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Editors Selection IGR 9-4

Clinical Forms of Glaucoma: Glaucoma after Vitreoretinal Surgery

Comment by Taylor Nayman & Arthur Sit on:

100408 Risk of glaucoma after vitreoretinal surgery - Findings from a population-based cohort study, Loukovaara S; Gucciardo E; Korhonen A et al., Acta Ophthalmologica, 2022; 100: 665-672

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Vitrectomy has been linked to an increased risk of glaucoma.^1,2 While vitrectomy leads to oxidative damage at the trabecular meshwork (TM) and likely increases outflow resistance, ^3,4 previous studies have also shown an increased risk of normal-tension glaucoma.²

Loukovaara and colleagues reported results from a longitudinal population-based study in Finland evaluating the risk of glaucoma following vitreoretinal surgery. In this case-control study of 261 individuals, of which 103 had glaucoma and 158 were age- and sex-matched controls, patients were separated into three groups based on the type of vitrectomy they had undergone. These were single vitrectomy (Vit), vitrectomy with a retinal procedure (VitRet), and phacoemulsification and/or lensectomy with/without intraocular lens implantation and vitrectomy (PhacoVit).

All three types of vitrectomies were associated with an increased risk of any subtype of glaucoma. The highest risk was associated with VitRet (OR 4.5), followed by Vit (OR 3.15), and PhacoVit (OR 2.7). Interestingly, risk of open-angle glaucoma (OAG) was increased after VitRet (OR 3.66), as well as Vit (OR 2.33), but not after PhacoVit. The risk of other types of glaucoma (unspecified or secondary) was highest with Vit (OR 5.37), followed by PhacoVit (OR 4.58), and VitRet (OR 4.06).

Authors suggest that VitRet induces more inflammation and oxidative stress, while membrane peeling may contribute to secondary glaucoma by directly damaging retinal ganglion cells. They also note the possible protective role of cataract extraction.

Diabetes was not associated with glaucoma. Five-year exposure to statins was associated with decreased risk of glaucoma (OR 0.86), and four- and five-year exposure decreased the risk of other subtypes (OR 0.87 and 0.81, respectively), but not OAG. Authors speculate that statins may play a role in mitigating inflammation that could affect outflow facility.

One limitation was the way glaucoma was defined without precise criteria (openangle glaucoma with subtypes of exfoliation, normal tension, pigmentary, chronic primary OAG, and unspecified OAG; unspecified glaucoma or glaucoma secondary to other eye disorder).

This study confirms the increased risk of glaucoma post-vitrectomy and the need for increased monitoring of these patients

The authors discussed potential reasons why the risk may be different between groups, including internal limiting membrane peeling and increased inflammation causing higher rates in the VitRet group, while opening of the angle and TM decreased risk in the PhacoVit group. Unfortunately, they did not report the degree of vitrectomy, but it is possible that more complete vitrectomies in the VitRet group increased oxidative stress in the TM. While further studies are needed to better establish the pathophysiology, this study confirms the increased risk of glaucoma post-vitrectomy and the need for increased monitoring of these patients.

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