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Purpose To describe specific maneuvers and technical modifications to the standardized "no-touch" technique of Descemet membrane endothelial keratoplasty (DMEK) to successfully handle the presence of a glaucoma drainage device (GDD) tube in the anterior chamber of an eye with a failed primary penetrating keratoplasty (PK) graft. Methods A 42-year-old male patient underwent DMEK because of a failed primary PK graft in his phakic right eye. The patient was then evaluated at 3 and at 6 months after surgery. Results A modified no-touch DMEK technique proved a feasible treatment option for a decompensated primary PK graft in the presence of a long GDD tube. Conclusions With specific technical modifications DMEK can be successfully performed in eyes with decompensated primary PK grafts in the presence of a long GDD tube. The very thin DMEK graft allows positioning between the GDD tube and the failed PK graft, leaving the tube in place.

To evaluate the outcome of the Boston type 1 keratoprosthesis (KPro-1) in eyes with iridocorneal endothelial syndromes and failed keratoplasties.A retrospective review was performed of every eye with a history of iridocorneal endothelial syndrome and a failed corneal transplant that was treated with a KPro-1 at a tertiary eye care center between January 1, 2008, and July 1, 2014. The main outcome measures were visual outcome, prosthesis retention, and postoperative complications.Four eyes met the inclusion criteria. Two eyes had essential iris atrophy and 2 eyes had Chandler syndrome. All 4 eyes had failed corneal transplants and successful glaucoma drainage devices. The mean patient age at the time of KPro-1 surgery was 68.3 years (range, 60-80 years). The mean postoperative follow-up duration was 47 months (range, 27-69 months). Preoperatively, the best-corrected visual acuity (BCVA) was worse than 20/200 in all 4 eyes, including 2 eyes that had hand motions vision. After KPro-1, all 4 eyes initially obtained a BCVA of ≥20/70. At the most recent examination, the BCVA was still ≥20/100 in 3 eyes. The KPro-1 device was retained in all 4 eyes. Postoperative complications included glaucoma progression (1 eye), a retroprosthetic membrane (1 eye), and sterile vitritis (1 eye).The Boston KPro-1 may offer a better prognosis than repeat traditional keratoplasty in reestablishing corneal clarity in eyes with iridocorneal endothelial syndromes. Despite anatomic success, visual rehabilitation may be compromised by preexisting glaucomatous optic neuropathy and its postoperative progression.

Purpose: The aim of this study was to compare the efficacy and safety between standard trabeculectomy and the Ex-PRESS shunt implantation. Methods: A retrospective review of the records of 100 eyes of 100 patients who underwent trabeculectomy or Ex-PRESS shunt implantation between July 2010 and June 2012 was conducted. Of these, 61 (61%) eyes underwent trabeculectomy and 39 (39%) eyes underwent Ex-PRESS shunt implantation. Demographic information, glaucoma type, surgical details, preoperative, and postoperative data including intraocular pressure (IOP), number of medications, reoperation, and occurrence of any complications were recorded. Results: No differences in IOP reduction or number of postoperative IOP-lowering medications were demonstrated between the 2 procedures. Success rates were 86.9% for trabeculectomy and 84.6% for Ex-PRESS shunt. Rates of failure and hypotony were not significantly different between the groups. No parameter was correlated with success or failure of any procedure. Conclusions: Standard trabeculectomy and Ex-PRESS shunt have similar efficacy and safety profiles. As the Ex-PRESS shunt is considerably more expensive, its use may be unjustified, especially as a primary procedure.

We present a case of an explanted gold glaucoma micro shunt (GMS Plus) and the subsequent light and electron microscopic analyses. The shunt was implanted in a patient with medically refractive glaucoma. The intraocular pressure (IOP) was stable at 12 mm Hg 6 months postoperatively but spiked to 26 mm Hg 6 months later; membranous growth was visible on the implant gonioscopically. A second gold micro shunt was placed 2 years after the first. The IOP was 7 mm Hg 1 week postoperatively but increased to 23 mm Hg 3 weeks later; similar membranous growth was visible on this implant. One of the shunts was explanted, and light and scanning electron microscopic analyses revealed encapsulation around the shunt exterior and connective tissue invasion of the microstructure. This represents the first electron microscopic analysis of an explanted gold glaucoma micro shunt and the first unequivocal images of the fibrotic pseudo-capsule traversing its microchannels and fenestrations. Financial Disclosure Dr. Ahmed is a consultant to and has received research grants from Solx, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Two new translimbal glaucoma devices (Xen Gel Stent and InnFocus MicroShunt) have been developed with the goal of optimizing the predictability and safety for subconjunctival glaucoma surgery.The new subconjunctival glaucoma implants are manufactured from nonsilicone, biocompatible materials, which may reduce the postoperative inflammatory and fibrotic reactions that can lead to failure. Early data suggests a favorable safety profile with significant reductions in intraocular pressure (IOP). The prevention of chronic hypotony has been a hallmark of the devices, which utilize an intrinsic flow-limiting design based on the tube length and internal lumen diameter.Early data with the XEN Gel Stent and InnFocus MicroShunt show promising results. Prospective comparative studies comparing these devices with tube shunt and trabeculectomy will be needed.

This is a review on Ahmed valve application in glaucoma surgery. It contains, in particular, data on the Ahmed valve efficiency, results of experimental and histological studies of filtering bleb encapsulation, examines the use of antimetabolites and anti-VEGF agents, and discusses implantation techniques. The current appraisal of antimetabolites delivery systems integrated into the Ahmed valve is presented. Various complications encountered in practice and preventive measures are also covered.Представлен обзор источников литературы по применению клапана Ахмеда в хирургии глаукомы. В частности, приведены данные эффективности клапана Ахмеда, экспериментального и гистологического исследований инкапсуляции фильтрационной подушки, применения антиметаболитов и анти-VEGF-препаратов, техники имплантации. Представлено современное состояние оценки систем доставки антиметаболитов в составе клапана Ахмеда. В статье описаны различные осложнения, встречающиеся на практике, и меры профилактики.

Although minimally invasive glaucoma surgery using different types of implants is a promising strategy for treating glaucoma, potential long-term complications require further evaluation. Here, we report a case of the anterior chamber displacement of a Xen implant due to a maneuver aimed at correcting a dysfunctional and bent subconjunctival implant.

Purpose The purpose of this study was to provide the practicing clinical ophthalmologist with an update on relevant glaucoma literature published from 2013 to 2014. Design This study is a literature review. Methods The authors conducted a 1-year (October 1, 2013, to September 30, 2014) English-language glaucoma literature search on PubMed of articles containing "glaucoma" or "glaucomatous" with title/abstract as a filter. Medical subject headings filtered searching was not performed because of the newness of the reviewed material. Results Literature search yielded 2314 articles, after which we excluded reviews and letters to the editor. We highlighted articles featuring new or updated approaches to the pathophysiology, diagnosis, or treatment of glaucoma and gave preference to human research. Conclusions This review features literature that is of interest to ophthalmologists in practice and also highlights studies that may provide insight on future developments applicable to clinical ophthalmology.

Purpose To report a case of uveitic glaucoma with a congested optic disc where optical coherence tomography angiography (OCT-A) provided diagnostic utility in assessing glaucomatous damage but optical coherence tomography (OCT) alone had limited utility. Observations We report a case of a 33-year-old Caucasian female referred to the USC Roski Eye Institute for uncontrolled intraocular pressure (IOP) in the left eye. She was managed by an outside provider for 6 months, where her IOP ranged from 28 to 42 mm Hg in the left eye on maximally tolerated medical therapy. Her clinical exam was consistent with Herpes family trabeculitis, optic nerve congestion, and possible glaucomatous damage. Initial evaluation of the optic nerve by standard modalities (fundus exam and OCT) was limited by optic nerve congestion; however, OCT-A showed peripapillary hypoperfusion, as commonly observed in glaucomatous eyes. She underwent aqueous shunt implantation for elevated IOPs poorly controlled by medications. Conclusions and importance OCT-A can be a useful tool in the evaluation of glaucoma in instances where disc congestion masks both nerve excavation and retinal nerve fiber thinning normally seen on exam and on standard OCT of the optic nerve.

Rationale: Glaucoma drainage implant surgery is a treatment option for the management of neovascular glaucoma. However, tube obstruction by blood clot after Ahmed glaucoma valve (AGV) implantation is an unpredictable clinically challenging situation. Patient concerns-diagnoses-interventions: We report 4 cases using intracameral air injection for the prevention of the tube obstruction of AGV by blood clot. Outcomes: The first case was a 57-year-old female suffering from ocular pain because of a tube obstruction with blood clot after AGV implantation in neovascular glaucoma. Surgical blood clot removal was performed. However, intractable bleeding was noted during the removal of the blood clot, and so intracameral air injection was performed to prevent a recurrent tube obstruction. After the procedure, although blood clots formed around the tube, the tube opening where air could touch remained patent. In 3 cases of neovascular glaucoma with preoperative severe intraocular hemorrhages, intracameral air injection and AGV implantation were performed simultaneously. In all 3 cases, tube openings were patent. It appears that air impeded the blood clots formation in front of the tube opening. Lessons: Intracameral air injection could be a feasible option to prevent tube obstruction of AGV implant with a blood clot in neovascular glaucoma with high risk of tube obstruction.

Postoperative endophthalmitis is one of the most feared complications of intraocular surgery. The most common types of intraocular surgeries performed worldwide are cataract extraction, glaucoma drainage implants/trabeculectomy, and pars plana vitrectomy. This review will focus on the clinical features, risk factors, prophylaxis, and treatment of endophthalmitis in these three main intraocular surgeries.

Glaucoma Drainage Devices (GDDs) or shunts were proposed by Molteno and coll in 1968 for the treatment of refractory glaucomas, meaning those cases at a high risk of failure following filter surgery or in cases in which surgery was already not successful.

Cataract surgery has been reported to adversely affect the IOP control in eyes with the glaucoma drainage implant (GDI). One reason might be the flow of lens debris/viscoelastic material through the GDI tube into the bleb. This pilot study was conducted to determine the clinical results of a novel technique for temporary occlusion of the GDI tube with an iris retractor hook during phacoemulsification. Retrospective analysis of 15 patients (control group) who underwent phacoemulsification between January 2005 and December 2010 and 17 patients (treatment group) who underwent phacoemulsification with the hooked tube technique between January 2011 and April 2016 with a minimum 1-year follow-up. The IOP remained within 4 mmHg of the preoperative level in all eyes of the treatment group. Three eyes exhibited IOP spikes (≥ 10 mmHg) among controls. The mean postoperative IOP at 1 month was statistically significantly increased in the control group compared with the treatment group (P = 0.040). The number of antiglaucoma medications at 3 and 6 months was significantly increased in the control group (1.4 ± 1.1 vs. 1.7 ± 1.1; P = 0.041, 1.4 ± 1.1 vs. 2.3 ± 1.2; P = 0.017, respectively). After phacoemulsification, there was a significant increase in the mean number of antiglaucoma medications used at 6 months in the control group compared with the treatment group (P = 0.049). In both groups, one eye developed corneal decompensation. The hooked tube technique seems to provide an effective way to reduce the risk of the IOP spikes after cataract surgery in eyes with GDI.

We evaluated bleb fluid images taken after Baerveldt glaucoma implantation. T2-weighted images of bleb fluid were scanned with 3 Tesla magnetic resonance imaging in 52 patients who had undergone tube-shunt surgery using the 350-mm2 endplate Baerveldt glaucoma implant; three-dimensional images were constructed from these images. Bleb fluid images were classified into either a layer of bleb fluid on either side of the endplate (double bleb layer group; n = 24) or one layer outside the endplate (single bleb layer group; n = 28). Despite there being no correlation between the bleb volume and the postoperative IOP (r = −0.080; P = 0.57), the double bleb layer group had significantly lower postoperative IOPs than the single bleb layer group (12.3 ± 3.8 mmHg vs. 14.7 ± 4.1 mmHg, respectively; P = 0.033). The single bleb layer was significantly related to higher numbers of prior intraocular surgeries (relative risk = 2.85; P = 0.0014). Formation of a layer of bleb fluid on either side of the endplate may have resulted in the lower postoperative IOPs after Baerveldt glaucoma implantation. Repeated intraocular surgery adversely affects formation of the double bleb layer.

Compare intraocular pressure (IOP) control and complication rates of a second glaucoma drainage device (GDD) to diode transscleral cyclophotocoagulation (TSCPC) following failure of an initial GDD.Eyes with 1 GDD that required a second GDD or TSCPC for glaucoma control were included. Exclusion criteria were a cyclodestructive procedure before initial GDD, no light perception vision, or follow-up1 year. Failure was defined as ≥1 of (1) reoperation for lowering IOP; (2) explantation of second GDD; (3) persistent hypotony; (4) use of oral carbonic anhydrase inhibitor for lowering IOP in the study eye; or (5) loss of light perception. Reoperation for lowering IOP included additional GDD implantation or additional cyclodestruction, except if additional cyclodestruction was within 6 months of the initial session.A total of 75 eyes (35 in second GDD; 40 in TSCPC) were included (mean follow-up, 25.5 mo). Both procedures lowered IOP [-11.4 mm Hg (±13.6) for second GDD and -7.8 mm Hg (±11.8) for TSCPC groups] and decreased the number of IOP-lowering medications at the last visit. The second GDD group had significantly greater mean survival time [45.0 mo (±4.2)] than the TSCPC group [26.5 mo (±2.8)] but significantly more postoperative complications (60% of eyes) and non-IOP-related procedures (40% of eyes) than the TSCPC group (20% for postoperative complications and 18% for non-IOP-related procedures).Although both second procedures are efficacious in lowering IOP and number of IOP-lowering medications, TSCPC failed earlier, whereas a second GDD had significantly more complications.

Background Aqueous shunts are employed to control intraocular pressure (IOP) for people with primary or secondary glaucomas who fail or are not candidates for standard surgery. Objectives To assess the effectiveness and safety of aqueous shunts for reducing IOP in glaucoma compared with standard surgery, another type of aqueous shunt, or modification to the aqueous shunt procedure. Search methods We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 8), MEDLINE Ovid (1946 to August 2016), Embase.com (1947 to August 2016), PubMed (1948 to August 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to August 2016), ClinicalTrials.gov (www.clinicaltrials.gov); searched 15 August 2016, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 15 August 2016. We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 15 August 2016. We also searched the reference lists of identified trial reports and the Science Citation Index to find additional trials. Selection criteria We included randomized controlled trials that compared various types of aqueous shunts with standard surgery or to each other in eyes with glaucoma. Data collection and analysis Two review authors independently screened search results for eligibility, assessed the risk of bias, and extracted data from included trials. We contacted trial investigators when data were unclear or not reported. We graded the certainty of the evidence using the GRADE approach. We followed standard methods as recommended by Cochrane. Main results We included 27 trials with a total of 2099 participants with mixed diagnoses and comparisons of interventions. Seventeen studies reported adequate methods of randomization, and seven reported adequate allocation concealment. Data collection and follow-up times varied. Four trials compared an aqueous shunt (Ahmed or Baerveldt) with trabeculectomy, of which three reported one-year outcomes. At one-year, the difference in IOP between aqueous shunt groups and trabeculectomy groups was uncertain (mean difference (MD) 2.55 mmHg, 95% confidence interval (CI) -0.78 to 5.87; 380 participants; very low-certainty evidence). The difference in logMAR visual acuity was also uncertain (MD 0.12 units, 95% CI -0.07 to 0.31; 380 participants; very low-certainty evidence). In two trials, the difference in visual field score was uncertain (MD -0.25, 95% CI -1.91 to 1.40; 196 participants; very low-certainty evidence). The mean number of antiglaucoma medications was higher in the aqueous shunt group than the trabeculectomy group in one trial (MD 0.80, 95% CI 0.48 to 1.12; 184 participants; low-certainty evidence). The effect on needing additional glaucoma surgery was uncertain between groups in two trials (risk ratio (RR) 0.24, 95% CI 0.04 to 1.36; 329 participants; very low-certainty evidence). In one trial, fewer total adverse events were reported in the aqueous shunt group than the trabeculectomy group (RR 0.59, 95% CI 0.43 to 0.81; 212 participants; very low-certainty evidence). No trial reported quality-of-life outcomes at one-year follow-up. Two trials that compared the Ahmed implant with the Baerveldt implant for glaucoma found higher mean IOP in the Ahmed group at one-year follow-up (MD 2.60 mmHg, 95% CI 1.58 to 3.62; 464 participants; moderate-certainty evidence). The difference in logMAR visual acuity was uncertain between groups (MD -0.07 units, 95% CI -0.27 to 0.13; 501 participants; low-certainty evidence). The MD in number of antiglaucoma medications was within one between groups (MD 0.35, 95% CI 0.11 to 0.59; 464 participants; moderate-certainty evidence). More participants in the Ahmed group required additional glaucoma surgery than the Baerveldt group (RR 2.77, 95% CI 1.02 to 7.54; 514 participants; moderate-certainty evidence). The two trials reported specific adverse events but not overall number of adverse events. Neither trial reported visual field or quality-of-life outcomes at one-year follow-up. One trial compared the Ahmed implant with the Molteno implant for glaucoma over two-year follow-up. Mean IOP was higher in the Ahmed group than the Molteno group (MD 1.64 mmHg, 95% CI 0.85 to 2.43; 57 participants; low-certainty evidence). The differences in logMAR visual acuity (MD 0.08 units, 95% CI -0.24 to 0.40; 57 participants; very low-certainty evidence) and mean deviation in visual field (MD -0.18 dB, 95% CI -3.13 to 2.77; 57 participants; very low-certainty evidence) were uncertain between groups. The mean number of antiglaucoma medications was also uncertain between groups (MD -0.38, 95% CI -1.03 to 0.27; 57 participants; low-certainty evidence). The trial did not report the proportion needing additional glaucoma surgery, total adverse events, or quality-of-life outcomes. Two trials compared the double-plate Molteno implant with the Schocket shunt for glaucoma; one trial reported outcomes only at six-month follow-up, and the other did not specify the follow-up time. At six-months, mean IOP was lower in the Molteno group than the Schocket group (MD -2.50 mmHg, 95% CI -4.60 to -0.40; 115 participants; low-certainty evidence). Neither trial reported the proportion needing additional glaucoma surgery, total adverse events, or visual acuity, visual field, or quality-of-life outcomes. The remaining 18 trials evaluated modifications to aqueous shunts, including 14 trials of Ahmed implants (early aqueous suppression versus standard medication regimen, 2 trials; anti-vascular endothelial growth factor agent versus none, 4 trials; corticosteroids versus none, 2 trials; shunt augmentation versus none, 3 trials; partial tube ligation versus none, 1 trial; pars plana implantation versus conventional implantation, 1 trial; and model M4 versus model S2,1 trial); 1 trial of 500 mm2 Baerveldt versus 350 mm2 Baerveldt; and 3 trials of Molteno implants (single-plate with oral corticosteroids versus single-plate without oral corticosteroids, 1 trial; double-plate versus single-plate, 1 trial; and pressure-ridge versus double-plate with tube ligation, 1 trial). Authors' conclusions Information was insufficient to conclude whether there are differences between aqueous shunts and trabeculectomy for glaucoma treatment. While the Baerveldt implant may lower IOP more than the Ahmed implant, the evidence was of moderate-certainty and it is unclear whether the difference in IOP reduction is clinically significant. Overall, methodology and data quality among existing randomized controlled trials of aqueous shunts was heterogeneous across studies, and there are no well-justified or widely accepted generalizations about the superiority of one surgical procedure or device over another.

The purpose of this study is to assess surgical practice patterns among the American Glaucoma Society (AGS) membership.An anonymous online survey evaluating the use of glaucoma surgeries in various clinical settings was redistributed to AGS members. Survey responses were compared with prior results from 1996, 2002, and 2008 to determine shifts in surgical practice patterns. Questions were added to assess the preferred approach to primary incisional glaucoma surgery and phacoemulsification combined with glaucoma surgery.A total of 252 of 1091 (23%) subscribers to the AGS-net participated in the survey. Percentage use (mean±SD) of trabeculectomy with mitomycin C (MMC), glaucoma drainage device (GDD), and minimally invasive glaucoma surgery (MIGS) as an initial surgery in patients with primary open angle glaucoma was 59%±30%, 23%±23%, and 14%±20%, respectively. Phacoemulsification cataract extraction alone was the preferred surgical approach in 44%±32% of patients with primary open angle glaucoma and visually significant cataract, and phacoemulsification cataract extraction was combined with trabeculectomy with MMC in 24%±23%, with MIGS in 22%±27%, and with GDD in 9%±14%. Although trabeculectomy was selected most frequently to surgically manage glaucoma in 8 of 8 clinical settings in 1996, GDD was preferred in 7 of 8 clinical settings in 2016.The use of GDD has increased and that of trabeculectomy has concurrently decreased over the past 2 decades. Trabeculectomy with MMC is the most popular primary incisional surgery when performed alone or in combination with phacoemulsification cataract extraction. Surgeons frequently manage coexistent cataract and glaucoma with cataract extraction alone, rather than as a combined cataract and glaucoma procedure.

Purpose To describe a new approach for shortening silicone tubes of glaucoma drainage devices (GDDs). Materials and methods A retrospective intervention case series describing 3 patients undergoing the same treatment at a single institutional center RESULTS:: Three patients underwent successful ab interno trimming of GDD silicone tubes without complication CONCLUSIONS:: This technique allows for rapid and successful shortening of GDD tubes via an ab interno approach avoiding risks of traditional glaucoma tube trimming approaches.

PurposeTo evaluate outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with previous trabeculectomy or a drainage device.MethodsThis is a retrospective study of 108 consecutive DMEK performed between October 2013 and December 2015. All eyes were divided into 3 groups: surgical treatment (ST) group, medical treatment (MT) group, and control group. Visual improvement, endothelial cell loss, and postoperative complications, including rejection, graft failure, and intraocular pressure elevation (≥25 mm Hg) were evaluated.ResultsThe length of follow-up was 9.7 ± 7.3 months. Best-corrected visual acuity (BCVA) improved postoperatively in 85.3% of the ST group, 100% of the MT group, and 93% of the control (P = 0.24). Significantly more lines of BCVA were gained in the ST and MT groups (8.1 ± 8.1 and 9.2 ± 6.3 lines, respectively) than in the control (4.8 ± 5.6 lines, P < 0.05). The mean time to BCVA was 2.9 ± 2.8 months for the ST group, 4.7 ± 5.3 months for the MT group, and 3.0 ± 3.3 months for the control (P = 0.75). Endothelial cell loss was greater in the ST group (44.6 ± 17.8%) than in the MT group (29.9 ± 12.0%) and the control group (32.7 ± 11.3%, P = 0.001). There was one primary failure and no secondary graft failures. The overall rejection rate was 0.9%. Postoperative intraocular pressure elevation was less common in the ST group (14.7%) and control (23.3%) than in the MT group (50.0%, P = 0.04). There was no difference in the air injection rate among all groups (P = 1.0).ConclusionsDMEK in eyes with previous trabeculectomy and drainage device can result in very good short-term outcomes.

Background: Choroidal detachment (CD) is often observed at an early period particularly after trabeculectomy and glaucoma drainage implant surgery. However, topical antiglaucoma eye drop-induced CD is a rare complication. Here, we report a case of topical bimatoprost-induced late-onset CD after trabeculectomy and review the literature. Case report: A 74-year-old man who suffered from primary open-angle glaucoma underwent his initial trabeculectomy with mitomycin-C in the right eye. Before the surgery, his intraocular pressure (IOP) was 20 to 22 mm Hg with bimatoprost 0.03%, dorzolamide 1%, and brimonidine 0.1% and his best corrected visual acuity (BCVA) was 0.9. The mean deviation in Humphrey Visual Field Analyzer (24–2 program) was −27.83 db. After successful trabeculectomy, IOPs were 11 to 16 mm Hg without any medication. Eight months after the surgery, we restarted bimatoprost to further reduce the IOP in the right eye, which was 15 mm Hg. At a hospital visit 2 months later, he complained of blurred vision that had persisted for the past 1 month; his IOP had decreased to 9 mm Hg. His BCVA was 0.04 and 3 quadrant CD was found. We discontinued bimatoprost and started him on betamethasone 0.1% 4 times per day. However, CD marginally changed after 1 week, with IOP at 7 mm Hg; thus, we performed scleral drainage for CD. After 3 weeks of drainage, CD completely disappeared. IOP increased to 16 mm Hg and BCVA was 0.7. However, 3 months after the drainage, IOP increased to 29 mm Hg, and needling revision was thus performed. After the surgery, IOP remained at 14 to 16 mm Hg without any glaucoma medication and CD recurrence. A review of the literature showed that various antiglaucoma medications induce CD, regardless of the preceding glaucoma surgery and that CD is usually resolved by withdrawing the medication and administering topical steroids. However, most previous studies have shown the recurrence of CD by rechallenging the same drug. Conclusion: In our case, topical bimatoprost induced late-onset CD after trabeculectomy. Early scleral drainage may be a good option to quickly resolve drug-induced CD and prevent its recurrence. Therefore, it must be kept in mind that various antiglaucoma medications induce CD.

Case report: A 33-year-old lady with history of failed keratoplasty for decompensated cornea due to childhood trauma and secondary glaucoma, post glaucoma drainage implant, with pseudophakia in the right eye, developed bacterial keratitis following foreign body trauma to corneal graft. Corneal cultures yielded Burkholderia cenocepacia identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF- MS, bioMerieux, France). She healed with topical antibiotics (moxifloxacin 0.5%) in 1 month. Ours is the first report of ocular Burkholderia cenocepacia infection, possibly an under reported, aerobic, organism.

To investigate serial changes in the bleb wall using anterior segment optical coherence tomography (AS-OCT) in patients who had undergone Ahmed glaucoma valve (AGV) implantation.A total of 52 patients who had undergone AGV implantation were enrolled. Reflectivity and mean thickness of the bleb wall were examined using AS-OCT at 1 day, 1 week, 1 month, 3 months and 6 months postoperatively. Intra-ocular pressure (IOP) and the number of glaucoma medications were evaluated. The hypertensive phase was defined as IOP21 mmHg during the first 3 months after surgery. Patients were divided into two groups: hypertensive and non-hypertensive groups.Following AGV implantation, IOP decreased at each time-point during postoperative follow-up (p value0.001, all) with a peak in the first month. Mean bleb wall thickness showed a U-shaped curve postoperatively, being thinnest 1 month after the operation. Reflectivity showed an inverted U-shaped curve postoperatively, being brightest 1 month after the operation. A hypertensive phase was observed in 44 patients (84.6%). The bleb wall was significantly more reflective (130.67 ± 27.00 versus 106.57 ± 10.35; p = 0.044) in the hypertensive group than in non-hypertensive group 1 month postoperatively.Hypertensive phase peaked at 1 month after aqueous shunt surgery. At that time, the bleb wall had the highest reflectivity. The unique IOP pattern after tube surgery is related to fibrosis of the bleb wall qualitatively. Specific modulation of wound healing may be the target for attempts to decrease the development of hypertensive phase.

Although glaucoma filtration surgery options are generally effective means of surgically lowering intraocular pressure (IOP), complications have driven innovators to develop novel approaches to the lowering of IOP. Using the suprachoroidal space has been one novel way to avoid these complications. This article reviews how recent innovation has exploited this space to lower IOP. Financial Disclosure Dr. Sarkisian and Dr. Vold have received research support from Transcend Medical, Inc. and Glaukos Corp. No author has a financial or proprietary interest in any material or method mentioned.

Purpose This pilot study, the first of its type, was conducted to determine the clinical outcome of glaucoma drainage implant (GDI) surgery supplemented with injectable crosslinked hyaluronic acid (HA) in patients with severe glaucoma. Methods This was a retrospective chart study involving 10 eyes of 10 patients with severe glaucoma (glaucomatous visual field loss worse than −20 dB) who had previously undergone GDI surgery supplemented with crosslinked HA with a 2-year follow-up. Surgical success was defined as intraocular pressure (IOP) 5 mm Hg on 2 consecutive follow-up visits, and neither reoperation of glaucoma nor loss of light perception vision. Results The mean ± SD baseline IOP before GDI was 38.5 ± 10.7 mm Hg, and the mean IOP at the last follow-up visit was 13.0 ± 5.0 mm Hg, with a mean pressure drop of 24.4 ± 10.9 mm Hg (62%; p = 0.005). According to definition A, life-table analysis showed an overall success rate of 80%, while according to definition B, the success rate was 50% after 24 months of follow-up. Complications were infrequent and not serious. No complications resulting from the reticulated HA therapy itself were observed. Conclusions In eyes with severe glaucoma, the intraoperative application of crosslinked sodium HA gel may improve the efficacy of GDI surgery.

オープンアクセス CC-BY-NC, BACKGROUND: In patients with severe optic nerve damage, it is crucial to prevent the hypertensive phase that can develop after Baerveldt glaucoma drainage implant (BGI) surgery. We describe the combination of BGI surgery with surgical bleb revision to prevent the postoperative hypertensive phase. CASE REPORTS: We report two patients who underwent BGI surgery combined with surgical bleb revision. The combined surgery was performed in a 62-year-old man with open-angle glaucoma (patient 1) and a 37-year-old man with neovascular glaucoma (patient 2) at Asahikawa Medical University in 2013. Each patient had undergone a previous failed trabeculectomy and another trabeculectomy was expected to be unsuccessful. In patient 1, the early postoperative intraocular pressure (IOP) was well controlled due to a well-functioning bleb, despite development of a small amount of hyphema. In contrast, in patient 2 the postoperative IOP was higher with poor bleb formation; however, after bleb needling, the IOP was well controlled. Thus, the usual techniques used after trabeculectomy were also applicable in this combined surgery. For comparison, we also report the case of a 54-year-old woman with secondary glaucoma who underwent BGI surgery alone (patient 3). The postoperative IOP remained relatively high compared to patients 1 and 2. CONCLUSION: Combining BGI surgery with surgical bleb revision might be effective to prevent the hypertensive phase that can occur after BGI surgery.

The use of glaucoma drainage devices (GDD) in the treatment of glaucoma has become widely accepted for cases of refractory glaucoma. Expansion in the indications for implantation of GDD beyond refractory glaucoma is increasingly common. As such, tube implant complications are reviewed to aid in prevention and improve their management.Findings of the Tube Versus Trabeculectomy study resulted in an expanded use of tube implants in cases of refractory glaucoma. As interest in GDD implantation flourished, so too, did investigative comparison between devices; which includes the Ahmed Baerveldt Comparison study and Ahmed Verses Baerveldt study. Comparative analysis of success and complication rates between implantable devices is not only expanding the technology of tube implants, but also building a body of evidence that tube implantation has a strong safety profile and usage among specialists will continue to increase and indications will evolve. Complications resulting from GDD implantation include hypotony, postoperative elevated intraocular pressure, tube erosion, diplopia, motility disturbances, and corneal decompensation.Tube implant use is increasing and indications are expanding beyond refractory glaucoma. Understanding differences in GDD, their complications and management will result in improved patient care.

To retrospectively evaluate the safety and efficacy of an Ahmed glaucoma valve (AGV) modified with a polyethylene shell (M4) to reduce the fibrotic reaction around the drainage plate compared with the S2 and FP7 models in patients with glaucoma.The medical records of patients who underwent implantation of the AGV FP7, S2, and M4 were reviewed. The primary outcome measure was cumulative probability of success, defined as an intraocular pressure (IOP) between 5 and 18 mm Hg and20% reduction of IOP without loss of light perception, need for additional IOP-lowering surgical procedures, or removal of AGV.Seventy-six, 38, and 40 eyes received the FP7, S2, and M4 with a mean follow-up time of 578±157, 662±186, and 504±158 days, respectively. The mean IOP was reduced from 31.0±10.6 to 13.9±5.5 mm Hg in the FP7 group, 33.5±12.1 to 15.8±8.1 mm Hg in the S2 group, and 27.0±12.0 to 15.0±4.0 mm Hg in the M4 group at 1 year (P=0.31). At 1 year, the cumulative probability of success was 70%, 66%, and 80% and at 18 months, 61%, 53%, and 52% in the FP7, S2, and M4 groups, respectively (P=0.99). Complications were similar among groups.No significant difference was observed between the AGV M4, FP7, and S2 at 1 year. Additional follow-up is required to determine its long-term safety profile and efficacy.

Purpose: To report hydrophilic acylic intraocular lens (IOL) opacification after Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) in an eye with multiple prior intraocular surgeries and iatrogenic aniridia. Case Report: A 34-year-old woman with history of penetrating keratoplasty (PKP) for advanced keratoconus and subsequent Urrets-Zavalia Syndrome (UZS) underwent phacoemulsification and hydrophilic acrylic IOL implantation for her cataract. In order to control post-PKP glaucoma, multiple glaucoma surgeries including two glaucoma drainage implants were performed. As the original corneal graft failed, the patient subsequently underwent re-PKP. Four years later, she underwent DSAEK for treatment of the second graft failure. Ten months after DSAEK, a double semi-circular pattern of IOL opacification was observed on the anterior surface of the IOL. The patient did not report any complaints and we decided not to exchange the IOL. Conclusion: In an eye with UZS and iatrogenic aniridia, IOL opacification may result from direct contact between the IOL surface and exogenous air. Aniridia can be a risk factor for development of IOL opacification after DSAEK. Further studies are required to confirm this hypothesis.

Sturge-Weber Syndrome is a rare neuro-oculocutaneous disorder. The authors describe the case of a 13 years old boy, presented with bilateral Sturge-Weber Syndrome and glaucoma. Surgical treatment with Ahmed valve implantation in both eyes was carried out achieving lower levels of intraocular pressure.

Introduction Micro-invasive glaucoma surgical implantation of trabecular micro-bypass stents, previously shown to be safe and effective for open-angle glaucoma (OAG) subjects during cataract surgery, was considered for evaluation as a sole procedure. The aim of this study was to evaluate the safety and intraocular pressure (IOP)-lowering efficacy after ab interno implantation of two Glaukos Trabecular Micro-Bypass iStent inject second generation devices in subjects with OAG. This study was performed at sites in France, Germany, Italy, Republic of Armenia, and Spain. Methods In this pan-European, multi-center prospective, post-market, unmasked study, 99 patients with OAG on at least two topical ocular hypotensive medications who required additional IOP lowering to control glaucoma disease underwent implantation of two GTS400 stents in a stand-alone procedure. Patients were qualified if they presented with preoperative mean IOP between 22 and 38 mmHg after medication washout. Postoperatively, subjects were assessed at Day 1, Months 1, 3, 6, 7, 9, and 12. IOP, medication use and safety were assessed at each visit. Results Sixty-six percent of subjects achieved IOP ≤18 mmHg at 12 months without medication, and 81% of subjects achieved Month 12 IOP ≤ 18 mmHg with either a single medication or no medication. Mean baseline washout IOP values decreased by 10.2 mmHg or 39.7% from 26.3 (SD 3.5) mmHg to 15.7 (SD 3.7) mmHg at Month 12. Mean IOP at 12 months was 14.7 (SD 3.1) mmHg in subjects not using ocular hypotensive medications. Reduction from preoperative medication burden was achieved in 86.9% of patients, including 15.2% with reduction of one medication and 71.7% with reduction of two or more medications. Postoperative complications occurred at a low rate and resolved without persistent effects. Conclusion In this series, implantation of two trabecular micro-bypass second generation stents in subjects with OAG resulted in IOP and medication reduction and favorable safety outcomes. Electronic supplementary material The online version of this article (doi:10.1007/s12325-014-0095-y) contains supplementary material, which is available to authorized users.

Aims: To investigate the histopathology of the fibrous capsule around Ahmed glaucoma valves (AGVs) implanted with adjunctive amniotic membranes in rabbits. Methods: AGV implantation with or without adjunctive amniotic membrane was performed in a single eye of 20 albino rabbits. The upper surface of the AGV body was covered with amniotic membrane in the study group. After 2 months, histology was used to compare the thickness and characteristics of the fibrous capsule, transdifferentiation of myofibroblasts, and density of blood vessels and leukocytes between the study and control groups. Results: The fibrous capsule along the roof of the bleb was composed of compact collagen fibers with minimal vascularization in the control group. In contrast, in the study group, the fibrous capsule was looser and had a more disorganized collagen architecture. The thickness of the fibrous capsule and the myofibroblast layer was significantly thinner in the study group than in the control group (p < 0.001). The number of CD31-positive blood vessels did not differ between the two groups (p = 0.235). CD45-positive inflammatory cells were more frequently observed in the study group than the control group (p = 0.001). The groups did not differ in the thickness of the fibrous capsule or myofibroblast layer, or the density of blood vessels and leukocytes along the floor of the bleb. Conclusions: Adjunctive amniotic membranes could reduce the risk of encapsulation and aqueous outflow resistance by altering the tissue response to implanted AGVs and subsequent formation of a loose thin capsule.

Glaucoma may develop or worsen after ocular surface transplantation and often requires surgical management for adequate intraocular pressure control. Traditional glaucoma filtering procedures in patients with prior ocular surface transplant may be problematic for several reasons, which include mechanical disruption of the pre-existing graft, epithelial and stem cell toxicity induced by antifibrotic agents, and increased risk of future corneal transplantation failure. We describe the implantation of a glaucoma drainage implant via a limbal-based conjunctival incision with tube placement in the ciliary sulcus in three eyes of two patients with prior ocular surface transplantation. At a follow-up interval of 3-7 months, all three eyes have excellent postoperative control of intraocular pressure, stable vision, and healthy ocular surface grafts.