Transient anterior subcapsular vacuolar lens opacities after Tanito microhook trabeculotomy: report of six cases.

OBJECTIVE: To present six cases exhibiting transient anterior subcapsular vacuolar lens opacities following early postoperative Tanito microhook trabeculotomy (TMH) performed by the same surgeon. METHODS: Six patients who underwent lens-sparing TMH at Meizankai Shimizu Eye Clinic from November 2021 to May 2023, and developed anterior subcapsular vacuolar lens opacities postoperatively were reviewed. Detailed records of surgeries, follow-up findings were collected and reported. RESULTS: In all six cases, anterior vacuolar subcapsular lens opacities were observed on the day after surgery, gradually decreasing without affecting visual acuity or contrast sensitivity. In all cases, without any specific interventions, the opacities disappeared by 21 months postoperatively. CONCLUSION: Anterior subcapsular cataracts, characterized by a vacuolar appearance and transient existence, should be recognized as an early complication of ab interno glaucoma surgery, possibly linked to use of distributed ophthalmic viscosurgical devices and excessive anterior chamber irrigation leading to traumatic cataracts on the lens surface.

Glaucoma medical treatment as a predictor of XEN45 subconjunctival gel implant hypotensive efficacy.

PURPOSE: The aim of this study was to determine the preoperative characteristics influencing hypotensive efficacy of the XEN45 gel stent in patients with open-angle glaucoma at one-year follow-up. MATERIALS AND METHODS: This was a retrospective multicentre study. All patients who underwent XEN45 gel stent implantation between January 2017 and January 2021 were included. The main study outcome was the assessment of one-year postoperative intraocular pressure (IOP) and glaucoma medication differences according to the number and type of preoperative topical treatments or glaucoma surgery, glaucoma stage and time since diagnosis. Follow-up period was 1-year post-surgery in all cases. IOP reduction and surgery success (not requiring reoperation or pressure failures [IOP > 18 mmHg and < 20% reduction in IOP]), safety and cost savings in topical glaucoma therapy after surgery were secondarily assessed. Linear regression analysis to determine the preoperative parameters influence on 1-year postoperative results was performed. RESULTS: XEN45 gel stent was implanted in 85 patients. One-year postoperative mean IOP dropped from 20.6 ± 4.1 to 13.7 ± 2.8 mmHg (p < 0.0001). Likewise, mean number of topical treatments decreased from 2.05 ± 0.9 to 0.36 ± 0.65 (p < 0.001). Both were mainly influenced by the number of preoperative glaucoma treatments, such that for each one-glaucoma medication increase, postoperative intraocular pressure increased by 1.18 mmHg (95% CI 0.56-1.79, p < 0.0001) and number of glaucoma medications increased by 0.3 (95% CI 0.16-0.43, p < 0.001). Overall success rates (with and without supplemental glaucoma medication use) were 97.6% (95% CI 94.5-100%), 87.1% (95% CI 80.2-87.1%) and 61.2% (95% CI 51.6-72.5%) at 3, 6 months and 1 year after surgery. No sight-threatening adverse events were reported. Mean annual cost savings on medical treatment since surgery reached EUR 251.19 ± 169. 93 euros. CONCLUSIONS: One year after surgery, XEN45 gel implant significantly reduced IOP and number of topical medications with an adequate safety profile being both mainly influenced by the number of preoperative glaucoma treatments.

Theoretic scientific rationale of double XEN 45 Gel Stent implant in severe glaucomatous ocular hypertension.

PURPOSE: To investigate the theoretical hydrodynamic effects of a single or a double XEN 45 Gel Stent (XEN45) implant in glaucomatous eyes. METHODS: A prospective non-randomized clinical study on 63 glaucomatous eyes of 63 patients. The preoperative intraocular pressure (IOP) values after 14 days of medical therapy washout was correlated to the postoperative IOP values 7 and 45 days after the implant of a XEN45. A mathematical model based on the Hagen-Poiseuille law was designed to assess the residual aqueous humor outflow (AHO) facility in glaucomatous eyes in function of the postoperative IOP reduction. Using XEN45 as unit of measurement, we transformed through equations the residual preoperative AHO in XEN45 equivalent in order to establish theoretical number of stents needed to reach the target IOP. RESULTS: The mean preoperative washout IOP was 28.9 ± 5.4 mmHg, after 7 and 45 days the mean postoperative IOP was 12.6 ± 4.3 and 15.3 ± 4.4 mmHg, respectively (p < 0.001). A significant positive correlation was found between preoperative and postoperative IOP values. We obtained a mathematical relationship to estimate the theoretical number of XEN45 stents needed to reach the target IOP. CONCLUSION: The basal IOP (after medical therapy washout) is a predictive factor for the surgical success after a XEN45 implant. Establishing the residual preoperative AHO it is possible to predict the theoretical number of stents to implant. A double XEN45 implant could be considered a possible further tool to reach the target IOP in patients with severe AHO deficiency.

Reasons for choice of glaucoma surgery in eyes not treated with anti-glaucoma medications.

BACKGROUND: In the real world, some glaucoma patients can undergo an incisional glaucoma surgery without using medication. The rate of cases with no medication treatment at the time of surgery among those that underwent incisional glaucoma surgeries performed in our department was reported. METHODS: The department database of Shimane University Hospital for eyes that underwent incisional surgeries to manage glaucoma at the hospital between April 2018 and September 2020 were searched. By reviewing the medical charts of 1,417 consecutive eyes listed, 90 (6.4%) eyes of 67 subjects (mean age of 72 ± 16 years; 22 men, 29 eyes; 45 women, 61 eyes) who underwent a surgery without use of antiglaucoma medication were identified. The types of glaucoma, glaucoma procedures, and reasons for choosing the glaucoma surgeries rather than medical therapy were collected for the 90 eyes. RESULTS: Among the 90 eyes, primary angle-closure disease (PACD) (60%) was the most frequent type of glaucoma followed by EXG (17%), POAG (16%), and others (8%). Among the reasons for the choice of incisional surgery, relief of angle closure (64%) was the most frequent, the second most frequent was the incidental diagnosis of glaucoma during the ocular examinations both for that eye's cataract surgery or the contralateral glaucoma surgery (13%). Other reasons included poor medication adherence (10%), dementia (6%), multiple medication allergy (3%), and acute IOP elevation other than PACD (3%). Cataract extraction (CE) alone (33%) was the most frequent glaucoma procedures performed in these eyes, followed by CE combined with goniosynechialysis (27%), CE + iStent (16%), CE + goniotomy by Tanito microhook ab interno trabeculotomy or using the Kahook Dual Blade (11%), Ahmed Glaucoma valve implantation (11%), and trabeculectomy (2%). CONCLUSION: In the real-world, 6.4% of incisional glaucoma surgeries were performed in the absence of medication use; of them, 32 eyes (2.3%) were with open angle glaucoma. In open angle glaucoma, the reasons can be classified into; 1) patients' inability to instill the medication, 2) incidental diagnosis of glaucoma during the pre-surgical examinations, and 3) the eyes with acute IOP rise.

Roles of Toric intraocular Lens implantation on visual acuity and astigmatism in glaucomatous eyes treated with iStent and cataract surgery.

BACKGROUND: To assess the efficacy of toric intraocular lenses (IOLs) in combined cataract and minimally invasive glaucoma surgery (MIGS), visual and refractive outcomes were compared between eyes implanted with non-toric and toric IOLs during iStent triple procedures. METHODS: In this retrospective study, open angle glaucoma eyes with preexisting corneal astigmatism of -1.5 diopter (D) or more and implanted with non-toric (n = 9) or toric (n = 9) IOLs were included. The main outcome measures were the intergroup difference in the uncorrected visual acuity (UCVA) and refractive astigmatism at 3 months postoperatively. RESULTS: Preoperatively, the logarithm of the minimum angle of resolution (logMAR) UCVAs and refractive astigmatism were equivalent between the groups. Postoperatively, the logMAR UCVA (non-toric, 0.45 ± 0.31; toric, 0.14 ± 0.15; P = 0.021) was significantly better and the refractive astigmatism (non-toric, -2.03 ± 0.63 D; toric, -0.67 ± 0.53 D; P = 0.0014) significantly less in the toric group. The toric group had postoperative improvements in the logMAR UCVA (-0.21, P = 0.020) and refractive astigmatism (+ 1.72 D, P = 0.0039). Vector analyses showed the postoperative centroid magnitude and confidence eclipses of refractive astigmatism was less in the toric group (0.47 D at 173°±0.73D) than the non-toric group (1.10 D at 2°±1.91D). Postoperatively, 78% of eyes in the toric group had 1.0 D or less refractive astigmatism compared with 11% in the non-toric group. Surgically induced astigmatism (non-toric, 0.18 D at 65°; toric, 0.29 D at 137°) did not differ between groups. CONCLUSION: Use of toric IOLs is a reasonable option for better visual outcomes when the combined cataract and iStent surgery is performed in glaucomatous eyes with corneal astigmatism.

Long-term clinical results of trabectome surgery in patients with open-angle glaucoma.

PURPOSE: To evaluate the 72-month clinical results of trabectome surgery (TOM) in patients with primary open-angle glaucoma (POAG), secondary OAG and childhood glaucoma. METHOD: A total of 305 eyes from 249 glaucoma patients were analyzed in the current retrospective single-center study. Kaplan-Meier analysis was performed using three criteria: criterion A (postoperative intraocular pressure [IOP] ≤ 21 mmHg and ≥ 20% reduction from baseline IOP); criterion B (postoperative IOP ≤ 18 mmHg and ≥ 20% reduction from baseline IOP); and criterion C (postoperative IOP ≤ 16 mmHg and ≥ 20% reduction from baseline IOP). The changes in IOP, medication score, success probability, results of the multivariate analysis for success and failure risk factors, and complications were analyzed. RESULTS: The baseline IOP in all glaucoma patients decreased from 29.2 ± 9.8 mmHg with a 5.3 ± 1.7 medication score to 16.4 ± 5.8 mmHg (- 43.8%) with a 4.2 ± 1.5 medication score at 72 months (p < 0.01). The success probabilities in all cases for 72 months based on criterion A, B, and C were 44%, 35%, and 17%, respectively. For criterion A, no significant differences were found in the success probability according to the glaucoma subtype for 72 months. The combined surgical procedure significantly decreased the failure risk (hazard ratio [HR]: 0.59). On the other hand, the presence of POAG (HR: 1.6) and a history of past selective laser trabeculoplasty (HR: 2.2) significantly increased failure risk. One patient (0.3%) demonstrated endophthalmitis after TOM but recovered through appropriate treatment. CONCLUSION: At the 72-month time point, approximately half of the glaucoma patients maintained an IOP ≤ 21 mmHg with ≥ 20% IOP reduction. TOM is a safe surgery but may not yield sufficient IOP reduction in patients who have received SLT or have POAG.

Trabeculotomy opening size and IOP reduction after Trabectome® surgery.

BACKGROUND: Trabeculotomy with the Trabectome® is an effective surgical procedure to lower intraocular pressure (IOP). However, in some patients it does not lead to a significant IOP reduction despite a gonioscopically well visible opening of Schlemm's canal. This study investigated whether the size of the trabeculotomy opening and other parameters, including anterior chamber depth (ACD) are related to IOP reduction. METHODS: Retrospective observational case series with 93 eyes of 93 patients who underwent Trabectome surgery. Trabeculotomy opening and ACD were measured with an anterior segment swept source OCT. IOP was taken pre-operatively and at a single follow-up visit [follow-up time 125 ± 66 days (mean ± SD)]. The relationship between IOP reduction and OCT parameters and possible confounding factors was analyzed in a multiple linear regression model. RESULTS: The trabeculotomy opening size did not correlate with IOP reduction (slope of regression line = 0.0016; 95% confidence interval of slope: -0.025 to 0.028). The same applied for all other parameters tested, including ACD, which showed a tendency towards better IOP reduction with a deeper AC (slope = -1.9; 95% confidence interval: -5.54 to 1.73). Comparison between the 1st and 4th quartile of the trabeculotomy opening showed a significantly higher ACD in the largest trabeculotomy opening quartile (3.32 ± 0.05 mm vs. 3.16 ± 0.04 mm; p = 0.031). CONCLUSIONS: The fact that the trabeculotomy opening size did not correlate with IOP reduction points to the poorly understood role of the intrascleral aqueous outflow pathway in glaucomatous IOP elevation. A deeper AC might be a factor promoting a larger trabeculotomy opening.

Minimally invasive glaucoma surgery as primary stand-alone surgery for glaucoma.

Recently, many new devices and procedures have been developed to lower intraocular pressure in a less invasive and purportedly safer manner than traditional glaucoma surgery. These new devices might encourage an earlier transition to surgery and reduce the long-term commitment to topical glaucoma medications with their associated compliance and intolerance issues. Although often seen as an adjunct to cataract surgery, a growing body of evidence suggests that primary minimally invasive glaucoma surgery may be a viable initial treatment option. New studies have shown that primary ab interno trabeculectomy (Trabectome, NeoMedix Inc., Tustin, CA, USA), trabecular micro-bypass stent insertion (iStent and iStent Inject, Glaukos Corporation, Laguna Hills, CA, USA), canalicular scaffolding (Hydrus, Invantis Inc., Irvine CA, USA), the ab interno gel Implant (XEN, Allergan, Dublin, Ireland) or supraciliary stenting (CyPass Micro-Stent, Alcon, Fort Worth, TX, USA) may lower the lowering intraocular pressure and/or topical medication burden in phakic or pseudophakic patients with glaucoma. This effect seems to last at least 12 months but reliable cost-effectiveness and quality of life indicators have not yet been established by investigator-initiated randomized trials of sufficient size and duration.

Early Outcomes of Combined Phacoemulsification and Ab Interno Tanito Microhook Trabeculotomy in Open-Angle Glaucoma.

PURPOSE: To study the early postoperative efficacy and safety of an Ab Interno microhook trabeculotomy (microLOT) combined with cataract surgery in patients with open-angle glaucoma. METHODS: This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and mild-moderate open-angle glaucoma. One hundred fourteen patients were included for analysis. The patients were randomized to undergo microhook trabeculotomy with phacoemulsification (group 1) or phacoemulsification alone (group 2). All patients were evaluated on postoperative day 1, 15, and 30, as well as 3, 6, and 12 months postoperatively. A P value < 0.05 was considered statistically significant. Baseline and follow-up visits were compared to determine significant differences in the number of antiglaucoma medications (AGMs), intraocular pressure (IOP), and best-corrected visual acuity. RESULTS: There were 57 patients in each group. The baseline characteristics were similar between the 2 groups, except the number of AGMs, which was greater in group 2. The mean preoperative IOP for group 1 (phaco-microLOT) was 26.5 mmHg ± 5.2 and group 2 (phaco-alone group) was 25.3 mmHg ± 3.1 which decreased to 12.5 mmHg ±3.6 (P < 0.001) and 20.0 mmHg ± 2.7(P < 0.001) at 12 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.48 (interquartile range [IQR], 0.30-0.60) preoperatively to 0.00 (0.00-0.18) postoperatively (P < 0001) in group 1 and improved from 0.30 (IQR, 0.30-0.48) to 0.00 (0.00-0.00) in group 2 (P < 0.001). In group 1, the mean (standard deviation [SD]) AGM used preoperatively was 0.6 (0.9) which was significantly reduced to 0.2 (0.5) at 12 months postoperatively, whereas in group 2, at 12 months, the mean (SD) AGM used was reduced from 1.4 (0.6) to 1.1 (0.9). In group 1, 90.3% of eyes achieved complete success at the end of 1 year. The most common complication was hyphema, noted in 4 patients with 1 eye requiring an anterior chamber washout. CONCLUSION: Ab interno microhook trabeculotomy (microLOT) combined with phacoemulsification in patients with open-angle glaucoma is an efficacious procedure with relatively minimal complications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Three-Year Outcomes of a Schlemm Canal Microstent (Hydrus Microstent) with Concomitant Phacoemulsification in Open-Angle Glaucoma.

PURPOSE: HORIZON trials have reported the medium- and long-term outcomes of the Hydrus microstent. However, outside of randomized clinical trials, outcomes beyond 24 months have not been previously reported. Here, we examine the 3-year outcomes of the Hydrus microstent with cataract surgery outside of a randomized clinical trial setting. DESIGN: Single-surgeon consecutive case series. PARTICIPANTS: Glaucomatous eyes that underwent implantation of a Hydrus microstent with concomitant cataract surgery at a single ophthalmology center in Montreal, Canada. METHODS: Success was defined according to the absence of specific failure criteria: (A) glaucoma reoperation; (B) selective laser trabeculoplasty; (C) intraocular pressure (IOP) < 5 mmHg, > 18 mmHg, or increase in the number of antiglaucoma medications (AGMs) used (after the first postoperative month), or loss of light perception due to glaucoma; (D) aggregation of criteria A-C. Predictors of treatment failure and postoperative changes in IOP and AGM use were assessed. Safety included best-corrected visual acuity (BCVA), cup-to-disc ratio (CDR), retinal nerve fiber layer (RNFL) thickness, ganglion cell inner plexiform layer (GC-IPL) thickness, visual field mean deviation (VF-MD) and pattern standard deviation (VF-PSD), and adverse events. MAIN OUTCOME MEASURES: Surgical success, predictors of treatment failure, postoperative changes in IOP and AGM use, and structural and functional markers of disease stability. RESULTS: One hundred six eyes were included. The 3-year surgical success according to Criteria A to D was 86%, 83%, 91%, and 67%, respectively. Intraocular pressure decreased by 26.5% from 18.9 ± 4.8 to 13.9 ± 2.3 mmHg (P < 0.001) and AGM use reduced by 33% from 3.0 ± 1.2 to 2.0 ± 1.2 medications (P < 0.001). The postoperative improvement in BCVA was preserved (P < 0.001). The structural and functional markers of disease stability, including CDR, RNFL, and GC-IPL thickness, as well as VF-MD and VF-PSD, remained stable (P > 0.05). Postoperative adverse events were few and transient. CONCLUSIONS: The 36-month results from this study show that the Hydrus microstent with phacoemulsification is safe and effective in reducing the IOP and AGM among patients with mild to severe open-angle glaucoma and can slow down the disease progression by preserving both structural and functional parameters. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Case report: Surgical management of vitreous obstruction following PreserFlo ® MicroShunt implantation.

Purpose: To describe a clinical case of lumen obstruction a few days after implantation of the PreserFlo® Microshunt which has been resolved by anterior vitrectomy. Observation: A 76-year-old patient with advanced and progressing primary open-angle glaucoma (POAG) presented ten days after PreserFlo® Microshunt implantation in his left eye with an intraocular pressure (IOP) of 24 mmHg because of vitreous obstruction. Anterior vitrectomy with 25 Gauge vitrector was performed to remove the vitreous using a bimanual technique with two corneal accesses. The surgery was successful in lowering uncontrolled IOP without device repositioning. A free lumen and a IOP in the low range of tens was observed during follow-up. Conclusions and importance: PreserFlo ® MicroShunt obstruction by vitreous in pseudophakic patient is a possible complication. Anterior vitrectomy without the need of tube repositioning was successful in lowering uncontrolled IOP.

A case of endophthalmitis following needling procedure after PRESERFLO® Micro Shunt implantation.

PURPOSE: To report a case of endophthalmitis following bleb needling in a patient previously implanted with a PRESERFLO® MicroShunt. METHODS: Case report. RESULTS: A 40-year-old woman with bilateral malformative glaucoma repeatedly operated on in childhood underwent PRESERFLO® MicroShunt implantation in her right eye and six needling revisions (NRs) and a surgical revision due to unsatisfactory intraocular pressure (IOP) control due to bleb encapsulation. About 3 months after the surgical revision the bleb encapsulation relapsed and she underwent a further NR with betamethasone. About 4 days after the last NR, she experienced visual acuity reduction and was therefore advised to come immediately to the hospital for an unscheduled visit, showing up with hypopyon and diffuse vitreous haze. A clinical diagnosis of endophthalmitis (later confirmed by bacteria culture tests) was made and she was treated with pars-plana vitrectomy with silicone oil and intravitreal antibiotics. Preoperative visual function was luckily completely restored. CONCLUSIONS: Endophthalmitis can occur after NR in an eye with PRESERFLO® MicroShunt implant which therefore does not prevent reflux of bacteria from a filtering bleb to the anterior chamber.

Comparison of Different Procedures in a Combination of Ab Interno Microhook Trabeculotomy and Cataract Surgery.

The purpose of this study was to compare the clinical outcomes of ab interno microhook trabeculotomy (µLOT) before and after cataract surgery for the combination of µLOT and cataract surgery. This retrospective case series included 40 eyes that underwent µLOT combined with cataract surgery at Kochi University Hospital. Groups 1 (20 eyes) and 2 (20 eyes) included eyes that underwent µLOT before and after cataract surgery, respectively. The patient characteristics and clinical outcomes were also analyzed. The mean preoperative intraocular pressure (IOP) in Groups 1 and 2 (26.1 ± 12.2 mmHg and 20.6 ± 8.8 mmHg) was reduced significantly to 14.1 ± 3.3 mmHg and 12.9 ± 3.2 mmHg, respectively, at 5-7 months postoperatively. The median preoperative number of antiglaucoma medications in Groups 1 and 2 (4.0 and 3.5) also decreased significantly, to 2.5 and 1.0, respectively, at 5-7 months postoperatively. Postoperative hyphema with niveau formation in Groups 1 and 2 was observed in one eye (5.0%) and six eyes (30.0%), respectively. For the combination of µLOT and cataract surgery, performing µLOT before cataract surgery may be less likely to result in postoperative hyphema with niveau formation.

Survey of glaucoma surgical preferences among glaucoma specialists in Spain.

PURPOSE: To evaluate the spectrum of glaucoma surgery undertaken among members of the Spanish Glaucoma Society (SEG). METHODS: A 10 question web-based anonimous survey was mailed through the Annals of the Spanish Glaucoma Society to all its members on January, February and July 2019 to determine their preferred surgical approach. MAIN OUTCOME MEASURES: Age, type of Glaucoma, surgery undertaken, type of anti-scarring strategy and prothesis introduced for the last 10 surgeries since the survey was received. The surgeon experience was registered in years of practice. RESULTS: A total of 97 SEG members across the country answered the survey. Sixty-two (63.4%) responders had more than 10 years of experience. Primary open angle glaucoma was the most frequent type of glaucoma (60.6%). The most popular surgery was deep-sclerectomy (37.3%) followed by trabeculectomy (17,6%) and the collagen microshunt (XEN® Allergan Inc., Irvine, CA) (14.1%). Glaucoma drainage device (GDD) was used in 10.5% of the cases. Up to 21.7% of surgeries were reinterventions, where GDD was used in 27.3% and trabeculectomy in 20.3% of the cases. Glaucoma surgery was combined with phacoemulsification in 47.3% of the eyes. Mitomycin C (MMC) was used in 54,8% of the cases, collagen matrix (Ologen®, Aeon Astron Corporation, Taipei, Taiwan) was used alone in 8.2% of the cases and in 13,7% combined with MMC. MMC was used in a soaked sponge in 79% of cases (concentrations of 0.02% in 99% and 0.04% in 1%) and in 21% of cases MMC was injected subconjunctivally (concentrations of 0,01% in 81% and 0.02% in 19%). CONCLUSIONS: Although the glaucoma surgeon performs a wide range of surgical techniques, deep sclerectomy remains the most widely used surgical technique in Spain. Combined cataract and glaucoma surgery is performed almost in half of the patients and MMC is the most frequently selected antifibrotic agent, alone or combined with collagen matrix. The new minimal invasive surgical techniques represent the 20% of the total.

Effects of Preoperative Intraocular Pressure Level on Surgical Results of Microhook Ab Interno Trabeculotomy.

To assess the roles of preoperative intraocular pressure (IOP) level on the IOP reducing efficacy of microhook ab interno trabeculotomy (µLOT), 126 consecutive open-angle glaucomatous eyes (90 primary open angle glaucoma, 36 exfoliation glaucoma) of 126 Japanese subjects (60 men, 66 women; mean age ± standard deviation, 70.5 ± 11.4 years) who underwent µLOT alone (25 eyes, 20%) or combined µLOT and cataract surgery (101 eyes, 80%) were retrospectively included, and subdivided into four groups based on the quartile of preoperative IOP: Q1, ≤15 mmHg; Q2, 15-18 mmHg, Q3, 18-21 mmHg, and Q4, >21 mmHg. Preoperative and 12 months postoperative IOPs and numbers of antiglaucoma medications were compared among IOP groups. Factors associated with postoperative IOP were assessed using multivariate analysis, and the success of IOP control was assessed with various definitions. Postoperatively, IOP was significantly higher in Q3 (p < 0.0146) and Q4 (p = 0.0320) groups than Q1 group, while the number of medications was not significantly different among four IOP groups (p = 0.1966). Older age was associated with lower postoperative IOP, and higher preoperative IOP was associated with higher postoperative IOP, while sex, glaucoma type, surgical procedure, lens status, extent of trabeculotomy incision, and preoperative number of medications were not associated with postoperative IOP. The success rates for IOP ≤ 18 and ≤15 mmHg were higher in lower preoperative IOP groups (i.e., Q1 and Q2) than higher preoperative IOP groups (Q3 and Q4), while the success rate for ≥20% IOP reduction was higher in higher preoperative IOP groups than in lower preoperative IOP groups; the success rate for ≥0% IOP reduction was equivalent among groups. By reviewing the previous studies in ab interno trabeculotomy/goniotomy procedures, positive correlation between preoperative and postoperative IOPs was preserved throughout the studies and surgical procedures. After the µLOT, larger %IOP reduction was achieved in higher preoperative IOP groups than in lower preoperative IOP groups, while postoperative IOP was still lower than in lower preoperative IOP groups.

Midterm Results of Microhook ab Interno Trabeculotomy in Initial 560 Eyes with Glaucoma.

All the 560 glaucomatous eyes of 375 Japanese subjects (181 men, 194 women; mean age ± standard deviation, 76.0 ± 13.2 years) who underwent microhook ab interno trabeculotomy (µLOT) alone (159 eyes, 28%) or combined µLOT and cataract surgery (401 eyes, 72%) performed by one surgeon at Matsue Red Cross Hospital between May 2015 and March 2018 to control intraocular pressure (IOP) were retrospectively assessed. Preoperative and postoperative IOPs, numbers of antiglaucoma medications, the logarithm of the minimum angle of resolution visual acuity (logMAR VA), anterior chamber (AC) flare, visual field mean deviation (MD), and corneal endothelial cell density (CECD) were compared up to 36 months. Surgical complications and required interventions were described. The duration of the follow-up was 405 ± 327 (range, 2-1326) days. The mean preoperative IOP (20.2 ± 7.0 mmHg) and number of antiglaucoma medications (2.8 ± 1.1) decreased to 13.9 ± 4.5 mmHg (31% reduction, p < 0.0001) and 2.5 ± 1.0 (11% reduction, p < 0.0001), respectively, at the final visit. After combined surgery, compared with preoperatively, the final VA improved 0.11 logMAR (p < 0.0001), AC flare increased 4.5 photon counts/msec (p = 0.0011), MD improved 0.6 decibel (p < 0.0001), and the CECD decreased 6% (p < 0.0001). Layered hyphema (172 eyes, 31%) and hyphema washout (26 eyes, 5%) were the most common postoperative complication and intervention, respectively. At the final visit, 379 (69%) eyes achieved successful IOP control of ≤18 mmHg and ≥20% IOP reduction, and 349 (64%) eyes achieved successful IOP control of ≤15 mmHg and ≥20% IOP reduction. Older age, steroid-induced glaucoma, developmental glaucoma, and the absence of postoperative complications were associated with lower final IOP; exfoliation glaucoma, other types of glaucoma, and higher preoperative IOP were associated with higher final IOP. µLOT has a significant IOP-lowering potential in patients with glaucoma, and improves visual function when combined with cataract surgery.

Microinvasive Glaucoma Surgery: An Evidence-Based Review.

PURPOSE: Interest in micro-invasive glaucoma surgery (MIGS) has exploded over the last 8 years with an increase in MIGS procedures of at least 400% in the United States, according to Medicare data. MIGS is an umbrella term that can cover many different types of surgeries. This review focuses on peer-reviewed evidence for Trabectome®, iStent inject®, Kahook Dual Blade®, XEN® Gel Stent, and Hydrus®. METHODS: We present key recent studies evaluating the efficacy and safety of MIGS in various types of glaucoma patients with different stages of disease. CONCLUSION: We conclude that MIGS is generally safe and efficacious, although only some MIGS have been studied through randomized clinical trials. When comparing and contrasting the different MIGS procedures, large prospective studies are not yet the norm. High-quality large prospective studies involving MIGS will be an important next step as ophthalmologists decide how to incorporate MIGS into their surgical armamentarium.

Comparison of Postoperative Hyphemas between Microhook Ab Interno Trabeculotomy and iStent Using a New Hyphema Scoring System.

We have been using our in-house scoring system of hyphemas, i.e., Shimane University RLC postoperative hyphema scoring system (SU-RLC), which we designed to classify postoperative hyphema. SU-RLC classifies the severities of hyphemas based on three factors, i.e., red blood cells (RBCs) (R) 0-3, layer formation (L) 0-3, and clot (C) 0-1, by slit-lamp observation. To test the clinical usefulness of the SU-RLC for quantifying the postoperative hyphema severity, the SU-RLC scores were compared between eyes that underwent different minimally invasive glaucoma surgery (MIGS) procedures, i.e., Tanito microhook ab interno trabeculotomy and cataract extraction (TMH-CE) (n = 64 eyes of 64 subjects; mean age ± standard deviation, 72.4 ± 8.1 years) and iStent-CE (n = 21 eyes of 21 subjects; 76.1 ± 10.6 years). Compared to the iStent-CE, higher hyphema scores with the TMH-CE were found for the R scores on postoperative days 1, 2, and 3; for the L score on postoperative day 1; and for the C score on postoperative day 2. The sums of the R, L, and C scores (RLC) on postoperative day 1 were 3.2 ± 1.1 with the TMH-CE and 1.1 ± 1.3 with the iStent-CE; the scores reached almost 0 by 2 weeks in both groups. Significant differences in the RLC scores between the surgical groups were found on postoperative days 1, 2, and 3. Multivariate analyses showed that the TMH-CE rather than iStent-CE was associated with higher R, C, and RLC scores; anticoagulant/antiplatelet use was associated with higher R score; and myopia was associated with a higher C score. In the TMH-CE group, myopia was associated with a higher C score. In the iStent-CE group, anticoagulant/antiplatelet use was associated with higher R and RLC scores; and higher postoperative 1-day intraocular pressure was associated with a higher C score. The SU-RLC successfully detected the difference in hyphema severity between different MIGS procedures; thus, we concluded that our classification system may be feasible to evaluate hyphemas after glaucoma surgery.

Selective Laser Trabeculoplasty Versus MIGS: Forgotten Art or First-Step Procedure in Selected Patients with Open-Angle Glaucoma.

INTRODUCTION: To evaluate the long-term effect on intraocular pressure (IOP) and glaucoma medication of selective laser trabeculoplasty (SLT) compared to minimally invasive glaucoma surgery (MIGS) in primary open-angle glaucoma (POAG) and its potential in clinical practice. METHODS: A total of 342 consecutive patients (stand-alone procedures) were included. One hundred and five patients underwent SLT treatment (360° SLT, 95-105 spots, Trabeculas SLT ARCLaser, Nürnberg, DE), 107 patients had an ab interno-derived trabeculotomy (Trabectome®, NeoMedix, Tustin, USA), and 130 patients received iStent inject® implantation (2 implants-Glaukos, CA, USA). IOP and glaucoma therapy were evaluated preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1, 2, and 3 years postoperatively. Statistical analysis was performed using a regression model and propensity matching score (reduced cohort number) using SPSS v20.0. Kaplan-Meier analysis was included using the following six criteria: criterion A (IOP ≤ 21 mmHg with or without medication, qualified success), criterion B (IOP ≤ 18 mmHg with or without medication, qualified success), criterion C (IOP ≤ 21 mmHg without medication, complete success), criterion D (IOP ≤ 18 mmHg without medication, complete success), criterion E (IOP ≤ 21 mmHg and IOP reduction > 20% after therapy), and criterion F (IOP ≤ 18 mmHg and IOP reduction > 20% after therapy). RESULTS: In the matched cohort, the SLT cohort showed an IOP reduction of 31.2% from 19.9 ± 2.3 to 13.7 ± 2.7 mmHg (p < 0.001) 3 years postoperatively; in Trabectome® IOP decreased by 31.4% from 20.5 ± 1.3 to 13.8 ± 2.0 mmHg (p < 0.001) and in iStent inject® by 29.9% from 19.5 ± 2.0 to 13.8 ± 2.7 mmHg (p < 0.001). Trabectome® and iStent inject® could not demonstrate a significant reduction in glaucoma therapy (Trabectome® p = 0.138, iStent inject® p = 0.612); a significant drop was noted in SLT (2.2 ± 1.2 to 1.7 ± 1.2, p = 0.046). SLT and MIGS achieved good to moderate survival rates using criterion A (93.3% SLT, 79.7% Trabectome®, 77.6% iStent inject®) and criterion B (74.5% SLT, 48.0% Trabectome®, 56.2% iStent inject®). As expected, low survival rates were obtained with non-filtering procedures: criterion C 11.1% in SLT, 6.5% in Trabectome®, 7.0% in iStent inject® and criterion D 3.0% in SLT, 4.3% in Trabectome®, 3.7% in iStent inject® in 3-year follow-up. CONCLUSION: The SLT is a low-complication and effective method for reducing pressure in mild to moderate POAG. SLT is suitable as an initial procedure when setting up a step scheme; MIGS is the treatment of choice as a follow-up for mild to moderate forms of glaucoma and accepted topical therapy. Ethic approval had been given by the Ethikkommission Charité - Universitätsmedizin Berlin, EA4/047/20-retrospectively registered.