Gonioscopy-assisted Transluminal Trabeculotomy in Uveitic Glaucoma Secondary to Juvenile Idiopathic Arthritis

Gonioscopy-Assisted Transluminal Trabeculotomy in Uveitis-Related Ocular Hypertension and Glaucoma

PRCIS

Gonioscopy-assisted transluminal trabeculotomy (GATT) may be an effective first-line surgery for decreasing intraocular pressure (IOP) and medication burden in patients with uveitis-related ocular hypertension (OHT) or glaucoma.

OBJECTIVE

The purpose of the study is to determine the efficacy of GATT in lowering IOP in uveitis-related OHT or glaucoma.

METHODS

Retrospective case series that included patients with uveitis-related OHT or glaucoma who underwent GATT with or without concomitant cataract extraction and intraocular lens implantation at 2 Canadian academic centres from July 2018 to May 2022. Primary outcomes were: complete (no medications) and qualified success (with medication), and failure defined as (1) IOP >21 mm Hg with maximal medical therapy, (2) the need for additional glaucoma procedure, (3) loss of light perception secondary to glaucoma, and (4) IOP <6 mm Hg for 3 months.

RESULTS

Twenty-one eyes from 18 patients were included with a mean preoperative IOP of 26.2 ± 7.3 mm Hg on 4.3 ± 0.7 classes of glaucoma drops. The average follow-up was 29.2 ± 17.6 months and 76% of eyes (n = 16) had reached at least 12 months of follow-up. At the 12-month follow-up visit, there was a significant decrease in average IOP by 9.9 ± 7.9 mm Hg (38%, P = 0.005) and a decrease of 1.9 in glaucoma medication classes ( P = 0.002). Of eyes, 14% achieved complete success, whereas 80% of eyes achieved qualified success. Six eyes failed (29%) and 5 patients (24%) required additional glaucoma surgery. The most common postoperative complication was hyphema (n = 9; 43%).

CONCLUSION

This small case series suggests that GATT may be an effective first-line surgery for decreasing IOP and medication burden in patients with uveitis-related OHT or glaucoma. Further studies with longer follow-ups should be conducted to assess its long-term outcomes.

Uveitic Flare-Ups After Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Patients with Uveitic Glaucoma

PURPOSE

To assess the risk of gonioscopy-assisted transluminal trabeculotomy (GATT) inducing an uveitic flare-up in patients with uveitic glaucoma (UG).

METHODS

This retrospective study included consecutive UG patients who underwent GATT at a single medical center between June 2020 and September 2022. The main outcome measure was the occurrence of a surgery-related uveitic complication defined as either an uveitic flare-up defined by the Standardization of Uveitis Nomenclature (SUN) criteria, or the appearance of cystoid macular edema (CME) from 2 weeks to 3 months after surgery.

RESULTS

A total of 25 eyes of 22 patients were included in the study. Age ranged from 10-78 and 64% were women. The most common uveitic etiologies were juvenile idiopathic arthritis (JIA, 24%) and herpetic infection (24%). A total of 48%of the patients were on systemic immunosuppressants prior and unrelated to surgery. Eight eyes (32%) had severe glaucomatous damage prior to surgery, and 20% of the patients had undergone previous glaucoma surgery. Two cases (8%) demonstrated uveitic flare-up in the early postoperative period: a case of mild anterior chamber reaction and a case of CME with persistent edema prior to surgery. Average intraocular pressure (IOP) was reduced from 26.7 mm Hg on four medications to 12.2 on 1.1 after 1 year. One patient required reoperation for IOP control.

CONCLUSIONS

With careful pre and postoperative care, GATT seems to be a low-risk procedure for uveitic flare-ups in patients with UG.

Update on Diagnosis and Treatment of Uveitic Glaucoma

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

Outcomes of Gonioscopy-Assisted Transluminal Trabeculotomy as a Primary Surgical Treatment for Glaucoma Secondary to Juvenile Idiopathic Arthritis-Associated Uveitis

Gonioscopy-assisted transluminal trabeculotomy (GATT) has been used as a safe and effective procedure in the treatment of open angle glaucoma. In the present report, we demonstrated successful IOP control in two uveitic glaucoma cases secondary to juvenile idiopathic arthritis (JIA) following 360° GATT. Case 1 was a 7-year-old pseudophakic male with a preoperative IOP of 38 mmHg; his IOP stabilized at 17 mmHg with two topical antiglaucoma medications over 18 months. Case 2 was a 8-year-old aphakic male with a preoperative IOP of 42 mmHg; his IOP decreased to 12 mmHg over 15 months. We observed postoperative IOP spike in case 1 which was successfully controlled conservatively. Peripheral anterior synechia formation also occured in both cases during follow-up. One should be vigilant for possible complications after GATT in such cases. As glaucoma surgery success can have a tendency to decline with time in pediatric cases with uveitis-associated glaucoma, we believe that further evidence is still required to shed more light about the benefits of GATT technique in complex cases of pediatric secondary glaucoma subtypes like JIAU-induced glaucoma.

Gonioscopy-assisted transluminal trabeculotomy for open-angle glaucoma with failed incisional glaucoma surgery: two-year results

BACKGROUND

To evaluate the safety and efficacy of gonioscopy-assisted transluminal trabeculotomy (GATT) in treating patients with open-angle glaucoma (OAG) who had failed prior incisional glaucoma surgery.

METHODS

A consecutive case series of OAG patients aged ≥ 18 who underwent GATT with previous failed glaucoma incision surgery was retrospectively analyzed. Main outcome measures included intraocular pressure (IOP), the number of glaucoma medications, surgical success rate, and occurrence of complications. Success was defined as an IOP of ≤ 21 mmHg and a reduction of IOP by 20% or more from baseline with (qualified success) or without (complete success) glaucoma medications. For eyes with preoperative IOP of < 21 mmHg on 3 or 4 glaucoma medications, postoperative IOP of ≤ 18 mmHg without any glaucoma medications was also defined as complete success.

RESULTS

Forty-four eyes of 35 patients (21 with juvenile-onset open-angle glaucoma and 14 with adult-onset primary open-angle glaucoma) with a median age of 38 years were included in this study. The proportion of eyes with 1 prior incisional glaucoma surgery was 79.5%, and the others had 2 prior surgeries. IOP decreased from 27.4 ± 8.8 mm Hg on 3.6 ± 0.7 medications preoperatively to 15.3 ± 2.7 mm Hg on 0.5 ± 0.9 medications at the 24-month visit (P < 0.001). The mean IOP and the number of glaucoma medications at each follow-up visit were lower than the baseline (all P < 0.001). At 24 months postoperatively, 82.1% of the eyes had IOP ≤ 18 mmHg (versus 15.9% preoperatively, P < 0.001), 56.4% reached IOP ≤ 15 mmHg (versus 4.6% preoperatively, P < 0.001), and 15.4% achieved IOP ≤ 12 mmHg (compared to none preoperatively, P = 0.009). While 95.5% of eyes took 3 or more medications preoperatively, 66.7% did not take glaucoma medication 24 months after GATT. Thirty-four (77.3%) eyes achieved IOP reduction greater than 20% on fewer medications. The complete and qualified success rates were 60.9% and 84.1%, respectively. No vision-threatening complications occurred.

CONCLUSIONS

GATT was safe and effective in treating refractory OAG patients who failed prior incisional glaucoma surgery.

Systematic Review of MIGS and Non-Penetrating Glaucoma Procedures for Uveitic Glaucoma

Minimally invasive glaucoma surgeries (MIGS) and non-penetrating glaucoma procedures have changed the surgical management of glaucoma in recent years and are being explored in the management of uveitic glaucoma. Deep sclerectomy, Xen45 gel stent, gonioscopy-assisted transluminal trabeculotomy (GATT), trabectome, and canaloplasty are described in the literature as alternative surgeries that may work for uveitic glaucoma. While most of the published studies are retrospective case series, the results suggest success even in refractory cases and with less inflammation than more traditional surgeries.

Gonioscopy-assisted Transluminal Trabeculotomy Following Failed iStent Surgery

We describe four cases of eyes initially treated with phacoemulsification and iStent trabecular micro-bypass (Glaukos Corporation, Laguna Hills, CA, USA). These patients subsequently required further surgery and were successfully treated with removal of the iStent device followed by Gonioscopy-assisted transluminal trabeculotomy (GATT) using the iTrack catheter (Ellex Medical Lasers Ltd., Adelaide, SA, Australia). Three of the cases had prior first-generation iStent (G1), and one had prior second-generation iStent (G2). This case series demonstrates that in selected cases a further angle procedure in the form of a GATT can show efficacy and durability in the medium term. Our patients had controlled intraocular pressures at one year post GATT; two on IOP-lowering therapy and two without any IOP-lowering medications. Three patients had transient hyphaema and two with high IOP in the immediate postoperative period. No patients experienced a decrease in BCVA postoperatively. To our knowledge, there is no prior literature describing this surgical strategy. This series demonstrates that GATT could potentially be an effective procedure in the case of a failed initial iStent microtrabecular bypass.

Gonioscopy-Assisted Transluminal Trabeculotomy; A Review

AIM

To review the recent evidence in the literature regarding the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in the management of pediatric and adult glaucoma.

METHODS

A literature search was performed in the electronic databases of PubMed, Google Scholar, Embase the Register of Controlled Trials, and Ovid Medline for studies evaluating the safety and outcomes of GATT in glaucoma.

RESULTS

GATT is a novel minimally invasive glaucoma surgery that allows the incision of the inner wall of Schlemm's canal increasing aqueous drainage through the physiologic outflow pathway with subsequent intraocular pressure reduction in different types if of glaucoma.

CONCLUSION

GATT demonstrated favorable results in a wide range of both primary and secondary open-angle and angle-closure glaucoma.

Gonioscopy-assisted transluminal trabeculotomy is an effective surgical treatment for uveitic glaucoma

BACKGROUND

To assess the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in uveitic glaucoma (UG).

METHODS

A retrospective interventional case series in which 33 eyes of 32 patients with UG underwent GATT with or without concomitant cataract extraction and intraocular lens implantation (CE/IOL) at three Canadian treatment centres from October 2015 to 2020. The main outcome measure was surgical success defined as an intraocular pressure (IOP) ≤18 mm Hg and at least one of the following: IOP within one mm Hg of baseline on fewer glaucoma medications as compared with baseline or a 30% IOP reduction from baseline on the same or fewer medications. Secondary outcome measures were IOP, medication usage and surgical complications.

RESULTS

Mean patient age (mean±SD) was 49±16 years (range: 18-79) and 44% were female. GATT was performed as a standalone procedure in 52% of cases and the remainder were combined with CE/IOL. Surgical success was achieved in 71.8% (SE: 8.7%) of cases. Mean preoperative IOP (±SD) was 31.4±10.8 mm Hg on a median of 4 medications. 59% of patients were on oral carbonic anhydrase inhibitors (CAIs) prior to surgery. After 1 year, average IOP was 13.8 mm Hg on a median 1 medication, with 6% of patients being on oral CAIs. No sight threatening complications occurred during surgery or follow-up.

CONCLUSION

GATT is an effective surgical strategy in the management of UG. This microinvasive conjunctival-sparing procedure should be considered early in these patients.