Surgical technique, perioperative management and early outcome data of the PAUL® glaucoma drainage device.

OBJECTIVES: To describe a surgical technique and early post-operative outcomes for a novel glaucoma drainage device-the PAUL® glaucoma implant (PGI). METHODS: A consecutive cohort study of subjects who had PGI surgery between February 2019 and May 2020 with a minimum of 6-month follow-up. Primary outcome measures included failure (intraocular pressure (IOP) > 21 mmHg or a <20% reduction of IOP, removal of the implant, further glaucoma intervention or visual loss to no light perception). Secondary outcomes included mean IOP, mean number of medications, logMAR visual acuity (VA) and complications. RESULTS: Ninety-nine eyes of 97 patients had a preoperative IOP (mean ± standard deviation) of 28.1 ± 9.0 mmHg, falling to 18.2 ± 6.8 mmHg at 1 month, 17.9 ± 6.7 mmHg at 3 months and 13.6 ± 4.7 mmHg at 6 months. 52 patients had a 12-month mean IOP of 13.3 ± 4.4 mmHg. The mean change in number of medications was a reduction of 2.38 ± 1.48. A significant reduction in the number of medications and intraocular pressure was demonstrated after PGI (p < 0.0001). No significant change was demonstrated in VA (p = 0.1158). A total of nine cases were deemed failures (six had <20% IOP reduction from baseline and three had IOP >21 mmHg). Thirty-eight (38.4%) of eyes had complete success and achieved an unmedicated IOP <21 mmHg. Ninety (90.1%) of eyes were qualified successes (with or without topical medications). Seventy-four (74.7%) eyes have achieved an intraocular pressure of <15 mmHg. Two cases of hypotony were observed. CONCLUSION: This study presents a safe surgical technique, which significantly reduces IOP and number of medications with minimal complications.

Effectiveness of MicroShunt in Patients with Primary Open-Angle and Pseudoexfoliative Glaucoma: A Retrospective European Multicenter Study.

PURPOSE: To evaluate the effectiveness and safety of the Preserflo MicroShunt implant (Santen) in patients with primary open-angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG). DESIGN: Retrospective, open-label, multicenter study. PARTICIPANTS: Patients with insufficiently controlled primary POAG or PXG who underwent a standalone MicroShunt implantation procedure. METHODS: Consecutive patients with POAG and PXG who underwent surgery with the ab externo minimally invasive glaucoma surgery device Preserflo MicroShunt with mitomycin C. MAIN OUTCOME MEASURES: Primary end points were mean change in intraocular pressure (IOP) and number of hypotensive medications from baseline through month 12. Success was defined as an IOP of 18 mmHg or less and an IOP reduction of 20% or more, with (qualified) or without (complete) any hypotensive medication. RESULTS: Among the 130 patients who underwent MicroShunt implantation, 104 fulfilled the inclusion and exclusion criteria and were included in the analysis. Eighty-one eyes (77.9%) were diagnosed with POAG and 23 eyes (22.1%) were diagnosed with PXG. The mean age was 71.4 ± 12.6 years, and 45 patients (43.3%) were women. Mean IOP was lowered significantly from 25.1 ± 6.5 mmHg at baseline to 14.1 ± 3.4 mmHg at month 12 (P < 0.0001). At month 12, 27 eyes (26.0%) were categorized as complete successes and 61 eyes (58.7%) were categorized as qualified successes. The mean number of hypotensive medications was reduced significantly from 3.0 ± 1.0 medications at the preoperative visit to 0.77 ± 0.95 medication at month 12 (P < 0.001). Throughout the study, 19 eyes (18.3%) required needling and 14 eyes (13.5%) underwent surgical revision. Eight eyes (7.7%) showed hyphema and 5 eyes (4.8%) showed choroidal detachment. These were resolved with medical therapy without sequelae. Four patients underwent subsequent surgeries, and 2 patients underwent trabeculectomy (at months 3 and 6): One patient underwent transscleral cyclophotocoagulation at month 3 and 1 patient underwent MicroPulse cyclophotocoagulation at month 4. CONCLUSIONS: In this retrospective study, the MicroShunt effectively lowered IOP and the need for IOP-lowering medications.

Management of Corneal Clouding in Patients with Mucopolysaccharidosis.

Mucopolysaccharidoses (MPS) are a rare group of lysosomal storage disorders characterized by the accumulation of incompletely degraded glycosaminoglycans (GAGs) in multiple organ systems including the eye. Visual loss occurs in MPS predominantly due to corneal clouding and retinopathy, but the sclera, trabecular meshwork and optic nerve may all be affected. Despite the success of therapies such as enzyme replacement therapy (ERT) and hematopoietic stem-cell transplantation (HSCT) in improving many of the systemic manifestations of MPS, their effect on corneal clouding is minimal. The only current definitive treatment for corneal clouding is corneal transplantation, usually in the form of a penetrating keratoplasty or a deep anterior lamellar keratoplasty. This article aims to provide an overview of corneal clouding, its current clinical and surgical management, and significant research progress.

Manchester iStent study: long-term 7-year outcomes.

OBJECTIVES: To determine the efficacy and safety of combined phacoemulsification and single first-generation iStent implantation over 84 months. SUBJECTS/METHODS: Single-surgeon, single-centre, uncontrolled prospective interventional study in real-world settings. Forty-one patients with open-angle glaucoma on at least one antihypertensive drop underwent phaco-iStent surgery. This cohort was monitored over the subsequent 84 months. The primary outcome measure was intraocular pressure (IOP). Secondary outcome measures were number of glaucoma drops, visual acuity, cup-disc-ratio (CDR), mean deviation (MD) and visual field index (VFI). Thirty-one (76%) patients survived to 48 months and 19 (46%) patients to 84 months. RESULTS: At 84 months, we demonstrate an absolute mean reduction of 4.87 mmHg (95% CI 1.62-7.64) for IOP and 0.59 (95% CI 0.03-1.16) for number of glaucoma drops. At the final clinic visit, LogMAR VA improved by 0.21 (95% CI 0.08-0.34), with no significant change in CDR, MD and VFI. Attrition was mainly due to death (27%) and further glaucoma surgery (12%). A single patient suffered from postoperative hyphaema, with no sequalae. Patients at high risk for progression to filtration surgery were defined as those on oral acetazolamide for IOP control, or those fulfilling all the following criteria: IOP ≥ 20 mmHg, CDR ≥ 0.7, MD ≤ -4.0 dB, number of drops ≥ 2. This group is to be considered for surgery as the next step in management according to NICE glaucoma guidelines. These patients (n = 14) demonstrated a more marked final IOP reduction of 6.85 mmHg (95% CI 3.97-9.75) vs 1.62 mmHg (95% CI 0.04-3.22) in their low-risk counterparts (n = 27). Reduction in glaucoma drops was 0.86 (95% CI 0.07-1.64) for the high-risk and 0.56 (95% CI 0.06-1.05) for the low-risk cohort. Further glaucoma surgery was required for 4 (29%) high-risk and 1 (0.5%) low-risk patients over the study period. CONCLUSIONS: Our results strongly suggest that the expected outcome of phaco-iStent surgery is a maintained reduction in intraocular pressure and number of glaucoma medications over 7 years. This is combined with a negligible rate of complications, a sustained improvement in central visual acuity, and a reliable maintenance of peripheral visual function.

Subconjunctival Ab Externo Gel Stent Implantation for Refractory Glaucoma After High-Risk Penetrating Keratoplasty.

This case study reports the successful deployment of the XEN45 gel stent (AbbVie Inc, Chicago, IL) through an ab externo approach in a 73-year-old woman with refractory glaucoma following high-risk penetrating keratoplasty (PK) 10 years prior. The PK was for corneal perforation secondary to peripheral ulcerative keratitis, which required systemic immunosuppression comprising intravenous cyclophosphamide, azathioprine, and corticosteroids to stabilise the disease and prevent corneal graft rejection. The patient's intraocular pressure was reduced from 40 mmHg preoperatively to 12 mmHg six months after surgery, off medication. The patient's visual acuity and visual fields remained stable. The XEN45 gel stent utilising the ab externo approach can be considered as a potential tool to lower intraocular pressure in patients with glaucoma after corneal keratoplasty.

Technique of Xen Implant Revision Surgery and the Surgical Outcomes: A Retrospective Interventional Case Series.

PURPOSE: The Xen® Gel Stent (Allergan, Irvine, CA, USA) is a minimally invasive glaucoma surgery device implanted to reduce intra-ocular pressure (IOP) in glaucoma. The stents can fail to drain post-operatively due to scarring of the conjunctiva around the stent opening. Data on the success rates of revision surgery in patients with Xen stent failure are scarce. We present the first detailed report of the steps, outcomes and complications of Xen revision surgery with 12 months of follow-up data. METHODS: We share our experiences on the circumstances in which to perform Xen revision surgery, the steps of the surgery and the results of a retrospective interventional case series of all Xen revisions performed at a single centre from 2013 to 2018. RESULTS: A total of 151 Xen implants were inserted into eyes at our tertiary centre during the study period, of which 21 eyes (patients) underwent revision surgery. Mean pre-operative IOP was 26.1 (standard deviation 8.3) mmHg with the patient on two drops of anti-glaucoma medication. Four patients were excluded from the analysis due to incomplete data (medical records were unavailable for 2 patients; 1 patient died shortly after surgery; and 1 patient moved to another area). A non-functioning Xen implant was identified in another patient during revision surgery, and the procedure was converted to a trabeculectomy. The remaining 16 patients were included in the analysis, all of whom had a minimum follow-up of 12 months, with the longest follow-up being 4 years following revision surgery. Of these 16 patients, four required needling and 5-fluorouracil injection in the first 12 months following revision surgery, three required further glaucoma drainage surgery due to the failure of the revision surgery to control IOP in the first year and one suffered bleb-related endophthalmitis at the site of previous trabeculectomy surgery. Mean IOP at 12 months following revision surgery was 16.3 (standard deviation 3.7) mmHg on 0.7 drops of anti-glaucoma medication, which equates to a 37.5% reduction in IOP and a 65% reduction in the amount of IOP-lowering drops required. CONCLUSION: Our study shares experience on when to perform Xen revision surgery and the steps required. The results of our small cohort are the first in the literature and show that revisions can achieve promising IOP and medication reductions. Some patients still require needling in the post-operative period to optimise outcomes.

Trabeculectomy Training: Review of Current Teaching Strategies.

The aim of this paper is to introduce readers to potential strategies available for teaching trabeculectomy surgery. Trainee surgical outcomes and various surgical simulation techniques are discussed, with suggestions on how to measure progress and consideration of relevant educational theories.

Conjunctival bleb compression as a treatment for hypotony post XEN45 implant in uveitic glaucoma.

PURPOSE: Over-filtration and subsequent hypotony are recognised complications of penetrating glaucoma procedures, especially when augmented with antimetabolites. Patients with uveitis are especially at risk of hypotony and this can reduce the final acuity achieved, compromise surgical outcomes and adversely affect the inflammatory status. The incidence of hypotony following XEN45 implant insertion is higher for uveitic patients and we present a method of surgically addressing this hypotony with transconjunctival compression sutures that are placed over the overdraining XEN45 implant. METHODS: We present a retrospective case series of consecutive uveitic glaucoma patients who had conjunctival compression sutures between 2015 and 2018 following XEN45 insertion, at the Manchester Royal Eye Hospital, UK. Two 9/0 nylon sutures were placed in a horizontal figure-of-eight conformation transconjunctivally across the overdraining bleb: one directly over the XEN45 implant and one at the posterior limit of the implant in order to restrict flow. RESULTS: Three patients underwent conjunctival compression sutures following XEN45 implant-related hypotony and all three had successful resolution of their hypotony and visual symptoms. No patients required long-term topical agents to control their intraocular pressure. CONCLUSION: Conjunctival compression sutures are an effective option for addressing persistent hypotony following XEN45 implant insertion in patients with uveitic glaucoma.

A Prospective Randomized Trial Comparing Hydrus and iStent Microinvasive Glaucoma Surgery Implants for Standalone Treatment of Open-Angle Glaucoma: The COMPARE Study.

PURPOSE: To compare the efficacy of different microinvasive glaucoma surgery (MIGS) devices for reducing intraocular pressure (IOP) and medications in open-angle glaucoma (OAG). DESIGN: Prospective, multicenter, randomized clinical trial. PARTICIPANTS: One hundred fifty-two eyes from 152 patients aged 45 to 84 years with OAG, Shaffer angle grade III-IV, best-corrected visual acuity (BCVA) 20/30 or better, and IOP 23 to 39 mmHg after washout of all hypotensive medications. Eyes with secondary glaucoma other than pseudoexfoliative or pigmentary glaucoma, angle closure, previous incisional glaucoma surgery, or any significant ocular pathology other than glaucoma were excluded. INTERVENTION: Study eyes were randomized 1:1 to standalone MIGS consisting of either 1 Hydrus Microstent (Ivantis, Inc, Irvine, CA) or 2 iStent Trabecular Micro Bypass devices (Glaukos Inc, San Clemente, CA). Follow-up was performed 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. MAIN OUTCOME MEASURES: Within-group and between-group differences in IOP and medications at 12 months and complete surgical success defined as freedom from repeat glaucoma surgery, IOP 18 mmHg or less, and no glaucoma medications. Safety measures included the frequency of surgical complications, changes in visual acuity, slit-lamp findings, and adverse events. RESULTS: Study groups were well matched for baseline demographics, glaucoma status, medication use, and baseline IOP. Twelve-month follow-up was completed in 148 of 152 randomized subjects (97.3%). At 12 months, the Hydrus had a greater rate of complete surgical success (P < 0.001) and reduced medication use (difference = -0.6 medications, P = 0.004). More Hydrus subjects were medication free at 12 months (difference = 22.6% P = 0.0057). Secondary glaucoma surgery was performed in 2 eyes in the 2-iStent group (3.9%) and in none of the Hydrus eyes. Two eyes in the Hydrus group and 1 in the 2-iStent group had BCVA loss of ≥2 lines. CONCLUSION: Standalone MIGS in OAG with the Hydrus resulted in a higher surgical success rate and fewer medications compared with the 2-iStent procedure. The 2 MIGS devices have similar safety profiles.

Urgent Management of Secondary Glaucoma in Uveitis Using the Xen-45 Gel Stent.

PRECIS: The Xen-45 implant is an effective and safe treatment option for patients with medically uncontrolled glaucoma in the setting of uveitis, including those where urgent surgical intervention is required. PURPOSE: The purpose of this study was to report the efficacy and safety of the Xen-45 gel stent in eyes with glaucoma secondary to uveitis. METHODS: Retrospective observational case series of 37 eyes, with medically uncontrolled glaucoma in uveitis using Xen-45 implantation. All patients had at least 12 months follow-up. Primary outcome measures included visual acuity, intraocular pressure (IOP), degree of inflammation and ocular hypotensive medications. In addition, the time taken from the decision to surgery was recorded. Data were collected preoperatively and 1 day, 1 week, 1, 3, 6, and 12 months postoperatively. Postoperative complications included hypotony and decompressive retinopathy. The requirement for further glaucoma surgery, including bleb needling, and failure were documented. RESULTS: The mean follow-up time was 16.7 months (range: 12 to 32 mo). Preoperatively all patients were on >3 ocular hypotensive medications and 75.7% were on oral acetazolamide. Systemic immunosuppression was used in 62.2% and all were on topical steroids. Mean preoperative IOP was 36.1 mm Hg (±SD 9.6) on an average 3.69 (±SD 0.47) drops. The median time from decision to operate to surgery was 5.5 days (range: 1 to 120 d). Mean postoperative IOP was 12.6 mm Hg (±SD 4.1) with an average 0.62 (±SD 1.1) drops at 1 year representing a 65% drop in IOP and 83% reduction in IOP-lowering medication. Bleb needling with 5-fluorouracil was performed on 5 eyes (13.5%). Symptomatic hypotony occurred in 7 eyes requiring further interventions. No decompressive retinopathy was found at last follow-up. Five eyes (13.5%) failed, needing drainage tube surgery or trabeculectomy. CONCLUSIONS: The Xen-45 implant is an effective treatment for hypertensive crises in glaucoma in uveitis, offering dramatic IOP lowering without significant uveitis flare-up. In this group of patients with uveitis, needling rates are lower than reported in primary open-angle glaucoma. However, complications including hypotony can still occur.

Five-Year, Prospective, Randomized, Multi-Surgeon Trial of Two Trabecular Bypass Stents versus Prostaglandin for Newly Diagnosed Open-Angle Glaucoma.

PURPOSE: To evaluate 5-year safety and efficacy of 2 trabecular micro-bypass stents versus prostaglandin as initial stand-alone treatment for newly diagnosed, treatment-naive primary open-angle glaucoma (POAG). DESIGN: Prospective, randomized, controlled, multi-surgeon clinical trial. PARTICIPANTS: Enrolled eyes (n = 101) were phakic and had a confirmed POAG diagnosis, normal angle anatomy, mean diurnal intraocular pressure (IOP) 21 to 40 mmHg, and vertical cup-to-disc (C:D) ratio ≤0.9. METHODS: Eyes were randomized (1:1) to receive either 2 stents (iStent trabecular micro-bypass; Glaukos Corporation, San Clemente, CA) or once-daily topical travoprost. MAIN OUTCOME MEASURES: The primary and secondary efficacy end points were the change from screening in mean diurnal IOP at months 12 and 24, respectively, without glaucoma surgery or add-on medication (any medication in stent eyes or a second medication in travoprost eyes). Two additional secondary end points were the proportion of eyes achieving treatment success at months 12 and 24, defined as IOP 6 to 18 mmHg without additional medication or glaucoma surgery. This report shows these efficacy measures through 60 months. Safety measures included best-corrected visual acuity, C:D ratio, visual field, pachymetry, complications, and adverse events. RESULTS: Of 101 enrolled eyes (54 stent eyes, 47 travoprost eyes), 90 eyes (49 stent eyes, 41 travoprost eyes) completed 5-year follow-up. Five-year mean diurnal IOP was 16.5±1.2 mmHg in stent eyes (35.3% reduced vs. 25.5±2.5 mmHg preoperatively; P < 0.0001) and 16.3±1.9 mmHg in travoprost eyes (35.1% reduced vs. 25.1±4.6 mmHg preoperatively; P < 0.0001). During follow-up, add-on medication was initiated in 12 stent eyes (22.2% of the initial 54-eyes) and 18 travoprost eyes (38.3% of the initial 47-eyes). By 5 years, 17% (6/35) of stent eyes and 44% (14/32) of travoprost eyes needed add-on medication to control IOP (P = 0.017). Treatment success was achieved in 77% (27/35) of stent eyes and 53% (17/32) of travoprost eyes (P = 0.04). Both groups exhibited excellent safety. CONCLUSIONS: This prospective randomized trial demonstrates 5-year effectiveness and safety of 2 trabecular bypass stents in patients with newly diagnosed, treatment-naive POAG, with comparably favorable outcomes as topical prostaglandin.

"Minimally Invasive Glaucoma Surgery (MIGS) Is a Poor Substitute for Trabeculectomy"-The Great Debate.

Surgical treatment for glaucoma has undergone a dramatic change over the last decade. Trabeculectomy has been the main surgical procedure worldwide for almost 50 years. However, there is a growth in development of new novel devices and surgical techniques designed to lower intraocular pressure in a less invasive fashion. The term minimally invasive glaucoma surgery (MIGS) has been coined and is the subject of investment, debate and, increasingly, research. The position of MIGS in the glaucoma treatment paradigm is yet to be clearly defined and its ability to replace conventional filtration surgery remains debatable. In this paper two glaucoma specialists were invited to debate the motion that "MIGS is a poor substitute for trabeculectomy".

Conjunctival bleb compression sutures: An effective method of addressing hypotony after trabeculectomy or trabeculectomy-related procedures.

PURPOSE:: Over-filtration is a well-known complication of trabeculectomy and related procedures, especially with adjunctive antimetabolites. Secondary hypotony can result in reduced visual acuity and compromise long-term surgical success. Persistent hypotony requires intervention and we describe an effective adaptation of placing conjunctival compression sutures directly over the scleral flap. METHODS:: A retrospective consecutive case series of all patients who underwent conjunctival compression suturing from 2012 to 2014 at Manchester Royal Eye Hospital, UK. Under sub-tenon's anaesthesia, two 9/0 nylon figure-of-eight transconjunctival sutures were placed horizontally across the bleb: the first over the anterior flap/ostium and the second over the posterior flap edge to reduce flow through the trabeculectomy flap. RESULTS:: A total of 10 patients underwent conjunctival compression suturing, and all patients had successful reversal of hypotony and symptom resolution within 1 week with corresponding clinical improvement. Intraocular pressure control was maintained without topical pressure-lowering agents in seven patients (median = 10 mmHg, range = 7-12 mmHg) with a median follow-up of 35.9 months (range = 11-61 months). Two patients required topical therapy to maintain intraocular pressure ≤ 14 mmHg and one patient's hypotony returned after 10 months but remained untreated due to pre-existing poor vision. No patients required a return to theatre. CONCLUSION:: This series demonstrates that conjunctival compression sutures can successfully provide long-term control of trabeculectomy-bleb-related hypotony. This technique offers an effective alternative for glaucoma surgeons in addressing post-trabeculectomy hypotony.

Evaluation of a Schlemm canal scaffold microstent combined with phacoemulsification in routine clinical practice: Two-year multicenter study.

PURPOSE: To evaluate the efficacy and the safety of a new Schlemm canal scaffold microstent (Hydrus) combined with cataract surgery in routine clinical practice. SETTINGS: Clinics in Italy, Poland, and the United Kingdom. DESIGN: Retrospective case series. METHODS: Clinical outcomes in patients with primary open-angle glaucoma who had combined phacoemulsification and microstent implantation were analyzed. Data (intraocular pressure [IOP], number of glaucoma medications, incidence of complications) were collected preoperatively and postoperatively through 24 months. RESULTS: Ninety-two eyes were included. Six patients had previous glaucoma surgeries. Sixty-seven patients completed a 2-year follow-up. The mean baseline IOP was 19.4 mm Hg ± 4.4 (SD). The mean IOP was 15.5 ± 2.7 mm Hg at 1 year and 15.7 ± 2.5 mm Hg at 2 years (P < .001). The IOP reduction was correlated with the baseline IOP (R2 = 0.72). The mean number of glaucoma medications was 2.1 ± 1.0 preoperatively, decreasing significantly at 1 year (0.6 ± 1.0) and 2 years (0.7 ± 1.0) (P < .001). At 2 years, 64% of patients were medication free. In patients with an IOP of 18 mm Hg or higher preoperatively, the reduction in IOP and in the number of medications was higher. Two patients required microstent repositioning intraoperatively. One patient was treated with an argon laser for microstent obstruction, and 1 patient had a trabeculectomy at 18 months. CONCLUSION: This microstent combined with cataract surgery safely and effectively reduced the IOP and medication use in a routine clinical practice setting with results comparable to those in previously published controlled clinical trials.

Vascularisation of the anterior lens capsule in an eye with excellent visual acuity.

A 53-year-old phakic female with a history of nanophthalmos and hyperopia was incidentally found to have unilateral neovascularisation on the left inferoanterior lens surface on routine review for ocular hypertension.

Newly Diagnosed Primary Open-Angle Glaucoma Randomized to 2 Trabecular Bypass Stents or Prostaglandin: Outcomes Through 36 Months.

PURPOSE: To examine outcomes through 36 months in phakic eyes with newly diagnosed primary open-angle glaucoma (POAG) naïve to therapy randomized to treatment with two trabecular micro-bypass stents or topical prostaglandin. METHODS: Subjects with POAG naïve to therapy, with intraocular pressure (IOP) ≥21 and ≤40 mmHg, were randomized to implantation of two stents or travoprost. Additional medication was to be prescribed post-treatment for elevated IOP or glaucomatous optic nerve findings. Of 101 randomized subjects, 100 subjects were followed for 24 months and 73 subjects were followed for 36 months. Follow-up on all subjects is ongoing. RESULTS: In this randomized cohort of 101 POAG subjects, 54 subjects underwent 2-stent surgery and 47 received topical travoprost. Mean pre-treatment IOP was 25.5 ± 2.5 mmHg in stent-treated eyes and 25.1 ± 4.6 mmHg in medication-treated eyes. By 3 years, mean IOP was 14.6 mmHg in stent eyes (with medication added in 6 eyes) and 15.3 mmHg in travoprost eyes (with a second medication added in 11 eyes). In the subset of eyes that did not require additional medical therapy, mean IOP was 14.5 mmHg and 15.7 mmHg in the respective groups. Ninety-one percent of stent eyes had 3-year IOP ≤18 mmHg without additional therapy (62% ≤ 15 mmHg) and 79% of travoprost eyes had 3-year IOP ≤18 mmHg (21% ≤ 15 mmHg). Safety was favorable in both groups. CONCLUSIONS: In this prospective, randomized comparison of subjects with newly diagnosed POAG naïve to therapy, substantial IOP reduction with a favorable low complication rate was shown through 3 years after either 2 trabecular stents implanted as the sole procedure or topical travoprost therapy. These data suggest 2-stent implantation may be a viable initial treatment option comparable to topical prostaglandin in newly diagnosed POAG patients. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT01443988. FUNDING: Glaukos Corporation, Laguna Hills, CA.

The New Era of Glaucoma Micro-stent Surgery.

Minimally invasive glaucoma surgery (MIGS) has been gaining popularity over the last decade. Although there is no strict definition for MIGS, all the new procedures share the common theme of intraocular pressure reduction with minimal tissue destruction, short surgical time, simple instrumentation and fast postoperative recovery. The use of glaucoma drainage implants has long been the traditional treatment for complex glaucoma, but a new wave of glaucoma micro-stents are now being manufactured with various materials designed to increase aqueous outflow via different channels. This review summarises the current published literature on these devices, including Sclemm's canal stents (iStent, Hydrus), Suprachoroidal stents (CyPass, iStent supra), and subconjunctival stents (Xen, Innfocus).