Intraocular pressure reduction after phacoemulsification with intraocular lens implantation in glaucomatous and nonglaucomatous eyes

Impacts and Correlations on Corneal Biomechanics, Corneal Optical Density and Intraocular Pressure after Cataract Surgery

The study aimed to investigate the extended effects and interrelations of corneal biomechanics, corneal optical density (COD), corneal thickness (CT), and intraocular pressure (IOP) following cataract surgery. Sixteen eyes were analyzed prospectively. The Corneal Visualization Scheimpflug Technology (Corvis ST) device assessed corneal biomechanics, while the Pentacam AxL® (Pentacam) measured COD and CT. Postoperative data were collected around six months after surgery, with a subgroup analysis of data at nine months. The Pearson correlation was used to examine the relationship between surgical-induced changes in corneal biomechanics and COD. At six months, significant postoperative differences were observed in various biomechanical indices, including uncorrected IOP (IOPuct) and biomechanics-corrected IOP (bIOP). However, many indices lost statistical significance by the nine-month mark, suggesting the reversibility of postoperative corneal changes. Postoperative COD increased at the anterior layer of the 2-6 mm annulus and incision site. The changes in COD correlated with certain biomechanical indices, including maximal (Max) deformative amplitude (DA) and stiffness parameter (SP). In conclusion, despite significant immediate postoperative changes, corneal biomechanics, COD, and IOP experienced a gradual recovery process following cataract surgery. Clinicians should maintain vigilance for any unusual changes during the short-term observation period to detect abnormalities early.

Three-Year Outcomes of the Paul Glaucoma Implant for Treatment of Glaucoma

PRCIS

In our case series, the 3-year failure for Paul Glaucoma Implant (PGI) implantation was 14.6%. At 3 years postoperatively, there was a significant reduction in mean intraocular pressure (IOP) and the number of glaucoma medications used.

OBJECTIVE

To determine the 3-year efficacy and safety of the PGI, a novel glaucoma tube shunt in patients with glaucoma.

METHODS

Retrospective review of all patients who had undergone PGI implantation in a single tertiary institution in Singapore between May 1, 2017 and January 1, 2022. Data were extracted from electronic health records (Computerized Patient Support System 2 and Epic). The primary outcome measure was failure, defined as IOP >18 mm Hg or <6 mm Hg on 2 consecutive visits after 3 months, reoperation for IOP-related indication, explantation of implant, or loss of light perception vision. Complete success was defined as the absence of failure without medications at 36 months, and qualified success similarly, but with medications. Postoperative mean IOP, mean number of IOP-lowering medications used, and visual acuity were also assessed.

RESULTS

Forty-eight eyes in 48 patients were identified. Thirty-one patients (64.6%) had primary open angle and angle closure glaucoma, and 18 (37.5%) had previous existing tube implants or trabeculectomy. At 3 years postoperatively, 7 cases (14.6%) fulfilled the criteria for failure and 36 (75%) met the criteria for complete success. The mean IOP at 36 months was 14.9 ± 4.11 mm Hg, from the mean preoperative IOP of 20.6 ± 6.13 mm Hg ( P < 0.001). The mean number of IOP-lowering medications used was reduced from 3.13 ± 0.959 preoperatively to 0.167 ± 0.476 at 36 months ( P < 0.001). The most common postoperative complication was hypotony (n = 17, 35.4%), of which the majority were self-limiting, followed by hyphema (n = 5, 10.4%) and tube exposure (n = 4, 8.3%).

CONCLUSION

The PGI demonstrated sustained IOP reduction and a reduction of medication burden at 3 years postoperatively.

Mid-term real world outcomes of the Hydrus® Microstent in open angle glaucoma

PURPOSE

To evaluate the mid-term clinical results and the safety aspects of the Hydrus® Microstent (Ivantis, Inc, Irvine, CA) in a real-life setting.

DESIGN

Retrospective case series.

METHODS

Hydrus® Microstent was implanted in phakic eyes (88 eyes, 87.1%) and in pseudophakic eyes (13 eyes, 12.9%), respectively. Mean follow-up time was 16 ± 9 months with 27 eyes having a follow-up time of more than 24 months.

MAIN OUTCOME MEASURES

The primary endpoint was reduction in IOP compared to baseline. Target IOP levels were set at ≤20 mmHg, ≤18 mmHg and ≤15 mmHg. Kaplan-Meier survival was defined as a reduction in IOP of ≥20% compared to baseline. Secondary endpoints were reduction in number of glaucoma medications and safety assessments addressing visual acuity, adverse events, re-surgery rate and identification of factors that made the implantation more difficult.

RESULT

101 eyes underwent Hydrus® implantation. The mean preoperative IOP was 21.60 mmHg (SD 6.6) on 2.18 (SD 1.3) medications. After a mean follow up time of 16 months, the mean IOP was reduced to 14.61 ± 3.7 mmHg on 1.12 (SD 1.1) medication classes (p < 0.001). Mean decrease in IOP was 26.7%. Analysis of the target IOP levels showed that in 29%, 34% and 35% of cases an IOP of ≤15 mmHg, ≤18 mmHg and ≤20 mmHg respectively could be achieved. BCVA improved from 0.56 ± 0.3 at baseline to 0.85 ± 0.3 more than 24 months after surgery (p < 0.001). The rate of re-operation was low at <3%. Adverse events occurred in 4 eyes (<4%).

CONCLUSION

This study underlines the effectiveness and the safety of the Hydrus® Microstent in an elective setting, but it also demonstrates certain limits and risk factors of this procedure.

Anterior Segment Changes in Patients With Glaucoma Following Cataract Surgery

This prospective observational study investigates the impact of cataract surgery on anterior segment parameters in nonglaucomatous and primary open-angle glaucoma (POAG) eyes, utilizing anterior segment optical coherence tomography (AS-OCT). The study involved 42 Caucasian patients, divided into a control group and a POAG group. Comprehensive ophthalmic examinations were performed along with AS-OCT imaging and biometry preoperatively, as well as on one day, one week, and one month following cataract surgery. The results showed significant post-operative changes in anterior chamber depth (ACD) and angle width in both groups, suggesting that cataract surgery may influence the structural parameters associated with glaucoma risk and management. Specifically, a marked increase in ACD and improvement in angle-opening distances were observed, highlighting the potential of cataract extraction to alter intraocular fluid dynamics favorably. Despite these changes, the study noted an initial spike in increased intraocular pressure (IOP) in POAG patients immediately post-operative, which stabilized during follow-up. For the control group, IOP showed gradually reducing IOP values in the follow-up visits. The findings underscore the role of advanced imaging technologies in understanding glaucoma's pathophysiology and the potential benefits of cataract surgery in glaucoma patients. The study advocates for further research with a larger, more diverse patient population and extended follow-up to explore the long-term implications of cataract surgery on glaucoma dynamics, emphasizing the importance of personalized management and treatment strategies particularly for glaucoma patients.

Risk Factors for Failure in Glaucoma Patients Undergoing Microshunt Implantation

PURPOSE

To evaluate risk factors for failure of Microshunt in glaucoma patients.

DESIGN

Multicenter retrospective cohort study.

METHODS

The study included 220 eyes from 220 consecutive glaucoma patients undergoing Microshunt implantation at six glaucoma units. Four intraocular pressure (IOP) success criteria were defined: (A) IOP ≤21 mm Hg with ≥20% IOP reduction; (B) IOP ≤18 mm Hg with ≥20% IOP reduction; (C) IOP ≤15 mm Hg with ≥25% IOP reduction; and (D) IOP ≤12 mm Hg with ≥30% IOP reduction from baseline. Kaplan-Meier analysis was used to estimate success rates according to the criteria above, and multivariable Cox models were used to identified risk factors for failure according to criterion A.

RESULTS

Success rates varied based on different criteria, ranging from 43.3% to 62.5% (overall success for criteria D and A, respectively) and from 35.3% to 44.4% (complete success for criteria D and A, respectively) at 1-year follow-up. Higher intraoperative MMC concentration was associated with reduced risk of failure to maintain complete (0.4 vs 0.2 mg/mL: hazard ratio [HR] = 0.441, P < .001) and overall (0.4 vs 0.2 mg/mL: HR = 0.360, P = .004) success. For complete success, other risk factors for failure were pseudoexfoliation glaucoma/pigmentary glaucoma (HR = 1.641, P = .004), primary angle closure glaucoma (HR = 1.611, P < .001), and previous non-glaucomatous ocular surgeries (HR = 2.301, P = .002). For overall success, other risk factors for failure were lower preoperative IOP (for 1-mm Hg increase, HR = 0.934, P = .005), higher number of preoperative antiglaucoma agents (HR = 1.626, P < .001), and Microshunt combined with cataract surgery (HR = 1.526, P = .033).

CONCLUSIONS

This study identified risk factors for Microshunt failure, highlighting the importance of high intraoperative MMC dose and careful patient selection to optimize surgical success.

Short-term report of early glaucoma surgery with a clear lens extraction and an intraocular lens, OMNI canaloplasty, and a HYDRUS microstent: a case series in younger patients

Purpose

The purpose of this case series is to report the surgical outcomes from the combination of a clear lensectomy, OMNI® canaloplasty, and a HYDRUS® microstent with an adjacent goniotomy.

Methods

This is a retrospective non-comparative single-center case series of four black patients of African descent with glaucoma who were treated with a clear lensectomy, OMNI canaloplasty, and a HYDRUS microstent with an adjacent goniotomy. The surgeries were performed by an experienced cataract and glaucoma surgeon, Daniel Laroche, MD. The parameters investigated in this study were postoperative intraocular pressure (IOP) and the mean number of preoperative and postoperative medications needed.

Results

The mean age of the four patients was 44.5 years. All patients had a mean postoperative reduction in IOP of 17 mmHg to 12.7 mmHg. The mean number of preoperative medications was 2.2, while the mean number of postoperative medications was 0.3. Potential complications such as hyphema, IOP spikes, or corneal edema were not seen in this series. All patients achieved a lower IOP and stable vision with less refractive error. Patients also experienced improved visual fields, clearer vision, and more open angles.

Conclusion

Clear lensectomy and combined microinvasive glaucoma surgery (MIGS) in patients with primary open-angle glaucoma (POAG) and narrow-angle glaucoma (NAG) results in the safe lowering of IOP. The limitations of this study include the small series size and the retrospective potential for bias. Further research with a larger series and a prospective trial with follow-up should be performed.

Anterior Chamber Biometric Parameters Associated With Intraocular Pressure Reduction After Phacoemulsification in Non-Glaucomatous Eyes With Open Angles

BACKGROUND

Decreased intra-ocular pressure after cataract surgery has been reported in eyes with and without glaucoma with variable magnitude. It is influenced by the anatomical structure of the anterior chamber. Preoperative evaluation of anterior chamber parameters can help to predict the change in intra-ocular pressure postoperatively.

OBJECTIVE

The objective of the study is to evaluate intraocular pressure (IOP) change after uneventful phacoemulsification in non-glaucomatous eyes with open angles and its correlation with preoperative anterior chamber parameters measured by anterior segment optical coherence tomography (AS-OCT).

METHODS

In this hospital-based prospective observational study, we included consecutive patients without glaucoma and open angles on gonioscopy who had undergone uncomplicated phacoemulsification with intraocular lens implantation (IOL). IOP and anterior chamber biometric parameters were measured preoperatively and compared with parameters obtained three months post-operatively by AS-OCT. The change in IOP and its relation to the parameters, including anterior chamber angle (ACA), anterior chamber depth (ACD), angle opening distance 500 μm anterior to the scleral spur (AOD500), anterior chamber width (ACW), lens vault (LV), and trabecular iris space area (TISA500) were evaluated. The main outcome measure was a change in IOP after phacoemulsification in normal eyes.

RESULTS

Sixty-four eyes of 64 patients were enrolled. The mean patient age was 58.5 ± 9.4 years. The average IOP reduction was 2.43±1.64 mm of Hg from a preoperative mean of 16.77±2.54 mmHg three months after phacoemulsification surgery. The mean AOD500 increased significantly (0.440 ± 0.07 to 0.522 ±0.092) from preoperatively to three months postoperatively (p < 0.001). Preoperative lens vault and preoperative IOP had a strong positive correlation with the change in IOP at three months (r-value = 0.606; p-value <0.001) and (r-value = 0.73; p-value <0.001). There was a significant negative correlation between pre-operative TISA and AOD with change in IOP at three months (r-value = -0.545; p-value <0.001) and (r-value = -0.69; p-value <0.01).

CONCLUSION

 Phacoemulsification surgery results in IOP reduction in non-glaucomatous eyes. Pre-operative IOP, lens vault, AOD, and TISA were significant predictors for IOP reduction.

Comparing corneal biomechanic changes among solo cataract surgery, microhook ab interno trabeculotomy and iStent implantation

Minimally invasive glaucoma surgery has expanded the surgical treatment options in glaucoma, particularly when combined with cataract surgery. It is clinically relevant to understand the associated postoperative changes in biomechanical properties because they are influential on the measurement of intraocular pressure (IOP) and play an important role in the pathogenesis of open-angle glaucoma (OAG). This retrospective case-control study included OAG patients who underwent cataract surgery combined with microhook ab interno trabeculotomy (µLOT group: 53 eyes of 36 patients) or iStent implantation (iStent group: 59 eyes of 37 patients) and 62 eyes of 42 solo cataract patients without glaucoma as a control group. Changes in ten biomechanical parameters measured with the Ocular Response Analyzer and Corneal Visualization Scheimpflug Technology (Corvis ST) at 3 and 6 months postoperatively relative to baseline were compared among the 3 groups. In all the groups, IOP significantly decreased postoperatively. In the µLOT and control groups, significant changes in Corvis ST-related parameters, including stiffness parameter A1 and stress‒strain index, indicated that the cornea became softer postoperatively. In contrast, these parameters were unchanged in the iStent group. Apart from IOP reduction, the results show variations in corneal biomechanical changes from minimally invasive glaucoma surgery combined with cataract surgery.

Trabecular Meshwork Movement Controls Distal Valves and Chambers: New Glaucoma Medical and Surgical Targets

Herein, we provide evidence that human regulation of aqueous outflow is by a pump-conduit system similar to that of the lymphatics. Direct observation documents pulsatile aqueous flow into Schlemm's canal and from the canal into collector channels, intrascleral channels, aqueous veins, and episcleral veins. Pulsatile flow in vessels requires a driving force, a chamber with mobile walls and valves. We demonstrate that the trabecular meshwork acts as a deformable, mobile wall of a chamber: Schlemm's canal. A tight linkage between the driving force of intraocular pressure and meshwork deformation causes tissue responses in milliseconds. The link provides a sensory-motor baroreceptor-like function, providing maintenance of a homeostatic setpoint. The ocular pulse causes meshwork motion oscillations around the setpoint. We document valves entering and exiting the canal using real-time direct observation with a microscope and multiple additional modalities. Our laboratory-based high-resolution SD-OCT platform quantifies valve lumen opening and closing within milliseconds synchronously with meshwork motion; meshwork tissue stiffens, and movement slows in glaucoma tissue. Our novel PhS-OCT system measures nanometer-level motion synchronous with the ocular pulse in human subjects. Movement decreases in glaucoma patients. Our model is robust because it anchors laboratory studies to direct observation of physical reality in humans with glaucoma.

Predictors of long-term intraocular pressure control after lens extraction in primary angle closure glaucoma: results from the EAGLE trial

BACKGROUND/AIMS

To assess baseline ocular parameters in the prediction of long-term intraocular pressure (IOP) control after clear lens extraction (CLE) or laser peripheral iridotomy (LPI) in patients with primary angle closure (PAC) disease using data from the Effectiveness of Early Lens Extraction for the treatment of primary angle-closure glaucoma (EAGLE) tria.

METHODS

This study is a secondary analysis of EAGLE data where we define the primary outcome of 'good responders' as those with IOP<21 mm Hg without requiring additional surgery and 'optimal responders' as those who in addition were medication free, at 36-month follow-up. Primary analysis was conducted using a multivariate logistic regression model to assess how randomised interventions and ocular parameters predict treatment response.

RESULTS

A total of 369 patients (182 in CLE arm and 187 in LPI arm) completed the 36-month follow-up examination. After CLE, 90% met our predefined 'good response' criterion compared with 67% in the LPI arm, and 66% met 'optimal response' criterion compared with 18% in the LPI arm, with significantly longer drops/surgery-free survival time (p<0.05 for all). Patients randomised to CLE (OR=10.1 (6.1 to 16.8)), Chinese (OR=2.3 (1.3 to 3.9)), and those who had not previously used glaucoma drops (OR=2.8 (1.6 to 4.8)) were more likely to maintain long-term optimal IOP response over 36 months.

CONCLUSION

Patients with primary angle closure glaucoma/PAC are 10 times more likely to maintain drop-free good IOP control with initial CLE surgery than LPI. Non-Chinese ethnicity, higher baseline IOP and using glaucoma drops prior to randomisation are predictors of worse long-term IOP response.

Change in Subfoveal Choroidal Thickness following Cataract Surgery Imaged with Enhanced Depth Imaging Optical Coherence Tomography

BACKGROUND

Due to its invasive nature, cataract surgery can lead to inflammatory processes in the posterior segment, which can result in prolonged recovery times, reduced functional outcomes, and late-onset complications. The aim of the current study was to identify wherever phacoemulsification parameters play a role in choroidal thickness change following cataract surgery.

METHODS

This prospective single-center study enrolled 31 patients (31 eyes) scheduled to undergo routine cataract surgery. Patients with previous ocular surgeries, pathologies or general disorders affecting vision were excluded. Patients were examined preoperatively, as well as 1, 4, and 12 weeks after surgery. Corrected distance visual acuity (CDVA), intraocular pressure (IOP) as well as cumulative dissipated energy (CDE), ultrasound time (UT), and fluids used during surgery were recorded. Subfoveal choroidal thickness was measured manually by two masked independent experts using enhanced depth imaging (EDI) optical coherence tomography (OCT). Furthermore, cataract density was automatically calculated using a custom MATLAB script and an anterior segment OCT.

RESULTS

Subfoveal choroidal thickness increased significantly (p < 0.001, Student's paired sample t-test) and continuously during the 12-week-long follow-up period. Both the nuclear lens density and the improvement in CDVA correlated significantly with this increase (r = 0.413, p = 0.021 and r = 0.421, p = 0.018, respectively). Neither the CDE (r = 0.334, p = 0.071), the UT (r = 0.102, p = 0.629), the amount of fluid used (r = 0.237, p = 0.27) nor the decrease in IOP (r = - 0.197, p = 0.288) showed any significant correlation with the choroidal swelling.

CONCLUSION

Cataract surgery leads to an increase in subfoveal choroidal thickness. While no statistically significant correlation to the phacoemulsification parameters could be established, this might be because of a selection bias due to the technological constraints of the OCT. Nevertheless, the choroid might play a central role in early- and late-onset complications.

Combined phacoviscocanalostomy versus phacoemulsification alone in patients with coexisting cataract and mild-to-moderate open-angle glaucoma; a randomized-controlled trial

BACKGROUND/OBJECTIVE

Management of concomitant cataract and glaucoma depends on the stage of glaucoma and the patient's situation. There are different surgical options for handling visually significant cataract and mild-to-moderate open-angle glaucoma (OAG). We aimed to compare the one-year results of phacoemulsification alone versus phacoviscocanalostomy in these patients.

SUBJECTS/METHODS

This was a parallel-arm, single-masked, randomized-controlled trial, conducted at Farabi Eye Hospital, Tehran, Iran between January 2016 and January 2018. We enrolled 89 eyes from 89 patients with mild-to-moderate primary OAG or pseudoexfoliative glaucoma (PEXG) with visually significant age-related cataract. They randomly underwent phacoemulsification alone (n = 44) or combined phaco-viscocanalostomy (n = 45). All patients had a 12-month follow-up period, and the mean intraocular pressure (IOP), the number of antiglaucoma medications, and complete and qualified success rates were compared.

RESULTS

After the 1st and 3rd months, the mean IOP showed significantly decreased in the phaco-visco group compared to the phaco group (P < 0001 and P = 0.004, respectively), but it was not statistically significant at 6th and 12th months (P = 0.540 and P = 0.530). The need for antiglaucoma medication and the complete and qualified success rates were significantly in favour of the phaco-visco group in all postoperative visits (P < 0.05).

CONCLUSIONS

Although both phacoemulsification alone and phacoviscocanalostomy procedures can be considered for patients with mild-to-moderate OAG, we found better success rates using phacoviscocanalostomy. Therefore, if the surgeon is an expert in performing this technique, this non-penetrating procedure can be applied in patients with visually significant cataract and earlier stages of OAG, especially in patients with PEXG.

Changes in Anterior Segment Morphology and Intraocular Pressure after Cataract Surgery in Non-glaucomatous Eyes

BACKGROUND

It is known that cataract extraction is associated with a significant reduction in intraocular pressure, especially in narrow angled eyes; however, the modifications of anterior segment parameters associated with this phenomenon have still not been completely defined. The purpose of this study was to evaluate changes in anterior segment anatomy and intraocular pressure after cataract surgery in non-glaucomatous eyes.

METHODS AND MATERIAL

This retrospective case series study included 64 eyes of 64 consecutive patients who underwent phacoemulsification with intraocular lens implantation. Anterior segment parameters and intraocular pressure were assessed and compared before and 6 months after surgery. Anterior segment imaging was performed using Casia SS-1000 anterior segment optical coherence tomography (Tomey, Nagoya, Japan). Anterior segment measurements included anterior chamber depth, anterior chamber width, anterior chamber volume, angle opening distance at 500 µm anterior to the scleral spur, angle recess area 750 µm from the scleral spur, lens vault, trabecular iris space area at 500 µm from the scleral spur, and trabecular iris angle at 500 µm from the scleral spur. Intraocular pressure was measured using the Goldmann applanation tonometer (Model AT 900 C/M, Haag-Streit, Bern, Switzerland). Anterior segment parameters and the relationship of changes in intraocular pressure were also evaluated.

RESULTS

All anterior segment parameters increased significantly after surgery (p < 0.05). Both angle opening distance at 500 µm anterior to the scleral spur and anterior chamber depth changes were positively correlated with the preoperative lens vault. The mean intraocular pressure significantly decreased from 14.91 mmHg (± 2.8 SD) to 12.91 mmHg (± 3.13 SD) (p < 0.001). Changes in intraocular pressure correlated negatively with values for the width of the preoperative anterior chamber (r = - 0.533; p = 0.001).

CONCLUSION

Cataract surgery led to significant widening of the anterior chamber angle and lowering of intraocular pressure. Further investigations are needed to better understand whether anterior chamber width may be a new independent predictive factor for reduction in postoperative intraocular pressure.

Transscleral vs endoscopic cyclophotocoagulation: safety and efficacy when combined with phacoemulsification

PURPOSE

To compare the effectiveness and safety of phacoemulsification combined with endoscopic cyclophotocoagulation (phaco/ECP), phacoemulsification combined with MicroPulse transscleral cyclophotocoagulation (phaco/MP-TSCPC), and phacoemulsification alone (phaco) in the treatment of coexisting cataract and glaucoma.

METHODS

Retrospective cohort study of consecutive cases at Massachusetts Eye & Ear. The main outcome measures were the cumulative probabilities of failure between the phaco/ECP group, phaco/MP-TSCPC group, and the phaco alone group with failure defined as reaching NLP vision at any point postoperatively, undergoing additional glaucoma surgery, or the inability to maintain ≥ 20% IOP reduction from baseline with IOP between 5-18 mmHg while maintaining ≤ baseline medications. Additional outcome measures included changes in average IOP, number of glaucoma medications, and complication rates.

RESULTS

Sixty-four eyes from 64 patients (25 phaco/ECP, 20 phaco/MPTSCPC, 19 phaco alone) were included in this study. The groups did not differ in age (mean 71.04 ± 6.7 years) or length of follow-up time. Baseline IOPs were significantly different between groups (15.78 ± 4.7 mmHg phaco/ECP, 18.37 ± 4.6 mmHg phaco/MP-TSCPC, 14.30 ± 4.2 mmHg phaco alone, p = 0.02). Primary open-angle glaucoma was the most common type of glaucoma in the phaco alone (42%) and phaco/ECP (48%) groups while mixed-mechanism glaucoma was the most common type in the phaco/MP-TSCPC group (40%). Surgical failure was less likely in eyes in the phaco/MP-TSCPC (3.40 times, p = 0.005) and phaco/ECP (1.40 times, p = 0.044) groups compared to phaco alone based on the Kaplan-Meier survival criteria. These differences maintained statistical significance when differences in preoperative IOP were taken into account using the Cox PH model (p = 0.011 and p = 0.004, respectively). Additionally, surgical failure was 1.98 times less likely following phaco/MP-TSCPC compared to phaco/ECP (p = 0.038). This difference only approached significance once differences in preoperative IOP were accounted for (p = 0.052). There was no significant difference in IOP reduction at 1 year between groups. Mean IOP reductions at 1 year were 3.07 ± 5.3 mmHg from a baseline of 15.78 ± 4.7 in the phaco/ECP group, 6.0 ± 4.3 mmHg from a baseline of 18.37 ± 4.6 in the phaco/MP-TSCPC group and 1.0 ± 1.6 from a baseline of 14.30 ± 4.2 mmHg in the phaco alone group. There were no differences in complication rates among the three groups.

CONCLUSIONS

Both Phaco/MP-TSCPC and phaco/ECP appear to provide superior efficacy for IOP control when compared to phaco alone. All three procedures had similar safety profiles.

Effect of Conventional Cataract Surgery and Femtosecond Laser-Assisted Cataract Surgery on Bruch's Membrane Opening-Minimum Rim Width, Retinal Nerve Fiber Layer, and Macular Thickness

Purpose

To evaluate the effect of conventional cataract surgery (CCS) and femtosecond laser-assisted cataract surgery (FLACS) on Bruch's membrane opening-minimum rim width (BMO-MRW), peripapillary retinal nerve fiber layer thickness (RNFL), and macular thickness (MT) using spectral-domain optical coherence tomography (SD-OCT).

Methods

BMO-MRW, RNFL, and MT were measured using SD-OCT preoperatively, 1 month and 6 months after surgery in both CCS and FLACS groups. Differences between preoperative and postoperative values were evaluated in both groups. The postoperative changes were evaluated in each group and compared between groups.

Results

A total of 146 eyes of 146 patients were included in this study, 65 underwent CCS, and 81 underwent FLACS. One month after surgery, there was an increase (in microns) of 20.93 in BMO-MRW, 4.26 in RNFL, and 7.85 in MT in CCS group (P < 0.001), and 17.7, 3.73, and 5.65, respectively, in FLACS group (P < 0.001). Six months after surgery, there was an increase of 12.53 in BMO-MRW, 1.42 in RNFL, and 4.72 in MT in CCS group (P < 0.001), and 13.7, 1.88, and 4.14, respectively, in FLACS group (P < 0.001). The postoperative changes in CCS group were similar to those in FLACS group.

Conclusion

CCS as well as FLACS result in a slight increase in BMO-MRW, RNFL, and MT values one month and six months after surgery. Neither CCS nor FLACS lead to a deterioration in the parameters that define the structure of the optic nerve head and the macula. These results suggest that FLACS is as safe as CCS regarding the optic nerve head and the macula in normal eyes.

Glaucoma medical treatment as a predictor of XEN45 subconjunctival gel implant hypotensive efficacy

PURPOSE

The aim of this study was to determine the preoperative characteristics influencing hypotensive efficacy of the XEN45 gel stent in patients with open-angle glaucoma at one-year follow-up.

MATERIALS AND METHODS

This was a retrospective multicentre study. All patients who underwent XEN45 gel stent implantation between January 2017 and January 2021 were included. The main study outcome was the assessment of one-year postoperative intraocular pressure (IOP) and glaucoma medication differences according to the number and type of preoperative topical treatments or glaucoma surgery, glaucoma stage and time since diagnosis. Follow-up period was 1-year post-surgery in all cases. IOP reduction and surgery success (not requiring reoperation or pressure failures [IOP > 18 mmHg and < 20% reduction in IOP]), safety and cost savings in topical glaucoma therapy after surgery were secondarily assessed. Linear regression analysis to determine the preoperative parameters influence on 1-year postoperative results was performed.

RESULTS

XEN45 gel stent was implanted in 85 patients. One-year postoperative mean IOP dropped from 20.6 ± 4.1 to 13.7 ± 2.8 mmHg (p < 0.0001). Likewise, mean number of topical treatments decreased from 2.05 ± 0.9 to 0.36 ± 0.65 (p < 0.001). Both were mainly influenced by the number of preoperative glaucoma treatments, such that for each one-glaucoma medication increase, postoperative intraocular pressure increased by 1.18 mmHg (95% CI 0.56-1.79, p < 0.0001) and number of glaucoma medications increased by 0.3 (95% CI 0.16-0.43, p < 0.001). Overall success rates (with and without supplemental glaucoma medication use) were 97.6% (95% CI 94.5-100%), 87.1% (95% CI 80.2-87.1%) and 61.2% (95% CI 51.6-72.5%) at 3, 6 months and 1 year after surgery. No sight-threatening adverse events were reported. Mean annual cost savings on medical treatment since surgery reached EUR 251.19 ± 169. 93 euros.

CONCLUSIONS

One year after surgery, XEN45 gel implant significantly reduced IOP and number of topical medications with an adequate safety profile being both mainly influenced by the number of preoperative glaucoma treatments.

Comparison of Efficacy of Combined Phacoemulsification and iStent Inject versus Combined Phacoemulsification and Hydrus Microstent

Aim

This study aims to compare the efficacy and safety of combined phacoemulsification with iStent inject (Phaco-iStent) and Hydrus microstent (Phaco-Hydrus).

Methods

This was a retrospective comparative study of patients who underwent Phaco-iStent from April 2019 to August 2020 and Phaco-Hydrus from August 2019 to December 2020 at a tertiary eye centre in Singapore. Sixty-nine Phaco-iStent eyes and 49 Phaco-Hydrus eyes were included in this study. Complete surgical success was defined as freedom from second glaucoma surgery, Intraocular pressure (IOP) of 18 mmHg or less, and discontinuation of all antiglaucoma medications.

Results

At 12 months, both Phaco-iStent and Phaco-Hydrus groups had comparable surgical success rate (68.1% vs 51%, p=0.061), reduction in antiglaucoma medication use (-1.3 ± 0.1 vs -1.4 ± 0.10, p=0.880) and intraocular pressure reduction (-1.1 ± 0.5 mmHg vs -1.6 ± 0.9 mmHg, p=0.323). Overall intraoperative and postoperative complications rate were similar in both groups, though hyphema was more commonly seen in early postoperative period in the Phaco-Hydrus compared to the Phaco-iStent group (8% vs 0%, p=0.028), with majority of cases resolving without any need for surgical intervention. Device obstruction was also more common in the Phaco-Hydrus group compared to the Phaco-iStent group (14% vs 4.3%, p=0.04).

Conclusion

Phaco-iStent and Phaco-Hydrus have similar surgical efficacy and safety profiles at 12 months.

Intraocular Pressure Changes Following Stand-Alone Phacoemulsification: An IRISɌ Registry Analysis

PURPOSE

To describe real-world intraocular pressure (IOP) changes following stand-alone cataract surgery by comparing postoperative IOP to phakic fellow eyes.

DESIGN

Retrospective clinical cohort study.

METHODS

A total of 1,334,868 patients (336,060 with glaucoma and 998,808 without glaucoma) in the IRIS® Registry (Intelligent Research in Sight) underwent stand-alone phacoemulsification from 1 January 2013 to 30 September 2019 with a fellow eye that had subsequent cataract surgery. Postoperative daily mean IOP was compared between surgical and control eyes from postoperative day 1 to 90. A generalized linear model determined when the postoperative daily mean IOP stabilized to calculate a final mean IOP, which was then compared to baseline IOP.

RESULTS

Postoperative daily mean IOP was initially greater for surgical than for control eyes because of an early postoperative IOP spike. By postoperative day 13, postoperative daily mean IOP was significantly lower for surgical than for control eyes every day through postoperative day 90 (P < .001). There was a mean (SD) decrease from baseline to final mean IOP of 1.55 (3.52) mm Hg or 7.79% for all surgical eyes, 1.91 (3.93) mm Hg or 8.89% for surgical eyes with glaucoma, and 1.37 (3.28) mm Hg or 7.24% for surgical eyes without glaucoma, respectively. There was a statistically significant decrease from baseline to the final mean IOP for all surgical eyes, surgical eyes without glaucoma, and all categories of pre-glaucoma and glaucoma (P < .0001 for all, excluding uveitic glaucoma [P = .0016]).

CONCLUSIONS

Eyes both with and without glaucoma that underwent stand-alone phacoemulsification had a significant decrease in IOP through the 90-day postoperative period compared to baseline and phakic fellow eyes.

Assessment of Iridotrabecular Contact and Its Association With Intraocular Pressure After Phacoemulsification in Primary Angle Closure

PURPOSE

To investigate the association between the quantitative assessment of iridotrabecular contact (ITC), measured by swept-source anterior segment optical coherence tomography (SS AS-OCT), and intraocular pressure (IOP) control after phacoemulsification in patients with primary angle closure disease (PACD).

DESIGN

Retrospective, clinical cohort study.

METHODS

Preoperative and postoperative anterior chamber angle parameters were measured using SS AS-OCT. IOP was measured preoperatively and until 6 months postoperatively. Percent IOP reduction and fluctuation after surgery were calculated, and their relationships with SS AS-OCT parameters were assessed by correlation analyses and locally weighted scatterplot smoothing (LOWESS) regression with change-point analysis.

RESULTS

A total of 51 eyes of 51 PACD patients were included. Preoperative ITC index and area (r = 0.626, r = 0.551), as well as changes in ITC index and area (r = 0.632, r = 0.543) after surgery, were significantly correlated with postoperative IOP reduction, after adjusting for age and gender (all P <.001). Higher postoperative ITC index (r = 0.405, P = .005) and ITC area (r = 0.460, P = 0.001) were associated with greater postoperative IOP fluctuations. Change points on LOWESS curves were observed for preoperative ITC index (33.0%) and change in ITC index (27.0%) and percent IOP reductions were significantly correlated with them above (β = 0.386, β = 0.664, all P < .001) but not below the change points.

CONCLUSIONS

Quantitative assessment of circumferential ITC can predict postoperative IOP control after phacoemulsification, and thus it may be used as a reference for determining lens extraction in PACD eyes.

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.

Comparison of surgical outcomes with and without Ologen collagen matrix augmentation during XEN gel stent implantation

Background

To compare the surgical outcomes and postoperative complications with and without Ologen collagen matrix augmentation during XEN gel stent implantation.

Methods

We retrospectively analyzed patients who underwent XEN gel stent implantation with an ab externo technique. The amount of intraocular pressure (IOP) reduction, percentage of postoperative complications and additional management, and surgical success defined as IOP reduction greater than 20% compared with the preoperative IOP measurement were compared between Ologen-augmented and non-augmented groups. Groups of patients who underwent XEN gel stent implantation alone and combined with phacoemulsification were analyzed separately.

Results

A total 103 eyes of 103 participants were included. Of those, 72 eyes underwent standalone XEN gel stent implantation: 42 eyes with Ologen augmentation (Oloxen group) and 30 eyes without Ologen augmentation (Xen group). Thirty-one eyes underwent XEN gel stent implantation with phacoemulsification: 19 eyes with Ologen augmentation (Phaco-Oloxen group) and 12 eyes without Ologen augmentation (PhacoXen group). The surgical success rate at six months postoperatively was not different between the Oloxen and Xen groups (56.4% vs 43.3%, P > 0.05) or between the Phaco-Oloxen group and PhacoXen group (57.9% vs 41.7%, P > 0.05). The prevalence of postoperative hypotony, 5-fluorouracil injections, use of anti-glaucoma medications, bleb needling, and additional glaucoma surgeries was not different between the Oloxen and Xen groups or between the Phaco-Oloxen and PhacoXen groups when assessed six months postoperatively.

Conclusions

All groups showed significant IOP reduction after XEN gel stent implantation, but there was no significant difference between the Ologen collagen matrix augmented and non-augmented groups in surgical outcomes.

Predictors of visual acuity improvement after phacoemulsification cataract surgery

Purpose

This study aimed to assess preoperative predictors of visual outcome after phacoemulsification cataract surgery in Jordan, a Middle Eastern country.

Methods

This was a retrospective longitudinal study of adult patients who underwent phacoemulsification cataract surgery from January 2019 to July 2021. For each patient, we included only the first operated eye. We obtained pre-operative ocular history, cataract surgery complication risk based on a predesigned score, visual acuity, best correction, and best corrected visual acuity. We recorded intraoperative complications. We also obtained postoperative best corrected visual acuity and refractive error for correction after 1–3 months.

Results

A total of 1,370 patients were included in this study, with a mean age of 66.39 (± 9.48). 48.4% of patients achieved visual acuity ≥ 0.8, and 72.7% achieved visual acuity ≥ 0.5. The mean visual acuity improvement after phacoemulsification cataract surgery was 0.33 (95% CI 0.31–0.35). In the regression model, significant predictors that affected visual acuity improvement included the presence of diabetic retinopathy, glaucoma, and complication risk factors (i.e., high-risk surgery).

Conclusion

Predictors of visual acuity improvement vary between studies. This study was conducted in a developing country; we defined predictors of visual acuity improvement. We also provided a new preoperative phacoemulsification cataract surgery complication risk score.

Meta-Analysis of the Comprehensive Efficacy of Intraocular Lens Implantation in Glaucoma Patients

This study is aimed at investigating the efficacy of intraocular lens (IOL) implantation in patients suffering from glaucoma through meta-analysis of the previously published research. For this purpose, different literature databases were searched for identification of clinical studies published between January 2000 and January 2022 on evaluating IOL's efficacy in treating glaucoma. RevMan 5.3 was used to conduct a meta-analysis of the pertinent data. The central anterior chamber depth (ACD), corneal endothelial cell counts, best-corrected visual acuity (BCVA), intraocular pressure (IOP), anti-glaucoma medications (AGM), and axial length (AL) changes were compared, and the incidence of postoperative complications was thoroughly evaluated. The Cochran chi-square test was used to examine the heterogeneity of the evaluation results. According to the inclusion and exclusion criteria, 20 studies included 948 glaucomatous eyes. IOP was significantly lower than before treatment (MD = 8.64, 95 CI: 5.75-11.53; Z = 5.86, P < 0.0001), while ACD increased significantly (MD = -1.38, 95 percent CI: -1.74-1.02; Z = 7.49, P < 0.0001). The corneal endothelial cell counts were homogeneous (MD = 225.08, 95% CI: -64.17 to -514.33; Z = 1.53, P = 0.20). AGM utilisation decreased (MD = 1.43, 95% CI: 0.752.12, Z = 4.09, P < 0.0001). AL decreased significantly (MD = 0.31; 95% CI: 0.09-0.54; Z = 2.71; P = 0.007). The incidence of complications remained insignificant after IOL treatment (OR = 1.05, 95% CI: 0.42 to 2.60; Z = 0.10, P = 0.92; P = 0.92). These findings indicate that IOL treatment can significantly reduce intraocular pressure, glaucoma drug use, and aqueous level (AL) in glaucoma patients while increasing the depth of the central anterior chamber. This study offers a theoretical foundation for selecting glaucoma treatment methods.

Intraocular Pressure and Medication Burden With Cataract Surgery Alone, or Cataract Surgery Combined With Trabecular Bypass or Goniotomy

PRCIS

When compared with cataract surgery in glaucoma patients, trabecular micro-bypass and goniotomy resulted in a large decrease in the incidence of intraocular pressure (IOP) spikes, a modest effect on IOP, and a minimal effect on medication burden.

PURPOSE

To compare changes in IOP and ocular hypotensive medications in 3 surgical cohorts: cataract surgery, cataract surgery with trabecular micro-bypass (cataract/trabecular), and cataract surgery with goniotomy (cataract/goniotomy).

MATERIALS AND METHODS

We included 138 eyes diagnosed with open-angle glaucoma: (1) 84 eyes with cataract surgery alone, (2) 25 eyes with cataract/trabecular surgery, and (3) 29 eyes with cataract/goniotomy surgery. We compared the groups for postoperative IOP and the number of ocular hypotensive medications. We adjusted for preoperative IOP, and preoperative and postoperative number of ocular hypotensive medications. We defined an IOP spike as IOP ≥21 mm Hg and 10 mm Hg higher than preoperative on postoperative day 1.

RESULTS

All 3 surgeries showed a decrease in IOP (P≤0.004) and medication burden (P≤0.001) at 3 and 6 months postoperatively when compared with their own preoperative baselines. When compared with cataract surgery alone, cataract/trabecular and cataract/goniotomy had similar IOP lowering at 1 month postoperatively, and variable results at 3 and 6 months. The change in ocular hypotensive medications was not statistically different between the surgical groups at any postoperative visit. Cataract/trabecular and cataract/goniotomy decreased IOP on postoperative day 1, and had relative risk reduction of ~70% for IOP spikes (P≤0.001 for both).

CONCLUSION

Trabecular micro-bypass and goniotomy when added to cataract surgery resulted in a large decrease in IOP spikes, a modest effect on IOP, and a minimal effect on medication burden when compared with cataract surgery alone in glaucoma patients.

Cataract Surgery Lowers Intraocular Pressure and Medication Use in the Medication Group of the Ocular Hypertension Treatment Study

PURPOSE

To determine the change in intraocular pressure (IOP) and ocular hypotensive medication use after cataract extraction in the Medication Group of the Ocular Hypertension Treatment Study.

DESIGN

Secondary analysis of randomized clinical trial data.

METHODS

We included 92 participants (n = 149 eyes) of the Medication Group of the Ocular Hypertension Treatment Study who underwent cataract surgery in at least 1 eye during the study and 531 participants (n = 1004 eyes) of the Medication Group who did not undergo cataract surgery. We defined the "split date" as the first study visit that cataract surgery was reported for the cataract surgery group and the 15th visit in the control group to equalize the median number of visits. We then compared the 2 groups at visits relative to this split date.

MAIN OUTCOME MEASURES

Difference in preoperative and postoperative IOP, and number of classes of ocular hypotensive medications between the cataract and control group over a 72-month period.

RESULTS

Cataract surgery significantly decreased the number of ocular hypotensive medications at all postoperative visits (mean, -0.4 medications; P ≤ .005) through the 48-month postoperative visit when compared with the control group. At the split date, approximately 23% of eyes were medication free and 41% had a reduced medication burden. Cataract surgery resulted in a decrease in IOP (P < .001), but the difference in IOP between the groups reduced over time and became nonsignificant after 12 months.

CONCLUSIONS

Cataract surgery in patients with ocular hypertension produced sustained reductions in the average number of ocular hypotensive medications and transient reductions in IOP.

Force of lifelong crystalline lens growth: chronic traumatic mechanical insult to the choroid

PURPOSE

To calculate the forces applied to the uvea and retina as a result of lifelong crystalline lens growth.

DESIGN

Retrospective study.

SETTING

MRI Research, Inc., Middleburg Heights, Ohio; Institute of Ophthalmology and Visual Science UMDNJ-New Jersey Medical School, Newark, New Jersey; USC Psychology University of Southern California, Los Angeles.

METHODS

Magnetic resonance images were acquired from 15 phakic/pseudophakic eye pairs in patients with cataract (ages 46 to 83 years). Choroidal lengths were measured. The forces required to produce differences between phakic/pseudophakic choroidal lengths were calculated.

RESULTS

The length of the choroid is greater in the phakic eye compared with the corresponding pseudophakic eye (n = 15), and this difference increases with age (P = .00006; power = 0.99). The corresponding choroidal strain also increases with age (P = .00003, power = 0.99) as do the forces required to produce such a change in choroidal length (P = .000008, power = 0.99).

CONCLUSIONS

The authors theorize that lifelong crystalline lens growth applies a chronic, traumatic, mechanical insult to the uvea and retina. This previously unknown, ever-increasing, force appears to stretch the choroidal tissue and may be an intraocular pressure-independent modifiable risk factor for retinal disease. Implications exist for understanding the pathophysiology of retinal diseases in the aging eye that are often comorbid with cataracts, for example, glaucoma, macular degeneration, and diabetic retinopathy.

Predictors of intraocular pressure change after cataract surgery in patients with pseudoexfoliation glaucoma and in nonglaucomatous patients

Background/Aim. The cataract surgery in eyes with and without glaucoma results in the sustained intraocular pressure (IOP) reduction but it is still unknown which glaucomatous patients will achieve clinically significant reduction. The preoperative IOP and some ocular biometric parameters have been shown as potential predictors of the postoperative IOP reduction. The aim of our prospective intervention study was to evaluate that relationship in medically controlled patients with the pseudoexfoliation glaucoma (PXG) and in the nonglaucomatous patients. Methods. Thirty-one PXG patients (31 eyes) and 31 nonglaucomatous patients (31 eyes), all with clinically significant cataract, were enrolled. The preoperative IOP, anterior chamber depth (ACD), axial length (AL), lens thickness (LT), lens position (LP) [LP = ACD + 0.5 LT], relative lens position (RLP) [RLP = LP / AL] and the pressure-to-depth ratio (PD ratio) [PD ratio = preoperative IOP/preoperative ACD] were evaluated as potential predictors of the IOP change in the 6th postoperative month. Results. In the 6th postoperative month, in the PXG group, the IOP reduction was -3.23 ? 3.41 mmHg (-17.67 ? 16.86%) from the preoperative value of 16.27 ? 3.08 mmHg and in the control group, the reduction was -2.26 ? 1.71 mmHg (-15.06 ? 10.93%) from the preoperative value of 14.53 ? 2.04 mmHg. In the PXG group, the significant predictors of the absolute and the percentage IOP reduction were the preoperative IOP, AL, and PD ratio. In the same group, RLP was shown as a significant predictor of absolute change in the IOP in multi-variate analysis, and the percentage IOP change in both the univariate and the multivariate analyses. In the control group, the preoperative IOP and the PD ratio were the only significant parameters that could predict absolute change in the postoperative IOP. Conclusion. The cataract surgery leads to the IOP reduction both in the PXG and nonglaucomatous eye. Predictors monitored in this study are widely available and simply calculable parameters that can be potentially used in managing glaucoma.

Cataract Surgery Is Not Associated with Decreased Risk of Retinal Vein Occlusion

Purpose

Design

Participants

Methods

Main Outcome Measure

Results

Conclusions

Cost-utility analysis of trabecular micro-bypass stents (TBS) in patients with mild-to-moderate open-angle Glaucoma in Italy

Background

Glaucoma is a disease characterized by progressive damage of the optic nerve. Several therapeutic options are available to lower intraocular pressure (IOP). In primary open-angle glaucoma (POAG) patients with inadequate IOP control (or controlled with multiple medical therapies or for whom medical therapy is contraindicated), the implantation of micro-invasive glaucoma surgery devices (MIGS) and concomitant cataract surgery has proved to be more effective in reducing intraocular pressure (IOP), as compared to cataract surgery alone. The objective of this study was to assess the cost-effectiveness of iStent inject® device with concurrent cataract surgery vs. cataract surgery alone, in patients with mild-to-moderate POAG, adopting the Italian National Health Service (NHS) perspective.

Methods

Simulation of outcomes and costs was undertaken using a Markov model with 4 health states and one-month cycles, that is used to simulate the prognosis of these patients. Efficacy data were obtained from the randomized clinical trial (RCT). A lifetime horizon was adopted in the analysis. A discount rate of 3.5% was applied to both costs and effects. The Italian National Healthcare Service (NHS) perspective was considered, therefore only healthcare direct costs (acquisition of main interventions and subsequent procedures; medications; monitoring and follow-up; adverse events). Model robustness was tested through sensitivity analyses.

Results

Results of the base-case analysis showed that the total lifetime costs were higher in the iStent inject® + concurrent cataract surgery, compared with the cataract surgery alone group (€8368.51 vs. €7134.71 respectively). iStent inject® + concurrent cataract surgery was cost-effective vs. cataract surgery alone, with an incremental cost-effectiveness ratio of €13,037.01 per quality-adjusted life year (QALY) gained. Both one-way deterministic and probabilistic sensitivity analyses confirmed robustness of base-case results. The cost-effectiveness accessibility curve (CEAC) showed that iStent inject® + cataract surgery would have a 98% probability of being cost-effective, compared to cataract surgery alone, when the willingness to pay (WTP) is equal to €50,000 per QALY gained.

Conclusions

The results of the cost-utility analysis confirm that iStent inject® + cataract surgery is a cost-effective option for the treatment of patients affected by mild-to-moderate POAG, compared with cataract surgery alone, when evaluated from the Italian NHS perspective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06862-x.

Treatment Success Across Different Levels of Preoperative Disease Burden: Stratified Two-Year Outcomes from the Pivotal Trial of iStent inject ® Trabecular Micro-Bypass in Primary Open-Angle Glaucoma and Cataract

PURPOSE

To examine effectiveness outcomes stratified by preoperative disease burden in the pivotal trial of iStent inject ® with cataract surgery (INJ) vs cataract surgery alone (CS).

MATERIALS AND METHODS

Prospective, 3:1 randomized, single-masked, concurrently-controlled, multicenter trial enrolling 505 subjects with cataract and mild-to-moderate primary open-angle glaucoma who underwent iStent inject implantation with phacoemulsification or phacoemulsification alone, and were followed for 2 years including annual medication washouts. Post hoc stratification was completed for baseline mean diurnal intraocular pressure (BL DIOP; Low-DIOP <25mmHg, Mid-DIOP ≥25 to <30 mmHg, High-DIOP ≥30mmHg) and preoperative medication burden (Low-Med 1 medication, Mid-Med 2 medications, High-Med ≥3 medications).

RESULTS

The 24-month primary and secondary effectiveness endpoints were met, with significant treatment-over-control differences in percent of eyes achieving ≥20% unmedicated DIOP reduction and in unmedicated DIOP reduction, respectively. In subgroup analyses, the proportions of INJ eyes achieving the primary endpoint remained steady across all BL DIOP (75.4%, 77.1%, 74.4% in Low/Mid/High-DIOP strata, respectively) and preoperative medication levels (76.8%, 70.8%, 79.7% in Low/Mid/High-Med strata, respectively); meanwhile, the proportions of CS eyes diminished with higher BL DIOP (64.5%, 63.6%, 33.3%, respectively) and more medications (69.0%, 63.3%, 29.4%, respectively). Regarding secondary effectiveness, postoperative DIOP reduction increased with higher BL DIOP in INJ eyes (6.2mmHg, 7.8mmHg, 9.8mmHg, respectively) but plateaued in CS eyes (5.2mmHg, 5.8mmHg, 5.4mmHg, respectively). INJ eyes also had consistent DIOP reduction regardless of preoperative medication burden (6.8mmHg, 6.7mmHg, 7.8mmHg, respectively), while DIOP reduction diminished with more medications in CS eyes (6.1mmHg, 5.0mmHg, 3.3mmHg, respectively). Safety was favorable, comparable to phacoemulsification alone.

CONCLUSION

Significant IOP reductions occurred across all levels of BL DIOP and preoperative medication burden in iStent inject eyes. DIOP reductions increased with higher BL DIOP and remained stable across all levels of preoperative medication burden, suggesting the device's potential utility in more medically challenging cases.

Safety and Effectiveness of the PRESERFLO® MicroShunt in Primary Open-Angle Glaucoma: Results from a 2-Year Multicenter Study

OBJECTIVE

To assess the safety and effectiveness of the PRESERFLO® MicroShunt (formerly InnFocus MicroShunt®) in patients with primary open-angle glaucoma (POAG).

DESIGN

The MicroShunt, a controlled ab-externo glaucoma filtration surgery device, was investigated in a 2-year, multicenter, single-arm study.

PARTICIPANTS

Eligible patients were aged 18-85 years with POAG inadequately controlled on maximal tolerated medical therapy with intraocular pressure (IOP) ≥18 and ≤35 mmHg and/or where glaucoma progression warranted surgery.

INTERVENTION

The MicroShunt was implanted as a standalone procedure with adjunctive use of topical Mitomycin C (MMC; 0.2-0.4 mg/mL) for 2-3 minutes.

MAIN OUTCOME MEASURES

The primary effectiveness outcome was IOP reduction and success (not requiring reoperation or pressure failures [IOP >21 mmHg and <20% reduction in IOP]) at year 1. Additional endpoints at year 2 included IOP reduction, success, glaucoma medications, adverse events (AEs), and reoperations. Results are reported in the overall population, and subgroups of patients receiving 0.2 or 0.4 mg/mL MMC.

RESULTS

In 81 patients, mean (± standard deviation [SD]) IOP reduced from 21.7±3.4 mmHg at baseline to 14.5±4.6 mmHg at year 1 and 14.1±3.2 mmHg at year 2 (P<0.0001). Overall success (with and without supplemental glaucoma medication use) at year 1 was 74.1%. Mean (± SD) number of medications decreased from 2.1±1.3 at baseline to 0.5±0.9 at year 2 (P<0.0001), 73.8% of patients were medication free. Most common non-serious AEs were increased IOP requiring medication and/or selective laser trabeculoplasty (25.9%) and mild-to-moderate keratitis (11.1%). There were 6 (7.4%) reoperations and 5 (6.2%) needlings by year 2. In an analysis (post-hoc) according to MMC concentration, overall success was 78.1% (0.2 mg/mL) and 74.4% (0.4 mg/mL; P=0.710). In the 0.2 and 0.4 mg/mL MMC groups, 51.9% and 90.3% of patients were medication-free, respectively (P=0.001). There was a trend towards lower IOP and higher medication reduction in the 0.4 mg/mL MMC subgroup.

CONCLUSIONS

In this study, mean IOP and glaucoma medication reductions were significant and sustained over 2 years post-surgery. No long-term, sight-threatening AEs were reported. Further studies may confirm potential risk/benefits of higher MMC concentration.

Aqueous outflow regulation - 21st century concepts

We propose an integrated model of aqueous outflow control that employs a pump-conduit system in this article. Our model exploits accepted physiologic regulatory mechanisms such as those of the arterial, venous, and lymphatic systems. Here, we also provide a framework for developing novel diagnostic and therapeutic strategies to improve glaucoma patient care. In the model, the trabecular meshwork distends and recoils in response to continuous physiologic IOP transients like the ocular pulse, blinking, and eye movement. The elasticity of the trabecular meshwork determines cyclic volume changes in Schlemm's canal (SC). Tube-like SC inlet valves provide aqueous entry into the canal, and outlet valve leaflets at collector channels control aqueous exit from SC. Connections between the pressure-sensing trabecular meshwork and the outlet valve leaflets dynamically control flow from SC. Normal function requires regulation of the trabecular meshwork properties that determine distention and recoil. The aqueous pump-conduit provides short-term pressure control by varying stroke volume in response to pressure changes. Modulating TM constituents that regulate stroke volume provides long-term control. The aqueous outflow pump fails in glaucoma due to the loss of trabecular tissue elastance, as well as alterations in ciliary body tension. These processes lead to SC wall apposition and loss of motion. Visible evidence of pump failure includes a lack of pulsatile aqueous discharge into aqueous veins and reduced ability to reflux blood into SC. These alterations in the functional properties are challenging to monitor clinically. Phase-sensitive OCT now permits noninvasive, quantitative measurement of pulse-dependent TM motion in humans. This proposed conceptual model and related techniques offer a novel framework for understanding mechanisms, improving management, and development of therapeutic options for glaucoma.

Intraocular pressure changes after phacoemulsification in pseudoexfoliation versus healthy eyes

Background

Pseudoexfoliation (PXF) syndrome is the most common cause of secondary glaucoma worldwide. This systemic disorder causes further damage to the optic nerve and ultimately increases the need for surgical interventions. Therefore, intraocular pressure (IOP) control is very important in these patients. The aim of this study was to compare IOP changes after phacoemulsification in subjects with PXF syndrome compared to those without this syndrome.

Methods

61 patients were enrolled in this prospective clinical study. Subjects were assigned into two groups based on presence or absence of PXF syndrome. IOP and anterior chamber angle parameters including: angle opening distance (AOD) and trabecular-iris surface area (TISA) measured one day preoperatively and 3 months postoperatively. Intraoperative metrics factors including: infusion fluid usage (IFU), cumulative dissipated energy (CDE) and aspiration time (AT) were obtained from the phacoemulsification machine at the end of each surgery. IOP changes, anterior chamber angle parameters and intraoperative metrics factors were compared between groups.

Results

Mean IOP before surgery was significantly higher in the PXF group (14.70 mm Hg) compared to controls (12.87 mm Hg) (P-value < 0.01). Phacoemulsification decreased IOP in both, but to greater extent in the PXF group (p-value < 0.01). AOD and TISA also increased significantly following surgery in both groups. The results showed that postoperative IOP was negatively correlated with preoperative IOP in both groups (p-value < 0.01). Also, IOP after phacoemulsification was negatively correlated with IFU in the PXF group (p-value = 0.03).

Conclusions

Patients with PXF syndrome exhibited a reduction in IOP and increase in anterior chamber angle parameters after phacoemulsification. We observed a greater IOP reduction in PXF subjects when it was compared to controls. Higher preoperative IOP and intraoperative IFU were associated with more IOP reduction in the PXF group.

Intraocular Pressure Reduction after Femtolaser Assisted Cataract Surgery and Its Association with the Use of Ultrasound

Background and Objectives: To quantify the change in intraocular pressure (IOP) after phacoemulsification in patients having undergone femtolaser assisted cataract surgery (FLACS), and study the influence of the use of ultrasound on this change. Setting: Jules-Gonin Eye Hospital, University Department of Ophthalmology, Lausanne, Switzerland. Materials and Methods: Interventional study. Methods: All consecutive cases operated with FLACS and with complete data for the studied parameters were selected for inclusion in the study. Data had been prospectively collected and was analysed retrospectively. Linear regression was performed to explore the association of change in IOP with time of measure, ultrasound use, sex, age, and duration of surgery. Results: There was a mean decrease in intraocular pressure of 2.5 mmHg (CI 95% −3.6; −1.4, p < 0.001) postoperatively. No association between the change in intraocular pressure and ultrasound time or effective phaco time was observed when the data were analyzed one at a time or in a multiple linear regression model. There was no association with sex, age, nuclear density, presence of pseudoexfoliation, duration of surgery, and time of ocular pressure measurement. Eyes with preoperative IOP ≥ 21 mmHg had a more significant IOP reduction after surgery (p < 0.0001) as did eyes with an anterior chamber depth <2.5 mm (p = 0.01). Conclusion: There was a decrease in intraocular pressure six months after FLACS in our study similar to that in the published literature for standard phacoemulsification. The use of ultrasound may not influence the size of the decrease, whereas the preoperative IOP and anterior chamber depth do. FLACS may be as valuable as standard phacoemulsification for cases where IOP reduction is needed postoperatively.

Standalone XEN45 Gel Stent implantation versus combined XEN45-phacoemulsification in the treatment of open angle glaucoma-a systematic review and meta-analysis

PURPOSE

The XEN45 Gel Stent is currently the only FDA-approved sub-conjunctival minimally invasive glaucoma surgery (MIGS) procedure. It has been used worldwide either as a standalone implantation procedure or in combination with phacoemulsification surgery. Concomitant phacoemulsification is understood to influence outcomes of traditional subconjunctival filtering surgery. However, the comparative efficacy between standalone XEN45 Gel Sent implantation ("Standalone XEN45") and combined XEN-phacoemulsification surgery ("XEN45-Phaco") remains unclear. This study aims to appraise current literature to compare the efficacy of Standalone XEN45 and XEN45-Phaco in open-angle glaucoma.

METHODS

A comprehensive search of PubMed, CINAHL, CENTRAL databases was performed with the terms "Xen surgery" followed by selective vetting. Pilot, cohort, observational studies and randomised controlled trials that included at least 10 patients undergoing either Standalone XEN45 or XEN45-Phaco surgeries for the treatment of open-angle glaucoma were deemed eligible for inclusion after independent assessment by 2 authors. The search workflow was reported according to the PRISMA guidelines. Data was pooled using random-effects model. A meta-analysis of continuous outcome and proportions was performed using the meta routine in R v3.2.1.

RESULTS

Ten studies were included. There was a statistically significant difference in IOP reduction favouring Standalone XEN45 at post-operative day 1, week 1, months 1, 3 and 6. There was a statistically significant difference in decrease in IOP-lowering medications favouring Standalone XEN45 at post-operative week 1 and month 1.

CONCLUSION

Standalone XEN45 has superior IOP-lowering outcomes compared to XEN45-Phaco in the early post-operative period, up to 6 months after surgery.

Surgical and Perioperative Considerations for the Treatment of Cataract in Eyes with Glaucoma: A Literature Review

Cataract surgery in the presence of glaucoma poses certain challenges that need to be addressed to offer the maximum benefit without complications. In this paper, we are reviewing the preoperative assessment, surgical options, the planning, and postoperative care. Cataract surgery can help reduce the intraocular pressure alone or combined with MIGS. When performed in patients with glaucoma, it can transiently increase the intraocular pressure and later on decrease the IOP to levels lower than the postoperative. The preoperative IOP and biometric characteristics are the main predictors of the postoperative course of IOP. The combination of cataract surgery with trabeculectomy remains controversial, in terms of best timing of each operation.

The impact of late-treated pediatric cataract on intraocular pressure

PURPOSE

To assess the intraocular pressure and visual acuity before and after pediatric congenital cataract surgery performed at a relatively older age.

METHODS

A retrospective analysis of all consecutive pediatric patients diagnosed and operated for bilateral congenital cataracts during a seven-year period (2012-2018) in rural southern Ethiopia. Non-ambulatory vision was defined as hand motion or worse. The main outcome measures were intraocular pressure (IOP) and visual acuity.

RESULTS

Thirty-two children were included, 17 females (53.1%), with a mean age of 11 years (± 2.83) [range, 7-18]. A total of 59 eyes were operated on. The mean follow-up was 4.8 ± 1.8 years (range, 2-8). VA improved from 20/1400 preoperatively to 20/440 postoperatively OD and 20/540 OS (p < 0.001). More eyes had ambulatory vision after cataract surgery than pre-surgery (56 eyes [95%] vs. 29 eyes [49%], p < 0.001). The IOP decreased from a mean preoperative value of 18.4 ± 7.1 mmHg to 14.5 ± 2.9 postoperatively OD (p < 0.001) and 16.3 ± 5.9 mmHg to 13.9 ± 3.5 OS (p < 0.001). Fifteen eyes (24%) had increased IOP (> 21 mmHg) preoperatively, of which three remained high after surgery. Positive correlations were found between IOP, axial length and cup-to-disc ratio. None of the patients required pressure-lowering procedures.

CONCLUSION

Bilateral congenital cataracts may be associated with ocular hypertension, with possible progression to glaucoma if left untreated. Surgery at a relatively older age often was associated with a significant improvement in intraocular pressure and ambulatory vision.

Intraocular Pressure Reduction After Real-world Cataract Surgery

PRéCIS:: A large cohort undergoing cataract extraction was retrospectively analyzed to ascertain the degree of real-world intraocular pressure (IOP) reduction in normal eyes and those with glaucoma, and a predictive formula was developed.

PURPOSE

The purpose of this study was to define the real-world degree of IOP reduction after cataract extraction to guide its role as an isolated intervention for glaucoma.

MATERIALS AND METHODS

A retrospective analysis was carried out of clinical data collected in 8 clinical sites in the United Kingdom from an electronic medical record system between January 2006 and May 2015. A total of 20,508 eyes without known pathology and 2251 eyes from patients with glaucoma undergoing phacoemulsification and intraocular lens insertion were included. Eyes with intraoperative complications, undergoing additional procedures, axial lengths outside 22 to 26.5 mm, preoperative IOP under 6 mm Hg or over 30 mm Hg, and copathology, except for amblyopia or glaucoma, were excluded. The main outcome measure was the change in preoperative IOP compared with the next recorded visit for up to 12 weeks.

RESULTS

In eyes without pathology, the mean reduction in IOP was 1.40 mm Hg (±3.74) compared with 1.03 (±5.02), P-value <0.001, in eyes with a diagnosis of glaucoma. A multiple linear regression model identified preoperative IOP, a glaucoma diagnosis, preoperative corrected visual acuity, age, and axial length as determinants of IOP reduction. The model was validated against an independent cohort.

CONCLUSIONS

We quantify mean IOP reduction achieved in a real-world setting from cataract surgery alone. In glaucomatous eyes where angle closure is not differentiated, phacoemulsification alone yields only a modest reduction of IOP.

The Effect of Phacoemulsification on Intraocular Pressure in Eyes with Preexisting Glaucoma Drainage Implants

PURPOSE

To study the effect of phacoemulsification on intraocular pressure (IOP) control in patients with preexisting glaucoma drainage implants (GDIs).

DESIGN

Retrospective, observational case series.

PARTICIPANTS

A total of 45 patients (51 eyes) with previously placed GDIs who underwent phacoemulsification between January 2013 and March 2018.

METHODS

The list of patients was obtained from billing records. Clinical data were retrieved from the corresponding electronic medical records.

MAIN OUTCOME MEASURES

Intraocular pressure, number of glaucoma medications before and after phacoemulsification (postoperative day 1, week 1, months 1, 3, 6, 12, 18, and 24), rate of failure (failure defined as IOP >18 mmHg and IOP increase >20% at 2 consecutive visits after month 1, need for additional glaucoma surgery, or loss of light perception vision), and postoperative complications.

RESULTS

Mean follow-up was 23.0 ± 11.1 months. The average interval between GDI surgery and phacoemulsification was 9.4 ± 6.7 months. An Ahmed glaucoma valve (AGV; New World Medical) was implanted in 12 eyes, a Baerveldt glaucoma implant (BGI; Johnson & Johnson Surgical Vision) was implanted in 36 eyes, and a Molteno (Molteno Ophthalmic Limited) glaucoma implant was implanted in 3 eyes. Before phacoemulsification, the mean IOP was 14.4 ± 4.4 mmHg on 2.1 ± 1.3 glaucoma medications. At postoperative month 24, the mean IOP was 12.6 ± 4.4 mmHg (n = 29, P = 0.519) on 2.0 ± 1.6 (P = 0.457) glaucoma medications. The reduction in IOP was significant only at postoperative week 1 (P = 0.031). The cumulative failure rate was 3.9% at 1 year and 11.8% at 2 years. The AGV group had a significantly higher mean IOP before phacoemulsification than the BGI group (P = 0.016). Analysis of covariance, taking the baseline IOP as a covariate, revealed no differences in postoperative IOP and number of glaucoma medications between groups, except for month 18 (1 patient in the BGI group had uncontrolled IOP requiring surgery). Postoperative complications included cystoid macular edema (10%), corneal decompensation (6%), and choroidal effusion (4%).

CONCLUSIONS

Phacoemulsification after GDI surgery resulted in a transient reduction in IOP at postoperative week 1. Patients with previously placed AGVs had similar postoperative outcomes compared with those with BGIs.

Combining Baerveldt Implant with Trabectome Negates Tube Fenestration: A Coarsened-matched Comparison

Purpose

To assess the efficacy and survival rate of the Trabectome-mediated ab interno trabeculectomy combined with non-fenestrated Baerveldt glaucoma implant compared with the Baerveldt glaucoma implant alone.

Methods

In this retrospective comparative case series, 175 eyes undergoing primary glaucoma surgery (Baerveldt–Trabectome [BT] group: 60 eyes and Baerveldt [B] group: 115 eyes) were included. Participants were identified using the procedural terminology codes. Groups were then matched by Coarsened Exact Matching that resulted in the inclusion of 51 eyes in each group. The primary outcome measure was surgical success defined as 5 mmHg < intraocular pressure (IOP) ≤ 21 mmHg, and IOP reduction ≥ 20% from baseline, and no need to reoperation for glaucoma. Secondary outcome measures were IOP, number of glaucoma medications, and best-corrected visual acuity (BCVA).

Results

The cumulative probability of success at one year was 61% in the BT group and 50% in the B group. IOP decreased from 23.5 ± 2.4 mmHg at baseline to 14.1 ± 2.7 mmHg at the final follow-up in the BT group (P = 0.001). The corresponding values for the B group were 23.2 ± 2.0 mmHg and 13.9 ± 1.6 mmHg, respectively (P = 0.001). There was no significant difference between the groups in terms of IOP at the final follow-up (P = 0.56). The number of medications at baseline was 2.3 ± 0.3 in both groups. However, the BT group needed fewer drops at all postoperative time intervals and used 1.1 ± 0.3 versus 2.0 ± 0.4 eye drops (group B) at the final follow-up visit (P = 0.004). Eyes in B with phacoemulsification had a significantly higher IOP on day 1 compared to B (23.2 ± 14.3 versus 17.9 ± 11.4, P = 0.041). During the one-year follow-up, 7 (13.7%) patients in BT group and 18 (35.2%) in B group experienced hypotony (P = 0.04). No dangerous hypotony or hypertension occurred in BT group. The mean BCVA at baseline was 0.64 ± 0.85 logMAR and changed to 0.55 ± 0.75 logMAR in BT and B groups, respectively (P = 0.663). The corresponding numbers for the final follow-up visit was 0.72 ± 1.07 and 0.63 ± 0.97 logMAR, respectively (P = 0.668).

Conclusion

We observed similar rates of success and IOP reduction using BT and B techniques. BT group needed fewer glaucoma medications. Tube fenestration was unnecessary in BT group resulting in less postoperative ocular hypotony and hypertension. The results of our study indicate that additional trabectome procedure makes Baerveldt glaucoma implant safer, easier to handle, and more predictable in the most vulnerable patients with advanced glaucoma.

iStent Trabecular Micro-Bypass Stent Implantation with Cataract Surgery in a Japanese Glaucoma Population

Introduction

This study assesses two-year efficacy and safety following implantation of a single trabecular micro-bypass stent (iStent^®) with concomitant phacoemulsification cataract surgery in Japanese patients with open-angle glaucoma (OAG).

Materials and Methods

This retrospective, consecutive case series included eyes that underwent iStent implantation with phacoemulsification and were followed for 24 months postoperative. Efficacy and safety measures included intraocular pressure (IOP), number of glaucoma medications, adverse events, secondary surgeries, visual fields, and endothelial cell counts.

Results

Of 73 operated eyes, 53 eyes had 24 months of follow-up and are analyzed. Diagnoses included primary open-angle glaucoma (POAG, n=25), normal-tension glaucoma (NTG, n=16), and pseudoexfoliative glaucoma (PXG, n=12). At 24 months, mean IOP reduced by 18% to 13.6±3.0 mmHg versus 16.5±3.4 mmHg preoperatively (p<0.0001), and mean medication number reduced by 81% to 0.37±0.74 versus 1.96±0.98 preoperatively (p<0.0001). The percentage of medication-free eyes was 77% versus 0% preoperatively, and 81% of eyes had IOP ≤15 mmHg versus 42% preoperatively. Results were similarly favorable across glaucoma subtypes (POAG, NTG, PXG). Notably, mean IOP in NTG eyes decreased to 12.8±1.4 mmHg from 14.4±3.0 mmHg preoperatively (p=0.03), and medications decreased by 87% to 0.31±0.70 versus 2.38±0.72 preoperatively (p<0.0001). At 24 months, 81% of NTG eyes were medication-free (versus 0% preoperatively); 2 NTG eyes (13%) were on ≥2 medications (versus 100% preoperatively). Throughout the follow-up, visual fields and endothelial cell counts remained stable; 1 eye (1.9%) underwent filtration surgery.

Discussion

Favorable safety and significant IOP and mediation reductions were achieved through two years following iStent implantation with phacoemulsification in a Japanese population. These gains were achieved across all glaucoma subtypes (including POAG, NTG, PXG).

Conclusion

This real-world study supports the viability of iStent implantation to treat Japanese patients with glaucoma and shows that the benefits extend to those with NTG or PXG in addition to POAG.

Outcome of phacoemulsification in patients with open-angle glaucoma after selective laser trabeculoplasty

Purpose

To investigate the outcome of phacoemulsification in selective laser trabeculoplasty (SLT)-treated eyes.

Methods

This retrospective study included patients who had open angle glaucoma (OAG) with previous SLT who underwent phacoemulsification. We evaluated intraocular pressure (IOP), length of glaucoma control without treatment, and antiglaucoma medication or surgery. SLT-treated eyes that did not receive phacoemulsification were retrospectively chosen as a control. We investigated factors related to outcome of phacoemulsification by multivariate analysis.

Results

42 eyes with previous SLT that underwent phacoemulsification and 40 controls were retrospectively evaluated. Phacoemulsification was performed 52 ± 15 months after SLT. After a mean follow-up of 74 ± 21 months, mean IOP was significantly decreased in the phaco group by 2.2 ± 2.7 mmHg (p < 0.001). In the SLT group, mean IOP was decreased by 0.8 ± 2.8 mmHg (p < 0.001). 9 eyes (16.7%) in the phaco group and 11 eyes (19.0%) of the SLT group needed topical treatment, and no eye needed glaucoma surgery in both groups. The factor related to success was higher baseline IOP (p = 0.002).

Conclusion

Prior SLT didn’t negatively influence phacoemulsification in patients with OAG. Phacoemulsification lowered IOP effectively and safely in OAG patients who were treated with SLT.

Minimally Invasive Surgery in Mild-to-Moderate Glaucoma Patients in Italy: Is It Time to Change?

Medical therapy is the first treatment choice for most patients with glaucoma; however, in a relevant proportion of patients, intraocular pressure (IOP) reduction is achieved with multi-therapy and/or high therapeutic doses. Conventional surgery is the standard alternative to medical therapy when this is not effective or not tolerated. Recently, selective laser trabeculoplasty (SLT) has been advocated as first-line therapy, and "minimally invasive glaucoma surgery" (MIGS) has been developed as safer and less traumatic surgical intervention for patients with glaucoma. Schlemm's canal surgery has emerged as one of the approaches with the most favorable risk-benefit profile for glaucoma patients in need of cataract surgery. However, despite the promising results, use of MIGS in Italy has been extremely low. We aimed to investigate the reasons of the lower-than-expected use of Schlemm's canal-based MIGS devices in Italy, share our perspective on their potential place in therapy, and give practical suggestions to improve the management of glaucoma patients.

Personalising surgical treatments for glaucoma patients

Surgical treatments for glaucoma have relied for decades on traditional filtering surgery such as trabeculectomy and, in more challenging cases, tubes. Antifibrotics were introduced to improve surgical success in patients at increased risk of failure but have been shown to be linked to a greater incidence of complications, some being potentially vision-threatening. As our understanding of glaucoma and its early diagnosis have improved, a more individualised management has been suggested. Recently the term "precision medicine" has emerged as a new concept of an individualised approach to disease management incorporating a wide range of individual data in the choice of therapeutic modalities. For glaucoma surgery, this involves evaluation of the right timing, individual risk factors, targeting the correct anatomical and functional outflow pathways and appropriate prevention of scarring. As a consequence, there is an obvious need for better knowledge of anatomical and functional pathways and for more individualised surgical approaches with new, less invasive and safer techniques allowing for earlier intervention. With the recent advent of minimally invasive glaucoma surgery (MIGS) a large number of novel devices have been introduced targeting potential new sites of the outflow pathway for lowering intraocular pressure (IOP). Their popularity is growing in view of the relative surgical simplicity and apparent lack of serious side effects. However, these new surgical techniques are still in an era of early experiences, short follow-up and lack of evidence of their superiority in safety and cost-effectiveness over the traditional methods. Each year several new devices are introduced while others are withdrawn from the market. Glaucoma continues to be the primary cause of irreversible blindness worldwide and access to safe and efficacious treatment is a serious problem, particularly in the emerging world where the burden of glaucoma-related blindness is important and concerning. Early diagnosis, individualised treatment and, very importantly, safe surgical management should be the hallmarks of glaucoma treatment. However, there is still need for a better understanding of the disease, its onset and progression, the functional and structural elements of the outflow pathways in relation to the new devices as well as their long-term IOP-lowering efficacy and safety. This review discusses current knowledge and the future need for personalised glaucoma surgery.

Predictive factors for the IOP reduction in phacocanaloplasty with suprachoroidal drainage

PURPOSE

Although the pressure-reducing effect of cataract surgery alone is not very high, it is often cited in the literature. Some authors describe predictive factors correlated with the IOP (intraocular pressure) reduction: in particular noteworthy are age, axial length, preoperative pressure level and the ratio of preoperative pressure/anterior chamber depth. The aim of this study was to determine the applicability of these predictive factors to phacocanaloplasty with suprachoroidal drainage. Setting Eye Clinic Sulzbach Germany.

DESIGN

Retrospective study with a 12-month follow-up, including patients that underwent phacocanaloplasty with suprachoroidal drainage between 2012 and 2014.

METHODS

Preoperatively, baseline information was collected (including age, diagnosis, medication), and the patients underwent a basic examination and optical biometry. To investigate the relationship between preoperative parameters and the IOP reduction, Pearson's correlation analysis and linear regression were used. Patients with missing data pre- or postoperatively were excluded from the analysis.

RESULTS

The study comprised 89 patients. Mean preoperative IOP was 23.0 ± 5.3 mmHg with 4.0 different antiglaucomatous eye drops. After 12 months, IOP was reduced to 12.1 ± 1.4 mmHg with a median medication of 0.0. The preoperative IOP and the ratio of preoperative IOP/anterior chamber depth were identified as predictive factors. There was no influence of axial length and anterior chamber depth.

CONCLUSION

Unlike in cataract surgery, anterior chamber depth and axial length have no influence on the pressure reduction caused by phacocanaloplasty. However, a strong predictive factor is the preoperative pressure level. The higher the preoperative IOP, the greater the postoperative pressure reduction.

Combined iStent® Inject Trabecular Micro-Bypass and Phacoemulsification in Australian Patients with Open-Angle Glaucoma

Purpose

This retrospective audit aimed to evaluate the impact of combined iStent^®Inject (iSI) and phacoemulsification on medication number in Australians with open-angle glaucoma. Secondary outcomes included intraocular pressure (IOP), best-corrected visual acuity, refraction and visual fields.

Patients and Methods

Patients with glaucoma that received combined iSI and phacoemulsification by the same surgeon between 1 February 2016 and 1 February 2018 were audited for postoperative medication number, pressures after 1 day, 1 week, 4 weeks and 6, 12, 18 and 24 months, visual acuity, refraction and visual fields. These parameters were compared to baseline levels and with those from a separate cohort of patients without glaucoma that received standalone phacoemulsification.

Results

Forty-one patients (63 eyes) received the combined procedure. Thirty-four patients (59 eyes) received standalone phacoemulsification. Four weeks after receiving combined iSI and phacoemulsification the mean medication number was significantly reduced by 1.3 (p < 0.001) for those on medication at baseline and by 0.5 (p = 0.002) overall. Mean IOP was significantly reduced from baseline after 6 months (–16%; p = 0.012; n = 35) and 12 months (–29%; p = 0.004; n = 16). Patients receiving standalone phacoemulsification had short-term reductions in IOP at 4 weeks (–8%; p < 0.001; n = 57) and 6 months (–16%; p < 0.001; n = 32). These patients without glaucoma had lower pressures overall compared to those with glaucoma that received the combined procedure (p = 0.019). There were no differences in final visual acuity or refractive outcomes between groups.

Conclusion

This audit suggests that iSI and phacoemulsification are at least as effective in controlling IOP as medical therapy. It may have an important role in reducing the medication burden in Australians with cataract and glaucoma. This study is one of the first to confirm refractive stability in concomitant iSI and phacoemulsification.

Cataract surgery and intraocular pressure in glaucoma

PURPOSE OF REVIEW

To review the current literature on the relationship between cataract extraction and intraocular pressure (IOP).

RECENT FINDINGS

Cataract extraction can be an effective IOP lowering treatment for open and closed angle glaucoma as well as ocular hypertension. In comparative trials studying novel micro-invasive glaucoma surgeries in open angle glaucoma, the control group undergoing cataract extraction alone routinely achieved significant reductions in IOP and medication use postoperatively. Data from the Effectiveness in Angle Closure Glaucoma of Lens Extraction (EAGLE) trials have demonstrated that lens extraction is more effective at lowering IOP than peripheral iridotomy in patients with angle closure and should be considered as first line therapy. Additionally, patients in the ocular hypertension treatment study who underwent cataract extraction over the course of follow-up demonstrated significant IOP lowering sustained over 3 years.

SUMMARY

Cataract extraction is an effective method to lower IOP in patients with glaucoma. Pressure lowering is more significant in eyes with narrow angles and those with higher baseline IOP levels. In eyes with angle closure, phacoemulsification alone can lower IOP, but when combined with GSL it may be even more effective. Recent large multicenter randomized trials have further elucidated the benefit of standalone cataract extraction to treat mild to moderate primary open angle glaucoma. Prospective and longitudinal studies that systematically investigate the variables that may influence degree and duration of IOP lowering post cataract extraction are lacking.

Outcomes of phacoemulsification combined with two iStent inject trabecular microbypass stents with or without endocyclophotocoagulation

AIM

Comparing outcomes after combined phacoemulsification, two iStents insertion and endocyclophotocoagulation (ECP) versus phacoemulsification-iStents alone.

METHODS

This is a longitudinal retrospective 12 months study in eyes with ocular hypertension or early-to-moderate open angle glaucoma. Level of disease, intraocular pressure (IOP) and tolerance of glaucoma medication were considered before planning surgery. Best-corrected visual acuity (BCVA-logMAR), IOP (mm Hg), number of medications were assessed at baseline, week 1, week 5, month 3, 6, 12 postop.

MAIN OUTCOME

percentage (%) in IOP reduction at 12 months vs medicated baseline.

SECONDARY OUTCOMES

absolute values of IOP/medication reduction, BCVA and postop complications.

RESULTS

The ICE2 (two iStents-cataract extraction-ECP) group included 63 eyes and Phaco-iStent group included 46 eyes. Baseline IOP was higher in the ICE2 than phaco-iStent group (19.97±4.31 mm Hg vs 17.63±3.86 mm Hg, p=0.004) and mean deviation was lower (-7.20±2.58 dB vs -4.94±4.51 dB, p=0.037). Number of medications were comparable at baseline: 2.22±1.06 (ICE2) vs 2.07±1.02 (phaco-iStent), p=0.442. At month 12 postop, IOP in the ICE2 group decreased 35% from baseline vs 21% in the phaco-iStent group (p=0.03); absolute IOP reduction was significantly lower than baseline in each group (p<0.001), yet final IOP was lower in the ICE2 group than phaco-iStent group (13.05±2.18 mm Hg vs 14.09±1.86 mm Hg, p=0.01). Similar results were found for glaucoma medication (1.24±1.05 in ICE2 group vs 1.39±1.03 in phaco-iStent group, p=0.01). Final BCVA was 0.11±0.18 (phaco-iStent group) vs 0.08±0.08 (ICE2 group), p=0.309. Safety outcomes were comparable between groups.

CONCLUSION

ICE2 procedure offers better results in IOP/medication reduction at 12 months than phacoemulsification-iStents alone.

Evaluation of Anterior Chamber Depth and Anterior Chamber Angle Changing After Phacoemulsification in the Primary Angle Close Suspect Eyes

BACKGROUND:

Phacoemulsification surgery has the ability to deeply alter the segment anterior morphology, especially in eye with shallow anterior chamber (AC), narrow anterior chamber angle (ACA). However, the changes of anterior chamber depth (ACD) and ACA on the close angle suspect eyes after phacoemulsification have not been mentioned in many studies. So, we conduct this research.

AIM:

To evaluate the alteration in the ACA and ACD after phacoemulsification in the close angle suspect eyes.

METHODS:

Interventional study with no control group. Subjects were the primary angle closure suspect (PACS) eyes, that were operated by phacoemulsification with intraocular lens (IOL) at Glaucoma Department of VNIO from December 2017 to October 2018.

RESULTS:

29 PACS eyes with cataract were operated by phacoemulsification with intraocular lens. After 3 months of monitoring, the average ACD augmented from 2.082 ± 0.244 to 3.673 ± 0.222 mm. AOD500 increase from 0.183 ± 0.088 to 0.388 ± 0.132 μm, AOD750 increased from 0.278 ± 0.105 to 0.576 ± 0.149 μm. The TISA500 enlarged from 0.068 ± 0.033 to 0.140 ± 0.052 mm², TISA750 enlarged from 0.125 ± 0.052 to 0.256 ± 0.089 mm² at the third month (p < 0.01).

CONCLUSION:

Phacoemulsification surgery increases the ACD and enlarged the angle in the PACS eyes.