Department of Ophthalmology, Sydney Eye Hospital, Sydney.
Discipline of Ophthalmology, The University of Sydney.
J Glaucoma. 2023 Jul 1;32(7):600-608. doi: 10.1097/IJG.0000000000002195. Epub 2023 Mar 3.
Adding trabecular bypass surgery (TBS) to phacoemulsification creates unpredictable short-term intraocular pressure (IOP) control that may be undesirable for patients with advanced glaucoma. Aqueous outflow (AO) responses after TBS are complex and probably multifactorial.
To assess IOP spikes in patients with open angle glaucoma up to 1 month after iStent inject and their relationship to AO patterns measured by hemoglobin video imaging (HVI).
We studied IOP for 4 weeks after TBS with iStent inject in 105 consecutive eyes with open angle glaucoma (6 TBS only and 99 combined with phacoemulsification). The change in IOP after surgery at each time point was compared with baseline measurements and the prior postoperative visit. IOP-lowering medications were stopped on the day of surgery in all patients. A smaller pilot study of 20 eyes (TBS only = 6 and combined = 14) underwent concurrent HVI to observe and quantify perioperative AO. Aqueous column cross-sectional area (AqCA) of one nasal and one temporal aqueous vein was calculated at each time point, and qualitative observations were documented. An additional 5 eyes were studied after phacoemulsification only.
Mean IOP for the entire cohort (preoperative 17.3 ± 5.6 mm Hg) was lowest the day after TBS (13.1 ± 5.0 mm Hg) and peaked at 1 week (17.2 ± 8.0 mm Hg), before stabilizing by 4 weeks (15.2 ± 5.2 mm Hg; P < 0.00001). The same IOP pattern was seen when separating the group into a larger cohort without HVI (respectively 15.9 ± 3.2 mm Hg, 12.8 ± 4.9 mm Hg, 16.4 ± 7.4 mm Hg, and 14.1 ± 4.1 mm Hg; N = 85, P < 0.00001) and the smaller HVI pilot study (respectively 21.4 ± 9.9 mm Hg, 14.2 ± 4.9 mm Hg, 20.2 ± 9.7 mm Hg, and 18.9 ± 7.6 mm Hg; N = 20, P < 0.001). More than 30% IOP elevation above baseline occurred in 13.3% of the entire cohort at 1 week after surgery. This increased to 46.7% when IOP was compared with 1 day after surgery. Inconsistent AqCA values and patterns of aqueous flow were demonstrated after TBS. AqCA after phacoemulsification alone was maintained or increased within 1 week in all 5 eyes.
After iStent inject surgery in patients with open angle glaucoma, intraocular spikes were most commonly seen at 1 week. AO patterns were variable and additional studies are needed to understand the pathophysiology underlying IOP responses after this procedure.
在白内障超声乳化术中加入小梁旁路手术（TBS）会导致不可预测的短期眼压（IOP）控制，这可能不适合患有晚期青光眼的患者。TBS 后的房水流出（AO）反应很复杂，可能是多因素的。
评估 iStent inject 后 1 个月内开角型青光眼患者的眼压峰值及其与血红蛋白视频成像（HVI）测量的 AO 模式的关系。
我们研究了 105 例连续开角型青光眼患者（6 例仅 TBS 和 99 例联合白内障超声乳化术）在 TBS 后 4 周内的 IOP。在每个时间点，将手术后的 IOP 变化与基线测量值和前一次手术后的测量值进行比较。所有患者在手术当天停止使用降眼压药物。对 20 只眼（仅 TBS = 6 只眼，联合 = 14 只眼）进行了较小的平行研究，同时进行 HVI 以观察和量化围手术期的 AO。在每个时间点计算一个鼻侧和一个颞侧房水静脉的房水柱横截面积（AqCA），并记录定性观察结果。另外 5 只眼只接受了白内障超声乳化术。
整个队列的平均 IOP（术前 17.3 ± 5.6 mm Hg）在 TBS 后一天最低（13.1 ± 5.0 mm Hg），并在 1 周时达到峰值（17.2 ± 8.0 mm Hg），然后在 4 周时稳定（15.2 ± 5.2 mm Hg；P < 0.00001）。当将该组分为没有 HVI 的更大队列（分别为 15.9 ± 3.2、12.8 ± 4.9、16.4 ± 7.4 和 14.1 ± 4.1 mm Hg；N = 85，P < 0.00001）和较小的 HVI 试点研究（分别为 21.4 ± 9.9、14.2 ± 4.9、20.2 ± 9.7 和 18.9 ± 7.6 mm Hg；N = 20，P < 0.001）时，也观察到了相同的 IOP 模式。在整个队列中，13.3%的患者在手术后 1 周时 IOP 升高超过基线 30%以上。当与手术后第 1 天相比，这一比例上升至 46.7%。在 TBS 后，房水的 AqCA 值和流动模式表现出不一致。在所有 5 只眼的白内障超声乳化术后 1 周内，房水 AqCA 保持或增加。
在开角型青光眼患者中进行 iStent inject 手术后，最常见的眼压升高发生在术后 1 周。AO 模式各不相同，需要进一步研究以了解该手术后继发性眼压升高的病理生理学机制。
