Outcomes and risk factors for ab interno trabeculotomy with a Kahook Dual Blade

Outcomes and risk factors for Kahook Dual Blade excisional goniotomy with concomitant phacoemulsification: a multicentre Canadian study

OBJECTIVE

To assess the outcomes and failure risk factors for Kahook Dual Blade (KDB) excisional goniotomy with cataract surgery (phaco-KDB) in eyes with various glaucoma subtypes and severities.

METHODS

This multisurgeon consecutive case series included glaucomatous eyes with cataract that underwent phaco-KDB and had a minimum follow-up of 12 months postoperatively. Efficacy was assessed by absolute and qualified surgical success (defined by different criteria) and changes in intraocular pressure (IOP) and antiglaucoma medication (AGM) at the last postoperative follow-up. Safety included best-corrected visual acuity, cup-to-disc ratio, visual field mean deviation, retinal nerve fibre layer thickness, and adverse events.

RESULTS

A total of 108 eyes of 89 patients with a median follow-up of 18 months (range, 12-47 months) were included. IOP decreased by 26% from 19.1 ± 5.0 mm Hg to 14.1 ± 3.5 mm Hg (p < 0.001), AGM use decreased by 29% from 2.4 ± 1.3 medications to 1.7 ± 1.3 (p < 0.001), and 25% of eyes became free of AGMs (vs 3% at baseline). Qualified success rates achieved for IOP cutoffs of 18, 15, and 12 mm Hg were 87%, 68%, and 46%, respectively. Higher baseline IOP and postoperative incidence of IOP spikes were associated with a higher risk of surgical failure. Best-corrected visual acuity improved postoperatively (p < 0.001), and visual field mean deviation, cup-to-disc ratio, and retinal nerve fibre layer thickness remained stable. Overall, safety was favourable, and adverse events were transient and not sight threatening.

CONCLUSION

This multicentre Canadian study provides real-world data that support the safety and efficacy of phaco-KDB in reducing IOP and AGM use with no evidence of disease progression during the follow-up period.

Historical and Contemporary Debates in Schlemm's Canal-Based MIGS

Glaucoma is one of the primary causes of blindness worldwide. Canal opening surgery, a type of minimally invasive glaucoma surgery (MIGS) applied in cases of mild to moderate glaucoma, has gained increasing popularity in recent years due to its efficacy in reducing the intraocular pressure, its safety profile, the simplicity of its technique, and the reduced likelihood of compromised vision. Nevertheless, the existing body of histopathological studies remains insufficient for a comprehensive understanding of post-surgical wound healing. Consequently, debates persist among researchers regarding the mechanism through which Schlemm's canal opening surgery reduces the intraocular pressure, as well as the surgical techniques that may impact the outcomes and the factors influencing surgical success. As the history of MIGS is relatively short and lacks sufficient systemic reviews or meta-analyses evaluating the influence of individual factors, this review was conducted to illuminate the disparities in researchers' opinions at the current stage of research.

Update on Diagnosis and Treatment of Uveitic Glaucoma

Glaucoma is a common and potentially blinding complication of uveitis. Many mechanisms are involved alone or in combination in the pathogenesis of uveitic glaucoma (UG). In terms of diagnostic evaluation, the effects of inflammatory activity in the retinal nerve fiber layer may be a source of bias in the interpretation of optical coherence tomography measurements. For the successful treatment of UG, the control of intraocular inflammation specific to the cause or anti-inflammatory treatment, combined with IOP management, is mandatory. The early institution of specific treatment improves the prognosis of UG associated with CMV. The young age of UG patients along with increased failure rates of glaucoma surgery in this group of patients warrants a stepwise approach. Conservative and conjunctival sparing surgical approaches should be adopted. Minimally invasive surgical approaches were proved to be effective and are increasingly being used in the management of UG along with the traditionally used techniques of trabeculectomy or tubes. This review aims to summarize the progress that recently occurred in the diagnosis and treatment of UG.

Risk factors for Baerveldt glaucoma drainage implantation for uveitic glaucoma

Uveitic glaucoma (UG) is sometimes intractable, including intricate interaction between intraocular pressure (IOP) elevation associated with inflammation and side effects of steroids. Based on the Tube Versus Trabeculectomy study in refractory glaucoma results in 2012, tube shunt surgeries have been performed for UG, but few reports have focused on UG. We retrospectively examined the surgical efficacy, complications, and risk factors in 62 eyes with UG that underwent Baerveldt glaucoma drainage device (BGD) implantation at Kumamoto University. The IOPs significantly dropped, and the mean number of glaucoma medications was reduced by more than two. Kaplan‒Meier survival curves were presented under 2 conditions: an IOP reduction of 20% and 6 ≤ IOP ≤ 18 mmHg (criterion A) or 6 ≤ IOP ≤ 15 mmHg (criterion B). In criterion A, the median survival times (MST) were 124 days (complete) and 997 days (qualified). In criterion B, the MST was 129 days (complete) and 867 days (qualified). The Cox hazard proportional model found that the hazard ratio was 0.170 for a history of cataract surgery (95% CI 0.0303-0.950) and 8.669 for systemic immunosuppressive therapy (95% CI 1.810-41.51). BGD implantation is effective for treating UG, but the presence of systemic treatment and the lens status should be considered.

Kahook Dual Blade versus Trabectome (KVT): Comparing Outcomes in Combination with Cataract Surgery

Purpose

To compare the safety and efficacy of Kahook Dual Blade (KDB) versus Trabectome with cataract surgery in reducing intraocular pressure (IOP) and medications used by patients with glaucoma.

Methods

Retrospective chart review comparing eyes after KDB or Trabectome with cataract surgery at 2 academic centers. Surgical success was defined as IOP <21 mmHg with ≥20% IOP reduction at post-operative month 12 (POM12). Changes in IOP, number of glaucoma medications, and adverse events were assessed.

Results

Ninety eyes in the KDB group and 125 eyes in the Trabectome group were included. Mean changes in IOP at POM12 were -1.9 ± 4.9 mmHg (11.2%, P = 0.002) in the KDB group and -3.5 ± 5.5 mmHg (19.1%, P < 0.001) in the Trabectome group, without a significant difference between the groups (P = 0.20). Mean change in glaucoma medications at POM12 was -0.8 ± 1.5 in the KDB group (58%, P < 0.001) and -0.3 ± 1.3 (38%, P = 0.003) in the Trabectome group, with KDB having a greater decrease in medications (P = 0.02). The percentage of eyes achieving success was 30% for the KDB group and 54% for the Trabectome group (P = 0.01). Hyphema was the most common complication, with an incidence of 3% for the KDB group and 14% for the Trabectome group (P = 0.01).

Conclusion

KDB or Trabectome with cataract surgery is safe and effective at lowering IOP and medication burden, with KDB resulting in a greater reduction in medications and Trabectome more frequently achieving success with an increased incidence of hyphema. Considering the study's limitations, the outcomes were similar.