Publications by authors named "Joseph F Panarelli"

32 Publications

Comparison of Safety and Efficacy Between Ab Interno and Ab Externo Approaches to XEN Gel Stent Placement.

Clin Ophthalmol 2021 26;15:299-305. Epub 2021 Jan 26.

Department of Ophthalmology, Mount Sinai School of Medicine, New York, NY, USA.

Purpose: To compare the safety and efficacy of two different techniques for implantation of the XEN Gel Stent, a minimally invasive surgical device for the treatment of refractory glaucoma.

Methods: A retrospective chart review of eyes that received ab interno or ab externo XEN Gel Stent placement from February 2017 to October 2019 was conducted. A single surgeon (NMR) performed all operations. Eyes that received the XEN implant concomitant with a glaucoma drainage device insertion or that were lost to 6-month follow-up were excluded. Intraocular pressure (IOP) change, change in glaucoma medications, frequency of slit lamp revision procedures, and frequency of secondary glaucoma surgeries were the primary outcomes compared between groups.

Results: Fifty eyes that underwent ab interno placement and 30 eyes that underwent ab externo placement were studied. The ab interno cohort demonstrated a mean IOP reduction of 8.4 ± 1.7 mmHg (28.6% decrease) by 12 months, compared to a mean reduction of 12.8 ± 3.0 mmHg (40.1% decrease) in the ab externo group (p = 0.208). Mean reduction in medication use was 1.81 ± 0.29 medications in the ab interno group and 1.86 ± 0.37 in the ab externo group (p = 0.913). By 12 months, 58% of ab interno eyes had required 5-fluorouracil injection compared to 36.7% of ab externos (p = 0.105). Bleb needling was applied to 42% and 26.7% of the eyes, respectively (p = 0.231). A second glaucoma surgery was necessary for 20% of the ab interno cohort and 10% of the ab externo cohort (p = 0.351).

Conclusion: There were no differences in outcomes between ab interno and ab externo placement of the XEN Gel Stent. Both approaches are safe and effective for lowering IOP.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2147/OPTH.S292007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7847364PMC
January 2021

Comparison of Clinical Outcomes with Open Versus Closed Conjunctiva Implantation of the XEN45 Gel Stent.

Ophthalmol Glaucoma 2020 Dec 13. Epub 2020 Dec 13.

Glaucoma Center of Excellence, The Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland. Electronic address:

Purpose: To describe the efficacy and safety of open versus closed conjunctival implantation of the XEN45 Gel Stent (Allergan Inc).

Design: Retrospective, multicenter study.

Participants: A total of 137 patients with glaucoma who underwent XEN45 implantation via open or closed conjunctival methods. The XEN45 was implanted as a stand-alone procedure or at the time of cataract surgery by 5 surgeons.

Methods: Patient demographics, diagnoses, preoperative and postoperative clinical data, outcome measures including intraocular pressure (IOP), use of glaucoma medications, visual acuity, and complications were collected. Statistical analyses were performed with P < 0.05 as significant.

Main Outcome Measures: Failure was defined as less than 20% reduction of IOP from medicated baseline or IOP >21 mmHg at 2 consecutive visits at postoperative month 1 and beyond, the need for subsequent operative intervention or additional glaucoma surgery, or a catastrophic event such as loss of light perception. Eyes that had not failed by these criteria and were not on glaucoma medications were considered complete successes. Eyes that had not failed but required glaucoma medications were defined as qualified successes.

Results: Complete success was achieved in 31% and 56% of the closed and open groups, respectively (P = 0.01). Qualified success was achieved in 53% and 71% of the closed and open groups, respectively (P = 0.06). At postoperative month 12, the open conjunctiva group was using fewer glaucoma medications than the closed group (0.9 vs. 1.8, respectively; P = 0.02). At postoperative month 12, the open group had a significantly greater percentage of IOP reduction compared with the closed group (43.1% vs. 24.8%, respectively; P = 0.02). Postoperative needling rates were higher in the closed group compared with the open group (36.1% vs. 11.8%, P = 0.001).

Conclusions: Implantation of the XEN45 with opening of the conjunctiva is a safe and efficacious procedure to lower IOP with comparable success rate and lower needling rate compared with the closed conjunctiva technique. Prospective evaluation of the various methods for XEN45 implantation will allow for further comparison.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ogla.2020.12.003DOI Listing
December 2020

The Effect of Phacoemulsification on Intraocular Pressure in Eyes with Preexisting Glaucoma Drainage Implants.

Ophthalmol Glaucoma 2020 Nov 24. Epub 2020 Nov 24.

Department of Ophthalmology, New York University Langone Health, New York, New York.

Purpose: To study the effect of phacoemulsification on intraocular pressure (IOP) control in patients with preexisting glaucoma drainage implants (GDIs).

Design: Retrospective, observational case series.

Participants: A total of 45 patients (51 eyes) with previously placed GDIs who underwent phacoemulsification between January 2013 and March 2018.

Methods: The list of patients was obtained from billing records. Clinical data were retrieved from the corresponding electronic medical records.

Main Outcome Measures: Intraocular pressure, number of glaucoma medications before and after phacoemulsification (postoperative day 1, week 1, months 1, 3, 6, 12, 18, and 24), rate of failure (failure defined as IOP >18 mmHg and IOP increase >20% at 2 consecutive visits after month 1, need for additional glaucoma surgery, or loss of light perception vision), and postoperative complications.

Results: Mean follow-up was 23.0 ± 11.1 months. The average interval between GDI surgery and phacoemulsification was 9.4 ± 6.7 months. An Ahmed glaucoma valve (AGV; New World Medical) was implanted in 12 eyes, a Baerveldt glaucoma implant (BGI; Johnson & Johnson Surgical Vision) was implanted in 36 eyes, and a Molteno (Molteno Ophthalmic Limited) glaucoma implant was implanted in 3 eyes. Before phacoemulsification, the mean IOP was 14.4 ± 4.4 mmHg on 2.1 ± 1.3 glaucoma medications. At postoperative month 24, the mean IOP was 12.6 ± 4.4 mmHg (n = 29, P = 0.519) on 2.0 ± 1.6 (P = 0.457) glaucoma medications. The reduction in IOP was significant only at postoperative week 1 (P = 0.031). The cumulative failure rate was 3.9% at 1 year and 11.8% at 2 years. The AGV group had a significantly higher mean IOP before phacoemulsification than the BGI group (P = 0.016). Analysis of covariance, taking the baseline IOP as a covariate, revealed no differences in postoperative IOP and number of glaucoma medications between groups, except for month 18 (1 patient in the BGI group had uncontrolled IOP requiring surgery). Postoperative complications included cystoid macular edema (10%), corneal decompensation (6%), and choroidal effusion (4%).

Conclusions: Phacoemulsification after GDI surgery resulted in a transient reduction in IOP at postoperative week 1. Patients with previously placed AGVs had similar postoperative outcomes compared with those with BGIs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ogla.2020.11.006DOI Listing
November 2020

XEN Gel Stent Open Conjunctiva Technique: A Practical Approach Paper.

Adv Ther 2020 05 21;37(5):2538-2549. Epub 2020 Mar 21.

Wilmer Eye Institute, Bethesda, MD, USA.

The Xen Gel Stent lowers intraocular pressure by shunting aqueous humor to the subconjunctival space. While published studies include both open conjunctiva and closed conjunctiva approaches, most publications feature a closed conjunctiva, ab interno approach. While this approach is widely used, other approaches may be preferred for some patients. This paper provides details on surgical steps and tips for enhancing outcomes for an open conjunctiva technique for the implantation of the Xen Gel Stent, as well as reasoning as to when this approach should be used.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12325-020-01278-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467501PMC
May 2020

Subconjunctival microinvasive glaucoma surgeries: an update on the Xen gel stent and the PreserFlo MicroShunt.

Curr Opin Ophthalmol 2020 Mar;31(2):132-138

New York University Langone Health, New York, New York, USA.

Purpose Of Review: This review will provide an update on surgical techniques, outcomes, and complications for two new translimbal bleb-forming surgical glaucoma devices.

Recent Findings: The XEN Gel Microstent and PreserFlo MicroShunt comprise a category of subconjunctival microinvasive glaucoma surgery developed with the aim of improving the predictability and safety profile of bleb-forming procedures. Both devices are made of noninflammatory material which limits postsurgical inflammation and scarring and have a valve-less intrinsic flow-limiting design, which decreases the risk of hypotony. There are various techniques of implantation for the XEN Gel Microstent each with their own advantages and disadvantages.

Summary: These devices have demonstrated promising outcomes in early experimental literature with similar intraocular pressure-lowering effects to traditional incisional surgery such as trabeculectomy or tube shunt surgery, but with fewer risks. Future randomized, prospective studies should be done to compare these gel stents and microshunts both to each other and to other traditional glaucoma surgeries.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ICU.0000000000000643DOI Listing
March 2020

Utility of the Modified Isolated-check Visual Evoked Potential Technique in Functional Glaucoma Assessment.

J Glaucoma 2020 04;29(4):258-263

New York Eye & Ear Infirmary of Mount Sinai.

PRE[COMBINING ACUTE ACCENT]CIS:: Cortical response to low-contrast stimuli, as measured by isolated-check visual evoked potential (icVEP) technology, has the potential to provide functional assessment that may complement standard achromatic perimetry in assessing glaucomatous change.

Purpose: To evaluate the utility of modified icVEP testing in detecting functional glaucomatous damage.

Materials And Methods: Subjects who met predetermined criteria of controls, glaucoma suspects, preperimetric glaucoma, or glaucoma were enrolled in this prospective cross-sectional study from a single tertiary care center. Glaucoma patients were further categorized as early, moderate, advanced, or severe on the basis of Hodapp-Anderson-Parrish criteria. icVEP testing was performed with ten 2-second runs per qualified eye using the EvokeDx testing software. Multivariate statistics were used to calculate signal-to-noise ratios (SNR) and perform outlier analysis.

Results: In total, 140 eyes met criteria (mean±SD; age of 63±14 y; 49% male; logMAR visual acuity, 0.11±0.089). There was no significant difference in age, sex, or logMAR visual acuity among the groups. Controls had a significantly higher SNR than all other groups (P<0.003), including patients with preperimetric glaucoma. Among those with glaucoma, the early glaucoma patients had significantly higher SNR than the moderate, advanced, or severe glaucoma cohorts (P<0.04). The optimal SNR cutoff for differentiating between glaucomatous and nonglaucomatous eyes was 0.95, both with (sensitivity 82%, specificity 76%) and without (sensitivity 82%, specificity 100%) glaucoma suspects included in analysis.

Conclusions: icVEP technology has the potential to complement standard achromatic perimetry in functional assessment of glaucomatous defects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0000000000001439DOI Listing
April 2020

Downsizing a Baerveldt Glaucoma Implant For the Management of Persistent Postoperative Hypotony: A Case Series.

J Glaucoma 2019 11;28(11):1019-1022

Department of Ophthalmology, Icahn School of Medicine at Mount Sinai.

Purpose: The purpose of this study was to describe a surgical technique for treating persistent hypotony after Baerveldt glaucoma implant (BGI) surgery.

Materials And Methods: The medical records of 10 patients with persistent postoperative hypotony who underwent truncation of one or both wings of a previously placed BGI, combined with external ligation of the tube using a polypropylene suture, were retrospectively reviewed.

Results: All 10 eyes that underwent BGI truncation and placement of a single, external, nonabsorbable (polypropylene) tube ligature exhibited resolution of hypotony within 24 hours and resolution of choroidal effusions within the first 2 postoperative weeks. The median time interval between primary BGI surgery and truncation was 5 months (range, 1.5 mo to 8 y). Median postrevision follow-up time was 12 months (range, 5 mo to 16.2 y). The mean preoperative intraocular pressure (IOP) was 2.1±1.0 mm Hg, and the mean IOP rose to 29.2±13.9 mm Hg on postoperative day 1. Mean IOP at week 1, month 1, and month 3 was 20.5±10.4, 19.7±11.8, and 18.0±8.2 mm Hg, respectively, using an average of 1.4±1.4 glaucoma medications at postoperative month 3. Ligature release after BGI revision was performed in 9 (90%) of the 10 patients. The median time to ligature release was 1.5 months (range, 3 wk to 4 y). There was no recurrence of hypotony in any of these patients. At most recent follow-up, the mean IOP was 12.9±6.0 mm Hg on an average of 1.5±1.3 glaucoma medications. Five patients demonstrated improvement in visual acuity from their prerevision best-corrected visual acuity.

Conclusions: Truncation of one or both wings of a BGI and complete closure of the tube with nonabsorbable, but releasable, suture ligature is an effective and safe method for reversing persistent postoperative hypotony while maintaining IOP control.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0000000000001365DOI Listing
November 2019

Patient Preferences for Physician Attire in Ophthalmology Practices.

J Acad Ophthalmol 2019 Jan;11(1):e36-e42

Envision Eye & Aesthetics, Rochester, New York.

Importance: Interest is growing in targeting physician attire to improve the patient experience. Few studies in ophthalmology have examined patient preferences for physician attire.

Objective: To understand patient preferences for physician attire in ophthalmology practices in the United States.

Design: Survey-based, cohort study.

Setting: Two private and two academic ophthalmology practices.

Participants: A convenience sample of patients receiving ophthalmic care between June 1, 2015 and October 31, 2016.

Methods: A questionnaire containing 22 questions and photographs of a male and female physician in seven forms of attire were presented to patients; 14 unique questionnaires were randomly distributed. Patient preference for physician attire was the primary outcome determined by summing ratings of how knowledgeable, trustworthy, caring, approachable, and comfortable the pictured physician made the respondent feel. One-way ANOVA assessed differences in mean composite scores. Comparisons between respondent demographics, practice type, and attire preferences were assessed by chi-square tests. Patient satisfaction was assessed by agreement with questions about importance of physician attire and whether this influences happiness with care.

Results: In total, 1,297 of 1,826 (71.0%) questionnaires were completed. Physician attire was rated as "important" by 62.9% of participants. A total of 43.6% of participants indicated that physician attire influenced how happy they were with their care. Overall, formal attire with white coat was preferred to casual, formal, and business attire (all comparisons, < 0.05). No differences in composite scores between formal attire with white coat, scrubs alone, scrubs with white coat, or casual attire with white coat were observed. However, compared with formal attire with white coat, physicians wearing scrubs without white coat appeared less knowledgeable (mean [standard deviation]: 8.2 [1.8] vs. 7.4 [2.1]; < 0.05) and trustworthy (8.3 [1.8] vs. 7.6 [2.1]; < 0.05). Additionally, casual attire with white coat was rated as less knowledgeable compared with formal attire with white coat (7.4 [2.0] vs. 8.2 [1.8]; < 0.05). Preferences for attire varied by clinical setting: patients preferred surgeons (45.2%) and physicians in emergency rooms (41.7%) in scrubs rather than formal attire with white coat.

Conclusions: Physician attire is important to patients receiving ophthalmic care. Policies aimed at physician attire in ophthalmology practices should be considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0039-1688913DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716523PMC
January 2019

Descemet's membrane detachment following an intracameral injection of viscoelastic.

Am J Ophthalmol Case Rep 2019 Dec 20;16:100466. Epub 2019 May 20.

NYU Langone Eye Center, New York University School of Medicine, New York, NY, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajoc.2019.100466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6700441PMC
December 2019

Genetic Architecture of Primary Open-Angle Glaucoma in Individuals of African Descent: The African Descent and Glaucoma Evaluation Study III.

Ophthalmology 2019 01 21;126(1):38-48. Epub 2018 Oct 21.

Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California, San Diego, La Jolla, California. Electronic address:

Purpose: To find genetic contributions to glaucoma in African Americans.

Design: Cross-sectional, case-control study.

Participants: One thousand eight hundred seventy-five primary open-angle glaucoma (POAG) patients and 1709 controls, self-identified as being of African descent (AD), from the African Descent and Glaucoma Evaluation Study (ADAGES) III and Wake Forest School of Medicine.

Methods: MegaChip genotypes were imputed to Thousand Genomes data. Association of single nucleotide polymorphisms (SNPs) with POAG and advanced POAG was tested by linear mixed model correcting for relatedness and population stratification. Genetic risk scores were tested by receiver operator characteristic curves (ROC-AUCs).

Main Outcome Measures: Primary open-angle glaucoma defined by visual field loss without other nonocular conditions (n = 1875). Advanced POAG was defined by age-based mean deviation of visual field (n = 946).

Results: Eighteen million two hundred eighty-one thousand nine hundred twenty SNPs met imputation quality of r > 0.7 and minor allele frequency > 0.005. Association of a novel locus, EN04, was observed for advanced POAG (rs185815146 β, 0.36; standard error, 0.065; P < 3×10). For POAG, an AD signal was observed at the 9p21 European descent (ED) POAG signal (rs79721419; P < 6.5×10) independent of the previously observed 9p21 ED signal (rs2383204; P < 2.3×10) by conditional analyses. An association with POAG in FNDC3B (rs111698934; P < 3.9×10) was observed, not in linkage disequilibrium (LD) with the previously reported ED SNP. Additional previously identified loci associated with POAG in persons of AD were: 8q22, AFAP1, and TMC01. An AUC of 0.62 was observed with an unweighted genetic risk score comprising 11 SNPs in candidate genes. Two additional risk scores were studied by using a penalized matrix decomposition with cross-validation; risk scores of 50 and 400 SNPs were identified with ROC of AUC = 0.74 and AUC = 0.94, respectively.

Conclusions: A novel association with advanced POAG in the EN04 locus was identified putatively in persons of AD. In addition to this finding, this genome-wide association study in POAG patients of AD contributes to POAG genetics by identification of novel signals in prior loci (9p21), as well as advancing the fine mapping of regions because of shorter average LD (FNDC3B). Although not useful without confirmation and clinical trials, the use of genetic risk scores demonstrated that considerable AD-specific genetic information remains in these data.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ophtha.2018.10.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6309605PMC
January 2019

Update on Microinvasive Glaucoma Surgery.

Int Ophthalmol Clin 2018 ;58(3):101-115

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IIO.0000000000000229DOI Listing
February 2019

Suture Stenting of a Tube Fenestration for Early Intraocular Pressure Control After Baerveldt Glaucoma Implant Surgery.

J Glaucoma 2018 03;27(3):291-296

New York Eye and Ear Infirmary of Mount Sinai, New York, NY.

Purpose: To evaluate the efficacy and safety of a tube fenestration stented with a 10-0 polyglactin suture for controlling early postoperative intraocular pressure (IOP) after Baerveldt glaucoma implant (BGI) surgery.

Methods: The medical records of 110 patients (119 eyes) who underwent BGI surgery with a tube fenestration stented with a 10-0 polyglactin suture anterior to an occlusive tube ligature were retrospectively reviewed. Main outcome measures included IOP and number of glaucoma medications at postoperative day 1, week 1, and weeks 2 to 3 as well as complications occurring before ligature release.

Results: Mean±SD preoperative IOP was 30.9±9.3 mm Hg using an average of 3.8±1.1 glaucoma medications. A statistically significant reduction in IOP and glaucoma medications was observed at all timepoints during the first 3 postoperative weeks compared with baseline (P<0.001). Mean IOP on postoperative day 1, week 1, and weeks 2 to 3 was 18.4±12.2 mm Hg on no medication, 15.9±9.4 mm Hg on 1.0±1.3 medications, and 16.7±8.2 mm Hg on 1.2±1.5 medications, respectively. In total, 44 eyes (37%) achieved IOP control without glaucoma medication during period of tube occlusion.

Conclusions: The use of a single, monofilament 10-0 polyglactin suture to stent a fenestration proximal to the occlusive ligature of a BGI tube is effective in controlling IOP in the early postoperative period. Hypotony-related complications were infrequent and resolved in all cases with in-office interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0000000000000885DOI Listing
March 2018

The African Descent and Glaucoma Evaluation Study (ADAGES) III: Contribution of Genotype to Glaucoma Phenotype in African Americans: Study Design and Baseline Data.

Ophthalmology 2019 01 1;126(1):156-170. Epub 2018 Feb 1.

Department of Ophthalmology, Hamilton Glaucoma Center, Shiley Eye Institute, University of California, San Diego, La Jolla, California. Electronic address:

Purpose: To describe the study protocol and baseline characteristics of the African Descent and Glaucoma Evaluation Study (ADAGES) III.

Design: Cross-sectional, case-control study.

Participants: Three thousand two hundred sixty-six glaucoma patients and control participants without glaucoma of African or European descent were recruited from 5 study centers in different regions of the United States.

Methods: Individuals of African descent (AD) and European descent (ED) with primary open-angle glaucoma (POAG) and control participants completed a detailed demographic and medical history interview. Standardized height, weight, and blood pressure measurements were obtained. Saliva and blood samples to provide serum, plasma, DNA, and RNA were collected for standardized processing. Visual fields, stereoscopic disc photographs, and details of the ophthalmic examination were obtained and transferred to the University of California, San Diego, Data Coordinating Center for standardized processing and quality review.

Main Outcome Measures: Participant gender, age, race, body mass index, blood pressure, history of smoking and alcohol use in POAG patients and control participants were described. Ophthalmic measures included intraocular pressure, visual field mean deviation, central corneal thickness, glaucoma medication use, or past glaucoma surgery. Ocular conditions, including diabetic retinopathy, age-related macular degeneration, and past cataract surgery, were recorded.

Results: The 3266 ADAGES III study participants in this report include 2146 AD POAG patients, 695 ED POAG patients, 198 AD control participants, and 227 ED control participants. The AD POAG patients and control participants were significantly younger (both, 67.4 years) than ED POAG patients and control participants (73.4 and 70.2 years, respectively). After adjusting for age, AD POAG patients had different phenotypic characteristics compared with ED POAG patients, including higher intraocular pressure, worse visual acuity and visual field mean deviation, and thinner corneas (all P < 0.001). Family history of glaucoma did not differ between AD and ED POAG patients.

Conclusions: With its large sample size, extensive specimen collection, and deep phenotyping of AD and ED glaucoma patients and control participants from different regions in the United States, the ADAGES III genomics study will address gaps in our knowledge of the genetics of POAG in this high-risk population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ophtha.2017.11.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050158PMC
January 2019

Complications of micro-invasive glaucoma surgery.

Curr Opin Ophthalmol 2018 Mar;29(2):147-154

Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Purpose Of Review: Micro-invasive glaucoma surgery (MIGS) is gaining favor with both comprehensive ophthalmologists and glaucoma specialists due in part to its improved safety profile when compared to traditional incisional glaucoma surgery. Despite a micro-invasive approach and minimal induced tissue trauma, each MIGS procedure is associated with unique complications. The present article summarizes evidence from the 2016 to 2017 review period regarding the safety profiles of Schlemm's canal-based, suprachoroidal, and subconjunctival microstents.

Recent Findings: Ab-interno microstents are subject to intraoperative malpositioning, which can result in luminal obstruction and decreased efficacy. Acutely elevated intraocular pressure (IOP) has been observed with the iStent (Glaukos Corp., Laguna Hills, CA, USA; 2-4.3%), Hydrus Microstent (Ivantis Inc., Irvine, CA, USA; 6%), Cypass Microstent (Alcon, Fort Worth, TX, USA; 3-10.8%), and Xen Gel Stent (Allergan Plc, Dublin, Ireland; 21.5%). Meanwhile, most cases of hypotony (IOP < 6 mmHg) occurred within the first postoperative month, resolved with conservative treatment and without further surgical intervention, and were not associated with vision-threatening sequelae.

Summary: Interest in MIGS continues to grow as these procedures allow surgeons to intervene earlier in the disease course for patients with milder stages of glaucoma. Complications associated with MIGS, albeit infrequent and mostly transient, do occur despite a less invasive approach than trabeculectomy and tube shunt surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ICU.0000000000000457DOI Listing
March 2018

Practice Preferences for Glaucoma Surgery: A Survey of the American Glaucoma Society.

J Glaucoma 2017 Aug;26(8):687-693

*Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, Icahn School of Medicine, New York, NY †Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL ‡Department of Ophthalmology, University of Washington, Seattle, WA.

Purpose: The purpose of this study is to assess surgical practice patterns among the American Glaucoma Society (AGS) membership.

Methods: An anonymous online survey evaluating the use of glaucoma surgeries in various clinical settings was redistributed to AGS members. Survey responses were compared with prior results from 1996, 2002, and 2008 to determine shifts in surgical practice patterns. Questions were added to assess the preferred approach to primary incisional glaucoma surgery and phacoemulsification combined with glaucoma surgery.

Results: A total of 252 of 1091 (23%) subscribers to the AGS-net participated in the survey. Percentage use (mean±SD) of trabeculectomy with mitomycin C (MMC), glaucoma drainage device (GDD), and minimally invasive glaucoma surgery (MIGS) as an initial surgery in patients with primary open angle glaucoma was 59%±30%, 23%±23%, and 14%±20%, respectively. Phacoemulsification cataract extraction alone was the preferred surgical approach in 44%±32% of patients with primary open angle glaucoma and visually significant cataract, and phacoemulsification cataract extraction was combined with trabeculectomy with MMC in 24%±23%, with MIGS in 22%±27%, and with GDD in 9%±14%. Although trabeculectomy was selected most frequently to surgically manage glaucoma in 8 of 8 clinical settings in 1996, GDD was preferred in 7 of 8 clinical settings in 2016.

Conclusions: The use of GDD has increased and that of trabeculectomy has concurrently decreased over the past 2 decades. Trabeculectomy with MMC is the most popular primary incisional surgery when performed alone or in combination with phacoemulsification cataract extraction. Surgeons frequently manage coexistent cataract and glaucoma with cataract extraction alone, rather than as a combined cataract and glaucoma procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0000000000000720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726398PMC
August 2017

Vitreous Occlusion of a Glaucoma Drainage Implant-Surgical Management.

J Glaucoma 2017 Jul;26(7):669-672

Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, NY.

Vitreous occlusion of a glaucoma drainage implant (GDI) can lead to failure of the device and severely elevated intraocular pressure. The pathophysiology of tube obstruction is related to central and anterior displacement of vitreous that is drawn into and condenses within the proximal lumen of the tube. This can occur from days to years following GDI surgery. Successful management of vitreous-tube obstruction generally requires manual removal of the condensed vitreous plug with end-grasping forceps. This technique achieves reversal of tube blockage and restoration of GDI function. Amputation of the incarcerated vitreous alone with vitrectomy or neodymium:yttrium-aluminum-garnet vitreolysis does not consistently restore GDI function and risks persistent intraluminal tube obstruction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0000000000000694DOI Listing
July 2017

Long-term Outcomes and Complications of Pars Plana Baerveldt Implantation in Children.

J Glaucoma 2017 Mar;26(3):266-271

Department of Ophthalmology, Icahn School of Medicine at Mount Sinai and New York Eye and Ear Infirmary of Mount Sinai, New York, NY.

Purpose Of The Study: The purpose of the study was to report long-term outcomes and complications of Baerveldt glaucoma implant (BGI) surgery with pars plana tube insertion in children.

Materials And Methods: The medical records of consecutive aphakic and pseudophakic children (<16 y of age) who underwent BGI surgery with pars plana tube insertion between 1990 and 2013 were retrospectively reviewed. Main outcome measures were intraocular pressure and number of glaucoma medications. Postoperative complications were recorded. Failure was defined as an intraocular pressure <5 or ≥21 mm Hg (with or without glaucoma medications), loss of light perception, or need for additional glaucoma surgery.

Results: Thirty-seven children were identified with a mean age of 6.0±4.7 years (range, 4 mo to 14.5 y). Mean follow-up after pars plana BGI surgery was 6.5±3.4 years (range, 9 mo to 12.8 y) for patients who met success criteria. Mean intraocular pressure and mean number of glaucoma medications at most recent follow-up for patients with successful intraocular pressure control were 13.8±4.1 and 2.3±1.9 mm Hg, respectively. The Kaplan-Meier survival analysis revealed 1-, 3-, 5-, and 7-year success rates of 94.5%, 74.6%, 65.0%, and 45.8%, respectively. Complications included tube exposure in 1 patient (2.7%), tube obstruction in 8 patients (21.6%), and retinal detachment in 9 patients (24.3%). Seventeen patients (45.9%) failed due to inadequate intraocular pressure control, of whom 9 (24.3%) required additional glaucoma surgery.

Conclusions: Although pars plana BGI surgery is a reasonable option for managing refractory glaucoma in aphakic and pseudophakic children, surgeons must be aware of the potential need for additional glaucoma surgery and/or posterior segment complications with extended follow-up.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0000000000000611DOI Listing
March 2017

Optical Coherence Tomography Angiography Analysis of Perfused Peripapillary Capillaries in Primary Open-Angle Glaucoma and Normal-Tension Glaucoma.

Invest Ophthalmol Vis Sci 2016 07;57(9):OCT611-OCT620

Department of Ophthalmology, The New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, New York, United States.

Purpose: To compare perfused peripapillary capillary density in primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG), and normal patients using optical coherence tomography angiography (OCT-A).

Methods: A retrospective review of POAG, NTG, and normal patients imaged with OCT-A was performed. En face OCT angiograms identifying peripapillary vessels were obtained using a spectral-domain OCT system (Avanti RTVue-XR). A custom image analysis approach identified perfused peripapillary capillaries, quantified perfused capillary density (PCD), and generated color-coded PCD maps for 3.5- and 4.5-mm-diameter scans. We compared PCD values, PCD maps, standard automated perimetry (Humphrey visual field [HVF]) parameters, and OCT retinal nerve fiber layer (RNFL) thickness analyses across all groups.

Results: Forty POAG, 26 NTG, and 26 normal patients were included. Annular PCD in POAG (34.24 ± 6.76%) and NTG (37.75 ± 3.52%) patients was significantly decreased compared to normal patients (42.99 ± 1.81%) in 4.5-mm scans (P < 0.01 and P < 0.01, respectively). Similar trends and statistical significances were seen in 3.5-mm scans. Linear regression analysis resulted in moderate correlations between annular PCD values and other glaucomatous parameters. Pearson coefficients comparing annular PCD from 4.5-mm scans in POAG and NTG groups to HVF mean deviation, HVF pattern standard deviation, and average RNFL thickness all showed statistical significance (P < 0.05). Color maps showed that POAG and NTG patients had a reduction of perfused capillaries that progressed in size when comparing early, moderate, and severe glaucoma groups.

Conclusions: Optical coherence tomography angiography can uniquely identify changes in peripapillary PCD in glaucoma patients. Optical coherence tomography angiography may offer insights into the pathophysiology of glaucomatous damage and risk factors for disease progression.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1167/iovs.15-18945DOI Listing
July 2016

Reply.

Ophthalmology 2016 10;123(10):e62-3

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ophtha.2016.03.004DOI Listing
October 2016

Transconjunctival Revision With Mitomycin-C Following Failed Trabeculectomy.

J Glaucoma 2016 07;25(7):618-22

Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai and Icahn School of Medicine at Mount Sinai, New York, NY.

Purpose: To evaluate the efficacy of transconjunctival revision (TCR) with mitomycin-C (MMC) following failed trabeculectomy.

Materials And Methods: The medical records of 27 patients (27 eyes) who underwent TCR with subconjunctival injection of MMC by a single surgeon between September 2001 and August 2013 were retrospectively reviewed. The same surgical protocol was followed for all patients. Revision was performed using a microvitreoretinal blade through a small conjunctival incision. Main outcome measures included visual acuity, intraocular pressure (IOP), and number of glaucoma medications. Failure was defined as an IOP<5 or >14 mm Hg, loss of light perception, or need for additional glaucoma surgery.

Results: Mean interval between trabeculectomy and TCR was 56.4±57.2 months. Mean preoperative IOP was 21.9±6.8 mm Hg using 4.0±1.2 glaucoma medications. Fifteen (55.6%) patients met success criteria. At most recent follow-up, mean IOP and number of glaucoma medications for successful patients were 9.7±3.8 mm Hg and 0.6±1.1, respectively. Kaplan-Meier analysis revealed 1-, 2-, and 3-year success rates of 62%, 58%, and 53%, respectively. Three additional patients achieved success after undergoing a second TCR, and 1 patient achieved success after a third TCR. Postoperative complications included transient choroidal effusion (n=8), shallow anterior chamber requiring reformation (n=5), 5-fluorouracil-related corneal epitheliopathy (n=10), and bleb leak (n=1).

Conclusions: TCR with adjunctive MMC is a safe and effective procedure following failure of a trabeculectomy. More than 1 revision may be necessary to achieve long-term IOP reduction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0000000000000408DOI Listing
July 2016

A Retrospective Comparison of Primary Baerveldt Implantation versus Trabeculectomy with Mitomycin C.

Ophthalmology 2016 Apr 30;123(4):789-95. Epub 2015 Dec 30.

Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.

Purpose: To compare the safety and efficacy of Baerveldt implantation (Abbott Medical Optics, Santa Ana, CA) and trabeculectomy with mitomycin C (MMC) in patients who have not undergone prior incisional ocular surgery.

Design: Retrospective, comparative case series.

Participants: A total of 125 patients with low-risk glaucoma undergoing primary glaucoma surgery, including 55 patients who received a 350-mm(2) Baerveldt glaucoma implant and 70 patients who underwent trabeculectomy with MMC.

Methods: Eligible patients were identified using Current Procedural Terminology codes, and their medical records were reviewed retrospectively.

Main Outcome Measures: The primary outcome measure was surgical success (intraocular pressure [IOP] ≤21 mmHg and reduced ≥20% from baseline, IOP >5 mmHg, no reoperation for glaucoma, no loss of light-perception vision). Secondary outcome measures included visual acuity, IOP, number of glaucoma medications, and complications.

Results: The cumulative probability of success at 3 years with or without medical therapy was 87% in the Baerveldt group and 76% in the trabeculectomy group (P = 0.23). Postoperative complications occurred in 11 patients (20%) in the Baerveldt group and 20 patients (29%) in the trabeculectomy group (P = 0.27). Mean follow-up ± standard deviation was 27±19 months in the Baerveldt group and 34±20 months in the trabeculectomy group (P = 0.053).

Conclusions: Similar rates of surgical success and postoperative complications were observed in patients undergoing trabeculectomy with MMC and in those undergoing Baerveldt implantation during 3 years of follow-up. Both are viable primary glaucoma procedures in patients who have not undergone prior ocular surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ophtha.2015.11.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5584064PMC
April 2016

Postoperative management of trabeculectomy and glaucoma drainage implant surgery.

Curr Opin Ophthalmol 2016 Mar;27(2):170-6

Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai and the Icahn School of Medicine at Mount Sinai, New York, USA.

Purpose Of Review: This article describes important aspects of postoperative management after trabeculectomy and glaucoma drainage implant surgery.

Recent Findings: Postoperative management of glaucoma drainage implant surgery includes stabilization of intraocular pressure, possible ligature release, and management of complications such as corneal edema, and tube/plate exposure. Postoperative management of trabeculectomy includes evaluation of bleb encapsulation, management of hypotony, and assessment of need for adjuvant therapy. Recent advances in surgical techniques, device/tissue availability, and imaging continue to shape the postoperative course.

Summary: Careful preoperative planning and postoperative care may decrease the likelihood of complications in tube surgery or trabeculectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ICU.0000000000000240DOI Listing
March 2016

Clinical impact of 8 prospective, randomized, multicenter glaucoma trials.

J Glaucoma 2015 Jan;24(1):64-8

*Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL †Department of Ophthalmology, New York Eye and Ear Infirmary, New York ‡New York Medical College, Valhalla, NY §Department of Ophthalmology, University of North Carolina at Chapel Hill, Chapel Hill, NC ∥Department of Ophthalmology, Stanford University, Palo Alto, CA.

Purpose: To determine the impact of 8 multicenter randomized clinical trials (RCTs) on glaucoma practice.

Methods: An electronic survey was distributed to the members of the American Glaucoma Society (AGS). Each participant was asked 2 study-specific questions and 1 standard question common to all 8 RCTs assessing the study's impact on clinical practice. RCTs included in the survey were the Advanced Glaucoma Intervention Study (AGIS), Collaborative Initial Glaucoma Treatment Study (CIGTS), Collaborative Normal Tension Glaucoma (CNTG) Study, European Glaucoma Prevention Study (EGPS), Early Manifest Glaucoma Trial (EMGT), Glaucoma Laser Trial (GLT), Ocular Hypertension Treatment Study (OHTS), and Tube Versus Trabeculectomy (TVT) Study. A 5-point Likert scale was used for rating all responses. The practice setting and duration of glaucoma practice was determined for all AGS members who responded.

Results: A total of 206 (23.0%) of 894 AGS members participated in the survey. Among those who responded, 46.4% were self classified as academic practitioners and 53.6% worked in a private practice setting. Mean Likert scores for the standard question evaluating the overall impact of the RCT were OHTS 4.47, CNTG Study 4.13, AGIS 3.78, TVT Study 3.53, EMGT 3.48, CIGTS 3.44, GLT 3.39, and 2.69 EGPS.

Conclusions: Substantial differences were observed in the clinical impact of several RCTs in glaucoma. The reported impact of each study likely reflects several factors including study timing, design, conduct, and interpretation of results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0b013e318295200bDOI Listing
January 2015

Evidenced-based comparison of aqueous shunts.

Curr Opin Ophthalmol 2013 Mar;24(2):87-95

Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL 33136, USA.

Purpose Of Review: This review provides an evidence-based comparison of aqueous shunts in common use.

Recent Findings: Aqueous shunts are being used with increasing frequency in the surgical management of glaucoma. Recent retrospective studies and prospective clinical trials have compared the outcomes of different shunt designs. Larger end-plate size is associated with greater intraocular pressure (IOP) reduction, but there may be an upper limit beyond which a further increase in plate surface area does not contribute beneficially to pressure control. The biocompatibility of plate material may also influence shunt efficacy. The flow restrictor of the Ahmed glaucoma valve provides an added level of safety by reducing the risk of postoperative hypotony, but this implant also appears to have a higher incidence of bleb encapsulation.

Summary: Several aqueous shunts are commercially available, and all have been shown to be safe and effective in lowering IOP. Studies comparing aqueous shunts have provided valuable information to assist in surgical decision-making in similar patient groups.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/ICU.0b013e32835cf0f5DOI Listing
March 2013

Transscleral diode laser cyclophotocoagulation after baerveldt glaucoma implant surgery.

J Glaucoma 2014 Aug;23(6):405-9

*Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL †Department of Ophthalmology, The New York Eye and Ear Infirmary, New York, NY ‡New York Medical College, Valhalla, NY.

Purpose: To evaluate the safety and efficacy of transscleral cyclophotocoagulation (TSCPC) in patients requiring intraocular pressure (IOP) reduction despite prior Baerveldt glaucoma implant (BGI) surgery.

Participants And Methods: Twenty eyes of 20 patients who had previously undergone BGI placement and subsequently underwent TSCPC with the red (810 nm) diode laser between April 2005 and January 2010 were retrospectively reviewed.

Results: All patients underwent BGI placement an average of 34.7±24.2 months before TSCPC. The mean follow-up period after TSCPC was 25.6±17.4 months (range, 2.3 to 56.5 mo). IOPs were reduced from a mean of 21.8±4.6 to 10.8±3.2 mm Hg at the most recent follow-up, which represents a 50.2% reduction in mean IOP. Successful postoperative IOP control was achieved in 16 (80%) of 20 patients. The number of glaucoma medications decreased from 4.2±0.6 to 2.2±1.2. The life-table success rate was 78.6% at 12, 24, and 36 months. Postoperative complications included persistent corneal edema in 1 patient and both persistent corneal edema and cystoid macular edema in another patient. Both patients sustained a >2 line reduction in Snellen visual acuity.

Conclusions: TSCPC is safe and effective in the management of patients requiring IOP reduction after BGI surgery. Although our sample size was limited, the safety profile of TSCPC after BGI seems promising.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0b013e318279c957DOI Listing
August 2014

Scleral fistula closure at the time of glaucoma drainage device tube repositioning: a novel technique.

Arch Ophthalmol 2012 Nov;130(11):1447-51

Bascom Palmer Eye Institute, 900 17th St NW, Miami, FL 33136, USA.

Repositioning a glaucoma drainage device tube from the anterior chamber to the ciliary sulcus or pars plana can be a challenging procedure owing to the difficulty in obtaining tight closure of the original limbal fistula. Failure to achieve watertight and airtight closure of the fistula can result in substantial difficulty in completing other key portions of the surgery and may lead to postoperative hypotony and associated complications. A novel technique using a Tutoplast scleral plug, polyglactin sutures, and, in certain cases, fibrin tissue sealant to close a limbal fistula at the time of glaucoma drainage device tube repositioning is described. This technique can be replicated with ease and provides a tight seal so that other concurrent surgical procedures can safely be completed and postoperative hypotony is avoided.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/archophthalmol.2012.2219DOI Listing
November 2012

Angle closure after Boston keratoprosthesis.

J Glaucoma 2013 Dec;22(9):725-9

*Department of Ophthalmology, New York Eye and Ear Infirmary †New York Medical College, New York, NY ‡Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL.

Purpose: To evaluate changes in the anterior chamber angle after Boston keratoprosthesis (KPro) placement.

Patients/methods: Ten patients were serially imaged with anterior segment optical coherence tomography after Boston KPro surgery. Angles were judged to be open or closed in the horizontal axis.

Results: Seven of 10 patients had open angles before KPro placement. Within 4 months, 4 of 7 patients developed angle closure. Contact between the iris and the backplate was seen in 3 of these patients. Two of the 4 eyes demonstrated progressive angle closure. Intraocular pressure was elevated in 3 patients postoperatively due to the obstruction of a glaucoma drainage device tube (1 eye) and angle closure (2 eyes).

Conclusions: After Boston KPro surgery, patients must be carefully monitored for the onset or progression of glaucoma. Progressive angle closure can occur after placement of a Boston KPro and may be seen in conjunction with irido-backplate touch.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/IJG.0b013e318259b2fcDOI Listing
December 2013