Systematic Literature Review of Clinical and Economic Outcomes of Micro-Invasive Glaucoma Surgery (MIGS) in Primary Open-Angle Glaucoma

Success of Primary Trabeculectomy in Advanced Open Angle Glaucoma

Aim

The study assesed trabeculectomy survival in advanced open angle glaucoma (OAG).

Methods

This is a retrospective longitudinal study in advanced OAG undergoing primary trabeculectomy. Clinical and demographic parameters were recorded. Surgical survival (qualified/complete) was calculated by Kaplan–Meier analysis for multiple upper limits of intraocular pressure (IOP) with/without medication (≤21 mmHg, ≤18 mmHg, ≤15 mmHg, ≤12 mmHg); Cox hazard ratio analysis identified parameters influencing survival.

Results

We included 165 eyes from 165 OAG patients: primary forms (POAG) – 86 eyes and secondary (pseudoexfoliative, SOAG) – 79 eyes; mean follow-up interval was 36.21 ± 13.49 months. Clinical parameters were comparable between sub-groups at baseline, except a higher IOP in SOAG vs POAG (36.6 ± 13.2 vs 32.7 ± 11.1 mmHg, p = 0.04); IOP reduction was similar (SOAG vs POAG) 53.93% vs 56.19%, p = 0.45, yet longer hospitalization (8.47 ± 4.39 (SOAG) vs 6.69 ± 3.01 days (POAG), p=0.03) and more medications (0.65 ± 0.24 vs 0.36 ± 0.16, p = 0.05) were needed to achieve comparable final IOP (16.0 ± 9.1 vs 15.1 ± 7.8 mmHg, p = 0.45). Kaplan Meier survival analysis applied for IOP ≤21 mmHg, ≤18 mmHg, ≤15 mmHg and ≤12 mmHg, revealed complete success in 26.2%, 27.3%, 34.5% and 54.6% eyes, respectively; qualified success was found in 45.7%, 48.6%, 77% and 88.6% eyes, respectively. Multiple medications at baseline diminished survival in all tested models (hazard ratio HR > 1, p<0.05), while 5FU+needling improved survival, mostly if combined with lower IOP regime: HR = 0.15, 95% CI = [0.07 −1.12], p = 0.06, if IOP ≤15 mmHg and HR = 0.09, 95% CI = [0.02–1.25], p = 0.06, if IOP ≤12 mmHg.

Conclusion

Trabeculectomy in advanced OAG reached very good survival rates (77% and 88.6%) at 36 months postoperative, if IOP could be maintained ≤15 mmHg, respectively ≤12 mmHg with medication and additional needling+5FU maneuvers. Specific factors influencing survival were identified for each success definition.

Fellow-Eye Comparison between Phaco-Microhook Ab-Interno Trabeculotomy and Phaco-iStent Trabecular Micro-Bypass Stent

The aim of this study is to compare the surgical efficacy and safety between microhook ab-interno trabeculotomy (µLOT) and iStent trabecular micro-bypass stent implantation when both were combined with cataract surgery in both eyes of patients. Sixty-four glaucomatous eyes (32 participants; mean age, 75.9 ± 7.6 years; 15 men, 17 women) were included retrospectively. Intraocular pressure (IOP), number of antiglaucoma medications, best-corrected visual acuity (BCVA), anterior chamber flare (ACF) and corneal endothelial cell density (CECD) were evaluated preoperatively, as well as 2, 3, 6, and 12 months postoperatively. Surgical complications and interventions were compared between the procedures. The preoperative IOP and medications with µLOT (18.8 ± 5.7 mmHg and 3.0 ± 1.2, respectively) were higher than with the iStent (15.5 ± 3.4 mmHg and 2.7 ± 1.2, respectively) (p = 0.0001 and p = 0.0437, respectively). At 12 months, the µLOT values (12.6 ± 2.3 mmHg and 2.3 ± 0.9, respectively) were identical to iStent (12.8 ± 2.5 mmHg and 2.3 ± 0.9, respectively) (p = 0.0934 and p = 0.3251, respectively). At 12 months, the IOP decreased more with µLOT (6.2 mmHg, 29.5%) than iStent (2.7 mmHg, 15.6%) (p = 0.0003). The decrease in medications was greater with µLOT (0.7) than iStent (0.4) (p = 0.0437). Survival rate of IOP control ≤15 mmHg and IOP reduction ≥20% was significantly higher after µLOT (40.6% at 12 months) than iStent (18.8%) (p = 0.0277). The frequency of layered hyphema was significantly greater with µLOT (8 eyes, 25%) than iStent (0 eyes, 0%) (p = 0.0048). The increase in the ACF at 2 weeks postoperatively was significantly greater with µLOT than iStent (p = 0.0156), while changes in the BCVA and CECD were identical between groups. The fellow-eye comparison showed that the IOP reduction was greater with µLOT than iStent when combined with cataract surgery.

Selective Laser Trabeculoplasty Versus MIGS: Forgotten Art or First-Step Procedure in Selected Patients with Open-Angle Glaucoma

Introduction

To evaluate the long-term effect on intraocular pressure (IOP) and glaucoma medication of selective laser trabeculoplasty (SLT) compared to minimally invasive glaucoma surgery (MIGS) in primary open-angle glaucoma (POAG) and its potential in clinical practice.

Methods

A total of 342 consecutive patients (stand-alone procedures) were included. One hundred and five patients underwent SLT treatment (360° SLT, 95–105 spots, Trabeculas SLT ARCLaser, Nürnberg, DE), 107 patients had an ab interno-derived trabeculotomy (Trabectome^®, NeoMedix, Tustin, USA), and 130 patients received iStent inject^® implantation (2 implants-Glaukos, CA, USA). IOP and glaucoma therapy were evaluated preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1, 2, and 3 years postoperatively. Statistical analysis was performed using a regression model and propensity matching score (reduced cohort number) using SPSS v20.0. Kaplan–Meier analysis was included using the following six criteria: criterion A (IOP ≤ 21 mmHg with or without medication, qualified success), criterion B (IOP ≤ 18 mmHg with or without medication, qualified success), criterion C (IOP ≤ 21 mmHg without medication, complete success), criterion D (IOP ≤ 18 mmHg without medication, complete success), criterion E (IOP ≤ 21 mmHg and IOP reduction > 20% after therapy), and criterion F (IOP ≤ 18 mmHg and IOP reduction > 20% after therapy).

Results

In the matched cohort, the SLT cohort showed an IOP reduction of 31.2% from 19.9 ± 2.3 to 13.7 ± 2.7 mmHg (p < 0.001) 3 years postoperatively; in Trabectome^® IOP decreased by 31.4% from 20.5 ± 1.3 to 13.8 ± 2.0 mmHg (p < 0.001) and in iStent inject^® by 29.9% from 19.5 ± 2.0 to 13.8 ± 2.7 mmHg (p < 0.001). Trabectome^® and iStent inject^® could not demonstrate a significant reduction in glaucoma therapy (Trabectome^®p = 0.138, iStent inject^®p = 0.612); a significant drop was noted in SLT (2.2 ± 1.2 to 1.7 ± 1.2, p = 0.046). SLT and MIGS achieved good to moderate survival rates using criterion A (93.3% SLT, 79.7% Trabectome^®, 77.6% iStent inject^®) and criterion B (74.5% SLT, 48.0% Trabectome^®, 56.2% iStent inject^®). As expected, low survival rates were obtained with non-filtering procedures: criterion C 11.1% in SLT, 6.5% in Trabectome^®, 7.0% in iStent inject^® and criterion D 3.0% in SLT, 4.3% in Trabectome^®, 3.7% in iStent inject^® in 3-year follow-up.

Conclusion

The SLT is a low-complication and effective method for reducing pressure in mild to moderate POAG. SLT is suitable as an initial procedure when setting up a step scheme; MIGS is the treatment of choice as a follow-up for mild to moderate forms of glaucoma and accepted topical therapy. Ethic approval had been given by the Ethikkommission Charité – Universitätsmedizin Berlin, EA4/047/20—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00347-0.

Ethics of Glaucoma Widgets

How to cite this article: Dada T, Ramesh P, Sethi A, et al. Ethics of Glaucoma Widgets. J Curr Glaucoma Pract 2020;14(3):77–80.

What Is New in Glaucoma: From Treatment to Biological Perspectives

Glaucoma is a chronic silent disease and an irreversible cause of blindness worldwide. Research has made many efforts to improve disease control and especially to anticipate both early diagnosis and treatment of advanced stages of glaucoma. In terms of prevention, networking between professionals and nonprofessionals is an important goal to disseminate information and help diagnose the disease early. On the other hand, the most recent approaches to treat glaucoma outcomes in its advanced stages include electrical stimulation, stem cells, exosomes, extracellular vesicles, and growth factors. Finally, neuronal plasticity-based rehabilitation methods are being studied to reeducate patients in order to stimulate their residual visual capacity. This review provides an overview of new approaches to future possible glaucoma treatment modalities and gives insight into the perspectives available nowadays in this field.

Safety and efficacy of incisional goniotomy as an adjunct with phacoemulsification in primary angle-closure glaucoma

PURPOSE

To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of incisional goniotomy as an adjunct to phacoemulsification in primary angle-closure glaucoma (PACG) patients.

METHODS

Consecutive patients with PACG (high or borderline IOP) deemed fit for phacoemulsification were enrolled. After phacoemulsification, incisional goniotomy was performed with or without goniosynechialysis. Patient demographic profile, clinical data, and adverse events, if any, were analyzed during at least a 6-month follow-up period. Success was defined as IOP of 18 mm Hg or lesser with or without medications.

SETTING

Tertiary care Ophthalmic hospital.

DESIGN

Prospective interventional case series.

RESULTS

Of 46 eyes (38 patients) included, 69.6% eyes were classified as having advanced glaucoma. The mean treated IOP decreased by 7.3 ± 1.0 (SE) mm Hg (95% CI, 5.2-9.3) from 21.4 ± 6.6 to 14.2 ± 3.7 mm Hg at a mean duration of 11.7 ± 5.5 months (6-22 months) postoperatively (P < .001, paired t test). There was 66.6% reduction in median number of hypotensive medications (P < .001, Wilcoxon signed-rank test). Observed complications included hyphema (13 eyes [28%]), IOP spike (3 eyes [6.5%]), and cyclodialysis (1 eye [2.17%]). High treated IOP and number of medications were significantly associated with failure in univariate analysis (P < .05, Fisher exact test). The cumulative survival probability for qualified success at 22 months was 87.8% ± 0.07 (95% CI, 0.65-0.96).

CONCLUSIONS

Incisional goniotomy as an adjunct with phacoemulsification resulted in a significant and sustained reduction in IOP along with decrease in number of glaucoma medications in chronic PACG eyes, irrespective of the disease stage.

Factors Associated With Unqualified Success After Trabecular Bypass Surgery: A Case-control Study

PRECIS

An older age, a low number of baseline glaucoma medications, an early glaucoma stage, lower intraocular pressure (IOP) values during the first postoperative month, and combined surgery are possible predictors of unqualified success after a trabecular by-pass microinvasive glaucoma surgery (MIGS) procedure.

PURPOSE

The purpose of this study was to identify the potential predictors of unqualified success (IOP<18 mm Hg with no glaucoma medication) after trabecular by-pass MIGS.

MATERIALS AND METHODS

We designed a case-control study using logistic regression modeling that included all trabecular by-pass surgeries with at least 3 months of follow-up, performed at a single center from June 2017 to December 2019. Eyes that achieved an endpoint of unqualified success (dependent variable) were considered cases. All other eyes were used as the controls. Cases and controls were paired by sex and postoperative time. We tested the following independent variables: age, race, laterality (right eye or left eye), glaucoma stage, type of surgery (combined or stand-alone), type of trabecular bypass, intraoperative complications, baseline number of medications, baseline IOP, and postoperative IOP on days 1, 15, and 30. Additional analysis using IOP <15 mm Hg as a threshold and including eyes with at least 12 months of follow-up were performed.

RESULTS

One hundred ninety-four eyes were included in the analysis. We observed complete success in 56.7% of eyes. The mean follow-up time for the entire population was 12.3±6.8 months. All variables were considered in the first step of the modeling process; however, only age, day-15 IOP, day-30 IOP, baseline number of medications, glaucoma stage, and type of surgery remained until the completion of our model, with adequate significance (P<0.05). The additional analysis confirmed our results.

CONCLUSION

We identified that an older age, a low number of baseline glaucoma medications, an early glaucoma stage, lower IOP values during the first postoperative month, and combined surgery were associated with a higher chance of unqualified success at 12 months after a trabecular by-pass MIGS procedure.

Standalone iStent Trabecular Micro-bypass Glaucoma Surgery: A Systematic Review and Meta-Analysis

PRECIS

Standalone trabecular micro-bypass glaucoma surgery with the iStent devices is associated with clinically relevant reductions in intraocular pressure (IOP) sustained over a reasonably long-term while simultaneously reducing medication burden and a relatively favorable safety profile.

PURPOSE

While there is a relatively large body of evidence supporting the implantation of the iStent trabecular micro-bypass devices during phacoemulsification in patients with open-angle glaucoma (OAG), its efficacy as a standalone procedure has been less widely reported. The aims of this study were to systematically identify and quantitatively evaluate the efficacy of iStent devices (iStent and iStent inject) when performed independently of cataract surgery in patients with OAG.

METHODS

A systematic review of the literature was undertaken in August 2019 to identify studies of standalone trabecular micro-bypass glaucoma surgery with iStent devices in patients with OAG. All randomized trials were considered and nonrandomized studies that included at least 6 months of follow-up or more than 10 eyes. Key efficacy analyses included postoperative IOP and medication use, which were used to evaluate weighted mean differences from baseline, and the proportion of eyes free of ocular medication. Postoperative adverse events were descriptively summarized.

RESULTS

A total of 13 studies were identified including 4 randomized controlled trials and 9 nonrandomized or single-arm studies providing data for 778 eyes. In eyes implanted with iStent devices, a weighted mean IOP reduction of 31.1% was observed at 6 to 12 months. In studies reporting longer-term outcomes (36 to 48 mo or 60 mo), the weighted mean IOP reduction was 30.4% and 32.9%, respectively. The pooled weighted mean reduction in IOP from baseline across all studies at 6 to 12 months and 36 to 60 months poststent implantation was 7.01 mm Hg (95% confidence interval: 5.91, 8.11) and 6.59 mm Hg (95% confidence interval: 5.55, 7.63), respectively. Medication burden was reduced by ~1.0 medication at 6 to 18 months and 1.2 medications at 36 to 60 months. Adverse events reported in more than 5% of participants were progression of pre-existing cataract/cataract surgery and loss of best-corrected visual acuity but these rates were no different to those reported in comparator medical therapy study arms.

CONCLUSIONS

The results from these studies support the independent effect of the iStent trabecular bypass devices on IOP and medication burden over a duration of follow-up of up to 5 years.

Demographic and Clinical Characteristics Associated with Minimally Invasive Glaucoma Surgery Use: An Intelligent Research in Sight (IRIS®) Registry Retrospective Cohort Analysis

PURPOSE

Minimally invasive glaucoma surgery (MIGS) is increasingly performed at the time of cataract extraction. Understanding the demographic and clinical characteristics of patients undergoing MIGS procedures may provide insight into patient selection. This study evaluates racial-ethnic and other differences in the use of MIGS in persons with cataract and open-angle glaucoma (OAG).

DESIGN

Retrospective cohort study using Intelligent Research in Sight (IRIS) Registry data.

PARTICIPANTS

Patients aged ≥ 40 years with a diagnosis of OAG and no history of MIGS or cataract surgery who were undergoing cataract extraction, with or without MIGS, during 2013 to 2017 in the United States.

METHODS

Multivariable logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

MAIN OUTCOME MEASURES

Variables assessed include age, sex, race-ethnicity, disease severity, insurance type, census region, comorbidity, and cup-to-disc ratio (CDR).

RESULTS

The odds of MIGS use was greater among patients who were aged ≥ 60 years (OR, 1.10 [95% CI, 1.05-1.16]); Black (OR, 1.11 [CI, 1.07-1.15]) compared with White; a Medicare recipient (OR, 1.12 [CI, 1.10-1.15]) versus privately insured; or in the Midwest (OR, 1.32 [CI, 1.28-1.36]) or Northeast (OR, 1.26 [CI, 1.22-1.30]) compared with the South. Having moderate rather than mild glaucoma (OR, 1.07 [CI, 1.04-1.11]) and a higher CDR (OR for 0.5 to 0.8 vs. <0.5, 1.24 [CI, 1.21-1.26]; OR for >0.8 to 1.0 vs. <0.5, 1.27 [CI, 1.23-1.32]) were also each associated with increased odds of MIGS use. Use of MIGS was less likely in women (OR, 0.96 [CI, 0.94-0.98]); patients taking 5 to 7 glaucoma medications (OR, 0.94 [CI, 0.90-0.99]) compared with 1 to 2 medications; and patients with severe, compared with mild, glaucoma (OR, 0.64 [CI, 0.61-0.67]).

CONCLUSIONS

This analysis highlights the importance of capturing race-ethnicity data and other pertinent patient characteristics in electronic health records to provide insight into practice patterns. Such data can be used to assess the long-term performance of MIGS and other procedures in various patient populations.

Effects of Ripasudil on Open-Angle Glaucoma after Circumferential Suture Trabeculotomy Ab Interno

We evaluated the effects of ripasudil on the distal aqueous outflow tract in patients with open-angle glaucoma (OAG) who underwent a 360° suture trabeculotomy ab interno followed by ripasudil treatment beginning 1 month postoperatively. We compared 27 of these patients, by using propensity score analysis, with 27 patients in a matched control group who had no ripasudil treatment. We assessed the changes in the mean intraocular pressure (IOP) and the relationship between the IOP changes and background factors. All eyes had a complete 360° Schlemm’s canal incision and phacoemulsification. The mean IOP at 1 and 3 months after ripasudil administration were significantly reduced by −1.7 ± 1.9 mmHg (p < 0.0001) and −1.3 ± 2.3 mmHg (p = 0.0081) in the ripasudil group, respectively, but IOP in the control group was not significantly reduced. The IOP reduction was significantly associated with the IOP before ripasudil treatment (p < 0.001). In conclusion, the use of ripasudil for patients with OAG after circumferential incision of the Schlemm’s canal produced significant IOP reductions. Ripasudil may affect the distal outflow tract, thereby leading to the IOP reduction.

Treatment Complexity in Primary Open-Angle Glaucoma (POAG): Perspectives on Patient Selection in Micro-Invasive Glaucoma Surgery (MIGS) Using Stents

BACKGROUND

Primary open-angle glaucoma (POAG) is still one of the most common causes of impaired vision worldwide, despite the further development of therapy options, and can lead to blindness. Micro-invasive glaucoma surgery (MIGS) using stents aims at reducing intraocular pressure (IOP), as it is the main risk factor. With regard to adherence and adverse drug reactions it also aims at reducing the drug burden on patients. The study investigates under everyday conditions the criteria according to which ophthalmologists in Germany select patients for MIGS using stents. In addition, it will be investigated which patients (could) benefit most from the therapy.

MATERIAL AND METHODS

In this qualitative study, 11 narrative interviews were conducted between May 2017 and July 2018 with ophthalmologists working in the hospital or in a private practice. They were interviewed on their experiences in the treatment of POAG with microstents. The interviews were analysed by an interdisciplinary team using the qualitative content analysis.

RESULTS

The stages of therapy escalation form the frame of reference for patient selection in MIGS using stents. Only if the IOP cannot be sufficiently reduced by drop therapy or when this causes drug-related side effects that are intolerable for the patients, stents are apparently used as the next higher escalation stage. The intensive post-operative medication and the frequent check-up appointments are perceived as barriers by the interviewees, especially for people with or without disabilities, who are dependent on external help and/or those living in rural areas. The active cooperation of the patients in the demanding aftercare seems to be indispensable for the ophthalmologists. In addition, necessary revisions are sometimes stressful for patients (physical/psychological) and doctors (work organisation/therapy). Against the background of the organisational and economic challenges in the outpatient spectrum of tasks, especially physicians in private practice seem to weigh up carefully for which patients microstent therapy would be reasonable.

CONCLUSION

In view of the therapeutic requirements, the current microstent therapy seems to be used in a selected, adherent patient group. Further qualitative and quantitative studies (in other health care regions and structures) are necessary to verify and extend the available results.

Evaluation of the IOP-Lowering Effect of a Multi-Pressure Dial at Different Negative Pressure Settings

Purpose

To evaluate the intraocular pressure (IOP)-lowering effect of a multi-pressure dial (MPD) at targeted negative pressure settings.

Methods

Prospective, intrasubject controlled study of 65 healthy subjects randomized to receive no negative pressure for 60 minutes or negative pressure application at designated levels of 25%, 50%, and 75% of baseline IOP for 20 minutes each. The main outcome measure was mean IOP with application of negative pressure.

Results

In the study eye group, from a baseline IOP of 15.8 ± 3.6 mm Hg, the mean IOP was 13.5 ± 3.4, 11.5 ± 3.1, and 10.2 ± 2.7 mm Hg with negative pressure settings of 25%, 50% and 75%, respectively. In the control eye group, from a baseline IOP of 15.5 ± 3.0 mm Hg, the mean IOP values at the same time points, without negative pressure, were 15.6 ± 3.0, 15.5 ± 2.5 and 15.3 ± 2.4 mm Hg. The difference between the mean IOPs of the two groups was significantly different at all negative pressure settings (P < 0.001) in comparison with baseline. There was one minor adverse event, a corneal abrasion, that was unrelated to device wear.

Conclusions

Negative pressure application to the periocular space with a multi-pressure dial can produce titratable IOP reduction while the device is worn with active negative pressure. To our knowledge, this technology represents the first nonpharmacologic, nonlaser, nonsurgical method for IOP reduction.

Translational Relevance

This represents the first study demonstrating the IOP-lowering ability of the multi-pressure dial, a device that uses a novel IOP-lowering strategy by delivering negative pressure to the periocular region.

Numerical model to predict and compare the hypotensive efficacy and safety of minimally invasive glaucoma surgery devices

Purpose

To predict and compare the hypotensive efficacy of three minimally-invasive glaucoma surgery (MIGS) implants through a numerical model.

Methods

Post-implant hypotensive efficacy was evaluated by using a numerical model and a computational fluid dynamics simulation. Three different devices were compared: the XEN 45 stent (tube diameter, 45 μm), the XEN 63 stent (63 μm) and the PreserFlo microshunt (70 μm). The influence of the filtration bleb pressure (Bp) and tube diameter, length, and position within the anterior chamber (AC) on intraocular pressure (IOP) were evaluated.

Results

Using baseline IOPs of 25, 30 and 50 mmHg, respectively, the corresponding computed post-implant IOPs for each device were as follows: XEN 45: 17 mmHg (29% decrease), 19 mmHg (45%) and 20 mmHg (59%) respectively; XEN 63: 13 mmHg (48%), 13 mmHg (62%), and 13 mmHg (73%); PreserFlo: 12 mmHg (59%), 13 mmHg (73%) and 13 mmHg (73%). At a baseline IOP of 35 mmHg with an increase in the outflow resistance within the Bp from 5 to 17 mmHg, the hypotensive efficacy for each device was reduced as follows: XEN45: 54% to 37%; XEN 63: 74% to 46%; and PreserFlo: 75% to 47%. The length and the position of the tube in the AC had only a minimal (non-significant) effect on IOP (<0.1 mmHg).

Conclusions

This hydrodynamic/numerical model showed that implant diameter and bleb pressure are the two most pertinent determinants of hypotensive efficacy. In distinction, tube length and position in the AC do not significantly influence IOP.

Predictors of Intraocular Pressure Lowering after Phacoemulsification and iStent Implantation

PURPOSE

To explore the demographic and clinical variables associated with intraocular pressure (IOP) lowering after cataract extraction (CE) alone or CE in combination with the iStent (Glaukos Corporation) placement (CE+IS).

DESIGN

Retrospective data extraction and survival analysis of consecutive patients identified over a 2-year period.

PARTICIPANTS

Patients with mild to moderate glaucoma who underwent CE (48 eyes of 32 patients) or CE+IS (61 eyes of 37 patients) were analyzed.

METHODS

Inability to reduce the number of medications or the IOP by at least 20% compared with baseline on 2 consecutive visits was considered surgical failure. Using Cox proportional hazards models, survival analysis was performed, and demographic and clinical variables were evaluated as risk factors.

MAIN OUTCOME MEASURES

Time to failure after surgical procedure.

RESULTS

CE+IS had lower odds of failure than CE alone (hazard ratio [HR], 2.01; P = 0.047). In White patients, CE+IS showed greater odds of success compared with CE alone (HR, 2.86; P = 0.007). For non-White patients, no difference was found in the outcomes for the 2 procedures (HR, 0.59; P = 0.48). In the multivariate analysis, non-White race (HR, 8.75; P = 0.0002) and longer axial length (HR, 1.61; P = 0.03) were associated with greater hazard of failure after CE+IS. In the CE group, greater odds of failure were associated with steeper corneal curvature (HR, 1.74; P = 0.008), shallower anterior chamber (HR, 0.22; P = 0.008), and longer axial length (HR, 1.58; P = 0.01).

CONCLUSIONS

Addition of the iStent to CE improved the duration of IOP lowering in White patients, but not in non-White patients. Associations between IOP lowering after CE and biometric parameters may allow for leveraging these clinical parameters for better case selection for these procedures.

The Diagnosis and Treatment of Glaucoma

BACKGROUND

Glaucoma is a group of chronically progressive disorders of the optic nerve. In this article, we present the epidemiology of and risk factors for glaucoma, as well as the diagnostic work-up and treatment options.

METHODS

This review is based on pertinent publications retrieved by a selective search in Medline and the Cochrane Library, supplemented by further articles chosen by the authors.

RESULTS

In Europe, the prevalence of glaucoma is 2.93% among persons aged 40 to 80 years. The prevalence rises with age, reaching 10% in persons over 90 years old. The available diagnostic methods include ophthalmoscopy, tonometry, perimetry, and imaging techniques. The treatment of glaucoma is focused on lowering the intraocular pressure with topical drugs, laser therapy, and glaucoma surgery. In patients with manifest glaucoma, lowering the intraocular pressure prevents the progression of visual field defects, with a number needed to treat of 7.

CONCLUSION

The diagnostic evaluation of glaucoma rests on multiple pillars, all of which must be considered for establishing the diagnosis and defining the desired target pressure: these are, among others, the intraocular pressure and ocular function and morphology. Individually tailored pressure-lowering treatment should be evaluated in regularly scheduled follow-up visits for assessment of function and morphology and adjusted as necessary to minimize the risk of progression.

12-month randomised trial of 360° and 180° Schlemm's canal incisions in suture trabeculotomy ab interno for open-angle glaucoma

Background/Aims

To perform a 12-month comparison between the different extents and locations of Schlemm’s canal incisions during suture trabeculotomy ab interno for open-angle glaucoma (OAG).

Methods

This is a prospective, single-centre, three-arm randomised trial. A total of 99 eyes of 99 patients were randomly assigned to one of three groups: the 360° incision group (n=34), the upper-180° incision group (n=34) and the lower-180° incision group (n=31). Intraocular pressure (IOP), number of medications and complications were evaluated until 12 months after surgery. Surgical success (with or without medication) was defined as IOP ≤21 mmHg and ≥20% IOP reduction (criterion A) or IOP ≤15 mmHg and ≥20% IOP reduction (criterion B).

Results

The mean IOP (±SD) in all eyes was reduced from 18.6 (5.9) mmHg with 3.1 (1.1) medications to 13.7 (3.4) mmHg (20.8% reduction; p<0.001) with 1.4 (1.3) medications (p<0.001) at postoperative 12-month. Each group produced comparable mean reductions in both IOP and the number of medications throughout 12 months of follow-up. Kaplan-Meier cumulative survival analyses showed no significance among these three groups for criterion A and criterion B. Postoperative hyphema with niveau formation occurred significantly more in the 360° group than in the lower-180° group (p=0.031).

Conclusions

The different extents and locations of Schlemm’s canal incisions during suture trabeculotomy ab interno for OAG, including the 360° incision, the upper-180° incision and the lower-180° incision, do not affect both the IOP reduction and the medications throughout 12 months of follow-up.

Trial registration number

UMIN000021169.

A European Study of the Performance and Safety of MINIject in Patients With Medically Uncontrolled Open-angle Glaucoma (STAR-II)

PRECIS

In this European study (STAR-II), MINIject, a novel, ab-interno, supraciliary minimally invasive glaucoma surgery device, effectively lowered intraocular pressure (IOP) and the need for IOP-lowering medications in patients with primary open-angle glaucoma.

PURPOSE

This study evaluates the safety and performance of a minimally invasive supraciliary glaucoma drainage device (MINIject DO627) for surgical treatment of primary open-angle glaucoma in patients refractory to topical hypotensive medications.

METHODS

In a prospective, interventional, single-arm, multicenter, European study (STAR-II), MINIject was successfully implanted in a stand-alone procedure in 29 of 31 patients in 8 sites in 3 countries. The primary endpoint was the success rate 6 months after surgery >60% (defined as diurnal IOP ≤21 and >5 mm Hg with ≥20% IOP reduction from baseline, with/without glaucoma hypotensive medication). ClinicalTrials.gov: NCT03624361.

RESULTS

At the 6-month follow-up, the primary endpoint was fulfilled, with 75.9% of patients reaching prospectively defined success. The mean IOP was reduced by 40.2% (9.9 mm Hg) to 14.7±6.0 mm Hg at 6 months from 24.6±3.8 mm Hg at baseline. The use of IOP-lowering medication ingredients was reduced by 63.4% from 2.9±1.2 at baseline to 1.0±1.3. Furthermore, 79.3% of the patients had mean IOP ≤18 mm Hg, 82.8% achieved a ≥20% IOP reduction, and 55.2% were medication free at 6 months. Six device-related serious adverse events were reported in the study eye: IOP increase (3/31 patients, 9.7%), and single reports of eye pain, corneal erosion, and chorioretinal folds (1/31, 3.2%), all of which resolved. There was minimal change to corneal endothelial cell density.

CONCLUSION

Ab-interno supraciliary surgical implantation using MINIject DO627 in a stand-alone procedure significantly lowers IOP by 40% at the 6-month follow-up, while reducing the need for IOP-lowering medication.

Nano-structured glaucoma drainage implant safely and significantly reduces intraocular pressure in rabbits via post-operative outflow modulation

Glaucoma is a leading cause of irreversible vision loss predicted to affect more than 100 million people by 2040. Intraocular pressure (IOP) reduction prevents development of glaucoma and vision loss from glaucoma. Glaucoma surgeries reduce IOP by facilitating aqueous humor outflow through a vent fashioned from the wall of the eye (trabeculectomy) or a glaucoma drainage implant (GDI), but surgeries lose efficacy overtime, and the five-year failure rates for trabeculectomy and tube shunts are 25-45%. The majority of surgical failures occur due to fibrosis around the vent. Alternatively, surgical procedures can shunt aqueous humor too well, leading to hypotony. Electrospinning is an appealing manufacturing platform for GDIs, as it allows for incorporation of biocompatible polymers into nano- or micro-fibers that can be configured into devices of myriad combinations of dimensions and conformations. Here, small-lumen, nano-structured glaucoma shunts were manufactured with or without a degradable inner core designed to modulate aqueous humor outflow to provide immediate IOP reduction, prevent post-operative hypotony, and potentially offer significant, long-term IOP reduction. Nano-structured shunts were durable, leak-proof, and demonstrated biocompatibility and patency in rabbit eyes. Importantly, both designs prevented hypotony and significantly reduced IOP for 27 days in normotensive rabbits, demonstrating potential for clinical utility.

Twelve-Month Outcomes of Stand-Alone Excisional Goniotomy in Mild to Severe Glaucoma

PURPOSE

To describe 12-month intraocular pressure (IOP) and medication use outcomes following excisional goniotomy (EG) as a stand-alone procedure in eyes with medically uncontrolled glaucoma.

METHODS

This was a retrospective analysis of data from surgeons at 8 centers (6 US, 2 Mexico). Eyes with glaucoma undergoing standalone EG with a specialized instrument (Kahook Dual Blade, New World Medical, Rancho Cucamonga, CA) for IOP reduction and followed for 12 months postoperatively were included. Data were collected preoperatively, intraoperatively, and 1 day, 1 week, and 1, 3, 6, and 12 months postoperatively. The primary outcome was reduction from baseline in IOP, and key secondary outcomes included IOP-lowering medication reduction as well as adverse events.

RESULTS

A total of 42 eyes were analyzed, of which 36 (85.7%) had mild to severe primary open-angle glaucoma (POAG). Mean (standard error) IOP at baseline was 21.6 (0.8) mmHg, and mean number of medications used at baseline was 2.6 (0.2). At 3, 6, and 12 months postoperatively, mean IOP reductions from baseline were 4.6 mmHg (22.3%), 5.6 mmHg (27.7%), and 3.9 mmHg (19.3%) (p≤0.001 at each time point). At the same time points, mean medications reductions of 0.7 (25.8%), 0.9 (32.6%), and 0.3 (12.5%) medications were seen (p<0.05 at months 3 and 6, not significant at month 12). Six eyes (14.3%) underwent additional glaucoma surgery during the 12-month follow-up period.

DISCUSSION

Standalone EG with KDB can reduce IOP, and in many cases reduce medication use, through up to 12 months in eyes with mild to severe glaucoma. Statistically significant and clinically relevant reductions in IOP were seen at every time point. While the goal of surgery was not to reduce medication burden, mean medication use was significantly reduced at all but the last time point. In the majority of eyes, the need for a bleb-based glaucoma procedure was delayed or prevented for at least 12 months.

Personalising surgical treatments for glaucoma patients

Surgical treatments for glaucoma have relied for decades on traditional filtering surgery such as trabeculectomy and, in more challenging cases, tubes. Antifibrotics were introduced to improve surgical success in patients at increased risk of failure but have been shown to be linked to a greater incidence of complications, some being potentially vision-threatening. As our understanding of glaucoma and its early diagnosis have improved, a more individualised management has been suggested. Recently the term "precision medicine" has emerged as a new concept of an individualised approach to disease management incorporating a wide range of individual data in the choice of therapeutic modalities. For glaucoma surgery, this involves evaluation of the right timing, individual risk factors, targeting the correct anatomical and functional outflow pathways and appropriate prevention of scarring. As a consequence, there is an obvious need for better knowledge of anatomical and functional pathways and for more individualised surgical approaches with new, less invasive and safer techniques allowing for earlier intervention. With the recent advent of minimally invasive glaucoma surgery (MIGS) a large number of novel devices have been introduced targeting potential new sites of the outflow pathway for lowering intraocular pressure (IOP). Their popularity is growing in view of the relative surgical simplicity and apparent lack of serious side effects. However, these new surgical techniques are still in an era of early experiences, short follow-up and lack of evidence of their superiority in safety and cost-effectiveness over the traditional methods. Each year several new devices are introduced while others are withdrawn from the market. Glaucoma continues to be the primary cause of irreversible blindness worldwide and access to safe and efficacious treatment is a serious problem, particularly in the emerging world where the burden of glaucoma-related blindness is important and concerning. Early diagnosis, individualised treatment and, very importantly, safe surgical management should be the hallmarks of glaucoma treatment. However, there is still need for a better understanding of the disease, its onset and progression, the functional and structural elements of the outflow pathways in relation to the new devices as well as their long-term IOP-lowering efficacy and safety. This review discusses current knowledge and the future need for personalised glaucoma surgery.

Cataract and glaucoma combined surgery: XEN® gel stent versus nonpenetrating deep sclerectomy, a pilot study

Background

To compare the efficacy of phacoemulsification (PKE) combined with nonpenetrating deep sclerectomy (NPDS) with mitomycin C (MMC) versus XEN® gel stent with MMC.

Methods

In this nonrandomized, retrospective, comparative, single-center pilot study, 105 consecutive eyes of 75 patients with uncontrolled primary open-angle glaucoma (POAG) and cataract who underwent PKE combined with either XEN implantation (n = 47) or NPDS (n = 58) between May 2013 and November 2018 were included. The primary outcome was complete success at 9 months, which was defined as intraocular pressure (IOP) ≤18, 15 or 12 mmHg without treatment; qualified success was IOP ≤18, 15 or 12 mmHg with antiglaucoma medications. Secondary outcome measures included the number of antiglaucoma medications, visual acuity (VA), and postoperative adverse events.

Results

Using the 18 mmHg threshold, complete or qualified success was achieved in 69.6 and 89.1% in the PKE + XEN group, and 63.8 and 89.7% in the PKE + NPDS group (p = .54 and p = .93), respectively, at 9 months. The mean IOP decreased from 20.8 ± 6.8 mmHg to 16.2 ± 2.8 mmHg in the PKE + XEN group (p < .001, 18.9% mean drop), and from 21.5 ± 8.9 mmHg to 14.9 ± 3.9 mmHg in the PKE + NPDS group (p < .001, 25.6% mean drop). Best-corrected VA significantly improved (p < .001) in both groups. The mean number of antiglaucoma medications was significantly reduced from 2.66 ± 1.1 to 0.49 ± 1.0 in the PKE + XEN group (p < .001) and from 2.93 ± 0.9 to 0.69 ± 1.2 in the PKE + NPDS group (p < .001).

Conclusions

The XEN stent combined with PKE seemed to be as effective and safe as PKE + NPDS at 9 months in this pilot study.

The Cost and Economics of Endoscopic Cyclophotocoagulation in the United Kingdom: A Tertiary Center Experience

PRECIS

As the only microinvasive glaucoma surgery (MIGS) with a reusable component, the cost per procedure of endoscopic cyclophotocoagulation (ECP) diminishes with each successive use. We present a cost comparison of ECP with other MIGS devices, based on our clinical practice.

PURPOSE

ECP delivers diode laser via a reusable probe to the ciliary processes under direct visualization. The aim of our study is to evaluate the direct cost of ECP based on a retrospective review of cases and compare the cost per procedure with other MIGS devices.

METHODS

We conducted a retrospective review of ECP procedures performed at St Thomas' Hospital over 4.5 years. The cost of the ECP endoscope and diode laser consoles, reusable probes, and maintenance contracts were obtained from the hospital procurement log. The on-site Central Sterile Services Department was contacted for probe sterilization and repackaging costs. The cost per device for ECP and commonly performed MIGS procedures were obtained from the product specialists of each company.

RESULTS

A total of 332 procedures were performed using 37 ECP probes during the study period. Each reusable ECP laser probe was found to give an average of 8.97 laser treatments. The cost per procedure decreased over the course of 4.5 years from £819.43 for the first 42 cases to £341.50 after 332 cases. Compared with other MIGS devices, the cost per procedure of ECP after 100 procedures is second lowest to the Kahook Dual Blade and reduces with each successive procedure performed.

CONCLUSION

The ability to reuse each ECP probe significantly lowers the cost per procedure compared with other MIGS devices in the United Kingdom. The cost per procedure continues to reduce with each successive procedure.

The Pro-Fibrotic Behavior of Human Tenon's Capsule Fibroblasts in Medically Treated Glaucoma Patients

Purpose

The aim of this study was to compare human Tenon’s capsule fibroblasts (HTCFs) obtained from patients who received medical therapy for glaucoma (glaucomatous patients) and patients not treated for glaucoma (non-glaucomatous patients) in terms of wound healing and fibrosis.

Patients and Methods

Bioartificial tissues (BATs) were generated using primary HTCF-populated collagen lattices. Pro-fibrotic gene expression within HTCFs was compared between glaucomatous patients and non-glaucomatous patients after BAT culture. The BATs were also assessed regarding fibroblast–myofibroblast transition, collagen remodeling and collagen contraction using alpha-smooth muscle actin immunohistochemistry, picrosirius red staining and collagen contraction assays, respectively.

Results

Pro-fibrotic gene expression in BAT-cultured HTCFs derived from glaucomatous patients was significantly increased compared to non-glaucomatous patients. BATs imbued with HTCFs collected from glaucomatous patients exhibited a greater proportion of myofibroblasts as well as increased collagen contraction/remodeling compared to HTCFs isolated from non-glaucomatous patients.

Conclusion

HTCFs from glaucomatous and non-glaucomatous patients differ in the expression of genes involved in fibrosis, proportion of fibroblasts undergoing transdifferentiation into myofibroblasts, contractile properties and collagen remodeling. These results suggest that for any number of reasons, at a cellular level, patients who received medical therapy for glaucoma have eyes primed for fibrosis.

Minimally Invasive Glaucoma Surgery: What Do We Know? Where Should We Go?

With the arrival of a plethora of new and revolving minimally invasive glaucoma surgery techniques, glaucoma specialists currently are fortunate to have various surgical options that aim to recovery of the function of the aqueous outflow system in different ways. Meanwhile, the aqueous outflow system has become the hot point of researching. In ARVO 2019, a special interest group session was held on new perspectives on minimally invasive glaucoma surgery. Ten surgeons, clinical professors, and experimental scientists were invited to report their latest studies and discussed on five hot topics in this special interest group. This review summarizes the special interest group session and posts the issues of greatest concern, providing insight to the aqueous outflow system and areas that require further study.

Comparing Medium-Term Clinical Outcomes following XEN® 45 and XEN® 63 Device Implantation

Purpose

To evaluate medium-term clinical outcomes with XEN® 45 or XEN® 63 Gel Stent (Allergan, Dublin, Ireland) for treatment of primary open angle glaucoma (POAG). Materials and Methods. Retrospective, descriptive, and observational study involving 40 patients implanted with a XEN® 45 Gel Stent and 34 implanted with a XEN® 63 Gel Stent who had undergone POAG surgery and had been followed up and controlled between 12 and 36 months.

Results

IOP dropped from 18.02 ± 5.23 mmHg preop to 13.81 ± 1.88, 14.80 ± 2.23, and 14.62 ± 1.90 at 1, 2, and 3 years after surgery (p < 0.001) consecutively with XEN® 45 and from 19.00 ± 6.11 mmHg preop to 15.47 ± 2.45, 14.66 ± 2.45, and 15.46 ± 2.48 at 1, 2, and 3 years after surgery (p < 0.001) with XEN® 63. The number of drugs used by patients to treat their glaucoma decreased after undergoing surgery in both groups. Within the XEN® 45 group, mean changes at 1 year, 2 years, and 3 years amounted to 70%, 74.3%, and 37.5%, respectively, whereas within the XEN® 63 group, the mean reduction was 75%, 79.8%, and 71.9%. When comparing the outcomes for two groups, the differences did not prove to be statistically significant. More than 90% of the procedures included in the study (using either gel-stent device) were completed without any noteworthy complications.

Conclusion

POAG surgical procedures with either XEN® 45 or XEN® 63 Gel Stent implantation could be a safe and effective treatment approach.

Ab interno trabecular bypass surgery with Schlemm´s canal microstent (Hydrus) for open angle glaucoma

BACKGROUND

Glaucoma is a leading cause of irreversible blindness. A number of minimally-invasive surgical techniques have been introduced as a treatment to prevent glaucoma from progressing; ab interno trabecular bypass surgery with the Schlemm's canal Hydrus microstent is one of them.

OBJECTIVES

To evaluate the efficacy and safety of ab interno trabecular bypass surgery with the Hydrus microstent in treating people with open angle glaucoma (OAG).

SEARCH METHODS

On 7 May 2019, we searched CENTRAL (2019, Issue 5), which contains the Cochrane Eyes and Vision Trials Register; Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov; and the WHO ICTRP.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) of the Hydrus microstent, alone or with cataract surgery, compared to other surgical treatments (cataract surgery alone, other minimally-invasive glaucoma device techniques, trabeculectomy), laser treatment, or medical treatment.

DATA COLLECTION AND ANALYSIS

A minimum of three authors independently extracted data from reports of included studies, using a data collection form and analysed data, based on standard Cochrane methods.

MAIN RESULTS

We included three published studies, with 808 people randomised. Two studies had multiple international recruitment centres in the USA and other countries. The third study had several sites based in Europe. All three studies were sponsored by the Hydrus manufacturer Ivantis Inc. All studies included participants with mainly mild or moderate OAG (mean deviation between -3.6 dB (decibel) and -8.4 dB in all study arms), which was controlled with medication in many participants (mean medicated intraocular pressure (IOP) 17.9 mmHg to 19.1 mmHg). There were no concerns regarding allocation concealment bias, but masking of outcome assessors was high or unclear risk in all studies; masking of participants was achieved, and losses to follow-up were not a concern. Two studies compared the Hydrus microstent combined with cataract surgery to cataract surgery alone, in participants with visually significant cataracts and OAG. We found moderate-certainty evidence that adding the Hydrus microstent to cataract surgery increased the proportion of participants who were medication-free from about half to more than three quarters at 12-month, short-term follow-up (risk ratio (RR) 1.59, 95% confidence interval (CI) 1.39 to 1.83; 2 studies, 639 participants; I² = 0%; and 24-month, medium-term follow-up (RR 1.63, 95% CI 1.40 to 1.88; 2 studies, 619 participants; I² = 0%). The Hydrus microstent combined with cataract surgery reduced the medium-term mean change in unmedicated IOP (after washout) by 2 mmHg more compared to cataract surgery alone (mean difference (MD) -2.00, 95% CI -2.69 to -1.31; 2 studies, 619 participants; I² = 0%; moderate-certainty evidence), and the mean change in IOP-lowering drops (MD -0.41, 95% CI -0.56 to -0.27; 2 studies, 619 participants; I² = 0%; low-certainty evidence). We also found low-certainty evidence that adding a Hydrus microstent to cataract surgery reduced the need for secondary glaucoma surgery from about 2.5% to less than 1% (RR 0.17, 95% CI 0.03 to 0.86; 2 studies, 653 participants; I² = 27%; low-certainty evidence). Intraocular bleeding, loss of 2 or more visual acuity (VA) lines, and IOP spikes of 10 mmHg or more were rare in both groups; estimates were imprecise, and included both beneficial and harmful effects. There were no cases of endophthalmitis in either group. No data were available on the proportion of participants achieving IOP less than 21 mmHg, 17 mmHg, or 14 mmHg; health-related quality of life (HRQOL), or visual field progression. One study provided short-term data for the Hydrus microstent compared with the iStent trabecular micro-bypass stent (iStent: implantation of two devices in a single procedure) in 152 participants with OAG (148 in analyses). Use of the Hydrus increased the proportion of medication-free participants from about a quarter to about half compared to those who received iStent, but this estimate was imprecise (RR 1.94, 95% CI 1.21 to 3.11; low-certainty evidence). Use of the Hydrus microstent reduced unmedicated IOP (after washout) by about 3 mmHg more than the iStent (MD -3.10, 95% CI -4.17 to -2.03; moderate-certainty evidence), and the use of IOP-lowering medication (MD -0.60, 95% CI -0.99 to -0.21; low-certainty evidence). Both devices achieved a final IOP < 21 mmHg in most participants (Hydrus microstent: 91.8%; iStent: 84%; RR 1.09, 95% CI 0.97 to 1.23; low-certainty evidence). None of the participants who received the Hydrus microstent (N = 74) required additional glaucoma surgery; two participants who received the iStent (N = 76) did. Few adverse events were found in either group. No data were available on the proportion of participants achieving IOP less than 17 mmHg or 14 mmHg, or on HRQOL.

AUTHORS' CONCLUSIONS

In people with cataracts and generally mild to moderate OAG, there is moderate-certainty evidence that the Hydrus microstent with cataract surgery compared to cataract surgery alone, likely increases the proportion of participants who do not require IOP lowering medication, and may further reduce IOP at short- and medium-term follow-up. There is moderate-certainty evidence that the Hydrus microstent is probably more effective than the iStent in lowering IOP of people with OAG in the short-term. Few studies were available on the effects of the Hydrus microstent, therefore the results of this review may not be applicable to all people with OAG, particularly in selected people with medically uncontrolled glaucoma, since IOP was controlled with medication in many participants in the included studies. Complications may be rare using the Hydrus microstent, as well as the comparator iStent, but larger studies are needed to investigate its safety.

Prospective Studies of Minimally Invasive Glaucoma Surgeries: Systematic Review and Quality Assessment

Glaucoma is a common blinding disease; while there is no cure, effective treatments include medications, laser, and incisional surgery. There is significant interest from patients and doctors to develop safer surgical options throughout the spectrum of disease, to minimize treatment burden in mild glaucoma patients and to minimize risk of complications in patients needing more aggressive treatment. Surgical procedures called Minimally or Micro-Invasive Glaucoma Surgery (MIGS) are growing in popularity. Eighty-seven prospective studies on MIGS were identified and assessed for quality. Most (74%) did not have a control group. Twelve of the highest quality were reviewed. MIGS procedures appeared to have fewer complications, and lowered intraocular pressure, and reduced medication use. Studies were limited by small sample size, narrow spectrum of glaucomatous disease, and/or conflicts of interest. There is a need for high quality, independently funded and performed, comparative studies on the MIGS to help make treatment decisions.

Medium-term clinical outcomes following Xen45 device implantation

PURPOSE

To evaluate medium-term clinical outcomes with microstent XEN^® 45 Gel Stent (Allergan Dublin, Ireland) for treatment of primary open-angle glaucoma (POAG).

MATERIAL AND METHODS

This is a retrospective, descriptive and observational study involving 93 eyes from 63 patients who had undergone POAG surgery with a XEN^® 45 Gel Stent implantation and had been followed up and controlled between 12 and 36 months.

RESULTS

IOP dropped from 18.23 ± 5.00 mmHg pre-op to 14.16 ± 2.14, 14.47 ± 2.16 and 14.63 ± 1.91 at 1, 2 and 3 years after surgery (p = 0.000, 0.000 and 0.001) consecutively. Mean number of medications dropped from 1.87 ± 0.94 preoperatively to 0.31 ± 0.69, 0.34 ± 0.63 and 1.00 ± 0.88 (p = 0.000, 0.000 and 0.017) at 12, 24 and 36 months. Mean visual field deviation values never turned out to be significant for any of the follow-up visit data. A total of 94.6% of the surgical procedures turned out to be complication-free. In one surgery, the procedure failed and 18 months later other device was implanted.

CONCLUSION

POAG surgical procedures with XEN^® 45 Gel Stent implants are a safe and effective treatment approach.

Open-Angle Glaucoma: Burden of Illness, Current Therapies, and the Management of Nocturnal IOP Variation

Glaucoma is a chronic, debilitating disease and a leading cause of global blindness. Despite treatment efforts, 10% of patients demonstrate loss of vision. In the US, > 80% of glaucoma cases are classified as open-angle glaucoma (OAG), with primary open-angle (POAG) being the most common. Although there has been tremendous innovation in the surgical treatment of glaucoma as of late, two clinical variants of OAG, normal-tension glaucoma (NTG) and severe POAG, are especially challenging for providers because patients with access to care and excellent treatment options may progress despite achieving a “target” intraocular pressure value. Additionally, recent research has highlighted the importance of nocturnal IOP control in avoiding glaucomatous disease progression. There remains an unmet need for new treatment options that can effectively treat NTG and severe POAG patients, irrespective of baseline IOP, while overcoming adherence limitations of current pharmacotherapies, demonstrating a robust safety profile, and more effectively controlling nocturnal IOP.

Funding The Rapid Service Fees were funded by the corresponding author, Tanner J. Ferguson, MD.

Modified Cortex Mori Capsules improving the successful rate of functional filtering blebs after reclinical glaucoma filtering surgery

BACKGROUND

The major reason for filtering bleb failure or scarring of the bleb site is due to excessive scarring after glaucoma filtration surgery in the clinic. Traditional Chinese medicine has preeminence in the prevention of fibrosis formation through the regulation of systemic circulation and improvement of the properties of the inflammatory cells in the blood.

AIM

To examine the clinical efficacy of using the Modified Cortex Mori Capsules (MCMC; Chinese name: Jiawei Sangbaipi Capsules) in the success rate of functional filtering blebs after glaucoma filtering surgery in clinical patients.

METHODS

Sixty resurgery glaucoma patients were randomly divided into two groups: 30 patients in surgery with the placebo group and 30 patients in surgery with the MCMC group. Patients took either the placebo or the MCMC 2 wk before and after surgery. Postoperative morphology and function filtering bleb, visual acuity, intraocular pressure, postoperative complications, the success rate of filtration surgery and clinical efficacy were observed.

RESULTS

Fifty patients completed the study. The percentage of functional filtering blebs in the surgery plus MCMC group was 84% at 6 mo after surgery, which was higher than surgery plus placebo group (64%, P < 0.05). The surgical success rate in the MCMC and placebo groups were 79% ± 8.3% and 57% ± 10.6% respectively (P < 0.05). The visual acuity, intraocular pressure and the postoperative complications in the two groups had no significant differences.

CONCLUSION

Glaucoma filtering surgery while taking MCMC not only reduced excessive scar formation and increased the success rate of functional filtering blebs but also improved the success of glaucoma filtration operations.

Progression on canaloplasty for primary open angle glaucoma

As a non-penetrating glaucoma surgery (NPGS), canaloplasty aims to reconstruct the physiological outflow of aqueous humor by dilating the Schlemm's canal. Ab interno canaloplasty (ABiC), which can reconstruct the natural outflow pathways of aqueous humor in mild-to-moderate primary open angle glaucoma (POAG) patients, is a new minimally invasive glaucoma surgery (MIGS) procedure improving from traditional canaloplasty. Canaloplasty can reduce intraocular pressure (IOP) with high efficiency and security. There are no complications such as scar formation and encapsulation for this no-bleb canaloplasty.

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

Purpose

To compare reductions in intraocular pressure (IOP) and IOP-lowering medication use following sectoral excisional goniotomy with the Kahook Dual Blade (KDB) or 360° trabeculotomy (via either Trab360 or gonioscopy-assisted transluminal trabeculotomy [GATT]) in eyes with open-angle glaucoma (OAG) undergoing phacoemulsification cataract surgery.

Methods

A retrospective review was conducted to collect data from adult subjects with early to advanced primary or secondary OAG undergoing phacoemulsification combined with either KDB or 360° trabeculotomy (Trab360 or GATT) between August 1, 2016 and July 30, 2018 for which 6-month follow-up was available. Data collected included IOP, glaucoma medications, adverse events, and additional IOP-lowering procedures. The primary outcome measure was surgical success (≥20% IOP or ≥1 medication reduction without additional IOP-lowering procedures) at 6 months.

Results

Data were collected from 74 eyes of 61 subjects undergoing KDB excisional goniotomy and 27 eyes of 25 subjects undergoing 360° trabeculotomy (19 eyes of 17 subjects undergoing Trab360 and 8 eyes of 8 subjects undergoing GATT). At 6 months, 81.7% (58/71) of KDB eyes and 84.6% (22/26) of 360° trabeculotomy eyes achieved surgical successes (P=0.737). Mean IOP reductions and medication reductions were similar between groups at 6 months. However, more eyes undergoing KDB than Trab360/GATT achieved target IOP ≤18 mmHg (80.0% [56/70] vs 59.3% [16/27], P=0.040) and ≤15 mmHg (61.4% [43/70] vs 25.9% [7/27], P=0.003) without further IOP-lowering interventions at 6 months. The nature and frequency of adverse events were similar between groups.

Conclusions

Both KDB and Trab360 or GATT procedures similarly lowered both IOP and the need for IOP-lowering medications during the first 6 postoperative months. More eyes undergoing KDB excisional goniotomy than 360° trabeculotomy attained target IOP ≤18 mmHg and ≤15 mmHg at 6 months. A full 360° trabecular bypass may not be necessary to achieve maximal efficacy from this class of micro-invasive glaucoma procedures.

12-Month Retrospective Comparison of Kahook Dual Blade Excisional Goniotomy with Istent Trabecular Bypass Device Implantation in Glaucomatous Eyes at the Time of Cataract Surgery

PURPOSE

To compare the efficacy and safety of combined cataract extraction and either excisional goniotomy performed with the Kahook Dual Blade (KDB; phaco-KDB group) or single iStent trabecular bypass implantation (phaco-iStent group) in eyes with mild to moderate glaucoma and visually significant cataract.

METHODS

This was a retrospective analysis of 315 eyes from 230 adults with mild or moderate glaucoma treated with one or more intraocular pressure (IOP)-lowering medications (190 eyes of 134 subjects in the phaco-KDB group and 125 eyes of 96 subjects in the phaco-iStent group) that required no subsequent surgical intervention for IOP control through 12 months of follow-up. Data included best-corrected visual acuity (BCVA), IOP, and IOP-lowering medications, collected preoperatively and at 1 week and 1, 3, 6, and 12 months postoperatively as well as intraoperative and postoperative adverse events. The primary efficacy outcomes were the proportion of subjects in each group achieving ≥ 20% IOP reduction and ≥ 1 medication reduction at month 12. Subgroup analysis by baseline IOP (≤ 18 mmHg vs. > 18 mmHg) was also performed.

RESULTS

Mean (standard error) baseline IOP was 18.2 (0.3) mmHg in the phaco-KDB group and 16.7 (0.3) mmHg in the phaco-iStent group (p = 0.001). Statistically significant mean IOP and mean IOP medication reductions from baseline were achieved at all time points in both groups. Mean IOP reductions were significantly greater in the phaco-KDB group than in the phaco-iStent group at all time points including month 12 [- 5.0 (0.3) mmHg vs. - 2.3 (0.4) mmHg, p < 0.001], while mean medication reductions were similar between groups at all time points except week 1, when greater mean medication reduction was seen in the phaco-iStent group (- 1.23 vs. - 0.60 medications, p < 0.001). At month 12, IOP reductions ≥ 20% were achieved by 64.2% and 41.6% (p < 0.001) in the phaco-KDB and phaco-iStent groups, respectively, and IOP medication reductions of ≥ 1 medication were achieved by 80.4% and 77.4% (p = 0.522), respectively. Intraocular pressure subgroup analysis revealed significant reductions in IOP-lowering medications without compromise of IOP control in lower IOP subgroups and significant reductions in both IOP and IOP-lowering medications in the higher IOP subgroups. The most common adverse events were transient IOP elevations and transient anterior chamber inflammation, which occurred with similar frequency in both groups and resolved spontaneously.

CONCLUSION

Goniotomy with the KDB lowered IOP significantly more than iStent implantation, with few adverse events in both groups. In eyes with mild to moderate glaucoma undergoing combined cataract extraction and glaucoma surgery, goniotomy with the KDB can safely deliver statistically significant and clinically meaningful reductions in both IOP and IOP medication burden through 12 months of follow-up.

FUNDING

New World Medical, Inc., provided funding for the study, medical writing assistance, Rapid Service Fees, and the open access fee.

A First-in-Human Study of the Efficacy and Safety of MINIject in Patients with Medically Uncontrolled Open-Angle Glaucoma (STAR-I)

PURPOSE

To describe the safety and efficacy of a novel, supraciliary, microinvasive glaucoma surgery drainage system, MINIject (iSTAR Medical, Wavre, Belgium), in the study.

DESIGN

Prospective, multicenter, interventional, single-arm trial.

PARTICIPANTS

Twenty-six patients with primary open-angle glaucoma uncontrolled with 1 or more intraocular pressure (IOP)-lowering medications.

METHODS

Using an ab interno approach, 25 eyes were implanted successfully in a stand-alone procedure with a 5-mm long device made of biocompatible STAR material, which is soft and flexible silicone in a microporous, network design. Intraocular pressure, medication use, and other ocular parameters were evaluated before surgery, 1 day, 1 and 2 weeks, and 1, 3, and 6 months after surgery.

MAIN OUTCOME MEASURES

Intraocular pressure reduction at 6 months compared with baseline analyzed using a paired t test. Safety evaluation entailed tabulation of the nature and frequency of adverse events.

RESULTS

Mean baseline diurnal IOP was 23.2 mmHg (standard error, 0.6 mmHg) using a mean ± standard deviation of 2.0±1.1 IOP-lowering medication classes. During the 6-month follow-up period, mean IOP ranged from 10.0-16.3 mmHg (mean reductions, 6.9-13.2 mmHg or 31.0%-56.8%). Six months after surgery, mean diurnal IOP was 14.2 mmHg (standard error, 0.9 mmHg), equivalent to a reduction of 9.0 mmHg or 39.1% (P < 0.0001). The mean ± standard deviation number of IOP-lowering medications was 0.3±0.7. Of 24 patients seen at 6-month follow-up, 21 (87.5%) were medication-free and 23 (95.8%) achieved a minimum 20% IOP reduction from baseline. There were no serious adverse events related to the device or procedure, and no additional glaucoma surgery was required. Frequently reported events included anterior chamber inflammation (n = 8), IOP elevation (n = 6), of which 1 event was an IOP spike per protocol, visual acuity reduction (n = 3), and hyphema (n = 3), all of which resolved. There was no change to mean central or peripheral corneal endothelial cell density. No device-related adverse events were reported.

CONCLUSIONS

The MINIject glaucoma drainage system significantly lowered IOP and eliminated the need for medication in most patients 6 months after surgery when implanted in a standalone procedure. There were no serious ocular adverse events.

Precision medicine to prevent glaucoma-related blindness

PURPOSE OF REVIEW

Approximately 10% of patients become blind despite using evidence-based guidelines developed from clinical trials and epidemiology studies. Our purpose is to review opportunities to decrease glaucoma-related blindness using the emerging principles of precision medicine.

RECENT FINDINGS

The current review focuses on three topics: first, candidate biomarkers for angle-based surgeries, second, head-mounted display (HMD) technology for vision and testing, and third, glaucoma risk alleles discovered by genome-wide association studies. First, in angle-based surgeries, tracers injected into the anterior chamber or Schlemm's canal have allowed visualization of aqueous veins. We describe an innovative use of optical coherence tomography angiography to visualize aqueous veins in a case with 6-year successful outcome following catheter-based trabeculotomy. Second, HMD technology can augment perceived vision and can be used for perimetry testing. Third, developing genetic risk scores that characterize patients who are at highest risk for blindness is a priority. Such biomarker risk scores will integrate genome-wide association study-based risk alleles for glaucoma along with well known demographic and clinical risk factors.

SUMMARY

As we gain more knowledge, precision medicine will enable clinicians to decrease glaucoma-related blindness by providing more timely interventions to those patients who are at highest risk for progression to blindness. VIDEO ABSTRACT: http://links.lww.com/COOP/A29.

Miniaturization in Glaucoma Monitoring and Treatment: A Review of New Technologies That Require a Minimal Surgical Approach

In the management of glaucoma, recent and upcoming innovations have the potential to contribute to both the efficacy of intraocular pressure (IOP) monitoring and the number of available treatment options. These new devices and procedures have two things in common: they are part of the trend in medicine towards miniaturization, and they require a limited surgical procedure to become effective. This review focuses on the Eyemate (Argos) intraocular sensor, which offers a new way to reliably measure 24 h IOP, and on intraocular sustained release systems for pharmacological glaucoma therapy. It also briefly reflects on the miniature implants currently used in minimally invasive glaucoma surgery (MIGS).

Therapeutic efficacy of latanoprost on primary open angle glaucoma: A protocol for a systematic review of randomized controlled trial

BACKGROUND

Latanoprost is quiet new formulation that is approved for the treatment of primary open angle glaucoma (POAG). However, no updated systematic review has addressed its efficacy for POAG. This systematic review of randomized controlled trials (RCTs) aims to assess its efficacy and safety for the treatment of patients with POAG.

METHODS

This study will search the databases of CENTRAL, EMBASE, MEDILINE, CINAHL, AMED and Chinese databases without language restrictions from their inception to the present. It will only include RCTs of latanoprost for POAG. The quality of the included RCTs will be evaluated by the tool of Cochrane risk of bias. The primary outcomes will be measured by the mean IOP reduction from baseline to the endpoint. The secondary outcomes will be assessed by the mean IOP, adjusted mean IOP reduction at each time point, quality of life, and adverse events. The RevMan V.5.3 software will be used to compute the data synthesis carefully if the meta-analysis is allowed. The summary results of the included RCTs will be conducted by using the models of random-effects or fixed-effects based.

RESULTS

The results of this study will be published at the peer-reviewed journals. It will provide evidence to determine the efficacy and safety of latanoprost for POAG.

CONCLUSION

The results of this study will provide helpful evidence for both clinicians and patients, and for the health policy makers to refer for the policy or guideline making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018115416.

Variation in Prostaglandin Analog Prices Paid for Through Medicare Part D

OBJECTIVE

Determine the prices and price variation of the prostaglandin analogs (PGAs) used in the United States and examine their trends from 2013 to 2016 using Medicare Part D data.

DESIGN

This is a retrospective cross-sectional study.

PARTICIPANTS

All ophthalmologists and optometrists in all 50 states and DC who prescribed any PGA purchased through Part D from 2013 through 2016.

MATERIALS AND METHODS

Outcome measures were calculated using Excel 2016 based off of the 2013 to 2016 Medicare Part D Prescriber Data.

MAIN OUTCOME MEASURES

The 2013 to 2016 nationwide prices of 7 PGAs, the states with the 2016 minimum and maximum average prices, the SDs in PGA prices among the cities in each state, and the nationwide average of these SDs for 2013 to 2016.

RESULTS

The 2016 nationwide prices of 30-day supplies of bimatoprost, latanoprost, lumigan, travatan Z, travoprost, xalatan, and zioptan in 2016 were: $107.90±25.19, $10.16±1.52, $167.30±17.66, $171.36±19.44, $92.53±15.14, $153.41±15.16, and $162.75±13.22, respectively. Each drug's SD in city prices within each state averaged nationwide for 30-day supplies in 2016 were $10.89, $1.44, $16.68, $17.23, $10.30, $10.07, and $9.48, respectively. Spending on these drugs totaled $861,180,924 in 2016. There was less price variation within each state as compared with the whole country. No substantial decreases in price variation exist for any drug from 2013 to 2016.

CONCLUSIONS

There is substantial variation in PGA prices when purchased by Medicare Part D enrollees across the United States and within each state itself. Simultaneously, the prices and total expenditure on these medications are increasing yearly. Physicians should be cognizant of this price variation for these expensive and chronically used drugs and should educate patients to optimize their Part D supplemental plan.