Publications by authors named "Marlene R Moster"

77 Publications

Netarsudil's Effect in Eyes with a History of Selective Laser Trabeculoplasty.

Ophthalmol Glaucoma 2020 Jul - Aug;3(4):306-308. Epub 2020 Jan 22.

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1016/j.ogla.2020.01.005DOI Listing
January 2020

Comparison of Silicone- and Porous-Plate Ahmed Glaucoma Valves.

Med Devices (Auckl) 2020 16;13:213-221. Epub 2020 Jul 16.

Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada.

Purpose: Our aim was to evaluate and compare the clinical outcomes after implantation of the silicone-plate (model FP7) and porous polyethylene-plate (model M4) Ahmed Glaucoma Valves.

Patients And Methods: This was a prospective, multicenter, comparative series. A total of 52 eyes (52 patients) were treated with either the silicone or porous plate Ahmed Glaucoma Valve implant. Hypertensive phase was defined as intraocular pressure >21 mmHg during the first 3 months postoperatively. Success was defined as 5 mmHg ≤intraocular pressure ≤21 mmHg (with or without additional glaucoma medications), without loss of light perception and without additional glaucoma procedures. Patients were monitored for 1 year after surgery.

Results: The pre-operative intraocular pressure was 29.9 ± 6.6 mmHg and 33.8 ± 10.5 in the silicone-plate and porous-plate groups, respectively (P = 0.118). At 12 months after surgery, the mean intraocular pressure was 13.6 ± 4.7 mmHg in the silicone-plate group and 17.9 ± 10.9 mmHg in the porous-plate group (P = 0.141). The mean number of glaucoma medications at 12 months was 1.64 ± 1.40 mmHg and 1.89 ± 1.54 mmHg in the silicone- and porous-plate groups, respectively (P = 0.605). Hypertensive phase was not significantly different in the two groups (50.0% of the silicone-plate and 57.7% of the porous-plate groups, P = 0.578). At 12 months after surgery, the percent success for the silicone-plate and porous-plate groups was 88.5% and 53.8%, respectively (P = 0.005). Complications were similar in the two groups.

Conclusion: The porous-plate Ahmed Glaucoma Valve showed similar average intraocular pressure reduction compared with the silicone-plate model. At 12 months after surgery, there was a significantly lower success rate in the porous-plate compared with the silicone-plate group.
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http://dx.doi.org/10.2147/MDER.S258498DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371999PMC
July 2020

Predictors of Success in Selective Laser Trabeculoplasty.

Ophthalmol Glaucoma 2020 Mar - Apr;3(2):97-102. Epub 2019 Nov 30.

Wills Eye Hospital, Philadelphia, Pennsylvania. Electronic address:

Purpose: Selective laser trabeculoplasty (SLT) is a common procedure to lower intraocular pressure (IOP) in patients with glaucoma. However, reports are conflicting regarding what factors contribute to SLT success. The purpose of this study was to determine predictors of SLT success.

Design: Retrospective case series.

Participants: All patients treated with SLT between January 1, 2012, and June 30, 2018.

Methods: Baseline, demographic, procedural, and ophthalmic examination data were recorded at the time of first SLT treatment. Intraocular pressure and medication data were recorded at all follow-up visits.

Main Outcome Measures: Selective laser trabeculoplasty success was defined as IOP decrease of 20% or more from baseline at the 3-month, 6-month, and 12-month follow-up visits. Eyes were considered to have failed and were censored when additional SLT or glaucoma surgery was performed. Patients were excluded if they had less than 3 months of follow-up.

Results: A total of 997 eyes from 677 patients were included in the study. Mean age was 70.2±11.5 years. Selective laser trabeculoplasty success was achieved in 227 eyes (22.8%), whereas 770 eyes (77.2%) did not meet success criteria. Intraocular pressure before SLT was 21.9±5.2 mmHg while taking 2.0±1.2 medications in eyes with successful SLT, compared with 19.0±5.0 mmHg (P < 0.0001) while taking 2.1±1.3 medications (P = 0.52) in eyes with SLT failure. At the 1-year follow-up, mean IOP in eyes with SLT success was 14.7±3.2 mmHg with 2.0±1.2 medications, compared with 16.3±4.7 mmHg (P = 0.008) with a mean of 1.9±1.3 medications (P = 0.37) in eyes with SLT failure. Eyes with SLT success more often showed greater angle pigment (P = 0.03). Age, glaucoma severity, total SLT power, type of glaucoma, severity of glaucoma, visual field mean defect, and retinal nerve fiber layer thickness were not found to correlate with success. No difference was found between the rate of success based on treatments before SLT, whether surgical or medical.

Conclusions: In this large cohort of eyes undergoing SLT, greater IOP and angle pigment before SLT correlated positively with SLT success. Age, total SLT power, severity of glaucoma, and prior treatments were not associated with SLT success or failure.
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http://dx.doi.org/10.1016/j.ogla.2019.11.010DOI Listing
November 2019

In Reply: A Novel Surgical Technique for Ahmed Glaucoma Valve Implantation Without Plate Sutures.

J Glaucoma 2020 09;29(9):e108-e109

Glaucoma Research Center Wills Eye Hospital Philadelphia, PA.

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http://dx.doi.org/10.1097/IJG.0000000000001603DOI Listing
September 2020

Ahmed Versus Baerveldt Glaucoma Drainage Device in Uveitic Glaucoma: A Retrospective Comparative Study.

J Glaucoma 2020 09;29(9):750-755

Wills Eye Hospital, Glaucoma Research Center.

Precis: Baerveldt glaucoma drainage device demonstrated a greater reduction in intraocular pressure (IOP) than Ahmed in patients with uveitic glaucoma. The most common cause of failure was uncontrolled IOP in Ahmed and hypotony in the Baerveldt group.

Purpose: To compare the efficacy and safety of Ahmed and Baerveldt glaucoma drainage devices in uveitic glaucoma.

Materials And Methods: The retrospective comparative study included patients with uveitic glaucoma who underwent Ahmed or Baerveldt glaucoma drainage device implantation with a minimum follow-up of 3 months. Success was defined as IOP ≥6 and ≤21 mm Hg and >20% reduction on 2 consecutive visits after the third month with (qualified success) or without (complete success) medications and no further glaucoma surgery or loss of vision. IOP, number of medications, visual acuity, complications, and interventions were compared between groups.

Results: In total, 137 eyes of 122 patients (67 Ahmed, 70 Baerveldt) were included. The preoperative IOP and number of medications in the Ahmed group (32.7±10.3 mm Hg; 4.1±1.3) were similar to Baerveldt (32.1±10.2 mm Hg; 4.3±1.3; P=0.73, 0.35). These at the last follow-up were (18.1±9.8 mm Hg; 2.1±1) in Ahmed and (12.7±6.9 mm Hg; 1.3±1.3) in Baerveldt groups (P=0.04, 0.01). The Baerveldt had greater IOP reduction (60.3% vs. 44.5%) and complete success rate (30% vs. 9%) with higher complication rate (51.4% vs. 20.9%) (all P≤0.05). The de novo glaucoma reoperation rate was 19% in the Ahmed group and 4% in the Baerveldt group (P=0.006). Hypotony resulted in failure in 7 eyes (10%) in the Baerveldt group and none in the Ahmed group (P=0.013).

Conclusions: Higher complete success rate and significantly greater reduction in mean IOP and number of medications were observed in the Baerveldt group, but with a higher rate of complications including hypotony.
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http://dx.doi.org/10.1097/IJG.0000000000001583DOI Listing
September 2020

Outcomes of Ahmed Glaucoma Valve Implantation With Viscoelastic Fill at Both Beginning and End of Surgery.

J Glaucoma 2020 08;29(8):704-710

Wills Eye Hospital Glaucoma Department.

PRéCIS:: Intracameral injection of viscoelastic at the beginning of Ahmed FP7 implantation did not reduce early postoperative complication rates.

Purpose: To evaluate early postoperative complication rates after a modified technique in which the anterior chamber (AC) is filled with viscoelastic at the beginning of Ahmed FP7 implantation before conjunctival peritomy.

Subjects And Methods: A retrospective chart review was performed of eyes that underwent Ahmed FP7 implantation with or without viscoelastic fill to ~20 mm Hg by finger tension by a single surgeon (M.R.M). Viscoelastic prevented the AC from becoming shallow at any time during surgery, and additional viscoelastic was injected into the AC at the end of surgery to achieve a final intraocular pressure (IOP) of 20 mm Hg.

Results: A total of 159 eyes of 159 patients were included. Mean age was 76.4±10.4 years. Mean preoperative IOP was 30.3±9.7 mm Hg on 2.7±1.2 glaucoma medications. On postoperative day 1, there was an IOP spike ≥30 mm Hg in 0% of patients. Within the first postoperative month, hypotony (<5 mm Hg) occurred in 19 (21.8%) eyes that received viscoelastic fill compared with 5 (13.2%) eyes that did not receive viscoelastic fill (P=0.26). During the early postoperative period (≤3 mo), there was no difference in AC depth, microhyphema, choroidal effusion, or leakage between the 2 groups (P≥0.30 for all). There was a higher rate of layered hyphemas in the viscoelastic-fill group at postoperative week 1 (P=0.01). At 3-month follow-up, mean IOP was 14.9±5.5 mm Hg on 1.6±0.8 medications in the viscoelastic-fill group and 16.0±5.2 mm Hg on 1.0±1.2 medications in the nonviscoelastic-fill group (IOP P=0.35). Compared with baseline, change in IOP at 3 months was similar between both groups (P=0.15). Rates of additional medications and procedures did not differ between the 2 groups at any postoperative visit.

Conclusions: Early intracameral injection of viscoelastic during Ahmed glaucoma valve implantation did not reduce early postoperative complication rates.
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http://dx.doi.org/10.1097/IJG.0000000000001536DOI Listing
August 2020

A Novel Surgical Technique for Ahmed Glaucoma Valve Implantation Without Plate Sutures.

J Glaucoma 2020 03;29(3):161-167

Glaucoma Research Center.

PRéCIS:: A modification to the surgical technique of Ahmed glaucoma valve (AGV) implantation without plate sutures or surgical glue products has a similar safety and efficacy profile than the standard procedure, in the short and mid-term follow-up.

Purpose: The purpose of this study was to assess the safety and efficacy of a modified AGV implantation technique without plate sutures.

Methods: A retrospective case-control study including patients seen in the Glaucoma service of an academic institution. Patients that underwent a modified AGV implantation without plate sutures were included as cases and patients that underwent standard AGV implantation, as controls. Success was defined as intraocular pressure (IOP) reduction >20%, IOP >5 and <21 without the need for additional surgical intervention, and maintenance of light perception.

Results: A total of 170 eyes were included. Mean (range) follow-up was 11.2±7.39 (3 to 24) months. There was no statistically significant difference in visual acuity and IOP between the groups during the postoperative period. In a univariate analysis, there was a larger decrease in IOP for the no plate suture group at the 6 months (-15.6±11.6 vs. -11.5±10.5, P=0.04) and 1 year (-16.4±10.4 vs. -11.1±10.4, P=0.02) visits. There was also a larger decrease in number of medications in the no plate suture group in the 3 months (-1.65±1.5 vs. -1.13±1.22, P=0.02), 6 months (-1.55±1.44 vs. -0.98±1.3, P=0.01) and 1 year (-1.70±1.5 vs. -1.04±1.2, P=0.04) visits. However, those differences were not confirmed by a multivariable model after adjusting for glaucoma type and number of previous glaucoma surgeries. No differences in the trajectory of the survival curves were noted between groups (P=0.36).

Conclusion: The comparison of short and mid-term outcomes of patients undergoing AGV implantation using both techniques showed similar outcomes and success rates.
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http://dx.doi.org/10.1097/IJG.0000000000001428DOI Listing
March 2020

XEN Gel Stent to Treat ICE Syndrome: 4 Cases.

J Glaucoma 2019 12;28(12):1090-1094

Wills Eye Hospital, Philadelphia, PA.

PRéCIS:: This case series reports safe, effective implantation of XEN gel stents to treat iridocorneal endothelial (ICE) syndrome. The stents continue to function well and have not been occluded by membranes or peripheral anterior synechiae, but continued follow-up is necessary.

Purpose: ICE syndrome-related glaucoma is often refractory to medical treatment, and traditional surgical treatment has lower success rates than typical for other types of glaucoma. We present a series of patients who were treated with XEN gel stent implantation.

Patients And Methods: Retrospective case series of 4 patients with ICE syndrome who underwent XEN with subconjunctival mitomycin C injection.

Results: Average preoperative intraocular pressure was 28.5 mm Hg on 3.8 glaucoma medications, and average postoperative intraocular pressure was 10.5 mm Hg on 1.0 medication. No patients required return to the operating room for additional procedures over an average of 6.9 months of follow-up. One patient had shallow anterior chamber that resolved with conservative management. Another had shallow anterior chamber that resolved with anterior chamber reformation with viscoelastic and developed nonappositional choroidal effusions that had resolved at most recent follow-up of 7 months after surgery. No XEN implants have been occluded by membrane formation or peripheral anterior synechiae.

Conclusions: XEN is a safe and effective option for surgical management of ICE syndrome-related glaucoma. Further follow-up surveillance is necessary.
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http://dx.doi.org/10.1097/IJG.0000000000001341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6888868PMC
December 2019

Vision-related Performance and Quality of Life of Patients With Rapid Glaucoma Progression.

J Glaucoma 2019 03;28(3):216-222

Glaucoma Research Center, Wills Eye Hospital.

Purpose: The purpose of this study was to determine how clinical measures, performance-based measures and subjective assessments of vision-related quality of life (VRQoL) are affected in patients with rapid glaucoma progression.

Methods: Prospective longitudinal study that included 153 patients diagnosed with moderate glaucoma. A subset of patients that presented with rapid glaucoma progression (n=22), defined as visual field (VF) mean deviation (MD) loss >2.0 dB/y, were compared with patients with nonrapid progression (n=131). Groups were compared using t tests, χ, or Fisher exact test. Main outcome measures were visual acuity (VA), VF MD, retinal nerve fiber layer thickness (RNFL), contrast sensitivity (CS), Compressed Assessment of Ability Related to Vision (CAARV), and Rasch calibrated National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) scores.

Results: At baseline, patients who progressed rapidly had lower measurements of VA (P=0.041), VF MD (P<0.001), Pelli-Robson score (P=0.004), Spaeth/Richman Contrast Sensitivity (SPARCS) score (P=0.001), RNFL thickness (P=0.009), CAARV total score (P<0.001), and NEI-VFQ-25 composite score (P=0.03). A multivariable logistic regression was performed and showed VF MD to be the only baseline independent predictor of rapid progression. After 1 year, patients who progressed rapidly also had a significant decrease in SPARCS score (P=0.04).

Conclusions: Factors associated with rapid glaucoma progression included worse VF MD decreased scores of performance-based measures and subjectively worse VRQoL. After 1 year, rapid progressors had a significant reduction in contrast sensitivity as measured by SPARCS.
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http://dx.doi.org/10.1097/IJG.0000000000001179DOI Listing
March 2019

Visual Field Changes in Professional Wind versus Non-wind Musical Instrument Players in the Philadelphia Orchestra.

J Ophthalmic Vis Res 2018 Jul-Sep;13(3):224-230

Wills Eye Hospital Glaucoma Research Center, Philadelphia, PA, USA.

Purpose: We compare the prevalence of glaucoma in professional wind versus non-wind instrument players in the Philadelphia Orchestra. Visual field changes in individuals with glaucoma and glaucoma suspects were evaluated, and the results were correlated with cumulative practice time.

Methods: In this cross-sectional, observational study, fifty-one Philadelphia Orchestra musicians were enrolled and categorized as wind or non-wind instrument players. All study participants underwent screening fundus photography. Participants with optic discs suspicious for glaucoma underwent further evaluation, including standard automated visual field perimetry and a comprehensive eye examination by a glaucoma specialist.

Results: Of the 51 musicians enrolled, 9 of the 21 wind instrument players (43%) and 8 of the 30 non-wind instrument players (27%) were suspected of developing glaucoma in at least one eye ( = 0.25), with examinations performed on 12 of the 17 returning musicians (71%) for further confirmation. Wind instrument players exhibited significantly higher Octopus visual field mean defect scores (1.08 ± 1.5 dB) than non-wind instrument players (-0.43 ± 0.7 dB; < 0.001). There was a significant association between cumulative hours playing wind instruments and visual field mean defect ( < 0.001).

Conclusion: Among members of the Philadelphia Orchestra, the difference in prevalence of glaucoma suspicious optic discs between wind and non-wind instrument players was not significant. The clinical significance of the greater visual field mean defect found in wind instrument players, and the association between the degree of visual field mean defect and the cumulative practice-time of playing wind instruments, needs further investigation.
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http://dx.doi.org/10.4103/jovr.jovr_155_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6058539PMC
August 2018

Clinical Efficacy and Safety Profile of Micropulse Transscleral Cyclophotocoagulation in Refractory Glaucoma.

J Glaucoma 2018 05;27(5):445-449

Glaucoma Research Center, Tel-Aviv Medical Center, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Purpose: To investigate the clinical efficacy and safety profile of micropulse transscleral cyclophotocoagulation (MP-CPC) in patients with refractory glaucoma.

Materials And Methods: Retrospective case series of 79 consecutive patients who underwent MP-CPC at the Wills Eye Hospital from March 23, 2014 to June 23, 2016 and who had at least 3 months of follow-up. Treatment success was defined as an intraocular pressure (IOP) of 6 to 21 mm Hg or a reduction of IOP by 20%. Failure was defined as an inability to meet the criteria for success, need for retreatment >3 times, or need for incisional glaucoma surgery.

Results: Patients had a mean follow-up time of 7.8±4.5 months. The mean IOP before MP-CPC was 31.9±10.2 mm Hg. The IOP was reduced by an average of 51% at the last follow-up and the mean number of IOP lowering medications was reduced from 2.3 at baseline to 1.5 at last follow-up. Treatment success rates were 75% at 3 months, 66% at 6 months, and 67% at last follow-up. Complications of MP-CPC included 7 patients with hypotony (8.8%), 21 patients with prolonged anterior chamber inflammation (1+ cell or flare for >3 mo, 26%), 13 patients with loss of ≥2 lines of best-corrected visual acuity at 3 months (17%), 4 patients with macular edema (5%), 2 patients with corneal edema and 2 patients with phthisis.

Conclusions: MP-CPC is an effective treatment for patients with refractory glaucoma. Shorter treatment times with more frequent repeat treatments, if necessary, should be considered given the incidence of significant vision loss in this study.
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http://dx.doi.org/10.1097/IJG.0000000000000934DOI Listing
May 2018

Evolution of Cyclophotocoagulation.

J Ophthalmic Vis Res 2018 Jan-Mar;13(1):55-61

Wills Eye Hospital, Glaucoma Research Center, Philadelphia, PA, USA.

Cyclodestructive techniques have been a treatment option for refractory glaucoma since its first use in the 1930s. Over the past nine decades, cyclodestruction has advanced from the initial cyclodiathermy to micropulse transscleral cyclophotocoagulation (MP-TSCPC) which is the current treatment available. Complications associated with cyclodestruction including pain, hyphema, vision loss, hypotony and phthisis have led ophthalmologists to shy away from these techniques when other glaucoma treatment options are available. Recent studies have shown encouraging clinical results with fewer complications following cyclophotocoagulation, contributing greatly to the current increase in the use of cyclophotocoagulation as primary treatment for glaucoma. We performed our literature search on Google Scholar Database, Pubmed, Web of Sciences and Cochrane Library databases published prior to September 2017 using keywords relevant to cyclodestruction, cyclophotocoagulation and treatment of refractory glaucoma.
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http://dx.doi.org/10.4103/jovr.jovr_190_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5782458PMC
February 2018

Trypan Blue for the Assessment of Filtering Bleb Function During Cataract Surgery.

J Glaucoma 2018 03;27(3):246-250

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, PA.

Purpose: Phacoemulsification has been cited as a possible cause of bleb failure in eyes with prior trabeculectomy. No method has been developed to directly evaluate the risk of bleb failure after phacoemulsification. We investigate the use of trypan blue during cataract surgery in the setting of a preexisting trabeculectomy to evaluate the functional status of the bleb and predict postoperative bleb function.

Materials And Methods: In total, 14 patients contributing 1 eye each with a history of prior trabeculectomy with mitomycin C undergoing phacoemulsification with intraocular lens implantation were enrolled in this prospective, nonrandomized clinical trial. At the time of phacoemulsification, trypan blue was instilled into the anterior chamber before capsulorhexis creation. Staining of the bleb was grouped as being mild or diffuse using intraoperative photographs. These eyes were followed for 1 year postoperatively and evaluated for intraocular pressure (IOP) control.

Results: The change in IOP was not significantly different between the 2 groups (P=0.14). A trend towards greater need for IOP-lowering medications was noted (P<0.10) in eyes with mild bleb staining. No statistically significant difference in rates of decreased bleb function was noted at 1-year follow-up after phacoemulsification.

Conclusion: The intensity of bleb staining with trypan blue during phacoemulsification is not associated with changes in IOP postoperatively. A trend towards decreased need for IOP-lowering medications was noted in eyes with diffuse bleb staining at 1 year after cataract surgery.
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http://dx.doi.org/10.1097/IJG.0000000000000865DOI Listing
March 2018

Pilot Study Assessing the Use of High-density Polyethylene (Su-Por) for Tube Shunt Patch Grafts.

J Glaucoma 2018 01;27(1):e14-e16

Glaucoma Service, Wills Eye Hospital, Philadelphia, PA.

Purpose: To assess the viability of a manufactured high-density polyethylene patch graft material (Su-Por) for prevention of tube shunt exposure.

Materials And Methods: Retrospective review of the first 11 patients from the Wills Eye Hospital Glaucoma Service to receive the high-density polyethylene patch graft during tube shunt surgery.

Results: Four patients (36.3%) experienced an extrusion of the Su-Por patch without a leak within 2.5 months of postoperative follow-up. All 4 patients developed either symptomatic or progressive extrusion. Operative repair was completed with Su-Por removal and replacement with a new human donor patch graft. No patient developed any sign of infection despite the extrusions. The remaining 7 patients had an uneventful postoperative course and continue to have no complications from the Su-Por patch with 9 months of follow-up.

Conclusions: Given the high rate of extrusion of the Su-Por graft, this material seems to be an inadequate alternative for covering tube shunts. Harvested human tissue or other more flexible, manufactured grafts remain the standard of care for covering tube shunts.
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http://dx.doi.org/10.1097/IJG.0000000000000809DOI Listing
January 2018

Surgical Outcomes of Gonioscopy-assisted Transluminal Trabeculotomy (GATT) in Patients With Open-angle Glaucoma.

J Glaucoma 2017 Dec;26(12):1137-1143

Wills Eye Hospital, Glaucoma Research Center.

Purpose: To evaluate the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in patients with open-angle glaucoma.

Participants And Methods: A retrospective chart review of adult patients who underwent GATT due to inadequately controlled intraocular pressure (IOP) or intolerance to medication. Main outcome measures were success rate, IOP, and number of glaucoma medications. Success was defined as IOP reduction >20% from baseline or IOP between 5 to 21 mm Hg, and no need for further glaucoma surgery. When success criteria were not met for any postoperative visit >3 months after surgery, failure was determined.

Results: In total, 66 patients, average age 62.9±14.9 years (50.8% female) were included in the analysis. Average follow-up was 11.9 months (range, 3 to 30 mo) and overall success rate was 63.0%. Mean IOP was 26.1±9.9 mm Hg preoperatively and 14.6±4.7 mm Hg at 12 months (44% IOP decrease; P<0.001). Mean number of medications decreased from 3.1±1.1 preoperatively to 1.2±0.9 at 12 months (P<0.001). No significant differences between patients with primary open-angle glaucoma and other types of glaucoma were found.The rate of hyphema at 1 week and 1 month postoperatively was 38% and 6%, respectively. Overall GATT success rate among white and black patients was 69% and 42%, respectively, which was statistically significant (P<0.05).

Conclusions: The future of GATT as a minimally invasive glaucoma surgery in adults seems promising. This position is supported by its low rate of long-term complications and the conjunctiva-sparing nature of the surgery.
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http://dx.doi.org/10.1097/IJG.0000000000000802DOI Listing
December 2017

The Effects of Latanoprost With Benzalkonium Chloride Versus Travoprost With SofZia on the Ocular Surface.

Eye Contact Lens 2018 Nov;44 Suppl 2:S93-S98

Glaucoma Research Center (K.R., S.S.W., M.R.M., L.A.H., L.J.K.), Wills Eye Hospital, Philadelphia, PA; and Cornea Department (C.J.R.), Wills Eye Hospital, Philadelphia, PA; Formerly Glaucoma Research Center (P.I.), Wills Eye Hospital, Philadelphia, PA; Currently Department of Ophthalmology (P.I.), Government Medical College and Hospital, Chandigarh, India.

Purpose: To assess ocular surface changes in participants using latanoprost with benzalkonium chloride (Xalatan) and travoprost with SofZia (Travatan Z).

Methods: In this prospective, open-label, nonrandomized cohort study, participants were classified into two groups: group 1 (n=28) naive to glaucoma therapy, group 2 (n=27) on previous Xalatan monotherapy in both eyes. Both groups started (or continued) Xalatan in the right eye and Travatan Z in the left eye. Baseline, 1-, and 2-month measurements of tear breakup time (TBUT), corneal staining score, conjunctival staining score, conjunctival hyperemia score, tear production, and intraocular pressure were obtained. The Ocular Surface Disease Index questionnaire measured participants' comfort and dryness symptoms. Medication preference was recorded.

Results: Data were collected from 55 participants. Tear breakup time at baseline and 1-month follow-up in group 1 was significantly longer than that of group 2 (P=0.005). At 2 months, there was no significant difference in TBUT between the two groups (P=0.779). Tear production in group 1 at all three time points was significantly higher than group 2 (P<0.05). Conjunctival staining score at 2 months in group 1 was significantly higher than group 2 (P=0.031). There was no significant difference in other parameters between the groups at any other time point. No significant difference in any parameter was found between Xalatan and Travatan Z (intragroup comparison).

Conclusions: Significant differences in ocular surface characteristics were detected between groups, but no significant difference was detected between participants treated with Xalatan and Travatan Z.
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http://dx.doi.org/10.1097/ICL.0000000000000405DOI Listing
November 2018

Steady-state pattern electroretinogram and short-duration transient visual evoked potentials in glaucomatous and healthy eyes.

Clin Exp Ophthalmol 2018 01 20;46(1):54-61. Epub 2017 Jul 20.

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, PA, USA.

Importance: This study evaluates two rapid electrophysiological glaucoma diagnostic tests that may add a functional perspective to glaucoma diagnosis.

Background: This study aimed to determine the ability of two office-based electrophysiological diagnostic tests, steady-state pattern electroretinogram and short-duration transient visual evoked potentials, to discern between glaucomatous and healthy eyes.

Design: This is a cross-sectional study in a hospital setting.

Participants: Forty-one patients with glaucoma and 41 healthy volunteers participated in the study.

Methods: Steady-state pattern electroretinogram and short-duration transient visual evoked potential testing was conducted in glaucomatous and healthy eyes. A 64-bar-size stimulus with both a low-contrast and high-contrast setting was used to compare steady-state pattern electroretinogram parameters in both groups. A low-contrast and high-contrast checkerboard stimulus was used to measure short-duration transient visual evoked potential parameters in both groups.

Main Outcome Measures: Steady-state pattern electroretinogram parameters compared were MagnitudeD, MagnitudeD/Magnitude ratio, and the signal-to-noise ratio. Short-duration transient visual evoked potential parameters compared were amplitude and latency.

Results: MagnitudeD was significantly lower in glaucoma patients when using a low-contrast (P = 0.001) and high-contrast (P < 0.001) 64-bar-size steady-state pattern electroretinogram stimulus. MagnitudeD/Magnitude ratio and SNR were significantly lower in the glaucoma group when using a high-contrast 64-bar-size stimulus (P < 0.001 and P = 0.010, respectively). Short-duration transient visual evoked potential amplitude and latency were not significantly different between the two groups.

Conclusions And Relevance: Steady-state pattern electroretinogram was effectively able to discern between glaucomatous and healthy eyes. Steady-state pattern electroretinogram may thus have a role as a clinically useful electrophysiological diagnostic tool.
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http://dx.doi.org/10.1111/ceo.13006DOI Listing
January 2018

Implantation of trabecular micro-bypass stent using a novel "landing strip" technique.

Int J Ophthalmol 2017 18;10(5):738-741. Epub 2017 May 18.

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, PA 19107, USA.

Aim: To describe a novel technique of creating a landing strip within the trabecular meshwork to guide trabecular micro-bypass stent (iStent) implantation in patients who underwent phacoemulsification.

Methods: Thirty-four eyes from 30 patients who underwent iStent implantation after phacoemulsification from May 2014 to February 2015 were included in our retrospective study. All iStents were implanted the "landing strip" technique. A 25-gauge microvitreoretinal blade was used to bisect the trabecular meshwork to less than 1 clock-hour, effectively creating a landing strip. The iStent applicator was pressed along the landing strip and then the stent was released into the trabecular meshwork.

Results: Of the 34 eyes with iStent implantation, 27 (79.4%) eyes had primary open-angle glaucoma, 6 (17.6%) eyes had pseudoexfoliation glaucoma, and 1 (2.9%) eye had ocular hypertension. At 6-month follow-up (=17), the mean number of hypotensive medications decreased from 2.2±1.2 at baseline to 0.8±1.3 (=0.05) and mean intraocular pressure decreased from 19.7±4.1 mm Hg at baseline to 16.7±2.1 mm Hg (=0.58). Two eyes (5.9%) required subsequent trabeculectomy.

Conclusion: The "landing strip" technique appears to be an effective way to assist with iStent implantation.
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http://dx.doi.org/10.18240/ijo.2017.05.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5437461PMC
May 2017

Sequential versus concomitant surgery of glaucoma drainage implant and Boston keratoprosthesis type 1.

Eur J Ophthalmol 2016 Nov 12;26(6):556-563. Epub 2016 Apr 12.

 Glaucoma Research Center, Wills Eye Hospital, Philadelphia, PA - USA.

Purpose: To compare sequential versus concomitant surgery of glaucoma drainage implant (GDI) and Boston keratoprosthesis type 1 (KPro).

Methods: Patients who received GDI and KPro in the same eye were divided into 2 groups: GDI placement prior to KPro surgery (sequential group) or GDI placement concomitant with KPro surgery (concomitant group). Main outcome measures were GDI failure, defined as intraocular pressure (IOP) >21 mm Hg, less than a 20% IOP reduction from baseline, or IOP <5 mm Hg on 2 consecutive follow-up visits, any reoperation for glaucoma, or loss of light perception; best-corrected visual acuity (BCVA); and surgical complications.

Results: Thirty-five eyes were included in the study: 17 in the sequential group and 18 in the concomitant group. The cumulative incidence of failure after 5 years of follow-up was 23.5% in the sequential group and 27.8% in the concomitant group (p = 0.250). Mean BCVA was significantly better in the concomitant group after 6 months, 1 year, 2 years, and at the last follow-up (p<0.05). Both groups had similar rates of complications (p = 1.000). The most frequent complication was GDI erosion, which occurred in 23.5% (n = 4/17) in the sequential group and in 27.8% (n = 5/18) in the concomitant group (p = 1.000).

Conclusions: Glaucoma drainage implant placement at the time of KPro surgery had similar cumulative incidence of failure, but significantly favorable visual outcomes, compared to sequential surgeries. The most frequent complication was GDI erosion, occurring in approximately one fourth of the patients.
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http://dx.doi.org/10.5301/ejo.5000794DOI Listing
November 2016

INFECTIOUS ENDOPHTHALMITIS AFTER GLAUCOMA DRAINAGE IMPLANT SURGERY: Clinical Features, Microbial Spectrum, and Outcomes.

Retina 2017 Jun;37(6):1160-1167

*Wills Eye Hospital, Glaucoma Research Center, Philadelphia, Pennsylvania; and †Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Philadelphia, Pennsylvania.

Purpose: To report the clinical features, microbial spectrum, and treatment outcomes of endophthalmitis after glaucoma drainage implant (GDI) surgery.

Methods: Records of patients diagnosed with endophthalmitis after GDI surgery were reviewed. Data on clinical course, microbiological laboratory results, and treatment were analyzed.

Results: Of 1,891 eyes that underwent GDI surgery, 14 eyes (0.7%) developed endophthalmitis. The mean time interval between GDI surgery and diagnosis of endophthalmitis was 2.6 ± 3.2 years (median, 1.3 years; range, 11 days-11.4 years). For initial treatment, 13/14 eyes underwent vitreous tap and injection of intravitreal antibiotics and 1/14 eyes underwent primary pars plana vitrectomy. Three additional eyes underwent pars plana vitrectomy because of deteriorating clinical course. Glaucoma drainage implant erosion was present in 9/14 eyes. All 9 eroded GDIs were surgically removed within a mean of 9 ± 5 days (range 2-29 days) after diagnosis of endophthalmitis. Overall, mean logarithm of the minimum angle of resolution best-corrected visual acuity worsened from 0.7 ± 0.7 (Snellen equivalent 20/100) at baseline to 1.6 ± 1.1 (Snellen equivalent 20/800) at final follow-up (P = 0.005). Mean duration between the onset of symptoms and presentation was significantly longer in patients with decreased final best-corrected visual acuity (>2 Snellen lines) compared to patients with stable final best-corrected visual acuity (6.8 vs. 1.0 days; P = 0.005).

Conclusion: Glaucoma drainage implant-related endophthalmitis is rare and often associated with GDI erosion. Patients who presented earlier after the onset of symptoms had better final visual outcomes. Prompt evaluation and treatment is required, often with removal of the eroded GDI.
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http://dx.doi.org/10.1097/IAE.0000000000001329DOI Listing
June 2017

July consultation #4.

Authors:
Marlene R Moster

J Cataract Refract Surg 2016 Jul 2;42(7):1101. Epub 2016 Aug 2.

Philadelphia, Pennsylvania, USA.

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http://dx.doi.org/10.1016/j.jcrs.2016.06.013DOI Listing
July 2016

Glaucoma Surgery in Pregnancy: A Case Series and Literature Review.

Iran J Med Sci 2016 Sep;41(5):437-45

Glaucoma Service, Wills Eye Institute, Jefferson Medical College, Philadelphia, USA.

Glaucoma management in pregnant patients is a real challenge, especially when the glaucoma is not controlled with medications. We report the results of 6 incisional glaucoma surgeries for the management of medically uncontrolled glaucoma patients during pregnancy. This retrospective, case series was conducted on the 6 eyes of 3pregnant patients with uncontrolled glaucoma using maximum tolerable medications. Details of the glaucoma surgical management of these patients as well as their postoperative care and pregnancy and clinical outcomes on longitudinal follow-up are discussed. All 3 patients had juvenile open-angle glaucoma and were on various anti-glaucoma medications, including oral acetazolamide. The first case described underwent trabeculectomy without antimetabolites in both eyes because of uncontrolled intraocular pressure with topical medications. The surgery was done with topical lidocaine jelly and subconjunctival lidocaine during the second and third trimesters. The second patient had an Ahmed valve implantation in both eyes during the second and third trimesters because of uncontrolled IOP with topical medications and no response to selective laser trabeculoplasty. Surgery was done with topical tetracaine and subconjunctival and sub-Tenon's lidocaine. The third case had a Baerveldt valve implantation under general anesthesia in the second trimester. In selected pregnant glaucoma patients with medically uncontrolled intraocular pressure threatening vision, incisional surgery may lead to good outcomes for the patient with no risk for the fetus.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967489PMC
September 2016

The Wills Eye Glaucoma App: Interest of Patients and Their Caregivers in a Smartphone-based and Tablet-based Glaucoma Application.

J Glaucoma 2016 09;25(9):e787-91

*Glaucoma Research Center, Wills Eye Hospital †Drexel University's iSchool and College of Engineering, Philadelphia, PA.

Purpose: To evaluate the interest of glaucoma patients and their caregivers in a smartphone-based and tablet-based glaucoma application (App), developed by the Wills Eye Glaucoma Research Center in collaboration with Drexel University.

Materials And Methods: Cross-sectional survey of patients with glaucoma and their caregivers. Main outcome measures are answers to survey questions regarding how receptive participants are to using the Glaucoma App.

Results: Fifty subjects completed the survey. The mean age (SD) was 59.5 (±17.3) years. A total of 88.6% of the participants lived in a household with access to a smartphone or tablet. The majority (72.3%) of participants would consider downloading the Glaucoma App, and younger participants (<65 y) were more likely to do so compared with their older (≥65 y) counterparts, P=0.025. Participants were more likely to download the App if it was free of charge, compared with a version that costs $3, P=0.018. Although only about one third (37.8%) of participants used eye drop reminders, nearly 3 of 4 (72.9%) participants were receptive to using the automated reminder feature of the Glaucoma App.

Conclusions: Glaucoma patients and their caregivers were very interested in using a Glaucoma App; however, many were not willing to spend $3 for an App they seem to value. The free Wills Eye Glaucoma App currently available on the Apple store, includes educational videos, eye drop and appointment reminders, medical and ocular data storage, visual field tutorial, and intraocular pressure tracker. These features aim to increase patients' level of knowledge about glaucoma and improve their adherence to medication and follow-up appointment recommendations.
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http://dx.doi.org/10.1097/IJG.0000000000000504DOI Listing
September 2016

Ahmed Versus Baerveldt Glaucoma Drainage Implantation in Patients With Markedly Elevated Intraocular Pressure (≥30 mm Hg).

J Glaucoma 2016 09;25(9):738-43

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, PA.

Purpose: Glaucoma patients with markedly elevated intraocular pressure (IOP) are at risk for developing severe hypotony-related complications. The goal of this study was to compare the surgical outcomes of the Ahmed Glaucoma Valve (AGV) and the Baerveldt Glaucoma Implant (BGI) in this patient population.

Methods: Patients with preoperative IOP≥30 mm Hg were included. Outcome measures were: (1) surgical failure (IOP>21 mm Hg or <30% reduction from baseline or IOP≤5 mm Hg on 2 consecutive follow-up visits after 3 mo, or additional glaucoma surgery, or loss of light perception) and (2) surgical complications.

Results: A total of 75 patients were included: 37 in the AGV group and 38 in the BGI group. The mean±SD follow-up was 2.3±1.6 years for the AGV group and 2.4±1.7 years for the BGI group (P=0.643). Mean preoperative IOP was 38.7±6.5 mm Hg for the AGV group and 40.8±7.6 mm Hg for the BGI group. At the last follow-up, 10 (27.0%) patients failed in the AGV group compared with 6 (15.8%) patients in the BGI group (P=0.379). The BGI group had higher rate of flat or shallow anterior chamber (n=4, 10%) compared with the AGV group (n=0, 0%) (P=0.043).

Conclusions: Failure rates of AGV and BGI in patients with IOP≥30 mm Hg were comparable. There were more early hypotony-related complications in the BGI group; however, none were vision threatening. Both glaucoma drainage implants were effective in treating patients with uncontrolled glaucoma in an emergency setting.
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http://dx.doi.org/10.1097/IJG.0000000000000515DOI Listing
September 2016

Comparison of 3 different releasable suture techniques in trabeculectomy.

Eur J Ophthalmol 2016 Jun 29;26(4):307-14. Epub 2015 Dec 29.

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, PA - USA.

Purpose: The use of releasable sutures provides an effective and simple way of titrating intraocular pressure (IOP) postoperatively. The purpose of this study was to compare the surgical outcome of 3 releasable suture techniques for closing scleral flaps in patients undergoing primary trabeculectomy.

Methods: The Wills Eye Glaucoma Research Center retrospectively reviewed the charts of patients who underwent primary trabeculectomy by 3 surgeons using 3 different releasable suture techniques. Ninety eyes of 90 glaucoma patients were divided into 3 groups by releasable suture technique (n = 30 eyes for each group). Main outcome measures included best-corrected visual acuity (BCVA), intraocular pressure (IOP), rate of surgical success, use of supplemental medical therapy, need for additional glaucoma surgery, and complications during suture removal.

Results: The BCVA and IOP were similar among the groups for all follow-up visits. As a determinant of success rate of trabeculectomy, mean decrease of IOP after surgery was over 30% in all groups (p = 0.43). The number of postoperative antiglaucomatous medications, number of complications, and need for an additional glaucoma surgery were similar in all groups (p = 0.40, p = 0.87, and p = 0.47, respectively). The differences in suture-related complications, defined as suture break or need for laser suture lysis, were not significant among the groups (p = 0.09).

Conclusions: We found that the 3 most common surgical techniques had similar mechanisms of action. All techniques were safe and effective, yielding similar outcomes. All 3 techniques can be used for closing scleral flaps in patients undergoing primary trabeculectomy.
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http://dx.doi.org/10.5301/ejo.5000718DOI Listing
June 2016

Treatment outcomes of micropulse transscleral cyclophotocoagulation in advanced glaucoma.

Lasers Med Sci 2016 Feb 29;31(2):393-6. Epub 2015 Dec 29.

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, PA, 19107, USA.

Glaucoma is the leading cause of irreversible blindness worldwide. The goal of this study was to describe our experience with the novel micropulse transscleral cyclophotocoagulation (MP-TSCPC; IRIDEX IQ810 Laser Systems, CA) in patients with advanced glaucoma. Patients with advanced glaucoma who underwent MP-TSCPC were included in our study. Laser settings were 2000 mW of 810 nm infrared diode laser set on micropulse delivery mode. The laser was delivered over 360° for 100-240 s. The duty cycle was 31.3 %, which translated to 0.5 ms of "on time" and 1.1 ms of "off time." Surgical success was defined as an intraocular pressure (IOP) of 6-21 mmHg or a reduction of IOP by 20 % at the last follow-up visit. Failure was defined as an inability to meet the criteria for success or a need for incisional glaucoma surgery. Nineteen patients underwent MP-TSCPC with mean follow-up of 60.3 days. Mean IOP dropped from 37.9 mmHg preoperatively to 22.7 mmHg at last follow-up, representing a 40.1 % decrease. The success rate for initial treatment was 73.7 % (n = 14). Three patients underwent a second treatment, increasing the overall success rate to 89.5 % (n = 17). Four patients gained one line of vision, and four patients lost one line of vision. The novel MP-TSCPC laser had a high rate of surgical success after a short follow-up period in patients with advanced glaucoma. Further long-term evaluation and comparison to the traditional transscleral cyclophotocoagulation are warranted.
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http://dx.doi.org/10.1007/s10103-015-1856-9DOI Listing
February 2016

Outcomes of Sequential Glaucoma Drainage Implants in Refractory Glaucoma.

J Glaucoma 2016 Apr;25(4):e340-5

*Glaucoma Research Center, Wills Eye Hospital †Department of Pharmacology and Experimental Therapeutics, Division of Biostatistics, Thomas Jefferson University, Philadelphia, PA.

Purpose: To describe the outcomes of eyes that have undergone a second glaucoma drainage implant (GDI) surgery.

Methods: A retrospective review of eyes that underwent a second GDI surgery from 2006 to 2013 was conducted. Primary outcome measures included intraocular pressure (IOP) reduction and success rates. Secondary outcome measures included glaucoma medication use, visual acuity, and number of reoperations. Success was defined as 6 ≤ IOP ≤ 21 with at least 20% IOP reduction, and no increase in the number of glaucoma medications from baseline at 3 months of follow-up or more.

Results: Sixty-five eyes (63 patients) had a mean follow-up of 22.4 ± 19.9 months. The most frequently placed second GDIs were an Ahmed FP7 (49%) or a Baerveldt 250 (26%) in the inferotemporal (46%) or inferonasal (35%) quadrant. At 3-year follow-up, IOP was reduced from 25.8 ± 7.7 to 17.4 ± 9.9 mm Hg (P = 0.004) and the number of glaucoma medications decreased from 3.6 ± 1.2 to 2.5 ± 1.4 (P = 0.01) compared with baseline. The median time to failure was 24.7 ± 5.8 months. There was no significant difference in failure rates for type of sequential GDI (P = 0.80) or plate location (P = 0.34). There was no significant difference in visual acuity between baseline and 3-year follow-up (P = 1.0). The most common postoperative complication was corneal edema (n = 9, 14%).

Conclusions: Most eyes undergoing a second GDI achieve adequate IOP control with fewer antiglaucoma medications. Failure rates were similar regardless of quadrant selection or GDI type.
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http://dx.doi.org/10.1097/IJG.0000000000000362DOI Listing
April 2016

Initial Experience With the New Ahmed Glaucoma Valve Model M4: Short-term Results.

J Glaucoma 2016 05;25(5):e475-80

Glaucoma Research Center, Wills Eye Hospital, Philadelphia, PA.

Purpose: To evaluate the clinical outcomes of the new Ahmed glaucoma valve (AGV) model M4. The device consists of a porous polyethylene shell designed for improved tissue integration and reduced encapsulation of the plate for better intraocular pressure (IOP) control.

Methods: Medical records of patients with an AGV M4 implantation between December 1, 2012 and December 31, 2013 were reviewed. The main outcome measure was surgical failure, defined as either (1) IOP<5 mm Hg or >21 mm Hg and/or <20% reduction of IOP at last follow-up visit, (2) a reoperation for glaucoma, and/or (3) loss of light perception.

Results: Seventy-five eyes of 73 patients were included. Postoperative IOP at all follow-up visits significantly decreased from a baseline IOP of 31.2 mm Hg (P<0.01). However, IOP increased significantly at 3 months (20.4 mm Hg), 6 months (19.3 mm Hg), and 12 months (20.3 mm Hg) compared with 1 month (13.8 mm Hg) postoperatively (P<0.05). At 6 months and 1 year, the cumulative probability of failure was 32% and 72%, respectively.

Conclusions: The AGV M4 effectively reduced IOP in the first postoperative month, but IOP steadily increased thereafter. Consequently, failure rates were high after 1 year of follow-up.
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http://dx.doi.org/10.1097/IJG.0000000000000324DOI Listing
May 2016

Use of Gamma-Irradiated Cornea to Plug Sclerostomy Site During Tube Shunt Revision.

Semin Ophthalmol 2017 8;32(2):182-184. Epub 2015 Jul 8.

b Wills Eye Hospital , Philadelphia , PA , USA.

Tube shunt implantation is a common procedure for control of intraocular pressure (IOP). However, tube revision and repositioning must sometimes be performed, and this involves removing the tube from its sclerostomy site. This site is prone to leaking and this may cause postoperative hypotony. We describe a novel and cosmetically acceptable technique of plugging and covering the sclerostomy site with gamma-irradiated corneal tissue.
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http://dx.doi.org/10.3109/08820538.2015.1045302DOI Listing
March 2017