DOS Jan-Feb- 2021-Glaucoma

Subspeciality-Glaucoma

reduced by 20% below baseline on two Ahmed valve is associated with lower MD of -0.81. At baseline, there was no
consecutive visits after 3 months; 2. IOP intra ocular pressure in early post- difference between patients with POAG
≤ 5 mm Hg on two consecutive visits operative period but Baerveltdt lead in and patients with OHT on the EQ-5D-
after 3 months; 3. Additional glaucoma long term follow up. However, the risk 5DL.41
surgery; 4. Removal of implant; 5. Loss of hypotony was more in the Baerveldt EQ-5D score was 0·89 in the SLT group
of light perception vision. Complete group. versus 0·90 in the eye drops group, with
success was defined as controlled no significant difference. At 36 months,
intraocular pressures (≤ 21 mm HG and Laser in Glaucoma and ocular 74·2% of patients in the SLT group
>5 mmHg and reduced by at least 20% HyperTension study (LiGHT) maintained intraocular pressure at
from baseline). 37 target without drops. IOP reduction was
Results: Objectives similar in both groups in all stages of
276 patients were enrolled with a glaucoma. 36 eyes in the eye drop group
mean age of 63.8years. Overall mean To compare selective laser showed disease progression compared
baseline IOP was 31.5mmhg with trabeculoplasty (SLT) versus eye to 23 eyes in the SLT group. 11 patients
average 3.4 glaucoma medication. drops as primary therapy for ocular in the eye drop group required surgery
40% patients had POAG, 29% had hypertension and primary open angle while none required surgery in SLT
neovascular glaucoma, 7% had PACG glaucoma. group. Eyes of patients in the selective
and 7% had uveitic glaucoma. 143 eyes laser trabeculoplasty group were within
received AGV and 133 eyes received Methodology target intraocular pressure at more
BGI. 57% of AGV as compared to 14% visits (93·0%) than in the eye drops
of BGI had viscoelastic injected after 718 previously untreated POAG or group (91·3%). When ophthalmology
the conclusion of surgery. Hyphema ocular hypertensive patients were costs were taken into consideration,
was most common complication with randomized into two arms: SLT followed SLT was more cost effective than eye
similar rates in AGV and BGI.37 by medical therapy (as required) or drops.42
One year outcome: At 1 year, IOP was medical therapy only. Eligible patients Limitations
15.4±5.5 mm Hg in the AGV group with were newly diagnosed and untreated The eye drop adherence was not
1.8±1.3 glaucoma medications. IOP OAG or ocular hypertensives in one measured in the study. Although the
was 13.2±6.8 mm Hg in the BGI group or both eyes with visual field MD ≥ study used detailed disease management
with 1.5±1.4 glaucoma medications. -12dB in better eye or -15dB in worse approach, the patients and clinicians
The IOP was significantly lower in BGI eye with corresponding disc damage. were not masked to the treatment of the
group with similar medications to AGV Patients with symptomatic cataract, or patient.
group. The probability of failure was unable to sit at slit lamp or using eye Conclusions
16.4% in AGV group and 14% in BGI drops were excluded. Disease severity Selective laser is a cost effective
group.38 and pre-treatment intraocular pressure alternative to eyedrops for reduction of
5 year follow up: IOP was 14.7±4.4 were used to set target IOP, treatment IOP in OAG and ocular hypertensives
mmHg in the AGV group with intensity and monitoring intervals with a similar quality of life score
2.2±1.4 glaucoma medications. IOP for individual patients. First line eye in 74.2% patients. However repeat
was 12.7±4.5 mmHg in the BGI group drops were prostaglandin analogues, treatments may be needed in approx.
with 1.8±1.5 glaucoma medications. second line were beta blockers, third 25% of patients.
The IOP was significantly lower in BGI and fourth line treatment were topical
group with similar medications to AGV carbonic anhydrase inhibitors and References
group. 39 The probability of failure was alpha agonists. The primary outcome
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a mean age of 64 year, median IOP of archophthalmol.2010.20
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had OHT with a mean age of 58 years,
median IOP of 26mmHg and median

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Subspeciality-Glaucoma

3. Kass MA, Heuer DK, Higginbotham EJ, et 12. Bengtsson B, Leske MC, Yang Z, Heijl The Collaborative Initial Glaucoma
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and glaucoma progression: results Glaucoma Study Group. Factors EK, AGIS Investigators. The Advanced
from the Early Manifest Glaucoma that predict the benefit of lowering Glaucoma Intervention Study (AGIS): 1.
Trial. Arch Ophthalmol Chic Ill 1960. intraocular pressure in normal Study design and methods and baseline
2002;120(10):1268-1279. doi:10.1001/ tension glaucoma. Am J Ophthalmol. characteristics of study patients.
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9. Leske MC, Heijl A, Hyman L, Bengtsson
B, Komaroff E. Factors for progression 18. Drance S, Anderson DR, Schulzer 26. The Advanced Glaucoma Intervention
and glaucoma treatment: the Early M, Collaborative Normal-Tension Study (AGIS): 3. Baseline characteristics
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Ophthalmol. 2004;15(2):102-106. progression of visual field abnormalities Ophthalmology. 1998;105(7):1137-1145.
doi:10.1097/00055735-200404000-00008 in normal-tension glaucoma. Am doi:10.1016/s0161-6420(98)97012-9
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10. Leske MC, Heijl A, Hyman L, et al. doi:10.1016/s0002-9394(01)00964-3 27. The Advanced Glaucoma Intervention
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Ophthalmology. 2007;114(11):1965-1972. Standardi CL. The Collaborative and visual field deterioration.The
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study design, methods, and baseline 2000;130(4):429-440. doi:10.1016/s0002-
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Fluctuation of intraocular pressure doi:10.1016/s0161-6420(99)90147-1 28. AGIS Investigators. The Advanced
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2001;132(3):311-320. doi:10.1016/s0002- year of follow-up. Am J Ophthalmol. trial: design and methodology. Br J
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29. AGIS Investigators. The Advanced ajo.2006.07.020
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and argon laser trabeculoplasty. Am Treatment outcomes in the Tube Versus Vickerstaff V, et al. The Laser in Glaucoma
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doi:10.1016/s0002-9394(02)01658-6 years of follow-up. Am J Ophthalmol. A multicentre randomised controlled
2012;153(5):789-803.e2. doi:10.1016/j. trial: baseline patient characteristics.
30. AGIS Investigators. The Advanced ajo.2011.10.026 Br J Ophthalmol. 2018;102(5):599-603.
Glaucoma Intervention Study (AGIS): doi:10.1136/bjophthalmol-2017-310870
12. Baseline risk factors for sustained 36. Gedde SJ, Herndon LW, Brandt JD, et
loss of visual field and visual acuity al. Postoperative complications in the 42. Gazzard G, Konstantakopoulou E,
in patients with advanced glaucoma. Tube Versus Trabeculectomy (TVT) Garway-Heath D, et al. Selective laser
Am J Ophthalmol. 2002;134(4):499-512. study during five years of follow-up. Am trabeculoplasty versus eye drops for first-
doi:10.1016/s0002-9394(02)01659-8 J Ophthalmol. 2012;153(5):804-814.e1. line treatment of ocular hypertension
doi:10.1016/j.ajo.2011.10.024 and glaucoma (LiGHT): a multicentre
randomised controlled trial. Lancet
31. AGIS (Advanced Glaucoma Intervention 37. Barton K, Gedde SJ, Budenz DL, Lond Engl. 2019;393(10180):1505-1516.
Study) Investigators. The Advanced Feuer WJ, Schiffman J, Ahmed doi:10.1016/S0140-6736(18)32213-X
Glaucoma Intervention Study: 8. Risk of Baerveldt Comparison Study Group.
cataract formation after trabeculectomy. The Ahmed Baerveldt Comparison
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2001;119(12):1771-1779. doi:10.1001/ characteristics, and intraoperative
archopht.119.12.1771 complications. Ophthalmology.
2011;118(3):435-442. doi:10.1016/j.
32. Gedde SJ, Schiffman JC, Feuer WJ, et al. ophtha.2010.07.015
The tube versus trabeculectomy study:
design and baseline characteristics 38. Budenz DL, Barton K, Feuer WJ, et al.
of study patients. Am J Ophthalmol. Treatment outcomes in the Ahmed
Baerveldt Comparison Study after
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ajo.2005.03.031
2011;118(3):443-452. doi:10.1016/j. Corresponding Author:
33. Gedde SJ, Herndon LW, Brandt JD, ophtha.2010.07.016
Budenz DL, Feuer WJ, Schiffman Dr. Talvir Sidhu
JC. Surgical complications in the 39. Budenz DL, Barton K, Gedde SJ, et al. Department of Ophthalmology,
Tube Versus Trabeculectomy Study Five-year treatment outcomes in the GMC Patiala, Rajindra Hospital
during the first year of follow-up. Ahmed Baerveldt comparison study. Patiala, Punjab -147001
Am J Ophthalmol. 2007;143(1):23-31. Ophthalmology. 2015;122(2):308-316.
doi:10.1016/j.ajo.2006.07.022 doi:10.1016/j.ophtha.2014.08.043

34. Gedde SJ, Schiffman JC, Feuer WJ, 40. Gazzard G, Konstantakopoulou E,
Herndon LW, Brandt JD, Budenz Garway-Heath D, et al. Laser in Glaucoma
DL. Treatment outcomes in the tube and Ocular Hypertension (LiGHT) trial.
versus trabeculectomy study after one A multicentre, randomised controlled

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Subspeciality-Glaucoma

Newer Advances in Glaucoma
Diagnosis and Management

Kumar Ravi, Ankita Mitra, Sagar Bhargava, Maneesh Singh
Netralayam, The Superspeciality Eye Care Centre, Santoshpur, Kolkata, West Bengal 700099

Abstract: Glaucoma is an ever expanding branch of ophthalmology which is witnessing a surge of new ideas and technologies
to aid in the detection, treatment and further understanding of glaucoma. In this article we shall discuss some of the recent
advances in diagnosis and treatment of glaucoma. We are hopeful that coming years will see advances in early detection,
efficacious treatments and neuroprotection.

Introduction optic nerve head configuration, and Fig 1 Triggerfish consists of a silicone
Glaucoma, a leading cause of blindness hence contributes in early detection contact lens with an embedded strain gauge
comprises a group of conditions of glaucoma progression. Another new to measure changes in the corneal radius
characterised by typical changes to the investigative method in form of Optical of curvature as it fluctuates with pressure
retinal nerve fibre layer and optic nerve coherence tomography measures within the eye (IOP).
head resulting in reduced visual field peripapillary retinal nerve fiber layer
sensitivity. Various glaucoma research and macular thicknes. Both these tests The device detects the circumferential
is being done especially in the fields are objective and requires less patient changes in the area of the corneo-scleral
of diagnosis and management of the cooperation than visual field. However, junction and the corresponding IOP
disease. There have been several new these devices have their own limitations value is transmitted wirelessly via a
and exciting advances in methodologies . Although we have been using these flexible adhesive antenna worn around
for earlier diagnosis, identification of devices since several decades, both the eye to the portable recorder worn on
modifiable risk factors and developing imaging and perimetric techniques the body ( Fig 2).
better intraocular pressure (IOP) have improved considerably. Newer The device was approved by the FDA in
-dependant and non IOP-dependant strategies are emerging to complement 2016 to detect the variation in IOP over
treatments. these established techniques. a period of 24 hours.  High correlation
has been noted between CLS output
Newer advances can be divided into 2 Inspite of these recent advances, the role and imposed IOP2. It is a useful device
groups: of IOP measurement and IOP control to detect nocturnal or non clinic hours
remains of paramount importance in IOP peak in glaucoma patients.
A. Newer advances in diagnosis glaucoma management. Trigger fish is a
B. Newer advances in management new device which helps in continuous
monitoring of IOP.
A. Newer Advances in
diagnosis 1. Trigger fish CLS-
It is a non invasive, soft disposable
As glaucoma causes irreversible contact lens embedded with a
damage to eye, early disease detection miniaturised telemetric sensor for
is of paramount importance which may continuous 24 hours intraocular
be achieved by assessing optic nerve pressure monitoring (IOP) monitoring
structure and function using optic nerve ( Fig 1). The contact lens is of 14.1 mm
imaging and perimetry, respectively. in diameter and 585 μm in thickness in
its center1 with base curve of 8.4, 8.7,
Heidelberg Retina Tomograph, a and 9 mm( Fig 1).  Embedded within
method for measurement of optic disc the contact lens are two strain gauges,
parameters, detects subtle changes in a microprocessor, and an antenna.

104 DOS Times - Volume 26, Number 4, January-February 2021 www.dosonline.org/dos-times

Subspeciality-Glaucoma

3. Virtual and home
perimetry – 
It is a head-mounted, eye-tracking
perimeter, that does the equivalent of a
full threshold 24-2 visual field ( Fig 5).
In addition to manual patient response
with a click, it can also track changes in
gaze while detection of stimulus (Visual
Grasp).

Fig 4 . Use of iCare tonometer

Fig 2 . [1] contact lens with sensor [2] Studies have shown a strong correlation Fig 5. Virtual perimetry headset ( Image
adhesive antenna [3] cable [4] portable between the iCare HOME and courtesy BioFormatix)
recorder. (Photo Credit: www.sensimed.ch) Applanation Tonometry measured IOP It has the advantage of being portable,
2. Home tonometry (iCare with inter-device variation within 5 affordable, convenient. Useful in
Tonometer)- mmHg3,4. bedridden or wheelchair patients (Fig 6) .
It is an FDA approved (2017) self Major disadvantage of this device is the
IOP monitoring device, based on the inability of patients to accurately use Fig 6. Virtual perimetry can be done in
principle of rebound tonometer( Fig the device. About 16-25% of patients sitting position. (Image courtesy micro
3). The iCare Tonometer device has have difficulties in completing training medical devices)
a 40mm metal probe with a 1.7mm of self IOP monitoring5,6. This device is However its not as sensitivity as
diameter plastic end-tip which is not useful in picking up nocturnal IOP Standard Automated Perimetry,
accelerated through a solenoid chamber spikes7. and may miss early glaucomas. It is
towards the corneal surface, and the How to use iCare tonometer- patients uncomfortable for claustrophobic
speed of rebounding probe is recorded power on the device using the power patients.
to give the IOP. The procedure does not button on the back of the device. After Normative database in this device is
require anaesthesia ( Fig 4). pressing the top button, a new probe still being validated.
is loaded with the metal end entering
Fig 3. Rebound tonometer the chamber and plastic tip facing
externally. Pressing the top button once
more activates the solenoid chamber
and locks the probe into place, the device
becomes ready for use. The patient lines
the green/red indicator ring 4-8 mm
from their cornea. Adjustable forehead
and cheek rests are used to accurately
position the probe away from the
cornea with unique settings for each
eye. When the device is parallel to the
ground, the circular light will glow
green indicating a measurement may
be taken. Pushing the top button again
will accelerate the probe towards the
cornea. Six consecutive measurements
are averaged together to create one
IOP reading. Each IOP measurement is
saved along with the time, date, and eye
of the reading.

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Subspeciality-Glaucoma

Procedure- The subject wears the I. Netarsudil (0.02%) - ROCK+ nor reaction is conjunctival hyperemia.
Virtual Perimetry headset while seated epinephrine transporter (NET) Others being blepharitis and
comfortably. The subject also holds inhibitor. allergic conjunctivitis18.
a wireless clicker to respond to the
visual stimuli. The operator activates Mechanism of action- It reduces 2. Latanoprostene bunod ( 0.024%)-
the headset from their controls on the cell contraction, decreases the It is a nitric oxide donating PGA
Tablet computer. This displays a visual expression of fibrosis-related approved in USA for reduction of
acuity test and to which they respond proteins, and reduces cell stiffness IOP in patients with open angle
verbally. Then the appropriate visual in the TM and SC cells. Inhibition glaucoma or ocular hypertension.
field test is started. Subject keeps both of the NET prevents reuptake of
eyes open and looks at the fixation norepinephrine at noradrenergic Mechanism of action-
point, while stimuli are displayed in the synapse, thus reducing ciliary body
periphery. On seeing the stimuli, they blood flow and aqueous formation13. Combines the complementary
are supposed to press the button on the mechanisms of PGF2a and
wireless clicker. Live result of the test Dose- Once daily. IOP reduction nitric oxide.
will be continuously be displayed on about 3.3-5mmHg.
the Tablet computer. After completion Increase uveo scleral outflow
of test for both the eyes, the final report ROCKET-1 trial demonstrated that (mediated by PGA).
is displayed and can be exported as a Netarsudil once a day produced
PDF file. Headset can be removed as significant lowering from baseline Increase conventional outflow
soon as the test is completed, and can IOP, which was non-inferior to (relaxing effect of NO).
also be removed during the test if the timolol14.
subject wants to take a pause. Results from two multinational,
Most common adverse drug phase III studies (APOLLO and
B. Newer advances in reaction is conjunctival hyperemia. LUNAR studies) demonstrated
management the non inferiority of
Netarsudil 0.02% + Latanoprost latanoprostene bunod 0.024%
Present proven medical and surgical 0.005% fixed dose combination- to timolol 0.5% in terms of
therapies for glaucoma work by IOP lowering efficacy over 3
reducing IOP. They are limited in their MOA- Increase aqueous outflow months in patients with OAG
capacity to stop glaucoma progression (ROCK inhibitor) or ocular hypertension19,20.
as even significant IOP reduction may Decrease aqueous production (NET
not guard against glaucoma progression inhibitor) Dose- once daily.
in all patients.
Recent exciting developments in Increase uveo scleral outflow (PGA) Adverse drug reaction-
glaucoma management hope to, in part, Dose- once daily. IOP reduction conjunctival hyperemia, eye
address these concerns. These include irritation, eye pain.
the development of a new class of IOP of additional 1.8-3.0 mmHg over
lowering medications (Rho-kinase Netarsudil and 1.3-2.5 mmHg over 3. Triple drug therapy- The
inhibitors), newer and safer techniques latanoprost15. combination contains PGA
for surgical IOP reduction and the II. Ripasudil (0.4%)- (Bimatoprost 0.01%) + Brimonidine
development of non-IOP dependant World’s first Rho-associated coiled- 0.15% + Timolol 0.5%.
therapies such as neuroprotection. coil-containing protein kinase
1. ROCK inhibitors- (ROCK) inhibitor eyedrop. Dose is twice daily. The
These are a new group of IOP reducing Mechanism of action- It directly acts masked, randomized, phase 3
drugs. It acts by reducing the on the trabecular meshwork and comparison of Triple Fixed-
resistance in TM outflow pathway by increasing conventional outflow Combination Bimatoprost/
altering cellular components of TM through the trabecular meshwork Brimonidine/Timolol
and Schlemm’s canal9,10. It also acts and Schlemm’s canal16. versus Fixed-Combination
as vasodilator and increases ocular Dose- twice daily. Brimonidine/Timolol have
blood flow11. There is possibly some The Ripasudil–Timolol Study shown that the triple fixed-
neuroprotective benefits associated12. and Ripasudil–Latanoprost combination bimatoprost
Some of the available drops from this Study showed that the mean 0.01%/brimonidine 0.15%/
category are discussed below. IOP reduction from baseline was timolol 0.5% ophthalmic
2.4-2.9 mmHg after addition of solution is superior to dual
ripasudil to timolol, and 2.2-3.2 fixed-combination brimonidine
mmHg after addition of ripasudil to 0.2%/timolol 0.5% in lowering
latanoprost17. IOP in patients with POAG and
Most common adverse drug OHT21,22.

Commonest adverse drug
reaction is conjunctival
hyperemia.

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Subspeciality-Glaucoma

4. Injectable preparations The implant is designed to target ring. (Fig 8). Effective for 6
(intracameral)- drug delivery directly to the iris– months.
ciliary body, the main site of Comes in multiple sizes (24-29
• Envisia- Intracamerally injected action of PGAs. Once in place, the mm).
biodegradable extended release polymer matrix of the insert slowly Studies have demonstrated
formulation of Travoprost degrades (to lactic and glycolic that a clinically relevant
(Travoprost XR). acid) and releases bimatoprost. sustained reduction in IOP of
The IOP lowering effect lasts for approximately 4 to 6 mmHg
6 months preclinical study on 4–6 months25. (≥20% reduction compared
hypertensive and normotensive with washout baseline) for
Beagle dog showed- Comparedwithtopicalbimatoprost, 6 months can be achieved
intracameral bimatoprost implant with the bimatoprost ring.
Mean IOP reduction from enhances delivery of the drug to However, daily timolol 0.5%
baseline= 7.2+/- 0.5 mmHg. target tissue26. ophthalmic solution provided
approximately 0 to 1.5 mmHg
Mean% IOP reduction is 30+/-  According to the trials (ARTEMIS-1 more IOP reduction compared
2%23. and 2), the mean reductions in IOP with the bimatoprost insert27.
from the baseline in bimatoprost Adverse drug reactions are
• Bimatoprost sustained release implant recipients were about discharge, irritation and
implant ( Bimatoprost SR)- 7–8 mmHg at weeks 2 and 6, hyperemia.
In March 2020, bimatoprost and about 6–7 mmHg at week 1224.
implant received its first Fig 8. Schematic of a bimatoprost ring.
approval in the USA in patients   The most common adverse The soft ring-shaped insert is constructed
with open angle glaucoma or reactions in the ARTEMIS-1 of a bimatoprost and silicone-matrix
ocular hypertension. (Fig 7) and -2 trials were conjunctival polymer and is placed on top of the ocular
hyperaemia (reported in 27% of surface. Right, The insert maintains its
Fig 7. Bimatoprost SR single-use applicator patients), others were foreign body radial integrity because of its internal
(top). Implant positioned next to a dime for sensation, eye pain, photophobia, polypropylene support structure. ( Image
size comparison (bottom). Figure adopted conjunctival haemorrhage, dry eye, courtesy AAO)
from “Jai G. Parekh, MD, MBA, FAAO; and eye irritation, raised IOP, corneal
Michael R. Robinson, MD. Bimatoprost SR endothelial cell loss, vision blurred,
and iritis. 

5. New drug delivery systems-

• Bimatoprost ring- soft,
flexible ocular insert that
rests circumferentially in the
fornices on top of conjunctiva.

Contains 13 mg of bimatoprost
mixed into a silicone matrix
over an inner polypropylene

A first-in-class, sustained-release,

investigational, biodegradable

implant for the treatment of patients

with open-angle glaucoma or ocular

hypertension. CRST.2019 June”.

It is a biodegradable, solid Fig 9. DEVICE INSERTION. The ring (A) is inserted first in the upper conjunctival
polymer, sustained-release drug fornix (B), then in the lower (C), where a scleral depressor may be used to ease insertion (D).
delivery system containing a 10-μg After placement, the ring is barely visible (E). Reproduced by courtesy of ForSight Vision5,
bimatoprost for single intracameral Inc. [for photographs].
administration24.

For administration, bimatoprost
implant is supplied preloaded in a
single-use applicator for its direct
injection into anterior chamber.

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Subspeciality-Glaucoma

• OTX-TP punctum plugs-
Travoprost punctum plug
is composed of travoprost
encapsulated in polylactic acid
micro-particles suspended
within a polyethylene glycol
resorbable hydrogel rod.
Designed to be placed in the
vertical portion of the superior
or inferior canaliculus. (Fig 10).

On exposure to the tear film,
the rod swells to occupy the
space within the upper or lower
canaliculus. Hydrolysis of the
polylactic acid microparticles
takes place resulting in
sustained release of the
travoprost drug into the tear
film over 90 days period.

Fluorescein incorporated Fig 11. Xen implant drains aqueous from anterior chamber into the subconjunctival space.
within hydrogel rod to aid in (Image courtesy myalconstore.com)

visualization of the device. 6. Xen implant- This subconjunctival internal dimensions of a tube
implant is a ab-interno MIGS that would prevent hypotony
Studies have shown significant approach to subconjunctival at average aqueous humor
IOP reduction of up to 24% from outflow. It is a 6 mm hydrophilic production of 2–3 μl/min
baseline over a 1-month period, tube of collagen derived gelatin by providing a steady-state
combined with good retention cross-linked with glutaraldehyde30. pressure of approximately 6–8
and low adverse events. It is 3 Xen models have been designed- mmHg.
a well-tolerable in glaucoma 45, 63, and 140 μm internal lumen
patients, especially those with a diameters for varying levels of IOP Mechanism of action- It reduces
history of poor compliance28. control31. IOP by creating a permanent
drainage shunt from AC to
Clinical trials comparing OTX- Based upon the principles subconjunctival space through
TP and timolol 0.5% showed of laminar fluid dynamics a scleral channel32. (Fig 11)
clinically meaningful IOP (Hagen–Poiseuille equation)32.
reduction (4.5–5.7 and 6.4–7.6 It calculates the required Patients with primary
mmHg for the OTX-TP and
timolol groups respectively)29.

open-angle glaucoma,

and pseudoexfoliative

or pigmentary glaucoma

with open angles that are

unresponsive to maximum

tolerated medical therapy are

the most suitable candidates

for Xen implant.

Most studies document an
IOP reduction of >29% and
a significant reduction in
the number of IOP-lowering
medications33,34.

Fig 10. External photograph demonstrating insertion of the travoprost punctum plug into Studies showed no difference
the lower canaliculus. ( Image - Ocular Therapeutix, Inc ) in efficacy, risk of failure, and
safety profile between Xen
implant and trabeculectomy32.

108 DOS Times - Volume 26, Number 4, January-February 2021 www.dosonline.org/dos-times

Subspeciality-Glaucoma

References meshwork cells. Exp Eye Res. 2006; ocular hypertension: the APOLLO study.
82(3):362–70. Ophthalmology. 2016;123(5):965–973.
1. Mottet B, Aptel F, Romanet JP,
Hubanova R, Pépin JL, Chiquet C. 24- 11. Moura-Coelho N, Tavares Ferreira 20. Medeiros FA, Martin KR, Peace J, et al.
hour intraocular pressure rhythm J, Bruxelas CP, Dutra-Medeiros M, Comparison of latanoprostene bunod
in young healthy subjects evaluated Cunha JP, Pinto Proença R. Rho kinase 0.024% and timolol maleate 0.5%
with continuous monitoring using a inhibitors—a review on the physiology in open-angle glaucoma or ocular
contact lens sensor. JAMA Ophthalmol. and clinical use in Ophthalmology. hypertension: the LUNAR study. Am J
2013;131(12):1507–1516. Graefe’s Arch Clin Exp Ophthalmol. Ophthalmol. 2016;168:250–259.
2019;257(6):1101-1117.
2. Leonardi M, Pitchon EM, Bertsch A, 21. Curt Hartleben, Juan Camilo Parra,
Renaud P, Mermoud A. Wireless contact 12. Hall A, Lalli G. Rho and Ras GTPases in Amy Batoosingh, Paula Bernstein,
lens sensor for intraocular pressure axon growth, guidance, and branching. Margot Goodkin, “A Masked,
monitoring: assessment on enucleated Cold Spring Harb Perspect Biol. Randomized, Phase 3 Comparison of
pig eyes. Acta Ophthalmol. 2009; 2010;2(2):a001818. Triple Fixed-Combination Bimatoprost/
87(4):433–437. Brimonidine/Timolol versus Fixed-
13. Lin CW, Sherman B, Moore LA, Laethem Combination Brimonidine/Timolol for
3. Takagi D, Sawada A, Yamamoto T. CL, Lu DW, Pattabiraman PP, et al. Lowering Intraocular Pressure”, Journal
Evaluation of a new rebound self- Discovery and Preclinical Development of Ophthalmology, vol. 2017, Article ID
tonometer, icare home: Comparison of Netarsudil, a Novel Ocular 4586763, 9 pages, 2017.
with Goldmann Applanation Hypotensive Agent for the Treatment
Tonometer. J Glaucoma. 2017; 26(7):613- of Glaucoma. J Ocul Pharmacol Ther. 22. M. Menon, M. Goodkin, P. Bernstein,
618. 2018;34(1-2):40–51. C. Liu, and A. Batoosingh, Safety and
Efficacy of Triple Fixed-Combination
4. Dabasia PL, Lawrenson JG, Murdoch 14. Serle JB, Katz LJ, McLaurin E, Heah Bimatoprost 0.01%/Brimonidine
IE. Evaluation of a new rebound T, Ramirez-Davis N, Usner DW, et al. 0.15%/Timolol 0.5% Twice Daily in
tonometer for self-measurement of Two Phase 3 Clinical Trials Comparing Patients with Glaucoma or Ocular
intraocular pressure. Br J Ophthalmol. the Safety and Efficacy of Netarsudil Hypertension Previously Treated with
2016;100(8):1139-1143. to Timolol in Patients With Elevated Brimonidine 0.2% and Timolol 0.5%
Intraocular Pressure: Rho Kinase Twice Daily: A Multicenter, Open-Label
5. Mudie LI, LaBarre S, Varadaraj V, Elevated IOP Treatment Trial 1 and Study, Presented at the 11th European
et al. The icare home (ta022) study: 2 (ROCKET-1 and ROCKET-2) Am J Glaucoma Society Congress, Nice,
Performance of an intraocular pressure Ophthalmol. 2018;186:116–27. France, 2014.
measuring device for self-tonometry
by glaucoma patients. Ophthalmology. 15. Asrani S, Robin AL, Serle JB, Lewis RA, 23. Tomas Navratil; Andres Garcia; Janet
2016; 123(8):1675-1684. Usner DW, Kopczynski CC, Heah T; Tully; Benjamin Maynor; Iqbal Ike K
MERCURY-1 Study Group. Netarsudil/ Ahmed; Donald L Budenz; Richard A
6. Meier-Gibbons F, Berlin MS, Toteberg- Latanoprost Fixed-Dose Combination Lewis; Steven L Mansberger; Brian C
Harms M. Twenty-four hour intraocular for Elevated Intraocular Pressure: Gilger; Benjamin R Yerxa, Preclinical
pressure measurements and home Three-Month Data from a Randomized Evaluation of ENV515 (travoprost)
tonometry. Curr Opin Ophthalmol. Phase 3 Trial. Am J Ophthalmol. 2019 Intracameral Implant - Clinical
2018;29(2):111-115. Nov;207:248-257. Candidate for Treatment of Glaucoma
Targeting Six-Month Duration of
7. Young CC, Seibold LK. 24-hour IOP 16. Honjo M, Tanihara H. Impact of the Action. Investigative Ophthalmology &
monitoring: Current state and future clinical use of ROCK inhibitor on the Visual Science April 2014;55: 3548.
directions. Glaucoma Physician. pathogenesis and treatment of glaucoma.
2018:10-14. Jpn J Ophthalmol. 2018;62(2):109–126. 24. Allergen. DurystaTM (bimatoprost
doi:10.1007/s10384-018-0566-9. implant), for intracameral
8. Wroblewski D, Francis BA, Sadun A, administration: US prescribing
Vakili G, Chopra V. Testing of visual 17. Tanihara H, Inoue T, Yamamoto T, et al. information. 2020. https://media.
field with virtual reality goggles in Additive intraocular pressure-lowering allergan.com/products/durysta_pi.pdf.
manual and visual grasp modes. Biomed effects of the rho kinase inhibitor Accessed 20 Apr 2020.
Res Int. 2014;2014:206082. ripasudil (K-115) combined with timolol
or latanoprost: a report of 2 randomized 25. Shirley, Matt. “Bimatoprost Implant:
9. Honjo M, Tanihara H, Inatani M, Kido clinical trials. JAMA Ophthalmol. First Approval.” Drugs & aging vol.
N, Sawamura T, Yue BY, et al. Effects of 2015;133(7):755–761. 2020;37: 457-462.
rho-associated protein kinase inhibitor
Y-27632 on intraocular pressure and 18. Saito H, Kagami S, Mishima K, Mataki 26. Seal JR, Robinson MR, Burke J, et
outflow facility. Invest Ophthalmol Vis N, Fukushima A, Araie M. Long-term al. Intracameral sustained-release
Sci. 2001;42(1):137–44. side effects including blepharitis bimatoprost implant delivers
leading to discontinuation of ripasudil. J bimatoprost to target tissues with
10. Koga T, Koga T, Awai M, Tsutsui J, Yue Glaucoma. 2019;28(4):289–293. reduced drug exposure to off-target
BY, Tanihara H. Rho-associated protein tissues. J Ocul Pharmacol Ther.
kinase inhibitor, Y-27632, induces 19. Weinreb RN, Scassellati Sforzolini B, 2019;35(1):50–57.
alterations in adhesion, contraction and Vittitow J, et al. Latanoprostene bunod
motility in cultured human trabecular 0.024% versus timolol maleate 0.5% in 27. Brandt JD, Sall K, DuBiner H, Benza
subjects with open-angle glaucoma or

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R, Alster Y, Walker G, Semba CP; Jacopo Guidotti, André Mermoud & L, Morselli S. Minimally invasive
Collaborators. Six-Month Intraocular Kaweh Mansouri (2017): XEN Gel combined glaucoma and cataract
Pressure Reduction with a Topical Implant: a new surgical approach in surgery: clinical results of the smallest
Bimatoprost Ocular Insert: Results of a glaucoma. Expert Review of Medical ab interno gel stent. Int Ophthalmol.
Phase II Randomized Controlled Study. Devices. 2017;15. 2018 Jun;38(3):1129-1134.
Ophthalmology. 2016 Aug;123(8):1685-
1694. 31. Green, A. Lind, J. Sheybani, A. Review Corresponding Author:
of the Xen Gel Stent and Inn Focus
28. Perera SA, Ting DS, Nongpiur ME, MicroShunt. Curr Opin Ophthalmology. Dr. Maneesh Singh
et al. Feasibility study of sustained- 2018;29(2):162-170. Netralayam, The Superspeciality Eye Care Centre,
release travoprost punctum plug for Santoshpur, Kolkata, West Bengal 700099
intraocular pressure reduction in an 32. De Gregorio A, Pedrotti E, Stevan G,
Asian population. Clin Ophthalmol. Bertoncello A, Morselli S. XEN glaucoma
2016;10:757-764. treatment system in the management of
refractory glaucomas: a short review on
29. Ocular Therapeutix, Inc. Ocular trial data and potential role in clinical
Therapeutix TM reports on topline practice. Clinical Ophthalmology
results of phase 2b glaucoma clinical (Auckland, NZ). 2018;12:773-782.
trial. Press Release. 22 October
2016. http:// investors.ocutx.com/ 33. Galal A, Bilgic A, Eltanamly R, et
phoenix.zhtml?c=253650&p=irol- al. XEN glaucoma implant with
newsArticle&ID=2100516. [Accessed 6 mitomycin C 1-year follow-up: result
September 2016] and complications. J Ophthalmol.
2017;2017:5457246.
30. Ankita Chaudhary, Lauriane Salinas,
34. De Gregorio A, Pedrotti E, Russo

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Subspeciality-Glaucoma

Trabeculectomy: Tips for Better
Outcomes

Madhuri Akella, Faisal Thattaruthody, Surinder S Pandav
Glaucoma Services, Advanced eye Center, Postgraduate Institute of Medical Education & Research,
Chandigarh

Trabeculectomy was first introduced 1) Patient’s age, life expectancy, scarring and failure of filtration
by Cairns as a procedure to reduce general health. Younger patients surgery. Hence a judicious use
intraocular pressure (IOP) for the have more aggressive healing of antimetabolites while during
treatment of glaucoma.1 It is the responses and need aggressive trabeculectomy is imperative. Eyes
most commonly performed surgical postoperative care as compared to with previous history of vitrectomy
procedure to control IOP in those who elderly patients. Hence dose and have high risk for hypotony and
have failed medical therapy, and till now exposure time to anti-metabolite suprachoroidal haemorrhage. A
is the gold standard surgical procedure can vary according to age of the primary glaucoma drainage device
for high.2 The basic principle of this patients. Patients with other co- is preferred in silicon oil exposed
surgery is the creation of an alternative morbidities like coronary artery eyes and eyes with pre-existing
passage for the flow of aqueous humour diseases, valvular disease, strokes scleral buckle.
by creating a communication between and Parkinsonism may require
the anterior chamber (AC) and the thorough systemic evaluation. 4) Ocular surface evaluation: Eyes
sub-Tenon’s space. This establishes a Good systemic control of BP and with ocular surface disorders like
fistula at the limbus which bypasses the blood sugars are mandatory prior to dry eyes, Meibomian gland disease
trabecular meshwork. After a successful surgery to avoid intra-operative or and ocular allergy have high risk for
surgery there is formation of a diffuse postoperative complications postoperative fibrosis and failure.
microcystic, filtering subconjunctival Hence theses co morbidities should
bleb which is caused by the flow of 2) Systemic medication history: be addressed and if required a short
diverted aqueous humour. The aqueous Systemic use of antiplatelets course of topical steroids should be
are then absorbed by the conjunctival (eg- Asprin, Clopidogrel) and given preoperatively to achieve an
vessels, lymphatics and tear film. anticoagulant should be enquired optimal outcome.
and discontinued atleast 5-7 days
Indications of trabeculectomy prior to surgery in consultation 5) Intraocular inflammation/retinal
with the treating physician to
The major indications for reduce the incidence of retrobulbar disorders: A thorough history to rule
trabeculectomy are as follow. 1) haemorrhage during peribular
Medically uncontrolled glaucoma. 2) injection of anaesthesia, excessive out intraocular inflammation
Progressively deteriorating visual field conjunctival bleeding while tissue
even with medically controlled IOP. 3) dissection and intraoperative is essential. In general all active
Drug allergies, compromising ocular suprachoroidal bleeding.
surface. 4) Poorly compliant patient and intraocular inflammation should
financial barriers to treatment.
be adequately controlled at least
Pre-operative evaluation A
good pre-operative evaluation, patient for 3 month prior to surgery.
selection and thorough examination
are imperative in the long-term success Treatment of retinal disorders like
of the surgery. The following points
should be kept in mind. proliferative diabetic retinopathy,

3) Previous ocular surgery. Previous vascular occlusion or macular

ocular procedure involving the oedema is also essential before

conjunctiva like ICCE, ECCE, SICS, surgery.

phacoemulsification through 6) Visual acuity and refractive
error. Baseline visual acuity
a scleral tunnel, scleral buckle documentation is mandatory prior
to trabeculectomy and possible
surgery, pars plana vitrectomy postoperative drop in BCVA should

is associated with increased risk

of post operative conjunctival

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Subspeciality-Glaucoma

be explained to patients. Eyes with of lignocaine 2% and 0.5% bupuvicain C (0.2mg% for 2 minutes) in the form
high myopia and thin sclera have (50:50 mixtures). Topical anaesthesia of soaked sponges is applied to the
high risk for scleral perforation with proparacaine in combination scleral bed followed by a thorough
during peribulbar anaesthesia, with subconjunctival infiltration of wash. Intracameral pilocarpine is then
and high risk for hypotony lignocaine can be uses in cooperative injected to anterior chamber (AC) to
and hypotonic maculopathy patients. constrict the pupil through a separate
postoperatively. Hyperopic or paracentesis incision . Then AC entry
nanophthalmic eyes have high risk Surgical Procedure: is made just anterior to the blue-gray
for suprachoroidal haemorrhage junction with 15 degree stab knife/11-
and malignant glaucoma. After attaining good anaesthesia, a number blade.. The sclerostomy is
traction suture, either superior rectus then completed by a Kelly’s Descemet
7) Visual field evaluation/Optic disc bridle or clear corneal is applied punch/11 number blade/Vannas scissor.
evaluations: Recent visual field to rotate the globe inferiorly to get One punch bite removes 0.25 to 0.5mm2
evaluation is mandatory. Patients adequate exposure of surgical the tissue so that making 3-4 punches creates
with advanced visual field loss site. Superior rectus bridle suture a sclerostomy of size 1-1.5 mm. This is
(within central 5O) have increased has the disadvantages of iatrogenic followed by a peripheral iridectomy (PI)
risk of vision loss after surgery. muscle hematoma and damage. Hence, which should be broad based and larger
superior clear corneal traction suture is than the size of the sclerostomy. This
8). Preoperative IOP: Baseline IOP preferred, usually applied 1 mm away is followed by closure of the flap with
should be obtained prior to surgery from the limbus, with a width of about fixed and releasable sutures using 10-0
and target IOP should be calculated. 4-5 mm passing three-fourth of the nylon. The conjunctival flap is then
Patients with low target IOP often corneal thickness. Li et al3 compared secured with 8-0 vicryl. Additionally,
require anti-metabolite. A high the outcomes of clear corneal versus mild debridement of epithelium near
preoperative IOP increases the risk superior rectus suture and found a more the limbus prior to conjunctival closure
for intra-operative suprachoroidal diffuse bleb, less vascularisation lesser in a limbal based flap help to prevent
haemorrhage and hence the incidence of encysted bleb and better any post-operative bleb leaks. For a
measures to reduce the IOP are must success rates in clear corneal traction fonix based flap initial two water tight
be taken. Intravenous injection suture assisted trabeculectomy.3 wings sutures are placed at the edges (the
of mannitol or oral hygroscopic Alternatively, an Ong-Lieberman eye bites must be taken trough scleral tissue),
agents are often required to shrink speculum could be used obliviating and then close the relaxing incision in
the vitreous. the need for a traction suture.4 It has interrupted fashion. In a limbal based
a wider blade (12-15 mm) inferiorly, flap the conjunctival incision is closed
9) Coexisting cataract. The which when placed in the inferior in continuous fashion (Tenon and
fornix presses the globe and rotates the conjunctiva separately). At the end
visually significant co-existing eyeball inferiorly, providing adequate hydrate the paracentesis port, titrate
exposure of the superior conjunctiva. the bleb and check for any conjunctival
cataract should be addressed. A conjunctival peritomy is done next leak. Various steps of trabeculectomy are
to raise a limbal or a fornix based depicted in figure 1.
A sequential surgery or a conjunctival flap followed by dissection
using a conjunctival scissors to expose Follow-up and post-operative
combined phacoemulsification the bare sclera. A study by Wang et al
concluded no significant difference in interventions
with trabeculectomy is planned IOP lowering between Limbal based or
fornix based trabeculectomies.5 This Immediate post-operative follow-
according to patients need, is followed by light cauterisation of up period is critical for a successful
the scleral bed vessels. Next, a partial bleb outcome. It is critical to monitor
preoperative IOP, anterior thickness (about 1/3-1/2) scleral flap IOP, bleb morphology with AC depth
4 mm x 4mm hinged at the limbus is and fundus evaluation at each visit.
chamber angle and other biometric dissected up to the blue-gray junction Typically, follow-ups are scheduled
parameters. of the limbus. Variations in shape exist twice-weekly in the first two weeks
(triangular/rectangular/trapezoid), followed by weekly for next six weeks.
Anaesthesia with no difference in post-operative Timing interventions in this period
General anaesthesia is uses in outcomes.6 Then, timed application and titrating to the healing response
children, anxious uncooperative of antimetabolites 5-FU or Mitomycin of the patient are critical for a diffuse
adults. Significant fluctuation in IOP bleb. Releasable sutures and laser
is associated with general anaesthesia
and most of the anaesthetic agents are
associated with significant decreases
in IOP. Local anaesthesia is preferred
in adult patient and it has low risk of
systemic complications. Various mode
of local anaesthesia include peribulbar,
retrobulbar, sub-Tenon and sub-
cojuntival injections of combination

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Subspeciality-Glaucoma

Figure 1: Various steps of trabeculectomy. A; clear corneal traction suture B; Hydro dissection trough sub-Tenon level. C; Fornix based
conjunctival flap D; Gentle dissections of sub-Tenon tissue. E&F Creation of partial thickness scleral flap triangular/rectangular G;
Application of sponge soaked with MMC. H; Thorough wash with balanced salt solution I; Surgical limbus anatomy showing blue gray
zone J; AC entry anterior to blue gray zone using a 15 degree knife after pilocarpine intracameral injection K; Creating sclerostomy by using
Kelly’s punch L; Peripheral iridectomy using Vannas scissors M; Visualisation of one-two ciliary processes N; Scleral Flap closure- one fixed
and two releasable using 10-0 nylon suture O; De-epithelisation of limbus with light cautery to fasten the wound healing P; Tight closure of
conjunctival flap using 8-0 vicryl. Formation of diffuse bleb is appreciated at the end of procedure

suterolysis can be done to lower the IOP classified in to two category, early and steroids and cycloplegic therapy.
and titrate the bleb height. Attempts to late complications. Small conjunctival leake/
diffuse the bleb with gentle superior retraction can be managed by
eyelid massage must be done early in Early post-operative complications may bandage contact lens or fibrin glue.
cases of localisation due to underlying be classified into four groups 7 Resuturing is often required in
fibrosis. Early sub-Tenon fibrosis and large size defects.
corckscrewing of vessels if present • Low IOP with flat/shallow blebs-
can be managed by5-Fluorouracil The reasons for low IOP could • Low IOP with elevated blebs- Over
injections. In cases of early Tenon cyst be over filtration (figure 2), bleb filtering blebs due to inadequate or less
formation, needling of the bleb is done leaks, wound defects or serous tight closure which usually responds
to break the adhesions. choroidal detachments. Often well to mydriatic-cycloplegic therapy
such complication can be managed and pressure patch
Complications and conservatively with antibiotic,
managements steroids and cycloplegic. Serous • High IOP with deep AC- Common
choroidal detachments usually reasons are tight scleral flap suture
In general the complications are responding well to oral/systemic and obstruction of the ostium by
fibrin or blood. It is sually managed

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Subspeciality-Glaucoma

by removal of releasable sutures or Figure 2: A well diffused over filtering bleb
increasing the dose of postoperative
steroids respectively. Early bleb Figure 3: Scarred and encapsulated bleb. A: shallow bleb with subconjunctival fibrosis.
failure in the form of Tenon cyst is B: Large avascular thick Tenon cyst
another cause of bleb failure should
be kept in mind. operative monitoring of IOP and cost for long-term medications, poor
inflammation is required to prevent compliance, poor accessibility and
• High IOP with shallow AC- The bleb fibrosis and failure. regular ophthalmic review are the
causes are pupillary block, aqueous major barriers of medical therapy in
misdirection and suprachoroidal • Blebitis and Endophthalmitis- Indian scenario. Late presentation with
haemorrhage. Pupillary block managed intensively by fortified advanced glaucomatous neuropathy
usually respond well to a laser antibiotics, intravitreal injections is common in our scenario, and these
peripheral iridotomy if PI is not or vitrectomy patients required a low target IOP and
patent. Aqueous misdirection hence need trabeculectomy.
requires mydriatic-cycloplegic Trabeculectomy outcomes Trabeculectomy has generally been
therapy or pars-plana vitrectomy considered as the gold standard
with AC reformation in refractory Anti-glaucoma medical therapy has procedure among all glaucoma surgical
cases. Suprachoroidal haemorrhage been found to be par on trabeculectomy procedure.2 During the last 3-4 decade
managed initially by conservatively in the management of glaucoma for studies have confirmed the effectiveness
with topical and systemic steroids visual field progression.8 Advances of procedure in short and long term
for 2-3 week. Persistent choroidal in the medical therapy have been basis. The reported success rate varies
detachments or kissing choroidals significantly led to decrease glaucoma
warrant drainage. surgical procedures. However, the

Late complications

• Scarred encapsulated non-
functioning blebs (figure 3): Often
requiring additional surgeries
like bleb revision, needling, a
repeat trabeculectomy or alternate
surgeries like glaucoma drainage
device implantation

• Thin, cystic dysthetic avascular
blebs (Figure 4): it is likely due
to over dose of antimetabolites,
often requiring bleb excisions and
repair by advancement of healthy
conjunctiva.

• Persistent hypotony. Persistent
hypotony due to over filtering bleb
can lead to drop in visual acuity
or causes irreversible changes in
macula due to maculopathy. The
visual acuity should be monitored
regularly. Decrease in visual
acuity and maculopathy warrants
resuturing of conjunctiva.

• Cataract: Trabeculectomy often
accelerates the cataractogenisis and
visually significant cataract must
be removed. Care must be taken to
avoid the bleb area superiorly while
making entry ports. Also, post-

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Subspeciality-Glaucoma

Figure 4: Thin dysthetic cystic bleb. A: Thin avascular cystic bleb. B: Bleb leaking on Tips for a successful
fluorescence staining trabeculectomy

from 65% to 85%.1,9 Success rates vary table analysis. Studies have showed • Preoperative evaluation of ocular
with various factors like age, ethnicity, that the use of MMC was associated adnexa to look for meibomian gland
and type of glaucoma. Previous studies with significantly lower postoperative disease and dry eye are important.
have reported lower success rate in IOP and higher long-term success as
African and African-American than compared to 5 FU. 18 • Minimise tissue trauma while
Caucasians.10-12 Study by Sihota et al13 dissecting conjunctival flap.
showed that 10 years qualified success However, the use of MMC and 5 FU
rate of trabeculectomy without uses during surgery has increased the • Light cautery is advised to avoid the
of anti-metabolite in Asian are not risk of bleb related complication incidence of avascular blebs.
different from those reported from like thin avascular cystic bleb,
Caucasian population. hypotony, maculopathy, blebitis and • Using a callipers to measure the size
bleb related endophthalmitis.19-21 of the flap and placing the crescent
The trabeculectomy is indented to get Trabectulectomy combined with the flat on the scleral bed while
a shallow, diffuse and normal looking use of a biodegradable, porous collagen- dissecting creates a flap of uniform
conjunctival vessel with good control of glycosaminoglycan matrix implant thickness in a single plane.
IOP for a prolonged duration. However, (Ologen) in subconjunctival space
fibrosis of sub-conjunctival tissue leads has been showed good results. Ologen • Contact of antimetabolite soaked
to scarring and failure of bleb and implant act as scaffold for the growth of sponges with conjunctival flap
decrease in the long-term success of fibroblast into the pores of the implant, margins should be avoided to
trabeculectomy.14,15 Anti-metabolites and thus help tissue remodeling and decrease the chances of post
like MMC and 5-FU significantly decreases the scar formation. Studies operative wound leaks. Also
decreases the post operative sub have showed that trabeculectomy with minimise exposure of limbal stem
conjunctival scarring. Studies have Ologen appears to be as effective as cells to MMC by applying it more
showed that adjunctive use of anti- trabeculectomy with MMC for lowering posteriorly.
metabolite had improved the long- IOP in glaucomatous eyes with lesser
term success rate of trabeculectomy.14,15 bleb related complication.22 • Pre placement of an apex suture
In a study by Scott et al16 showed on scleral flap will help in quick
primary trabeculectomy with the use Nevertheless trabeculectomy is closure of flap.
of intraoperative MMC to lower the still been considered as a gold
IOP by 30% or more in 86% and 78%at standard procedures, it is not free of • The punch need to be oriented
1 and 2 years respectively. Study done complications. Olayanju et al23 reported vertically so as create a cut
by Casson et al17showed 80.9% eyes that the 20-year cumulative chances of perpendicular to scleral bed.
had an IOP of less than 21 mm Hg early, late, or any complication were
without medical treatment at the end 19.7%, 26.0%, and 45.0% respectively. • Tight well apposed closure of
of three years post trabeculectomy The cumulative probabilities of vision- conjunctival flap in fornix based
with 0.02% MMC application. Their threatening complications during 20 trabeculectomy.
study had a 67% and 90% probability years were 2.0% for blebitis and 5.0%
of IOP being less than 21 mm Hg at the for endophthalmitis. • Early recognition and prompt
end of five years using Kaplan Meir life management of any operative/post-
operative complications.

• Recognise early signs of bleb
failure like vessel corkscrewing
and fibrosis for timely intervention
in the immediate post operative
period.

References

1. Cairns JE. Trabeculectomy. Preliminary
report of a new method. Am J
Ophthalmol. 1968; 66:673-9.

2. Nouri-Mahdavi K, Brigatti L,
Weitzman M, Caprioli J. Outcomes
of trabeculectomy for primaryopen-
angle glaucoma. Ophthalmology. 1995;
102:1760-9.

3. Li B, Zhang M, Liu W, Wang J.
Comparison of Superior Rectus and

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Subspeciality-Glaucoma

Peripheral Lamellar Corneal Traction Blumenthal M. Filtering operations in subconjunctival 5-fluorouracil. Am J
Suture during Trabeculectomy. Curr Eye blacks. Am J Ophthalmol 1972; 56: 783– Ophthalmol.1992;114:544–553.
Res. 2016;41(2):215-221. 7. 20. Ticho U, Ophir A. Late complications
after glaucoma filtering surgery
4. Ong, K.. Ong eye speculum for 13. Sihota R, Gupta V, Aggarwal HC. Long- with adjunctive 5-fluorouracil. Am J
glaucoma surgery. Asian Journal of term evaluation of trabeculectomy Ophthalmol. 1993; 115:506–510.
Ophthalmology. 2013;13(2): 71-72. in primary open angle glaucoma and 21. DeBry PW, Perkins TW, Heatley G,
chronic primary angle closure glaucoma et al. Incidence of late onset bleb-
5. Wang W, He M, Zhou M, Zhang X. in an Asian population. Clinc Exp related complications following
Fornix-based versus limbus-based Ophthalmol. 2004; 32: 23–28. trabeculectomy with mitomycin. Arch
conjunctival flap in trabeculectomy: a Ophthalmol. 2002;120:297–300.
quantitative evaluation of the evidence. 14. Bindlish R, Condon GP, Schlosser JD, 22. Perez CI, Mellado F, Jones A, Colvin
PLoS One. 2013;8(12):e83656. D’Antonio J, Lauer KB, Lehrer R. Efficacy R. Trabeculectomy Combined With
and safety of mitomycin-C in primary Collagen Matrix Implant (Ologen). J
6. Sharma A, Das H, Adhikari S, Lavaju trabeculectomy: five-year follow-up. Glaucoma. 2017 Jan;26(1):54-58.
P, Shrestha BG. A randomised clinical Ophthalmology. 2002 Jul;109 (7):1336- 23. Olayanju JA, Hassan MB, Hodge DO,
trial comparing the outcome of 41. Khanna CL. Trabeculectomy-Related
trabeculectomy using triangular Complications in Olmsted County,
versus rectangular scleral flaps. Nepal J 15. Beckers HJ, Kinders KC, Webers CA. Minnesota, 1985 Through 2010. JAMA
Ophthalmol. 2009;1(1):20-24. Five-year results of trabeculectomy with Ophthalmol. 2015;133(5):574–580.
mitomycin C. Graefes Arch Clin Exp
7. Vijaya L, Manish P, Ronnie G, Shantha Ophthalmol. 2003 Feb;241(2):106-10. Corresponding Author:
B. Management of complications in
glaucoma surgery. Indian J Ophthalmol. 16. Scott IU, Greenfield DS, Schiffman J, et Dr. Surinder S Pandav
2011;59 Suppl (Suppl1):S131-S140. al. Outcomes of primary trabeculectomy Prof. Ophthalmology, Glaucoma Services,
with the use of adjunctive mitomycin. Advanced eye Center, Postgraduate Institute of
8. Lichter Paul R. Interim clinical outcomes Arch Ophthalmol. 1998;116(3):286-291. Medical Education & Research,
in the collaborative initial glaucoma Chandigarh – 160012
treatment study comparing initial 17. Casson R, Rahman R, Salmon JF. Long
treatment randomized to medications term results and complications of
or surgery. Ophthalmology 2001;108: trabeculectomy augmented with low
1943–53. dose mitomycin C in patients at risk
for filtration failure. Br J Ophthalmol.
9. Watson PG, Jakeman C, Ozturk M. The 2001;85(6):686-688.
complications of trabeculectomy (a 20
year follow up). Eye 1990; 4: 425–38. 18. De Fendi LL, Arruda GV, Scott IU, et
al. Mitomycin C versus5-fluorouracil
10. Merritt JC. Filtering procedures in as an adjunctive treatment for
American Blacks. Ophthalmic Surg trabeculectomy: a meta-analysis of
1980; 11: 91–4. randomized clinical trials. Clin Exp
Ophthalmol. 2013;41:798–806.
11. Miller RD, Barber JC. Trabeculectomy in
black patients. Ophthalmic Surg 1981; 19. Stamper RL, Mc Menemy MG,
12: 46–50. Lieberman MF. Hypotonous
maculopathy after trabeculectomy with
12. Berson D, Zuberman H, Landau L,

116 DOS Times - Volume 26, Number 4, January-February 2021 www.dosonline.org/dos-times

DOS Times Quiz

DOS Times Glaucoma Quiz

Jatinder Singh Bhalla, MS, DNB, MNAMS, Mahsa Jamil, MS
Department of Ophthalmology , Deen Dayal Upadhyay Hospital, New Delhi 110064

1. Which of the following gene d. The stimuli employed activate 6. A patient presents in the
mutation-phenotype pairings is the M cells. ophthalmology OPD and on slit
incorrect? lamp examination the following
a. GLC1A—associated with Answer : ___________ clinical findings as shown in the
photographs are seen .In regard
myocilin production in the 4. Which one of the following to treatment options for the
trabecular meshwork after visual field patterns will most patient in question which of the
treatment with dexamethasone quickly progress to loss of following is not true?
in both juvenile and adult fixation?
forms of glaucoma. a. Medical treatment is often
b. GLC1B—associated with a. Split fixation to the I4e isopter. successful in reducing IOP.
normal-tension forms of open- b. Central 5° island.
angle glaucoma. c. A large superior nasal step b. Patients respond well to laser
c. GLC1C—associated with high trabeculoplasty, although the
pressure, late onset forms of encroaching on fixation (<10°). effect may be short-lived.
d. Superior and inferior nasal
c. Laser iridectomy has been
steps encroaching to 20°. proposed as a means of
minimizing posterior bowing
glaucoma. Answer : ___________ of the iris.
d. GLC1D—associated with a
protein that catalyzes the 5. A 60-year-old white woman d. Filtering surgery is usually
formation of elastin fibers in presents with glaucomatous unsuccessful in these patients.
exfoliation syndrome. optic nerve head changes in
each eye and split fixation in Answer : ___________
Answer : ___________ her right eye, consistent with
her disc findings. Review of
2. Which method of gonioscopy is her record documents that she
considered best for evaluating a has progressively lost visual
patient with potential traumatic field and neural rim tissue
(angle- recession) glaucoma? while running IOPs in the
low teens. Gonioscopy has
a. Goldmann been documented as normal
b. Koeppe repeatedly. She is currently
c. Zeiss on maximal tolerated medical
d. Sussman therapy and reports subjective
decrease in vision in her right
Answer : ___________ eye. A surgical intervention in
the right eye is felt to be the next
3. Which of the following is indicated maneuver. Which
not a characteristic of short- procedure might be the one of
wavelength automated choice?
perimetry (SWAP)?
a. A blue stimulus is projected

onto a yellow background.
b. This method is sensitive in early
identification of glaucomatous a. Iridoplasty.
b. Surgical peripheral iridectomy.
damage.
c. The rate of perimetric change c. Trabeculectomy.
d. Cyclocryotherapy or
from early glaucoma may be cyclophotocoagulation.
higher than with conventional
white-on-white visual fields. Answer : ___________

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DOS Times Quiz

7. Which one of the following eye. Hours later, he is examined 10. The following measures can be
is the most common cause of in an emergency room of a local taken to limit postoperative
glaucoma in eyes being treated rural hospital; his eye has an hypotony with the device in the
for the condition depicted in the IOP of 62 mm Hg by Schiotz Figure except:
Figure? tonometry. Treatment with
timolol drops and acetazolamide a. two-stage procedure
1. Tumor cells invading the angle tablets is instituted, and the b. collagen plugs
2. Neovascularization lawyer rushes home to the care c. pressure-sensitive valve
3. Acute-angle closure of his ophthalmologist. What d. ligature occlusion of tube
4. Uveitis is the most likely cause for this Answer : ___________
Answer : ___________ sudden elevation in IOP?
8. A 32-year-old lawyer is struck Corresponding Author:
1. Angle-recession glaucoma a
in the eye by a cricket ball 2. Ghost cell glaucoma Dr Jatinder Singh Bhalla
by an ophthalmologist. The 3. Recurrent hyphema MS, DNB, MNAMS
ophthalmologist rushes the 4. Spontaneous closure of HOD (Department of Ophthalmology)
lawyer to his office and examines DDU Hospital, New Delhi 110064
his eye. A 30% hyphema is cyclodialysis cleft
present in the anterior chamber.
No rupture of the globe is Answer : ___________
present. The hyphema clears
within a week; however, the 9. All of the following may be
eye remains hypotonus for associated with the abnormality
several months while retaining depicted in the figure except:
good vision. Suddenly, while on
vacation in a remote region of the a) Inflammation heterochromic
country, the lawyer experiences b) PXF
extreme pain and blurred vision c) Neoplasm
in the previously traumatized d) Fuchs

iridocyclitis

Answer : ___________

ANSWER

Answer _______________________________________________________________________________________________________________________________________
Name: ________________________________________________________________________________________________ Degree: _______________________________
Designation:_________________________________________________________________________ Address:_______________________________________________
_______________________________________________________________________ State _______________________________ Pin _______________________________
Mobile No: ________________________________________________________________________________________ DOS Membership no: ___________________
Email ID: _______________________________________________________________________________________Signature: ___________________________________
Email your answer to: [email protected]

118 DOS Times - Volume 26, Number 4, January-February 2021 www.dosonline.org/dos-times

Tearsheet

Malignant Glaucoma

Amit Mehtani, Jatinder Singh Bhalla
Department of Ophthalmology , Deen Dayal Upadhyay Hospital, New Delhi 110064

Malignant Glaucoma

Introduction: Pathophysiology: Clinical Scenarios: Differential Diagnosis:

Described by Von graefe in a) Posterior pooling 1) Classical malignant 1. Pupillary block
1869, called so because of its of aqueous- glaucoma- incisional glaucoma (unlike
progressive course and poor ciliolenticular surgery in angle closure malignant glaucoma
response to conventional block(phakia) patients that produces uniform
glaucoma therapy. It refers flattening of the
to a uniform shallowing or Ciliovitreal block 2) In pseudophakia- anterior chamber,
flattening of both the central (aphakia) Early post-operative, pupillary block
and peripheral anterior Delayed, glaucoma presents
chambers in an eye with Anterior rotation of Phakic IOL with iris bombe
normal to elevated IOP the ciliary processes and shallow to flat
despite one or more patent against the lens 3) Aphakia- ciliovitreal peripheral anterior
iridotomies. equator in phakic eyes block chamber but with
or the anterior hyaloid moderate depth of
Also known as: Aqueous face in aphakic eyes 4) Induced by miotic the central anterior
misdirection, ciliary block, therapy chamber.
direct lens block angle closure. b) Anterior hyaloid
obstruction-valvular 5) Bleb needling 2. Ciliary detachment
Diagnosis of malignant breaks in anterior 3. Suprachoroidal
glaucoma is a diagnosis of hyaloid (near base) 6) Anterior chamber
exclusion and many signs and allows posterior inflammation and haemorrhage
symptoms such as pain and pooling of aqueous infection- fungal 4. Wound leak/
elevated IOP are nonspecific. keratomycosis
ACG with pupillary block c) Slackness of lens overfiltration
should be ruled out by zonules 7) Post RD/PPV/
ensuring patent PI. The Cyclophotocoagulation
clinical presentation includes d) Choroidal expansion
diffuse shallowing of the 8) Spontaneous
anterior chamber with normal
or elevated IOP. The consensus is that
malignant glaucoma is
Clinical setting: a multifactorial disease
in which more than one
of the aforementioned
mechanisms may play a role
in its pathogenesis.

post op patient with ACG +
shallowing of both the central
and peripheral anterior
chamber + elevated IOP +
patent PI.

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Tearsheet

EVALUATION
Should begin preoperatively, with particular attention to risk factors such as hyperopia, chronic angle closure with plateau
iris configuration.

INVESTIGATIONS
UBM: is used for making the diagnosis and for the treatment. The features includes swollen ciliary process, anteriorly
rotated, ciliolenticular, ciliovitreal block, irido corneal touch and anterior displacement of lens iris diaphragm.
B-SCAN: facilitates ruling out other causes of shallow or flat anterior chamber, such as suprachoroidal hemorrhage or
choroidal effusions.
AS-OCT: provides objective and quantitative imaging of the anterior segment. Although the resolution is lower and details
behind the iris are not reliably seen, AS-OCT has the benefit of being easier to use and does not require a coupling agent.

MANAGEMENT

MEDICAL SURGICAL

IOP lowering agents 1. Nd- YAG hyaloidotomy
a) Through PI in phakics
a) Hyperosmotic agents- glycerol 50% orally (1 ml per b) Pupillary zone in pseudophakic or aphakic
pound body weight) daily or mannitol (2g per kg body 2. Transcorneal needling of anterior vitreous phase
weight) orally daily or twice daily- to decrease vitreous 3. PPV.core vitrectomy alone or in combination with
volume
iridectomy, zonulectomy and hyaloidectomy
b) Beta blockers (in pseudophakic patients) (in phakic patients)
vitrectomy with lensectomy.
c) Adrenergic agonist: (phenylephrine 10% QID) to 4. peripheral iridotomy should be performed initially to
stimulate the iris dilator muscle, exclude pupillary block mechanism
5. post sclerotomy and air injection
d) topical or systematic aqueous suppressants decrease the 6. lens extraction
posterior pooling of the aqueous humor by reducing its
production.

e) Cycloplegics: atropine 1% QID tightens the lens
zonules by relaxing the ciliary muscle, pulling the lens-
iris diaphragm posteriorly thus alleviating the ciliary
block. Atropine may be continued for 6 months or
longer because of the high risk of recurrence with the
cessation of these agents patients should be maintained
on this regimen for 3 to 5 days to monitor clinical
improvement. If the patient responds to aggressive
medical therapy, the treatment can be gradually
tapered.

Management of fellow eye:
PI (if the drainage angle is found to be narrow or closed) before any surgical intervention.

Corresponding Author:

120 DOS Times - Volume 26, Number 4, January-February 2021 Amit Mehtani MS, DNB
Department of Ophthalmology,
Deen Dayal Upadhyay Hospital,
New Delhi 110064

www.dosonline.org/dos-times

Subspeciality-Glaucoma

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