone XEN gelstent insertion with Mitomycin C, stand-alone Preserflo with Mitomycin C or trabeculectomy with Mitomycin C. The primary outcome was the proportion of complete surgical success at 6 months post-operatively (i.e. intraocular pressure between 5mmHg and 18mmHg, no revision surgery, no loss of light perception and no post-operative pharmaceutical antiglaucomatous treatment). The reduction of intraocular pressure after 6 months, the classes of antiglaucomatous medication used post-operatively, best-corrected visual acuity, spherical refractive errors and astigmatism were assessed as secondary outcomes., Results: We included 35 eyes in each group. After 6-month follow-up, complete success was 73.5% [95%-CI: 57.9%-89.2%] in the trabeculectomy group, 51.4% [95%-CI: 34.0%-68.8%] in the XEN group and 74.2% [95%-CI: 57.9%-90.5%] in the Preserflo group (p = 0.08). Regarding secondary outcomes, the reduction of intraocular pressure was 12.1 ± 7.9 mmHg in the trabeculectomy group and was thereby 5.8 [95%-CI: 2.2-9.6] mmHg greater compared with the XEN group (p < 0.001) and 4.8 [95%-CI: 0.9-8.7] mmHg higher than the Preserflo group (p = 0.01)., Conclusions: No statistically significant differences were found between trabeculectomy, XEN45 ® gelstent implantation and Preserflo ® MicroShunt implantation regarding surgical success after 6 months. Yet reduction in intraocular pressure was significantly higher in the trabeculectomy group. However, all three interventions resulted in sufficiently low post-operative intraocular pressure and may therefore be considered individually for glaucoma treatment., (© 2021 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose: To evaluate long-term results of glaucoma surgery in newborn and infants with glaucoma., Methods: Seventy-nine eyes of 52 children (age: 3 weeks-15.3 years) with primary congenital or secondary glaucoma treated between 2015 and 2017 were included. The median follow-up time was 3.9 years. Conventional probe trabeculotomy, 360° catheter-assisted trabeculotomy, filtering and cyclodestructive surgery were compared. Strict criteria for surgical success were applied: Complete surgical success (IOP below target IOP, no further surgery) and incomplete surgical success (additional surgery allowed) were analyzed, and IOP at baseline and last follow-up was compared., Results: Intraocular pressure (IOP) was significantly reduced in primary congenital (preoperative IOP: 27.8 ± 7.5 mmHg vs. postoperative IOP: 14.2 ± 4.5 mmHg) and secondary glaucoma (preoperative IOP: 29.2 ± 9.1 mmHg vs. postoperative IOP: 16.6 ± 4.7 mmHg). 90% of all eyes reached target IOP with or without medication allowing for additional surgeries. As first surgery, 360° catheter-assisted trabeculotomy had a tendency to higher surgical success than other surgical approaches, while cyclodestructive procedures had lowest., Conclusions: We found very promising surgical results in our childhood glaucoma patient group. Surgical success in both congenital and secondary glaucoma was high., (© 2021 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose: This study assesses short-term intraocular pressure (IOP) change in the fellow eye of glaucoma patients after mitomycin C-augmented trabeculectomy, filtering canaloplasty, or PreserFlo™ microshunt implantation in the treated eye., Materials and Methods: Retrospective chart review of 235 glaucoma patients (235 eyes) was performed. Patients underwent initial trabeculectomy (187 patients), filtering canaloplasty (25 patients), or PreserFlo™ microshunt implantation (23 patients) in one eye, while the fellow eye was naïve to any previous glaucoma surgery. IOP was evaluated before and on the 1st and 2nd days and at 1 week after surgery. Main outcome measure was IOP change in the fellow eye. Secondary outcomes were proportion of clinically significant IOP elevation in the fellow eye and evaluation of potential risk factors associated with postoperative IOP fluctuation., Results: IOP in the fellow eye at 1 week after trabeculectomy was statistically significantly lower than preoperatively (p < 0.0001), while the IOP did not change significantly in the fellow eyes in filtering canaloplasty or PreserFlo groups. The higher the preoperative IOP was in the fellow eye, the larger was the intraocular pressure-lowering effect at 1 week after trabeculectomy (p < 0.0001). A clinically significant IOP elevation was noted in 14.2%, 9.5%, and 5% of fellow eyes after trabeculectomy, filtering canaloplasty, or PreserFlo™ microshunt implantation, respectively., Conclusions: This study shows an IOP-lowering effect in the fellow eye of glaucoma patients after trabeculectomy. Significant IOP rise might occur in the fellow eye of some glaucoma patients after different types of glaucoma surgery., (© 2021. The Author(s).)

Prcis: Treatment of leakage with ocular hypotony after trabeculectomy with mitomycin C (MMC) can be safely achieved through conjunctival patch alone or combined with donor scleral graft in cases of melted underlying sclera., Purpose: To report outcomes of 2 surgical approaches for treating ocular hypotony in eyes with blebs with late-onset leakage after standard trabeculectomy with MMC., Methods: Thirty consecutive cases with bleb leakage and hypotony underwent bleb revision surgery between 2009 and 2014 by the same surgeon (J.W.) at the Department of Ophthalmology of the Mainz University Medical Center, Germany. In 18 patients, an autologous conjunctival patch graft was applied. In 12 patients, the underlying sclera was found melted and an additional scleral donor graft was sutured in place. The authors analyzed intraocular pressure, visual acuity, and optical coherence tomography of the macula preoperatively at 1 day, 1 week, 4 weeks, and 6 months after surgery., Results: The mean IOP was 6.2±3.5 mm Hg preoperatively and 21.7±16.4 mm Hg at 1 day, 13.7±6.7 at 1 week, 13.1±5.1 mm Hg at 4 weeks, and 12.1±4.7 mm Hg at 6 months after surgery. Visual acuity (logMar) increased from 0.57±0.49 preoperatively to 0.49±0.40 at 6 months. Optical coherence tomography showed flattening of macular folds that were present before treatment. No serious adverse event was reported., Conclusions: This revision technique with conjunctival patch and/or additional donor scleral graft is an effective and safe method for treating late bleb leakage and hypotony maculopathy after trabeculectomy with MMC., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

PRéCIS:: The closing limbal suture after trabeculectomy with a fornix-based conjunctival flap plays no critical role in the development of corneal astigmatism and intraocular pressure (IOP). A standard removal is not recommended., Purpose: To investigate the effect of removal of the conjunctival suture after trabeculectomy with fornix-based conjunctival flap on corneal astigmatism, visual acuity, and IOP., Methods: Eighty-seven cases of trabeculectomy with mitomycin C with a fornix-based conjunctival flap performed in the eyes of 82 patients (5 patients underwent bilateral trabeculectomy) were enrolled in a prospective randomized study. All surgeries were conducted by the same surgeon (J.W.) in the Ophthalmology Department of the University Medical Center of Mainz, Germany. All eyes received a corneal-conjunctival, continuous, mattress, interlocked suture for closing the conjunctiva at the limbus. After randomization, in 46 cases the suture was removed 6 weeks postoperatively; in 41 patients, the suture was left in place. All patients were examined preoperatively, and at 6 weeks, 3 months, 6 months, and 12 months after surgery. Astigmatism was measured using objective refraction and corneal topography, IOP and visual acuity were also assessed. Results were compared using a Wilcoxon test or Mann-Whitney U test for single time-points., Results: During follow-up, no significant differences between the 2 study groups regarding refractive or topographic values were found. Patients in the suture removal group had a significantly higher visual acuity than controls at 3 months, 6 months, and 1 year after surgery. IOP was similar in both groups throughout the study., Conclusions: Removal of the conjunctival suture in trabeculectomy with a fornix-based conjunctival flap leads to a faster rehabilitation of visual acuity but does not significantly affect corneal astigmatism or IOP.

Purpose: To determine feasibility, efficacy, and safety of ab externo 360-degree trabeculotomy with illuminated microcatheter for congenital glaucoma., Patients and Methods: The postoperative results of 36 eyes in 23 consecutive patients who underwent 360-degree trabeculotomy for primary congenital glaucoma (PCG) or secondary congenital glaucoma using an illuminated microcatheter were retrospectively analyzed. Success criteria were defined as intraocular pressure (IOP) ≤18 mm Hg without (complete success) and with medication (qualified success)., Results: In all previously nonoperated eyes with PCG (group 1), the Schlemm's canal was identified and circumferentially cannulated for 360-degree trabeculotomy. In group 2 comprising of operated eyes with PCG and eyes with secondary congenital glaucoma, the performance of 360-degree trabeculotomy failed in 4 eyes because of the Schlemm's canal occlusion or high tissue resistance of the trabecular meshwork. Mean preoperative IOP was 28.6±5 and 29.6±9 mm Hg with 7 of 20 eyes and 7 of 9 eyes receiving IOP-lowering medication in group 1 and group 2, respectively. Mean postoperative IOP was reduced to 13±2.7 and 20.2±7.1 mm Hg after a mean follow-up of 15.3 and 12.7 months with 4 of 20 eyes and 5 of 9 eyes receiving medication in group 1 and group 2, respectively. Four eyes underwent further surgery. Complete success was achieved in 16 and 3 eyes, whereas qualified success was achieved in 20 and 4 eyes from group 1 and group 2, respectively. In all eyes, a mild to moderate postoperative hyphema was observed., Conclusions: Ab externo catheter-assisted 360-degree trabeculotomy controls IOP in a majority of patients with congenital glaucoma after a single operation. Moderate blood reflux in the anterior chamber is considered as a common postoperative finding. We did not observe hypotony or other severe complications in our series. In 1 patient, we experienced catheter misdirection in an eye that had previously undergone trabeculotomy.

Trabeculectomy is the most proven method for the treatment of open angle glaucoma. The long-term results of this method show an 80% success rate in lowering intraocular pressure over 20 years. The surgical technique is demonstrated in detail with the help of a video of the operation and which is available online. For more than 15 years trabeculectomy has been performed with the use of antifibrotic substances, such as mitomycin C. Long-term treatment with antiglaucoma eyedrops leads to a proven inflammation of the conjunctiva and the ocular surface with an increase in lymphocytes, mast cells, and fibroblasts. Discontinuation of antiglaucoma therapy in turn allows regeneration of the ocular surface. From the knowledge gained from these histopathological studies it has been recommended to stop glaucoma treatment prior to glaucoma surgery and to pretreat the conjunctiva with eyedrops containing cortisone. Administration of nonsteroidal antiphlogistic substances or local steroids to the conjunctiva 4 weeks prior to surgery increases long-term success of the filtering bleb function.

Objectives: The objective of this study is to investigate the results of an adaptive approach of bleb revision surgery for late onset hypotony after trabeculectomy with mitomycin C because of bleb leakage and/or scleral melting., Methods: A total of 29 eyes of 27 patients, aged 63.8±11.7 years with hypotony maculopathy [intraocular pressure (IOP), ≤6 mm Hg] because of late onset bleb leakage and/or scleral melting after trabeculectomy with mitomycin C in which minimally invasive transconjunctival suturing of the scleral flap was impossible were enrolled in this retrospective interventional case series. External bleb leakage was seen in 16 eyes, 11 eyes suffered from scleral melting. Because of the intraoperative findings regarding appearance of conjunctiva and sclera 4 different surgical approaches were used: (1) bleb excision (in case of external leakage) and conjunctival reapproximation, (2) bleb excision and free conjunctival autografting, (3) human donor scleral patch grafting (in case of scleral flap defect) with conjunctiva reapproximation and (4) combined conjunctival and scleral patch grafting. Outcome measures were IOP and visual acuity (VA) development over time. Data analysis comparing changes in the parameters (IOP and VA) before and after bleb revision surgery was carried out using the paired t test., Results: Changes in IOP and VA were analyzed over 9.3±8.3 months (range, 1.1 to 36.5 mo). IOP increased from 4.0±1.8 mm Hg, (P<0.001) before revision surgery to 13.1±4.1 mm Hg at 3 months after revision and 12.6±3.8 mm Hg at last follow-up visit, showing no significant difference in IOP between 3 months post revision and at the last documented patients' follow-up visit (P=0.28). The VA before revision surgery (0.42±0.28 logMAR) significantly increased (P=0.05) 3 months after revision (0.32±0.23 logMAR) and remained stable (P=0.65) until the last follow-up visit (9.3±8.3 mo; range, 1.1 to 36.5) (0.35±0.32 logMAR)., Conclusions: In patients with hypotony an adaptive approach of bleb management shows good results both in terms of IOP control and improvement in VA.

We report a case of a rare complication after trabeculotomy combined with a small trabeculectomy with mitomycin C in a young patient with juvenile glaucoma. The patient underwent uneventful surgery. However, postoperatively, he experienced a long-lasting hypotony with the need of 2 revision surgeries and 2 short episodes of high-intraocular pressure. He developed a fixed dilated pupil over time.

Purpose: Intraocular pressure (IOP) fluctuation is considered as a risk factor for glaucoma progression. We investigated IOP values and IOP fluctuation before and after trabeculectomy (TE) with mitomycin C (MMC) measured by 48-hour diurnal-nocturnal-IOP-profiles (DNP)., Methods: Pre- and postoperative DNPs of 92 eyes undergoing primary TE with MMC were analysed. Each 48-hour IOP-profile involved 10 IOP measurements (8:00 a.m., 2:00 p.m., 6:00 p.m., and 9:00 p.m. in sitting and at 00:00 in supine position). The "preoperative DNP" was performed a few weeks before TE. The "postoperative DNP" was performed at least six months (range: 6 months-2 years) after TE. Mean IOP values and IOP fluctuations were calculated., Results: After TE with MMC mean IOP was reduced from 16.94±3.83 to 11.26±3.77 mmHg at daytime and from 18.17±4.26 to 11.76±3.90 mmHg at night. At daytime mean IOP-fluctuation decreased from 8.61±4.19 to 4.92±2.52 mmHg, at night from 3.15±2.95 to 1.99±1.82 mmHg. Mean IOP was lower on the second day of the preoperative DNP. This effect was not present in the postoperative DNP. Preoperatively, IOP was controlled in all eyes with a mean of 3.22±0.94 antiglaucomatous agents. Postoperatively, IOP≤15 mmHg was achieved in 71.7%, IOP≤18 mmHg in 77.1% and a decrease in IOP of >30% in 47.8% without antiglaucomatous therapy. Postoperatively, pseudophakia was associated by a higher mean IOP-fluctuation compared to the phakic eyes., Conclusions: TE with MMC significantly reduces both mean IOP-values and IOP- fluctuations at day and night at least 6 months postoperatively. The effect of TE on the IOP fluctuation was less pronounced in pseudophakic eyes.

Purpose: To compare two surgical approaches for treating encapsulated blebs after trabeculectomy with mitomycin C, in terms of the development of intraocular pressure and progression of glaucoma in a long-term follow up: 1. bleb needling alone vs. 2. a combined approach of needling with additional transconjunctival scleral flap sutures, to prevent early ocular hypotony., Methods: Forty-six patients with failing blebs after trabeculectomy with mitomycin C were enrolled in this study. Patients received either needling revision alone (group 1; n = 23) or a combined needling with additional transconjuctival flap sutures, if intraoperatively the intraocular pressure was estimated to be low (group 2; n = 23). Intraocular pressure (IOP), visual acuity, visual fields, and optic nerve head configuration by means of Heidelberg Retina Tomograph (HRT®) were analysed over time. Results from both groups were compared using Mann-Whitney U-test for single timepoints., Results: IOP did not differ significantly between the two groups during follow-up at three months (P = 0.13), six months (P = 0.12), one year (P = 0.92) and two years (P = 0.57) after surgery. Furthermore, there was no significant difference in the course of glaucoma concerning the optic nerve anatomy between the two groups (Rim Area Change in the Moorfields Regression Analysis of HRT®) till two years after surgery (P = 0.289). No functional impairment in visual acuity and visual fields was found in the groups of the study., Conclusions: Single needling procedure is a standard successful method for restoring the function of encapsulated blebs. Postoperative hypotony represents a possible hazard, which can be minimized by additional transconjunctival flap sutures. Long-term results suggest that this modification is equally effective in lowering the IOP and preventing the progression of glaucoma as the standard needling procedure. To our knowledge this is the first study to investigate the long-term effect of tranconjunctival sutures for the prevention of hypotony.

Purpose: A simple needling procedure is the standard method for restoring the function of an encapsulated bleb after trabeculectomy. However, postoperative hypotony represents a possible hazard. This study describes a new surgical approach for treating encapsulated blebs with reduced risk of early postoperative hypotony: bleb needling combined with transconjunctival sutures tightening the scleral flap directly., Methods: The study included two groups of 23 patients with failing bleb following trabeculectomy: "Group 1" underwent simple needling revision of the filtering bleb and served as a control group, while "Group 2" received needling revision with additional transconjunctival scleral flap sutures, if intraoperatively the intraocular pressure was estimated to be very low. Intraocular pressure (IOP), postoperative management and complications were analyzed over a follow-up period of 4 weeks postoperatively. Results were compared using t-test or Mann-Whitney U-tests., Results: Adverse effects occurred with a higher frequency after sole needling of the bleb (5 cases of choroidal effusion and 1 case of choroidal hemorrhage) than after the combined method with additional scleral sutures (1 case of choroidal effusion). The IOP on the first postoperative day was significantly lower in group 1, with 9.43 ± 9.01 mm Hg vs. 16.43 ± 8.35 mm Hg in group 2 (P = 0.01). Ten patients with ocular hypotony (IOD of 5 mmHg or lower) were found in group 1 and only two in group 2. One week and one month after surgery the intraocular pressure was similar in both groups (P>0.05)., Conclusions: This new needling technique with additional transconjunctival scleral flap sutures appears to reduce postoperative hypotony, and may thus protect from further complications, such as subchoroidal hemorrhage.

Purpose: To compare the outcome of fornix-based trabeculectomy with mitomycin C (MMC) using 2 different sizes of subconjunctival preparation (36 mm² compared with 72 mm²)., Methods: Prospective, randomized interventional case series., Study Population: Patients 18 to 85 years of age with open-angle glaucoma and progressive visual field defects under maximum tolerated medical therapy were randomized to undergo initial fornix-based trabeculectomy with MMC (0.2 mg/mL for 5 min) with subconjunctival preparation of 6×6 mm (group A) or 8×9 mm (group B). Main outcome parameters were: intraocular pressure (IOP), best-corrected visual acuity (BCVA), number of 5-fluorouracil (5-FU) injections, and laser suturolyses (SL)., Results: Twenty-eight eyes of 26 patients were enrolled, including 14 eyes in group A and 14 in group B. At 12 months, IOP (mean±SD) was 9.69±2.5 mm Hg in group A and 9.93±3.2 mm Hg in group B (P=0.17) without glaucoma medication. Mean BCVA (logMAR) at month 12 was 0.29±0.26 in group A and 0.26±0.2 in group B (P=0.71). Patients required 3.0 5-FU in group A and 4.1±2.9 5-FU in group B (P=0.16); 1.3±1.1 SL and 1.8±1.1 SL, respectively (P=0.23). We noted 2 cases of intraocular hypotony in the 6×6 mm group (14.3%) and 1 in the 8×9 mm group (7.1%)., Conclusions: There were no significant differences between study groups in mean IOP reduction, change in BCVA, or number of applied 5-FU and SL at 1-year follow-up. The area of subconjunctival preparation is only one of several factors playing a role in the outcome of trabeculectomy with MMC.

Purpose: To present the 4-year follow-up results in the surgical treatment of hypotony following trabeculectomy with mitomycin C in glaucoma patients with additional flap sutures., Design: Retrospective interventional case series., Methods: Since 2006, 53 patients with hypotony maculopathy attributable to overfiltration following glaucoma surgery (trabeculectomy with mitomycin C) were included in this institutional study. We were able to follow up intraocular pressure (IOP) and distance-corrected visual acuity in 33 (62%) over 4 years, whereas all were followed over 2 years. To elevate IOP, we placed tangential transconjunctival sutures through the scleral flap and connected them to the adjacent sclera in all 53 patients., Results: Mean IOP prior to surgery was 3.55 mm Hg (± 2.05; range 0-8 mm Hg), 20.08 mm Hg (± 12.48) on the first postoperative day, 10.69 mm Hg (± 4.73) after 1 month, 10.12 mm Hg (± 3.95) after 6 months, 10.42 mm Hg (± 4.17) after 2 years, and 9.5 mm Hg (± 3.93) after 4 years. Mean visual acuity (VA) improved from 0.8 logarithm of minimal angle of resolution (logMAR) preoperatively to 0.5 after 1 month, and remained stable after 6 months at 0.3. Macular folds resolved in all patients and choroidal detachment in 51 patients (96%) after 6 months. IOP increase and vision improvement were statistically significant (<.05)., Conclusion: Even 4 years after resuturing of the scleral flap through the intact conjunctiva, there is evidence that this surgical method is an effective and simple technique to treat hypotony maculopathy after glaucoma surgery., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Osteogenesis imperfecta (OI) is a connective tissue metabolic disorder with autosomal inheritance. Ocular involvement includes blue sclera, myopia, glaucoma and keratoconus in addition to bone synthesis defects. We report the case of a male patient with OI who suffered from progressive visual field defects and advanced glaucomatous optic atrophy and underwent trabeculectomy on both eyes. Intraocular pressures (IOP) of 7-11 mmHg were measured 1 year postoperatively. This report illustrates peculiarities in the surgical therapy of open angle glaucoma in patients with OI as well as the options for complication management.

Background: A serious complication following trabeculectomy with mitomycin C (MMC) is intraocular hypotony with hypotony maculopathy, papilledema, flattening of the anterior chamber, corneal decompensation and a decrease in visual acuity. We describe a new simple surgical technique for the treatment of hypotony maculopathy following trabeculectomy with MMC., Methods: In a prospective consecutive case study, 16 patients with hypotony maculopathy following trabeculectomy with MMC were included. Through the intact conjunctiva, additional 10.0 nylon sutures were placed through the scleral flaps into the adjacent sclera. Assessment of visual acuity, intraocular pressure (IOP) measurement and fundoscopy were performed on the 1st and 7th day postoperatively and 1, 3 and 6 months postoperatively. Photography of the bleb and the posterior pole and optical coherence tomography imaging of the posterior pole were performed., Results: Before surgery (flap suture), the mean IOP was 2.8 mmHg (+/-1.1; range from 1 to 4 mmHg). It was 24.9 +/- 11.7 mmHg (range; 9-48 mmHg) on the 1st postoperative day, 15.7 +/-8.1 mmHg (range; 5-35 mmHg) on day 7, 11.1 +/-4.1 mmHg (range; 5-20 mmHg) 1 month after surgery, 9.3 +/-3.9 mmHg (range; 2-20 mmHg) after 3 months, and 9.6 +/-4.2 mmHg (range; 2-20 mmHg) after 6 months. The best corrected mean visual acuity was 20/50 before trabeculectomy and 20/160 before flap suture. It improved to 20/63 at 6 months postoperatively. Clinical signs of hypotony maculopathy disappeared in all patients. No bleb leakage was observed in any patient during follow-up., Conclusion: Resuturing the scleral flap through the intact conjunctiva is an effective and minimally invasive method to treat hypotony maculopathy following trabeculectomy with MMC. Thus, opening the conjunctiva can be avoided.

Background: Long-term glaucoma medication has been suspected to be a risk factor for bleb failure following trabeculectomy. It was the goal of our study to investigate whether additive preoperative treatment with latanoprost has an effect on the outcome of subsequent trabeculectomy., Methods: We retrospectively analysed the outcome of trabeculectomy in 32 eyes of 16 patients who had received bilateral trabeculectomy within the Mainz-II study. This study had been designed to examine the effect of 6 months' use of topical latanoprost therapy on iris darkening. The first eye of each patient was operated upon without preoperative latanoprost therapy; the other eye was operated on after 6 months' treatment with latanoprost in addition to existing medical glaucoma treatment. We analysed the outcome of these patients and compared success rates and average intra-ocular pressures (IOPs) between the latanoprost-treated and the untreated partner eyes. Success was defined as an average postoperative IOP of 18 mmHg or less., Results: We obtained IOP values from 13 of 16 patients, with a mean follow-up period of 6.8 years. Three patients were lost to follow-up. In both groups eight eyes (61.5%) had an average postoperative IOP (average of all IOPs measured in the follow-up period) of 18 mmHg or less. The mean average postoperative IOPs in the control group and in the latanoprost group were 15.2 mmHg and 15.8 mmHg, respectively. Intra-individual comparison revealed that one pair of eyes had equal IOPs, while six eyes in each group showed better postoperative IOP control than the respective partner eye. However, mean delta IOPs (maximum preoperative IOP minus average postoperative IOP) were 17.8 mmHg and 14.2 mmHg for the control group and latanoprost group, respectively., Conclusion: In this small group 6 months of additive preoperative treatment with latanoprost did not have a statistically significant effect on the success rate of trabeculectomy or on the postoperative IOP level following trabeculectomy. However, trabeculectomy in eyes preoperatively receiving latanoprost for 6 months might lead to a slightly smaller delta IOP than in eyes naive to prostaglandins.

Background: It was investigated whether a very low target pressure could be achieved by modification of deep sclerectomy without losing the advantages of non penetrating surgery in comparison to conventional filtration surgery., Patients and Methods: A total of 22 eyes from 22 patients with advanced open angle glaucoma were randomly assigned to receive a deep sclerectomy or a trabeculectomy. Both groups received 0.02% mitomycin C under the conjunctiva prior to preparation of the scleral flap. In the deep sclerectomy group at least parts of the outer trabecular meshwork were removed until an apparent filtration was achieved. A dry cross-linked hyaluronate served as an implant. In the other group a classical trabeculectomy was performed., Results: The median intraocular pressure 12 months post-operation was 11.5 mm Hg in the deep sclerectomy group compared to 11 mm Hg in the trabeculectomy group; the median of the relative IOP reduction was -47% in the deep sclerectomy group, and -57% in the trabeculectomy group. The best corrected visual acuity was unchanged 12 months postoperatively in both groups., Discussion: As a more aggressive IOP-lowering procedure (intended filtration, use of antimetabolites) deep sclerectomy proved to be as effective as trabeculectomy. Nevertheless, the advantages of the more difficult surgical procedure concerning visual acuity, complications and surgical interventions were lost postoperatively.

Objective: To investigate by masked electron microscopy whether 6 months of topical latanoprost caused pathological changes in the peripheral iris of patients with glaucoma., Methods: Seventeen patients with bilateral primary open-angle glaucoma requiring trabeculectomy were recruited for this study. The iridectomy taken during surgery on the first eye served as a control. The second test eye was treated topically with latanoprost for 6 months before its trabeculectomy. Fourteen patients completed the treatment arm of the study, and 1 of these underwent marked color change. As a result, 31 iridectomy specimens were fixed, coded, and evaluated., Results: The specimens were evaluated for evidence of stromal inflammation, vascular alterations, and stromal and posterior epithelial degeneration. None of these features was evident in any of the 31 iridectomy specimens. There was evidence of the incidence of free melanin granules in the stroma, melanin turnover, abundance of stromal clump cells, atypical cellular features in melanocytes, and prominence of the anterior border. After code breaking, it was evident that none of these features distinguished the test from the fellow irises in our group. The patient with color change in the test iris did not stand out from the others in this analysis. Qualitative reexamination of further sections after unmasking gave the impression of increased melanin granule numbers in the melanocytes of the anterior border region., Conclusions: The ultrastructure of the iridectomies from the latanoprost-treated eyes and the fellow eyes conformed to published standards for normal iris. There was no evidence of early ultrastructural changes, which might have been the harbingers of latanoprost-induced iris abnormality.

Background: There are different surgical approaches for cataract and concomitant primary open-angle glaucoma (POAG). In a retrospective study we examined the long-term results of cataract extraction combined with trabeculotomy., Patients and Methods: Between 1990 and 1997, 194 eyes with cataract and POAG were operated on in a combined manner. Eighty-eight eyes received a trabeculotomy (TT), in 82 eyes a trabeculectomy was added to the trabeculotomy (TT+TE) and in 24 eyes, in which probing of Schlemm's canal was impossible, standard trabeculectomy (TE) was performed. Pre- and postoperative intraocular pressure (IOP), glaucoma medication, and the intra- and postoperative complications of all patients were analyzed., Results: Hyphema was the most common complication in the TT group (20.5%). Fibrin reaction occurred in 27.8% of all cases. There was no statistically significant difference in postoperative IOP between the TT group and the TT+TE group. A statistically significant decrease in IOP compared to preoperatively lasted 60 months in the TT group. In eyes with a preoperative IOP < or = 20 mmHg, none of the three procedures reduced IOP significantly (<20% of the preoperative IOP). In the first 2 years after operation 50% of the patients had no need for antiglaucomatous medication., Conclusions: Cataract surgery combined with TT resulted in few complications. In low-tension glaucoma the combination with TT is not sufficient to decrease the IOP. In patients with higher preoperative IOP, however, cataract surgery combined with TT could be--on the basis of a postoperative observation time of 72 months--a suitable method for lowering the IOP sufficiently. Furthermore, the use of antiglaucomatous substances was reduced by this combined procedure.

Purpose: To determine whether hypotony after filtration surgery has any influence on visual acuity and intraocular pressure (IOP) lowering., Patients and Methods: We prospectively investigated 43 eyes of 43 patients undergoing trabeculectomy without the use of antimetabolites for 12 months., Results: The lowest postoperative IOP valued 4.9 +/- 3.6 mm Hg (range, 0-14 mm Hg). It correlated statistically significant with the IOP 6 weeks (P = 0.016), 6 months (P = 0.009), and 1 year after surgery (P = 0.027). Eyes with a deterioration of visual acuity 6 weeks after surgery had undergone a stronger postoperative hypotony (correlation with lowest postoperative IOP, P = 0.035). The mean period with an IOP less than 5 mm Hg was 3.5 +/- 8.0 days, and the mean period with an IOP less than 10 mm Hg lasted 45.4 +/- 68.8 days (range, 0-276 days). A hypotony score based on IOP and duration of hypotony was introduced. A correlation was detected between morphologic signs of hypotony, such as tiny retinal folds, at the 6-month follow-up and the duration of hypotony (P = 0.029) and hypotony score (P = 0.001)., Conclusions: Hypotony after filtration surgery may decrease visual acuity in the early postoperative period. Conversely, early postoperative hypotony correlated with better long term IOP control. There was no deleterious effect on visual acuity after 6 months.

Background: Congenital glaucoma is a potentially blinding disease that requires surgical therapy. This paper describes the outcome of trabeculotomy in primary congenital glaucoma., Methods: Thirty-nine eyes of 22 children with congenital glaucoma who underwent trabeculotomy with or without a simultaneous trabeculectomy between 1992 and 1997 were retrospectively analyzed., Results: Mean follow-up was 24.7+/-17.9 months. A mean of 1.3 operations per eye were performed. The mean IOP at the end of follow-up (n=39) was 17.7+/-6.0 mmHg; in 8 eyes (20.5%) the IOP was >21 mmHg, in 31 eyes (79.5%) it was < or =21 mmHg. The mean difference between pretreatment IOP and IOP at the end of follow-up (n=39) was -10.5+/-9.4 mmHg (-37.2%). Success rates were calculated: IOP was < or =21 mmHg in 36/39 eyes (92.3%) after 1/2 year of follow-up, in 25/27 eyes (92.6%) after 1 year, in 15/18 eyes (83.3%) after 2 years, in 8/12 (66.7%) eyes after 3 years, in 4/8 eyes (50%) after 4 years and in 4/4 (100%) eyes after 5 years of follow-up. Complications included hypotony (three eyes), subchoroidal bleeding (one eye ), detachment of Descemet's membrane (one eye) and macular pucker (one eye in which later mitomycin C was used). Visual acuity (VA) was tested with various methods in 35 eyes. VA was within the normal nomogram range in 12 eyes and below the normal range in 23 eyes at the end of follow-up. Axial length measurements showed normalization according to the age nomogram in 22 of 35 eyes., Conclusion: This study shows that trabeculotomy is an effective surgical procedure in congenital glaucoma with satisfactory success rates up to 5 years of follow-up.

Filtering procedures have been the gold standard in glaucoma surgery for more than 30 years. Trabeculotomy, deep sclerectomy, and viscocanalostomy might become the procedures of first choice in the future. These new, non-penetrating procedures have not yet been compared to filtering procedures in prospective randomized studies with long-term follow-up. In addition, it is not really known how they modify outflow of the aqueous humor. The surgical technique is described and the most likely underlying effects are discussed.

14 eyes of 14 patients with medically untreatable glaucoma and extremely bad surgical prognosis because of young age, secondary glaucomas or following previous surgery were treated by means of goniotrephination with a scleral flap and a fornix-based conjunctival flap. Postoperatively, all eyes received 5 mg 5-fluorouracil in 0.5 ml NaCl 0.9% subconjunctivally daily for 7 days and weekly for another 6 weeks. IOP was lowered in all eyes from 33.9 +/- 5.0 mmHg preoperatively to 15.6 +/- 8.4 mmHg 1 year postoperatively. 71% of eyes were IOP controlled without further therapy. Results were unfavourable in eyes with irido-corneo-endothelial syndrome. Local side effects were less frequent than described previously, possible due to the reduced but prolonged administration of 5-fluorouracil. Also, all eyes received corneal supportive therapy with hyaluronic acid and polyvinyl alcohol.

Major problems in the early postoperative phase in filtering surgery are hypotony, flattening of the anterior chamber and choroidal detachment. We describe a new suture technique for the closure of the conjunctiva in goniotrephination with a fornix-based conjunctival flap which is helpful in reducing these complications. After dissecting the conjunctiva from the limbus, a shallow groove is cut directly behind the former conjunctival insertion. At the end of the operation the conjunctiva is sutured into this groove using a running 10.0 nylon suture in a meander-like fashion. A very tight wound closure results. We used this technique in 104 consecutive goniotrephinations. We found a low incidence of only mild external fistulation, hypotony, flattening of the anterior chamber and choroidal detachment. Astigmatism induced by the operation was -1.2 +/- 1.2 D, usually with the rule.

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