Ab Interno Canaloplasty and Trabeculotomy Outcomes for Mild, Moderate, and Advanced Open-Angle Glaucoma: A ROMEO Analysis.

Purpose: To determine if there was an association between severity of glaucoma and intraocular pressure (IOP) and medication (med) outcomes for patients in the ROMEO (Retrospective, Observational, Multicenter Evaluation of OMNI) study. Setting: Eleven ophthalmology practices in 8 US states. Design: Post-hoc analysis of all eyes enrolled and treated with ab interno canaloplasty and trabeculotomy in the retrospective, multicenter ROMEO study. Methods: Eyes were grouped according to visual field mean deviation (MD): mild (MD better than -6 dB), moderate (MD between -6 and -12 dB), advanced (-12 dB or worse). IOP and med outcomes at 12 months were compared across groups. Least squares regression was used to assess the relationship of MD with month 12 IOP. Outcomes for 1st and last MD deciles were compared as a sensitivity analysis. Results: One hundred and twenty-seven eyes were available for analysis including 79 mild, 42 moderate, 6 advanced. Most eyes had a reduction in IOP at Month 12 (70%) with most at 18 mmHg or less. Percentage IOP reduction was similar across the groups (mild 16.9%, moderate 18.6%, advanced 18.0%) with mean month 12 IOP between 14 and 16 mmHg. Medications were also reduced in all three groups; -0.8 (mild, P < 0.001), -0.55 (moderate, P < 0.05), and -1.0 (advanced, P = 0.139, ns). Regression analysis revealed no relationship between month 12 IOP and MD. Med reductions were observed for all groups with a reduction of 1 or more medications seen in (%, 95% CI) 69%, 59-79 (mild), 50%, 35-65 (moderate), and 60%, 21-99 (advanced). Secondary interventions tended to have greater incidence with worse MD likely reflecting lower desired IOP targets. Conclusion: Analysis of data from the ROMEO study suggests that similar meaningful IOP and med reductions can be expected across the range of disease severity studied.

Circumferential canal surgery: a brief history.

PURPOSE OF REVIEW: Most microinvasive glaucoma surgery (MIGS) procedures bypass outflow resistance residing proximally in the trabecular meshwork and inner wall of Schlemm's canal. A novel procedure combining trabeculotomy with viscodilation adds to this by also addressing distal resistance of the canal and collector channel ostia. This review examines the development and evidence for both trabeculotomy and canaloplasty separately and the combination in a single procedure. RECENT FINDINGS: Recent aqueous angiography studies have confirmed the segmental nature of outflow through Schlemm's canal highlighting the need to address distal outflow pathway resistance. Combined trabeculotomy and viscodilation ab interno is a novel approach with a new purpose-designed device (OMNI Surgical System) becoming available to surgeons in early 2018. Recent results as both a standalone and combined with cataract procedure demonstrate significant intraocular pressure reductions with an average 41% reduction from baseline in the pseudophakic group. SUMMARY: Targeting both distal as well as proximal points of outflow resistance in the conventional pathway may prove to be a highly efficacious MIGS modality. Additional large prospective studies are currently ongoing to confirm these preliminary results.

Two-Year COMPASS Trial Results: Supraciliary Microstenting with Phacoemulsification in Patients with Open-Angle Glaucoma and Cataracts.

PURPOSE: We evaluated 2-year safety and efficacy of supraciliary microstenting (CyPass Micro-Stent; Transcend Medical, Inc., Menlo Park, CA) for treating mild-to-moderate primary open-angle glaucoma (POAG) in patients undergoing cataract surgery. DESIGN: Multicenter (24 US sites), interventional randomized clinical trial (RCT) (ClinicalTrials.gov identifier, NCT01085357). PARTICIPANTS: Subjects were enrolled beginning July 2011, with study completion in March 2015. Subjects had POAG with mean diurnal unmedicated intraocular pressure (IOP) 21-33 mmHg and were undergoing phacoemulsification cataract surgery. METHODS: After completing cataract surgery, subjects were intraoperatively randomized to phacoemulsification only (control) or supraciliary microstenting with phacoemulsification (microstent) groups (1:3 ratio). Microstent implantation via an ab interno approach to the supraciliary space allowed concomitant cataract and glaucoma surgery. MAIN OUTCOME MEASURES: Outcome measures included percentage of subjects achieving ≥20% unmedicated diurnal IOP lowering versus baseline, mean IOP change and glaucoma medication use, and ocular adverse event (AE) incidence through 24 months. RESULTS: Of 505 subjects, 131 were randomized to the control group and 374 were randomized to the microstent group. Baseline mean IOPs in the control and microstent groups were similar: 24.5±3.0 and 24.4±2.8 mmHg, respectively (P > 0.05); mean medications were 1.3±1.0 and 1.4±0.9, respectively (P > 0.05). There was early and sustained IOP reduction, with 60% of controls versus 77% of microstent subjects achieving ≥20% unmedicated IOP lowering versus baseline at 24 months (P = 0.001; per-protocol analysis). Mean IOP reduction was ↓7.4 mmHg for the microstent group versus ↓5.4 mmHg in controls (P < 0.001), with 85% of microstent subjects not requiring IOP medications at 24 months. Mean 24-month medication use was 67% lower in microstent subjects (P < 0.001); 59% of control versus 85% of microstent subjects were medication free. Mean medication use in controls decreased from 1.3±1.0 drugs at baseline to 0.7±0.9 and 0.6±0.8 drugs at 12 and 24 months, respectively, and in the microstent group from 1.4±0.9 to 0.2±0.6 drugs at both 12 and 24 months (P < 0.001 for reductions in both groups at both follow-ups vs. baseline). No vision-threatening microstent-related AEs occurred. Visual acuity was high in both groups through 24 months; >98% of all subjects achieved 20/40 best-corrected visual acuity or better. CONCLUSIONS: This RCT demonstrated safe and sustained 2-year reduction in IOP and glaucoma medication use after microinterventional surgical treatment for mild-to-moderate POAG.

Toric Intraocular Lens Outcomes in Patients With Glaucoma.

PURPOSE: To report the outcomes of toric intraocular lens implantation in patients with glaucoma and corneal astigmatism. METHODS: One hundred twenty-six eyes of 87 patients with glaucoma and corneal astigmatism that underwent cataract surgery with an AcrySof toric intraocular lens (Alcon Laboratories, Inc., Fort Worth, TX) implant were selected for this single-center, retrospective case series. Corrected distance visual acuity, intraocular pressure, and refractive astigmatism were measured in each eye preoperatively and postoperatively. Uncorrected distance visual acuity and toric alignment were measured postoperatively. RESULTS: The uncorrected distance visual acuity was 0.04 ± 0.08 logMAR (20/22 Snellen) for all eyes. Ninety-eight percent of all eyes achieved an uncorrected distance visual acuity of 20/40 or better, with 76% achieving 20/25 or better and 47% achieving 20/20. The corrected distance visual acuity for all eyes was 0.01 ± 0.03 logMAR (20/20.5 Snellen) postoperatively. The refractive cylinder improved from 1.47 ± 1.10 diopters preoperatively to 0.31 ± 0.37 diopters postoperatively. The residual refractive cylinder was 1.00 diopter or less in 97% of eyes, 0.75 diopters or less in 90% of eyes, and 0.50 diopters or less in 83% of eyes. Mean misalignment was 4.4° ± 5.1°. Intraocular pressure decreased by a mean of 2.3 ± 3.3 mm Hg following the surgery. CONCLUSION: Toric intraocular lenses can reliably reduce astigmatism and improve uncorrected vision in eyes with cataract and glaucoma.

Lens-based glaucoma surgery: using cataract surgery to reduce intraocular pressure.

UNLABELLED: Cataract surgery has been demonstrated to lower intraocular pressure (IOP) in eyes with glaucoma. The evidence is strong in angle-closure patients that cataract surgery improves IOP and dramatically reduces the future risk for IOP spikes and acute attacks. Randomized controlled trials (RCTs) have shown that cataract surgery may be preferable to laser iridotomy or phacotrabeculectomy. The data are so convincing that an RCT has been undertaken to assess whether clear lens extraction may be appropriate following acute attacks and in cases of uncontrolled IOP. The case favoring cataract surgery in open-angle glaucoma (OAG) is more controversial. Impressive IOP reduction has been shown in OAG patients when the patients are stratified by preoperative IOP. The patients with the highest preoperative IOPs have pressure reductions up to 8.5 mm Hg. However, these findings have been criticized for methodological weaknesses. Combining cataract surgery with microinvasive glaucoma surgery in phaco-plus procedures provides further options for lens-based glaucoma surgery. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Ab interno stenting procedures.

UNLABELLED: Trabecular bypass was first used as a surgical treatment for glaucoma more than 100 years ago and aims to circumvent the trabecular meshwork, thought to be the main site of aqueous humor outflow resistance. The emerging field of microinvasive glaucoma surgery has brought a new ab interno trabecular microbypass stent through the U.S. Food and Drug Administration-approval process, and data from long-term randomized prospective trials have shown the safety and intraocular pressure-lowering value of trabecular microbypass. This review discusses the historical evolution of trabecular microbypass and describes new and forthcoming surgical options along with available clinical safety and efficacy data. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Reduced intraocular pressure after cataract surgery in patients with narrow angles and chronic angle-closure glaucoma.

PURPOSE: To evaluate the effect of cataract surgery on intraocular pressure (IOP) in patients with narrow angles and chronic angle-closure glaucoma (ACG) and to determine whether the change in IOP was correlated with the preoperative pressure, axial length (AL), and anterior chamber depth (ACD). SETTING: Private practice, Atlanta, Georgia, USA. DESIGN: Retrospective case series. METHODS: Charts of patients with narrow angles or chronic ACG who had cataract surgery were reviewed. All eyes had previous laser iridotomies. Data recorded included preoperative and postoperative IOP, AL, and ACD. The preoperative IOP was used to stratify eyes into 4 groups. RESULTS: The charts of 56 patients (83 eyes) were reviewed. The mean reduction IOP in all eyes was 3.28 mm Hg (18%), with 88% having a decrease in IOP. There was a significant correlation between preoperative IOP and the magnitude of IOP reduction (r = 0.68, P < .001). The mean decrease in IOP was 5.3 mm Hg in eyes with a preoperative IOP above 20 mm Hg, 4.6 mm Hg in the over 18 to 20 mm Hg group, 2.5 mm Hg in the over 15 to 18 mm Hg group, and 1.4 mm Hg in the 15 mm Hg or less group. The mean follow-up was 3.0 years ± 2.3 (SD). CONCLUSIONS: Cataract surgery reduced IOP in patients with narrow angles and chronic ACG. The magnitude of reduction was highly correlated with preoperative IOP and weakly correlated with ACD. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

A persistency and economic analysis of latanoprost, bimatoprost, or beta-blockers in patients with open-angle glaucoma or ocular hypertension.

PURPOSE: The aim of this study was to evaluate differences in the persistency and treatment costs for latanoprost, bimatoprost, or beta-blockers in open-angle glaucoma or ocular hypertensive patients. METHODS: This study was a retrospective, multicenter, parallel, active-controlled comparison of patients who were prescribed with ocular hypotensive monotherapy between September 1996 and August 2002. RESULTS: 1,182 patients were included. The Kaplan Meier life table analysis showed that latanoprost was continued longest among the groups for the first year of therapy (p=0.02). A significant difference existed between groups in the final intraocular pressure for latanoprost (17.3+/-3.9, N=357), for bimatoprost (18.0+/-3.6, N=146), and for the beta-blockers (17.9+/-3.7, N=335) (p=<0.0001). The average number of visits was statistically higher for beta-blockers (3.3), compared to latanoprost (2.9) and bimatoprost (3.1) (p=0.01). Further, the mean number of medicine changes was greater for bimatoprost (0.45) and beta-blockers (0.47) than for latanoprost (0.27) (p=0.0008). The cost of visits and medications was lowest for beta-blockers ($119.3+/-$78.9) and highest for bimatoprost ($163.8+/-$51.2) (p<0.0001). CONCLUSIONS: Patients were more persistent with latanoprost and demonstrated lower intraocular pressure, fewer visits, and fewer medicine changes when compared to bimatoprost or beta-blocker therapy. In contrast, the beta-blocker group provided lower overall cost.