Phaco-trabectome versus phaco-iStent in patients with open-angle glaucoma

Short-Term Efficacy and Safety of Phacoemulsification Associated With iStent Inject W in Patients With Controlled Open Angle Glaucoma

PRCIS

The iStent inject W implanted during phacoemulsification effectively reduces IOP.

PURPOSE

The purpose of this study was to evaluate the efficacy and safety of iStent inject W combined with phacoemulsification in patients with controlled open angle glaucoma undergoing cataract surgery.

PATIENTS AND METHODS

We conducted a retrospective, bicentric study of patients with controlled chronic open angle glaucoma who underwent phacoemulsification combined with the injection of 2 iStent inject Ws. Patient characteristics, including intraocular pressure (IOP) and the number of glaucoma medications, were evaluated preoperatively and 1 week, 1 month, and 6 months postoperatively. The primary end point was IOP reduction, and the secondary end point was the reduction in the number of glaucoma medications.

RESULTS

In this study, 85 eyes were included. The majority of patients had primary open angle glaucoma (85% of eyes). Preoperative mean IOP was 16.1±2.0 mm Hg with a mean of 2.3±0.5 glaucoma medications. At 1 week postoperatively, the mean IOP was 16.7±3.1 mm Hg with a mean of 2.0±0.7 hypotensive medications. At 1 and 6 months, the mean IOP was 14.2±2.1 and 13.0±1.5 mm Hg, with a mean of 2.0±0.6 and 1.8±0.5 glaucoma medications, respectively. The percentage IOP reduction at 1 and 6 months was 11.6% ( P =0.001) and 19.3% ( P <0.0001), respectively. Regarding glaucoma medications, at 1 and 6 months, the reduction in the number of medications was 12.9% ( P =0.025) and 22.4% ( P =0.003), respectively. The most frequent significant postoperative adverse events were corneal edema in 7%, IOP spikes in 6%, and hyphema in 6% of eyes, which resolved spontaneously.

CONCLUSIONS

The iStent inject W implanted during phacoemulsification effectively reduces IOP and the number of glaucoma medications needed at 6 months of follow-up, with a favorable safety profile in patients with controlled open angle glaucoma.

Minimally Invasive Glaucoma Surgery: Latest Developments and Future Challenges

The development of minimally invasive glaucoma surgeries (MIGSs) was intended to provide safe and modestly efficacious modalities for early intervention of mild-to-moderate glaucoma, with minimal trauma and rapid recovery. They were mainly ab interno procedures that reduce intraocular pressure by facilitating the aqueous outflow by bypassing the trabecular meshwork resistance, reinforcing the uveoscleral flow via the supraciliary space, and reducing aqueous production by the ciliary body. While the cumulating evidence helps shape the role of the available MIGS, the exponential new development and advancement in this field has expanded the territory of MIGS. Apart from developing subconjunctival MIGS filtration devices (Xen gel stent and PRESERFLO MicroShunt), there is a tendency to revisit the "traditional" MIGS for alternative use and to modify the procedures with consideration of the fundamental aqueous outflow physiology. Combined MIGS has also been suggested, based on the theory that their different mechanisms may provide additive or synergistic effects. The advancement of laser procedures is also promising and could supplement unmet needs along the glaucoma treatment algorithm. This review examines the broad array of MIGS, updates the recent findings, discusses their potential alternative applications, and explores future challenges.

[Minimally invasive glaucoma surgery-Comparison of angle based procedures]

Surgical procedures are playing an increasing role in the care of patients with glaucoma. Within the last decade, new surgical procedures have been established, which are summarized under the term minimally invasive glaucoma surgery (MIGS). A wide variety of different procedures are aimed at the structures in the angle of the anterior chamber, such as the trabecular meshwork and Schlemm's canal, to improve the physiological outflow or to improve the alternative uveoscleral outflow. The implementation of the treatment goal differs in the individual procedures, as does the maximum pressure reduction that can be achieved. Compared to trabeculectomy with the use of cytostatic agents, the achievable pressure reduction is usually significantly lower. In contrast, the significantly lower intraoperative and postoperative complication rates are emphasized as an advantage of these procedures. With increasing clinical experience and the growth of sufficient data on these new surgical procedures, a well-founded classification in the treatment algorithm of glaucoma surgery becomes easier; nevertheless, due to the small differences with respect to efficacy and safety profile, the final decision for an individual procedure often remains dependent on the surgeon's personal preferences.

Advanced glaucoma. Clinical practice guideline

OBJECTIVE

To present an update clinical practice guideline that serve as a guide for the detection, evaluation and treatment of adults patients with advanced glaucoma.

METHODS

After defining the objectives and scope of the guide, the working group was formed and structured clinical questions were formulated following the PICO (Patient, Intervention, Comparison, Outcomes) format. Once all the existing clinical evidence had been independently evaluated with the AMSTAR 2 (Assessment of Multiple systematic Rewiews) and Cochrane "Risk of bias" tools by at least two reviewers, recommendations were formulated following the Scottish Intercollegiate methodology. Guideline Network (SIGN).

RESULTS

Recommendations with their corresponding levels of evidence that may be useful in the diagnosis, monitoring and treatment of adults patients with advanced glaucoma.

CONCLUSIONS

Despite the fact that for many of the questions the level of scientific evidence available is not very high, this clinical practice guideline offers an updated review of the different existing aspects related to the evaluation and management of advanced glaucoma.

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.

Role of minimally invasive glaucoma surgery in the management of chronic open-angle glaucoma

To compare the safety and efficacy of phacoemulsification combined with ab-interno trabeculectomy (Trabectome) and phacoemulsification combined with I-Stent inject in patients with medically uncontrolled primary open-angle glaucoma (POAG). A retrospective comparative case series. 70 eyes of 66 patients completed 2 years follow up after these treatments performed in 2017–2018. 35 eyes of 33 patients underwent combined Phaco-Trabectome (PT); and 35 eyes of 33 patients underwent combined Phaco-I-Stent inject (Pi). Patient demographics and preoperative characteristics are comparable. A 20% drop in IOP was achieved in 27 eyes (77.14%) in PT group and 28 eyes (80%) in Pi group (p = 0.77). Success rate (target IOP achieved and maintained for 2 years) in advance glaucoma was 25% in PT group and 30.7% in Pi group (p = 0.90). In mild to moderate glaucoma, success rate was 85.71% in PT group and 90% in Pi group (p = 0.67). There was no significant difference between two groups with regards to mean reduction in glaucoma medications and complication rates. Trabectome and I-Stent combined with phacoemulsification are equally efficacious and safe for treating patients with medically uncontrolled mild and moderate primary open-angle glaucoma (POAG). However, they are not an effective treatment for patients with advanced glaucoma.

Selective Laser Trabeculoplasty Versus MIGS: Forgotten Art or First-Step Procedure in Selected Patients with Open-Angle Glaucoma

Introduction

To evaluate the long-term effect on intraocular pressure (IOP) and glaucoma medication of selective laser trabeculoplasty (SLT) compared to minimally invasive glaucoma surgery (MIGS) in primary open-angle glaucoma (POAG) and its potential in clinical practice.

Methods

A total of 342 consecutive patients (stand-alone procedures) were included. One hundred and five patients underwent SLT treatment (360° SLT, 95–105 spots, Trabeculas SLT ARCLaser, Nürnberg, DE), 107 patients had an ab interno-derived trabeculotomy (Trabectome^®, NeoMedix, Tustin, USA), and 130 patients received iStent inject^® implantation (2 implants-Glaukos, CA, USA). IOP and glaucoma therapy were evaluated preoperatively, 1 day, 6 weeks, 3 months, 6 months, and 1, 2, and 3 years postoperatively. Statistical analysis was performed using a regression model and propensity matching score (reduced cohort number) using SPSS v20.0. Kaplan–Meier analysis was included using the following six criteria: criterion A (IOP ≤ 21 mmHg with or without medication, qualified success), criterion B (IOP ≤ 18 mmHg with or without medication, qualified success), criterion C (IOP ≤ 21 mmHg without medication, complete success), criterion D (IOP ≤ 18 mmHg without medication, complete success), criterion E (IOP ≤ 21 mmHg and IOP reduction > 20% after therapy), and criterion F (IOP ≤ 18 mmHg and IOP reduction > 20% after therapy).

Results

In the matched cohort, the SLT cohort showed an IOP reduction of 31.2% from 19.9 ± 2.3 to 13.7 ± 2.7 mmHg (p < 0.001) 3 years postoperatively; in Trabectome^® IOP decreased by 31.4% from 20.5 ± 1.3 to 13.8 ± 2.0 mmHg (p < 0.001) and in iStent inject^® by 29.9% from 19.5 ± 2.0 to 13.8 ± 2.7 mmHg (p < 0.001). Trabectome^® and iStent inject^® could not demonstrate a significant reduction in glaucoma therapy (Trabectome^®p = 0.138, iStent inject^®p = 0.612); a significant drop was noted in SLT (2.2 ± 1.2 to 1.7 ± 1.2, p = 0.046). SLT and MIGS achieved good to moderate survival rates using criterion A (93.3% SLT, 79.7% Trabectome^®, 77.6% iStent inject^®) and criterion B (74.5% SLT, 48.0% Trabectome^®, 56.2% iStent inject^®). As expected, low survival rates were obtained with non-filtering procedures: criterion C 11.1% in SLT, 6.5% in Trabectome^®, 7.0% in iStent inject^® and criterion D 3.0% in SLT, 4.3% in Trabectome^®, 3.7% in iStent inject^® in 3-year follow-up.

Conclusion

The SLT is a low-complication and effective method for reducing pressure in mild to moderate POAG. SLT is suitable as an initial procedure when setting up a step scheme; MIGS is the treatment of choice as a follow-up for mild to moderate forms of glaucoma and accepted topical therapy. Ethic approval had been given by the Ethikkommission Charité – Universitätsmedizin Berlin, EA4/047/20—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-021-00347-0.

Intraocular Pressure After Cataract Surgery Combined With Ab Interno Trabeculectomy Versus Trabecular Micro-bypass Stent: An Intrasubject Same-surgeon Comparison

PRECIS

Combining Trabectome or iStent with phacoemulsification equally reduces intraocular pressure (IOP) and IOP-lowering medication burden during a 24-month follow-up, with a possible advantage to the Trabectome in the early postoperative period.

PURPOSE

Intrasubject same-surgeon comparison between phacoemulsification combined with Trabectome (Phaco/Trabectome) versus one first-generation iStent (Phaco/iStent).

SETTINGS

Private glaucoma and cataract practice.

DESIGN

This is a retrospective interventional case series.

METHODS

Data collected at 3 to 4 and 20 to 24 hours and up to 30 months following Phaco/Trabectome in 1 eye and Phaco/iStent in the contralateral eye in patients with bilateral visually-significant cataract and open-angle glaucoma. Evaluations included IOP, intraocular pressure-lowering medications (IOPmeds), visual acuity, and complications.

RESULTS

Forty-five patients (90 eyes) were identified (age 76.5, 57 to 95 y). At 3 to 4 hours, IOP was above baseline in 12 and 13 eyes following Phaco/Trabectome and Phaco/iStent, respectively, but the degree of IOP elevation was smaller (P=0.048) following Phaco/Trabectome: 4.3 mm Hg, 2.0 to 6.6 mm Hg (95% confidence interval) versus Phaco/iStent: 8.7 mm Hg, 3.8 to 13.6 mm Hg. At 20 to 24 hours, compared with baseline, IOP was significantly lower after Phaco/Trabectome (P=0.004) but not after Phaco/iStent (P=0.14) although the rate of hyphema was higher following Phaco/Trabectome (12/45 vs. 2/45 eyes, P=0.007). IOP reduction from baseline at 3 to 4 hours was significantly larger (P=0.020) in the 21 eyes with hyphema: -3.9, -6.4 to -1.4 versus the 69 eyes without hyphema: -0.3, -2.0 to +1.4. At 1, 6, 12, and 24 months, IOP and number of IOPmeds were similar and significantly lower compared with baseline following either procedure. No complications were encountered in either group.

CONCLUSIONS

Combined phacoemulsification with either Trabectome or first-generation iStent similarly lowers IOP and IOPmeds burden at 1, 6, 12, and 24 months following surgery. The Trabectome may have an advantage in lowering IOP faster and lessening the degree of IOP elevations in the early postoperative period.

Comparison of a second-generation trabecular bypass (iStent inject) to ab interno trabeculectomy (Trabectome) by exact matching

Purpose

To achieve a highly balanced comparison of trabecular bypass stenting (IS2, iStent inject) with ab interno trabeculectomy (T, Trabectome) by exact matching.

Methods

Fifty-three IS2 eyes were matched to 3446 T eyes. Patients were matched using exact matching by baseline intraocular pressure (IOP), the number of glaucoma medications, and glaucoma type, and using nearest neighbor matching by age. Individuals without a close match were excluded. All surgeries were combined with phacoemulsification.

Results

A total of 78 eyes (39 in each group) could be matched as exact pairs with a baseline IOP of 18.3 ± 5.1 mmHg and glaucoma medications of 2.7 ± 1.2 in each. IOP in IS2 was reduced to 14.6 ± 4.2 mmHg at 3 months and in T to a minimum of 13.1 ± 3.2 mmHg at 1 month. In IS2, IOP began to rise again at 6 months, eventually exceeding baseline. At 24 months, IOP in IS2 was 18.8 ± 9.0 mmHg and in T 14.2 ± 3.5 mmHg. IS2 had a higher average IOP than T at all postoperative visits (p < 0.05 at 1, 12, 18 months). Glaucoma medications decreased to 2.0 ± 1.5 in IS2 and to 1.5 ± 1.4 in T.

Conclusion

T resulted in a larger and sustained IOP reduction compared with IS2 where a rebound occurred after 6 months to slightly above preoperative values.

Two-year data comparison of ab interno trabeculectomy and trabecular bypass stenting using exact matching

PURPOSE

To create a balanced comparison of ab interno trabeculectomy (AIT) (Trabectome) and trabecular bypass stenting (TBS) (iStent).

SETTING

Eye and Ear Institute, Pittsburgh, Pennsylvania, Ross Eye Institute, Buffalo, New York, and Glaucoma Associates of Texas, Dallas, USA.

DESIGN

Retrospective case series.

METHODS

The primary outcome measure was an unmedicated intraocular pressure (IOP) of 21 mm Hg or less and the secondary measure was an unmedicated IOP reduction of 20% or more at 2 years. Patients were matched by baseline IOP, number of glaucoma medications, and glaucoma type using exact matching and by age using nearest neighbor matching. Individuals without a close match were excluded. All surgeries were combined with phacoemulsification.

RESULTS

One hundred fifty-four AIT eyes and 110 TBS eyes were analyzed. Forty-eight AIT patients were exactly matched with 48 TBS patients. Both groups had a mean baseline IOP of 15.3 mm Hg ± 3.1 (SD). At 24 months, the mean IOP was 13.9 ± 3.3 mm Hg in AIT patients and 16.8 ± 2.8 mm Hg in TBS patients and the mean number of medications was 0.7 ± 1.0 and 1.7 ± 1.2, respectively (both P = .04). At 24 months, the IOP was 21 mm Hg or less without medications in 53% of AIT patients and 16.6% of TBS patients (P < .05). At that time, 17.6% of patients in the AIT group but no patient in the TBS group had an IOP reduction of 20% or more without medication.

CONCLUSION

An exact matching comparison of AIT and TBS showed greater IOP reduction with fewer medications after AIT.

Influence of oral anticoagulation on success rates and risk of bleeding events after iStent inject implantation combined with phacoemulsification

Purpose

We conducted a retrospective study to evaluate the intraocular pressure (IOP) lowering effect, the success rates, and the risk of bleeding events of patients receiving an iStent inject combined with phacoemulsification under anticoagulation therapy compared with a matched control group.

Methods

In this retrospective study, sixty-four eyes underwent an iStent inject implantation combined with phacoemulsification at two centers. Thirty-two eyes received surgery while under anticoagulation therapy, and another thirty-two eyes served as a control group matched for visual acuity, IOP, and medication score. Success was defined as criteria A and B (IOP < 18/21 mmHg, > 20% IOP reduction, no resurgery) and criteria C (IOP ≤ 15 mmHg, IOP reduction ≥ 40%, no resurgery). The clinical goal of the study was to determine the difference between the study and control groups with respect to IOP, medication score, and the frequency of intraoperative and postoperative bleeding events.

Results

After a mean follow-up time of 1 year, the IOP lowered 28% from 20.1 ± 4.8 to 14.5 ± 3.7 mmHg in the group of 64 eyes. The medication score lowered 38% from 2.1 ± 1.1 to 1.3 ± 1.2. The two groups with and without anticoagulant agents did not significantly differ in postoperative IOP, medication score, success rates, or number of bleeding events.

Conclusion

We conclude that in cataract surgery combined with the iStent inject a discontinuation of anticoagulant agents might not be necessary. It might be a good option in glaucoma surgery when anticoagulation treatment should not be interrupted and the target pressure is not very low.

Minimally Invasive Glaucoma Surgery: Where Is the Evidence?

PURPOSE

The last decade has witnessed an unprecedented growth in glaucoma treatment options through the introduction of minimally invasive glaucoma surgeries (MIGS). The aim of the present review is to provide an understanding of the currently available MIGS and to examine what data are currently available to guide treatment choice.

DESIGN

Meta-analysis and systematic review of randomized and non-randomized control trials.

METHODS

Out of 2567 articles identified, a total of 77 articles were retained for analysis, including 28 comparative studies and 12 randomized control trials. Overall, 7570 eyes were included. When data permitted, the weighted mean difference in intraocular pressure reduction was calculated for comparison purposes.

RESULTS

Weighted mean intraocular pressure reductions from all analyzed studies were: 15.3% (iStent), 29.1% (iStent inject), 36.2% (ab interno canaloplasty), 34.4% (Hydrus), 36.5% (gonioscopically-assisted transluminal trabeculotomy), 24.0% (trabectome), 25.1% (Kahook dual blade), 30.2% (Cypass), 38.8% (XEN), and 50.0% (Preserflo).

CONCLUSIONS

One of the advantages of the heterogenous range of available MIGS options is the chance to tailor therapy in an individualized manner. However, high-quality data are required to make this choice more than an educated guess. Overall, this review confirms the efficiency of assessed MIGS compared with standalone phacoemulsification, but it highlights that only few studies compare different MIGS techniques and even fewer assess MIGS against criterion standard treatments. Current evidence, while non-negligible, is mostly limited to heterogenous nonrandomized studies and uncontrolled retrospective comparisons, with few quality randomized control trials. We suggest that future research should be comparative and include relevant comparators, standardized to report key outcome features, long-term to assess sustainability and late complications, and ideally randomized.

The Efficacy and Safety of High-Frequency Deep Sclerotomy in Treatment of Chronic Open-Angle Glaucoma Patients

Purpose

Highlights the high-frequency deep sclerotomy as a competing ab interno surgery in open-angle glaucoma patients and evaluates the efficacy of high-frequency deep sclerotomy in lowering IOP of chronic open-angle glaucoma patients, in addition to the evaluation of the safety of the procedure on the corneal endothelium.

Design

A prospective study. It was performed in the Research Institute of Ophthalmology, Cairo.

Participants

43 eyes were enrolled for the study. All eyes were diagnosed with chronic open-angle glaucoma.

Methods

The procedure was performed using the abee® glaucoma tip of Oertli phacoemulsification machine (OS3, Switzerland) and goniolens performing nasal six pockets penetrating 1 mm deep into the trabecular meshwork and Schlemm's canal. Patients were followed up regarding vision and intraocular pressure (IOP) for 9 months. Endothelial cell count and coefficient of variation were calculated using specular microscopy preoperatively and 9 months postoperatively.

Results

The mean preoperative IOP was 31.4 ± 4.71 mmHg (range: 22 to 42 mmHg). All patients were followed up for nine months. The mean IOP was 19.06 ± 1.907 mmHg (range: 15 to 26 mmHg) by the end of the study. The reduction across the follow-ups was statistically significant (P < 0.0001). The percentage of total success was 90.7% (39 eyes). Four eyes (9.3%) had IOP > 21 (failed) after surgery and continued on antiglaucoma therapy.

Conclusion

High-frequency deep sclerotomy is a safe and promising minimally invasive procedure which successfully achieves a lower IOP for chronic open-angle glaucoma patients, but not adequate for advanced glaucoma patients. This trial is registered with PACTR201910823824561.

Success of combined cataract extraction plus excimer laser trabeculotomy exceeds that of combined ab interno trabeculectomy with the trabectome or cataract extraction alone

PURPOSE

To determine the efficacy of cataract surgery alone and combined with two minimally invasive glaucoma surgery (MIGS) procedures (phaco-ELT and phaco-aiT).

METHODS

Data was collected from 12/2007 to 02/2012 in this retrospective, non-randomized, comparative single surgery center study. Reduction in IOP and hypotensive medication (AGD), change in visual acuity, success rates, and complications were computed by comparing preoperative data with data at 1 year postoperatively.

RESULTS

A total of 245 eyes of 245 subjects were included. Study eyes underwent phaco alone (38 eye) or combined phaco-ELT (105 eye) and phaco-aiT (102 eye). Phaco alone, combined phaco-ELT, and combined phaco-aiT lowered IOP by 1.5 ± 4.0 mmHg, 4.3 ± 5.6, and 5.3 ± 4.5 mmHg, respectively (P < 0.01). Survival time of phaco-ELT outreached survival time of phaco alone and combined phaco-aiT (20.6 ± 1.0 vs. 13.2 ± 0.4 and 12.9 ± 0.6 month, respectively). No serious complications or adverse events occurred. None of the cases required a subsequent procedure within the first year to lower IOP further.

CONCLUSIONS

All three surgical procedures lowered IOP and reduced medication. However, the IOP-lowering efficacy of the two combined MIGS procedures exceeded the effect of phaco alone. A combined phaco and MIGS procedures seem reasonable to consider whenever a cataract surgery in an eye with glaucoma or ocular hypertension is considered. In addition, the combined MIGS procedure effectively lowers IOP whenever a target IOP in the mid-teens is sufficient. In this study, the nonthermal phaco-ELT procedure showed superior efficacy at 1 year over phaco alone and phaco-aiT in the Kaplan-Meier statistics.

Effect of combined goniotomy and phacoemulsification on intraocular pressure in open-angle glaucoma patients

IMPORTANCE

Although goniotomy is known to be successful in treating congenital glaucoma, its effect in adult glaucoma patients remains unclear.

BACKGROUND

To evaluate the efficacy and safety of goniotomy performed simultaneously with cataract surgery in treatment of open-angle glaucoma (OAG).

DESIGN

Retrospective comparative study.

PARTICIPANTS

A total of 76 patients with moderately controlled OAG (intraocular pressure [IOP] ≤ 21 mmHg using medications) undergoing cataract surgery.

METHODS

Comparison of patients who underwent the conventional goniotomy during cataract surgery (combined goniotomy group) with those who underwent cataract surgery alone (phaco group).

MAIN OUTCOME MEASURES

Changes in IOP and medications, and complications through 12 months.

RESULTS

Baseline IOP was 18.2 ± 2.4 mmHg in the combined goniotomy group and 17.4 ± 1.9 mmHg in the phaco group; number of medications was 2.6 ± 1.1 and 2.4 ± 0.9, respectively (P > 0.05). The reduction in IOP and medication use from baseline in the combined goniotomy group was significantly greater at 12 months compared to the phaco group (-3.1 ± 2.9 mmHg vs -1.3 ± 2.4 mmHg and -1.2 ± 0.9 vs -0.7 ± 0.9, respectively, both P < 0.05). The success rate was 76.7% in the combined goniotomy group and 50.0% in the phaco group at 12 months (P = 0.021). No significant complication was observed in either group.

CONCLUSIONS AND RELEVANCE

Combined goniotomy and cataract surgery showed a significantly greater reduction in IOP and number of medications compared to cataract surgery alone at 1 year after surgery, with similarly favourable safety profiles.

Efficacy and Adverse Event Profile of the iStent and iStent Inject Trabecular Micro-bypass for Open-angle Glaucoma: A Meta-analysis

Aim

This meta-analysis explores the efficacy and adverse event profile of the iStent, an ab interno implant for the treatment of open-angle glaucoma.

Methods

A systematic literature search of Ovid MEDLINE and EMBASE was used to identify peer-reviewed original studies that provided efficacy data on the first or second generation iStent for at least five eyes. Intraocular pressure (IOP) was the primary efficacy endpoint, while the number of medication classes was the secondary outcome. Weighted mean differences were reported for continuous endpoints, while a relative risk was computed for dichotomous variables.

Review Results

The search revealed 545 results, of which 1767 eyes from 28 studies were included. The cohort age was 71.4 ± 5.4 years, and 44.9% of patients were male. There was a significantly greater IOP reduction after the use of two first-generation stents compared to one, irrespective of phacoemulsification status (p < 0.001). Additionally, there was a significantly greater IOP reduction following iStent alone relative to phaco-iStent for the first-generation iStent (p < 0.001) and the iStent inject (p < 0.001). For the first generation stent, combined phaco-iStent provided a greater level of IOP reduction (p < 0.001) and reduction in the number of medication classes relative to phacoemulsification alone (p < 0.001). In total, 22.5% of eyes that received iStent implantation sustained some type of adverse event. The most common adverse events were intraocular pressure elevation, stent blockage or obstruction, stent malposition and hyphema.

Conclusion and Clinical Significance

Statistically significant differences in efficacy outcomes exist between different numbers of stents and the presence or absence of concurrent phacoemulsification.

How to cite this article: Popovic M, Campos-Moller X, Saheb H, Ahmed IIK. Efficacy and Adverse Event Profile of the iStent and iStent Inject Trabecular Micro-bypass for Open-angle Glaucoma: A Meta-analysis. J Curr Glaucoma Pract 2018;12(2):67-84.

Combined glaucoma and cataract surgery: Comparison of viscocanalostomy, endocyclophotocoagulation, and ab interno trabeculectomy

PURPOSE

To compare outcomes of phacoemulsification combined with viscocanalostomy, endocyclophotocoagulation (ECP), or ab interno trabulectomy for intraocular pressure (IOP) control and safety in eyes with open-angle glaucoma and visually significant cataract.

SETTING

Farabi Eye Hospital, Tehran, Iran.

DESIGN

Retrospective case series.

METHODS

Medical records of patients who had combined surgery and were followed for at least 1 year were reviewed. Complete success, postoperative IOP, number of medications at each visit, and complications were evaluated and compared before and after adjustments for confounders.

RESULTS

Forty-six eyes had combined phacoviscocanalostomy, 35 had phaco-ECP, and 28 eyes phaco-ab interno trabulectomy. The groups were matched for baseline IOP (P = .24). At the final follow-up (mean 17.2 months ± 5.5 [SD]), the phacoviscocanalostomy group had the lowest mean IOP (13.5 ± 4.7 mm Hg, 29% decrease) (P = .01). There was no significant difference in the final IOP between phaco-ECP and phaco-ab interno trabulectomy (16.4 ± 3.9 mm Hg, 20% decrease versus 15.8 ± 4.2 mm Hg, 15% decrease) (P = .88). The reduction in the number of medications was greater with phacoviscocanalostomy (77%) than with phaco-ECP (40%) and phaco-ab interno trabulectomy (44%) (P = .01). Phacoemulsification-ab interno trabulectomy had the fewest complications. Intraocular pressure spikes were more frequent in the phaco-ECP group (20%) than in the other groups (4%) (P = .05).

CONCLUSIONS

All procedures significantly lowered IOP. Phacoemulsification-ab interno trabulectomy resulted in fewest complications and phacoviscocanalostomy led to the largest IOP drop and largest reduction of medications.

Systematic Literature Review of Clinical and Economic Outcomes of Micro-Invasive Glaucoma Surgery (MIGS) in Primary Open-Angle Glaucoma

INTRODUCTION

Primary open-angle glaucoma is estimated to affect 3% of the population aged 40-80 years. Trabeculectomy is considered the gold standard in surgical management of glaucoma; however, it is a technically complex procedure that may result in a range of adverse outcomes. Device-augmented, minimally invasive procedures (micro-invasive glaucoma surgeries, MIGS) have been developed aiming for safer and less invasive intraocular pressure (IOP) reduction compared with traditional surgery.

METHODS

This paper presents results from a systematic literature review conducted in accordance with National Institute for Health and Care Excellence requirements for the Medical Technology Evaluation Programme via multiple databases from 2005 to 2016. For clinical outcomes, randomized clinical trials (RCTs) comparing MIGS with trabeculectomy or other therapies, observational studies, and other non-RCTs were included. Clinical outcomes reviewed were the change from baseline in mean IOP levels and change in topical glaucoma medication. Safety was assessed by reported harm and adverse events. For economic evidence, trials on cost-effectiveness, cost-utility, cost-benefit, cost-consequences, cost-minimization, cost of illness, and specific procedure costs were included. Risk of bias was assessed for clinical studies using the Cochrane Risk of Bias tool.

RESULTS

A total of nine RCTs (seven iStents®, one Hydrus®, and one CyPass®), seven non-RCTs (three iStent®, three CyPass®, and one Hydrus®), and 23 economic studies were analyzed. While various forms of trabeculectomy can achieve postoperative IOP of between 11.0 and 13.0 mmHg, MIGS devices described in this review were typically associated with higher postoperative IOP levels. In addition, MIGS devices may result in increased hypotony rates or bleb needling in subconjunctival placed devices, requiring additional medical resources to manage. There is limited available evidence on the cost-effectiveness of MIGS and therefore it remains unclear whether the cost of using MIGS is outweighed by cost savings through decreased medication and need for further interventions.

CONCLUSION

Larger randomized trials and real-world observational studies are needed for MIGS devices to better assess clinical and economic effectiveness. Given the shortage of published data and increasing use of such procedures, living systematic reviews may help to provide ongoing and timely evidence-based direction for clinicians and decision makers. This review highlights the current unmet need for treatments that are easy to implement and reduce long-term IOP levels without increasing postoperative aftercare and cost.

FUNDING

Santen GmbH, Germany.

Co-management of cataract and glaucoma in the era of minimally invasive glaucoma surgery

PURPOSE OF REVIEW

This review discusses the options available to be used in conjunction with phacoemulsification cataract surgery to control intraocular pressure. We present a strategy for planning which surgery should be performed based on goals of care.

RECENT FINDINGS

New clinical evidence for using the CyPass, Kahook and Xen45 devices has been published recently and is summarized.

SUMMARY

Cataract and glaucoma frequently exist together. Because the field of glaucoma surgical care is expanding and cataract surgery is becoming progressively safer, it is important to frequently re-evaluate our treatment paradigms. We review and evaluate current studies and treatment options.

Minimally-invasive glaucoma surgeries (MIGS) for open angle glaucoma: A systematic review and meta-analysis

Background

MIGS have been developed as a surgical alternative for glaucomatous patients.

Purpose

To analyze the change in intraocular pressure (IOP) and glaucoma medications using different MIGS devices (Trabectome, iStent, Excimer Laser Trabeculotomy (ELT), iStent Supra, CyPass, XEN, Hydrus, Fugo Blade, Ab interno canaloplasty, Goniscopy-assisted transluminal trabeculotomy) as a solo procedure or in association with phacoemulsification.

Methods

Randomized control trials (RCT) and non-RCT (non randomized comparative studies, NRS, and before-after studies) were included. Studies with at least one year of follow-up in patients affected by primary open angle glaucoma, pseudoexfoliative glaucoma or pigmentary glaucoma were considered. Risk of Bias assessment was performed using the Cochrane Risk of Bias and the ROBINS-I tools. The main outcome was the effect of MIGS devices compared to medical therapy, cataract surgery, other glaucoma surgeries and other MIGS on both IOP and use of glaucoma medications 12 months after surgery. Outcomes measures were the mean difference in the change of IOP and glaucoma medication compared to baseline at one and two years and all ocular adverse events. The current meta-analysis is registered on PROSPERO (reference n° CRD42016037280).

Results

Over a total of 3,069 studies, nine RCT and 21 case series with a total of 2.928 eyes were included. Main concerns about risk of bias in RCTs were lack of blinding, allocation concealment and attrition bias while in non-RCTs they were represented by patients’ selection, masking of participants and co-intervention management. Limited evidence was found based on both RCTs and non RCTs that compared MIGS surgery with medical therapy or other MIGS. In before-after series, MIGS surgery seemed effective in lowering both IOP and glaucoma drug use. MIGS showed a good safety profile: IOP spikes were the most frequent complications and no cases of infection or BCVA loss due to glaucoma were reported.

Conclusions

Although MIGS seem efficient in the reduction of the IOP and glaucoma medication and show good safety profile, this evidence is mainly derived from non-comparative studies and further, good quality RCTs are warranted.