1
|
Levin AM, Sheybani A. Glaucoma surgical procedures under development. Curr Opin Ophthalmol 2024; 35:111-115. [PMID: 38108372 DOI: 10.1097/icu.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
PURPOSE OF REVIEW Rapid innovation in glaucoma surgery is expanding surgical options in the angle, subconjunctival space, and supraciliary space. RECENT FINDINGS Advancements in glaucoma surgery make it possible for surgeons to provide treatments with less risk. In particular, new devices and lasers are available for minimally invasive glaucoma surgeries. There are also new implants and techniques for bleb-forming glaucoma surgery. SUMMARY As glaucoma surgeons have access to an increasing number of procedures, devices, and treatments, it is important for evidence to drive decision-making.
Collapse
Affiliation(s)
| | - Arsham Sheybani
- Washington University School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
2
|
Gillmann K, Hornbeak DM. Rates of visual field change and functional progression in glaucoma following trabecular microbypass implantation of iStent technologies: a meta-analysis. BMJ Open Ophthalmol 2024; 9:e001575. [PMID: 38360043 PMCID: PMC10875546 DOI: 10.1136/bmjophth-2023-001575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/30/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND/AIM While intraocular pressure (IOP) remains the only modifiable risk factor for glaucoma progression, the ultimate goal of glaucoma management is to preserve patients' functional vision and quality of life. To this end, minimally invasive glaucoma surgeries (MIGSs) aim to reduce IOP with minimal eye trauma. Commonly used MIGS devices include iStent technologies, which have well-documented IOP-reducing potential and favourable safety profiles. However, no study concluded on their effect on the rates of visual field (VF) changes. The aim of this meta-analysis is to determine the long-term effect of iStent technology implantation on glaucoma functional progression. METHODS Electronic medical literature databases were searched to identify studies reporting on iStent technologies. Reports with follow-up durations <12 months, retention rates <75% and missing VF data were excluded. Fifteen studies reporting on 1115 eyes were identified. The overall weighted mean VF mean deviation (MD) progression, IOP reduction and follow-up duration were calculated. RESULTS Weighted mean IOP at baseline was 19.0±3.1 mm Hg. At the end of a 37.9-month mean follow-up (range 12-96 months), a weighted mean 26.6% IOP reduction was achieved (range 15.2%-42.3%). Over the same duration, the weighted mean VF MD progression rate was -0.02±0.34 dBs/year, from a mean baseline of -5.76±5.68 dBs. CONCLUSION In this review, which examines functional stability of 1115 eyes, iStent technologies achieved a mean rate of progression of -0.024 dBs/year with serial standard automated perimetry, which is similar to that reported in non-glaucomatous eyes and slower than that reported in medically treated glaucoma.
Collapse
Affiliation(s)
- Kevin Gillmann
- Genève Ophtalmologie, Geneva, Switzerland
- Stanford University, Palo Alto, California, USA
| | | |
Collapse
|
3
|
Wagner IV, Ang B, Checo L, Simsek D, Draper C, Dorairaj S. Spotlight on Schlemm's Canal MicroStent Injection in Patients with Glaucoma. Clin Ophthalmol 2023; 17:1557-1564. [PMID: 37288002 PMCID: PMC10243342 DOI: 10.2147/opth.s388293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/30/2023] [Indexed: 06/09/2023] Open
Abstract
Minimally invasive glaucoma surgery (MIGS) has revolutionized glaucoma care with its favorable safety profile and ability to delay or minimize the need for traditional, bleb-based procedures. Microstent device implantation is a type of angle-based MIGS, which reduces intraocular pressure (IOP) through bypass of the juxtacanalicular trabecular meshwork (TM) and facilitation of aqueous outflow into the Schlemm's canal. Although there are limited microstent devices on the market, multiple studies have evaluated the safety and efficacy of iStent® (Glaukos Corp.), iStent Inject® (Glaukos Corp.), and Hydrus® Microstent (Alcon) in the treatment of mild-to-moderate open-angle glaucoma, with and without concurrent phacoemulsification. This review attempts to provide a comprehensive evaluation of injectable angle-based microstent MIGS devices in the treatment of glaucoma.
Collapse
Affiliation(s)
| | - Bryan Ang
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
| | - Leticia Checo
- Department of Ophthalmology, Mayo Clinic, Jacksonville, FL, USA
| | - Derya Simsek
- Department of Ophthalmology, Baskent University Medical School, Ankara, Turkey
| | | | - Syril Dorairaj
- Department of Ophthalmology, Mayo Clinic, Jacksonville, FL, USA
| |
Collapse
|
4
|
Feinberg L, Swampillai AJ, Byles D, Smith M. Six year outcomes of combined phacoemulsification surgery and endoscopic cyclophotocoagulation in refractory glaucoma. Graefes Arch Clin Exp Ophthalmol 2022; 261:1339-1347. [PMID: 36482212 DOI: 10.1007/s00417-022-05906-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/13/2022] [Accepted: 11/08/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This study is to describe the 6-year results of combined phacoemulsification surgery and endoscopic cyclophotocoagulation (Phaco-ECP) surgery in patients with uncontrolled glaucoma and no previous glaucoma surgery. METHODS This is a retrospective case series of 84 eyes. The primary outcome measure was intraocular pressure (IOP) reduction 6 years postoperatively. Secondary outcome measures were the cumulative probability of failure of the surgical procedure at 6 years. Failure was defined as IOP higher than 21 mm Hg or lower than 6 mm Hg or IOP not reduced by 20% from baseline at the 1, 2, 3, 4, 5, or 6-year time points or further laser or other surgery to reduce IOP at any timepoint. RESULTS There was a statistically significant decrease in mean IOP from 18.9 mmHg pre-operatively to 13.7, 12.8, 13.0, 12.7, 12.5, and 12.3 mmHg at the 1, 2, 3, 4, 5, and 6 years post-operatively respectively (p < 0.001). Fifty-seven (68%) reached criteria for failure by 6 years. In 36% of cases, this was due to inadequate IOP control, whereas 32% required further laser or surgery. When we excluded patients who only had selective laser trabeculoplasty rather than further surgery, the failure rate reduced to 51%. Eleven percent had a post-operative complication, 2.4% requiring further surgical intervention. CONCLUSIONS At 6 years postoperatively, combined phaco-ECP achieved a significant reduction in IOP in patients with uncontrolled glaucoma and no previous drainage surgery. Significant complications were uncommon, but 68% was classified as surgical failures by the six year point.
Collapse
Affiliation(s)
- Leo Feinberg
- West of England Eye Unit, Royal Devon University Healthcare NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, Devon, UK.
| | - Andrew J Swampillai
- West of England Eye Unit, Royal Devon University Healthcare NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, Devon, UK
| | - Daniel Byles
- West of England Eye Unit, Royal Devon University Healthcare NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, Devon, UK
| | - Michael Smith
- West of England Eye Unit, Royal Devon University Healthcare NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, Devon, UK
| |
Collapse
|
5
|
Paletta Guedes RA, Gravina DM, Paletta Guedes VM, Chaoubah A. Standalone Implantation of 2-3 Trabecular Micro-Bypass Stents (iStent inject ± iStent) as an Alternative to Trabeculectomy for Moderate-to-Severe Glaucoma. Ophthalmol Ther 2022; 11:271-292. [PMID: 34825352 PMCID: PMC8770764 DOI: 10.1007/s40123-021-00424-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION This retrospective consecutive study compared standalone implantation of multiple (2-3) trabecular micro-bypass stents (iStent inject ± iStent) (Multi-Stent group) vs trabeculectomy + mitomycin C (Trab group) in moderate to severe open-angle glaucoma (OAG). METHODS Eligible patients underwent Multi-Stent or Trab surgery from 2018 to 2020 and had at least 3-month follow-up; visual field mean deviation (VF MD) - 6 dB or worse; inadequate prior response to maximum medications ± laser procedures; and had trabeculectomy as their next planned intervention. Primary effectiveness, safety-adjusted treatment success, was defined as ≥ 20% intraocular pressure (IOP) reduction on the same or fewer medications, without clinically significant safety events (severe complications, secondary surgeries, reinterventions). Secondary effectiveness included mean IOP and medications; qualified and complete attainment of target IOP (≤ 21/18/15/12 mmHg and > 6 mmHg); health-economic and quality-of-life (QoL) measures; and 2-vs-3-stent subgroup analysis. RESULTS The baseline groups (n = 70 Multi-Stent/40 Trab) were similar: mean IOP (21.1 mmHg/22.3 mmHg); medications (2.87/3.10 medications); disease stage (30%/35% severe); VF MD (- 10.1 dB/- 10.4 dB); and mean last follow-up (LFU, 13.1 months/15.7 months) (all differences non-significant). Primary effectiveness: treatment success at LFU was 62.9% vs 30.0% in Multi-Stent vs Trab eyes, respectively (p = 0.001). Secondary effectiveness: At LFU in Multi-Stent vs Trab groups, respectively: mean IOP decreased by 31% to 14.2 mmHg (p < 0.001) vs by 43% to 12.5 mmHg (p < 0.001); mean medications decreased by 51% to 1.31 medications (p < 0.001) vs by 84% to 0.43 medications (p < 0.001). Multi-Stent eyes, compared to Trab eyes, had fewer visits ± reinterventions within 3 months (3.6 vs 6.1, p < 0.001); longer time to first reintervention (12.2 months vs 4.5 months, p = 0.01); fewer total reinterventions (0.26 vs 0.75, p = 0.006); and earlier lifting of postoperative restrictions (12.6 vs 32.1 days, p < 0.001). In 2-vs-3-stent analysis, there was a trend toward more 3-stent eyes achieving target IOP than 2-stent eyes. Visual fields remained stable in both Multi-Stent and Trab eyes. CONCLUSION Implanting 2-3 trabecular micro-bypass stents was a viable alternative to trabeculectomy for moderate-to-severe OAG, with clinically appropriate IOP/medication reductions and higher safety-adjusted treatment success vs trabeculectomy.
Collapse
Affiliation(s)
- Ricardo Augusto Paletta Guedes
- Paletta Guedes Eye Institute, Juiz de Fora, Brazil.
- Federal University of Juiz de Fora, 79, Oscar Vidal Street, Juiz de Fora, MG, Brazil.
| | | | | | - Alfredo Chaoubah
- Federal University of Juiz de Fora, 79, Oscar Vidal Street, Juiz de Fora, MG, Brazil
| |
Collapse
|
6
|
Salimi A, Watt H, Harasymowycz P. Long-term outcomes of two first-generation trabecular micro-bypass stents (iStent) with phacoemulsification in primary open-angle glaucoma: eight-year results. EYE AND VISION 2021; 8:43. [PMID: 34782017 PMCID: PMC8594216 DOI: 10.1186/s40662-021-00263-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023]
Abstract
Background The short- and medium-term outcomes of iStent have been extensively studied; however, only few studies have investigated its long-term outcomes. Here, we assessed the long-term efficacy and safety of two iStents with concomitant cataract surgery in glaucomatous eyes while also evaluating measures of disease stability using visual field and optical coherence tomography (OCT) of the optic nerve and the macula throughout 8 years of follow-up. Methods This longitudinal, single-center consecutive case series included glaucomatous eyes that underwent implantation of two first-generation trabecular micro-bypass stents (iStent) with concomitant cataract surgery. Eight-year efficacy outcomes included mean intraocular pressure (IOP) and medications, as well as surgical success. Eight-year safety outcomes included best-corrected visual acuity (BCVA), visual field mean deviation (VF-MD), cup-to-disc ratio (CDR), retinal nerve fiber layer (RNFL) thickness, ganglion cell-inner plexiform layer (GC-IPL) thickness, and adverse events. Results A total of 62 eyes with primary open-angle glaucoma (POAG) were included. At 8 years postoperative, IOP reduced by 26% from 19.2 ± 3.9 mmHg preoperatively to 14.2 ± 2.4 mmHg (P < 0.001), 91.1% of eyes achieved IOP ≤ 18 mmHg (vs. 51.6% preoperatively), 69.6% of eyes achieved IOP ≤ 15 mmHg (vs. 14.5% preoperatively), and 25% of eyes achieved IOP ≤ 12 mmHg (vs. 1.6% preoperatively). Medication use decreased by 17.9% from 2.8 ± 1.1 preoperatively to 2.3 ± 1.2 (P = 0.018). Surgical success was 90%, as six eyes underwent subsequent glaucoma surgeries. Safety measures of BCVA, CDR, RNFL thickness and GC-IPL thickness remained stable through 8 years postoperative. VF-MD remained stable until postoperative year 5 and subsequently progressed according to the natural history of glaucomatous disease. Conclusions Implantation of two iStents with concomitant cataract surgery is an effective and safe treatment option for surgery-naïve POAG eyes, evidenced by significant IOP and medication reductions, reasonable surgical success, and favorable safety outcomes, throughout the 8-year follow-up. Our data additionally supports the efficacy of this combined procedure in stabilizing or slowing disease progression. Supplementary Information The online version contains supplementary material available at 10.1186/s40662-021-00263-1.
Collapse
Affiliation(s)
- Ali Salimi
- Department of Ophthalmology, Faculty of Medicine, McGill University, Montreal, QC, Canada.,Montreal Glaucoma Institute, Montreal, QC, Canada
| | - Harrison Watt
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Paul Harasymowycz
- Montreal Glaucoma Institute, Montreal, QC, Canada. .,Department of Ophthalmology, University of Montreal, 4135 de Rouen, Montreal, QC, H1V1G5, Canada.
| |
Collapse
|
7
|
Al Habash A, Otaif W. Surgical Outcomes of Combined 2nd-Generation Trabecular Microbypass (iStent Inject) and Cataract Surgery for the Treatment of Primary Open-Angle Glaucoma in the Saudi Population. Ophthalmol Ther 2021; 10:923-933. [PMID: 34351592 PMCID: PMC8589900 DOI: 10.1007/s40123-021-00380-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/19/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION To investigate the 24-month efficacy and safety of iStent inject trabecular microbypass system implantation combined with phacoemulsification in subjects with primary open-angle glaucoma (POAG) and concomitant cataract. METHODS This prospective, uncontrolled, interventional case series included 36 eyes (29 subjects) with POAG of mild to moderate severity and coexisting cataract that underwent combined phacoemulsification and implantation of a second-generation trabecular microbypass stent (iStent inject®). Main outcome measures involved mean intraocular pressure (IOP), number of antiglaucoma medications, and proportional analysis of eyes with IOP ≤ 18 mmHg or ≤ 15 mmHg, or with 0 or ≥ 2 glaucoma medications. Secondary outcome measures involved the cup-to-disc ratio, corrected distance visual acuity (CDVA), and adverse issues. RESULTS In 36 eyes, the mean IOP at baseline was 18.28 ± 2.87 mmHg, which decreased to 14.24 ± 1.36 (22.1%) and 14.46 ± 1.56 mmHg (20.9%) at 18 and 24 months, respectively (p < 0.001). At the last follow-up, 100% of eyes had an IOP ≤ 18 mmHg (vs. 50% preoperatively), and 75.7% of eyes had an IOP ≤ 15 mmHg (vs. 16.7% preoperatively); 58.3% of eyes achieved ≥ 20% IOP reduction from preoperative status. At baseline, eyes were treated with a mean of 2.35 ± 1.18 medications, which was reduced to 0.80 ± 1.04 (66% reduction) and 0.69 ± 0.95 medications (70.6% reduction) at 18 and 24 months, respectively (p < 0.001). At the last follow-up, 54.1% of eyes were medication-free (vs. 0% preoperatively) and 24.3% of eyes were treated with ≥ 2 medications (vs. 64.9% preoperatively). This combined procedure demonstrated an excellent safety profile with no reported intraoperative complications or adverse events; CDVA was maintained throughout the entire follow-up period. CONCLUSIONS This real-world series demonstrated that iStent inject device implantation at the time of phacoemulsification is a safe and effective method to decrease IOP and the necessity for antiglaucoma medications in patients with mild-to-moderate POAG and cataract; no associated vision-threatening complications were noted.
Collapse
Affiliation(s)
- Ahmed Al Habash
- Department of Ophthalmology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Wael Otaif
- Department of Ophthalmology, King Khalid University, Abha, Saudi Arabia
| |
Collapse
|
8
|
Standalone iStent Trabecular Micro-bypass Glaucoma Surgery: A Systematic Review and Meta-Analysis. J Glaucoma 2021; 30:606-620. [PMID: 33596009 DOI: 10.1097/ijg.0000000000001805] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/07/2021] [Indexed: 11/25/2022]
Abstract
PRECIS Standalone trabecular micro-bypass glaucoma surgery with the iStent devices is associated with clinically relevant reductions in intraocular pressure (IOP) sustained over a reasonably long-term while simultaneously reducing medication burden and a relatively favorable safety profile. PURPOSE While there is a relatively large body of evidence supporting the implantation of the iStent trabecular micro-bypass devices during phacoemulsification in patients with open-angle glaucoma (OAG), its efficacy as a standalone procedure has been less widely reported. The aims of this study were to systematically identify and quantitatively evaluate the efficacy of iStent devices (iStent and iStent inject) when performed independently of cataract surgery in patients with OAG. METHODS A systematic review of the literature was undertaken in August 2019 to identify studies of standalone trabecular micro-bypass glaucoma surgery with iStent devices in patients with OAG. All randomized trials were considered and nonrandomized studies that included at least 6 months of follow-up or more than 10 eyes. Key efficacy analyses included postoperative IOP and medication use, which were used to evaluate weighted mean differences from baseline, and the proportion of eyes free of ocular medication. Postoperative adverse events were descriptively summarized. RESULTS A total of 13 studies were identified including 4 randomized controlled trials and 9 nonrandomized or single-arm studies providing data for 778 eyes. In eyes implanted with iStent devices, a weighted mean IOP reduction of 31.1% was observed at 6 to 12 months. In studies reporting longer-term outcomes (36 to 48 mo or 60 mo), the weighted mean IOP reduction was 30.4% and 32.9%, respectively. The pooled weighted mean reduction in IOP from baseline across all studies at 6 to 12 months and 36 to 60 months poststent implantation was 7.01 mm Hg (95% confidence interval: 5.91, 8.11) and 6.59 mm Hg (95% confidence interval: 5.55, 7.63), respectively. Medication burden was reduced by ~1.0 medication at 6 to 18 months and 1.2 medications at 36 to 60 months. Adverse events reported in more than 5% of participants were progression of pre-existing cataract/cataract surgery and loss of best-corrected visual acuity but these rates were no different to those reported in comparator medical therapy study arms. CONCLUSIONS The results from these studies support the independent effect of the iStent trabecular bypass devices on IOP and medication burden over a duration of follow-up of up to 5 years.
Collapse
|
9
|
Mercer R, Alaghband P. Critique of the Study, "Five-year Outcomes Prospective Study of Two First-Generation Trabecular Micro-Bypass Stents (Istent®) in Open-Angle Glaucoma" by Hady Saheb Et Al. Curr Eye Res 2021; 46:1073-1074. [PMID: 33302706 DOI: 10.1080/02713683.2020.1863429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|