12-Month Outcomes of Goniotomy Performed Using the Kahook Dual Blade Combined with Cataract Surgery in Eyes with Medically Treated Glaucoma

Outcomes of an extended combined phaco-kahook dual blade procedure in glaucoma patients

PurposeTo compare the outcomes of standard combined Phaco-Kahook Dual Blade (KDB) surgery (GI) with those of the extended technique (GII).MethodsThis retrospective, comparative, multicenter, case-control study enrolled patients with one-year follow-up. GI removed 90° of the trabecular meshwork (TM) extension during KDB, whereas GII removed 150°. The successful criteria were based on a modification of the AAO PPP recommendations - Reporting Clinical Endpoints in Studies of Minimally Invasive Glaucoma Surgery. Qualified success was achieved with or without medication, while absolute success was achieved without the use of any ocular hypotensive medication.ResultsA total of 72 eyes (36 in both groups) were included. The IOP was similar between groups preoperatively (GI: 17.0 ± 2.7 mmHg vs. GII: 17.5 ± 4.2 mmHg, p = 0.5), and at 12 months postoperatively (GI: 13.5 ± 2.8 mmHg vs. GII: 12.3 ± 2.7 mmHg, p = 0.06). The number of glaucoma medications was reduced from 1.7 ± 0.9 to 0.4 ± 0.8 in GI (p < 0.001) and from 2.1 ± 0.8 to 0.4 ± 0.7 in GII (p < 0.001). At 12 months, both groups reduced comparable glaucoma medications (p = 0.9). Qualified success was achieved in 77.1% of the eyes with GI and 94.4% with GII (p = 0.03), whereas complete success was achieved in 68.6% of the eyes with GI and 69.4% with GII (p = 0.7). No serious complications were observed in any of the groups.ConclusionExtended combined Phaco-KDB surgery showed greater relative success than the Standard Phaco-KDB technique. Both techniques achieved similar IOP reduction at 12 months postoperatively.

Affordable Sinskey Hook Goniotomy and Cataract Surgery in Black and Afro-Latino Patients Diagnosed with Glaucoma: Retrospective Real-World One-Year Results

Background/Objectives: This study aimed to evaluate the effectiveness of early phacoemulsification cataract surgery combined with goniotomy using a Sinskey hook in patients with glaucoma. Methods: This was a retrospective study conducted at Advanced Eye Care of New York; a private practice located in New York City. Most patients carried diagnoses of mild to moderate glaucoma and were mainly Black and Afro-Latino in origin. The patients included in this study were those who underwent early phacoemulsification cataract surgery combined with goniotomy performed with a reusable Sinskey hook (Ambler 200 μm tip) between January 2022 and August 2023 and completed 1 year of follow-up. The primary outcome measures were intraocular pressure, number of medications used, visual acuity, visual field indices, pre-/post-operative spherical refractive error, and adverse events. Results: A total of 121 eyes were identified with a 1-year follow-up that underwent this combined surgery. The mean age was 65. The mean medically treated pre-operative intraocular pressure ± standard deviation (SD) was lowered from 16.40 ± 4.5 mmHg at baseline to 14.66 ± 3.1 mmHg at 1 year, a statistically significant reduction of 10.6%. There was an 82% reduction in the mean ± SD number of intraocular pressure-lowering medications used, from 1.67 ± 1.2 at baseline to 0.30 ± 0.8 at 1 year. Out of the 121 eyes, 83% (103 eyes) remained medication-free at 1-year post-operation. Post-operatively, there were five IOP spikes (IOP ≥ 30 mmHg) and eight hyphemas that were noted, addressed, and resolved. Conclusions: Early cataract surgery combined with Sinskey hook goniotomy microinvasive surgery effectively reduced intraocular pressure and medication burden in this cohort of predominantly Black and Afro-Latino patients diagnosed with glaucoma with 1-year follow-up.

Postoperative Use of Pilocarpine After Kahook Dual Blade Goniotomy in Mild to End-Stage Glaucoma

PURPOSE

This study aims to determine if using pilocarpine postoperatively affects clinical outcomes after goniotomy.

METHODS

Retrospective series comparing 532 Kahook Dual Blade goniotomy (KDB-G) procedures with (P+) or without (P-) pilocarpine use in the postoperative period. This study includes patients with both primary and secondary glaucoma ranging from mild to end-stage, undergoing KDB-G with or without phacoemulsification (phaco). The primary outcome measure was surgical success defined as intraocular pressure (IOP) < 21 mmHg in addition to either a reduction of >20% and/or the reduction of ≥1 topical glaucoma medications. Secondary outcomes were mean IOP, number of medications, and rate of hyphema and IOP spike at one week postoperatively.

RESULTS

The success rate was significantly greater in Group P + at postoperative month 1 (p = .02), 3 (p = .01), 12 (p = .048), and 16 (p = .02). The differences in mean IOP (p = .084) and number of medications (p = .15) were not significantly different at one year. However, Group P + required significantly less medications than Group P - at nearly all time points (months 1, 3, 6, 20, and 24). There were no differences in rates of hyphema (p = .30) or postoperative week 1 IOP spikes (p = .66) between groups.

CONCLUSION

The use of pilocarpine postoperatively may improve surgical success and may reduce the number of glaucoma medications needed after goniotomy.

Kahook dual blade goniotomy combined with phacoemulsification in eyes with primary open angle glaucoma and pseudoexfoliation glaucoma: comparative study

PURPOSE

To compare outcomes of phacoemulsification combined with a Kahook Dual Blade (KDB) goniotomy in eyes with primary open angle glaucoma (POAG) and pseudoexfoliation glaucoma (PXG).

METHODS

This retrospective comparative study was conducted in a tertiary medical center. Sixty eyes of 60 patients (27 with POAG, 33 with PXG) underwent phacoemulsification combined with a KDB goniotomy. Intraocular pressure (IOP), number of medications used, best corrected visual acuity preoperatively and at 1 day, 1 week and 1, 3, 6 and12 months postoperatively, surgical success, and surgical complications were reviewed. If IOP reduction was >%30 or postoperative IOP < 18 mmHg, the procedure was considered as surgical success.

RESULTS

The mean IOP reduced from 26.4 ± 5.9 mmHg at baseline to 17.9 ± 6.1mmHg at 12 months for POAG (p < 0.01) and from 27.1 ± 7.9 at baseline to 15.1 ± 2.3 mmHg at 12 months for PXG (p < 0.01). Medication use reduced from 3.4 ± 0.9 to 2.0 ± 1.3 for POAG (p < 0.01) and from 3.7 ± 0.5 to 1.8 ± 1.3 for PXG (p < 0.01) at 12 months. Mean IOP was significantly lower in PXG than POAG at week 1 and months 1, 3, 6 and 12 (all p < 0.05). Surgical success rate was 74% for POAG and 84% for PXG (p = 0.30) at 12 months. No vision-threatening complications occurred.

CONCLUSION

KDB goniotomy combined with cataract surgery was safe and effectively reduced the IOP and drug burden in patients with POAG and PXG. In the first year, significantly lower IOPs were noted in PXG compared with POAG.

Visual Function After Schlemm's Canal-Based MIGS

Filtration surgery is highly effective in lowering intraocular pressure; however, it is associated with a higher risk of severe complications. Visual dysfunction may persist in relatively uneventful cases because of induced astigmatism or worsening optical aberrations. Therefore, for early- to moderate-stage glaucoma, an increasing number of surgeons are prioritizing surgical safety and preserving postoperative visual function by opting for minimally invasive glaucoma surgery (MIGS). Among the various MIGS techniques, canal-opening surgery-targeting aqueous outflow through the Schlemm's canal (Schlemm's canal-based MIGS, CB-MIGS)-has gained increasing popularity. Unlike filtration surgery, CB-MIGS does not require creating an aqueous outflow pathway between the intraocular and extraocular spaces. Consequently, it is considered a minimally invasive procedure with a reduced risk of severe complications and is increasingly being chosen for suitable cases. Although this surgical technique has limitations in lowering intraocular pressure, it avoids the manipulation of the conjunctiva or sclera and is primarily performed through a small corneal incision. Therefore, a minimal impact on induced astigmatism or postoperative refractive changes is expected. However, few reviews comprehensively summarize postoperative changes in visual function. Therefore, this study reviews the literature on visual function after CB-MIGS, focusing on changes in best-corrected visual acuity (BCVA), refraction, astigmatism, and the effectiveness of visual field preservation to assess the extent of these postoperative changes. Hyphema is the primary cause of early postoperative vision loss and is often transient in cases in which other complications would have led to visual impairment. Severe complications that threaten vision are rare. Additionally, compared with filtration surgery, postoperative visual recovery tends to be faster, and the degree of induced astigmatism is comparable to that of standalone cataract surgery. When combined with cataract surgery, the refractive error is at the same level as that of cataract surgery alone. However, in some cases, mild hyperopic shifts may occur because of axial length shortening, depending on the extent of intraocular pressure reduction. This possibility has been highlighted in several studies. Regarding the effectiveness of slowing the progression of visual field defects, most studies have focused on short- to medium-term postoperative outcomes. Many of these studies have reported the sufficient suppression of progression rates. However, studies with large sample sizes and long-term prospective designs are limited. To establish more robust evidence, future research should focus on conducting larger-scale, long-term investigations.

Kahook Dual Blade Goniotomy Outcomes in the Underserved Dominican Republic Black and Afro-Latinx Population

Background/Objectives: Black and Afro-Latinx communities have a higher propensity for more-severe glaucoma at a younger age. This study aimed to use the Kahook Dual Blade (KDB) to treat all glaucoma subtypes and severity levels in this historically underserved community. Materials and Methods: This study involved a retrospective analysis of surgical case records, with follow-up through 20 months. The subjects were glaucoma patients at Hospital Elias Santana in Santo Domingo, Dominican Republic. Inclusion criteria were age >18 years and a minimum follow-up of 1 year after surgery. All glaucoma subtypes and disease severities were included, including previous glaucoma procedures. Sequential patients undergoing KDB goniotomy alone or in combination with phacoemulsification cataract surgery were assessed. IOP data and number of medications were collected at specific time points: baseline, postoperative day 1, postoperative week 1, and postoperative months 1, 3, 6, 12, 16, and 20. Surgical outcome was determined using IOP and number of medications. Success was defined as either a 20% or more reduction in IOP or a decrease in at least one topical therapy. Recorded postoperative complications were hyphema, ocular hypertension, and need for additional glaucoma surgery. Results: A total of 90 eyes from 90 patients were included. A total of 100% of the patient population was Black or Afro-Latinx. The most common glaucoma subtype was primary open-angle (76.7%). Most of the eyes had severe glaucoma (53.3%). The mean preoperative baseline IOP was 20.5 mmHg. The mean postoperative IOP from all time points ranged from 12.9 to 13.5 mmHg (all time points were significantly lower than baseline IOP, p < 0.0001). A mean reduction in IOP percent of at least 31.5% was seen at every time point. There was a mean reduction of two medications by postoperative month 20. Surgical success was achieved in 95.6% of patients at postoperative month 1 and remained high throughout the study period (95.4% at month 20). Conclusions: KDB goniotomy achieved successful IOP and medication reduction across all levels of glaucoma severity. Surgical success rates were maintained to 20 months. While MIGS has historically been used as an intervention in mild-to-moderate glaucoma, our study results show that the KDB can play a significant role in all stages of glaucoma, including severe. MIGS should be considered as a favorable intervention in all disease severities in Black and Afro-Latinx communities around the world.

Efficacy and safety of combined Kahook Dual Blade goniotomy with phacoemulsification in Chinese patients with primary open angle glaucoma

AIM

To report the one-year surgical outcome Kahook Dual Blade goniotomy combined with phacoemulsification (KDB-Phaco) in Chinese patients with primary open angle glaucoma (POAG).

METHODS

This is a retrospective study included 43 eyes of 28 Chinese POAG patients with cataract who accepted KDB-Phaco and followed-up for 12mo. Intraocular pressure (IOP), glaucoma medications and surgical complications were recorded. Success 1 and success 2 was defined as 5-21 mm Hg and 5-18 mm Hg, and success plus was determined if additional criteria of IOP reduction ≥20% from baseline was reached. A corrected IOP by adding 3 mm Hg for each medication was used to do correlation test. Cox's proportional hazards regression model was used to test the hazard ratio for factors associated with surgical success.

RESULTS

After a 12-month follow up, the IOP decreased from 28.1±6.3 to 13.8±3.0 mm Hg (47.92% reduction, P<0.001), and the medications used decreased from 2.0 (1.0) to 0.0 (0.0) (95% reduction, P<0.001). The mean IOP of all postoperative visits were lower than preoperative IOP (all P<0.001), so as the number of glaucoma medications (all P<0.001). Complete success 1 and qualified success 1 were 87.80% and 100.00% respectively. The complete success 1 plus and qualified success 1 plus were 85.37% and 97.56%, respectively. Totally 82.93% and 90.24% of patients got complete success 2 and qualified success 2 while 80.49% and 87.80% of patients satisfied complete success 2 plus and qualified success 2 plus. Age (r=-0.511, P=0.001) and visual acuity (VA; r=-0.321, P=0.041) were negatively correlated with postoperative corrected IOP at 12mo, while anterior chamber depth (r=0.432, P=0.005), mean deviation (r=0.617, P<0.001) and visual field index (r=0.524, P<0.001) were positively correlated with it. Preoperative VA (OR=33.092, P=0.004) and MD (OR=1.481, P=0.018) were hazard factors associated with failure based on qualified success as 18 mm Hg. The main complications of KDB were hyphema (9.30%), IOP spike (11.63%) and peripheral anterior synechia (6.98%).

CONCLUSION

KDB goniotomy is a safe and effective in the treatment for Chinese POAG patients. Preoperative VA and mean deviation may predict the surgical success.

Phacoemulsification combined with Kahook Dual Blade Goniotomy versus with Trabectome in the treatment of open angle glaucoma

PURPOSE

To compare the surgical effectiveness and safety of phacoemulsification combined with KDB (Phaco-KDB) and with Trabectome (Phaco-Trabectome) at 6 months follow-up in patients with open-angle glaucoma (OAG) METHODS: This comparative case series was conducted at Beijing Tongren Hospital, including patients diagnosed with OAG who underwent Phaco-KDB from November 2021 to April 2022 and Phaco-Trabectome from April 2017 to December 2017. Surgical success was defined as an IOP reduction ≥ 20% or a postoperative IOP ≤ 21 mmHg. Kaplan-Meier methods were used to calculate cumulative rates of success among groups RESULTS: A total of 35 eyes from 29 patients were included in the analysis. At 6-month, Both groups exhibited a significant reduction in IOP and the number of IOP-lowering medications compared to preoperative (P=0.01 and P<0.01, respectively). There were no significant differences among groups in terms of reducing IOP and the number of IOP-lowering medications (all P values<0.05). In the Phaco-KDB and Phaco-Trabectome groups, 53.8% and 45.0% of patients achieved an IOP reduction of ≥ 20%, while 92.3% and 85% achieved a mean IOP ≤ 21 mmHg 6 months after surgery. The incidence of IOP spike was 20%, and 3 eyes (8.6%) needed further surgery to control the IOP CONCLUSIONS: Both Phaco-KDB and Phaco-Trabectome demonstrate a significant reduction in IOP and the number of IOP-lowering medications. Phaco-Trabectome appears to provide a more predictable postoperative course in the early postoperative period compared to Phaco-KDB, and the postoperative mean IOP is lower in Phaco-KDB compared to Phaco-Trabectome, despite not being statistically significant.

Outcomes and risk factors for Kahook Dual Blade excisional goniotomy with concomitant phacoemulsification: a multicentre Canadian study

OBJECTIVE

To assess the outcomes and failure risk factors for Kahook Dual Blade (KDB) excisional goniotomy with cataract surgery (phaco-KDB) in eyes with various glaucoma subtypes and severities.

METHODS

This multisurgeon consecutive case series included glaucomatous eyes with cataract that underwent phaco-KDB and had a minimum follow-up of 12 months postoperatively. Efficacy was assessed by absolute and qualified surgical success (defined by different criteria) and changes in intraocular pressure (IOP) and antiglaucoma medication (AGM) at the last postoperative follow-up. Safety included best-corrected visual acuity, cup-to-disc ratio, visual field mean deviation, retinal nerve fibre layer thickness, and adverse events.

RESULTS

A total of 108 eyes of 89 patients with a median follow-up of 18 months (range, 12-47 months) were included. IOP decreased by 26% from 19.1 ± 5.0 mm Hg to 14.1 ± 3.5 mm Hg (p < 0.001), AGM use decreased by 29% from 2.4 ± 1.3 medications to 1.7 ± 1.3 (p < 0.001), and 25% of eyes became free of AGMs (vs 3% at baseline). Qualified success rates achieved for IOP cutoffs of 18, 15, and 12 mm Hg were 87%, 68%, and 46%, respectively. Higher baseline IOP and postoperative incidence of IOP spikes were associated with a higher risk of surgical failure. Best-corrected visual acuity improved postoperatively (p < 0.001), and visual field mean deviation, cup-to-disc ratio, and retinal nerve fibre layer thickness remained stable. Overall, safety was favourable, and adverse events were transient and not sight threatening.

CONCLUSION

This multicentre Canadian study provides real-world data that support the safety and efficacy of phaco-KDB in reducing IOP and AGM use with no evidence of disease progression during the follow-up period.

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 Outcomes of Excisional Goniotomy with the Kahook Dual Blade: 6-Year Results

INTRODUCTION

This study aims to evaluate the long-term clinical outcomes of excisional goniotomy with the Kahook Dual Blade (KDB) in the management of various types of glaucoma.

METHODS

This was a retrospective, noncomparative chart review of 90 eyes of 53 patients with glaucoma that underwent standalone KDB goniotomy (KDB-alone group) or KDB goniotomy with concomitant phacoemulsification (KDB-phaco group) between October 2015 and October 2017. Surgical success was defined as an intraocular pressure (IOP) reduction by ≥ 20% at the last follow-up with no surgical reinterventions required and a final IOP ≥ 4 mmHg and ≤ 21 mmHg. We also report on changes from baseline in IOP, number of glaucoma medications, best-corrected visual acuity (BCVA), and visual field parameters, for up to 72 months.

RESULTS

At 72 months, mean (standard deviation [SD]) IOP was reduced from 17.5 (5.7) to 13.6 (3.0) mmHg (P < 0.0001) in the KDB-phaco group and from 23.3 (5.9) to 15.1 (6.2) mmHg (P = 0.0593) in the KDB-alone group. The mean (SD) number of glaucoma medications was reduced from 1.3 (1.0) to 0.8 (0.9) (P < 0.0001) in the KDB-phaco group and from 1.2 (1.0) to 0.7 (0.8) (P = 0.3409) in the KDB-alone group. During the 72-month follow-up, surgical success was achieved in 24 of the 52 available eyes (46.2%). Four eyes underwent a glaucoma surgical reintervention by 72 months.

CONCLUSIONS

Excisional goniotomy with the KDB effectively lowered the IOP (by an average of 28.0% from baseline) and maintained or further reduced glaucoma medication burdens (by an average of 30.8% from baseline) under an excellent safety profile, independent of phacoemulsification status. The procedure exhibited favorable success for up to 6 years, providing valuable insights into its long-term efficacy as a glaucoma treatment.

Outcomes 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.

Historical and Contemporary Debates in Schlemm's Canal-Based MIGS

Glaucoma is one of the primary causes of blindness worldwide. Canal opening surgery, a type of minimally invasive glaucoma surgery (MIGS) applied in cases of mild to moderate glaucoma, has gained increasing popularity in recent years due to its efficacy in reducing the intraocular pressure, its safety profile, the simplicity of its technique, and the reduced likelihood of compromised vision. Nevertheless, the existing body of histopathological studies remains insufficient for a comprehensive understanding of post-surgical wound healing. Consequently, debates persist among researchers regarding the mechanism through which Schlemm's canal opening surgery reduces the intraocular pressure, as well as the surgical techniques that may impact the outcomes and the factors influencing surgical success. As the history of MIGS is relatively short and lacks sufficient systemic reviews or meta-analyses evaluating the influence of individual factors, this review was conducted to illuminate the disparities in researchers' opinions at the current stage of research.

Effectiveness of Angle-Based Minimally Invasive Glaucoma Surgery after Laser Trabeculoplasty: An Analysis of the IRIS® Registry (Intelligent Research in Sight)

OBJECTIVE

Angle-based minimally invasive glaucoma surgery (ab-MIGS) has grown substantially, although long-term efficacy is poorly understood. We analyze ab-MIGS effectiveness with and without preceding laser trabeculoplasty (LTP).

DESIGN

Retrospective cohort study.

SUBJECTS

Eyes undergoing ab-MIGS (Canaloplasty, Goniotomy, Trabectome, and iStent) with and without prior laser trabeculoplasty (< 2 years preceding MIGS) were identified in the IRIS® Registry (Intelligent Research in Sight) 2013 to 2018.

METHODS

Propensity score matching (PSM) was undertaken to define the following 4 cohorts: (1) standalone ab-MIGS, no prior LTP vs. (2) standalone ab-MIGS, with prior LTP; and (3) ab-MIGS + phacoemulsification, no prior LTP vs. (4) ab-MIGS + phacoemulsification, with prior LTP.

MAIN OUTCOME MEASURES

Failure was defined as subsequent glaucoma reoperation after ab-MIGS (either MIGS or traditional glaucoma surgery). Time-to-event outcome and incidence rates were calculated using survival analysis, and adjusted hazard ratios (aHRs) were generated using multivariate Cox proportional hazards models. Medication data were not available for analysis.

RESULTS

A total of 164 965 unique MIGS procedures were performed, from 2013 to 2018. After PSM, we identified 954 eyes undergoing standalone ab-MIGS and 7522 undergoing ab-MIGS + phacoemulsification. For eyes undergoing standalone ab-MIGS, those with prior LTP (n = 477) were more likely to undergo reoperation vs. those without LTP (n = 477) at 6 and 12 months. In multivariable models, those with prior LTP were more likely to undergo reoperation over the 36-month period vs. those without prior LTP (aHR, 1.53; CI, 1.15-2.04; P = 0.004). For eyes undergoing ab-MIGS + phacoemulsification, those with prior LTP (n = 3761) were more likely to undergo reoperation vs. those without LTP (n = 3761) at 12, 24, and 36 months. In multivariable models, those with prior LTP were more likely to undergo reoperation over the 36-month period vs. those without prior LTP (aHR, 1.53 CI, 1.15-2.04; P = 0.004).

CONCLUSIONS

Prior LTP may be associated with a higher chance of subsequent glaucoma surgery following ab-MIGS, either with or without concurrent phacoemulsification. These findings have important implications for understanding who may benefit most from ab-MIGS, and for guiding patient and surgeon treatment expectations.

FINANCIAL DISCLOSURES

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Long-Term Efficacy of Successful Excisional Goniotomy with the Kahook Dual Blade

Purpose

To report clinical outcomes of successful excisional goniotomy with the Kahook Dual Blade (KDB), through 60 months.

Patients and methods

This was a noncomparative, single-surgeon, retrospective review of eyes receiving successful KDB goniotomy with or without concomitant phacoemulsification between October 2015 and January 2016 with five years of uninterrupted follow-up. Intraocular pressure (IOP), number of glaucoma medications, best corrected visual acuity (BCVA), and complications were recorded. Primary outcomes included changes from baseline in IOP, medication use, and BCVA, through five years.

Results

Fifty-two eyes of 28 patients were analyzed. Most eyes had mild primary open angle glaucoma (73%). Of the eyes analyzed, 41 underwent combined surgery and 11 underwent standalone surgery. With all eyes combined, mean (standard deviation) baseline IOP was 21.0 (4.1) mmHg and mean baseline medication use was 1.8 (1.1) medications per eye. Across time points at months 6, 12, 24, 36, 48, and 60, mean postoperative IOP ranged from 13.0 to 13.7 mmHg, representing mean reductions of 7.3-8.0 mmHg (34.7-38.3%; p <0.0001 at every time point). Similarly, mean medication use ranged from 0.4 to 0.6 medications per eye, representing mean reductions of 1.2-1.4 medications (66-75.5%; p <0.0001 at every time point). Mean logMAR BCVA improved from 0.321 (0.177) preoperatively to 0.015 (0.035) at month 60 (p < 0.0001).

Conclusion

In eyes not requiring secondary surgical procedures (eg, long-term surgical successes), excisional goniotomy provided clinically and statistically significant reductions in both IOP and the need for medications that were highly consistent through five years of follow-up. KDB goniotomy appears to be highly successful in Caucasian patients with open angle glaucoma on ≥1 IOP-lowering medications at baseline and with no history of prior ocular surgery. Successful excisional goniotomy with the KDB can be expected to improve long-term glaucoma-related visual outcomes through IOP reduction and to improve quality of life through medication reduction.

Reduced Aqueous Humor Outflow Pathway Arborization in Childhood Glaucoma Eyes

Purpose

To compare aqueous humor outflow (AHO) pathway patterns between eyes of childhood glaucoma patients and non-glaucomatous patients receiving cataract surgery.

Methods

Aqueous angiography was performed in childhood glaucoma eyes (n = 5) receiving glaucoma surgery and in pediatric (n = 1) and healthy adult (n = 5) eyes receiving cataract surgery. Indocyanine green (0.4%) was introduced into the anterior chamber, and AHO was imaged using an angiographic camera (SPECTRALIS HRA+OCT with Flex Module). Images were acquired and analyzed (ImageJ with Analyze Skeleton 2D/3D plugin) from the nasal sides of the eyes, the usual site of glaucoma angle procedures. Image analysis endpoints included AHO vessel length, maximum vessel length, number of branches, number of branch junctions, and vessel density.

Results

Qualitatively, childhood glaucoma eyes demonstrated lesser AHO pathway arborization compared to pediatric and adult eyes without glaucoma. Quantitatively, childhood glaucoma and healthy adult cataract eyes showed similar AHO pathway average branch lengths and maximum branch lengths (P = 0.49-0.99). However, childhood glaucoma eyes demonstrated fewer branches (childhood glaucoma, 198.2 ± 35.3; adult cataract, 506 ± 59.5; P = 0.002), fewer branch junctions (childhood glaucoma, 74.6 ± 13.9; adult cataract, 202 ± 41.2; P = 0.019), and lower vessel densities (childhood glaucoma, 8% ± 1.4%; adult cataract, 17% ± 2.5%; P = 0.01).

Conclusions

Childhood glaucoma patients demonstrated fewer distal AHO pathways and lesser AHO pathway arborization. These anatomical alternations may result in a new source of trabecular meshwork-independent AHO resistance in this disease cohort.

Translational Relevance

Elevated distal outflow pathway resistance due to decreased AHO pathway arborization may explain some cases of failed trabecular bypass surgery in childhood glaucoma.

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.

Minimally Invasive Glaucoma Surgery: Latest Developments and Future Challenges

The development of minimally invasive glaucoma surgeries (MIGSs) was intended to provide safe and modestly efficacious modalities for early intervention of mild-to-moderate glaucoma, with minimal trauma and rapid recovery. They were mainly ab interno procedures that reduce intraocular pressure by facilitating the aqueous outflow by bypassing the trabecular meshwork resistance, reinforcing the uveoscleral flow via the supraciliary space, and reducing aqueous production by the ciliary body. While the cumulating evidence helps shape the role of the available MIGS, the exponential new development and advancement in this field has expanded the territory of MIGS. Apart from developing subconjunctival MIGS filtration devices (Xen gel stent and PRESERFLO MicroShunt), there is a tendency to revisit the "traditional" MIGS for alternative use and to modify the procedures with consideration of the fundamental aqueous outflow physiology. Combined MIGS has also been suggested, based on the theory that their different mechanisms may provide additive or synergistic effects. The advancement of laser procedures is also promising and could supplement unmet needs along the glaucoma treatment algorithm. This review examines the broad array of MIGS, updates the recent findings, discusses their potential alternative applications, and explores future challenges.

Postoperative Management of Kahook Dual Blade Goniotomy with Phacoemulsification Cataract Extraction

Aim

To review the efficacy and safety of two common postoperative regimens following Kahook Dual Blade goniotomy with phacoemulsification cataract extraction (KDB-CE).

Materials and methods

This is a retrospective review of eyes undergoing KDB-CE from May 2016 to 2018 by a single surgeon. Almost 12-month follow-up data were assessed for two common postop regimens-treatment with (1) topical prednisolone acetate 1% with pilocarpine 1% (pred-pilo) or (2) difluprednate 0.05% postoperatively. Postoperative results were compared to each respective baseline intraocular pressure (IOP) levels.

Results

There were 53 eyes in the difluprednate group and 25 eyes in the pred-pilo group. In the difluprednate group, the IOP decreased at postoperative day 1 (POD1) [16 ± 5 baseline vs 15 ± 5 POD1, mean ± standard deviation (SD) in mm Hg, and p = 0.321], but increased at postoperative week 1 (POW1) due to a 15% rate of IOP-spikes (19 ± 9, p = 0.099). The number of IOP-lowering drops decreased from baseline (2 ± 1 drops) to 1 ± 1 drops at POD1 (p < 0.0001), and remained at 1 ± 1 drops through postoperative month 12 (POM12) (p < 0.0001). In the pred-pilo group, there was a statistically significant decrease in mean IOP at POW1 (16 ± 4 POW1 vs 18 ± 6 baseline, p = 0.044), which persisted through POM6. The number of IOP-lowering drops was not statistically significantly lower from baseline at POM3 (2 ± 1 at POM3, p = 0.188). Spikes in IOP, corneal edema, and hyphema were the most common complications.

Conclusion

Both postoperative regimens were effective following KDB-CE at reducing IOP at 12 months. The difluprednate group was likely to experience an IOP-spike at POW1 but used fewer IOP-lowering drops 12 months after KDB goniotomy. In the pred-pilo group, the number of IOP-lowering drops was equivalent to baseline levels at POM3. Aside from IOP spikes, there were similar complication rates observed between the two postoperative regimens. Due to demographic differences, it was not possible to compare relative IOP-lowering efficacy between the two postoperative regimens.

Clinical significance

It is efficacious and safe to use either postoperative regimen following KBD-CE. Postoperative trajectories may differ with respect to the postoperative regimen, but further randomized controlled trials are needed to compare various topical steroid medications for postoperative regimens following KDB-CE.

How to cite this article

Birnbaum F, Wakil S, Vu DM, et al. Postoperative Management of Kahook Dual Blade Goniotomy with Phacoemulsification Cataract Extraction. J Curr Glaucoma Pract 2023;17(4):169-174.

Outcomes of 60-Degree Nasal Goniotomy for Open Angle Glaucoma

PRCIS

Sixty-degree nasal sectoral juxtacanalicular space goniotomy with the single-use Espaillat juxtacanalicular space slider device significantly reduced intraocular pressure and the number of required glaucoma hypotensive medications, with sustained reductions over 24 months.

PURPOSE

This study analyzed the safety and efficacy of the Espaillat juxtacanalicular space slider during minimally invasive 60-degree nasal sectoral goniotomy for mild-to-moderate open angle glaucoma (OAG).

PATIENTS AND METHODS

This prospective, observational case series performed at a private clinical practice and outpatient surgery center assessed the eyes of patients with mild-to-moderate OAG who underwent phacoemulsification cataract surgery with 60-degree nasal sectoral goniotomy using the Espaillat juxtacanalicular space slider. The same surgeon performed all procedures. Intraocular pressure, intraocular pressure-lowering drugs, and adverse effects were assessed over 24 months, and a regression analysis of intraocular pressure reduction was performed. Success was defined as (1) A reduction in the intraocular pressure of at least 20% for at least 12 months, compared with the baseline value, and (2) a decrease in the number of medications by at least one for at least 12 months.

RESULTS

Among 38 eyes, 27 (72%) had moderate glaucoma, and 11 (28%) had mild glaucoma. Postoperatively, intraocular pressure was decreased by 38% at 12 months (mean 13.7±1.7 mmHg), 35% at 18 months (mean 14.4±1.8 mmHg), and 31% at 24 months (mean 15.2±1.9 mmHg). In addition, the number of topical glaucoma medications used decreased from a mean of 1.6 to 0.4 ( P <0.001). The main adverse event was temporary focal corneal edema (29 patients; 76%).

CONCLUSIONS

Using the Espaillat juxtacanalicular space slider during invasive 60-degree nasal sectoral goniotomy for OAG yielded a significant and sustained reduction in intraocular pressure and reduced the need for glaucoma medications with minimal adverse events.

Factors associated with 1-year outcomes and transient intraocular pressure elevation in minimally invasive glaucoma surgery using Kahook Dual Blades

In this retrospective case-control study, we aimed to investigate the mid- to long-term outcomes and factors involved in minimally invasive glaucoma surgery using the Kahook Dual Blade. Of the 229 cases since 2018 in which the dual blades were used for glaucoma surgery at the Tenri Hospital, 133 eyes of 98 patients who followed up for more than 3 months were included. Intraocular pressure (IOP), number of drops score, and need for reoperation were evaluated on day 1 and at 1, 3, 6, 9, and 12 months postoperatively. Intraocular pressure spikes occurred in 25 patients postoperatively (18.8%), occurring at approximately 4.5 days (1-10.25). The preoperative number of eye drops used and ocular axial length were found to be associated with the occurrence of spikes (OR = 1.45, 95% CI 1.02-2.06; P = 0.025 and OR = 1.41, 95% CI 0.98-1.25; P = 0.072, respectively). At the 12-month mark, no significant relationship was found between the presence of spikes or incisional extent scores and the amount of change in IOP and number of drops scores. Patients with severe visual field impairment, high preoperative IOP and drop scores, and long ocular axial length may require more frequent follow-ups after surgery to check for spikes.

Minimally Invasive Glaucoma Surgery: A Review of the Literature

Minimally invasive glaucoma surgery (MIGS) has emerged as a novel approach in the glaucoma treatment spectrum, offering a range of diverse procedures and devices aimed at reducing intraocular pressure (IOP). MIGS can be broadly classified into several categories: those that enhance trabecular outflow (Trabectome, iStent, Hydrus Microstent, Kahook Dual Blade, high frequency deep sclerotomy, and gonioscopy-assisted transluminal trabeculotomy), those that augment suprachoroidal outflow (CyPass Microstent and iStent Supra), those that target Schlemm's canal (TRAB360 and the OMNI Surgical System, Streamline, and Ab Interno Canaloplasty), and conjunctival bleb-forming procedures (EX-PRESS Glaucoma Filtration Device, Xen Gel Stent and PreserFlo MicroShunt). MIGS is considered to have a shorter surgical time and fewer severe complications when compared to traditional glaucoma surgeries such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves). This literature review comprehensively examines the distinct MIGS devices and procedures, their underlying mechanisms, and clinical outcomes, emphasizing the importance of evaluating the efficacy and complications of each approach individually. As the field of MIGS continues to evolve, it is crucial to prioritize high-quality, long-term studies to better understand the safety and effectiveness of these innovative interventions in glaucoma management.

[Ab interno trabeculotomy without/with cataract operation-An alternative treatment before or instead of trabeculectomy in patients with high intraocular pressure?]

BACKGROUND

Trabeculotomy with the Kahook knife is a new ab interno minimally invasive glaucoma surgery (MIGS) procedure. The MIGS are usually performed in early to intermediate glaucoma eyes. In this retrospective study we analyzed the intraocular pressure (IOP) and topical glaucoma eye drop therapy (Meds) reduction achieved by the Kahook trabeculotomy (TO) without (n = 19) or with (n = 18) combined cataract operation (Cat-TO) as initial treatment before or to avoid filtering surgery.

MATERIAL AND METHODS

A total of 37 eyes of 37 patients were examined when IOP was > 21 mm Hg in at least 2 examinations despite the maximum tolerable Meds applied. Cat-TO was performed in 18 phakic eyes (primary open-angle glaucoma, POAG = 11, pseudoexfoliation glaucoma, PEX = 5, ocular hypertension, OHT = 2). In 19 pseudophakic eyes (POAG = 12, PEX = 6, OHT = 1) an isolated TO was executed. Complete success (no Meds) and relative success (irrespective of Meds) for IOP ≤ 21 mm Hg, ≤ 18 mm Hg, ≤ 16 mm Hg were evaluated 2, 6 and 12 months postoperatively.

RESULTS

The IOP was significantly reduced from preoperatively to 2 months after Cat-TO as well as after TO (Cat-TO: 26.8 ± 5.9 mm Hg to 16.0 ± 2.9 mm Hg, p < 0.001; TO: IOD 28.2 ± 5.6 mm Hg to 16.3 ± 3.5 mm Hg, p < 0.001). Meds reduction after Cat-TO as well as after TO was not significant (Cat-TO: 2.1 ± 1.3 to 1.3 ± 1.3, p = 0.11; TO: Meds 2.7 ± 1.1 to 2.2 ± 1.3, p = 0.23); however, Meds reduction after 6 and 12 months was significantly greater in the Cat-TO group compared to the TO group (p = 0.02). The IOP and Meds did not change significantly from 2 to 6 months. After Cat-TO, qualified success after 12 months for IOP ≤ 18 mm Hg was 61% (11/18) and for IOP ≤ 16 mm Hg 28% (5/18). After TO, qualified success after 12 months for TO was 47% (9/19) for IOP ≤ 18 mm Hg and 26% (5/19) for IOP ≤ 16 mm Hg. The intervention was not sufficient for 7 patients after TO and 2 patients after Cat-TO (IOP two times > 21 mm Hg).

CONCLUSION

The first year results show that TO as well as Cat-TO are effective minimally invasive interventions to delay or even avoid a filtrating operation. In case of Meds intolerance and target IOP ≤ 16 mm Hg Cat-TO is not sufficient.

12-month outcomes of ab interno excisional goniotomy combined with cataract surgery in primary open-angle glaucoma and normal tension glaucoma

PURPOSE

To evaluate the efficacy and safety of excisional goniotomy performed with the Kahook Dual Blade (KDB) combined with cataract surgery in patients with pimary open angle glaucoma (POAG) and Normal Tension Glaucoma (NTG) under topical therapy. Further sub-analysis was performed to compare between 90 and 120 degrees goniotomy.

METHODS

This was a prospective case series of 69 eyes from 69 adults (age 78 ± 5.9 years; male = 27, female = 42). Indications for surgery included insufficient IOP control with topical medication, glaucomatous damage progression under topical therapy and reduction of medication burden. Complete success was defined as IOP lowering below 21 mmHg without the need for topical medication. For NTG patients, complete success was defined as IOP lowering below 17 mmHg without the need for topical medication.

RESULTS

IOP was significantly lowered from 19.7 ± 4.7 to 15.1 ± 2.7 at 2 months, 15.8 ± 2.3 at 6 months and 16.1 ± 3.2 at 12 months (p < 0.05) for POAG and 15.1 ± 2.5 to 14.1 ± 2.4 at 2 months, 14.1 ± 3.1 at 6 months and 13.6 ± 1.8 at 12 months (p > 0.08) for NTG, respectively. Complete success was achieved in 64% of the patients. IOP lowering under 17 mmHg without the need for topical medication was achieved in 60% of the patients at 12 months. In NTG patients (14 eyes) IOP lowering under 17 mmHg without the need for topical medication was achieved in 71%. No significant difference was recorded in terms of IOP lowering at 12 months in-between 90° and 120° of treated trabecular meshwork (p > 0.7). No severe adverse reactions were recorded in this study.

CONCLUSION

One-year results show that KDB combined with cataract surgery is an effective treatment option for glaucoma patients. IOP lowering was successfully achieved in NTG patients with complete success in 70% of the patients. In our study, no significant differences were recorded in-between 90° and 120° of treated trabecular meshwork.

Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study

Aims and background

As the use of minimally invasive or microinvasive glaucoma surgery (MIGS) continues to expand, it is important to look at its outcomes in the hands of trainees. This study aims to examine the efficacy and safety of Kahook Dual Blade (KDB) goniotomy and endocyclophotocoagulation (ECP) with cataract extraction (CE) done by residents and fellows.

Methods

All cases of KDB or ECP performed with CE between 2012 and 2020 at Parkland were reviewed, excluding cases with multiple MIGS procedures or other procedures.

Results

A total of 153 eyes of 136 patients who underwent KDB and 125 eyes of 124 patients who underwent ECP were included. Mean intraocular pressure (IOP) decreased from 17.2 ± 5.2 at baseline to 15.4 ± 5.5 mm Hg at postoperative (post-op) month (POM) 12 in the KDB group (p = 0.02) and from 18.6 ± 6.3 at baseline to 15.1 ± 4.9 mm Hg at POM12 in the ECP group (p < 0.001), with wide variation in IOP change among subjects for both. The mean change in IOP across all time points was statistically significant for both groups. Medication counts were reduced from baseline at POMs 1, 3, and 6, but not 12, in both the KDB and ECP groups (p = 0.43 and p = 0.35, respectively). The rate of serious complications was very low; the most common complication was cystoid macular edema (CME) (six cases) and active inflammation beyond POM1 (15 cases) for KDB and ECP, respectively.

Conclusion

Combined CE/MIGS procedures performed by trainees were safe but less efficacious in lowering IOP and medications compared to literature reporting outcomes of attending surgeons, apart from ECP/MIGS with regards to IOP lowering, which was found to be similarly efficacious.

Clinical significance

Cataract extraction (CE) combined with KDB or ECP in the hands of trainees decreased mean IOP from baseline and was safe. IOP and medication reduction of MIGS/CE in the hands of trainees were overall lesser than reported values by attending surgeons.

How to cite this article

Da J, Gillings M, Kamat S, et al. Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study. J Curr Glaucoma Pract 2023;17(3):134-140.

Combined MIGS: Comparing Additive Effects of Phacoemulsification, Endocyclophotocoagulation, and Kahook Dual Blade

Purpose

Combining two or more MIGS (cMIGS) promises to be more efficacious than single MIGS (sMIGS). This study compared the efficacy of PEcK, which combines Phacoemulsification (Phaco), Endocyclophotocoagulation (ECP), and Kahook dual blade (KDB), relative to both of its constituent sMIGS, Phaco/ECP (Endo Optiks, NJ) and Phaco/KDB (New World Medical, CA) for the first time.

Patients and methods

Data was collected retrospectively from 1833 visits of 271 patients who underwent PEcK, Phaco/ECP, or Phaco/KDB from 2016-2021 at Massachusetts Eye and Ear. Primary outcomes included Generalized Estimating Equations (GEE) of intraocular pressure (IOP) and medication burden, as well as survival models.

Results

Mean preoperative IOP was 17.6 ± 5.0 (SD) mmHg on 3.0 ± 1.4 medications in the PEcK group (n = 128), 17.9 ± 5.1 mmHg on 2.2 ± 1.5 medications in the Phaco/ECP group (n = 78), and 16.1 ± 4.3 mmHg on 0.4 ± 1.0 medications in the Phaco/KDB group (n = 65). For more than 36 months, all procedures resulted in significant patterns of IOP and medication reduction (all p < 0.001), before and after statistical adjustment. The reduction pattern in IOP was significantly different when comparing all groups over time and favored PEcK (p = 0.04), but the reduction pattern in medications was not significantly different (p = 0.11). Procedures did not differ in procedural time (p = 0.18) or in survival to maintain ≥20% IOP reduction (p = 0.43) without additional medication or procedure. There was a trend toward significant difference in maintaining IOP ≤ goal IOP that favored PEcK over Phaco/ECP after adjustment (p = 0.09).

Conclusion

PEcK may confer greater IOP reduction without added procedural time compared to Phaco/ECP and Phaco/KDB in predominantly mild or moderate glaucoma. Further research on cMIGS may benefit from adopting this comparative analysis to constituent MIGS.

Gonioscopy-Assisted Transluminal Trabeculotomy and Goniotomy, With or Without Concomitant Cataract Extraction, in Steroid-Induced and Uveitic Glaucoma: 24-Month Outcomes

PRCIS

Gonioscopy-assisted transluminal trabeculotomy (GATT) and goniotomy with Kahook Dual Blade both achieved sustained reductions in intraocular pressure (IOP) and medication burden in eyes with steroid-induced or uveitic glaucoma at 24 months. Both procedures had favorable safety profiles.

PURPOSE

To characterize the 24-month surgical outcomes of GATT and excisional goniotomy in eyes with steroid-induced or uveitic glaucoma.

PATIENTS AND METHODS

A retrospective chart review was performed of eyes with steroid-induced or uveitic glaucoma that underwent GATT or excisional goniotomy, either standalone or combined with phacoemulsification cataract surgery, by a single surgeon at the Cole Eye Institute. IOP, number of glaucoma medications, and steroid exposure were recorded preoperatively and at multiple postoperative timepoints up to 24 months. Surgical success was defined as at least 20% IOP reduction or IOP <12, 15, or 18 mm Hg (Criterion A, B, or C). Surgical failure was defined as need for additional glaucoma surgery or loss of light perception vision. Intraoperative and postoperative complications were reported.

RESULTS

Forty eyes of 33 patients underwent GATT, and 24 eyes of 22 patients underwent goniotomy, of which 88% and 75%, respectively, had 24-months' follow-up. Concomitant phacoemulsification cataract surgery was performed in 38% (15/40) GATT eyes and 17% (4/24) goniotomy eyes. IOP and number of glaucoma medications were reduced at all postoperative timepoints in both groups. At 24 months, GATT eyes had mean IOP 12.9±3.5 mm Hg on 0.9±1.2 medications, and goniotomy eyes had mean IOP 14.3±4.1 mm Hg on 1.8±1.3 medications. Surgical failure was 8% for GATT and 14% for goniotomy at 24 months. Transient hyphema and transient IOP elevation were the most common complications, and 10% GATT eyes required surgical evacuation of hyphema.

CONCLUSIONS

Both GATT and goniotomy demonstrate favorable efficacy and safety in steroid-induced and uveitic glaucoma eyes. Both procedures achieved sustained reductions in IOP and glaucoma medication burden at 24 months.

Comparative outcomes of phacoemulsification combined with micro-invasive glaucoma surgery plus: Schlemm canal microstent versus Ab interno trabecular excision

PURPOSE

To report the relative efficacy of combining phacoemulsification with a Schlemm's canal microstent (Phaco/Hydrus) or dual blade trabecular excision (Phaco/KDB).

DESIGN

Retrospective study.

METHODS

One hundred and thirty-one eyes of 131 patients who underwent Phaco/Hydrus or Phaco/KDB procedures from January 2016 to July 2021 at a tertiary care center were included and assessed for up to 36months postoperatively. Primary outcomes were intraocular pressure (IOP) and number of glaucoma medications, evaluated by generalized estimating equations (GEE). Two Kaplan-Meier estimates (KM) assessed survival without additional intervention or pressure lowering medication while maintaining: (1) IOP≤21mmHg and≥20% IOP reduction or (2) IOP≤preoperatively designated goal.

RESULTS

Mean preoperative IOP was 17.70±4.91 (SD) mmHg on 0.28±0.86 medications in the Phaco/Hydrus cohort (n=69) and 15.92±4.34mmHg on 0.19±0.70 medications in the Phaco/KDB cohort (n=62). At 12months, mean IOP was reduced to 14.98±2.77mmHg on 0.12±0.60 medications after Phaco/Hydrus and 13.52±4.13mmHg on 0.04±0.19 medications after Phaco/KDB. GEE models of IOP (P<0.001) and medication burden (P<0.05) showed significant patterns of reduction across all timepoints in both cohorts. There were no differences in IOP reduction (P=0.94), number of medications (P=0.95) or survival (P=0.72 by KM1, P=0.11 by KM2) between procedures.

CONCLUSIONS

Both Phaco/Hydrus and Phaco/KDB resulted in significantly reduced IOP and medication burden for over 12months. Phaco/Hydrus and Phaco/KDB confer similar outcomes in terms of IOP, medication burden, survival, and procedural time in a population with predominantly mild and moderate open-angle glaucoma.

Effectiveness of Microinvasive Glaucoma Surgery in the United States: Intelligent Research in Sight Registry Analysis 2013-2019

PURPOSE

To evaluate the effectiveness of microinvasive glaucoma surgery (MIGS) with and without concurrent phacoemulsification.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

Patients in the Intelligent Research in Sight (IRIS®) Registry who underwent Xen gel stent (ab interno) implantation, endoscopic cyclophotocoagulation (ECP), or goniotomy or canaloplasty from 2013 through 2019.

METHODS

Kaplan-Meier survival analysis was used to assess reoperation rates. We defined reoperation as any subsequent glaucoma surgery occurring 1 month to 3 years after the initial procedure. Multivariable Cox proportional hazard models were used to determine factors predictive of reoperation.

MAIN OUTCOME MEASURES

Reoperation rate, mean intraocular pressure (IOP) and visual acuity (VA), postoperative complications, predictors of reoperation, and reoperation procedure type.

RESULTS

A total of 79 363 eyes from 57 561 patients were included, with 15 118 eyes (19%) receiving stand-alone MIGS and 64 245 eyes (81%) receiving MIGS concurrent with phacoemulsification. Overall, patients who underwent MIGS concurrently with phacoemulsification showed lower reoperation rates compared with stand-alone MIGS, most pronounced in ECP and goniotomy or canaloplasty. At postoperative year 2, the cumulative reoperation rate for stand-alone procedures was 15% for ECP, 24% for Xen implantation, and 24% for goniotomy or canaloplasty compared with 3% for ECP, 19% for Xen implantation, and 6% for goniotomy or canaloplasty concurrent with phacoemulsification (P < 0.001 for each stand-alone MIGS vs. MIGS with phacoemulsification). Black race, older age, moderate and severe glaucoma, higher baseline IOP, and glaucoma subtype were associated with higher reoperation risk. Although IOP decreased in all groups, stand-alone MIGS showed a more substantial decrease in mean IOP. Complication rates from MIGS were low overall: 1% for ECP, 1% for Xen implantation, and 2% for goniotomy or canaloplasty.

CONCLUSIONS

In current United States clinical practice, MIGS has substantially lower reoperation rates when performed with phacoemulsification, especially for ECP and goniotomy or canaloplasty. Approximately one-sixth of patients undergoing stand-alone ECP and one-quarter of patients undergoing stand-alone Xen implantation or goniotomy or canaloplasty require reoperation by 2 years. Black race, diagnosis coding of moderate to severe glaucoma, and higher baseline IOP were associated with higher risk of reoperation after MIGS procedures.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Risk factors of surgical failure in combined phacoemulsification and excisional goniotomy for angle-closure glaucoma

PURPOSE

To evaluate the therapeutic success, and risk factors for combined phacoemulsification and Kahook Dual Blade excisional goniotomy (Phaco/KDB) in primary angle-closure glaucoma (PACG).

METHODS

A retrospective review was conducted on glaucoma patients who underwent Phaco/KDB between September 2019 and August 2021 at 2 ophthalmology centers. Complete success was defined as unmedicated intraocular pressure (IOP) ≤ 18 mmHg with no further glaucoma surgery, while the medicated IOP ≤ 18 mmHg was defined as qualified success with lesser medications than at baseline.

RESULTS

Seventy-two eyes (64 patients) with a mean age of 67.1 ± 8.1 years were included in this study, and 70.2% were female. The mean medicated baseline IOP decreased from 23.4 ± 8.1 to 16.6 ± 3.9 mmHg at an average of 11.6 ± 3.7 months of follow-up (- 29.1%; P < 0.00). Medications decreased from 2.6 ± 1.3 to 0.4 ± 0.9 (- 82.6%; P < 0.001). Complete success and qualified success were achieved in 65.3% and 79.2% of eyes, respectively. Male gender [hazard ratio (HR): 6.00 (1.57-22.9); P = 0.009] was observed a risk factor for surgical failure, whereas higher axial length (HR:0.37 (0.16-0.86); P = 0.021), and a combined circumferential goniosynechialysis procedure (HR: 0.13 (0.02-0.74); P = 0.022) lowered the risk of surgical failure. Hyphema, postoperative shallowing anterior chamber, and IOP spike were the most common complications. The cumulative survival proportion for qualified success at 12 months was 82.5% ± 0.05 (95% CI, 0.70-0.90).

CONCLUSION

Phaco/KDB provided acceptable therapeutic success rate and may, therefore, be recommended in patients with coexisting cataract and PACG. Identifying patients with risk factors preoperatively may help clinicians predict surgical success.

Outcomes and risk factors for ab interno trabeculotomy with a Kahook Dual Blade

PURPOSE

To verify the surgical results and risk factors for ab interno trabeculotomy using a Kahook Dual Blade (KDB-LOT) in patients with various glaucoma types.

METHODS

This study was a retrospective case series of 205 eyes that underwent KDB-LOT. For Kaplan-Meier survival analysis, criterion A was defined as a ≤ 20% reduction in intraocular pressure (IOP) from baseline. Criteria B, C, and D were IOPs of ≤ 21, 18, and 15 mmHg, respectively. The Cox proportional hazard (CPH) model investigated prognostic factors.

RESULTS

The mean (SD) IOP decreased from 24.7 (7.98) to 17.6 (4.80) mmHg in all cases, from 21.3 (6.88) to 17.8 (3.52) mmHg in primary open-angle glaucoma (POAG), from 25.4 (7.32) to 17.1 (4.65) mmHg in exfoliation glaucoma, from 30.6 (8.88) to 17.8 (8.29) mmHg in uveitic glaucoma, and from 30.8 (7.29) to 17.3 (0.83) mmHg in steroid-induced glaucoma at 1 year after KDB-LOT. The Kaplan-Meier survival analysis showed that patients with POAG had the best prognosis under criteria B and C, and the 1-year survival rate in patients under criterion D was less than 35% for any disease type. CPH analysis revealed that age and KDB-LOT with phacoemulsification were good prognostic factors. Risk factors for surgical failure were previous cataract surgery, selective laser trabeculoplasty, and postoperative peripheral anterior synechiae.

CONCLUSION

KDB-LOT was effective in treating patients with several glaucoma types but showed difficulty in pushing IOP below 15 mmHg. Prognostic factors should be considered when making decisions regarding surgical indications.

Kahook Dual Blade versus Trabectome (KVT): Comparing Outcomes in Combination with Cataract Surgery

Purpose

To compare the safety and efficacy of Kahook Dual Blade (KDB) versus Trabectome with cataract surgery in reducing intraocular pressure (IOP) and medications used by patients with glaucoma.

Methods

Retrospective chart review comparing eyes after KDB or Trabectome with cataract surgery at 2 academic centers. Surgical success was defined as IOP <21 mmHg with ≥20% IOP reduction at post-operative month 12 (POM12). Changes in IOP, number of glaucoma medications, and adverse events were assessed.

Results

Ninety eyes in the KDB group and 125 eyes in the Trabectome group were included. Mean changes in IOP at POM12 were -1.9 ± 4.9 mmHg (11.2%, P = 0.002) in the KDB group and -3.5 ± 5.5 mmHg (19.1%, P < 0.001) in the Trabectome group, without a significant difference between the groups (P = 0.20). Mean change in glaucoma medications at POM12 was -0.8 ± 1.5 in the KDB group (58%, P < 0.001) and -0.3 ± 1.3 (38%, P = 0.003) in the Trabectome group, with KDB having a greater decrease in medications (P = 0.02). The percentage of eyes achieving success was 30% for the KDB group and 54% for the Trabectome group (P = 0.01). Hyphema was the most common complication, with an incidence of 3% for the KDB group and 14% for the Trabectome group (P = 0.01).

Conclusion

KDB or Trabectome with cataract surgery is safe and effective at lowering IOP and medication burden, with KDB resulting in a greater reduction in medications and Trabectome more frequently achieving success with an increased incidence of hyphema. Considering the study's limitations, the outcomes were similar.

Kahook Dual-Blade Goniotomy with and without Phacoemulsification in Medically Uncontrolled Glaucoma

Purpose

To evaluate the 2-year efficacy and safety of Kahook dual-blade (KDB) goniotomy in patients with medically uncontrolled glaucoma.

Methods

This was a retrospective case-series study of 90 consecutive patients with primary open-angle glaucoma (POAG) or pseudoexfoliation glaucoma (PEXG) that underwent KDB goniotomy alone (KDB-alone group) or KDB goniotomy in combination with phacoemulsification (KDB-phaco group) during 2019-2020. All patients were uncontrolled on three or more medications. Surgical success was defined as an IOP reduction ≥20% and/or a reduction of one or more medications at 24 months. We also report IOP levels and number of medications from baseline to 24 months, as well as the need for further glaucoma interventions.

Results

At 24 months, mean IOP had reduced from 24.8±8.3 to 15.0±5.3 mmHg in the KDB-alone group (P<0.001) and from 22.3±5.8 to 13.9±3.0 mmHg in the KDB-phaco group (P<0.001). Medications had reduced from 3.5±0.6 to 3.1±0.9 in the KDB-alone group (P=0.047) and from 3.3±0.5 to 2.3±1.1 in the KDB-phaco group (P<0.001). An IOP reduction ≥20% and/or a reduction with one or more medications was achieved by 47% of eyes in the KDB-alone group and by 76% of eyes in the KDB-phaco group. Eyes with PEXG and POAG responded equally well to the success criteria. During the 24-month follow-up, additional glaucoma surgery or transscleral photocoagulation was performed in 28% of eyes in the KDB-alone group and in 12% of eyes in the KDB-phaco group.

Conclusion

In patients with medically uncontrolled glaucoma, KDB had a significant IOP-lowering effect after 24 months, but success rates were higher when KDB was performed in combination with cataract surgery compared to stand-alone treatment.

Pigment dispersion syndrome: A brief overview

BACKGROUND

Pigment dispersion syndrome (PDS) is characterized by dispersion of pigment in the anterior chamber structures and can present with deposits on the central corneal endothelium or Krukenberg spindle, iris trans-illumination spoke-like defects, and increased pigmentation in the iridocorneal angle. It is more common in myopic patients with a predominance in young males in the third to fifth decade of life that affects about 1-2% of the population. PDS is a risk factor and can give lead to a rise in intraocular pressure (IOP) and secondary glaucoma. Pigmentary glaucoma (PG) can develop from PDS in the presence of elevated IOP coupled with glaucomatous optic neuropathy, retinal nerve fiber thinning, and/or visual field defects. PDS and PG have the same clinical features, representing different levels of severity on the same clinical spectrum.

RELEVANCE FOR PATIENTS

Early diagnosis, appropriate management, and follow-up of patients with PDS are important to prevent vision deterioration or blindness due to glaucomatous optic neuropathy.

Ab Interno Goniotomy with the Kahook Dual Blade in a Monocular Patient with Mucous Membrane Pemphigoid and Refractory Open Angle Glaucoma: A Case Report

Purpose

To describe the case of a monocular patient with ocular mucous membrane pemphigoid (MMP) and open angle glaucoma refractory to medical treatment, who was successfully managed with ab interno goniotomy at the time of cataract surgery.

Methods

A 63-year-old woman with a history of severe MMP presented with exacerbation of the disease in both eyes. Vision was 20/80 in the right eye and light perception in the left eye. Symblepharon formation, trichiasis and forniceal foreshortening were present in the right eye, while the cornea of the left eye was completely conjunctivalized. Following aggressive systemic immunosuppressive therapy with corticosteroids and cyclophosphamide, the disease was brought under control. However, the patient developed a mature cataract and high intraocular pressure (IOP) of 28 mmHg on maximal medical therapy. Due to the high risk of ocular MMP exacerbation with glaucoma filtration surgery, the decision was made to proceed with cataract extraction combined with ab interno goniotomy with the Kahook Dual Blade.

Results

There were no intraoperative complications. The IOP has remained in the 12–14 mmHg range without any topical glaucoma medications over a total follow up of 3.5 years.

Conclusion

Ab interno goniotomy using the Kahook Dual Blade can significantly reduce IOP and medication burden in MMP cases, where any type of conjunctival incisional surgery could induce disease flare up. In this case, it represented a safe and effective surgical procedure for ocular MMP with concomitant refractory open angle glaucoma.

Three-year clinical outcomes of phacoemulsification combined with excisional goniotomy using the kahook dual blade for cataract and open-angle glaucoma in Saudi Arabia

PURPOSE

The aim of this study was to describe the changes in intraocular pressure (IOP), IOP-reducing drugs, and visual acuity (VA) through up to 3 years of follow-up in patients undergoing combined phacoemulsification and excisional goniotomy with the Kahook Dual Blade (KDB-phaco) by a single surgeon in Saudi Arabia.

METHODS

The health records of 55 eyes of 47 patients undergoing KDB-phaco by a single surgeon were reviewed. Data were extracted from visits occurring preoperatively (n = 55), intraoperatively (n = 55), and 1-day (n = 55), 2 weeks (n = 55), 4-6 weeks (n = 49), 2-3 months (n = 55), and 6 (n = 55), 9 (n = 55), 12 (n = 55), 18 (n = 49), 24 (n = 46), and 36 months (n = 16) postoperatively. Data collection included IOP, IOP-lowering medications, and VA at each time point. Adverse events were also collected. Paired t-tests were used to compare IOP, medications, and VA at each time point to preoperative values.

RESULTS

Mean (standard error) baseline IOP was 20.4 (0.7) mmHg and through up to 36 months of follow-up (minimum 12 months, mean 26.1 [1.0] months) ranged from 13.6 to 14.1 mmHg; significant reductions (P < 0.0007) of 5.7-7.0 mmHg (23.0%-29.5%) were achieved at every time point. Medications were reduced from 3.2 (0.1) to 0.2-2.0 (reductions of 1.2-3.1 medications [50.0%-94.9%]; P < 0.0001 at every time point). At months 24 and 36, the mean IOP was 13.9 (0.3) and 13.9 (0.5) mmHg and mean medications were 1.4 (0.2) and 2.0 (0.4). Mean logMAR VA improved from 1.0 (0.1) preoperatively to (0.2 [0.0]; P < 0.001) by month 6 and remained stable thereafter through the duration of follow-up.

CONCLUSION

KDB-phaco significantly lowered IOP approximately 30% by day 1 with consistency and durability through 3 years. Medication use was reduced by >50% through 36 months. Mean logMAR VA improved from 1.0 to 0.2 (Snellen equivalent 20/200-20/32). This procedure provides meaningful long-term reductions in IOP and the need for IOP-lowering medications without compromising visual rehabilitation in Saudi Arabian eyes with cataract and glaucoma.

Six months' follow-up of combined phacoemulsification-kahook dual blade excisional goniotomy

PURPOSE

This study reports on the combination of excisional goniotomy and cataract extraction in the management of glaucoma in terms of intraocular pressure (IOP) and glaucoma medication reduction.

METHODS

This is a retrospective case series. Twenty-eight eyes of 22 patients with the diagnosis of cataract and ocular hypertension or glaucoma of any stage underwent combined phacoemulsification and Kahook Dual Blade (KDB) goniotomy, between March 2019 and September 2020. The parameters evaluated were postoperative best-corrected visual acuity, mean IOP reduction, number of IOP-lowering medications, and the surgical success rate defined as IOP reduction >20% and/or reduction in glaucoma medications >1.

RESULTS

The mean IOP reduction at 6 months was 4.5 mmHg (P = 0.0007), which translates to 24.9% reduction from preoperative IOP. The mean preoperative number of glaucoma medications was 2.9 ± 1.0 (median of 3). It was reduced to 1.1 ± 1.1 (median of 1.5), 1.46 ± 1.17 (median of 2), 1.44 ± 1.28 (median of 2), and 1.56 ± 1.28 (median of 2) at 1 week, 1 month, 3 months, and 6 months, respectively. Twenty-nine percent (8/28) of the patients were off glaucoma medications at 6 months and 46% (13/28) had a reduction of more than 50% of their glaucoma medications.

CONCLUSION

Combined phacoemulsification-KDB excisional goniotomy may be an effective and safe alternative to more invasive filtering surgery in glaucoma patients of any stage.

Predictive Factors of Outcomes in Kahook Dual Blade Excisional Goniotomy Combined with Phacoemulsification

Aim

To identify factors that were significant predictors of Kahook Dual Blade (KDB) excisional goniotomy outcomes.

Materials and methods

One hundred and thirty-two eyes from 99 adult glaucoma patients who underwent combined KDB and phacoemulsification (KDB-phaco) with a minimum 6-month follow-up were assessed for baseline patient characteristics to determine correlation to the success of KDB-phaco at 6 and 12 months postoperatively. Success was defined as ≥20% intraocular pressure (IOP) reduction or ≥1 medication reduction as well as IOP ≤18 mm Hg without any additional IOP-lowering procedures after KDB-phaco.

Results

63.6% (84/132) and 46.1% (41/89) of cases were successful at the 6- and 12-month follow-ups, respectively. KDB-phaco reduced patient's preoperative IOP (in mm Hg) from 17.6 ± 4.6 to 14.9 ± 3.2 at 6 months (15.3%, p < 0.001) and 15.4 ± 4.7 at 12 months (12.5%, p = 0.001). KDB-phaco reduced patient's preoperative IOP-lowering medications from 2 ± 1.2 to 1.1 ± 1.2 at 6 months (45%, p < 0.001) and 1.32 ± 1.3 at 12 months (34%, p < 0.001). At 6 months, patients on >1 IOP lowering medication had a greater chance of meeting our success criteria (p = 0.037). Visually significant postoperative hyphema was not associated with the use of anticoagulation (p = 0.943) but was significantly associated with postoperative day 1 IOP ≤ 10 mm Hg (p = 0.011).

Conclusion

Patients who underwent KDB-phaco significantly reduced their IOP and medication burden at both 6 and 12 months compared with their baseline preoperative values. KDB-phaco outcome was associated with higher baseline IOP-lowering medications and increased rate of hyphema was associated with lower postoperative day 1 IOP, regardless of anticoagulation status. Age, ethnicity, prior laser trabeculoplasty, type and severity of glaucoma, and baseline preoperative IOP were not associated with surgical success.

Clinical significance

Patients with a higher number of baseline medications may experience a greater probability of success following KDB-phaco.

How to cite this article

Pratte EL, Cho J, Landreneau JR, et al. Predictive Factors of Outcomes in Kahook Dual Blade Excisional Goniotomy Combined with Phacoemulsification. J Curr Glaucoma Pract 2022;16(1):47-52.

Early Results of Irrigating Goniectomy With TrabEx+: A Novel Device for the Treatment of Open-angle Glaucoma

PRCIS

Irrigating goniectomy with the TrabEx+ device can lower intraocular pressure (IOP) in patients with glaucoma, as a standalone procedure or combined with cataract surgery.

PURPOSE

The aim was to describe the efficacy and safety of irrigating goniectomy performed using the TrabEx+ device, either as a standalone procedure or combined with cataract surgery, in eyes with medically treated open-angle glaucoma.

METHODS

A retrospective case series of eyes treated by a single surgeon at a single UK teaching hospital. Data was collected at follow-up visits at 1 week, 3, 6, 12, 18, and 24 months postoperatively. Primary outcomes included IOP and glaucoma medication reduction after surgery. Proportion of eyes achieving >20% IOP reduction, IOP <21 mm Hg, and no reoperation were classified as surgical success.

RESULTS

Seventy-three consecutive eyes of 64 patients (mean age 68.4±13.7 y) were enrolled. 62% were treated as combined procedures with cataract surgery. Overall, mean IOP decreased from 31.3±7.3 to 20.9±10.4 mm Hg at the latest follow-up (34% reduction) (P<0.001) at the latest follow-up (16.1±10.3 mo) with mean preoperative medications decreased from 2.9±1.2 to 1.9±1.3 (P<0.001). 73% met the definition of success at latest follow-up. Postoperative complications were recorded including hyphaema (17%), uveitis (3%), hypotony (1%), and persistent vitreous hemorrhage (1%). Eighteen percent required reoperation because of treatment failure.

CONCLUSION

TrabEx+ appears to be effective in lowering IOP and medication with or without cataract surgery. However, long-term safety and efficacy will be better understood in a prospective study with longer follow-up.

Outcomes of combined single-use dual blade goniotomy and cataract surgery

Purpose

Single-use dual blade goniotomy (SBG) is a novel ab interno procedure that removes three to five clock hours of trabecular meshwork (TM). We analysed the reduction of intraocular pressure (IOP) and topical glaucoma medication (Meds) in eyes following combined cataract surgery and SBG (Cat-SBG).

Methods

IOP and Meds were evaluated retrospectively in 55 eyes of 38 patients. 44 eyes had high tension glaucoma (HTG) and eleven eyes had normal tension glaucoma (NTG). Complete success (no Meds) and qualified success (with Meds) for IOP levels ≤ 21, ≤ 18 , ≤ 16 mmHg or ≥ 20% IOP reduction at the two- and six-month follow-up were evaluated.

Results

IOP and Meds were significantly reduced from before to two months after Cat-SBG in HTG- and NTG-patients (HTG: IOP 19.4 ± 3.3 to 15.1 ± 3.3 mmHg; p < 0.001; Meds 2.1 ± 1.3 to 0.8 ± 1.3; p < 0.001; NTG: IOP 14.0 ± 2.3 to 11.5 ± 2.3 mmHg; p = 0.004; Meds 1.6 ± 0.7 to 0.3 ± 0.7; p < 0.001). IOP and Meds did not change significantly from two to six months after Cat-SBG.

In HTG, complete and qualified success rates were 43% (19/44) and 93% (41/44) for IOP ≤ 18 mmHg, 36% (16/44) and 64% (28/44) for IOP ≤ 16 mmHg and 30% (13/44) and 43% (19/44) for ≥ 20% IOP reduction six months after surgery. In NTG, complete and qualified success was 81% (9/11) and 100% (11/11) for IOP ≤ 18 and ≤ 16 mmHg, and 27% (3/11) for IOP reduction ≥ 20%.

IOP and Meds reduction were comparable between HTG and NTG eyes.

Only minor postoperative complications occurred.

Conclusion

Cat-SBG is an efficient method to significantly lower IOP in patients with HTG and NTG.

A novel use of the endoscopic cyclophotocoagulative probe for the management of excisional goniotomy induced chronic recurrent hyphema

Purpose

To describe the management of a case of chronic, recurrent hyphema following excisional goniotomy with the Kahook Dual Blade.

Observations

One week following uncomplicated surgery, the patient presented with eye pain, elevated intraocular pressure, and layered hyphema. The hyphema resolved with conservative measures but recurred several times with similar symptoms over the next several months. An attempt to stenose the "oozing" collector channel using the argon laser was unsuccessful. Treatment of the angle with an endoscopic semi-conductor diode laser (endoscopic cyclophotocoagulative or ECP) probe successfully altered the angle preventing further episodes of recurrent hyphema. The primary glaucoma procedure failed necessitating a filtering procedure.

Conclusions and importance

Clinician should be aware of this potential complication, its treatment options, and outcomes.

Response to netarsudil in goniotomy-treated eyes and goniotomy-naïve eyes: a pilot study

PURPOSE

To compare the intraocular pressure (IOP)-lowering effects of netarsudil on goniotomy-treated eyes versus goniotomy-naïve control eyes.

METHODS

Retrospective cohort study of 70 eyes from 49 adult glaucoma patients treated with netarsudil. Thirty-five eyes received sectoral goniotomy using Kahook Dual Blade (KDB) combined with cataract surgery with minimum of 3 months prior to netarsudil treatment. Thirty-five eyes in the control cohort received only cataract surgery prior to netarsudil. Primary outcome was treatment success, defined as ≥ 20% decrease in IOP at minimum 1 month follow-up. Secondary outcome measures included percent of IOP reduction, adverse effects of medication, medication discontinuation rate, and relationship between KDB goniotomy response and netarsudil response.

RESULTS

Eighty-three percent of KDB-treated eyes achieved netarsudil treatment success compared to 54% of control eyes (P = .012). IOP reduction was 30.3 ± 16.2% (IQR 21-38%) in KDB-treated eyes and 19.4 ± 12.4% (IQR 9.2-30.8) in control eyes (P = .007). History of prior KDB increased the likelihood of success to netarsudil treatment compared to eyes without prior KDB, regardless of surgical response to KDB (odds ratio 4.51, 95% CI 1.34-15.14, P = .015). The overall rate of adverse effects of netarsudil was 42%, most commonly reported as conjunctival hyperemia, allergy, and blurred vision.

CONCLUSIONS

Netarsudil had a greater IOP-lowering effect in eyes treated with prior goniotomy and may serve as a promising adjunctive ocular hypotensive agent to further reduce IOP in eyes with prior goniotomy.

Long-Term Outcomes of a Kahook Dual Blade Procedure Combined with Phacoemulsification in Japanese Patients with Open-Angle Glaucoma

We retrospectively evaluated the long-term surgical outcomes of phacoemulsification combined with a Kahook dual blade (KDB) procedure in Japanese patients with open-angle glaucoma. The primary outcome was surgical success or failure. Surgical failure was indicated by a <20% reduction in preoperative intraocular pressure (IOP) or IOP > 18 mmHg (criterion A), IOP > 14 mmHg (criterion B), or requirement for reoperation. Glaucoma medications after surgery and postoperative complications were recorded. Surgical outcomes were compared between primary open-angle glaucoma (POAG) and exfoliation glaucoma (ExG) groups. The probability of success at 36 months postoperation was 52.5% using criterion A and 36.9% using criterion B. Mean IOP decreased significantly from 19.5 ± 6.9 mmHg preoperatively to 11.9 ± 2.7 mmHg at 36 months, and the mean number of glaucoma medications from 2.4 ± 1.4 to 1.6 ± 1.4 (both p < 0.01). IOP spikes were significantly more common in the ExG group (23.7% vs. 9.1%; p = 0.045), as was the need for additional glaucoma surgery (10.5% vs. 1.8%; p = 0.038). A KDB procedure combined with cataract surgery resulted in significant long-term decreases in IOP and the number of glaucoma medications. The complication rate was higher in eyes with ExG. Therefore, these eyes require more careful management after a KDB procedure.

Three-dimensional heads-up surgery in ab-interno trabeculotomy: Image processing-assisted trabeculotomy

Purpose

We compared the visibility and surgeon posture between image-processing-assisted trabeculotomy (IP-LOT) using the NGENUITY^® 3D visual system and conventional microsurgery (microscope-assisted trabeculotomy; MS-LOT).

Methods

IP-LOT was performed for five pig eyes. The visibility of the trabecular mesh work was evaluated on images of the trabecular mesh work and the posterior surface of the cornea (Cor) obtained under three different conditions. Images were then analyzed using ImageJ^® to measure differences in luminance between the trabecular mesh work and Cor. IP-LOT was also performed for eleven human eyes, and the data were analyzed using the same approach as that used for the pig eyes. The length from the surgeon’s abdomen to the operative eye (working distance) during MS-LOT and IP-LOT was measured for 12 different surgeons and compared to evaluate surgeon posture.

Results

Image processing significantly increased the difference in luminance between the trabecular mesh work and Cor in both pig and human eyes (p < 0.05). Moreover, the working distance in IP-LOT was significantly shorter than that in MS-LOT (p < 0.05).

Conclusion

Our findings suggest that the NGENUITY^® 3D visual system provides better trabecular mesh work visibility than a normal microscope in conventional surgical methods, and it allows surgeons to operate without moving far from the operative eye.

A Review of Excisional Goniotomy Performed with the Kahook Dual Blade for Glaucoma Management

Aim

To review the published literature describing clinical outcomes of excisional goniotomy using the Kahook Dual Blade (KDB) for the management of glaucoma.

Background

A family of less invasive glaucoma procedures-including excisional goniotomy with the KDB-has been developed to provide moderate reductions in intraocular pressure and/or medication burden in eyes with therapeutic needs that may not warrant the risks associated with more traditional procedures such as trabeculectomy and tube-shunt implantation. This review's goal is to synthesize the existing literature into a compendium of excisional goniotomy's indications, technique, efficacy and safety outcomes, and optimal place in glaucoma management.

Review results

Excisional goniotomy with the KDB effectively lowers IOP and reduces the medication burden in eyes with POAG and other forms of glaucoma across the spectrum of both baseline IOP and disease severity. The procedure exhibits a safety profile that is on par with other angle-based surgical interventions and enhanced safety compared to filtration procedures. It can be performed by comprehensive ophthalmologists as well as glaucoma specialists. This procedure as a standalone operation delivers IOP reductions consistent with filtration surgery, and in combination with cataract surgery delivers both IOP and medication reductions at least as great as other minimally invasive procedures.

Conclusion

Given the broad base of evidence supporting its use in a wide variety of clinical scenarios, excisional goniotomy with the KDB can play a meaningful role in the achievement of patient-specific glaucoma therapy goals.

Clinical significance

These aggregate findings support the efficacy and safety of excisional goniotomy with the KDB and clarify the patient profiles best suited for this procedure.

How to cite this article

Dorairaj S, Radcliffe NM, Grover DS, et al. A Review of Excisional Goniotomy Performed with the Kahook Dual Blade for Glaucoma Management. J Curr Glaucoma Pract 2022;16(1):59-64.

Trends and Usage Patterns of Minimally Invasive Glaucoma Surgery in the United States: IRIS® Registry Analysis 2013-2018

PURPOSE

Understanding trends and patterns in the use of minimally invasive glaucoma surgery (MIGS) and patient profiles undergoing each procedure is important given their relative expense and unknown long-term safety and effectiveness.

DESIGN

Retrospective analysis.

PARTICIPANTS

Minimally invasive glaucoma surgeries and standard glaucoma surgeries recorded in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry.

METHODS

We used the data from IRIS Registry between 2013 and 2018 (inclusive) to measure the annual number of MIGS and standard surgical techniques (trabeculectomy or glaucoma drainage device [GDD] placement) performed in the United States, stratified by demographic characteristics. Secondary analyses of concurrent surgeries and of subsequent surgeries for MIGS and standard surgical technique also were conducted.

MAIN OUTCOME MEASURES

Trends and sociodemographic characteristics of MIGS use in the United States.

RESULTS

Two hundred three thousand three hundred thirty-two eyes and 232 537 unique procedures had associated, documented International Statistical Classification of Diseases and Related Health Problems (ICD), Ninth or Tenth Revision, codes for glaucoma and were included in final analyses. Among eyes with documented glaucoma diagnoses, a substantial increase in annual MIGS procedures occurred over the study period (from 7586 in 2013 to 39 677) and a smaller decrease in standard glaucoma procedures (from 16 215 to 13 701). The proportion of iStent procedures almost tripled during the study period (from 14% to 40%), and by 2017 accounted for almost half (43.7%) of all glaucoma surgeries in the United States. Twenty-one thousand twenty-five of all eyes (10.3%) underwent multiple procedures: 7638 (36.3%) on the same day and 13 387 (63.7%) on subsequent days. Endocyclophotocoagulation and iStent placement were the most common concurrent procedures (55.4% of all concurrent procedures). Trabeculectomy and GDD placement were most commonly followed by another standard glaucoma surgery, but when followed by sequential MIGS, endocyclophotocoagulation and goniotomy were the most common procedures performed (33.0% and 21.9%, respectively).

CONCLUSIONS

A significant increase in MIGS use occurred over the recent 6-year period, despite limited evidence of their long-term safety or effectiveness, highlighting the need for trials comparing safety and outcomes of novel MIGS versus traditional surgical treatments for glaucoma.

Phacoemulsification with Kahook Dual Blade goniotomy in eyes with medically treated glaucoma: analysis of surgical outcomes and success predictors

PURPOSE

The purpose of this study was to investigate the postoperative outcomes and evaluate the success predictors of phacoemulsification with Kahook Dual Blade goniotomy for cataract and glaucoma management in eyes with primary open-angle glaucoma.

METHODS

This was a retrospective, non-comparative; inter ventional case series in which all patients with primary open-angle glaucoma who underwent phacoemulsification with Kahook Dual Blade goniotomy between June 2018 and April 2019 were enrolled. All the participants had a minimum follow-up period of 6 months. Preoperative and postoperative intraocular pressure values (at 1, 3, and 6 months), number of antiglaucoma medications, best-corrected visual acuity, surgical complications, and any subsequent related events or procedures were recorded. A logistic regression analysis was performed to investigate the association between the different variables and surgical outcomes.

RESULTS

A total of 47 patients (57 eyes) were included (mean age, 70.5 ± 7 years). The mean intraocular pressure was reduced from 15.5 ± 4.2 mmHg to 12.2 ± 2.4 mmHg at the last follow-up visit (p<0.001). The mean number of antiglaucoma medications decreased significantly from 1.9 ± 1.0 to 0.6 ± 1.0 during the same period (p<0.001). On the basis of the predefined criterion (intraocular pressure reduction ≥20% and/or reduction ≥1 medication), the 6-month success rate was 86%. A higher preoperative intraocular pressure value (odds ratio [OR]= 2.01; p=0.016) and greater percentage of initial (30 days) intraocular pressure reduction (OR= 1.02; p=0.033) were sig nificantly associated with surgical success.

CONCLUSION

Our findings suggest that phacoemulsification with Kahook Dual Blade goniotomy is an effective and safe alternative for cataract management in eyes with primary open-angle glaucoma that positively impacts intraocular pressure control and medication burden. Eyes with higher baseline intraocular pressure and a more pronounced initial response to the procedure appeared to present better outcomes at 6 months. Further studies are needed to evaluate the long-term efficacy and safety profile of the procedure.

Initial experience with phacoemulsification and goniotomy using the Kahook dual blade in advanced open-angle glaucoma: Six-month outcomes in Indian eyes

Purpose:

The aim of this study was to report our initial experience on the outcomes of phacoemulsification in combination with goniotomy using the Kahook Dual Blade (KDB) in eyes with advanced open-angle glaucoma (OAG).

Methods:

The outcomes of phaco-goniotomy with KDB in advanced OAG in Indian eyes were retrospectively analyzed. Based on the Hodapp-Anderson-Parrish criteria of visual field defects, severe glaucoma (mean deviation on standard automated perimetry worse than 12 dB) was considered as advance glaucoma. Preoperative, intraoperative, and postoperative data were collected through 6 months of follow-up. Outcome measures included antiglaucoma medications (AGM), the proportion of eyes achieving >1AGM reduction, intraocular pressure (IOP), and visual acuity.

Results:

Median (interquartile range) number of AGM in eyes that underwent phaco-KDB goniotomy reduced from 2 (2,3) at baseline to 1 (0,1) at 6 months (P = 0.002). Median IOP reduced from 20 (20,26) mmHg at baseline to 14 (12,15) mmHg at 6 months (P = 0.02). The proportion of eyes achieving >1 medication reduction was 88% eyes (8/9). Adverse events noted were IOP spike (22 mmHg) in 2 eyes and intra-op hyphema in 1 eye on postoperative day-1, both resolved in a week with conservative management. Except one eye with central corneal scar due to prior pterygium surgery, 8 eyes had 20/20 vision at 1 week which was maintained till last follow-up.

Conclusion:

Phacoemulsification with KDB Goniotomy significantly lowered the need for AGM with moderate IOP reduction in advanced OAG eyes. There were no serious complications and the visual recovery was good and early.

Excisional goniotomy vs trabecular microbypass stent implantation: a prospective randomized clinical trial in eyes with mild to moderate open-angle glaucoma

PURPOSE

To compare reduction in intraocular pressure (IOP) and IOP-lowering medication in eyes undergoing excisional goniotomy with Kahook Dual Blade (KDB) vs iStent microbypass implantation, both combined with phacoemulsification, in eyes with mild to moderate open-angle glaucoma (OAG).

SETTING

Nine practices in the United States.

DESIGN

Prospective, randomized, active-controlled, parallel-group clinical trial.

METHODS

Eyes were randomized to KDB-Phaco or iStent-Phaco group. Demographics, corrected distance visual acuity, IOP, IOP-lowering medications, and adverse events were collected at baseline and at day 1, week 1, and months 1, 3, 6, and 12 postoperatively. The primary outcome measure was the proportion of eyes at 12 months with IOP reduction of 20% or greater or IOP medication reduction of 1 or more compared with baseline.

RESULTS

For this study, 164 eyes of 164 patients were analyzed (82 in each group). Mean IOP was reduced at 12 months compared with baseline from 18.5 (standard of error 0.4) to 15.4 (0.4) mm Hg in the KDB-Phaco group and from 18.5 (0.3) to 16.1 (0.4) mm Hg in the iStent-Phaco group (P = .24). Mean IOP-lowering medications were reduced from 1.3 (0.1) to 0.3 (0.1) in the KDB-Phaco group and from 1.4 (0.1) to 0.4 (0.1) in the iStent-Phaco group (P = .17). Among study completers, the primary outcome was attained in 74 (93.7%) of 79 patients of KDB-Phaco eyes and 65 (83.3%) of 78 patients of iStent-Phaco eyes (P = .04). Both procedures had similar safety profiles.

CONCLUSIONS

Both procedures lowered both IOP and the need for IOP-lowering medications effectively and safely in eyes with mild to moderate OAG and cataract. Significantly, more KDB-Phaco eyes than iStent-Phaco eyes met the primary outcome of 20% or greater IOP reduction or 1 or more medication reduction at 12 months.