Search

Prcis: In this retrospective study, nonpenetrating deep sclerectomy (NPDS) and penetrating deep sclerectomy (PDS) interventions showed similar >90% complete success rates at 1-year postsurgery. However, NPDS achieved a superior safety profile in terms of best-corrected visual acuity (BCVA) recovery and rates of post-surgical complications., Objective: Comparing the surgical outcomes of 2 surgical techniques: NPDS and PDS., Patients and Methods: This was a retrospective, longitudinal, comparative study including 66 eyes from 57 patients aged 69 ± 9 years who underwent either NPDS or PDS for medically uncontrolled open angle glaucoma. Outcome measurements included intraocular pressure (IOP), BCVA, rates of complications, postoperative corrective interventions, and glaucoma medications at baseline and at all postoperative appointments up to 1 year. An exploratory mixed-effect model was used to assess the intergroup differences between IOP and BCVA., Results: One-year postsurgery, a similar significant IOP reduction from baseline was observed in NPDS (from 19.9 ± 1.3 to 11.5 ± 0.9 mm Hg, P < 0.001) and PDS (from 19.5 ± 1.1 to 10.7 ± 0.6 mm Hg, P < 0.001). A conservative complete success rate (defined as medicated IOP ≤16 mm Hg and ≥20% reduction in IOP) was 87% for NPDS and 97% for PDS. No BCVA changes were observed between baseline and 1-year postsurgery in both groups, and glaucoma medications showed a similar 10-fold reduction in both groups ( P < 0.001 vs baseline). However, a significant difference in the speed of postoperative BVCA recovery was observed between NPDS and PDS ( P < 0.01), with NPDS showing a faster recovery. Moreover, lower numbers of postsurgical complications and postoperative interventions were observed after NPDS compared with PDS [NPDS, n = 30 and 34 vs PDS, n = 80 and 48 ( P < 0.05), respectively]., Conclusions: The present study confirmed that both NPDS and PDS are highly effective surgical interventions for the management of primary open angle glaucoma. However, NPDS had a superior safety profile in terms of BCVA recovery, complication rates, and postoperative interventions., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background/aim: While intraocular pressure (IOP) remains the only modifiable risk factor for glaucoma progression, the ultimate goal of glaucoma management is to preserve patients' functional vision and quality of life. To this end, minimally invasive glaucoma surgeries (MIGSs) aim to reduce IOP with minimal eye trauma. Commonly used MIGS devices include iStent technologies, which have well-documented IOP-reducing potential and favourable safety profiles. However, no study concluded on their effect on the rates of visual field (VF) changes. The aim of this meta-analysis is to determine the long-term effect of iStent technology implantation on glaucoma functional progression., Methods: Electronic medical literature databases were searched to identify studies reporting on iStent technologies. Reports with follow-up durations <12 months, retention rates <75% and missing VF data were excluded. Fifteen studies reporting on 1115 eyes were identified. The overall weighted mean VF mean deviation (MD) progression, IOP reduction and follow-up duration were calculated., Results: Weighted mean IOP at baseline was 19.0±3.1 mm Hg. At the end of a 37.9-month mean follow-up (range 12-96 months), a weighted mean 26.6% IOP reduction was achieved (range 15.2%-42.3%). Over the same duration, the weighted mean VF MD progression rate was -0.02±0.34 dBs/year, from a mean baseline of -5.76±5.68 dBs., Conclusion: In this review, which examines functional stability of 1115 eyes, iStent technologies achieved a mean rate of progression of -0.024 dBs/year with serial standard automated perimetry, which is similar to that reported in non-glaucomatous eyes and slower than that reported in medically treated glaucoma., Competing Interests: Competing interests: KG received honoraria from Glaukos for conducting the present study. DMH is an employee of Glaukos., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate long-term intraocular temperature (IOT) variations in eyes with primary open-angle glaucoma (POAG) using an intraocular telemetric sensor., Methods: This prospective, open-label, multicentre observational study analysed the IOT variations in 22 eyes of 22 patients with POAG. All enrolled patients underwent implantation of an intraocular pressure (IOP) sensor during cataract surgery. The telemetric system uses a built-in temperature sensor to control measured IOP for temperature. Each time a patient measures their IOP, both the IOP and IOT are recorded in the reader device. Patients were instructed to self-measure their IOP as often as desired, but at least four times daily. Recorded readings were retrieved and analysed using mixed effect models and pairwise comparisons using Bonferroni correction to assess the statistical significance of average IOT variations between each individual weekday and calendar month., Results: The mean age of patients was 67.8±6.8 years and 36.4% were women. A total of 132 745 readings over 21 102 measurement-days were obtained. On average, IOT was significantly higher on Sundays (34.57°C; 95% CI 34.37 to 34.78) than on any other day of the week (p<0.001). Mean IOT on other weekdays ranged from 34.48°C to 34.51°C. Over the year, IOT followed a clear seasonal pattern, reaching its maximum in July (34.8°C; 95% CI 34.56 to 34.97) and its minimum in January (34.4°C; 95% CI 34.15 to 34.56; p<0.001)., Conclusions: This study demonstrates the feasibility of continual and long-term measurement of IOT using intraocular sensors. The results show significant short-term and long-term fluctuations of IOT. Research is warranted to understand the impact of IOT variations on IOP, ocular perfusion and glaucoma progression., Competing Interests: Competing interests: KM: Santen (C), Sensimed (C), Topcon (S), Alcon (S), Allergan (S), Optovue (S), ImplanData (C); HLR: Santen (C), Carl-Zeiss Meditec (C), Allergan (C); RNW: Aerie Pharmaceuticals (C), Allergan (C), Bausch & Lomb (C), Eyenovia (C), ImplanData (C), Meditec-Zeiss (S), Centervue (S), Heidelberg Engineering (S), Konan (S), Unity Biosciences ©., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To describe the efficacy and safety of goniotomy with trabecular meshwork excision using the Kahook Dual Blade (KDB, New World Medical Inc., Rancho Cucamonga, CA) in patients with severe or refractory glaucoma., Methods: This retrospective multicentre case series reports on 40 eyes with severe or refractory open-angle glaucoma that underwent standalone or combined KDB goniotomy and were followed for 12 months post-operatively in the United-States, Mexico and Switzerland. Surgical success was defined as an intraocular pressure (IOP) reduction ≥20% from baseline at 12 months, with fewer medications than preoperatively. Mean IOP and antiglaucoma medication reduction, probabilities of achieving an IOP ≤16 or 18 mmHg, and adverse events were also analysed., Results: Mean IOP decreased from 18.1 ± 5.0 mmHg at baseline to 14.8 ± 3.7 mmHg at 12 months (18.2% reduction, P < 0.001). Concomitantly, the mean number of glaucoma medications decreased from 2.5 ± 1.4 to 1.7 ± 1.2 (32% reduction, P = 0.002). The proportion of eyes achieving an IOP reduction of more than 20% from baseline was 37.5% (n = 15) at 12 months. At 12 months, 67.5% and 82.5% achieved a medicated IOP ≤ 16 and ≤18 mmHg, respectively. No severe complications were reported., Conclusion: Excisional goniotomy with KDB achieves a statistically significant IOP and antiglaucoma medication reduction in severe or refractory glaucoma over a period of 12 months. While its efficacy decreases with time, its favourable safety profile makes it a potentially useful primary or adjunctive procedure in high-risk eyes., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: Measuring and controlling intraocular pressure (IOP) provide the foundation for glaucoma treatment. Self-tonometry has been proposed as an alternative to measure IOP throughout the entire day better. The novel EYEMATE-SC sensor (Implandata) is implanted in the suprachoroidal space to enable contactless continual IOP monitoring. The aim of the present study was to investigate the 1-year safety, performance, and accuracy of the EYEMATE-SC in patients with primary open-angle glaucoma undergoing simultaneous nonpenetrating glaucoma surgery (NPGS)., Design: Prospective, multicenter, open-label, single-arm, interventional clinical trial., Participants: Twenty-four eyes of 24 patients with primary open-angle glaucoma who were due to undergo NPGS (canaloplasty or deep sclerectomy)., Methods: An EYEMATE-SC sensor was implanted during NPGS. Goldmann applanation tonometry (GAT) measurements were compared with the sensors' IOP measurements at all postoperative visits through 12 months., Main Outcome Measures: Device position and adverse events., Results: Fifteen eyes underwent canaloplasty, and 9 underwent deep sclerectomy. Successful implantation of the sensor was achieved in all eyes with no reported intraoperative difficulties. Through the 12-month follow-up, no device migration, dislocation, or serious device-related complications were recorded. A total of 536 EYEMATE-SC measurements were pairwise included in the IOP agreement analysis. The overall mean difference between GAT and EYEMATE-SC measurements was 0.8 mmHg (95% confidence interval [CI] of the limits of agreement [LoA], -5.1 to 6.7 mmHg). The agreement gradually improved, and from 3 months after surgery until the end of the follow-up, the mean difference was -0.2 mmHg (95% CI of LoA, -4.6 to 4.2 mmHg) over a total of 264 EYEMATE-SC measurements, and 100% of measurements were within ±5 mmHg of GAT., Conclusions: The EYEMATE-SC sensor was safe and well tolerated through 12 months. Moreover, it allowed accurate, continuous IOP monitoring., Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references., (Copyright © 2022. Published by Elsevier Inc.)

Background: The purpose of this study is to evaluate the outcome of deep sclerectomy (DS) as a secondary procedure following failed ab-interno XEN gel stent implantation in patients with open-angle glaucoma. Methods: Prospective, single-center, non-randomized, interventional study. Consecutive eyes that underwent mitomycin C (MMC) augmented XEN gel stent surgery, with uncontrolled intraocular pressure (IOP) or signs of disease progression, were included to undergo MMC-augmented DS. Primary efficacy outcome was surgical success, defined as complete when the unmedicated IOP was 12 mmHg or less, or 15 mmHg or less and 20% lower than at the timing of XEN failure and defined as qualified when the IOP fulfilled the same conditions with fewer medications than before deep sclerectomy. Secondary measures were mean reduction in IOP and in the number of medications, and the rates of complications. Results: Seventeen eyes were enrolled with a mean age of 72.1 ± 8.2 years (66.7% women). The mean follow-up was 20.1 ± 4.9 months, with more than 12-month data available from 15 eyes. Following DS, IOP decreased significantly from 22.6 ± 5.3 mmHg to 12.3 ± 5.5 (45.6%; p < 0.001). Antiglaucoma medications dropped from 1.1 ± 0.9 to 0.3 ± 0.7. Complete success was obtained in 40% of eyes using the threshold of 12 mmHg or less and a 20% decrease of IOP, and in 60% using the 15 mmHg or less threshold. Adverse events were observed in 20% of eyes (bleb leakage (13.3%); hypotony (6.7%)). No cases of choroidal detachment or hypotony maculopathy were reported. Conclusions: Failed XEN gel stent implantation does not seem to negatively affect the safety and efficacy of subsequent deep sclerectomy surgery.

Purpose: In response to the spread of COVID-19 in Switzerland, ophthalmology practices implemented a variety of preventive measures in order to minimise the risk of contamination to their patients and staff. Yet, some studies suggested that over a quarter of all glaucoma patients never returned to the clinic after the first lockdown eased. This raises the question of the factors influencing Patients' likelihood to keep their appointments in this COVID-19 era. The aim of this study was therefore to assess ophthalmology Patients' perception of COVID-19 preventive measures, as well as their impact on glaucoma Patients' clinic attendance and follow-up., Methods: This was a prospective study based on primary data collected from 12 private ophthalmology clinics in French-speaking Switzerland. A web-based patient experience questionnaire was designed to assess Patients' appreciation of the preventive measures in place at their eye care provider as well as their intention to attend further follow-up appointments. These measures were made on modified 10-point Likert scales. Every patient who attended an appointment at one of the participating clinics on randomly selected dates in October 2020 was offered voluntary enrolment into the study., Results: In all, 118 surveys were completed and analysed. The mean age of respondents was 57.8 ± 18.0 years, 59.3% were female, and 71.2% were Swiss nationals. Fifty-four (45.8%) of them suffered from glaucoma. Overall, patients were highly satisfied with the measures in place to safeguard them from COVID-19 infection, with a mean score of 9.29 ± 1.35. This was higher amongst Swiss nationals (9.55 ± 0.77) than foreigners (8.65 ± 2.09). On average, responders expressed a 90.2 ± 17.5 percent likelihood to keep their follow-up appointment. The figure went down to 88.5 ± 19.9 percent amongst glaucoma patients (p = 0.58), and 86.3 ± 22.1 percent amongst glaucoma patients aged 65 and over (p = 0.29). Interestingly, older glaucoma Patients' satisfaction with preventive measures in place strongly correlated with their likelihood to keep follow-up appointments (r = 0.72). The correlation was moderate amongst all glaucoma patients (r = 0.46) and weak amongst all respondents (r = 0.38) and those over 65 (r = 0.44)., Conclusions: The present research highlights the importance of Patients' perception on COVID-19 preventive measures in place in ophthalmology clinics, which was directly associated with their likelihood to keep follow-up appointments. Vulnerable subgroups of patients were more likely to miss their follow-up appointments altogether, and their decision to attend was more strongly influenced by their perceived risk of contracting COVID-19. This suggests a role for telemedicine in more vulnerable patients suffering from progressive diseases such as glaucoma., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Objectives: To determine the effect of laser trabeculoplasty on peripapillary retinal nerve fibre layer thickness (RNFL), fovea avascular zone (FAZ), peripapillary and macular vessel density (VD) in glaucoma using with optical coherence tomography angiography (OCT-A)., Methods: This was a prospective observational study performed at the Glaucoma Research Centre, Montchoisi Clinic, Lausanne, Switzerland. Thirty-seven eyes with primary open-angle glaucoma from 21 patients were included. Optical coherence tomography angiography (OCT-A) scans were performed before laser trabeculoplasty and at 2 and 6 months after the procedure. AngioVue AngioAnalytic (Optovue Inc, Fremont, CA, USA) software was used to analyse the RNFL, FAZ, peripapillary and macular VD. Changes were analysed using mixed models, controlling for intraocular pressure (IOP) and signal strength index (SSI) variations., Results: Mean IOP decreased from 18.5 (±3.7) mmHg at baseline to 15.6 (±2.7) mmHg after 2 months (-15.3%; p < 0.001). No significant changes in RNFL thickness were noted following laser trabeculoplasty. Changes in peripapillary VD were mostly nonsignificant. Parafoveal (p = 0.001) and perifoveal VD (p = 0.025) significantly increased at 2 months, before reverting to near-baseline values at 6 months. No significant changes were observed in foveal parameters. Retinal nerve fibre layer thickness (RNFL) and VD changes were independent from IOP, but SSI had a significant influence on VD., Conclusions: Following laser trabeculoplasty, peripapillary and macular VD temporarily increased before returning to near-baseline values by 6 months. No correlation was found between microvascular fluctuations and IOP, and no significant effect of laser trabeculoplasty on VD or RNFL was observed at 6 months despite persistent IOP reduction. Further research is warranted to understand its exact causes and clinical relevance., (© 2021 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background/aim: The aim of this study was to assess the difference in outcome between the first-operated and the second-operated eyes after nonpenetrating deep sclerectomy (DS), and to identify potential success predictors for the second eye., Methods: This single-surgeon, retrospective study analyzed the outcomes of all bilateral nonsimultaneous DS with at least 24 months of follow-up. Its main outcome measure was surgical success, defined as unmedicated intraocular pressure (IOP) ≤15 mm Hg associated with a relative reduction ≥20%., Results: In all, 104 eyes of 52 patients who underwent bilateral (standalone or combined) DS, within a mean of 344.3±526.3 days of each other, were analyzed. Postoperatively, the mean medicated IOP decreased from 20.7±7.9 (first-operated eyes) and 19.3±6.6 mm Hg (second-operated eyes) at baseline (P=0.107) to 13.8±4.8 [(-33.3%; P<0.001) first-operated eyes) and 12.7±3.8 mm Hg [(-34.2%; P<0.001) second-operated eyes] after 2 years (P=0.619). Postoperative IOP and treatment reduction, respectively, showed fair (r=0.53) and good (r=0.71) levels of correlation between fellow eyes. The rates of complete success were comparable between first-operated and second-operated eyes (32.7% and 40.4%, respectively; P=0.364). At 2 years, among patients whose first-operated eyes were considered a success, 82.4% of surgeries in second eyes were successful (P=0.001). The odds ratio of a second-operated eye experiencing complete success were 6.32 (P=0.011) if the first-operated eye experienced complete success., Conclusions: The present study demonstrated a strong association between first-operated and second-operated eyes after DS, in terms of surgical outcomes and IOP reduction. In effect, surgical success in the first-operated eye increases the odds of success in the second eye by 6-fold., Competing Interests: Disclosure: K.M. is a consultant for Santen, Sensimed, and ImplanData; received support from Topcon, Alcon, Allergan, and Optovue. A.M. received support from Alcon, Allergan; is a consultant for Santen, Swiss Advanced Vision, Rheon Medical, Glaukos, Diopsys Inc., and DeepCube. H.L.R. is a consultant for Allergan, Santen, and Carl-Zeiss Meditec. The remaining authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The aim of this study was to analyse the safety profile and efficacy of ab interno viscocanaloplasty (ABiC) through to 12 months post-operatively., Methods: In this retrospective study, the medical records of all patients who underwent ABiC between September 2015 and December 2019 were analysed. Complete success was defined as a 12-month reduction in intraocular pressure (IOP) ≥ 20% from baseline with no concomitant medications. Qualified success criteria were identical, with no more medications than at baseline., Results: In all, 54 eyes of 41 patients were analysed. Mean IOP decreased from 23.6 ± 7.4 mmHg preoperatively to 14.2 ± 2.9 mmHg (-39.8%; p < 0.001) after 12 months. Concomitantly, the number of anti-glaucoma treatment dropped from 2.9 ± 1.0 to 0.6 ± 1.1 (-79.3%; p < 0.001). Amongst patients with a baseline MD < -12.0 dBs, mean IOP decreased from 22.8 ± 9.8 mmHg to 13.8 ± 4.4 mmHg (p = 0.049), with a concomitant reduction of medications from 2.8 ± 1.3 to 1.2 ± 1.3 (p < 0.001). Complete success at 12 months was achieved in 46% of eyes, and qualified success was achieved in 65% of eyes. Amongst eyes with a baseline MD < -12.0 dBs, 50% achieved complete success, and 83.3% achieved qualified success. A total of 19 eyes (35.2%) were considered surgical failure, all due to uncontrolled IOP. Of them, 7 eyes (13.0%) required further filtering surgery. Twelve post-operative adverse events were observed, with early post-operative IOP spikes being the most common (22.2%)., Conclusions: ABIC achieved a statistically significant reduction in IOP and anti-glaucoma medications through 12 months, while maintaining a favourable safety profile in mild-to-severe open-angle glaucoma., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: Intravitreal injections (IVIs) may create transient intraocular pressure (IOP) elevation. This report describes continuous IOP fluctuations following multiple IVI measured with a permanent implantable sensor., Patients and Methods: We report the case of a 49-year-old white glaucomatous male with refractory macular edema secondary to central retinal vein occlusion in his left eye who underwent deep sclerectomy combined with the implantation of a suprachoroidal tonometry sensor. Serial IOP measurements were performed immediately before and after each IVI over a 1-year period., Results: During the first 7 months following deep sclerectomy, IOP remained below 10 mm Hg. During this period, mean IOP before each injection was 2.1±2.6 mm Hg, and each IVI caused a reduction of 1.2±0.8 mm Hg on average, with a maximum reduction of 2.7 mm Hg, before IOP normalized within 50 minutes to 24 hours. From 7 months postoperatively, mean IOP increased to the low teens. During this period, mean IOP before each injection was 9.9±1.8 mm Hg, and each IVI caused an increase of 15.8±11.7 mm Hg on average, with a maximum increase of 44.8 mm Hg, before IOP normalized within 20 minutes to 4 hours., Conclusions: During the initial postoperative phase, IVI may cause acute reduction in IOP, either through subconjunctival leaks or increased filtration secondary to increased fluid pressure. Several months after surgery, this effect subsides and IOP spikes sharply immediately after each IVI, suggesting the resolution of the initial mechanism, most likely through scarring and fibrosis., Competing Interests: Disclosure: K.M. received grants from Santen, Topcon, Alcon, Allergan, ImplanData. The remaining authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the 3-year treatment outcomes of XEN 45 gel stent in open-angle glaucoma patients., Methods: In this prospective, single-centre interventional study, consecutive eyes with uncontrolled intraocular pressure (IOP) or signs of disease progression despite medical treatment underwent XEN implantation either alone or combined with phacoemulsification (Phaco + XEN)., Main Outcome Measures: Surgical success was defined as 'complete' when 36-month unmedicated IOP was ≤15 mmHg with a relative IOP reduction ≥ 20% from medicated baseline, while the definition of qualified success allowed no more medications than at baseline. Other definitions of success with different IOP thresholds were also analysed. Secondary outcomes included mean IOP reduction, changes in ocular hypotensive medications and rates of reoperations., Results: Out of 149 eyes initially included, 92 eyes (61.7%) of 68 patients had complete 3-year data (XEN: n = 26; Phaco + XEN: n = 66) after 38.2% were lost to follow-up. Mean age was 76.3 ± 9.1 years, and 66.2% were female. Mean medicated IOP decreased from 20.8 ± 7.4 mmHg (21.0 ± 7.4 [XEN] vs. 20.0 ± 6.9 mmHg [Phaco + XEN]) at baseline to 13.1 ± 3.4 mmHg (12.9 ± 2.9 [XEN] vs. 12.9 ± 3.4 [Phaco + XEN]) at 3 years (-37.0%; p < 0.001). Medications decreased from 1.9 ± 1.3 (2.4 ± 1.5 [XEN] vs. 1.9 ± 1.2 [Phaco + XEN]) to 0.4 ± 0.9 (0.3 ± 0.8 [XEN] vs. 0.5 ± 0.9 [Phaco + XEN]) (-78.9%; p < 0.001). Complete success and qualified success were achieved in 29.0% and 31.0% of eyes, respectively. Needling revision was performed in 51 eyes (55.4%), and 26.1% underwent reoperations. Risk factors for surgical failure included male gender (odds ratio [OR]:3.6; p = 0.03), diagnosis of POAG (OR: 4.5; p < 0.01) and undergoing needling revision (OR: 4.6; p < 0.01). While the type of procedure had no effect on the outcomes of PEXG, POAG eyes undergoing combined surgery had significantly higher rates of failure (OR: 7.29; p = 0.023). Most patients stable at 12-month remained so through to 3 years., Conclusions: At 3 years, XEN gel stent implantation achieved clinically significant IOP and medication reduction despite relatively high rates of needling and reoperations. Identifying patients at risk preoperatively may help optimize surgical outcomes., (© 2020 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

The recent advent of continuous intraocular pressure (IOP) telemetry has led to an increased awareness of the importance of IOP fluctuations, and theories have emerged that IOP variations could play as much a role in glaucoma progression as the mean level of IOP. The aim of the present study was to evaluate the direct effect of common daily activities on IOP-related profiles. Primary open-angle glaucoma and glaucoma suspect patients were prospectively enrolled from specialist clinics at the University of California San Diego (UCSD), USA. Patients were fitted with a SENSIMED Triggerfish (TF) contact lens sensor (CLS) and were instructed to return to their usual daily activities for 24 h. They were asked to record each specific activity or event in a diary. The protocol was repeated twice. The following events were recorded: "walking/cycling", "resistance training", "yoga/meditation", and "emotional stress". CLS measurements recorded 60-to-30 min prior to each event were used as a baseline reference, and all IOP-related fluctuations for 120 min after the start of each event were reported in relation to this reference. Forty relevant events from 22 CLS recordings in 14 patients were retrieved from the diaries. Walking/cycling (n = 10) caused a small but statistically significant elevation of the IOP-related profile during the activity (p = 0.018). Resistance training (n = 11) caused a persistent elevation of the IOP-related profile from the onset of the activity (p = 0.005) through 120 min after the activity was stopped (p = 0.007). Yoga/meditation (n = 4) caused a sustained drop in the IOP-related profiles through to 120 min, although this was not statistically significant (p > 0.380). Emotional stress (n = 13) was associated with a gradual elevation of the IOP-related profile from the start of the stressful stimulus. Both early and late variations were statistically significant (p = 0.038 and p = 0.021, respectively). The present study suggests that emotional stress and resistance training may be associated with persistent IOP-related profile elevation.

Purpose: To address the unmet need of continuous IOP monitoring, a Pressure-Measuring Contact Lens (PMCL) was developed to measure IOP in millimeters of mercury (mmHg) continuously over 24 hours. The present study assessed the reliability of the novel PMCL., Methods: In this prospective open-label clinical study, healthy and open-angle glaucoma (OAG) subjects were fitted with the PMCL, and pneumatonometry was performed on study eyes (in absence of the PMCL) and on fellow eyes before, during, and after provocative tests. The primary outcome measures were (1) mean IOP difference between same-eye measurements, and (2) percentage of timepoints at which IOP measured by the PMCL was within 5 mmHg of that measured by pneumatonometry in the fellow eye., Results: Eight subjects were analysed (4 healthy, 4 OAG). The average difference in successive IOP measurements made by pneumatonometry and with the PMCL was 2.0±4.3mmHg at placement-time, and 6.5±15.2mmHg at removal time. During water drinking test, a significant increase in IOP was detected both by PMCL in the study eye (2.4±2.5mmHg, p = 0.03) and by pneumatonometry in the fellow eye (1.9±1.9mmHg, p = 0.02). Over the 24-hour recording, 88.0% of IOP variations measured by the PMCL were within 5mmHg of that measured with the pneumatonometer in the fellow eye. A transient corneal erosion of severe intensity was observed following removal of the PMCL on one single eye, and may have affected measurement accuracy in that eye., Conclusions: This study is a proof-of-concept for this novel PMCL, and its results are encouraging, with a fair accuracy in IOP values measurement and good sensitivity to subtle IOP variations., Competing Interests: The authors have read the journal’s policy, and the authors of this manuscript have the following competing interests to declare: SSZ is a paid employee of Sensimed AG, and KM is a consultant for Sensimed AG. This does not alter our adherence to PLOS ONE policies on sharing data and materials, and the other authors have no conflict of interest to disclose. There are no patents, products in development or marketed products associated with this research to declare.

Background/aims: To better understand seasonal and weekday intraocular pressure (IOP) variations, long-term daily IOP measurements were assessed in patients with glaucoma using an intraocular telemetric sensor., Methods: This prospective, open-label, multicentre observational study analysed the IOP variation patterns in 22 eyes of 22 patients with primary open-angle glaucoma (67.8±6.8 years, 36.4% female) who had undergone placement of an intraocular telemetric sensor at the time of cataract surgery. The telemetric system combines an implantable IOP sensor with a hand-held reading device. Patients were instructed to self-measure their IOP as often as desired, but at least four times daily. Analysis of variance and Tukey multiple-comparison correction were used to assess the statistical significance of average and peak IOP variations between individual weekdays and months., Results: Each enrolled patient recorded daily IOP measurements for an average duration of 721 days. On average, IOPs were highest on Wednesdays and lowest on Fridays (p=0.002). There were significant variations of IOP throughout the year, and IOP showed a seasonal pattern. Between mid-winter (December-January) and mid-summer months, there was a reduction in mean IOP of 8.1% (-1.55 mm Hg, p<0.05)., Conclusion: This study confirms previously observed seasonal variations of IOP. IOP was significantly higher in winter compared with summer months. Moreover, IOP was lower on Friday than on other days. The explanation for these results is not known., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Pseudoexfoliative glaucoma (PEXG) is the most common cause of secondary open-angle glaucoma worldwide. It is more aggressive and often more resistant to conventional treatments than primary open-angle glaucoma, yet there is currently no clear consensus on best management practices. This review explores current literature on PEXG to assess the safety and efficacy of currently available surgical techniques, and discusses clinical considerations on the diagnosis and management of the disease., Methods: A PubMed and Google Scholar search identified 2271 articles. These were reviewed to exclude irrelevant or duplicate data. A total of 47 studies reporting specifically on PEXG were retained and analyzed., Review: One of the most significant ophthalmic consequences of pseudoexfoliative (PEX) syndrome is the compromising of the blood-aqueous barrier resulting in the leakage of inflammatory cytokines and extracellular matrix material into the anterior chamber. Considering the high risk of developing PEXG and the aggressive nature of this type of glaucoma, accurate and timely diagnosis of PEX is critical. Therefore, systematic attentive examination for PEX deposits is crucial. Patients diagnosed with PEX need frequent glaucoma assessments. Patient information is key to improving compliance. Gonioscopy and diurnal tension curves or 24-hour intraocular pressure (IOP) monitoring are integral part of the diagnostic work-up and risk-assessment of PEXG. Because of the lability of IOP in PEX, clinical decisions on the basis of single IOP measurements should be avoided. Cataract extraction was shown to provide persistent IOP-lowering effect in the order of 10% in PEXG. A number of other surgical options may offer wider IOP reduction, and both XEN 45 gel stents and angle-based glaucoma procedures were suggested to achieve better outcomes in PEXG than in primary open-angle glaucoma. Yet, more significant IOP reductions may be achieved with filtering surgery or glaucoma drainage device. Same day postoperative IOP monitoring is recommended to treat the frequent IOP spikes following surgery, and more aggressive anti-inflammatory therapy may reduce the rates of postoperative adverse events in PEXG., Conclusion: Specific studies of the surgical management of PEXG remain scarce in the medical literature, and more long-term and comparative studies are warranted to define more robust recommendations., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: To investigate the reliability of anterior chamber angle (ACA) measurements in narrow angles and assess the effect of laser peripheral iridotomy (LPI) on these measurements using novel swept-source optical coherence tomography (SS-OCT) technology., Materials and Methods: In this prospective observational study, patients with gonioscopically narrow angles were enrolled and scheduled for prophylactic LPI. Twelve ACA sections were obtained in each eye using SS-OCT (ANTERION, Heidelberg Engineering, Germany) before and after Nd:YAG LPI. A built-in algorithm calculated ACA measurements after manual identification of the scleral spur and ACA recess. Eight ACA parameters were evaluated: ACA (ACA 500, ACA 750); scleral spur angle (SSA 500, SSA 750); angle opening distance (AOD 500, AOD 750); and trabecular iris space area (TISA 500, TISA 750). The effect of LPI was assessed for each parameter, both nasally and temporally., Results: Ten patients (18 eyes) were enrolled (mean age, 61.8±13.6 y; 60.0% female individuals). On average, the ACA was wider nasally than temporally (P=0.004). LPI significantly widened the ACA (range, 26.7-29.4%; P<0.05). ACA 500 increased by 29.4% (P<0.001), ACA 750 by 29.2% (P=0.002), SSA 500 by 27.3% (P=0.003), SSA 750 by 28.1% (P=0.001), AOD 500 by 28.6% (P=0.009), AOD 750 by 28.6% (P=0.003), TISA 500 by 27.3% (P=0.004), and TISA 750 by 26.7% (P=0.200)., Conclusions: SS-OCT ANTERION imaging can be used to reliably measure ACA before and after LPI. ACA, AOD, SSA, and TISA are all valid ACA measurement methods.

Glaucoma management has changed dramatically over the last decades, through clinical advances and technological revolutions. This review discusses the latest innovations and challenges faced in the field around three major axes: minimally-invasive glaucoma surgery (MIGS), implantable sensors and injectable therapeutics. Indeed, the vast number of recently developed MIGS techniques has not only provided clinicians with a wide range of therapeutic options, but they have also enabled them to adjust their therapies more finely which may have contributed a more patient-centric decision-making process. Yet, despite considerable advances in the field, the wide heterogeneity in clinical trial designs blurs the surgical outcomes, specificities and indications. Thus, more high-quality data are required to make the choice of a specific MIGS procedure more than an educated guess. Beyond the scope of MIGS, the potential of IOP telemetry for self-assessment of IOP-control through implantable sensors is developing into a real option for clinicians and an empowering opportunity for patients. Indeed, providing patients with direct feedback enables them to take control and have a clearer representation of their care, in turn leading to a better control of the disease. However, there are potential issues with self-monitoring of IOP, such as increased anxiety levels induced by measured IOP fluctuations and peaks, leading to patients self-treating during IOP spikes and additional office visits. Furthermore, the advent of implantable therapeutics may soon provide yet another step towards personalized glaucoma treatment, by offering not only an efficient alternative to current treatments, but also a therapeutic option that may better adapt to patients' lifestyle. After several decades of relative stagnation through the last century, glaucoma has now entered what many view as a golden age for the specialty. Like every revolution, this one brings its fair share of uncertainty, clinical questioning and uneasy periods of adaptation to ever-changing expectations. Yet, while it is impossible to guess what the landscape of glaucoma surgery will be like in ten or fifteen years, data suggest a bright outlook both for patients and clinicians., Competing Interests: There are no conflicts of interest., (Copyright © 2020 Gillmann et al.)

Purpose: To evaluate outcomes of XEN-augmented Baerveldt drainage device implantation in refractory glaucoma and factors predicting surgical success., Method: All eyes undergoing XEN-augmented Baerveldt for refractory open-angle glaucoma at a tertiary glaucoma centre between January 2016 and November 2017 were retrospectively enrolled. Intraocular pressure (IOP), number of anti-glaucomatous medications and postoperative adverse events (AEs) were analysed for 1 year postoperatively. Surgical success was defined as achieving (1) an IOP ≤ 15 mmHg or (2) ≤ 18 mmHg, with or without (qualified) or without medications (complete). Any subsequent glaucoma surgery was considered failure., Results: Out of 60 eyes enrolled, 12-month data were available for 41 eyes (71.4%). Mean age was 64.7 ± 23.1 years (50% female). Following surgery, IOP decreased significantly from a baseline of 29.9 ± 13.2 to 15.2 ± 6.6 mmHg (- 49.2%; P < 0.0001) at 12 months. Anti-glaucoma medications decreased from 3.0 ± 1.3 to 1.3 ± 0.9. Complete success was achieved by 14.6% of eyes using both the ≤ 15 mmHg and the ≤ 18 mmHg thresholds, and qualified success was achieved in 43.9% and 48.8%, respectively. Throughout the follow-up period, AEs were observed in 51.2% (hypotony = 24.4%; XEN blockage = 17.1%; displacement of XEN gel stent = 4.9%; hyphema = 4.9%). The 12-month success rate was significantly higher in patients who presented an IOP ≤ 10 mmHg at 1 week (58.6%, P = 0.001). Overall, 41.5% of patients required reoperation at 12 months (58.8% revision of the surgery; 41.2% transscleral cyclodestruction)., Conclusion: XEN-augmented Baerveldt is a safe and moderately effective technique to reduce IOP and anti-glaucoma medications in refractory glaucoma. IOP at 1 week seems to be a predictor for surgical success. Nevertheless, a high proportion of patients requires reoperation.

Purpose: Scarce data are available on the symmetry of 24-hour intraocular pressure (IOP) variations between fellow eyes of glaucoma patients, and such evidence could have profound consequences on the interpretation of monocular therapeutic trials. The objective is to evaluate the intereye correlation of continuously measured circadian IOP-related patterns in untreated glaucoma patients., Methods: In this single-center prospective study, a total of 29 untreated patients with open-angle glaucoma underwent bilateral ambulatory 24-hour monitoring of IOP-related patterns using a contact lens sensor (CLS; SENSIMED Triggerfish). IOP was measured before and after CLS monitoring using Goldmann applanation tonometry. Intereye agreement of 24-hour patterns was calculated using Spearman correlation (r) of raw data and after cosinor rhythmometry modeling., Results: Complete bilateral CLS data could be obtained in 20 patients (mean age: 55.5±15.7 y; 51.7% women). On average, intereye correlation was r=0.76±0.19 (range: 0.16 to 0.95) and r=0.77±0.15 (range: 0.49 to 0.91), after excluding 8 patients with lower quality recordings. Cosine rhythmometry modeling showed mean acrophases occurring at 4:21±2:20 AM in left eyes and 3:39±1:50 AM in right eyes (r=0.48; P=0.034). Mean acrophase amplitude was 110.9±51.9 for left eyes and 107.8±46.2 for right eyes (r=0.79; P<0.001). No serious adverse events related to CLS monitoring were recorded. Transient conjunctival hyperemia (13 patients) and blurred vision (11 patients) were the most frequent adverse events., Conclusions: In this group of untreated glaucoma patients, there was good intereye agreement for circadian IOP-related patterns using the CLS. These results show a higher degree of intereye symmetry, in terms of IOP peak timings and amplitudes, than previously reported with standard tonometry.

Precis: The surgical outcome of iStent inject devices is associated with device protrusion within the anterior chamber. Schlemm canal (SC) dilatation has a prognostic value. iStent inject devices do not move within the first year after implantation., Introduction: The iStent inject is a device designed to be implanted ab-interno through the trabecular meshwork. The present study follows up on our preliminary report, using successive in vivo anterior segment optical coherence tomography (AS-OCT) imaging to analyze the associations between stent positioning, iridocorneal angle structures, and surgical outcomes., Methods: In total, 54 eyes of 42 patients (73.3±7.4 y) with cataract and mild-to-moderate open-angle glaucoma were examined in this prospective study. All patients underwent implantation of 2 iStent inject devices combined with phacoemulsification. Patients were followed up over a 12-month period. AS-OCT was performed after 3 and 12 months. Thirty unoperated fellow eyes served as control eyes., Results: Intraocular pressure (IOP) decreased from 16.5±4.2 mm Hg at baseline to 15.1±3.7 mm Hg at 12 months (-8.7%; P=0.004), while medications decreased from 1.8±1.0 to 0.5±0.9 (-72.2%; P<0.001). Unmedicated IOP≤18 mm Hg was achieved in 58.8% of operated eyes. No sight-threatening complications were reported. On AS-OCT, 44.9% of devices were buried within the trabeculum. Device position was unchanged between scans. Regression analysis elicited significant predictors: SC dilatation effect [risk ratio (RR)=0.230; P=0.003], greatest SC diameter (RR=0.991; P=0.049), extrusion of the most anterior device (RR=0.993; P=0.012), gonioscopically visible devices (RR=0.406; P=0.040), baseline treatments (RR=2.214; P=0.001), and baseline IOP (RR=0.184; P=0.006). Endothelial cell density decreased by 14.6% at 12 months (P<0.001)., Conclusions: This study demonstrates the IOP-lowering and medication-lowering potential of iStent inject surgery in primary open-angle and pseudoexfoliative glaucoma. It confirms that surgical outcomes are positively associated with device protrusion within the anterior chamber, and suggests SC dilatation effect as a favorable prognostic indicator. It shows that stents are stable in time, highlighting the importance of the initial implantation location.

Background/aims: Both eyes of a same person are not completely independent entities. The purpose of this study was to assess the difference in outcome between the first-operated eye and the fellow-operated eye following bilateral XEN surgery, and to identify potential success predictors for the fellow eye., Methods: This single-site, prospective, nonrandomized interventional study investigated bilateral nonsimultaneous XEN gel stent implantation over 24 months. Its main outcome measure was surgical success, defined as unmedicated intraocular pressure (IOP) ≤15 mm Hg associated with a relative reduction ≥20%., Results: Of 149 enrolled eyes, 74 eyes of 37 patients who underwent bilateral (standalone or combined) XEN implantation, within a mean of 50.5±74.3 days of each other, were analyzed. Postoperatively, mean medicated IOP decreased from 19.0±6.6 (first-operated) and 18.2±5.2 mm Hg (fellow) at baseline (P=0.209) to 13.7±4.0 (-27.9%; P<0.001; first-operated) and 14.1±3.6 mm Hg (-22.5%; P<0.001; fellow) after 2 years (P=0.673). Rates of complete success were comparable between first-operated and fellow eyes (P=0.65). At 2 years, among patients whose first-operated eyes were considered a failure, 92.0% of fellow eyes failed (P=0.001). The odd ratio of a fellow eye experiencing complete success were 16.1 (95% confidence interval: 2.5-101.9, P=0.003) if the first operated eye experienced complete success., Conclusions: The present study demonstrated a strong association between first-operated eyes and fellow eyes following XEN gel stent implantation, in terms of surgical outcomes and IOP reduction. In effect, surgical success in the first-operated eye increases the odds of success in the fellow eye by 16-folds.

Purpose: In recent years, new technologies have emerged to better analyze and interpret intraocular pressure (IOP) fluctuations. Among them is the progression report (PR), an algorithm based on continuous contact lens sensor (CLS) readings to estimate the likelihood of fast visual field (VF) glaucomatous progression. The objective of this study is to validate the PR., Methods: In this retrospective study, 30 open-angle glaucoma patients were enrolled. Twenty-four hours IOP-related variations were recorded using a CLS. Recordings were used to generate PR. The likelihood of fast VF progression (<-1 dB/y mean deviation) was estimated by 2 masked assessors based on clinical parameters. At least 3 VF were performed over the 2 years following the initial assessment, to determine actual progression., Results: Mean age was 65.9±10.45 years, with a mean baseline mean deviation of -5.4±5.1. After a mean follow-up of 29.5±12.9 months, 26.7% of eyes were assessed as fast progressors (-2.9±1.9 dBs/y). The average risk-score attributed by the PR was 42% [41% (slow) vs. 44% (fast); P=0.035]. Correlations between the 2 assessors were good (r=0.59), and identical to that between PR and the averaged assessors' gradings. Correlations between mean deviation progression rates and PR, Assessor 1 and Assessor 2's gradings were, r=0.57, 0.31, and 0.43, respectively., Conclusions: PR provided comparable predictions of the risk of fast VF progression as did physician estimates based on all available clinical data. With their relationship to the eye's biomechanical properties and the ocular tissues' response to pressure variations, CLS recordings may offer new information that complements conventional examinations.

Purpose: The purpose of this study was to evaluate the outcome of pericardium patch graft (Tutoplast) as an adjuvant to either bleb repair or bleb reduction after nonpenetrating filtering surgery., Methods: Retrospective study, at a tertiary glaucoma center. Bleb revision with Tutoplast positioning was performed either for bleb repair to treat early leaks or hypotony with maculopathy, either for bleb reduction to improve ocular pain, discomfort, burning, foreign body sensation, tearing, and fluctuations of visual acuity. Intraocular pressure (IOP), best corrected visual acuity, number of antiglaucoma medications, and postoperative complications were analyzed postoperatively at 1 week, 1, 3, 6 months, and compared with the preoperative baseline. Surgical success was defined as achieving an IOP between 8 and 16 mm Hg., Results: Six-month data were available from 15 eyes of 15 patients; mean patient age was 69.6±11.7 (66.7% male). Bleb revision was necessary for 10 patients due to bleb dysesthesia (bleb reduction), and in 5 patients due to leaking filtering bleb (bleb repair). The success rate was 73.3% at 6 months, with a significant IOP increase from 4.9±2.2 mm Hg preoperatively to 12.7±3.5 mm Hg at 6 months (P=0.0001), and a concomitant rise of best corrected visual acuity from 0.5±0.3 to 0.6±0.3 (P=0.2871). To control IOP, antiglaucoma medications were needed for 3 patients (20%) at 6 months. Overall, 3 patients (20%) required additional bleb revision for persistent hypotony, and 1 patient underwent a subsequent glaucoma surgery (transscleral cyclodestruction)., Conclusion: Pericardium patch graft (Tutoplast) is a safe and effective adjuvant for bleb revision due to bleb dysesthesia of leaking filtering bleb after nonpenetrating filtering surgery.

Purpose: The last decade has witnessed an unprecedented growth in glaucoma treatment options through the introduction of minimally invasive glaucoma surgeries (MIGS). The aim of the present review is to provide an understanding of the currently available MIGS and to examine what data are currently available to guide treatment choice., Design: Meta-analysis and systematic review of randomized and non-randomized control trials., Methods: Out of 2567 articles identified, a total of 77 articles were retained for analysis, including 28 comparative studies and 12 randomized control trials. Overall, 7570 eyes were included. When data permitted, the weighted mean difference in intraocular pressure reduction was calculated for comparison purposes., Results: Weighted mean intraocular pressure reductions from all analyzed studies were: 15.3% (iStent), 29.1% (iStent inject), 36.2% (ab interno canaloplasty), 34.4% (Hydrus), 36.5% (gonioscopically-assisted transluminal trabeculotomy), 24.0% (trabectome), 25.1% (Kahook dual blade), 30.2% (Cypass), 38.8% (XEN), and 50.0% (Preserflo)., Conclusions: One of the advantages of the heterogenous range of available MIGS options is the chance to tailor therapy in an individualized manner. However, high-quality data are required to make this choice more than an educated guess. Overall, this review confirms the efficiency of assessed MIGS compared with standalone phacoemulsification, but it highlights that only few studies compare different MIGS techniques and even fewer assess MIGS against criterion standard treatments. Current evidence, while non-negligible, is mostly limited to heterogenous nonrandomized studies and uncontrolled retrospective comparisons, with few quality randomized control trials. We suggest that future research should be comparative and include relevant comparators, standardized to report key outcome features, long-term to assess sustainability and late complications, and ideally randomized.

Objectives: To determine the effect of surgical intraocular pressure (IOP) lowering on peripapillary retinal nerve fibre layer thickness (RNFL), fovea avascular zone (FAZ), peripapillary and macular vessel density (VD) in glaucoma using with optical coherence tomography angiography (OCT-A)., Methods: This was a prospective observational study performed at the Glaucoma Research Centre, Montchoisi Clinic, Lausanne. In total 40 eyes with open-angle glaucoma were included. OCT-A scans were performed before glaucoma surgery, and at 1-month, 3-month, 6-month, and 12-month post-operatively. AngioVue AngioAnalytic (Optovue Inc, Fremont, CA) software was used to analyse the RNFL, FAZ, peripapillary and macular VD. Changes were analysed using analysis of variance (ANOVA) models., Results: Mean IOP dropped from 19.4 (±7.0) mmHg pre-surgery and stabilized at 13.0 (±3.1) mmHg at 12 months (p < 0.001). The number of topical medications reduced from 2.2 (±1.2) preoperatively to 0.4 (±0.8) at 1 year (p < 0.001). Peripapillary RNFL thickness was transiently increased at 1-month postoperatively (p = 0.03). Peripapillary VD fluctuated throughout the follow-up. Foveal VD showed increased perfusion at 3 and 6 months post-operatively with minimal changes at 1 month (p < 0.01). Glaucoma surgery had a significant effect initially on FAZ area (p = 0.03), FAZ perimeter (p = 0.02) and Acircularity Index (AI) (p = 0.04). By 12-months FAZ measurements had reversed to baseline values., Conclusions: Peripapillary and macular microcirculations responded differently to surgically induced IOP reduction. Peripapillary microcirculation was IOP-independent within the studied range of surgically-controlled IOP. Macular microcirculation, however, exhibited a "delayed response" followed by near-normal reperfusion after glaucoma surgery. FAZ parameters could be potentially useful modalities to assess vascular reperfusion after glaucoma surgery as, amongst all studied parameters, the area was the most sensitive to surgically induced IOP changes.

Introduction: Corneal integrity has long been a preoccupation of glaucoma surgeons considering glaucoma drainage device surgery or antimetabolite-enhanced trabeculectomy. Despite having demonstrated a good safety profile and significant intraocular pressure-lowering capacities, the impact of XEN gel stents on endothelial density was never specifically investigated. The purpose of this study is to assess the effect of XEN gel stents on central endothelial cell density (ECD) over 24 months. To achieve this, we compared the effect on ECD of combined XEN surgery with that of a standard phacoemulsification procedure., Methods: This was an investigator-initiated, retrospective study, conducted at a single tertiary glaucoma center. Patients with primary or secondary open-angle glaucoma who underwent XEN implantation combined with phacoemulsification between January 2015 and June 2016 were retrospectively enrolled. Patients who had undergone standalone phacoemulsification over the same period of time were enrolled to form the control group of this comparative study. The primary outcome measure was the ECD. Patients who had undergone standalone XEN implantation and patients for whom both a baseline and 24-month ECD could not be obtained were excluded from the analysis. Percentages of ECD reductions were calculated for each studied eye, and the mean of ECD reductions was calculated for each group as well as for subgroups., Results: Thirty-two eyes of 23 patients (mean age=76.0±7.9 y, 60% female) underwent standalone phacoemulsification (n=15) or combined XEN surgery (n=17) and had an ECD both at baseline and 24-month postoperatively. Mean baseline ECDs were 2568±491 versus 2379±335 cells/mm, respectively (P=0.21). In the combined XEN surgery group, 58.8% of eyes (n=10) required at least 1 mitomycin C (MMC)-enhanced needling revision to maintain their target intraocular pressure. In the standalone phacoemulsification group, ECD decreased by a mean 14.5%, from 2567.7±491.2 to 2196.1±591.9 cell/mm (P=0.072). In the combined XEN surgery group, ECD decreased by a mean 14.3%, from 2378.8±334.7 to 2039.6±451.1 cell/mm (P=0.018). The difference in percentage reduction of ECD between the 2 groups was not statistically significant (P=0.226). Within the combined XEN surgery group, the ECD decreased by a mean of 15.4% in patients who did not undergo needling revisions and by 13.1% in patients who underwent the MMC-augmented procedure (P=0.485). In the 3 patients who underwent >1 needling revision, a 21.3% reduction in ECD was observed, but the difference was not statistically significant (P=0.653). Neither the time of the first needling (P=0.452), the patients' age (P=0.285), or sex (P=0.308) was statistically associated with ECD loss., Discussion: The present study demonstrated that the XEN gel implant combined with phacoemulsification produces 24-month ECD loss of a similar magnitude to that observed following standalone phacoemulsification. MMC-augmented needling revisions do not appear to have an impact on ECD.

The most effective way to control glaucoma is by lowering intraocular pressure (IOP) in order to prevent the progression of the disease. Glaucoma drainage devices (GDDs) are surgical option reserved for refractory cases and have been designed to address known complications of conventional filtering surgery. They are, however, associated with a higher rate of complications related to early hypotony and late corneal decompensation. In the case of the commonly used Baerveldt Glaucoma Implant (BGI), techniques exist in an attempt to prevent early postoperative hypotony but can be highly variable and surgeon dependent. Moreover, the additional steps required can result in unstable IOP in the immediate postoperative period. In 2014, Villamarin and colleagues described for the first time an adjustable GDD, called the eyeWatch implant, designed to better control IOP fluctuations and avoid hypotony during the early postoperative period via magnetic control of the device tube lumen. This innovation provides the possibility to adjust the amount of aqueous humor outflow after device implantation in a noninvasive manner. We report the case of an 83-year-old patient with advanced pseudoexfoliative glaucoma, referred to our tertiary center because of disease progression despite topical therapy and having undergone deep sclerectomy. First, a BGI was implanted but was unfortunately complicated by a 3-month chronic refractory hypotony from day 8, and choroidal detachment despite medical management, choroidal drainage, and viscoelastic injections. After 3 months, the decision was made to rescue the situation with an eyeWatch adjunction to the BGI. Postoperatively, the IOP was successfully controlled through fine adjustments of the eyeWatch opening position, until the last visit 8 months after the rescue, with complete resolution of the choroidal detachment and without any medications. This demonstrates that the eyeWatch may offer an answer not only to the immediate postoperative hypotonic phase of the GDD surgery but also to the later cystic bleb hypertonic phase.

Introduction: The XEN gel stent is currently the only minimally invasive glaucoma surgical device that targets the subconjunctival outflow pathway through an ab interno placement. It has demonstrated a significant intraocular pressure (IOP)-lowering potential and a favorable safety profile compared with traditional filtering surgery. However, despite a less invasive approach, the presence of a filtering bleb inevitably implies some risk of complications. The most commonly reported bleb-related complication, with rates as high as 45%, is bleb fibrosis associated with raised IOP. To restore filtration in those failing blebs, needling revision is considered the procedure of choice. In this study, we present the results of mitomycin C-augmented needling after XEN implantation., Methods: This was a prospective, interventional study, conducted at a single tertiary glaucoma center. Fifty-one eyes of 51 patients with raised IOP associated with either a fibrotic or shallow bleb or increased vascularity following XEN gel stent implantation at the investigation site between January 2015 and June 2016 were enrolled in this study. Patients with other identified causes of filtration failure (stent malposition, internal ostium obstruction, retained viscoelastic) were excluded. Included patients who underwent mitomycin C-augmented needling revision, and follow-up examinations were conducted at 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months. The primary outcome was the magnitude of IOP reduction following needling revision at the last follow-up visit. Secondary outcome measures were the number of needling procedures carried out in all patients, the rate of patients requiring further filtering surgery following needling revision, and the rate of intraoperative and postoperative complications associated with needling revisions., Results: The average age was 74.4±9.6 years; 66.7% (n=34) were female individuals. Primary open-angle glaucoma was the most common diagnosis (n=21, 41.2%). A total of 78 needling procedures were performed over the 24-month follow-up. Overall 20 of 51 eyes (39.2%) required >1 needling revision, and 14 eyes (24.5%) eventually required reoperation to maintain IOP within their desired target range. Before XEN implantation, mean preoperative IOP was 22.3±8.2 mm Hg and decreased to 14.1±8.0 mm Hg at day 1 postoperatively (-36.8%). The last measured IOP before the first needling revision was on average 23.6±8.9 mm Hg, which reduced to a mean 12.1±4.2 mm Hg at the first postrevision appointment (-48.7%). At the last follow-up appointment, on average 17.0±7.0 months after the first needling, the mean IOP was 14.3±4.1 mm Hg (-35.9% and -39.4% from preoperative and prerevision baselines, respectively). Complications associated with needling revisions were partial amputation of the XEN implant during needling (n=2, 3.9%), hypotony with choroidal detachment (n=1, 2%), and failure to achieve target IOP requiring subsequent surgery (n=14, 27.5%). No association was found between any of the recorded characteristics and the number of needling revisions performed or their outcomes., Discussion: The present study shows that needling revision following XEN gel stent implantation is a relatively safe and efficient intervention to restore filtration in failing blebs, with a significant and durable IOP-reduction potential.

Purpose: To evaluate the 2-year treatment outcomes of the XEN gel stent (Allergan, Inc, Irvine, CA) in glaucoma patients., Design: Prospective, single-center interventional study., Participants: One hundred forty-nine eyes of 113 patients with open-angle glaucoma., Methods: Consecutive eyes with uncontrolled intraocular pressure (IOP) or signs of disease progression despite medical treatment were included to undergo either standalone XEN implantation or combined XEN implantation plus phacoemulsification surgery, both with mitomycin C injections., Main Outcome Measures: Primary efficacy outcome was success, defined as complete when the unmedicated IOP was 12 mmHg or less, 15 mmHg or less, or 18 mmHg or less and 20% lower than at baseline over the 2-year period and defined as qualified when the IOP fulfilled the same conditions with fewer medications than at baseline. Secondary measures were mean reduction in IOP and in the number of medications and the rates of reoperations., Results: One hundred nine eyes (84 patients; mean age, 74.3 years) underwent XEN plus phacoemulsification surgery and 40 eyes (29 patients; mean age, 74.7 years) underwent standalone XEN surgery. Overall, 129 eyes (86.6%; 96 eyes of 75 XEN plus phacoemulsification patients and 33 eyes of 24 XEN standalone surgery patients) completed the study. Mean medicated IOP was 20.0±7.5 mmHg at baseline and 14.1±3.7 mmHg at 2 years (P < 0.01), a 29.3% IOP reduction. Mean number of medications dropped from 2.0±1.3 before surgery to 0.6±0.9 at 2 years (P < 0.001). Complete success was achieved in 18.2% of eyes using the 12 mmHg or less and 20% reduction criteria and in 44.4% using the 15 mmHg or less threshold. Needling with mitomycin C was performed in 58 eyes (45%). In all, 11.4% underwent reoperations., Conclusions: After 2 years, XEN gel stent surgery achieved a clinically and statistically significant reduction both in IOP and the number of antiglaucoma medications, while requiring a high rate of needling interventions., (Copyright © 2019 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

PRéCIS:: This study confirms the safety and efficacy of XEN gel stents in the management of pseudoexfoliative glaucoma 2 years after implantation, with success rates similar to primary open-angle glaucoma regardless of the definition of success., Purpose: To compare the long-term safety and efficacy of XEN gel implant surgery (Allergan Inc., Irvine, CA) in patients with pseudoexfoliative glaucoma (PEXG) and primary open-angle glaucoma (POAG)., Setting: Prospective, interventional study in a tertiary glaucoma center., Methods: A total of 110 eyes of 85 patients with POAG (57 eyes) or PEXG (53 eyes) and uncontrolled intraocular pressure (IOP) despite medical treatment underwent combined XEN+cataract surgery or standalone XEN surgery. Mean IOP, mean number of medications, needling rates, and incidence of adverse effects were compared between the 2 groups. Complete surgical success was defined as an unmedicated IOP≤12, 15, 16, or 18 mm Hg at 2 years, both with and without a 20% reduction from baseline., Results: Combined XEN+cataract surgery was performed in 72% of POAG and 76% of PEXG eyes (P=0.67), the remainder underwent standalone XEN surgery. Patient characteristics were similar between the 2 groups except for older age for the patients with PEXG (78.5±8.5 vs. 71.3±8.7 y; P<0.005). Mean medicated IOP were 19.8±5.8 mm Hg (POAG) versus 19.8±8.2 mm Hg (PEXG) at baseline (P=0.98), and 14.5±3.6 mm Hg (-26.8%) versus 14.2±3.8 mm Hg (-28.3%), respectively, at 2 years (P=0.75). Mean medications concomitantly dropped from 1.9±1.6 (POAG) versus 2.0±1.3 (PEXG) to 0.6±0.9 versus 0.4±0.7, respectively (P=0.29). Using the 16 mm Hg threshold, 51.4% (POAG) versus 57.1% (PEXG) eyes achieved complete success (P=0.70) at 2 years. The difference in success rates between the 2 groups was not statistically significant under any of the definitions of success. By 24 months, needling was performed in 42.8% (POAG) and 43.2% (PEXG) (P=0.64), with an average time to needling of 162.8 and 134.9 days, respectively (P=0.46). The rates of adverse effects were 30.6% (POAG) and 36.4% (PEXG) (P=0.66), and additional glaucoma surgeries were carried out in 14.3% (POAG) versus 15.9% (PEXG) (P=0.89)., Conclusions: The XEN gel implant as a standalone or combined procedure demonstrated similar efficacy and safety results in PEXG and POAG eyes.

PRéCIS:: A larger proportion of iStent inject microstents than suggested by gonioscopic examination could be entirely burrowed within the trabeculum (45.7%). The length of device protrusion within the anterior chamber is linked to postoperative intraocular pressure (IOP)., Introduction: The iStent inject is a relatively new device designed to be implanted ab-interno through the trabecular meshwork. Although some preliminary studies have shown IOP-lowering potential, the full extent of the mechanisms through which IOP is reduced remains unconfirmed. The aim of this study was to use in vivo optical coherence tomography analysis of the anatomic and physiological effects of iStent inject device positioning on the structures of the iridocorneal angle and IOP., Methods: In total, 25 eyes of 19 subjects (mean age, 75.5±10.5 y) with mild to moderate open-angle glaucoma were enrolled in this prospective study. All patients underwent implantation of 2 iStent inject devices combined with cataract surgery. In the postoperative period, after IOP stabilized, anterior segment optical coherence tomography (AS-OCT) was performed and several measurements were made of the Schlemm canal (SC) and the devices' positions. Thirteen unoperated fellow eyes served as control eyes., Results: Overall, 92% of devices were visible on AS-OCT versus 88% visible on gonioscopic examination. Of all visible devices, 54.3% had a protruding portion into the anterior chamber with a mean protruding length of 88.5 µm, and 72% of the devices' heads were not positioned within the SC, with a mean shortest distance of 109.4 µm. In operated eyes, the average major diameter of SC was 308.7±197.4 µm (median, 303.8 µm) versus 126.9±60.3 µm in control eyes. Device protrusion and larger SC diameters were associated with lower postoperative IOP (rs=-0.54; P=0.005 and rs=-0.43; P=0.04, respectively), whereas the distance between the devices' heads and SC was inversely associated with SC dilatation (rs=-0.41; P=0.04)., Conclusions: This study highlights the value of AS-OCT in exploring the positioning of trabecular bypass devices such as the iStent inject. Our study shows that more microstents than suggested by gonioscopy could be completely burrowed within the trabeculum. It also suggests that the surgical outcomes of cataract surgery combined with iStent inject implantation may be connected to the amplitude of device protrusion within the anterior chamber as well as the postoperative dimensions of the SC.

Introduction: Kabuki syndrome (KS) is a rare congenital and polymalformative condition, traditionally associated with mental retardation, unusual facial features, and skeletal abnormalities. We hereby describe a case of bilateral congenital glaucoma associated with MLL2-mutation KS. To the best of our knowledge, this is the first association of KS with congenital glaucoma., Case Report: The patient was a 3-year-old male of North African ethnicity diagnosed with KS and bilateral congenital glaucoma at the age of 3 months and the first child of a nonconsanguineous healthy couple, with no known genetic conditions within the family. The patient was referred to our tertiary glaucoma center with uncontrollable intraocular pressures between 50 and 60 mm Hg in both eyes. Past ophthalmic history included bilateral trabeculectomies and right retinal detachment with phthisis bulbi. We performed left lensectomy combined with Baerveldt tube insertion in the vitreous cavity, revealing extensive posterior synechiae. Postoperatively, he developed intense inflammation with fibrin and vitreous strand formation, requiring subsequent surgeries and subconjunctival injections of betamethasone. Despite these complications, IOP stabilized between 3 and 6 mm Hg., Discussion: This case confirms congenital glaucoma as a rare association of KS, and highlights the potential high-risk nature of such cases. In our opinion, the presence of high levels of inflammation perioperatively and postoperatively is an indication for primary glaucoma drainage device surgery given the high risk of bleb scarring resulting in recurrent surgical revisions. In view of these observations, we also advocate the use of intensive postoperative anti-inflammatory therapy.

Introduction: Although there are several examples of glaucoma drainage devices' dislocations in the literature, the movement of XEN gel stents is scarcely documented, and the impact of such displacements on the corneal endothelium remains unknown. In light of the recent global market withdrawal of the CyPass microstent over concerns with regard to endothelial cell loss, we present a case of XEN gel stent dislocation into the anterior chamber, with localized corneal damage., Case Report: We describe the case of a 64-year-old female patient who underwent bilateral XEN gel stent implantation for normal-tension glaucoma. While right eye surgery was uneventful, intraocular pressure increased in the left eye, and examination revealed a flat filtration bleb with no microstent visible through the conjunctiva. A 3 mm segment of the XEN stent was visible within the anterior chamber, with corneal contact during eye movement and blinking. Endothelial cell density was measured twice 1 month apart before the XEN gel stent was replaced., Discussion: First, our observations confirm that XEN gel stents can dislocate and advance within the anterior chamber. We speculate that this displacement was caused by regular eye rubbing after surgery. Second, this report illustrates that the position of a drainage device within the anterior chamber is dynamic and significantly influenced by eye movements and blinking. Finally, occasional corneal contact of a XEN gel stent can cause a reduction in endothelial cell density of 2.1% in a month, which represents 46.2% of the annual endothelial loss observed by Tan and colleagues in patients with a Baerveldt tube (4.54% annual decrease).

Purpose: To assess the visual performance, clinical and quality of life outcomes, and subjective patient satisfaction after implantation of a new refractive/extended depth of focus (EDOF) hybrid intraocular lens (IOL)., Methods: This is a monocentric, retrospective study of 29 patients (45 eyes), carried out in a tertiary care glaucoma research centre. All patients underwent implantation of a Lucidis (Swiss Advanced Vision, SAV-IOL SA, Neuchâtel, Switzerland) IOL during cataract surgery. Near, intermediate, and distance best-corrected visual acuities and uncorrected visual acuities were collected at baseline and 3 months postoperatively. Adverse events, contrast sensitivity, optical aberrations, subjective satisfaction, and spectacle independence were also analysed at 3 months., Results: At 3 months postoperatively, the mean photopic uncorrected monocular distance, and intermediate and near visual acuities were 0.2 logMAR (~ 20/32), 0.07 logMAR (~ 20/23), and 0.15 logMAR (~ 20/28), respectively. Mean best-corrected visual acuity was 0.05 logMAR (~ 20/23) for distance and 0.03 logMAR (~ 20/21) for near vision. Mean photopic contrast sensitivity was 1.5 log. The mean root mean square (RMS) was 0.119 ± 0.05 µm. Subjectively, over the 3-month follow-up, 9% of patients (n = 4) complained of halos, and 2% (n = 1) of photophobia. No other adverse events were noted., Conclusions: The Lucidis IOL demonstrates a good safety profile, with an acceptably low complication rate. While the uncorrected visual performance of this new optical design is inferior to that of other EDOF IOLs for distance vision, it achieves better results in intermediate and near vision, with consistently near-normal contrast sensitivity. Interestingly, self-reported spectacle independence and subjective patient satisfaction were high for all distances., Competing Interests: Full disclosures: Dr. Gillmann K: None. Dr. Mermoud A: Alcon (S), Allergan (S), Santen (C), Swiss Advanced Vision (C), Rheon Medical (C), Glaukos (C), Diopsys Inc. (C), DeepCube (C). Financial support: No external financial support., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Stress-induced activation of the sympathetic nervous system leads to a cascade of metabolic reactions. Emotional stress is a more specific form of stress in which the stressor is a psychological response to a situation subjectively perceived as traumatic. Stress hormones can have a wide range of effects on the body, however, it is still unclear if and how it can affect ophthalmic physiology. This report presents a case of severe ocular hypertension in which emotional stress was the only cause elicited, and explores potential aggravating factors., Case Presentation: A 78-year-old, personality type A, lady with a history of pseudo-exfoliative glaucoma presented with an acute asymmetrical raise in intraocular pressure (IOP) immediately following a family breakdown. Her IOP had previously remained stable following a deep sclerectomy in the right eye and an Ex-PRESS shunt in the left eye. Her examination was entirely normal otherwise, with a patent filtration and diffuse bleb as confirmed with anterior segment OCT imaging. Near-normalisation of her IOP was observed within 24 h, concomitantly with the reduction of her stress levels. No other cause for the transient acute hypertensive episode were found., Conclusions: This case report suggests that acute emotional stress could severely affect IOP in patients suffering from glaucoma. This could be important when looking after glaucoma patients. It would also suggest that the personnality types, and the emotional and social context are more factors to take into account in glaucoma studies. These observations are based on a single case report and would need to be verified on a larger scale.

Purpose: To investigate indocyanine green angiography (ICGA), fluorescein angiography (FA), and enhanced depth imaging optical coherence tomography measured choroidal thickness (EDI-OCT-CT) in the follow-up of inflammatory activity in stromal choroiditis [Vogt-Koyanagi-Harada disease (VKH) and birdshot retinochoroiditis (BRC)] under treatment in order to monitor tapering of therapy or readjustment of therapy in case of subclinical disease recurrence., Methods: Patients with initial onset disease and/or treatment-naive stromal choroiditis (VKH & BRC) at entry, quiet under therapy, and having had a follow-up of at least four years monitored with dual FA and ICGA and EDI-OCT-CT measurements were analyzed retrospectively. ICGA and FA scores and EDI-OCT-CT values were correlated with therapy, and significant changes of each modality were correlated with disease evolution., Results: Of the 31 VKH and 29 BRC patients seen from 1995 to 2017 in our center, four patients (2 VKH and 2 BRC patients) fulfilled the inclusion criteria. During tapering, two patients (both VKH) showed no significant ICGA, FA, and EDI-OCT-CT changes (mean follow-up time 5.6 years) and allowed for safe tapering. In the other two (BRC) patients (mean follow-up time 6.25 years), a total of seven significant subclinical changes were demonstrated by ICGA alone after therapy modifications due to side-effects or during attempted tapering of therapy, while FA and EDI-OCT-CT remained unchanged., Conclusions: ICGA was the most sensitive monitoring modality of stromal choroiditis, able to identify subclinical recurrences following change of therapy and inversely treatment responses after readjusted therapy, events otherwise missed by FA and EDI-OCT. ICGA proved efficient for safe therapy tapering or for timely adjustment of therapy in stromal choroiditis when necessary.