Risk Factors for Hyphema Following Kahook Dual Blade Goniotomy Combined With Phacoemulsification

PRCIS

Hyphema development after Kahook Dual Blade (KDB) excisional goniotomy was significantly associated with postoperative day 1 intraocular pressure (IOP) ≤12 mm Hg, male sex, and narrow iridocorneal angles, but not with continuation of anticoagulation or antiplatelet therapy.

PURPOSE

To identify risk factors of hyphema development after KDB goniotomy combined with phacoemulsification.

METHODS

In all, 202 eyes in 145 patients who received a KDB goniotomy combined with phacoemulsification between February 21, 2017 and February 18, 2020 were evaluated for preoperative factors that were predictive of postoperative hyphema. Hyphema was defined as the development of ≥1 mm layered blood in the anterior chamber. The primary outcome was the association between various preoperative factors and the development of postoperative hyphema. Binomial logistic regression was used to analyze risk factors of hyphema development while controlling for other variables.

RESULTS

Hyphema occurred in 8.4% (17/202) of patients on day 1 after KDB goniotomy combined with phacoemulsification. Male sex ( P =0.008), angle closure glaucoma ( P =0.036), and postoperative day 1 IOP ≤12 mm Hg ( P =0.049) were significantly correlated with hyphema development while controlling for other variables. Preoperative anticoagulation and antiplatelet therapy had no association with hyphema development ( P =0.538).

CONCLUSIONS

Postoperative hyphema was associated with male sex, narrow iridocorneal angles, and a postoperative day 1 IOP lower than typical episcleral venous pressure when controlling for other variables. Preoperative anticoagulation or antiplatelet therapy was not associated with developing postoperative hyphema in this study; however, further investigation is needed before recommendations can be made.

Predictive Factors of Outcomes in Kahook Dual Blade Excisional Goniotomy Combined with Phacoemulsification

Aim

To identify factors that were significant predictors of Kahook Dual Blade (KDB) excisional goniotomy outcomes.

Materials and methods

One hundred and thirty-two eyes from 99 adult glaucoma patients who underwent combined KDB and phacoemulsification (KDB-phaco) with a minimum 6-month follow-up were assessed for baseline patient characteristics to determine correlation to the success of KDB-phaco at 6 and 12 months postoperatively. Success was defined as ≥20% intraocular pressure (IOP) reduction or ≥1 medication reduction as well as IOP ≤18 mm Hg without any additional IOP-lowering procedures after KDB-phaco.

Results

63.6% (84/132) and 46.1% (41/89) of cases were successful at the 6- and 12-month follow-ups, respectively. KDB-phaco reduced patient's preoperative IOP (in mm Hg) from 17.6 ± 4.6 to 14.9 ± 3.2 at 6 months (15.3%, p < 0.001) and 15.4 ± 4.7 at 12 months (12.5%, p = 0.001). KDB-phaco reduced patient's preoperative IOP-lowering medications from 2 ± 1.2 to 1.1 ± 1.2 at 6 months (45%, p < 0.001) and 1.32 ± 1.3 at 12 months (34%, p < 0.001). At 6 months, patients on >1 IOP lowering medication had a greater chance of meeting our success criteria (p = 0.037). Visually significant postoperative hyphema was not associated with the use of anticoagulation (p = 0.943) but was significantly associated with postoperative day 1 IOP ≤ 10 mm Hg (p = 0.011).

Conclusion

Patients who underwent KDB-phaco significantly reduced their IOP and medication burden at both 6 and 12 months compared with their baseline preoperative values. KDB-phaco outcome was associated with higher baseline IOP-lowering medications and increased rate of hyphema was associated with lower postoperative day 1 IOP, regardless of anticoagulation status. Age, ethnicity, prior laser trabeculoplasty, type and severity of glaucoma, and baseline preoperative IOP were not associated with surgical success.

Clinical significance

Patients with a higher number of baseline medications may experience a greater probability of success following KDB-phaco.

How to cite this article

Pratte EL, Cho J, Landreneau JR, et al. Predictive Factors of Outcomes in Kahook Dual Blade Excisional Goniotomy Combined with Phacoemulsification. J Curr Glaucoma Pract 2022;16(1):47-52.

Long-Term Safety and Tolerability of BMP7 and HGF Gene Overexpression in Rabbit Cornea

Purpose

Tissue-targeted localized BMP7+HGF genes delivered into the stroma via nanoparticle effectively treats corneal fibrosis and rehabilitates transparency in vivo without acute toxicity. This study evaluated the long-term safety and tolerability of BMP7+HGF nanomedicine for the eye in vivo.

Methods

One eye each of 36 rabbits received balanced salt solution (group 1, naïve; n = 12), naked vector with polyethylenimine-conjugated gold nanoparticles (PEI2-GNP; group 2, naked-vector; n = 12), or BMP7+HGF genes with PEI2-GNP (group 3, BMP7+HGF; n = 12) via a topical delivery technique. Safety and tolerability measurements were performed by clinical biomicroscopy in live rabbits at predetermined time intervals up to 7 months. Corneal tissues were collected at 2 months and 7 months after treatment and subjected to histology, immunofluorescence, and quantitative real-time PCR analyses.

Results

Clinical ophthalmic examinations and modified MacDonald-Shadduck scores showed no significant changes in corneal thickness (P = 0.3389), tear flow (P = 0.2121), intraocular pressure (P = 0.9958), epithelial abrasion, or ocular abnormality. Slit-lamp, stereo, confocal, and specular biomicroscopy showed no signs of blepharospasm chemosis, erythema, epiphora, abnormal ocular discharge, or changes in epithelium, stroma, and endothelium after BMP7+HGF therapy for up to 7 months, as compared with control groups. Throughout the 7-month period, no significant changes were recorded in endothelial density (P = 0.9581). Histological and molecular data were well corroborated with the subjective clinical analyses and showed no differences in the naïve, naked-vector, and BMP7+HGF groups.

Conclusions

Localized BMP7+HGF therapy is a safe, tolerable, and innovative modality for the treatment of corneal fibrosis.

Translational Relevance

Nanoparticle-mediated BMP7+HGF combination gene therapy has the potential to treat corneal fibrosis in vivo without short- or long-term toxicity.

Review on the Myopia Pandemic: Epidemiology, Risk Factors, and Prevention

Nearsightedness, or myopia, is becoming more prevalent worldwide. The eye experiences dynamic growth throughout adolescence, but the etiopathogenesis of myopia progression is not fully understood. Myopia is associated with several pathologic eye conditions, leading to irreversible vision loss. Treatment for preventing myopia progression is reliant on effective screening and initiating treatment early in life. This article will review risk factors for myopia progression and discuss treatment strategies that are most effective in halting its spread.

A Novel Topical Ophthalmic Formulation to Mitigate Acute Mustard Gas Keratopathy In Vivo: A Pilot Study

Purpose

This pilot study investigated the in vivo therapeutic potential and tolerability of a multimodal ophthalmic formulation, topical eye drops (TED), for acute mustard gas keratopathy (MGK) using a rabbit model.

Methods

Twenty New Zealand White rabbits were used. Only right eyes of 18 rabbits (oculus dexter [OD]) received single sulfur mustard gas (SM) vapor injury, whereas contralateral eyes were left untreated or received TED for tolerabilty evaluation. Two rabbit eyes received no treatment and served as age-matched naive control. The four groups were: Naive (oculus sinister [OS] untreated eyes; n = 9); TED (OS treated only with TED BID for 3 days; n = 9); SM (OD exposed to SM vapor; n = 9); and SM+TED (OD exposed to SM+TED BID for 3 days; n = 9). Ocular examination in live rabbits were performed utilizing slit-lamp biomicroscopy, Fantes grading system, fluorescein staining, Schirmer's tests, pachymetry, and applanation tonometry. Cellular and molecular changes in rabbit corneas were assessed after humane euthanasia on day-3 and day-7 with histopathological and real-time polymerase chain reaction PCR techniques.

Results

TED to rabbit eyes was found tolerable in vivo. SM-exposed eyes showed significant increase in Fantes scores, central corneal thickness (CCT), Schirmer's test, epithelium-stroma separation, and corneal edema. TED mitigated clinical symptoms by reducing corneal edema, Fantes scores, CCT, and Schirmer's test. Further, TED decreased SM-induced corneal haze, inflammatory and profibrotic markers, transforming growth factor-TGF-β1 and cyclooxygenase-2COX-2, and damage to corneal structure, including epithelial-stromal integrity.

Conclusions

The developed multimodal eyedrop formulation, TED, has potential to mitigate acute MGK effectively in vivo.

Translational Relevance

TED is effective against MGK.

Comparison of 12-Month Outcomes of Kahook Dual Blade Excisional Goniotomy Performed by Attending versus Resident Surgeons

Objective Kahook Dual Blade goniotomy (KDB) has proven effective in lowering intraocular pressure (IOP) and reducing the medication burden in patients with glaucoma. This study compares outcomes up to 12 months postoperatively after KDB combined with phacoemulsification (phaco-KDB) between an ophthalmology attending and residents.

Methods A retrospective analysis was performed on 160 eyes of 113 patients who received a phaco-KDB performed by either an ophthalmology attending or a resident under direct guidance of the attending. Data for each patient was collected preoperatively and at 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months postoperatively. The primary outcome measure was surgical success, defined as 20% IOP reduction or at least 1 medication reduction at 12 months. The secondary outcome measures included mean IOP and medication reduction at each postoperative time point, adverse events, operating time, and survival time, defined as time to failure to meet the criteria for surgical success or requiring a secondary IOP-lowering procedure.

Results Preoperative mean IOP was comparable between the two groups (p = 0.585), while baseline medications were higher in the attending group (p = 0.040). Rate of successful outcomes was similar in both groups at 12 months (73.3% attending vs. 87.5% residents, p = 0.708). Mean IOP reduction (1.7 vs. 4.3%, p = 0.278) and medication reduction (0.7 vs. 0.6, p = 0.537) also did not differ at 12 months. Presence of adverse events was similar between the groups (21.6 vs. 27.3%, p = 0.938). The survival time was significantly longer in the attending group (356.3 ± 20.2 days vs. 247.1 ± 26.8 days, p = 0.003). Resident cases took ∼10 minutes longer compared with attending cases (p < 0.001).

Conclusion IOP lowering outcomes and rate of adverse events of KDB were similar whether the primary surgeon was an attending or a resident surgeon. The survival time was significantly longer in the attending group, but overall success rate was 77.5% for both groups. This suggests phaco-KDB is an effective procedure that can be safely performed by a trainee under direct supervision of an experienced surgeon.

Preoperative (3-dimensional) computed tomography lung reconstruction before anatomic segmentectomy or lobectomy for stage I non-small cell lung cancer

OBJECTIVES

Accurate cancer localization and negative resection margins are necessary for successful segmentectomy. In this study, we evaluate a newly developed software package that permits automated segmentation of the pulmonary parenchyma, allowing 3-dimensional assessment of tumor size, location, and estimates of surgical margins.

METHODS

A pilot study using a newly developed 3-dimensional computed tomography analytic software package was performed to retrospectively evaluate preoperative computed tomography images of patients who underwent segmentectomy (n = 36) or lobectomy (n = 15) for stage 1 non-small cell lung cancer. The software accomplishes an automated reconstruction of anatomic pulmonary segments of the lung based on bronchial arborization. Estimates of anticipated surgical margins and pulmonary segmental volume were made on the basis of 3-dimensional reconstruction.

RESULTS

Autosegmentation was achieved in 72.7% (32/44) of preoperative computed tomography images with slice thicknesses of 3 mm or less. Reasons for segmentation failure included local severe emphysema or pneumonitis, and lower computed tomography resolution. Tumor segmental localization was achieved in all autosegmented studies. The 3-dimensional computed tomography analysis provided a positive predictive value of 87% in predicting a marginal clearance greater than 1 cm and a 75% positive predictive value in predicting a margin to tumor diameter ratio greater than 1 in relation to the surgical pathology assessment.

CONCLUSIONS

This preoperative 3-dimensional computed tomography analysis of segmental anatomy can confirm the tumor location within an anatomic segment and aid in predicting surgical margins. This 3-dimensional computed tomography information may assist in the preoperative assessment regarding the suitability of segmentectomy for peripheral lung cancers.

Extended Chamberlain minithoracotomy: a safe and versatile approach for difficult lung resections

BACKGROUND

We present the perioperative outcomes of patients undergoing an anterior "extended Chamberlain" minithoracotomy as an alternative approach to a hemi-clamshell sternotomy or extended lateral thoracotomy for safe and reliable access to the pulmonary hilum and subsequent anatomic pulmonary resection.

METHODS

This study is a retrospective review of 162 patients undergoing anatomic lung resection through a mini anterior thoracotomy from 2002 to 2010. An 8-cm anterior thoracotomy was performed with the patient in a supine position, entering the chest through the second intercostal space. The pectoralis muscle fibers were split with preservation of the mammary artery medially and the thoracoacromial neurovascular bundle laterally. Primary outcome variables included hospital course, complications, and mortality rate.

RESULTS

The mean age was 63.9 (range, 20 to 85 years); female to male ratio was 71:91. Neoadjuvant therapy was used in 49 (30.2%) patients. Proposed resections were successful in 161 of 162 (99%) patients. Conversion to hemi-clamshell was required in 1 patient for vascular control. Complications occurred in 48 (29.6%) patients. Three (1.9%) perioperative deaths (2 pneumonectomies [6.3%], 1 lobectomy [1.0%]) occurred. Median length of stay was 8 days.

CONCLUSIONS

The "extended Chamberlain" mini anterior thoracotomy provides direct and expeditious, less-invasive access to the pulmonary hilum. This approach preserves muscle function and avoids partial sternotomy or extended lateral thoracotomy, and their associated incisional-related morbidity.

Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer

BACKGROUND

Segmentectomy for early-stage non-small cell lung cancer (NSCLC) remains controversial and has been previously associated with high local recurrence rates. We compared the outcomes of anatomic segmentectomy with lobectomy for stage I NSCLC and investigated the impact of surgical resection margins on recurrence.

METHODS

From 2002 to 2006, 182 anatomic segmentectomies (114 open, 68 video-assisted thoracic surgery [VATS]), were performed for stage 1A (n = 109) or IB (n = 73) NSCLC. These were compared with 246 lobectomies (1A, 114; 1B, 132). Variables analyzed included hospital course, mortality, and patterns of recurrence and survival.

RESULTS

All segmentectomy surgical margins were free of tumor (average margin, 18.2 mm). Operative time (147 versus 216 minutes; p < 0.0001) and estimated blood loss (185 versus 291 mL; p = 0.0003) were significantly reduced after segmentectomy compared with lobectomy. Thirty-day mortality (1.1% versus 3.3%), total complications, disease-free recurrence, and survival were similar between segmentectomy and lobectomy at a mean follow-up of 18.1 and 28.5 months, respectively. There were 32 recurrences after segmentectomy (17.6%) at a mean of 14.3 months (14 locoregional [7.7%], 18 distant [9.9%]), and 89% of recurrences were seen when tumor margins were 2 cm or less. Margin/tumor diameter ratios exceeding 1 were associated with a significant reduction in recurrence rates compared with ratios of less than 1 (25.0% versus 6.2%; p = 0.0014).

CONCLUSIONS

Anatomic segmentectomy can be performed safely by an open or VATS approach. Segmentectomy outcomes compare favorably with standard lobectomy for stage I NSCLC. Margin/tumor ratios of less than 1 are associated with a higher rate of recurrence. Lobectomy should be considered as primary therapy when such margins are not obtainable with segmentectomy in the good-risk patient.