Influence of Goniotomy Size on Treatment Safety and Efficacy for Primary Open-Angle Glaucoma: A Multicenter Study

Two-year outcome of phacogoniotomy for advanced primary angle-closure glaucoma with cataracts: a multicentre study

PURPOSE

To report the 2-year effective and safety profile of integrated phacoemulsification with intraocular lens implantation (PEI), goniosynechialysis (GSL) and 120° goniotomy (GT) in advanced primary angle-closure glaucoma (PACG) and cataracts.

DESIGN

Multicentre prospective study.

METHODS

201 eyes of 196 patients who received combined PEI+GSL+ GT were assessed at baseline and re-evaluated at days 1, 7, and at 1, 3, 6, 12 and 24 months postsurgery. The intraocular pressure (IOP), the number of topical hypotensive medications, surgical complications and achievements of surgery success were also evaluated.

RESULTS

All participants were followed up for a 2-year period. The average IOP declined from 33.0±10.7 mm Hg to 13.6±2.9 mm Hg, and the number of topical hypotensive medication decreased from an average of 2.4 types to 0.4 at month 24. For the safety profile, the major complications were hyphema (n=14, 7.0%), IOP spike (n=9, 4.9%) and transit corneal oedema (n=23, 11.4%). The complete success was achieved in 72.6% of the eyes (146 out of 201), and the qualified success rate was 91.5% (184 out of 201). Only one eye required tube shunt surgery while no one developed severe vision-threatening complications. The best-corrected visual acuity increased from 0.80±1.08 to 0.54±0.78 LogMAR.

CONCLUSIONS

PEI+GSL+GT is shown to be effective and safe in treating advanced PACG with cataract over a 2-year follow-up period. The combined surgery may be considered as an alternative for patients with advanced PACG.

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.

Phacoemulsification combined with trabecular meshwork-Schlemm canal-based minimally invasive glaucoma surgery in primary angle-closure glaucoma: a systematic review and meta-analysis

BACKGROUND

To summarize the efficacy and safety of the phacoemulsification with intraocular lens implantation (PEI) ± goniosynechialysis (GSL) + trabecular meshwork-Schlemm canal (TM-SC)-based minimally invasive glaucoma surgery (MIGS) in primary angle-closure glaucoma (PACG).

METHODS

A comprehensive literature search was conducted across seven electronic databases: PubMed, ScienceDirect, The Cochrane Library, Scopus, Embase, Ovid MEDLINE, and Web of Science. Studies focused on TM-SC-based MIGS with PEI for PACG were included in this review. The efficacy was assessed by the reduction in intraocular pressure (IOP) values and the decrease in the number of anti-glaucoma medications (AGMs), while safety was evaluated by incidence of complications.

RESULTS

Out of 5158 studies initially identified, this meta-analysis included 12 articles with a total of 633 eyes with PACG. At 12 months postoperatively, PEI ± GSL + TM-SC-based MIGS yielded an IOP decrease of 10.25 mmHg (95% CI: 7.06 to 13.43), PEI ± GSL + goniotomy yielded an IOP decrease of 13.10 mmHg (95% CI: 7.59 to 18.62), PEI ± GSL + gonioscopy-assisted transluminal trabeculotomy yielded an IOP decrease of 11.54 mmHg (95% CI: 7.18 to 15.90), and PEI ± GSL + trabecular micro-bypass stent yielded an IOP decrease of 3.94 mmHg (95% CI: 2.58 to 5.30). The most common complications were hyphema (16.3%) and IOP spike (7.4%). Specifically, the iStent group had the lowest incidence of each complication.

CONCLUSIONS

PEI ± GSL + TM-SC-based MIGS is effective in reducing IOP and medication burden while maintaining a favorable safety profile in PACG. More randomized controlled trials are required to support this therapeutic recommendation.

REGISTRATION

This meta-analysis was registered on PROSPERO (registration number: CRD42024583864).

Comparison of Standalone Tanito Microhook Trabeculotomy Between Unilateral and Bilateral Incision Groups

Background/Objectives: Trabeculotomy using the Tanito microhook (TMH) is a minimally invasive glaucoma surgery (MIGS) technique that effectively reduces intraocular pressure (IOP). The optimal incision extent for standalone TMH remains unclear. This study aimed to compare the surgical efficacy and safety of unilateral (120-degree) and bilateral (240-degree) incisions in standalone TMH for primary open-angle glaucoma or late-onset juvenile open-angle glaucoma in patients without a history of intraocular surgery. Methods: This retrospective study analyzed 81 eyes of 48 patients who underwent standalone TMH at Shimane University Hospital. Patients were categorized into unilateral (29 eyes) or bilateral (52 eyes) incision groups. The primary outcomes were IOP reduction and medication score changes over 12 months. Secondary outcomes included best-corrected visual acuity (BCVA), anterior chamber (AC) flare, corneal endothelial cell density (CECD), and postoperative complications, particularly hyphema, assessed using the Shimane University Postoperative Hyphema Scoring System (SU-RLC). Multivariate mixed-effects regression and Kaplan-Meier survival analyses were performed. Results: At 12 months, IOP reduction was comparable between the unilateral (23%) and bilateral (28%) groups (p = 0.29). The unilateral group had a significantly lower medication score at postoperative day 3 (p = 0.0057) and week 2 (p = 0.033). No significant differences were observed in BCVA, AC flare, CECD, or visual field mean deviation (MD). However, the bilateral group had significantly higher hyphema scores (p = 0.017), with more cases of layered hyphema. Conclusions: Unilateral standalone TMH achieved equivalent IOP and medication score reductions compared to bilateral incisions, with a lower risk of early postoperative hyphema. The unilateral approach may be preferable for faster visual recovery.

Outcomes of Circumferential Versus Hemi-gonioscopy-Assisted Transluminal Trabeculotomy for Congenital Glaucoma

PURPOSE

To compare the efficacy of circumferential gonioscopy-assisted transluminal trabeculotomy (GATT) vs hemi-GATT in primary congenital glaucoma (PCG).

DESIGN

Prospective randomized controlled trial.

METHODS

This study included children with PCG having corneal diameters <14 mm and relatively clear cornea. The eyes included were randomized to undergo either circumferential GATT (360-GATT) or hemi-GATT (180-GATT). The intraocular pressure (IOP) reduction, requirement for glaucoma medications after surgery, need for repeat surgery, and the incidence and type of complications in each group were analyzed. Surgical success was defined as absolute when IOP ≤18 mm Hg (criterion A) and ≤15 mm Hg (criterion B) was achieved without medications and qualified when the same was achieved with pressure-lowering medications. Eyes with an IOP ≥18 mm Hg on maximum medications, those with IOP <6 mm Hg, or need for further intervention for IOP control were considered failures.

RESULTS

Fifty-two eyes of children with PCG were randomized into either the 360-GATT group (22 eyes) or the 180-GATT group (30 eyes) and followed up for at least 1 year. The median follow-up duration was 22.5 months (range: 12-30 months). IOP fell by 49% and 20.5% with 360-GATT and 180-GATT, respectively, with the final IOP being significantly lower in the former group (P = .0003). For absolute success, the cumulative survival was superior with 360-GATT for both criterion A and B at 1 year (P = .009). Average cup-to-disc ratio, corneal diameter, and axial length reversal were significant in the 360-GATT group but not in the 180-GATT group.

CONCLUSIONS

This study reinforces the superior efficacy of circumferential GATT for IOP control in eyes with congenital glaucoma.

Two-year randomized controlled trial of circumferential versus segmental ab externo angle surgery in patients with primary open angle glaucoma

PURPOSE

To compare the surgical outcomes of visco-circumferential-suture-trabeculotomy (VCST) and rigid probe segmental viscotrabeculotomy (VT) in primary open-angle glaucoma (POAG).

STUDY DESIGN

A prospective randomized controlled study.

PATIENTS AND METHODS

Patients presenting with POAG and operated upon in Mansoura Ophthalmic Center in Mansoura, Egypt between February 2017 and September 2021 were enrolled. Study eyes were randomized to either VCST or VT and follow up extended for 24 months. Success was defined as an intra ocular pressure (IOP)≤18 mmHg with a 40% reduction from baseline. Complications were noted.

RESULTS

The study enrolled 166 (82 in the circumferential group) eyes of 107 patients. There were no statistically significant differences between both groups in any demographic or preoperative clinical characteristics. The IOP trend demonstrated marked initial reduction (from 32.3±2.4 and 31.8±2.6 mmHg preoperatively in VCST and VT groups respectively) followed by a slow gradual rise over subsequent follow-up settling at lower IOP values in the circumferential (12.4±1.2 mmHg) than in the segmental group (15.5±0.9 mmHg) (p<0.001), both settling at significantly lower levels than preoperative values. The survival curve demonstrates complete success rates at 12, 15, 18, and 24 months were 98.8%, 96.4%, 95.1%, and 85.4% in the circumferential group and 98.8%, 92.9%, 91.7%, 79.8% in the segmental group respectively. Minimal self-limiting hyphema was universal in all study eyes.

CONCLUSIONS

Angle procedures -segmental and circumferential- are effective in lowering the IOP for at least 2 years in eyes with POAG, with circumferential angle surgery providing a greater reduction of IOP and requiring fewer subsequent glaucoma procedures.

The aqueous humour dynamics in primary angle closure disease: a computational study

PURPOSE

To create a computational fluid dynamics (CFD) model of ocular anterior segment for primary angle closure diseases (PACD) and assess the aqueous humour (AH) dynamics in different angle closure ranges (ACRs).

METHODS

The ocular anterior segment geometry was obtained from an optical coherence tomography image by SOLIDWORKS. Three different angle opening distance at 750 µm from the scleral spur (AOD750) values were established to mimic three widths of anterior chamber angle. The AH dynamics were modelled using the Navier-Stokes equation. The 3D CFD model of the ocular anterior segment was created in COMSOL Multiphysics. The major outcome was the maximum flow velocity (MFV) and pressure in the ocular anterior segment. An in vitro simulation model was used to validate the computational results of the pressure and ACRs.

RESULTS

The MFV and pressure both showed a non-linear association with ACR in the CFD models of PACD. The MFV and pressure started to elevate when ACR was larger than 180°, and increased dramatically when the ACR was larger than 270°. The in vitro experiment of the pressure changes was consistent with the CFD model. No significant differences of the MFV and pressure among the three AOD750 models.

CONCLUSIONS

The association among the ACR, MFV and pressure is an ascending curve in PACD, and ACR of 180° and 270° are two critical turning points. Our results are consistent with clinical phenomenon and may be used to provide better guidances for the clinical management of PACD in different stages.

Relationship between Schlemm's canal incision length and the results of ab interno gonioscopy-assisted transluminal suture trabeculotomy

We retrospectively investigated the relationship between Schlemm's canal incision length and the results of ab interno gonioscopy-assisted transluminal suture trabeculotomy (GATST) with/without cataract surgery in open-angle glaucoma patients at Tsukazaki Hospital from 2018-2021. The study included 113 eyes from 76 patients (age: 70.0 ± 10.8 years; female/male: 43 [56.6%]/33 [43.4%]). GATST with and without cataract surgery was performed on 87 (phakia) [77.0%] and 26 eyes (pseudophakia) [23.0%], respectively; 102 [90.3%] eyes had primary open-angle glaucoma, and 11 [9.7%] had pseudoexfoliation glaucoma. Intraocular pressure (IOP) significantly decreased at 3/6/12 months, and the antiglaucoma eyedrop number significantly decreased at 6/12 months (all P values < 0.001). Linear mixed-effects models showed that incision length had significant positive associations with IOP spikes, hyphema grade, and IOP changes (amount/percentage) at 6 months; surgical success rate (IOP ≤ 15 mmHg, ≥ 20% reduction, no additional surgeries [criterion B]) at 6/12 months; and surgical success rate (IOP ≤ 21 mmHg, ≥ 20% reduction, no additional surgeries [criterion A]) at 12 months (Ps < 0.05). There were no significant associations with IOP changes at 12 months, surgical success rate (criterion A) at 6 months, or antiglaucoma eyedrop number at either timepoint (Ps > 0.05). Longer incisions were more likely to produce greater IOP reduction, requiring more attention to IOP spikes/hyphema.

ChatGPT-Assisted Classification of Postoperative Bleeding Following Microinvasive Glaucoma Surgery Using Electronic Health Record Data

Purpose

To evaluate the performance of a large language model (LLM) in classifying electronic health record (EHR) text, and to use this classification to evaluate the type and resolution of hemorrhagic events (HEs) after microinvasive glaucoma surgery (MIGS).

Design

Retrospective cohort study.

Participants

Eyes from the Bascom Palmer Glaucoma Repository.

Methods

Eyes that underwent MIGS between July 1, 2014 and February 1, 2022 were analyzed. Chat Generative Pre-trained Transformer (ChatGPT) was used to classify deidentified EHR anterior chamber examination text into HE categories (no hyphema, microhyphema, clot, and hyphema). Agreement between classifications by ChatGPT and a glaucoma specialist was evaluated using Cohen's Kappa and precision-recall (PR) curve. Time to resolution of HEs was assessed using Cox proportional-hazards models. Goniotomy HE resolution was evaluated by degree of angle treatment (90°-179°, 180°-269°, 270°-360°). Logistic regression was used to identify HE risk factors.

Main Outcome Measures

Accuracy of ChatGPT HE classification and incidence and resolution of HEs.

Results

The study included 434 goniotomy eyes (368 patients) and 528 Schlemm's canal stent (SCS) eyes (390 patients). Chat Generative Pre-trained Transformer facilitated excellent HE classification (Cohen's kappa 0.93, area under PR curve 0.968). Using ChatGPT classifications, at postoperative day 1, HEs occurred in 67.8% of goniotomy and 25.2% of SCS eyes (P < 0.001). The 270° to 360° goniotomy group had the highest HE rate (84.0%, P < 0.001). At postoperative week 1, HEs were observed in 43.4% and 11.3% of goniotomy and SCS eyes, respectively (P < 0.001). By postoperative month 1, HE rates were 13.3% and 1.3% among goniotomy and SCS eyes, respectively (P < 0.001). Time to HE resolution differed between the goniotomy angle groups (log-rank P = 0.034); median time to resolution was 10, 10, and 15 days for the 90° to 179°, 180° to 269°, and 270° to 360° groups, respectively. Risk factor analysis demonstrated greater goniotomy angle was the only significant predictor of HEs (odds ratio for 270°-360°: 4.08, P < 0.001).

Conclusions

Large language models can be effectively used to classify longitudinal EHR free-text examination data with high accuracy, highlighting a promising direction for future LLM-assisted research and clinical decision support. Hemorrhagic events are relatively common self-resolving complications that occur more often in goniotomy cases and with larger goniotomy treatments. Time to HE resolution differs significantly between goniotomy groups.

Financial Disclosures

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

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

PRCIS

The combination of surgical peripheral iridectomy, goniosynechialysis, and goniotomy is a safe and effective surgical approach for advanced primary angle closure glaucoma without cataract.

PURPOSE

To evaluate the efficacy and safety of surgical peripheral iridectomy (SPI), goniosynechialysis (GSL), and goniotomy (GT) in advanced primary angle closure glaucoma (PACG) eyes without cataract.

PATIENTS AND METHODS

A prospective multicenter observational study was performed for patients who underwent combined SPI, GSL, and GT for advanced PACG without cataract. Patients were assessed before and after the operation. Complete success was defined as achieving intraocular pressure (IOP) between 6 and 18 mm Hg with at least a 20% reduction compared with baseline, without the use of ocular hypotensive medications or reoperation. Qualified success adopted the same criteria but allowed medication use. Factors associated with surgical success were analyzed using logistic regression.

RESULTS

A total of 61 eyes of 50 advanced PACGs were included. All participants completed 12 months of follow-up. Thirty-six eyes (59.0%) achieved complete success, and 56 eyes (91.8%) achieved qualified success. Preoperative and postsurgical at 12 months mean IOPs were 29.7±7.7 and 16.1±4.8 mm Hg, respectively. The average number of ocular hypotensive medications decreased from 1.9 to 0.9 over 12 months. The primary complications included IOP spike (n=9), hyphema (n=7), and shallow anterior chamber (n=3). Regression analysis indicated that older age (odds ratio [OR]=1.09; P =0.043) was positively associated with complete success, while a mixed angle closure mechanism (OR=0.17; P =0.036) reduced success rate.

CONCLUSIONS

The combination of SPI, GSL, and GT is a safe and effective surgical approach for advanced PACG without cataract. It has great potential as a first-line treatment option for these patients.

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.

Gonioscopy-Assisted Transluminal Trabeculotomy Outcomes Under Different Levels of Glaucoma Severity: A Multicenter, Comparative Study

PURPOSE

To evaluate the outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) under different levels of glaucoma severity.

DESIGN

Retrospective, multicenter, before-and-after study.

METHODS

One eye from all primary open-angle glaucoma patients who underwent GATT combined with cataract surgery (Phaco-GATT) or GATT stand-alone with 12 months of follow-up were included and divided according to glaucoma severity (mild = GI, moderate = GII, and advanced = GIII) and the outcomes compared.

RESULTS

A total of 270 eyes were included: 90 in GI, 75 in GII, and 105 in GIII. The IOP was reduced from 18.6 ± 6.0 mm Hg in GI, 19.7 ± 6.4 mm Hg in GII, and 21.0 ± 7.9 mm Hg in GIII, preoperatively, to 11.9 ± 2.6 mm Hg in GI, 11.8 ± 2.1 mm Hg in GII, and 11.9 ± 3.0 mm Hg in GIII at 12 months postoperatively (P < .001 for all). The number of hypotensive ocular medications were reduced from 2.7 ± 1.0 in GI, 3.1 ± 0.8 in GII, and 3.2 ± 1.2 in GIII to 0.6 ± 0.9 in GI, 1.0 ± 1.1 in GII, and 1.2 ± 1.1 in GIII at the last postoperative visit (P < .001 for all). Relative success was achieved, at 1 year, in 93.8% of the eyes in GI, 89.0% in GII, and 88.1% in GIII (P = .3). Complete success was achieved in 61.8% of the eyes in GI, 43.8% in GII, and 37.6% in GIII (P = .007). No serious adverse event was observed in any group.

CONCLUSIONS

GATT is a safe and effective procedure in glaucoma, regardless of its preoperative severity.

A Prospective Comparison of 180 Versus 360-Degree Gonioscopy-Assisted Transluminal Trabeculotomy Outcomes in Pseudoexfoliation Glaucoma

PRCIS

Analysis of surgical success and intraocular pressure (IOP), best-corrected visual acuity (BCVA), and antiglaucomatous medication (AGM) changes between segmental 180-degree and 360-degree gonioscopy-assisted transluminal trabeculectomy (GATT) in patients with pseudoexfoliation glaucoma (PEXG) showed no significant difference.

OBJECTIVE

To compare surgical outcomes of segmental 180-degree and 360-degree GATT in patients with PEXG.

MATERIALS AND METHODS

Prospective, comparative study of 65 PEXG eyes, who underwent segmental 180-degree GATT (GATT 180-degree group, 31 eyes) and 360-degree GATT (GATT 360-degree group, 34 eyes) in a tertiary academic center over a 12-month of follow-up. Primary outcome was qualified and complete surgical success rates for criterion A (IOP <18 mm Hg and >30% reduction) and criterion B (IOP <15 mm Hg and >30% reduction). Secondary outcome measures included IOP reduction, BCVA change, AGM use, and postoperative complications.

RESULTS

The probabilities of qualified and complete success rates both for criteria A and B did not significantly differ between the groups ( P > 0.05). IOP and BCVA levels were similar at each time point ( P > 0.05). IOP reduction was 59.3 ± 9.5% in the GATT 180-degree group and 55.8 ± 18.1% in the GATT 360-degree group ( P = 0.33). No significant difference in the mean number of AGM was present at the 12-month visit (1.2 ± 1.1 in GATT 180-degree group vs 1.5 ± 1.2 in GATT 360-degree group, P = 0.25). Significantly higher incidences of postoperative hyphema and IOP spikes were observed in the GATT 360-degree group ( P = 0.01 and P = 0.008, respectively).

CONCLUSION

Both segmental 180-degree and 360-degree GATT similarly reduced IOP and AGM with comparable surgical success rates in patients with PEXG at the end of 12 months. Postoperative hyphema and IOP spike rates were significantly higher after 360-degree GATT. Segmental 180-degree GATT may be sufficient to adequately modulate IOP with a lower incidence of postoperative complications in PEXG.

Impact of Peripheral Anterior Synechiae on the Outcome of Combined Phacoemulsification, Goniosynechialysis, and Goniotomy for Primary Angle Closure Glaucoma and Cataract: A Multicenter Observational Study

PRCIS

The combination of phacoemulsification, goniosynechialysis and goniotomy is an effective treatment for primary angle closure glaucoma patients with cataract, and this is not linked to the extent of preoperative peripheral anterior synechiae.

PURPOSE

To evaluate the impact of the extent of peripheral anterior synechiae (PAS) on the effectiveness and safety of combined phacoemulsification (PEI), goniosynechialysis (GSL), and goniotomy (GT) in eyes with primary angle closure glaucoma (PACG) and cataract.

PATIENTS AND METHODS

This study included patients diagnosed with PACG and cataracts who underwent combined PEI and 120 degrees GSL plus GT (PEI+GSL+GT) between April 2020 and October 2022 at 10 ophthalmic institutes. Eligible patients were divided into 3 groups based on the extent of PAS: 180°≤PAS<270°, 270°≤PAS<360°, and PAS=360°. Data on intraocular pressure (IOP), the number of ocular hypotensive medications, and complications were collected and compared. The study defined complete success as postoperative IOP within the 6-18 mm Hg range and a 20% reduction from baseline without the use of topical medications. Qualified success was defined in the same way as complete success, but it allowed for the use of ocular hypotensive medications.

RESULTS

Three hundred four eyes of 283 patients were included. The mean follow-up was 12.50±1.24 months. All groups experienced a significant reduction in IOP after the surgery ( P <0.05). There were no significant differences in final IOP, number of medications, and cumulative complete and qualified success rates among the 3 groups ( P >0.05). The groups with 270°≤PAS<360°had a higher frequency of hyphema compared with 180°≤PAS<270° ( P = 0.044).

CONCLUSIONS

PEI+GSL+GT has proven to be an effective treatment for PACG with cataracts over a 1 year period. However, the outcome was not correlated with the preoperative extent of PAS.

Comparison of Superior versus Inferior Canaloplasty and Trabeculotomy Using the OMNI Surgical System

Purpose

To compare outcomes of ab-interno canaloplasty and trabeculotomy of the superior versus inferior angle.

Patients and methods

This was a prospective, non-randomized, interventional comparison study done at the Veteran Affairs Hospital in Long Beach, California. All patients underwent cataract surgery with intraocular lens implantation combined with ab-interno canaloplasty and trabeculotomy with the OMNI Surgical System (SightSciences, Menlo Park, CA, USA), either superiorly or inferiorly. Pre- and post-operative intraocular pressure using Goldmann applanation tonometry and best corrected visual acuity were obtained and compared using paired t-tests. Patients were excluded if they had any prior intraocular surgery or prior laser trabeculoplasty procedures.

Results

38 eyes from 29 patients were analyzed. 19 eyes were included in the superior group and 19 eyes in the inferior group. Mean pre-operative IOP in the superior group was 17.6 ± 5.2 mmHg and in the inferior group was 17.6 ± 4.6 mmHg (p > 0.99). At 12 months, mean postoperative IOP for the superior group decreased 24% to 13.3 ± 2.8 mmHg while the inferior group decreased 26% to 13.1 ± 2.2 mmHg (p = 0.92). Mean preoperative medications in the superior group were 2.2 ± 1.3 and in the inferior group was 2.4 ± 1.3 (p = 0.88). At 12 months, this decreased to 1.3 ± 1.5 post-operatively in the superior group and 2.2 ± 1.6 post-operatively in the inferior group (p = 0.64).

Conclusion

There was no statistical difference in efficacy between superior versus inferior canaloplasty/trabeculotomy with OMNI. Therefore, surgeons can perform the procedure in the direction that is most comfortable for them without affecting outcomes.

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

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

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.