Alex S. Huang, MD, PhD, Rafaella C

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Aqueous Angiographic Outflow Improvement after Trabecular Microbypass in Glaucoma Patients Alex S. Huang, MD, PhD, Rafaella C. Penteado, MD, Vahan Papoyan, MD, Lilit Voskanyan, MD, PhD, Robert N. Weinreb, MD Ophthalmology Glaucoma Volume 2, Issue 1, Pages 11-21 (January 2019) DOI: 10.1016/j.ogla.2018.11.010 Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 1 Diagram showing aqueous angiography perfusion system. Sequential steps (1–6) spell out the process of delivering tracer (fluorescein or indocyanine green) or balanced salt solution into the eye. AC = anterior chamber. Ophthalmology Glaucoma 2019 2, 11-21DOI: (10.1016/j.ogla.2018.11.010) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 2 Sequential aqueous angiography in a patient without glaucoma. A–D, Aqueous angiography with indocyanine green (ICG) was performed first. E–H, Aqueous angiography with fluorescein (FL) was conducted immediately after ICG angiography. Green arrows point out regions with postlimbal angiographic signal. Red arrows point out regions without postlimbal angiographic signal. s = seconds after signal initiation. Ophthalmology Glaucoma 2019 2, 11-21DOI: (10.1016/j.ogla.2018.11.010) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 3 Sequential aqueous angiography in glaucoma patients with trabecular microbypass (TMB) in initially low outflow regions showing new angiographic patterns. A–H, First patient. I–P, Second patient. A–D, I–L, First, indocyanine green (ICG) aqueous angiography was performed. D, L, Second, TMB was conducted (blue arrows). E–H, M–P, Third, fluorescein (FL) aqueous angiography was performed immediately after TMB. B, F, In the first patient, black arrows point out conjunctival pigment on the cornea that blocked fluorescence transmission. This location serves as a reference point across all images for that eye. D, L, Red arrows point out nasal regions of the eyes without initial ICG angiographic signal. H, P, Green arrows point out regions of new fluorescein angiographic signal after TMB. C, Example of how to calculate an angiographic signal intensity ratio. A 75×75-pixel region of interest was placed postlimbal near the region of TMB (white boxes). Then for each region of interest, the signal intensity was normalized by dividing it by the signal in a region of known background away from proposed areas of TMB (yellow box). This allowed for assessment of signal intensity in any image, internally normalized to the settings on the Spectralis. A ratio of 1 implies that the signal intensity in that region of interest was no different than that of the background. Because these values were ratios, they have no units. s = seconds after signal initiation. Ophthalmology Glaucoma 2019 2, 11-21DOI: (10.1016/j.ogla.2018.11.010) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 4 Sequential aqueous angiography in glaucoma patients with trabecular microbypass (TMB) showing new or earlier signal development. A–H, First patient. I–P, Second patient. A–D, I–L, First, indocyanine green (ICG) aqueous angiography was performed. D, L, Second, TMB was conducted (blue arrows). E–H, M–P, Third, fluorescein aqueous angiography was performed immediately after TMB. In the first patient, the upper TMB location (D; upper blue arrow) had a larger area for insertion into a low ICG angiographic region. The lower TMB (D; lower blue arrow) was placed approximately 2 clock hours inferior and close to a pre-existing ICG angiographic structure (D; orange arrow). In the second patient, the lower TMB location (L; lower blue arrow) had a larger area for insertion into a low ICG angiographic region. The upper TMB location (L; upper blue arrow) was placed approximately 2 clock hours superior and close to a pre-existing ICG angiographic structure (L; orange arrow). Red arrows in (D) and (L) point out regions with initially low ICG angiographic signal that showed the development of new fluorescein angiographic patterns (H, P; green arrows) after TMB. Yellow arrows demonstrate nasal regions of the eye that showed ICG angiographic signal (D, L; orange arrows) that appeared earlier on fluorescein angiography after TMB: (E) and (N), fluorescein versus (A) and (J), ICG. s = seconds after signal initiation. Ophthalmology Glaucoma 2019 2, 11-21DOI: (10.1016/j.ogla.2018.11.010) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 5 Sequential aqueous angiography in a glaucoma patient with trabecular microbypass (TMB) showing transient and earlier signal development. A–D, First, indocyanine green (ICG) aqueous angiography was performed. D, Second, TMB was conducted (blue arrows). The lower TMB location (D; lower blue arrow) had a large enough area for insertion into a low ICG angiographic region. The upper TMB (D; upper blue arrow) was placed approximately 2 clock hours superior and close to a pre-existing ICG angiographic structure (D; orange arrow). E–H, Fluorescein (FL) aqueous angiography was performed immediately after TMB. Red arrows show a nasal region of the eye (D) without initial ICG angiographic signal that (H) did not appear to improve after TMB. I–L, However, FL angiography between 2 and 8 seconds after TMB did show a transiently appearing new angiographic pattern in the initially low ICG angiographic region (green arrows). Yellow arrows demonstrate nasal regions of the eye that showed initial ICG angiographic signal (D; orange arrow) that appeared earlier on FL angiography after TMB: (F) and (I), FL versus (B), ICG. s = seconds after signal initiation. Ophthalmology Glaucoma 2019 2, 11-21DOI: (10.1016/j.ogla.2018.11.010) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 6 Sequential aqueous angiography in a glaucoma patient with trabecular microbypass (TMB) showing no alteration and earlier signal development. A–D, First, indocyanine green (ICG) aqueous angiography was performed. D, Second, TMB was conducted (blue arrows). The lower TMB location (D; lower blue arrow) had a large enough area for insertion into a low ICG angiographic region. The upper TMB (D; upper blue arrow) was placed approximately 2 clock hours superior and close to a pre-existing ICG angiographic structure (D; orange arrow). E–H, Fluorescein (FL) aqueous angiography was performed immediately after TMB. Red arrows show a nasal region of the eye (D) without initial ICG angiographic signal that (H) did not improve after TMB. Yellow arrows demonstrate a nasal region of the eye that showed ICG angiographic signal (D; orange arrow) that appeared earlier on FL angiography after TMB: (F), FL versus (B) ICG. s = seconds after signal initiation. Ophthalmology Glaucoma 2019 2, 11-21DOI: (10.1016/j.ogla.2018.11.010) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions

Figure 7 Sequential aqueous angiography in a representative glaucoma patient with trabecular microbypass (TMB) in initially high outflow regions. A–D, First, indocyanine green (ICG) aqueous angiography was performed. D, Note uniform nasal ICG angiographic signal such that there were no low angiographic signal regions to place TMB. D, Second, TMB was conducted (blue arrows). E–H, Third, fluorescein (FL) aqueous angiography was performed immediately after TMB. The lower TMB (D; lower blue arrow) demonstrates initial ICG angiographic signal (D; green arrow) that did not improve after TMB (H; red arrow). Yellow arrows demonstrate nasal regions of the eye that showed ICG angiographic signal (D; orange arrow) that appeared earlier on FL angiography after TMB: (F), FL versus (B), ICG. s = seconds after signal initiation. Ophthalmology Glaucoma 2019 2, 11-21DOI: (10.1016/j.ogla.2018.11.010) Copyright © 2018 American Academy of Ophthalmology Terms and Conditions