36-Month Outcomes of Standalone Kahook Dual Blade Goniotomy Compared with Ab-Interno Closed Conjunctiva Xen Gel Stent Implantation.

Purpose: To compare the safety and effectiveness of standalone Kahook Dual Blade (KDB) excisional goniotomy to standalone ab-interno Xen gel stent implantation in eyes with moderate-to-severe open-angle glaucoma (OAG). Methods: A single-center, retrospective study including eyes with moderate-to-severe OAG undergoing standalone KDB goniotomy or Xen gel stent implantation was conducted. Intraocular pressure (IOP), the number of antiglaucoma medications taken daily, and best-corrected visual acuity (BCVA) were recorded at baseline and for up to 36-months. Primary outcomes assessed included changes from baseline in IOP and the number of antiglaucoma medications taken. Intergroup comparisons were conducted using independent-samples Student's t-tests. The incidence of intraoperative and postoperative adverse events and the need for glaucoma surgical re-interventions were also recorded. Results: Eyes receiving standalone KDB (n=26) or Xen gel stent (n=45) surgery were analyzed. The baseline mean IOP and number of antiglaucoma medications in both groups were as follows: KDB: 23.2 ± 6.0 mmHg, 2.2 ± 1.4 medications; Xen: 22.7 ± 8.8 mmHg, 3.0 ± 1.0 medications. At 36 months, IOP was reduced to 16.6 ± 5.4 mmHg in KDB eyes (n=23, -23.5%; p=0.0004) and 15.3 ± 5.6 mmHg in Xen gel stent eyes (n=15, -22.1%; p=0.006), while number of antiglaucoma medications was reduced to 1.1 ± 0.7 (-30.8%; p=0.0005) and 2.2 ± 1.4 (-25.6%; p=0.01), respectively. Three eyes (11.5%) in the KDB group and 19 eyes (42.2%) in the Xen gel stent group required additional surgery before month 36 due to refractory high IOP. Conclusion: Both KDB goniotomy and Xen gel stent implantation significantly lowered the IOP and antiglaucoma medication burden in patients with moderate-to-severe OAG. While the Xen gel stent is frequently used to treat moderate-to-severe OAG patients with uncontrolled IOP, standalone KDB goniotomy may be equally effective as a long-term intervention, reducing the need for subsequent glaucoma surgery.

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.

Long-Term Outcomes of Combined Phacotrabeculectomy Surgery in a Singapore Tertiary Hospital.

PURPOSE: To describe the long-term outcomes of phacotrabeculectomy from a tertiary glaucoma service in Singapore. DESIGN: Retrospective case series. METHODS: Seven hundred ninety-six eyes of 698 patients who underwent phacotrabeculectomy surgery at the Singapore National Eye Centre between 2005 and 2007 with a minimum follow-up of three years were included. The primary outcome measure was intraocular pressure (IOP). Secondary outcomes included best-corrected visual acuity (BCVA), number of glaucoma medications, and surgical complications. RESULTS: The mean age was 69.5 years, 51% were male, and 86% were Chinese. Most eyes had primary glaucoma (90.6%). The mean follow-up duration was 9.4 years. The overall success rate at three years was 97% if surgical success was defined as IOP ≤ 21mm Hg, 92% if IOP ≤ 18mm Hg, 66% if IOP ≤ 15mm Hg. By Kaplan-Meier survival analysis over 13 years, the cumulative success rate fell from 98.1% to 89.1% if IOP ≤ 21mm Hg, 98.1% to 76.9% if IOP ≤ 18mm Hg, 98% to 50.3% if IOP ≤ 15mm Hg. The postoperative IOP improved significantly at all time points (P < 0.05) and 72% had at least 20% IOP reduction. There was a slight improvement in postoperative BCVA (P < 0.05). The mean number of glaucoma medications was reduced postoperatively (P < 0.001). There were no significant risk factors for surgical failure. CONCLUSIONS: Phacotrabeculectomy was found to be safe, resulting in clinically significant IOP lowering for 13 years with reduced dependency on glaucoma medications and improved BCVA.

Preserflo MicroShunt versus Trabeculectomy: Efficacy and Surgical Success within a Heterogenous Patient Cohort.

To compare success rates of trabeculectomy (TE) and Preserflo MicroShunt (PMS) in heterogenous glaucoma cohorts with regards to different pre- and postoperative therapeutic regimens. Data of 187 glaucoma patients who either received TE (73 eyes) or PMS implantation (114 eyes) between January 2018 and December 2022 were retrospectively evaluated. Surgical success and failure rates were analyzed within six months of follow-up. Intraocular pressure (IOP) development over the course of follow-up was compared between both groups. Tertiary outcome measures were best-corrected visual acuity (BCVA), number and type of medications, frequency of postoperative complications and revision surgeries. Outcome measures underwent additional assessment based on subgroup categorizations, and failure time hazard ratios were computed. The success rates were comparable between both procedures (TE: 54.1%, PMS: 60.0%; p = 0.17). Both procedures showed significant IOP reduction (p < 0.01); however, overall IOP reduction was greater in the TE group than in the PMS group (TE: Reduction by 12 mmHg (188.9%), PMS: Reduction by 7 mmHg (51.3%); p = 0.01). The number of topical medications decreased significantly in both groups over the course of follow-up (TE: 4 to 0, PMS: 3 to 0; p < 0.01). While the number of complications and revision surgeries were similar in both groups, the time interval until the first revision surgery within the TE group was significantly shorter (TE: 13.5 d, PMS: 163 d; p = 0.01) than within the PMS group. No difference could be detected between TE and PMS with regard to the follow-up regimen. In particular, there was no significant difference in the need for 5-floururacil injections postoperatively (p = 0.29). Less invasive glaucoma surgery with the PMS appeared comparable to the TE within a heterogenous glaucoma cohort with regards to IOP development and freedom from medication.

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.

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.

Removable regulating sutures during trabeculectomy for a safer and more effective intraocular pressure control.

PURPOSE: Comparing the effect of standard trabeculectomy with direct sutures versus trabeculectomy with compression and everting sutures. METHODS: Mono-centric randomized prospective comparative study on 38 glaucomatous eyes undergoing trabeculectomy: 19 with standard fixed sutures (group A) and 19 withremovable regulating sutures (group B). Preoperatively and at day-7, 1-month, 2-months, 3-months and 6-months after surgery, we recorded best-corrected visual acuity (BCVA), intraocular pressure (IOP) and possible complications. Complete, partial success and failure rates were recorded at the end of the study. RESULTS: In group B, we pulled everting sutures with the "horse bridle" technique at the 14th day, and successively removed all sutures between the 14th-30th post-operative day. At month-1, we recorded a significant IOP reduction in both groups (mean reduction of 11.5 mmHg for group A and of 14.4 mmHg for Group B, p = 0.001 and p < 0.0001, respectively). Furthermore, group B showed a significantly lower IOP than group A (-4.2 mmHg, 95% confidence interval [CI] -7.0 to -0.5 mmHg for group B, p = 0.01). At 2, 3 and 6-months, no significant IOP differences were reported between the two groups (all p > 0.05), but failure rate was higher for group A (21%) than for group B (11%). No differences in visual outcomes at any timepoints were noted. CONCLUSIONS: Trabeculectomy with removable regulating sutures showed a good safety profile, comparable to standard trabeculectomy. Moreover, we reported a lower IOP one month postoperatively, suggesting this technique may optimize early management of trabeculectomy.

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.

A Review of Canaloplasty in the Treatment and Management of Glaucoma.

Aim: To review the published literature evaluating the safety and efficacy outcomes of canaloplasty performed in the treatment of glaucoma. Background: Canaloplasty is a nonpenetrating glaucoma procedure involving combined 360° circumnavigation and viscodilation of Schlemm's canal. The procedure may be performed under an ab externo (with tensioning suture) or ab-interno (conjunctiva-sparing) approach. Given the wide variety of glaucoma procedure types and approaches, further investigation into the role of canaloplasty in ophthalmological practice is warranted. The objectives of this narrative review are to synthesize the existing literature in order to investigate indications, safety and efficacy outcomes, and the optimal place of canaloplasty in glaucoma treatment and management. Review of results: A total of 60 articles were included in this review. Both ab externo and ab-interno canaloplasty (ABiC) were found to be significantly effective at reducing intraocular pressure (IOP) and glaucoma medication burdens in patients with mild-to-moderate open-angle glaucoma (OAG). These findings remained consistent regardless of phacoemulsification status. ABiC was found to exhibit a safety profile favorable compared to trabeculectomy and comparable to minimally invasive trabecular bypass implants. Conclusion: Canaloplasty is a nonpenetrating surgical intervention that is highly effective in treating patients with mild-to-moderate OAG across a large variety of clinical scenarios. Clinical significance: These findings support the clinical use of canaloplasty in ophthalmological practice, clarify its patient profile, and compare procedural outcomes to other minimally invasive glaucoma surgery (MIGS) devices on the market. How to cite this article: Wagner IV, Towne C, Saade MC, et al. A Review of Canaloplasty in the Treatment and Management of Glaucoma. J Curr Glaucoma Pract 2024;18(2):79-85.

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.

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.

[Glaucoma surgeries: Long-term results - A review]. / Les principales chirurgies du glaucome : résultats à long terme ­ une revue de la littérature.

The surgical treatment of glaucoma has been and is still based on filtering surgeries, commonly used for about half a century. The safety and efficacy of these techniques have been well described, as it has also been done for cyclophotocoagulation and valves or tubes, indicated in France mostly for refractory glaucoma. Minimally invasive glaucoma surgeries have emerged in recent decades, increasing the number of therapeutic options, and allowing treatment decisions to be as patient-centered as possible. Most of these techniques have now been studied for more than five years. Since glaucoma is a chronic, progressive optic neuropathy, the sustainability of each surgery's results is essential. The amount of available data concerning long-term efficacy and safety of glaucoma surgeries is increasing, so we have decided to describe it through this review of the literature.

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.

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.

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 one month to one year with similar clinical features in both eyes. INTERVENTION: The two 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 one 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, one 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 versus 17+6.0 mm Hg; p=0.48) in eyes randomized to goniotomy or BANG. The mean number of AGMs (1.7±1.11 versus 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 one year (15.3 ± 3.4 versus 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 one patient required repeat surgery for IOP control and underwent a combined trabeculotomy with trabeculectomy at nine months and one year post-operatively, 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.

Complications Following XEN45 Gel Stent and Glaucoma Drainage Device Implantation During Glaucoma Fellowship.

Purpose XEN45 Gel Stent and glaucoma drainage device (GDD) implantation is safe and effective for glaucoma treatment and should be taught during glaucoma fellowship training. However, complications may still occur, with potentially sight-threatening consequences. The purpose of this study is to describe the management of complications following a series of XEN45 Gel Stent and GDD surgeries performed over the course of glaucoma fellowship training. Methods This is a retrospective case series of XEN45 Gel Stent surgeries performed on 16 eyes and GDD surgeries performed on seven eyes. Patient demographics, disease characteristics, and complications are reviewed. The intra- and postoperative course of five select cases with complications are described in detail. Results The most frequent complications following XEN45 implantation were transient hypotony (10 eyes, 63%), reduced visual acuity (VA) (five eyes, 31%), choroidal effusion (three eyes, 19%), hyphema (two eyes, 13%), and intraocular pressure (IOP) spike (two eyes, 13%). Thirteen eyes (81%) required bleb needling, and three eyes (19%) required XEN45 replacement. Complications following GDD implantation included hypotony (three eyes, 43%), reduced VA (two eyes, 29%), choroidal effusion (two eyes, 29%), IOP spike (two eyes, 29%), implant exposure (two eyes, 29%), and shallow anterior chamber (one eye, 14%). Three eyes (43%) required revision or explantation with a secondary glaucoma surgery. One choroidal effusion following XEN45 surgery and one following GDD surgery were hemorrhagic choroidal effusions requiring surgical drainage. Conclusion Significant and potentially sight-threatening complications may occur following XEN45 Gel Stent and GDD implantation performed over the course of fellowship training. Glaucoma fellows should be ably equipped to recognize, diagnose, and manage these complications both intra- and postoperatively.

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.

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.

A 4-Year Retrospective Study: Clinical Outcomes of XEN45 in Patients with Glaucoma.

INTRODUCTION: The main purpose of the current study was to evaluate the long-term effectiveness and safety of XEN45 implant, either alone or in combination with cataract surgery, in patients with glaucoma. METHODS: Retrospective and single center study conducted on consecutive patients who underwent a XEN45 implant, either alone or in combination with cataract surgery, between November 2016 and October 2021. The primary endpoint was the mean intraocular pressure (IOP) lowering from preoperative values. RESULTS: Among the 230 screened patients, 206 eyes (176 patients) were included. Fifty-three (25.7%) eyes had undergone XEN alone and 153 (74.3%) eyes had undergone a combined procedure (XEN+phacoemulsification). The mean preoperative IOP was significantly higher in the XEN-alone (22.2 ± 5.9 mm Hg) than in the XEN+Phaco (19.8 ± 4.5 mm Hg) group (p = 0.0035). In the overall study population, the mean preoperative IOP was significantly lowered from 20.5 ± 5.0 mm Hg to 15.8 ± 4.4 at year-4, p < 0.0001. The mean preoperative (95% confidence interval) IOP was significantly lowered from 22.2 (20.6-23.8) mm Hg and 19.8 (19.1-20.6) mm Hg to 15.6 (12.2-16.9) mm Hg and 15.9 (15.2-16.5) mm Hg at year-4 in the XEN-alone and XEN+Phaco groups, respectively (p < 0.0001 each, respectively). The number of ocular hypotensive medications was significant reduced from 2.6 ± 1.0 drugs to 1.3 ± 1.3 drugs, with no significant differences between XEN-alone and XEN+Phaco groups (p = 0.1671). On the first postoperative day, 62 (30.1%) eyes presented some type of complication. Fifteen (7.3%) eyes underwent a needling procedure. CONCLUSION: XEN45, either alone or in combination with phacoemulsification, significantly lowered the IOP and reduced the need of ocular hypotensive medication in the long-term.