ChatGPT-Assisted Classification of Postoperative Bleeding Following Microinvasive Glaucoma Surgery Using Electronic Health Record Data.

Purpose: To evaluate the performance of a large language model (LLM) in classifying electronic health record (EHR) text, and to use this classification to evaluate the type and resolution of hemorrhagic events (HEs) after microinvasive glaucoma surgery (MIGS). Design: Retrospective cohort study. Participants: Eyes from the Bascom Palmer Glaucoma Repository. Methods: Eyes that underwent MIGS between July 1, 2014 and February 1, 2022 were analyzed. Chat Generative Pre-trained Transformer (ChatGPT) was used to classify deidentified EHR anterior chamber examination text into HE categories (no hyphema, microhyphema, clot, and hyphema). Agreement between classifications by ChatGPT and a glaucoma specialist was evaluated using Cohen's Kappa and precision-recall (PR) curve. Time to resolution of HEs was assessed using Cox proportional-hazards models. Goniotomy HE resolution was evaluated by degree of angle treatment (90°-179°, 180°-269°, 270°-360°). Logistic regression was used to identify HE risk factors. Main Outcome Measures: Accuracy of ChatGPT HE classification and incidence and resolution of HEs. Results: The study included 434 goniotomy eyes (368 patients) and 528 Schlemm's canal stent (SCS) eyes (390 patients). Chat Generative Pre-trained Transformer facilitated excellent HE classification (Cohen's kappa 0.93, area under PR curve 0.968). Using ChatGPT classifications, at postoperative day 1, HEs occurred in 67.8% of goniotomy and 25.2% of SCS eyes (P < 0.001). The 270° to 360° goniotomy group had the highest HE rate (84.0%, P < 0.001). At postoperative week 1, HEs were observed in 43.4% and 11.3% of goniotomy and SCS eyes, respectively (P < 0.001). By postoperative month 1, HE rates were 13.3% and 1.3% among goniotomy and SCS eyes, respectively (P < 0.001). Time to HE resolution differed between the goniotomy angle groups (log-rank P = 0.034); median time to resolution was 10, 10, and 15 days for the 90° to 179°, 180° to 269°, and 270° to 360° groups, respectively. Risk factor analysis demonstrated greater goniotomy angle was the only significant predictor of HEs (odds ratio for 270°-360°: 4.08, P < 0.001). Conclusions: Large language models can be effectively used to classify longitudinal EHR free-text examination data with high accuracy, highlighting a promising direction for future LLM-assisted research and clinical decision support. Hemorrhagic events are relatively common self-resolving complications that occur more often in goniotomy cases and with larger goniotomy treatments. Time to HE resolution differs significantly between goniotomy groups. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Global tendency and research trends of minimally invasive surgery for glaucoma from 1992 to 2023: A visual bibliometric analysis.

Background: Minimally invasive glaucoma surgery has become a popular research topic over the past decade. However, no published studies have provided a systematic overview for this field. A bibliometric analysis is urgently required to characterise current international trends and provide an intuitive description of past and emerging trends. Methods: This study analysed minimally invasive glaucoma surgery-related studies by searching the Web of Science for relevant articles published between 1992 and 2023. All the retrieved titles and abstracts were screened for eligibility, and only articles and reviews written in English were included in the analysis. CiteSpace (version 6.1.6), VOSviewer (version 1.6.19), and the bibliometric package in RStudio were used to construct and visualise the results. Results: A total of 1533 publications were included in the analysis with 26072 citations. A total of 4482 authors from 1191 organizations in 57 countries and regions published papers in 139 journals. After 2010, the number of publications increased significantly, with the highest annual productivity occurring in 2022 (n = 229, 15 %). Most of these studies were published in ophthalmology journals. The journal "Ophthalmology" ranked first with 30 papers and 5275 citations. Among the 10 most productive countries, the United States had the largest share of publications (n = 423, 36 %) and Switzerland had the highest proportion of multiple-country publications (70 %). Neodymium was the first keyword discovered, appearing in 1992 and continuing for 21 years. Kahook dual-blade, progression, gonioscopy-assisted transluminal trabeculotomy, efficacy, minimally invasive glaucoma surgery, cataract extraction, and primary open-angle glaucoma were the most recent keywords since 2020. Conclusions: This was the first bibliometric analysis of minimally invasive glaucoma surgery and provides an overview of the developments in this field. Our results identified outstanding studies, countries, institutions, journals, and authors in the field to point the way forward for scientific research and clinical applications of minimally invasive glaucoma surgery.

Visualization of the Postoperative Position of the Hydrus® Microstent Using Automatic 360° Gonioscopy.

Introduction: Glaucoma, one leading cause of irreversible vision loss worldwide, is primarily caused by elevated intraocular pressure (IOP). Recently, minimally invasive glaucoma surgeries (MIGSs) have become popular due to their shorter surgical times, tissue-sparing nature, and faster recovery. One such MIGS, the Hydrus® nickel-titanium alloy Microstent, helps lower IOP by improving aqueous humor outflow. The NIDEK GS-1 automated 360° gonioscope provides advanced imaging of the chamber angle for evaluation and documentation. The aim of this study was to test automated 360° gonioscopy for the detection of postoperative positional variations after Hydrus® Microstent implantation. This study is the largest to date to evaluate post-op positioning of the Hydrus® Microstent using the NIDEK GS-1. Materials and Methods: This study analyzed postoperative outcomes and stent location in eyes diagnosed with mild to moderate glaucoma that underwent Hydrus® Microstent implantation with or without phacoemulsification. Patients with prior IOP-lowering surgery or vitrectomy were excluded. Analyses of the postoperative Hydrus® Microstent position were based on the evaluation of automated 360° gonioscopy images. Results: Twenty-three eyes were included in the study, and all showed a reduction in IOP and a decrease in antiglaucomatous drop use postoperatively. Postoperative gonoscopic images showed variations in implant position. In all cases, the proximal inlet was clearly visible in the anterior chamber. The degree of protrusion into the anterior chamber was variable. The distal tip of the stent was visible behind the trabecular meshwork in Schlemm's canal in five cases, in the anterior chamber in one case, and not visible in seven cases. In no case did postoperative alterations in the position of the implant lead to explantation. Conclusions: This study demonstrated that the Hydrus® Microstent can effectively lower IOP even in the presence of postoperative positional variations. Automated 360° gonioscopy was found to be a useful tool to verify and document the postoperative position of the implant. Positional changes did not require device explantation in any of the cases evaluated.

Six-Month Outcomes of Goniotomy Performed with a Trapezoidal Dual Blade in Combination with Cataract Surgery.

Purpose: To assess the efficacy and safety of goniotomy using a uniquely shaped trapezoidal, serrated dual blade (TDB), designed to accommodate variability in patient anatomy, in reducing intraocular pressure (IOP) or anti-glaucoma medications (AGM) in adult glaucoma patients when combined with cataract surgery. Patients and Methods: Retrospective consecutive case series of patients with glaucoma who underwent phacoemulsification with TDB-goniotomy were included. Preoperative, intraoperative, and postoperative data were collected over 6 months. The primary outcome measure was surgical success, defined as IOP reduction ≥20% from baseline at 6 months, and/or reduction of at least 1 AGM. Postoperative adverse events were collected as a secondary outcome measure. Results: Sixty-five eyes of 46 patients were included with data available on 53 eyes at 6 months. Primary open-angle (38%), primary angle-closure (37%), and mixed-mechanism glaucoma (11%) were the most common diagnoses. Most cases were severe (48%) or moderate (32%) stage. At the 6-month mark, surgical success was achieved in 92% of eyes by either or both criteria. Mean preoperative IOP decreased from 18.4 mmHg (SE 0.83) to 13.0 mmHg (SE 0.37) (p<0.001) at postoperative month 6. Mean AGM decreased from 2.46 (SE 0.19) preoperatively to 1.45 (SE 0.17) (p<0.001). The most common postoperative complication was an IOP spike at postoperative week 1 (11%). No serious adverse events occurred related to the goniotomy. Conclusion: TDB-goniotomy in combination with cataract surgery safely and effectively lowered IOP and reduced AGM burden in adults with various types and severities of glaucoma over 6-months of follow-up.

There are many tools available to perform goniotomy, a popular minimally invasive glaucoma surgery, but data is lacking on many of these devices. This study sought to determine the safety and efficacy of excisional goniotomy using a uniquely shaped trapezoidal dual blade (TDB) in combination with cataract surgery for adult glaucoma patients. At 6 months, the primary outcome measure of intraocular pressure (IOP) reduction ≥20% from baseline and/or reduction of at least 1 anti-glaucoma medication was met by 92% of eyes. Six months postoperatively, there was a statistically significant decrease in mean IOP from 18.4 mmHg to 13.0 mmHg and mean antiglaucoma medications from 2.5 to 1.5. Therefore, TDB-goniotomy in combination with cataract surgery can safely decrease IOP and/or antiglaucoma medications in a mixed population of various glaucoma types and severities.

Background of Minimally Invasive Glaucoma Surgery (MIGS)-Adapted Patients for Cataract Surgery in Glaucoma.

Purpose: To investigate whether it is better to perform minimally invasive glaucoma surgery (MIGS) when performing cataract surgery on glaucoma patients. Methods: The study enrolled a total of 159 eyes of subjects with mild-to-moderate glaucoma, including primary open angle glaucoma (POAG), normal tension glaucoma (NTG), and combined mechanism glaucoma (CMG) with visually significant cataract, who were treated with one or more ophthalmic antiglaucoma agents. Phacoemulsification and aspiration with intraocular lens insertion (PEA + IOL, phaco group) or MIGS with PEA + IOL (µLot-phaco group) was performed on patients with glaucoma. Age, sex, glaucoma type, pre- and postoperative IOP, and ratio of IOP reduction were estimated. Results: The rate of IOP reduction in the µLot-phaco group was found to be significantly higher than in the phaco group at the 6-month postoperative assessment. Specifically, a strong correlation was observed between preoperative IOP levels, the presence of POAG, and patient age within the µLot-phaco group, all of which contributed significantly to the IOP reduction observed at the 6-month follow-up. Conclusions: Simultaneous cataract and MIGS were found to be more effective in older POAG patients with higher preoperative IOP.

Historical and Contemporary Debates in Schlemm's Canal-Based MIGS.

Glaucoma is one of the primary causes of blindness worldwide. Canal opening surgery, a type of minimally invasive glaucoma surgery (MIGS) applied in cases of mild to moderate glaucoma, has gained increasing popularity in recent years due to its efficacy in reducing the intraocular pressure, its safety profile, the simplicity of its technique, and the reduced likelihood of compromised vision. Nevertheless, the existing body of histopathological studies remains insufficient for a comprehensive understanding of post-surgical wound healing. Consequently, debates persist among researchers regarding the mechanism through which Schlemm's canal opening surgery reduces the intraocular pressure, as well as the surgical techniques that may impact the outcomes and the factors influencing surgical success. As the history of MIGS is relatively short and lacks sufficient systemic reviews or meta-analyses evaluating the influence of individual factors, this review was conducted to illuminate the disparities in researchers' opinions at the current stage of research.

Clinical Outcomes of Excisional Goniotomy with the Kahook Dual Blade: 6-Year Results.

INTRODUCTION: This study aims to evaluate the long-term clinical outcomes of excisional goniotomy with the Kahook Dual Blade (KDB) in the management of various types of glaucoma. METHODS: This was a retrospective, noncomparative chart review of 90 eyes of 53 patients with glaucoma that underwent standalone KDB goniotomy (KDB-alone group) or KDB goniotomy with concomitant phacoemulsification (KDB-phaco group) between October 2015 and October 2017. Surgical success was defined as an intraocular pressure (IOP) reduction by ≥ 20% at the last follow-up with no surgical reinterventions required and a final IOP ≥ 4 mmHg and ≤ 21 mmHg. We also report on changes from baseline in IOP, number of glaucoma medications, best-corrected visual acuity (BCVA), and visual field parameters, for up to 72 months. RESULTS: At 72 months, mean (standard deviation [SD]) IOP was reduced from 17.5 (5.7) to 13.6 (3.0) mmHg (P < 0.0001) in the KDB-phaco group and from 23.3 (5.9) to 15.1 (6.2) mmHg (P = 0.0593) in the KDB-alone group. The mean (SD) number of glaucoma medications was reduced from 1.3 (1.0) to 0.8 (0.9) (P < 0.0001) in the KDB-phaco group and from 1.2 (1.0) to 0.7 (0.8) (P = 0.3409) in the KDB-alone group. During the 72-month follow-up, surgical success was achieved in 24 of the 52 available eyes (46.2%). Four eyes underwent a glaucoma surgical reintervention by 72 months. CONCLUSIONS: Excisional goniotomy with the KDB effectively lowered the IOP (by an average of 28.0% from baseline) and maintained or further reduced glaucoma medication burdens (by an average of 30.8% from baseline) under an excellent safety profile, independent of phacoemulsification status. The procedure exhibited favorable success for up to 6 years, providing valuable insights into its long-term efficacy as a glaucoma treatment.

Comparison of Bent Ab-Interno Needle Goniectomy and Goniotomy in Primary Congenital Glaucoma: A Randomized Controlled Trial.

PURPOSE: Primary congenital glaucoma (PCG) is a potentially blinding disease, and the search for the best surgical option always remains. This study investigated the efficacy of Bent Ab-Interno Needle Goniectomy (BANG) compared to the established standard of traditional goniotomy. DESIGN: Parallel-group randomized controlled trial. PARTICIPANTS: Infants with PCG aged 1 month to 1 year with similar clinical features in both eyes. INTERVENTION: The 2 eyes of eligible patients were randomized to either goniotomy or BANG using a 25-gauge needle bent as a reverse cystitome, and the surgeries were done on the same day in both eyes. Postoperatively each infant was followed up for a minimum period of 1 year. MAIN OUTCOME MEASURES: The primary outcomes measured were intraocular pressure (IOP) control and the requirement for antiglaucoma medications (AGMs). The secondary outcome measures included corneal clarity enhancement, axial length stability, incidence of surgical complications, or the need for repeat surgery. RESULTS: Eight infants with both eyes eligible, were included. In each infant, 1 eye was randomized to BANG and the other to conventional goniotomy. The mean age was 7.6 ± 3.6 months. There was no significant difference in the mean preoperative IOP (16.8 ± 8.87 mm Hg vs. 17 ± 6.0 mm Hg; P = 0.48) in eyes randomized to goniotomy or BANG. The mean number of AGMs (1.7 ± 1.11 vs. 2 ± 0.81 respectively; P = 0.26) were similar in both groups. Postoperatively, the IOP at 6 months (14.05 ± 4.1 vs. 16.2 ± 4.07; P = 0.22) and 1 year (15.3 ± 3.4 vs. 17.1 ± 3.0; P = 0.15) were similar in eyes that underwent goniotomy or BANG respectively. Both procedures demonstrated significant improvements in corneal clarity and maintained normal axial length growth. However, the BANG group required slightly more AGMs than the goniotomy group. There were no serious complications in either group. Both eyes of 1 patient required repeat surgery for IOP control and underwent a combined trabeculotomy with trabeculectomy at 9 months and 1 year postoperatively, respectively. CONCLUSIONS: This study indicates that goniotomy remains an effective surgical treatment for PCG. The absence of discernible superiority in IOP control or overall outcomes implies that the added complexity of excising the trabecular meshwork in BANG may not confer additional benefits over the established approach. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Experimental glaucoma microstent implantation in two animal models and human donor eyes-an ex vivo micro-computed tomography-based evaluation of applicability.

Background: Minimally invasive glaucoma surgery (MIGS) has become an important treatment approach for primary open angle glaucoma. Restoration of aqueous humour drainage by means of alloplastic implants represents a promising treatment option and is itself subject of methodological development. An adequate positioning in the targeted tissue regions is essential is important for the performance of our in-house developed Rostock glaucoma microstent (RGM). The aim of this study was to evaluate the applicability of two animal models and human donor eyes regarding RGM placement. Methods: Eyes were obtained from rabbits, pigs, and human body donations. After orbital exenterations, RGMs were placed in the anterior chamber draining in the subconjunctival space. X-ray contrast was increased by incubation in aqueous iodine solution for subsequent detailed micro-computed tomography (micro-CT)-based visualization and analysis. Results: In contrast to the human and porcine eyes, the stent extended far to the posterior pole with a more pronounced curvature along the globe in the rabbit eyes due to their smaller size. However, dysfunctional deformations were not depicted. Adequate positioning of the stent's inflow area in the anterior chamber and the outflow area in the Tenon space was achieved in both the animal models and the human eye. Conclusions: Micro-CT has proven to be a valuable tool for postoperative ex vivo evaluation of glaucoma drainage devices in its entire complexity. With regard to morphology, the porcine eye is the ideal animal model to test implantation procedures of the RGM. Nevertheless, rabbit eye morphology facilitates successful implantation results and provides all prerequisites for preclinical animal studies.

Reviving XEN63 Gel Stent Patency in Uveitic Glaucoma: A Novel Approach Using 10-0 Nylon Probe.

Purpose: This case report describes the possibility of XEN63 lumen obstruction at the middle of the device and emphasizes the potential to restore its flow using an ab-externo revision technique involving a 10-0 nylon suture probe, before considering more aggressive surgical interventions. Methods: A 55-year-old female with uveitic glaucoma underwent XEN63 implantation but experienced elevated intraocular pressure (IOP) (35 mm Hg) 1 month after the operation, despite medical therapy. A flat bleb, lack of response to medication, yttrium aluminum garnet (YAG) laser treatment, and slit-lamp needling necessitated revision. Results: An ab-externo surgical procedure was performed using a 10-0 nylon probe to release the obstruction, followed by the application of mitomycin C and removal of fibrous tissue and subconjunctival Tenon's capsule. Intraoperatively, flow was observed only after probing with the 10-0 nylon. Postoperatively, the patient's IOP decreased immediately and remained well-controlled at 2 months (8 mm Hg) without requiring further medication. Conclusion: For patients experiencing increased inflammatory response, the XEN63 gel stent may develop deep lumen occlusion that is unresponsive to conventional treatments. This case report introduces a novel surgical technique applicable to various glaucoma devices, utilizing an ab-externo approach with a 10-0 nylon probe. The demonstrated success in reducing IOP suggests its potential as a less invasive alternative to consider before resorting to more aggressive surgical interventions. How to cite this article: Marchese V, Randazzo V, Badalamenti R, et al. Reviving XEN63 Gel Stent Patency in Uveitic Glaucoma: A Novel Approach Using 10-0 Nylon Probe. J Curr Glaucoma Pract 2024;18(2):74-78.

Minimally Invasive Glaucoma Surgery (MIGS) recommendations in Clinical Practice Guidelines for open angle glaucoma and MIGS procedures: A scoping review.

Introduction: To assess the recommendations of open angle glaucoma Clinical Practice Guidelines (CPG) addressing Minimally Invasive Glaucoma Surgery (MIGS) or MIGS procedures CPG. Methods: A scoping review of CPG was conducted, based on an ongoing systematic review (CRD42024510656). A systematic literature search of CPG was carried out in November 2023, with an update in January 2024. CPG published in the last 8 years, full text available and addressing MIGS were selected. CPG details and recommendations concerning MIGS were extracted. Results: 13 CPG addressing MIGS were selected (8 recovered from databases and 5 from registers). Four health Technology Assessments were assessed but recommendations were not considered. Finnish and Swedish guidelines, published in 2024, and Japanese guidelines, published in 2023, are English versions of their native language guidelines, but none of them make specific recommendations about MIGS. The Spanish Glaucoma Society - Advanced Glaucoma guideline (2023) describes the available techniques but does not make recommendations about MIGS. The European Glaucoma Society (2023) guideline only makes recommendations for 4 devices and the National Institute for Health and Care Excellence Interventional procedures guidance makes recommendations both for specific procedures and devices. Conclusion: MIGS is a relevant topic that has not been adequately addressed in terms of updated evidence, available procedures, and recommendations in open angle glaucoma CPG or MIGS procedures CPG.

A Comprehensive Review of Recent Advances in Minimally Invasive Glaucoma Surgery: Current Trends and Future Directions.

Glaucoma, a leading cause of blindness globally, necessitates effective management strategies to prevent irreversible vision loss. Traditional glaucoma surgeries, while effective, are associated with significant risks and complications. Minimally invasive glaucoma surgery (MIGS) has emerged as a transformative approach, offering safer and less invasive alternatives. This review provides a comprehensive overview of recent advancements in MIGS, highlighting current trends, technological innovations, and future directions. MIGS procedures, characterized by smaller incisions and quicker recovery times, have expanded the therapeutic landscape, enabling earlier intervention and improved patient outcomes. The review evaluates various MIGS techniques, their efficacy, safety profiles, and clinical outcomes, drawing insights from comparative studies and meta-analyses. Technological innovations, including enhanced device designs and integration with digital health technologies, have further bolstered the field. Despite challenges in patient selection and long-term outcomes, the future of MIGS is promising, with ongoing research and development poised to enhance its impact. By synthesizing the latest research, this review aims to inform clinicians, researchers, and policymakers, ultimately contributing to improved management of glaucoma and patient care.

Outcomes and Baseline Predictors of Failure in Primary Standalone Xen45 Gel Stent versus Trabeculectomy for Glaucoma.

PURPOSE: To compare safety, effectiveness, and baseline predictors of failure in standalone primary Xen45 gel stent (Xen) versus trabeculectomy (Trab) in glaucoma. DESIGN: Retrospective study. SUBJECTS: Subjects that underwent primary Xen or Trab augmented by mitomycin-C with at least 12 months follow-up. METHODS: Multinational observational study of eyes in the Fight Glaucoma Blindness international registry MAIN OUTCOME MEASURES: The primary outcome was success at 12 months defined by intraocular pressure (IOP) reduction ≥ 20% from baseline and ≤ threshold IOPs of 15, 18, and 21 mmHg with (qualified) or without (complete) medications and without secondary glaucoma surgery. Multivariable mixed effects Cox regression models were used to identify risk factors for failure in each cohort. RESULTS: A total of 701 eyes (Xen, 308; Trab, 393) of 596 subjects were included with baseline IOP being significantly higher (22.4 vs. 19.9 mmHg, P < 0.001) and baseline medications significantly lower in the Xen versus the Trab group (2.9 vs. 3.4, P < 0.001). Baseline visual field mean deviation was less severe in the Xen group (-9.47 vs. -13.04 dB, P < 0.001). The proportion of complete surgical success was significantly lower in the Xen versus Trab group across the 3 upper IOP limits at 12 months; 32% versus 52% at 15 mmHg, 37% versus 54% at 18 mmHg, and 39% versus 55% at 21 mmHg (P < 0.001). The incidence of postoperative numerical and symptomatic hypotony was lower in the Xen versus Trab group. In the Xen cohort, a higher failure rate was associated with Asian ethnicity (hazard ratio [HR], 1.97; 95% confidence interval (CI), 1.03-3.79) and use of oral acetazolamide at baseline (HR, 1.74; 95% CI, 1.13-2.70), whereas a lower failure rate was associated with diagnosis of ocular hypertension/open-angle glaucoma suspect (HR, 0.40; 95% CI, 0.20-0.82) and secondary open-angle glaucoma (HR, 0.46; 95% CI, 0.26-0.82). Exposure to prostaglandin analog was associated with greater failure in the Trab group (HR, 2.66; 95% CI, 1.18-6.01). CONCLUSIONS: There was significantly greater complete success at 12 months across all complete success definitions for Trab compared with Xen, whereas the rate of postoperative hypotony was significantly lower in the Xen group. Asian ethnicity and use of oral acetazolamide at baseline were associated with greater failure in Xen, whereas exposure to prostaglandin analog was associated with greater failure in Trab patients. Such baseline predictors of success and failure may help guide patient selection for subconjunctival minimally invasive glaucoma surgery in patients undergoing surgical intervention. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Is the Advent of New Surgical Procedures Changing the Baseline Features of Patients Undergoing First-Time Glaucoma Surgery?

Background: The aim of this study was to determine if the rise in new surgical procedures for glaucoma is changing the baseline features of patients. Methods: In this retrospective study, we reviewed the baseline features of patients undergoing their first glaucoma surgery in 2011 and 2021, collecting data regarding intraocular pressure (IOP), visual field (VF) parameters, stage of disease, and the type of surgery. Results: In the study, 455 patients were included in the analysis. From these, 230 eyes had glaucoma surgery performed in 2011 (Group A) and 225 eyes in 2021 (Group B). When considering the baseline features, Group A was older than Group B (72.7 ± 10.7 and 70 ± 12.4 years; p = 0.02, respectively), and showed a significantly more advanced VF mean defect (-16.4 ± 8.8 and -13.8 ± 8.7 dB; p < 0.01, respectively) and a higher IOP (25.9 ± 6.6 and 24.9 ± 7.8 mmHg; p = 0.02, respectively). Overall, severe VF damage at the time of surgery was more frequent in Group A (74.3%) than in Group B (60.8%) (p < 0.01). The overall number of traditional glaucoma surgeries was 211 in 2011, reducing to 94 ten years later, with similar severe pre-operative VF defects. In 2021, minimally invasive bleb surgery (MIBS) represented 58% of all surgeries. Conclusions: In the last ten years, patients receiving glaucoma surgery for the first time were younger, had less severe disease, and a more contained IOP. The baseline feature modifications were probably related to the diffusion of new procedures, especially MIBS, which allowed for treating patients at an earlier stage, reserving traditional procedures for advanced cases.

Angle-based minimally invasive glaucoma surgery in normal tension glaucoma: A systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis quantitatively examines the efficacy of angle-based minimally invasive glaucoma surgery (MIGS) in normal tension glaucoma (NTG). METHODS: A literature search was performed on Medline, Embase, PubMed, CINAHL and Cochrane Library from inception until 20 December 2022. Pilot, cohort, observational studies and randomised controlled trials including at least 5 subjects undergoing angle-based MIGS (trabecular-bypass devices, excisional trabeculotomy, goniotomy and ab-interno canaloplasty) for NTG, with or without cataract surgery, were included. Meta-analysis of continuous outcome using the meta routine in R version 2022.12.0+353 was performed to determine mean intraocular pressure (IOP) and anti-glaucoma medication (AGM) reduction post-operatively. RESULTS: Of the 846 studies initially identified, 15 studies with a pooled total of 367 eyes which underwent combined phacoemulsification and angle-based MIGS were included for final meta-analysis. Outcomes of the iStent were reported in 5 studies, iStent inject in 7 studies, Hydrus Microstent in 1 study, Kahook Dual Blade in 3 studies, and Trabectome in 2 studies. There was significant reduction in both IOP and AGM post-operatively at 6 months (2.44 mmHg, 95%CI: 1.83-3.06; 1.21 AGM, 95%CI: 0.99-1.44), 12 months (2.28 mmHg, 95%CI: 1.71-2.84; 1.18 AGM, 95%CI: 0.90-1.47), 24 months (2.10 mmHg, 95%CI: 1.51-2.68; 1.26 AGM, 95%CI: 0.85-1.68) and 36 months (2.43 mmHg, 95%CI: 1.71-3.15, 0.87 AGM, 95%CI: 0.21-1.53) (all p < 0.05). Subgroup analysis on combined phacoemulsification-iStent inject surgery demonstrated a reduction in both IOP (2.31 mmHg, 95%CI: 1.07-3.56, p < 0.001) and AGM (1.07 AGM, 95%CI: 0.86-1.29, p < 0.001) at 12 months post-operatively. CONCLUSIONS: Angle-based MIGS combined with phacoemulsification effectively reduces IOP and AGM in NTG eyes for up to 36 months after surgery.

Double implantation of Xen 45 gel stent in primary open-angle glaucoma: a pilot study.

PURPOSE: To describe the outcomes of double implantation of Xen 45 Gel Stent (Xen) using an ab externo approach with closed conjunctiva. METHODS: Retrospective single-centre case series of primary open-angle glaucoma patients with at least six months of follow-up after implantation of a second Xen in the same eye via ab externo technique without conjunctival opening. RESULTS: Eight pseudophakic eyes of 8 patients were included. Intraocular pressure (IOP) dropped from 30 ± 2.6 mmHg pre-operatively to 22.4 ± 2.3 mmHg one month after the first Xen implant (mean difference: -7.6 mmHg [95% confidence interval: -9.4, -5.9 mmHg], p = 0.0092). A second Xen was then implanted to achieve the target IOP. The procedure showed no significant intraoperative or postoperative complications. The IOP dropped to 16.1 ± 2.7 mmHg six months following this second implant (mean difference: -6.3 mmHg [95% confidence interval: -7.2, -5.3 mmHg], p = 0.0183); however, 3 patients needed medical therapy to further reduce the IOP towards the target value. CONCLUSION: Sequential implantation of two Xen 45 Gel Stents using an ab externo approach with closed conjunctiva appears a promising procedure that showed a favorable safety and efficacy profile in this small case series. This pilot data might pave the way for further studies to evaluate the safety and efficacy of the procedure.

XEN45 gel stent in the treatment of pigmentary glaucoma: A two-year follow-up.

PURPOSE: To investigate safety and efficacy of the XEN gel stent in patients with pigmentary glaucoma (PG). METHODS: A retrospective analysis of 26 eyes of 19 patients with PG undergoing XEN gel stent implantation was performed. Best-corrected visual acuity, intraocular pressure (IOP), and number of antiglaucoma medications were analyzed preoperatively, and at 2 weeks and 3, 6, 12, and 24 months after surgery. Success, needling, and complications were analyzed. Complete success was defined as an IOP reduction of >20% and achieving a target IOP of ≤18, ≤15, or ≤12 mmHg without antiglaucoma medication. Qualified success was indicated if the IOP target was reached with or without medication. RESULTS: Mean IOP decreased significantly from 27.6 ± 14.3 (standard deviation, SD) mmHg to 14.3 ± 4.6 mmHg after one year (p < 0.001) and 15.1 ± 2.7 mmHg (p < 0.001) after two years. The median number of hypotensive drugs declined significantly from 4 (range: 3-5) to 0 (0-2) and 0 (0-3) after one and two years, respectively. After two years, complete success with an IOP of ≤18 mmHg and ≤15 mmHg was achieved in 73.1% and 61.5%, respectively. Half of the eyes required needling after a median time of 8 months (0.5-34 months). No sight-threatening complications were observed. CONCLUSION: The XEN gel stent is a safe and effective surgical treatment option for PG. Needling is an important part of the procedure and should be communicated preoperatively to the patients.

Advancing Glaucoma Care in Bangladesh With Minimally Invasive Glaucoma Surgery.

Minimally invasive glaucoma surgery (MIGS) is a cutting-edge approach to treating glaucoma that provides a range of techniques and technology to reduce intraocular pressure (IOP). An 80-year-old man with visually significant cataracts and primary open-angle glaucoma (POAG) underwent combined cataract surgery and TrabEx+ (MicroSurgical Technology, Washington, United States) in his left eye, a unique type of MIGS, as we described in this study. Over the one-year follow-up, this patient showed improved visual function with well-controlled IOP without anti-glaucoma medications.

XEN45 Implant in Medically Controlled vs. Uncontrolled Eyes-Differential IOP Changes in Real-Life Conditions.

Background: To assess intraocular pressure (IOP) changes and complications after XEN45 implants in medically controlled eyes (MCE) vs. medically uncontrolled eyes (MUE). Methods: A retrospective study, in a tertiary referral hospital, on mild-to-moderate primary open-angle glaucoma (POAG) cases under topical medication, including 32 eyes with IOP < 21 mmHg (MCE group) and 30 eyes with IOP ≥ 21 mmHg (MUE group). The success criteria using Kaplan-Meier analysis was IOP < 21 mmHg without medications (complete success) or fewer drugs than preoperatively (qualified success) at the last visit, without new surgery or unresolved hypotony. Results: No significant preoperative differences were found between the groups. The mean IOP was 15.6 ± 3.8 mmHg in MCE and 15.1 ± 4.1 mmHg in the MUE group (p > 0.05; Mann-Whitney test) at the end of the follow-up (mean of 26.1 ± 15.6 months and 28.3 ± 15.3 months, respectively) (p = 0.414, Mann-Whitney Test). The device caused a significant IOP reduction at 24 h in both groups. Thereafter, the MCE group significantly tended to increase IOP, recovering baseline values at 1 month and maintaining them until the end of the follow-up. In contrast, in the MUE group, the IOP values tended to be similar after the first reduction. No relevant complications and no significant differences between the groups in the survival analysis were found. Conclusions: XEN45 provided stable IOP control in both the MCE and MUE group without important complications in the medium term. The IOP increasing in the MCE group, after a prior decrease, led to restored baseline values 1 month after surgery. The homeostatic mechanism that causes the rise in the IOP to baseline values and its relationship with failure cases remains to be clarified.

Long-term efficacy and safety of XEN-45 gel stent implantation in patients with normal-tension glaucoma.

BACKGROUND: Minimally invasive bleb surgery using the XEN-45 gel stent has not been established for the treatment of normal-tension glaucoma (NTG). The main objective of this study was to evaluate the long-term treatment efficacy and safety of XEN-45 in eyes with uncontrolled NTG. METHODS: A retrospective analysis of patients with NTG who underwent XEN-45 gel stent implantation at university hospital Tuebingen between 2016 and 2021. The primary outcome measure was surgical success after three years defined as lowering of intraocular pressure (IOP) of ≥ 20%, with target IOP between 6 and 15 mmHg. Success was complete without and qualified irrespective of topical antiglaucoma medication use. The need for further glaucoma surgery, except for needling, was regarded as a failure. The secondary outcome measures included changes in mean IOP, number of antiglaucoma medications, and needling and complication rates. RESULTS: Twenty-eight eyes from 23 patients were included in the final analysis. Complete and qualified success rates were 56.5% and 75% after three years, respectively. Mean postoperative IOP ± standard deviation decreased significantly after three years from 19.3 ± 2.0 mmHg at baseline to 13.7 ± 4.2 mmHg (n = 22; p < 0.0001). The median number of antiglaucoma medications decreased from 2 (range 0-4) to 0 after three years (range 0-3; p < 0.0001). Sixteen eyes (57%) required a median of 1 (range 1-3) needling procedures. One eye required further glaucoma surgery. No sight-threatening complications were observed. CONCLUSION: The XEN-45 stent is effective and safe for the long-term treatment of NTG. However, needling was frequently required to improve outcomes.