SPS-305 Glaucoma Surgical Outcomes & Procedures | ASCRS
2020 ASCRS Virtual Annual Meeting

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Papers in this Session
Expand each tab below to view the paper abstract for each paper within this session.
A Survey of Glaucoma Surgery Practice Patterns in the US Veterans Health Administration
Authors
Daniel J. Olivieri
Mary G. Lynch, MD, ABO
Glenn C. Cockerham, MD
Paul B. Greenberg, MD, MPH, ABO

Purpose
To evaluate the current role of and potential barriers to receiving surgical intervention for glaucoma in the US Veterans Health Administration (VHA).

Methods
A link to an anonymous 10-question survey was emailed and sent by mail with a $1 incentive to 86 chiefs of ophthalmology at Veterans Affairs Medical Centers (VAMCs) with academic affiliations. Academic-affiliated VAMCs were chosen because of their patient range and role in ophthalmic education. Contact information for the ophthalmologists was obtained from the Office of the National Program Director for Ophthalmology (Central Office, VHA, Washington DC). Non-responders received two reminder e-mails and two phone calls, and the survey was closed after six weeks. The data was then analyzed using descriptive statistics.

Results
Most respondents (92%) worked in an integrated optometry and ophthalmology clinic. Non-compliance to therapy or visits was the most common indication for laser trabeculoplasty (LTP) (95%); and 49% (19/39) of respondents used LTP as initial therapy. Non-compliance was a major indication for surgical intervention for tube shunt (65%); MIGS (59%;), and trabeculectomy (48.7%). Uncontrolled glaucoma despite medication and/or LTP was the most common indication for a tube-shunt procedure (95%) and trabeculectomy (90%). Significant barriers in access to surgery included lack of transportation (69%), scheduling issues (62%), and delayed referral despite significant progression (62%).

Conclusion
This survey suggests that within the VHA there is broad consensus in glaucoma surgery practice patterns, though significant barriers remain for timely access to surgical glaucoma care
Improved Efficacy of Topical Latanoprost 0.005% Demonstrated By Corneal Biomechanical Correcting Modified Goldmann Prism
Authors
Nathan M. Radcliffe, MD, ABO
Sean J. McCafferty, MD, FACS

Purpose
Evaluate intraocular pressure (IOP) reduction measured by a Goldmann applanation tonometer (GAT) prism and a correcting applanation tonometry surface (CATS) prism with the institution of a topical prostaglandin analog (PGA) or alternatively a topical beta blocker

Methods
Design: Prospective, open-label, randomized, controlled, reference device comparison Methods: Seventy-two (72) treatment naïve glaucoma patients were randomized (36 in each group) to treatment with latanoprost 0.005% or timolol maleate 0.5%. Each patient underwent IOP measurement with standard GAT and CATS prisms before and at 1,3, and 6 months of treatment. Central corneal thickness (CCT) and corneal hysteresis (CH) were also measured. Medication response was defined as a 20% reduction in IOP from baseline

Results
The CATS prism demonstrated the IOP reduction with topical latanoprost at a mean of 2.0 mmHg lower than the IOP measured with GAT (p<0.0001). The CATS and GAT prisms detected no difference in IOP reduction with timolol(p=0.17). The number of latanoprost treatment non-responders was reduced from 36.1% measured with GAT to 13.8% when measured with the CATS prism(p=0.005). Timolol indicated no difference in the treatment non-response rate at 22.2% (p=0.999). CH increased significantly with latanoprost treatment by an average of 0.55 mmHg(p=0.014) and remained unchanged with timolol at -0.014 mmHg(p=0.68)

Conclusion
Improved IOP reduction and responder rates were demonstrated with a CATS prism in patients using latanoprost and not with timolol use. Latanoprost induced alterations in corneal biomechanics likely dampen the actual IOP reduction measured with a standard GAT prism and the increase in CH support these findings
Surgical Management of Glaucoma Following Ocular Surface Stem Cell Transplantation.
Authors
Matthew R. Denny, MD
Albert Y. Cheung, MD, ABO
Fred B. Chu, MD, ABO
Edward J. Holland, MD

Purpose
To assess surgical and ocular surface outcomes in patients requiring glaucoma surgery following ocular surface stem cell transplantation (OSST).

Methods
Retrospective chart review of 420 eyes that underwent OSST between May 2000 and March 2019 by a single surgeon. Inclusion criteria include patients who received either transscleral cyclophotocoagulation or implantation of a glaucoma drainage device performed by one of three glaucoma surgeons at the same institution. Primary outcome was the need for additional ocular surface or glaucoma surgery. Secondary outcomes were changes in intraocular pressure and number of glaucoma medications.

Results
35 glaucoma surgeries (6 Ahmed, 19 Baerveldt, 10 CPC) were performed in 30 eyes with a history of prior OSST. Ocular surface failure rate was 20% for tubes and 10% for CPC (p = 0.65). Rate of repeat glaucoma surgery was 32% for tubes and 60% for CPC (p = 0.15). Mean IOP reduction was 50% for tubes and 28% for CPC (p = 0.02). Mean drop reduction was 1.6 for tubes and 0.1 for CPC (p = 0.01). All glaucoma failures in the tube group were related to tube erosion and/or hypotony, while all glaucoma failures in the CPC group were due to uncontrolled IOP. There were no statistically significant differences in primary or secondary outcomes between the Ahmed and Baerveldt groups.

Conclusion
Glaucoma is a frequent comorbidity in severe ocular surface disease, however treatment can pose unique challenges in patients with limbal stem cell grafts. In this study, tubes were more effective for IOP and drop reduction, but benefits must be weighed against the additional risks of incisional surgery.
Prospective Study of Health-Related Quality of Life in Patients with Baerveldt 250 and 350, and Ahmed FP7 Glaucoma Drainage Devices
Authors
Cheryl L. Khanna, MD
Khin P. Kilgore, MD
Feng Wang, MD
Nicole C. Stern, MD
Launia J. White
David Hodge, MS

Purpose
To compare Health-Related Quality of Life (HRQoL) in patients with Baerveldt 250 (B250), Baerveldt 350 (B350), or Ahmed FP7 (FP7) Glaucoma Drainage Devices (GDDs), and medically-treated controls using the Diplopia Questionnaire (DQ), the 25-Item Visual Function Questionnaire (VFQ-25) and the Adult Strabismus Quality of Life Questionnaire (AS-20).

Methods
Adult glaucoma patients with B250, B350, or FP7 GDDs, and medically-treated controls, were prospectively and consecutively enrolled from Aug 2017 through July 2019. The DQ, VFQ-25 and AS-20 were conducted ≥30 days post-operatively, upon enrollment for controls. Those with multiple GDDs, GDDs in quadrants other than the superotemporal, scleral buckles, or language or cognitive barriers to taking the surveys were excluded. Using univariate regression analyses, age, sex, treatment type, visual acuity, mean deviation, and diplopia were examined for association with HRQoL. The GDD and control groups were then compared after adjusting for age, diplopia, mean deviation and visual acuity.

Results
In total, 137 GDD and 102 control patients were enrolled, 37 (27.0%) with FP7, 35 (25.5%) with B250 and 65 (47.4%) with B350. Decreased HRQoL was associated with younger age (r2 range, 0.041 -0.068), diplopia (r2 range, 0.037-0.112), and worse visual acuity (r2 range, 0.017-0.212) or mean deviation (r2 range, 0.030-0.141). All GDD groups had lower HRQoL subscores than the controls. HRQoL scores were lower than controls among B350 patients for Self-perception (p=0.024), B250 and B350 for Reading (p=0.024 and p=0.003) and General Function (p=0.029 and p=0.002), and FP7 and B350 for Visual Functioning (p=0.003 and p=0.004). There were no significant differences among the GDDs on any subscale.

Conclusion
Glaucoma patients with a younger age, diplopia, lower visual acuity, worse mean deviation, or a GDD had lower HRQoL. Those with B350, the GDD with the largest plate area, have lower self-perception scores, perhaps due to greater implant visibility or awareness.
Angle Closure and the Prevalence of Zonulopathy
Authors
Anthony Fanous
Paul J. Harasymowycz, MD

Purpose
Recent studies have shown that the average rate of zonulopathy in the general cataract population is 0.50%. It has also been shown that lens extraction may be an appropriate and cost-effective management of angle closure. Rates of zonulopathy in this specific population have not been extensively studied.

Methods
This is a retrospective cohort study looking at 859 consecutive eyes with a diagnosis of PACS (227), PAC (330), and PACG (302) that underwent lens extraction by a single surgeon with a femtosecond laser procedure. The primary outcome measure was the rate of intra-operative zonulopathy. The presence of secondary pigment dispersion as well as the use of capsular hooks, CTRs, and anterior vitrectomy were also noted. Patients with a history of trauma, pseudo-exfoliation syndrome or other hereditary diseases were excluded. Chi-square tests were used to establish significance.

Results
In the 859 eyes operated, zonulopathy was noted in the operative report in 31 (3.6%) eyes, 19 of which required CTR insertion (61.3% of zonulopathy cases). 1 case requiring capsular hooks, and 3 cases required anterior vitrectomy. The rates of zonulopathy in the individual groups were as follows: 6/227 PACS (2.6%), 15/330 PAC (4.5%), 10/302 PACG (3.3%), and 4/138 with secondary PDS (2.9%). There was no statistically significant difference between the 4 groups.

Conclusion
The rate of zonulopathy in patients with PACS, PAC and PACG undergoing lens extraction was found to be significantly higher than reported in the general population, and may be responsible in it’s pathogenesis. Ophthalmologists should be aware of risks and be prepared to manage the zonulopathy intra-operatively.
Midterm Study of the Neuroprotective Effects of Stimulation By Super-High Frequency Electromagnetic Waves Induced in Glaucomatous Neuropathy
Authors
Pier Domenico D'Andrea, MD
Stefano Benedetti, MD

Purpose
Demonstrate the possibility to induce improvements in retinal function in glaucomatous optic neuropathy by means of electromagnetic (EM)stimulation convoyed by nanotechnology devices (HITtm)

Methods
23 Eyes of an experimental group (EG) affected by glaucomatous optic neuropathy (glaucoma stage system2 S1-S4) were stimulated by means of HIT devices convoying EM waves 800nm and 660nm , 8 hs/day for 6 months.Perimetry 30-2 (Humphrey)was performed at the start and the end points . MD and PSD considered and were comparate with control group (23 eyes ).Statistical analysys.

Results
We observed in the EG improvement of MD and PSD (p<0,03). No side effects .

Conclusion
The effect correlate to the specificity of the signal . The mechanisms of action are linked to the variables of the stimulus adjustable according to frequency ,Intensity ,Duration , Wave Form and Phase .Esogenous electromagnetic field interferes with target tissue .
OCT Angiography Analysis of Moderate Primary OPEN Angle Glaucoma and Its Correlation with Rnfl, GCC and Visual Fields
Authors
Aadithreya Varman, MBBS
Arulmozhi Varman, MD

Purpose
The purpose of this study is to evaluate the correlation between the following parameters observed in OCT-Angiography in patients of Primary Open Angle Glaucoma. 1) Vessel density 2) Nerve Fibre layer thickness 3) Ganglion Cell Count This study will establish whether Vessel densitycan be used as a surrogate marker in the diagnosis of POAG

Methods
Retrospective observational cross sectional study. All patients included in this study were known cases of moderate-severe glaucoma using the AAO ICD-10 staging of glaucoma based on VF changes. OCTA Imaging was obtained for 19 eyes of POAG.Patients had clear media on imaging with no other retinal abnormalities. Visual acuity corrected to at least 6/12. Refractive errors of more than -5D were excluded from the study. Patients with history of trauma or intraocular inflammation were excluded. Included 27 controls. Controls were patients over the age of 40, who underwent the same examinations as mentioned. Had no family history of glaucoma. IOP<21mmHg. Corrected Visual acuity of at least 6/12.

Results
Analysis was performed between RNFL segments with the respective segments of the Vascular density using the Pearson Correlation coefficient. The degree of correlation is denoted between -1 to +1. A negative value indicating that the two variables are not linearly correlating. The degree of correlation coefficient between Superior Disc Vessel Density and Superior RNFL was found to be the strongest at +0.871.Followed by Inferior Disc Vessel Density and Inferior RNFL at +0.836. Nasal Disc Vessel Density and Nasal RNFL correlated at +0.709. Temporal Vessel Density and Temporal RNFL was found to have the weakest correlation at +0.151

Conclusion
Optic disc vessel density could be a parameter to be considered while diagnosing patients of Primary Open Angle Glaucoma. Sectoral correlations of optic disc vessel density,more specifically the Superior,Inferior and Nasal quadrants with the corresponding RNFL prove that Vascular changes occur during the course of the disease.
Association between Obstructive Sleep Apnea and Exfoliation Syndrome
Authors
Caleb L. Shumway, MD
Karen Curtin, PhD
Samuel C Taylor
Krishna M. Sundar, MD
Robert Ritch, MD, ABO
Barbara Wirostko, MD, ABO

Purpose
Exfoliation syndrome (XFS) is associated with systemic deposition of abnormal fibrillary material in the extracellular matrix (ECM) and is associated with a lysyl oxidase-like-1 (LOXL1) gene mutation. Since patients with obstructive sleep apnea (OSA) also demonstrate ECM tissue changes, we hypothesized there may be a link between XFS and OSA.

Methods
Patients were analyzed from the Utah Population Database medical records and were matched to controls in a 5:1 ratio according to sex and birth year. From 1996 to 2015, there were 2,943 patients with XFS, and 81,735 patients with OSA and a total of 248 patients with both disorders. Using International Classification of Diseases, Ninth Revision (ICD-9) or their ICD-10 equivalent, ICD-9 codes 365.52 and 366.11 defined XFS, and 327.23 defined OSA. Odds Radios were used to estimate risk of OSA in patients with XFS, and vice-versa. Covariate analysis included race, Body-Mass Index (BMI), tobacco use, atrial fibrillation, and chronic obstructive pulmonary disease.

Results
We observed an increased likelihood of XFS diagnosis in OSA patients compared with controls (OR = 1.29; 95% CI, 1.11-1.49; P = 0.0006). Overall, there was no increased diagnosis of OSA in XFS patients. However, in a subset of XFS patients with hypertension, likelihood of OSA was increased (OR = 1.53; 95% CI,1.22-1.93; P = 0.0003), and likewise the risk of having an XFS diagnosis for patients with OSA was increased (OR = 2.67; 95% CI, 2.06-3.46; P < 0.0001).

Conclusion
Patients with OSA may have an increased risk of XFS compared to non-OSA diagnosed individuals. XFS patients with hypertension may have an increased risk of an OSA diagnosis compared with non-XFS individuals.
Effect of Cumulative Dissipated Energy in Phacoemulsification on Intraocular Pressure in Eyes with Prior Trabeculectomy with Mitomicin
Authors
Amer Alwreikat, MD
Cansu Yuksel Elgin, MD
Paul Cotran, MD, ABO

Purpose
To evaluate the effect of cumulative dissipated energy (CDE) in phacoemulsification on previous functioning filtering bleb and intraocular pressure (IOP) control preoperative steroid effect on trabeculectomy survey

Methods
34 patients were studied (34 eyes) who underwent phacoemulsification after successful trabeculectomy with mitomycin (MMC). Preoperative IOP, mean deviation (MD) values of visual field test and preoperative steroid medication, and CDE were recorded. Failure was defined as IOP>21 with or without antiglaucoma medication on least two consecutive visits, or significant morphological changes on bleb appearance (sudden decrease in bleb height and microcysts, thickening of bleb wall, excessive vascularization of the bleb) or requiring further glaucoma surgery. Preoperative and intraoperative factors were evaluated for association with postoperative failure using Kaplan-Meier method.

Results
According to the Kaplan-Meier survival analysis, failure rates after phacoemulsification were %17.6, %26.47 and %.32.35 at 6, 12 and months, respectively. The IOP levels of the failing group were 13.00±3.85 mmHg before phaco, and all significantly different (p-value<0.05) after phacoemulsification to those of patients with normal blebs. CDE for patients with failing blebs in the two-year window was 19.81 (±6.61) seconds compared to 13.90 (±8.19) seconds for those with healthy blebs. (p=0.04) There were also significant differences in failure rates between those having an IOP less than 10mmHg before phacoemulsification and those having an IOP level greater than 10 mmHg. (p=0.0032).

Conclusion
Phacoemulsification significantly increased IOP and bleb failure rates. Eyes with higher IOP before phacoemulsification and higher CDE during phacoemulsification had greater postoperative antiglaucomatous failure.
Use of Micropulse Transscleral Cyclophotocoagulation in Glaucoma Associated with Penetrating Keratoplasty or Keratoprotesis
Authors
Juan Carlos Izquierdo, MD
Consuelo Gajardo Menzel, MD
Josselyne G. Lopez, MD
Katia Ruiz Montengro, MD
Mirel Rincon, MD
Natalia Agudelo, MD

Methods
Retrospective case series of 29 patients with penetrating keratoplasty or Boston keratoprosthesis who underwent Micropulse Transscleral Cyclophotocoagulation with 12 months of follow-up. Treatment success was defined as an IOP of 6-18 mmHg or a reduction of IOP by 20%. Failure was defined as an inability to meet the criteria for success or need for incisional glaucoma surgery.
 Two differents groups were comparated. Group one with 2000 mW power for 90 seconds per hemisphere and group two with 180 seconds per hemisphere. Mean preoperative and postoperative IOP, reduction in number of glaucoma medications, visual acuity (BCVA), keratoplasty survival and complicationswere compared.

Results
The mean IOP prior to MP-CPC was 24.68 ± 8.6 mmHg and was reduced to 12.41 ± 3.71 mmHg (p < 0.001), with a greater reduction in the group two (p < 0.001). The majority of patients (65,5%) used 4 medications which were reduced to 3 in 27.58% and 2 in 37.93% of patients at the last follow-up (p <0.001). The mean BCVA changed from 1.11 to 0.92 logMAR (p= 0.83).The more significant complication included 8 (28%) patients with loss of 2 or more lines of BCVA at 12 months. Grafts remained clear in 89% and 90% of eyes in group 1 and 2 at 1 year, respectively. Failure of glaucoma outcome was associated with prior intraocular surgeries. 2 eyes (7%) received subsequent glaucoma filtration surgery.

Conclusion
MP-CPC is an effective and safe treatment for patients with Keratoplasty and keratoprothesis. With 180 seconds per hemisphere, the mean intraocular pressure is more greatly reduced, but this difference between two parameters is no clinically significant.

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