Manchester iStent study: 3-year results and cost analysis

Two-Year Data on the Efficacy and Safety of the MINIject Supraciliary Implant in Patients with Medically Uncontrolled Primary Open-Angle Glaucoma

Background/Objectives: The aim of this study is to evaluate the long-term efficacy and safety of the MINIject supraciliary device in patients with medically uncontrolled primary open-angle glaucoma (POAG) with up to 2 years of follow-up. Methods: A retrospective study was conducted using electronic medical records. Patients with medically uncontrolled POAG were included. Patients were either phakic, receiving combined phacoemulsification and MINIject, or pseudophakic receiving standalone MINIject. They were followed up for 24 months postoperatively. The primary outcomes were intraocular pressure (IOP) and use of IOP-lowering medications at 24 months postoperatively. Other secondary outcomes included IOP and use of glaucoma medications at 6, 12, and 18 months, success defined as 6 ≤ IOP ≤ 18 mmHg without the use of medications (complete) or regardless of the use of medications (qualified), average change in visual field (VF) mean deviation (MD) from baseline to 24 months, and adverse events. Results: The study included 37 eyes of 37 consecutive glaucoma patients. Of these, 27 underwent combined phacoemulsification with MINIject implantation and 10 had standalone MINIject. The mean preoperative IOP was 17.95 ± 4.75 mmHg on 2.16 ± 1.12 glaucoma drops. At 24 months, the mean IOP was 14.58 ± 4.55 on 0.69 ± 0.98 medications (p = 0.002). No difference in IOP was noted between the combined and the standalone group, although the latter had a trend for more glaucoma drops. The qualified success and the complete success rates were 67.6% and 56.8%, respectively. Average VF mean deviation progression was 0.19 ± 1.19 dB. No sight threatening complications occurred. Conclusions: MINIject can be a safe and effective alternative to current glaucoma devices, offering significant reduction in IOP and medication use with a good safety profile. Longer term data are needed to confirm its prolonged safety.

Comparison of Safety and Efficacy of Hydrus and iStent Combined with Phacoemulsyfication in Open Angle Glaucoma Patients: 24-Month Follow-Up

The paper presents the results of a 24-month-long observation comparing the effectiveness and safety of two micro-invasive glaucoma surgery (MIGS) devices: Hydrus Microstent and iStent Trabecular Bypass in combination with cataract phacoemulsification in the treatment of open-angle glaucoma. We also analyzed the impact of preoperative factors on achieving surgical success in both surgical methods. The prospective, comparative, non-randomized study included 65 glaucoma surgeries. In 35 patients (53.8%), an iStent implant procedure was performed, while 30 patients (46.2%) underwent a Hydrus implant procedure. The demographic data was similar in both treatment groups. At 24 months after surgery, the mean IOP in the iStent group was 15.9 ± 3.0 mmHg and in the Hydrus group 16.2 ± 1.8 mmHg. The difference between the mean iStent vs Hydrus after two years of treatment was -0.3 (p = 0.683). At the 24 month follow-up, the average change in the number of antiglaucoma medications used was 71.7% in the iStent group and 79.6% in the Hydrus group. The difference in mean percentage change between groups was 7.9% in favor of Hydrus. Patients under the age of 70 may benefit from a greater risk reduction in the Hydrus group (HR = 0.81), while those over the age of 70 may benefit from a risk reduction in the iStent group (HR = 1.33). IOP cases with >18 mmHg before the surgery have a better chance of surgical success with the Hydrus method (HR = 0.28), and with IOP < 18 mmHg in the iStent group (HR = 1.93). Cases with more drugs (≥3 drugs) are more favorable in the Hydrus group (HR = 0.23), while those with a maximum of two drugs have a better prognosis in the iStent group (HR = 2.23). The most common postoperative complication was the presence of erythrocytes in the anterior chamber (AC), found in 40.0% of operated eyes in the Hydrus group. The profile of observed complications and significant improvement in visual acuity allows us to consider both implants as a safe way of treating patients with early or moderate glaucoma and co-existing cataracts.

Systematic Literature Review of Clinical, Economic, and Humanistic Outcomes Following Minimally Invasive Glaucoma Surgery or Selective Laser Trabeculoplasty for the Treatment of Open-Angle Glaucoma with or Without Cataract Extraction

Introduction

Selective laser trabeculoplasty (SLT) and minimally invasive glaucoma surgery (MIGS) are increasingly used options for mild-to-moderate open-angle glaucoma (OAG) care. While most MIGS devices are indicated for use in combination with cataract surgery only, with phacoemulsification playing a role in lowering IOP, newer technologies can also be used as standalone glaucoma surgery.

Methods

This systematic literature review (SLR) aimed to assess the clinical, economic, and humanistic outcomes of MIGS and SLT for the treatment of OAG and was conducted according to PRISMA guidelines. Studies that assessed MIGS or SLT in at least one treatment arm versus any other glaucoma treatment in adults with mild-to-moderate OAG were included. Clinical, humanistic (health-related quality of life [HRQoL] and patient burden), and economic data were extracted, and the methodological quality of included studies was evaluated.

Results

A total of 2720 articles were screened, and 81 publications were included. Fifty-eight reported clinical outcomes. The majority assessed iStent or iStent inject (n=41), followed by OMNI (n=9), gonioscopy-assisted transluminal trabeculotomy (GATT) or the Kahook Dual Blade (KDB) (n=7), Hydrus (n=6), SLT (n=5), Xen Gel Stent (n=2), PreserFlo (n=1), and iTrack (n=1). IOP reduction was observed across prospective studies, varying from -31% to -13.7% at month 6 and from -39% to -11.4% at year 1 versus baseline. Most adverse events were transient and non-serious. Limited humanistic and economic data were identified.

Conclusion

Given their established efficacy and safety, there is a rationale for wider use of MIGS in mild-to-moderate OAG. Of the MIGS devices, iStent and OMNI have the largest clinical evidence base supporting their sustained effectiveness.

Comparison of Efficacy of Combined Phacoemulsification and iStent Inject versus Combined Phacoemulsification and Hydrus Microstent

Aim

This study aims to compare the efficacy and safety of combined phacoemulsification with iStent inject (Phaco-iStent) and Hydrus microstent (Phaco-Hydrus).

Methods

This was a retrospective comparative study of patients who underwent Phaco-iStent from April 2019 to August 2020 and Phaco-Hydrus from August 2019 to December 2020 at a tertiary eye centre in Singapore. Sixty-nine Phaco-iStent eyes and 49 Phaco-Hydrus eyes were included in this study. Complete surgical success was defined as freedom from second glaucoma surgery, Intraocular pressure (IOP) of 18 mmHg or less, and discontinuation of all antiglaucoma medications.

Results

At 12 months, both Phaco-iStent and Phaco-Hydrus groups had comparable surgical success rate (68.1% vs 51%, p=0.061), reduction in antiglaucoma medication use (-1.3 ± 0.1 vs -1.4 ± 0.10, p=0.880) and intraocular pressure reduction (-1.1 ± 0.5 mmHg vs -1.6 ± 0.9 mmHg, p=0.323). Overall intraoperative and postoperative complications rate were similar in both groups, though hyphema was more commonly seen in early postoperative period in the Phaco-Hydrus compared to the Phaco-iStent group (8% vs 0%, p=0.028), with majority of cases resolving without any need for surgical intervention. Device obstruction was also more common in the Phaco-Hydrus group compared to the Phaco-iStent group (14% vs 4.3%, p=0.04).

Conclusion

Phaco-iStent and Phaco-Hydrus have similar surgical efficacy and safety profiles at 12 months.

Surgical Outcome of Combined MicroPulse Transscleral Laser Therapy with Phaco Emulsification in Patients with Cataract and Glaucoma

Purpose:

To determine the effectiveness and safety of combined MicroPulse transscleral laser therapy (TLT) and phacoemulsification in patients with co-existing cataracts and glaucoma.

Methods:

A retrospective consecutive case series of 22 eyes of 19 patients with co-existing cataract and glaucoma. The patients underwent MicroPulse TLT, phacoemulsification, and intraocular lens implantation during the same setting. A comparison of baseline data with the data at 18 months follow-up was made to determine the variation in best-corrected visual acuity (BCVA), intraocular pressure (IOP), and changes in the number of anti-glaucoma drugs.

Results:

Twenty-two eyes of 19 patients (57.9% were female) underwent combined MicroPulse TLT and phacoemulsification. The mean age was 60.5±9.3 years (range: 39.0 to 76.0). Nine eyes (40.9%) had primary open-angle glaucoma, nine eyes (40.9%) had chronic angle-closure glaucoma, and four eyes (18.2%) had pseudoexfoliation glaucoma. The mean baseline IOP was 26.3±4.7, which was significantly reduced to 15.3±2.4 mmHg (43.9%±10.2%) at 18 months (p<0.001). The median number of glaucoma medications was 4 (2 to 5) at baseline and 2 (0 to 4) at 18 months (p=0.002). The mean BCVA was 0.84±0.31 LogMAR (Snellen: 20/138) at baseline and 0.28±0.23 LogMAR (Snellen:20/38) at 18 months (p<0.001). The mean follow-up period was 15.8±3.0 months (range 12 to 18).

Conclusions:

Combined MicroPulse TLT and phacoemulsification was a safe and effective procedure that achieved reduction in both IOP and glaucoma medications for up to 18 months, with no associated vision-threatening complications.

A multicenter prospective comparative study evaluating cataract surgery and endoscopic cyclophotocoagulation either with or without iStent inject implantation in Brazilian patients with glaucoma

Purpose

Compare 12-month (12 M) safety and efficacy of endoscopic cyclophotocoagulation (ECP) + cataract surgery (Group 1) versus ECP + cataract surgery + iStent inject trabecular micro-bypass implantation (Group 2) in Brazilian patients with open-angle glaucoma (OAG).

Methods

This prospective, multicenter, comparative case series included patients with OAG and cataract who were randomized to receive treatment in Group 1 or Group 2. Outcomes included mean and percent reduction versus preoperative in intraocular pressure (IOP) and number of glaucoma medications; visual acuity; occurrence of adverse events; and rate of secondary surgeries.

Results

Preoperatively, Groups 1 and 2 had similar mean IOP (mean ± standard deviation 22.1 ± 3.6 and 22.0 ± 2.5 mmHg, respectively) and mean number of medications (3.3 ± 0.6 and 3.4 ± 0.6 medications, respectively). At all follow-up timepoints through 12 M, both groups achieved significant IOP and medication reductions versus preoperative (IOP p < 0.001 and number of medications p < 0.001 for both groups). At 12 M, IOP reductions were 24.2% (Group 1) and 43.6% (Group 2) (p < 0.001); mean medication reductions were 50.2% and 71.5%, respectively. Mean postoperative IOP and number of medications were higher in Group 1 than Group 2 (IOP p < 0.01 all visits, medication p < 0.01 at 6 M and 12 M). Adverse events were generally mild and infrequent in both groups.

Conclusion

Both treatment groups (ECP + phacoemulsification, with/without iStent inject implantation) achieved significant and safe reductions in IOP and medications versus preoperative in Brazilian OAG patients. Percent reductions were significantly greater, and mean IOP and medications were significantly lower, in the group receiving iStent inject.

Clinical trial registration (CTR)

CAAE project identification #20053019.5.0000.5078. Protocol #3.587.147. Clinical Trial Database of the Federal University of Goiás, Brazil. Registration Date: September 19, 2019.

Advances in Excimer Laser Trabeculostomy within the Landscape of Minimally-Invasive Glaucoma Surgery

Primary open-angle glaucoma (POAG) is currently treated with a variety of surgical and non-surgical approaches. Minimally invasive glaucoma surgery (MIGS) involves several devices and procedures that lower intraocular pressure (IOP) by increasing aqueous outflow. The first laser-based MIGS procedure, Excimer Laser Trabeculostomy (ELT), has emerged as a safe and effective treatment option. This article reviews ELT within the context of alternative MIGS procedures and focuses on the historical development of ELT, principles and techniques of the ELT procedure, safety and efficacy data, comparison to other outflow procedures, and future augmentations to expand the use of ELT. Performed alone or as an adjunct to cataract surgery, ELT has minimal complications and has shown long-term effectiveness in lowering intraocular pressure in thousands of patients. The non-thermal laser-tissue interactions of excimer lasers minimize peripheral tissue damage and ensure outflow channel patency without requiring foreign body implants or creating blebs. The development of 2D optical and 3D optical coherence tomography (OCT) guidance systems will eliminate the need for a goniolens to visualize angle structures and enable thousands more surgeons to perform ELT in the future.

Anterior segment imaging in minimally invasive glaucoma surgery - A systematic review

Minimally invasive glaucoma surgery (MIGS) has grown in popularity over the past decade. This systematic review explores the peri-operative and intraoperative application of anterior segment imaging to maximize the efficacy and safety of MIGS. A review of the PubMed, EMBASE and CINAHL databases was conducted, with inclusion criteria restricted to MIGS that had received United States Food and Drug Administration (FDA) premarket approval, FDA 510(K) premarket notification, or were listed as a class 1 device exempt from FDA approval or notification. 21 manuscripts from 21 unique studies were identified pertaining to MIGS devices including the XEN Gel Stent, Trabectome, iStent Inject, 1st-generation iStent and the Kahook Dual Blade (KDB). Anterior segment imaging modalities included anterior segment optical coherence tomography (AS-OCT), ultrasound biomicroscopy (UBM), aqueous angiography, OCT volumetric scans and in vivo confocal microscopy. Identification and evaluation of aqueous outflow pathways before and after MIGS have potential for improving patient preoperative patient selection and postoperative outcomes. Intraoperative imaging potentially provides the resolution needed for good visualization of angle anatomy and accurate evaluation of surgical endpoints in angle-based MIGS. Anterior segment imaging has been used to identify procedural complications, provide objective information on implant location in relation to surrounding anatomy, assess the post-implantation structural impact of MIGS devices and manage bleb failure and scarring. Technical difficulties in incorporating imaging modalities into the surgical microscope, variable quality of images and optical interference from ocular structures or surgical instruments are remaining barriers, which discourage the widespread clinical use of this technology.

Endocyclophotocoagulation combined with phacoemulsification in surgically naive primary open-angle glaucoma: three-year results

OBJECTIVE

To assess the safety and efficacy of endocyclophotocoagulation with phacoemulsification (phaco-ECP) in surgically naive, primary open-angle glaucoma (POAG).

METHODS

A retrospective case series of patients undergoing phaco-ECP between 2007 and 2017 at a single centre in London, UK. The primary outcome was intraocular pressure (IOP). Secondary outcomes were visual acuity, visual field global indices, topical medications and surgical complications. Failure criteria were: (1) IOP > 21 mmHg or <20% reduction at two consecutive visits, (2) IOP <5 mmHg and (3) further IOP-lowering surgery.

RESULTS

Eighty-three eyes from 83 patients were eligible. Pre-operatively, mean IOP (±SD) was 18.4 ± 5.2 mmHg. The mean number of topical agents (±SD) was 2.7 ± 0.9. Mean IOP (±SD) significantly reduced to 14.3 ± 4.7 at 1 year, 14.1 ± 4.0 at 2 years and 13.6 ± 3.7 at 3 years (p < 0.0001). Topical medications were significantly reduced to 1.3 ± 1.2 at 1 year, 1.7 ± 1.2 at 2 years and 1.8 ± 1.3 at 3 years (p < 0.0001). Annual IOP 'survival' was 70%, 54% and 45% at year 1, 2 and 3, respectively. Complications included uveitis (6%), macular oedema (2%), IOP spikes (1%) and corneal decompensation (1%) with no episodes of hypotony or retinal detachment. One patient underwent filtration surgery within 3 years (1%).

CONCLUSION

Phaco-ECP facilitates significant IOP lowering and reduction of medication burden in surgically naive POAG requiring cataract extraction. The procedure is relatively safe and without the use of implants and their associated risks.

Minimally Invasive Glaucoma Surgery: A Critical Appraisal of the Literature

Micro- or minimally invasive glaucoma surgeries (MIGS) have been the latest addition to the glaucoma surgical treatment paradigm. This term refers not to a single surgery, but rather to a group of distinct procedures and devices that aim to decrease intraocular pressure. Broadly, MIGS can be categorized into surgeries that increase the trabecular outflow [Trabectome, iStent (first and second generations), Hydrus microstent, Kahook Dual Blade and gonioscopy-assisted transluminal trabeculotomy], surgeries that increase suprachoroidal outflow (Cypass microstent and iStent Supra), and conjunctival bleb-forming procedures (Xen gel stent and InnFocus microshunt). Compared to traditional glaucoma surgeries, such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves), MIGS are touted to have less severe complications and shorter surgical time. MIGS represent an evolving field, and the efficacy and complications of each procedure should be considered independently, giving more importance to high-quality and longer-term studies.

Combined and stand-alone XEN 45 gel stent implantation: 3-year outcomes and success predictors

PURPOSE

To evaluate the 3-year treatment outcomes of XEN 45 gel stent in open-angle glaucoma patients.

METHODS

In this prospective, single-centre interventional study, consecutive eyes with uncontrolled intraocular pressure (IOP) or signs of disease progression despite medical treatment underwent XEN implantation either alone or combined with phacoemulsification (Phaco + XEN).

MAIN OUTCOME MEASURES

Surgical success was defined as 'complete' when 36-month unmedicated IOP was ≤15 mmHg with a relative IOP reduction ≥ 20% from medicated baseline, while the definition of qualified success allowed no more medications than at baseline. Other definitions of success with different IOP thresholds were also analysed. Secondary outcomes included mean IOP reduction, changes in ocular hypotensive medications and rates of reoperations.

RESULTS

Out of 149 eyes initially included, 92 eyes (61.7%) of 68 patients had complete 3-year data (XEN: n = 26; Phaco + XEN: n = 66) after 38.2% were lost to follow-up. Mean age was 76.3 ± 9.1 years, and 66.2% were female. Mean medicated IOP decreased from 20.8 ± 7.4 mmHg (21.0 ± 7.4 [XEN] vs. 20.0 ± 6.9 mmHg [Phaco + XEN]) at baseline to 13.1 ± 3.4 mmHg (12.9 ± 2.9 [XEN] vs. 12.9 ± 3.4 [Phaco + XEN]) at 3 years (-37.0%; p < 0.001). Medications decreased from 1.9 ± 1.3 (2.4 ± 1.5 [XEN] vs. 1.9 ± 1.2 [Phaco + XEN]) to 0.4 ± 0.9 (0.3 ± 0.8 [XEN] vs. 0.5 ± 0.9 [Phaco + XEN]) (-78.9%; p < 0.001). Complete success and qualified success were achieved in 29.0% and 31.0% of eyes, respectively. Needling revision was performed in 51 eyes (55.4%), and 26.1% underwent reoperations. Risk factors for surgical failure included male gender (odds ratio [OR]:3.6; p = 0.03), diagnosis of POAG (OR: 4.5; p < 0.01) and undergoing needling revision (OR: 4.6; p < 0.01). While the type of procedure had no effect on the outcomes of PEXG, POAG eyes undergoing combined surgery had significantly higher rates of failure (OR: 7.29; p = 0.023). Most patients stable at 12-month remained so through to 3 years.

CONCLUSIONS

At 3 years, XEN gel stent implantation achieved clinically significant IOP and medication reduction despite relatively high rates of needling and reoperations. Identifying patients at risk preoperatively may help optimize surgical outcomes.

Intraocular Pressure After Cataract Surgery Combined With Ab Interno Trabeculectomy Versus Trabecular Micro-bypass Stent: An Intrasubject Same-surgeon Comparison

PRECIS

Combining Trabectome or iStent with phacoemulsification equally reduces intraocular pressure (IOP) and IOP-lowering medication burden during a 24-month follow-up, with a possible advantage to the Trabectome in the early postoperative period.

PURPOSE

Intrasubject same-surgeon comparison between phacoemulsification combined with Trabectome (Phaco/Trabectome) versus one first-generation iStent (Phaco/iStent).

SETTINGS

Private glaucoma and cataract practice.

DESIGN

This is a retrospective interventional case series.

METHODS

Data collected at 3 to 4 and 20 to 24 hours and up to 30 months following Phaco/Trabectome in 1 eye and Phaco/iStent in the contralateral eye in patients with bilateral visually-significant cataract and open-angle glaucoma. Evaluations included IOP, intraocular pressure-lowering medications (IOPmeds), visual acuity, and complications.

RESULTS

Forty-five patients (90 eyes) were identified (age 76.5, 57 to 95 y). At 3 to 4 hours, IOP was above baseline in 12 and 13 eyes following Phaco/Trabectome and Phaco/iStent, respectively, but the degree of IOP elevation was smaller (P=0.048) following Phaco/Trabectome: 4.3 mm Hg, 2.0 to 6.6 mm Hg (95% confidence interval) versus Phaco/iStent: 8.7 mm Hg, 3.8 to 13.6 mm Hg. At 20 to 24 hours, compared with baseline, IOP was significantly lower after Phaco/Trabectome (P=0.004) but not after Phaco/iStent (P=0.14) although the rate of hyphema was higher following Phaco/Trabectome (12/45 vs. 2/45 eyes, P=0.007). IOP reduction from baseline at 3 to 4 hours was significantly larger (P=0.020) in the 21 eyes with hyphema: -3.9, -6.4 to -1.4 versus the 69 eyes without hyphema: -0.3, -2.0 to +1.4. At 1, 6, 12, and 24 months, IOP and number of IOPmeds were similar and significantly lower compared with baseline following either procedure. No complications were encountered in either group.

CONCLUSIONS

Combined phacoemulsification with either Trabectome or first-generation iStent similarly lowers IOP and IOPmeds burden at 1, 6, 12, and 24 months following surgery. The Trabectome may have an advantage in lowering IOP faster and lessening the degree of IOP elevations in the early postoperative period.

Comparison of 1-Year Effectiveness of Trabecular Microbypass Stent implantation (iStent) in Conjunction With Phacoemulsification Among Mild, Moderate, and Severe Primary Open-angle Glaucoma Patients

PRECIS

The study compared 1-year effectiveness of single trabecular microbypass stent (iStent) implantation with phacoemulsification among glaucoma severities in primary open-angle glaucoma. The study found that mild glaucoma had greater success rate and lower number of medications compared with moderate and severe glaucoma.

PURPOSE

To evaluate the effectiveness of iStent implantation in combination with cataract surgery in moderate to severe glaucoma compared with mild glaucoma.

METHODS

Medical charts of primary open-angle glaucoma subjects undergoing 1 iStent implantation were retrospectively reviewed. Glaucoma was classified on the basis of mean deviation (MD) of the preoperative standard automated perimetry into mild (MD>-6 dB), moderate (MD -6 to -12 dB), and severe (MD<-12 dB). Mixed effect regression models were performed to determine the effect of iStent at 1 year. The outcomes included as follows: (1) intraocular pressure (IOP) and the number of medications, (2) eyes with IOP ≤ severity-based target (18 mm Hg for mild, 15 mm Hg for moderate, 12 mm Hg for severe) (2A) without medication, and (2B) with medication reduction.

RESULTS

In total, 104 eyes from 89 subjects were analyzed. Cataract combined with iStent surgery significantly lowered the number of medications in all groups and significantly decreased IOP in moderate and severe glaucoma (P<0.05). There was significantly higher number of medications in moderate (β: 0.58, P=0.002) and severe (β: 1.20, P<0.001) compared with mild glaucoma. Eyes with moderate glaucoma had significantly lower rate of success (criterion 2A) compared with mild glaucoma [odds ratio (OR): 0.008, P=0.047]. Eyes with moderate and severe glaucoma had significantly lower rates of success (criterion 2B) (moderate vs. mild OR: 0.002, P=0.028; severe vs. mild OR: 0.026, P=0.026).

CONCLUSIONS

Combined phacoemulsification with iStent seems to have a better IOP-lowering and medication-lowering effect in mild glaucoma cases versus those with moderate and severe glaucoma. This difference was found in real-world data over one-year follow-up period. Long-term studies with defined IOP goals and medication removal protocols are warranted.

Manchester iStent study: long-term 7-year outcomes

OBJECTIVES

To determine the efficacy and safety of combined phacoemulsification and single first-generation iStent implantation over 84 months.

SUBJECTS/METHODS

Single-surgeon, single-centre, uncontrolled prospective interventional study in real-world settings. Forty-one patients with open-angle glaucoma on at least one antihypertensive drop underwent phaco-iStent surgery. This cohort was monitored over the subsequent 84 months. The primary outcome measure was intraocular pressure (IOP). Secondary outcome measures were number of glaucoma drops, visual acuity, cup-disc-ratio (CDR), mean deviation (MD) and visual field index (VFI). Thirty-one (76%) patients survived to 48 months and 19 (46%) patients to 84 months.

RESULTS

At 84 months, we demonstrate an absolute mean reduction of 4.87 mmHg (95% CI 1.62-7.64) for IOP and 0.59 (95% CI 0.03-1.16) for number of glaucoma drops. At the final clinic visit, LogMAR VA improved by 0.21 (95% CI 0.08-0.34), with no significant change in CDR, MD and VFI. Attrition was mainly due to death (27%) and further glaucoma surgery (12%). A single patient suffered from postoperative hyphaema, with no sequalae. Patients at high risk for progression to filtration surgery were defined as those on oral acetazolamide for IOP control, or those fulfilling all the following criteria: IOP ≥ 20 mmHg, CDR ≥ 0.7, MD ≤ -4.0 dB, number of drops ≥ 2. This group is to be considered for surgery as the next step in management according to NICE glaucoma guidelines. These patients (n = 14) demonstrated a more marked final IOP reduction of 6.85 mmHg (95% CI 3.97-9.75) vs 1.62 mmHg (95% CI 0.04-3.22) in their low-risk counterparts (n = 27). Reduction in glaucoma drops was 0.86 (95% CI 0.07-1.64) for the high-risk and 0.56 (95% CI 0.06-1.05) for the low-risk cohort. Further glaucoma surgery was required for 4 (29%) high-risk and 1 (0.5%) low-risk patients over the study period.

CONCLUSIONS

Our results strongly suggest that the expected outcome of phaco-iStent surgery is a maintained reduction in intraocular pressure and number of glaucoma medications over 7 years. This is combined with a negligible rate of complications, a sustained improvement in central visual acuity, and a reliable maintenance of peripheral visual function.

Ab interno trabecular bypass surgery with iStent® and iStent inject® for open angle glaucoma

Glaucoma is one of the leading causes of visual loss in industrialized world. Local lowering intra-ocular pressure drops are the first-line treatment for glaucoma. Penetrating and nonpenetrating surgery is considered when topical lowering intra-ocular pressure drops fail. Recently, the iStent® device has been introduced in the management of glaucoma nonresponding sufficiently to local treatment. In this review, we present the results of the trials concerning the efficacy and safety of iStent for the treatment of open angle glaucoma.

Impact of iStent Micro-Bypass Shunt on Medicare Part B Glaucoma Surgical Expenditure

PURPOSE

To examine the impact of the iStent (Glaukos) on the recent glaucoma surgical expenditure for Medicare Part B beneficiaries.

DESIGN

Retrospective, observational, population-based analysis.

PARTICIPANTS

All applicable cases in the Centers for Medicare and Medicaid Services Part B Summary Data Files.

METHODS

The Part B National Summary Data Files from 2007 to 2017 were obtained through the Centers for Medicare and Medicaid Services. Glaucoma surgical procedures, including trabeculectomy, glaucoma drainage implants (GDIs), and select minimally invasive glaucoma surgeries (MIGS) including the iStent, were queried from the database using Current Procedural Terminology (CPT) codes. We used Chow's test to confirm significant changes in expenditure trajectories. We built a mixed-effects regression model to examine the effect of demographic factors on each state's iStent adoption speed.

MAIN OUTCOME MEASURES

Proportion of iStent in total glaucoma surgical spending for individual states for each year.

RESULTS

Total Medicare part B payment for the selected glaucoma procedures increased from $52.0 million in 2007 to $179.9 million in 2017. The percentage for trabeculectomy and GDIs decreased from 92.3% to 21.2%. Conversely, the iStent, approved by the Food and Drug Administration in 2012, increased to represent 57.9% of total payment by 2017. There were significant changes in the slope of glaucoma surgical Medicare payment (P < 0.00001) and iStent payment (P < 0.0001) trajectories in 2012. Mixed-effect regression analysis showed a wide range among the states' rates of increase in iStent proportion between 2012 and 2017 (range, 5.12%-14.54% per year). Higher male proportion in the population was associated with faster increases in iStent proportions (12.4% per 5% increase in male proportion, 95% confidence interval [CI], 4.3-20.5, P = 0.003). Higher median age of the population was associated with slower increases (-3.6% per 1-year increase in median age, 95% CI, -0.4 to -6.8, P = 0.026).

CONCLUSIONS

Increasing payment for the iStent represents the majority of the increase in glaucoma surgical spending in the recent decade. Male gender and age significantly affect the state-wise speed of adoption for the iStent. The impact of the iStent on the comprehensive glaucoma Medicare expenditure in the same time period warrants further study.

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

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

Second-generation trabecular micro-bypass stent implantation: Retrospective analysis after 12- and 24-month follow-up

BACKGROUND

The study aimed to investigate the 24-month safety and efficacy of implantation of two second-generation iStent inject trabecular micro-bypass stents with concomitant cataract surgery.

METHODS

This consecutive case series included 164 eyes of 109 patients implanted with the iStent inject® device with concomitant cataract surgery. The series was comprised of eyes with primary open-angle glaucoma (n = 84), pseudoexfoliation glaucoma (n = 42), normal-tension glaucoma (n = 18), and ocular hypertension (n = 20). All 164 eyes reached 9-14 months of follow-up ("12-month consistent cohort"), with a subset of 88 eyes reaching 21-26 months of follow-up ("24-month consistent cohort"). Performance outcome measures included intraocular pressure (IOP) and number of glaucoma medications. Safety outcomes included intra- or postoperative complications, the need for secondary procedures and corrected distance visual acuity. Comparisons of change in continuous (e.g., IOP) and categorical (e.g., proportions of eyes on zero medications) measures between baseline and postoperative times were made with the paired t-test and McNemar's chi-squared test, respectively.

RESULTS

At 12 months postoperatively, IOP was reduced by 25.5% (from 20.0 ± 5.5 mmHg to 14.9 ± 2.0 mmHg; p < 0.001); at 24 months postoperatively, IOP was reduced by 26.6% (from 20.3 ± 6.1 mmHg to 14.9 ± 1.9 mmHg; p < 0.001). At 12 months postoperatively, mean number of glaucoma medications was reduced by 85.0% (from 2.0 ± 1.0 to 0.3 ± 0.8 medications; p < 0.001); at 24 months postoperatively, mean number of medications was reduced by 81.0% (from 2.1 ± 1.1 to 0.4 ± 0.8 medications; p < 0.001). After 12 months, 96.3% of eyes had an IOP ≤ 18 mmHg and 58.5% of eyes had an IOP ≤ 15 mmHg, with 81.1% of eyes free of any medication, compared to 1.8% of eyes medication-free in the 12-month cohort at baseline. After 24 months, 98.9% of eyes had an IOP ≤ 18 mmHg and 53.4% of eyes had an IOP ≤ 15 mmHg, with 72.7% free of medication compared to 1.1% of eyes medication-free in the 24-month cohort at baseline. Overall, a high safety profile was observed with no significant postoperative complications.

CONCLUSIONS

The insertion of iStent inject (comprised of two second-generation trabecular micro-bypass stents) with cataract surgery effectively provides a sustained reduction in IOP with a markedly improved medication burden up to 24 months postoperatively.

Real-world Case Series of iStent or iStent inject Trabecular Micro-Bypass Stents Combined with Cataract Surgery

INTRODUCTION

This real-world retrospective case series assessed 12-month effectiveness and safety following implantation of iStent® or iStent inject® trabecular micro-bypass with cataract surgery.

METHODS

Consecutive patients were implanted with either iStent (comprising 1 stent) or iStent inject (comprising 2 stents), together with cataract surgery. Most patients had primary open-angle glaucoma. Effectiveness outcomes through 12 months included intraocular pressure (IOP) and glaucoma medications. Proportional analyses were completed for eyes achieving IOP ≤ 18 mmHg, IOP ≤ 15 mmHg, or IOP reduction ≥ 20% from preoperative; and eyes on 0 medications or ≥ 2 medications. Safety outcomes included adverse events, secondary surgeries, visual acuity, and visual fields.

RESULTS

This analysis included 137 eyes (67 iStent, 70 iStent inject) with cataract and mild to moderate glaucoma or ocular hypertension. Over 73% of eyes in both groups had early disease, and ~ 22% had prior glaucoma surgery. At 12 months postoperatively, mean IOP decreased from 18.4 ± 4.2 mmHg to 14.2 ± 2.5 mmHg in iStent eyes (p < 0.0001), and from 20.4 ± 5.6 mmHg to 14.4 ± 2.1 mmHg in iStent inject eyes (p < 0.0001). The IOP reduction was significantly greater for iStent inject eyes than iStent eyes (6.0 mmHg versus 4.2 mmHg reduction, p = 0.034). Both groups had high proportions of patients achieving the 12-month IOP endpoints, although consistently greater proportions reached these endpoints after iStent inject than iStent: 95.7% versus 92.5% had IOP ≤ 18 mmHg, respectively; 74.3% versus 71.6% had IOP ≤ 15 mmHg, respectively; and 68.6% versus 62.7% had IOP reduction ≥ 20% from baseline, respectively. Mean medication burden at 12 months decreased from 1.8 ± 0.7 to 0.3 ± 0.5 medications in iStent eyes (84.0% reduction, p < 0.0001), and from 1.3 ± 0.9 to 0.1 ± 0.3 medications in iStent inject eyes (94.7% reduction, p < 0.0001). Significantly more iStent inject eyes were medication-free at 12 months than iStent eyes (92.9% versus 76.1% medication-free, respectively; p = 0.0068). Favorable safety included few adverse events, no secondary glaucoma surgeries, and stable visual acuity and visual fields in both groups.

CONCLUSION

Significant and safe IOP and medication reductions were achieved through 12 months after iStent or iStent inject implantation with cataract surgery. iStent inject eyes had greater absolute IOP reduction and more eyes medication-free versus iStent eyes.

FUNDING

Glaukos Corporation.

Ocular Antihypertensive Medication Use After iStent Implantation Concurrent With Cataract Surgery vs Cataract Surgery Alone in a Large US Health Care Claims Database

Importance

The iStent Trabecular Micro-Bypass (Glaukos Corporation) is a minimally invasive glaucoma implant used in conjunction with cataract surgery to lower intraocular pressure.

Objective

To determine whether implantation of the iStent concurrent with cataract surgery is associated with reduced use of ocular antihypertensive medications in a US health care claims database.

Design, Setting, and Participants

Retrospective, observational longitudinal cohort study of individuals enrolled in a US managed care network who underwent iStent implantation with cataract surgery (iStent/CEIOL) from 2012 to 2016 (n = 1509 bilateral and n = 1462 unilateral surgery). A control group of individuals who underwent bilateral cataract surgery only (CEIOL) were matched 1:1 to patients undergoing bilateral iStent/CEIOL on baseline demographic and clinical factors. Data were analyzed between November 1, 2017, and January 31, 2018.

Main Outcomes and Measures

The number of topical ocular antihypertensive agents used postoperatively by patients undergoing iStent/CEIOL compared with baseline and with matched CEIOL control individuals, and hazard ratios with 95% confidence intervals for sustained reduced use of at least 1 topical ocular antihypertensive agent postoperatively.

Results

Of the 2971 eligible enrollees, mean age at first surgery was 74.3 years, and 1659 (55.8%) were women. Patients undergoing iStent/CEIOL had diagnoses that included primary open-angle glaucoma (n = 2329; 78.4%), narrow angles (n = 381; 12.8%), and secondary glaucomas (n = 261; 8.8%). At baseline, 1223 (41.2%) were receiving no topical glaucoma agents; 876 (29.5%), 437 (14.7%), and 435 (14.6%) were receiving 1, 2, or at least 3 agents, respectively. Although only 678 persons (22.8%) completed at least 2 years of postoperative follow-up, the proportion of patients receiving no drops increased postoperatively (64.7%, 20-24 months, P < .001, χ2). Patients receiving at least 1 topical agent at baseline had mean reduction of 1.01 and 0.61 medications used at 20 to 24 months with bilateral or unilateral surgery, respectively (both P < .001, paired t). Sustained reduction in glaucoma medication use was more likely in patients receiving at least 3 vs 1 medication at baseline (hazard ratio, 1.68; 95% CI, 1.36-2.09). Compared with matched control individuals undergoing CEIOL, patients undergoing bilateral iStent/CEIOL had a greater mean reduction in drops used (0.99 vs 0.49; postoperative month 20-24; P < .001; paired t) and a higher proportion receiving no drops postoperatively (73.5% vs 55.3%, postoperative month 20-24; P < .001; χ2).

Conclusions and Relevance

Implantation of the iStent trabecular micro-bypass stent concurrent with cataract surgery was associated with moderately reduced use of topical ocular antihypertensive medication. Reduction in the use of glaucoma medications may lessen the burden of medication adverse effects and promote better adherence.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

FUNDING

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

Second-Generation Trabecular Micro-Bypass Stents as Standalone Treatment for Glaucoma: A 36-Month Prospective Study

INTRODUCTION

To evaluate long-term outcomes following stand-alone implantation of two second-generation trabecular micro-bypass stents (iStent inject®, Glaukos Corp., San Clemente, CA, USA) in eyes with predominantly primary open-angle glaucoma (POAG) and considerable preoperative disease burden.

METHODS

Eyes with POAG, pseudoexfoliative glaucoma (PXG), appositional narrow-angle glaucoma (NAG, with open-angle configuration in the area of implantation), or secondary glaucoma were included in this prospective, non-randomized, consecutive case series. All eyes underwent ab interno iStent inject implantation as a sole procedure. Assessments through 36 months included IOP, medications, corrected distance visual acuity (CDVA), secondary glaucoma surgeries, and complications and adverse events.

RESULTS

Two iStent inject stents were implanted in 44 consecutive eyes (POAG = 38, PXG = 4, appositional NAG = 1, secondary neovascular glaucoma = 1) of 31 patients, and 33 eyes had 36-month follow-up data. Preoperative mean IOP was 25.3 ± 6.0 mmHg on a mean of 2.98 ± 0.88 medications, with 75% of eyes on 3-5 medications, no eyes medication-free, and 50% of eyes with history of prior glaucoma surgery. At 36 months postoperatively, mean IOP reduced by 42% to 14.6 ± 2.0 mmHg (p < 0.0001) and 87.9% of eyes achieved an IOP reduction of ≥ 20% versus preoperatively. In addition, 97% of eyes reached IOP ≤ 18 mmHg (vs. 9.1% preoperatively; p < 0.0001) and 70.0% of eyes reached IOP ≤ 15 mmHg (vs. 2.3% preoperatively; p < 0.0001). Mean medication burden decreased by 82% to 0.55 ± 0.79 (p < 0.0001), and 61% of eyes became medication-free. All eyes maintained or decreased their 36-month medication burden versus preoperatively. Safety was favorable, including minimal adverse events and stable CDVA through 36 months postoperatively.

CONCLUSION

This real-world cohort of glaucomatous eyes with substantial preoperative disease burden experienced significant, sustained, safe IOP and medication reductions through 36 months following stand-alone iStent inject implantation.

FUNDING

Article processing charges and writing assistance were provided by Glaukos Corp. (San Clemente, CA, USA).

Intermediate Results of iStent or iStent inject Implantation Combined with Cataract Surgery in a Real-World Setting: A Longitudinal Retrospective Study

INTRODUCTION

In this real-world, retrospective, comparative study we evaluated 6-month performance and safety in consecutive eyes following implantation of the iStent® or iStent inject® trabecular micro-bypass device with concomitant cataract surgery.

METHODS

Performance outcomes included intraocular pressure (IOP) reduction; glaucoma medication reduction; proportions of eyes achieving an IOP of < 18, < 16, < 14, or < 12 mmHg; and proportions of eyes on 0, 1, 2, or ≥ 3 medications. Safety outcomes included adverse events, secondary surgeries, and best-corrected visual acuity (BCVA).

RESULTS

A total of 73 eyes with open-angle glaucoma and cataract were included in the study; of these, 38 eyes were implanted with the iStent device and 35 were implanted with the iStent inject device. The two groups of patients had similar baseline characteristics, with the exception of mean age and medication burden (both higher in patients receiving the iStent inject device); over 90% of eyes in both groups had early glaucoma. At 6 months after surgery, mean IOP had fallen from 16.5 ± 3.9 to 13.9 ± 2.3 mmHg in eyes with the iStent implant (p < 0.001), and from 17.3 ± 3.0 to 12.7 ± 1.8 mmHg in those with the iStent inject implant (p < 0.001). This reduction was significantly greater in the iStent inject eyes than in the iStent eyes (26.6 vs. 15.8%) (p = 0.005). Significantly more eyes receiving the iStent inject device compared to the iStent device achieved an IOP of < 18 mmHg at 6 months post surgery (100 vs. 86.8%) (p = 0.033). Average medication usage was reduced from 1.8 to 0.4 medications in iStent eyes (p < 0.001) and from 2.3 to 0.4 medications in iStent inject eyes (p < 0.001). Over 70% of eyes in both groups became medication-free by 6 months post implantation. Adverse events in iStent eyes were mild and resulted in no sequelae; two iStent eyes underwent non-penetrating deep sclerectomy during follow-up. No complications or secondary surgeries were noted in iStent inject eyes. All eyes in both groups maintained or showed improved BCVA versus baseline.

CONCLUSION

Significant and safe IOP and medication reductions were observed after iStent or iStent inject implantation with concomitant cataract surgery. Trends toward greater effectiveness and fewer adverse events were observed with the iStent inject device compared with the iStent device.

FUNDING

Article processing charges were provided by Glaukos Corporation.

Comparing iStent versus CyPass with or without phacoemulsification in patients with glaucoma: a meta-analysis

Bacground

The aim of this study was to conduct a meta-analysis to compare the overall intraocular pressure (IOP)-lowering effect of iStent or CyPass as isolated procedures or in combination with cataract extraction.

Materials and methods

Cochrane review manager 5.3 software (RevMan^® 5.3) was used for a meta-analysis of IOPs and the number of antiglaucoma medications in six groups according to the type and number of stents and whether the procedure was isolated or in combination with cataract extraction.

Main results

A total of 33 out of 446 publications retrieved have been enrolled. The mean changes in IOP in the groups with one iStent and more than two iStents with concurrent cataract extraction were -3.78 ± 0.53 mmHg and -3.89 ± 0.73 mmHg, respectively. The mean differences in IOP in the groups with one iStent and more than two iStents without concurrent cataract extraction were -3.96 ± 0.25 mmHg and -7.48 ± 0.55 mmHg, respectively. The mean changes in IOP in the groups with CyPass implantation with and without concurrent cataract extraction were -4.97 ± 1.38 mmHg and -8.96 ± 0.16 mmHg, respectively.

Conclusions

Both iStent and CyPass either in combination with cataract extraction or as isolated procedures effectively decrease IOP. This effect is greatest with isolated implantation of CyPass followed by multiple iStents and then single iStent implantation and lasts up to 2 years.

Efficacy of Cataract Surgery With Trabecular Microbypass Stent Implantation in Combined-Mechanism Angle Closure Glaucoma Patients

PURPOSE

To evaluate the effectiveness of trabecular microbypass stent (iStent) implantation in combined mechanism glaucoma (CMG).

DESIGN

Retrospective cohort study.

METHODS

We reviewed the medical charts of patients with the following scenarios: (1) primary open-angle glaucoma (POAG) undergoing phacoemulsification (PE), (2) POAG undergoing PE with iStent (POAG-PE/iStent), (3) CMG undergoing PE (CMG-PE), and (4) CMG undergoing PE with iStent (CMG-PE/iStent). CMG was defined as narrow-angle glaucoma patients whose angle had opened after iridotomy. Linear mixed-effects models were performed to determine the effect of iStent on postoperative 1-year success rate (intraocular pressure [IOP] ≤ 18 without medication), IOP, and number of medications.

RESULTS

Data from 301 eyes were available. The number of eyes (subjects) was 61 (45) in the POAG-PE, 60 (50) in POAG-PE/iStent, 93 (76) in CMG-PE, and 87 (70) in CMG-PE/iStent group. Success criteria were achieved in 13.1% for POAG-PE, 33.3% for POAG-PE/iStent (POAG-PE vs POAG-PE/iStent B 3.01; P < .001), 37.6% for CMG-PE, and 43.7% for CMG-PE/iStent (CMG-PE vs CMG-PE/iStent B 2.25; P < .001). There was no difference in the IOP between POAG-PE and POAG-PE/iStent, and between CMG-PE and CMG-PE/iStent. The iStent significantly reduced number of medications in the POAG (B -0.70; P < .001) and CMG group (B -0.52; P < .001). Comparing the effect of iStent on POAG and CMG, the analysis showed similar iStent efficacy in terms of the success rate, IOP, and number of medications (P > .05).

CONCLUSIONS

Combined PE/iStent significantly increased success rate and reduced number of medications in CMG patients compared to PE alone. The effects of iStent were comparable between POAG and CMG groups.

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

INTRODUCTION

Primary open-angle glaucoma is estimated to affect 3% of the population aged 40-80 years. Trabeculectomy is considered the gold standard in surgical management of glaucoma; however, it is a technically complex procedure that may result in a range of adverse outcomes. Device-augmented, minimally invasive procedures (micro-invasive glaucoma surgeries, MIGS) have been developed aiming for safer and less invasive intraocular pressure (IOP) reduction compared with traditional surgery.

METHODS

This paper presents results from a systematic literature review conducted in accordance with National Institute for Health and Care Excellence requirements for the Medical Technology Evaluation Programme via multiple databases from 2005 to 2016. For clinical outcomes, randomized clinical trials (RCTs) comparing MIGS with trabeculectomy or other therapies, observational studies, and other non-RCTs were included. Clinical outcomes reviewed were the change from baseline in mean IOP levels and change in topical glaucoma medication. Safety was assessed by reported harm and adverse events. For economic evidence, trials on cost-effectiveness, cost-utility, cost-benefit, cost-consequences, cost-minimization, cost of illness, and specific procedure costs were included. Risk of bias was assessed for clinical studies using the Cochrane Risk of Bias tool.

RESULTS

A total of nine RCTs (seven iStents®, one Hydrus®, and one CyPass®), seven non-RCTs (three iStent®, three CyPass®, and one Hydrus®), and 23 economic studies were analyzed. While various forms of trabeculectomy can achieve postoperative IOP of between 11.0 and 13.0 mmHg, MIGS devices described in this review were typically associated with higher postoperative IOP levels. In addition, MIGS devices may result in increased hypotony rates or bleb needling in subconjunctival placed devices, requiring additional medical resources to manage. There is limited available evidence on the cost-effectiveness of MIGS and therefore it remains unclear whether the cost of using MIGS is outweighed by cost savings through decreased medication and need for further interventions.

CONCLUSION

Larger randomized trials and real-world observational studies are needed for MIGS devices to better assess clinical and economic effectiveness. Given the shortage of published data and increasing use of such procedures, living systematic reviews may help to provide ongoing and timely evidence-based direction for clinicians and decision makers. This review highlights the current unmet need for treatments that are easy to implement and reduce long-term IOP levels without increasing postoperative aftercare and cost.

FUNDING

Santen GmbH, Germany.

One-year result of XEN45 implant for glaucoma: efficacy, safety, and postoperative management

PurposeTo report the efficacy, safety profile, and postoperative management of XEN45 implant at 12-month follow-up.Patients and methodsThis was a retrospective, non-randomised interventional case series involving patients who underwent XEN45 implantation by a single, experienced glaucoma specialist in a tertiary centre. Primary outcome measures were the intraocular pressure (IOP) and the number of medications at 1-year follow-up visit. Two IOP criteria were chosen to measure success: IOP ≤21 mm Hg and ≥20% reduction from baseline (criteria one); and IOP ≤15 mm Hg and ≥30% reduction from baseline (criteria two).ResultsAll 39 eyes completed 1-year follow-up. The mean preoperative IOP was 24.9±7.8 mm Hg on three drops, which reduced to 14.5±3.4 mm Hg at month 12 (P<0.005) on 0.7 drops (P<0.005). On the basis of criteria one, the cumulative probability of success at 1 year was 87.0% without medication and 92.0% with medication. On the basis of criteria two, cumulative probability of success was 62.0% without medication and 64.0% with medication. Bleb intervention with a median of 2 (range 1-4) was required for 51.3% of eyes. Implant was obstructed by iris tissue in three eyes (7.7%); one eye (2.6%) developed hyphaema; eight eyes (20.5%) had numerical hypotony (IOP≤5 mm Hg) at day 1, of which all spontaneously resolved by week 4 apart from one eye.ConclusionsThe XEN45 implant proved to be an effective treatment with a good safety profile at 1-year follow-up period. The high rate of postoperative bleb intervention does not make XEN45 a 'fit-and-forget' procedure and therefore the procedure should ideally be performed by surgeons experienced in bleb management.

An Update on Implants for Minimally Invasive Glaucoma Surgery (MIGS)

For several years, the gold standard for surgical treatment of glaucoma has been trabeculectomy. Although very successful at reducing intraocular pressure (IOP), there are several potential complications of trabeculectomy, including sight-threatening ones. This has stimulated much research aimed at the development of new and effective procedures to lower IOP with an enhanced safety profile. Minimally invasive glaucoma surgery (MIGS) procedures prioritise patient safety but also demonstrate efficacy in reducing IOP. We performed an online search of peer-reviewed literature using PubMed, entering keywords relevant to this clinical discipline. In summary, there is a lack of long-term safety and efficacy data, a lack of comparative data and a lack of data on standalone (i.e. without simultaneous cataract surgery) procedures. Most implants are not yet FDA approved. Although not exhaustive, since it does not discuss MIGS procedures that are not implants, this article summarises the range of different MIGS implants that are available to the ophthalmic surgeon.

Safety and Efficacy of Microinvasive Glaucoma Surgery

Microinvasive glaucoma surgery (MIGS) is emerging as a new therapeutic option for glaucoma patients who wish to reduce their medication burden and avoid the postoperative complications of conventional glaucoma filtration surgery. These devices differ in terms of their efficacy and safety profile. Schlemm's canal devices have the most favorable safety profile at the compromise of modest efficacy, while subconjunctival and suprachoroidal devices are potentially more effective at lowering the intraocular pressure at the expense of a higher rate of complications. This review consolidates the latest evidence on the efficacy and safety of the MIGS devices in clinical use and provides an overview on upcoming devices which would likely also become viable treatment options in the near future. These clinical data would assist a glaucoma surgeon in selecting the most appropriate MIGS device for each patient based on the glaucoma severity and patient expectations.