BACKGROUND: To report the incidence and clinical characteristics of aqueous misdirection (AM) after glaucoma surgery in Chinese patients with primary angle-closure glaucoma.
METHODS: Medical records of all patients diagnosed with primary angle-closure glaucoma who underwent glaucoma surgery in the Eye Hospital of Wenzhou Medical University between January 2012 and December 2021 were retrospectively reviewed. Cases of AM were identified through a keyword-based search. The incidence of AM was calculated. Demographic and clinical characteristics of the AM patients were also described.
RESULTS: A total of 5044 eyes with primary angle-closure glaucoma were included (mean age 65.81 ± 9.96 years, 68.11% women). Thirty-eight eyes developed AM, presenting an overall incidence of 0.75%. The mean time interval between surgery and first record of AM diagnosis was 2.57 ± 5.24 months (range, 0 day to 24 months). The incidence of AM was significantly higher in patients aged ≤ 40 years (21.28%) and those aged 40-50 years (3.32%), compared to those > 50 years (0.42%) (P < 0.001). AM developed much more frequently among patients with chronic angle-closure glaucoma (1.30%), compared to those with acute angle-closure glaucoma (0.32%, P < 0.001). Eleven eyes (0.37%) developed AM following non-filtering surgery compared to 24 eyes (2.27%) after filtering surgery (P < 0.001).
CONCLUSIONS: The incidence of AM after glaucoma surgery was 0.75% in Chinese patients with primary angle closure glaucoma. Younger age, chronic angle-closure glaucoma, and undergoing filtering surgery, were identified as associated risk factors for developing AM. Phacoemulsification may have less risk of developing AM compared to filtering surgery.

OBJECTIVE: To evaluate trends in glaucoma procedures at the Peking University Eye Center in 2016-2020.
METHODS: A retrospective search of all glaucoma procedures performed at our institution were performed. Data were analyzed by calculating the absolute numbers and relative weightage of each procedure per year.
RESULTS: The average age of glaucoma patients undergoing surgical procedures was 62.33±17.87y, and 55% were women. From 2016 to 2019, the number of surgical procedures performed in glaucoma patients showed an overall upward trend from 749 to 1460, although it decreased slightly in 2020 (n=1393), probably due to the COVID-19 pandemic. The number of trabeculectomies did not change significantly in 2016 (n=161) to 2018 (n=164) but decreased in 2019 (n=139) to 2020 (n=121), indicating a reduction in its relative weightage among glaucoma procedures (from 21.50% to 8.69%). The number of glaucoma drainage device implantations and minimally invasive glaucoma surgeries both increased (50 and 58 respectively in 2019), except in 2020. The number of transscleral cyclophotocoagulation procedures was relatively stable, increasing until 2017 (n=218) and then decreasing. Cataract surgeries with or without glaucoma procedures accounted for a large number of the total surgeries, increasing from 247 (32.97%) in 2016 to 967 (69.42%), among which cataract extraction combined with goniosynechialysis was the most frequent.
CONCLUSIONS: The overall increase in the number of operating room-based surgical procedures is significant. Trabeculectomy is one of the most commonly performed procedures, despite the relative decline in its weightage. Other procedures, including use of glaucoma drainage devices and mini shunts and minimally invasive glaucoma surgeries, are gaining greater acceptance. Notably, lens-related surgery plays an important role in glaucoma management.

OBJECTIVE: To investigate the anti-fibrotic effect of ZD6474 (a novel inhibitor of VEGF and EGF) in TGF-β1 stimulated human Tenon\'s capsule fibroblasts (HTFs) and the anti-angiogenetic role in HUVECs, compared to that of mitomycin C (MMC).
METHODS: The effects of ZD6474 on cell proliferation or migration in TGF-β1-stimulated HTFs and HUVECs were determined, using CCK8 or wound healing assay, respectively. The typical markers of fibrosis in TGF-β1-stimuated HTFs were detected, vimentin by immunofluorescence, α-SMA and snail by western blot. Tube formation was applied to validate the anti-angiogenesis effect in HUVECs following ZD6474 treatment. Furthermore, phosphorylated AKT and mTOR (p-AKT and p-mTOR) were evaluated, compared to the standardized total AKT and mTOR, using western blot.
RESULTS: There was almost no decreased cell viability in HTFs following ZD6474 (≤ 1 μM/mL) treatment, but MMC (> 50 μg/mL) significantly impaired cell viability. ZD6474 significantly inhibited TGF-β1-stimulated proliferation and migration in HTFs, compared to control group (**P < 0.01). ZD6474 also significantly attenuated the TGF-β1-stimulated expression of vimentin, α-SMA and snail in HTFs. Tube formation was notably interrupted in HUVECs following ZD6474 treatment (**P < 0.01). P-AKT and p-mTOR were significantly decreased in response to ZD6474 treatment in TGF-β1- induced HTFs and HUVECs.
CONCLUSIONS: ZD6474 exerts anti-proliferation and anti-fibrotic effects in TGF-β1-stimulated HTFs perhaps via regulating AKT-mTOR signaling pathway. ZD6474 also inhibited proliferation, migration and tube formation in HUVECs via the same signaling pathway. We concluded that ZD6474 may be potentially a novel agent in preventing bleb dysfunction following glaucoma filtration surgery (GFS).

OBJECTIVE: To confirm whether exosome-mediated delivery of aptamer S58 (Exo-S58) has a better antifibrotic effect than naked S58 in human conjunctival fibroblasts (HConFs) and a rat glaucoma filtration surgery (GFS) model.
METHODS: To enhance the effective reaction time of aptamer S58 in vivo, we loaded aptamer S58 into exosomes derived from HEK293T cells by PEI transfection to determine the effect of Exo-S58 in HConFs and a rat GFS model.
RESULTS: Exo-S58 can significantly reduce cell proliferation, migration and fibrosis in TGF-β2-induced HConFs. In an in vivo experiment, Exo-S58 treatment prolonged filtering bleb retention and reduced fibrosis compared with naked S58 treatment in GFS rats.
CONCLUSIONS: The exosomes are safe and valid carriers to deliver aptamers. Furthermore, Exo-S58 exhibited superior antifibrotic effect than naked S58 both in HConFs cells and rat GFS models.

OBJECTIVE: This study aimed to determine degree of postoperative pain and the incidence of serious postoperative pain after glaucoma surgery and further to identify the associated risk factors.
METHODS: A total of 194 consecutive patients who were diagnosed with glaucoma and underwent glaucoma surgery were enrolled in this study. The intensity of postoperative pain was evaluated using numerical rating scale (NRS) within 24 h after surgery; NRS ≥ 5 was considered as clinically significant postoperative pain. Risk factors associated with the development of postoperative pain were analyzed by multivariate logistic regression analysis.
RESULTS: Clinically significant postoperative pain was experienced at any time after glaucoma surgery in 41.75% of the patients, which peak at 2 h. 27.8% of the patients requested analgesic medication within 24 h after surgery. According to multivariate logistic regression analysis, preoperative anxiety (OR = 4.13 [1.29-13.2], p = 0.017), cyclophotocoagulation (OR = 30.9 [3.47-375.1], p = 0.002), and phacotrabeculectomy combined with or without intraocular lens implantation (OR = 30.0 [2.69-335.6], p = 0.006) were associated with increased clinically significant postoperative pain. Interestingly, patients with diabetes and/or hypertension were associated with less postoperative pain after glaucoma surgery (OR = 0.23 [0.08-0.64], p = 0.005).
CONCLUSIONS: Patients undergoing glaucoma surgery tend to experience postoperative pain in the early postoperative period. Anxiety level and surgery types of cyclophotocoagulation and phacotrabeculectomy are risk factors for postoperative pain. Patients with diabetes and/or hypertension are less likely to develop postoperative pain.

The purpose of this study is to evaluate outflow pathways from subconjunctival blebs and to identify their identity. Post-mortem porcine (n = 20), human (n = 1), and bovine (n = 1) eyes were acquired, and tracers (fluorescein, indocyanine green, or fixable/fluorescent dextrans) were injected into the subconjunctival space to create raised blebs where outflow pathways were visualized qualitatively and quantitatively. Rodents with fluorescent reporter transgenes were imaged for structural comparison. Concurrent optical coherence tomography (OCT) was obtained to study the structural nature of these pathways. Using fixable/fluorescent dextrans, tracers were trapped to the bleb outflow pathway lumen walls for histological visualization and molecular identification using immunofluorescence against lymphatic and blood vessel markers. Bleb outflow pathways could be observed using all tracers in all species. Quantitative analysis showed that the nasal quadrant had more bleb-related outflow pathways compared to the temporal quadrant (nasal: 1.9±0.3 pathways vs. temporal: 0.7±0.2 pathways; p = 0.003). However, not all blebs resulted in an outflow pathway (0-pathways = 18.2%; 1-pathway = 36.4%; 2-pathways = 38.6%; and 3-pathways = 6.8%). Outflow signal was validated as true luminal pathways using optical coherence tomography and histology. Bicuspid valves were identified in the direction of flow in porcine eyes. Immunofluorescence of labeled pathways demonstrated a lymphatic (Prox-1 and podoplanin) but not a blood vessel (CD31) identity. Therefore, subconjunctival bleb outflow occurs in discrete luminal pathways. They are lymphatic as assessed by structural identification of valves and molecular identification of lymphatic markers. Better understanding of lymphatic outflow may lead to improved eye care for glaucoma surgery and ocular drug delivery.

OBJECTIVE: To investigate the effect of long-term use of topically administered latanoprost on conjunctival thickness (CT) and conjunctival epithelium thickness (CET) in the patients with glaucoma.
METHODS: A series of 106 glaucomatous patients were included. Of the 106 eyes, 55 eyes were treated with latanoprost eye drops once a day (latanoprost group), while 51 eyes were treated with carteolol hydrochloride eye drops (carteolol group). All the included patients completed a 2-year follow-up. CT and CET were measured with optical coherence tomography (OCT) in all patients at presentation and at 2-year visit, respectively. Statistical analysis was then performed to compare the change in CT and CET.
RESULTS: At presentation, there was no difference in CET (t=0.400, P=0.689) or CT (t=1.14, P=0.259) between the two groups. No significant difference was found in CET (61.65±5.35 µm at baseline, 60.36±6.36 µm at 2-year follow-up, respectively; t=1.977, P=0.0531), while there was a significant decrease in CT from 201.45±14.99 µm at baseline to 167.81±14.57 µm at 2-year visit (t=14.1407, P<0.001) in the latanoprost group. At 2-year follow-up, no statistically difference was found in CET (62.24±5.27 µm; t=1.086, P=0.282) or CT (201.23±12.45 µm; t=1.44, P=0.154) compared to it at baseline (CET: 61.23±5.42 µm; CT: 198.76±13.68 µm, respectively) in the carteolol group.
CONCLUSIONS: A significant decrease in conjunctival thickness is found in glaucoma patients treated with long-term topical latanoprost; its potential effect on the outcome of filtration surgery should be considered.

OBJECTIVE: To conduct a systematic review and quantitative Meta-analysis of the efficacy and safety of combined surgery for the eyes with coexisting cataract and open angle glaucoma.
METHODS: We performed a systematic search of the related literature in the Cochrane Library, PubMed, EMBASE, Web of Science databases, CNKI, CBM and Wan Fang databases, with no limitations on language or publication date. The primary efficacy estimate was identified by weighted mean difference of the percentage of intraocular pressure reduction (IOPR%) from baseline to end-point, the percentage of number of glaucoma medications reduction from pre- to post-operation, and the secondary efficacy evaluations were performed by odds ratio (OR) and 95% confidence interval (CI) for complete and qualified success rate. Besides, ORs were applied to assess the tolerability of adverse incidents. Meta-analyses of fixed or random effect models were performed using RevMan software 5.2 to gather the consequences. Heterogeneity was evaluated by Chi2 test and the I2 measure.
RESULTS: Ten studies enrolling 3108 patients were included. The combined consequences indicated that both glaucoma and combined cataract and glaucoma surgery significantly decreased IOP. For deep sclerectomy vs deep sclerectomy plus phacoemulsification and canaloplasty vs phaco-canaloplasty, the differences in IOPR% were not all statistically significant while trabeculotomy was detected to gain a quantitatively greater IOPR% compared with trabeculotomy plus phacoemulsification. Furthermore, there was no statistical significance in the complete and qualified success rate, and the rates of adverse incidents for trabeculotomy vs trabeculotomy plus phacoemulsification.
CONCLUSIONS: Compared with trabeculotomy plus phacoemulsification, trabeculectomy alone is more effective in lowering IOP and the number of glaucoma medications, while the two surgeries can not demonstrate statistical differences in the complete success rate, qualified success rate, or incidence of adverse incidents.

Our study retrospectively reviewed the surgical outcomes up to 3mo of 38 consecutive Chinese glaucoma patients who underwent trabeculectomy (n=18) or phacotrabeculectomy (n=20). Baseline age, visual acuity, and intraocular pressure were comparable. Intraocular pressure from post-operative 1d to 3mo were similar between 2 groups. Complete success was achieved in 65% of phacotrabeculectomy, and 66.7% of trabeculectomy cases; while failure occurred in 16.7% of phacotrabeculectomy, and 10% of trabeculectomy cases at 3mo. Phacotrabeculectomy group consistently showed better improvement in visual acuity. Diffuse blebs occurred in 65% of phacotrabeculectomy and 83% of trabeculectomy eyes; and flat blebs in 35% of phacotrabeculectomy, but none after trabeculectomy. There was more hypotony (5% vs 0) after phacotrabeculectomy. To conclude, phacotrabeculectomy and trabeculectomy demonstrated comparable intraocular pressure control up to 3mo post-operatively. However, phacotrabeculectomy patients had better visual acuity improvement. Nonetheless, more diffuse bleb and less hypotony were present following trabeculectomy.

OBJECTIVE: To describe a case of free migration of intraocular glass in aphakia after glaucoma surgery.
METHODS: We report the case of a 27-year-old man with a history of perforating injury to the right eye 10 years previously and glaucoma surgery 1 year previously presenting with 1 month of pain and frequent floaters in front of the right eye. On examination, the glass fragment was seen to lie free in the anterior chamber or migrate backwards through the pupil, remaining mobile on the inferior retinal surface when the patient was prone or supine, respectively.
RESULTS: The fragment was surgically removed.
CONCLUSIONS: Late migration of glass intraocular foreign bodies is a rare clinical entity, and the exact mechanism causing the migration of intraocular glass remains controversial. Early intervention must be weighed against the hazards of removal and the necessity of close follow-up.