AbstractThe PreserFlo MicroShunt (PMS) is a minimally invasive surgical device for glaucoma management. However, postoperative hypotony remains a significant complication. This retrospective cohort study analyzed 471 eyes to evaluate the efficacy of PMS implantation in reducing intraocular pressure (IOP) and medication dependency, as well as to identify risk factors associated with hypotony. The median IOP decreased significantly from 19 mmHg preoperatively to 10 mmHg three months postoperatively, with the median medications score dropping to zero. Postoperative hypotony occurred in 18.7% of the cases. Multivariate analysis identified preoperative IOP ≥ 25 mmHg (odds ratio (OR): 2.01, 95% confidence interval (CI): 1.00–4.02, p = 0.049) and medication scores ≥ 5 (OR: 2.12, 95% CI: 1.13–3.96, p = 0.019) as significant risk factors for hypotony, while axial length ≥ 25.5 mm (OR: 0.19, 95% CI: 0.09–0.39, p < 0.001) and intraluminal suture stenting (OR: 0.08, 95% CI: 0.03–0.25, p < 0.001) were significantly protective. Importantly, intraluminal suture stenting mitigated the risk of hypotony without compromising the short-term surgical outcomes. These findings emphasize the need for careful patient selection and the potential of intraluminal suture stenting as an effective intraoperative strategy to improve the safety and outcomes of PMS implantation.
IntroductionGlaucoma remains a leading cause of irreversible blindness globally, affecting millions of people and posing substantial public health challenges1,2. Its prevalence is projected to increase significantly, underlining the urgent need for effective therapeutic strategies. While medical therapy and laser procedures constitute the first-line treatment for reducing intraocular pressure (IOP), surgical interventions are indispensable for patients with advanced or refractory glaucoma. Among surgical options, trabeculectomy has long been the gold standard3,4,5, yet its invasive nature and associated complications have spurred interest in less invasive glaucoma surgeries.One promising innovation is the PreserFlo MicroShunt (PMS) (Santen Pharmaceutical Co., Ltd., Osaka, Japan), a device designed to achieve significant IOP reduction with a less invasive approach than traditional surgeries6. PMS, fabricated from a biocompatible polymer, diverts aqueous humor from the anterior chamber to the subconjunctival space, forming a bleb. PMS implantation has been reported to be associated with lower rates of bleb-related complications and reinterventions than trabeculectomy7,8,9. However, postoperative hypotony remains an encountered complication after PMS implantation, with reported rates ranging from 1.7 to 39% in the literature10. During the early postoperative period, it has been reported that hypotony is significantly more common with PMS implantation than with trabeculectomy11. While transient hypotony often resolves without surgical intervention12, persistent hypotony can lead to irreversible damage, emphasizing the need to elucidate the associated risk factors.This study aims to assess the efficacy of PMS implantation in reducing IOP and glaucoma medications during the early postoperative period, while also identifying risk factors associated with hypotony following PMS implantation.ResultsPatient demographics and baseline characteristicsA total of 471 eyes of 372 patients that underwent PMS implantation were included in this study. The median age of the participants was 74 (interquartile range; IQR, 65–80) years, and 45.9% were female. The glaucoma subtypes were distributed as follows: primary open-angle glaucoma (POAG, 60.9%), pseudoexfoliative glaucoma (XFG, 23.6%), and secondary glaucoma excluding pseudoexfoliative glaucoma (SG, 15.5%). Table 1 summarizes the demographic and baseline characteristics of the enrolled patients.Table 1 Demographic and baseline characteristics of the 471 enrolled patients.Full size tablePostoperative changes and incidence of postoperative complicationsThe median (IQR) IOP significantly decreased from 19 (15–24) mmHg at baseline to 7 (5–10) mmHg at 1 day, 9 (8–11) mmHg at 1 month, 10 (8–12) mmHg at 2 months, and 10 (9–13) mmHg at 3 months after PFM implantation (all, p < 0.001). The median (IQR) medication scores also significantly decreased from 4 (3–5) at baseline to 0 (0–0) at 1 month (p < 0.001), and 0 (0–0) at 3 months after PFM implantation (p < 0.001) (Fig. 1). Postoperative hypotony occurred in 88 eyes (18.7%). Among these cases, 36 eyes (7.6%) had a shallow anterior chamber, 78 eyes (16.6%) had choroidal detachment, and 1 eye had hypotony maculopathy. Additionally, 29 eyes (6.2%) had both a shallow anterior chamber and choroidal detachment. Within three months after PMS implantation, surgical interventions were required in 7 eyes (1.5%) for severe hypotony, in 10 eyes (2.1%) for elevated IOP, and 3 eyes (0.6%) for malignant glaucoma.Fig. 1Changes in intraocular pressure (IOP) and medication scores. Left: Boxplot showing intraocular pressure (IOP) at baseline, postoperative day 1, and months 1, 2, and 3. A significant reduction in IOP was observed at all time points compared with baseline (all p < 0.001, Steel’s multiple comparison test). Right: Boxplot showing medication scores at baseline, month 1 and 3 months. Medication scores were significantly reduced at months 1 and 3 compared with baseline (all p < 0.001, Steel’s multiple comparison test). In both boxplots, the horizontal lines within each box represent the median values, the boxes indicate the interquartile range (IQR), and the whiskers represent the range excluding the outliers. Individual points represent outliers beyond 1.5 times the IQR.Full size imageRisk factors for hypotonyTable 2 shows the results of the univariate and multivariate analyses to identify the risk factors associated with hypotony following PMS implantation. Univariate analysis identified several risk factors associated with hypotony after PMS implantation. Advanced age (≥ 80years) was significantly associated with hypotony (odds ratio (OR): 3.07, 95% confidence interval (CI): 1.90–4.96, p < 0.001). Preoperative IOP ≥ 25mmHg (OR: 2.66, 95% CI: 1.62–4.35, p < 0.001) and preoperative medication scores of ≥ 5 (OR: 2.06, 95% CI: 1.29–3.31, p = 0.002) were also significant risk factors. The glaucoma subtype, specifically XFG versus POAG, showed a significant association (OR: 2.73, 95% CI: 1.61–4.61, p < 0.001). Conversely, an axial length ≥ 25.5 mm (OR: 0.22, 95% CI: 0.12–0.40, p < 0.001) and intraluminal suture stenting (OR: 0.11, 95% CI: 0.03–0.27, p < 0.001) were associated with a significantly reduced risk of hypotony.Table 2 Univariate and multivariate analyses to identify the risk factors associated with hypotony following PMS implantation.Full size tableIn the multivariate analysis, after adjusting for confounders, preoperative IOP ≥ 25mmHg (OR: 2.01, 95% CI: 1.00–4.02, p = 0.049) and preoperative medication scores of ≥ 5 (OR: 2.12, 95% CI: 1.13–3.96, p = 0.019) remained independent risk factors for hypotony. Axial length ≥ 25.5 mm (OR: 0.19, 95% CI: 0.09–0.39, p < 0.001) and intraluminal suture stenting (OR: 0.08, 95% CI: 0.03–0.25, p < 0.001) were significant protective factors. Other variables, such as age ≥ 80years, glaucoma type, history of cataract surgery (i.e., pseudophakic eyes), and combination of PMS implantation with cataract surgery were not statistically significant in the multivariate analysis.Impact of intraluminal suture stenting on IOP and medication scoresFigure 2 shows the intraoperative images of intraluminal suture stenting. The impact of intraluminal suture stenting on IOP control is shown in Table 3. IOP and medication scores were compared with and without intraluminal suture stenting. Preoperative IOP was comparable between the two groups, with a median (IQR) of 20.0 (16.0-24.3) mmHg in the stenting group and 19.0 (15.0-23.5) mmHg in the non-stenting group. On postoperative day 1, the median (IQR) IOP was significantly higher in the stenting group than in the non-stenting group (12.0 (8.8–14.0) mmHg vs. 6.0 (4.0–8.0) mmHg, p < 0.001). However, at 1, 2, and 3 months postoperatively, there was no significant difference in IOP between the two groups. Medication scores were similar between the two groups at all time points.Table 3 Intraocular pressure changes with and without intraluminal suture stenting.Full size tableFig. 2Intraoperative images of the intraluminal suture stenting. Left: Intraoperative image during the procedure. The green arrow and the black dotted line indicate the posterior end of the tube fixation to prevent the tube from rising or bending. A 9 − 0 or 10 − 0 nylon suture was inserted into the outer lumen of the PMS and the other side was passed through the cornea and placed beneath the conjunctiva. The blue arrow and white dotted curve highlight the suture loop on the cornea. Right: Image at end of surgery. The blue arrow and white dotted curve highlight the suture loop on the cornea, with the majority of the suture positioned beneath the conjunctiva. The suture can be easily removed by pulling the loop.Full size imageDiscussionThis study demonstrated that PMS implantation effectively reduced the IOP and medication burden in patients with glaucoma during the first three months postoperatively. The median IOP significantly decreased from 19 mmHg at baseline to 10 mmHg at three months postoperatively, whereas the median medication score dropped to zero within the same period, underscoring the efficacy of the procedure in achieving sustained IOP control with reduced pharmacological dependence. In contrast, postoperative hypotony was observed in 18.6% of the cases. Risk factors for hypotony included preoperative IOP ≥ 25mmHg and medication scores ≥ 5, whereas longer axial length (≥ 25.5 mm) and intraluminal suture stenting emerged as significant protective factors.To the best of our knowledge, this is the first study to comprehensively investigate the risk factors associated with hypotony following PMS implantation. Although risk factors for hypotony after traditional filtering surgery have been reported, the identified risk factors for developing hypotony and its associated complications include young age13,14,15,16,17,18, myopia13,14,15,16,17,18, preoperative use of carbonic anhydrase inhibitors15, male gender13,16, primary filtering surgery16,17,18, and higher preoperative intraocular pressure18,19. In this study, a higher preoperative intraocular pressure and greater medication scores were identified as significant risk factors for postoperative hypotony. Greater medication scores may indicate increased preoperative use of carbonic anhydrase inhibitors.Interestingly, longer axial length is a significant protective factor for hypotony following PMS implantation. Myopia has been considered a risk factor for hypotony, not only following traditional filtering surgery, but also following PMS implantation20. After XEN Gel Stent implantation, which is a 6 mm long, 45 μm wide hydrophilic tube of porcine gelatine, a longer axial length (over 24.3 mm) predisposes the eye to the development of hypotony21. In this study with a large number of cases, a longer axial length was significantly protective against hypotony following PMS implantation. The aqueous humor outflow through the PMS follows the Hagen-Poiseuille equations22,23. In eyes with a longer axial length, the larger ocular volume results in a more gradual pressure change, potentially reducing the risk of postoperative hypotony. Further studies are needed to elucidate this discrepancy.Recent studies have revealed the efficacy of intraluminal suture stenting for PMS implantation in preventing postoperative hypotony20,24,25,26,27. The stent can be safely removed after surgery, resulting in a controlled IOP reduction. Notably, surgical success and long-term IOP control were not compromised by stent placement20,24,26. In our study, intraluminal suture stenting also significantly reduced the incidence of postoperative hypotony and made no difference in the reduction of IOP and medication scores for up to 3 months. Optimal timing for stent removal remains a topic of discussion, however, intraluminal suture stenting should be considered, especially in patients with a higher preoperative intraocular pressure or greater medication scores.This study had several limitations. First, its retrospective design introduces the potential for selection bias and limits its ability to establish causality. Since the use of intraluminal suture stenting was started at some point, it was not randomized. Second, the follow-up period in this study was limited to three months. Although this has allowed for the assessment of early postoperative outcomes, long-term data on the durability of IOP control and the long-term influence of intraluminal suture stenting are lacking. Future research should focus on validating these results and assessing the long-term outcomes to enhance the safety and efficacy of PMS implantation.In conclusion, this study identified key factors influencing hypotony following PMS implantation. Higher preoperative intraocular pressure and greater medication scores were significant risk factors, while longer axial length and intraluminal suture stenting were protective factors. Importantly, intraluminal suture stenting mitigated the risk of hypotony without compromising the short-term surgical outcomes. These findings emphasize the need for careful patient selection and the potential of intraluminal suture stenting as an effective intraoperative strategy to improve the safety and outcomes of PMS implantation.Materials and methodsStudy designThis multicenter retrospective cohort study was included 476 consecutive eyes that underwent PMS implantation between August 2022 and May 2024 at Kyoto Prefectural University of Medicine and affiliated institutions. Ethical approval was obtained from the institutional review board (ERB-C-1909-2) and the study adhered to the tenets of the Declaration of Helsinki. Informed consent of surgery was obtained from all the participants.We included all patients aged ≥ 18 years with a previous diagnosis of glaucoma, having an IOP above the target despite maximal medical treatment, and receiving PMS implantation. We excluded patients who were lost to follow-up before the three-month postoperative visit.Data were obtained via a review of the medical records of the patients, and included the following data points: 1) patient demographics (i.e., age, sex, preoperative best-corrected visual acuity, preoperative IOP, preoperative medication scores, central cornea thickness, axial length, mean deviation, glaucoma subtypes, and previous surgery), 2) surgical procedure performed (PMS stand-alone or PMS combined with cataract surgery), and 3) additional procedures with PMS (posterior end of the tube fixation, intraluminal suture stenting). In all patients, IOP was measured using a Goldmann applanation tonometer and the medication scores were calculated based on the number of glaucoma medications used, that is, single medical agents were scored as 1, combination medical agents were scored as 2, and oral acetazolamide medication was scored as ‘1 point’ per tablet.In this study, hypotony was defined as an IOP < 5 mmHg associated with complications such as a shallow anterior chamber, choroidal detachment, and hypotony maculopathy. Cases with lower intraocular pressure and no symptoms were not classified as hypotony.Surgical proceduresAll surgeries were performed by three experienced glaucoma surgeons (H.M., K.M., and M.U.) using a standardized PFM implantation technique. After placing a corneal traction suture, the surgical procedure began with a superior fornix-based conjunctival peritomy. After meticulous dissection of Tenon’s capsule, mitomycin-C (MMC) was applied to the exposed sclera using the soaked sponges (0.4 mg/mL) for 5 min. After copious irrigation with saline solution, the path for PMS insertion into the anterior chamber was established using a dedicated double-step knife. The knife was inserted at a point 3 mm from the limbus, reaching a 4.5 mm depth marker. This design ensured that the fin was positioned 3 mm from the limbus. The fins of the tube were securely seated and fixed within the sclera. After verifying the aqueous humor drainage from the distal end of the PFM, in some cases, the posterior end of the tube was fixed with 10 − 0 nylon (Mani, Inc., Tochigi, Japan) to prevent it from rising or bending. Subsequently, the tenon and conjunctiva were sutured using 10–0 nylon, followed by a subconjunctival injection of dexamethasone (1.65 mg) to complete the procedure. Postoperatively, the patients were instructed to use corticosteroids and antibacterial eye drops four times daily.During the study period, an additional step was introduced in the surgical procedure to prevent postoperative hypotony. From January 2024, a 9 − 0 (Mani, Inc., Tochigi, Japan) or 10 − 0 nylon suture was inserted into the PMS lumen in all patients to restrict aqueous flow during the early postoperative period. The selection of nylon suture diameter was determined by institutional availability rather than being individualized for each patient. The stent was generally removed two weeks after surgery. However, in cases where the intraocular pressure (IOP) remained below 10 mmHg, the surgeon opted to delay removal by an additional one to two weeks based on clinical judgment. Due to concerns regarding the risk of infection, all patients in this study underwent stent removal within one month.Statistical analysisAll statistical analyses were performed using the R software version 4.3.3 (R Foundation for Statistical Computing, Vienna, Austria). Continuous variables were expressed as medians with interquartile ranges (IQR), and a P-value < 0.05 was considered statistically significant. Steel’s multiple comparison test was used for within-group comparisons of the preoperative and postoperative IOP and medication scores. Comparisons between the groups were conducted using the Wilcoxon rank-sum test.Univariate and multivariate analyses were conducted to identify risk factors for hypotony following PMS implantation. Univariate and multivariate analyses were performed using a logistic regression model, and ORs and 95% CIs were calculated.
Data availability
The datasets generated in the current study are available from the corresponding author upon reasonable request.
ReferencesReis, T. F., Paula, J. S. & Furtado, J. M. Primary glaucomas in adults: epidemiology and public health-A review. Clin. Exp. Ophthalmol. 50, 128–142. https://doi.org/10.1111/ceo.14040 (2022).Article
PubMed
MATH
Google Scholar
Tham, Y. C. et al. Global prevalence of glaucoma and projections of glaucoma burden through 2040: a systematic review and meta-analysis. Ophthalmology 121, 2081–2090. https://doi.org/10.1016/j.ophtha.2014.05.013 (2014).Article
PubMed
MATH
Google Scholar
Al Habash, A., Aljasim, L. A., Owaidhah, O. & Edward, D. P. A review of the efficacy of mitomycin C in glaucoma filtration surgery. Clin. Ophthalmol. 9, 1945–1951. https://doi.org/10.2147/OPTH.S80111 (2015).Article
PubMed
Google Scholar
Kirwan, J. F. et al. Trabeculectomy in the 21st century: a multicenter analysis. Ophthalmology 120, 2532–2539. https://doi.org/10.1016/j.ophtha.2013.07.049 (2013).Article
PubMed
MATH
Google Scholar
Landers, J., Martin, K., Sarkies, N., Bourne, R. & Watson, P. A twenty-year follow-up study of trabeculectomy: risk factors and outcomes. Ophthalmology 119, 694–702. https://doi.org/10.1016/j.ophtha.2011.09.043 (2012).Article
PubMed
Google Scholar
Ahmed, I. I. K., Sadruddin, O. & Panarelli, J. F. Subconjunctival filtration in evolution: current evidence on microshunt implantation for treating patients with glaucoma. Eye Vis. (Lond). 10, 10. https://doi.org/10.1186/s40662-022-00322-1 (2023).Article
PubMed
Google Scholar
Khan, A. & Khan, A. U. Comparing the safety and efficacy of preserflo microshunt implantation and trabeculectomy for glaucoma: A systematic review and meta-analysis. Acta Ophthalmol. 102, e443–e451. https://doi.org/10.1111/aos.16658 (2024).Article
PubMed
MATH
Google Scholar
Jamke, M. et al. PRESERFLO microshunt versus trabeculectomy: 1-year results on efficacy and safety. Graefes Arch. Clin. Exp. Ophthalmol. 261, 2901–2915. https://doi.org/10.1007/s00417-023-06075-4 (2023).Article
PubMed
MATH
Google Scholar
Pillunat, K. R. et al. PRESERFLO microshunt versus trabeculectomy: first results on efficacy and safety. Acta Ophthalmol. 100, e779–e790. https://doi.org/10.1111/aos.14968 (2022).Article
PubMed
Google Scholar
Pawiroredjo, S. S. M. et al. Efficacy of the PRESERFLO microshunt and a Meta-Analysis of the literature. J. Clin. Med. 11 https://doi.org/10.3390/jcm11237149 (2022).Bohler, A. D. et al. Hypotony in the early postoperative period after microshunt implantation versus trabeculectomy: A registry study. Acta Ophthalmol. 102, 186–191. https://doi.org/10.1111/aos.15727 (2024).Article
PubMed
MATH
Google Scholar
Storp, J. J. et al. Long-Term outcomes of the PRESERFLO microshunt implant in a heterogeneous Glaucoma cohort. J. Clin. Med. 12 https://doi.org/10.3390/jcm12134474 (2023).Fannin, L. A., Schiffman, J. C. & Budenz, D. L. Risk factors for hypotony maculopathy. Ophthalmology 110, 1185–1191. https://doi.org/10.1016/S0161-6420(03)00227-6 (2003).Article
PubMed
Google Scholar
Park, H. Y., Lee, N. Y. & Park, C. K. Risk factors of shallow anterior chamber other than hypotony after Ahmed glaucoma valve implant. J. Glaucoma. 18, 44–48. https://doi.org/10.1097/IJG.0b013e31816b2fe7 (2009).Article
PubMed
MATH
Google Scholar
Seah, S. K. et al. Hypotony following trabeculectomy. J. Glaucoma. 4, 73–79 (1995).Article
PubMed
Google Scholar
Thomas, M., Vajaranant, T. S. & Aref, A. A. Hypotony maculopathy: clinical presentation and therapeutic methods. Ophthalmol. Ther. 4, 79–88. https://doi.org/10.1007/s40123-015-0037-z (2015).Article
PubMed
Google Scholar
Suner, I. J., Greenfield, D. S., Miller, M. P., Nicolela, M. T. & Palmberg, P. F. Hypotony maculopathy after filtering surgery with mitomycin C. Incidence and treatment. Ophthalmology 104, 207–214. https://doi.org/10.1016/s0161-6420(97)30332-7 (1997). discussion 214 – 205.Article
PubMed
Google Scholar
Costa, V. P. & Arcieri, E. S. Hypotony maculopathy. Acta Ophthalmol. Scand. 85, 586–597. https://doi.org/10.1111/j.1600-0420.2007.00910.x (2007).Article
PubMed
Google Scholar
Risk factors for suprachoroidal hemorrhage after filtering surgery. The fluorouracil filtering surgery study group. Am. J. Ophthalmol. 113, 501–507. https://doi.org/10.1016/s0002-9394(14)74720-8 (1992).Article
Google Scholar
Lupardi, E., Laffi, G. L., Moramarco, A., Barboni, P. & Fontana, L. Systematic preserflo microshunt intraluminal stenting for hypotony prevention in highly myopic patients: A comparative study. J. Clin. Med. 12 https://doi.org/10.3390/jcm12041677 (2023).Galimi, M. E., Weller, J. M., Kruse, F. E. & Laemmer, R. Risk factors for ocular hypotony after XEN gel stent implantation. Graefes Arch. Clin. Exp. Ophthalmol. 261, 769–778. https://doi.org/10.1007/s00417-022-05831-2 (2023).Article
PubMed
Google Scholar
Sadruddin, O., Angeles, P. L., Palmberg, P. & R. & Ab externo implantation of the microshunt, a Poly (styrene-block-isobutylene-block-styrene) surgical device for the treatment of primary open-angle glaucoma: a review. Eye Vis. (Lond). 6 https://doi.org/10.1186/s40662-019-0162-1 (2019).Ibarz Barberá, M. et al. Evaluation of the ultrastructural and in vitro flow properties of the PRESERFLO microshunt. Transl Vis. Sci. Technol. 10 https://doi.org/10.1167/tvst.10.13.26 (2021).Verma-Fuehring, R. et al. The use of intraluminal PRESERFLO stenting in avoiding early postoperative hypotony. Graefes Arch. Clin. Exp. Ophthalmol. 262, 3925–3932. https://doi.org/10.1007/s00417-024-06567-x (2024).Article
PubMed
MATH
Google Scholar
Moktar, A. A., Ha, J. & Kong, Y. X. G. Routine placement of an intraluminal suture should be considered for preserflo microshunt to prevent early hypotony. Clin. Exp. Ophthalmol. 52, 601–603. https://doi.org/10.1111/ceo.14374 (2024).Article
PubMed
Google Scholar
Luke, J. N. et al. Intraoperative primary partial occlusion of the preserflo microshunt to prevent initial postoperative hypotony. Int. Ophthalmol. 43, 2643–2651. https://doi.org/10.1007/s10792-023-02664-8 (2023).Article
PubMed
MATH
Google Scholar
Miura, Y., Fukuda, K. & Yamashiro, K. Ab interno intraluminal stent insertion for prolonged hypotony after preserflo microshunt implantation. Cureus 16, e60221. https://doi.org/10.7759/cureus.60221 (2024).Article
PubMed
Google Scholar
Download referencesAuthor informationAuthors and AffiliationsDepartment of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, JapanHiroki Mieno, Kazuhiko Mori, Yoko Ikeda, Morio Ueno & Chie SotozonoBaptist Eye Institute, Nagaokakyo, JapanKazuhiko MoriDepartment of Mathematics and Statistics in Medical Sciences, Kyoto Prefectural University of Medicine, Kyoto, JapanKengo YoshiiDepartment of Ophthalmology, National Center for Geriatrics and Gerontology, Obu City, Aichi, JapanYo OkadaOike-Ikeda Eye Clinic, Kyoto, JapanYoko IkedaAuthorsHiroki MienoView author publicationsYou can also search for this author in
PubMed Google ScholarKazuhiko MoriView author publicationsYou can also search for this author in
PubMed Google ScholarKengo YoshiiView author publicationsYou can also search for this author in
PubMed Google ScholarYo OkadaView author publicationsYou can also search for this author in
PubMed Google ScholarYoko IkedaView author publicationsYou can also search for this author in
PubMed Google ScholarMorio UenoView author publicationsYou can also search for this author in
PubMed Google ScholarChie SotozonoView author publicationsYou can also search for this author in
PubMed Google ScholarContributionsH.M., K.M., and M.U.: conception and design; H.M., K.M., and Y.O.: collection and assembly of data; H.M., K.M., K.Y., Y.I., M.U., and C.S.: data analysis and interpretation; H.M., K.M., K.Y., M.U., and C.S.: writing the manuscript. All authors have reviewed the manuscript.Corresponding authorCorrespondence to
Kazuhiko Mori.Ethics declarations
Competing interests
Kazuhiko Mori received consultant fees from Santen Pharmaceutical Co., Ltd., Morio Ueno received research support from Santen Pharmaceutical Co., Ltd., and Chie Sotozono received grants and personal fees from Santen Pharmaceutical Co., Ltd.Santen Pharmaceutical Co., Ltd., played no role in the conduct of the study or in writing the manuscript. All other authors declare no potential conflicts of interest regarding the subjects described in this manuscript.
Additional informationPublisher’s noteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Reprints and permissionsAbout this articleCite this articleMieno, H., Mori, K., Yoshii, K. et al. Risk factors and protective strategies for hypotony following preserflo microshunt implantation.
Sci Rep 15, 8344 (2025). https://doi.org/10.1038/s41598-025-92879-9Download citationReceived: 29 December 2024Accepted: 03 March 2025Published: 11 March 2025DOI: https://doi.org/10.1038/s41598-025-92879-9Share this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard
Provided by the Springer Nature SharedIt content-sharing initiative
KeywordsGlaucomaHypotonyPreserFlo microshuntIntraluminal suture stentingRisk factors