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

Five-Year Outcomes of iStent inject Implantation With or Without Phacoemulsification in Eyes with Open-Angle Glaucoma

INTRODUCTION

Minimally invasive glaucoma surgery (MIGS) has become more widespread in open-angle glaucoma (OAG) management. Broad evidence has shown a greater decrease in mean intraocular pressure (IOP) when cataract surgery is combined with MIGS, compared with cataract surgery alone. In this study, we evaluated the effectiveness and safety of second-generation trabecular micro-bypass implantation (iStent inject®) either in combination with cataract surgery (Combined subgroup) or as a standalone procedure (Standalone subgroup) in eyes with OAG. Our hypothesis was that implementing interventional glaucoma management would provide meaningful reductions in IOP and topical medication burden.

METHODS

This long-term retrospective consecutive case series included patients with mild to moderate OAG who received the iStent inject® Trabecular Micro-bypass stent with or without phacoemulsification between 2018 and 2024. Eligible patients were ≥ 18 years of age with mild or moderate OAG, cataract requiring surgery (for the Combined subgroup), and the need for IOP and/or medication reduction. Study outcomes included mean and proportional analyses of IOP and medications over time. Analyses were completed for the overall population and for the Combined/Standalone and Mild/Moderate subgroups.

RESULTS

The study included 271 eyes with mean age 69 years and a mean of 40 months of follow-up (range 10-79 months). In the overall population, mean IOP decreased from 16.4 mmHg at baseline to 13.7 mmHg at last follow-up (p = 0.001), while the mean number of medications decreased from 2.24 at baseline to 0.62 at last follow-up (p = 0.001). IOP reductions were also significant in the Combined/Standalone subgroups and in the Mild/Moderate subgroups (p = 0.001 for all), and all subgroups experienced increased proportions of eyes on no topical medications at last follow-up versus preoperative (p = 0.001 for all).

CONCLUSION

This 5-year real-world study showed significant and sustained reductions in IOP and topical medication burden following iStent inject trabecular micro-bypass with or without cataract surgery in eyes with mild and moderate open-angle glaucoma.

Three-years follow-up of combined phacoemulsification, iStent and endocyclophotocoagulation

ObjectivesTo assess the efficacy and safety of phacoemulsification combined with endocyclophotocoagulation (ECP) and iStent implantation in surgically naïve patients.MethodsRetrospective observational cross-sectional series of 82 surgically naïve eyes treated with combined phacoemulsification, ECP and iStent between January 2018 and July 2019 at a single centre facility.ResultsA total of 82 eyes underwent the procedure. Average age was 80.9 (±6.4) years and 61% were female. Fifteen (18.29%) eyes had preperimetric glaucoma, the remaining were primary open angle glaucoma as follows: mild 32.92% (N = 27), moderate 35.37% (N = 29) and advanced 13.41% (N = 11). Baseline mean IOP was 19.5 (±4.5) mmHg, falling to 14.4 (±3.2) mmHg at 36-months (p ≤ 0.001). 82% of eyes were a qualified success at 3-year post-op with IOP ≤ 18 mmHg. 26% of eyes were a complete success at 3-years with IOP ≤ 18 mmHg and no medications. At baseline, mean number of medications was 2 reducing to 1.3 ± 1.1 at 3-years; Nineteen (23.2%) were patients medication-free. Best corrected visual acuity improved, increasing from 0.28 ± 0.2 LogMAR preoperatively to 0.10 ± 0.1 LogMAR at 36-months follow-up (p ≤ 0.001). Two patients developed cystoid macular oedema that resolved with topical treatment. Average MD remained stable over 3-years (p = 0.94). Due to suboptimal IOP, 3 patients underwent selective laser trabeculoplasty (SLT). No patients required further glaucoma surgical intervention.ConclusionsCombination of cataract surgery with iStent and ECP is a safe and effective procedure to lower IOP and medication burden. The procedure halted glaucoma progression and prevented further surgery over a 3-years follow up.

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

Purpose

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

Design

Retrospective cohort study.

Participants

Eyes from the Bascom Palmer Glaucoma Repository.

Methods

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

Main Outcome Measures

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

Results

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

Conclusions

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

Financial Disclosures

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

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.

Meta-Analysis of MINIject vs. Two iStents as Standalone Treatment for Glaucoma with 24 Months of Follow-Up

Background: This study compares the long-term intraocular pressure (IOP)-lowering efficacy of standalone MINIject (iSTAR Medical, Belgium) suprachoroidal implantation and two iStent (Glaukos, CA, USA) trabecular bypass implantation using a systematic review and meta-analysis. Methods: Systematic review of standalone implantation of MINIject or iStent inject with at least 24 months of follow up. The mean and standard deviation of IOP and the number of IOP-lowering medications at baseline and at 24 months were extracted. Weighted estimates of the outcome variables were calculated using random-effects meta-analysis models. Heterogeneity in the outcome measures among the studies was quantified using I². Results: Seven studies (three studies for MINIject and four for iStent) comprising 280 eyes were included. At 24 months, there was a greater reduction in IOP from baseline in the MINIject vs. two iStent cohorts (-9.57 vs. -4.92 mmHg, p = 0.03). The change from baseline in mean medication use was -1.00 with MINIject and -0.56 medications with iStent (p = 0.26). The mean percentage IOP reduction at 24 months ranged from 36.3-42.2% with MINIject compared to 5.2-40.7% with iStent, with greater variability in mean change from baseline in IOP observed in the iStent group (I2 = 96.5% vs. 0%). The most frequent adverse events for MINIject were anterior chamber inflammation, best-corrected visual acuity (BCVA) loss, hyphema, and conjunctival hemorrhage, and for iStent, these were device obstruction, BCVA loss, IOP spike, and cataract progression. Conclusions: While both MINIject and iStent inject devices resulted in significant reductions in IOP and IOP medication use, standalone MINIject may provide a greater and more consistent reduction in IOP.

Outcomes and Baseline Predictors of Failure in Primary Standalone Xen45 Gel Stent versus Trabeculectomy for Glaucoma

PURPOSE

To compare safety, effectiveness, and baseline predictors of failure in standalone primary Xen45 gel stent (Xen) versus trabeculectomy (Trab) in glaucoma.

DESIGN

Retrospective study.

SUBJECTS

Subjects that underwent primary Xen or Trab augmented by mitomycin-C with at least 12 months follow-up.

METHODS

Multinational observational study of eyes in the Fight Glaucoma Blindness international registry MAIN OUTCOME MEASURES: The primary outcome was success at 12 months defined by intraocular pressure (IOP) reduction ≥ 20% from baseline and ≤ threshold IOPs of 15, 18, and 21 mmHg with (qualified) or without (complete) medications and without secondary glaucoma surgery. Multivariable mixed effects Cox regression models were used to identify risk factors for failure in each cohort.

RESULTS

A total of 701 eyes (Xen, 308; Trab, 393) of 596 subjects were included with baseline IOP being significantly higher (22.4 vs. 19.9 mmHg, P < 0.001) and baseline medications significantly lower in the Xen versus the Trab group (2.9 vs. 3.4, P < 0.001). Baseline visual field mean deviation was less severe in the Xen group (-9.47 vs. -13.04 dB, P < 0.001). The proportion of complete surgical success was significantly lower in the Xen versus Trab group across the 3 upper IOP limits at 12 months; 32% versus 52% at 15 mmHg, 37% versus 54% at 18 mmHg, and 39% versus 55% at 21 mmHg (P < 0.001). The incidence of postoperative numerical and symptomatic hypotony was lower in the Xen versus Trab group. In the Xen cohort, a higher failure rate was associated with Asian ethnicity (hazard ratio [HR], 1.97; 95% confidence interval (CI), 1.03-3.79) and use of oral acetazolamide at baseline (HR, 1.74; 95% CI, 1.13-2.70), whereas a lower failure rate was associated with diagnosis of ocular hypertension/open-angle glaucoma suspect (HR, 0.40; 95% CI, 0.20-0.82) and secondary open-angle glaucoma (HR, 0.46; 95% CI, 0.26-0.82). Exposure to prostaglandin analog was associated with greater failure in the Trab group (HR, 2.66; 95% CI, 1.18-6.01).

CONCLUSIONS

There was significantly greater complete success at 12 months across all complete success definitions for Trab compared with Xen, whereas the rate of postoperative hypotony was significantly lower in the Xen group. Asian ethnicity and use of oral acetazolamide at baseline were associated with greater failure in Xen, whereas exposure to prostaglandin analog was associated with greater failure in Trab patients. Such baseline predictors of success and failure may help guide patient selection for subconjunctival minimally invasive glaucoma surgery in patients undergoing surgical intervention.

FINANCIAL DISCLOSURE(S)

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

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.

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

OBJECTIVE

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

DESIGN

Retrospective cohort study.

SUBJECTS

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

FINANCIAL DISCLOSURES

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

Long-term efficacy and safety of XEN-45 gel stent implantation in patients with normal-tension glaucoma

BACKGROUND

Minimally invasive bleb surgery using the XEN-45 gel stent has not been established for the treatment of normal-tension glaucoma (NTG). The main objective of this study was to evaluate the long-term treatment efficacy and safety of XEN-45 in eyes with uncontrolled NTG.

METHODS

A retrospective analysis of patients with NTG who underwent XEN-45 gel stent implantation at university hospital Tuebingen between 2016 and 2021. The primary outcome measure was surgical success after three years defined as lowering of intraocular pressure (IOP) of ≥ 20%, with target IOP between 6 and 15 mmHg. Success was complete without and qualified irrespective of topical antiglaucoma medication use. The need for further glaucoma surgery, except for needling, was regarded as a failure. The secondary outcome measures included changes in mean IOP, number of antiglaucoma medications, and needling and complication rates.

RESULTS

Twenty-eight eyes from 23 patients were included in the final analysis. Complete and qualified success rates were 56.5% and 75% after three years, respectively. Mean postoperative IOP ± standard deviation decreased significantly after three years from 19.3 ± 2.0 mmHg at baseline to 13.7 ± 4.2 mmHg (n = 22; p < 0.0001). The median number of antiglaucoma medications decreased from 2 (range 0-4) to 0 after three years (range 0-3; p < 0.0001). Sixteen eyes (57%) required a median of 1 (range 1-3) needling procedures. One eye required further glaucoma surgery. No sight-threatening complications were observed.

CONCLUSION

The XEN-45 stent is effective and safe for the long-term treatment of NTG. However, needling was frequently required to improve outcomes.

How much does cataract surgery contribute to intraocular pressure lowering?

PURPOSE OF REVIEW

To review the literature evaluating the effect of cataract surgery on intraocular pressure (IOP) in patients with glaucoma.

RECENT FINDINGS

Recent high-quality secondary analyses of large and primary trials continue to show IOP lowering following cataract surgery. Likewise, cataract surgery remains a key treatment for angle closure glaucoma. Some micro-invasive glaucoma surgeries (MIGS) have strong evidence to be performed at the time of cataract surgery. Data clarifying when these surgeries should be combined with cataract surgery is emerging. The mechanism underlying IOP lowering after cataract surgery remains unclear.

SUMMARY

Patients who are glaucoma suspects with visually significant cataracts would benefit from cataract surgery alone. Those with mild-moderate damage on 1-2 classes of medications would most likely benefit from additional MIGS. Patients with advanced disease would benefit from cataract surgery and a choice of additional surgery, which depends on disease status and patient factors. Clear lens extraction is becoming a more accepted practice as a primary procedure for patients with angle closure and high IOP or glaucoma. The role of additional MIGS in angle closure needs further study.

The Evolution and Current Landscape of Minimally Invasive Glaucoma Surgeries: A Review

This review examines the evolution, current status, and future potential of minimally invasive glaucoma surgeries (MIGS), a significant advancement in the treatment of glaucoma, a leading cause of irreversible blindness. MIGS offer a less invasive alternative to traditional glaucoma surgeries, primarily aimed at reducing intraocular pressure, minimizing tissue trauma, and providing a safer profile. With the emergence of devices such as the Trabectome, iStent, and others, MIGS have expanded the surgical toolkit, allowing personalized, patient-centered care. Despite their advantages, MIGS face challenges such as efficacy in severe cases, long-term data, and accessibility. Ongoing research and technological innovations continue to refine their capabilities and applications, promising to further transform glaucoma management and patient outcomes. This paper provides an in-depth analysis of MIGS, reflecting on their impact and contemplating future directions in this dynamically evolving field.

Glaucoma Fellows-in-Training Recent Surgery Trends

PURPOSE

The volume of microinvasive glaucoma surgery (MIGS) has increased dramatically in recent years, from 31 059 in 2013 to 69 420 in 2018. We investigated the impact of this trend on trainees by determining the proportion of glaucoma surgeries performed by fellows-in-training comprised by MIGS, trabeculectomies, and aqueous shunts.

DESIGN

Retrospective analysis.

PARTICIPANTS

Fellows-in-training at Glaucoma Fellowship Programs certified by the Association of University Professors of Ophthalmology Fellowship Compliance Committee (AUPO-FCC) METHODS: We analyzed aggregate summaries of surgeries performed by fellows as reported to the AUPO-FCC from the academic years (AYs) beginning in 2014 through AY 2020. Each report lists the average number of procedures performed per surgery type per fellow. We combined these averages to create a sum "average number surgeries performed" across glaucoma surgeries and computed the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of surgeries performed per year.

MAIN OUTCOME MEASURES

Average number of procedures performed for each surgery type as well as the proportion that each surgery type (MIGS, trabeculectomies, and aqueous shunts) represented within the total average number of procedures performed per year.

RESULTS

Average number of MIGS performed is significantly greater in later years compared with earlier years (P < 0.001). The average number of trabeculectomies performed between AYs 2014 and AY 2020 ranged from 21.8 to 31.9 and decreased, on average, by - 0.80 year-to-year. The average number of aqueous shunts performed between AY 2014 and AY 2020 ranged from 44.7 to 49.5, with an average increase of + 0.8 year-to-year. The total average number of procedures performed (across all 3 surgical subtypes) increased on average by + 4.8 procedures each year.

CONCLUSIONS

Since 2014, fellows are performing increasing numbers of MIGS procedures, whereas the total number of trabeculectomies and aqueous shunt surgeries performed each year remain similar, resulting in a net increase in total number of procedures performed per fellow each year. This suggests the increase in MIGS is not associated with a substantial decline in trabeculectomies or aqueous shunts performed by glaucoma fellows.

FINANCIAL DISCLOSURE(S)

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

Preventing Blindness with Early Cataract Surgery and Micro-Invasive Glaucoma Surgery in Patients Over 50: Guidance for Patients, Physicians and World Governments in Dealing with Glaucoma

Purpose

To offer clinical guidance and address safety and efficacy concerns regarding the growing use of micro-invasive glaucoma surgery (MIGS) as an initial treatment for glaucoma in adult patients.

Design

Narrative literature review.

Methods

A review was conducted to assess outcomes and complications of MIGS in the treatment of glaucoma, both alone and in combination with lens replacement. These outcomes were compared with those of standard glaucoma surgery and/or glaucoma management with medication.

Results

MIGS are effective at lowering intraocular pressure (IOP) over long periods of follow-up. These techniques share a similarly high safety profile between one another. MIGS were found to have lower complication rates and to be more effective in reducing the total amount of medication needed to maintain control of intraocular pressure than standard surgery approaches.

Conclusion

MIGS techniques are growing in popularity and have been demonstrated to be a safe and effective alternative to standard glaucoma surgery. Guidance in the implementation of these procedures has been outlined.

Cystoid Macular Edema after Cataract Surgery in the United States: IRIS® Registry (Intelligent Research in Sight) Analysis

PURPOSE

To determine the incidence, risk factors, and visual outcomes of cystoid macular edema (CME) after cataract surgery in the United States.

DESIGN

Retrospective, longitudinal, case-control study.

PARTICIPANTS

Patients aged ≥ 18 years who underwent phacoemulsification cataract surgery.

METHODS

The American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) was used to analyze patients who underwent cataract surgery between 2016 and 2019. Patients who received a diagnosis of CME within 90 days after cataract surgery were classified as cases, and the rest were classified as controls. Multivariable logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for risk factors associated with the development of CME as well as poor visual outcome (defined as a best-recorded visual acuity worse than 20/40 Snellen equivalent at postoperative month 12).

MAIN OUTCOME MEASURES

Incidence, demographics, baseline characteristics, and visual outcomes.

RESULTS

Of 3.1 million cataract surgeries performed during the study period, CME was diagnosed in 25 595 eyes (0.8%), with an average onset of 6 weeks. Patients with CME were more likely to be male, to be aged < 65 years, to be Black, and to have preexisting diabetic retinopathy. Patients with CME were more likely to have a poor visual outcome (OR, 1.75; 95% CI, 1.66-1.84; P < 0.001), with a mean best-recorded visual acuity of 20/30 at postoperative month 12 (compared with 20/25 for those without CME; P < 0.001). Other factors associated with a poor visual outcome included smoking, Medicaid insurance, non-White race, and baseline ocular comorbidities such as macular degeneration and retinal vein occlusion.

CONCLUSIONS

Although the incidence of CME after cataract surgery is low and most eyes achieve a visual acuity of 20/40 or better, there are significant outcome disparities that warrant further exploration.

FINANCIAL DISCLOSURE(S)

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

Recent Trends in Treatment and Associated Costs of Primary Angle-Closure Glaucoma: A Retrospective Cohort Study

PURPOSE

To describe recent trends in the treatment for primary angle-closure glaucoma (PACG) and its associated costs in a clinical setting.

DESIGN

A retrospective cohort study.

SUBJECTS

We included patients with PACG from 2011 to 2020 using a large-scale administrative claims database in Japan.

METHODS

We calculated the frequencies and costs of antiglaucoma drugs, ophthalmic examinations, and glaucoma-related surgeries, stratified by fiscal years and age groups.

MAIN OUTCOME MEASURES

Frequencies and costs of antiglaucoma drugs, ophthalmic examinations, and glaucoma-related surgeries.

RESULTS

We identified 5654 patients with PACG (15 338 patient-years). Prostanoid FP receptor agonist, nonselective β-blocker, and topical carbonic anhydrase inhibitor use decreased, whereas prostanoid EP2 receptor agonist, α-2 adrenergic agonist, Rho-associated protein kinase inhibitor, and fixed-combination eyedrops use increased. The total amount of drug per patient-year significantly decreased. In recent years, the frequency of cataract surgery increased, whereas that of laser peripheral iridotomy decreased. Visual field testing, slit-lamp examination, intraocular pressure measurement, and funduscopy were performed 0.83, 6.65, 5.15, and 4.61 times/patient-year, respectively. The total cost of drugs, examinations, and surgeries was 60 338 yen per patient-year. Patients with PACG spent more than twice the money on surgeries and examinations than they did on antiglaucoma drugs.

CONCLUSION

The amount of antiglaucoma drugs dispensed decreased, and the proportion of fixed-combination and newly introduced eyedrops increased. Frequency of cataract surgery increased whereas that of laser peripheral iridotomy decreased in recent years. Surgeries and examinations were the major cost drivers for PACG treatment. The current results would be valuable information for future economic analyses and policy making.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Safety and Efficacy of Resident-Performed Gonioscopy-Assisted Transluminal Trabeculotomy

PRCIS

GATT can be performed efficaciously and safely by PGY-3 and PGY-4 residents, with clinical outcomes and complication rates that mirror those of attending-performed GATT cohorts from the literature.

PURPOSE

Report outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) performed by PGY-3 and PGY-4 residents.

METHODS

A retrospective chart review was performed for patients undergoing resident-performed GATT. Eyes with previous traditional glaucoma surgery (trabeculectomy or aqueous shunt) or neovascular glaucoma were excluded from this analysis. The primary aim was to assess whether resident-performed GATTs demonstrated success rates comparable with the GATT literature. Surgical success was defined as intraocular pressure (IOP)<21 mmHg, and an IOP reduction of 20% from baseline, and no subsequent IOP-lowering surgery. The secondary and tertiary aims were to describe complication rates and operating times for resident-performed GATTs, respectively.

RESULTS

A total of 50 eyes from 40 patients with various types of glaucoma were included. Eyes either underwent resident-performed GATT-alone (N=9) or GATT+cataract extraction with intraocular lens implantation (CEIOL) (N=41). The surgical success rate at 6 months was 71% for GATT-alone and 42% for GATT+CEIOL. Three eyes required subsequent IOP-lowering surgery. The hyphema rate was 16% at postoperative week 1 and 6% at postoperative month 1. The IOP spike (>30 mmHg) rate was 18%. Mean surgical time for both GATT-alone and GATT+CEIOL was longer for PGY-4s than for PGY-3s, attributable to less attending assistance during PGY-4 cases and more resident-performed cataracts in PGY-4 GATT+CEIOL cases (85%) compared with PGY-3 cases (35%).

CONCLUSIONS

GATT can be performed efficaciously and safely by PGY-3 and PGY-4 residents, with clinical outcomes and complication rates that mirror those of attending-performed GATT cohorts from the literature.

Normal-tension glaucoma: Current concepts and approaches-A review

Normal tension glaucoma (NTG) has remained a challenging disease. We review, from an epidemiological perspective, why we should redefine normality, act earlier at lower pre-treatment intraocular pressure (IOP) level, and the role of ocular perfusion pressures, noting that perfusion is affected by defective vascular bed autoregulation and endothelial dysfunction. The correlation of silent cerebral infarcts (SCI) and NTG may indicate that NTG belongs to a wider spectrum of small vessel diseases (SVD), with its main pathology being also on vascular endothelium. Epidemiological studies also suggested that vascular geometry, such as fractal dimension, may affect perfusion efficiency, occurrence of SCI, SVD and glaucoma. Artificial intelligence with deep learning, may help predicting NTG progression from vascular geometry. Finally, we review latest evidence on the role of minimally-invasive glaucoma surgery, lasers, and newer drugs. We conclude that IOP is not the only modifiable risk factors as, many vascular risk factors are readily modifiable.