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.

Comparison of 1-year effectiveness between phaco-microhook ab-interno trabeculotomy and phaco-iStent trabecular micro-bypass stent in primary open-angle glaucoma with low-teen intraocular pressure.

PURPOSE: To investigate the surgical effectiveness of combined cataract surgery with microhook ab-interno trabeculotomy (phaco-µLOT) or iStent trabecular micro-bypass stent (phaco-iStent) in eyes with primary open-angle glaucoma (POAG) and preoperative intraocular pressure (IOP) controlled below 15 mmHg (low-teen IOP). METHODS: This retrospective cohort study included consecutive patients with POAG and low-teen IOP who underwent phaco-µLOT or phaco-iStent as their initial glaucoma surgery and were followed up for 1 year postoperatively. Surgical failure was defined as the inability to achieve the following criteria twice in a row: (A) IOP of 6-15 mmHg with over 20% IOP reduction; (B) IOP of 6-12 mmHg with over 20% IOP reduction. RESULTS: A total of 75 eyes from 75 subjects were included, with 48 in the phaco-µLOT group and 27 in the phaco-iStent group. The mean preoperative IOP and number of antiglaucoma medications were 13.1 ± 2.1 mmHg and 3.4 ± 0.9 in the phaco-µLOT group, and 12.6 ± 2.0 mmHg and 2.5 ± 1.2 in the phaco-iStent group, respectively. The number of antiglaucoma medications was significantly reduced to 2.5 ± 0.9 (phaco-µLOT) and 2.0 ± 1.1 (phaco-iStent) at 1-year postoperatively (all p < 0.05). For criteria A and B, the survival rates were significantly higher in the phaco-µLOT group than in the phaco-iStent group (all p < 0.01). CONCLUSION: Both phaco-µLOT and phaco-iStent hold promise in reducing the need for antiglaucoma medications in POAG eyes with low-teen IOP. Phaco-µLOT may be more effective than phaco-iStent in controlling IOP. KEY MESSAGES: What is known Minimally invasive glaucoma surgeries (MIGS) procedures target the pressure gradient pathways in patients with higher preoperative intraocular pressure (IOP) levels, however, evidence on their effectiveness in normotensive glaucoma patients remains limited. What is new Combined cataract surgery with microhook ab-interno trabeculotomy (phaco-µLOT) or iStent trabecular micro-bypass stent (phaco-iStent) significantly reduced the number of antiglaucoma medications in primary open-angle glaucoma (POAG) eyes with preoperative IOP controlled below 15 mmHg (low-teen IOP). Phaco-µLOT may be more effective than phaco-iStent in controlling IOP. These procedures should be limited to reducing the number of antiglaucoma medications used, as they did not significantly reduce the postoperative IOP in POAG eyes with low-teen IOP.

Ab Interno Intraluminal Stent Insertion for Prolonged Hypotony After PreserFlo MicroShunt Implantation.

This study aimed to present an effective and minimally invasive method for treating prolonged hypotony after PreserFlo MicroShunt (PMS) implantation, which can cause serious complications. A 79-year-old man with primary open-angle glaucoma of the right eye underwent ab interno intraluminal stent insertion for prolonged hypotony after PMS implantation. After making two corneal incisions at the 5 and 8 o'clock positions in the right eye, a viscoelastic material was injected into the anterior chamber. A 10-0 nylon suture was inserted into the anterior chamber through a corneal incision in the 5 o'clock position. Next, the 10-0 nylon suture was grasped and inserted into the PMS lumen as a stent with forceps, following which it was cut approximately 1 mm from the tip of the PMS using micro-iris scissors. Finally, the viscoelastic material in the anterior chamber was washed with a balanced salt solution, and self-closure of the two corneal incisions was confirmed. After ab interno intraluminal stent insertion, hypotony improved and stabilized at approximately 10 mmHg. The shallow anterior chamber, choroidal detachment, and hypotonic maculopathy improved rapidly. This novel technique demonstrated effectiveness and minimal invasiveness in treating prolonged hypotony after PMS implantation.

Minimally Invasive Direct Internal Cyclopexy in the Management of Goniotomy-Related Cyclodialysis Cleft with Hypotony Maculopathy.

Introduction: Although ab-interno trabeculotomy-related (goniotomy-related) surgeries has a favorable safety profile, cyclodialysis cleft refractory to conservative management could occur, thereby requiring additional surgical treatment. External and, more recently, internal cycloplexy have been attempted to treat cyclodialysis clefts with hypotony maculopathy, however the traditional methods require conjunctival or scleral incisions and have been inappropriate for glaucoma patients who need to undergo future trabeculectomy. Therefore, we report two cases who underwent a novel reliable technique for suture fixation of the detached ciliary body onto the original scleral bed directly through the intraocular approach without conjunctival or scleral incision, minimally invasive direct internal cyclopexy, in the management of goniotomy-related cyclodialysis cleft with hypotony maculopathy. Case Description: Goniotomy-related cyclodialysis cleft exceeded 45° and vision-threatening hypotony maculopathy was observed in two eyes in two patients with normal tension glaucoma and myopia gravis without a prior history of trauma who had undergone Kahook Dual Blade goniotomy combined with cataract surgery. The patients were followed conservatively for a while, however the cyclodialysis clefts and hypotony maculopathies did not resolve. Therefore, a 72-year-old man underwent minimally invasive direct internal cyclopexy on postoperative day 65 after the goniotomy, and another 67-year-old man underwent minimally invasive direct internal cyclopexy on postoperative day 149. In both cases, topical antibiotic and steroid eye drops were prescribed postoperatively. The cyclodialysis clefts were repaired successfully; however, the latter patient developed delayed-onset acute transient ocular hypertension 33 days after minimally invasive direct internal cyclopexy and required glaucoma medications. The hypotony maculopathies resolved approximately 3 months after suturing, and eventually visual acuity improved from preoperative levels and good intraocular pressure control was achieved in both. No further postoperative complications have been observed to date. Conclusion: We successfully managed two cases of goniotomy-related cyclodialysis cleft with hypotony maculopathy using minimally invasive direct internal cyclopexy.

Gas Tamponade Improved Cilio-Choroidal Effusion Induced by an Ab Interno Trabeculotomy with a Microhook: Two Cases.

Purpose: We treated two patients with ciliary detachment due to an ab interno trabeculotomy. The ciliary detachment was improved by the use of sulfur hexafluoride (SF6) gas or octafluoro propane (C3F8) tamponade. Patients and Methods: Patient 1 was a 52-year-old Brazilian man with primary open angle glaucoma (POAG). His preoperative intraocular pressure (IOP) was 29 mmHg. Patient 2 was a 57-year-old Japanese woman with POAG. Her preoperative IOP was 35 mmHg. Both patients underwent an ab interno trabeculotomy with a microhook. They caused ciliary detachment as a postoperative complication. We could observe their ciliary detachment with anterior segment optical coherence tomography (AS-OCT). Hypotony persisted for 2 months and the patients' ciliary detachment had not improved. They each underwent a pars plana vitrectomy (PPV) with simultaneous 20% SF6 filling. Results: In Patient 1, the use of the SF6 gas tamponade successfully attached the ciliary body. His IOP was increased to 30 mmHg after this resolution of the ciliary detachment. He underwent additional tube shunt surgery. For Patient 2, the SF6 gas tamponade improved the ciliary detachment but the ciliary body could not be attached. We injected 0.6 cc of 100% C3F8 gas into the vitreous cavity, and this gas tamponade was able to attach the ciliary body. Conclusion: AS-OCT is very useful to evaluate ciliary detachment. PPV+Gas tamponade can be a treatment option for ciliary detachment.

Navigating hypotony challenges with XEN gel implantation.

INTRODUCTION: The XEN Gel, a hydrophilic tube meticulously crafted to adhere to the principles of the Hagen - Poiseuille law, is designed to facilitate efficient aqueous shunting without inducing hypotony. Implantable ab interno or ab externo, with or without conjunctival opening, the device shows no significant outcome differences. Despite numerical hypotony signaling failure, patients may fare well below 6 mmHg. AREAS COVERED: This review provides insights into device variability, challenges related to hypotony, associated risk factors, and hypotony management. EXPERT OPINION: The progressive evolution of the XEN Gel constitutes a significant advancement in the field of glaucoma management. Comparative studies investigating diverse implantation methodologies, particularly the ab interno and closed conjunctival approaches, highlight the device versatility in addressing individual patient needs. Exploring hypotony from both statistical and clinical perspectives challenges the traditional view of intraocular pressure as a straightforward success or failure indicator. The incidence of hypotony-related issues varies between device models, emphasizes the need for an individualized approach during device selection. Overall, understanding the dynamics of hypotony is crucial for optimizing the outcomes of XEN Gel implantation.

Early Outcomes of Combined Phacoemulsification and Ab Interno Tanito Microhook Trabeculotomy in Open-Angle Glaucoma.

PURPOSE: To study the early postoperative efficacy and safety of an Ab Interno microhook trabeculotomy (microLOT) combined with cataract surgery in patients with open-angle glaucoma. METHODS: This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and mild-moderate open-angle glaucoma. One hundred fourteen patients were included for analysis. The patients were randomized to undergo microhook trabeculotomy with phacoemulsification (group 1) or phacoemulsification alone (group 2). All patients were evaluated on postoperative day 1, 15, and 30, as well as 3, 6, and 12 months postoperatively. A P value < 0.05 was considered statistically significant. Baseline and follow-up visits were compared to determine significant differences in the number of antiglaucoma medications (AGMs), intraocular pressure (IOP), and best-corrected visual acuity. RESULTS: There were 57 patients in each group. The baseline characteristics were similar between the 2 groups, except the number of AGMs, which was greater in group 2. The mean preoperative IOP for group 1 (phaco-microLOT) was 26.5 mmHg ± 5.2 and group 2 (phaco-alone group) was 25.3 mmHg ± 3.1 which decreased to 12.5 mmHg ±3.6 (P < 0.001) and 20.0 mmHg ± 2.7(P < 0.001) at 12 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.48 (interquartile range [IQR], 0.30-0.60) preoperatively to 0.00 (0.00-0.18) postoperatively (P < 0001) in group 1 and improved from 0.30 (IQR, 0.30-0.48) to 0.00 (0.00-0.00) in group 2 (P < 0.001). In group 1, the mean (standard deviation [SD]) AGM used preoperatively was 0.6 (0.9) which was significantly reduced to 0.2 (0.5) at 12 months postoperatively, whereas in group 2, at 12 months, the mean (SD) AGM used was reduced from 1.4 (0.6) to 1.1 (0.9). In group 1, 90.3% of eyes achieved complete success at the end of 1 year. The most common complication was hyphema, noted in 4 patients with 1 eye requiring an anterior chamber washout. CONCLUSION: Ab interno microhook trabeculotomy (microLOT) combined with phacoemulsification in patients with open-angle glaucoma is an efficacious procedure with relatively minimal complications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Impact of glaucoma medications on subsequent Schlemm's canal surgery outcome: Cox proportional hazard model and propensity score-matched analysis.

PURPOSE: The impact of various preoperative glaucoma medications on Schlemm's canal surgery outcomes remains unclear. This study aimed to investigate the impact of preoperative glaucoma medications on the postoperative 1-year outcomes of µTLO. METHODS: We analyzed the medical records of 218 patients who underwent their first µTLO to investigate the 1-year postoperative outcomes. Cox proportional hazard regression analysis was performed with surgical failure as the dependent variable and each type of preoperative medication as the independent variable. We also compared the 1-year outcomes of µTLO between users and non-users of specific medications using propensity score matching. Surgical success was defined as a postoperative intraocular pressure ranging from 5 to 21 mmHg, a ≥20% reduction in IOP from baseline, and no additional glaucoma surgery within 1 year postoperatively. RESULTS: The Cox proportional hazard analysis showed that all drugs that do not increase the conventional outflow exhibited hazard ratios greater than 1.0, and the preoperative use of ß-blockers and oral CAI was a significant surgical risk factor (hazard ratio: 2.65 and 2.45, p = 0.04 and <0.001). In the propensity score matching analysis, success rates at 1 year postoperatively were 55/85, 54/79, 60/73, and 40/76% for users/non-users of ß-blockers, topical CAIs, an alpha-2 adrenergic agonist, and an oral CAI, respectively. Kaplan-Meier survival curves in these comparisons also demonstrated that preoperative ß-blockers and oral CAI use were significant surgical risks (p = 0.01, <0.001). CONCLUSION: Our study suggests that preoperative medications that do not involve conventional pathway outflow have a detrimental effect on subsequent Schlemm's canal surgery outcomes.

Comparison of the 1-year surgical outcomes of ab interno trabeculotomy using three types of microhooks.

PURPOSE: We compared the 1-year surgical outcomes of microhook ab interno trabeculotomy (µLOT) using three types of microhooks. METHODS: We retrospectively analyzed 81 eyes that underwent µLOT, in which three microhooks, the Sinskey hook, Tanito Micro-Hook-trabeculotomy-device (TMH), and Matsushita ed. TMH, were used. We collected the data from the medical records. We analyzed the success rates and risk factors. Failure was defined as the need for additional surgery for IOP reduction, loss of light perception, and IOP ≧22 mmHg and IOP reduction <20% (definition 1), IOP ≧17 mmHg and IOP reduction <20% (definition 2), IOP ≧15 mmHg and IOP reduction <25% (definition 3), or IOP ≧12 mmHg and IOP reduction <30% (definition 4) at two consecutive follow-up visits. RESULTS: Twenty-six eyes underwent µLOT using the Sinskey microhook (group S), 21 eyes using the TMH (group T), and 34 eyes using the Matsushita ed. TMH (group M). The mean postoperative IOP and IOP-lowering medication score decreased significantly. The respective success rates among groups S, T, and M did not differ significantly (definition 1, 65.4%, 61.9%, and 55.9%; definition 2, 42.3%, 47.6%, and 32.3%; definition 3, 15.4%, 28.6%, and 23.5%; definition 4, 0%, 9.5%, and 2.9%). In group S, the hyphema-related IOP spikes decreased within 2 weeks postoperatively, and in group M, the non-hyphema-related IOP spikes decreased significantly. CONCLUSION: The 1-year surgical outcomes and complications after µLOT did not differ significantly among the three microhooks. The differences in the microhook tips might be associated with postoperative transient IOP spikes.

Sulcus Tube Internal Needle Guidewire Technique for Glaucoma Drainage Device Placement: Improving Surgical Ease and Precision.

INTRODUCTION: Despite the rise of micro-invasive glaucoma surgery (MIGS), glaucoma drainage device implantation continues to be a mainstay among glaucoma surgical treatment options. Anterior chamber tube placement, while effective in reducing intraocular pressure (IOP), poses corneal endothelial risks. Ciliary sulcus tube placement shows promise in reduced corneal endothelial cell loss, but proper sulcus placement can be challenging. Our study describes the initial safety and effectiveness results using  a novel sulcus tube internal needle guidewire (STING) technique for glaucoma drainage device insertion into the ciliary sulcus. METHODS: We retrospectively reviewed the charts of all consecutive patients who underwent the STING technique using the Ahmed ClearPath, Ahmed Glaucoma Valve, or Baerveldt glaucoma implant with at least 6 months of follow-up. Demographic characteristics, type of glaucoma, previous medical and surgical treatment, pre- and postoperative IOP, pre- and postoperative medications, complications, and success rates were recorded. RESULTS: Out of nine eyes, seven resulted in qualified success (77.8%). Preoperative mean IOP was 23.8 ± 6.3 mmHg, and postoperative IOP decreased significantly to 14.9 ± 3.7 mmHg (p = 0.008). The average number of preoperative medications per patient was 4.4 ± 0.7, while the average number of postoperative medications per patient was reduced significantly to 3.6 ± 1.0 (p = 0.039). CONCLUSION: The STING technique is a novel method for placing a glaucoma drainage device into the ciliary sulcus, leading to IOP lowering with minimal complications. The STING technique is designed to improve surgical ease and increase anatomical precision of sulcus tube placement. Video available for this article.

The effect of axial length on the short-term outcomes of cataract surgery combined with ab interno trabeculotomy.

PURPOSE: Minimally invasive glaucoma surgery is safer and effective surgical modality for patients with glaucoma. To compare the effect of axial length (AL) on the surgical outcomes of combined cataract surgery and ab interno trabeculotomy (phaco-LOT), a retrospective, non-randomized comparative study was performed. METHODS: In total, 458 eyes of 458 open-angle glaucoma patients who underwent phaco-LOT and were followed-up without any intervention for at least 6 months were enrolled. All were divided into a long-AL group (AL ≥ 26.0 mm, 123 eyes) and a not-long-AL group (AL < 26.0 mm, 335 eyes). The principal outcomes were the changes in intraocular pressure (IOP) and medication scores. We also sought a correlation between postoperative IOP spike and hyphema. RESULTS: Significant postoperative reductions in IOP and medication scores were apparent in all subjects. The IOP reductions were significant at all timepoints in the not-long-AL group, but not until 1 month postoperatively in the long-AL group, and the IOP change was significantly lower in the long-AL group from postoperative day 1 to 3 months. On subanalysis of subjects by age, the microhook used, the pre-operative IOP, and the medication score, a significantly higher incidence of IOP spike was observed in the long-AL group in weeks 1 and 2 (both p < 0.05), but this did not correlate with hyphema status, implying that a different mechanism was in play. CONCLUSION: Phaco-LOT was effective regardless of AL, but the postoperative IOP decrease was lower and the early postoperative incidence of IOP spike was higher in long-AL eyes.

Comparison of Phaco-Tanito Microhook Trabeculotomy between Propensity-Score-Matched 120-Degree and 240-Degree Incision Groups.

This study compared the effectiveness and safety of 120-degree (nasal) and 240-degree (bilateral) incisions in Tanito Microhook Trabeculotomy (TMH) combined with cataract surgery in patients with open-angle glaucoma. From a pool of 185 eyes, 67 eyes from 67 subjects were selected for each incision group using propensity score matching to align age, sex, glaucoma type, and preoperative intraocular pressure (IOP). The study found that preoperative IOP, initially 18.6 mmHg in both groups, decreased to 13.2 mmHg in the nasal group and 12.8 mmHg in the bilateral group 12 months postoperatively, representing reductions of 29% and 31%, respectively. Similarly, medication scores decreased from 3.4 to 2.7 in the nasal group and from 3.1 to 2.5 in the bilateral group. Notably, the bilateral incision group exhibited a significantly higher hyphema red blood cell score compared to the nasal group (p < 0.0001). Across the study period, other parameters such as IOP, medication score, visual acuity, anterior chamber flare, corneal endothelial cell density, visual field mean deviation, and the frequency of surgical complications other than hyphema were similar between the groups. The study concluded that TMH combined with cataract surgery is equally effective and safe regardless of incision width, although narrower incisions resulted in reduced early postoperative hyphema.

Fellow-Eye Comparison between Phaco-Tanito Microhook Trabeculotomy and Phaco-iStent Inject W.

This study aims to compare the surgical efficacy and safety of the Tanito microhook trabeculotomy (TMH-CE) and iStent inject W (Inject-CE) when performed in combination with cataract surgery on the eyes of glaucoma patients. A total of 78 glaucomatous eyes from 39 participants were retrospectively analyzed. Intraocular pressure (IOP), the number of antiglaucoma medications, best-corrected visual acuity (BCVA), anterior chamber flare (ACF), and corneal endothelial cell density (CECD) were all evaluated preoperatively and at multiple postoperative time points. The preoperative IOP was significantly higher in the TMH-CE (19.6 ± 6.7 mmHg) than in the Inject-CE (15.7 ± 3.8 mmHg) (p < 0.0001). At the 12-month follow-up, reductions in IOP and the number of medications were more pronounced in the TMH-CE (6.6 mmHg, 27.6% and -1.1, respectively) group than Inject-CE (2.7 mmHg, 12.4% and -0.7, respectively) (p < 0.0001 and p = 0.0034), while the IOP and medication-number levels were identical between TMH-CE (13.0 ± 3.3 mmHg and 1.3 ± 0.9, respectively) and Inject-CE (12.9 ± 2.6 mmHg and 1.9 ± 0.9, respectively) (p = 0.88 and p > 0.99, respectively). The TMH-CE group exhibited a higher ACF, a higher frequency of layered hyphema, and a greater anterior chamber floating red blood cells score in the early postoperative periods. Despite these differences, the changes in BCVA, ACF, and CECD were equivalent between the two groups in later follow-up periods. TMH-CE provides a more significant IOP reduction and medication-number reduction compared to Inject-CE, while Inject-CE shows quicker BCVA recovery. This study provides valuable insights for ophthalmologists choosing the most suitable surgical approach for glaucoma and cataract patients.

Endoscopic cyclophotocoagulation for glaucoma compared to alternative procedures -A Systematic review.

INTRODUCTION: Despite many recent developments, preference in the choice of surgical treatment of uncontrolled intraocular pressure (IOP) remains a challenge. OBJECTIVE: This study compares the clinical efficacy and safety of endoscopic cyclophotocoagulation (ECP) to alternative surgical procedures, for all types of glaucoma. METHODOLOGY: The methodology adheres to the preferred reporting items for systematic reviews and meta-analyses guidelines for systematic review reporting. Studies reporting ECP and alternative surgeries in treating refractory glaucoma, neovascular glaucoma, aphakic glaucoma, filtering surgical failure-induced glaucoma, congenital or juvenile glaucoma, and secondary glaucoma such as uveitis glaucoma, traumatic glaucoma, secondary glaucoma postcorneal transplantation, etc. were included. The efficacy was evaluated from the number of IOP-lowering drugs, and mean change in pre- and post-IOP were the outcomes assessed in ECP and non-ECP groups in this review. Evaluations of the postoperative complications revealed the safety assessment of the procedure. RESULTS: In total, 11 relevant studies were selected in this study with a total of 5418 eyes, including 763 eyes in the ECP group and 4655 in the non-ECP group. This review observed that both ECP and non-ECP procedures had been successful in reducing postoperative IOP. CONCLUSION: It can be deduced from this review, that all types of glaucoma can be treated efficiently with significantly higher success rates with ECP and ECP demonstrates lowest postoperative complications when compared to non ECP procedures. This review provides updated scientific evidence which caters to support clinical decisions for surgical treatment of glaucoma.

Four-Year Outcome of XEN 45 Gel Stent Implantation in a Swedish Population.

Purpose: To report the long-time success rate of XEN 45 gel stent implantation in a Scandinavian population. Patients and Methods: This was a retrospective single-center analysis of all patients undergoing XEN 45 stent surgery between December 2015 and May 2017. The main outcome was success rate according to several definitions of success. Subgroup analysis was performed. Secondary outcomes were change in intraocular pressure (IOP) and number of IOP-lowering agents. Need for secondary glaucoma surgery, needling rate and complications were recorded. Results: A total of 103 eyes could be evaluated after four years. Mean age was 70.6 years. Primary open-angle glaucoma (POAG) accounted for 46.6% and exfoliative glaucoma (PEXG) for 39.8%. Mean IOP dropped from 24.0 to 15.9 mmHg (p<0.001) and IOP-lowering agents from 3.5 to 1.5 (p<0.001). The success rate with individual target pressures after four years was 43.7%. Secondary glaucoma surgery was performed in 45 (43.7%) of cases. Combined cases (n=12) were not statistically different to stand-alone procedures (p=0.28). No difference between PEXG and POAG could be detected (p=0.44). During the learning curve, stent misplacement was common and resulted in worse outcome for less experienced surgeons. Conclusion: The overall success rate of XEN 45 gel stent surgery in the present cohort is relatively low in a long-time follow-up under the given circumstances if all initial patients are included to follow-up. The influence of the surgeon's learning curve is obvious, and improvement in success can be expected when used by experienced and high-volume surgeons. No significant differences were found in PEXG compared to POAG or in XEN surgery combined with cataract surgery compared to stand-alone.

Coarsened Exact Matching of Excisional to Plasma-ablative Ab Interno Trabeculectomy.

Aim: To compare ab interno trabeculectomy by trabecular meshwork (TM) excision to plasma-mediated ablation in primary open-angle glaucoma (POAG) patients. Methods: Retrospectively collected data of TrabEx+ (TEx) (n = 56) and Trabectome (T) (n = 99) patients were compared by coarsened exact matching to reduce confounding and matched based on baseline intraocular pressure (IOP) and age. The primary outcomes were IOP and the number of glaucoma medications. Complications and the need for additional glaucoma surgery were assessed. Patients were followed for up to 1 year. Results: A total of 53 TEx could be matched to T. Baseline IOP was 16.5 ± 4.6 mm Hg in both; age was 73.7 ± 8.8 and 71.5 ± 9.9 years in TEx and T, respectively. TEx was taking more medications than T (p < 0.001). IOP was reduced to 14.8 ± 4.3 in TEx and to 13.4 ± 3.4 in T at 6 months, and to 14.9 ± 6.0 (p = 0.13) in TEx and to 14.1 ± 3.8 mm Hg (all p < 0.05) in T at 12 months. Medications were reduced at both 6 and 12 months (p < 0.05). No differences were seen between TEx and T at 6 and 12 months. In TEx, only one serious complication occurred, and two patients required further glaucoma surgery. Conclusion: Although both groups had a baseline IOP considered low for ab interno trabeculectomy, IOP and medications were reduced further at 6 and 12 months. IOP reduction did not reach significance in TEx at 12 months. The intergroup comparison did not reveal any significant differences. Both had a low complication rate. Clinical significance: This study investigated subtle differences between a plasma-ablative device, the T, and an excisional device, the TEx, by applying coarsened exact matching. IOP and medications were reduced in both groups at 6 and 12 months, although IOP reduction did not reach significance in TEx at 12 months. The intergroup comparison did not reveal any significant differences, with both devices having a low complication rate. How to cite this article: Dakroub M, Verma-Fuehring R, Strzalkowska A, et al. Coarsened Exact Matching of Excisional to Plasma-ablative Ab Interno Trabeculectomy. J Curr Glaucoma Pract 2023;17(1):9-14.

IOP-lowering and drug-sparing effects of trabectome surgery with or without cyclodialysis ab interno.

PURPOSE: To compare the postoperative intraocular pressure (IOP) after ab interno trabeculectomy (AIT; trabectome surgery) alone or combined with cyclodialysis ab interno (AITC). PATIENTS AND METHODS: Forty-three eyes with insufficiently controlled open-angle glaucoma were included in this consecutive case series. All eyes received AIT, combined with phacoemulsification and IOL-implantation in phakic instances, with or without additional cyclodialysis ab interno. Postoperative visual acuity, IOP, number of IOP-lowering medications and complications were registered over 12 months. RESULTS: A total of 19 eyes (14 patients) received AIT and 24 (19 patients) received AITC. Both groups were comparable for baseline IOP (AIT: 19.7 ± 8.2 mmHg; AITC: 19.4 ± 6.8 mmHg; p = 0.96), there was a comparable IOP reduction after 6 months (AIT: - 3.8 ± 12.3, median (interquartile range (IQR)): - 3.8 (- 7.8-4.8) mmHg; AITC: - 4.9 ± 8.3, median (IQR): - 2.0 (- 10.8-2.0) mmHg; p = 0.95) and 12 months (AIT: - 4.3 ± 6.6, median (IQR): - 4.0 (- 8.0 to - 1.0) mmHg; AITC: - 3.7 ± 6.7, median (IQR): - 1.5 (- 5.5 to - 0.5) mmHg; p = 0.49). While final visual acuity was similar between the groups, they differed regarding topical IOP-lowering medications (baseline: AIT 2.9 ± 1.2 and AITC 2.9 ± 1.2; 1 year after surgery: AIT 2.6 ± 1.5 (p = 0.16) and AITC 1.3 ± 1.3; p < 0.001)). Depending on the definition, a complete or qualified success of 33.4-45.8% was achieved in AITC compared to 15.8-21.1% in AIT. CONCLUSION: The additional suprachoroidal outflow when AIT is combined with cyclodialysis ab interno (AITC) seems to result in an additional drug sparing effect for at least 1 year without critical safety signals. Thus, AITC might be further investigated prospectively prior to advocating its use in routine minimally invasive glaucoma surgery.

[Minimally invasive glaucoma surgery-Comparison of angle based procedures]. / "Minimally invasive glaucoma surgery" ­ Kammerwinkelbasierte Verfahren im Vergleich.

Surgical procedures are playing an increasing role in the care of patients with glaucoma. Within the last decade, new surgical procedures have been established, which are summarized under the term minimally invasive glaucoma surgery (MIGS). A wide variety of different procedures are aimed at the structures in the angle of the anterior chamber, such as the trabecular meshwork and Schlemm's canal, to improve the physiological outflow or to improve the alternative uveoscleral outflow. The implementation of the treatment goal differs in the individual procedures, as does the maximum pressure reduction that can be achieved. Compared to trabeculectomy with the use of cytostatic agents, the achievable pressure reduction is usually significantly lower. In contrast, the significantly lower intraoperative and postoperative complication rates are emphasized as an advantage of these procedures. With increasing clinical experience and the growth of sufficient data on these new surgical procedures, a well-founded classification in the treatment algorithm of glaucoma surgery becomes easier; nevertheless, due to the small differences with respect to efficacy and safety profile, the final decision for an individual procedure often remains dependent on the surgeon's personal preferences.

Long-Term Clinical Results of Trabectome Surgery in Turkish Patients with Primary Open Angle Glaucoma and Pseudoexfoliative Glaucoma.

Objectives: The objectives of the study were to analyze the long-term results of trabectome surgery in Turkish patients with primary open angle glaucoma (POAG) and pseudoexfoliative glaucoma (PEXG) and to characterize the risk factors for failure. Methods: This single-center retrospective non-comparative study included 60 eyes of 51 patients diagnosed with POAG and PEXG, who underwent trabectome alone or phacotrabeculectomy (TP) surgery between 2012 and 2016. Surgical success was defined as a 20% decrease in intraocular pressure (IOP) or IOP≤21 mmHg and no further glaucoma surgery. Risk factors for further surgery were analyzed with the Cox proportional hazard ratio (HR) models. The cumulative success analysis was undertaken with the Kaplan-Meier method based on the time to further glaucoma surgery. Results: The mean follow-up period was 59.4±14.3 months. During the follow-up period, 12 eyes required additional glaucoma surgery. The mean pre-operative IOP was 26.9±6.8 mmHg. The mean IOP at the last visit was 18.8±4.7 mmHg (p<0.01). IOP decreased 30.1% from the baseline to the last visit. The average number of antiglaucomatous drug molecules used was 3.4±0.7 (range 1-4) preoperatively and 2.5±1.3 (range 0-4) at the last visit (p<0.01). The risk factors for further surgery requirement were determined as a higher baseline IOP value (HR: 1.11, p=0.03] and the use of a higher number of preoperative antiglaucomatous drug molecules (HR: 2.54, p=0.09). The cumulative probability of success was calculated as 94.6%, 90.1%, 85.7%, 82.1%, and 78.6% at three, 12, 24, 36, and 60 months, respectively. Conclusion: The success rate of trabectome was 67.3% at 59 months. A higher baseline IOP value and the use of a higher number of antiglaucomatous drug molecules were associated with an increased risk of further glaucoma surgery requirement.

Favorable effect of ripasudil use on surgical outcomes of microhook ab interno trabeculotomy.

PURPOSE: We have previously demonstrated that prolonged use of glaucoma medications was associated with a poor surgical outcome of ab interno trabeculotomy (µTLO). Given that almost all types of glaucoma eye drop either enhance the drainage through the uveoscleral pathway or reduce aqueous humor production, we hypothesized that prolonged use of these medications might cause disuse atrophy of the conventional pathway. In contrast, ripasudil increases the conventional outflow and eventually shows a favorable outcome of µTLO. This study aimed to evaluate the effect of ripasudil use on µTLO outcomes. METHOD: The medical charts of 218 patients who underwent µTLO were analyzed retrospectively. We compared the 1-year outcome between ripasudil users versus nonusers by using propensity score matching. We set the covariates as age, sex, glaucoma types, preoperative intraocular pressure (IOP), the mean deviation values of visual field tests, the presence or absence of concomitant cataract surgery, trabecular meshwork incision range, the presence or absence of any glaucoma medication except ripasudil and duration of glaucoma medical therapy. Success was defined as a postoperative IOP between 5 and 21 mmHg, a ≥ 20% IOP reduction from baseline, and no additional glaucoma surgery at postoperative 1 year. RESULT: Fifty-seven patients each were allocated to the ripasudil users or nonusers. The 1-year success rates were 74% in ripasudil users and 51% in nonusers (p = 0.01). Kaplan‒Meier survival curves also showed that the ripasudil users had a higher survival distribution (p = 0.01). CONCLUSION: The patients who took ripasudil showed a favorable 1-year outcome of µTLO.