The deep sclerectomy technique was modified to enhance aqueous humor (AH) outflow via the non-trabecular pathway. A pilot study was carried out to assess its safety and effectiveness. Thirty-eight patients were under observation. After superficial scleral flap (4 × 4 mm), deep scleral layers were divided into three parts by three parallel-to-limbus incisions. Deep sclerectomy without creating a window in the Descemetes’ membrane was carried out in the distal part. A collagen implant was placed under the sclera of the remaining two parts with one end in the intrascleral pool. The third proximal part was excised to expose the uvea and implant. A Nd:YAG laser trabeculotomy at the surgery site was made on postoperative days 7–10. Outcome measures were IOP change, use of hypotensive medication(s), complications, and the need for a second surgery. At six months, the mean IOP decreased from 29.1 ± 9.2 mm Hg to 14.0 ± 4.3 mm Hg (p = 1.4 × 10⁻⁹); hypotensive medication use reduced from 2.9 ± 0.9 to 0.6 ± 1.0 (p = 1.3 × 10⁻¹⁰); complete success was achieved in 68.4% of cases and partial success was achieved in 31.6% of cases. Intraoperative and postoperative complications were rare and manageable. The OCT of the surgery site revealed the absence of bleb in all cases. Lymphatic vessels with characteristic bicuspid valves in their lumen were detected in conjunctiva near the operation site and over it in 32 patients. IOP decrease in the proposed technique was achieved by activation of the uveolymphatic route of AH outflow.

A surgical technique was developed to enhance aqueous humor (AH) flow through the non-trabecular outflow pathway by rerouting it from the anterior chamber (AC) to the suprachoroidal space (SCS) without detaching the ciliary body from the scleral spur. Medium- and long-term surgical outcomes were retrospectively analyzed in a case series of 58 glaucoma patients. At 6, 12, and 24 months, the mean IOP decreased from 27.8 ± 8.3 to 14.9 ± 5.0 mmHg, median 15.0 (25th percentile (p²⁵)13.0; 75th percentile (p⁷⁵) 18.0) and 15.2 ± 3.3 mmHg, and hypotensive medication use reduced from a median (p²⁵; p⁷⁵) of 3 (2; 3) to 0 (0; 2), 0 (0; 2), and 0 (0; 1.5), respectively. Intra- and postoperative complications were few and manageable. Following surgery, no bleb formation occurred in any of the cases (as confirmed by optical coherence tomography). Conjunctival lymphatic vessels (CLVs) developed in 50% of eyes (29/58). Clinically, they developed directly from sclera and had no connection to the surgical site. Analysis further showed that the development of CLVs and their longer visibility period had poor prognostic value for IOP control. If the fluid flow from the SCS to CLVs was resistance-free, no CLV development was evident. However, if any resistance existed in the flow, the fluid accumulated in lymphatics, resulting in their engorgement. The proposed technique was safe and effective in decreasing IOP in glaucoma patients by enhancing AH flow from the SCS to CLVs via connecting intrascleral microchannels.

A surgical technique aimed at rerouting aqueous humor (AH) outflow from the anterior chamber to the suprachoroidal space (SCS) without performing surgical cyclodialysis was developed to decrease intraocular pressure (IOP) in glaucoma patients. The surgical outcomes of the technique were retrospectively analyzed in fifty-eight patients. At 6, 12, and 24 months, the mean IOP decreased from 27.8±8.3 to 14.95.0 mmHg, median 15.0 (25th percentile (p25 )13.0; 75th percentile (p75) 18.0), and 15.23.3 mmHg; hypotensive medication use reduced from median (p25; p75) 3 (2; 3) to 0 (0; 2), 0 (0; 2), and 0 (0; 1.5), and complete success was achieved in 62.8%, 51.2%, and 32.5% cases, with partial success in 28.4%, 44.2%, and 62.5% cases, respectively. Eight cases (13.8%) presented unsatisfactory outcomes. Intra- and postoperative complications were few and manageable. No bleb formation was observed in any of the cases. In 50% of cases, conjunctival lymphatic vessels (CLVs) developed following surgery in superior quadrants. The technique is safe and effective in providing a long-term decrease in IOP and hypotensive medication use. It was hypothesized in this study that the IOP decrease occurred as a result of enhanced AH outflow from the SCS to CLVs through intrascleral microchannels connecting the SCS to CLVs.

Purpose: To evaluate long-term outcomes and safety of non-cyclodialytic, bleb-independent surgical enhancement of uveoscleral outflow for intraocular pressure (IOP) reduction in open-angle glaucoma (OAG), and to assess the role of conjunctival lymphatic vessels (CLVs) in suprachoroidal drainage. Methods: In this single-center consecutive case series, 70 eyes of 63 patients (mean age 75.0 years; 70% female) with moderate-to-severe OAG underwent uveoscleral outflow enhancement. Twenty-two eyes had standalone surgery; 48 eyes had combined phacoemulsification with glaucoma surgery. Mean follow-up was 24.1 months (range 5.3–60.4). Primary outcomes were IOP reduction and surgical success by Kaplan–Meier analysis (sustained failure: IOP > 18 mmHg or < 20% reduction from baseline at two consecutive available postoperative visits, excluding day 1). CLVs were assessed by slit-lamp and OCT at 11 time points over 36 months. Mixed-effects models with random intercept per eye were used for repeated measurements. Logistic regression with cluster-robust standard errors evaluated predictors of CLV visibility. Results: Baseline IOP of 28.8 ± 8.4 mmHg decreased to 12.3 ± 4.5 mmHg at 1 month (54.5% reduction) and 14.5 ± 2.5 mmHg at 36 months (46.2% reduction, n = 22). Medications decreased from 2.77 ± 0.94 to 1.36 ± 1.09 at 36 months. Overall surgical survival was 91.4% at 1 month, 82.0% at 12 months, and 74.1% at 36 months. Fifteen eyes (21.4%) met sustained failure criteria (standalone surgery group: eight, combined surgery group: seven; and log-rank p = 0.038). The combined surgery group showed higher survival at 36 months (82.6% vs. 58.5%), but the difference did not reach significance. CLVs were detected in 51.4% by slit-lamp and 96.4% by OCT, peaking at 1 month. Before surgery, CLVs were not detected on OCT in any eye. Time was a significant negative predictor of CLV visibility on both slit-lamp (OR 0.953/month, p = 0.046) and OCT (OR 0.935/month, p = 0.003), without independent association with IOP or medication burden, suggesting that CLVs facilitate suprachoroidal drainage as a structural mechanism rather than a reactive response to IOP changes. Conclusions: Non-cyclodialytic, bleb-independent uveoscleral outflow enhancement provides sustained IOP reduction with favorable safety. CLVs, nearly universally detected by OCT after surgery, appear to contribute to suprachoroidal drainage. Combined surgery showed a trend toward greater surgical success than standalone procedures.

This was an interventional consecutive case series including 63 patients (70 eyes) who underwent enhancement of uveoscleral outflow by rerouting aqueous humor (AH) flow from the anterior chamber (AC) to the suprachoroidal space (SCS) without detaching the ciliary body from the scleral spur. Long-term outcomes were evaluated retrospectively. Inclusion required a minimum follow-up of 6 months, with data collected longitudinally for up to 36 months after baseline. In addition to evaluating the safety and efficacy of the applied technique, the role of the scleral, episcleral and conjunctival lymphatic vessels (CLVs) in suprachoroidal drainage was assessed clinically and using optical coherence tomography (OCT) technologies. The primary outcome was the proportion of eyes with a final IOP < 18 mm Hg and a > 20% reduction in IOP with the same or fewer medications compared to baseline. This outcome was achieved in 90.1, 88.3, 90.4, 93.5, 96.2 and 100% of cases at months 6, 12, 18, 24, 30 and 36, respectively. No bleb formation occurred after surgery in any of the cases. Intra- and postoperative complications were rare and easily manageable. Transparent CLVs arising directly from the sclera and far from the surgical site were visible on biomicroscopy in the superior bulbar conjunctiva in 52.9% of eyes (37/70). Long-lasting CLVs were related to higher values of intraocular pressure (IOP). In comparison to the preoperative evaluation, when no CLVs were identified on OCT, they were identified in 94.6% of eyes after surgery. Long-term CLV’s identification on OCT was related to a long-term decrease in IOP and less additional hypotensive medication. The technique was safe and effective in achieving a long-term reduction in IOP and decreasing the medication burden. A novel SCS–scleral–episcleral–CLV outflow route was identified for suprachoroidal drainage.