A comparison of the 1-year surgical outcomes of ab externo trabeculotomy and microhook ab interno trabeculotomy using propensity score analysis

Impact of glaucoma medications on subsequent Schlemm's canal surgery outcome: Cox proportional hazard model and propensity score-matched analysis

PURPOSE

The impact of various preoperative glaucoma medications on Schlemm's canal surgery outcomes remains unclear. This study aimed to investigate the impact of preoperative glaucoma medications on the postoperative 1-year outcomes of μTLO.

METHODS

We analyzed the medical records of 218 patients who underwent their first μTLO to investigate the 1-year postoperative outcomes. Cox proportional hazard regression analysis was performed with surgical failure as the dependent variable and each type of preoperative medication as the independent variable. We also compared the 1-year outcomes of μTLO between users and non-users of specific medications using propensity score matching. Surgical success was defined as a postoperative intraocular pressure ranging from 5 to 21 mmHg, a ≥20% reduction in IOP from baseline, and no additional glaucoma surgery within 1 year postoperatively.

RESULTS

The Cox proportional hazard analysis showed that all drugs that do not increase the conventional outflow exhibited hazard ratios greater than 1.0, and the preoperative use of β-blockers and oral CAI was a significant surgical risk factor (hazard ratio: 2.65 and 2.45, p = 0.04 and <0.001). In the propensity score matching analysis, success rates at 1 year postoperatively were 55/85, 54/79, 60/73, and 40/76% for users/non-users of β-blockers, topical CAIs, an alpha-2 adrenergic agonist, and an oral CAI, respectively. Kaplan-Meier survival curves in these comparisons also demonstrated that preoperative β-blockers and oral CAI use were significant surgical risks (p = 0.01, <0.001).

CONCLUSION

Our study suggests that preoperative medications that do not involve conventional pathway outflow have a detrimental effect on subsequent Schlemm's canal surgery outcomes.

Favorable effect of ripasudil use on surgical outcomes of microhook ab interno trabeculotomy

PURPOSE

We have previously demonstrated that prolonged use of glaucoma medications was associated with a poor surgical outcome of ab interno trabeculotomy (µTLO). Given that almost all types of glaucoma eye drop either enhance the drainage through the uveoscleral pathway or reduce aqueous humor production, we hypothesized that prolonged use of these medications might cause disuse atrophy of the conventional pathway. In contrast, ripasudil increases the conventional outflow and eventually shows a favorable outcome of µTLO. This study aimed to evaluate the effect of ripasudil use on µTLO outcomes.

METHOD

The medical charts of 218 patients who underwent µTLO were analyzed retrospectively. We compared the 1-year outcome between ripasudil users versus nonusers by using propensity score matching. We set the covariates as age, sex, glaucoma types, preoperative intraocular pressure (IOP), the mean deviation values of visual field tests, the presence or absence of concomitant cataract surgery, trabecular meshwork incision range, the presence or absence of any glaucoma medication except ripasudil and duration of glaucoma medical therapy. Success was defined as a postoperative IOP between 5 and 21 mmHg, a ≥ 20% IOP reduction from baseline, and no additional glaucoma surgery at postoperative 1 year.

RESULT

Fifty-seven patients each were allocated to the ripasudil users or nonusers. The 1-year success rates were 74% in ripasudil users and 51% in nonusers (p = 0.01). Kaplan‒Meier survival curves also showed that the ripasudil users had a higher survival distribution (p = 0.01).

CONCLUSION

The patients who took ripasudil showed a favorable 1-year outcome of µTLO.

Comparison of minimally invasive glaucoma surgery with trabecular micro-bypass stent and microhook ab interno trabeculotomy performed in conjunction with cataract surgery

AIM

To evaluate the effectuality and safety of cataract surgery combined with either ab interno trabeculotomy by the microhook (µLOT) or a single iStent^® trabecular bypass implantation (iStent) in eyes with cataract and mild-to-moderate glaucoma.

METHODS

This study enrolled subjects with mild-to-moderate open angle glaucoma with visually significant cataract who used two or more ophthalmic antiglaucoma agents between 60 and 90y of age. Patients underwent cataract surgery cooperated with either implantation of an iStent (iStent-phaco) or excisional goniotomy with the µLOT (µLOT-phaco). Patients underwent µLOT-phaco in the eye with lower the mean deviation, according to the Humphrey field analyzer, while iStent-phaco was carried out on the other eye. Intraocular pressure (IOP) pre- and post-surgery, alterations in anterior chamber flare (ACF), and corneal endothelial cell density (ECD) were estimated.

RESULTS

Twenty subjects were enrolled (mean age: 73.6±7.3y). The mean medicated preoperative IOP was 16.7 mm Hg in the µLOT and 16.2 mm Hg in the iStent eyes. The mean final IOP at 12mo was 13.6 mm Hg in the µLOT eyes and 13.6 mm Hg in the iStent eyes, representing a 17.8% and 17.2% reduction, respectively. The preoperative ACF in the µLOT eyes was 9.5 pc/ms and it returned to normal in 30d postoperatively, with a value of 11.4 pc/ms. In the iStent eyes, ACF was 9.6 pc/ms preoperatively and it returned to normal by 7d postoperatively (11.2 pc/ms at day 7), demonstrating that postoperative inflammation was less in the iStent eyes. The corneal ECD in both groups was not significantly decreased.

CONCLUSION

In this study, iStent and µLOT are both effective through 12mo of follow-up. Safety is more favorable in the iStent eyes, based on early anterior chamber inflammation.

Persistent corneal blood staining after microhook trabeculotomy: A case report

INTRODUCTION

Hyphema, that is, massive anterior chamber hemorrhage, is one of the major complications after a recent minimally invasive glaucoma surgery. Hyphema along with high intraocular pressure increases the risk of corneal bloodstaining.

PATIENT CONCERNS

A 71-year-old female was receiving 0.1% fluorometholone drops in both eyes for severe dry eye. She was also receiving antiplatelet agents for platelet aggregation hyperactivity and prednisolone for interstitial pneumonia internally. Her right eye was suffering from increased intraocular pressure.

DIAGNOSIS

We diagnosed her right eye as steroid-induced glaucoma.

INTERVENTIONS

We performed microhook trabeculotomy.

OUTCOMES

At postoperative day 10, she had total anterior chamber hemorrhage and high intraocular pressure, and subsequently developed corneal blood staining at postoperative day 15, for which we performed anterior chamber cleaning. After that, we did not perform additional anterior chamber cleaning, and during the 1-year follow-up, a gradual improvement was noted in the entire cornea with reddish-brown opacity, from the periphery to the center. However, almost the entire pupil was still covered with opacity, and her visual acuity was at the light perception at the final visit.

LESSONS

Corneal bloodstaining takes a considerable time to resolve and causes severe vision loss. Special attention should be given to persistent corneal blood staining when hyphema and high intraocular pressure are observed after minimally invasive glaucoma surgeries.

Risk of surgical failure and hemorrhagic complications associated with antithrombotic medication in glaucoma surgery

PURPOSE

The purpose of this retrospective study was to determine the extent to which the use of antithrombotic drugs during glaucoma surgery contributes to surgical failure and postsurgical hemorrhagic complications.

METHODS

Glaucoma surgeries were categorized into three groups: trabeculotomy (TLO), trabeculectomy (TLE), and long-Tube shunt surgery (Tube). At 1 year after surgery, the following criteria for surgical success were met: intraocular pressure (IOP) in the 5-21-mmHg range, IOP reduction of at least 20% from the preoperative level, and no additional glaucoma surgeries. We compared the percentages of the success rates and hemorrhagic complications between antithrombotic medication experiencers and non-experiencers. Furthermore, we adjusted the preoperative factors between the two groups using a propensity score analysis in TLO and TLE surgeries.

RESULTS

A total of 910 glaucoma surgeries were included, with TLO, TLE, and Tube accounting for 353, 444, and 113 surgeries, respectively. Preoperative antithrombotic medications were administered to 149 patients in all glaucoma surgeries: 37 patients used only anticoagulants, 102 used only antiplatelets, and 10 used both. There was no significant difference in the success rates of any of the procedures. The hemorrhagic complications (hyphema and vitreous hemorrhage rate) were significantly higher in the patients who underwent TLE and Tube. The surgical success rates of TLO and TLE were not significantly different after the two groups were matched by propensity score.

CONCLUSION

The perioperative use of antithrombotic drugs did not affect success for any of the procedures. However, it increased early postoperative hemorrhagic complications for TLE and Tube.

Association of the prolonged use of anti-glaucoma medications with the surgical failure of ab interno microhook trabeculotomy

PURPOSE

This study examined the perioperative factors affecting surgical success in ab interno microhook trabeculotomy (μTLO).

METHODS

A total of 146 consecutive patients who underwent μTLO were included in this retrospective study. We performed Cox proportional hazard modelling by setting surgical success at 1 year as an objective variable. The explanatory variables included age, sex, glaucoma type, preoperative intraocular pressure (IOP), glaucoma drug score, mean deviation (MD) of the Humphrey visual field test, duration of glaucoma drug use, antithrombotic drug use, combined cataract surgery, incision range and diabetes mellitus. Additionally, we performed 1:1 matching using propensity score analysis and compared the perioperative parameters between durations of glaucoma drug use of <4.5 years and ≥ 4.5 years (50 patients each). We defined surgical success as satisfaction of all three criteria: IOP 5-21 mmHg, IOP reduction of ≥20% from the preoperative IOP and no additional glaucoma surgery.

RESULTS

The Cox proportional hazard model revealed that a longer duration of anti-glaucoma medication was significantly associated with surgical failure. Propensity score matching analysis showed that the <4.5-year users of anti-glaucoma drugs had significantly higher success rates than the ≥4.5-year users (72% versus 52%; p = 0.04).

CONCLUSIONS

The prolonged use of multiple glaucoma drugs adversely affected the outcome of μTLO at least at 1 year postoperatively.

The effects of antithrombotic therapy in ab interno trabeculotomy with a spatula-shaped microhook

To evaluate the effects of the discontinuation of antithrombotic drugs on intraocular pressure (IOP) reduction and complications from ab interno trabeculotomy for patients with glaucoma. We performed a retrospective chart review on the data of patients treated with antithrombotic agents who have undergone ab interno trabeculotomy through Tanito microhook combined with cataract surgery at the Asahi General Hospital and the Tokyo University Hospital, with 6 months of follow-up. The patients were classified into two groups depending on whether they discontinued (AT-) or continued (AT+) antithrombotic therapy during the perioperative phase. The demographics, pre- and postoperative IOP, medication score, best-corrected visual acuity (BCVA), and postoperative complications were analyzed preoperatively and postoperatively at 1 week and 1–6 months. The series included 44 eyes from 44 Japanese patients. The AT- and AT+ groups included 21 eyes from 21 patients and 23 eyes from 23 patients, respectively. The decrease in IOP from the baseline at 1 week postoperative was significantly different between the two groups (p = 0.009), but there were no significant differences observed in the other visits. Hyphema and IOP spikes exceeding 30 mmHg occurred in 10% and 10% of AT- participants, and in 43% and 26% of AT+ participants, respectively. Hyphema and spikes with hyphema occurred more frequently in the AT+ than in the AT- group (p = 0.02 and p = 0.05). The number of patients who had spikes was not significantly different (p = 0.27). In trabeculotomy using the Tanito microhook®, discontinuing antithrombotic therapy had better IOP-lowering effects and less postoperative complications.

Comparison of efficacy and early surgery-related complications between one-quadrant and two-quadrant microhook ab interno trabeculotomy: a propensity score matched study

PURPOSE

We compared the 1-year outcomes and early surgery-related complications between 1-quadrant and 2-quadrant microhook ab interno trabeculotomy (TLO).

METHODS

Medical chart extraction was performed on 47 consecutive patients with 1-quadrant incision and 37 consecutive patients with 2-quadrant incision of trabecular meshwork. Logistic regression analysis was conducted to calculate the propensity score to create a 1:1 match for a comparative analysis of 1-year postoperative success. Success was defined as postoperative intraocular pressure (IOP) between 5-21 mmHg, >20% IOP reduction from baseline, and no additional glaucoma surgery. Outcome-related covariates were age, glaucoma type, mean deviation of visual field tests, preoperative IOP, the number of preoperative glaucoma eye drops and the presence of combined cataract surgery. Thirty eyes from each group were compared.

RESULTS

The median preoperative IOP was not different between the 1-quadrant and 2-quadrant groups (28.5 mmHg, quartile range 23-33.5 versus 27 mmHg, 23.3-30.0, p = 0.47). There was no difference in median postoperative IOP at 1 year (15 mmHg versus 16 mmHg, p = 0.80). The success rate was 73% in the 1-quadrant group versus 70% in the 2-quadrant group (p = 1.00). The 2-quadrant group had a significantly higher proportion of patients with transiently elevated IOP (47%) than the 1-quadrant (17%; Fisher's exact test, p = 0.02). There was no difference of hyphema formation (Fisher's exact test, p = 0.18).

CONCLUSION

The 1-year success rate was not significantly different between 1- and 2-quadrant incisions of microhook TLO. However, the 2-quadrant TLO showed significantly higher proportion of post-surgical transient IOP elevation.

Non-inferiority of Microhook to Trabectome: Trabectome vs. ab interno Microhook Trabeculotomy Comparative Study (TramTrac Study)

PURPOSE

To elucidate the non-inferiority of ab interno microhook trabeculotomy (μTLO) using a recently developed reusable stainless spatula-type microhook device to incise the trabecular meshwork to trabectome (TOM) in terms of the 1-year postoperative outcomes of Japanese patients with glaucoma by means of propensity score analyses.

DESIGN

A multicenter retrospective cohort study.

PARTICIPANTS

We enrolled 553 and 392 patients who underwent TOM and μTLO, respectively, between January 2014 and March 2020 at 10 facilities.

METHODS

Logistic regression analysis was conducted to calculate the propensity score, which indicates the likelihood of treatment assignment (TOM or μTLO). We set the following factors as outcome-related covariates: age, sex, facility, glaucoma disease types, preoperative intraocular pressure (IOP), glaucoma drug score, mean deviation of the Humphrey visual field test and antithrombotic drug use, the presence or absence of combined cataract surgery, and incision range of trabecular meshwork (one or two quadrants). We analyzed four different methods (matching, inverse probability of treatment weighting (IPTW), stratification, and regression adjustment) using the propensity score. We set 15% as the non-inferiority margin based on previous trabectome meta-analysis results.

MAIN OUTCOME MEASURES

The primary outcome was surgical success at 1 year postoperatively. We defined surgical success as satisfying all three criteria: (1) IOP within 5-21 mmHg; (2) IOP reduction of ≥20% from preoperative IOP; and (3) no additional glaucoma surgery.

RESULTS

The 95% confidence interval of risk difference of surgical failure in μTLO in reference to TOM was -12.1 to +9.5% in matching, -12.7 to +11.1% in IPTW, -12.2 to +7.0 in stratification, and -9.7 to +8.1% in regression adjustment, all of which fell within the predetermined non-inferiority margin of 15%.

CONCLUSIONS

Surgical success of μTLO at 1-year postoperatively was not inferior to that of TOM.

Comparison of effectiveness and complications in trabeculotomy with phacoemulsification between ab externo and ab interno using a spatula-shaped microhook

To compare the short-term surgical effectiveness and safety profile of trabeculotomy ab externo and ab interno with microhook in terms of the recovery of visual acuity. A retrospective chart review was performed on patients who underwent trabeculotomy combined with phacoemulsification and lens implantation at Asahi General Hospital, with 6 months of follow-up. The patients treated by trabeculotomy were classified into two groups depending on the surgical procedures: ab interno with Tanito microhook (TMH) and ab externo with rigid probe trabeculotome (LOT). The demographics, preoperative and postoperative intraocular pressure (IOP), number of medications (Med), best-corrected visual acuity (BCVA), surgical-induced astigmatism (SIA), and postoperative complications were analyzed at pre-operation, and 1 week and 1–6 months post-operation. Fifty-two eyes of 38 Japanese patients underwent TMH and 42 eyes of 32 patients underwent LOT. The decreases in IOP and Med from the baseline were significant at all time points in both groups (p < 0.001), but there were no significant differences between the two groups. BCVA improved significantly in TMH and LOT after the operation (p < 0.001). BCVA and SIA significantly improved, mostly at 1 week in TMH, compared with LOT (p = 0.02 and 0.003). Hyphema and IOP spike exceeding 30 mmHg (spike) occurred in 11% and 6% of participants in TMH, and 33% and 26% of participants in LOT, respectively. Hyphema and IOP spike occurred more frequently in the LOT than in the TMH group (p = 0.01 and 0.005). Ab interno trabeculotomy showed similar IOP-lowering effects as ab externo, but had less postoperative complications.

Comparison of Surgical Outcomes Between Ab Interno Suture Trabeculotomy and Ab Externo Metal Trabeculotomy in Adult Patients with Glaucoma

Purpose

To compare the outcomes of ab interno suture trabeculotomy (AbI-TLO) and ab externo metal trabeculotomy (AbE-TLO) in adult patients with glaucoma aged over 40 years.

Patients and Methods

A retrospective chart review was conducted, including adult patients with glaucoma who underwent AbI-TLO or AbE-TLO between January 2015 and June 2019. A single surgeon (YO) performed all the operations. Eighty-one patients (81 eyes) were included in this study. Surgical success was defined as a postoperative intraocular pressure (IOP) of ≤18 mmHg and an IOP reduction of ≥20% from the preoperative IOP, without requiring additional glaucoma surgery. Success rates were assessed using Kaplan-Meier survival curves and log-rank (Mantel-Cox) tests, while risk factors were analyzed using the Cox proportional hazards model.

Results

Forty-nine patients who underwent AbI-TLO and 32 patients who underwent AbE-TLO were studied; the preoperative IOPs were 27.9 ± 7.3 (mean ± standard deviation) mmHg and 25.6 ± 8.1 mmHg in the AbI-TLO and AbE-TLO groups, respectively (p=0.217). The 12-month postoperative IOPs were 15.8 ± 4.0 mmHg and 16.3 ± 4.2 mmHg in the AbI-TLO and AbE-TLO groups, respectively (p=0.724). The surgical success rates at 12 months were 77.6% and 62.5% in the AbI-TLO and AbE-TLO groups, respectively (p=0.144). Postoperative hyphema with level formation and ocular hypertension over 30 mmHg were observed in 22.4% and 26.5% of patients in the AbI-TLO group and 18.8% and 12.5% of those in the AbE-TLO group, respectively. Stepwise multivariate Cox regression analysis showed that a longer axial length was a risk factor for surgical failure (hazard ratio: 2.030; p=0.042).

Conclusion

AbI-TLO and AbE-TLO had similar surgical outcomes and postoperative complications. A longer axial length was associated with an insufficient IOP reduction.

Comparison of 12-month surgical outcomes of ab interno trabeculotomy with phacoemulsification between spatula-shaped and dual-blade microhooks

PURPOSE

To compare 12-month clinical results of spatula-shaped and dual-blade microhooks ab interno trabeculotomy with phacoemulsification.

STUDY DESIGN

Retrospective comparative study.

METHODS

We conducted a retrospective chart review of Japanese open-angle glaucoma patients who underwent ab interno trabeculotomy with phacoemulsification with a 12-month follow-up. Two types of trabecular hook were used: the spatula-shaped Tanito Trabeculotomy ab interno Micro-hook^® and the Kahook Dual Blade^®. Changes in intraocular pressure (IOP) and medication scores comprised the main outcome metrics. We also analyzed and compared patient demographics and the occurrence of complications.

RESULTS

Trabeculotomy was performed using a spatula-shaped hook in 17 eyes and a dual-blade hook in 15 eyes. Significant reductions in IOP (p < 0.001) and medication scores (p < 0.001) were noted in both groups after the 1-month time point. The percentage changes of IOP from baseline at each time point were not significantly different between groups, though there was a significant difference in medication scores at 12 months (p = 0.0192). Postoperative complications occurred similarly in both groups; one case in the dual-blade group required additional filtration surgery.

CONCLUSIONS

Ab interno trabeculotomy with phacoemulsification was effective in lowering IOP both with spatula-shaped and with double-blade microhooks. At 12 months more medications were used postoperatively in the spatula-shaped microhook group; however, the reductions in the medication scores from baseline were statistically significant in both groups.