PURPOSE: To report long-term outcomes of primary deep sclerectomy (DS) in open-angle glaucoma (OAG) and identify factors influencing surgical failure and postoperative complications. DESIGN: Retrospective cohort study. PARTICIPANTS: Consecutive OAG patients undergoing primary DS with follow-up ≥1 year. METHODS: Three intraocular pressure (IOP) success cutoffs were defined: ≤18 mmHg and 20% reduction, ≤15 mmHg and 25% reduction, and ≤12 mmHg and 30% reduction. Cox multivariable regression analysis investigated factors influencing failure and postoperative complications. MAIN OUTCOME MEASURES: The primary outcome was the success rate of DS according to the defined criteria. Secondary outcomes included: IOP over time; factors predictive of failure; incidence and predictive factors of serious post-operative complications. RESULTS: 513 eyes of 409 patients with a mean (±SD) age of 70.2 (±9.8) years and follow-up of 84.1 (±41.6) months. Mean (±SD) IOP decreased from 23.5 (±7.3) mmHg to 13.3 (±3.9), 12.8 (±4.3), 12.4 (±4.3) mmHg at 3, 5, and 7 years, respectively (p<0.001). Success rates at 3, 5 and 7 years were respectively 66.3% (62.2-70.7%), 57.9% (53.4-62.7%) and 54.0% (49.4-59.1%) for IOP≤18 mmHg; 44.5% (40.3-49.1%), 34.6% (30.4-39.4%) and 29.8% (25.6-34.6%) for IOP≤15 mmHg; and 18.1% (15.0-21.9%), 11.9% (9.2-15.4%) and 10.0% (7.5-13.4%) for IOP≤12 mmHg. For all cutoffs, laser goniopuncture (p<0.001), needling (p<0.001), and post-operative anti-glaucoma medications (p<0.001) were associated with increased failure. Intraoperative mitomycin C (MMC) was associated with reduced failure for IOP≤15 (p=0.006) and IOP≤12 (p=0.001); whereas higher preoperative IOP (p=0.001) with increased failure for IOP≤12. Serious complications occurred in 49 eyes, with an estimated incidence (95% CI) of 3.5% (1.9-5.1%), 6.0% (3.9-8.0%), 8.3% (5.7-11.8%), and 9.3% (6.3-12.2%) at 1, 3, 5, and 7 years, respectively. Pseudoexfoliation (p=0.04) or pigmentary (p=0.023) glaucoma, poorer preoperative vision (p=0.017), intraoperative macroperforation (p=0.002), avascular blebs (p=0.009), subsequent phacoemulsification (p=0.007), and intraoperative bevacizumab (p=0.004), but not MMC (p=0.79), were associated with increased serious post-operative complications. For phakic patients, the estimated incidence (95% CI) of subsequent phacoemulsification was 16.4% (12.6-20.0%), 23.6% (19.2-27.8%), and 33.0% (27.7-38.0%) at 3, 5, and 7 years. CONCLUSION: DS is an effective long-lasting primary surgical procedure for OAG.
Department of Ophthalmology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom; Department of Ophthalmology, University Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy.Full article