Beyond PhacoTrainer: Deep Learning for Enhanced Trabecular Meshwork Detection in MIGS Videos.

Purpose: The purpose of this study was to develop deep learning models for surgical video analysis, capable of identifying minimally invasive glaucoma surgery (MIGS) and locating the trabecular meshwork (TM). Methods: For classification of surgical steps, we had 313 video files (265 for cataract surgery and 48 for MIGS procedures), and for TM segmentation, we had 1743 frames (1110 for TM and 633 for no TM). We used transfer learning to update a classification model pretrained to recognize standard cataract surgical steps, enabling it to also identify MIGS procedures. For TM localization, we developed three different models: U-Net, Y-Net, and Cascaded. Segmentation accuracy for TM was measured by calculating the average pixel error between the predicted and ground truth TM locations. Results: Using transfer learning, we developed a model which achieved 87% accuracy for MIGS frame classification, with area under the receiver operating characteristic curve (AUROC) of 0.99. This model maintained a 79% accuracy for identifying 14 standard cataract surgery steps. The overall micro-averaged AUROC was 0.98. The U-Net model excelled in TM segmentation with an Intersection over union (IoU) score of 0.9988 and an average pixel error of 1.47. Conclusions: Building on prior work developing computer vision models for cataract surgical video, we developed models that recognize MIGS procedures and precisely localize the TM with superior performance. Our work demonstrates the potential of transfer learning for extending our computer vision models to new surgeries without the need for extensive additional data collection. Translational Relevance: Computer vision models in surgical videos can underpin the development of systems offering automated feedback for trainees, improving surgical training and patient care.

Outcomes of bent ab interno needle goniectomy with phacoemulsification in moderate to severe primary open angle glaucoma.

PURPOSE: To assess the safety and efficacy of bent ab interno needle goniectomy (BANG) in moderate to severe primary open angle glaucoma (POAG) eyes undergoing phacoemulsification (phaco). DESIGN: Single-arm, prospective, interventional study. METHODS: POAG patients with medically uncontrolled intraocular pressure (IOP), >15 mmHg for moderate and >12 mmHg for severe POAG, with visually significant cataract were recruited. All patients underwent BANG using a 26-gauge needle to excise 30° of the trabecular meshwork, along with phaco. Primary outcome was IOP. Secondary outcomes were success rate, percentage reduction in IOP/antiglaucoma medications (AGMs), and intraoperative complications. Success at 12 months was defined as: criterion A: IOP <15 mmHg for moderate glaucoma or <12 mmHg for severe glaucoma with or without AGMs OR criterion B: reduction in number of AGMs by >1. RESULTS: Thirty-two eyes of 32 patients underwent BANG + phaco. Mean age of the participants was 62.7 ± 8.4 years and there were 25 males and seven females. At 12 months, a significant decrease was noted in both IOP (from 17.6 ± 3.6 to 12 ± 1.6 mmHg, 31.8%; P < 0.001) and AGMs (from 3.7 ± 0.9 to 2.8 ± 0.8, 24.3%; P < 0.001). Twenty percent or more reduction in IOP was achieved in 62.5% (20/32) of eyes. Overall success (meeting either of the criteria A or B) at 12 months was achieved in 87.5% eyes. Mild postoperative hyphema was noted in 10 (31.2%) eyes, and two eyes (6.2%) required additional filtration surgery at 7 months. CONCLUSION: A 30-degree BANG with phaco in patients of POAG appears to be a safe, effective and affordable MIGS for developing countries.

Healing responses at the angle after micro-invasive glaucoma surgery-an AS-OCT study.

PURPOSE: To evaluate structural alterations and healing responses in the trabecular meshwork region with optical coherence tomography (AS-OCT) following after gonioscopy assisted transluminal trabeculotomy (GATT) and microincisional trabeculectomy (MIT). METHODS: 73 eyes of 67 patients (M:F = 45:22) with ≥6 months of follow-up after MIT (n = 41) or GATT (n = 32) with or without combined cataract surgery were included for this prospective study. The angle as seen on AS-OCT at 1, 3, 6 months after surgery were evaluated for structural alterations like peripheral anterior synechiae (PAS), hyphema, and hyperreflective scarring responses. The scarring was graded according to the linear extent measured from the centre of the trabecular meshwork (TM) gutter to the sclera/cornea as mild (<250µ), moderate (250-500µ), and severe(˃500µ), while the pattern of scarring was graded as open saucer/gutter, closed gutter, and trench pattern. The association of the need for medication or surgical outcome and clinical variables and AS-OCT parameters including the pattern and severity of scarring were analysed using multivariate regression. RESULTS: All eyes achieved significant reduction of IOP and number of medications with a final IOP of 15±3.2mm Hg at a mean follow-up of 8±32. months. While mild scarring was seen more common in MIT, severe scarring was seen in >65% of GATT eyes compared to 31% of MIT eye, p<0.001. An open saucer was equally seen in MIT and GATT while the trench pattern was more commonly seen in GATT eyes (>50%). Severe scarring in a trench pattern seemed to predict the need for medications for IOP control, though they independently did not seem to influence the final IOP or surgical outcome. CONCLUSION: A severe form of scarring in a trench pattern on AS-OCT predicted the need for glaucoma medications after MIGS surgery. Regular monitoring of the scarring responses by AS-OCT and clinical examination are necessary to identify those at need for medications after MIGS.

Predictive biomarkers of intra-ocular pressure decrease after cataract surgery associated with trabecular washout in patients with pseudo exfoliative glaucoma.

To investigate biomarkers of intra-ocular pressure (IOP) decrease after cataract surgery with trabecular washout in pseudo-exfoliative (PEX) glaucoma. A single-center observational prospective study in PEX glaucoma patients undergoing cataract surgery with trabecular washout (Goniowash) was performed from 2018 to 2021. Age, gender, visual acuity, IOP, endothelial cell count, central corneal thickness, medications, were collected over 16-month follow-up. Multivariable binomial regression models were implemented. 54 eyes (35 subjects) were included. Mean preoperative IOP (IOPBL) was 15.9 ± 3.5 mmHg. Postoperative IOP reduction was significant at 1-month and throughout follow-up (p < 0.01, respectively). IOPBL was a predictive biomarker inversely correlated to IOP decrease throughout follow-up (p < 0.001). At 1 and 12 months of follow-up, IOP decrease concerned 31 (57.4%) and 34 (63.0%) eyes with an average IOP decrease of 17.5% (from 17.6 ± 3.1 to 14.3 ± 2.2 mmHg) and 23.0% (from 17.7 ± 2.8 to 13.5 ± 2.6 mmHg), respectively. Performance (AUC) of IOPBL was 0.85 and 0.94 (p < 0.0001, respectively), with IOPBL threshold ≥ 15 mmHg for 82.1% and 96.8% sensitivity, 84.2% and 75.0% specificity, 1.84 and 3.91 IOP decrease odds-ratio, respectively. All PEX glaucoma patients with IOPBL greater than or equal to the average general population IOP were likely to achieve a significant sustainable postoperative IOP decrease.

[To discuss the minimally invasive glaucoma surgery related to trabeculotomy from the perspective of physiological function of trabecular meshwork drainage pathway].

The advent of minimally invasive glaucoma surgery (MIGS) has broadened the therapeutic options for managing glaucoma. In recent years, MIGS procedures targeting the trabecular meshwork-Schlemm's canal aqueous outflow resistance site have garnered significant attention. This focus has extended to the pathophysiological changes occurring within the aqueous outflow pathway. However, questions persist regarding the efficacy of near-peripheral or peripheral trabeculotomy in achieving the anticipated reduction of outflow resistance and the suitability of MIGS surgery for patients with primary open-angle glaucoma. By integrating clinical experience with pertinent clinical research, this paper advocates for a reevaluation of MIGS procedures to aid clinicians in making informed decisions regarding various glaucoma surgical interventions.

Efficacy and Safety of Surgical Peripheral Iridectomy, Goniosynechialysis, and Goniotomy for Advanced Primary Angle Closure Glaucoma Without Cataract: 1-Year Results of a Multicenter Study.

PRCIS: The combination of surgical peripheral iridectomy, goniosynechialysis, and goniotomy is a safe and effective surgical approach for advanced primary angle closure glaucoma without cataract. PURPOSE: To evaluate the efficacy and safety of surgical peripheral iridectomy (SPI), goniosynechialysis (GSL), and goniotomy (GT) in advanced primary angle closure glaucoma (PACG) eyes without cataract. PATIENTS AND METHODS: A prospective multicenter observational study was performed for patients who underwent combined SPI, GSL, and GT for advanced PACG without cataract. Patients were assessed before and after the operation. Complete success was defined as achieving intraocular pressure (IOP) between 6 and 18 mm Hg with at least a 20% reduction compared with baseline, without the use of ocular hypotensive medications or reoperation. Qualified success adopted the same criteria but allowed medication use. Factors associated with surgical success were analyzed using logistic regression. RESULTS: A total of 61 eyes of 50 advanced PACGs were included. All participants completed 12 months of follow-up. Thirty-six eyes (59.0%) achieved complete success, and 56 eyes (91.8%) achieved qualified success. Preoperative and postsurgical at 12 months mean IOPs were 29.7±7.7 and 16.1±4.8 mm Hg, respectively. The average number of ocular hypotensive medications decreased from 1.9 to 0.9 over 12 months. The primary complications included IOP spike (n=9), hyphema (n=7), and shallow anterior chamber (n=3). Regression analysis indicated that older age (odds ratio [OR]=1.09; P =0.043) was positively associated with complete success, while a mixed angle closure mechanism (OR=0.17; P =0.036) reduced success rate. CONCLUSIONS: The combination of SPI, GSL, and GT is a safe and effective surgical approach for advanced PACG without cataract. It has great potential as a first-line treatment option for these patients.

Outcomes of Phacoemulsification With or Without Kahook Dual Blade Goniotomy for Glaucoma Patients With Cataract.

PRCIS: This meta-analysis examines the comparative efficacy of phacoemulsification with and without Kahook Dual Blade Goniotomy in individuals with glaucoma and cataract, aiming to elucidate optimal surgical approaches for coexisting conditions. PURPOSE: The purpose of this current study is to compare the effect of combining Kahook Dual Blade (KDB) goniotomy with phacoemulsification versus phacoemulsification alone on intraocular pressure (IOP) and medication reduction in patients with glaucoma and cataract. METHODS: We conducted a systematic review and meta-analysis utilizing computer databases, including Embase (OVID), MEDLINE (OVID and PubMed), CINHAL (EBSCO), and the Cochrane Library (Wiley). We included studies examining the IOP-lowering effect of KDB goniotomy combined with phacoemulsification and studies that examined the IOP-lowering effect of phacoemulsification alone in patients with open angle glaucoma or ocular hypertension. The mean reduction of IOP and the reduction in topical glaucoma eye drops after surgery were determined. RESULTS: A total of 26 studies were included, reporting on 1659 patients, 684 patients underwent phacoemulsification alone, and 975 underwent combined phacoemulsification and KDB goniotomy. A 9.62% IOP reduction from baseline occurred following phacoemulsification as a solo procedure compared with 22.74% following combined KDB goniotomy with phacoemulsification. Similarly, the combination of the procedures caused a significant drop in the mean number of glaucoma eye drops used [mean reduction=1.35, 95% CI (1.08, 1.61)] compared with phacoemulsification alone [mean reduction=0.36, 95% CI (0.06, 0.66)]. Funnel plots suggested the absence of publication bias. CONCLUSIONS: Both phacoemulsification alone or combined with KDB goniotomy result in a significant decrease in post-op IOP and topical glaucoma eye drops. The combination of these 2 procedures outperforms phacoemulsification alone in terms of both parameters.

Clinical applications of aqueous angiography in glaucoma.

Aqueous humor outflow (AHO) pathways are the main site of resistance causing elevated intraocular pressure in glaucoma, especially primary open-angle glaucoma patients. With the recently introduced technique of aqueous angiography (AA); functional, real time assessment of AHO from proximal (trabecuar meshwork) to distal pathways under physiological conditions has been made possible. AHO pathways are segmental, and AA can identify high-flow region (increased angiographic signals) and low flow region (decreased angiographic signals) in an individual. With the introduction of canal-based minimally invasive glaucoma surgeries (MIGS), the assessment of AHO can help guide the placement of stents/incisions during MIGS procedures. This can allow individualized and targeted MIGS procedures in glaucoma patients for better results. Based on the density of AHO pathways visualized on AA, surgeons can decide whether to perform MIGS or conventional glaucoma surgery for improved outcomes for the patient. Immediate intraoperative assessment for functionality of the MIGS procedure performed is possible with AA, allowing for surgical adjustments of MIGS procedure in the same sitting, if needed. This review provides a summary of the studies performed with AA to date, with a special focus on Indian patients. It covers the basics and clinical applications of AA for improving surgical outcomes in glaucoma patients.

Comparative evaluation of iStent versus iStent inject W combined with phacoemulsification in open angle glaucoma.

PURPOSE: The study aimed to compare the 12-month post-operative outcomes of iStent and iStent inject W (inject W), and the factors associated with their success in open-angle glaucoma. METHODS: This single-center, retrospective comparative case series evaluated the medical records of patients who underwent iStent (comprising 1 stent) or inject W (comprising 2 stents) implantation with cataract surgery for primary open-angle glaucoma and normal tension glaucoma between January 2019 and March 2022. The 12-month post-operative efficacy outcomes included intraocular pressure (IOP), glaucoma medications, and survival analysis of the probability of success. "Failure" was defined as any of the following conditions compared to baseline: 1) IOP elevation, 2) increased glaucoma medication, or 3) IOP decline not exceeding 20% when glaucoma medication scores were comparable, and 4) need for additional glaucoma surgery. The safety outcomes included intra- and post-operative adverse events and changes in the best-corrected visual acuity and visual field. RESULTS: The study comprised 55 eyes in the iStent and 105 in the inject W groups. At 12 months, treatment success was achieved in 66.0% of iStent and 78.4% of inject W eyes. The mean IOP was lower, and the percent reduction from baseline was equal in iStent-treated eyes (8.0% reduction, 14.8 mmHg to 13.7 mmHg, P<0.01) and inject W-treated eyes (11.9% reduction, 15.0 mmHg to 13.8 mmHg, P<0.01) (between-group comparison, P = 0.23). The mean medication burden decreased significantly from 2.5 to 1.1 for iStent (55.0% reduction, P<0.01) and 2.9 to 1.7 for iStent inject (46.8% reduction, P<0.01), with no significant differences between the two groups (P = 0.17). Both devices exhibited excellent safety. CONCLUSIONS: Both devices significantly reduced IOP and glaucoma medication 12 months post-operatively. The outcome measures did not differ significantly between the two groups, and lower baseline IOP was predictive of surgical failure.

Twelve-month outcomes of Kahook dual blade goniotomy combined with cataract surgery in Latino patients.

PURPOSE: To evaluate 12 month surgical outcome of Kahook Dual Blade (KDB) goniotomy in combination with cataract surgery in Latino patients with open angle glaucoma (OAG) and ocular hypertension (OHT). METHODS: This retrospective study included 45 eyes of 40 patients who underwent KDB goniotomy combined with cataract extraction from January 2016 to September 2020 at two centers in South America. Primary outcome was surgical success defined as ≥ 20% intraocular pressure (IOP) reduction or ≥ 1 medication reduction from preoperative without additional IOP-lowering procedures and an IOP ≥ 5 mmHg or ≤ 21 mmHg. Additionally, we used 2 cutoffs values for success of IOP ≤ 18 and ≤ 15 mmHg. Secondary outcomes included: IOP, medication use, best corrected visual acuity, complications and failure-associated factors. RESULTS: Success rates at 12 months with cutoff limits of 21, 18 and 15 mmHg were 84.3%, 75.6% and 58.7%, respectively. At 12 months, mean preoperative IOP significantly decreased from 19.23 ± 0.65 mmHg on 2.3 ± 1.0 medications to 14.33 ± 0.66 mmHg on 0.6 ± 0.9 medications (p < 0.001) , with 62% of eyes free of hypotensive medication. Eyes that developed postoperative IOP spikes showed a higher risk for failure using the cutoff limit of IOP ≤ 18 mmHg with a hazard ratio of 3.6 (95% confidence interval [CI], 1.80-7.13; p < 0.001). There were no serious ocular adverse events. CONCLUSIONS: KDB combined with cataract extraction showed safety and efficacy for decreasing IOP in OAG and OHT Latino patients. Additionally, dependence on medications was reduced significantly after surgery.

Effect of Preoperative Trabecular Meshwork Pigmentation and Other Eye Characteristics on Outcomes of Combined Phacoemulsification/Minimally Invasive Glaucoma Surgery.

PURPOSE: To investigate associations between pigmentation of the trabecular meshwork (PTM) and other preoperative eye characteristics and outcomes of minimally invasive glaucoma surgery combined with phacoemulsification (Phaco/MIGS). DESIGN: Retrospective interventional case series. PARTICIPANTS: Academic glaucoma clinic patients with symptomatic cataract and glaucoma treated with combined Phaco/MIGS. METHODS: Analyzing preoperative PTM, intraocular pressure (IOP), IOP-lowering medications and visual acuity (VA) data in relation to Phaco/MIGS outcomes. MAIN OUTCOME MEASURES: Pigmentation of the trabecular meshwork and other preoperative eye characteristics in relation to Phaco/MIGS success defined as postoperative IOP between 5 and 21 mmHg and IOP reduction of ≥ 20% and/or a reduction of ≥ 1 IOP-medications compared to baseline, and final IOP, IOP-lowering medications and VA. RESULTS: A total of 265 eyes (172 patients, mean age, 73.5 [standard deviation, 10.0], range 35-95 years, male 40.0%) were identified and categorized with high PTM (108 eyes, 40.8%) or low PTM (157 eyes, 59.2%). The high PTM group, compared with the low PTM group, demonstrated higher preoperative IOP (16.7 [standard error 0.4] vs. 15.2 [0.4] mmHg, P = 0.009), included more eyes with primary open-angle glaucoma (POAG, P = 0.03), fewer eyes with normal-tension glaucoma (NTG, P = 0.01), and fewer eyes with mild stage glaucoma (P = 0.001). Compared to baseline, final IOP decreased by 6.5 [2.4]% and 13.4 [3.0]% (P = 0.075) to 13.5 [0.3] mmHg and 13.6 [0.4] mmHg (P = 0.77) in the low and high PTM groups, respectively, and IOP-lowering medications decreased by 34.6 [4.9]% (n = 116) and 18.1 [7.3]% (n = 85), respectively (P = 0.062). Surgical success was 59.9% and 58.3%, respectively (P = 0.87). It was positively associated with higher preoperative IOP (hazard ratio 1.08 [95% confidence interval 1.04-1.12] P < 0.0001) and higher number of preoperative IOP-medications (1.20 [1.05-1.37] P = 0.007), negatively associated with history of selective laser trabeculoplasty (SLT, 0.40 [0.23-0.68] P = 0.0009) and longer axial length (0.87 [0.80-0.94], P = 0.0006), but was not associated with PTM. CONCLUSIONS: Higher PTM was associated with POAG rather than NTG, with more severe glaucoma and higher preoperative IOP, but not with Phaco/MIGS success. Surgical success was positively associated with higher preoperative IOP and number of IOP-medications and negatively associated with history of SLT and longer axial length. These findings may help guide glaucoma surgeons in surgical planning and patient counseling. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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.

Selective Laser Trabeculoplasty for the Treatment of Glaucoma: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the current published literature for high-quality studies on the use of selective laser trabeculoplasty (SLT) for the treatment of glaucoma. This is an update of the Ophthalmic Technology Assessment titled, "Laser Trabeculoplasty for Open-Angle Glaucoma," published in November 2011. METHODS: Literature searches in the PubMed database in March 2020, September 2021, August 2022, and March 2023 yielded 110 articles. The abstracts of these articles were examined to include those written since November 2011 and to exclude reviews and non-English articles. The panel reviewed 47 articles in full text, and 30 were found to fit the inclusion criteria. The panel methodologist assigned a level I rating to 19 studies and a level II rating to 11 studies. RESULTS: Data in the level I studies support the long-term effectiveness of SLT as primary treatment or as a supplemental therapy to glaucoma medications for patients with open-angle glaucoma. Several level I studies also found that SLT and argon laser trabeculoplasty (ALT) are equivalent in terms of safety and long-term efficacy. Level I evidence indicates that perioperative corticosteroid and nonsteroidal anti-inflammatory drug eye drops do not hinder the intraocular pressure (IOP)-lowering effect of SLT treatment. The impact of these eye drops on lowering IOP differed in various studies. No level I or II studies exist that determine the ideal power settings for SLT. CONCLUSIONS: Based on level I evidence, SLT is an effective long-term option for the treatment of open-angle glaucoma and is equivalent to ALT. It can be used as either a primary intervention, a replacement for medication, or an additional therapy with glaucoma medications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Proposal for the Use of a Fixed Low-Energy Selective Laser Trabeculoplasty for Open Angle Glaucoma.

Selective laser trabeculoplasty (SLT) has been in routine clinical use for over 20 years with millions of patients successfully treated and a low rate of clinically significant complications. The procedure requires the clinician to manually position the laser beam on the trabecular meshwork using a gonioscopy lens and to titrate the SLT laser energy based on the amount of pigmentation in the angle, as well as the observation of small bubbles produced by the laser effect. We propose that SLT energy titration is unnecessary either to achieve intraocular pressure (IOP) reduction or to minimize potential side effects. Ample evidence to support our proposal includes multiple clinical reports demonstrating comparable levels of IOP reduction resulting from different laser energies, a large variety of energy and other laser parameters used in commercially available SLT lasers, and the nature of the laser-induced changes in the trabecular meshwork tissue with respect to energy. Despite these variations in laser parameters, SLT consistently reduces IOP with a low complication rate. We propose that using low fixed energy for all patients will effectively and safely lower patients' IOP while reducing the complexity of the SLT procedure, potentially making SLT accessible to more patients.

[Trabeculotomy (ab externo) as primary intervention for open-angle glaucoma : 5-year results]. / Trabekulotomie (ab externo) als Ersteingriff bei Offenwinkelglaukomen : 5-Jahres-Ergebnisse.

BACKGROUND: The published results of trabeculotomy ab externo (TOT), as an outflow channel surgery in adults with open-angle glaucoma, are underrepresented in comparison with other pressure-lowering glaucoma procedures. OBJECTIVE: To determine the long-term pressure lowering effect and complications of TOT as a stand-alone procedure or in combination with phacoemulsification with intraocular lens implantation (PIT) as a primary pressure-lowering procedure in adult patients with forms of chronic open-angle glaucoma. METHOD: This was a retrospective analysis of 121 eyes of 106 patients wherby 90 eyes underwent TOT and 31 eyes underwent PIT. The follow-up period was 5 years. Follow-up was performed in the same center under standardized conditions. Preoperative as well as postoperative best-corrected distance visual acuity, intraocular pressure, pressure-lowering medication, and complications were recorded. For success criterion 1, the intraocular pressure was not allowed to exceed 17 mm Hg at any control. For success criterion 2, the intraocular pressure was allowed to be above 17 mm Hg at 1 control throughout the follow-up period. RESULTS: Preoperative intraocular pressure in the TOT group was 25.92 mm Hg (SD 6.58) and 26.32 mm Hg (SD 6.06) in the PIT group. The annual cumulative success rates with pressure-lowering medications for success criterion 1 were 92.8%, 82.5%, 70.5%, 52.7% and 26.1%. For success criterion 2 these were 97.9%; 94.9%, 93.2%, 91.3%, and 89%. We found no relevant difference in pressure reduction between TOT and PIT. Without pressure-lowering medications, success rates were significantly lower for both success criteria. No serious complications occurred. The most common postoperative complication was spontaneously resorbable hyphema. CONCLUSION: Performing TOT or PIT as a primary glaucoma procedure for chronic open-angle glaucoma in adults is reasonable, has a significant pressure-lowering effect and very low complication rate.

Long-term follow-up of laser trabeculoplasty in multi-treated glaucoma patients.

PURPOSE: To evaluate the long-term effect of laser trabeculoplasty (LTP) in patients randomized to multi-treatment in the Glaucoma Intensive Treatment Study (GITS). METHODS: Patients with untreated newly diagnosed open-angle glaucoma were treated with three intraocular pressure (IOP)-lowering substances for 1 week and then 360° argon or selective LTP was performed. IOP was measured just before LTP and repeatedly during the 60-month study period. Our previous report on 12 months follow-up data revealed no effect of LTP in eyes having an IOP <15 mmHg before the laser treatment. RESULTS: Before LTP, the mean IOP ± standard deviation in all 152 study-eyes of 122 multi-treated patients was 14.0 ± 3.5 mmHg. Three eyes of three deceased patients were lost to follow-up during the 60 months. After exclusion of eyes that received increased therapy during follow-up, the IOP was significantly reduced at all visits up to 48 months in eyes with pre-LTP IOP ≥15 mmHg; 2.6 ± 3.1 mmHg at 1 month and 1.7 ± 2.8 mmHg at 48 months, n = 56 and 48, respectively. No significant IOP reduction was seen in eyes with pre-LTP IOP <15 mmHg. Seven eyes, i.e., <13%, with pre-LTP IOP ≥15 mmHg at baseline had required increased IOP-lowering therapy at 48 months. CONCLUSION: LTP performed in multi-treated patients may provide a useful IOP reduction that is maintained over several years. This was true on a group level when the initial IOP was ≥15 mmHg, but if the pre-laser IOP was lower than that, chances of LTP success were small.

Phacoemulsification with gonioscopy-assisted transluminal trabeculotomy versus phacoemulsification alone in primary angle closure glaucoma: A randomized controlled study.

PURPOSE: To assess the safety and efficacy of combining phacoemulsification with gonioscopy-assisted transluminal trabeculotomy (GATT) compared to phacoemulsification alone in the management of primary angle closure glaucoma (PACG). METHODS: Prospective, institutional study in which eyes requiring surgery for PACG were randomized to undergo phacoemulsification followed by GATT (phaco-GATT group) or phacoemulsification alone. Success was defined as having a final IOP of 6-20 mmHg with no subsequent glaucoma surgery or vision-threatening complications. RESULTS: Thirty-six eyes underwent phaco-GATT with 360° angle incision and 38 eyes underwent phacoemulsification alone. IOP and glaucoma medications were significantly lower in the phaco-GATT group at 1, 3, 6, 9 and 12 months. The success rate in the phaco-GATT group was 94.4% after 12.16 ± 2.03 months, with 75% of eyes being off medications compared to 86.8% after 12.47 ± 4.27 months in the phaco group, with 42.1% off medications. (p = 0.008). Hyphema and fibrinous anterior chamber reaction were the most common complications in the phaco-GATT group and resolved with conservative treatment or required YAG capsulotomy. Although this delayed visual rehabilitation in the phaco-GATT group, it did not affect the final visual outcome with no significant difference in the final best-corrected visual acuity between both groups (p = 0.25). CONCLUSION: Combining phacoemulsification with GATT in PACG yielded more favourable outcomes in terms of IOP, glaucoma medications and surgical success. Although the postoperative hyphema and fibrinous reaction may delay visual rehabilitation, GATT further lowers the IOP by breaking residual peripheral anterior synechiae and removing the dysfunctional trabeculum circumferentially, while avoiding the risks inherent in more invasive filtering procedures.

The effect of uneventful cataract surgery on Schlemm's canal and the trabecular meshwork in cases with pseudoexfoliation.

PURPOSE: To evaluate the effect of uneventful cataract surgery on Schlemm's canal (SC) and the trabecular meshwork (TM) in cases with pseudoexfoliation (PX). METHODS: In this prospective study, 37 PX and 37 normal eyes, who underwent cataract surgery, were included. The PX group was further divided into two subgroups: PX syndrome (PXS) and PX glaucoma (PXG). Preoperative complete ophthalmologic examination, anterior segment (AS) imaging using a Scheimpflug camera, and measurements of SC length and area and TM thickness and length using AS optical coherence tomography (AS-OCT) were performed in all cases. All measurements were repeated at the first and third months after surgery. RESULTS: Preoperative intraocular pressure (IOP), AS parameters, SC, and TM values showed no significant differences between the groups (p > 0.05). After surgery, there was a significant increase in AS parameter values and a significant decrease in IOP values in both the PX and control groups (p < 0.05). The nasal and temporal SC area showed a significant increase in the PX group after surgery (p = 0.007, p = 0.003, respectively). In the subgroup analysis, the only significant change in the nasal and temporal SC area was in the PXS group (p = 0.006, p = 0.003, respectively). CONCLUSION: Cataract surgery resulted in an increase in the SC area in patients with PXS. This increase may be due to multiple mechanisms including the IOP-lowering effect of cataract removal, change in AS, and removal of intraocular PX material after surgery.

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.