BACKGROUND: Selective laser trabeculoplasty (SLT) is relatively safe and effective in lowering intraocular pressure (IOP). However, although rare, complications can occur after SLT. This report describes a patient with choroidal detachment due to hypotony following SLT without anterior chamber (AC) inflammation.
METHODS: A 67-year-old man was referred for elevated IOP in his left eye with advanced glaucomatous visual field loss. He had previously been diagnosed with idiopathic uveitic glaucoma in the left eye, for which he underwent laser iridotomy, trabeculectomy, and cataract surgery. At the first visit, the IOP of his left eye measured by Goldmann tonometry was 28 mmHg despite maximally tolerated medical treatment. SLT was performed in his left eye, resulting in an IOP of 7 mmHg 7 days later. At 3 weeks post-procedure, the patient experienced ocular pain and decreased visual acuity in his left eye. Slit-lamp examination revealed deep anterior chamber depth and no inflammation reaction, but the IOP in his left eye was 4 mmHg, and both fundus and B-scan ultrasonography showed serous choroidal detachment. All anti-glaucoma agents were stopped, and the patient was started on treatment with oral prednisolone and cyclopentolate eye drops. Three weeks later, choroidal detachment had resolved and the IOP in his left eye had stabilized at 8 mmHg. Follow-up 3 months later showed that the IOP in his left eye remained stable.
CONCLUSIONS: Choroidal detachment-related hypotony is a rare complication of SLT. This possible complication following SLT should be informed to the patients and considered when performing the procedure.

BACKGROUND: We report a case with two connected stents ejected simultaneously during an iStent inject W surgery, a modified second-generation iStent Trabecular Micro-Bypass System.
METHODS: A 57-year-old woman with primary open-angle glaucoma underwent a combined cataract and iStent inject W surgery in her left eye. After the trabecular meshwork/Schlemm\'s canal was pierced by the trocar of injector, the delivery button was pressed a first time, but the stent was not ejected. After the button was pressed a second time, connected two stents were ejected. After removing the dislocated stents from the anterior chamber, two stents were implanted into the desired places using another injector. Except for mild hyphema, no postoperative complication occurred. Stereomicroscopic observation showed that the two stents were connected by a broken trocar shaft. An X-ray showed that the trocar shaft was broken at the part referred to as the \"sprayed trocar\". Scanning electron microscopy showed that the surface features of the broken trocar and trocar tip represented tensile failure.
CONCLUSIONS: Although rare, considering that the damage was seen at the structurally weak part (i.e., sprayed trocar), the same phenomenon can happen. For patient safety, surgeons are recommended to inspect the device when the deployment of either the first or second stent is unsuccessful during the iStent inject surgery.

BACKGROUND: In January 2021, we found one case of Axenfeld-Rieger syndrome combined with pigment dispersion syndrome (PDS), and this patient additionally manifested a symptom of ectropion uveae. The co-existence of both 2 syndromes is very rare and has not been reported in any literature yet.
METHODS: A 34-year-old female truck driver presented to our institution with a dimness of vision in her right eye. The patient had obvious posterior embryotoxons at bitamporal, and peripheral anterior synechia could be visualized by the slit lamp. The dispersion of pigment granules was observed behind the cornea. The pupil was slightly shifted upwards the nose, with 360° ectropion uveae. Gonioscopy revealed pigment accumulation on the trabecular meshwork. The patient underwent cataract surgery on her right eye, during which, flaky pigmentation around the posterior capsule was observed. These signs were consistent with Axenfeld-Rieger syndrome and PDS.
CONCLUSIONS: We report a rare case of Axenfeld-Rieger syndrome with PDS and uveal eversion. Although the patient did not present with glaucoma, follow-up should be noted. Besides, the correlation between these 2 syndromes needs to be demonstrated by more cases or further evidence.

OBJECTIVE: To report a case of a patient with juvenile-onset open-angle glaucoma (JOAG) who was successfully treated with combination cataract extraction and Hydrus stent implantation.
METHODS: An interventional case report.
RESULTS: The patient underwent cataract surgery and Hydrus stent implantation in the right eye. Preoperative intraocular pressure (IOP) was 25 mmHg in the right eye (OD) and 21 mmHg in the left eye (OS). Best-corrected visual acuities (BCVA) were 20/80 in the right eye and 20/200 in the left eye. Postoperatively, vision improved to 20/40 in the right eye with an IOP of 14 mmHg after 21 months follow up. No device-related complications were observed.
CONCLUSIONS: Cataract surgery in combination with the Hydrus stent implant effectively lowers intraocular pressures and can be used to surgically manage patients with JOAG. This intervention is a probable adjunct or substitute to first line treatments such as trabeculotomy.

An older age, a low number of baseline glaucoma medications, an early glaucoma stage, lower intraocular pressure (IOP) values during the first postoperative month, and combined surgery are possible predictors of unqualified success after a trabecular by-pass microinvasive glaucoma surgery (MIGS) procedure.
The purpose of this study was to identify the potential predictors of unqualified success (IOP<18 mm Hg with no glaucoma medication) after trabecular by-pass MIGS.
We designed a case-control study using logistic regression modeling that included all trabecular by-pass surgeries with at least 3 months of follow-up, performed at a single center from June 2017 to December 2019. Eyes that achieved an endpoint of unqualified success (dependent variable) were considered cases. All other eyes were used as the controls. Cases and controls were paired by sex and postoperative time. We tested the following independent variables: age, race, laterality (right eye or left eye), glaucoma stage, type of surgery (combined or stand-alone), type of trabecular bypass, intraoperative complications, baseline number of medications, baseline IOP, and postoperative IOP on days 1, 15, and 30. Additional analysis using IOP <15 mm Hg as a threshold and including eyes with at least 12 months of follow-up were performed.
One hundred ninety-four eyes were included in the analysis. We observed complete success in 56.7% of eyes. The mean follow-up time for the entire population was 12.3±6.8 months. All variables were considered in the first step of the modeling process; however, only age, day-15 IOP, day-30 IOP, baseline number of medications, glaucoma stage, and type of surgery remained until the completion of our model, with adequate significance (P<0.05). The additional analysis confirmed our results.
We identified that an older age, a low number of baseline glaucoma medications, an early glaucoma stage, lower IOP values during the first postoperative month, and combined surgery were associated with a higher chance of unqualified success at 12 months after a trabecular by-pass MIGS procedure.

Gonioscopy-assisted transluminal trabeculotomy (GATT) is a surgery that opens the trabecular meshwork (TM) circumferentially after cannulation of the Schlemm canal (SC) with a flexible illuminated microcatheter or suture. The main purpose of this case report was to describe a new complication of GATT. Herein, we report a case of partial SC, TM, and Descemet membrane (DM) separation during GATT. The patient was a 60-year-old man with a history of glaucoma who underwent GATT. SC, TM, and DM separation occurred intraoperatively during 360 degrees trabeculotomy. The separated tissue fragment was removed from the anterior chamber and later confirmed to be a part of the SC, TM, and DM by histopathologic examination. In our patient, this complication did not cause surgical failure. Various complications associated with GATT have been reported previously. Partial SC, TM, and DM separation may occur during this surgery.

To describe a case of photoreceptor outer segment glaucoma (Schwartz-Matsuo syndrome) with electron microscopic evidence of photoreceptor outer segments in the trabecular meshwork (TM).
This is a clinicopathologic case report.
A 48-year-old Filipino man.
Specimens of aqueous humor and TM in a clinical case of Schwartz-Matsuo syndrome were examined by electron microscopy.
Electron photomicroscopy.
Electron microscopy showed evidence of retinal photoreceptor outer-segments in both an aqueous humor and a TM specimen.
Schwartz-Matsuo syndrome is associated with the presence of photoreceptor outer segments in the TM.

To evaluate the safety and efficacy of combined iStent® trabecular micro-bypass device (Glaukos, Laguna Hills, CA) and phacoemulsification in eyes with primary angle closure disease.
A two-center prospective interventional case series of consecutive patients with primary angle closure (PAC) or primary angle closure glaucoma (PACG) on at least one glaucoma medication, who underwent iStent implantation with cataract surgery. Postoperatively, patients were assessed on days 1 and 7, and months 1, 3, 6, and 12. The intraocular pressure (IOP), glaucoma medication use, visual acuity, and the presence of complications were assessed at each visit. Complete success was defined as IOP reduction of at least 20% without the use of glaucoma medications.
Thirty-seven eyes with angle closure disease were included in this study. At 1-year, postoperative mean IOP (14.8 ± 3.94 mmHg) was significantly decreased compared with preoperative medicated (17.5 ± 3.82 mmHg, p = 0.008) and unmedicated (24.6 ± 3.41 mmHg, p < 0.001) IOP. Complete success was achieved in 89.2% of the eyes. The number of glaucoma medications decreased from 1.49 ± 0.77 to 0.14 ± 0.48 (p < 0.001). Preoperative medicated IOP was a risk factor for failure (hazard ratio 3.45, 95% confidence interval 1.52-7.85, p = 0.003), after adjustment for age, gender, and race. The most common postoperative complications were iStent occlusion with iris (27.0%) and hyphema (18.9%). There were no sight-threatening intraoperative or postoperative complications.
Combined iStent implantation with cataract surgery was effective in lowering the IOP and the number of glaucoma medications for at least 12 months, with a favorable safety profile.
Glaukos Corporation; NMRC Science Translational and Applied Research (STAR) award.

BACKGROUND: Trabectome surgery combined with phacoemulsification is effective in lowering (intraocular pressure) IOP in pseudoexfoliation glaucoma. Trabectome surgery usually aims to remove two to four clock hours of the trabecular meshwork. When adding trabecular aspiration, the remaining meshwork can be treated as well, and therefore 360 degrees of the meshwork can be reached. This study was conducted to investigate the additional benefits and risks of adding trabecular aspiration to the combination of phacoemulsification and trabectome as a triple procedure.
METHODS: Two groups of patients from two centres were compared. The first group underwent phacoemulsification and trabectome (Freiburg), and the second group underwent additional trabecular aspiration (Düsseldorf). Using a case-matched retrospective study design, 50 patients were included into each group. The clinical endpoint was the intraocular pressure at follow up.
RESULTS: The mean follow up was 22 months. Mean intraocular pressure decreased in all 100 patients from 25.0 (SD 4.3) to 14.9 mmHg (SD 4.0). Comparing the two groups, the IOP reduction was from 25.0 (SD 5.0) to 14.1 (SD 4.4) mmHg in the triple procedure group compared to a reduction from 25.0 (3.6) to 15.7 (SD 3.4) mmHg in the phaco/trabectome group. The difference was statistically significant (p = 0.03). The number of medication after surgery was reduced from 2.2 (SD 0.9) to 1.7 (SD 0.9) while in the phaco/trabectome group the medication score was reduced from 2.2 (SD 1.0) to 1.1 (SD 0.1) (p < 0.001).
CONCLUSIONS: This study shows that the combination of trabectome surgery and phacoemulsification leads to a clinically significant reduction of IOP over several years in patients with pseudoexfoliation glaucoma. The addition of trabecular aspiration as a triple procedure results in further lowering of IOP without causing more side effects. This finding might be biased by the higher medication score in the triple procedure group.

We report a rare case with histologically proven melanocytoma of the iris that demonstrated diffuse melanocytic proliferation with uncontrolled secondary glaucoma and investigate the etiology of the intraocular pressure elevation. The patient was a 78-year-old man with a history of darkened iris of his left eye. The intraocular pressure was 39 mm Hg. A slit-lamp examination showed a diffuse darkened iris, and a gonioscopic examination revealed open angle with circumferential heavy pigmentation. There was no pigment dispersion of the anterior chamber and no pigment deposition of the cornea. We suspected malignant ring melanoma in the left eye and enucleated it. The globe was examined with light and electron microscopy. Light microscopy revealed the presence of heavily pigmented tumor cells in the iris, ciliary body, trabecular meshwork, and Schlemm\'s canal. A bleached preparation showed large tumor cells with central and paracentral nuclei without mitosis. Electron microscopy of the trabecular meshwork revealed melanin-bearing tumor cells invading the intertrabecular spaces, and the melanin granules were not phagocytosed in the trabecular cells. The mechanical obstruction of the aqueous flow by the tumor cells may be a major cause of secondary glaucoma in eyes with iris melanocytoma presenting diffuse proliferation.