Comparison of ExPress Mini-Device Implantation Alone or Combined with Phacoemulsification for the Treatment of Open-Angle Glaucoma

Minimally invasive bleb surgery versus minimally invasive glaucoma surgery: a 12-month retrospective study

This study aimed to compare the IOP-lowering effectiveness and safety of standalone Preserflo MicroShunt and iStent 1st generation implantation combined with phacoemulsification in Caucasian patients with a 12-month follow-up period. This retrospective study analyzed the medical histories of patients undergoing antiglaucoma surgery at the Department of Ophthalmology, Medical University of Bialystok, between January 2019 and January 2022. The main outcome measures were success rates (complete: proportion of eyes with IOP < 18 mmHg (criterion A) and < 15 mmHg (criterion B) or 20% reduction in IOP without any glaucoma medication; qualified: proportion of eyes achieving IOPs < 18 mmHg and < 15 mmHg or 20% reduction in IOP from baseline with or without medications), mean reduction (%) in IOP, medication burden, number of complications and additional interventions. In both groups, a significant decrease in IOP and medication burden were observed at 6 and 12 months when compared with baseline. At 12 months, qualified surgical success in criterion A was recorded in 67.4% and 85.7% of patients in the Preserfo and iStent groups, respectively (p = 0.045). Complete surgical success in criterion B at 12 months accounted to 61.4% of patients from Prserflo group and 32.7% patients in iStent group (p = 0.04). Surgical failure at 12 months was documented in 30.2% and 6.3% of patients, respectively (p = 0.003). There was a significant difference between groups in %IOP reduction after 12 months. Greater reduction was observed in Preserflo group, MD = - 8.41 CI95 [- 15.88; - 0.95], p = 0.028, (- 33.49% ± 21.59 vs - 25.07% ± 14.15 in iStent group). Both procedures effectively reduced IOP and postoperative use of antiglaucoma medications in glaucoma patients.

Comparison of bleb morphologies between phacoemulsification combined with Ex-PRESS mini shunt implantation, phacotrabeculectomy and trabeculectomy alone: a two-year retrospective in vivo confocal microscopy study

BACKGROUND

To compare the bleb morphologies of phacoemulsification combined with Ex-PRESS implantation (Phaco-ExPRESS), phaco trabeculectomy (Phaco-Trab), and trabeculectomy (Trab) in postoperative two years.

METHODS

Patients with primary open-angle glaucoma (POAG) with or without cataracts were included in this study. All patients underwent surgeries of either Phaco-ExPRESS, Phaco-Trab, or Trab. The morphologic structures of the filtering bleb, including microcysts area, hyperreflective dot density, and stromal connective tissue under in vivo confocal microscope (IVCM), were compared between the three groups. The data were collected preoperatively and postoperatively at 2 weeks, 1 month, 3 months, 6 months, 12 months, 18 months, and 24 months.

RESULTS

Eighty-nine eyes from 89 patients were enrolled, including 32 in the Phaco-ExPRESS group, 25 in the Phaco-Trab group, and 32 in the Trab group. In a 24-month follow-up, bleb morphologies in Phaco-ExPRESS were similar to the Trab group. The area of epithelial microcysts was significantly increased in Phaco-ExPRESS and Trab groups while significantly decreased in Phaco-Trab. At postoperative 24 months, the complete success rate was 65.1% in Phaco-ExPRESS, 32.0% in Phaco-Trab, and 59.4% in the Trab group (P = 0.03). The phaco-Trab group had more postoperative anti-glaucoma medications than the other two groups (P < 0.05).

CONCLUSIONS

Phaco-ExPRESS group and Trab group had similar blebs morphologies in IVCM, with larger microcyst area, looser connective tissue, and less inflammation than Phaco-Trab, indicating that the function of blebs in the Phaco-ExPRESS and Trab group, was more potent than that of Phaco-Trab. All these surgical methods provided adequate IOP control, but Phaco-Trab required more anti-glaucoma medications.

Comparison of Ex-PRESS implantation versus trabeculectomy combined with phacoemulsification in primary open-angle glaucoma: a retrospective in vivo confocal microscopy study

BACKGROUND

To compare the efficacy of Ex-PRESS implantation versus trabeculectomy combined with phacoemulsification.

METHODS

A retrospective 12-month study on patients with coincident primary open-angle glaucoma (POAG) and cataract. The patients underwent combined phacoemulsification and Ex-PRESS implant (Phaco-ExPRESS, n = 35) or phacotrabeculectomy (Phaco-Trab, n = 35). The morphological structures of the filtering bleb were examined by slit-lamp, anterior segment optical coherence tomography (AS-OCT) and in vivo confocal microscopy (IVCM). Complete success was defined as postoperative intraocular pressure (IOP) < 18 mmHg without the use of anti-glaucoma medication. Qualified success was defined as postoperative IOP < 18 mmHg with or without anti-glaucoma medications. The data were collected preoperatively and postoperatively at 2 weeks, 1 month, 3 months, 6 months, and 12 months.

RESULTS

No significant difference in the variables such as age, IOP and perimetry was found between the groups of Phaco-ExPRESS and Phaco-Trab. At the one-year postoperative visit for filtering blebs, Phaco-ExPRESS increased the mean area of epithelial microcysts significantly from 0.10 ± 0.05 to 0.20 ± 0.09 μm² per μm², while Phaco-Trab decreased the mean area significantly from 0.08 ± 0.04 to 0.04 ± 0.06 μm² per μm². Notably, the hyperreflective dots detected by IVCM decreased by 84.9% in Phaco-ExPRESS but increased by 36.3% in Phaco-Trab. The hyperreflective dots were further identified as neutrophil- and monocyte-like cells. The number of these cells were negatively correlated with the microcysts area (r =  - 0.7, P < 0.01) but positively associated with the grade of connective tissue (r = 0.5, P < 0.01). By creating different microstructural changes in the filtering blebs, Phaco-ExPRESS produced a higher complete success rate (84.9% vs. 41.2%, P < 0.01) and significant decrease in the number of anti-glaucoma medications (P < 0.01) when compared with those in Phaco-Trab. However, the qualified success showed no significant difference between the two groups (100.0% vs. 91.2%, P = 0.24).

CONCLUSIONS

At the one-year follow-up, Phaco-ExPRESS generated better filtering bleb with larger area of microcysts, looser connective tissues, and less inflammation than that of Phaco-Trab, providing adequate IOP control and less IOP-lowering medications. These findings indicate that Phaco-ExPRESS could be more preferred than Phaco-Trab for the treatment of patients with coincident POAG and cataract.

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.

Phacotrabeculectomy versus Phaco with Implantation of the Ex-PRESS Device: Surgical and Refractive Outcomes-A Randomized Controlled Trial

The aim of this study was to compare surgical and refractive outcomes between phacotrabeculectomy (P-Trab) and phaco with Ex-PRESS (P-Ex-PRESS) for glaucoma at a 6-month follow-up. This prospective randomized controlled trial included 81 eyes; 43 eyes (53%) and 38 eyes (47%) were assigned to the P-Ex-PRESS and P-Trab groups, respectively. Refraction, intraocular pressure (IOP), and best-corrected visual acuity were measured. Refractive change was analyzed using the cylinder’s magnitude, and polar analysis assessed the change in the trend of astigmatism [with-the-rule, against-the-rule (ATR), oblique (OBL)], evaluating mean astigmatism in centroid form. All patients showed a statistically significant postoperative decrease in IOP (P < 0.05). There were no differences between the groups in terms of postoperative IOP and visual outcomes or in astigmatism preoperatively or postoperatively (P = 0.61, P = 0.74). In both groups, the mean preoperative and postoperative astigmatism were ATR and OBL, respectively. Preoperative and postoperative centroids in the P-Ex-PRESS group were 0.44 ± 1.32 D at 177° and 0.35 ± 1 D at 8°, respectively, (P = 0.5) and in the P-Trab group were 0.16 ± 1.5 D at 141° and 0.39 ± 1.38 D at 29°, respectively (P = 0.38). Both P-Ex-PRESS and P-Trab showed comparable antihypertensive efficacy in treating open-angle glaucoma over 6 months. Preoperative and postoperative astigmatism did not differ between groups. The groups showed comparable results for final visual acuity.

A prospective, randomised study of the effect of fixation sutures during phacotrabeculectomy on intraocular pressure and incidence of ptosis

We investigated the effects of different intraoperative eyeball fixation techniques (superior rectus muscle suture [MS] and traction suture at the corneal limbus [CS]), on intraocular pressure (IOP) and the incidence of ptosis after phacotrabeculectomy. Forty-one eyes with different glaucoma types which qualified for phacotrabeculectomy were included. Twenty-three and eighteen patients were included in the CS and MS groups, respectively. The IOP, best-corrected visual acuity (BCVA), and margin reflex distance were assessed preoperatively and 3, 6, and 12 months post-operatively. Preoperatively, the mean IOPs (± standard deviation) in the CS and MS groups were 23.6 ± 7.3 mmHg and 24.3 ± 6.6 mmHg (p > 0.05), respectively. At 3 and 6 months post-surgery, the mean IOPs were significantly lower in the CS group than in the MS group: 13.9 ± 3.0 mmHg vs. 17.7 ± 3.5 mmHg (p = 0.001), and 13.9 ± 4.9 mmHg vs. 17.2 ± 3.5 mmHg (p = 0.005), respectively (mean difference: 3.9, 95% confidence interval 1.7–6.1). At 12 months, the mean postoperative IOPs were 15.2 ± 3.5 mmHg and 14.9 ± 3.6 mmHg in the CS and MS groups, respectively (p > 0.05). At 6 months, the BCVAs were 0.91 ± 0.15 and 0.71 ± 0.3 (p = 0.029) in the CS and MS groups, respectively; BCVAs were 0.91 ± 0.15 and 0.71 ± 0.3 (p = 0.029) in the CS and MS groups, respectively; the difference was non-significant 12 months post-surgery (0.78 ± 0.32 vs. 0.74 ± 0.30, p = 0.553). Postoperative ptosis was observed in 4 (17%) and zero patients in the CS and MS groups, respectively, but the difference was not statistically significant (p = 0.118). The study was not powered sufficiently to detect statistically significant changes in exploratory endpoints. The study was not powered sufficiently to detect statistically significant differences between groups in exploratory endpoints.

Effectiveness of iStent Trabecular Microbypass System Combined with Phacoemulsification versus Phacoemulsification Alone in Patients with Glaucoma and Cataract Depending on the Initial Intraocular Pressure

INTRODUCTION

To assess the effect of iStent trabecular microbypass implantation combined with phacoemulsification on intraocular pressure (IOP) and glaucoma medications and to compare this to outcomes of phacoemulsification alone in patients with mild to moderate primary open-angle glaucoma (POAG) depending on initial IOP.

MATERIALS AND METHODS

Eighty subjects with cataract and POAG were randomized 1:1 into either iStent implantation and cataract surgery (iStent group) (n = 44) or cataract surgery alone (control group) (n = 36). Groups were divided according to initial IOP (after washout period) into IOP <26 mm Hg and IOP ≥26 mm Hg. Patients were assessed preoperatively and at postoperative day 1, week 1, and months 1, 3, 6, 12, and 24. Outcome measures included best-corrected visual acuity, IOP, and glaucoma medications.

RESULTS

Postoperatively at 24 months, mean IOP decreased from 20.93 ± 1.28 to 17.79 ± 2.50 mm Hg in the IOP subgroup <26 mm Hg and from 26.00 ± 0.00 to 19.86 ± 2.19 in the subgroup ≥26 mm Hg in the control group. In the iStent group <26 mm Hg, IOP decreased from 22.04 ± 1.64 to 15.57 ± 2.13 mm Hg and from 26.6 ± 1.09 to 17.06 ± 2.43 mm Hg in the iStent group ≥26 mm Hg.

CONCLUSION

In patients with open-angle glaucoma and cataract, iStent implantation combined with cataract surgery reduced IOP significantly through 2 years, with greater reductions achieved versus phacoemulsification alone. In patients with baseline IOP <26 mm Hg, surgery reduced IOP and medication use significantly declined through 2 years, with greater reductions achieved versus patients with baseline IOP ≥26 mm Hg. The study was registered at ClinicalTrials.gov under the number NCT03807869.

Mini-canaloplasty as a modified technique for the surgical treatment of open-angle glaucoma

Authors present a modified surgical technique for canaloplasty without preparing the classical trabeculo-Descemet’s membrane (TDM) and having to close sutures. Twelve patients with open-angle glaucoma (OAG) (aged 58–77 years) received the modified technique, which does not require the deep scleral flap to be excised, an intrascleral lake to be created, or TDM dissection. After accessing the Schlemm’s canal (SC), cannulation and placement of the sutures are made similar to those in the classical canaloplasty. The conjunctiva is closed via bipolar diathermy. The mean intraocular pressure (IOP) before surgery was 18.0 ± 8 mmHg, and the mean number of anti-glaucoma medications taken was 3 ± 1. Mean IOP at the end of the observation period (18.0 ± 6.0 months) was reduced by 23% (15.5 ± 4.1 mmHg), while the mean number of medications taken was reduced to 0.25 ± 1.0. In all eyes, the SC was successively opened, with no cheese-wiring. Adverse events included microhyphaema, mild corneal oedema, and folds in the TDM. The eyes recovered spontaneously within a few days after the procedure. The mini-canaloplasty technique may reduce the risk of complications associated with classical canaloplasty while effectively lowering the IOP in patients with OAG.

Comparison of the 1-year postoperative results of phacoemulsification-trabeculectomy and phacoemulsification-ExPRESS miniature shunt combined surgeries

BACKGROUND AND OBJECTIVE

This study aimed to compare the 1-year postoperative phacoemulsification-trabeculectomy (P-Trab) and phacoemulsification-ExPRESS^® (P-200 model) miniature shunt (P-ExPRESS) combined surgeries.

MATERIALS AND METHODS

This retrospective, comparative clinical study investigated 41 eyes of 41 patients diagnosed with open-angle glaucoma and cataract. Of these, 21 eyes underwent P-Trab surgery and 20 eyes underwent P-ExPRESS surgery. The 1-year follow-up results, including intraocular pressure (IOP), visual acuity (VA), medications, and complications, were reviewed and compared. A 5 ≤ IOP ≤ 18 mmHg or 30% reduction from baseline was defined as Qualified Success (QS-1), and target IOP without medication was defined as Complete Success (CS-1). A 5 ≤ IOP ≤ 15 mmHg or 40% reduction from baseline was defined as Qualified Success (QS-2), and target IOP without medication was defined as Complete Success (CS-2).

RESULTS

The mean follow-up time was 16 months (12-26 months). Results after the twelfth month for P-Trab versus P-ExPRESS are: CS-1: 42.8% versus 60.0% (P = 0.354); QS-1: 86.7% versus 95% (P = 0.606); CS-2:33.3% versus 40% (P = 0.751); QS-2: 66.6% versus 75% (P = 0.733). Kaplan-Meier survival analysis was not statistically significant between two groups for both QS-1, CS-1 and QS-2, CS-2 (P = 0.329 vs P = 0.365, P = 0.765 vs P = 0.789, respectively). Pre-op mean IOP was: 33.19 ± 8.7 versus 34.55 ± 11.3 mmHg; post-op mean IOP was: 15.19 ± 3.07 versus 15.30 ± 3.32 mmHg (P = 0.913); pre-op mean VA was: 1.17 ± 1.04 versus 1.15 ± 1.07 logMAR; and post-op mean VA was: 0.61 ± 0.80 versus 0.66 ± 0.99 logMAR (P = 0.869). The pre-op mean number of antiglaucomatous medications was 3.76 ± 0.53 versus 3.30 ± 1.45, and the post-op results were 1.52 ± 1.53 versus 0.85 ± 1.26 (P = 0.135). Comparing the pre-op and post-op values, both types of surgeries were equally effective (P = 0.00). Surgical failure was 14.2% (3/21) versus 5% (1/20), and the incidence ratios of significant complications were: 47% (10/21) versus 10% (2/20) and P-Trab versus P-ExPRESS, respectively (P = 0.015).

CONCLUSION

The 1-year postoperative results suggest that P-ExPRESS is as effective as P-Trab, with fewer complications.