Preparing the ocular surface for glaucoma filtration surgery: an unmet clinical need

Abstract

The mutual relationship among medical therapy, ocular surface (OS) and filtration surgery (FS) represents one of the most crucial issues in glaucoma management. As the long-term use of intraocular pressure-lowering medications significantly affect the OS health, patients with an uncontrolled disease frequently undergo glaucoma surgery in less-than-ideal conditions. As we known, OS changes strongly affect the post-operative bleb filtration capability. Therefore, improving the OS conditions before proceeding with FS is needed. Currently, given the rapid diffusion of new surgical procedures, this need is even more perceived. Nevertheless, despite surgeons retain the OS preparation of primary importance, and recognize the OS disease (OSD) as the only modifiable risk factor for filtration failure, there is no agreement on which strategies should be preferred to prepare patients. This is largely due to the lack of validated guidelines, which forces clinicians to adopt personal approaches based on evidence derived from low-quality studies. In this review, we provided an overview of risk factors involved in the FS failure, with particular attention to those depending on OS changes, and how OSD negatively affects the aqueous humor resorption after surgery. Moreover, we reported the most exploited measures to mitigate the OSD before surgery, the possible reasons underlying the absence of shared approaches, and the upcoming area of intervention to preserve the OS health during glaucoma management. Finally, based on the current evidence, we proposed a pre-operative outline reporting the main risk factors that should be considered before surgery, and the therapeutical options available to improve the OS.

Topical Steroids and Glaucoma Filtration Surgery Outcomes: An In Vivo Confocal Study of the Conjunctiva

“…The bulk of the literature clearly demonstrates that the pre-operative features of the ocular surface and the outcomes of glaucoma filtration surgery have a strong mutual relationship [ 6 , 14 , 26 ]. Therefore, improving the ocular surface quality plays a critical role in the management of patients who are candidates for surgery [ 13 , 14 ].…”

“…Based on these findings, one cannot completely rule out a potential impact of sodium hyaluronate on surgical outcomes. As is known, the use of sodium hyaluronate represents one potential strategy to prepare patients for FS, since it mitigates dry eye and, thus, may contribute to reducing inflammation [ 13 , 14 ]. In addition, sodium hyaluronate seems to stimulate GCs, which play an active role in the aqueous humor resorption through the bleb-wall after FS [ 8 , 9 , 11 ].…”

“…First, we did not consider patients treated with topical non-steroidal anti-inflammatory drugs (NSAIDs). However, previous studies documented that the effects of steroids and NSAIDs on FS outcomes are similar, although a significantly higher efficacy of steroids over NSAIDs was described [ 14 , 27 , 28 ]. Second, since SMR is an arbitrary index and an indirect indicator of the tissue density, this parameter could not clearly indicate the collagen amount of the conjunctival stroma.…”

“…The progressive alterations of these structures increase the risk of inadequate AH drainage and surgical failure [ 4 , 5 , 6 , 7 , 12 ]. Therefore, the need to manage the ocular surface before FS, especially by mitigating inflammation, is keenly felt by surgeons [ 13 , 14 ].…”

Clinical Tear Fluid Proteomics—A Novel Tool in Glaucoma Research

“…In light of this information, emerging recommendations are suggesting preoperative outlines, which could be used to stabilize the ocular surface state prior to surgery. For example, a switch from preserved to preservative-free eye drops or an administration of artificial tears and preoperative anti-inflammatory drugs, e.g., fluorometholone, and management of lid hygiene could help reduce the ocular surface inflammation and increase the chances of a successful surgery [ 91 ].…”