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Minimally Invasive Glaucoma Surgery: Safety of Individual Devices. J Clin Med 2022; 11:jcm11226833. [PMID: 36431310 PMCID: PMC9696404 DOI: 10.3390/jcm11226833] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/30/2022] [Accepted: 11/11/2022] [Indexed: 11/22/2022] Open
Abstract
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the earliest product attempting to increase outflow to the suprachoroidal space, Alcon's CyPass Micro-Stent, was withdrawn from the market due to concerns regarding increased corneal endothelial cell loss at five years post-implantation.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.
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Abstract
Micro- or minimally invasive glaucoma surgeries (MIGS) have been the latest addition to the glaucoma surgical treatment paradigm. This term refers not to a single surgery, but rather to a group of distinct procedures and devices that aim to decrease intraocular pressure. Broadly, MIGS can be categorized into surgeries that increase the trabecular outflow [Trabectome, iStent (first and second generations), Hydrus microstent, Kahook Dual Blade and gonioscopy-assisted transluminal trabeculotomy], surgeries that increase suprachoroidal outflow (Cypass microstent and iStent Supra), and conjunctival bleb-forming procedures (Xen gel stent and InnFocus microshunt). Compared to traditional glaucoma surgeries, such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves), MIGS are touted to have less severe complications and shorter surgical time. MIGS represent an evolving field, and the efficacy and complications of each procedure should be considered independently, giving more importance to high-quality and longer-term studies.
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Affiliation(s)
- David J Mathew
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario M5T 2S8, Canada;
| | - Yvonne M Buys
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario M5T 2S8, Canada;
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Kasahara M, Shoji N. Effectiveness and limitations of minimally invasive glaucoma surgery targeting Schlemm's canal. Jpn J Ophthalmol 2020; 65:6-22. [PMID: 33150512 DOI: 10.1007/s10384-020-00781-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/07/2020] [Indexed: 12/15/2022]
Abstract
Glaucoma surgery is performed to lower intraocular pressure (IOP); ideally, the IOP reduction is safely maintained for an extended period of time. Although trabeculectomy was considered the gold standard for glaucoma surgery for many years because of its effective IOP reduction, yet now it is considered unsafe because of serious complications. In recent years, minimally invasive glaucoma surgery (MIGS), which emphasizes safety and can be performed rapidly, has become widespread. Because MIGS does not involve conjunctival incisions, patients can undergo future trabeculectomy. If IOP reduction can be maintained safely, the number of anti-glaucoma drops can be reduced and visual function maintained, good outcomes for patients with glaucoma. Currently, many types of MIGS approved in Japan are reported to yield relatively good results, with targets of approximately 15-19 mmHg. However, the IOP-lowering effects of MIGS are limited. In procedures targeting Schlemm's canal, it is difficult to lower IOP beyond episcleral venous pressure. In some instances, a beneficial effect cannot be achieved if function is reduced beyond the collector channel. There are many unclear aspects regarding long-term outcomes following MIGS. Notably, investigation is ongoing to determine which patients are likely to benefit most from surgery. Based on previous reports, this review describes the characteristics and results of MIGS, approved in Japan, as well as underlying factors that affect the preoperative predictions and outcomes of the surgical procedure.
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Affiliation(s)
- Masayuki Kasahara
- Department of Ophthalmology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Nobuyuki Shoji
- Department of Ophthalmology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
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Xie Z, Mu ZX, Du ML, Zhu YT, Sun H. Two-year outcome of Trabeculo-Canalectomy for Chinese Glaucoma Patients. Int J Med Sci 2020; 17:2024-2030. [PMID: 32788881 PMCID: PMC7415382 DOI: 10.7150/ijms.46729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/10/2020] [Indexed: 11/23/2022] Open
Abstract
To evaluate the efficacy of trabeculo-canalectomy in treating glaucoma patients, a retrospective investigation of 53 glaucoma patients (53 eyes) who underwent trabeculo-canalectomy was conducted at the First Affiliated Hospital of Nanjing Medical University, China, from April 2017 to January 2019. Intraocular pressure (IOP), visual acuity, surgical success rates, medications, and complications were monitored at post-operative 1 day, 1 week, 1, 3, 6, 12 and 24 months. Surgical success criteria were defined as 6 mm Hg≤IOP≤21 mmHg with or without additional medications. Our results showed that average IOP was statistically significant between pre-operative visit and each follow-up visit (all P <0.05). The total success rate of trabeculo-canalectomy at 1, 3, 6, 12 and 24 months was 92.5%, 86.8%, 94.3%, 92.5% and 90.6% respectively. After 3 months post-operatively, all patients had no obvious filtering blebs. The main early complications included postoperative hyphema (7.5%), elevated IOP (5.7%) and anterior chamber exudation (3.8%), which were all cured after conservative treatment. No blebitis, shallow anterior chamber, choroidal detachment and endophthalmitis were observed. Logistic regression analysis showed that patients with secondary glaucoma were more likely to undergo surgical failure 24 months post-operatively (P= 0.008). Thus, we conclude that trabeculo-canalectomy is effective and safe for the treatment of glaucoma.
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Affiliation(s)
- Zhan Xie
- Department of Ophthalmology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 210029, China
| | - Zhao-Xia Mu
- Department of Ophthalmology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 210029, China
| | - Mu-Long Du
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu Province 210029, China
| | | | - Hong Sun
- Department of Ophthalmology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province 210029, China
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Sheppard JD, Singh IP. Real world use of loteprednol etabonate ophthalmic gel 0.5% in cases representative of comorbid pathologies responding to minimally invasive glaucoma surgery. Clin Ophthalmol 2019; 13:1279-1288. [PMID: 31409967 PMCID: PMC6645598 DOI: 10.2147/opth.s206424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 06/12/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose With the increasing use of minimally invasive surgical techniques for intraocular pressure (IOP) lowering in glaucoma patients, there is a need to examine best practices regarding the postoperative management of these patients. Corticosteroids, though effective in controlling postoperative ocular pain and inflammation, present distinct challenges in glaucoma surgery patients, as their use can be associated with IOP elevation. Loteprednol etabonate (LE) is an ocular corticosteroid designed to have an improved safety profile relative to other corticosteroids. Methods We report here a representative selection of cases in which patients were successfully treated with LE ophthalmic gel 0.5% (LE gel) following a variety of minimally invasive glaucoma surgery (MIGS) procedures. Cases included patients undergoing various procedures including a Trabectome combined with cataract surgery; micro-stent surgery (iStent) combined with cataract surgery; supraciliary CyPass Micro-Stent placement combined with cataract surgery; Kahook Dual Blade goniotomy; and ab interno canaloplasty using the iTrack catheter. Observations In all cases, use of LE gel during the postoperative period appeared effective and safe in reducing inflammation and controlling pain. No adverse events or IOP elevations were noted, even in those patients continuing use of LE gel past the postoperative period for longer than six months with documented follow-up. In two cases, patients with elevated IOP using either prednisolone or difluprednate postoperatively were switched to LE gel, with a subsequent reduction in IOP. Conclusions This selection of cases involving patients undergoing MIGS suggests that LE gel may be an effective and safe option for treating postoperative inflammation and pain following such procedures with minimal to no effect on IOP or other negative sequalae.
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Affiliation(s)
- J D Sheppard
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - I P Singh
- Department of Glaucoma, The Eye Centers of Racine & Kenosha, Racine, WI, USA
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Refractive outcomes of phacoemulsification cataract surgery in glaucoma patients. J Cataract Refract Surg 2018; 44:348-354. [PMID: 29605284 DOI: 10.1016/j.jcrs.2017.12.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 12/02/2017] [Accepted: 12/19/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate refractive outcomes after phacoemulsification cataract surgery in patients with glaucoma. SETTING University of Colorado Health Eye Center, Aurora, Colorado, USA. DESIGN Retrospective case series. METHODS The incidence of refractive surprise was evaluated in patients with and without glaucoma after phacoemulsification cataract surgery. Refractive surprise was defined as the difference in spherical equivalent of the refractive target and postoperative refraction in diopters (D). RESULTS The study comprised 206 eyes in the glaucoma group and 1162 control eyes. The refractive surprise greater than ±0.5 D and ±1.0 D was 29.9% and 4.9% in the control group and 40.3% (P = .0061) and 11.2% (P = .0011) in the glaucoma group. Primary open-angle glaucoma (POAG) (n = 154 eyes), chronic angle-closure glaucoma (n = 18 eyes), and pseudoexfoliation glaucoma (n = 23 eyes) had odds ratios of 1.90 (P = .1760), 14.54 (P = .0006), and 7.27 (P = .0138), respectively, of refractive surprise greater than ±1.0 D compared with patients without glaucoma. Refractive surprise was noted more often in POAG eyes with axial lengths longer than 25.0 mm (P = .0298). Glaucoma eyes had worse mean postoperative corrected distance visual acuity than control eyes (glaucoma: 0.1088 logarithm of the minimum angle of resolution [logMAR]; controls: 0.0358 logMAR; P = .01). CONCLUSION Patients with a diagnosis of glaucoma were more likely to have a refractive surprise and/or worse visual outcome after phacoemulsification cataract surgery.
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Bendel RE, Patterson MT. Long-term Effectiveness of Trabectome (Ab-interno Trabeculectomy) Surgery. J Curr Glaucoma Pract 2018. [DOI: 10.5005/jp-journals-10078-1235] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Three-year results of ab interno trabeculectomy (Trabectome): Berlin study group. Graefes Arch Clin Exp Ophthalmol 2017; 256:611-619. [DOI: 10.1007/s00417-017-3882-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 12/14/2017] [Accepted: 12/19/2017] [Indexed: 10/18/2022] Open
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Safety and Efficacy of Microinvasive Glaucoma Surgery. J Ophthalmol 2017; 2017:3182935. [PMID: 28512578 PMCID: PMC5420434 DOI: 10.1155/2017/3182935] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 03/20/2017] [Indexed: 01/27/2023] Open
Abstract
Microinvasive glaucoma surgery (MIGS) is emerging as a new therapeutic option for glaucoma patients who wish to reduce their medication burden and avoid the postoperative complications of conventional glaucoma filtration surgery. These devices differ in terms of their efficacy and safety profile. Schlemm's canal devices have the most favorable safety profile at the compromise of modest efficacy, while subconjunctival and suprachoroidal devices are potentially more effective at lowering the intraocular pressure at the expense of a higher rate of complications. This review consolidates the latest evidence on the efficacy and safety of the MIGS devices in clinical use and provides an overview on upcoming devices which would likely also become viable treatment options in the near future. These clinical data would assist a glaucoma surgeon in selecting the most appropriate MIGS device for each patient based on the glaucoma severity and patient expectations.
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Short-Term Clinical Results of Ab Interno Trabeculotomy Using the Trabectome with or without Cataract Surgery for Open-Angle Glaucoma Patients of High Intraocular Pressure. J Ophthalmol 2017; 2017:8248710. [PMID: 28484649 PMCID: PMC5412169 DOI: 10.1155/2017/8248710] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 12/19/2016] [Accepted: 02/19/2017] [Indexed: 11/21/2022] Open
Abstract
Purpose. To assess the safety and efficacy of Trabectome procedure in patients with preoperative intraocular pressure (IOP) of 30 mmHg or higher. Methods. All patients who had underwent Trabectome stand-alone or Trabectome combined with phacoemulsification were included. Survival analysis was performed by using Kaplan-Meier, and success was defined as IOP ≤ 21 mmHg, 20% or more IOP reduction from baseline for any two consecutive visits after 3 months, and no secondary glaucoma surgery. Results. A total of 49 cases were included with an average age of 66 (range: 13–91). 28 cases had Trabectome stand-alone and 21 cases had Trabectome combined with phacoemulsification. Mean IOP was reduced from a baseline of 35.6 ± 6.3 mmHg to 16.8 ± 3.8 mmHg at 12 months (p < 0.01∗), while the number of medications was reduced from 3.1 ± 1.3 to 1.8 ± 1.4 (p < 0.01∗). Survival rate at 12 months was 80%. 9 cases required secondary glaucoma surgery, and 1 case was reported with hypotony at day one, but resolved within one week. Conclusion. Trabectome seems to be safe and effective in patients with preoperative IOP of 30 mmHg or greater. Even in this cohort with high preoperative IOP, the end result is a mean IOP in the physiologic range.
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Amoozgar B, Chang I, Kuo J, Han Y. Newer Surgical Options for Glaucoma. CURRENT OPHTHALMOLOGY REPORTS 2017. [DOI: 10.1007/s40135-017-0121-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Combined Ab Interno Glaucoma Surgery Does not Increase the Risk of Pseudophakic Cystoid Macular Edema in Uncomplicated Eyes. J Glaucoma 2017; 26:227-232. [DOI: 10.1097/ijg.0000000000000586] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bendel RE, Patterson MT. Long-term Effectiveness of Trabectome (Ab-interno Trabeculectomy) Surgery. J Curr Glaucoma Pract 2017; 12:119-124. [PMID: 31354204 PMCID: PMC6647824 DOI: 10.5005/jp-journals-10028-1256] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Aim To evaluate the long-term safety and efficacy of ab-interno trabeculectomy with trabectome for the treatment of glaucoma. Materials and methods Data collected for 339 eyes which included demographics, intraocular pressure (IOP) measurements using Goldmann applanation tonometry, best-corrected visual acuity (BCVA), visual field results, optic nerve status, gonioscopic findings, prior glaucoma procedures, number of glaucoma medications and pain level. The main data points of interest were preoperative IOP vs. postoperative IOP and BCVA, medication use, pain status, and complications. Results Of the 339 eyes that underwent trabectome, we found a statistically significant reduction in IOP (p < 0.01) at final follow-up (average = 18.35 months) of nearly 23%, with a complication rate of 5.86%. Furthermore, this reduction was maintained up to 8 years post procedure. LogMAR visual acuity was significantly improved in 69% of eyes at the final visit (p < 0.05), while only 1.77% of cases saw a significant reduction. Based on these findings, we determined a success rate of around 80% to 100 months following trabectome. Conclusion Trabectome is a safe and effective long term for most forms and severities of glaucoma. How to cite this article Bendel RE, Patterson MT. Long-term Effectiveness of Trabectome (Ab-interno Trabeculectomy) Surgery. J Curr Glaucoma Pract 2018;12(3):119-124.
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Affiliation(s)
- Rick E Bendel
- Department of Ophthalmology, Mayo Clinic Foundation of Florida, Jacksonville, Florida, USA
| | - Michael T Patterson
- Department of Ophthalmology, Mayo Clinic Foundation of Florida, Jacksonville, Florida, USA
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