Risk Factors for Hyphema Following Kahook Dual Blade Goniotomy Combined With Phacoemulsification.

PRCIS: Hyphema development after Kahook Dual Blade (KDB) excisional goniotomy was significantly associated with postoperative day 1 intraocular pressure (IOP) ≤12 mm Hg, male sex, and narrow iridocorneal angles, but not with continuation of anticoagulation or antiplatelet therapy. PURPOSE: To identify risk factors of hyphema development after KDB goniotomy combined with phacoemulsification. METHODS: In all, 202 eyes in 145 patients who received a KDB goniotomy combined with phacoemulsification between February 21, 2017 and February 18, 2020 were evaluated for preoperative factors that were predictive of postoperative hyphema. Hyphema was defined as the development of ≥1 mm layered blood in the anterior chamber. The primary outcome was the association between various preoperative factors and the development of postoperative hyphema. Binomial logistic regression was used to analyze risk factors of hyphema development while controlling for other variables. RESULTS: Hyphema occurred in 8.4% (17/202) of patients on day 1 after KDB goniotomy combined with phacoemulsification. Male sex ( P =0.008), angle closure glaucoma ( P =0.036), and postoperative day 1 IOP ≤12 mm Hg ( P =0.049) were significantly correlated with hyphema development while controlling for other variables. Preoperative anticoagulation and antiplatelet therapy had no association with hyphema development ( P =0.538). CONCLUSIONS: Postoperative hyphema was associated with male sex, narrow iridocorneal angles, and a postoperative day 1 IOP lower than typical episcleral venous pressure when controlling for other variables. Preoperative anticoagulation or antiplatelet therapy was not associated with developing postoperative hyphema in this study; however, further investigation is needed before recommendations can be made.

Predictive Factors of Outcomes in Kahook Dual Blade Excisional Goniotomy Combined with Phacoemulsification.

Aim: To identify factors that were significant predictors of Kahook Dual Blade (KDB) excisional goniotomy outcomes. Materials and methods: One hundred and thirty-two eyes from 99 adult glaucoma patients who underwent combined KDB and phacoemulsification (KDB-phaco) with a minimum 6-month follow-up were assessed for baseline patient characteristics to determine correlation to the success of KDB-phaco at 6 and 12 months postoperatively. Success was defined as ≥20% intraocular pressure (IOP) reduction or ≥1 medication reduction as well as IOP ≤18 mm Hg without any additional IOP-lowering procedures after KDB-phaco. Results: 63.6% (84/132) and 46.1% (41/89) of cases were successful at the 6- and 12-month follow-ups, respectively. KDB-phaco reduced patient's preoperative IOP (in mm Hg) from 17.6 ± 4.6 to 14.9 ± 3.2 at 6 months (15.3%, p < 0.001) and 15.4 ± 4.7 at 12 months (12.5%, p = 0.001). KDB-phaco reduced patient's preoperative IOP-lowering medications from 2 ± 1.2 to 1.1 ± 1.2 at 6 months (45%, p < 0.001) and 1.32 ± 1.3 at 12 months (34%, p < 0.001). At 6 months, patients on >1 IOP lowering medication had a greater chance of meeting our success criteria (p = 0.037). Visually significant postoperative hyphema was not associated with the use of anticoagulation (p = 0.943) but was significantly associated with postoperative day 1 IOP ≤ 10 mm Hg (p = 0.011). Conclusion: Patients who underwent KDB-phaco significantly reduced their IOP and medication burden at both 6 and 12 months compared with their baseline preoperative values. KDB-phaco outcome was associated with higher baseline IOP-lowering medications and increased rate of hyphema was associated with lower postoperative day 1 IOP, regardless of anticoagulation status. Age, ethnicity, prior laser trabeculoplasty, type and severity of glaucoma, and baseline preoperative IOP were not associated with surgical success. Clinical significance: Patients with a higher number of baseline medications may experience a greater probability of success following KDB-phaco. How to cite this article: Pratte EL, Cho J, Landreneau JR, et al. Predictive Factors of Outcomes in Kahook Dual Blade Excisional Goniotomy Combined with Phacoemulsification. J Curr Glaucoma Pract 2022;16(1):47-52.

Response to netarsudil in goniotomy-treated eyes and goniotomy-naïve eyes: a pilot study.

PURPOSE: To compare the intraocular pressure (IOP)-lowering effects of netarsudil on goniotomy-treated eyes versus goniotomy-naïve control eyes. METHODS: Retrospective cohort study of 70 eyes from 49 adult glaucoma patients treated with netarsudil. Thirty-five eyes received sectoral goniotomy using Kahook Dual Blade (KDB) combined with cataract surgery with minimum of 3 months prior to netarsudil treatment. Thirty-five eyes in the control cohort received only cataract surgery prior to netarsudil. Primary outcome was treatment success, defined as ≥ 20% decrease in IOP at minimum 1 month follow-up. Secondary outcome measures included percent of IOP reduction, adverse effects of medication, medication discontinuation rate, and relationship between KDB goniotomy response and netarsudil response. RESULTS: Eighty-three percent of KDB-treated eyes achieved netarsudil treatment success compared to 54% of control eyes (P = .012). IOP reduction was 30.3 ± 16.2% (IQR 21-38%) in KDB-treated eyes and 19.4 ± 12.4% (IQR 9.2-30.8) in control eyes (P = .007). History of prior KDB increased the likelihood of success to netarsudil treatment compared to eyes without prior KDB, regardless of surgical response to KDB (odds ratio 4.51, 95% CI 1.34-15.14, P = .015). The overall rate of adverse effects of netarsudil was 42%, most commonly reported as conjunctival hyperemia, allergy, and blurred vision. CONCLUSIONS: Netarsudil had a greater IOP-lowering effect in eyes treated with prior goniotomy and may serve as a promising adjunctive ocular hypotensive agent to further reduce IOP in eyes with prior goniotomy.

Six-Month In Vivo Safety Profiling of Topical Ocular AAV5-Decorin Gene Transfer.

Purpose: A significant remission of corneal fibrosis and neovascularization in rabbit eye in vivo was observed from a tissue-selective localized adeno-associated virus (AAV)5-Decorin (Dcn) gene therapy. This study sought to investigate 6-month toxicity profiling of this gene therapy for the eye in vivo using a rabbit model. Methods: A small epithelial scrape followed by corneal drying was performed unilaterally in 12 rabbit eyes and either AAV5-Dcn (n = 6) or naked vector (n = 6) was delivered topically using a cloning cylinder technique. Contralateral eyes served as naïve control (n = 6). Safety and tolerability measurements in live rabbits were performed periodically until month 6 using multimodel clinical ophthalmic imaging tools-a slit lamp, stereomicroscope, and HRT3-RCM in vivo confocal microscope. Thereafter, corneas were excised and subjected to hematoxylin and eosin staining, Mason trichome staining, propidium iodide nuclear staining, and quantitative real-time polymerase chain reaction analyses. Results: Clinical eye examinations based on the modified Hackett-McDonald ocular scoring system, and in vivo confocal imaging of the cornea showed no signs of ocular toxicity in rabbit eyes given AAV5-Dcn gene transfer vs control eyes (P > 0.05) through 6 months after treatment. The histologic and molecular analyses showed no significant differences in AAV5-Dcn vs AAV naked or naïve control groups (P > 0.05) and were in accordance with the masked clinical ophthalmic observations showing no abnormalities. Conclusions: Topical tissue-targeted localized AAV5-Dcn gene therapy seems to be safe and nontoxic to the rabbit eye in vivo. Translational Relevance: AAV5-Dcn gene therapy has the potential to treat corneal fibrosis and neovascularization in vivo safely without significant ocular toxicity.

Comparison of Outcomes for Laser Trabeculoplasty after Kahook Dual Blade Goniotomy Versus in Goniotomy-Naive Eyes.

INTRODUCTION: This was a comparison of laser trabeculoplasty (LTP) outcomes in eyes with prior Kahook Dual Blade (KDB) goniotomy versus in goniotomy-naive control eyes. METHODS: This was a retrospective matched comparative case series. We identified a cohort of patients undergoing LTP between February 2017 and July 2020 at University of Missouri. Patients were grouped by history of KDB goniotomy versus goniotomy-naivety as a control group. Inclusion criteria included age at least 18 years, minimum of 6 months follow-up after LTP, and minimum period of 6 months between KDB goniotomy and LTP. All KDB procedures were combined with uncomplicated phacoemulsification. Patients who had any additional intraocular pressure (IOP)-lowering procedures between KDB goniotomy and LTP were excluded. Patients in the control group received a single LTP procedure. Primary outcome consisted of the comparison of LTP success, defined as IOP reduction of at least 20% or reduction of glaucoma medications from pre-LTP baseline. Secondary outcomes included IOP and medication reduction from pre-LTP baseline. RESULTS: Twenty-one eyes of 19 patients with history of KDB goniotomy and 42 eyes of 36 control patients without previous angle or laser procedures were included. Baseline characteristics including age, gender, ethnicity, type and severity of glaucoma, baseline IOP, and baseline medications were matched between groups. The LTP success rate was higher in the control group, but was not statistically significant (64% vs 57%, p = 0.58). IOP reduction was only significant in the control eyes (2.50 ± 4.0 mmHg, p = 0.01 vs 2.35 ± 4.7 mmHg, p = 0.08). The number of glaucoma medications was not significantly reduced in either group. CONCLUSION: LTP may have a limited IOP- and medication-lowering effect in eyes with a history of KDB goniotomy compared to goniotomy-naive eyes.

Comparative outcome analysis of bleb needling of fibrotic blebs in the clinic versus the operating room: a retrospective case series.

BACKGROUND: To compare 6 month outcomes of bleb needling performed in the clinic vs. the operating room (OR) in adult glaucoma patients with failed bleb. METHODS: A retrospective case series of 47 eyes from 41 glaucoma patients who received needling with mitomycin C (MMC) of scarred bleb from prior bleb-forming procedures in clinic (32 eyes) vs. the OR (15 eyes), including trabeculectomy (14 eyes), ExPress shunt (16 eyes), and ab-interno XEN gel stent (17 eyes). The primary outcome was needling success, defined as IOP ≤ 18 mmHg on 0 glaucoma medications without requiring an additional IOP lowering procedure within 6 months after needling. RESULTS: At 6 months, bleb needling success rate was similar when performed in the clinic vs. in the OR (28% vs. 20%, P = 0.54). Success rate was not statistically different in patients with prior trabeculectomy, ExPress shunt, and XEN gel stent (29% vs. 38% vs. 12%, P = 0.26). When comparing clinic vs. the OR needling procedures at 6 months, there was no difference in mean IOP (14.2 vs. 14.9 mmHg, P = 0.73), mean glaucoma medications (1.4 vs. 1.7, P = 0.69), additional IOP-lowering procedure rate (16% vs. 27%, P = 0.37), or complication rate (0% vs. 7%, P = 0.32). CONCLUSION: Bleb needling with MMC in clinic may be a safe and effective way to revise failed bleb after trabeculectomy, ExPress shunt, and XEN gel stent procedures when compared to needling in the OR.

Comparison Of Surgical Outcomes Of 360° Circumferential Trabeculotomy Versus Sectoral Excisional Goniotomy With The Kahook Dual Blade At 6 Months.

PURPOSE: To compare reductions in intraocular pressure (IOP) and IOP-lowering medication use following sectoral excisional goniotomy with the Kahook Dual Blade (KDB) or 360° trabeculotomy (via either Trab360 or gonioscopy-assisted transluminal trabeculotomy [GATT]) in eyes with open-angle glaucoma (OAG) undergoing phacoemulsification cataract surgery. METHODS: A retrospective review was conducted to collect data from adult subjects with early to advanced primary or secondary OAG undergoing phacoemulsification combined with either KDB or 360° trabeculotomy (Trab360 or GATT) between August 1, 2016 and July 30, 2018 for which 6-month follow-up was available. Data collected included IOP, glaucoma medications, adverse events, and additional IOP-lowering procedures. The primary outcome measure was surgical success (≥20% IOP or ≥1 medication reduction without additional IOP-lowering procedures) at 6 months. RESULTS: Data were collected from 74 eyes of 61 subjects undergoing KDB excisional goniotomy and 27 eyes of 25 subjects undergoing 360° trabeculotomy (19 eyes of 17 subjects undergoing Trab360 and 8 eyes of 8 subjects undergoing GATT). At 6 months, 81.7% (58/71) of KDB eyes and 84.6% (22/26) of 360° trabeculotomy eyes achieved surgical successes (P=0.737). Mean IOP reductions and medication reductions were similar between groups at 6 months. However, more eyes undergoing KDB than Trab360/GATT achieved target IOP ≤18 mmHg (80.0% [56/70] vs 59.3% [16/27], P=0.040) and ≤15 mmHg (61.4% [43/70] vs 25.9% [7/27], P=0.003) without further IOP-lowering interventions at 6 months. The nature and frequency of adverse events were similar between groups. CONCLUSIONS: Both KDB and Trab360 or GATT procedures similarly lowered both IOP and the need for IOP-lowering medications during the first 6 postoperative months. More eyes undergoing KDB excisional goniotomy than 360° trabeculotomy attained target IOP ≤18 mmHg and ≤15 mmHg at 6 months. A full 360° trabecular bypass may not be necessary to achieve maximal efficacy from this class of micro-invasive glaucoma procedures.

Reversal of Toric Intraocular Lens-corrected Corneal Astigmatism after Kahook Dual Blade Goniotomy.

A 79-year-old man underwent phacoemulsification (phaco) with TORIC intraocular lens (IOL) insertion combined with Kahook dual blade (KDB) goniotomy of the right eye several months after a stand-alone phaco in the fellow eye. He had significant against-the-rule astigmatism in both eyes (2.41D @ 10° right, 2.40D @ 160° left) preoperatively. Postoperatively, nearly all corneal astigmatism disappeared in the right eye (0.60D @ 37°), while it remained the same in the left eye (2.00D @ 167°). Ophthalmologists should be aware that KDB may have an unreported effect of altering corneal astigmatism, which should be considered when inserting TORIC IOL. HOW TO CITE THIS ARTICLE: Hirabayashi MT, McDaniel LM, et al. Reversal of Toric Intraocular Lens-corrected Corneal Astigmatism after Kahook Dual Blade Goniotomy. J Curr Glaucoma Pract 2019;13(1):42-44.

Comparison of successful outcome predictors for MicroPulse® laser trabeculoplasty and selective laser trabeculoplasty at 6 months.

Purpose: To identify and compare factors predictive of successful outcome for MicroPulse® laser trabeculoplasty (MLT) and selective laser trabeculoplasty (SLT). Methods: 50 MLT-treated eyes and 50 SLT-treated eyes of open-angle glaucoma patients were reviewed for baseline characteristics, pre- and postoperative IOP and medications, and adverse events including postoperative IOP elevation >5 mmHg (IOP spikes) through 6 months of follow-up. Success was defined as ≥20% IOP reduction or ≥1 medication reduction without additional IOP lowering procedures at 6 months follow-up. Results: MLT and SLT had similar success rates (44% vs 40%, P=0.983). Older age predicted success for SLT (P=0.013) but not MLT (P=0.154). Both MLT and SLT led to greater IOP lowering in patients with baseline IOP >18 mmHg, but only for SLT did baseline IOP have a significant association with success (P=0.035 vs P=0.983). Number of laser shots was associated with success in MLT (P=0.031) but not in SLT (P=0.970). Glaucoma severity and pigmentation of the trabecular meshwork (PTM) were not associated with rate of success for either group. The rate of IOP spikes was significantly (P=0.022) higher in the SLT group (10%) compared to none in the MLT group. No other complications or visually significant adverse events occurred in either group. Conclusion: Although MLT and SLT resulted in similar success rates, older age and higher baseline IOP predicted success for SLT while MLT was equally efficacious regardless of these factors. Glaucoma severity and PTM were not associated with success of either laser procedures. 10% of SLT patients experienced IOP spike post procedure, whereas none in the MLT group did. MLT may be a safer alternative to SLT that is effective in lowering IOP and need for medications for a wider variety of patients with open angle glaucoma.

Outcome of phacoemulsification combined with excisional goniotomy using the Kahook Dual Blade in severe glaucoma patients at 6 months.

PURPOSE: The aim of this study was to describe 6-month rates of achieving target IOP without requiring additional glaucoma surgery after excisional goniotomy using the Kahook Dual Blade combined with phacoemulsification (phaco-KDB) in patients with severe-stage glaucoma. METHODS: Retrospective review of 42 eyes from 36 patients with severe glaucoma who received phaco-KDB. Primary and secondary open-angle and combined-mechanism glaucoma were included. Preoperative, intraoperative, and postoperative data were collected through the 6-month follow-up period. The primary outcome was proportion of patients achieving IOP ≤15 mmHg without additional glaucoma procedures. Secondary outcomes were mean change in IOP, reduction of glaucoma medications, additional glaucoma procedures needed, and adverse events. RESULTS: Preoperative baseline mean IOP was 17.1±4.8 mmHg (mean ± SD) and number of medications was 2.4±1.3. At 6 months, 64.3% (27/42) of eyes had achieved IOP ≤15 mmHg without additional glaucoma procedures, 45.2% (19/42) reached this target IOP on fewer medications, and 31.0% (13/42) on no medications. Mean IOP reduction was 2.1±4.67 mmHg (P=0.022) and mean medication reduction was 1.2±1.4 (P≤0.001). Visually significant complications were experienced by 7.1% (3/42) of eyes, and 7.1% (3/42) required additional IOP-lowering procedures within 6 months of surgery. CONCLUSION: Patients with severe-stage open-angle glaucoma achieved significant IOP and medication reductions following phaco-KDB. Notably, about two-thirds of eyes achieved an IOP of ≤15 mmHg at 6 months without additional glaucoma procedures. Complications and need for additional procedures were rare. Phaco-KDB may be an effective and safe alternative to more invasive filtering surgery in many patients with severe glaucoma.

Inadvertent Cyclodialysis Cleft and Hypotony Following Ab-Interno Trabeculotomy Using the Trabectome Device Requiring Surgical Repair.

PURPOSE: To report the first case of inadvertent cyclodialysis cleft and hypotony requiring surgical repair following ab-interno trabeculotomy (AIT) using the Trabectome device, and the postoperative clinical results following direct suture cyclopexy. METHODS: A 55-year-old man with hypotonous maculopathy secondary to cyclodialysis cleft inadvertently created 3 years earlier during AIT using the Trabectome device was referred for repair. Direct suture cyclopexy was performed and topical homatropine and dexamethasone drops were prescribed postoperatively. RESULTS: Gonioscopic examination revealed complete cleft closure on postoperative day 1 confirmed by anterior segment optical coherence tomography. At 11 weeks postoperatively, visual acuity had improved from 20/400 to 20/40, with resolution of preoperative macular folds on fundoscopic examination. At 9 months postoperatively, visual acuity had further improved to 20/20 with intraocular pressure stable at 9 mm Hg maintained on travoprost and brimonidine. CONCLUSIONS: Inadvertent cyclodialysis cleft from a malpositioned AIT and resultant hypotony is rare and in this case was successfully treated by direct suture cyclopexy.