Effectiveness of iStent Trabecular Microbypass System Combined with Phacoemulsification versus Phacoemulsification Alone in Patients with Glaucoma and Cataract Depending on the Initial Intraocular Pressure

Minimally invasive bleb surgery versus minimally invasive glaucoma surgery: a 12-month retrospective study

This study aimed to compare the IOP-lowering effectiveness and safety of standalone Preserflo MicroShunt and iStent 1st generation implantation combined with phacoemulsification in Caucasian patients with a 12-month follow-up period. This retrospective study analyzed the medical histories of patients undergoing antiglaucoma surgery at the Department of Ophthalmology, Medical University of Bialystok, between January 2019 and January 2022. The main outcome measures were success rates (complete: proportion of eyes with IOP < 18 mmHg (criterion A) and < 15 mmHg (criterion B) or 20% reduction in IOP without any glaucoma medication; qualified: proportion of eyes achieving IOPs < 18 mmHg and < 15 mmHg or 20% reduction in IOP from baseline with or without medications), mean reduction (%) in IOP, medication burden, number of complications and additional interventions. In both groups, a significant decrease in IOP and medication burden were observed at 6 and 12 months when compared with baseline. At 12 months, qualified surgical success in criterion A was recorded in 67.4% and 85.7% of patients in the Preserfo and iStent groups, respectively (p = 0.045). Complete surgical success in criterion B at 12 months accounted to 61.4% of patients from Prserflo group and 32.7% patients in iStent group (p = 0.04). Surgical failure at 12 months was documented in 30.2% and 6.3% of patients, respectively (p = 0.003). There was a significant difference between groups in %IOP reduction after 12 months. Greater reduction was observed in Preserflo group, MD = - 8.41 CI95 [- 15.88; - 0.95], p = 0.028, (- 33.49% ± 21.59 vs - 25.07% ± 14.15 in iStent group). Both procedures effectively reduced IOP and postoperative use of antiglaucoma medications in glaucoma patients.

Early Outcomes of Combined Phacoemulsification and Ab Interno Tanito Microhook Trabeculotomy in Open-Angle Glaucoma

PURPOSE

To study the early postoperative efficacy and safety of an Ab Interno microhook trabeculotomy (microLOT) combined with cataract surgery in patients with open-angle glaucoma.

METHODS

This prospective, randomized, interventional study was conducted on consecutive patients with visually significant cataract and mild-moderate open-angle glaucoma. One hundred fourteen patients were included for analysis. The patients were randomized to undergo microhook trabeculotomy with phacoemulsification (group 1) or phacoemulsification alone (group 2). All patients were evaluated on postoperative day 1, 15, and 30, as well as 3, 6, and 12 months postoperatively. A P value < 0.05 was considered statistically significant. Baseline and follow-up visits were compared to determine significant differences in the number of antiglaucoma medications (AGMs), intraocular pressure (IOP), and best-corrected visual acuity.

RESULTS

There were 57 patients in each group. The baseline characteristics were similar between the 2 groups, except the number of AGMs, which was greater in group 2. The mean preoperative IOP for group 1 (phaco-microLOT) was 26.5 mmHg ± 5.2 and group 2 (phaco-alone group) was 25.3 mmHg ± 3.1 which decreased to 12.5 mmHg ±3.6 (P < 0.001) and 20.0 mmHg ± 2.7(P < 0.001) at 12 months, respectively. Logarithm of the minimum angle of resolution visual acuity improved from 0.48 (interquartile range [IQR], 0.30-0.60) preoperatively to 0.00 (0.00-0.18) postoperatively (P < 0001) in group 1 and improved from 0.30 (IQR, 0.30-0.48) to 0.00 (0.00-0.00) in group 2 (P < 0.001). In group 1, the mean (standard deviation [SD]) AGM used preoperatively was 0.6 (0.9) which was significantly reduced to 0.2 (0.5) at 12 months postoperatively, whereas in group 2, at 12 months, the mean (SD) AGM used was reduced from 1.4 (0.6) to 1.1 (0.9). In group 1, 90.3% of eyes achieved complete success at the end of 1 year. The most common complication was hyphema, noted in 4 patients with 1 eye requiring an anterior chamber washout.

CONCLUSION

Ab interno microhook trabeculotomy (microLOT) combined with phacoemulsification in patients with open-angle glaucoma is an efficacious procedure with relatively minimal complications.

FINANCIAL DISCLOSURE(S)

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

Consistency in Standalone Canaloplasty Outcomes Using the iTrack Microcatheter

Purpose

To study the consistency in outcomes of standalone canaloplasty performed via an ab-interno surgical technique in reducing intraocular pressure (IOP) and number of medications in uncontrolled open-angle glaucoma (OAG) eyes over a 12-month period.

Methods

This retrospective multicenter case series included patients who underwent standalone canaloplasty via an ab-interno surgical technique using the iTrack microcatheter (Nova Eye, Inc., Fremont, USA) and had preoperative uncontrolled OAG (IOP≥18mmHg) along with no previous glaucoma surgery. The iTrack microcatheter is used to circumnavigate 360° and viscodilate Schlemm's canal. Consistency of IOP and medications reduction on an eye-by-eye basis were evaluated to understand the outcomes in each single eye.

Results

Sixty-four eyes of 60 patients (age 71.5±13.4 years) were included. Six eyes (9%) that underwent additional glaucoma surgery were considered a failure and were subsequently excluded from analysis. At 12 months, IOP was reduced in 57 of the 58 (89%) remaining eyes; one eye had the same IOP with a reduced number of medications. Of the 57/58 eyes with a reduced IOP: 44 eyes (69%) required fewer medications; 12 eyes (19%) required the same number of medications. Of these 58 eyes, 78% of eyes had a ≥20% reduction in IOP compared to baseline; 69% eyes had a postoperative IOP ≤15 mmHg, and 86% eyes ≤18 mmHg at 12 months. Forty percent of the eyes were medication-free at 12 months compared to none at baseline.

Conclusion

Canaloplasty performed via an ab-interno surgical technique as a standalone procedure consistently reduced IOP and glaucoma medications in almost all eyes.

Four-Year Efficacy and Safety of iTrack Ab-interno Canaloplasty as a Standalone Procedure and Combined with Cataract Surgery in Open-Angle Glaucoma

PURPOSE

To evaluate the long-term effectiveness of ab-interno canaloplasty (ABiC), performed with the iTrack microcatheter (Nova Eye Medical, Fremont, CA, USA), in reducing intraocular pressure (IOP) as well as the number of required glaucoma medications in patients with open-angle glaucoma (OAG).

METHODS

In this retrospective single-center consecutive case series, 27 eyes of 21 patients (mean age 77.3 ± 5.8 years) were treated with ABiC performed as a standalone procedure or combined with cataract surgery. Patients with uncontrolled IOP OAG or controlled IOP (≤ 18 mmHg) OAG with intolerance to medications or lack of compliance were included. Patients were followed for up to 4 years following the procedure. The iTrack microcatheter was used to perform a 360-degree circumferential intubation and viscodilation of Schlemm's canal. Primary efficacy endpoints included IOP and the number of glaucoma medications at 12, 24, 36, and 48 months after surgery.

RESULTS

In all eyes, mean IOP and number of glaucoma medications were significantly reduced from 19.8 ± 5.2 mmHg and 1.9 ± 1.00 at baseline to 14.6 ± 3 mmHg and 0.9 ± 0.8, respectively, at the 48-month follow-up (p < 0.001). IOP was stable from 12 months to 48 months (p > 0.005). After 48 months, 39% of the eyes required zero medications compared to 3.7% at baseline, and 72.2% of eyes required only one medication or less. Of all eyes, 77.8% recorded an IOP ≤ 17 mmHg. No serious complications were recorded.

CONCLUSION

iTrack ABiC performed as a standalone procedure or in combination with cataract surgery significantly reduced IOP and number of medications in patients with OAG up to 4 years after the procedure.

First-Generation iStent Bypass Implantation versus ab Externo Canaloplasty Combined with Phacoemulsification in Patients with Primary Open Angle Glaucoma-12-Month Follow-Up

This prospective, non-randomized, interventional clinical study evaluated the efficacy and safety profile of first-generation iStent bypass implantation versus ab externo canaloplasty, both combined with phacoemulsification, in patients with primary open-angle glaucoma (POAG) after 12-month follow-up. A total of 138 patients with POAG and their 138 eyes (69 phaco-iStent and 69 phacocanaloplasty) were included. Postoperatively at 12 months, the mean intraocular pressure (IOP) decreased from 18.44 ± 3.88 to 15.51 ± 2.50 mmHg and from 17.20 ± 4.04 to 14.97 ± 2.37 mmHg in the phaco-iStent (PiS) and phacocanaloplasty (PC) groups, respectively (p = 0.480). In both groups, 35.7% achieved >20% IOP reduction from baseline. A total of 86% and 71.4% of the eyes were medication-free at 12 months in the PiS and PC groups, respectively. In both groups, all eyes showed improvement in best-corrected visual acuity compared with baseline and demonstrated similar safety profiles throughout the 12-month follow-up period. This study showed equal hypotensive effects of PiS and PC. Both procedures significantly reduced the IOP and the requirement for IOP-lowering medications for at least 12 months postoperatively, with no significant differences between the groups.

Phacoemulsification with and without iStent: A Systematic Review and Meta-Analysis of Comparative Studies

BACKGROUND

The iStent (Glaukos Corporation; Laguna Hills, CA, USA) is one of the minimally invasive glaucoma devices. It can be inserted at the time of phacoemulsification or as a stand-alone procedure to lower the intraocular pressure (IOP).

OBJECTIVE

Our aim was to conduct a systematic review and meta-analysis comparing the effect of iStent insertion at the time of phacoemulsification with phacoemulsification alone in patients with ocular hypertension or open-angle glaucoma.

METHODS

We searched EMBASE, MEDLINE (OVID and PubMed), CINAHL, and Cochrane Library for articles published between 2008 and June 2022 (PRISMA 2020 for the checklist). Studies comparing the IOP-lowering effect of iStent with phacoemulsification versus phacoemulsification alone were included. The endpoints were IOP reduction (IOPR) and the mean reduction in the number of glaucoma drops. A quality-effects model was used to compare both surgical groups.

RESULTS

Ten studies were included, reporting on 1,453 eyes. Eight hundred fifty three eyes had the combined iStent and phacoemulsification, and 600 eyes underwent phacoemulsification alone. IOPR was higher in the combined surgery at of 4.7 ± 2 mm Hg compared to 2.8 ± 1.9 mm Hg in phacoemulsification alone. A greater decrease in postoperative eye drops was noted in the combined group having a decrease of 1.2 ± 0.3 eye drops versus of 0.6 ± 0.6 drops in isolated phacoemulsification. The quality effect model showed an IOPR weighted mean difference (WMD) of 1.22 mm Hg (confidence interval [CI]: [-0.43, 2.87]; Q = 315.64; p < 0.01; I2 = 97%) and decreased eye drops WMD 0.42 drops (CI: [0.22, 0.62]; Q = 42.6; p < 0.01; I2 = 84%) between both surgical groups. Subgroup analysis shows that the new generation iStent may be more effective in reducing IOP.

CONCLUSION

iStent has a synergetic effect with phacoemulsification. The reduction of IOP and glaucoma eye drops was higher when iStent is combined with phacoemulsification compared with isolated phacoemulsification.

Emerging glaucoma treatments: are we seeing an improvement in adherence?

Introduction

Non-adherence to glaucoma medication and poor follow-up is a global health concern.

Areas covered

Glaucoma remains one of the largest causes of irreversible blindness worldwide. Traditional treatment guidelines suggest topical eye drop medication as first line therapy followed by addition of supplementary medications before proceeding to more invasive glaucoma surgeries. Unfortunately, poor glaucoma self-management remains high, leading to disease progression and blindness. Recent advancements in the field of pharmacotherapies, surgeries, and behavioral approaches have taken aim at increasing support for glaucoma self-management. We review the current and emerging approaches towards glaucoma management, with the exception of bleb-based surgical approaches, to investigate if they have had an impact on adherence. Literature searches were conducted via MEDLINE (PubMed), Embase (Elsevier), Cochrane Library (Wiley), and Preprints from January 1st, 2018, to January 26th, 2023.

Expert opinion

The ability to offer patients a multitude of choices enables patients to tailor their glaucoma treatment to their values and lifestyle. Offering personalized patient education and coaching to support chronic glaucoma self-management would better enable patient engagement in whichever treatment path is chosen. Currently, literature regarding the impact of these new advancements on treatment engagement is lacking; this field is ripe for additional intervention and assessment.

Comparison of Outcomes of Phacoemulsification Combined with Endoscopic Cyclophotocoagulation, iStent, or Both in the Management of Open-Angle Glaucoma

INTRODUCTION

To compare outcomes of phacoemulsification combined with endoscopic cyclophotocoagulation (phaco/ECP), first generation iStent implantation (phaco/iStent), or both (phaco/iStent/ECP) in patients with open-angle glaucoma.

METHODS

A retrospective chart review was performed on patients at the University of Colorado Department of Ophthalmology. Outcomes included intraocular pressure (IOP), medication use, best corrected visual acuity (BCVA), and surgical complications were analyzed. Success was defined as IOP reduction of ≥ 20% and/or reduction by at least one glaucoma medication.

RESULTS

A total of 394 eyes were included in the study. There were 170 eyes (43.1%) in the phaco/ECP group, 175 eyes (44.4%) in the phaco/iStent group, and 49 eyes (12.4%) in the phaco/iStent/ECP group. The mean pre-operative IOP was 15.9 mmHg for phaco/ECP, 15.8 mmHg for phaco/iStent, and 15.2 mmHg for phaco/iStent/ECP. At 24 months, the mean IOP was 13.7 mmHg (p < 0.0001), 14.2 mmHg (p = 0.0001), and 13.0 mmHg (p = 0.0007), respectively. The mean pre-operative number of glaucoma medications was 2.0 for phaco/ECP, 1.4 for phaco/iStent, and 2.2 for phaco/iStent/ECP and at 24 months post-surgery decreased to, 1.8 (p = 0.011), 0.9 (p < 0.0001), and 1.7 (p = 0.01), respectively. The success rate at 24 months was 54.4% for phaco/ECP, 75.3% for phaco/iStent, and 55.6% for phaco/iStent/ECP.

CONCLUSION

Phacoemulsification when combined with ECP, iStent, or both, lowered IOP and glaucoma medication reliance at 24 months. The success rate for phaco/iStent was significantly higher than phaco/ECP. When iStent was added to phaco/ECP, the success rate was higher at earlier postoperative visits compared to the phaco/ECP alone.

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.

Impact of minimally invasive glaucoma surgery on the ocular surface and quality of life in patients with glaucoma

Background:

Minimally invasive glaucoma procedures are emerging as clinically effective and safe glaucoma management approaches; however, evidence regarding quality-of-life outcomes is limited.

Objectives:

To explore the impact of minimally invasive glaucoma surgery (MIGS) combined with phacoemulsification on patient-reported outcomes and clinical parameters related to ocular surface disease in people with glaucoma.

Design:

Retrospective observational study.

Methods:

Fifty-seven consecutive patients were examined prior to undergoing iStent combined with phacoemulsification with or without adjunctive endocyclophotocoagulation and at 4-month follow-up.

Results:

At follow-up, on average patients returned statistically significantly improved scores on glaucoma-specific (GQL-15, p < 0.001; GSS, p < 0.001), general health (EQ-5D, p = 0.02) and ocular surface PROMs (OSDI, p = 0.001). Patients were using fewer eye drops on average after MIGS compared with before surgery (1.1 ± 0.9 versus 1.8 ± 0.8; p < 0.001). Undergoing MIGS was associated with improved tear film break-up time ( p < 0.001) and reduced corneal fluorescein staining ( p < 0.001).

Conclusion:

This retrospective audit shows quality of life and clinical parameters related to the ocular surface are improved following MIGS combined with phacoemulsification in patients previously treated with anti-glaucoma therapy.

Prospective 12-month outcomes of combined iStent inject implantation and phacoemulsification in Asian eyes with normal tension glaucoma

Background

Glaucoma is the leading cause of irreversible blindness. Normal tension glaucoma (NTG) is a subset of open-angle glaucoma, demonstrating glaucomatous optic nerve damage in the absence of raised intraocular pressure (IOP). NTG is more prevalent in Asian populations. While generally slow-progressing, NTG may be associated with significant central visual field loss. In recent years, minimally invasive glaucoma surgery has been added to the armamentarium of glaucoma surgery. This prospective study aims to evaluate 12-month surgical outcomes of combined iStent inject (Glaukos Corporation, Laguna Hills, CA) implantation and phacoemulsification in Asian eyes with NTG.

Methods

This is a prospective, single-centre case series of 30 eyes followed up until 12 months after surgery. Outcome measures included IOP, number of glaucoma medications, best-corrected visual acuity (BCVA) and intra and postoperative complications.

Results

Mean age of subjects was 73.1 ± 6.3 years. Majority were ethnic Chinese (n = 27, 90%). Baseline medicated mean IOP was 13.8 ± 2.4 mmHg and mean number of glaucoma medications was 1.3 ± 0.7. Mean Humphrey visual field mean deviation was − 13.7 ± 7.6. The mean IOP reduction at all timepoints from postoperative month (POM) 3 onwards was statistically significant (all P < 0.05), with mean reduction of 1.2 mmHg (95% CI: 0.1–2.2, P = 0.037) by POM12. There was statistically significant reduction in mean number of medications from postoperative day (POD) 1 onwards (all P < 0.05), with mean decrease of 1.0 medication (95% CI: 0.9–1.1, P < 0.001) by POM12. By POM12, 25 (83.3%) eyes were medication-free. Three (10%) eyes had stent occlusion by iris requiring laser iridoplasty. One eye had gross hyphema which resolved on conservative management before POM1. Mean BCVA improved from the baseline 0.3 ± 0.3 logMAR to 0.1 ± 0.1 logMAR postoperatively (P < 0.001). There were no major adverse or sight-threatening events. No eyes required further glaucoma surgery during the 12-month follow-up period.

Conclusion

Asian eyes with NTG which underwent combined iStent inject implantation and phacoemulsification demonstrated a significant and sustained reduction in IOP and glaucoma medications, up to 12 months postoperatively.

Cataract surgery and IOP: a systematic review of randomised controlled trials

PURPOSE

Cataract and glaucoma are two of the most common ocular comorbidities. Cataract surgery has been shown to influence intra-ocular pressure (IOP) in patients with glaucoma; nevertheless, the extent of this effect remains controversial, especially in patients with open-angle glaucoma (OAG). The aim of this review is to determine the real effect of cataract surgery on IOP change in patients with OAG, focusing on data retrieved from randomised controlled trials (RCTs).

METHODS

A systematic review was performed, including six different RCTs that studied the net effect of cataract surgery on IOP. Eligibility criteria required a full washout from hypotensive therapy, allowing accurate measurement of unmedicated IOP, both before and after surgery.

RESULTS

Included studies revealed a consistent reduction on IOP occurring after surgery, varying between 4.1 and 8.5 mmHg depending on the RCT. There was also a decrease in the number of glaucoma medications, with a mean reduction of 0.2-1.0 agents postoperatively. Evaluation of adverse outcomes of cataract surgery showed a very favourable safety profile.

CONCLUSION

Although the role of cataract surgery in the algorithm of glaucoma treatment remains to be established, this review highlights a consistent decrease on IOP following surgery and a reduced dependency on glaucoma medications. Potential downgrade in medication can thus be considered in well-controlled glaucoma patients after phacoemulsification. PROSPERO registry: CRD42022343378.

Minimally Invasive Glaucoma Surgery: Safety of Individual Devices

Primary open-angle glaucoma progression in those already on maximal medical therapy has traditionally been treated with trabeculectomy, a surgical procedure that carries a high degree of morbidity. In the last few decades, significant advances have been made in the field of minimally invasive glaucoma surgery (MIGS) devices, which aim to defer or prevent trabeculectomy via less arduous surgical techniques in certain types of glaucoma. Although reviews have been published examining the efficacy of various MIGS techniques, no article synthesises the comparative safety of all available devices. We performed a literature review examining the safety of MIGS devices. Fifteen devices were included, variously attempting to increase aqueous outflow through the trabecular meshwork or the suprachoroidal space, shunting into the subconjunctival space, or reducing aqueous production through ciliary body ablation. Notably, the earliest product attempting to increase outflow to the suprachoroidal space, Alcon's CyPass Micro-Stent, was withdrawn from the market due to concerns regarding increased corneal endothelial cell loss at five years post-implantation. All other devices were described as well-tolerated, with the most common adverse effects including hyphaema, intraocular pressure spikes, and device migration or obstruction. MIGS devices are purported to be uniformly safe, and many studies report no statistically significant increased complications beyond those associated with cataract surgery alone. It is important to note, however, the generally poor quality of current studies, with a dearth of randomised, or even prospective, data, and a large proportion of studies funded by device producers.

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

Purpose

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

Materials and Methods

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

Results

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

Conclusion

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

Analysis of the Effect of Phacoemulsification and Intraocular Lens Implantation Combined With Trabeculectomy on Cataract and Its Influence on Corneal Endothelium

Objective

This study aimed to discuss the effect of phacoemulsification and intraocular lens implantation (PHACO + IOL) combined with trabeculectomy (TRAB) on cataracts and its influence on the corneal endothelium.

Methods

We selected 120 cataract patients admitted to our hospital from January 2018 to January 2021. According to different surgical methods, they were divided into the control group and the observation group. The observation group was treated with PHACO + IOL combined with TRAB, the control group only received PHACO. The clinical effect, ophthalmic-related parameters, corneal endothelium, complications, the satisfaction of the two groups were observed.

Results

The total effective rate and total satisfaction rate of the observation group were significantly higher than the control group (P < 0.05). One month after the operation, the vision and central anterior chamber depth of the observation group were higher than those of the control group, and intraocular pressure (IOP) was lower than that of the control group (P < 0.05). One month after the operation, the corneal endothelial cell area and cell density in the observation group were not significantly different from those before operation (P > 0.05). There was no significant difference in the total incidence of complications between the two groups (P > 0.05).

Conclusion

This study concluded that PHACO + IOL combined with TRAB has a good curative effect in the treatment of cataracts, which can improve the patients' vision and IOP, keep the functional integrity of corneal endothelial cells, and does not increase the occurrence of complications, the patients' satisfaction is high.

Evaluation of the Efficacy and Safety of Canaloplasty and iStent Bypass Implantation in Patients with Open-Angle Glaucoma: A Review of the Literature

The aim of the paper was to evaluate the efficacy and safety of minimally invasive antiglaucoma procedures: Canaloplasty and iStent bypass implantation with and without phacoemulsification in patients with primary open-angle glaucoma (POAG). A systematic review of the recent literature was performed based on the PubMed, Google Scholar, Web of Science and Scopus databases. The effectiveness of the procedures was evaluated based on the reduction of intraocular pressure (IOP) and the amount of antiglaucoma medication used before and after surgery. Safety of the treatments was evaluated based on the number of incidences of certain intraoperative and postoperative complications. Independent prospective randomized controlled trials (PRCTs) have demonstrated that both procedures, canaloplasty and iStent implantation, are effective in reducing IOP and the amount of antiglaucoma medication. Considering the safety profile of these procedures, both canaloplasty and iStent implantation are associated with low rates of postoperative complications and have similar safety profiles. Further studies are needed to confirm the results of our analysis, including a high-quality randomized controlled trial comparing canaloplasty and iStent bypass implantation

XEN Glaucoma Implant for the Management of Glaucoma in Naïve Patients versus Patients with Previous Glaucoma Surgery

This retrospective study analyzed the surgical and refractive outcomes of a XEN Gel Implant (Allergan, Abbvie Company, Irvine, CA, USA) in naïve patients versus those with previous glaucoma surgery. We evaluated the efficacy of XEN implantation in 86 glaucoma patients during a long-term follow-up period. Patients were divided into two groups: naïve patients (Group 1) and patients with previous glaucoma surgery (Group 2). Eyes that received a XEN Gel Stent placement from December 2014 to October 2019 were included. Intraocular pressure (IOP) change, corrected distance visual acuity (CDVA), change in glaucoma medications, frequency of slit lamp revision procedures, and frequency of secondary glaucoma surgeries were the primary outcomes. In Group 1, the mean IOP before surgery was decreased significantly from 25.00 ± 7.52 mmHg to 16.83 ± 5.12 mmHg by the end of the study. In Group 2, the mean IOP decreased significantly from 25.35 ± 7.81 mmHg to 17.54 ± 5.34 mmHg. The mean IOP decrease from baseline was 29% in Group 1 and 27% in Group 2 (p = 0.567). There were no significant differences between the groups in the IOP baseline level, the final level, or the change between preoperative and final levels. The qualified success rate for Group 2 was 68.7% versus 76.5% for Group 1 for the initial procedure and 15.4% vs. 20.2%, respectively, for complete success rate (p > 0.05). However, at the end of the follow-up, more patients achieved an IOP < 18 mmHg in Group 1 than in Group 2. Despite the need for more anti-glaucoma medications, repeat XEN Gel implantation appears to show promising results in patients with previously failed anti-glaucoma procedures, owing to its minimal invasiveness.

Evaluation of the Effect of the First Generation iStent on Corneal Endothelial Cell Loss-A Match Case-Control Study

Glaucoma is the leading cause of irreversible blindness worldwide. The only proven factor in slowing the progression of glaucomatous neuropathy is lower intraocular pressure (IOP), which can be achieved with pharmacology, laser therapy, or surgery. However, these treatments are associated with various adverse effects, including corneal endothelial cell loss (CECL). In recent years, several novel surgeries for reducing the IOP, collectively referred to as minimally invasive glaucoma surgery (MIGS), have been developed, one of which is the iStent. However, the long-term effects of such surgeries remain unknown. We compared a group of patients with open-angle glaucoma and cataract who underwent phacoemulsification alone with a group of patients with similar demographic and clinical characteristics who underwent simultaneous phacoemulsification and iStent implantation. Overall, 26 eyes of 22 subjects who underwent a combined phacoemulsification-iStent procedure and 26 eyes of 24 subjects who underwent cataract surgery were included. Before surgery, endothelial cells accounted to 2228.65 ± 474.99 in iStent group and 2253.96 ± 404.76 in the control group (p = 0.836). After surgery, their number declined to 1389.77 ± 433.26 and 1475.31 ± 556.45, respectively (p = 0.509). There was no statistically significant difference in CECL between the two groups 18–24 months after surgery, despite increased manipulation in the anterior chamber and the presence of an implant in the trabecular meshwork in those with an iStent implant. Thus, iStent bypass implantation is a safe treatment in terms of CECL for mild-to-moderate open-angle glaucoma.

Efficacy of Selective Laser Trabeculoplasty after iStent Implantation in Primary Open-Angle Glaucoma

iStent implantation is thought to augment the trabecular outflow channel in the anterior segment of the eye. We hypothesized that iStent with subsequent selective laser trabeculoplasty (SLT) would better control the intraocular pressure (IOP) compared to standalone SLT in patients with primary open-angle glaucoma (POAG). We, therefore, determined if the presence of an iStent combined with SLT was statistically associated with IOP lowering compared to standalone SLT. Through retrospective electronic medical record review, records of 824 eyes from 440 patients who received primary SLT without a history of iStent were considered. Additionally, 42 eyes from 28 patients who received SLT after combined phacoemulsification and iStent implantation that failed to control intraocular pressure (IOP) and/or the progression of the disease were retrospectively reviewed. IOP and number of medications, which were tracked in each patient for up to 12 months post laser, were also examined. Successful outcome was defined as a statistically significant reduction in IOP or number of medications at 6 months. As defined in univariate analysis (p ≤ 0.01), multivariate analysis included iStent, age, sex, race, and initial IOP as variables. IOP reduction was statistically associated with patients pre-SLT IOP (p < 0.001) but not with patients with iStent (p = 0.222). Medication reduction was statistically associated with the pre-SLT number of medications (p < 0.001) and iStent (p < 0.001). In eyes that received SLT, iStent was not statistically associated with a greater reduction in IOP compared to controls, but was associated with a higher reduction in the overall number of medications used 6 months after receiving SLT. The work presented should guide clinicians to consider SLT as an effective therapy after iStent implantation, in terms of glaucoma medication reduction in iStent patients, but clinicians should know that the presence of an iStent does not necessarily make subsequent SLT more effective at lowering IOP.

XEN Glaucoma Implant for the Management of Operated Uncontrolled Glaucoma: Results and Complications during a Long-Term Follow-Up

This study aimed to analyze the surgical and refractive outcomes of XEN glaucoma implant (Allergan, an Abbvie company, Irvine, CA, USA), a minimally invasive surgical device for the treatment of operated uncontrolled glaucoma. Eyes that received XEN Gel Stent placement from December 2014 to October 2019 were retrospectively investigated. Intraocular pressure (IOP) change, best-corrected visual acuity (BCVA), change in glaucoma medications, frequency of slit lamp revision procedures, and frequency of secondary glaucoma surgeries were the primary outcomes. Seventy-two eyes of 72 subjects were included in the study: 32 (44%) men and 40 (56%) women. The follow-up period ranged from 1 to 50 months (median, 26.13 months). The mean IOP before surgery was 24.82 ± 8.03 mmHg and decreased to 17.45 ± 5.84 mmHg at the end of the study (mean difference [MD] = −7.48, 95% confidence interval [CI]: −10.04, −4.93; p < 0.001). The mean decrease from baseline was 23%. BCVA before surgery was 0.38 ± 0.30, and that at the end of the follow-up period improved to 0.47 ± 0.37, MD = 0.09, 95% CI: 0.04, 0.13; p < 0.001. Additional procedures (fluorouracil injection and bleb needling) were performed in 11/72 patients (15%). Further glaucoma surgery was necessary for 23.9% of the patients. XEN Gel Stent implantation is both safe and reasonably effective for lowering IOP in operated uncontrolled glaucoma patients.

Fellow-Eye Comparison between Phaco-Microhook Ab-Interno Trabeculotomy and Phaco-iStent Trabecular Micro-Bypass Stent

The aim of this study is to compare the surgical efficacy and safety between microhook ab-interno trabeculotomy (µLOT) and iStent trabecular micro-bypass stent implantation when both were combined with cataract surgery in both eyes of patients. Sixty-four glaucomatous eyes (32 participants; mean age, 75.9 ± 7.6 years; 15 men, 17 women) were included retrospectively. Intraocular pressure (IOP), number of antiglaucoma medications, best-corrected visual acuity (BCVA), anterior chamber flare (ACF) and corneal endothelial cell density (CECD) were evaluated preoperatively, as well as 2, 3, 6, and 12 months postoperatively. Surgical complications and interventions were compared between the procedures. The preoperative IOP and medications with µLOT (18.8 ± 5.7 mmHg and 3.0 ± 1.2, respectively) were higher than with the iStent (15.5 ± 3.4 mmHg and 2.7 ± 1.2, respectively) (p = 0.0001 and p = 0.0437, respectively). At 12 months, the µLOT values (12.6 ± 2.3 mmHg and 2.3 ± 0.9, respectively) were identical to iStent (12.8 ± 2.5 mmHg and 2.3 ± 0.9, respectively) (p = 0.0934 and p = 0.3251, respectively). At 12 months, the IOP decreased more with µLOT (6.2 mmHg, 29.5%) than iStent (2.7 mmHg, 15.6%) (p = 0.0003). The decrease in medications was greater with µLOT (0.7) than iStent (0.4) (p = 0.0437). Survival rate of IOP control ≤15 mmHg and IOP reduction ≥20% was significantly higher after µLOT (40.6% at 12 months) than iStent (18.8%) (p = 0.0277). The frequency of layered hyphema was significantly greater with µLOT (8 eyes, 25%) than iStent (0 eyes, 0%) (p = 0.0048). The increase in the ACF at 2 weeks postoperatively was significantly greater with µLOT than iStent (p = 0.0156), while changes in the BCVA and CECD were identical between groups. The fellow-eye comparison showed that the IOP reduction was greater with µLOT than iStent when combined with cataract surgery.

Treatment of Open-Angle Glaucoma with iStent Implantation Combined with Phacoemulsification in Polish Caucasian Population

Purpose

The aim of this investigation was to evaluate the impact of iStent (the first-generation trabecular bypass) implantation with phacoemulsification on the intraocular pressure (IOP) and glaucoma medication in subjects with mild to moderate open-angle glaucoma (OAG) and cataract in a Polish Caucasian population.

Patients and Methods

This prospective case series covered 78 eyes of (57 Polish Caucasian patients) that had undergone iStent implantation in conjunction with cataract surgery. Patients were surveyed preoperatively and at postoperative day 1, week 1, and months 1, 3, 6, 12, and 24. Pre- and postoperative outcome measurements included visual acuity, IOP, and medication burden. Intraoperative and postoperative complications were noted for the safety profile. For effective treatment, an IOP reduction ≥20% was assumed, regardless of the use of IOP-lowering drops. Complete surgical success was defined as an IOP ≤ 15 mmHg, medications free, and a qualified surgical success as IOP ≤ 15 mmHg with or without medications.

Results

Post-operatively at two years, mean IOP reduced from 18.5 mmHg to 16.1 mmHg. The mean medication burden dropped from 1.8 to 0.4 at the end of follow-up. Preoperatively, 2 (2.6%) eyes were medication free, but by postoperative month 24, 53 (68%) eyes were medication-free (p < 0.05). Effective treatment was achieved in 50 cases (64%) at the end of follow-up period. Kaplan–Meier cumulative incidence of qualified success was 51.9% after 24 months, CI₉₅ [41.9%; 64.4%], while cumulative incidence of complete success after 2 years of observation was 35.1%, CI₉₅ [25.9%; 47.5%].

Conclusion

The iStent device combined with a cataract surgery served to decrease, significantly and positively, both IOP and medication use in the 24-months follow-up in patients with coexistent OAG and cataract in Polish patients.