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

Clinical Practice Preferences for Glaucoma Surgery in Japan in 2024

Objectives: This study evaluated the clinical preferences of glaucoma specialists regarding glaucoma surgery and postoperative management in Japan in 2024. Methods: A survey about clinical practice preferences regarding glaucoma surgery and postoperative care was administered among 50 glaucoma specialists who were councilors in the Japan Glaucoma Society. Results: Minimally invasive glaucoma surgery (MIGS) plus phacoemulsification was the most preferred procedure for nonoperated mild to moderate cases of primary open-angle glaucoma (POAG) (94.6%) and normal tension glaucoma (NTG) (67.3%) associated with cataract. Microhook surgery was the most preferred among the MIGS procedures. Meanwhile, PreserFlo MicroShunt (PMS) surgery is emerging as a popular option for cases of POAG and NTG, especially in advanced-stage pseudophakic eyes that underwent prior corneal incision phacoemulsification (40.1%). Long-tube shunt surgeries were predominantly preferred for POAG after two failed trabeculectomies (69.4%) and for neovascular glaucoma with prior vitrectomy after a failed trabeculectomy (73.0%). Among long-tube shunt surgeries, the Ahmed glaucoma valve (AGV) was preferred over the Baerveldt glaucoma implant. Trabeculectomy required the most frequent follow-up visits within the first postoperative year, whereas PMS and long-tube shunt surgeries required comparatively fewer follow-up visits. Overall, MIGS involved less frequent follow-up visits versus filtering surgeries. Conclusions: MIGS is currently the procedure of choice for primary glaucoma surgery in Japan. Among glaucoma specialists of the Japan Glaucoma Society, PMS surgery is becoming popular for cases of POAG and NTG. Refractory glaucoma is commonly treated with long-tube shunt surgeries, especially the AGV.

Standalone Canaloplasty and Trabeculotomy Using the OMNI Surgical System in Eyes with Primary Open-Angle Glaucoma: A 36-Month Analysis from the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)

PURPOSE

To characterize long-term real-world clinical outcomes of standalone canaloplasty and trabeculotomy using the OMNI Surgical System (Sight Sciences) in patients with primary open-angle glaucoma (POAG).

DESIGN

Retrospective, clinical cohort study utilizing the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) data.

SUBJECTS

Patients/eyes in the IRIS Registry with POAG or ocular hypertension with known laterality on or after January 1, 2016 and undergoing standalone canaloplasty and trabeculotomy using the OMNI Surgical System with at least 6 months and up to 36 months of postoperative follow-up were included. Eyes were excluded for prior filtration surgery, trabeculoplasty within 90 days of the OMNI procedure, or concomitant cataract surgery.

METHODS/OUTCOME MEASURES

Outcome measures included intraocular pressure (IOP) and glaucoma medication changes postoperatively.

RESULTS

230 eyes in 196 patients were analyzed. Most eyes had moderate (40.0 %) or severe (41.3 %) POAG. Two-thirds (153 of 230) were pseudophakic. Fewer than half of procedures (44.4 %) were performed by glaucoma specialists. Mean baseline IOP was 22.1 (6.4) mmHg and over 36 months of follow-up ranged from 15.1 to 16.7 mmHg (p < 0.0001 at every time point compared to baseline), with average eye-level reductions of 5.6-7.1 mmHg. The mean number of glaucoma medications used at baseline was 2.1 (1.5) and over 36 months ranged from 1.1 to 1.8 medication classes, with statistically significant decreases in utilization through 18 months postoperatively (p ≤ 0.0011) and nonsignificant at months 24 and 36. Eyes with lower baseline IOP (≤18 mmHg) had reductions in medication use through 36 months, and eyes with higher baseline IOP (>18 mmHg) had statistically significant reductions in IOP through 36 months.

CONCLUSIONS

Standalone canaloplasty and trabeculotomy provides clinically and statistically significant reductions in IOP through up to 36 months postoperatively. Eyes with lower baseline IOP had long-term glaucoma medication reductions and eyes with higher baseline IOP had statistically significant long-term IOP reductions. Standalone OMNI surgery is a reasonable MIGS option for patients with POAG seeking IOP reduction, medication reduction, or both.

Risk factors for hyphema following goniotomy or trabecular bypass stent placement combined with phacoemulsification

PURPOSE

To report the rates and risk factors for layered hyphemas after goniotomy (PG) and trabecular bypass stent (PTBS) surgery combined with phacoemulsification.

METHODS

Patient data was obtained using a retrospective chart review from adult patients (18 years of age or older) undergoing either PG or PTBS at the West Virginia University Eye Institute between 2013 and 2023. Generalized estimating equations were used to identify significant predictors of layered hyphema on post-operative day one. Predictors evaluated included age, race, glaucoma severity, glaucoma type, surgical time, complex cataract extraction, pre-operative intraocular pressure, post-operative day one intraocular pressure, peri-operative anti-thrombotic therapy (ATT) use, body mass index, and surgery type (i.e., PG or PTBS).

RESULTS

Of the 405 eyes from 279 patients included in the study, the overall layered hyphema rate was 10.1% in the whole sample. In multivariate generalized estimating equation model controlling for glaucoma stage and preoperative IOP, only surgery type (PG vs PTBS) predicted post-operative day one hyphema (β = 2.47, SE = 1.01, p = 0.02). The hyphema rates in the PG group and PTBS groups were 40/316 (12.7%) and 1/89 (1.1%), respectively. Eyes of patients on ATT had a hyphema rate of 16/189 (8.5%) compared to 25/216 (11.6%) in eyes of patients not on ATT.

CONCLUSIONS

Performing PG over PTBS was a significant predictor of a post-operative day one layered hyphema. No other systemic or ocular features, including the use of ATT, showed a statistically significant relationship with post-operative hyphemas.

KEY MESSAGES

What is Known. • The prevalence of minimally invasive glaucoma surgery has significantly increased in recent years. • Hyphema is a common postoperative complication of minimally invasive glaucoma surgery, however risk factors for hyphema in this setting have not been thoroughly evaluated.

WHAT IS NEW

• The use of perioperative antithrombotic therapy did not significantly increase the risk for postoperative hyphema following angle based minimally invasive glaucoma surgery. • Hyphema risk was significantly higher in patients undergoing goniotomy combined with phacoemulsification compared to trabecular bypass stent surgery with phacoemulsification.

Comparing Traditional and Newer Glaucoma Procedures by Physician Experience and Practice Location in the United States

PRCIS

Analysis of Centers for Medicare and Medicaid Services (CMS) Physician Payment data found that physician certification year, degree of urbanization, and estimated income by zip code were significant in predicting the proportion of traditional glaucoma procedures performed by each provider in the United States.

OBJECTIVE

The prevalence of microinvasive glaucoma surgery (MIGS) compared with traditional procedures has been increasing in glaucoma management. It is important to understand whether the uptake of new glaucoma procedures is associated with aspects of the physician practice.

METHODS

In this cross-sectional study, data on glaucoma procedure distribution, degree of urbanization, and physician certification in the United States were extracted from the 2019 CMS Physician Payment and American Board of Ophthalmology databases. The distribution of traditional and MIGS procedure numbers for metropolitan versus non-metropolitan providers was visualized with boxplots and statistically compared using Mann-Whitney U tests. We used two-dimensional histograms and regression analyses to assess the relationship between certification year and volume of traditional versus MIGS procedures. A multivariable linear regression model was created using certification year, rural-urban commuting area code, and estimated income by practice zip code to predict the number and proportion of each type of glaucoma procedure.

RESULTS

This study included 2625 providers from the CMS physician payment data who performed only traditional procedures (n = 370), MIGS procedures (n = 1727), or both procedure types (n = 528) in 2019. The median number of MIGS procedures performed by each provider was greater in non-metropolitan areas (31 vs 29, P = 0.015), whereas the proportion of traditional procedures performed by each provider was greater in metropolitan areas (0.24 vs 0.08, P < 0.001). Regression analysis showed a positive relationship between the certification year and the proportion of traditional procedures performed by each provider ( P < 0.001). Multivariable regression models found that certification year, rural-urban commuting area code, and estimated income of practice location were all significant predictors ( P < 0.02) of the proportion of traditional procedures performed by each provider.

CONCLUSION

In the United States, physicians in metropolitan areas and more recent certification years are more likely to perform a larger proportion of traditional procedures. This finding suggests that the distribution of glaucoma procedure types is related to physician factors such as degree of urbanization and duration of practice. More research is needed to better understand how such differences affect patient access and outcomes.

Characteristics and publication status of minimally invasive glaucoma surgery trials registered in ClinicalTrials.gov, 2007-2024: a cross-sectional study

PURPOSE

To investigate the characteristics and publication status of minimally invasive glaucoma surgery (MIGS) clinical trials registered on ClinicalTrials.gov.

DESIGN

A cross-sectional study.

METHODS

All 1212 interventional glaucoma trials registered on ClinicalTrials.gov with start dates between 1 October 2007 and 30 April 2024 were included. All trials were categorised into 'MIGS trials' and 'other interventional glaucoma trials'. Based on the anatomical site of action and the research content, MIGS trials were classified into different groups, and intergroup comparisons were conducted. The characteristics and publication status of MIGS trials were comprehensively analysed.

RESULTS

Compared with all other interventional glaucoma trials, MIGS trials had a higher proportion of single-arm trials (p<0.001) and industry funding (p<0.001), but a lower proportion of randomisation and blinding (p<0.001). The majority of MIGS trials were not overseen by a Data Monitoring Committee (DMC) (71.4%) and enrolled fewer than 200 participants (85.2%). MIGS trials targeting Schlemm's canal (SC) (60.2%) were significantly more prevalent than those targeting subconjunctival space (24.6%) and suprachoroidal/supraciliary space (15.3%). Trials focused on stand-alone MIGS (48.4%) or its combination with cataract surgery (32.0%) significantly outnumbered those investigating MIGS with other antiglaucoma surgeries (12.3%), MIGS with laser treatments (4.1%) and MIGS with medications (3.3%). A total of 34 MIGS trials (27.0%) published their results, of which 20 trials focused on stand-alone MIGS.

CONCLUSIONS

Most MIGS trials were industry-funded, non-randomised, non-blinded and not overseen by a DMC. Researchers tend to focus on stand-alone MIGS or its combination with cataract surgery. The efficacy and safety of MIGS targeting SC remain a prominent focus of the field. Currently, the publication rate of MIGS clinical trials is relatively low. It remains difficult for ophthalmologists to choose among different MIGS procedures. Overcoming the design limitations of trials will be essential for generating more robust evidence to guide clinical practice and policy decisions.

The effect of cataract surgery on lowering intraocular pressure

PURPOSE OF REVIEW

To review the literature evaluating the effectiveness of cataract surgery alone and cataract surgery in combination with other procedures and surgeries on intraocular pressure (IOP) in patients with ocular hypertension and glaucoma.

RECENT FINDINGS

Recent studies of large trials have shown the IOP-lowering effect of cataract surgery and the beneficial effect of minimally invasive glaucoma surgery (MIGS). More studies are being published on when to use cataract surgery alone, with MIGS, or with traditional glaucoma surgeries for both primary open angle glaucoma and primary angle closure glaucoma.

SUMMARY

Patients with ocular hypertension and visually significant cataracts would benefit from cataract surgery alone to lower intraocular pressure. Patients with mild to moderate glaucoma would likely benefit from cataract surgery and MIGS to achieve a lower IOP. Patients with more advanced glaucoma would benefit from cataract surgery combined with a traditional incisional glaucoma surgery. Clear lens extraction can be used in patients with primary angle closure and early primary angle closure glaucoma. In patients with more advanced disease, phacoemulsification and another glaucoma surgery is likely to be required to achieve IOP control. MIGS are starting to be used in angle closure glaucoma, although more research needs to be done to define its role.

Factors Associated with Missing Sociodemographic Data in the IRIS® (Intelligent Research in Sight) Registry

Purpose

To describe the prevalence of missing sociodemographic data in the IRIS® (Intelligent Research in Sight) Registry and to identify practice-level characteristics associated with missing sociodemographic data.

Design

Cross-sectional study.

Participants

All patients with clinical encounters at practices participating in the IRIS Registry prior to December 31, 2020.

Methods

We describe geographic and temporal trends in the prevalence of missing data for each sociodemographic variable (age, sex, race, ethnicity, geographic location, insurance type, and smoking status). Each practice contributing data to the registry was categorized based on the number of patients, number of physicians, geographic location, patient visit frequency, and patient population demographics.

Main Outcome Measures

Multivariable linear regression was used to describe the association of practice-level characteristics with missing patient-level sociodemographic data.

Results

This study included the electronic health records of 66 477 365 patients receiving care at 3306 practices participating in the IRIS Registry. The median number of patients per practice was 11 415 (interquartile range: 5849-24 148) and the median number of physicians per practice was 3 (interquartile range: 1-7). The prevalence of missing patient sociodemographic data were 0.1% for birth year, 0.4% for sex, 24.8% for race, 30.2% for ethnicity, 2.3% for 3-digit zip code, 14.8% for state, 5.5% for smoking status, and 17.0% for insurance type. The prevalence of missing data increased over time and varied at the state-level. Missing race data were associated with practices that had fewer visits per patient (P < 0.001), cared for a larger nonprivately insured patient population (P = 0.001), and were located in urban areas (P < 0.001). Frequent patient visits were associated with a lower prevalence of missing race (P < 0.001), ethnicity (P < 0.001), and insurance (P < 0.001), but a higher prevalence of missing smoking status (P < 0.001).

Conclusions

There are geographic and temporal trends in missing race, ethnicity, and insurance type data in the IRIS Registry. Several practice-level characteristics, including practice size, geographic location, and patient population, are associated with missing sociodemographic data. While the prevalence and patterns of missing data may change in future versions of the IRIS registry, there will remain a need to develop standardized approaches for minimizing potential sources of bias and ensure reproducibility across research studies.

Financial Disclosures

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

Microinterventional system for robot-assisted gonioscopic surgery- technical feasibility and preclinical evaluation in synthetic eye models

BACKGROUND

Preclinical technical feasibility study of robot-assisted microinvasive glaucoma surgery using a novel ophthalmic robot-assisted surgery system.

METHODS

Feasibility was assessed in synthetic eye models in two stages: Stage I, nonimplantable robot-assisted goniotomy; and Stage II, robot-assisted stent implantation using a trabecular bypass stent. Robot-assisted interventions were subsequently compared to the manual approach.

RESULTS

Stage I: Two surgeons completed 10 trials each of ab-interno sectoral goniotomy with and without robotic assistance for at least 3 clock hours using a standard goniotomy knife and more than 10 clock hours of extended goniotomy using a flexible, guided goniotomy instrument. Stage II: Trabecular bypass stent deployment was successfully achieved in 100% of the attempts with and without robotic assistance. Surgical time was recorded and compared between the robotic-assisted and the manual approach.

CONCLUSIONS

A system for robot-assisted microinvasive glaucoma surgery can successfully achieve implantable and nonimplantable interventions in the anterior segment. This is the first known demonstration of the feasibility of robot-assisted glaucoma surgery.

Treatment Outcomes Comparing the Paul and Baerveldt Glaucoma Implants After One Year of Follow-Up

PRCIS

In reducing intraocular pressure (IOP), Paul (PGI) and Baerveldt (BGI) glaucoma implants are safe and effective in patients with glaucoma.

OBJECTIVE

To compare efficacy and safety profiles of the PGI and BGI in the treatment of medically uncontrolled glaucoma at 1 year of follow-up.

METHODS

Retrospective analysis of patients implanted with a PGI or BGI with a minimum of 12 months follow-up. The primary outcome was surgical success defined as IOP ≥6 and ≤18 mm Hg and at least 20% IOP reduction from baseline. Secondary outcomes included IOP measurements, number of medications, and complications.

RESULTS

Twenty-three patients implanted with PGI and 27 with BGI were included. At last visit (12 mo), mean IOP had decreased from 23.7 ± 6.9 to 0.1 ± 2.9 mm Hg in the PGI group versus 26 ± 7.3 to 10.4 ± 4.9 mm Hg with the BGI ( P < 0.001 for both comparisons). Overall qualified success rates were similar between groups (PGI 91% vs BGI 89%, P = 0.784). IOP was significantly lower in the PGI at week 1 and month 1 of follow-up versus the BGI (13.6 ± 6.1 vs 20.1 ± 7.4; 14.6±3.8 vs 21.2 ± 5.8 mm Hg; P < 0.002 for both) with a lower number of medications (1.57 ± 1.47 vs 2.52 ± 1.16 at mo 1, P = 0.015). Most complications were minor and similar in both groups.

CONCLUSION

Both PGI and BGI are safe and effective in reducing IOP in patients with glaucoma, with similar success rates.

Ten-Year Effectiveness and Safety of Trabecular Micro-Bypass Stent Implantation with Cataract Surgery in Patients with Glaucoma or Ocular Hypertension

INTRODUCTION

This study evaluated 10-year results of implanting one iStent trabecular micro-bypass stent during cataract surgery in eyes with open-angle glaucoma (OAG) or ocular hypertension.

METHODS

This retrospective, non-randomized study examined 10-year outcomes of iStent trabecular micro-bypass stent implantation with cataract surgery by one surgeon in eyes with OAG [including primary OAG (POAG) and pseudoexfoliative glaucoma (PXG)] or ocular hypertension at a multi-specialty German ophthalmology center. Study visits were conducted preoperatively and at 2.5, 3, 5, and 10 years postoperatively; examinations included intraocular pressure (IOP), medications, corrected-distance visual acuity (CDVA), and adverse events.

RESULTS

A total of 63 eyes of 45 patients with OAG (n = 60 eyes) or ocular hypertension (n = 3 eyes) and data through 10 years were analyzed. Mean preoperative IOP was 18.6 ± 4.4 mmHg on 1.83 ± 1.03 mean medications. At study visits through 10 years postoperative, mean IOP reduced by 12.9-19.0% (p < 0.005 at all points), and mean medication burden reduced by 37.8-51.4% (p ≤ 0.006 at all points). At 10 years postoperatively, 77.8% of eyes had IOP ≤ 18 mmHg and 47.6% had IOP ≤ 15 mmHg (vs. 50.8% and 25.4% preoperatively, respectively; p = 0.016). One-third (33.3%) of eyes were medication-free vs. 3.2% preoperatively (p < 0.001); 17.5% were on 2-5 medications (vs. 55.6% preoperatively, p = 0.005); and 93.7% of eyes were on the same or fewer medications vs. preoperative. Post-phacoemulsification CDVA improvement was maintained; no filtering surgeries were completed over 10-year follow-up.

CONCLUSIONS

Significant and safe IOP and medication reductions were observed through 10 years after iStent implantation with cataract surgery in patients with OAG or ocular hypertension.

Big data to guide glaucoma treatment

Ophthalmology has been at the forefront of the medical application of big data. Often harnessed with a machine learning approach, big data has demonstrated potential to transform ophthalmic care, as evidenced by prior success on clinical tasks such as the screening of ophthalmic diseases and lesions via retinal images. With the recent establishment of various large ophthalmic datasets, there has been greater interest in determining whether the benefits of big data may extend to the downstream process of ophthalmic disease management. An area of substantial investigation has been the use of big data to help guide or streamline management of glaucoma, which remains a leading cause of irreversible blindness worldwide. In this review, we summarize relevant studies utilizing big data and discuss the application of the findings in the risk assessment and treatment of glaucoma.

Big data and electronic health records for glaucoma research

The digitization of health records through electronic health records (EHRs) has transformed the landscape of ophthalmic research, particularly in the study of glaucoma. EHRs offer a wealth of structured and unstructured data, allowing for comprehensive analyses of patient characteristics, treatment histories, and outcomes. This review comprehensively discusses different EHR data sources, their strengths, limitations, and applicability towards glaucoma research. Institutional EHR repositories provide detailed multimodal clinical data, enabling in-depth investigations into conditions such as glaucoma and facilitating the development of artificial intelligence applications. Multicenter initiatives such as the Sight Outcomes Research Collaborative and the Intelligent Research In Sight registry offer larger, more diverse datasets, enhancing the generalizability of findings and supporting large-scale studies on glaucoma epidemiology, treatment outcomes, and practice patterns. The All of Us Research Program, with a special emphasis on diversity and inclusivity, presents a unique opportunity for glaucoma research by including underrepresented populations and offering comprehensive health data even beyond the EHR. Challenges persist, such as data access restrictions and standardization issues, but may be addressed through continued collaborative efforts between researchers, institutions, and regulatory bodies. Standardized data formats and improved data linkage methods, especially for ophthalmic imaging and testing, would further enhance the utility of EHR datasets for ophthalmic research, ultimately advancing our understanding and treatment of glaucoma and other ocular diseases on a global scale.

Is the Advent of New Surgical Procedures Changing the Baseline Features of Patients Undergoing First-Time Glaucoma Surgery?

Background: The aim of this study was to determine if the rise in new surgical procedures for glaucoma is changing the baseline features of patients. Methods: In this retrospective study, we reviewed the baseline features of patients undergoing their first glaucoma surgery in 2011 and 2021, collecting data regarding intraocular pressure (IOP), visual field (VF) parameters, stage of disease, and the type of surgery. Results: In the study, 455 patients were included in the analysis. From these, 230 eyes had glaucoma surgery performed in 2011 (Group A) and 225 eyes in 2021 (Group B). When considering the baseline features, Group A was older than Group B (72.7 ± 10.7 and 70 ± 12.4 years; p = 0.02, respectively), and showed a significantly more advanced VF mean defect (-16.4 ± 8.8 and -13.8 ± 8.7 dB; p < 0.01, respectively) and a higher IOP (25.9 ± 6.6 and 24.9 ± 7.8 mmHg; p = 0.02, respectively). Overall, severe VF damage at the time of surgery was more frequent in Group A (74.3%) than in Group B (60.8%) (p < 0.01). The overall number of traditional glaucoma surgeries was 211 in 2011, reducing to 94 ten years later, with similar severe pre-operative VF defects. In 2021, minimally invasive bleb surgery (MIBS) represented 58% of all surgeries. Conclusions: In the last ten years, patients receiving glaucoma surgery for the first time were younger, had less severe disease, and a more contained IOP. The baseline feature modifications were probably related to the diffusion of new procedures, especially MIBS, which allowed for treating patients at an earlier stage, reserving traditional procedures for advanced cases.

Ab Interno Canaloplasty and Trabeculotomy Outcomes for Mild, Moderate, and Advanced Open-Angle Glaucoma: A ROMEO Analysis

Purpose

To determine if there was an association between severity of glaucoma and intraocular pressure (IOP) and medication (med) outcomes for patients in the ROMEO (Retrospective, Observational, Multicenter Evaluation of OMNI) study.

Setting

Eleven ophthalmology practices in 8 US states.

Design

Post-hoc analysis of all eyes enrolled and treated with ab interno canaloplasty and trabeculotomy in the retrospective, multicenter ROMEO study.

Methods

Eyes were grouped according to visual field mean deviation (MD): mild (MD better than -6 dB), moderate (MD between -6 and -12 dB), advanced (-12 dB or worse). IOP and med outcomes at 12 months were compared across groups. Least squares regression was used to assess the relationship of MD with month 12 IOP. Outcomes for 1st and last MD deciles were compared as a sensitivity analysis.

Results

One hundred and twenty-seven eyes were available for analysis including 79 mild, 42 moderate, 6 advanced. Most eyes had a reduction in IOP at Month 12 (70%) with most at 18 mmHg or less. Percentage IOP reduction was similar across the groups (mild 16.9%, moderate 18.6%, advanced 18.0%) with mean month 12 IOP between 14 and 16 mmHg. Medications were also reduced in all three groups; -0.8 (mild, P < 0.001), -0.55 (moderate, P < 0.05), and -1.0 (advanced, P = 0.139, ns). Regression analysis revealed no relationship between month 12 IOP and MD. Med reductions were observed for all groups with a reduction of 1 or more medications seen in (%, 95% CI) 69%, 59-79 (mild), 50%, 35-65 (moderate), and 60%, 21-99 (advanced). Secondary interventions tended to have greater incidence with worse MD likely reflecting lower desired IOP targets.

Conclusion

Analysis of data from the ROMEO study suggests that similar meaningful IOP and med reductions can be expected across the range of disease severity studied.

Hypotony in the early postoperative period after MicroShunt implantation versus trabeculectomy: A registry study

PURPOSE

A comparison of the safety and efficacy of the MicroShunt versus trabeculectomy in the early postoperative period, with a particular focus on hypotony.

METHODS

In this registry study, we evaluated 200 eyes of 200 glaucoma patients who underwent filtration surgery at Oslo University Hospital between 2017 and 2021. Of these patients, 100 had a Preserflo MicroShunt (Santen) implantation and 100 had a trabeculectomy procedure. The patients were examined per standard hospital protocol after filtration surgery. Data were extracted from the 4- and 8-week visits. We defined hypotony as intraocular pressure (IOP) < 6 mmHg.

RESULTS

The mean preoperative IOP was 20.6 ± 7.1 mmHg in the MicroShunt group and 21.6 ± 7.1 mmHg in the trabeculectomy group, and the patients used a mean of 3.0 ± 0.9 and 3.1 ± 0.9 glaucoma medications, respectively. After 8 weeks, IOP was reduced to 10.4 ± 5.4 mmHg and 11.3 ± 4.6 mmHg, respectively (p = 0.23). During the early postoperative period, hypotony was registered in 63% of the MicroShunt patients and in 21% of the patients in the trabeculectomy group (p < 0.001); and 11% and 1%, respectively, of the patients developed choroidal detachments (p < 0.003). One patient in the MicroShunt group required reoperation due to hypotony.

CONCLUSIONS

In this registry study, we found that the Preserflo MicroShunt and trabeculectomy had equally satisfactory IOP-lowering effects during the early postoperative period. In this same period, a high number of patients in the MicroShunt group developed hypotony.

Can ChatGPT Aid Clinicians in Educating Patients on the Surgical Management of Glaucoma?

PRCIS

ChatGPT can help health care providers automate the quality assessment of online health information, but it does not produce easier-to-understand responses compared with existing online health information.

PURPOSE

To compare the readability of ChatGPT-generated health information about glaucoma surgery to existing material online and to evaluate ChatGPT's ability to analyze the quality of information found online about glaucoma surgery.

METHODS

ChatGPT was asked to create patient handouts on glaucoma surgery using 7 independent prompts, aiming to generate sixth grade level reading material. Existing patient-targeted online health information about glaucoma surgery was selected from the top 50 search results of 3 search engines, excluding advertisements, blog posts, information intended for health professionals, irrelevant content, and duplicate links. Four validated tools were used to assess readability, and the readability of the ChatGPT-generated material was compared with the readability of existing online information. The DISCERN instrument was used for the quality assessment of online materials. The DISCERN instrument was also programmed to use ChatGPT to evaluate its ability to analyze quality. R software and descriptive statistics were used for data analysis.

RESULTS

Thirty-five webpages were included. There was no difference between the reading level of online webpages (12th grade) and the reading level of ChatGPT-generated responses (11th grade), despite the ChatGPT prompts asking for simple language and a sixth grade reading level. The quality of health content was "fair," with only 5 resources receiving an "excellent" score. ChatGPT scored the quality of health resources with high precision ( r =0.725).

CONCLUSIONS

Patient-targeted information on glaucoma surgery is beyond the reading level of the average patient, therefore at risk of not being understood, and is of subpar quality, per DISCERN tool scoring. ChatGPT did not generate documents at a lower reading level as prompted, but this tool can aid in automating the time-consuming and subjective process of quality assessment.

Proactive Decision Support for Glaucoma Treatment: Predicting Surgical Interventions with Clinically Available Data

A longitudinal ophthalmic dataset was used to investigate multi-modal machine learning (ML) models incorporating patient demographics and history, clinical measurements, optical coherence tomography (OCT), and visual field (VF) testing in predicting glaucoma surgical interventions. The cohort included 369 patients who underwent glaucoma surgery and 592 patients who did not undergo surgery. The data types used for prediction included patient demographics, history of systemic conditions, medication history, ophthalmic measurements, 24-2 VF results, and thickness measurements from OCT imaging. The ML models were trained to predict surgical interventions and evaluated on independent data collected at a separate study site. The models were evaluated based on their ability to predict surgeries at varying lengths of time prior to surgical intervention. The highest performing predictions achieved an AUC of 0.93, 0.92, and 0.93 in predicting surgical intervention at 1 year, 2 years, and 3 years, respectively. The models were also able to achieve high sensitivity (0.89, 0.77, 0.86 at 1, 2, and 3 years, respectively) and specificity (0.85, 0.90, and 0.91 at 1, 2, and 3 years, respectively) at an 0.80 level of precision. The multi-modal models trained on a combination of data types predicted surgical interventions with high accuracy up to three years prior to surgery and could provide an important tool to predict the need for glaucoma intervention.

Urrets-Zavalia Syndrome of Unresolving Mydriasis Following Endocyclophotocoagulation Combined with Phacoemulsification

Aim and background

Combined endocyclophotocoagulation and phacoemulsification (ECP/Phaco) are uncommonly associated with complications. We present the first case of a rare complication following ECP/Phaco.

Case description

A 72-year-old patient with dense nuclear sclerotic cataracts and primary open-angle glaucoma (POAG) underwent bilateral surgery uneventfully. He experienced a brief episode of postoperative elevated intraocular pressure (IOP), but only one eye with a lower baseline IOP developed a dilated pupil. No pupillary response was observed after applying 4% pilocarpine. The fixed mydriasis persisted without reaction to light or near stimulus, and the best-corrected vision (BCVA) was 20/30 in the affected eye.

Conclusion

This case reports a possible rare complication when undergoing ECP/Phaco therapy. The pathogenesis of Urrets-Zavalia syndrome is unknown, but we hypothesized that eyes with more pronounced increases in IOP from baseline may be more susceptible to ischemic injury to the pupillary sphincter, resulting in a chronically dilated pupil.

Clinical significance

Even a modest transient rise in postoperative IOP in a glaucomatous eye with normal baseline IOP could result in a chronically dilated pupil.

How to cite this article

Cheng AMS, Vedula GG, Kubal AA, et al. Urrets-Zavalia Syndrome of Unresolving Mydriasis Following Endocyclophotocoagulation Combined with Phacoemulsification. J Curr Glaucoma Pract 2024;18(1):28-30.

Glaucoma Surgery Shifts Among Medicare Beneficiaries After 2022 Reimbursement Changes in the United States

PRCIS

This study revealed the best-estimated surgical procedural counts for 2021 and 2022 and suggests a direct influence of coding and reimbursement changes on surgical device selection.

PURPOSE

To analyze utilization rates of glaucoma surgeries and minimally invasive (microinvasive) glaucoma surgery among US Medicare beneficiaries between 2021 and 2022.

DESIGN

Retrospective comparative analysis of 68,118 unique patients.

METHODS

National claims data from a 5% sample of all Medicare beneficiaries were utilized to compare glaucoma procedure counts between the first quarter of 2021 and the first quarter of 2022. Duplicate claims were excluded, and 50 modifiers were counted as 2 distinct procedures. A multiplier was applied to estimate annual utilization for the entire Medicare population. χ 2 analysis was employed to compare categorical data from the 2 time periods.

RESULTS

Current Procedural Terminology codes for angle-based stenting decreased by an estimated 20,960 procedures between 2021 and 2022 (28.60%). Goniotomy increased by an estimated 11,680 procedures (66.97%) and canaloplasty increased by an estimated 6640 procedures (47.43%). Glaucoma surgeries decreased by an estimated 5760 procedures (4.25%) despite an increase of cataract surgery by 234,960 procedures (15.63%), an increase in YAG capsulotomy by 19,280 procedures (3.31%), and an increase in intravitreal injections by 146,320 procedures (3.86%).

CONCLUSION

Despite overall surgical volume increases among the ophthalmology procedures, angle-based stenting utilization decreased significantly with an accompanying trend change following the coding and reimbursement changes implemented in January 2022. Of the minimally invasive (microinvasive) glaucoma surgery procedures, goniotomy and canaloplasty counts increased the most between these periods. Trabeculectomy and glaucoma drainage device procedures continued to decrease, following well-established trends. Future studies are warranted to examine how these shifts in utilization may impact patient care outcomes.

Estimation of Topical Glaucoma Medication Over-Prescription and Its Associated Factors

This study aims to report the disparity between the ideal and actual quantities of eyedrops prescribed to individual glaucoma patients. This retrospective observational study included 676 patients receiving treatment with antiglaucoma topical medication(s) in at least one eye. These patients had follow-up appointments scheduled at mean intervals of 3.4 ± 1.4 months and were actively using antiglaucoma medication. The mean age was 70.4 ± 11.9 years, with 372 (55%) being male. The over-prescription volume was 1.4 ± 1.7 bottles per month for each medication when prescribed for both eyes. Multiple regression analysis revealed that older age (p = 0.03), hyperopic refractive error (p < 0.0001), and the use of multiple medications (p = 0.03) were associated with a larger over-prescription volume, while the use of unit-dose medication only (p < 0.0001) was associated with a smaller over-prescription volume. Factors such as sex, Mini-Cog cognitive function score, best-corrected visual acuity, intraocular pressure, glaucoma type, and a history of cataract surgery were not significantly associated. This study revealed a significant over-prescription of eyedrops for glaucoma patients, with actual prescriptions often exceeding the theoretically ideal amount by 2.4 times, influenced by factors like age and the format of prescriptions, where unit-dose eyedrops show promise in reducing excess.

Annual trends of ophthalmic surgeries in Japan's super-aged society, 2014-2020: a national claims database study

This study aimed to analyze the trends and factors influencing the number of ophthalmic surgeries in Japan using the open data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan published by the Ministry of Health, Labour and Welfare. We calculated the number of cataract, glaucoma, and vitreoretinal surgeries, categorized by sex, age, and surgical type, for the fiscal years (FY) 2014 to 2020. The number of cataract surgeries remained stable at approximately 1.45 million cases from FY 2014 to 2018, increased to nearly 1.6 million cases in FY 2019, and decreased to 1.45 million cases in FY 2020. Among glaucoma surgeries, surgical treatments were increased 1.8 times over 7 years, from 33,000 to 60,000 cases. Laser treatment remained steady at around 55,000 cases from FY 2014 to 2017 and then increased to approximately 60,000 cases. The number of vitreoretinal surgeries was increased 1.2 times from FY 2014 to 2019, from 120,000 to 140,000, and decreased to 130,000 by FY 2020. Trends in ophthalmic surgeries over the past 7 years may be influenced by population aging, minimally invasive surgery, and the coronavirus disease pandemic. These findings have implications on surgical decision-making and resource allocation.

36-Month Outcomes from the Prospective GEMINI Study: Canaloplasty and Trabeculotomy Combined with Cataract Surgery for Patients with Primary Open-Angle Glaucoma

Purpose

To provide long-term intraocular pressure (IOP) and ocular hypotensive medication usage outcomes through 36 months for patients treated with canaloplasty and trabeculotomy (OMNI Surgical System) combined with cataract surgery as participants in the GEMINI study.

Setting

Eleven ophthalmology practices in 10 US states.

Design

Non-interventional 36-month extension of the 12-month, prospective, multicenter, GEMINI study.

Methods

GEMINI patients had visually significant cataract, mild-to-moderate glaucoma (ICD-10 guidelines), medicated IOP <33 mmHg, and unmedicated mean diurnal IOP (DIOP) (after washout) 21-36 mmHg. Patients from GEMINI were eligible for inclusion. Outcome measures were reduction in mean unmedicated DIOP, reduction in mean IOP-lowering medications, percent of eyes with ≥20% reduction in unmedicated DIOP, and percent of eyes with unmedicated DIOP ≥6 and ≤18 mmHg.

Results

A total of 66 patients provided consent and were enrolled. Mean (SD) unmedicated DIOP was 23.1 (2.7) mmHg at baseline, 16.7 (4.1), 16.3 (3.3) at 24 and 36 months; mean reductions of 6.2 (4.1) and 6.9 (3.4) mmHg. Twelve-month IOP at the end of GEMINI was 15.6 mmHg. The proportion of eyes with ≥20% reduction in IOP was 77% and 78% (months 24 and 36) compared to 87% at month 12 from GEMINI. About 68% of patients had an IOP between 6 and 18 mmHg at 24 months and 71% at 36 months. Mean IOP-lowering medications was 1.7 at baseline, which was reduced to 0.4 (24 months, -1.3) and 0.3 (36 months, -1.4). About 74% of patients (46 of 62) were medication free at 36 months.

Conclusion

GEMINI demonstrated 12-month effectiveness of canaloplasty and trabeculotomy with OMNI combined with cataract surgery for IOP and medication reduction in mild-to-moderate glaucoma. However, longer-term data is key to the decision making in the selection of a surgical treatment. This GEMINI extension demonstrates that the 12-month outcomes from GEMINI were sustained through 36 months.

Comparing corneal biomechanic changes among solo cataract surgery, microhook ab interno trabeculotomy and iStent implantation

Minimally invasive glaucoma surgery has expanded the surgical treatment options in glaucoma, particularly when combined with cataract surgery. It is clinically relevant to understand the associated postoperative changes in biomechanical properties because they are influential on the measurement of intraocular pressure (IOP) and play an important role in the pathogenesis of open-angle glaucoma (OAG). This retrospective case-control study included OAG patients who underwent cataract surgery combined with microhook ab interno trabeculotomy (µLOT group: 53 eyes of 36 patients) or iStent implantation (iStent group: 59 eyes of 37 patients) and 62 eyes of 42 solo cataract patients without glaucoma as a control group. Changes in ten biomechanical parameters measured with the Ocular Response Analyzer and Corneal Visualization Scheimpflug Technology (Corvis ST) at 3 and 6 months postoperatively relative to baseline were compared among the 3 groups. In all the groups, IOP significantly decreased postoperatively. In the µLOT and control groups, significant changes in Corvis ST-related parameters, including stiffness parameter A1 and stress‒strain index, indicated that the cornea became softer postoperatively. In contrast, these parameters were unchanged in the iStent group. Apart from IOP reduction, the results show variations in corneal biomechanical changes from minimally invasive glaucoma surgery combined with cataract surgery.

Comparison of Short-term Visual Acuity Changes After Trabeculotomy ab Interno Using Trabectome and Trabeculectomy ab Externo

PURPOSE

To compare short-term visual acuity (VA) changes after trabeculotomy ab interno (TAI) using trabectome and trabeculectomy ab externo (TAE) performed on pseudophakic eyes.

DESIGN

A single-center retrospective study.

PARTICIPANTS

Patients with pseudophakic eyes who had primary open-angle glaucoma or exfoliation glaucoma and underwent TAI or TAE alone.

METHODS

Changes in intraocular pressure (IOP), medication score, Snellen VA, and the number of eyes with vision loss (loss of ≥ 2 Snellen lines) were evaluated at baseline, week 1, and months 1, 3, and 6. The risk factors for vision loss at 6 months postoperatively were analyzed in both groups.

MAIN OUTCOME MEASURES

Visual acuity changes.

RESULTS

A total of 112 eyes of 112 patients were examined: 46 in the TAI group and 66 in the TAE group. Intraocular pressure was significantly lower in both groups at each visit than at baseline. The TAI group had a significantly higher mean postoperative IOP than the TAE group. Medication scores in the TAI group were significantly different after 3 months compared with baseline; however, decreased significantly at all study visits in the TAE group. The mean VA in the TAI group did not decrease significantly at each visit. In the TAE group, it decreased significantly up to 3 months but was not significantly different at 6 months. At all study visits, the number of eyes with vision loss was significantly lower in the TAI group than in the TAE group. Only 2 eyes in the TAI group (4.3%) had vision loss at 6 months, which was caused by macular edema. In the TAE group, 13 eyes (19.7%) experienced vision loss at 6 months. In all cases, the presence of preoperative split fixation [odds ratio = 7.30, P < 0.05] and the occurrence of hypotony-related complications [odds ratio = 6.76, P < 0.05] within 6 months were risk factors for vision loss.

CONCLUSIONS

TAI lowered IOP less than TAE; however, there was less vision loss with TAI. For eyes with a target IOP in the mid-teens, TAI can be recommended as initial surgery.

FINANCIAL DISCLOSURE(S)

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

Bleb morphology of glaucoma drainage devices on magnetic resonance imaging

PURPOSE

To evaluate bleb morphology features of different glaucoma drainage devices (GDD) using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Prospective cohort study of GDD and bleb morphology in consecutive glaucoma patients implanted with Ahmed Glaucoma Valve (AGV), Paul Glaucoma Implant (PGI), Baerveldt Glaucoma Implant (BGI) and Ahmed ClearPath (ACP) devices. Thirty-six eyes from 30 consecutive patients underwent standardized GDD implantation followed by MRI at least 1 month after surgery. Main outcomes included bleb volume and endplate position relative to the optic nerve. Secondary outcomes included intraocular pressure (IOP), medication and surgical complications during a 12-month follow-up.

RESULTS

Seven eyes were implanted with the AGV (19%), 5 with BGI (14%), 16 with PGI (44%) and 8 with ACP (22%). MRI scans were obtained 85 ± 66 days after surgery. Mean total bleb volume was 563 ± 390 mm3 . This bleb volume was inversely correlated with early post-operative IOP (day 7; rs  = -0.3326, p = 0.0475) but positively correlated with IOP at 12 months (rs  = 0.3592, p = 0.0341). No significant difference in total bleb volume was found between GDD types (p = 0.1223). A double-layered bleb was observed in 34 eyes (94%). The inferior bleb volume was significantly larger in PGI devices versus other GDD types (380 ± 205 vs. 193 ± 161 mm3 ; p = 0.0043). Distance from the endplate to the optic nerve was 9.5 ± 4.0 mm, similar across GDDs (p = 0.2519).

CONCLUSIONS

Double-layered blebs are a common finding with GDDs. Bleb volume showed different correlations with IOP at distinct timepoints and the PGI device formed larger blebs. A standardized GDD implantation technique ensures a safe distance from the GDD endplate to the optic nerve.

Eliciting preferences in glaucoma management-a systematic review of stated-preference studies

BACKGROUND

In most cases, glaucoma patients require long-term medical and/or surgical treatment. Preference studies investigate how different aspects of glaucoma management, such as health or process outcomes, are valued and herewith help stakeholders make care more responsive to patients' needs. As, to our knowledge, no overview of these studies is currently available, this study aims to systematically review and critically appraise these studies.

METHODS

A systematic literature review was conducted using keywords for stated-preference studies and glaucoma up to October 2021. Studies were included if they were original research and used a stated-preference methodology to investigate preferences in patients or healthcare professionals for different aspects of glaucoma management. Data were extracted and summarized. Furthermore, a quality appraisal of the included studies was performed using two validated checklists.

RESULTS

The search yielded 1214 articles after removal of duplicates. Of those, 11 studies fulfilled the inclusion criteria. Studies aimed to elicit preferences for glaucoma treatment (27%), glaucoma related health state valuation (36%), and services (36%) from the patient (91%) or ophthalmologists' perspective (9%). Altogether studies included 69 attributes. The majority of attributes were outcome related (62%), followed by process (32%) and cost attributes (6%). Outcome attributes (e.g., effectiveness) were most often of highest importance to the population.

CONCLUSIONS

This systematic review provides an up-to-date and critical review of stated-preference studies in the field of glaucoma, suggesting that patients have preferences and are willing to trade-off between characteristics, and revealed that outcome attributes are the most influential characteristics of glaucoma management.

Practice patterns and costs of glaucoma treatment in Japan

PURPOSE

Understanding the practice patterns and costs of glaucoma care in real-world clinical settings is important for optimizing medical expenses. However, glaucoma treatment trends and associated costs in Japan are unknown. We aimed to unveil glaucoma treatment trends and costs using a large administrative claims database in Japan.

STUDY DESIGN

Retrospective cohort study.

METHODS

We included patients diagnosed with glaucoma between April 2014 and March 2021 using the DeSC database. We calculated the frequencies and costs of antiglaucoma eyedrops, incisional or laser procedures, and ophthalmic examinations stratified by fiscal year and age. In the year-by-year analyses, the age distribution was standardized based on the 2020 distribution.

RESULTS

A total of 841,747 patient-years (429,051 patients) were included. The number of prescribed eyedrops significantly increased and the fixed-combination eyedrops proportion decreased with age. Trabeculectomy frequency decreased, and that of laser trabeculoplasty increased during the observation period. The frequencies of both incisional and laser procedures peaked in the 75-79 age group. In 2020, 16.1 bottles of eyedrops per patient-year were prescribed, and 15.9 incisional surgeries and 11.3 laser therapies were performed per 1000 patient-years. Intraocular pressure measurement and visual field testing were performed 6.5 times and 2.0 times per patient-year, respectively. The total direct cost of glaucoma treatment was 55,139 yen (US $399.5) per patient-year, of which medications accounted for 44.2%, ophthalmic examinations for 47.4%, and incisional or laser procedures for 8.4%.

CONCLUSION

These results may be useful for understanding glaucoma treatment trends and costs in Japan.

A Review of Cost-Effectiveness Analyses for Open Angle Glaucoma Management

PURPOSE

Cost-effectiveness analyses (CEAs) quantify and compare both costs and measures of efficacy for different interventions. As the costs of glaucoma management to patients, payers, and physicians are increasing, we seek to investigate the role of CEAs in the field of glaucoma and how such studies impact clinical management.

METHODS

We adhered to the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines for our systematic review structure. Eligible studies included any full-text articles that investigated cost-effectiveness or cost-utility as it relates to the field of open angle glaucoma management in the United States. Risk of bias assessment was conducted using the validated Joanna Briggs Institute Critical Appraisal Checklist for Economic Evaluations.

RESULTS

Eighteen studies were included in the review. Dates of publication ranged from 1983 to 2021. Most of the studies were published in the 2000s and performed CEAs in the domains of treatment/therapy, screening, and adherence for patients with primary angle open glaucoma. Of the 18 articles included, 14 focused on treatment, 2 on screening, and 2 on adherence. Most of these studies focused on the cost-effectiveness of different topical medical therapies, whereas only a few studies explored laser procedures, surgical interventions, or minimally invasive procedures. Economic models using decision analysis incorporating state-transition Markov cycles or Montecarlo simulations were widely used, however, the methodology among studies was variable, with a wide spectrum of inputs, measures of outcomes, and time horizons used.

CONCLUSION

Overall, we found that cost-effectiveness research in glaucoma in the United States remains relatively unstructured, resulting in unclear and conflicting implications for clinical management.

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.

The budget impact of introducing the OMNI® surgical system to a United States health plan for managing mild-to-moderate primary open-angle glaucoma

OBJECTIVES

Minimally invasive glaucoma surgery devices fill an unmet need in the treatment paradigm between topical intraocular pressure medicines and more invasive filtration procedures. This study evaluated the adoption of The OMNI® Surgical System with or without cataract surgery in primary open-angle glaucoma patients.

METHODS

A budget impact analysis estimated costs before and after adoption of OMNI® to a hypothetical US health plan with 1 million Medicare-covered lives over two years. Model input data were derived from published sources and development of the model included primary research with key opinion leaders and payers. The model compared total annual direct costs for OMNI® versus other treatment options (medications, other minimally invasive surgical procedures, selective laser trabeculoplasty) to calculate budget impact. A one-way sensitivity analysis was conducted to assess parameter uncertainty.

RESULTS

Increased adoption of OMNI® resulted in budget neutrality over the two years with a decrease in total costs of $35,362. Per member per month incremental costs were $0.00 when used without cataract surgery and yielded cost savings of -$0.01 when used with cataract surgery. Sensitivity analysis confirmed model robustness and identified surgical center fee variability as a key driver of costs.

CONCLUSION

OMNI® is budgetary efficient from a US payer perspective.

Nationwide Analysis of Glaucoma Surgeries in Fiscal Years of 2014 and 2020 in Japan

Nationwide trends in glaucoma surgical procedures were assessed by using the NDB Open Data 2014 and 2020. In Japan, 33,340 non-laser, 54,569 laser, and 88,019 total glaucoma surgeries were performed in 2014. In 2020, 60,108 non-laser, 60,547 laser, and 120,655 total glaucoma surgeries were performed. The rates from 2014 to 2020 were 180%, 111%, and 137%, respectively. In each procedure, angle surgery (326%), tube shunt surgery (383%), ciliary coagulation (489%), and gonio-laser (225%) were remarkably increased, while iridectomy (75%) and iris laser (77%) decreased during the same period. An increase in laser surgery was seen in young age groups, namely, 55-59 years old and younger, while non-laser surgery was increased in old age groups, namely, 45-49 years old and older. In 2020, 47.6 non-laser, 48.0 laser, and 95.6 total glaucoma surgeries were performed per 100,000 persons. None of the vital statistics, including prefectural population, mean age, and rate of ≥65-year-old people, were significantly associated with the number of glaucoma surgeries. Glaucoma practice patterns changed each time a new device or procedure was introduced. The results of the current study reflected the use of new procedures, such as minimally invasive glaucoma surgery, tube shunt, selective laser trabeculoplasty, and micropulse cyclophotocoagulation.

Recent Advances of Ocular Drug Delivery Systems: Prominence of Ocular Implants for Chronic Eye Diseases

Chronic ocular diseases can seriously impact the eyes and could potentially result in blindness or serious vision loss. According to the most recent data from the WHO, there are more than 2 billion visually impaired people in the world. Therefore, it is pivotal to develop more sophisticated, long-acting drug delivery systems/devices to treat chronic eye conditions. This review covers several drug delivery nanocarriers that can control chronic eye disorders non-invasively. However, most of the developed nanocarriers are still in preclinical or clinical stages. Long-acting drug delivery systems, such as inserts and implants, constitute the majority of the clinically used methods for the treatment of chronic eye diseases due to their steady state release, persistent therapeutic activity, and ability to bypass most ocular barriers. However, implants are considered invasive drug delivery technologies, especially those that are nonbiodegradable. Furthermore, in vitro characterization approaches, although useful, are limited in mimicking or truly representing the in vivo environment. This review focuses on long-acting drug delivery systems (LADDS), particularly implantable drug delivery systems (IDDS), their formulation, methods of characterization, and clinical application for the treatment of eye diseases.

The case for standalone micro-invasive glaucoma surgery: rethinking the role of surgery in the glaucoma treatment paradigm

PURPOSE OF REVIEW

To highlight progress in glaucoma therapy challenging the traditional medication-first approach and present evidence supporting early standalone surgery in the era of micro-invasive glaucoma surgery (MIGS).

RECENT FINDINGS

Medical therapy is limited by well documented poor adherence that compromises the quality of intraocular pressure reduction. Results from modern clinical trials demonstrate advantages of selective laser trabeculoplasty and MIGS procedures in terms of both IOP control and progression risk.

SUMMARY

The MIGS options for pseudophakic or precataractous patients are limited by regulatory rules that require the performance of some procedures only at the time of cataract surgery. These include the iStent/iStent Inject and the Hydrus implants. Nonbleb-forming procedures currently available for standalone use in eyes with mild-moderate primary open-angle glaucoma include gonioscopy-assisted transluminal trabeculotomy (which lowers IOP by 28-61% and medication use by 38-73% in various studies), trabecular ablation with the Trabectome (23-39% and 21-43%, respectively), excisional goniotomy with the Kahook Dual Blade (15-36% and 15-40%, respectively), ab interno canaloplasty (35% and 57%, respectively), and combined canaloplasty and trabeculotomy using the OMNI system (39-40% and 64-73%, respectively). For patients who would benefit from early standalone surgery, these procedures offer meaningful reductions in both IOP and medication burden.

Combined Microinvasive Glaucoma Surgery - A Review of the Literature and Future Directions

The use of microinvasive invasive glaucoma surgery (MIGS) in the treatment of glaucoma has increased exponentially over the last 10 years. However, practice patterns vary widely given the relative newness of these technologies. Some surgeons perform two or more MIGS simultaneously, such as those that target aqueous production and those that target aqueous outflow. These combined MIGS (cMIGS) may result in lower intraocular pressure (IOP) and reduced medication burden as compared to single MIGS (sMIGS). Current evidence suggests some cMIGS are more effective in reducing medication burden for at least 12 months versus sMIGS. This review focuses on the current evidence related to the efficacy of cMIGS as well as novel combinations of standalone MIGS, limitations of the current literature, and future directions for research.

Long-term effect of canaloplasty on intraocular pressure and use of intraocular pressure-lowering medications in patients with open-angle glaucoma

PURPOSE

To assess the long-term safety and effectiveness of canaloplasty in reducing intraocular pressure (IOP) and use of IOP-lowering medications in eyes with open-angle glaucoma (OAG).

SETTING

Surgical center (Augencentrum Köln, Köln, Germany).

DESIGN

Retrospective study.

METHODS

206 eyes from 130 patients were included. Canaloplasty was performed using the VISCO360 or OMNI surgical system as a stand-alone procedure in 22 eyes and concomitantly with cataract extraction (CE) in 185 eyes with chronic OAG insufficiently controlled or intolerant to IOP-lowering medications. The number of hypotensive medications and IOP were recorded at baseline, day 1, week 1, month 1, month 3, and every 3 months thereafter, with the last follow-up visit at 36 ± 6 months postoperatively. Patients were stratified by baseline IOP (Group 1, IOP >18 mm Hg; Group 2, IOP ≤18 mm Hg). Treatment success in Group 1 was defined as a reduction in IOP and the use of IOP-lowering medications; Group 2 success was defined as maintenance of a lower IOP and a reduction in medication use.

RESULTS

The preoperative mean IOP of both groups was 21.1 ± 8.8 mm Hg, with a mean of 2.0 ± 0.9 hypotensive medications. The primary success end point was met by 73% of patients, with a mean IOP reduction in Group 1 (131 eyes; 21.8 to 15.6 mm Hg, P < .0001) and a maintenance of IOP control in Group 2 (76 eyes; 15.4 to 13.9 mm Hg, P = .24). Medications decreased from 2.2 ± 0.9 to 0.9 ± 1.1 in Group 1 ( P = .024) and from 1.8 ± 0.8 to 0.7 ± 1.0 in Group 2 ( P = .003).

CONCLUSIONS

Canaloplasty alone or in conjunction with CE with the VISCO360 or OMNI surgical system is a safe, tissue-sparing, and effective minimally invasive glaucoma surgery, using a clear corneal incision in phakic or pseudophakic eyes. Canaloplasty performed with both evaluated devices achieved statistically significant, consistent, and clinically meaningful reductions in IOP and use of IOP-lowering medications in adult patients with OAG. In the consistent cohort (n = 42), the IOP-lowering effect lasted up to 42 months, with ongoing data collection expected to describe long-term effectiveness of this intervention.

Canaloplasty and trabeculotomy with the OMNI® surgical system in OAG with prior trabecular microbypass stenting

Purpose

Evaluate effectiveness and safety outcomes for patients treated with canaloplasty and trabeculotomy previously treated with a trabecular microbypass stent (TBS).

Methods

Retrospective, multicenter, IRB approved study. Patients treated with TBS (iStent/iStent inject, Glaukos) and subsequently with OMNI surgical system (OSS) (Sight Sciences). From 5 practices in 5 US states. Open-angle glaucoma (OAG), minimum 3 months follow-up after OSS surgery, Pre-OSS IOP ≥ 17 mmHg on ≥ 1 medication. No glaucoma procedures between TBS and OSS. Endpoints: proportion with ≥ 20% reduction in IOP, IOP between 6 and 18 mmHg, mean IOP, change in IOP, mean number of medications. Adverse events and secondary surgical interventions (SSI). Mann–Whitney rank sum test compared pre-OSS IOP and medications with follow-up.

Results

Twenty seven patients. Average age (SD) 72.2 (10.8), 22/27 primary OAG (82%), mean MD − 6.2 (7.0) dB. Mean IOP before OSS 22.3 (4.3) mmHg on 2.2 (1.3) medications. At last follow-up (mean 11 months) IOP was 17.2 mmHg on 1.8 medications, − 5.1 mmHg (− 23%, p < .001), − 0.4 meds (− 18%, p = .193); ≥ 20% IOP reduction (41%), IOP ≤ 18 (56%). Adverse events were non-serious. Hyphema > 1 mm (3, 11%), BCVA decrease (4, 15%), IOP spike (2, 7%). SSI (4, 15%) had higher pre-OSS IOP (23.4 mmHg) and worse MD (− 9.6 dB).

Conclusion

Patients uncontrolled by medication and a prior TBS would once have been candidates for trabeculectomy and tube shunts. OSS offered a minimally invasive option that provided IOP control and avoidance of traditional surgery for the majority over follow-up averaging 11 months and up to 42 months.

Clinical and Visual Field Outcomes Following Minimally Invasive Glaucoma Surgery Combined with Cataract Surgery

Purpose

To determine the change in Humphrey visual field and clinical parameters after minimally invasive glaucoma surgery combined with cataract surgery.

Patients and Methods

Patients undergoing minimally invasive glaucoma surgery combined with cataract surgery in a multicenter retrospective case series between 2013 and 2021 with reliable preoperative and 12 to 18 month postoperative visual field measurements were included. Devices included iStent, XEN, and Hydrus. Clinical parameters were compared with a generalized linear model with generalized estimating equations between preoperative and postoperative visits including best corrected visual acuity, intraocular pressure, number of glaucoma medications and visual fields. Visual field metrics included mean deviation (MD), pattern standard deviation (PSD), visual field index (VFI), and Collaborative Initial Glaucoma Treatment Study (CIGTS) score of total deviation probability and pattern deviation probability.

Results

Forty-four eyes from 39 patients were included. During the follow up period, visual acuity improved from 0.23±0.17 to 0.10±0.14 logMAR (mean ± standard deviation, p<0.001), number of glaucoma medications was reduced from 2.68±1.06 to 1.46±1.32 (p<0.001), and intraocular pressure decreased from 17.08±4.23 mmHg to 14.92±3.13 mmHg (p=0.003). Differences across devices were negligible. The only significant difference was a greater reduction in number of glaucoma medications in the XEN group (p<0.001). There were no significant changes in the global parameters of VFI, MD, PSD, or CIGTS.

Conclusion

Overall, minimally invasive glaucoma surgery combined with cataract surgery appears to be effective at stabilizing visual field function, reducing intraocular pressure, reducing number of glaucoma medications, and improving visual acuity over a 12 to 18 month follow-up period across MIGS devices.

Multicenter Effectiveness and Disease Stability Through 3 Years After iStentTrabecular Micro-Bypass with Phacoemulsification in Glaucoma and Ocular Hypertension

Purpose

To evaluate 3-year safety and efficacy of two second-generation trabecular micro-bypass stents. (iStent inject^®) with phacoemulsification.

Materials and Methods

This multicenter retrospective study of iStent inject implantation with phacoemulsification included data from eight surgeons across Australia. Eyes with cataract and mild to advanced glaucoma [predominantly primary open-angle (POAG), primary angle closure (PAC), or normal-tension (NTG) glaucoma] or ocular hypertension (OHT) were included. Study assessments included intraocular pressure (IOP); number of ocular hypotensive medications; proportions of eyes with 0, 1, 2, or ≥3 IOP-lowering medications; IOP ≤15 mmHg or ≤18 mmHg; visual fields (VF); retinal nerve fiber layer thickness (RNFL); central corneal thickness (CCT); intraoperative complications; adverse events; and secondary surgeries.

Results

A total of 273 eyes underwent surgery and had 36-month follow-up. At 36 months versus preoperative, mean IOP decreased by 15.5% (16.4±4.6 mmHg to 13.9±3.5 mmHg; p<0.001), and 70.3% of eyes achieved IOP of ≤15 mmHg (versus 49.1% preoperatively; p<0.001). The mean medication burden decreased by 68.5% (from 1.51±1.17 to 0.48±0.89 medications; p<0.001); 71.4% of eyes were medication-free (versus 21.6% preoperatively; p<0.001), while 6.2% of eyes were on ≥3 medications (versus 22.3% preoperatively; p<0.001); 96.3% of eyes maintained or reduced medications vs preoperative. Significant IOP and medication reductions occurred across glaucoma subtypes (POAG, PAC, NTG, OHT): 13–22% for IOP (p<0.05 for all) and 42–94% for medication (p<0.05 for all). Favorable safety included few adverse events; stable VF, RNFL, and CCT; and filtering surgery in only 8 eyes (2.9%) over 3 years.

Conclusion

In this multicenter cohort from 8 surgeons across Australia, significant IOP and medication reductions were sustained through 3 years after iStent inject implantation with phacoemulsification. Results were favorable across different glaucoma subtypes (including POAG, PAC, NTG, OHT), severities, and surgeons, thereby underscoring the real-world relevance and efficacy of iStent inject implantation for glaucoma treatment.

Minimally Invasive Glaucoma Surgery in Primary Angle-Closure Glaucoma

Primary angle-closure glaucoma (PACG) is responsible for half of the glaucoma-related blindness worldwide. Cataract surgery with or without trabeculectomy has been considered to be the first-line treatment in eyes with medically uncontrolled PACG. While minimally invasive glaucoma surgery has become an important surgical approach for primary open-angle glaucoma, its indications and benefits in PACG are less clear. This review summarizes the efficacy and safety profile of minimally invasive glaucoma surgery in PACG to unfold new insights into the surgical management of PACG.

Usage Patterns of Minimally Invasive Glaucoma Surgery (MIGS) Differ by Glaucoma Type: IRIS Registry Analysis 2013-2018

PURPOSE

To examine patterns of standard (trabeculectomy or glaucoma drainage devices, GDDs) vs novel (minimally invasive glaucoma surgery, MIGS) surgical techniques in the US.

METHODS

We used the American Academy of Ophthalmology (AAO) IRIS® Registry (Intelligent Research in Sight) queried between 2013 and 2018 (inclusive) to calculate the cumulative proportion of stand-alone, concurrent (same day) or sequential (subsequent day) glaucoma surgical techniques performed in each glaucoma diagnosis type. Secondary analyses of adjusted proportions of concurrent and sequential surgeries stratified by glaucoma diagnosis were also performed.

RESULTS

Of 203,146 eyes receiving glaucoma surgeries, open angle glaucoma (OAG) was most likely to undergo all types of intervention. The iStent was the most commonly performed MIGS, primarily for those with normal tension glaucoma (NTG) or OAG (p < .001). Conversely, GDD was the most commonly performed procedure in secondary glaucoma or other (specified) glaucoma (p < .001). ECP and iStent were the most common concurrent procedures performed; most often for OAG and NTG (p < .001). After an initial standard surgery, most eyes underwent recurrent standard interventions (90.3%). ECP was the most common MIGS performed after an initial standard surgery; particularly in primary angle-closure (PACG) and secondary glaucoma eyes (p < .001).

CONCLUSION

Glaucoma type may influence the choice of glaucoma procedures and the decision to perform concurrent as well sequential surgical procedures. Given the poorly understood long term safety and effectiveness of MIGS, and with substantially increasing use of MIGS procedures in recent years, future studies comparing their safety and effectiveness vs standard interventions, for a variety of glaucoma types, is needed.

iStent Trabecular Micro-bypass Stent Implantation Combined with Phacoemulsification for Open-Angle Glaucoma: A 2-Year Post-marketing Surveillance Study in Japan

Introduction

We report 2-year outcomes after implantation of iStent trabecular micro-bypass stent with phacoemulsification, in Japanese patients with mild–moderate open-angle glaucoma (OAG).

Methods

This was a 24-month, prospective, longitudinal, observational, post-marketing study conducted between July 2017 and September 2020. Patients consisted of adults with OAG on antiglaucoma medications who had cataract surgery combined with one iStent implantation. Outcome measures included intraocular pressure (IOP), antiglaucoma medications, treatment success rates (defined as eyes having lower IOP with same or reduced number of medications from baseline, or same IOP with reduced number of medications from baseline, and not requiring secondary glaucoma surgeries postoperatively), and safety. Outcomes were analyzed in the overall cohort and in glaucoma subtypes: primary OAG, normal-tension glaucoma, and exfoliative glaucoma.

Results

Overall, 232 eyes were enrolled. At 24 months, mean ± standard deviation IOP decreased from 17.6 ± 4.0 mmHg preoperatively to 14.3 ± 3.0 mmHg (p < 0.05), and mean number of medications reduced from 2.2 ± 1.2 preoperatively to 0.7 ± 1.2 (p < 0.05). Similar trends were observed across glaucoma subtypes. In the overall cohort, 96.7%, 95.3%, and 93.7% of patients achieved treatment success at 6, 12, and 24 months, respectively. There were 67.6% medication-free eyes at 24 months compared to 3.2% medication-free eyes preoperatively (p < 0.0001). Safety profile was favorable over the 2-year period.

Conclusions

Following iStent implantation with phacoemulsification, clinically relevant and statistically significant reductions in IOP and number of medications were observed in Japanese eyes with OAG over 2 years, with favorable safety profile. These reductions were observed across all glaucoma subtypes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-022-02207-0.

Canaloplasty and Trabeculotomy Combined with Phacoemulsification for Glaucoma: 12-Month Results of the GEMINI Study

Purpose

To report 12-month efficacy outcomes of 360° canaloplasty and 180° trabeculotomy using the OMNI surgical system in combination with phacoemulsification in patients with mild-moderate open-angle glaucoma (OAG) and visually significant cataract.

Setting

Fifteen multi-subspecialty ophthalmology practices and surgery centers located in 14 US states.

Design

Prospective, multicenter, IRB approved study of patients treated with canaloplasty (360°) and trabeculotomy (180°). Eligible patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤33 mmHg on 1 to 4 hypotensive medications. Unmedicated post-washout mean diurnal IOP (DIOP) ≥21 and ≤36 mmHg.

Methods

Medication washout preoperatively and prior to month 12 DIOP. Effectiveness outcomes were IOP and IOP lowering medication use. Safety outcomes included adverse events and secondary surgical interventions (SSIs). Evaluations at 1, 3, 6, and 12 months.

Results

A total of 149 subjects underwent surgery and 120 were included in the final effectiveness analysis. Mean (standard deviation) unmedicated diurnal IOP was reduced from 23.8 (3.1) mmHg at baseline to 15.6 (4.0) at month 12 (−35%) and medications (before washout) were reduced from 1.8 (0.9) at baseline to 0.4 (0.9) at month 12 (−80%). At month 12, 84.2% of eyes achieved IOP reductions >20% from baseline, 80% of eyes were medication-free, and 76% of eyes achieved IOP between 6–18 mmHg inclusive. Adverse events were uncommon. Most were mild and self-limited including transient hyphema (9 of 149; 6%) and transient IOP elevations (3 of 149; 2.0%). No eyes required SSIs or experienced loss of VA that was attributable to the device or procedure.

Conclusion

Canaloplasty and trabeculotomy performed with the OMNI surgical system at the time of phacoemulsification significantly reduces unmedicated mean diurnal IOP and medication use 12 months postoperatively, with an excellent safety profile. This procedure should be considered for eyes with mild-moderate OAG to reduce IOP, medication burden, or both.

The evolving field of Big Data: understanding geographic information systems analysis and its transformative potential in ophthalmic research

PURPOSE OF REVIEW

The purpose of this review to is to highlight alternative uses of Big Data in the pursuit of ophthalmologic public health. In particular, we highlight geographic information systems (GIS) analysis as a type of Big Data, summarize various GIS methods, and enumerate sources of geographic data.

RECENT FINDINGS

The recent implementation of the IRIS Registry Data, has expanded our real-world knowledge of ophthalmology in the United States. Such innovations in Big Data allow us to better define ophthalmic diseases, treatments, and outcomes for underserved individuals and subpopulations. One underutilized source of Big Data entails use of geographic information to evaluate geographic heterogeneity and access across the United States.

SUMMARY

GIS and Big Data allow for refined epidemiologic estimates of eye disease for specific communities. In particular, how GIS can enable researchers to examine disparities in access to ophthalmic care is reviewed. GIS best practices and some data sources for GIS in ophthalmology are also summarized.

An IRIS® Registry-Based Assessment of Primary Open-Angle Glaucoma Practice Patterns in Academic versus Non-Academic Settings

PURPOSE

To compare patient demographic data; level of severity; and clinical, diagnostic, and surgical practice patterns in patients with primary open-angle glaucoma (POAG) in an academic setting (AS) versus non-academic setting (NAS) using the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight).

METHODS

A retrospective cohort study of IRIS® Registry data that included patients with POAG who were seen between January 2016 and December 2019 and had at least one year of follow-up.

RESULTS

Of 3,707,084 distinct eyes with POAG, 3% (109,920) were included in the academic subcohort and 97% (3,597,164) were included in the non-academic subcohort. Among the findings of greatest note (P < .0001 for all comparisons) were a higher proportion of eyes of Black patients, a higher proportion of eyes with level 3 severity, and a higher mean cup-to-disc ratio in eyes in the AS. The relative frequency of gonioscopy, pachymetry, and visual field testing in conjunction with new patient visits was also notably higher in the AS. For glaucoma surgical procedures, the greatest proportional differences in relative frequency were seen for tube shunt procedures (2.55-fold higher in the AS), iStent and Hydrus procedures (2.52-fold higher in the NAS), and endoscopic cyclophotocoagulation (5.80-fold higher in the NAS).

CONCLUSIONS

Based on IRIS® Registry data, notable differences appear to exist with regard to ethno-racial groups, glaucoma severity, and diagnostic and surgical practice patterns in AS versus NAS. By understanding these differences, potential opportunities exist in the development of educational programs related to clinical and surgical glaucoma care.

Corneal endothelial cell density loss following glaucoma surgery alone or in combination with cataract surgery: A systematic review and meta-analysis

TOPIC

Corneal endothelial cell density (ECD) loss following glaucoma surgery with or without cataract surgery.

CLINICAL RELEVANCE

Corneal ECD loss may occur due to intraoperative surgical trauma in glaucoma surgery or postoperatively with chronic endothelial cell trauma or irritation.

METHODS

Trabeculectomy, glaucoma filtration surgery or microinvasive glaucoma surgery in participants with ocular hypertension, primary and secondary open angle glaucoma, normal tension glaucoma and angle-closure glaucoma were included. Pediatric populations and participants with pre-existing corneal disease were excluded. Laser treatments and peripheral iridotomy were excluded. Electronic databases searched in December 2021 included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and The International Prospective Register of Systematic Reviews (PROSPERO), FDA PMA and FDA 510(k).

RESULTS

39 studies were included in quantitative synthesis. 12 months following suprachoroidal MIGS mean ECD loss was 282 cells/mm² (95% Confidence Interval (CI) 220 to 345; p <0.00001; Chi² = 0.06; I² = 0%; 2 studies; very low certainty). Mean ECD loss after Schlemm's canal implantable devices was 338 cells/mm² (95% CI 185 to 491; p<0.0001; Chi² = 0.08; I² = 0%; 2 studies; low certainty) at 12 months. When compared to phacoemulsification alone, Schlemm's canal implants combined with phacoemulsification showed statistically significant mean ECD reduction at 24 months; mean difference of ECD was -19% (95% CI -37% to -2%; p=0.03; Chi² = 3.04; I² = 34%; 3 studies; low certainty). Mean ECD loss was 64 cells/mm² (95% CI 21 to 107; p=0.004; Chi² = 4.55; I² = 0%; 6 studies; low certainty) following Schlemm's canal procedures (without implantable devices) at 12 months. At 12 months the mean ECD loss after trabeculectomy was 33 cells/mm² (95% CI -38 to 105, p=0.36, Chi² = 1.17; I² = 0%; moderate certainty). At 12 months mean ECD loss was 121 cells/mm² (95% CI 53 to 189; p=0.0005; Chi² = 3.00; I² = 0%; 5 studies; low certainty) after Express implantation. When compared to control fellow eye, aqueous shunt surgery reduced ECD by 5.75% (95% CI -0.93 to 12.43; p=0.09 Chi² = 1.32; I² = 0%; low certainty) and 8.11% ECD loss (95%CI 0.06 to 16.16 p=0.05; Chi²= 1.93; I²=48%) at 12 and 24 months, respectively.

CONCLUSIONS

Overall there is low certainty evidence to suggest that glaucoma surgery involving long-term implants has a greater extent of ECD loss than glaucoma filtration surgeries without the use of implants. The results of this review support long-term follow-up (beyond 36 months) to assess ECD loss and corneal decompensation following implantation of glaucoma drainage implants.

Bleb Analysis Using Anterior Segment Optical Coherence Tomography and Surgical Predictors of XEN Gel Stent

Purpose

To determine the early predictors of surgical success 6 months after XEN surgery among clinical parameters, including anterior segment optical coherence tomography (AS-OCT).

Methods

A total of 31 eyes with medically uncontrolled primary open-angle glaucoma or pseudoexfoliation glaucoma was enrolled retrospectively. Using AS-OCT, XEN tip location was categorized into intraconjunctival, intratenon, or uviform at day 1 and blebs were classified into no or low, high sparse, high thick, cystic, or mixed walls at month 6. Using slit-lamp photography, blebs were classified into no or low, localized avascular, diffuse avascular, localized vascular, or diffuse vascular blebs at month 6. Surgical success was defined as an intraocular pressure (IOP) of less than 14 mm Hg.

Results

Intraconjunctival and intratenon locations of the tip mostly created a high sparse wall, whereas the uviform type mostly created no or low wall and no or low bleb. The uviform type was linked to pseudoexfoliation glaucoma. A high sparse wall and diffuse avascular bleb showed a lower mean IOP than a high thick wall and localized vascular bleb. In the multivariate analysis, female sex and IOP at week 1 were early predictors of surgical success (8.45 times and 33.1% per 1 mm Hg-decrease, respectively).

Conclusions

Bleb evaluation using AS-OCT is valuable to correlate tip location and bleb morphology with clinical profiles, considering that a lower early postoperative IOP is linked to surgical success.

Translational Relevance

Bleb analysis using AS-OCT on day 1 could help to predict bleb morphology after 6 months, which is important to maintain the functioning bleb in the longer term.

Cost-Effectiveness Analysis of Minimally Invasive Trabecular Meshwork Stents with Phacoemulsification

PURPOSE

To investigate the costs and effects of implanting trabecular meshwork bypass stents during cataract surgery from a societal perspective in the United States.

DESIGN

Cost-utility analysis using Markov models and efficacy/safety data from published pivotal or randomized control trials (RCTs) of devices investigated.

PARTICIPANTS

Patients aged 65 years and older with mild to moderate primary open-angle glaucoma with or without visually significant cataract.

METHODS

With the use of Markov models, glaucoma progression through 4 glaucoma states (mild, moderate, advanced, severe/blind) and death were simulated over 35 years. The cohort with cataract entered the model and received cataract surgery with or without device implantation. We included a medication management only reference group to calculate total costs and outcomes for those without cataract. Intraocular pressure (IOP) reductions from RCTs were converted to glaucoma state transition probabilities using visual field (VF) mean deviation (MD) decline rates from the Early Manifest Glaucoma Trial. Progressive thinning of the retinal nerve fiber layer (RNFL) on OCT imaging related to IOP control warranted further intervention, including adding medication, selective laser trabeculoplasty (SLT), or incisional glaucoma surgery. We estimated whole costs at Medicare rates and obtained utility values for glaucoma states from previous studies. Incremental costs per quality-adjusted life-year (QALY) gained were evaluated at a QALY threshold of $50 000. One-way deterministic sensitivity analysis, scenario analyses, and probabilistic sensitivity analyses addressed parameter uncertainty and demonstrated model robustness.

MAIN OUTCOME MEASURES

Total costs, QALY, and incremental cost-effectiveness ratio (ICER).

RESULTS

Over 35 years in the base case, the Hydrus (Ivantis, Inc.) implanted with cataract surgery arm cost $48 026.13 and gained 12.26 QALYs. The iStent inject (Glaukos Corp.) implanted with cataract surgery arm cost $49 599.86 and gained 12.21 QALYs. Cataract surgery alone cost $54 409.25 and gained 12.04 QALYs. Initial nonsurgical management cost $57 931.22 and gained 11.74 QALY. The device arms dominated or were cost-effective compared with cataract surgery alone within 5 years and throughout sensitivity analyses. The iStent inject arm was cost-effective in 94.19% of iterations in probabilistic sensitivity analyses, whereas the Hydrus arm was cost-effective in 94.69% of iterations.

CONCLUSIONS

Implanting the Hydrus Microstent or iStent inject during cataract surgery is cost-effective at a conservative QALY threshold.

Suppression of Diurnal (9AM-4PM) IOP Fluctuations with Minimally Invasive Glaucoma Surgery: An Analysis of Data from the Prospective, Multicenter, Single-Arm GEMINI Study

PURPOSE

This study analyzes diurnal IOP data (9AM, 12PM, 4PM) from a prospective 12-month trial of the OMNI Surgical System in open-angle glaucoma (OAG) patients with the aim of evaluating effect of MIGS surgery on the amplitude of the diurnal IOP profile pre- and postoperatively.

SETTING

Fifteen ophthalmology practices and surgery centers located in 14 states in the United States.

DESIGN

Prospective, multicenter, IRB approved study. Patients treated with canaloplasty (360°) and trabeculotomy (180°). Patients had cataract and mild-moderate OAG with intraocular pressure (IOP) ≤33 mmHg on zero to four hypotensive medications.

METHODS

Post-hoc analysis of diurnal IOP data from the multicenter GEMINI study. Analysis includes comparison of IOP preoperatively and at month 12 for each of the diurnal time points, 9AM, 12PM, 4PM, change in magnitude of spread between the maximum IOP and minimum IOP for each patient and the proportions of patients preoperatively and at month 12 with IOPs at or below 25, 21, 18, and 15 mmHg, average variability (standard deviation of the 9AM, 12PM, and 4PM IOP) preoperatively and at month 12.

RESULTS

A total of 128 patients included in this analysis. IOP at each diurnal timepoint was significantly lower postoperatively (p<0.0001). The difference between highest and lowest IOP measurement for each patient averaged 2.8 mmHg preoperatively (SD 2.4, MAX 14, MIN 0) and 1.8 mmHg (SD 1.7, MAX 10, MIN 0) month 12 (P<0.00001). The proportion with IOP ≤ to 25, 21, 18, and 15 mmHg increased; 75%-97%, 27%-88%, 1%-79%, and <1%-56%, respectively. The average variability was greater at all time points preoperatively (P<0.0001).

CONCLUSION

This study demonstrates that eyes with OAG can benefit from an overall decreased IOP and degree of IOP fluctuations for as long as 12 months after surgical treatment with canaloplasty and trabeculotomy.