Researchers from the Stein Eye Institute and the Doheny Eye Institute in Los Angeles evaluated the outcomes of trabeculectomy with adjunctive mitomycin C in patients with uncontrolled intraocular pressure after glaucoma drainage device implantation. 

Consecutive patients who had undergone a trabeculectomy after GDD were reviewed. The primary outcome was surgical success with stratified IOP targets based on the following criteria: IOP<18 mmHg and IOP reduction of 20 percent; IOP<15 mmHg and IOP reduction of 25 percent; and IOP<12 mmHg with an IOP reduction of 30 percent. Secondary outcomes were the number of glaucoma medications, complications and need for additional glaucoma surgery.

Twenty eyes (19 patients) were analyzed. Median follow-up and age were 3.7 years and 64.2 years, respectively. Mean IOP dropped from 19.3 ±4.2 mmHg preoperatively to 9.8 ±2.2 mmHg at one year, 8.8 ±3.2 mmHg at three years and 8.4 ±1.5 mmHg at five years (p<0.001 for all). Hypotony maculopathy was the only serious complication (10 percent: 2/19 patients) that needed surgical revision. The cumulative success rate for criteria 1 and 2 were 73.2 ±10 percent and 68.2 ±9.5 percent, respectively, between the first and fifth year of follow-up. For criterion three, it was 49.1 ±10.8 percent at the first year and 32.7 percent (±12 percent) between the second and fifth year of follow-up. 

Based on these results, researchers say trabeculectomy is a viable surgical option to treat IOP that is uncontrolled after GDD implantation. 

J Glaucoma 2018;27:2:133-139

Alizadeh R, Akil H, Tan J, Law SK, Caprioli J

Antithrombotics’ Risk for Intraocular Bleeding

Researchers from the University of Pennsylvania’s Perelman School of Medicine conducted a retrospective cohort study to evaluate the risk of developing intraocular hemorrhages with a novel oral antithrombotic therapy compared with that of traditional antithrombotic agents. 

These researchers used a large national insurance claims database to generate two parallel analyses. All patients with incident use of dabigatran etexilate or rivaroxaban between January 1, 2010, and September 30, 2015, were compared with patients with incident use of warfarin sodium. Similarly, patients with new use of prasugrel hydrochloride were compared with those with new use of clopidogrel bisulfate. Both analyses required the patient to be enrolled in the insurance plan for at least 24 months prior to initiation of therapy and excluded patients with any previous diagnosis of intraocular hemorrhages or any prescription for the comparator medications. 

Furthermore, the antiplatelet analysis required a diagnosis of acute coronary syndrome or a myocardial infarction within 60 days of initiation of pharmacologic therapy. The anticoagulant analysis excluded patients with end-stage renal disease, renal transplants and those with heart-valve disease.

A total of 146,137 patients taking warfarin (76,714 women and 69,423 men; mean age, 69.8 years) were compared with 64,291 patients taking dabigatran or rivaroxaban (31,576 women and 32,715 men; mean age, 67.6 years). Cox proportional hazards regression revealed a decreased hazard for developing an intraocular hemorrhage with dabigatran or rivaroxaban at 365 days (HR, 0.75; 95% CI, 0.58 to 0.97; p=0.03), but not at 90 days (HR, 0.73; 95% CI, 0.22 to 2.63; p=0.13). A total of 103,796 patients taking clopidogrel (37,578 women and 66,218 men; mean age, 68 years) were compared with 8,386 patients taking prasugrel (1,988 women and 6,380 men; mean age, 61 years), and no increased hazard for developing an intraocular hemorrhage with prasugrel was seen at 90 days (HR, 0.75; 95% CI, 0.29 to 1.92; p=0.55) or 365 days (HR, 1.19; 95% CI, 0.69 to 2.04; p=0.53).

According to these results, researchers say that there appears to be a decreased risk of intraocular hemorrhage associated with novel direct thrombin inhibitors and direct factor Xa inhibitors, but no difference for P2Y12 inhibitors compared with traditional vitamin K anticoagulation and antiplatelet therapy, respectively.

JAMA Ophthalmol 2018;136:2:122-130

Uyhazi KE, Miano T, Pan W, VanderBeek BL

Predictive Factors for Neovascular AMD

In a retrospective study, researchers from Italy investigated the risk factors predictive for the development of neovascular age-related macular degeneration, by means of spectral-domain optical coherence tomography. 

The study looked at 73 eyes graded Stage 2 and Stage 3 according to the AMD International Grading System, with a minimum follow-up of 24 months. Drusenoid pigment epithelial detachment, hyperreflective foci, external limiting membrane, inner ellipsoid band and retinal pigment epithelium integrity were analyzed at baseline and last follow-up. Researchers used a binary logistic regression model (represented by [Exp B]) to analyze significant predictors of neovascular conversion.

The discontinuity of external limiting membrane, inner ellipsoid band and retinal pigment epithelium bands were significantly more prevalent in the NVAMD group at baseline and last follow-up (p<0.001). Hyperreflective foci represented the single most important predictor of neovascular conversion (Exp [B], 15.15 times greater odds; p=0.005) as confirmed by Kaplan-Meier curve (p=0.002). Drusenoid pigment epithelial detachment width was significantly greater in the NVAMD group than in control subjects at baseline and last follow-up (p<0.001), and its delta value also resulted in a significant neovascular predictor (Exp [B], 0.99; p=0.04).

Researchers say that, based on these results, hyperreflective foci significantly increase the risk of NVAMD progression. The delta width of drusenoid pigment epithelial detachment also predicts disease progression, integrating the stratification of NVAMD progression risk.

Retina 2018;38:2:245-252

Fragiotta S, Rossi T, Cutini A, et al.